LIVE LIKE IF U HAVE TO DIE TOMARROW AND LEARN LIKE U HAVE TO LIVE .....FOREVER

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  • ALL U NEED NMB FORMS STEP 3 WITH ANS..AND MUCH MORE
      • Anonymous (no login)
      Posted Feb 5, 2008 12:11 PM

      chancroid is by hemophilus ducryei.. and there is a mneumonic fr it...
      u do cry in ducry so the lesions are painful...
      syphilis lesions are painless( just check on this one)
      granuloma inguinale has lymph nodes painless and may suppurate
      caused by calymmatobac ..
      condyloma accu is by hpv in and around genitalia and anal region
      warty lesions
      lymphogranu is by chlamydia has lymph nodes and may suppurate too


      There are four classifications of asthma:
      1. Mild intermittent -- symptoms less than 2×/week and FEV1 >80%
      2. Mild persistent -- symptoms greater than 2×/week but less than l×/day with FEV1 >80%
      3. Moderate persistent -- daily symptoms greater than 2×/week with FEV1 >60 and <80%
      4. Severe persistent -- continual symptoms with limited physical activity and FEV1 <60%

      This patient has chronic bacterial prostatitis. Chronic prostatitis can present with lower abdominal pain, perineal pain, or low back pain. There is usually no dysuria unless there is accompanying

      cystitis. On physical examination, the prostate usually feels normal and is nontender. As in this patient, chronic prostatitis may manifest as a recurrent urinary tract infection (UTI). The key to

      the diagnosis is culture of urine or urethral discharge. Pathogens for chronic prostatitis in older men are the same as for a UTI, with E. coli being the most common organism identified. One may

      extrude purulent discharge by massaging the prostate, which will grow the offending organism. One can also culture the urine post massage of the prostate, which should grow ten times more colonies

      than premassage urine. This patient cultured 10,000 colonies of E. coli in prior cultures, and currently he grew 100,000 colonies postprostatic massage. Ciprofloxacin for 7 days would be

      appropriate treatment if this were just a UTI. Therapy for one week is not long enough to clear chronic bacterial prostatitis. Most antibiotics don't have good penetration into the prostate, and

      it takes at least four weeks of therapy with ciprofloxacin to clear the infection. Ciprofloxacin and azithromycin for a single dose would be the treatment for urethritis. This patient does have a

      urethral discharge, which may be confused with urethritis. However, since the discharge is extruded only on palpation of the prostate, this strongly suggests that the prostate is the source of

      infection. Cystoscopy would be useful in a patient with recurrent UTIs in whom you suspected a structural malformation of the genitourinary tract. This patient's UTIs are originating from his

      chronically infected prostate. Trimethoprim/sulfamethoxazole for 12 weeks is an acceptable alternative for treating chronic prostatitis.
      This is a young patient who has an episode of atrial fibrillation in the absence of other preexisting conditions. The American College of Chest Physicians has established guidelines for

      anticoagulation in nonrheumatic atrial fibrillation. Patients with risk factors for the formation of thrombi such as a previous stroke, transient ischemic attack, systemic thromboembolism, left

      ventricular dysfunction, recent congestive heart failure, systemic hypertension, or diabetes should be placed on warfarin to an INR of 2 to 3. Patients with no risk factors who are younger than 65

      years are considered to be low risk and should take one aspirin daily. Aspirin is also suitable for patients with a contraindication to warfarin therapy. The efficacy of other antiplatelet agents

      has not been proven in patients with atrial fibrillation.
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      This patient has nephrotic syndrome based on the presence of edema, hyperproteinuria, hypoproteinemia, and hyperlipidemia. Such patients are predisposed to developing a hypercoagulable

      state secondary to the renal losses of proteins C and S and antithrombin III, as well as increased platelet activation. Patients with evidence of venous thrombosis should be anticoagulated for at

      least 6 months. Recurrent thrombosis and renal vein thrombosis warrant lifelong anticoagulation.

      Although he may need a renal biopsy, he needs to have his thrombus treated first as the "next" step. The same is true of using cyclophosphamide and prednisone. This patient most likely has

      membranous glomerulonephritis simply because he is an adult with nephrotic syndrome, and this is the most common cause in adults. Colonoscopy should also be done in a patient like this because

      there is a strong association of glomerulonephritis with solid tumors, such as colon and breast cancer.

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      Prednisone is effective in treating active Crohn's disease for short durations (3-6 months). Long-term use for maintenance is not indicated. 6-Mercaptopurine and azathioprine are

      steroid-sparing medications used to limit the need for prednisone. Prednisone, like other corticosteroids, has numerous side effects and should only be used for treating active flares of disease,

      not maintenance of remission. Cyclosporine and methotrexate have limited roles in the management of Crohn's disease.
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      The patient has lupus nephritis, probably exacerbated by her pregnancy. Pre-eclampsia is a frequent complication of pregnancy in SLE and is seen in the third trimester. It is often

      difficult to distinguish lupus nephritis from pre-eclampsia. Laboratory testing is often useful with lupus nephritis, which shows proteinuria and an active urine sediment, such as red cells and

      red cell casts, whereas pre-eclampsia has only proteinuria. Complement levels are low in flares of SLE in comparison with pre-eclampsia, which has normal complement levels. Pre-eclampsia is also

      associated with thrombocytopenia and elevated liver function tests.

      The treatment of pre-eclampsia includes bedrest in mild cases when the diastolic pressure is <105 mm Hg and there is only trace proteinuria. In severe cases, intravenous antihypertensive

      medications, magnesium sulfate, and emergency caesarian section are indicated. Treatment of active lupus nephritis in pregnancy is dependent on the absence of adverse effects of the medication on

      the fetus. High-dose prednisone can be used relatively safely. Hydralazine can be used to control the blood pressure. Azathioprine can also be used, with caution, if there is no evidence of

      leukopenia. Cyclophosphamide and methotrexate are absolutely contraindicated.

      The VDRL test is the initial test for syphilis. The VDRL is readily quantified, and for that reason is the test for following the response to treatment. The VDRL test begins to turn

      positive within one week after the onset of the chancre and is positive in 99% of patients with secondary syphilis. The quantitative titer of the VDRL test is somewhat useful in initial diagnosis

      of a chancre but quite useful in following a therapeutic response. Most patients with secondary syphilis have titers of at least 1:32, whereas most patients with false-positive VDRL tests have

      titers of less than 1:8. Significant rises of fourfold or greater of acute and convalescent sera are strongly indicative of acute syphilis. The FTA-ABS test is best used as a confirmatory test. It

      is more difficult to perform than the VDRL test and cannot be as easily quantified. It is reported in terms of relative brilliance of fluorescence, from borderline to 4+. The FTA-ABS test often

      remains reactive for life despite adequate therapy and therefore would not be useful in following a patient's response to treatment. Agglutination of red blood cells to which T. pallidum antigens

      have been fixed is the basis of the microhemagglutination assay for T. pallidum (MHA-TP). It is less sensitive than either the VDRL or the FTA-ABS test in primary syphilis. Treponemal tests, such

      as the FTA or MHA-TP, do not correlate well with the degree of disease activity. The Wright stain of the scrapings is diagnostic for granuloma inguinale, or donovanosis. The Tzanck prep detects

      multinucleated giant cells or intracellular inclusion bodies of herpes simplex or varicella zoster. Darkfield microscopy is diagnostic for primary syphilis alone and is not used to follow the

      response for treatment
      Cerebral perfusion pressure is defined as the mean arterial pressure minus the intracranial pressure. The patient is this case presented with cerebral vasospasm six days after the initial

      subarachnoid hemorrhage. This was confirmed by the transcranial Doppler. The repeat CT scan of the head showed no evidence of fresh blood. At this point, the cerebral perfusion pressure should be

      increased by raising the mean arterial pressure with crystalloids and dopamine. Repeating the angiogram is not indicated because the transcranial Doppler already showed spasm of the middle

      cerebral artery. Antihypertensive medications are not indicated unless the blood pressure is much higher. Intubation and hyperventilation and the ventriculostomy are indicated when there is an

      abnormally increased intracranial pressure, leading to a decrease in cerebral perfusion. Nimodipine has only a limited role in preventing vasospasm of the cerebral vessels. If spasm occurs while

      on nimodipine, there are few therapeutic alternatives, one of which is to volume expand the patient and try to increase the cerebral perfusion pressure. This will hopefully overcome the vasospasm

      and increase flow through the narrowed vessel.
      This patient has primary anorectal lymphogranuloma venereum (LGV). LGV is a sexually transmitted disease caused by Chlamydia trachomatis. People who engage in anal intercourse may get a

      primary anal or rectal infection. Patients with acute LGV infection typically have positive complement fixation tests in high titer. Patients with anorectal infection, as in patients with genital

      infection, often have inguinal lymphadenopathy and may present with fever, chills, and night sweats, mimicking malignant lymphoma. The presentation of rectal pain with discharge and blood may

      mimic ulcerative colitis. The biopsy finding of inflammatory cell infiltrates and granulomas with giant cells can closely resemble Crohn's disease, but these patients would have a negative

      complement fixation test and far less adenopathy. In this patient, sulfasalazine would not be effective, and corticosteroids would be detrimental because he has an infection. Metronidazole

      provides good coverage of anaerobic bacteria like Clostridium difficile that would cause a pseudomembranous colitis, but it would not be effective against C. trachomatis. At least three weeks of

      doxycycline or tetracycline would be the best treatment to clear the infection of C. trachomatis in this patient. Definitive diagnosis can also be with a blood antibody test in high titer or by

      aspiration of an enlarged lymph node when it shows the organism. Even if you thought this was Crohn's disease, sulfasalazine would not be the best therapy. Mesalamine would be used.
      Report Abuse

      Hairy-cell leukemia is an uncommon indolent cancer of B lymphocytes. It occurs most commonly in middle-aged men with an average age of 55. It has a 5:1 male to female ratio. Patients usually

      complain of a gradual onset of fatigue and symptoms related to an enlarged spleen. Some cases of hairy-cell leukemia come to the doctor's attention because of recurrent infections. The physical

      examination usually shows splenomegaly and sometimes hepatomegaly.

      Lymphadenopathy is uncommon in a patient with hairy-cell leukemia, unlike patients with chronic lymphocytic leukemia (CLL) or lymphoma. The course is usually marked by pancytopenia with recurrent

      infections. Nearly all patients have a profound monocytopenia. Monocytopenia is usually not seen in any other condition.

      The peripheral smear has cells with cytoplasmic projections or "hairy cells." The bone-marrow aspirate is usually dry, and biopsy is necessary. Staining with tartrate-resistant acid phosphatase

      (TRAP) is usually positive. Treatment is cladribine (2-chlorodeoxyadenosine; CdA).

      Recombinant interferon-alpha was formerly the standard treatment for a patient with chronic myelogenous leukemia (CML) but is not as effective as cladribine and also has more side effects. This

      patient does not have CML because he does not have an elevated white blood cell count. Hydroxyurea used to be the standard treatment for a patient with CML prior to the introduction of imitanib.

      Although this patient has organomegaly, anemia, and thrombocytopenia (which go along with CLL), he is lacking the high white blood cell count and lymphocytosis essential for diagnosis. The

      treatment of CLL is with fludarabine or chlorambucil/prednisone.


      The management of glomerulopathy due to diabetes mellitus is a common and important task that all general internists must face. In the United States, diabetes is the leading cause of

      end-stage renal disease (ESRD). It occurs in 33% of all diabetics. Diabetic nephropathy is a spectrum of progressive renal disease ranging from microalbuminuria (30-300 mg/24 h) to overt nephrotic

      syndrome and ESRD. In terms of incidence, 30 to 40% of type I diabetics and 15 to 20% of type II diabetics will acquire ESRD in 20 years.

      So how does one screen for diabetic nephropathy and try to prevent its progression? Urine dipsticks that are commonly found at internists' offices are not sensitive enough to detect

      microalbuminuria and will only be positive once the albumin level is above 300 mg. The collection of timed urine samples is required for the diagnosis of early nephropathy. One way of collecting

      is the 24-hour urine for microalbumin. However, there are wide variations in the amount of albumin that is excreted in that period of time. Upright posture, protein ingestion, and exercise all

      tend to increase urine albumin excretion. For all these reasons, a more accurate method to detect microalbuminuria is to do a morning spot urine for albumin/creatinine. Patients should be

      instructed to discard a voided urine sample before going to bed and then collecting urine samples thereafter until the morning. When the value is 30 to 300 mg albumin/per gram of creatinine,

      microalbuminuria is present. However, this test needs to be repeated 2 to 3 times for a duration of 3 to 6 months to confirm the diagnosis.

      The prevention of the progression of diabetic nephropathy once it is found can be accomplished by tight glycemic control, a low protein diet (0.8 g/kg/day), and initiation of

      angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors have been found to slow the progression of proteinuria, even in normotensive diabetics. This patient's glycemic control is nearly

      optimal and should be maintained to keep the HgbA1c approximately 7.0% by weight loss, as well as adjusting the insulin regimen. Although all these measures will be beneficial in reducing

      proteinuria, a diagnosis first needs to be made.

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      This patient has a positive PPD skin test because his level of induration is >5 mm and he uses steroids. Five millimeters is the cutoff for a positive test in HIV-positive patients, those

      who use steroids, close contacts, organ transplant recipients, and in those who have abnormal chest x-rays consistent with previous tuberculosis. Even though he is older than 35 years, he should

      receive nine months of isoniazid anyway. The age cutoff of 35 years as a criterion for whether or not to treat latent tuberculosis was eliminated several years ago. He is a good example of exactly

      who should undergo screening for tuberculosis with a PPD test. He is immunocompromised because of the steroid use, as well as the previous gastrectomy. In addition, he has potentially been exposed

      because he works in a homeless shelter. The ideal length of therapy was raised to nine months from six months several years ago. All of these recommendations are regardless of whether or not the

      patient has had a previous vaccination with BCG.
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      The presentation describes a case of chronic eosinophilic pneumonia. The initial differential diagnosis could include acute or chronic eosinophilic pneumonia, Loeffler's syndrome, fungal

      pneumonia, parasitic infections (such as strongyloides), Churg-Strauss syndrome, allergic bronchopulmonary aspergillosis, and idiopathic pulmonary fibrosis. Chronic eosinophilic pneumonia is seen

      primarily in women who are in their fifties. The symptoms of cough, fever, and dyspnea are often insidious. A history of asthma is seen in almost half of all cases. The chest x-ray classically

      reveals peripheral infiltrates, and blood eosinophilia is mild to moderate. The clinical presentation and chest x-ray are not sufficiently specific to confirm the diagnosis. Open lung biopsy is

      the gold standard; however, it is extremely invasive and potentially complicated. A CT scan would help identify the nature of the infiltrates but will not give a definitive diagnosis. Bronchoscopy

      with bronchial alveolar lavage (BAL) and biopsy is minimally invasive and has a high diagnostic yield. BAL will generally reveal a high percentage of eosinophils and can rule out other possible

      infectious agents.
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      best initial VQ scan.....
      then doppler of lower limbs
      gold standard is pulm angiography
      HIV positive adult or pediatric patient...have to be reported......you do not have to wait till they become full blown AIDS.....
      just like gonorrhea, chlamydia and syphillis.......
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      * Re:HIV-----------adlt and ped The patient presents with a ruptured mitral valve because of his recent myocardial infarction. The new systolic murmur, dyspnea, and rales are an indication

      of the rupture of the valve. It is also possible that he has a ventricular septal rupture (VSD). Both can give a systolic murmur. The mitral murmur is best heard at the apex, and a VSD is best

      heard at the lower-left sternal border. Therapy for both would be acute afterload reduction followed by surgical repair. Because he is so unstable, the ideal agent would be intravenous and readily

      titratable. Nitroprusside has an extremely short half-life and can easily be stopped or reduced if the blood pressure drops too far.
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      Oxybutynin is used for treatment of a hyperactive bladder producing urinary incontinence. This patient has hypertonicity as demonstrated on bladder cystometric evaluation. This is why the

      oxybutynin should be used. Because of the dyssynergy of the sphincter, intermittent straight catheters should be used as well. Steroids are used for the treatment of an acute exacerbation of

      multiple sclerosis (MS). Bethanechol is the treatment of choice for patients with MS complaining of urinary retention. Amitriptyline has significant anticholinergic effects that will only worsen

      her urinary retention. Amantadine treats mild tremor in elderly patients and will have no effect on urinary symptoms
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      It is extremely important to identify which drugs interact with warfarin in an anticoagulated patient. Amiodarone is one of those drugs. This medication will prolong the action of warfarin

      in a predictable manner. For this reason, it is advisable to decrease the warfarin dose by approximately 25% (in this case, from 6 mg/day to 4.5 mg/day) to avoid excessive anticoagulation.
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      The early use of corticosteroids has been shown to decrease the mortality rate and the rate of respiratory failure in patients with moderate to severe Pneumocystis carinii pneumonia (PCP).

      These observations are thought to be secondary to the anti-inflammatory effects, thus preventing further alveolar damage. Corticosteroid use is recommended in moderate to severe PCP infections

      with an alveolar-arterial oxygen gradient of 35 mmHg or more, and/or an arterial oxygen tension (PaO2) of 70 mmHg or less on room air.


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      The goal of erythropoietin therapy is to increase the hematocrit level by 4 to 6% in 4-6 weeks time, and the final hematocrit level should lie between 33% and 36%. If the hematocrit level fails to

      increase adequately within 4 to 6 weeks following erythropoietin treatment, iron saturation and ferritin levels should be measured. Iron deficiency is treated by weekly intravenous administration

      of iron
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      Ranson?s prognostic criteria gained widespread use in predicting the severity of acute pancreatitis. Since the criteria were initially designed for pancreatitis not induced by gallstones, the

      scoring system was modified so it could also be used in the evaluation of patients with gallstone-induced pancreatitis. The prognostic factors include admission criteria, and criteria observed

      during the initial 48 hours. Admission criteria are age > 55 years, high WBC count, high serum AST, high serum LDH, and high blood glucose level. Criteria observed during the initial 48 hours

      include a hematocrit fall (>10%), BUN elevation, hypocalcemia, hypoxemia (PO2 < 60 mmHg), base deficit > 4 mEq/L, and an estimated fluid sequestration > 6L.

      Report Abuse

      A prophylactic antiretroviral regimen is always indicated when a healthcare worker is exposed to the bodily fluids of an HIV-positive patient. Immediate consultation with the hospital?s infectious

      disease expert is recommended. The CDC recommends that two nucleoside reverse transcriptase inhibitors (e.g., zidovudine and lamivudine) be started immediately after exposure and continued for the

      next four weeks (Choice C). Some experts have suggested modifying the regimen to also include a protease inhibitor (e.g., indinavir) if viral resistance to the postexposure prophylaxis is known or

      suspected.


      ndividuals who have been in prolonged close contact with a case of invasive meningococcal infection should be placed on prophylactic antibiotics to eradicate pharyngeal carriage of the organism.

      Note that unless there has been direct exposure to respiratory secretions, the majority of healthcare workers do not require chemoprophylaxis. Rifampin (600 mg PO bid for 4 doses) is the standard

      treatment, but ciprofloxacin (500 mg PO single dose) is an equally acceptable alternative for adult patients who cannot tolerate rifampin. Because studies have demonstrated reduced steroid levels

      in women who used oral contraceptives concomitantly with rifampin, this daycare worker should be placed on ciprofloxacin instead.
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      When central hypothyroidism is suspected, it is pragmatic to rule out concomitant central adrenal insufficiency before beginning therapy. Patients with primary adrenal insufficiency (Addison?s

      disease) can have increased TSH levels without hypothyroidism due to the loss of an inhibitory effect of glucocorticoids on TSH secretion. Conversely, a patient on high-dose glucocorticoid

      treatment will have a transient decrease in TSH levels.


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      If the diagnosis of menopause is uncertain, the pathognomonic finding is an elevated level of follicle-stimulating hormone (FSH). The measurement of serum luteinizing hormone (LH) is of

      less help because serum LH concentrations may be elevated at certain points in the normal menstrual cycle and cannot be readily distinguished from a typical menopausal serum LH value.
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      It is likely that this patient is amenorrheic because she is pregnant. Numerous commonly used antiseizure medications (e.g., phenytoin, carbamazepine, ethosuximide, phenobarbital,

      topiramate) are known to decrease the efficacy of oral contraceptives through the induction of the cytochrome P450 system in the liver. Alternative antiseizure medications that do not decrease

      oral contraceptive efficacy include gabapentin and valproate.
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      Raloxifene is a selective estrogen receptor modulator (SERM) which selectively stimulates estrogen receptors on bone cells. It has been shown to improve bone mineral density at both the

      hip and lumbar spine. Studies have not shown that it reduces the risk for vertebral fractures. Side effects include hot flashes and an increased risk for deep venous thrombosis and pulmonary

      embolism. Raloxifene should therefore be discontinued at least 72 hours prior to an elective surgical procedure to prevent deep venous thrombosis. It can be restarted after the patient is fully

      ambulatory.
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      It is important to recognize the early signs and symptoms of phenytoin toxicity. The earliest sign is the presence of nystagmus on far lateral gaze. Some other effects include blurred

      vision, diplopia, ataxia, slurred speech, dizziness, drowsiness, lethargy, and decreased mentation, which progresses to coma. Systemic side effects and neurotoxicity is one of the major

      limitations to the use of phenytoin.

      Usual therapeutic range of phenytoin is between 10-20 mcg/mL and most patients will experience adverse dose related neurotoxic effects with levels greater than 20 mcg/mL. However, the serum levels

      associated with neurotoxicity vary from patient to patient. Some patients can experience toxic effects even when the measured levels are within the normal therapeutic range. The first step in the

      management of side effects due to higher drug levels is to reduce the dose or alter the treatment schedule to minimize the peak drug levels. Therefore, in this vignette, the dose of phenytoin

      should be reduced and patient should be observed for resolution of nystagmus.

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      Insect stings can lead to anaphylaxis or local reactions only. Single cutaneous lesions respond to histamine-blockers and topical steroids. Mild anaphylaxis is characterized by generalized rash

      and pruritus, and is managed with subcutaneous epinephrine and systemic antihistamines. Mild to moderate bronchospasm should receive the same management. Severe anaphylaxis must be readily treated

      with intravenous epinephrine
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      Contraindicated Drugs in Lactation
      1. Medications that decrease milk production
      Bromocriptine
      Diuretics
      2. Chemotherapeutic Medications
      Cyclophosphamide
      Cyclosporine
      Doxorubicin
      Methotrexate
      Gold salts
      Propylthiouracil
      Methimazole
      3.Radioactive Chemicals used in Nuclear Medicine
      4.Miscellaneous Medications
      Dextroamphetamine
      Ergotamine
      Lithium
      Metronidazole
      Chloramphenicol
      Potassium iodide
      Phenindione (anticoagulant)
      5.Drugs of Abuse
      Amphetamine
      Cocaine
      Heroin
      Marijuana
      Nicotine
      Phencyclidine
      please add to the list....
      Report Abuse

      cricoid i have this about preventive medicine and pregnancy
      1.measel, mump, rubella, yellow fever and chicken pox....are contraindicated.
      2. If a woman get pregnant after rubella..>reassurance. There is no evidence of damage to fetus. Before it used to be said after rubella not get pregnant for months. Now is just 28 days the

      advise.,
      3. In special situation: origin indications are not altered by pregnancy whit this:
      * rabies: consider particular situatiion
      * pneumococo, in pregnant asplenic woman with exposure
      * meningococo in outbreak or exposure


      Step 2 ck kaplan notes make a remark about varicella as a live attenuated vaccine, so not to immunocompromised, HIV positive when symptomatic or pregnant woman.
      MMR not in pregnant. Just HIV positive patient who are Asympotomatic may receive the vaccine.

      Report Abuse

      * Re:drugs contraindicated during breast feeding
      #1144469
      cricoid - 01/26/08 23:02

      casanova - 01/25/08 17:22

      immunocompromised child and mother with chikenpox 5 days prior delivery and 2 days post delivery : only situation where we give acyclovir and VZIG

      Report Abuse

      * Re:drugs contraindicated during breast feeding
      #1144476
      cricoid - 01/26/08 23:04

      #1142770
      arlete - 01/25/08 18:32

      Heat pack is NOT used. It increases local production and engorgement. Use cold packs instead.
      mastits: you'll see localized pain and redness, malaise and fever; Rx: Amoxicillin
      plugged duct: localized tender intumescent tissue, tend to be firmer, no local redness, no systemic symptoms; Rx: increase fluid intake, pump, local massage
      cracked/sore nipples: you diagnose through inspection, intense local pain; Rx: lanolin ointment, keep the area dry, teach appropriate latch positions, local sunbathing, exposure to a lamp; always

      remember to check if the baby has thrush, because she may have Candida infection over the cracked nipple, and they may be contaminating each other back and forth (in this case, treat with oral

      nystatin, diflucan for the mother if necessary)
      engorgement of breasts: diffuse enlargement of breasts, you may have some nodules; use cold packs, increase fluid intakes, pump
      breast abscess: look for local fluctuation, systemic symptoms; Rx: amoxacillin, incision and drainage
      In none of the cases we order breastfeeding cessation. The less the mother breastfeed, the worse everything gets, because of the accumulation of milk. Women who breastfeed should always drink lots

      of water and pump the breasts if the production is too big. Emptying the breasts through massage during shower also works.


