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The answer is E.
EXPLANATION: Pituitary adenomas, benign neoplasms associated with pituitary hormone secretory changes, may enlarge and become symptomatic. Symptoms are based upon the location and size of the tumor, and may include bitemporal hemianopsia, double vision, color desaturation, and visual acuity loss. Headaches may occur, due to associated pressure changes within the intrasellar space. Additional evaluation should include a T1-weighted MRI, screening laboratory tests, and a full ophthalmologic evaluation. These tests will also help evaluate for potential differential diagnoses, such as those listed. The patient's history is not consistent with an acute ischemic stroke or migraine headache. Although an unruptured aneurysm may have very similar findings to a pituitary tumor, ruptured aneurysms present with acute headache, nausea, vomiting, and potential changes in consciousness. Multiple sclerosis (MS) should remain on the differential for this patient and will also be evaluated through MRI (although the current findings are more consistent with a pituitary adenoma), and additional neurologic findings would be likely with MS. An 18-year-old female presents to your office with the complaint of palpitations for the last 2 months. The episodes are frequent and accompanied with lightheadedness and shortness of breath. The patient's mother has taken her pulse when some of the episodes occur and states that the rate gets as high as 170 beats per minute. On exam, she is alert, awake, and oriented. Her resting pulse is 55 and her blood pressure is 122/65. Her lungs are clear throughout, and her cardiac exam revealed a regular rate and rhythm, without murmurs, rubs, or gallops. An ECG is obtained, as shown. Based on her history, physical exam, and ECG, what is the best pharmacologic treatment plan for this patient?
A. Flecanide
B. Hydrochlorothiazide
C. Lisinopril
D. Adenosine The answer is B.
EXPLANATION: The rapid tests vary in terms of sensitivity and specificity. Research indicates that sensitivities are approximately 50% to 70%, while specificities are approximately 90% to 95%. Specimens to be used with rapid tests generally should be collected as close as is possible to the start of symptoms and usually no more than four to five days later in adults. In very young children, influenza viruses can be shed for longer periods; therefore, in some instances, testing for a few days after this period may still be useful. Most importantly, the positive and negative predictive values vary considerably depending upon the prevalence of influenza in the community. False-positive (and true-negative) influenza test results are more likely to occur when disease prevalence is low, which is generally at the beginning and end of the influenza season, as is the case here. False-negative (and true-positive) influenza test results are more likely to occur when disease prevalence is high, which is typically at the height of the influenza season. When disease prevalence is relatively low, the positive predictive value (PPV) is low and false-positive test results are more likely. By contrast, when disease prevalence is low, the negative predictive value (NPV) is high, and negative results are more likely to be true. The answer is A.
The correct choice is A, dexamethasone suppression test. This patient is presenting with classic signs and symptoms of Cushing's syndrome. The dexamethasone suppression test is a simple test of the hypothalamic-pituitary-adrenal axis, and requires ingestion of oral dexamethasone at nighttime and a blood test in the morning hour, to measure the amount of plasma cortisol. Most patients with Cushing's syndrome demonstrate a lack of normal axis suppression and present with a morning plasma cortisol level >5 mcg/dL. Choice B, radioactive iodine uptake, is used in patients with suspected thyroid disorders. Choice C, glucose tolerance test, is used in patients with suspected diabetes mellitus and in prenatal testing, to investigate gestational diabetes. Choice D, cosyntropin stimulating test, is used to investigate possible adrenal insufficiency. Choice E, plasma fractionated free metanephrines, is used in the diagnostic workup of pheochromocytoma. ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, thereby interrupting the renin-angiotensin-aldosterone system, which regulates blood pressure. The glomerular efferent arteriole dilates, given the decreased stimulus from angiotensin II to constrict. This lowers pressure in the glomerulus by lowering resistance to outflow. This effectively results in a decrease in GFR, resulting in increased serum creatinine and potassium levels. However, these changes are not necessarily indications to discontinue the ACE inhibitor. Usually, the creatinine increases 0.2 to 0.4 mg/dL and then levels out. Monitoring serum creatinine and potassium levels is indicated. If only mild increases occur and stabilize, or if there are no changes, the ACE inhibitor can, and should, be continued so that the patient derives the beneficial effect of the decline in pressure within the glomerulus, which will slow down the progression of CKD. A 70-year-old man, with a history of HTN and aortic valve replacement 3 months ago, presents with complaints of arthralgia, myalgia, anorexia, fatigue, and weight loss over the last month, with recent dyspnea on exertion and lower extremity edema. Vital signs are as follows: Temperature 38°C, BP 102/64, P 98, RR 20. On physical exam, a new high-pitched, blowing, decrescendo diastolic murmur is noted along the left lower sternal border. Two separate blood cultures are positive for S. aureus, and found to be methicillin-resistant. A transesophageal echocardiogram demonstrates a paravalvular abscess. Which of the following is the most appropriate therapy in the management of this patient?
