The answer is E.
The correct choice is E, proliferative retinopathy. The distinguishing factor in the patient's presentation, which signals this disorder, is the development of newly formed vessels. Proliferative retinopathy is the leading cause of blindness in the United States. Up to 20% of patients with type 2 diabetes have retinopathy at the time of diagnosis. Choice A, background retinopathy, or simple retinopathy includes retinal microaneurysms, hemorrhages, exudates, and edema, without new vessel formation. Choice B, closed angle glaucoma, is relatively uncommon in patients with diabetes, except after cataract extraction. Choice C, macular degeneration, is not associated with diabetes mellitus specifically. Choice D, diabetic cataracts, tends to occur in patients with diabetes earlier than the general population, and may correlate with the severity of the disease.
The answer is B.
The correct choice is B, type 2 polyglandular autoimmune syndrome. This patient is presenting with signs and symptoms of adrenal insufficiency including abdominal pain, nausea, anorexia, vomiting, weight loss, anxiety, and hyperpigmentation. Type 2 polyglandular autoimmune syndrome presents most commonly in young women between 20 and 40 years old, with evidence of adrenal insufficiency, type 1 diabetes mellitus, and autoimmune thyroid disease. Because of the strong family history of thyroid disease, it would be prudent to conduct an investigation into this disorder, starting with a serum TSH level. Primary ovarian failure and vitiligo may be symptoms of the autoimmune polyglandular syndrome as well. Choice A, type 1 autoimmune polyglandular syndrome, presents more commonly in childhood with adrenal insufficiency, hypoparathyroidism, and mucocutaneous candidiasis. Choices C and D are inherited disorders, characterized by the development of several different types of endocrine organ neoplasias. Choice E, metabolic syndrome, includes a constellation of several metabolic disorders that increase the risk of cardiovascular disease and diabetes mellitus in the patient.
The answer is E.
The correct choice is E, gemfibrozil and HMG-CoA reductase inhibitor. In combination, these can potentiate the risk of developing hepatic disease or myopathy. Choice A, Ezetimibe and HMG-CoA reductase inhibitor, is a synergistic treatment plan for patients with primary hypercholesterolemia. Choice B, low dose niacin and HMG-CoA reductase inhibitor, is a practical and effective treatment plan for patients with familial combined hyperproteinemia. Choice C, colestipol and gemfibrozil, is sometimes useful in patients with familial combined hyperlipidemia who are intolerant of niacin or HMG-CoA reductase inhibitors. Unfortunately, this combination may increase the risk of cholelithiasis. Choice D, niacin and cholestyramine, is useful in disorders with elevated VLDL and LDL, and useful in treating heterozygous familial hypercholesterolemia.
The answer is E.
EXPLANATION: This patient presents with classic symptoms for optic neuritis. Symptoms may include sudden or progressive unilateral vision loss, often with central field defect (scotoma). Pain may be present with eye movement. Vision changes will vary in severity, based on the level of inflammation. The majority of optic neuritis cases are retrobulbar, resulting in a normal fundoscopic exam. There is often a loss of color differentiation, and the affected eye may have decreased papillary light reactivity. The patient also exhibits additional symptoms that are suggestive of possible demyelinating disease (such as Multiple Sclerosis), which are strongly associated with optic neuritis. Conjunctivitis would have associated conjunctival injection, a clear cornea, no visual acuity changes, and would likely be associated with allergic, viral, or bacterial symptomology. Acute glaucoma would likely be associated with marked vision loss, headache, a fixed pupil, corneal cloudiness, and conjunctival injection. In addition, the intraocular pressure would be increased. Keratitis often presents with vision loss, pain, photophobia, conjunctival injection, stromal infiltrate, and corneal disruption. Macular degeneration develops gradually with increasing age, causing bilateral central visual loss.
The answer is A.