      Report Abuse

      * Re:drugs contraindicated during breast feeding
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      << < Step 3 > >>

      * These Notes were helpfull to me???????????????????
      #249550
      aiissman - 12/06/07 10:39

      these notes were helpfull to me since I took my step 2 long ago.. tried to go through kaplan ck2 but I did not have time..
      this is from step 2 forum..
      I left the name of the person who worked hard and was nice enough to share with everybody so the credit goes to him/her.

      drjiggy - 09/22/07 17:07

      Many have asked me for missing numbers that aren't in theirs, so I'm just going to post it the way I have it..complete (#1-666).
      Cram-Facts:
      CARDIOLOGY:
      1. Stable angina – chest discomfort, can be felt in back/arms/jaw/abdm, occurs c stress/emotion, relief c rest, dx c stress test. Tx c nitrates, bb, Cabs, heparin, aspirin, if 3 vessels or L

      main do CABG
      2. Unstable angina – unpredictable at rest or abruptly worsening pattern of angina, prolonged duration (>20), dx c ECG (st depression/t inversion) or cath shows CAD, but negative cardiac

      markers, tx c nitrates, cabs, bb, heparin
      3. Variant/Prinzmetal Angina – chest pain at rest, ST elevation (note the 3 causes of ST elevation are MI (inferior (LDA) is II, III AVF; lateral (circumflex a)is I, AVL, V5, V6; anterior is

      V1-V4), Pericarditis (diffuse, meaning every lead has it), and Variant Angina) with negative markers. Treat with Ca-channel blockers (Cabs) or nitrates.
      4. Acute MI – chest discomfort, crushing pain without warning (females and diabetics get atypical chest pain, which is abdm pain, fatigue, neck pain or weakness), prolonged duration (hours), ECG

      may be abnormal (st elevation or depression), increased markers, tx c MONA, ACEI, heparin, bb, tPA’s if <12 hrs after onset of pain, complications include MR, VSD, cardiac rupture and

      ventricular aneurysm.
      5. CAD risk factors: smoking, HTN, family h/o premature CAD (<55 in male, <65 in female), male >45, female >55, HDL <40, LDL >100. (If HDL >60, subtract one). >2 risk factors: diet if >160, drugs

      if >190; 2 or more risk factors: diet if >130, drugs if >160, pt has CHD: diet if >100, drugs if >130.
      6. Causes of high output heart failure – severe anemia, thyrotoxicosis, acute beriberi, paget’s dz, large AV fistula
      7. Acute Pulmonary edema – tx – 1st upright position and O2, 2nd loops, nitrates, morphine, and 3rd intubate if severe.
      8. HOCM – tx – 1st avoid dehydration, 2nd strenuous activity prohibited, 3rd BB, 4th Cab’s, 5th surgical myectomy. Best dx is history (screen family) and physical, then Echo.
      9. Restrictive CM – JVD, edema and ascites, dx c echo, tx 1st diuretics/ decrease salt
      10. Myocarditis – history or URI (coxsackie) then fever, dyspnea, CP, edema, tachy
      11. Acute Pericarditis – positional CP, tx c NSAIDS
      12. Pericardial effusion – pericardial friction rub, tx c pericardiocentesis
      13. Tamponade – becks triad (JVD, muffled heart sounds, pulsus paradoxicus c hypotension), tx c pericardiocentesis
      14. Constrictive pericarditis – pericardial knock, kussmaul breathing, CXR shows pericardial calcification, tx c diuretics
      15. Acute RF – PECCS (polyarthrtitis, erythema marginatum, carditis, chorea, subQ nodules) in kids 5-15yo due to group A strep. Tx is Abx, bed rest, salicylates, sedatives for chorea, steroids

      for carditis.
      16. Mitral stenosis – most associated c RHD, LA enlargement à hoarseness, dysphagia, and A.fib, diastolic rumble at LV apex, tx c diuretics, coumadin for a.fib, endocarditis prophylaxis, balloon

      vulvoplasty
      17. Mitral regurge – a/w marfans, RHD, myxomatous change, high-pitched holosystolic murmur at left sternal border, tx c diuretics, dilators, endocarditis prophylaxis, mitral valve

      respacement/repair
      18. Aortic regurge – congenital, marfans, trauma, aortitis, high-pitched decrescendo diastolic murmur at left sternal border and/or apex and wide pressure, tx c valve diuretics, dilators,

      endocarditis prophylaxis, valve replacement (last)

      19. Aortic stenosis – calcific in elderly, bucuspid in congenital, angina, dyspnea, syncope, mid-late systolic murmur at base radiating to carotids, tx c replacement (1st step)

      20. Endocarditis – if dental procedure give amoxicillin (clindamycin if allergic), if GI/GU procedure give amoxicillin c gentamycin (vanco with gentamycin in allergic)
      21. VSD – membranous septum, harsh systolic murmur at L sternal border, spontaneous closure in 30-50%, tx – for small vsd observe, for large vsd and significant shunt, surgical repair and

      endocarditis prophylaxis.
      22. ASD – wide, fixed splitting S2, tx – if small observe, if large surgery
      23. PDA – machinery murmur, wide systemic pulse pressure, tx c indomethacin then surgery
      24. Aortic Coarctation – UE HTN c LE hypotension, rib notching, LE claudication, HA, dx with MRA or contrast aortography, tx is surgery (best at 4-8yo).
      25. Tetralogy of Fallot – PROVe (Pulm HTN, RVH, Overriding aorta, VSD), kid squats to increase systemic resistance, thus decreased R to L shunt, cyanosis in kid >1yo, CXR c boot shaped heart,

      confirm dx with cath, tx is surgery, endo prophylaxis
      26. Transposition of great vessels – MCC of cyanosis in 24hrs of birth, tx c surgery
      27. Initial Tx’s: CHF à thiaz, bb, acei, arb, aldo ant; Post-MI à bb, acei, aldo ant; DM à acei, bb, thiaz, arb; recurrent strokes à thiaz, acei
      28. Hyperaldosteronism – hypokalemic met alkalosis, PRA ratio, captopril-suppression test, high aldo level, 24hr urinary aldo, salt loading test
      29. Pheochromocytoma – 24hr urine collection for VMA, MRI to visualize adrenal tumors, MIBG if chemistries positive by CT/MRI are negative.
      30. Renal artery stenosis – renal U/S c Doppler, captopril scanning, CT/MRA, high renin, ACEI contraindicated if B/L
      31. Urgent v Emergent HTN – Urgent is just one high reading (give nitroprusside or lobetolol, wait til BP goes down and d/c home). Emergent is when there are signs of end-organ damage (must

      admit and do workup).
      32. PAD – claudication, rest pain, ulceration at medial ankle, dx c ankle-brachial index before/after exercise, angiography, MCC is atherosclerosis, tx c meds (pentoxyfylline, cilastazol,

      cab’s), angioplasty/stenting, avoid constricting drugs (bb)
      33. Temporal Arteritis - >55yo pt c HA, scalp tenderness, visual s/s, next step is low-dose steroids (before temporal a biopsy or getting ESR).
      34. Polyerteritis – HTN, abdominal pain, numbness in legs, skin findings, cns s/s, dx c biopsy, tx with steroids.
      35. AV Fistula – thrill/bruit over fistula (buzzing sound), dx c angiography, tx c surgical excision, if congenital do conservative management instead.
      36. Varicose veins – pain, pigmentation, superficial ulcer, tx c elastic stockings
      37. Superficial thrombophlebitis – pain, erythema, embolism is rare, tx c warm compression, limb elevation and NSAIDS.
      38. Deep vein thrombophlebitis – pain, swelling, fever, + Homans sign, PE is risk, so must do plethysmography or Doppler, tx c heparin/warfarin, filter if recurrent.
      39. Dissecting aortic aneurysm – sharp CP radiating to back, dx c CT, TEE or MRI, tx – 1st decrease BP (nitroprusside), 2nd - If ascending aorta (up to aortic arch) do surgery, if descending

      aorta use meds
      40. Abdominal aortic aneurysm – bruit, dx with U/S, see abdominal notes
      41. Aneurysm of thoracic aorta (nondissecting) – may compress adjacent structures causing CP, dysphagia, hoarseness, dx c aortography, Atherosclerosis is MCC, also due to cystic medial necrosis.

      Tx c surgical graft replacement.


      SKIN:

      42. HSV – type 1 at mouth, type 2 in genitalia. Recurrent erythema nodosum is characteristic. Dx c Tzank, tx c acyclovir
      43. Herpes zoster (shingles) – dermatomal, reactivated at dorsal nerve root, tx c acyclovir
      44. Varicella (chickenpox) – lesions in all stages of development, tx c benadryl. In 1st TM, causes microcephaly, chorioretinitis, IUGR and cataracts. Treat neonates with VZIG if mom contracted

      varicella within 5 days of delivery.
      45. Impetigo – honey-crusted lesions. S aureus and B-hemolytic strep. Tx c muciprocin
      46. Rubella – 3 days of cervical/suboccipital/postauricular node enlargement, prevention best c immunization before 1st TM to prevent triad: visual (cataracts), hearing loss, heart (PDA)

      defects.
      47. Measles (Rubeola) – looks like spilled red paint over your head (rash spread beind ears and over forehead to neck to trunk and extremities), prevent c immunization
      48. Roseola – 3-5 days of fever, and THEN rash after (never together). No tx
      49. Erythema infectiosum – 5th dz – slapped cheek appearance, parvo B19, causes aplastic crisis in sickle cell patients, no tx
      50. Rocky Mountain Spotted Fever – fever, rash on wrists then palms and soles, dx c weil-felix test, tx c tetracycline (chloramphenicol if pregnant)
      51. Lyme dz – erythema chronicum migrans c central clearing, tx is doxycycline (amoxicillin if pregnant and children <9yo).
      52. Scabies – burrows in hands, axillae, genitalia, highly contagious, tx c permethrin to the whole family.
      53. Allergic contact dermatitis – type 4 (cell-mediated) hypersensitivity like poison ivy
      54. Psoriasis – a T-cell mediated epidermal hyperproliferation, scaling plaques on knees, elbows, a/w clubbing of fingers, worsened by antimalarial drugs, lithium, bb’s, tx c steroids,

      calcipotriene.
      55. Seborrheic Dermatitis – on scalp is dandruff, on kids is cradle cap. Tx c ketoconazole (pt on chronic azoles need to have LFTs monitored) If generalized, r/o histiocytosis X; if severe, r/o

      AIDS.
      56. Bullous Pemphigoid – >60yo, large tense blisters, - nikolsky, IgG/C3 at dermal-epidermal junction, tx c prednisone, tetracycline, azathioprine (remember BCDE – Bullous pemphigoid, C3 at

      Dermal Epidermal junction)
      57. Pemphigus Vulgaris – 40-60yo, multiple flaccid bullae, + nikolsky, biopsy shows acatholysis, antibodies to epidermal Ag, tx is prednisone, fluids, tetracycline
      58. Dermatitis herpetiformis – itchy papulovesicular eruption usually on shins, - nikolsky, a/w celiac sprue, tx c gluten-free diet and dapsone (r/o G6PD first)
      59. Factitial Dermatitis – no rash in nonreachable areas (midback, butterfly sign)
      60. Acne Vulgaris – common acne. Tx c 1st benzoyl peroxide, 2nd topical/oral Abx, 3rd Topical retinoids, 4th Isoretinoin (r/o pregnancy first)
      61. Hereditary angioedema – AD, C1 esterase inhibitor deficiency, subQ/mucosal edema
      62. Pilonidal cyst – swelling, tender sacral mass, tx c antibiotics, I&D
      63. Epidermoid cyst – contains keratin, asymptomatic, if infected (I&D, abx), if not excise
      64. Capillary Hemangioma – strawberry nevus, reddish-purple hemangioma, tx c pulse dye laser therapy
      65. Cavernous Hemangioma – purplish vascular anomaly, tx c reassurance, compression
      66. Seborrheic keratosis – benign skin tumor in elderly, brown flat macule that appears “stuck-on”. Observe unless eruption is multiple then do shave excision and curettage, cryotherapy
      67. Port-wine stain – a/w sturge-weber syndrome, brain calcfications, seizures
      68. Actinic Keratosis – precursor to SCC, sun induced kyperkeratotic coarse lesions that are hard to remove. Tx c cryosurgery, 5FY, excision
      69. Squamous cell ca – generally from the lower lip down. Ulcer that won’t heal. Tx c surgery or radiation
      70. Basal cell ca – generally from upper lip up. Pearly nodule c rolled border. Surgical removal has high cure rate.
      71. Melanoma – ABCD (asymmetry, borders irregular, color variation, diameter >6mm), MC is superficial spreading type, dx c total excision, loves to metastasize
      72. Behcet’s syndrome – apthous ulcers, genital ulcers and uveitis, tx c d/c abx, chlorambucil
      73. Dermatomyositis – difficulty rising from chair, proximal weakness, gottrons sign (purple papules on knees and knuckles), dx c mucle biopsy, tx c prednisone
      74. Lofgren Syndrome – fever, erythema nodosum (LE nodules), and sarcoidosis.
      75. Amyloidosis – macroglossia, waxy papules on face, congo red stain on biopsy
      76. Scleroderma – raynauds, dysphagia, masklike face, tight skin, dx c skin bx, tx symptomatically or c D-Penicillamine, a/w CREST syndrome
      77. Tuberous sclerosis – retinal phacomas, seizures, MR, sebaceous adenomas, ash-leaf hypopigmented macules, tx c seizure control.
      78. Porphyria Cutanea Tarda – no abdm pain, but + red urine and vesicles on back of hand after having alcohol, drugs, estrogens, a/w Hep C, tx c 1st stop EtOH then phlebotomy
      79. Acute Intermittend Porphyria – abdm pain, weakness in shoulders/arms, change in behavior. Blocks porphobilinogen deaminase, high ALA in the stool.
      80. Acathosis Nigrans – black axillary/neck patches, a/w PCOS, DM, obesity and abdm adenocarcinoma. Next step is get fasting glucose to rule out insulin resisitance.
      81. TTP – fever, thrombocytopenia (causing petechia/purpura), MAHA, renal problems (hematuria) and CNS symptoms (depression, HA, psychosis). Tx c plamapheresis
      82. DIC – all labs messed up (BT, PT, PTT, fibrinogen, fibrin split products) causing cutaneous hemorrhage and ecchymosis. Tx – 1st treat primary cause, 2nd heparin
      ENDOCRINE:
      83. Thyroid nodule – 1st do TSH, then do FNA (preferred) or scan to see if its hot or cold (cold is malignant, if hot, observe – do not biopsy). MC benign is follicular adenoma, MC malignant

      is papillary (psammoma bodies), must as h/o radiation, worse if pt is male, >40 or young, distant mets. If results turn out that it’s a cyst, aspirate it and follow-up, if cancer, surgery c

      radioiodine (if papillary or follicular).
      84. Goiter – high or low iodine uptake, lithium/amiodorone use, familial, tx c levothyroxine. Do not d/c drug, just continue the drug and add levothyroxine.
      85. De Quervains (subacute) thyroiditis – painful thyroid, tx is NSAIDS
      86. Sick Euthyroid Synd – low T4/T3, normal TSH. No s/s, just a goiter. Tx - nothing
      87. Riedel’s – tracheal compression due to sclerosing fibrosis (rare)
      88. Hashimoto’s – antimicrosomal ab, tx c levothyroxine
      89. Congenital hypothyroidism (cretinism) – jaundice, lethargy, umbilical hernia, low T4, high TSH, tx c synthroid (levothryoxine)
      90. Adult hypothyroidism – fatigue, myxedema, cold intolerant, wt gain, eyebrow thinning, high tsh, low T4, MCC is hashimotos, but also d/t prior graves tx, sheehan’s, amiodorone, lithium, tx

      c synthroid
      91. Graves – low tsh, high T4, tachy, palpitations, weight loss, opthalmopathy, smooth goiter, A. fib, tx c BB’s (tremor and tachy), PTU, methimazole, radioactive iodine or subtotal

      thyroidectomy. In pregnancy, PTU can be used, as well as surgery if appropriate. Pt <25yo get surgery, pt >40yo get radioactive iodine.
      92. Toxic Nodule – high RIAU, no eye s/s, nodular goiter, on scan there is ONE area of increased uptake, whereas the rest its decreased (in toxic multinodular goiter (plummers disease), there

      are several areas of increased uptake and in Graves the entire gland has increased uptake)
      93. Thyroid storm – very high fever, delirium, n/v, abdm pain, high t4, low tsh, tx c supportive care first (decrease temp, arrhythmia, BP), BB, glucocorticoids
      94. Type 1 DM – polyuria/dypsia/phagia, islet cell ab, HLA DR3/4, low C-peptide, tx c insulin. If having surgery, give 10 units insulin in AM, and then 0.1U/kg/hr infusion.
      95. Type 2 DM – polyuria/dypsia. Fasting glucose >126, random >200 on 2 visits. Tx first with diet/weight changes (decrease calories and carbs), oral agents, insulin. HBA1c to monitor glucose

      over 2-3 months. For retinal neovascularization, give laster photocoagulation therapy. For nephropathy, check for microalbuminuria (1st sign) and give ACEI. For neuropathy, give foot care and

      analgesia.
      96. DKA – lethargy, n/v, polyuria, abdm pain, confusion, kussmaul breathing, fruity breath, glucose 400-600, anion gap met acidosis. Tx Isotonic fluids with insulin, replace K+ if needed

      (prevent cerebral edema).
      97. Hyperosmolar coma – dehydration, lethargy, confusion, coma, high glucose without ketones, tx c fluids, insulin and electrolyte replacement.
      98. Lactic Acidosis – coma, confusion, hyperventilation, no ketones, anion gap met acidosis, rare a/w metformin, tx etiology (starvation).
      99. Pt with high blood glucose in the morning? Get 4AM blood glucose. If its high (Dawn effect), then increase morning NPH, if its low (Samogi effect) then decrease night-time NPH.
      100. Insulinoma – lethargy, diplopia, HA, glucose <40, high proinsulin, high c-peptide (low c-peptide if exogenous insulin used). Tx c surgery, if emergency then first give 50mL of 50% dextrose

      IV.
      101. Primary Hyperparathyroidism – kidney stones, osteitis fibrosa cystica, muscle weakness, high calcium, low phosphate, high PTH, a/w MEN. Tx c surgery if adenoma, but if pt has severe

      hypercalcemia, 1st tx c saline, then furosemide, calcitonin and/or pamidronate.
      102. Hypoparathyroidism – low calcium (chvostek’s sign, trousseau’s sign, tetany), high phosphate, normal renal function. Tx c vitamin D and calcium
      103. Diabetes Insipidus – water loss, polyuria, nocturia, thirst, craving for ice, low urine osm (<250), high serum osm. Dx – Give vasopressin, if corrected its central, if still getting worse

      its nephrogenic (can be due to demecyclone or lithium), if no change in urine osm its primary polydipsia. Tx – if central give vasopressin (DDAVP), if nephrogenic give diuretic (thiazides,

      amiloride).
      104. SIADH – low Na, low serum osm, high urine osm, a/w small cell ca/morphine/ chlorpropramide/oxytocin, tx c 1st fluid restriction, 2nd demeclocycline or hypertonic saline if Na is really low.

      Do not treat too rapidly to avoid central pontine myelinosis.
      105. Acromegaly – enlarging hands, feet, coarse features, deep voice, large tongue, hat/wedding ring doesn’t fit anymore (hat don’t fit anymore can be Paget’s), due to high GH, dx with

      glucose suppression test, then IGF-1, then MRI to confirm adenoma, tx c surgery (transphenoidal), or radiation/meds (bromocriptine, octreotide) if surgery doesn’t work.
      106. Acute adrenocortical insufficiency – shock, fever, abdm pain, low sugar, dx c cosyntropin testing, tx c hydrocortisone sodium succinate.
      107. Chronic adrenocortical insufficiency (Addisons) – MCC is US is autoimmune, MCC in world is TB. Lethargy, skin pigmentation, hypotension, low Na, high K+, low cortisol, high ACTH is primary,

      normal/low ACTH is secondary. Dx c ACTH stimulation test (cortisol should increase, but remains low in Addisons). Tx c hydrocortisone (glucocorticoid) and fludrocortisone (mineralcorticoid)
      108. Cushing’s syndrome – obesity, purple striae, HTN, hirsutism, buffalo hump, wakness, osteoporosis, dx c 1st 24hr urine free cortisol, then DXM suppression test (if suppressed that means

      its pituitary caused (Cushing disease), if not its adrenal or ectopic ACTH like small cell ca or carcinoid). Tx – if iatrogenic use smallest effective steroid dose possible, if cushing disease

      do surgery/radiation of pituitary adenoma.
      109. Adrenogenital syndrome – hirsutism, amenorrhea, high urinary 17-OH, MCC is 21-OH deficiency in kids, MCC in adults is PCOS or adrenal disease. Tx is surgery if ambiguous genitalia in

      girls), then estrogen spironolactone, meformin (if PCOS), gluco/mineralocorticoid if CAH.
      110. Conn’s synd – high aldo, low K+, high Na, High BP, low renin, tx is adrenalectomy c spironoloactone preop.
      111. Secondary Hyperaldosteronism – MCC is renal artery stenosis – high Na, low K, high rennin, renal bruit. Dx c aldo:renin ration, then CT Abdm.
      112. Prolactinoma – milky d/c from breast, if prolactin level 20-100 then r/o dopamine antagonist drugs (haloperidol, metaclopramide) and r/o hypothyroidism, if prolactin level >100, then do MRI

      of brain. Tx – if CNS s/s (bitemporal hemianopsia) do surgery, if not give bromocriptine.
      113. Pheochromocytoma – sudden episodes of flushing, HTN, HA, sweating, feeling of doom, a/w MEN II/III, dx c urinary VMA or catecholamines, then if + do CT of abdomen and tx c give

      phenoxybenzamine (then BB) followed by surgery.
      114. PCOS and Premature ovarian failure – see obgyn notes
      115. Hemochromatosis – AR, hepatomegaly, bronze skin, cardiomegaly, DM, dx c liver biopsy, tx c phlebotomy 1st, then deferoxamine (if needed).
      116. Gestational DM – measured at 26-28wks, glucose checked 1 hour after 50g load, if abnormal, check 3 hours after 100g load (fasting should be <95, 1hr <180, 2hr <155, 3hr <140). Tx c diabetic

      diet and insulin if needed.
      117. Carcinoid syndrome – diarrhea, flushing, bronchospasm, low bp, R heart valve lesions, dx c urinary 5HIAA, tx c surgery. MC is at appendix, but if symptomatic, MC is at small bowel.


      GI:

      118. Upper GI bleed – hematemisis, dx c EGD, tx (in order) – If bleeding ulcer: PPI, transfuse, urgent endoscopy when possible, epinephrine into vessel, surgery if needed. If esophageal

      varices: Octreotide, banding/sclerotherapy, ET intubation, TIPS (for esophageal varices, prevent next bleed with BB’s)
      119. Lower GI bleed – MCC of BRBPR is diverticulosis, then angiodysplasia. Dx c colonoscopy if bleeding stops, blood scan if bleeding continues and if +, angiography. Tx – replace blood,

      vasopressin at site.
      120. what is the cutoff between upper and lower GI bleeding? Ligament of Trietz.
      121. Crohn’s – all gi tract (usually rectal sparing), fistula, skipped lesions, all layers of bowel (transmural), fistula, abscess, noncaseating granuloma, gallstones, calcium oxalate kidney

      stones, extraintestinal manifestations, dx c colonoscopy and biopsy. Tx using infliximab (must do PPD before starting it), sulfasalazine, metronidazole, prednisone.
      122. Ulerative Colitis – rectum mainly (unless backwashing present), continuous, just mucosa/submucosa, crypt abscesses, toxic megacolon, small/frequent bloody diarrhea c tenesmus. Tx c

      azulfidine, sulfasalazine
      123. Toxic Megacolon – emergency, a/w UC, tx: NPO, NGT, IVF, D/C meds, Abx, surgery only if + perforation (free air on AXR)
      124. Peptic Ulcer – Duodenal decreases c food, Gastric increases with food, gastic is more a/w cancer, duodenal is more a/w H.pylori. Dx 1st c H.pylori testing, then endoscopy with biopsy to r/o

      cancer. Risks for NSAIDS: >70, h/o prior PUD, only available tx is misoprostol. H.pylori: breath test, gastric biopsy, urease. Dx for PUD: 1st Upper GI endoscopy, then biopsy for gastric ulcers to

      r/o cancer. Tx with amox, clarithro and omprazole. Follow-up with urea breath tests after 1 month of tx. Complications: hemorrhage (MC), perforation – do AXR to see free air in a pt c peritoneal

      s/s and tx c abx and laparatomy. After surgery (antreceomy, vagotomy, billroth I and II), watch out for Dumping Syndrome (weakness, n/v after eating), Afferent loop syndrome (bilious vomiting

      relieves abdm pain after meal), Iron/B12 deficiency.
      125. ZE syndrome – severe, non-healing ulcers. Get gastric levels and r/o ca (MEN).
      126. Oropharyngeal dysphagia – swallowing impaired d/t lack of neuromuscular control from prior CVA/Parkinsons/Alzheimers. Dx c barium swallow. Tx underlying dz.
      127. Achalasia – aperistalsis, incomplete LES relaxation c high LES pressure, dysphagia for solids and liquids, no regurge, dx c barium (dilated distal 2/3rd) then manometry (bird beak), then

      endoscopy to r/o cancer. Tx c pneumatic dilatation, then botox, then surgical Nissen’s fundoplication.
      128. Chagas Disease – achalasia, cardiomegaly, hepatomegaly in a south American.
      129. GERD – heartburn, CP, epigastric pain, older guy, MCC of nocturnal cough. Dx c 24hr pH, upper GI endoscopy to r/o barrett’s or ulcers. If you suspect it, treat it without doing any

      diagnostics. Tx c lifestyle changes, PPI, H2 blockers. If pt still has symptoms then do 24hr pH. If pt says drugs used to work but don’t work anymore, do EGD to rule out cancer.
      130. Zenker’s Diverticulum – a motility disorder, causing halitosis, dx c barium, tx c Sx.
      131. Esophagitis – painful swallowing (odynophagia), Candida so start c flucanazole.
      132. Diffuse Esophageal Spasm (Nutcracker) – Cp due to strong intermittent contractions. Dx c barium (corkscrew pattern) first, then manometry (shows nonperistaltic uncoordinated contractions),

      tx c calcium channel blockers or nitrates.
      133. Scleroderma Esophagus – younger guy with GERD symptoms, raynauds, heartburn, dysphagia for solids and liquids, dx c manometry (low LES pressure (unlike achalasia which is high), absent

      contractions in the smooth muscle esophagus, normal peristalsis in the striaghted muscle, normal UES). Tx c same things as GERD.
      134. Schatzki Ring – young pt with episodic difficulty (not pain) swallowing. Dx c barium, tx c pneumatic dilatation of LES
      135. Plummer vinson synd – hypopharyngeal web c iron deficiency. Risk of SCC. Middle-aged female c dysphagia immediately after meals. Dx c barium, tx c surgery.
      136. Barett’s Esophagus – 5yrs of dysphagia, weight loss, no reflux, s/s visible on EGD so do biopsy. If biopsy shows no dysplasia then repeat in 2-5yrs, if bx shows low dysplasia, repeat in

      3-6 months, if bx shows high grade dysplasia – resection
      137. Esophageal CA – progressive dysphagia for solids and eventually liquids, wt loss, CP, hypercalcemia (SCC), dx c barium, then comfirm c EGD and biopsy. Tx c surgery, chemotherapy (cisplatin,

      5-FU) and radiation.
      138. Gastroparesis – delayed gastric emptying causing n/v, bloating and upper abdm discomfort, common in DM, tx c metoclopramide
      139. When you suspect GI perforation, use gastrograffin (not barium), when you suspect aspiration, use barium (not gastrograffin).
      140. Diarrhea – see ID notes
      141. Irritable Bowel Syndrome – alternating constipation/diarrhea, pain relieved c defacation. Tx c increased fiber in diet.
      142. Diverticulosis – d/t low fiber/high fat diet. LLQ pain, fever, tenderness. Dx c colonoscopy. Tx c increased fiber.
      143. Diverticulitis – peritonitis, fever due to micro/macro-perforations, do CT scan. Tx c NPO, IVF and abx (cipro/metro or cefoxitine or ampicillin/sulbactam)
      144. Pseudomembranous Colitis – C.difficile overpopulation due to prior use of Abx weeks ago, dx c C.diff in stool. Colonoscopy shows yellow adherent plaques on mucosa. Tx: d/c drug, start

      metronidazole, if still +, vancomycin.
      145. Colorectal CA – 2nd MCCOD d/t cancer, rectal bleeding, change in BM, weight loss, sometimes asymptomatic (found incidentally on colonoscopy). Dx: FOBT yearly after age 50, flexible

      sigmoidoscopy every 4 years, colonoscopy at 50 then 53 then every 5 years, but start 10 years earlier than the age of which family relative was diagnosed with it. Tx – surgical resection of

      primary tumor.
      146. Chronic Liver Disease – causes include autoimmune hepatitis, hemochromatosis, chronic alcohol use, fatty liver dz (non-alcoholic stateohepatitis), wilsons dz, viral (HBV, HCV), s/s include

      fatigue, increased abdm girth, jaundice, spider angiomas, palmar erythema, HSM, gynecomastia, testicular atrophy, labs c high AST/ALT/PT/INR, thrombocytopenia, hyponatremia, hypoalbuminemia.
      147. Autoimmune hepatitis – 20-40yo female c +ANA, +anti-smooth muscle Ab, everything else normal. Tx c steroids.
      148. Wilson’s disease – young guy with parkinsonism due to hepatilenticular degeneration, kayser-Fleischer ring, hemolytic anemia, dx c low serum ceruloplasmin, low total copper (not free),

      high urine copper. CT shows hypdense regions in the basal ganglia. Confirm dx c liver biopsy. Tx c D-penicillamine.
      149. Ascites – U/S, CT and then paracentesis. Tx c Na/fluid restriction, diuretics, then furosemide, then large-volume paracentesis, then TIPS.
      150. Spontaneous bacterial peritonitis - >250polys in 3 bedside cultures, tx c cefotaxime
      151. Encephalopathy – tx c protein restriction and lactulose.
      152. HAV – shellfish, fecal-oral, dx c + anti-HAV IgM (IgG shows previous infxn)
      153. HBV – HbsAg is earliest marker, >6months is chronic, if vaccinated = +HbsAb, -HbcAb, if exposed in the past = +HbsAb, +HbcAb. Window period has anti-HBc IgM only. Prevent with vaccine +

      HBIG. Treat c Interferon alpha and lamivudine. Give vaccine at 0-2mo, 4-6mo, 13-18 months. If mom has +HbsAg, give baby vaccine + HBIG within 12 hours of birth.
      154. HCV – dx c anti-HCV Ab/IgG/IgM and HCV RNA by PCR. Tx – Inf-a c ribavirin
      155. Drug-induced – Tylenol, isoniazid, halothane, carbon tetrachloride, tetracycline. Dx c very high AST/ALT levels. Tx – D/C med
      156. Acute fatty liver of pregnancy – develops in 3rd TM. Tx – immediate surgery
      157. Primary Biliary Cirrhosis – antimitochondrial Ab in serum, pruritis, fatigue, hepatomegaly, high alk phos, destruction of intrahepatic and extrahepatic ducts. Tx c ursodeoxycholic acid,

      cholestyramine.
      158. Primary Sclerosing Cholangitis – young man c IBD (UC), destruction on extrahepatic ducts only (shows beading effect d/t fibrosis).
      159. Gallstones – female, fat, 40, fertile, RUQ or epigastric pain, worsened c food, radiates to midscapular area. Dx c U/S, then HIDA scan if negative. Tx c lap chole. ERCP if pt still has

      symptoms after (stone is in CBD).
      160. Mesenteric Ischemia – severe abdm pain/tenderness with paucity of clinical findings. Pt will usually have extensive ischemic history (MI, DM, etc), dx c angiography, tx with prompt

      laparotomy to reestablish arterial flow
      161. Acute Pancreatitis – MCC is gallstones, then alcohol. Epigastric pain radiating to midback, alleviated c sitting up, jaundice sometimes fever. High amylase/lipase. Dx c CT. Tx c NPO, NGT,

      analgesia, and then begin to consider ERCP and surgery if perforated, bleeding, abscess, pseudocyst or peritonitis.
      162. Pacreatic Pseudocyst vs Abscess – worsening of pain, n/v, fever high WBC and positive blood culture after initial improvement. Dx c CT. Tx c Abx, then surgical drainage of abscess.