A. IV vancomycin
B. IV vancomycin, IV gentamicin, and PO rifampin with surgical treatment
C. IV amphotericin plus flycytosine, and surgical treatment The answer is B.
EXPLANATION: In patients with prosthetic valve infection with methicillin-resistant S. aureus, the treatment of choice is IV vancomycin for 6 to 8 weeks, plus IV or IM gentamicin for the initial 2 weeks secondary to nephrotoxicity, and PO rifampin for 6 to 8 weeks, with susceptibility to gentamicin determined before initiation of rifampin. Surgical therapy decreases mortality in patients with S. aureus endocarditis, from over 70% with medical therapy alone to 25%, and should be considered in patients with paravalvular abscesses and symptoms suggestive of moderate to severe refractory congestive heart failure. Therefore, choice B is the most appropriate next step in the management of this patient. Choice A does not offer sufficient coverage for methicillin-resistant S. aureus. Choice C is appropriate therapy for infective endocarditis when the causative organism is Candida. Outpatient antibiotic therapy is only appropriate in patients who are stable, without clinical or echocardiographic findings to suggest complications, and IV Ceftriaxone is not appropriate for the treatment of methicillin-resistant S. aureus prosthetic valve endocarditis. Choice E is appropriate therapy for pencillin-susceptible streptococci, such as S. bovis. A 21-year-old female presents to clinic complaining of mild, low abdominal ache and intermittent dysuria. She denies N/V/D, and she is sexually active and uses condoms some of the time. Her LMP was 10 days ago, and she is a G0P0. Physical exam reveals a healthy female in no acute distress. Vitals are as follows: P 70, BP 120/80, T 99.9°F. Lungs are clear, CV RRR, abd soft non-tender, + BS. Pelvic exam reveals normal external genitalia, scant discharge, moderate cervical motion tenderness, and no adnexal masses. What is her most likely diagnosis?
A. Tubo-ovarian abscess
B. Gastroenteritis
C. Ectopic pregnancy
D. Cervicitis
E. Pelvic inflammatory disease tetanus immune globulin, tetanus toxoid, and flagyl---EXPLANATION: Clostridial tetani infection is a vaccine-preventable disease that results in approximately 50 cases/yr in the United States. Even with modern medical resources, one of four or one of five patients with generalized tetanus dies. Almost all cases occur in individuals who are not properly immunized. Sixty percent of cases occur in older adults for whom immunity has waned. Tetanus presents in different forms including generalized, localized, cephalad, and neonatal. Generalized is the most common and symptoms include mood changes, trismus, diaphoresis, dysphagia, and drooling. Later symptoms include painful flexion and adduction of the arms and pain with extension of the legs. Convulsions and spasms are possible, along with a variety of autonomic symptoms. Treatment includes airway protection, benzodiazepines for muscle spasm, tetanus immune globulin immediately, and three doses of tetanus toxoid given by the standard schedule. Metronidazole has been demonstrated to be the most effective antimicrobial. Labetalol may be used for catecholamine-induced hypertension but the patient must also be monitored for hypotension and bradycardia The answer is B.
The correct choice is B, Cortisol. The reader must first consider Cushing's syndrome as the diagnosis for this patient. The clinical manifestations of Cushing's syndrome are noted in this patient, and include easy bruising, proximal muscle weakness, pinkish-purple wide striae, weight gain, and central obesity. These findings are related to the excess Cortisol present in the plasma of these patients. In addition, hypertension is found in 75 to 85% of patients with Cushing's syndrome. Choices A, rennin, and C, testosterone, are noted to be low or normal in patients with Cushing's syndrome. Choice D, Antidiuretic hormone, is lacking in patients with diabetes insipidus. Choice E, thyroid stimulating hormone, is an anterior pituitary hormone that is essential in thyroid stimulation. The answer is C.