The correct choice is A, cancer related diabetes insipidus. Solid tumors, such as cranipharyngiomas and metastatic lung and breast cancer, are known to cause diabetes insipidus. This patient has a history of lung cancer. Choice B, diabetes mellitus, is not present in this patient. His pasting glucose and hemoglobin A1c are within the reference range. Choices C, nephrogenic diabetes insipidus, and choice D, familial hypothalamic diabetes indipidus, are causes of polyuria. Both are noted in young patients. Choice E, primary polydipsia, is associated with excessive drinking of liquids, which leads to excessive urination. There is no history of this occurring in this patient.
The answer is B.
EXPLANATION: Choice B is the most appropriate treatment, as the patient is demonstrating high output congestive heart failure secondary to beriberi, or thiamine deficiency. In 50% of patients, IV thiamine administration, along with other vitamins and glucose, will resolve the patient's symptoms. Choice A, IV dextrose alone in patients with very low thiamine stores, can worsen signs and symptoms of heart failure. Choice C, IV enalapril, is appropriate therapy for patients in need of better blood pressure control, and as an ACE inhibitor, in patients with left ventricular systolic dysfunction, which is not the cause of this patient's heart failure. Choice D, IV dopamine, is useful in patients in need of pressor support, but will not help treat high-output heart failure secondary to thiamine deficiency. Choice E, IV diltiazem, is useful for heart rate control in patients with atrial fibrillation with a rapid ventricular rate.
answer is E.
The correct choice is E, vasopressin. The reader must first understand that the patient's symptoms are classic for diabetes insipidus, with the increased thirst, frequency, and polyuria. These symptoms are also seen in diabetes mellitus, but this would be less likely since the patient doesn't have a family history of diabetes mellitus, and his hemoglobin A1c is not elevated. Choice A, sodium, should be within range, as long as the boy is able to drink when thirsty; otherwise, he would become hypernatremic. Choice B, glucose, is incorrect. Although the signs and symptoms also fit the pattern of diabetes mellitus, the glucose would most likely be elevated in this disorder, and not low. Choice C, thyroxine, is under control of TSH from the anterior pituitary gland, and choice D, prolactin, is secreted from the anterior pituitary gland. Vasopression is secreted from the posterior pituitary gland.
The answer is A.
EXPLANATION: This is a fairly classic presentation of adrenocortical insuffiency (Addison's disease). Diabetes mellitus, type 1, that has led to ketoacidosis (B) could also present with weight loss, nausea, and vomiting; but is also accompanied by hyperphagia and polydipsia, and does not have the hyperpigmentation associated with Addison's disease. Patients with hypercortisolism (Cushing Syndrome) (C) present with central obesity, hirsutism, thin skin, poor wound healing, and a host of other problems including emotional lability. Those with hyperglycemic hyperosmolar state (D) are typically older, have a high body mass index, and present with lethargy, confusion, and dehydration. Patients with hypothyroidism (E) usually have weight gain and constipation along with lethargy, fatigue, and weakness.
Your 48-year-old male diabetic patient presents for a new-patient visit and a complete physical examination. You elicit a history approximately one month ago of some vague complaints of left shoulder discomfort that lasted about 30 minutes and occurred during strenuous exercise. At the time, he broke out in a sweat. The patient has had no symptoms whatsoever since. The physical examination is normal, as are his vital signs, and his ECG is below. His ECG below is unchanged from previous ECGs. What is the most appropriate plan of action for this patient?
A. Give the patient a full-dose aspirin and call 911.
B. Draw labs including CBC, CMP, a fasting lipid panel, hs-CRP, HbA1C, TSH, and treat accordingly when the labs return with a follow-up visit in two weeks.
C. Draw labs including a CK-MB and troponin, and treat accordingly when the labs return with a follow-up visit in two weeks.
D. Draw labs including a CBC, CMP, fasting lipid panel, HS-CRP, HbA1C, TSH, and treat accordingly when the labs return with a follow-up visit in two weeks; until that time start the patient on an 81 mg enteric-coated aspirin, metoprolol ER 25 mg once daily and schedule an urgent appointment within the next 72 hours with a cardiologist for a nuclear stress test insuring that the patient knows to call 911 if the symptoms re-occur.