      Pseudocyst is generally asymptomatic.
      163. Pancreatic CA – vague abdm pain (doesn’t have to radiate to the back anymore), anorexia and weight loss with jaundice, n/v. Dx c CT. If negative do ERCP. Check CA 19-9. Tx: If only at

      pancreatic head c no spread, try resection. If not, do Whipple (pancreaticoduodenectomy) procedure.
      164. Malabsorption – Steatorrhea (dx c Sudan stain – 1st test). Then dx c D-xylose, if abnormal, suggests small bowel disease. Normal value suggests focus on pancreatic dz: CT of abdm, serum

      amylase, AST/ALT. If overgrowth considered, note response to malabsorption to Abx. Celiac sprue panel: antiendomysial/antigliadin Ab, tissue transglutaminase, total serum IgA, antigliadin Ab IgA

      and IgG; at least 3 biopsy specimens from distal duodenum is gold standard.
      165. Whipple’s – malabsorption, arthralgia and CNS symptoms (dementia). Dx c small bowel biopsy (shows foamy macrophages on PAS stain). Tx c TMP-SMX
      PEDS GI:

      NAME AGE VOMITUS FINDINGS
      Pyloric Stenosis 0-2mo Nonbilious, projectile M>F, olive-shaped mass, low K
      Intestinal Atresia 0-1wk Bilious, projectile Double bubble sign, a/w Downs
      TE Fistula 0-2wk Food regurgitation Resp problems c feeding, asp pneumo, dx via cant pass NGT
      Hirschsprung 0-1yr Feculent Distention, obstipation, no ganglia on biopsy
      Anal Atresia 0-1wk Late, feculent Seen on initial exam in nursery
      Choanal Atresia 0-1wk - Cyanosis c feeding, relieved c crying, CHARGE synd, cant pass NGT
      Intussusseption 4mo – 2yo Bilious Currant jelly stool, palpable abdm mass, kid draws up legs, dx c barium enema
      Nec Enterocolitis 0-2mo Bilious Premies, fever, rectal bleeding, air in bowel wall, tx c NPO/IVF
      Meconium Ileus 0-2wk Feculent, Late Cystic Fibrosis
      Midgut Volvolus 0-2yw Bilious D/t malrotation, sudden pain/n/v. dx c upper Gi, tx c Sx
      Meckel’s Diverticulum 0-2yw Varies GI ulcer/bleed, dx c Meckels (Technetium) scan, tx c Sx
      Strangulated Hernia Any Bilious Bowel loops in inguinal canal

      ONCOLOGY:

      166. Tumor markers – Bhcg – testicular cancer, choriocarcinoma, mole; AFP – hepatocellular carcinoma testicular ca; CEA – GI cancers; PSA – prostate ca; CA-125 – Ovarian ca; CA 19-9

      – colorectal/GI/pancreatic cancer
      167. Sigmoidoscopy - >50yo every 3-5yrs; FOBT - >50 annually; DRE - >40 annually; PSA - >50 annually in normal risk, >40 annually in high risk; Pap smear – onset of sexual activity or 18yo

      annually for 3 consecutive years then however often; Pelvic exam – 18-40yo every 1-3yr, >40 annually; Endometrial biopsy – menopause/high risk annually; Self breast exam - >20 monthly;

      Clinical breast exam – 20-40 every 3 years, >40 annually; Mammogram – 40-49 every 1-2 yrs, >50 annually.
      168. Cancerous Occupation Hazards – aromatic amines c bladder ca, arsenic c lung/skin/liver ca, asbestos c mesothelioma (bronchogenic MC), benzene c leukemia, mustard gas c lung/larynx/sinus

      cancer, vinyl chloride c liver cancer
      169. Hodgkin’s – fever, night sweats, chills, weight loss (like TB), and painless cervical adenopathy. Dx c CT chest/abdm and then lympangiography and then biopsy (for treatment purposes).

      Reed-sternberg cells. Tx – If no B s/s (fever, wt loss, sweats) give radiation alone. If B s/s give chemotherapy (MOPP or ABVD)
      170. Non-Hodgkin’s – variable nodes, monoclonal B/T-cell proliferation, dx c CT chest/abdm/pelvis then other stuff like BM bx, PET scan, gallium scan. Tx c radiation and chemo (CHOP) c

      Rituximab (CD20 Ab).
      171. Acute Lymphocytic Leukemia – kids, blasts, tx c intrathecal chemo (MTX)
      172. Acute Myelogenous Leukemia – M3 causes DIC, Aeur rods, blasts, add All-trans retinoic acid (Vit A) to tx.
      173. CML – high WBCs, high PMNs, splenomegaly, LUQ pain, fullness and early satiety, decreased LAP, dx c phili chromosome (t9;22 of brc:abl) in BM, tx c Imatinib (Gleevac).
      174. CLL – elderly, high WBCs, high lymphocytes, splenomegaly, dx c smudge cells, no tx if no lymphocytosis, if + lymphocytosis give fludarabine or chlorambucil.
      175. Hairy Cell Leukemia – CD10+ and TRAP+ (tartrate-resistant acid phosphatase), tx c cladribine
      176. Mycosis fungoidis – cutaneous T-cell lymphoma (look at 1st aid picture), lion-like facies, tx c PUVA chemotherapy. If affecting peripheral blood, its Sezary syndrome.
      177. Multiple Myeloma – high calcium, high OAF, high uric acid. Best initial test is X ray if bone pain or electrophoresis if high protein. Most accurate test is >10% plasma cells. Tx: <70yo get

      stem cell transplant, >70yo get Meiphelen or Thalidomide
      178. Aplastic Anemia – low rbc/wbc/platelet, drugs (chloramphenicol), parvo-B19 (sickle cell), tx: <50yo get BMT, >50yo get cyclosporine + anti-thymocyte globulin
      179. If pt has neck + pelvic mass after chemo the mass gets smaller, wheat test checks content of the lymph node? PET scan. So in a nutshell, a lymphoma gets excisional biopsy of the node, then

      PET scan, and chemo if they have B symptoms.
      180. Adverse effects of chemo: Vincristine/blastine – peripheral neuropathy, cyclophosphamide – hemorrhagic cystitis, Busulfan/Bleomycin – Irreversible Pulmonary Fibrosis (that’s why Lance

      Armstrong refused it), Cysplatin – renal dz, ototoxicity, anemia. Overall MC adverse effect with chemo drugs is sterility.
      181. Lung cancer – chronic cough (MC s/s), wt loss, smoker, hemoptysis. Dx: 1st CXR, then biopsy. Tx: Small cell get chemo only, Non-small cell – chemo c radiation. Horner’s syndrome –

      unilateral ptosis, meiosis, anhidrosis due to compression of ipsilateral superior cervical ganglion by lung tumor, particularly SCC. SVC syndrome – obstruction of SVC causes facial

      swelling/plethora, dyspnea, cough, JVD. Pancoast syndrome – tumor of the superior sulcus causes brachial plexus s/s. Small cell causes Cushings syndrome (ACTH) and SIADH, SCC causes

      hypercalcemia (PTH-like peptide)
      182. Solitary nodule – 1st step get old x-ray. If present and same size, its benign (send home), if increase in size its probably cancer. If it wasn’t there, assess risk (high is smoker and

      >35, low risk is nonsmoker and <35). If low risk follow up later, if high risk do biopsy.
      183. Breast Cancer – biopsy everyone c palpable mass >35 except if B/L, lumpy and s/s only occur c menses. If <35 its probably fibroadenoma (rubbery moveable mass, observe pt). After bx, get

      mammogram if >35yo. If mammo was already done, get FNA. If after biopsy, mass goes away, send pt home. Tx: tamoxifen, mastectomy, radiation, axillary dissection, chemotherapy (c platinum) if +

      nodes.
      184. Prostate cancer – s/s of BPH c hematuria, high PSA (only to screen/monitor, not for dx), irregular/boggy, back pain. Tx c surgery. If +mets, then do orchiectomy, leuprolide, flutamide, DES,

      but no chemo. Only do TURP and radiation of mets is local (bone).
      185. Colon cancer – R sided bleeds (bloody stools), L sided obstructs (constipation), wt loss. Dx c colonoscopy. Tx c surgery and 5-FU and then f/u CEA levels. If mets (MC is liver) to liver do

      surgery, but anywhere else do chemo.
      186. Pancreatic cancer – 40-80yo male smoker c jaundice, wt loss and vague abdm pain. May have migratory thromboplebitis (Trousseau’s syndrome) or palpable, nontender gallbladder

      (Courvoisier’s sign). Dx c CT, then FNA. Tx c whipples.


      HEMATOLOGY:

      187. Microcytic (MCV <80): Iron deficiency, Thalassemia, Anemia of Chronic Dz, Sideroblastic Anemia (lead poising, isoniazid, alcohol-induced)
      188. Normocytic (MCV 80-100): Check Reticulocyte count(should be <2% c anemia, otherwise marrow isn’t responding properly): <2% is acute blood loss (<5-7days), early iron deficiency, aplastic

      anemia, early AOCD, renal disease. >3% is due to either Intrinsic RBC defect (MAD: Membrane defects (Spherocytosis, PNH), Abnormal hemoglobins (Sickle cell), Deficient enzymes (G6PD, pyruvate

      kinase deficiency)) or Extrinsic RBC defect (Autoimmune hemolytic anemia, MAHA, blood loss >1 week)
      189. Macrocytic (MCV >100): B12 def, folate def, Myelodysplastic syndrome, drug-induced, hepatic dysfunction (d/t alcohol), reticulocytosis.
      190. Red Cell Morphologies: Rouleaux (myeloma), Burr cells (uremia), Tear drops and nucleated red cells (myelofibrosis), hypochromic/microcytic (iron def), target cells (HALT: Hemoglobinopathies,

      Asplenia, Liver dz (obstructive jaundice), Thalassemia), Oval macrocytes (B12/Folate def), basophilic stippling (Lead, B12 def), spherocytes (HS), Schistocytes (MAHA, AIHA, DIC), bite cells and

      Heinz bodies(G6PD), Howell-Jolly bodes (Asplenia like SCD).
      191. Iron deficiency – low MCV, high TIBC, low ferritin, low iron (<60), high RDW (why? Because some are normocytic and some are microcytic so the range of width will be high), pica kid who eats

      sand and ice, plummer-vinson (web, low iron, glossitis), cow milk before age 1, exclusive breast-feeding, pregnancy. Tx – 1st is to find the source of iron loss and fix that (before you give

      iron!), 2nd transfusion (if needed fast) or oral iron supplements for 6-12 months.
      192. Anemia of Chronic Dz – (how does this work? The body knows diseases (RA, TB, SLE, cancer) love iron, so it will hide iron away in stores (high ferritin) but keep it out of the serum (low

      serum iron and high TIBC)) if anemia is a/w chronic renal dz, look for Burr cells.
      193. Thalassemia – normal iron (so don’t give iron), target cells, nucleated rbc, x-ray shows crew-cut appearance of skull, dx c Hb electrophoresis, no tx for traits. Thal major gets

      transfusion 1st and deforoxamine to prevent iron overload, spelenectomy (now give pneumovax, penicillin prophylaxis, folate supplement).
      194. Lead Poisoning – pica kids who have ABCD (Anemia/Ataxia/Abdm pain, Basophillic stippling/Behavioral changes, Constipation, Drops (foot/wrist)/Death), high free erythrocyte protoporphyrin.

      Dx c blood Pb level and x-ray (pb visible in bones). Tx c EDTA or dimercaprol.
      195. B12 Deficiency – MCC is pernicious anemia (anti IF/parietal Ab), also d/t gastrectomy, terminal ileus resection, vegetarian, chronic pancreatitis and diphyllobothrium latum infection. Look

      for CNS s/s (symmetric parethesia in feet/fingers, disturbed proprioception and vibratory sense, irritability, somnolence, abnormal taste/smell, central scotomas, positive babinski) and

      achlorhydria (no stomach acid secretion so pH in stomach is high). Check serum B12. Schilling test (never used in real world). Hypersegmented PMN. High methylmalonic acid level. Tx c cobalamin.

      Folate may worsen the CNS s/s.
      196. Folate – usually d/t dietary lack (green vegetables, liver, kidney, yeast, mushrooms), alcoholism, pregnancy, celiac sprue, phenytoin, bactrim, MTX, 5-FU, OCPs. Tx c folate supplements.
      197. Autoimmune Hemolytic Anemia – Ab/complement binds to RBC mmb. Two types IgM (agglutination at colder temp like Mycoplasma) and IgG (warm agglutination like SLE, penicillin, methyldopa). Dx

      c direct Coomb’s positive. If hemolysis is mild, observe, if hemolysis is severe, give glucocorticoids. If recurrent, do splenectomy.
      198. Paroxysmal Nocturnal Hburia – Hypoventilate at night, so acidosis causes RBC burst d/t low DAF, therefore complement comes right off (CD 55/59). May die in 10 yrs d/t thrombosis. Best test

      is Sugar water test or Hams test (Acidic sounds like Hacidic, Hacidics don’t like Ham). s/s include Hburia in the morning time (not at night, that would be a prostate problem), increase risk of

      AML. Give steroids.
      199. G6PD Deficiency – MCC is infection (they usually wont say Greek, primaquine, fava beans, Dapsone). Hemolysis, jaundice abdm/back pain 1-3 days after exposure. Heinz bodes, bite cells. Best

      tx c avoiding offending agents.
      200. Spherocytosis – increased osmotic fragility, AD, low spectrin, splenomegaly. Dx c osmotic fragility test, tx c splenectomy (defer until 6yo), pneumo vaccine and folate
      201. Sickle Cell Disease – African descent, AR, s/s >6mo d/t HbF, if trait only gets UTI, best initial test is smear, most accurate test is Hb electrophoresis, for crisis 1st give fluids/pain

      management, if fever (d/t autosplenectomy) give Abx (Ceftriaxone), if eye/CNS/chest/Priapism give exchange transfusion, to prevent next aplastic crisis give folate, to prevent next vaso-occlussive

      pain crisis (they will just say “crisis”) give hydroxyurea, if Hct drops suspect Aplastic anemia d/t Parvovirus. Give prophylactic penicillin, Pnumococcal/Haemophilus influenza vaccine @

      childhood.
      202. Aplastic Anemia – low rbc/wbc/platelets, chloramphenicol, parvovirus, benzene, acute leukemia, AZT/zidovudine. Tx c 1st stop drug, then give antithymocyte globulin
      203. Myelophthisic anemia (Myelofibrosis) – malignant invasion of BM, anisocytosis (aniso = any size), poikilocytosis (shape), teardrop-shaped RBC, dx c BM biopsy showing no cells (dry tap).
      204. Transfusions: Whole blood (poisoning, TTP), Packed RBC (post-surgery/trauma transfusion or instead of whole blood), washed RBC (IgA deficiency), Platelets (>10,000), granulocytes (post

      chemo), FFP (bleeding diathesis like DIC, warfarin poisoning, liver failure), cryoprecipitate (vWD and DIC). MCC of transfusion rxn is lab error. If it occurs, 1st step is stop transfusion.
      205. Platelet problems = skin, gums, nose, gingival (ALL SUPERFICIAL), GI, CNS and vaginal bleeding; Factor problems – bleeding into join and muscles (DEEP), GI, CNS.
      206. von Willebran Dz – high PTT, normal PT, high BT, normal plt/rbc count, AD (look for family history) (a platelet type of bleeding c a normal platelet count). Best initial test is bleeding

      time, then ristocetin level. Best tx c desmopressin (DDAVP)
      207. Hemophilia A/B – really high PPT, normal PT, normal BT/plt/RBC, looking for delayed hemarthrosis in males only (A is factor 8, B is factor 9).
      208. DIC – high PT/PTT/BT, low plt, low RBC, low factor 8.
      209. Liver failure – high PT, normal/high PTT, normal BT, normal/low plt/RBC, jaundince, normal factor 8, do not give vitamin K (ineffective), give FFP’s.
      210. Heparin – high PTT, thrombocytopenia. Tx c d/c drug
      211. Warfarin – high PT, vit K antagonist (2,7,9,10), tx c FFP (fast) or vit K (slow), skin necrosis
      212. ITP –low platelets, high BT, h/o URI, next step is steroids (just treat it), auto-platelet Ab, if platelets fall <7000 give IVIG or RhoGam.
      213. TTP – high BT, low plt, low RBC, hemolysis, CNS, renal, fever, thrombocytopenia (petechia, purpura). Tx c plasmapheresis
      214. HUS – like TTP but no renal failure or CNS s/s, h/o infection, E. coli 015H7.
      215. Scurvy – all studies normal. Fingernal/gum/bone/perifollicular hemorrhage, poor diet (only eats hot dogs and soda or tea and toast). Tx c vitamin C.
      216. Neutropenia – PMN <2.0 x 10_9. Dx c bone marrow aspirate/bx. Tx: 1st determine the cause, 2nd Abx, 3rd steroids, 4th GM-CSF.
      217. Polycythemia Rubra Vera – 4 H’s (Hypervolemia, Hyperviscosity (thrombosis is MCCOD), Hyperuricemia, Histaminemia (itch all over after a hot shower)). Tx c phlebotomy.
      ________________________________________________________________________

      ID:

      218. Toxic Shock Syndrome – preformed toxin, prolonged tampon placement, hypotension, fever, dequamated rash (peeling of palms/soles), S.aureas
      219. Conjunctivitis – 1st 24 hours is chemical, 2-5 days is Neisseria, 4+ is Chlamydia. If they say painful conjunctivitis, that’s viral (HSV) so treat c acyclovir.
      220. External Otitis – pain, drainage, itchy swimmer’s ear, Pseudomonas.
      221. Otitis Media – 40% s.pneumo, 30% h.influenza, 30% m.catarrhalis, dx: 1st step is pneumatic otoscopy showing immobility of tympanic mmb, 2nd step is tympanocentesis, tx c amoxicillin.
      222. Sinusitis – same % as above. Yellow green d/c, sinus tenderness, best initial step – empiric abx (amox + decongestant), then X-ray, then Sinus biopsy (most accurate)
      223. Meningitis – 0-1mo – GBS, E.coli, Listeria, 2mo-2yo – S.pneumo, 2-18yo – Neisseria, 18+ - S.pneumo; Kernigs/Brudzinski sign, lethargy, fever, bulging fontanelle, photophobia, nuchal

      rigidity, n/v, dx c LP (bacteria: low glucose, high prtn, PMN’s; viral: normal glucose, slightly high prtn, low WBC, lymphocytes). If bacterial, give ceftraixone, vanco or steroids. Give

      ampicillin (listeria) if immunocompromised. If neisseria suspected (2-18yo c rash) next step is respiratory isolation and tx him and family members c rifampin. If >100 lymphocytes: Cryptococcus

      (r/o HIV, best initial test is India ink, most accurate test is crypt ag, tx c Amp B), Viral (no specific test), TB (pulm s/s, high CSF protein, give RIPE + steroids), Lyme Dz (serology, h/o bite,

      target rash, doxycycline, or if CNS s/s like cranial nerve 7 effects, give Ceftriaxone), RMSF (serology, rash on wrists/ankes moving centrally, h/o camping or hiking, tx c Doxycycline,

      chloramphenicol if pregnant). The MC sequela is hearing loss.
      224. Encephalitis – look for acute febrile confusion (if they say confusion, its encephalitis not meningitis), MCC is herpes (blood in csf), best initial test is CT (temporal lope), if negative

      do PCR (most accurate). Tx c acyclovir, then foscarnet if resistant.
      225. Brain Abscess – look for focal neurologic findings c ring/contrast enhancing lesions. If HIV (-), do biopsy, if HIV +, start sulfadiazine-pyrimethamine tx for Toxo and repeat CT.
      226. Spinal Abscess – local severe back pain that becomes radicular pain, then weakness c fever. Next step is CT, then surgical drainage c abx.
      227. Tetanus – rictus sardonicus (facial sneer), tonic muscle spasms (jaw, trismus), clostridium tetani, tx c tetanus IG and penicillin G.
      228. Diptheria – gray pharyngeal pseodommb c sore throat, tx c diphtheria antitoxin (DAT) and penicillin or erythromycin.
      229. Croup – aka acute laryngotracheitis – barking cough in a 1-2yo. Parainfluenza virus. Frontal neck x-ray shows steeple sign. Tx c racemic epinephrine.
      230. Epiglottitis – 2-5yo kid unimmunized (H.influenza) c rapid progression of high fever, drooling and respiratory distress c no coughing. X ray shows thumb sign. Do not examine throat or

      irritate the kid (worsen airway obstruction). Tx c airway assessment, then cephalosporins.
      231. Bronchiolitis – 0-18month old kid in the fall/winter gets expiratory wheezing due to RSV. Tx c ribavirin. (In a nutshell, 0-2yo c wheezing is bronchiolitis, 1-2yo c barking cough is croup,

      2-5yo c drooling is epiglottitis)
      232. Pertussis – whooping inspiratory wheeze.
      233. Lung abscess – fever for weeks, bad teeth, alcoholic, aspiration, stroke pt, intubated pt, next step is CXR, best way to prevent it is to remove all teeth, how do you differentiate from TB?

      The smell (very bad in abscess), most accurate test is biopsy, tx c clindamycin
      234. Bronchitis – mild cough c sputum, negative CXR, tx c azithro, levaquin or doxy
      235. Pharyngitis – sore throat, exudes, lymph nodes, no cough, no hoarseness, best test is rapid strep test, tx c penicillin
      236. Influenza – ahces, pains, tired, cough, HA, no fever. Best tx is oseltamivir or zanamivir (note the Ivir (for Influenze), not Ovir like acyclovir/famcyclovir for HSV or Avir like

      ritonavir/nelfinavir for AIDS)
      237. Pneumonia – outpt tx is same as bronchitis (azithro, levaquin, doxy), inpatient tx include ceftriaxone. In young healthy pt, think mycoplasma (get serologies) or if inpt, think S.pneumo. If

      CNS and GI symptoms, pick Legionella. If AIDS c CD<200 pick PCP (TMP-SMX tx). If exposed to sheep placenta, pick Coxiella burnetti. If lobar pneumonia (s.pneumo is MC) then stain and culture next.

      When do you give steroids? PO2 <75, A-a gradient <35. When do you admit and give pneumovax? Hypoxia, >65, splenectomy, hypotensive c high pulse, comorbidities, confusion, low Na (SIADH).
      238. TB – homeless, alcoholic, immigrant, HIV, health care worker, prisoner, fever, cough, sputum, wt loss, night sweats, first thing to do is CXR (NOT PPD – when do you choose PPD first?

      Screens asymptomatic pts!), 2nd step is AFP and then give RIPE c isolation for 2 months, then isoniazid and rifampin for another 4 months (6 months total). Adverse effects are Isoniazid is

      neurotoxic (less c B6), Rifampin c red urine, pyrizinimide c high uric acid (do not treat it, it will pass) and ethambutol with eye problems.
      239. PPD –Positive if: >5mm in HIV, steroid users, close contacts; >10mm in immigrants, health care workers (me!), >15 in pt c no risk facts. If PPD is positive, proceed to CXR, if (-) take INH

      for 9 months, if + get sputum AFB. If PPD is negative, repeat it in 1-2 weeks to rule out false negatives. If pt had PPD in the past that was +, don’t do PPD again (it will always be positive),

      go right to CXR.
      240. Endocarditis – fever and a murmur is key, h/o IVDA is s.aureas at tricuspid valve, #1 dx is blood culture (not ECHO), #2 dx is ECHO (TTE type, not TEE). For dental procedures (must be

      dental procedure c blood, cant be dental fillings) give amoxicillin or clinda if allergic, for GI/GU (strep bovis) procedure give amox + genta, or vanco + genta if allergic. Strongest indication

      for surgery is ruptured valve. So, 1st step is blood culture, 2nd step is start abx while waiting for results.
      241. Thrush – oral candida, removable white mouth patches (Candida CAN come off, hairy leukoplakia cant). Tx c nystatin mouth rinse.
      242. Lyme Disease –problems in joints, CNS (b/l bells palsy), heart (3 degree AV block). If its just a tick bite and no s/s, do nothing. If it’s a bite c lyme rash give amox (pregnant or kids)

      or doxy (not serology). If pt has b/l bells palsy get serology. If av block c cns s/s (except bells palsy) give ceftriaxone next.
      243. HIV – 1st ELISA, 2nd western blot (in kids, 1st is PCR). Peripheral neuropathy c stavudine/didanosine, anemia c zidovudine, rash c tmp/smx (start dapsone), nephrolithiasis c indinavir. MC

      overall adverse effect is increase lipids and glucose levels. Prophylaxis: <200 for PCP (tmp/smx), <50 MIA (azithromycin). What if pt finds out she has HIV during pregnancy? Continue all meds

      except effavirenz. When do you only continue c AZT? If she has high CD count, give it in end of pregnancy and to newborn for 6 weeks. If pt gets stuck c needs, start 2 nucleosides and 1 PI or 2

      nucleosides c effavirenz. Must you start tx if pt got splashed in eyes? Yes. Kissing? No.
      244. If pt is stuck c HBV needle, now has +HBsAg, what do you do? If vaccinated, do nothing. If not vaccinated, give IVIG + vaccine. If pt got stuck c HCV needle do nothing.
      245. How can you tell urethritis from cystitis? Urethritis has discharge. For both conditions, 1st step is swab, then stain, then DNA probe then tx. For urethritis tx GC (Ceftriaxone), for

      cervicitis, tx for Chlamydia (Azithro or Doxy)
      246. Genital ulcers and + Lymph could be syphilis, LGV or chancroid
      247. Syphilis – painless genital ulcer, skin rash (lata), CNS/aortitis. 1st step is Darkfield microscopy (not rpr/vdrl). DOC is penicillin. If allergic give doxycyline. If allergic and pregnant,

      desensitize c penicillin. If pt gets immediate allergic rxn to penicllin, give aspirin.
      248. LGV – painless ulcer c painful nodes. 1st step is serology (Chlamydia is culture negative), tx c doxycycline
      249. Chancroid – painful ulcer, 1st step is culture, tx c azithromycin
      250. Genital vesicles, next step is acyclovir (not Tzank because you already have dx), if resistant give foscarnet. When do you choose PCR? HSV in the brain.
      251. If they show or describe a vesicle (but don’t say vesicle), then do Tzank test
      252. If they describe or show warts, next step is remove (no tests needed).
      253. Septic Arthritis – 1st step is arthrocentesis (>50,000 wbc). If you suspect gonorrhea (look for tenosynovitis, rash or migratory polyarthritis), next step is culture pharynx, rectum,

      cervix, etc.
      254. Osteomyelitis – 1st step is xray (periosteal elevation), 2nd is MRI, 3rd is biopsy. When do you choose bone scan? If you cant do MRI (metal, pacemaker, hearing tubes, etc). After bx you can

      make dx: S.aureaus (nafcillin), MRSA (vanco, linezolid), E.coli (quinolones for bones) and then f/u ESR. When do you choose culture or sinus drainage? Never!