EXPLANATION: Histoplasmosis is caused by a dimorphic fungus, most commonly Histoplasma capsulatum (although other species exist). Within the United States, endemic areas include the Ohio and Mississippi river valleys. Additional areas of risk include other parts of North, South, and Central America, Africa, Mexico, and Central Asia. Large amounts of bird and bat droppings within specific soils promote the growth of the fungus, and exposure typically occurs during activities that disrupt the soil and aerosolize the spores. Depending upon the length and intensity of exposure, and the patient's immune system and previous lung history, infections may range from asymptomatic to severe. Treatment is based upon the patient's clinical picture, with mild to moderate disease being treated with oral antifungal agents. The answer is E.
EXPLANATION: Choice E, transthoracic echocardiogram, is a simple, sensitive and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in this patient. Choice A might be able to give evidence of cardiomegaly, but would not be sensitive enough to detect valvulopathy. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient who has no symptoms. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate for valvulopathy. In addition, a patient scheduled for left total knee replacement is unlikely to perform very well on a treadmill, thus the more appropriate test for preoperative evaluation, if necessary after transthoracic echocardiogram, would be a nuclear stress test. A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 1. His echocardiogram demonstrates normal LV systolic function and normal valvular function. He states that his symptoms began 3 days ago, and had gotten worse in the last 2 hours. What would be the most appropriate next step in management?
A. Morphine, oxygen, nitroglycerin sublingually, aspirin 81 mg PO X 4
B. Reassurance and anxiolytics
C. Diltiazem 20 mg bolus IVP over 2 minutes, then diltiazem 10 mg/h IV infusion
D. Aspirin 81 mg two tablets PO
E. Dopamine 5 mcg/kg/min The answer is A.
The correct choice is A, pituitary adenoma. The patient is presenting with classic signs and symptoms of acromegaly. This disorder is caused most commonly by a growth hormone secreting pituitary adenoma. On rare occasions, it has been caused by choice C, a GHRH secreting hypothalamic tumor. Choice B, pheochromocytoma, is a tumor of the adrenal glands that causes high blood pressure, but does not cause the classic body features of acromegaly. Choice D, adrenal carcinoma, and choice E, ectopic ACTH secretion, may cause Cushing's syndrome, but not acromegaly. The answer is C.
The correct choice is C, IGF-I or insulin like growth factor I. This growth factor leads to increased DNA, RNA, and protein synthesis, which leads to overgrowth of bone, soft tissue, and cartilage. Choice A, c-peptide, is a part of the prohormone of insulin. Choice B, IL-I or interleukin I, is an important cytokine that promotes cell activation. Choice D, thyroxine, potentiates the actions of growth hormone on tissues. The answer is E.
EXPLANATION: Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in a patient in this age group, who is likely demonstrating severe aortic stenosis secondary to a congenital bicuspid valve. Patients with a congenital bicuspid aortic valve typically develop symptoms once the valve leaflets have become calcified and thickened, secondary to the undue stress over many years on a structurally abnormal aortic valve. Choice A might be able to give evidence of cardiomegaly or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy, if present. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient, who has no symptoms of palpitations. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate the degree of aortic stenosis; as the patient is likely demonstrating severe aortic stenosis, cardiac catheterization to evaluate for coronary artery disease prior to surgery will need to be performed. The answer is C.
EXPLANATION: Clinical findings of obsessive-compulsive disorder include being a perfectionist, egocentric, and indecisive, with rigid thought patterns and need for control. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Narcissistic personality disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention. Clinical findings of someone who has paranoid personality disorder would include defensiveness, being overly sensitive, secretive, suspicious, hyper-alert, and with a limited emotional response. Schizotypal clinical findings include being superstitious, socially isolated, and suspicious, and having limited personality ability, odd speech, and eccentric behaviors. The answer is C.
