A 38 Year Old Man Complaining Of Cyclic Fever.

A 38-year-old man comes to the emergency department complaining of cyclic fevers and
headaches. The fevers began about 1 week ago; 2 weeks ago the patient returned from a trip to Africa. Physical examination reveals splenomegaly, and brain imaging shows signs of significant cerebral involvement. Which of the following parasites most likely caused this patient’s symptoms?

(A) Babesia microti
(B) Plasmodium falciparum
(C) Plasmodium malariae
(D) Plasmodium ovale
(E) Plasmodium vivax

Answer And Discussion:

A 25 Year Old Woman With A 2 Day History Of Dysuria And Urinary Frequency

A 25-year-old woman complains of a 2-day history of dysuria, urgency, and urinary frequency. She denies the use of any medications and has no significant past medical history.
On examination, her blood pressure (BP) is 100/70 mm Hg, heart rate (HR) is 90 beats per minute, and temperature is 98°F (36.6°C). The thyroid is normal on palpation. The heart and lung examinations are normal. She does not have back tenderness. The abdomen is non tender and without masses. The pelvic examination reveals normal female genitalia. There is no adnexal tenderness or masses.

1. What is the most likely diagnosis?
2. What is the next step in the diagnosis?
3. What is the most likely etiology of the condition?

Answers And Discussion:

A 19 Year Old Woman Presenting With A Vaginal Discharge

A 19-year-old nulliparous woman presents to her gynecologist with the complaint of a vaginal discharge with a fishy odor over the past 2 weeks. The patient is sexually active and states that the odor is especially prominent after intercourse. Her last menstrual period was 3 weeks ago. She denies having any history of sexually transmitted diseases. She is in good health and takes no medications other than an oral contraceptive agent.
On examination, her blood pressure (BP) is 110/70 mm Hg, heart rate (HR) is 80 beats per minute, and temperature is afebrile. The thyroid is normal to palpation. The heart and lung examinations are normal. The external genitalia are normal; the speculum examination reveals a homogeneous, white vaginal discharge and a fishy odor. No erythema or lesions of the vagina are noted.

1.  What is the most likely diagnosis?
2. What is the best treatment for this condition?

Answer And Discussion:

Case Discussion On Osteoporosis

Your patient is an overweight 75 years old female with no history of bone fracture. She has never had a bone mineral density test and asks if she should have one. You are unaware of any risk factors in her other than her postmenopausal status.

1. What will you tell this patient?
2. Which Of the Medications can increase her risk for osteoporosis?

1. What will you tell this patient?
Answer: Bone densitometry screening is currently recommended for all women age 65 years and older.

Case Discussion:

A 40 Year Old Woman With Symptomatic Gall Stone Disease

An otherwise healthy 40-year-old woman sees you because of recurrent abdominal pain. In the past month she has had four episodes of colicky epigastric pain. Each of these episodes has lasted about 30 minutes and has occurred within an hour of eating. Two of the episodes have been associated with sweating and vomiting. None of the episodes have been associated with fever or shortness of breath. There is no history of weight loss. She does not drink alcohol or take any prescription or over-the counter medications. Other than three previous uneventful vaginal deliveries, she has never been hospitalized.
Her examination is negative except for mild obesity (BMI = 32).
On investigation a complete blood count and liver function test is normal. A gallbladder sonogram reveals multiple gallstones.

What is the next best step in the treatment of this patient?

a. Omeprazole, 20 mg daily for eight weeks.
b. Ursodeoxycholic acid
c. Observation without specific therapy
d. Laparoscopic cholecystectomy
e. Weight reduction

Answer And Discussion:

Prognostic Factors For Acute Pancreatitis

A 35-year-old alcoholic man is admitted with nausea, vomiting, and abdominal pain that radiates to the back. He has had several previous episodes of pancreatitis presenting with the same symptoms. Which of the following laboratory values suggests a poor prognosis in this patient?

a. Elevated serum lipase
b. Elevated serum amylase
c. Leukocytosis of 20,000/μm
d. Diastolic blood pressure greater than 90 mm Hg
e. Heart rate of 100 beats/minute

Answer And Discussion:

A 30 Year Old Woman Presenting With Unilateral Arm Numbness

A 30-year-old woman presents to your office with a 2-day history of progressive, unilateral arm (proximal and distal) numbness without weakness. She has been diagnosed with fibromyalgia in the past. She is taking fluoxetine for depression and has a history of previous hospitalizations for depression.