      RHEUMATOLOGY:

      255. Osteoarthritis – stiff, not red, not hot. DIP (Heberdens node), PIP (Bouchards), worse in PM (not in AM like RA). X-ray shows osteophytes and joint narrowing. Tx c weight loss 1st, then

      NSAIDS.
      256. Rheumatoid Arthritis – red, hot, swollen, fever, subQ nodules, +RF, pericarditis, pleural effusion, uveitis, long morning stiffness, swan neck, PIP/MCP (not DIP). Xray shows pannus. Tx c

      NSAIDS (1st if mild), methotrexate (1st if severe), 2nd is TNF (infliximab – r/o TB 1st), then steroids.
      257. Gout – podagra, tophi (subQ uric acid deposits c punched-out bone lesions), (-) birefrigent crystals, a/w alcohol/aspirin/HCTZ use. Tx: Acute: 1st c NSAIDS (Indomethacin), then colchicines,

      then steroids (1st if renal dz). Chronic: If oversecretor give allopurinol (allo for ppl who make a lot), undersecretors get propenecid.
      258. Pseudogout – calcium rhomboid shaped crystals, + birefringence, chondrocalcinosis, a/w 4 H’s (hemochromatosis, hyperparathyroidism, hypophosphatemia, hypomagnesemia). MC @ knees/elbows.
      259. Psoriasis – scaly skin lesions, finger clubbing, RF negative. Tx c NSAIDS, MTX
      260. Ankylosing spondylitis – HLA-B27 (not diagnostic), family hx, back pain, bent over (bamboo spine), worse c rest (key), better c exercise, dx c 1st Sacral X-ray (sacroiliitis). Tx c exercise

      and NSAIDS
      261. Reiters Synd – HLA-B27, can’t see (conjunctivitis), pee (uvieitis), climb a tree (arthritis). Tx c NSAIDS, eye drops, STD treatment.
      262. Behcet’s syndrome – 20-40yo c painful oral/genital ulcers and arthritis. Tx c steroids.
      263. Kawasaki’s – (FEEL My Conjunctiva – Fever >5days, Edema, Erythema, Lymphadenopathy, Myositis, Conjunctivitis). Next step is Echo (r/o coronary aneurysms). Tx c Aspirin + IVIG
      264. Takayasu arteritis – Chinese 30-50yo female c pulselessness on 1 side. Dx c angiogram of aortic arch (coronaries to r/o stroke). Tx c steroids, cyclophosphamide
      265. Wegeners – nasal (sinusitis), lung (hemoptysis, dyspnea), kidney (hematuria), c-ANCA, tx c cyclophosphamide
      266. Fibromyalgia – young female with pain all over, multiple points of tenderness, irregular sleep pattern, anxiety, exams all normal. Tx c antidepressant, NSAIDS
      267. Polymyalgia Rheumatic – old female c pectoral/pelvic pain/stiffness, elevated ESR, normal biopsy, a/w temporal arteritis. Tx c steroids.
      268. Polymyositis – 40-60yo female c proximal muscle weakness, elevated ESR/CPK, abnormal muscle biopsy, dx c 1st muscle biopsy, then EMG. Tx c steroids
      269. Dermatomyositis – same as above, but c rash (heliotrope rash around eyelid).
      270. Paget’s disease - >40yo male c pevic/skull damage, hats don’t fit anymore, deafness, paraplegia, bone pain, very high alk phos, normal calcium/phos, increased risk of osteosarcoma. X-ray

      shows thickened bones. Tx c NSAIDS, bisphophonates (Etidronate) and calcitonin.
      271. Herniated disk – most at L4-5 (weak big toe), and L5-S1 (reduced Achilles reflex), positive straight leg test.
      272. Carpal Tunnels – median nerve compression (thumb, pointer, middle finger), Tinnels sign (tapping wrist causes numbing), Phalens sign (flexing wrist), tx c rest, splint, workplace

      modifications, then NSAIDS.
      273. Osgood-Shlatter – inflammation of tibial tubercle in boys. Tx c rest and immobilization.
      274. Slipped Capital Femoral Epiphysis – Obese kid c painful limp. Dx c xray. Tx c surgical pinning >5yo.
      275. Legg-Calve-Perthes – non-obese kid c a limp (d/t avascular necrosis @ hip). Tx c observation and pain relief, 2nd is bracing, 3rd is surgery.
      276. Osteoporosis – risks include early menopause, alcohol, Caucasian, thin body, tobacco. Dx c DEXA >-2.5 (-1 to -2.5 is osteopenia). Tx 1st weight-bearing exercise, 2nd lifestyle (smoking,

      alcohol cessation), 3rd calcium/vit D, bisphosphonates, etc.
      277. Patellar tendonitis – an NBME 3 test question, aka jumper’s knee, patellar tenderness due to overuse and jumping sports resulting in quadriceps contraction. Tx c rest, nsaids, quadriceps

      stretching.
      278. Osteosarcoma – 10-25yo c knee pain, mass, limping, high alk phos. X-ray c sunburst appearance. Tx c surgery and chemotherapy
      279. Osteoid Osteoma – bone pain worse at night and relieved c NSAIDS. Tx c nsaids
      280. Osteochondroma – bone pain, xray shows pedunculated metaphyseal tumor at distal femur. Tx c surgery.
      281. Ewing sarcoma – fever, pelvic/femur bone pain, swelling, xray shows onion skinning. Tx c radiation, chemo, surgery.
      282. Reflex Sympathetic Dystrophy – burning pain, skin changes (color/temp), edema in a pt who had prior injury to that area. Tx c pain management (hard to do).
      283. Nursemaids Elbow – from pulling your childs arm, he develops severe pain at elbow and will not use that arm. Tx c pushing back the head of the radius while the arm is supinated and flexed.

      Kid will feel much better immediately.

      NEUROLOGY:

      284. Migraine HA – 70% unilateral, throbbing, aura, photophobia, family history, possible risk of stroke, worse c OCPs/EtOH/chocolate. Tx c NSAIDS, triptans (contraindicated in heart disease),

      ergots. Prevent c BB 1st, cab’s 2nd, sodium valproate/SSRI/TCAs.
      285. Cluster headache – same time every month/year, males mostly, tearing, redness, pain, rhinorrhea, feels like an ice-pick is shoved in your eye (old question). Tx c 100% oxygen 1st, steroids

      2nd.
      286. Temporal Arteritis – >50yo c unilateral temporal HA, scalp tenderness, vision changes, high ESR. 1st step is give steroids, 2nd step temporal artery biopsy.
      287. Pseudotumor Cerebri – aka Benign Intracranial HTN – increased ICP, HA, visual changes, obese female, papilledema, no focal CNS findings, a/w vitamin A toxicity. Dx c MRI 1st then LP 2nd,

      tx c azetazolamide.
      288. Trigeminal Neuralgia – pain whenever you touch your face @ 5th cranial nerve distribution. Tx c carbamazapine. Definitive treatment with surgical rhizotomy.
      289. Essential Tremor – at rest and motion. Tx c propranolol. (Tremor at rest only is Parkinson’s or hyperthyroidism, tremor c motion only is cerebellar dysfunction)
      290. Nystagmus/Vertigo – if + focal defecits, the problem is central (vertical nystagmus): cerebellum (CT/MRI), M. Gravis (MRI), Stroke (MRI/CT), phenytoin without an hearing loss or tinnitus.

      If no focal defecits, the problem is peripheral (in the ears), so pt will have hearing loss and tinnitus. If pt only has vertigo, its benign positional vertigo. If pt has hearing loss and tinnitus

      with it: Miniere’s disease (chronic disease), Acoustic Neuroma (look for ataxia), Labyrinthitis (acute viral infxn)
      291. Epilepsy (as per Kaplan on what is important): do not treat 1st time seizures unless there is a family history, EEG is positive or pt has status epilepticus.
      292. Status Epilepticus – Dx: 1st sodium, 2nd glucose, 3rd calcium, 4th hypoxia, toxicology, CT-head, EEG (last!). Tx: 1st Benzo (lorazepam IV), 2nd Phenytoin, 3rd Barbiturate, 4th Anesthesia

      (succinylcholine/propofol – these will just stop the shaking, wont stop the seizure).
      293. Absence seizures – kid stares into space, doing poorly in school, eye blinking, lip smacking, EEG c 3/sec spike and wave pattern. Tx c ethosuximide.
      294. TIA – focal, abrupt onset lasting less than 1 hour, symptoms resolve after 1 day. Risk of stroke in days to weeks. Amorosis fugax (curtain over an eye due to retinal dysfunction) needs

      Doppler U/S of carotids or MRA. Give heparin acutely (if no contraindications), then long term aspirin. If stenosis >70%, amaurosis fugax/TIA or small, non-disabling stroke do CEA (carotid

      endarterectomy) and give aspirin. If stenosis <70%, severely disabling stroke, or TIA/stroke in evolution give daily aspirin alone.
      295. CVA – 1st test is CT without contrast (although, if ischemic, it will show negative), 2nd is MRI. Heparin is not given until hemorrhagic stroke is ruled out. If ischemic, give tPA’s if

      less than 3 hours of onset. If hemorrhagic, control BP and ICP.
      296. Ischemic Stroke Locations: MCA – contralateral hemiplegia, hemianopsia, Broca’ s (nonfluent, babbling)/Wernicke’s (fluent but doesn’t make sense) aphasia. ACA – contralateral leg

      paralysis, sphincter incontinence (they cant kick you, so they pee on you); Posterior – cortical blindness, hemianopsia; Vertebrobasilar – ataxia, horizontal gaze, nystagmus; Cerebellar –

      ataxia and dizziness; As for hemorrhagic, remember that in the thalamus its only sensory loss, in the pontine/internal capsule/putamen its only motor loss.
      297. Multiple Sclerosis – insidious onset of CNS s/s in a woman aged 20-40 with exacerbations and remissions of numbness, parasthesia, weakness, optic neuritis, gait disturbance, incontinence

      and emotional/mental status changes. Look for classic b/l internuclear opthalmoplegia (lesion @ MLF so you cannot adduct in horizontal gaze) and scanning speech. Babinski may be positive. Entirely

      CNS (M.gravis and G-Barre are entirely PNS). 1st step is MRI, 2nd test is LP (oligoclonal bands). Tx acute exacerbation c steroids. Prevent next attack c ABC (Avonex (Inf-B), Betaseron (Inf-B) and

      Copaxone (Glatiramer acetate)). If stuck in 1 position all day, give baclofen or Tizanidine. If incontinent give oxybutinin or bethanacol.
      298. Guillain-Barre Syndrome – h/o URI of GI infection (campylobacter jejuni) or immunization 1 week before develops onset of symmetric, assending progressive weakness or paralysis and loss of

      DTRs. 1st step is PFTs (MCCOD is respiratory dysfunction due to paralysis, so monitor the pt’s NIF (negative inspiratory force) and if it keeps decreasing, consider intubation). Most accurate

      test is EMG. When do you choose LP? Last (shows elevated CSF protein). Tx c IVIG or plasmapheresis (not steroids!).
      299. Myasthenia Gravis – Ab against Ach receptors in women 20-40yo. Look for ptosis, diplopia, difficulty swallowing and weakness c repetition (at the end of they day they are exhausted). Best

      initial test is Ach Ab (NOT edrophonium test, which is 2nd or if they already mention the Ach Ab). Most accurate test is EMG. Tx Myasthenia crisis (breathing problems) c D/C anitchonergics and

      give IVIG and Plasmapheresis (NOT steroids). Tx for chronic disease: <60 gets thymectomy (do CXR, Chest CT), >60 gets neostigmine and steroids, then azathiopine/cyclosporine/tacrolimus. What abx

      is contraindicated? Aminoglycosides.
      300. Eaton-Lambert – Ab against presynaptic calcium channels causing limb weakness that gets stronger c repetitive stimulation (opposite of gravis),no loss of DTRs or extraocular manifestations,

      a/w small cell lung cancer, tx c guanidine. (cab’s are contraindicated).
      301. Neurosyphilis – tertiary treponema pallidum disease. Treat c high dose penicillin. After giving penicillin, pt may develop hypotension, fever, HA, chills and tachycardia within 24 hours of

      treatment due to treponemal products (Jarisch-Herxheimer reaction, this is not a penicillin reaction). Tx c aspirin.
      302. Myotonic Dystrophy– 20-30yo guy grabs something and cant let go (impaired relaxation) d/t mutations in chloride channel. Tx c phenytoin.
      303. Duchenne Muscular Dystrophy – XLR, boys 3-7 have muscle weakness, very high CK, calf pseudohypertrophy, Gower’s sign (kid climbs his legs to stand, look at it in google videos its so

      sad). Kid is in wheelchair by teenager and dead by 20. Dx c muscle biopsy.
      304. Mitochondrial Myopathy – aka Lever’s hereditary optic atrophy – every mom gives to all overspring (no male transmission). Look for ragged red fibers on biopsy.
      305. Botulism – infant ingests honey and develops floppy baby syndrome. 1st step is intubate if needed, 2nd step is antitoxin. Spontaneous recovery in 1 week.
      306. Amyotrophic lateral Sclerosis – aka Lou Gehrig’s dz – 55yo male upper (spasticity, hyperreflexia, babinski) and lower motor neuron (fasciculations, atrophy, flaccidity) problem. Only

      motor problems, no sensory/sexual/bowel problems. Tx c Riluzole.
      307. Huntington’s Disease – AD (father had it, you have it at a younger age) c CAG repeats, chorea, personality change, psychiatric syndromes, progressive dementia. Dx c CT/MRI showing caudate

      nucleus and cerebral cortex atrophy, causing decreased Ach and GABA (thus causing increased dopamine). Tx c antipsychotics (haloperidol) When you see a movement disorder, dementia and emotional

      problems, think of Huntington’s. When you see dementia and emotional problems (no chorea), pick Pick’s disease.
      308. Parkinson’s – 60yo c extrapyramidal movement disorder (pill-rolling resting tremor, cogwheel rigidity, shuffling gait, bradykinesia, masked facies). Caused by loss of dopaminergic neurons

      in substantia nigra. Tx: Mild s/s (can still take care of themselves): <60yo c Anticholinergic (cabergeline/benztropine/trihexylphenidyl), >60yo c Amantidine. If Severe s/s: 1st Levo/Carbidopa,

      2nd is DA agonist (primapexole, ropinirole, pergolide), 3rd COMT-inhibitors (Talcopone), 4th MAOI (selegiline). Some antipsychotics (haloperidol, risperidone, MPTP) can cause parkinson-like

      symptoms, tx c anticholinergics (benztropine/ trihexylphenidyl/ cabergeline). Young guy c Parkinsonism, but not on meds, think of Wilson’s disease.
      309. Alzheimer’s – progressive dementia (memory, language, visuospatial, mood, hallucinations, personality/behavior) in mid-late life. a/w Down’s syndrome (amyloid precursor protein). Dx c

      MRI showing cortical atrophy, senile plaques, neurofibrillary tangles. Tx c donepezil, rivastigmine and galantamine to increase Ach just in brain.
      310. Pick’s – early aged (40) personality change, dementia. CT/MRI shows frontetemporal atrophy, argyrophilic neuronal (Pick) bodies in frontal and temporal lobe, sparing superior temporal

      gyrus (generally no memory problems).
      311. Multi-infarct Dementia – stepwise dementia in a pt c bad medical history (HTN, DM, etc.). They will describe the pt as progressively getting worse, little-by-little. Dx c PET/SPECT scan

      showing multifocal decreases in cerebral blood flow. Tx c aspirin
      312. Normal Pressure Hydrocephalus - “wet, wacky, wobbly” (incontinent, dementia, ataxia). Dx c CT scan, tx c ventriculoperitoneal shunt.
      313. Creutzfeldt-Jakob - young guy c rapidly progressive dementia, myoclonus due to abnormal isoform of prion protein. Dx c biopsy (nothing else). No treatment.
      314. Narcolepsy – daytime sleep attacks c cataplexy, hynogogic (going to sleep)/hypnopompic (waking up) hallucinations, sleep paralysis. Rapid onset of REM sleep. Tx c amphetamines for

      sleepiness, clomipramine for cataplexy.
      315. Obstructive sleep apnea – overweight, HTN, arrhythmia, gasping for air. Dx c polysymnography. Tx c CPAP.
      316. Central sleep apnea – old, non-obese pt c loss of respiratory drive. Tx c azetazolamide.
      317. Epidural Hematoma - + head trauma, + HA, + LOC, lucid intervals after brief LOC followed by increasing obtundation, middle meningeal artery. Dx c CT without contrast showing convex hematoma.

      Tx c 1st hyperventilate and elevate head, 2nd evacuate, 3rd mannitol
      318. Subdural Hematoma - +head trauma, + HA, + LOC, bridging veins injured, can be acute (CT showing concave or crescent-shaped hematoma), days (MRI), or gradual deterioration (MRI). Tx c same as

      above.
      319. Subarachnoid Hemorrhage - +HA, + LOC, no head trauma, spontaneous, sudden onset of meningitis (stiff neck, photophobia, kernig’s, brudzinski), worst HA of my life, a/w polycystic kidney

      disease, CSF c blood. Best initial test is Head CT, most accurate test is LP. Tx supportively (bed rest, analgesia)
      320. Concussion – + head trauma, + LOC, no focal CNS defecits. Tx – go home.
      321. Contusion – + head trauma, + LOC, blood/bruise on head. Tx – go home.
      322. Neuroleptic malignant syndrome – high temperature, muscular rigidity, confusion, high CPK, high K+, no sweating, tx c IV dantrolene or bromocriptine.
      323. Malignant hyperthermia – high temperature, confusion, high CPK, high K+, no sweating, h/o anesthesia (halothane). Tx c IV dantrolene
      324. Heat Stroke – high temperature, confusion, no sweating, normal CPK, normal K. Tx c fanning them (don’t overcool them) and water.
      325. Closed-angle Glaucoma – sudden eye pain, n/v, vision loss. Tx c surgical iridectomy
      326. Open-angle Glaucoma – progressive peripheral vision loss, disc cupping, no pain. Treat with bb (timolol), acetazolamide, eye drops and prostaglandins (latanoprost).

      Growth/Development/ Preventative Medicine:

      327. Gestational Age – fundus at pubic symphysis @ 8 wks, above symphysis @ 14wks, umbilicus @ 20wks, xiphoid @ 38wks.
      328. Naegele’s rule – assuming 28 day cycle, subtract three months, add 7 days (if more than 28 days, add the remaining days to the 7)
      329. Infant size – gains back birth weight by 2 weeks of age, double weight by 6 months, triples weight by 1 year.
      330. Lactation – estrogen makes mammary duct tissue grow, progesterone stimulates alveolar glands. Postportum, they both drop, prolactin increases (inhibiting ovulation) and oxytocin, via nipple

      stimulation, allows milk letdown. Contraindicated with HIV, CMV or certain meds.
      331. Newborn care: “Caput succedaneum” is a hematoma across the suture line, caphalohematoma is a hemotoma that does not cross the suture line. Mongolian spot is a bluish discoloration at the

      sacrum, always benign (do not assume abuse). Check for red eye reflex (r/o retinoblastoma and congenital cataracts), Orolani/Barlow maneuver (r/o DDH), abdm masses (ARPKD, Wilm’s tumor,

      neuroblastoma, umbilical hernia (r/o hypothyroidism))
      332. Development: 1 month – head lag/social smile; 3 months – lifts head, 6 months – rolls over/sits up alone/stranger anxiety, 9 months – crawls/takes steps if hands held, 12 months –

      walks if you hold one hand, speaks three words; 15 months – walks alone/separation anxiety, two-block tower; 2yo – six cube tower/poison-proof home.
      333. At 4 years old, must get objective hearing and visual exam.
      334. Puberty: Females sequence (estrogen): ovary growth, breat bud, growth spurt, then pubic hair. Male sequence (testosterone): testicular growth, growth spurt, then pubic hair.
      335. When to keep child-physician confidentiality? Drugs, EtOH, OCP, STD prevention.
      336. OCP – Barrier Method (condoms help prevent STDs, diaphragms might be annoying to prepare, thus inhibiting use), hormonal contraceptives (combined est/prog (safe, effective), minipill (more

      pregnancy/bleeding), or injectable and implanted progestins), vaginal spermicides, IUD, surgical sterilization.
      337. #1 stressor is death of a spouse, # 2 is divorce.
      338. Normal Aging: cardiac (decreased CO), musculoskeletal (decreased bone mass), pulmonary (decreased strength and compliance), immunity (thymus involution), senses (decreased visual, auditory,

      tactile and taste), endocrine (decreased insulin-secreting cells, glucose intolerance), mental (decreased memory, learning ability and calculation speed).
      339. Exceptions to informed consent: emergency, imcompetent pt, minors.
      340. Influenza - >50yo, high risk (COPD, cardiovascular, renal), women who WILL become pregnant in winter, household contacts of high-risk pt (to protect the high-risk pt). Pneumococcal - >65,

      comorbidities.
      341. Formulas: [A = True Positive; B = False positive; C = False negative; D = True Negative] (positives always on top) Sensitivity = TP/TP+FN; Specificity = TN/TN+FP; PPV = TP/TP+FP; NPV =

      TN/TN+FN; Attributable risk (attrib = subtract) = (a/a+b) – (c/c+d); Relative risk (only for propective studies like cohort study)= (a/a+b) / (c/c+d); Odds ratio (only for retrospective studies

      like case-control) = ad/bc; attack rate (how many ppl get attacked c dz) = a+c/b+d.
      342. Power = rejecting the null when its false (a good thing, like saying Viagra does not treat constipation, which it doesn’t do). However, sometimes FDA may not always make the right choice

      and end up approving something that doesn’t work, or not approving something that works. Type 1 error – rejecting the null when it’s true (saying Viagra does not treat erectile dysfunction).

      Type 2 error = acceptance of the null hypothesis when it is false (saying Viagra treats constipation). Generally, the only way to increase power is to increase the sample size.
      343. Mean = average; Median = middle #, Mode = MC #.
      344. Confidence Interval = [mean +/- Z score x standard error of mean], where Z is the standard score (If confidence interval is 95%, Z is 2, if CI is 99%, Z is 2.5) and standard error of mean is

      (S / square root of N), where S is the standard deviation and N is the sample size. For example, old TQ said the mean was 67%, standard deviation was 8% in a sample size of 16, calculate a 95% CI:

      (67 +/- 2 (8 / square root of 16) = (67 +/- 2 (8/4)) = 64 +/- 4. The answer was 63-71.
      345. When they give you a chart with different confidence intervals, just look for the one that has 1 within the range (ie. 0.89-2.3, not 1.12-2.25 or 0.56-0.93). That one is NOT statistically

      significant, meaning the risk is the same. If 1 is not within the range, is is statistically significant. If it was over 1 (1.12-2.25 used above), there is an increased risk. If it was under 1

      (0.56-0.93 used above), there is a decreased risk.
      346. When given statistical scales and asked for the statistical test: Nominal is categorical (how many you can split into groups, like genders, ethnicities, etc), Interval is a measurement

      (height, wt, BP, etc.). Pearson correlation = 2 intervals; Chi-square = 2 nominals; t-test = 1 nominal + 1 interval. For example, if you want to find out if men do better than women on step 2. Men

      vs women is nominal, Step 2 is an interval, therefore one of each makes it a t-test.
      347. If given the following data: After surgery: 90% survive 1year, 75% survive 2years, 50% survive 3years, 40% survive 40%, and asked: what is the life expectancy after surgery? Always pick

      closest to 50%, so the answer would be 3 years. If asked, if a pt survives 2 years, what is the chance of surviving 3 years? Always put the # ending on top, # starting on bottom, so it will be

      50/75, or 67%.
      348. Cohort study (think – Cohort to Go Forth) – a prospective study where people are followed for a period of time. Advantages are that incidence (# of new cases) can be determined, there is

      an accurate relative risk (remember RR with cohort), and less control group bias. Disadvantages are that it takes too long, expensive, the sample size can get too large, and you might run into an

      ethical problem.
      349. Case-control study – a retrospective study where you start with an outcome and then check backwards to evaluate the risk or cause. Advantages are that it’s cheap and easy, small sample

      size and minimal ethical risk is involved. Disadvantages are that incidence (new cases) are not determined, RR is just approximated (not exact, just taking odds, remember OR c case-control) and

      that there is some control group bias. Kaplan says, if you have no idea which type of study it is, pick this one.
      350. Confounding bias – when hidden factors affect the results. For example, an experimenter measures the # of ashtrays owned and incidence of lung cancer and finds that people c lung cancer

      have more ashtrays. He or she then concludes that ashtrays cause lung cancer. Smoking is the confounding bias here, because it increases both ashtrays and lung cancer. So how can you prevent this?

      Do multiple studies.
      351. Lead-time bias – when you confuse the facts that early screening will increase life expectancy. Look for false estimates of survival rates. For example, if I diagnosed you with cancer at 18

      and you lived until 30, you will think I treated you for 22 years. However if I didn’t diagnose you until 25 and didn’t treat you after, and then you lived until 30, you will think that you

      only survived 5 years. The difference is not that my drug treats you better, but that I am diagnosing you earlier, thus getting a good lead on time. The solution here is to measure the

      “back-end” survival (ie. Getting the age 30 as the age that they both die at, whether they were treated or not).
      352. Recall bias – subjects can’t remember events in the past. Solution is to make them confirm information with other sources.
      353. Late-look bias – subjects die before the end of the survey, so your information gets distorted. For example, a survey finds that AIDS pts only get mild symptoms. This is wrong because they

      die before the really bad symptoms occur. Solution here is to stratify the disease by severity.
      354. Experimenter/Interviewer bias – aka Pygmalion effect - when the experimenters expectations are inadvertently communicated to subjects, who then produce the desired effect. Solution is to

      make the study a double-blind one.
      355. Selection bias – aka sampling bias – when the sample selected is not a representative of the population. For example, taking the people from a health club and doing a survey on the lungs

      in the general population. Another cause is when a study uses hospital records to estimate population prevalence (Berkson’s bias). For example, a doctor says all the people in NY are sick

      because all day he works with sick patients in NY.
      356. Measurement bias – aka Hawthorne effect – when being observed makes you change how you answer to questions. Also, when the way the information is presented makes you answer in a certain

      way. For example, asking a pt “you don’t like your doctor, do you?” The pt is likely to say no because of the way the question was presented. In the law world, its termed “leading.”

      Prevent this by having a control/placebo group.

      ________________________________________________________________________

      OB:
      357. Numbers to note: How many weeks in each trimester? 13; what is so special about 37 weeks? Lungs are muture b/c lethicin/sphingomyelin ratio is 2:1; what is the risk of having Down’s if mom

      is 35? 1/350; risk @ 40? 1/100; risk @ 45? 1/50, so you absolutely must recommend amniocentesis. Pregnancy weight gain is about 25 pounds (5 in first 20 weeks, 1 pd every week after). Uterine

      height: 8 weeks @ iliac, 14 weeks @ pubic symphisis, 20 weeks @ umbilicus, 38 weeks @ xiphoid process.
      358. Dates to note: 6-8wks is prenatal workup. 15-18 weeks is triple screen. 18 weeks is ultrasound. 26 weeks is glucose challenge test for DM. 35 weeks is GBS culture.
      359. Diagnostics: Ultrasound (noninvasive, no adverse effects, done at 18-20 weeks), Chorionic villus sampling (“CVS,” invasive, done at 9-12 weeks, best for early gestation so mom has the

      chance to choose an abortion, may be fatal, f/u c triple screen after), Amniocentesis (done at 15-20 weeks for genetic purposes or high risk patients, done at 24 weeks for Rh isoimmunization, done

      at 34 weeks for gestation age, pregnancy loss about 0.5%)
      360. Diabetes workup: Done at 24-28 weeks in normal pt. Done c prenatal workup (6-8 weeks) if pt is obese or has h/o macrosomic baby, h/o DM or family h/o DM. The pt will come to your office

      fasting for 1 hour, her blood sugar should be >140. If <140, get her fasting glucose (should be <90) and proceed to a 3 hour 100g glucose tolerance test: 1hr <180, 2hr <155, 3hr <140.
      361. Embryology: Week 1 – implantation, week 2 – 2 layers formed (epiblast and hypoblast) and b-hCG is produced by syncytiotrophoblast, week 3 – 3 layers formed, week 4 – major organs

      formed. Note that weeks 3-8 are the period of greatest teratogenicity.
      362. Teratogens: Infections (TORCH), Radiation (>20 rads), Chemotherapy (In first TM, cant give MTX, Adrinomycin), Environmental (smoking causes IUGR, alcohol causes microcephaly, flat philtrum,

      thin upper lip), Recreational drugs (cocaine causes placental abruption and intraventricular hemorrhage, marijuana causes prematurity), Medications (DES (vaginal/cervical cell CA), Dilantin

      (gingival hyperplasia, nystagmus, craniofacial dysmorphism), Warfarin (Stippled epiphysis), Isoretinoin (deafness, CNS), Lithium (ebstein anomaly), Streptomycin (CN 8), Tetracycline (black teeth),

      Thalidomide (small limbs), Valproic acid (spina bifida)).
      363. B-hCG – 3 purposes: maintains corpus luteum (which keeps making progesterone) until placenta takes over at 9th week, regulates steroid production, stimulates testosterone production in

      fetal male testes. Levels may be too high (incorrect dates (MC), twins, hydatidiform mole, choriocarcinoma, ebryonal CA) or too low (incorrect dates (MC), ectopic, threatened/missed abortions). If

      levels are high or low, next step is to recheck the dates.
      364. Human Placental lactogen (HPL) – chemically similar to GH and prolactin, thus antagonizing insulin which will contribute to gestational diabetes if too high.
      365. Estrogens: Estradiol (nonpregnant reproductive years, made from granulose cell from testosterone via aromatase), estriol (pregnancy, made from DHEA via sulfatase in the placenta), estrone

      (menopause, made from adrenal adrostenedione in adipose).
      366. Changes in pregnancy: Skin (striae gravidarum (stretch marks), chadwick’s sign (bluish cervix), linea nigra, chloasma. Note the only cancer that increases c pregnancy is melanoma), CVS

      (decreased BP in 1st TM, highest CO in L lateral decubitus position, systolic ejection murmur is normal, diastolic murmur is abnormal), GI (progesterone causes increased salivation, gum

      hyperplasia, GERD/aspirations, decreased gastric motility, constipation), pulmonary (generally, most increase except tidal volume causing resp alkalosis), renal (increased GFR, decreased BUN/Cr,

      decreased uric acid, glycosuria is normal, proteinuria is not), pituitary (size increases, contributing to possible Sheehan’s syndrome), thyroid (increase in TBG and total T3/T4, not free T3/T4

      thus not causing s/s of hyperthyroidism, blood (increase RBC/WBC, normal platelets. Note low platelets c HELLP syndrome d/t preeclampsia, MCC of anemia is iron deficiency, then folate deficiency).
      367. Prenatal workup: done at 6-8 weeks. Check CBC, UA (r/o asymptomatic bacteruria where >1000 E.Coli will be found, treat c ampillin or nitrofurantoin if allergic), Rubella (worst at 1st TM),

      RPR, HBV, Rh blood typing, sickle cell prep (if (+), proceed to Hb electrophoresis). If pt is a teenager, do Chlamydia and gonorrhea cultures.
      368. Triple Screen – AFP, hCG, estriol (currenty inhibin-A makes for quad screen). If AFP is low, think of Down’s/Edwards synd. If AFP is high think of NTDs, gastrocele, omphalocele. Again, if

      AFP is high/low, next step is to get vaginal u/s to check dates. If dates are correct and U/S is non-explanatory (did not show nuchal fold thickening of Down’s), get amniocentesis for karyotype,

      amniotic fluid-AFP and acetylcholinesterase activity (both high in NTD). Down’s syndrome – high hCG, low AFP, low estriol. Edwards syndrome – all 3 are low.
      369. Mom says she doesn’t feel the baby move anymore. Next step is U/S. If it shows fetal cardiac activity, get non-stress test. If it doesn’t show fetal cardiac activity, this is fetal demise

      and the next step is D&E AT 12-16wk (not D&C (<12wk), not C/S, induce labor <16wk) followed by cervix/placental culture, autopsoy, karyotyping and total body x-ray (r/o osteochondroplasia).