EXPLANATION: Heparin is indicated as initial therapy for acute pulmonary thromboembolism, followed by oral anticoagulation with warfarin. Heparin promotes the effect of antithrombin, which inhibits factors Xa, IXa, Xia, and XIIa, and has been shown to decrease mortality and recurrent pulmonary embolism. Streptokinase, a thrombolytic agent, is recommended for hemodynamically unstable patients being treated with heparin, but with continued risk of death. Embolectomy, although associated with increased mortality, is another alternative for these patients. Pulmonary angiography, the gold standard for pulmonary embolus diagnosis, is being replaced with helical contrasted CT, due to angiography's invasiveness, time involvement, and cost. Aspirin, an antithrombotic agent, inhibits platelet aggregation and is effective for preventing platelet thrombosis. It also has a role in thrombosis prevention. However, anticoagulation with heparin remains the mainstay of therapy for pulmonary embolus. The answer is B.
EXPLANATION: Headaches and neurological changes may be seen with many conditions. However, intracerebral neoplasms are often associated with persistent headaches and described as worse in the morning, and may involve neurologic disturbances of many forms, based on the location of the lesion. Coordination deficits, sensory deficits, ataxia, and limb involvement are often seen with brainstem lesions. Amyotrophic lateral sclerosis, a progressive, degenerative nerve disorder with associated weakness, may have similar symptoms, but is not classically associated with headaches. With Lyme encephalitis, signs and symptoms such as fever, vomiting, meningeal signs, and photophobia would be expected. Simple partial seizures are not associated with headaches, although focal neurologic findings are possible. Transient ischemic attacks may have associated headache and neurologic symptoms, but should have improving symptoms and resolution within 24 hours, and are not likely to recur consistently. The answer is B.
The correct choice is B, malnutrition. When not associated with chronic diseases, this is the most common cause of short stature worldwide. Children with malnutrition commonly present with failure of weight gain before growth rate decreases. A dietary history is key to the diagnosis, as well as a history of any parasites in the local area. Choice A, acromegaly, is a disorder of growth hormone excess. Choice C, Prader-Willi syndrome, choice D, congenital growth hormone deficiency, and choice E, IGF-I receptor deficiency, have been found to cause short stature, but are not seen as commonly as malnutrition. The answer is A.
EXPLANATION: Struvite stones form when urea-splitting organisms, such as Proteus, Klebsiella, Pseudomonas, and Staphylococcus, are present in the urinary tract. Ammonia is formed when urease breaks down urea. This results in an alkaline urine, which decreases the solubility of struvite, favoring the production of stones. Calcium stones result from hyperabsorption of calcium in the intestine, impaired renal tubular reabsorption of calcium, primary hyperparathyroidism, intestinal hyperabsorption of oxalate, and hypocitraturia. Uric acid stones are due to hyperuricosuria or a urinary pH <5.5, which causes uric acid to dissociate. They are also the only radiolucent calculi. Cystinuria, an inborn error of metabolism, results in cystine stones. The answer is C.
EXPLANATION: Choice C, electrical alternans with sinus tachycardia, a beat-to-beat alteration in one or more components of the ECG signal, is considered a specific sign of pericardial effusion, often with cardiac tamponade, as it represents the periodic swinging motion of the heart in the effusion at a frequency that is ½ the heart rate. Choice A, torsades de pointes, is a type of ventricular tachycardia frequently seen, and is associated with electrolyte disturbances or the use of certain types of antiarrhythmic drugs. Choice B, U waves, are associated with hypokalemia. Choice D is frequently noted with severe hyperkalemia. Choice E, convex elevation of the J point, is seen in patients suffering from hypothermia. The answer is E.
EXPLANATION: Multiple sclerosis (MS) therapy is often discussed by the goal of the treatment. Medications, such as the glucocorticoids, are utilized for acute exacerbations or initial episodes of MS, to decrease exacerbation severity. Additionally, they are used for associated conditions, such as optic neuritis. Steroids have not been shown to decrease MS progression or impact the relapse rate.
Other medications have shown to be beneficial regarding altering disease progression and/or the relapse rate. These medications include Interferon-β agents, glatiramer acetate, and Natalizumab. Mitoxantrone, an antineoplastic agent, is also indicated as an MS disease-altering agent, but due to a high risk of cardiotoxicity with prolonged use, it is a second-line agent The answer is C.