The answer is E.
EXPLANATION: Choice E, emergent pericardiocentesis, should be considered when patients exhibit symptoms suggestive of severe cardiac tamponade, such as described above, with confirmatory echocardiographic findings of a large pericardial effusion, as this can be fatal if not treated promptly. Choice A is inappropriate, as this could lead to worsening of cardiac tamponade if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively. Choice B could provide additional confirmation of the diagnosis if a reduction in amplitude of QRS complexes is demonstrated, and electrical alternans of the P, QRS, and T waves, but would not provide any therapeutic benefit. Choice C could be the next appropriate step in management of myocardial infarction, but not in cardiac tamponade. Choice D represents appropriate therapy for patients with acute rheumatic fever, but not for patients with cardiac tamponade.
A 48-year-old male presents with an 8-day history of a productive cough, subjective fevers, and malaise. He is otherwise healthy without any active medical problems. He is a social drinker of alcohol, and denies any tobacco or drug use. On physical examination, the patient is alert and oriented. His temperature is 100.40F, pulse rate is 56, respiratory rate is 18, and blood pressure is 133/64. HEENT is within normal limits and a chest exam has diffuse expiratory wheeze with decreased sounds to the right lower lung fields. Blood labs reveal WBC 14.4, Hgb 11.3, Plt 233, ALT 65, AST 102, and PO4 2.1. A chest x-ray reveals a dense consolidation with bulging fissures. Based on these findings, what is the best medication to treat this patient?
One of your patients is requesting your help. He has seen three physicians in the past 3 months and is still having symptoms. He states, "I keep having these episodes of feeling like I am going to die. Out of the blue I feel real nervous, I get a splitting headache, break out in a sweat, and even feel like I am trembling. Sometimes I feel my heart beating out of my chest but don't have any pain or shortness of breath." He has had numerous tests including a cardiac stress test, multiple EKGs, complete blood count (CBC), basic metabolic panel (BMP), thyroid tests, and computed tomography (CT) scans of his head, which were normal. His last physician told him that he had an anxiety disorder and should try medications; he declined. His only medical problem is hypertension, which has worsened recently. He is currently taking lisinopril 20 mg QD, amlodipine 10 mg QD, and HCTZ 25mg QD. His physical examination is unremarkable except a BP of 190/92, P = 74. What is the best test to order to confirm your suspected diagnosis?
A. dexamethasone suppression test
B. sleep study
C. renal artery ultrasound
D. plasma fractionated free metanephrines
E. thyroid uptake scan
he answer is D.
EXPLANATION: The correct answer is (D). The patient's symptoms and uncontrolled hypertension with a previous negative evaluation for cardiac, electrolyte, or thyroid causes highly suggests a pheochromocytoma as the possible cause. Plasma fractionated free metanephrines is a very sensitive test for the diagnosis of pheochromocytoma. Another test to consider would be evaluation of the total urinary metanephrines. A dexamethasone suppression test, choice (A), is used to r/o Cushing's syndrome, which is unlikely due to the normal physical examination findings. A sleep study, choice (B), (suggesting sleep apnea) and renal artery ultrasound, choice (C), (suggesting renal artery stenosis) are used to diagnose secondary hypertension, but would unlikely explain all the symptoms in the scenario. A thyroid uptake scan, choice (E), is not indicated since there is no indication of abnormal thyroid testing suggesting hyperthyroidism, or examination stated findings suggestive of a thyroid nodule.