      Non-stress test (done in high risk, or if pt says she doesn’t feel the baby move anymore): reactive is good (2 accelerations in 20 minutes), nonreactive is bad (<2 accel/20 minutes)
      370. Nonstress test (NST): if reactive baby is ok (monitor). If non-reactive, baby may be sleeping or in danger, so do vibroacoustic stimulation (VAS) and repeat NST. If NST is now reactive, baby

      was sleeping and is now ok (monitor). If still non-reactive, get a Biophysical profile (BPP) c U/S. If BPP is 8-10, baby is ok (repeat in 4 days); if BPP is 6-4, do a stress test (check for

      decelerations). If BPP is 0-2, deliver immediately.
      371. BPP – measures 5 components (each worth 2): NST, amniotic fluid volume (normal is 5-15,<5 is oligohydramnios, >15 is polyhydramnios), fetal gross body movements, fetal extremity tone, fetal

      breathing movements.
      372. Stress test – checks for decelerations. Go in order (head, then cord, then placenta). Early deceleration means head compression, Variable deceleration means cord compression, Late

      deceleration means utero-placental insufficiency. Treatment for decelerations in a stress test: 1st D/C oxytocin, 2nd Give oxygen and fluids, 3nd position her to L lateral decubitus position, 4th

      get scalp pH (normal 7.25 – 7.4, if <7.2 go right to C-sxn).
      373. Group B Strep (GBS) – not a disease or pathogen to the mother, but if transmitted to the newborn during delivery can cause pneumonia, sepsis or meningitis. Prophylaxis c IV penicillin G (if

      allergic, give clinda, erythro of cefazolin) is given for +GBS culture @ 37 weeks, h/o previous child c infection, preterm gestation (even if culture negative), PROM >18 hours (must give enough

      time for penicillin to reach fetus), or maternal fever.
      374. Toxoplasma gondii – cat feces, raw goat milk, undercooked meat. Worst in 2/3rd TM. In neonate it can cause seizures, in fetus look for intracranial calcifications. Tx c

      pyrimethamine-sulfadiazine.
      375. Varicella – kid c “zigzag” lesions (due to nerve distribution), cataracts, chorioretinitis. Worst if mom has the pruritic vesicles 5 days antepartum-2 days postpartum. Prevent c VZIG 96

      hours prior to birth. Tx c acyclovir.
      376. Rubella – worst in 1st TM. Prevent 3 months before conceiving. Look for triad: deafness, cataracts and PDA. Sometimes “blue-berry muffin” rash. No treatment.
      377. CMV – look for cerebral calcifications, deafness and microphthalmia. Blood shows intranuclear inclusions. Tx c ganciclovir, or foscarnet if resistant.
      378. Syphilis – Dx c darkfield microscopy (rpr/vdrl may be negative until secondary disease). Child will have Hutchinson’s teeth, saber shins, saddle nose and 8th cranial nerve deafness. Tx c

      Penicillin, if allergic then desensitize penicillin.
      379. HSV – if vesicular lesions are present in vulvar area at time of delivery, do C/S. If lesions are only on legs, none of vulva/labia, cover with towel and proceed c vaginal delivery (never

      done in real world). If history of lesions of culture 1 week before delivery, do C/S.
      380. Hepatitis B – worst in 3rd TM. If mom has +HBsAg, next step is to get LFT’s (if high, she has active disease, if normal she may just be a carrier). Upon delivery, give baby vaccine and

      HbIG within 12 hours of birth. Give mom Inf-a c lamivudine.
      381. HIV – ELISA then western blot. If (+), get viral load and CD-4 count. If viral load >1000 or CD <500, give all the drugs except efavirenz. If CD>500, only give AZT throughout pregnancy

      (starting at 14 weeks) and 6 weeks postpartum. After 6 weeks, dx HIV c PCR (cant use ELISA yet). Mom must avoid breastfeeding.
      382. 4 big causes of 1st TM bleeding: Incomplete/Complete abortion, Threatened abortion, Ectopic pregnancy, Mole. Use Apt test to make sure blood is from fetus, not from mom.
      383. 1st TM bleeding: 1st step is speculum exam. If cervical os is open, pt had an incomplete/complete (depending how much products of conception passed), next step is D&C. If cervical os is

      closed, next step is vaginal U/S c hCG. If vaginal U/S shows an intrauterine pregnancy, pt had a threatened abortion, next step is bed rest. If vaginal U/S shows no intrauterine sac and hCG >1500,

      pt has an ectopic pregnancy and the next step salpingostomy or MTX treatment followed by serial hCG levels until zero. If vaginal U/S shows a snowstorm appearance, pt has a mole and the next step

      is D&C followed by serial hCG levels to zero (also put pt on OCP’s to prevent birth, which would increase hCG and not be able to allow you to monitor hCG appropriately).
      384. Ectopic – amenorrhea, vaginal bleeding, abdm pain, hCG>1500, no IUP on vaginal U/S. If unstable c peritonitis, do laparascopic salpingectomy. If stable and does not want surgery, give

      methotrexate and follow-up hCG levels until zero.
      385. Mole – preeclampsia before 3rdTM, very high hCG, in 1st TM you will see expulsion of grapes and a uterine size that’s too big for gestation age. Vaginal U/S shows snow-storm appearance.

      Complete (46XX, all from dad) have no fetal tissue, incomplete does. Tx c D&C and f/u hCG while pt is on OCP’s. If hCG still doesn’t fall, pt has choriocarcinoma and needs MTX and actinomycin.
      386. 3rd TM bleeding: 1st step is ultrasound (absolutely not pelvic exam). Possible choices are placenta previa, vasa previa, abruption placenta, uterine rupture.
      387. Placenta previa – painless bleeding c ultrasound showing placental implantation over the lower uterine segment. Pt may say she woke up in a pool of blood. Treatment: If preterm gestation,

      pt is stable and bleeding stops: 1st admit, then bedrest, get vital signs/labs, transfuse if needed and put on steroids (for lung maturity) c magnesium sulfate. If pt is >37 weeks, do C-section

      (whether she is still bleeding or not).
      388. Vasa previa – look for triad: rupture of membranes (gush of fluid), bright red painless vaginal bleeding and fetal bradycardia. Next step is C-section.
      389. Abruptio placenta – painful vaginal bleeding (if bleeding stops, it may be collecting in retroperiteal area), uterine tenderness and increased uterine tone with hyperactive contraction

      pattern. May even cause DIC. If mild to moderate, give fluids and deliver vaginally. If severe, pt will have acute abdm (rock hard) c profound hypotension, next step is immediate C-section.
      390. Uterine rupture – sudden abdm pain c profuse vaginal bleeding and abnormal fetal heart rate. Treat c immediate C-section and then uterine repair if mom wants kids in future, or hysterectomy

      if she doesn’t.
      391. Rh Isoimmunization – mom is Rh(-), dad is Rh (+), second baby is affected c erythroblastosis fetalis. Prevent c RhoGAM at 28 weeks and 72 hours of delivery, D&C or CVS. If mom already has

      Rh antibodies, RhoGAM is useless (only for prevention) and so the next step is to get Rh titers. If >1:8, do amniotic fluid spectrophotometry to assess severity of hemolysis.
      392. Premature rupture of membranes – sudden gush of fluid. Next step is fern test, nitrazine test. Risk of chorioamnionitis (maternal fever, uterine tenderness, PROM, culture/gram stain

      amniotic fluid, treat c ampicillin while awaiting results and if (+), deliver). Management: if infection present, deliver. If no infection present and fetus is <24 weeks, outcome is dismal (induce

      labor c bedrest at home). If baby is 24-35 weeks c no fever, hospitalize, IM betamethasone, Cx, Abx. If baby is >36 weeks, prompt vaginal delivery.
      393. Preterm Labor – must have cervical change >2cm (if none, pt has false (Braxton-hicks) contractions and send her home). MC risk factor is previous preterm labor. Dx c fetal fibronectin (if

      +, tocolytics and steroids, if (-), send home). Management: 1st L lateral decubitus position, bed reast, O2 and IVF. 2nd Start tocolytics (useless >4cm dilatation, r/o contraindications first),

      get cervical/urine culture before giving IV Pen G (for GBS), IM betamethasone and send home.
      394. Tocolytics – 1st Mg Sulfate (calcium blocker that may cause resp depression, loss of DTRs and pulmonary edema. If so, give IV calcium gluconate). 2nd Ritodrine/Terbutaline (B-adrenergic

      agonists that may cause hypotension and tachycardia so don’t give in pt c heart disease or DM). 3rd Nifedipine (calcium blocker that may cause hypotention). 4th Misoprostol (prostaglandin

      inhibitor that may cause in utero ductus arteriosus closure, so don’t give if gestation age >32 weeks). Some contraindications to tocolytics include (conditions where you may need to deliver)

      abruption placenta, ROM, chorioamnionitis, fetal demise, late decelerations, eclampsia, severe eclampsia and cervical dilatation >4cm.
      395. Post-date pregnancy (>40wk): complications include increased perinatal mortality, macrosomia, need for c-section, dysmaturity syndrome (mother’s support runs out). 1st step is to check

      dates (if dates still unsure, continue c conservative treatment and biweekly NSTs), 2nd step is induction of labor. If cervix is favorable (soft), begin aggressive tx c oxytocin and artificial

      ROM. If cervix is unfavorable (hard), give prostaglandins c oxytocin and wait for spontaneous delivery.
      396. Transient HTN – unsustained high BP without proteinuria or edema. No tx.
      397. Chronic HTN – high BP before 20 weeks gestation. Tx c methydopa, hydralazine.
      398. Mild preeclampsia – mild HTN (140/90), petal edema, 2+ proteinuria after 24 weeks gestation. Management: <36 wk – conservative (no meds). >36 wk – deliver
      399. Severe preeclampsia – sustained BP >160/110, >3+ proteinuria, edema, epigastric pain, HA, blurred vision, thrombocytopenia (r/o HELLP synd). Tx: prompt vaginal delivery c oxytocin, MgSO4

      (to prevent convulsions) and IV hydralazine/lobetolol.
      400. Eclampsia – HTN, proteinura, edema, seizures. Tx: 1st ABC’s, 2nd MgSO4 to stop seizure (do not deliver 1st, you can never attempt delivery if pt is seizing), 3rd aggressive prompt vaginal

      delivery c oxytocin and hydralazine to decrease BP.
      401. HELLP syndrome – hemolysis (schistocytes), elevated LFTs, low platelets. No CNS or renal problems (r/o TTP), no h/o URI/GI infection (r/o HUS). Tx c steroids and prompt delivery.
      402. Never recommend termination of pregnancy, unless: 1 – pulmonary HTN in mom, 2 – Marfan’s syndrome c an aortic aneurysm >4cm, 3 – Eisenmengers syndrome (pulm HTN c bidirectional shunt,

      4 – peripartum cardiomyopathy.
      403. If they ask about rheumatic heart disease in the context of pregnancy, know about mitral valve stenosis management (diuretics 1st, vasodilators, then balloon vulvoplasty). Management of

      cardiac disease in pregnancy is bed rest, decreased physical activity, decrease weight, correct anemia, analgesics, vacuum delivery.
      404. Management of hyperthyroid disease in pregnancy is to stay on PTU to prevent thyroid storm, but warn mom that baby might be mentally retarded or have IUGR.
      405. DM in pregnancy – a/w fetal NTD (most common fetal anomaly), hypoglycemia (d/t maternal insulin, tx c IV glucose), hypocalcemia (failure of PTH synthesis after birth), polycythemia (d/t

      increased erythropoietin from intrauterine hypoxia), respiratory distress (to check lung maturity, phosphatidylglycerol is a better choice than L:C ratio), hyperbilirubinemia.
      406. Prolonged latent phase – cervical dilatation <3cm (>20hrs in primipara, >14rhs in multipara). MCC is analgesia, so tx is bedrest and sedations.
      407. Prolonged active phase – cervical dilatation >3cm, but slow/no rate (<1.2cm/hr in primipara, <1.5cm/hr in multipara). Causes include the 3 P’s (passenger (macrosomia), pelvis

      (cephalopelvic disproportion) or power insufficiency). Tx: If contractions are hypotonic (<200MVU in 2hrs), give oxytocin. If contractions are hypertonic, give morphine and consider C-section.
      408. Prolonged 2nd stage – failure to deliver head (1hr in primi, 2hrs in multi). Causes are the same as above (3 P’s). If head is engaged, vacuum deliver. If head is not engaged, do

      C-section.
      409. Prolonged 3rd stage – failure to deliver placenta within 30 minutes. Causes include placenta accreta (A for A, accreta adheres to uterine wall, MCC is placenta previa), placenta increta (In

      for In, increta goes into uterine wall), placenta percreta (invades uterine wall). Tx c 1st manual placental removal, 2nd curettage in the OR and 3rd hysterectomy.
      410. Prolonged 4th stage: Postpartum hemorrhage: >500 in vaginal delivery, >1000 in C-section. MCC is uterine atony (tx: 1st massage uterus, 2nd pitocin, 3rd PGE, 4th methergin, 5th hysterectomy),

      then lacerations, retained placenta (tx c sedation, then ex-lap for b/l uterine and hypogastric artery ligation and hysterectomy), DIC, uterine inversion (from pulling).
      411. Prolapsed umbilical cord – emergency d/t cord compression. Do not hold the cord or attempt to reinsert it into the uterus. 1st step is place pt in knee-chest position, 2nd elevatate the

      presenting cord (avoid palpating), 3rd emergency c-section.
      412. Shoulder Dystocia – MCC is macrosomia (DM). 1st step is McRobert’s maneuver (maternal thigh flexion c suprapubic (not fundal) pressure). 2nd C-section.
      413. Postpartum Fever – Day 0 is atelectasis (d/t anesthesia), Day 1-2 is UTI, Day 2-3 is Endometritis (this is what they will ask, causes include C-sections, prolonged PROM, prolonged labor. Tx

      c ampicillin, gentamycin, metronidazole). Day 4-5 is wound infection, Day 5-6 is pelvix abscess/septic thrombophlebitis (they will say, pt still spikes fever despite antibiotics. 1st step is CT

      scan, if there is an abscess drain it, if there is no abscess, pt has thrombophlebitis, tx c heparin). It is normal to have discharge (first red, then white lochia) up to 10 days postpartum. If

      there is a bad smell, fever or tenderness, suspect endometritis.
      414. Mastitits – fever, unilateral breast tenderness, erythema and edema due to lactational nipple trauma. Treat c oral cloxacillin and continued breast feeding from that breast. If the same

      symptoms occur, but the woman was not lactating, think of cancer.
      415. If woman does not want to breast feed, tell her to wear tight-fitted bras c ice-packs and analgesia. If that is not enough, give bromocriptine or estrogens.
      416. In a pregnant female c antiphospholipid syndrome and recurrent abortions, tx c aspirin (otherwise, avoid aspirin in pregnancy).
      417. Cholestasis c pregnancy – jaundice, itchiness, increase LFT’s, tx c deliver baby. Acute Fatty liver of Pregnancy is more serious because it can progress to hepatic coma. Tx AFLP c fluids,

      IV glucose and FFPs.
      418. Amniotic Fluid Embolism - postpartum female c dyspnea, tachypnea, chest pain, hypotension and/or DIC.

      GYN:

      419. Cervical Dysplasia – firstly, note the word dysplasia (its not cancer, its precancer that has not yet invaded the basement membrane or affected lymphatics) asymptomatic or lesions on

      cervix. MCC is HPV 16/18 (6+11 are benign). Risk factors are early aged intercourse, smoking, multiple partners and immunosuppression. Screening c Pap smear (shows dysplasia at transformation

      zone). Start pap smears annually at 18yo or age of sexual activity onset for 3 consecutive years, and then every 3 years thereafter. If pt has risk factors, pap smear annually. In order: 1st Pap,

      2nd colposcopy (abnormal findings include mosaicism and white epithelium; colposcopy tells you where the disease is, so if a pt comes to you with a lesion on her cervix, you can skip pap smear and

      skip this phase because you already know where the lesion is and go right to stage 3), 3rd Ectocervical biopsy and Endocervical curettage (ECC should not be done on pregnant pts), 4th Cone biopsy

      and treat with cryotherapy (mild CIN) or LEEP (loop electrodiathermy excision procedure for moderate CIN). Remember, its not cancer, do not choose chemo, surgery or radiation for dysplasia.
      420. ASCUS – Pap smear may show atypical squamous cells of undetermined significance, which is basically the step right before HPV (so you would not yet find koilocytosis). The next step would

      be HPV/DNA testing. If the smear returns c HPV 6 or 11, proceed with colposcopy and biopsy/ECC. If the smear returns (-) HPV 11/16, then just repeat pap smear in 1 year.
      421. Invasive Cervical cancer – now it has penetrated the BM. Look for postcoital vaginal bleeding. Dx c cervical biopsy 1st (don’t pick pap or colposcopy). Only a pelvic exam and IVP can be

      used to stage cervical cancer. Tx: Stage Ia1 (<3mm invasion) do TAH (total abdominal hysterectomy). Stage Ia2 (3-5mm invasion) do modified radical hysterectomy. Stage Ib (>5mm) or IIa (upper 2/3

      vagina) do radical hysterectomy, para-aortic lymphadenectomy and radiation. All patients with cervical cancer should be followed-up c pap smears every 3months for 2 years after tx, then every 6

      months thereafter. MC site of metastasis is liver. MCCOD is uremia d/t ureteral obstruction.
      422. Cervical cancer in pregnancy – colposcopy and biopsy, but no ECC. If CIN (no invasion), pap every 3mo then repeat colposcopy and pap 2 months postpartum. If microinvasion (3-5mm), do cone

      biopsy (r/o frank invasion) and if (+), tx c LEEP and cryotherapy 2 months later. If invasive cancer, 1st punch biopsy, 2nd if <24wk give radiation c radical hysterectomy; if >24wks do C/S at

      37wks then hysterectomy.
      423. Uterine/Endometrial Cancer – postmenopausal bleeding. Dx c endometrial biopsy. If it comes back negative, pt is assumed to have bled from atrophy and is treated c HRT (estrogen AND

      progesterone, not estrogen alone). If it shows cancer, do TAH/SBO. If prognosis is poor (nodes affected, metastasis past the cervix into the uterus and beyond) give radiation and chemotherapy as

      well.
      424. Leiomyoma uterine – submucosal fibroids cause menometorrhagia, pain, infertility, visceral obstruction (causing urinary retention and constipation). Treat c leuprolide (GnRH anolog

      therapy), then myomectomy (if pt wants fertility) or hysterectomy (if pt is anemic or does not want to be fertile anymore). Leiomyomas are assymetrical and bumpy.
      425. Adenomyosis – endometrial glands and stroma located in the myometrium. Enlarged, symmetrical, tender uterus in the absence of pregnancy. Only definitive dx is histological sampling

      confirmation. Tx c hysterectomy.
      426. Ovarian Cancer – look for adnexal mass, abdm pain and ascites in a postmenopausal woman. Prevent c OCPs. Screen c bimanual pelvic exams. Dx (generally hard to dx) c U/S first, then CA-125.

      In kids, suspect germ cell tumors (teratoma, choriocarcinoma), in adults suspect epithelial tumor (mucinous, serious, clear cell). Tx c debulking (TAH, BSO, omentectomy) and chemotherapy

      (carboplatin and taxol).
      427. Vulvar cancer – vulvar itching in a 65yo. Dx c biopsy. Tx c surgery.
      428. Germ Cell Tumors – Teratoma/Dermatoid cyst (skin, hair, teeth and pelvic calcifications on X-ray), Sertoli-leydi cell tumor (high testosterone causing virilization), Granulose-theca cell

      tumor (high estrogen causing feminization and precocious puberty), Meig’s syndrome (ovarian fibroma, asicets and R hydrothorax), Krukenberg tumor (stomach cancer c metastasis to ovaries).
      429. Gestational Trophoblastic Neoplasia – s/s: very high hCG, large uterus, pregnancy c bleed, no fetal heart tones, high BP in 1st TM, hyperemesis, hyperthyroidism (must to TSH in a pt c GTN),

      snowstorm u/s. Can be benign (mole) or malignant (choriocarcinoma). Complete mole is an empty egg fertilized c single X-sperm (46XX so sperm duplicated), no fetus, uterus filled c grape-like

      vesicles (same description as sarcoma botyroides in young girls). Incomplete mole is a normal egg c 2 sperm (causing 69XXX), + fetus/cord, but fetus dies. For either mole, treatment is D&C, f/u

      hCG, start OCPs. If choriocarcinoma, 1st step is CT head/chest/abdo/pelvis to r/o METS. If poor prognosis (hCG >40,000, brain/liver mets, >6 months of D&C) do radiation and chemotherapy (MAC: MTX,

      Adenomycin, Cytotoxin). If good prognosis, give MTX only and f/u hCG every week for 3months while on OCPs.
      430. Uterine prolapse – loss of uterine support due to cardinal ligament dysfunction. MCC is childbirth. Best tx is vaginal hysterectomy c ant/post repair (yes, first!), but if pt refuses

      surgery, do Kegel exercises, estrogen HRT and pessaries.
      431. Stress Incontinence – weak pelvic floor causes you to urinate whenever you sneeze/cough, none at night. Dx c Q-tip test. Tx c Kegel exercises, then surgery (Marshall-Marcheli-Kranz

      procedure).
      432. Urge Incontinence – involuntary detrusor contractions causing spurts of urine to fall at any time. Dx c cystometric studies. Tx c anticholinergics (Ditropan)
      433. Overflow Incontinence – denervated bladder (DM, MS, CVA) causes bladder to keep filling up, thus high residual volume even after urination. Tx c cholinergics (bethanecol).
      434. Endometriosis – dymenorrhea, dyspareunia, infertility, uterosacral ligament nodularityin the cul-de-sac, chocolate cysts. Dx c laparoscopy. Tx: 1st OCP, 2nd Danazol and Leuprolide (best tx,

      but not 1st because of side-effects), 3rd surgical resection, 4th pregnancy (however hard, d/t infertility), 5th TAH/SBO. If endometriosis is present, and pt has no s/s, do nothing.
      435. Chancroid – painful chancre (H. ducreyi – you cry c ducreyi) c ragged, rolled edges. Tx c Azithromycin
      436. LGV – painless ulcer that heals and then forms painful nodes. Tx c erythromycin.
      437. Granuloma inguinale – painless, beefy-red ulcer. Dx c Donovan-bodies on smear. Tx c Azithromycin.
      438. Chlamydia – MC bacterial STD, can be asymptomatic or mild mucopurulent cervical discharge c or w/o cervical motion tenderness (CMT), (+) Cx/Ab test, (-) stain. Tx c azithromycin (1 dose) or

      oral doxycycline (7 days).
      439. Gonorrhea – Lower GU causes d/c, itching, burning, dysuria; Upper GU causes abdo/pelvic pain. Disseminated when there is dermatitis, polyarthritis or tenosynovitis. Pt has vulvovaginitis c

      mucopurulent d/c c CMT on bimanual exam. Dx c chocolate agar, Gram (-) diplococci on stain. Tx (for GC and Chlamydia) Ceftriaxone + Doxycycline.
      440. PID – lower abdominal pain, adnexal tenderness, CMT and fever 1 week after menses in a sexually active female. Cervicitis (only vaginal D/C, no pain – tx G/C), Salpingo-oophoritis (b/l

      lower abdo/pelvic pain c CVA tenderness – tx G/C), Tubo-ovarian abscess (pt will look septic, severe pain, n/v, dyschezia, fever – tx c Ampicillin, Gentamycin and Flagyl. If ruptured, ex-lap

      is done). Tx for G/C in these cases are: outpatient: ceftriaxone + doxycycline, inpatient: clindamycin + gentamycin
      441. Gardnerella Vaginosis – fishy odor on whiff test, pH 6, clue cells, tx c metronidazole (clindamycin if pregnant in 1st TM)
      442. Trichomonas vaginalis – frothy, green smelly discharge c strawberry cervix, pH 5. Tx c metronidazole for pt and partner (if pt pregnant, tx c vaginal betadine).
      443. Candida yeast infection – itchy, burning, dyspareunia, cottage-cheese discharge, that sticks to the vaginal wall, pseudohyphae, pH 4, tx c nystatin or Amp B.
      444. Contraception: remember effects of estrogen (increases BP, cholelithiasis, LFTs, HDL, art/venous thrombosis and decreases LDL) and progesterone (affects mood, increase weight, acne, increase

      LDL, decrease HDL). Absolute CI: pregnancy (causes VACTERL), liver dz, vascular dz (DVT, SLE, CVA) and hormonally-dependent cancers like breast). Benefits include decreased risk of

      ovarian/endometrial cancer, decreased dysmenorrhea/DUB/PID/ectopics.
      445. IUD – put it in 1 week after menses and f/u in 1 week. Does not affect risk of STDs. Absolute contraindications include pregnancy, pelvic cancer, salpingitis, steroid use (pt on Crohns,

      asthma), h/o PID. Increased risk of ectopics and PID when placed.
      446. Abnormal vaginal bleeding: Pre-menarchal (<12yo - foreign body, trauma, sarcoma botyroides, precocious puberty), reproductive (13-52yo - pregnancy, fibroids/adenomyosis, DUB), postmenopausal

      (>52yo - endometrial cancer). A neonate c vaginal bleeding is normal due to maternal estrogen, thus reassure mom.
      447. Precocious Puberty – normally: breast development @ 9yo, pubic/axillary hair @ 10yo, growth @ 11yo, menarche @ 12yo. If only 1 stage occurs early, this is Incomplete isosexual precocious

      puberty, next step is CT brain/abdo/pelvis. If all stages occur early, this is complete isosexual precocious puberty, next step is tx c constant GnRH stimulation (to decrease estrogen). If pt has

      bone lesions and café-au-lait spots, pt has McCune-Albright Syndrome. If pt has high estrogen c a pelvic mass, they have a granulose-theca cell tumor, tx c surgery.
      448. Dysfunctional Uterine Bleeding – MCC is anovulation d/t unopposed estrogen, so no secretory phase (d/t lack of progesterone) c unstable endometrial thickening. Pt will have h/o irregular,

      unpredictable menstrual bleeding without cramps. Next step is endometrial biopsy to r/o cancer. Tx c NSAIDS if she desires children, cyclic progestin therapy or daily combined OCPs if she

      doesn’t desire children or has menorrhagia.
      449. Primary Amenorrhea – 1st step is pregnancy test (whether she says she is sexually active or doesn’t), 2nd step is physical exam: (+) breasts and (+) uterus -> check prolactin, if normal

      r/o imporferate hymen (cyclic menstrul pain c bulging hymen, predisposition to endometriosis, tx c surgery) and tx c progesterone. (+) breasts and (-) uterus -> get karyotype, if 46 XY, pt has

      Androgen Insensitivity Syndrome (Testicular Feminization, no pubic hair, next step is remove testes from abdm), if 46XX, pt has Rokitanky-Hausen syndrome (she will have pubic hair). (-) breast and

      (+) uterus -> gonadal dysgenisis, so next step is get karyotype to r/o Turners syndrome (45XO, webbed neck, far spaced nipples, streak ovaries, premature ovarian failure, needs estrogen).
      450. Secondary Amenorrhea – 1st step is r/o pregnancy, 2nd r/o prolactinoma (if prolactin level is high, next step is MRI of head. If abnormal, pt has pituitary tumor, if normal, pt has

      drug-induced prolactinoma) and hypothyroidism, 3rd progesterone challenge test. If pt bleeds after 2 weeks (estrogen is adequate), check LH. If elevated pt has PCOS, if normal/low check

      TSH/prolactin again. If pt does not bleed after 2 weeks (inadequate estrogen) check FSH, if high pt has premature ovarian failure (next step is karyotype to r/o Turners vs Ovarian failure due to

      congenital adrenal hyperplasia), if normal/low pt has craniopharyngioma, next step is MRI. If MRI is insufficient, pt has Ahsermann’s syndrome (scarring due to prior D&C/D&E. Tx by surgically

      removing scarred tissue then giving high-dose estrogen for 1 month to regenerate lining). Again, if LH/FSH are high, next step is karyotype. If XO, pt has turners, if XX pt has ovarian failure

      (now r/o autoimmune dz versus CAH). If LH/FSH are normal or low, next step is MRI of head. If abnormal pt has pituitary tumor/destruction or hypothalamic dz (may be a/w Kallman’s syndrome

      (anosmia, amenorrhea), anorexia, exercise, tx c estrogen). If normal, pt has Asherman’s syndrome.
      451. Breast mass in a female <35yo – Fibrocystic Dz (b/l, tender esp with menses, multiple, tx c reassurance and f/u later), Fibroadenoma (painless, rubbery, mobile, tx c observe but try not to

      stare too long), Mastitis/Abscess (lactating, painful, red, tx c clocacillin, if still there, I&D), Fat Necrosis (h/o trauma, tx c observation). Avoid mammogram in women <35yo (tissue too dense)

      and if suspicious of cancer go right to biopsy.
      452. Breast mass in a female >35yo –Fibrocystic Dz (same as above, but this time you must aspirate it and do a mammogram. If mass resolves, observe. If FNA shows blood or if cyst recurs quickly,

      do biopsy), Fibroadenoma (mobile, get mammogram. If pt is low risk, observe, if high risk get biopsy). If pt is postmenopausal and has a mass, go right to biopsy.
      453. If bloody discharge from the nipple -> intraductal papilloma. Next step is galactogram-guided excision.
      454. Polycystic Ovarian Synd – female, hirsutism, amenorrhea, infertility (MCC of infertility in women <30yo c abnormal menses, while PID is MCC if normal menses) and insulin resistance (DM).