EXPLANATION: A febrile seizure is a brief (less than 15 minutes), generalized, symmetric, tonic-clonic seizure associated with a febrile illness (temperature greater than 38.8°C) without any central nervous system infection or neurologic cause. An absence (petit mal) seizure is a brief (2 to 25 seconds) loss of consciousness that can occur multiple times per day. There is no loss of tone, and frequently the only observable behaviors are staring or minor movements such as lip smacking and semipurposeful movements of the hands. There is no postictal period. Complex partial seizures (psychomotor) have varied symptoms including alterations in consciousness, unresponsiveness, and repetitive complex motor activities that are purposeless. Often, at the beginning of the attack, there is a psychoillusory phenomenon such as hallucinations, visual distortions, visceral sensations, or feelings of intense emotions. Simple partial seizures include focal motor, adversive, and somatosensory seizures. Manifestations of these seizures are varied including hallucinatory, psychoillusory, or complex emotional phenomena. Children will interact normally with their environment, with the exception of those limitations imposed by the seizure. Following the seizure (minutes to hours), there may be transient paralysis of the affected body part. The answer is A.
EXPLANATION: Choice A, reassurance and monitoring with periodic transthoracic echocardiogram, is the most appropriate choice given the patient's findings on echocardiogram. Most patients with mitral valve prolapse are asymptomatic, and do not demonstrate significant progression of their valvulopathy over their lifetime. Periodic transthoracic echocardiogram allows a noninvasive, highly sensitive method of monitoring. Choice B, cardiac catheterization, is useful for evaluation of coronary artery anatomy and for evaluation of valvulopathy; however, it is invasive, and usually reserved for investigation of serious valvular dysfunction, and/or following a stress test suggestive of myocardial ischemia. The chest pain experienced by patients with mitral valve prolapse is varied in presentation, and in this setting, with a young patient with no cardiac risk factors, unlikely to be secondary to coronary artery disease. According to the American Heart Association's most recent guidelines, patients with mitral valve prolapse alone do not require infectious endocarditis prophylaxis, so choice C is inappropriate. Choice D, mitral valve replacement, is only indicated with severe mitral valve prolapse, resulting in severe mitral regurgitation. Choice E, transesophageal echocardiogram, while an excellent diagnostic tool for the evaluation of mitral valve disease, would be more invasive than monitoring via transthoracic echocardiogram, and thus would not be an appropriate choice in this patient with only mild mitral valve prolapse 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.
EXPLANATION: Entamoeba histolytica has two stages in its life cycle. In the active stage in the human intestine, it causes symptoms of dysentery, abdominal pain, stool mucus, and tenesmus. In the dormant stage, the cystic form is excreted in the stool and in developing nations frequently contaminates the supply of drinking water. When the amoeba is in the dormant stage, the cystic form can be excreted in the stool and, in the case of food handlers with poor personal hygiene, be transmitted to others. In addition, because of the cystic stage, individuals engaging in anal intercourse can transmit the infection unknowingly. Diagnosis is made by microscopic evaluation of a stool wet prep and confirmed by serology. Treatment includes agents such as metronidazole or tinidazole. ( A 76-year-old man, is brought to the emergency department by his niece after she found him wandering around his yard in the cold wearing only a tee shirt and jeans. When she set up his pill container about 36 hours earlier, he seemed his usual self but, in retrospect, possibly a little more confused than usual. The niece says that he has "high blood," treated with a "white fluid pill," "sugar diabetes," treated with an oral medication, and early "old timer's" dementia treated with "a memory pill." Vital signs include an oral temperature of 100.8F, pulse 100 beats per minute, respirations 24 and somewhat shallow, and blood pressure of 88/52. Initial examination reveals a slightly dehydrated, stuporous man appearing older than his stated age, who smells strongly of urine. He has no lateralizing signs. What is the most likely cause of the mental status changes?
A. hyperglycemic hyperosmolar state
B. lactic acidosis
C. stroke
D. urinary tract infection
E. worsening dementia The answer is D.
EXPLANATION: Choice D, sepsis, is one of a long list of disease entities that can cause troponin elevation, including arrhythmias (both tachycardic and bradycardic), aortic valve disease, hypertrophic cardiomyopathy, invasive cardiac surgeries and procedures, severe pulmonary hypertension, pulmonary embolism, myocardial infiltrative diseases (such as amyloidosis, sarcoidosis, scleroderma, and hemochromatosis), acute respiratory failure, burns, pericarditis, endocarditis, myocarditis, and even occasionally due to extreme athletic activities such as marathon running. Not included on this long list, however, are choices A, B, C, and The answer is C.