Lorazepam-This patient has a known history of seizures, with current ongoing seizure activity and the concern of status epilepticus, a true emergency. Prolonged seizure activity is associated with hyperthermia, metabolic disturbances, cardiopulmonary dysfunction, and irreversible damage. Lorazepam, a benzodiazepine, increases the activity of gamma-aminobutyric acid (GABA) in the brain, thereby calming the excessive electrical nerve activity related to the seizure and slowing the central nervous system. It is the preferred first line agent for temporary control of seizure activity due to the duration of action of approximately 12 to 24 hours. This allows additional therapeutic agents to be administered while gaining control of the seizure activity. The other agents are antiepileptic medications, which are used for long-term seizure control. They are differentiated by efficacy, convenience, side effects, and drug-drug interactions. A 33-year-old IV drug user presents to the emergency department with pleuritic chest pain, cough, chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. No murmur could be appreciated. Two separate blood cultures are positive for S.aureus. An EKG, CXR, and transesophageal echocardiogram are ordered. Which of the following lesions is most likely to be seen on TEE in this patient?
A. Aortic valve vegetation
B. Tricuspid valve vegetation
C. Mitral valve vegetation
D. Left ventricular hypertrophy
E. Ventricular septal defect
The answer is B.
EXPLANATION: Fibromyalgia (B) is a diagnosis of exclusion most frequent in women aged 20-50 years. The patient with fibromyalgia complains of chronic aching pain and stiffness, frequently involving the entire body but with prominence of pain around the neck, shoulders, low back, and hips. Fatigue, sleep disorders, subjective numbness, chronic headaches, and irritable bowel symptoms are common. Objective signs of inflammation are absent and laboratory studies are normal. Physical examination is normal except for "trigger points" of pain produced by palpation of various areas such as the trapezius, the medial fat pad of the knee, and the lateral epicondyle of the elbow. Polymyositis (A) produces weakness rather than pain. Polymyalgia rheumatica (C) produces shoulder and pelvic pain and is associated with an elevated ESR, occurring after age 50. Rheumatoid arthritis (D) and systemic lupus erythematosus (SLE), (E), present with objective physical findings or abnormalities on routine testing.
A 70-year-old man with a history of congestive heart failure, CABG x 2, HTN, and diabetes mellitus, type 2, presents to the office with complaints of increasing dyspnea while walking across the room, 3 pillow orthopnea, and worsening lower extremity edema since he returned from a cruise. He admits to taking all of his medications regularly, including lisinopril 20 mg daily, carvedilol 12.5 mg twice daily, spironolactone 25 mg daily, furosemide 20 mg daily, and aspirin 81 mg daily. On physical exam, his vital signs are stable, although he has gained 10 lbs compared to his last office visit three months ago. He is also demonstrating jugular venous distention to the angle of the jaw, at 90 degrees of truncal elevation. There are crackles at the lung bases bilaterally, and 1+ pitting edemas to the knees bilaterally. His EKG is unchanged from previously (see Figure 7). Which of the following is the most likely etiology for this patient's acute exacerbation of congestive heart failure?
A. Labile hypertension
B. Acute myocardial infarction
C. Dietary noncompliance
D. Acute chordae tendinae rupture
E. Severe anemia
The answer is C.
EXPLANATION: Choice C is the most likely etiology for this patient's acute exacerbation of congestive heart failure. Although choices A, B, D, and E are all possible causes, a more common, though mundane cause of acute exacerbation of congestive heart failure, is dietary noncompliance, especially related to sodium restriction. Patients with congestive heart failure should maintain low sodium diets, which is difficult in everyday settings, and nearly impossible aboard a cruise ship while on vacation. There is no evidence to support labile hypertension as the cause of this patient's symptoms, as his blood pressure is currently well-controlled. Choice B is also less likely than choice C, given that the patient is not demonstrating chest discomfort and no EKG changes are noted. Choice d is less likely than choice C, as on physical exam there is no new murmur noted. Choice E is less likely than choice C in this patient, as no history or physical exam findings are noted that would raise the suspicion for severe anemia.
Your 36-year-old obese female patient complained of a single episode of right upper quadrant pain after eating fast food (a double cheeseburger, fries, and a vanilla shake) last week. The symptoms have resolved and have not reoccurred when she presents to your family practice. Your psychical examination is completely normal, as is blood work, including a complete blood count, comprehensive metabolic panel, acute viral hepatitis panel, amylase, and lipase. You suspect cholecystitis and order an abdominal sonogram. The radiologist makes note that the gall bladder appears thickened with an associated calcification with a single, large gallstone. Of the following, what is the most appropriate next step?