1, What will be your next step in management? 

Answer:  Get additional history; ask about previous similar episodes or other neurological concerns With a progressive neurological deficit, the first step in the workup is to further explore
the history. Frequently, patients will not mention previous neurological symptoms because the symptoms, not are vague.

When you ask about previous spells, she notes that she had an episode of left leg numbness that lasted about 1-week several years ago, but she thought nothing of it as it was mild. Six months ago, she had a 3-day visual disturbance in her right eye, during which she found it difficult to read and focus on objects; no blind spot was noticed. However, she had pain in the eye, especially when moving it.

2. What is the most likely diagnosis based on the history given?

A 59 Year Old Man Presenting With A Complication Following A Myocardial Infarction

A 59-year-old man is hospitalized after suffering a severe myocardial infarction. He is initially
treated with nitrates, β-blockers, and aspirin, and subsequently undergoes cardiac catheterization with placement of two stents. Following the procedure he is hemodynamically stable without recurrence of chest pain. However, 5 days after admission his heart rate is 134/min, blood pressure is 72/35 mm Hg, and respiratory rate is 29/min.
Physical examination reveals distant heart sounds and an elevated jugular venous pressure.
Which of the following complications is most likely causing this patient’s symptoms?

(A) Aneurysm formation
(B) Cardiac arrhythmia
(C) Fibrinous pericarditis
(D) Rupture of the papillary muscle
(E) Rupture of the ventricular free wall

Answer And Discussion: 

A 35 Year Old Woman Complains Of Pain And Swelling In Her wrist For Last 7 Weeks

A 35-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. She mentions that after a period of rest, resistance to movement is more striking. On examination, the metacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities.There is no alopecia, photosensitivity, kidney disease, or rash.
Which of the following is correct?

a. The clinical picture suggests early rheumatoid arthritis, and a rheumatoid factor should be obtained.
b. The prodrome of lethargy suggests chronic fatigue syndrome.
c. Lack of systemic symptoms suggests osteoarthritis.
d. X-rays of the hand are likely to show joint space narrowing and erosion.
e. An aggressive search for occult malignancy is indicated.

Answer And Discussion:

A 35 Year Old Man With Recurrent Infections

A 35-year-old male is seen by you in the hospital setting, after being admitted for pneumonia. Blood
cultures reveal Streptococcus pneumoniae. The patient was well until age 25 when he began having recurrent infections and developed an autoimmune hemolytic anemia. He also relates frequent sinus infections (real ones . . . not the kind we so often see) requiring antibiotics 8–10 times a year. His last bout of pneumonia required a stay in the ICU. You suspect immune deficiency in this individual.
What is the most useful test in making the diagnosis in this patient?

A) Complement levels.
B) Immunoglobulin levels.
C) CBC and differential.
D) Bone marrow biopsy.
E) Nitroblue tetrazolium test

Answer And Discussion:

A 74 Year Old Woman With Asymptomatic Bacteriuria

A 74-year-old woman is in your office for a complete physical. On further questioning, she has mentions having had stress urinary incontinence for a number of years, which is unchanged. She reports no fevers, hematuria, dysuria, flank pain, or other symptoms.
You obtain a urinalysis which shows 10–20WBC/hpf and is nitrite positive on dipstick. A culture of the urine shows 100,000 cfu/mL of E. coli.

How should you treat this patient?

A) Trimethoprim-sulfamethoxazole DS 1 tab PO BID for 10 days.
B) Erythromycin 500 mg PO q 6 hours for 14 days.
C) Ampicillin 250 mg PO q 6 hours for 10 days.
D) Ceftriaxone 1 g IM every day for 3 days.
E) With courtesy and respect, but not with antibiotics.