EXPLANATION: Choice C, Osler's nodes, confirms the clinical diagnosis of infective endocarditis, as it is a minor criteria. The Duke criteria for the clinical diagnosis of infective endocarditis requires the documentation of two major criteria, or one major criteria and three minor criteria, or five minor criteria. The patient demonstrates the presence of one major criteria (two separate blood cultures with typical microorganisms for infective endocarditis) and two minor criteria (fever greater than 38.0°C and predisposing condition of IV drug use). Only a new valvular regurgitation, not an increase or change in preexisting murmur, is considered sufficient to qualify as a major criteria, so choice A is incorrect. An irregularly irregular pulse, choice B, is commonly seen in patients with atrial fibrillation, not with infective endocarditis. Choice D, conjunctival hemorrhages, not buccal hemorrhages, are one of the minor criteria. Choice E, Koplik spots, are buccal lesions seen in patients infected with measles, whereas the presence of Roth's spots does fulfill one of the minor criteria. The answer is C.
The correct choice is C, levothyroxin 50 to 100 ug PO daily. This patient has classic signs and symptoms of hypothyroidism and required thyroid hormone supplementation. The most common form of hypothyroidism is primary hypothyroidism (e.g. Hashimoto's thyroiditis), and the most common thyroid hormone supplementation is levothyroxine. Choice A, lithium carbonate 300 mg PO twice daily, is a medication used in patients with psychiatric disorders and is known to cause hypothyroidism. Choice B, resection of the anterior pituitary, is not indicated without evidence of a tumor or other pituitary pathology. Secondary hypothyroidism related to the anterior pituitary is quite rare. Choice D, ferrous sulfate 325 mg PO three times daily, is a common treatment protocol for patients with iron deficiency anemia. This patient's MCV is elevated, indicating large red blood cells, as seen in disorders such as vitamin B12 deficiency or folic acid deficiency. Patients with iron deficiency anemia present with microcytic hypochromic anemia. Choice E, radioactive iodine protocol, is a treatment used in patients with hyperthyroidism. A 70-year-old man, with a history of HTN and aortic valve replacement 3 months ago, presents with complaints of arthralgia, myalgia, anorexia, fatigue, and weight loss over the last month, with recent dyspnea on exertion and lower extremity edema. Vital signs are as follows: Temperature 38°C, BP 102/64, P 98, RR 20. On physical exam, a new high-pitched, blowing, decrescendo diastolic murmur is noted along the left lower sternal border. Two separate blood cultures are positive for S. aureus. Which of the following is the most appropriate next diagnostic study?
A. EKG
B. CXR
C. TTE
D. ESR
E. TEE The answer is E.
EXPLANATION: Choice E, TEE or transesophageal echocardiogram, would be most useful in establishing a diagnosis of infective endocarditis, as a positive echocardiogram demonstrating presence of a vegetation would satisfy one of the Duke criteria's major criteria, as well as determine the extent of the prosthetic valvular dysfunction, if present. TEE is more sensitive than TTE, transthoracic echocardiogram, for detecting vegetations, so choice C is incorrect. Choices A and B, EKG and CXR, should be performed as part of this patient's evaluation, but would be less useful than TEE in establishing a diagnosis of infective endocarditis. Choice D, erythrocyte sedimentation rates, are frequently elevated in patients with endocarditis, but are not specific to the diagnosis of endocarditis. The answer is E.
EXPLANATION: This patient exhibits classic findings of Parkinson's disease. Parkinson's is a nervous system disorder due to decreased dopamine, resulting from a degeneration of the dopaminergic nigrostriatal system. Symptoms may include a combination of tremor, rigidity, bradykinesia, progressive postural instability, slowing of automatic movements, gait changes, decreased facial expression, speech changes, and cognition deficits. Muscle strength and reflexes are typically preserved. Chorea, an irregular, rapid, and involuntary movement, is typically seen with Huntington's and a variety of other disorders. Parkinson's must be differentiated from other nervous system disorders.