      Next step is U/S to show multiple cysts, then LH and FSH (ration should be 2:1), then testosterone and DHEA levels. Unopposed estrogen will increase risk of endometrial cancer. Tx c OCP’s,

      cyclic progestins, Metformin, Spironolactone and clomiphene if she wants kids.
      455. Congenital Adrenal Hyerplasia – overproduction of adrogens causing virlization and amenorrhea. Young girls get clitoromegaly. 90% is 21-OH deficiency (salt-wasting, high K, low BP, high

      urinary 12-hydroxyprogesterone). Tx c steroids + IVF (to prevent death). Must do karyotype to figure out gender.
      456. Review of hirsutism (excessive sexual hair) versus virilization (excess androgen, thus acne, balding, deep voice, clitoromegaly, amenorrhea): Hirsutism c high testosterone, normal DHEAS, CT

      shows enlarged ovaries is PCOS. Virilization c normal testosterone, high DHEAS, CT shows enlarged adrenals is Adrenal Tumor (CAH, tx c DXM suppression). Virilization c high testosterone, normal

      DHEAS, CT shows enlarged ovaries is ovarian tumor (tx c OCPs, GnRH analogs and surgery). Hirsutism c normal testosterone, normal DHEA, normal CT is familial hirsutism (a/w 5-alpha reductase

      defiency, tx c spironolactone, flutamide).
      457. Menopause – high LH/FSH, low estrogen/progesterone. Hot flashes, osteoporosis, atrophic vaginitis, abnormal lipi profile, atherosclerosis/CAD. Tx c HRT for <5years and then calcium,

      exercise, and lubricants for sexual activity. HRT increases risk of CAD, invasive breast cancer, memory loss, stroke, PE. Decreased osteoporosis and colon cancer. Contraindicated in breast and

      endometrial cancer (must do endometrial biopsy before giving it), acute liver dz, active thrombosis, vaginal bleeding. If contraindicated, give SERMS (Tamoxifen, Raloxifen, which still increase

      risk of endometrial cancer).
      458. Infertility: 1st step is semen analysis (tx c sperm injection), 2nd step is ovulation analysis (basal body temperature, endometrial biopsy, serum estrogen level to r/o anovulation. Tx c

      clomiphene), 3rd step is Hyterosalpingogram for tubal blockage, 4th step is laparoscopy.

      CONGENITAL ANOMALIES/PERINATAL MEDICINE:

      459. Down’s Synd – trisomy 21, 1/700 births (1/350 if >35yo), MR, endocardial cushing defect/ASD/VSD, duodenal atresia, simian crease, Alzheimers @ 40yo, epicanthal folds. Prenatal dx: high

      hCG, low AFP, low estriol, increased maternal age, amniocentesis, u/s shows thickened nuchal folds, CVS @ 9-12wk. Neonatal: 1st step is echo, then genetic counseling.
      460. Edwards Synd – trisomy 18, IUGR, rocker-bottom feet, clenched hands, PDA/VSD
      461. Patau’s Synd – trisomy 13 (P for P: cleft liP, cleft Palate), holoprosencephaly, renal and ocular malformations.
      462. Cri du Chat Synd – Chrom 5p deletion, cat-like cry, MR so tx c special schooling
      463. Turners Synd – Gonadal dysgenesis 45XO, 1/2000 newborn girls, short webbed neck, horseshoe kidney, coarctation of aorta, primary amenorrhea. Estrogen replacement
      464. Klinefelters Synd – seminiferous tubule dysgenesis 47XXY, hypogonadism, gynecomastia, tall stature, infertility, give testosterone replacement starting at 12yo.
      465. Fragile X Synd – macro-orchidism, MR
      466. Achondroplasia – AD, short limbs, hydrocephalus (must monitor closely)
      467. Xeroderma Pigmentosa – sunlight sensitivity from 1st exposure, conjunctitis leading to blindness, dx c skin biopsy and tx c strict sun avoidance (they will say kid only comes out at night).
      468. Fetal Alcohol Synd – MR, flat philtrum, thin upper lip, worst in 1st TM
      469. Tobacco in pregnancy – IUGR
      470. Cocaine in pregnancy – CNS damage, placental abruption
      471. Fetal Warfarin synd – epiphyseal stippling, CNS malformations, MR
      472. Thalidomide – phocomelia (absence of long bones in extremities)
      473. Syphilis – treponema pallidum, snuffles, palm/sole rash, anemia, hepatosplenomegaly, periostitis, Hutchinson’s teeth, sabir shings, saddle nose, tx c penicillin
      474. Toxoplasmosis – oocytes from cat litter and meat, hydrocephalus, chorioretinitis, scattered CNS calcifications, tx: 1st avoidance, 2nd pyrimethamine, 3rd shunt for hydrocephalus
      475. Rubella – blueberry muffin rash, PDA, deafness, cataracts
      476. CMV – deafness, perventricular CNS calcifications, microcephaly
      477. Herpes – aquired at birth (prevent c C-sxn), seizures (temporal lobe), encephalitis, vesicles, overwhelming sepsis, hepatitis, tx c acyclovir
      478. HIV – all meds (except efavirenz) if CD <500, AZT only if CD>500 in 2nd/3rd TM and 6 weeks postpartum. Dx in kid c PCR (not ELISA).
      479. Hypospadias – pee on your feet (ventral urethral opening), hooded prepuce, chordee (ventral curving of penis), tx c 1st avoid circumcision to save foreskin for reconstruction, 2nd surgery

      at 1yo
      480. Omphalocele/Gastrocele – absence of anterior wall (gastrocele has no sac, omphalocele does). Tx: 1st cover c plastic wrap, 2nd surgery within 24 hours.
      481. Posterior urethral valves – cause of UTI in young boys, a/w potters synd, dx c VCUG
      482. Undescended testicle – cryptorchidism, rarely descent after 1yo, must differentiate from retractable testis, tx: if testes is palpable – wait for descent and do orchieplexy after 1 year.

      If testes are not palpable – consider hCG trial if b/l. 2nd – Orchiectomy for atrophied testis due to risk of malignancy and infertility for other testis.
      483. Congenital Adrenal Hyperplasia – adrenogenital syndrome, no steroidogenisis due to 21-OH deficiency, ambiguous genitalia, clitoromegaly, salt-wasting, hyperkalemia. Tx: 1st fluids for low

      BP, 2nd treat hyperkalemia (calcium, alkalinization, insulin/glucose, kayexalate).
      484. Choanal atresia – respiratory distress/cyanosis relieved by crying, a/w CHARGE synd (Colobama of eye, Heart defect, Atresia of choanae, Retardation, Genital hypoplsia, Ear anomalies). Tx c

      respiratory support.
      485. Laryngomalacia – flexible larynx collapses causing obstruction on inspiration. Dx c fluoroscopy or direct laryngoscopy. Airway support if needed, otherwise self-limited.
      486. Diaphragmatic Hernia – either at foramen of Bochdalek (left sided (b/c R side has liver), severe newborn respiratory distress, scaphoid abdm, mediastinal shift, pulmonary hypoplasia) or at

      foramen of Morgagni (presents later c bowel obstruction). Tx c 1st aggressive rescucitation, 2nd extracorporeal membrane oxygenation (ECMO), 3rd surgery.
      487. Tetralogy of Fallot – PROVe (pulm HTN due to RV outflow obstruction, RVH, Overriding aorta, VSD), MC cyanotic CHD, presents >1yo, tet spells, boot-shaped heart
      488. Transposition of great vessels – cyanosis in 1st 24hrs, aorta from RV, pulm artery from LV, egg on a string heart, tx c balloon atrial septostomy, then arterial switch
      489. Total anomalous pulm venous return – pulmonary veins drain into systemic venous circulation (partial or total), snowman heart. 1st medications, 2nd surgery
      490. Truncus arteriosis – single great artery is origin of aorta and pulm arter and coronary artery, listen for truncal valve click. Tx: 1st treat CHF, 2nd surgery
      491. VSD – MC CHD, holosystolic murmur at 1-2months, tx c subacute bacterial endocarditis prophylaxis
      492. ASD – pulmonary ejection murmur plus wide, fixed split S2, no SBE prophylaxis, usually presents after infancy
      493. Coarctation of aorta – HTN in UE, low BP in LE, poor femoral pusles, Turners synd, rib notching on CXR, tx c balloon angioplasty
      494. PDA – premature babies, congenital rubella, continuous machinery murmur c wide pulse pressure.
      495. Hypoplastic left heart – underdeveloped LV and aorta, vascular collapse in 1st week of life, ductus dependent, tx: 1st prostaglandin E, 2nd Norwood or transplant
      496. Hydrocephalus – communicating (obstruction of arachnoid villi) or noncommunicating (Aqueduct of Sylvius stenosis, Chiari malformation at cerebellar tonsils or Dandy-walker cyst of 4th

      ventricle). Baby c rapid increase in head circumference, split sutures, bulging anterior fontanelle, setting-sun sign (of eyes), 6th nerve palse, papilledema, dx c CT scan (do not do LP in risk of

      herniation). Tx: 1st hyperventilate and elevate head, 2nd mannitol, 3rd ventriculoperitoneal shunt
      497. Congenital cataracts – rubella, CMV, toxo, galactosemia, tx c surgery right away to prevent permanent visual impairment.
      498. Congenital glaucoma – tearing, corneal clouding, photophobia, sturge-weber synd (facial port-wine stain, seizures, CNS calcifications), neurofibromatosis, rubella, tx c surgery.
      499. Congenital deafness – Alports (nephritis c deafness), CMV, rubella, maternal drugs.
      500. Osteogenesis Imperfecta – brittle bones cause multiple fractures in a kid, blue sclera, osteoporosis, family history, type I collagen disorder, teeth deformities.
      501. Developmental Dysplasia of the Hip – subloaxation of femoral head from the acetabulum, causing asymmetric thigh creases, clicking sound, + Ortolani sign (hip reducibility), + Barlow sign

      (hip dislocatability), dx c ultrasound. Tx c harness, then closed reduction, then open reduction (>6mo age) if closed reduction failed.
      502. Talipus Equinovarus – toes face medially, forefoot adduction. Tx c manipulative casting, then surgery if needed.
      503. Transesophageal Fistula – dx c failure to pass nasal catheter to stomach, AXR shows air-distended proximal esophagus. Tx: 1st NGT, 2nd surgery
      504. Duodenal atresia – bilious projectile emesis, a/w Downs syndrome, abdominal distention, double bubble on AXR (air-distended stomach and proximal duodenum). Tx: 1st correct

      fluids/electrolytes, 2nd surgery
      505. Pyloric stenosis – nonbilious projectile emesis, olive-shaped RUQ mass, dehydration c hypochloremic alkalosis. Tx:1st fluid/electrolyte correction, 2nd pyloromyotomy
      506. Meckel’s Diverticulum – 2yo c painless rectal bleeding and abdm pain. Dx c technetium-labeled nuclear scan (Meckel’s scan), tx: 1st correct life-threatening anemia, 2nd surgical

      excision.
      507. Hirschsprung’s Disease – congenital megacolon causing obstruction, absense of Auerbach’s and Messner’s plexus, failure to pass meconium in 1st week, dx c 1st barium enema (shows

      transitional zone) rectal biopsy (aganglionosis). Tx: 1st fluid/electrolyte correction, 2nd Abx if enterocolitis suspected, 3rd surgical excision of ganglionic segment.
      508. Hyaline membrane Disease – RSD, surfactant insufficiency, early onset (hours after birth) baby has tachypnea, grunting, nasal flaring and retractions. Early problems include breathing

      difficulty, metabolic disturbances and infection. Late problems include broncopulmonary dysplasia. Risk factors include prematurity, maternal DM and multiple pregnancies. Dx: 1st CXR (shows fine

      reticular granularity in b/l lungs), 2nd L:S ratio (should be >2:1) and phosphatridylglycerol. Tx: Prevention is the best tx (prevent prematurity, give maternal steroids 48-72 hours antepartum if

      <33 weeks to women who do not have toxemia, DM or renal disease), 2nd – correction of hypoxia, acidosis, hypercapnea, hypotension, hypothermia and anemia. 3rd neonatal surfactant (via ETT) at

      delivery but avoid uneccessary pulmonary barotraumas or oxygen toxicity.
      509. Chlamydia – conjunctivitis 4-7 days after birth, staccato cough, tx c erythromycin.
      510. Gonorrhea – conjunctivitis 3-5 days after birth, disseminated infxn, chocolate agar, Thayer-martin media, tx c parenteral abx.
      511. GBS – early onset (<3days old) has resp distress, pneumonia, meningitis; late onset (7days-3mo) has meningitis, osteomyelitis, septic arthritis and occult bacteremia. Prevent c culture at

      35-37wk and penicillin at birth. Neonates given abx if febrile.


      PSYCHIATRY

      512. If you see a question about the best next test and one of the answers is “mini-mental exam,” pick that one.
      513. Autism – starts by 3yo. Impaired social interactions (unaware of surroundings), impaired verbal/nonverbal communication (if verbal is okay, dx is Asperger’s syndrome), and restrictive

      activities and interest (head banging, strange movements). Linked to congenital rubella. Tx c 1st structured classroom training, behavioral modifications, family support, 2nd halorperidol,

      risperidone, SSRI’s. If child has normal development and then deteriorates into this condition or worse, that is Rett’s syndrome.
      514. Learning disorder – impairment in reading (80%), math, language, written expression with no mental retardation or lifestyle anomalies. Tx c educational intervention.
      515. ADHD – dx <7yo. Boy is hyperactive, impulsive and has a short memory span, but is not cruel. Tx: 1st individual/family therapy and behavioral modifications, 2nd methylphenidate (Ritalin) or

      dextroamphetamine, both of which may cause insomnia, abdm pain, HA, anorexia, exacerbations of tics, weight loss or growth suppression. Tx c 1st atimoxitine (but must be given everyday, so if mom

      says kid only has s/s Monday thru Friday, then you cannot give this, give tx #2), 2nd Methylphenidate or amphetamine.
      516. Conduct Disorder – violates society norms, pediatric form of antisocial disorder. Look for fire setting (if only this, dx is pyromania), cruelty to animals, lying, stealing, fighting. Must

      have this disorder in order to make diagnosis of antisocial d/o as adult. Tx: 1st evaluate suicide/violence potential, 2nd containment by parents, schools, legal system or hospital, 3rd tx

      aggression c SSRI or haloperidol, 4th individual/group/ family therapy.
      517. Oppositional Defiant Disorder – negative, hostile and defiant behavior towards authority figure. Note the different between this and conduct d/o is that here, the kid is just bad to adults

      behaves with peers and is not a cruel, lying criminal. Tx c individual/family therapy
      518. Separation anxiety Disorder – look for a kid who refuses to go to school or sleep alone or away from home by claiming sickness, stomachache, HA or temper tantrums. Must be >6months old

      (might ask about 8mo baby who cries when he sees grandma for 1st time = separation anxiety, but if kid was under 6mo, its normal) School refusal is a psychiatric emergency and needs prompt

      evaluation and treatment involving parents, school and peers.
      519. Tourette’s Disorder – (only 10-30% curse), look for males c motor tics (blinking, grunting, throat clearing, grimacing, barking, shrugging) that are exacerbated by stress and remit c

      activity or sleep. Linked to ADHD and OCD. Tx: 1st Haloperidol (improves 80% but watch for EPS, mental dulling and tardive dyskinesia). 2nd Pimozide or Clonidine
      520. Encopresis – >4yo c passage of feces into inappropriate places (clothing, floor). r/o Hirschsprungs disease. Tx c behavioral techniques, individual therapy.
      521. Enuresis - >5yo c inappropriate voiding of urine. Tx: 1st behavioral techniques (bell, buzzer, bed time fluid restriction), 2nd Imipramine (last resort).
      522. Dementia vs Delerium: Delerium (rapid onset, fluctuating consciousness, often reversible, perceptual disturbances, incoherent speech). Dementia (insidious onset, clear consciousness (until

      late in course), irreversible).
      523. Alzheimer’s vs Vascular (Multi-Infarct) Dementia: Alzheimers dementia (women, older, chrom 21, linear/progressive, no focal defecits (key), supportive tx). Vascular dementia (men, younger

      than alzheimers, HTN, stepwise/patchy pattern, (+) focal deficits (key), tx underlying condition).
      524. Alcohol – intoxication includes slurred speech, ataxia, disinhibition, impaired judgement, coma and blackouts. Withdrawal includes tremor, agitation, irritability, n/v, fever, seizures,

      delirium tremens (onset of delirium, vivid auditory/tactile/visual hallucinations, paranoid delusions 2-3 days post cessation of long-term heavy use). Tx intoxication supportively. Tx withdrawal c

      vital sign/electrolytes/Mg/thiamine/vit B12/folate/glucose monitoring. 2nd Hydration c thiamine before glucose (prevent Wernicke), 3rd benzodiazepine (chlordiazepoxide). Tx dependence c

      confrontation of denial and rehab (AA). Specific managements: Alcohol hallucinations (chlordiazepoxide, IVF, haloperidol), Wernicke’s encephalopathy (sudden ataxia, confusion, nystagmus, lateral

      rectus palsy from thiamine deficiency. Tx c thiamine) Korsakoff’s syndrome (severe anterograde/retrograde amnesia, confabulations and polyneuritis from thiamine defiency).
      525. Opioids – intoxication includes euphoria, analgesia, hypoactivity, anorexia, drowsiness, n/v, constipation, pin-point pupils, hypotension and bradycardia. Overdose includes CNS/respiratory

      depression, pinpoint pupils, pulm edema, seizure, coma and death. Withdrawal includes (not deadly) rhinorrhea, yawning, diarrhea, sweating, dilated pupils, tachycardia and HTN. Tx overdose c

      naloxone. Tx dependence c abstinence through methadoes titration.
      526. Stimulants – amphetamines/cocaine, rapid dependence of tolerance, IVDA risks, paranoid psychosis. Intoxication includes euphoria, alertness, increased energy, anxiety, talkativeness,

      mydriasis, tactile hallucinations (crawling bugs), HTN and tachycardia. Withdrawal includes (non-deadly) fatigue, hypersomnia, anxiety, dysphoria, suicidal ideation, craving. Tx intoxication

      symptomatically (antiarrhythmic, benzo for agitation, haloperidol). Tx withdrawal supportively (observe for suicidality). Tx dependence c rehab.
      527. Sedatives – benzo/barbs – intoxication causes slurred speech, drowsiness, impaired attention, disinhibition. (Flumetrazepam is the date-rape drug). Overdose c barbs for suicide, (not so

      much benzo b/c of high therapeutic index, unless taken with another drug or alcohol). Both cause resp depression, coma, death. Withdrawal causes anxiety and insomnia. Severe withdrawal is a

      medical emergency (n/v, autonomic hyperactivity, photophobia, tremor, hyperthermia, delerium, seizures, death) most severe c short-acting drugs. Overdose benzo c flumazenil (does not reverse resp

      depression), barbs c charcoal, gastric lavage. Tx barbiturate withdrawal c pentobarbital challenge test to get daily dose, and taper off. Tx benzo withdrawal c long-acting benzo (diazepam,

      clonazepam) and gradually withdraw.
      528. Nicotine – acetylcholine (nicotinic) agonist. Withdrawal causes irritability, wt gain, and difficulty c concentration. Tx: 1st obtain specific date to stop, 2nd educate/counsel.
      529. PCP – paranoia, assaultiveness, impulsiveness, vertical and/or horizontal nystagmus (dead give-away), diaphoresis, resp depression, seizures, normal size pupils. Tx symptomatically
      530. Hallucinogens – LSD, Ecstacy – sympathomimetic effects (mydriasis, tachycardia, sweating, diarrhea, urination), panic reactions, illusions, paranoia. Later on, pt may not be using drug

      anymore and reexperience intoxication (flashback).
      531. Cannabinoids – Marijuana/THC – intoxication has euphoria, bad judgement, slowed reactions, dry mouth, conjunctival injection (dead give-away). Chronic use causes amotivational syndrome

      and memory impairment.
      532. Hallucination is a disturbed sensory perception (visual, tactile, auditory). Delusion is a fixed, false belief (even if people prove to you otherwise). Psychosis is inability to judge

      boundary between real and unreal.
      533. Schizophrenia – presence of >2 s/s of the following for >6months: delusions, hallucinations (generally auditory, link visual c alcohol withdrawal), disorganized speech/behavior, negative

      s/s (flat affect, no speech, no motivation, anhedonia). Better prognosis (NBME 3 question) if acute, late onset, good social/occupation hx, positive s/s, medication compliance, married, female

      gender. Symptoms due to altered dopamine activity (newer antipsychotics affect serotonin also). Negative s/s have enlargement of cerebral ventricles and hypoactive frontal lobe. Tx: 1st assess if

      pt needs hospitalization (protect self/others), 2nd Antipsychotics (Risperidone), 3rd Psychosocial tx. [Timeline: <1month = brieft psychotic d/o, 1-6months = schizophreniform, >6mo =

      schizophrenia]
      534. Delusional (Paranoid) Disorder – persistent, nonbizarre, well-systematized delusion. Erotomanic (on is loved by a famous other, NBME 3 TQ), grandiose (one possesses great talent), jealous

      (conviction that lover is unfaithful), persecutory (one is conspired against, MC), somatic (one has a physical abnormality like odor). Tx: 1st hospitalization for inability to control

      suicidal/homicidal impulses or danger a/w delusions, 2nd psychotherapy, 3rd antipsychotics/antidepressants.
      535. Schizophreniform – schizophrenia <6months. Good prognosis c acute onset, confusion, disorientation, full affect, tx c antipsychotics for at least 6 months.
      536. Brief Psychotic Disorder – sudden onset of psychotic s/s c emotional turmoil and confusion, often following obvious stressor, duration <1month. Suicide risk, thus tx 1st hospitilization as

      needed, 2nd antipsychotics/antianxiety agent, 3rd psychotherapy
      537. Schizoaffective – schizophrenia c depression or mania for at least 2 weeks.
      538. Shared Psychotic disorder – submissive, dependent isolated relationship with person c established delusion. Suicide/homicide pacts. Tx: 1st separate the 2 people, 2nd antipsychotics.
      539. Mania – >1wk of elevated, expansive, irritable mood c grandiosity, no sleep, talkativeness, impulsitivity (shopping sprees, gambling, promiscuity) , racing thoughts, distractibility,

      agitation. Hypomania is less severe and lasts >4days.
      540. Major depression disorder (MDD)– 2 of SIGECAPS in >2wks– sleep changes (delayed sleep onset, decreased REM. Note the difference: Anxiety has increased REM latency, depression and

      narcolepsy have decreased REM latency), interest loss, guilt, energy loss, concentration decreased, appetite (up or down), psychomotor (retardation or agitation), suicidality. Decreased

      serotonergic activity a/w violence and suicide. Tx: Hospitalize if suicide risk, 2nd Antidepressant (SSRI 1st) for 6-12 months (not that it takes 4-6wks to start effects), 3rd ECT (rapid response

      in pregnancy, elderly, medically ill), 4th psychotherapy, 5th antipscyhotic + antidepressant for psychotic pts, 5th Phototherapy if depression is seasonal, 6th treat comorbid psychopathology

      (anxiety, substance abuse, personality d/o, ADHD).
      541. Depression vs Bereavement – Depression (mood pervasive/unremitting, constant low self-esteem/worthlessness, suicidal, sustained psychotic s/s, no improvement c treatment, social

      withdrawal). Bereavement (mood fluctuates, self-reproach regarding deceased, not suicidal, transient visual/auditory hallucinations or deceased, s/s improve c time and usually gone by 6 months,

      often welcomes social support). It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, while an MDD pt

      thinks its real. Other clues to MDD that are not normal are feeling of worthlessness, suicidality and psychomotor retardation.
      542. Bipolar Disorders: Type I is full-blown mania c MDD. Type II is hypomania c MDD. Tx: 1st assess risk of suicide, assaultiveness, dangerous poor judgement. 2nd For acute mania give mood

      stabilizer (lithium). For depression – modd stabilizer c or w/o antidepressant if necessary.
      543. Cyclothymia – numerous hypomanic episodes c depressive episodes for >2yrs. (Cyclo is a psycho, while dysthymia is just depression for >2yrs).
      544. Panic Disorder – minutes to hours of unexpected, sudden intense anxiety, dyspnea, parasthesia, CP, fear of dying. A/w agoraphobia (fear of places where escape is difficult such as bridges,

      public transportation, large crowds, traveling). Tx: 1st If acute, emergent case, give reassurance and benzo (alprazolam, clonazepam). 2nd R/o MI, PE, CVA, hypoglycemia, 3rd Antidepressants (SSRI

      is tx of choice for long-term management), 4th Cognitive-behavioral therapy (CBT) for agoraphobia.
      545. Obsessive-Compulsive Disorder – recurrent intrusive images, impulses, thoughts (obsessions) and ritualistic behaviors (compulsions) that produce anxiety and affect way of life. A/w Tourette

      syndrome. Abnormality is serotonin system. Tx c SSRIs (fluvoxamine), but if you only see TCA’s pick clomipramine.
      546. Specific Phobia – irrational, excessive fear and avoidance of a specific object or situation. Tx: Systemic desensitization.
      547. Social Phobia – fear of embarrassment, scrutiny of others (public speaking, eating in public, public bathrooms). Tx: 1st CBT, 2nd BB (propranolol) for stage fright, 3rd Antidepressants (not