Answer And Discussion:

A 27 Year Old Man Presents With Several Red, Tender Subcutaneous Nodules On The Anterior Lower Legs

A biopsy of one of several red, tender, subcutaneous nodules from the anterior lower legs of a
27-year-old man is obtained by a dermatologist.
On histopathology, she sees a panniculitis (inflammation of subcutaneous fat) with widening of tissue septa from edema, increased neutrophils, and fibrin exudation.
Which of the following diseases is often present in someone with these nodules?

(A) Acne vulgaris
(B) Crohn’s disease
(C) Eczema
(D) Pancreatitis
(E) Psoriasis

Answer And Discussion:

A Case Of Acute Tubular Necrosis

A 48-year-old man is hospitalized for shock after massive blood loss in a motor vehicle accident.
On the patient’s second day in the hospital, his blood urea nitrogen (BUN) and creatinine levels
begin to rise and he develops pitting edema to his knees. A subsequent urinalysis shows numerous
granular casts.
Which of the following is the most appropriate treatment?

(A) Angioplasty
(B) Broad-spectrum antibiotics
(C) Corticosteroids
(D) Fluids and dialysis
(E) Use of ultrasound to remove blockage

Answer And Discussion:

A Case Of Serotonin Syndrome

A 35-year-old man with depression presents to the emergency department with flushing, diarrhea, sweating, and muscle rigidity. During the physical examination, he says that he began seeing a new psychiatrist because his sertraline was not working for him. His new doctor gave him a different medication, but he decided to use both medicines to “get rid of the depression.”
Which of the following medications did the new doctor most likely prescribe for this patient?

(A) Citalopram
(B) Lithium
(C) Nortriptyline
(D) Tranylcypromine
(E) Trazodone

Answer And Discussion:

A 57 Year Old Man Presents With Blurry vision, Difficulty standing, and Mental confusion.

A 57-year-old man is brought to the emergency department because of blurry vision, difficulty standing, and mental confusion.
On physical examination the patient appears malnourished, he had diffuse crackles bilaterally, and on
standing his gait is wide-based and unsteady.
The patient’s friend, who accompanies him, says the patient “hasn’t been himself lately,” and is having difficulty remembering to do everyday tasks. Which neuropathologic findings are most consistent with this patient’s symptoms?

(A) Atrophy of the caudate nucleus
(B) Depigmentation within the substantia nigra pars compacta
(C) Neurofi brillary tangles and widening of ventricles
(D) No neuropathologic fi ndings
(E) Symmetric lesions in the paraventricular regions of the thalamus and hypothalamus, mammillary bodies, and periaqueductal region of the midbrain

Answer And Discussion:

A Young Patient Presenting With Headache

A 25-year-old woman presents to your clinic complaining of a bifrontal headache that started this morning. She describes the pain as throbbing and 8/10 in severity. She is complaining of photophobia and nausea. She has had similar headaches in the past, lasting a few hours to all day. She is unable to work during these headaches and prefers a dark, quiet room. The physical examination, including neurological exam, is unremarkable.

1. What is the most likely diagnosis?
2. What are the treatment options for this patient?
3.. What are the contraindications and reactions of triptans?

Answers:

A Woman Presenting With A Second Episode Of Loss Of Consciousness

A 24-year-old right-handed woman presents to you in the Emergency Department after her second episode of loss of consciousness. The first spell occurred 6 months ago and was associated with a 60 second loss of consciousness and jerking movements of her arms and legs. Following the spell, she was confused for about 15 minutes. At that time, her initial ED evaluation was unremarkable.
She presents today following a spell that occurred about 45 minutes ago. Her friends observed her to fall to the ground and shake her arms and legs for about 2 minutes. They could not get her to respond during this time. Afterward, she was confused and they brought her to the ED. Upon arrival in the ED, she is mildly drowsy but otherwise oriented. She has no memory of the earlier events. Her general medical examination and neurological examination are unremarkable.

Which of these tests would be helpful in determining the etiology of this spell?

A Patient Presenting With Symptoms Of Hypoglycemia

A 32-year-old female presents to your office complaining of “hypoglycemia.” She notices that about
2–3 hours after a meal she gets nauseated, shaky, and irritable. When she wakes up in the morning, she generally feels well even though she eats dinner at about 5:00 PM and does not eat any snacks afterward and generally does not have breakfast until 8:00 AM.