Counsel the patient on diet, exercise, and lifestyle changes and revisit the issue should symptoms reoccur.
B. Refer the patient for an abdominal computed tomography (CT) scan.
C. Refer the patient to a gastroenterologist.
D. Refer the patient to a surgeon for a laparoscopic cholecystectomy due to the risk of gall bladder cancer.
E. Re-evaluate the patient for symptomatology in four to six weeks.
The answer is C.
The correct choice is C, primary hyperparathyroidism. This patient has the characteristic signs and symptoms of hypercalcemia, along with the lab findings of primary hyperparathyroidism with elevated calcium, low phosphate, and elevated PTH. Other common presenting features include bone pain, paresthesias, polyuria, and gastrointestinal symptoms. Females are affected three times as much as males, and it is typically found accidentally. Choice A, vitamin D deficiency, is unlikely since she enjoys gardening outside in the sun. Vitamin D deficiency can be seen is association with primary hyperparathyroidism, but is not the cause of this disorder. Choice B, hypercalcemia of malignancy, is unlikely with her history of normal mammograms. Serum PTH is typically normal in this disorder as well. Choice D, factitious hypercalcemia, is unlikely since she doesn't take any calcium supplements or other medications. Choice E, hyperthyroidism, can be a cause of hypercalcemia if the patient is suffering from thyrotoxicosis, but this patient's TSH is within the reference range.
The answer is D.
EXPLANATION: This patient is exhibiting all of the characteristics of narcissistic personality disorder. Antisocial personality disorder is characterized by selfishness, callousness, promiscuousness, and impulsive behavior, and an inability to learn from experience and legal problems. Avoidant personality disorder presents clinically as someone who fears rejection, overreacts to rejection and failure, and has poor social endeavors and low self-esteem. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Schizoid personality disorder is characterized by shyness, introversion, being withdrawn, and avoiding close relationships.
The answer is C.
EXPLANATION: The patient presents with a combination of inadequate fluid intake and excessive losses due to perspiration, resulting in hypovolemia and hypernatremia. The most common causes of hypernatremia are inadequate fluid intake resulting in hemoconcentration and diabetes insipidus (DI), resulting in excessive renal fluid losses. Normal urine osmolality is 500 to 850 mOsm/kg but can range from 50 to 1,200 mOsm/kg depending on the patient's fluid intake. Urine osmolality >400 mOsm/kg indicates that the renal fluid-conserving mechanism is intact, as the kidneys are working to preserve volume. A lower urine osmolality would be consistent with DI, characterized by a lack of response to anti-diuretic hormone (ADH), resulting in excessive urinary losses of water with worsening hypernatremia. Treatment is directed at the cause. If the patient is dehydrated, restoring fluid volume is the goal. If the patient has DI, treating the underlying disease will lower the serum sodium level. For this dehydrated patient, the treatment would be to administer isotonic (normal) saline, which contains 0.9% sodium, because of the large free water deficit. Quarter-normal saline contains 0.25% sodium, half-normal saline contains 0.45% sodium, and lactated Ringer's solution is similar to half-normal saline in its sodium content. Dextrose 5% in water (D5W) contains no electrolytes. Isotonic saline is the appropriate choice because it treats not only the volume deficit but the serum osmolality as well. Its osmolality (308 mOsm/kg) is often lower than the plasma osmolality because of the hypovolemic state and, therefore, helps restore normal serum osmolality. Once serum osmolality becomes more normal, the isotonic saline can be replaced by D5W to replace the remaining free water deficit. If the free water deficit were less dramatic, initial IV fluid treatment could be half-normal saline, followed by D5W.