      TCAs) and high-potency benzodiazepines.
      548. Posttraumatic Stress Disorder – >1 month, must have 3: reexperiencing (flashbacks), emotional numbing (avoidance), autonomic arousal (insomnia, irritability). Tx: 1st hospitalize for acute

      suicide, violence risk. 2nd CBT, 3rd Antidepressants.
      549. Acute Stress Disorder - <1month of the same 3 symptoms. Tx c psychotherapy.
      550. Generalized Anxiety Disorder – unrealistic, persistent anxiety for >6months. Muscle tension, restlessness, poor concentration, fatiguability, irritability, loss of sleep. Tx: 1st

      psychotherapy, 2nd Antidepressants (Buspirone).
      551. Somatorofrm Disorders – unlike factitious disorder and malingering, the symptoms are not intentionally produced but are strongly linked to psychological factors. Examples include

      somatization disorder (multiple somatic complaints, tx c regularly scheduled visits c PMD), conversion disorder (neurologic s/s), pain disorder (pain in absence of adequate physical findings, tx c

      psychotherapy), hypochondriasis (fear of specific disease, tx c regular medical visits), and body dysmorphic disorder (preoccupation c defect in appearance, tx c psychotherapy and SSRI’s after

      you assess suicide risk).
      552. Factitious disorder – “Munchausen syndrome.” Intentional production of s/s for unconscious psychological reasons (need to assume sick role) usually in someone in medical occuption or c

      history of illness. If s/s produced by parent, this is Munchausen’s by proxy. Tx c psychiatric consult, confrontation may be helful.
      553. Malingering – intentional production of symptoms for a recognized gain (money, drugs, avoid work/military/prison).
      554. Dissociative Identity disorder – multiple personalities, which take over life and pt may or may not be aware of each other. Tx c intensive psychotherapy.
      555. Amnestic Disorder – 2 types: psychogenic fugue (sudden, unexpected travel c amnesia of old identity and assumption of new identity that lasts hours to months, pt is unaware of loss) and

      psychogenic amnesia (sudden inability to recall important personal information of a traumatic or stressful event, but aware of loss). Recovery usually returns spontaneously. If not, try hynosis,

      amobarbital or psychotherapy.
      556. Depersonalization disorder – recurrent feeling of detachment from one’s body or self (feel like you’re in an outside world).
      557. Anorexia Nervosa – must have 3: amenorrhea, minimal normal body weight, fear of gaining weight. Tx: 1st hospitalize for dehydration, starvation, hypotension, electrolyte, hypothermia,

      suicide risk. 2nd treatment contract for wt gain, 3rd CBT.
      558. Bulimia Nervosa – binge eating, normal weight, overconcerned c wt/diet/exercise, self-induced vomiting, laxatives/diuretics, a/w kleptomania. Tx: 1st hospitalize for ECG

      (hypokalemia-induced arrhythmia is MCCOD), electrolytes, amylase, LFTs, esophageal/gastric rupture, suicide risk. 2nd psychotherapy, nutritional counseling, SSRI for binging (do not give

      buproprion for risk of seizures).
      559. Old, classic USMLE TQ: Mom finds her son having sex c another boy, is this normal or homosexuality? Normal (unless they say he enjoys it). Another TQ is a man, who knows he is a man and likes

      women, dresses up like a woman and acts like a woman, what is his sexual orientation? Heterosexual (b/c he likes women).
      560. Projection – attributing your own wishes to someone else. A/w paranoid personality d/o (p for p – paranoia c projection)
      561. Denial – if they deny having a disease, next step is do nothing! (because it usually does not interfere c treatment, but if it does, next step is confront the pt).
      562. Splitting – all is good or bad. a/w borderline d/o. If they only say all is good, its idealization. If they only say all is bad, its devaluation. Splitting must have both.
      563. Regression – look for h/o bedwetting in a kid >5yo (<5yo is normal).
      564. Reaction formation vs Undoing – rxn formation is a thought, undoing is an action. Both are classically a/w obsessive compulsive d/o, where rxn formation is the obsession, and undoing is the

      compulstion.
      565. Reaction formation vs sublimation – sublimation does something good for mankind.
      566. Primary insomnia – disturbance in initiating, maintaining or feeling rested after sleep. Tx: 1st hygeine treatment: regularize sleep hours, use of bed only for sex/sleep, if not asleep in

      30 minutes then leave bed and return only when drowsy, no napping, regular exercise but not immediately prior to bedtime, reduce/eliminate alcohol/caffeine/smoking, relaxation exercise. 2nd

      sedative-hypnotics (benzo, zolpidem) for short-term relief
      567. Narcolepsy – daytime drowsiness, irresistible sleep attacks c hypnagogic/hympopompic hallucinations, sleep paralysis, cataplexy (loss of muscle control c strong emotions). Tx c short

      daytime naps, 2nd stimulants for sleep attacks and TCAs for cataplexy.
      568. Sleep apnea – obstructive type d/t occlusion of upper airway during sleep in an obese pt. Central type is d/t reduced nocturnal resp drive). Dx c polysomnography. Tx:1st wt reduction, 2nd

      CPAP for obstructive type, Acetazolamide or protriptyline for central type.
      569. Restless Legs Synd – agonizing, deep creeping sensations in leg/arm muscles relieved by moving or massage. Pt has trouble falling asleep at night because of it. Tx c benzodiazepam.
      570. Intermittent Explosive – discreet episodes of loss control of aggressive impulses, but otherwise not aggressive. Tx c benzo (causes disinhibition) and CBT.
      571. Kleptomania – failure to resist stealing unnecessary and unneeded things. a/w Bulimia.
      572. Pyromania – deliberate fire setting and fascination c fire, usually in kids. Make sure the guy is not getting paid to do it and that it is completely for self-satisfaction.
      573. Trichotillomania – recurrent pulling out of one’s own hair. Tx c psychotherapy, SSRI.
      574. Adjustment Disorder –excessive emotional/behavioral responses that occur within 3 months of a stressor that is within range of normal experience (unlike PTSD), such as school problems,

      marital discord, job loss or illness. Does not persist after 6 months of stressor. Lacks sufficient evidence to make for other diagnosis (MDD). Tx:1st evaluate suicide risk. 2nd psychotx,

      antianxiety, antidepressants, 3rd stress reduction.
      575. Personality Disorders - Cluster A (Weird: Paranoid, Schizoid (pt wants to be alone), Schizotypal (peculiar ideations/appearance/behavior magical thinking)), Cluster B (Wild: Antisocial

      (exploitative, destructive, impulsive behavior c no remorse. Childhood h/o conduct d/o essential for dx. Tx c SSRI), Borderline (instability of self-image, identity, relationships and mood. Does

      crazy things and still feels empty inside. h/o child abuse. Tx c pschotx (long-term), SSRI for mood stability and impulsitivity, haloperidol for psychosis. Avoid benzo), Histrionic (attention

      seeking, hits on the doctor, needs praise and reassurance), Narcissistic (grandiose, mad if humiliated, lack of empathy). Cluster C (Worried: Obsessive-compulsive (tx c fluvoxamine), Dependent,

      Avoidant (does not want to be alone (unlike schizoid), but fears rejection)
      576. Antipsychotics (Neuroleptics): Low-doses (thioridazine, chlorpromazein), high-doses/long-acting (haloperidol, fluphenazine. Highest risk of EPS, NMS), atypical (clozapine, risperidone,

      olanzapine, quetiapine, ziprasidone). Typicals block dopamine (D2) receptors, thus used for positive symptoms only and have many side-effects, while Atypicals block serotonin (5-HT), D2 and D4,

      thus can be used for positive and negative symptoms and have fever side-effects. Adverse-effects: Hours-Days: Dystonia (spasms), Torticollis and oculogyric crisis (eyes stay looking up). Tx c

      benztropine, diphenhydramine or trihexylphenidate. Weeks: Akathisia (restlessness). Tx c lowering drug-dose, benzo, BB, or switch to atypical (best). Months: Tardive dyskinesia (lip-smacking). Tx

      c switching to atypical. Neuroleptic malignant syndrome: MC c high-potency drugs, increased risk if used c lithium, fever, rigidity, autonomic instability, very high CPK levels, high K+, tx c IV

      dantrolene or bromocriptine. Clozapine causes agranulocytosis (must do weekly CBC if taking), thioridazine causes retinal pigment deposits, chlorpromazine causes jaundice and photosensitivity.
      577. Newer Atypicals Adverse Effects: Risperidone (less sedative, but increases prolactin, incrase risk of movement d/o), Olanzepine (love to ask about. weight gain (MC), risk of DM), Ziprasidone

      (prolonged QT), Quetiapine (risk of movement d/o)
      578. Antidepressants: block NE, 5-HT, Dopamine. MAOIs (bad b/c of Tyramine food reaction (cheese, red wine, chocolates, sausages). Must stop MAOI at least 2 weeks before starting TCAs or SSRI. Tx

      of choice for atypical depression (increased sleep/weight/appetite or Leaden paralysis)). TCAs (best ones are nortryptilline and desipramine, worst is amitriptylline. Causes hypotension,

      anti-cholinergic s/s, conduction defect (MCCOD, MC is sinus tachy, but USMLE loves widened QRS, tx c bicarb), sexual problems, changes in wt, sedation). SSRI (1st choice for MDD (fluoxetine,

      sertraline, peroxitine, citalopram, escitalopram), Anxiety (fluoxetine, sertraline, peroxitine) and OCD (fluvoxamine only). Causes headache (MC), GI upset, sedation, agitation, sexual dysfunction

      (worst s/s), weight gain). Others include Venlafaxine (MDD, anxiety), Duloxetine (MDD, pain d/o), Bupropion (MDD, smoking cessation), Mirtazipine (weight good (good for anorexia), sedation),

      Trazodone (priapism). In a nutshell, always answer SSRI unless: 1- pt c MDD and neuroleptic (spinal) pain, give duloxetine; 2 – pt c MDD and has sexual changes/weight gain, give bupropion (not

      buspirone for GAD).
      579. Mood stabilizers – Depressed pt (lithium or lamotrigine) or Mixed/Manic (Lithium, valproic acid, antipsychotics). Either way, lithium is 1st line. It causes tremors, GI upset,

      hypothyroidism, nephrotoxic, teratogenic, acne, wt gain, leukocytosis, ataxia, and seizures. Must get weekly blood levels and must get TSH, BUN/Cr, hCG before starting it. If renal disease, pick

      valproic acid, if very acute mania pick haloperidol, otherwise always go with lithium first. Never discontinue lithium abruptly and levels >3.0 is a medical emergency that needs IV saline or

      hemodialysis.
      580. Electroconvulsive therapy – increases serotonin for conditions like MDD, mania and schizophrenia. No absolute contraindications. Only relative CI is high intracranial pressure (brain

      tumors). Who gets it? Suicidal pt (tx of choice), those who don’t respond to meds, pregnancy, h/o benefit c ECT, medication complications. MC adverse effect is memory loss.
      581. Benzodiazepines – all work on CP450 exams OTL (Oxazepam, Temazepam, Lorazepam), so remember OTL for Outside The Liver.
      582. Suicide – if pt mentions it, next step is to ask more questions (attempt, ideations), then admit. Risks: h/o attempt (best indicator of eventual success), hopelessness, psychiatric/physical

      illness, drug abuse, elderly, social isolation (living alone is worse than single, they are not the same thing!), low job satisfaction. MC method in males are guns, females are guns. MC attempt in

      males are guns, females are pills.

      PULMONARY:

      583. When to intubate? pO2<50, pCO2>50, pH<7.3 @ room air. Remember if pt becomes fatigued, this is a bad sign, don’t assume he’s just tired, intubate him.
      584. Common cold – rhinitis, sneezing, headache, malaise and cough (no fever). Rhinovirus is MCC (also adenovirus, RSV, influenze). Tx: keep well hydrated, NSAIDS for fever, warm salt water

      gargles for pharyngitis (fever, dry/sore throat) and laryngitis, pseudoephedrine/phenylephrine for nasal congestion, avoid aspirin in children
      585. Pharyngitis (strep throat) – although viruses can be a common cause, r/o bacterial infection (group A strep, aka strep pyogenes) c rapid strep test. Clues to strep throat include cervical

      lymphadenopathy, fever, pharyngeal and tonsillar exudates and the absence of cough. Tx c penicillin/erythromycin is given to prevent complications (peritonsillar/retropharyngeal abscess,

      meningitis, endocarditis, acute RF and glomerulonephritis). If viral etiology, supportive care only.
      586. Peritonsillar abscess – dysphagia, fever, pain and trismus (hard to open mouth). Uvula displaced by swelling, tx c surgical drainage and antibiotics.
      587. Thrush – candidal infection that has removable white patches in the mouth (rememeber, candida CAN come off, hairy leukoplakia cant). Tx c nystatin, fluconazole.
      588. Sinusitis – facial pain/pressure, fever, greenish purulent rhinitis. If suspected, go ahead and begin tx c amoycillin, then get x-ray, then CT-scan of sinus. Only maxillary and ethmoid

      sinuses are present in children. Ethmoid sinusitis is more frequent in children. Cavernous sinus thrombosis is a complication that includes facial edema, meningitis and opthalmoplegia.
      589. Allergic rhinitis – sneezing, itchy/water eyes, nose blocked and/or runny. Tx c corticosteroids and cromolyn sodium, antihistamines, decongestants, allergy shots.
      590. Nasal polyps – swollen mucosa/submucosa polypoid tissue causing obstruction of nasal cavity. A/w allergic rhinitis, cystic fibrosis and aspirin intolerance.
      591. Croup – (laryngotracheobronchitis) an acute viral illness in young kids who get cold s/s at onset, then barking cough, slight fever and inspiratory/expiratory stridor. X-ray shows steeple

      sign. Tx c humidified air then racemic epinephrine.
      592. Epiglottitis – kid c drooling, high fever, resp obstruction, dyspnea, dysphagia, inspiratory stridor, lateral x-ray shows thumb sign. Do not irritate the kid or maneuver epiglottis as that

      would worsen obstruction. MCC is H. influenza type B. Tx c cephalosporins and intubation if needed.
      593. Pertussis – 3 stages: catarrhal (coryza for 1-2wk), paroxysmal (whooping cough, 2-4wk), convalescent stage weeks later. Tx c erythromycin in catarrhal stage, otherwise supportive care.
      594. Acute Bronchitis – large airway inflammation, productive cough, fever, mild dyspnea, CXR is clear (if there was an infiltrate, then its pneumonia). Tx c abx, hydration, expectorants,

      bronchodilators.
      595. Bronchiolitis – small airway inflammation, tachypnea, wheezing, fever, cough in a child <2yo. Caused by RSV. Tx c ribavirin and oxygen.
      596. Pulmonary Nodule – 1st step is get old xray. 2nd step If lesion was present and is the same size, its benign (hamartoma, discharge home). If the lesion was there and has gotten bigger,

      assume cancer. However, if the lesion was not in the old-xray, then classify his risk. If he is low risk (<40yo, nonsmoker) then its probably benign (hamartoma, CXR every 3mo for 2yrs). If he is

      high-risk (>50, smoker), assume cancer (do open-lung biopsy).
      597. Pneumonia – Typical (<2days prodrome, fever >102, >40yo, one lobe involved) is d/t strep pneumo (gram + diplococci, tx c levaquin, prevent c vaccine in >65yo and pt c comorbidities, tx c

      3rd generation cephalosporins). Atypical (>3days, HA, aches, dry cough, <40yo, multiple lobes, diffuse) in a young, otherwise healthy adult c atypical pneumonia is Mycoplasma/H.

      Influenza/Chlamydia and tx c Azithromycin. College student c dry cough, think of Mycoplasma (cold agglutinins) or Chlamydia. An elderly pt c COPD likely has bacterial pneumonia, or if in the

      winter, possible influenza. An AIDS pt c low CD4 and subacute illness has PCP (tx c bactrim (if allergic, give dapsone) or prophylax when CD<200). A pt whose mentation is altered (postop from

      anesthesia, demented, intoxicated) or who have swallowing dysfunction (CVA) has aspiration pneumonia. An alcoholic will likely have Klebsiella. If you see CNS (headache), GI (diarrhea) and

      pneumonia, its Legionella so give erythromycin (1st test is urine legionella Ag test, most accurate test is direct fluorescent antibody from sputum). If cystic fibrosis or hospitalized for a long

      time, think pseudomonas (though S.aureus is still a big one here) and tx c piperacillin/tazobactam or ceftazidime. If pt is a farmer (cattle, sheep, goats) or veterinarian, think of Coxiella

      burnetti (tx c doxycyline) or chlamydia psitacci (bird-exposure, tx c doxycycline). (Pediatric Wheezing: <1yo is RSV, 2-5yo is Croup (barking) or epiglottitis (drooling), >6yo is Asthma)
      598. Influenza – fever, chills, cough, sore throat c positive throat/nasal swabs in the winter-time. For prophylaxis, give Amantidine (influenza A only) or vaccine (>50yo or high-risk pt). If

      discovered <2days, give Oseltamivir. If >2days, rest/fluids/symptomatic tx c analgesics/antipyretics.
      599. Pneumococcal vaccine – everyone >65yo, anyone (>2yo) c COPD/DM/alcoholism/ immunocompromised (HIV/AIDS, cancer, steroid-use, chemotherapy)/post-splenecomy.
      600. Influenza vaccine – children 6-23months, >65 (Dr. Fisher says >50yo) c chronic medical conditions, residents of nursing homes, health care workers c pt contact, children (2-18) c chronic

      aspirin use (Kawasaki’s), caregivers of kids <6mo.
      601. TB – caseating granulomas, transmission by aerolized droplets (overcrowded areas, poor ventilation, health-care workers, immunocompromised, homeless), fever, productive cough, night sweats,

      chills, wt loss. If symptomatic, next step is CXR then AFB. If asymptomatic, next step is PPD (refer to ID notes for Mantoux reaction margins), then CXR then AFB. Tx c RIPE until culture

      sensitive.
      602. Histoplasma – Ohio/Mississipi river bird/bat droppings in soil grow spores, which are inhaled. If mild, no tx. If more ill give ketoconazole or amphotericin B. If disseminated (AIDS pt)

      then 1st step is blood/bone marrow culture, 2nd Ampho B.
      603. Coccidiomycosis – flulike s/s, arthralgia, erythema nodosum/multiforme rash. If mild, no tx. If severe, give Ampho B.
      604. Cryptococcus – AIDS or steroid-use pt gets infected c encapsulated yeast found in soil/pigeon droppings in NY area causing s/s in the lungs and CNS (meningitis). Tx c Ampho B + flucytosine

      for severe disease.
      605. Lung Abscess – purulent/putrid sputum, cough, chest pain, fever, pt c poor dentition and aspiraton, CXR shows cavities and air-fluid level. Tx c IV penicillin G.
      606. A-a gradient: 150 – (1.25 x PCO2) – PaO2. (NL = 5-15, high c all hypoxemia causes except hypoventilation and high altitude)
      607. Obstructive – low FEV1, low FVC, low FEV1/FVC, low DLCO in emphysema, normal DLCO in Chronic bronchitis/Asthma. FEV1 determines severity of disease (60-70% is normal-moderate COPD, <50% is

      severe COPD). Decreased lung flow.
      608. Restrictive – FEV1, FVC both decreased, but FEV1/FVC is normal. TLC is reduced. Decreased lung volume.
      609. COPD – what are the only things that decrease mortality? Home O2 (when PaO2 <60mmHg) and smoking cessation. If tx is not sufficient c bronchodilators, give theophylline (decreased clearance

      if also given c erythro, cipro, cimetidine). Tx 1st Anticholinergics (ipratropium bromide MDI), 2nd Albuterol, 3rd Theophylline. What is the best predictor of survival? FEV1. Vacccines? Influenza

      annually and pneumococcus every 5 years.
      610. Chronic Bronchitis – blue bloaters (due to cyanosis), productive cough, recurrent pulm infections.
      611. Emphysema – pink puffer, progressive dyspnea, low DLCO, less cough, cachexic, barrel chest, sits in tripod position, hyperresonant lungs, distant heart sounds, CXR shows huge lungs c

      bullae,. If in a young pt c no smoking history, pick alpha-1-antitripsyn (AAT) deficiency, tx c purified human AAT.
      612. Asthma – for attacks: 1st give oxygen, 2nd peek flow, 3rd Albuterol, 4th Steroids for 14 days (no abx). What if pt has attack secondary to BBs? Give anticholinergics (ipratropium bromide).

      For exercise-induced asthma, give cromolyn and albuterol before exercising. Chronic tx: daily inhaled steroids, albuterol as needed (other drugs depend on type of asthma). For acute evaluation get

      ABG (resp alkalosis, if it gets normal that’s bad), Pulse ox, CXR. For chronic evaluation, get PFTs, methacoline challenge, bronchodilator (test reversibility). Tx of choice for nocturnal cough

      is long acting B-agonist (Salmeterol).
      613. Bronchiectasis – cupfuls of purulent/malodorous productive cough, wt loss, hemoptysis, clubbing, a/w cystic fibrosis and kartegener’s syndrome (immotile cilia). Dx c CXR 1st then CT

      (best, but not 1st). For acute management, tx for pseudomonas (ticar/pipercillin, quinolones, ceftazidine). For chronic tx, give bronchodilators, postural drainage, rotate abx (prevent

      resistance), surgery and vaccines.
      614. Pulmonary Fibrosis – interstitial inflammation, exertional dyspnea (MC s/s), crackles, clubbing, cor pulmonale. Dx: 1st CXR (shows ground-glass appearance), 2nd CT, 3rd Lung biopsy (gold

      standard). Tx c steroids for 6months, then transplant if needed and f/u PFTs.
      615. Allergic Bronchopulmonary Aspergillosis (ABPA): must have 6 of the following 7: h/o asthma, peripheral eosinophilia, pulm infiltrates, + skin test to Aspergillus, high serum IgE, +IgE/IgG for

      Aspergillus, central bronchiectasis. Tx c prednisone.
      616. Atelectasis – MCC of postop fever after 1-2 days. Tx: 1st incentive spirometry, 2nd Deep breathing exercises, 3rd out of bed, 4th chest physical therapy, 5th CPAP, 6th Bronchoscopy (if

      atelectasis is severe and spontaneous-due to mucus plug).
      617. Hemothorax – blood in pleural space. Dyspnea c massive shock. Tx: if very small, observe. All others need a chest tube. Some need thoracotomy (bleeding >200mL/hr)
      618. Asbestosis – exposure to remoal sides, pipe maintenance, etc. Takes >20 years to develop mesothelioma, but much less to develop bronchogenic CA (esp if smoking). Dx c lung biopsy showing

      ferruginous bodies (not CXR or CT). No tx.
      619. Silicosis – increased risk of TB (must do annual PPD). Upper lob nodules c eggshell hilar node calcification.
      620. Caplan Synd – rheumatoid nodules in lung periphery c coal-workers pneumoconiosis.
      621. Sarcoidosis – blacks, females, biopsy shows non-caseating granulomas (most accurate), fever, dyspnea, skin (erythema nodosum)/eye (iritis)/CNS (nerve palsy)/cardiac (arrhythmia) s/s. CXR

      shows b/l enlarged hilar adenopathy, dx c biopsy, elevated ACE, high calcium. Tx c steroids.
      622. Acute Resp Distress Synd (ARDS) – acute lung damage from increased pulmonary (alveolar) permeability. Pt c dyspnea, tachypnea, tachycardia, no improvement c oxygen, arterial hypoxemia

      (PaO2/FiO2 ratio <300), hypercapnea, CXR shows b/l whited out lungs. H/o infection, aspiration, near-drowning, drugs, shock, burns, and pancreatitis. Tx c PEEP.
      623. Pulmonary Embolism – venous stasis/thrombosis, hypercoagulable state (pregnancy, SLE, cancer, prtn C/S def, OCP, antithrombin III def, Factor V leidin). Sudden onset of dyspnea, pleuritic

      CP, hemoptysis, syncope, split S2 sound. Clear CXR. EKG shows sinus tachycardia or S1Q3T3. ABG shows resp alkalosis c hypoxia and increased A-a gradient. Mostly from deep leg vein thrombi (above

      knee is not possible, must be below knee). Dx c spiral CT or V/Q scan (esp if pregnant). Definitive dx c pulmonary angiography. Tx c 1st anticoagulation c heparin(LMW-heparin if pregnant) c O2 if

      stable, 2nd thrombolytics (tPA) if unstable, 3rd embolectomy (if severe like a saddle embolism), 4th filter (if recurrent or if anticoagulation is contraindicated).
      624. Pulmonary HTN – CP, dyspnea, lethargy, shortened S2 split c louder P2, weak peripheral pulses/coldhands. Tx c oxygen and vasodilators.
      625. Goodpastures – renal c pulm so pt c hemoptysis and hematuria, anti-GBM Abs, tx:1st prednisone, 2nd cyclophosphamide, 3rd plasmapharesis.
      626. Wegeners – Upper airway, pulmonary, renal so pt c sinusitis, hemoptysis, hematuria, c-ANCA. Tx: 1st cyclophosphamide, 2nd prednisone.
      627. Pleural Effusion – once you see it on CXR, next step is tap (thoraentesis) to see if it is transudative (CHF, PE, nephrotic syndrom, atelectasis) or exudate (parapneumonic, cancer, PE,

      chylothorax, esophageal rupture, rheumatoid arthritis). For it to be exudates: Pleural fluid to serum protein ratio > 0.5, Pleural fluid to serum lactate dehydrogenase (LDH) ratio > 0.6, Pleural

      fluid LDH more than 2/3 of the upper limits of normal serum value. What if they don’t give you the serum levels? Then exudates is when pleural fluid cholesterol >45 mg/dL and pleural fluid

      protein > 2.9. If you think it is malignancy (old guy, wt loss, smoker, etc) then look for LDH >1000, glucose 30-50, and lymphocytes 50-70%. However, if you worry about parapneumonic effusion,

      look for LDH >1000, glucose >30, pH <7.2, next step is chest tube drainage.
      628. Lung Cancer – no available screening test. Squamous cell (central cavitation, a/w hypercalcemia d/t PTH-like peptide, dx c bronchoscopy), Small cell (central cavitation, a/w SIADH,

      Eaton-Lambort and Cushings syndrome, dx c bronchoscopy), Adenocarcinoma (peripheral lesion, MC is bronchoalveolar CA, increased hyaluronidase levels, dx c FNA then thoracotomy c pleural bx). When

      is it unresectable? Hoarseness, METS, wt loss >10%, CNS s/s, SVC syndrome (JVD c facial discoloration d/t SCC) or tumor at the trachea/esoph/pericardium. For small-cell Ca, tx c chemotherapy

      (VP16-etoposide and platinum). For non-small cell Ca give radiation and chemo (CAP – Cyclophosphamide, Adriamycin, Platinum).