You can tell her that:
A) She likely has an insulinoma.
B) She likely will have normal blood sugars when she feels shaky.
C) Hypoglycemia does not exist as an entity in this form and she likely has anxiety.
D) She likely has “fasting” hypoglycemia.
E) None of the above.

Discussion

A Pregnant Lady Presenting With A Bruise And Low Platelet Count

A 24-year-old female G1 P0 at 39 weeks of gestation presents to your office with a bruise on her anterior tibia, which she noticed after bumping into a coffee table. She has been well during her pregnancy and takes only prenatal vitamins.
Her physical exam is unremarkable with the exception of an 8-cm bruise over her right anterior tibia. She has a normal blood pressure (BP), normal reflexes, and no peripheral edema.
You obtain the following lab tests:
CBC, which demonstrates white blood cell (WBC) 9000/mm3, hemoglobin (Hb) 11.8 g/dL, and platelet count 95,000/mm3; negative urinalysis, normal liver enzymes.

What is your next step?
A) Recommend immediate delivery by cesarean section as the infant likely has thrombocytopenia as well and is at high risk for intracranial hemorrhage.
B) Recommend immediate delivery by cesarean section as this disorder will likely progress to
eclampsia.
C) Recommend close observation, and reassure the patient that this is typically a self-limited condition.
D) Start prednisone, 1 mg/kg daily, and taper slowly over the next 6 weeks.
E) Recommend splenectomy as soon as possible after delivery.

Answer And Discussion:

A Case Of Idiopathic Thrombocytopenic Purpura

An adolescent girl presents to the clinic with a rash that is made up of very small, bright red, non blanching macules. The girl had a non specific viral infection last week. She appears to be in excellent health except for the rash. She is not on any medications. 

What is the most common cause of this condition?

A. Penicillin

B. Hemolysis

C. Human immunodeficiency virus (HIV)

D. Lupus

E. Idiopathic thrombocytopenic purpura

Answer and Discussion: 

A Case Of Shoulder Dystocia (Obstertrics)

A 25-year-old G2P1 woman is delivering at 42 weeks’ gestation. She is moderately obese, but the fetal weight clinically appears to be about 3700 g. After a 4-hour first stage of labor, and a 2-hour second stage of labor, the fetal head delivers but  is noted to be retracted back toward the patient’s introitus. The fetal shoulders do not deliver, even with maternal pushing.

1. What is your next step in management?
2. What is a likely complication that can occur because of this situation?
3. What maternal condition would most likely put the patient at risk for this condition?

Answers And Discussion:

Goodpasture's Syndrome

Goodpasture’s syndrome is associated with

A) Osteoporosis and renal lithiasis
B) Pathologic fractures and thyroiditis
C) Hepatitis and recurrent cystitis
D) Pulmonary hemorrhage and glomerulonephritis
E) Pica and angioedema

Answer and Discussion

A Case Of Cocaine Abuse

A 21-year-old man is brought to the emergency room after suffering a seizure. He is tachycardic and hypertensive and has a temperature of 38.6°C. Physical examination shows that the patient is in a postictal state and has a nasal septum perforation. Electrocardiogram (ECG) findings suggest acute MI. Friends of the patient report recent cocaine use. Which of the following drugs is indicated?

A) Elumazenil
B) Diazepam
C) Dexfenfluramine
D) Propranolol
E) Phenytoin

Answer and Discussion

Child's Developmental Milestones

An infant presents to the pediatrician for a routine check-up. His mother reports that he plays
peek-a-boo at home, waves bye-bye, and will say “dada.” He cannot yet drink from a cup. He seemed somewhat apprehensive when the physician entered the room. He can lift his head when lying on his stomach, sit unassisted, and stand with help. He has a positive Babinski’s reflex. If this infant has met all his developmental milestones appropriately, how old is he?

(A) 4–5 months
(B) 7–11 months
(C) 12–15 months
(D) 18 months
(E) 24 months

Answers And Discussion:

A 26 Year Old Woman Presenting With Fatigue, Insomnia ,Irritability And Difficulty In Concentrating.