A 44-year-old female presents to the emergency department with a right-sided headache. She states the headache is located on the right temple region, is non-radiating, and does not cause photophobia. She is otherwise healthy and has no reported medical problems and has only taken acetaminophen for the pain, which has minimal relief. On physical exam she is alert, awake, and oriented. Her vitals are T 98.8, P 78, R 18, and BP 128/76. Her head is normocephalic, atraumatic, and pupils are equal and reactive. She has tenderness to the right temporal area of the temporal artery, and there is no noted swelling, redness, or abnormalities noted. There is no tenderness to the cervical muscles. She exhibits a non-focal neurological exam. Based on the clinical presentation, what test is the best test in confirming an accurate diagnosis?
A. C-reactive protein
B. Erythrocyte sedimentation rate (ESR)
C. Computed tomography of head
D. Temporal artery biopsy
The answer is E.
EXPLANATION: Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine are usually considered first-line antidepressants due to their relative safeness in overdose and their minimal affinity for muscarinic, α-adrenergic, and histamine receptors, thereby causing fewer side effects. Tricyclic antidepressants such as amitriptyline and desipramine produce several adverse effects associated with their antimuscarinic properties (eg, dry mouth, constipation, blurred vision, urinary retention, etc). The patient is already taking the antimuscarinic agent oxybutynin, so a tricyclic antidepressant could attenuate these adverse effects. Orthostatic hypotension is also common with tricyclic antidepressants, and because the patient is taking lisinopril for hypertension, the risk for a significant drop in blood pressure is high. Buspirone and alprazolam are not indicated for depression.
DTaP, IPV, MMR, varicella-The immunization schedule is developed biannually by the Centers for Disease Control and Prevention. Assuming that the child has had the appropriate immunizations at the regularly scheduled examinations, the recommended immunizations at the 4- to 6-year-old range are the DTaP (diphtheria, tetanus, acellular pertussis), IPV (inactivated polio), and the MMR (measles, mumps, and rubella). The hepatitis series should have been completed by the age of 6 months and the Haemophilus influenzae type B (Hib) should be completed by the age of 12 to 15 months. Varicella is given from 12 to 18 months and again from 4 to 6 years; the PCV (pneumococcal) should be finished by 12 to 15 months. A 64-year-old African American female presents to the clinic for evaluation of her hypertension, which she has had for several years. In the past she had been taking hydrochlorothiazide and lisinopril, with little effect on her blood pressure management. At today's visit, she has no complaints and feels well. Her vitals show Tm 96.6, P 85, R 18, BP 191/99. She has no jugular venous distention seen on the neck exam, her lungs are clear, and cardiac exam has a regular rate and rhythm without murmur or gallop. Her abdomen is soft, non-tender, and a bruit is appreciated at the mid-abdomen just a few centimeters below the epigastric region. There is no fullness or enlargement of the abdominal aorta on palpation. Based on the history and clinical findings, what is the most likely diagnosis?
A. Renal artery stenosis
B. Abdominal aortic aneurysmC. Mitral stenosis radiating murmur
The answer is A.
EXPLANATION: Complex biologic, psychological, and social factors determine onset and severity of eating disorders, along with mortality and morbidity. Patients with eating disorders have some of the highest rates of psychiatric comorbidities, including depression, affective disorders, anxiety disorders, obsessive-compulsive personality traits or disorder, and substance abuse. Eating disorders are risk factors for both attempted and completed suicide. Suicide attempts occur in up to 35% of patients with bulimia, but completed suicides do not appear to be elevated. In contrast, women with anorexia have been shown to have a fifty-fold increased risk for completed suicide. Suicide is one of the leading causes of death for patients with anorexia.
Nephrotic syndrome is defined as proteinuria >3.5 g/24 h resulting in hypoalbuminemia (<3.0 g/dL), hyperlipidemia (total cholesterol >250 mg/dL), and edema, probably due to increased renal tubule permeability. Causes include diabetic nephropathy, HIV nephropathy, chronic hepatitis B and C, amyloidosis, systemic lupus erythematosus, constrictive pericarditis, Hodgkin's disease, minimal change disease, and many medications, including phenytoin and NSAIDs.