A 26-year-old African-American woman presents to her primary care physician because of fatigue and insomnia for the past 8 months. She also complains of difficulty concentrating and irritability as well as feeling continually worried. She states that nothing seems to make her feel better or worse; she is still able to perform all of her work duties as a public relations officer and was recently promoted. She denies palpitations and any weight change in this time period and her past medical history is unremarkable. Her vitals signs are within normal range, and physical examination shows no focal findings, but the woman appears markedly agitated. Which of the following is this patient’s
most likely diagnosis?

(A) Adjustment disorder
(B) Attention deficit/hyperactivity disorder
(C) Generalized anxiety disorder
(D) Hyperthyroidism
(E) Social phobia disorder

Answer And Discussion:

Bell's Palsy

One fine morning a 15-year-old boy noticed that he is unable to close the left eye. The nasolabial fold was flattened on the left side and the mouth was deviated to the right side.

1. What is the most probable diagnosis?
2. What special precaution should be taken to protect the left eye?
3. What is the prognosis of recovery usually in such patients?

Answers:

Ectopic Thyroid Gland

A 5-year-old girl is brought to the pediatrician by her mother because she has noticed a single
soft, nontender mass underneath her daughter’s tongue. The physician reassures the mother that it is a common congenital ectopic anomaly that does not affect the function of the mass or the hormone it secretes. Hypersecretion of this hormone can cause which of the following conditions?

(A) Amenorrhea
(B) Cold intolerance
(C) Constipation
(D) Hyperlipidemia
(E) Weight gain

Answer And Discussion:

A Newborn Baby With An Extensive Skin Rash

A newborn boy is brought to the pediatrician for further evaluation of an extensive skin rash.
Physical examination shows that this child has microcephaly, hearing loss, and a petechial skin rash. The abdominal examination reveals hepatosplenomegaly.
Further questioning of the infant’s mother reveals that she had “the
fl u” early in her pregnancy. A tissue sample from the infant is sent for culture, which confirms the diagnosis. Which of the following is the correct diagnosis?

(A) Congenitally acquired cytomegalovirus
(B) Congenitally acquired Epstein-Barr virus
(C) Congenitally acquired herpes simplex virus
(D) Congenitally acquired HIV
(E) Congenitally acquired syphilis

Answer And Discussion:

Anemia In Pregnancy

A 29-year-old G2P1 woman at 20 weeks’ gestation is seen for her second prenatal visit. Her antenatal history is unremarkable except for a urinary tract infection treated with an antibiotic 2 weeks ago. The patient was noted to be anemic on her prenatal screen with a hemoglobin level of 9.5 g/dL, and a mean corpuscular volume (MCV) of 70 fL. On examination, her blood pressure (BP) is 100/60 mm Hg, heart rate (HR) 80 beats per minute (bpm), and she is afebrile. The thyroid gland appears normal on palpation. The heart and lung examinations are unremarkable. The fundus is at the umbilicus. The fetal heart tones are in the 140- to 150-bpm range. The evaluation of the anemia includes: ferritin level: 90 mcg/L (normal 30-100); serum iron 140 mcg/dL (normal 50-150); hemoglobin electrophoresis: Hb A1 of 95% and Hb A2 of 5.5% (normal 2.2% to 3.5%)

1.  What is the most likely diagnosis?
2. What is the underlying mechanism?

Case Discussion And Answers:

A Case Of Vaginal Bleeding In Third Trimester

Labor and delivery department calls you about a 27-year-old G1 P0 at 38 weeks gestation who awoke this morningcomplaining of wetness. However, when she went to the bathroom she discovered significant vaginal bleeding that had soaked her bed. She denies any cramping or abdominal pain. She is on her way to the hospital.
You would tell the nurses to initiate all of the following interventions immediately upon the patient’s
arrival EXCEPT:
A) Obtain IV access.
B) Draw blood for type and screen.
C) Perform a digital vaginal exam.
D) Initiate fetal monitoring.
E) Draw blood for complete blood count.

Discussion