      RENAL/UROLOGY:

      629. Prostatitis – dysuria, chills, fever, low back pain, perineal pain, frequency, prostate may feel boggy and large but is always tender. E.coli. Tx c levaquin and hydrate.
      630. Epididymitis – tender (relieved c scrotal elevation, opposite of torsion), enlarged testicle, fever, scrotal thickening. Caused by neisseria, e.coli, chlamydia. Tx c abx (tetracycline,

      levaquin), nsaids, scrotal support.
      631. Orchitis – fever, increase testicular size, scrotal pain/erythema, a/w mumps and TB. Tx c same as above.
      632. Urethritis – urethral d/c, dysuria. Next step is culture/gram stain (r/o STD). Tx c abx.
      633. Testicular torsion – MCC of scrotal swelling in kids, causing severe pain (especially when scrotum is lifted, opposite of epididymitis), abdm pain (sometimes this is their only s/s, so must

      check scrotum), vomiting. Urologic emergency for blood supply must be regained within 6 hrs to prevent loss of testicle.
      634. Cryptorchidism – no s/s. Dx c CT. Tx: Orchiopexy at age 1 to prevent cancer.
      635. Any testicular mass needs to have cancer ruled out, so excise and biopsy it.
      636. Benign Prostatic Hypertrophy – enlargement of prostat gland causing obstruction (hesitancy, dribbling, weak/low stream), urgency, nocturia and frequency. Dx: 1st DRE, 2nd U/S. Tx: 1st

      a-blocker (terazosin, remember tamsulosin (flomax) has the least adverse effects), 2rd 5-a-reductase inhibitors (finasteride), 3th Surgery (TURP). However, if pt is in ER in pain, 1st foley (if it

      wont pass, do suprapubic tap), 2nd TURP (skip meds).
      637. Hypospadia – meatus below penis tip, so you pee on your feet. Pt may have chordee (ventral penile curve causing penis to curve 90degrees). Tx:1st observe until 1yo (do not circumcise), 2nd

      surgery
      638. Hydrocele – fluid around the testis due to patent processus vaginalis. Dx c + transillumination. Tx c observation.
      639. Varicocele – pampiniform plexus vein dilation due to inefficient pampiniform valves. Disappears in supine position (no venous pooling). Dx c (-) transillumination. Tx c surgery.
      640. Cystitis – bladder infection causing dysuria, frequency, nocturia, urgency. Dx c UA/Ucx/Urine dip. MCC is E.coli. Tx:1st abx, 2nd IVP, cystoscopy (if recurrent).
      641. UTI – urgency, dysuria, low balck pain, low fever. Dx c midstream urine Cx to show high nitrates and leukocytes. Tx c TMP/SMX, amoxicillin, nitrofurantoin, levaquin. Any kid <6yo c UTI

      needs VCUG (MCC is vesicureteral reflux and posterior urthral valves).
      642. Nephrolithiasis – severe flank pain radiating to the groin c hematuria. Dx: 1st Xray (uric acid stones not visibile), 2nd CT scan abdo/pevis without contrast. Tx: 1st Hydration c analgesia,

      2nd (remember, ureter is 8mm wide, so a small stone (<5mm) will pass c supportive measures, but larger stones may completely obstruct) extracorporeal lithotripsy if upper GU tract, or ureteroscopy

      if lower GU tract.
      643. Anytime you suspect urethral injury (high riding prostate or blood at urethral meatus), next step is retrograde urethrogram (not foley!).
      644. We give cyclosporine for graft rejection, but cyclosporine itself is nephrotoxic. How do you differentiate renal graft rejection from cyclosporine toxicity? Do percutaneous needle biopsy.

      Also, if situation occurs, trying increasing cyclosporine: if kidney function worsens, its nephroxicity. If kidney function improves, its graft rejection (however try percutaneous needle biopsy

      first in risk of worsening kidney).
      645. Incontinence – discussed in Gyn notes. Functional/Overflow (nerve dysfunction, DM/MS, high voiding residual volume, tx c self-catheterization if pt cannot empty or anticholinergics if pt

      cannot store), Stress (weak pelvic floor, aggrevated by coughing/sneezing/laughing, tx c kegel exercises, then surgical MMK procedure), Urge (detrusor hyperreflexia causing spontaneous

      contractions, tx c anticholinergics).
      646. Hydronephrosis – kidney/ureter damage from ureter obstruction (in men, think BPH) causing flank/back pain and oliguria. Dx c ultrasound. Tx c 1st foley catheter to relieve distal

      obstruction, 2nd cystoscopy and ablation of stones.
      647. Pyelonephritis – ascending infection into kidney causing fever/chills, n/v, flank pain and anorexia. If pt is not seriously ill, tx c abx. If pt has severe n/v and appears ill (dehydration,

      hypotension) give IV hydration and abx for 2 weeks.
      648. Glomerulonephritis – hematuria, proteinuria, HTN, edema. If acute, give bed rest, anti-HTN. Causes include HIV, HBV, poststreptococcal, SLE, Goodpastures, Wegeners, RA, Polyareteritis

      nodoa, penicillamine, hydralizine, allopurinol and rifampin. If rapid progression give steroids, cytotoxics, plasmapharesis.
      649. Berger’s Disease – IgA nephropathy, gross hematuria after viral URI. Dx c biopsy (immune deposits of IgA in glomeruli). No tx. (Don’t confuse c Buerger’s disease, which is a problem

      of the fingers in smokers).
      650. Diabetic Nephropathy – microvascular glomerular damage (thickened GBM) and Kimmelsteil-Wilson lesions (nodular deposits in glomeruli). Best tx is prevention.
      651. Acute Renal Failure – rales, JVD, hyponatremia. Causes include prerenal, renal and postrenal. See below.
      652. Prerenal Failure – hypovolemia (dehydration) BUN/Cr >15:1, Tx c IVF. Causes include sepsis, CHF (tx c diuretic), Liver Failure (Hepatorenal Synd, which has no tx)
      653. Renal Failure – MCC is ATN (muddy-brown casts) due to: IV contrast (avoid in DM, renal dz, asthma, shellfish allergy), Rhabdo/Myoglobinuria (high CPK, tx c IVF and diuretics), SLE, Chronic

      NSAID use (papillary necrosis), aminoglycosides, cyclosporine, Goodpastures (anti-GBM Ab, linear on bx, tx c steroids and cyclophosphamide), Wegeners (tx c cyclophosphamide). ATN usually resolves

      in 6 weeks so just try to keep them alive (dialysis) until then. 2nd MCC is AIN (acute interstitial nephritis – look for wbc casts and eosinophilia. d/t drugs (B-lactam), calcium crystals,

      oxalate (antifreeze), chemotx (uric acid), tx c d/c stressor). 3rd MCC is Glomerulonephritis (RBC casts, dx c biopsy immediately) and 4th MCC is vasculitis (HUS< TTP, Multiple Cholesterol Emboli

      Syndrome (s/p cardiac cath pt gets blue feet, HTN and eosinophilia).
      654. Postrenal Failure – Anuria (no urine output with >25cc residual volume). Dx c renal u/s (shows hydronephrosis). MCC is BPH (then b/l renal stones). Tx c catheterization, then TURP.
      655. Minimal Change Disease – kids, glomerulus looks normal, but may have fusion of podoyctes. Dx c 24hr urine protein (no need for biopsy). Tx c steroids.
      656. Membranous Glomerulonephritis – elderly Caucasian c amyloidosis. No need to do biopsy for diagnosis.
      657. Focal Segmental Glomerulonephritis – h/o IVDA, 50% get ESRD, dx c biopsy
      658. Membranoproliferative Glomerulonephritis – a/w hepatitis C (give ribavirin) and endocarditis, dx c biopsy.
      659. When do you choose dialysis? Acidosis <7.25, Uremic encephopathy (1st give DDAVP, then dialysis), Increased K+ and creatinine, pericarditis, heart failure.
      660. Polycystic Kidney Disease – family history, HTN, hematuria, palpable flank mass, Dx c CT of abdo (shows multiple cysts).
      661. Chronic Renal Failure – azotemia (high BUN/Cr), metabolic acidosis, high K, hypervolemia (HTN, CHF, edema), low calcium/high phosphate. Tx c dialysis 1st, then water-soluble vitamins (lost

      in dialysis), calcium, EPO and anti-HTN meds.
      662. Hyponatremia: 3 types: Hypovolemic Hyponatremia (tx c saline), Hypervolemic Hyponatremia (pt c cardiomyopathy and edema, tx c correcting underlying cause), and Euvolemic Hyponatremia

      (Hypothyroidism (tx c thyroxine), SIADH (high urine osmolarity, tx c fluid restriction), Psychogenic polydipsia (low urine osmolarity, tx c fluid restriction)).
      663. Never give IV Potassium unless: 1- K+<2.8, 2 – pt on digoxin, 3 – arrhythmia.
      664. Only 2 conditions in Anion-gap acidosis (MUDPILES) where you do NOT give bicarb: DKA and Lactic acidosis.
      665. Vomiting vs Conn’s Synd – in vomiting (lose K and Cl, thus Cl is low) you treat c saline. In Conn’s synd (lose K, not Cl, thus Cl is normal) tx c Spironolactone and ACEI.
      666. Renal Artery Stenosis – high rennin HTN. 1st test is captopril imaging, 2nd test is Angiogram. Tx c angioplasty.


      1. An 83-year-old woman who has dementia, Alzheimer type, is brought to the office for a return visit by her daughter, with whom she lives. While intermittently somewhat confused, until recently

      the patient had been able to handle most of her activities of daily living. In the past month, however, she has shown little interest in eating and is awake most of the night. The daughter says

      the patient has been seeing things, especially at night. She has been accusing her daughter of stealing from her, and has also hit her daughter. The patient has fallen twice on her way to the

      bathroom at night. The daughter has been giving her diphenhydramine for 1 month to help her sleep, but she says it does not seem to be helping. You have also been treating the patient with

      ranitidine for esophageal reflux and with amitriptyline for depression. Vital signs are normal, and physical examination is unchanged from the last visit. Her mental status has deteriorated from

      her last visit 4 months ago. Today she is oriented only to name, does not seem to recognize you and appears to be visually hallucinating. Her daughter says she herself is overwhelmed and wonders

      if it is time to consider a nursing home for the patient. Which of the following is the most appropriate response?

      A

      ) "Her increased confusion may be due to her medicines. Let's explore that possibility first."

      B

      ) "Her worsening mental status may be due to an inadequate diet. Let's explore that first."

      C

      ) "It is a hard step to take, but I agree the time has come to arrange nursing home placement."

      D

      ) "It is a little premature for that. Let's try some home health services first."

      E

      ) "It is possible that medication might make her more manageable. Let's try a course of haloperidol."

      2. A 12-year-old boy is brought to the office by his parents for a follow-up visit after starting treatment with carbamazepine 3 months ago for temporal lobe seizures. He has been seizure-free

      since having attained a therapeutic serum carbamazepine level 2 months ago. He says that he feels well, is doing much better in school, and has no new symptoms or complaints. It is most

      appropriate to tell him and his parents that with this drug therapy, he will need monitoring to assess for which of the following conditions?

      A

      ) Agranulocytosis

      B

      ) Cardiac arrhythmias

      C

      ) Gastric ulcers

      D

      ) Proteinuria

      E

      ) Renal failure

      3. A 72-year-old professor emeritus comes to the office saying, "I am worried that I have Alzheimer's or small strokes or something." During the past year, he has noted increasing difficulty with

      his memory, especially for names, which has created several awkward moments professionally and socially. He adds, "I'll be doing fine, when all of a sudden my mind goes blank. I can't recall

      something I should easily know, and then suddenly it will come back to me a couple of minutes later." He complains that he frequently misplaces items like his keys, which is very unlike him. He

      also complains that his sleep is not restful anymore and that he tosses and turns all night. His wife has told him that she is not sleeping either, because he snores loudly. He says, "I'm tired

      much of the time, and I doze off whenever I try to read." He also complains of frequent headaches in the morning. Past medical history includes hypertension, which is well-controlled with

      diltiazem; peptic ulcer disease for which he takes ranitidine; and lumbar osteoarthritis, for which he takes ibuprofen. Height is 175 cm (5 ft 9 in) and weight is 72 kg (160 lb). Vital signs are:

      temperature 36.9°C (98.4°F), pulse 80/min and regular, respirations 12/min and blood pressure 158/100 mm Hg. Physical examination, including neurologic examination, is normal. He scores 29 out of

      30 on the Mini-mental state test. Which of the following is the most appropriate next step?

      A

      ) Order CT scan of the head

      B

      ) Order electroencephalography

      C

      ) Reassure him that his symptoms are probably normal

      D

      ) Refer him for neuropsychological testing

      E

      ) Refer him for polysomnography

      4. An 8-year-old boy is brought to the office because of a 5-day history of fever, coryza and cough that coincides with an epidemic of influenza in the community. Today he is unable to walk

      because of pain in the calves. His mother has been giving him acetaminophen for fever and pain. Physical examination shows a temperature of 38.3°C (101.0°F). He is alert, interactive and

      well-hydrated. He has clear rhinorrhea, mild pharyngeal erythema and a clear chest. His calves are tender to palpation. Strength cannot be tested because of pain. Neurologic examination, including

      deep tendon reflexes, is normal. Which of the following is the most appropriate therapy?

      A

      ) Acetaminophen, orally, as needed

      B

      ) Amantadine, orally

      C

      ) Immune globulin, intravenously

      D

      ) Influenza virus vaccine, intramuscularly

      E

      ) Prednisone, orally

      5. A 55-year-old Hispanic welder comes to the office for an initial visit because of a lesion in his right eye that has been present for several months. During this time his right and left eyes

      have been increasingly sensitive to wind. He has not had double vision and has not seen "spots" in his field of vision. He says that he has been generally healthy and has not seen a physician

      during the past 30 years. He takes no medications. He does not wear corrective lenses. Family history is significant for blindness in his mother at age 77 years. The patient has smoked a half pack

      of cigarettes daily for the past 40 years, and he drinks an occasional six-pack of beer on weekends. Vital signs today are temperature 37.2°C (99.0°F), pulse 110/min, respirations 20/min, and

      blood pressure 140/85 mm Hg. Examination of the right eye discloses the finding shown in the photograph. Visual acuity is 20/40 in both eyes. Musculoskeletal examination discloses symmetric

      enlargement of the proximal and distal interphalangeal joints of both hands. The joints are firm to palpation and cool to the touch. The remainder of the physical examination is noncontributory.

      Which of the following is the most likely diagnosis?

      A

      ) Corneal abrasion

      B

      ) Glaucoma

      C

      ) Keratitis

      D

      ) Pterygium

      E

      ) Stye

      6. A 3-year-old African-American boy who is a new patient is brought to the office by his grandmother. She says, "He was OK until this afternoon, when he suddenly developed a fever. He's been

      spitting a lot. He keeps his mouth open and he refuses to lie down. He won't eat." You learn that the child has received only one set of vaccinations at the age of 2 months. Vital signs are:

      temperature 39.4°C (103.0°F), pulse 110/min, respirations 24/min and blood pressure 110/70 mm Hg. On physical examination the child sits in a tripod position and salivation is evident. Which of

      the following is the most appropriate next step?

      A

      ) Administration of cefotaxime, intravenously

      B

      ) Complete blood count and blood culture

      C

      ) Determination of arterial blood gas values

      D

      ) Immediate otorhinolaryngology consultation

      E

      ) Lateral neck x-ray film

      7. A 19-year-old college student comes to the student health center because of palpitations, shortness of breath and a runny nose. He has asthma that he has treated with an over-the-counter cold

      preparation and an epinephrine metered-dose inhaler every 2 to 3 hours at night. He just used the bronchodilator in the waiting room. Vital signs are: temperature 38.2°C (100.8°F), pulse 82/min

      and respirations 18/min. He appears to be somewhat anxious and his breathing is labored. Auscultation discloses mildly diminished breath sounds in all lung fields accompanied by scattered

      wheezing. Which of the following is the most appropriate management?

      A

      ) Add oral aminophylline therapy

      B

      ) Admit him to the hospital for respiratory therapy

      C

      ) Prescribe decongestant/antihistamine therapy

      D

      ) Prescribe antihistamine therapy

      E

      ) Substitute an albuterol nebulizer for the epinephrine

      The following vignette applies to the next 2 items.

      A 6-month-old African-American girl is brought to the office in January for a well-child visit. She was born at 32 weeks' gestation after a pregnancy complicated by an incompetent cervix and

      premature labor. She has a 3-year-old brother. Her birth weight was 2700 g (6 lb). At birth, she had mild respiratory distress syndrome and required mechanical ventilation for 36 hours. She also

      has gastroesophageal reflux disease for which she is given ranitidine, daily. Vaccinations are up-to-date. Developmental milestones are appropriate for her adjusted chronological age. Head

      circumference and growth charts are shown.

      Item 1 of 2

      8. Regarding the results on the head circumference chart, which of the following is the most appropriate conclusion?

      A

      ) The growth pattern is most likely due to neonatal intraventricular hemorrhage

      B

      ) Her growth is normal for a premature infant

      C

      ) An MRI should be done to rule out a brain tumor

      D

      ) The parents' head circumferences should be measured to evaluate the infant for familial macrocephaly

      E

      ) She should be examined for possible papilledema to rule out hydrocephalus

      Item 2 of 2

      9. Two weeks later the girl is brought back by her mother because of a runny nose and difficulty breathing for the past 3 days. The mother says, "She's up every 2 hours now, and last night she had

      a fever. I think her brother picked up a cold from preschool and gave it to her. I can't keep him away from her." Vital signs now are temperature 38.5°C (101.3°F), pulse 144/min, and respirations

      60/min. On physical examination she is alert but in mild respiratory distress with slight nasal flaring. Auscultation of the chest discloses fine expiratory wheezes bilaterally, and mild

      intercostal retractions. Which of the following is the most likely cause of the infant's illness?

      A

      ) Aspiration pneumonia

      B

      ) Asthma

      C

      ) Bronchopulmonary dysplasia

      D

      ) Mycoplasma pneumoniae

      E

      ) Respiratory syncytial virus

      10. A 72-year-old woman comes to the health center for the first time because of palpitations for the past 3 weeks. She says she has felt tense and has had trouble sleeping. Vital signs are:

      temperature 37.0°C (98.6°F), pulse 104/min, respirations 18/min and blood pressure 142/80 mm Hg. Physical examination is normal except for a mild bilateral hand tremor. Electrocardiogram shows

      sinus tachycardia but is otherwise normal. Which of the following diagnostic studies will most likely rule out an organic cause for her symptoms?

      A

      ) 2-Hour postprandial serum glucose concentration

      B

      ) Echocardiography

      C

      ) Holter monitoring

      D

      ) Serum thyroid-stimulating hormone concentration

      E

      ) Toxicologic screening of the urine

      11. A 48-year-old man who smokes cigarettes has had progressive claudication in the left calf for the past month. He says the pain lasts about 5 minutes and then subsides. Physical examination

      shows absent pulses in the left foot and normal pulses in the right foot. Atrophic changes are noted in both legs. Doppler examination shows a 0.40 left ankle/brachial ratio; there is no change

      with exercise. Which of the following is the most likely diagnosis?

      A

      ) Aortic occlusive disease

      B

      ) Femoral popliteal occlusive disease

      C

      ) Leriche syndrome

      D

      ) Peripheral small-vessel occlusive disease

      E

      ) Thromboangiitis obliterans

      12. A 52-year-old Hispanic computer technician comes to the office because of a 3-week history of substernal chest discomfort when she climbs stairs or eats a heavy meal. She first noticed the

      discomfort after climbing two flights of stairs. The discomfort is nonradiating and sometimes only involves the left side of the chest. She has hypertension and type 2 diabetes mellitus. Current

      medications include metformin and an ACE inhibitor. She has recently had increased stress because her company is experiencing financial difficulty. Her husband receives medical disability

      benefits, and they are dependent on her income. Physical examination shows no abnormalities. Which of the following risk factors is most important to consider when assessing her chest pain?

      A

      ) Age

      B

      ) Diabetes mellitus

      C

      ) Gender

      D

      ) Hypertension

      E

      ) Stress level

      13. A 47-year-old woman returns to the office because of gastrointestinal symptoms. She says, "I still have burning pain in my stomach that travels up my chest to my neck after I eat." During the

      past 5 years she has been treated with antacids, H2-blocking medications, proton pump inhibitors and motility agents, with only mild relief. She smokes one pack of cigarettes per day and drinks

      one cup of coffee in the morning. There is no family history of peptic ulcer disease. Previous endoscopies, the last of which was 6 months ago, have shown lower esophagitis secondary to reflux

      with healing ulcers and scarring. Gastric and duodenal cultures for Helicobacter pylori have been negative. Vital signs today are normal. Physical examination, including rectal examination, is

      normal. Which of the following is the most appropriate next step?

      A

      ) Consider an alternative pharmacotherapeutic regimen

      B

      ) Continue current treatment

      C

      ) Do esophageal pH monitoring

      D

      ) Obtain surgical consultation

      E

      ) Repeat endoscopy

      14. A 38-year-old woman with systemic lupus erythematosus but no evidence of nephritis comes to the office because of a 3-week history of mood swings with crying spells, irritability and insomnia.

      She is especially upset because she has been yelling at her children "over small, everyday things." One month ago she started corticosteroid therapy. She is currently taking prednisone, 60 mg/day.

      Her other medications include an oral contraceptive (the same one for the past 6 years) and ibuprofen. She smokes one-half pack of cigarettes daily, drinks one to two beers 5 nights weekly and

      three cups of coffee each morning. Which of the following is the most appropriate intervention for her mood disturbance?

      A

      ) Add amitriptyline at bedtime

      B

      ) Discontinue the oral contraceptive

      C

      ) Reduce the prednisone dosage

      D

      ) Replace ibuprofen with acetaminophen

      E

      ) Urge her to stop smoking and to reduce her alcohol and caffeine intake

      15. A 76-year-old retired pharmacist is brought to the health center by his wife, who says, "He's afraid to go to sleep, Doctor. Tell him, Henry." He tells you that he was mugged and assaulted 1

      week ago while he was out for a walk early in the morning. The patient proceeds to tell you that he has been having nightmares, not about the assault, but of being in vulnerable situations. He

      also feels anxious during the day but he is able to leave the house without difficulty. In addition to supportive therapy, which of the following pharmacotherapies is most appropriate to

      prescribe?

      A

      ) Amitriptyline

      B

      ) Clonazepam

      C

      ) Diphenhydramine

      D

      ) Gabapentin

      E

      ) Risperidone

      16. A 58-year-old white store manager comes to the office for a periodic health evaluation. You have been treating both the patient and his wife for the past 15 years. Today the patient is tearful

      and agitated. He says that he is having difficulty with his son, who is age 32 years and has schizophrenia. The son has been living intermittently in a group home or on the streets. The patient

      says that his son is noncompliant with his antipsychotic medications. Recently, the son has been calling the patient's house asking for money, which the patient suspects his son uses to buy

      alcohol and illicit drugs. It is most appropriate to advise the patient to do which of the following?

      A

      ) Arrange an involuntary commitment to a psychiatric hospital for his son

      B

      ) Ask his son's psychiatrist to adjust his medication

      C

      ) Change his phone number

      D

      ) Contact the local chapter of the National Alliance for the Mentally Ill for support and advice

      E

      ) Obtain a restraining order against his son

      17. A 20-year-old man comes to the health center because of ankle pain. Two days ago he sustained an inversion injury of his left ankle in a basketball game. He has been able to walk unassisted

      since the injury. Today he has pain and moderate swelling and discoloration over the lateral malleolus. Physical examination shows tenderness on palpation over the anterolateral corner of the

      ankle joint. He has had two similar injuries in the past. Which of the following is the most appropriate initial management?

      A

      ) An ankle-strengthening exercise program

      B

      ) Application of a long-leg cast for 3 weeks

      C

      ) Application of a short-leg cast for 3 weeks

      D

      ) Protected weight bearing

      E

      ) Surgical repair of the ankle ligaments

      18. A 52-year-old woman comes to the office because of a 4-day history of increasing pain of the right hip and thigh. The pain is exacerbated by lying on her right side while sleeping. She says

      the pain often awakens her and is accompanied by a burning sensation along the right side of her posterior thigh that radiates to her knee. She usually has stiffness and pain in the hip during the

      following morning that gradually diminishes as she walks around her house and does house chores. She says the pain is also triggered by sitting with her right leg crossed over the left leg. The

      patient is otherwise healthy and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Vital signs are normal. Physical examination discloses tenderness

      on deep palpation of the right trochanter. Which of the following is the most likely diagnosis?

      A

      ) Arthritis of the hip

      B

      ) Aseptic necrosis of the femoral head

      C

      ) Bursitis

      D

      ) Gout

      E

      ) Osteosarcoma of the femoral head

      19. An 18-year-old man comes to the health center because he has had pain in his right leg for the past 5 days. He says that he recently added jogging to his weight-lifting workouts, and he

      started running 5 miles per day 2 weeks ago. He is 180 cm (5 ft 11 in) tall and weighs 83 kg (185 lb). On physical examination he has moderate tenderness over the midtibia. X-ray of the leg will

      most likely show which of the following?

      A

      ) A bone cyst

      B

      ) Displaced fracture

      C

      ) Metastatic disease

      D

      ) Soft-tissue calcification

      E

      ) Normal findings

      20. A 58-year-old woman comes to the office for follow-up of fibromyalgia. You had been treating her for the past several years for nonspecific muscular aches and pains. In the past you noted that

      occasionally the pain could be reproduced on physical examination by applying pressure to certain muscles; however, these trigger points seemed to change on each physical examination. Fibromyalgia

      was diagnosed 3 months ago and amitriptyline therapy was started at that time. At a follow-up visit 3 weeks ago she showed little response to the amitriptyline therapy, and naproxen was added to

      her regimen. Today she returns to the office complaining that "every time I get the least little bump on my hands the skin seems to tear." Her physical examination is unchanged except for the

      lesions shown. Which of the following is the most appropriate management?

      A

      ) Discontinue the amitriptyline

      B

      ) Discontinue the naproxen

      C

      ) Prescribe oral corticosteroids

      D

      ) Prescribe topical corticosteroids

      E

      ) Prescribe topical 5-fluorouracil

      21. A 10-year-old Asian girl is brought to the office by her mother because of a painful swelling in the girl's neck. The child says that for the past 4 days the right side of her neck has been

      sore. Today she showed it to her mother, who noticed a red swelling. She does not have fever or chills. She has not missed any days of school. She lives with her parents and two siblings in a

      suburban community. Further discussion discloses that the family recently adopted an 8-week old kitten from the animal shelter. Vital signs now are: temperature 37.2°C (98.9°F), pulse 80/min, and

      respirations 24/min. On physical examination, the girl has a 2H4-cm, red, tender mass with overlying erythema and induration in the right submandibular area. There is a crusted papule on the right

      cheek. Which of the following is the most likely cause of this patient's condition?

      A

      ) Bartonella henselae

      B

      ) Branchial cleft cyst

      C

      ) Epstein-Barr virus

      D

      ) Trauma

      E

      ) Untreated impetigo

      22. A 64-year-old retired teacher comes to the office with her husband. She has felt fatigued for several months and feels she is losing her memory. She says, "I feel slowed and can't remember

      what happened yesterday." Her husband reaffirms this history and notes that she recently got lost in a local mall and called him at home to come and get her. She was frightened by this episode and

      had insomnia that night, even though she otherwise has been sleeping longer than usual. She has a good appetite. There is a family history of senile dementia in her father and two uncles. Her only

      medication is daily conjugated estrogen. Her height is 163 cm (5 ft 4 in) and her weight is 64 kg (142 lb), which is an increase of 2.5 kg (6 lb) since you saw her 8 months ago. Pulse is 54/min

      and regular, and blood pressure is 140/86 mm Hg. On physical examination she appears pale. Deep tendon reflexes have a slow relaxation phase; the remainder of the examination is normal. A

      Mini-mental state test shows a delayed recall of one of three items and failure on serial 7s. She cannot recall any past presidents but she knows the current president. Based on these findings,

      which of the following is the most likely working diagnosis?

      A

      ) Early dementia, Alzheimer type

      B

      ) Hypothyroidism

      C

      ) Pernicious anemia

      D

      ) A transient ischemic attack

      E

      ) Vascular dementia

      23. A 38-year-old obese woman with a 2-year history of type 2 diabetes mellitus has not lost weight despite persistent advice concerning diet and exercise. She has also been irregular in keeping

      appointments and has failed to take her medication on a regular basis. There is increasing concern that serious complications will occur unless she becomes more cooperative. You decide to

      terminate the physician-patient relationship, hoping that another physician can establish better rapport and help her with her problems. The most appropriate way to terminate the relationship is

      to do which of the following?

      A

      ) Give her a copy of her medical records at the next appointment and advise her to find another physician

      B

      ) Give her a list of three physicians and ask her to pick one, to whom you will send her medical records

      C

      ) Refuse further treatment unless she loses 2.7 kg (6 lb) before her next appointment in 1 month

      D

      ) Tell her 19-year-old daughter, who brings her to the office, to convince her mother to find another physician and tell her the reasons for this suggestion

      E

      ) Tell her that the relationship will be terminated in 1 month, give her reasons for this decision, and offer her a list of three physicians' names

      24. A 56-year-old Native American man returns to the office to discuss results of studies obtained during a previous visit 8 weeks ago. The patient has a 19-year history of diabetes mellitus

      treated with sulfonylurea. He checks his serum glucose concentration approximately once daily. He does not smoke cigarettes and rarely drinks alcoholic beverages. He is 183 cm (6 ft) tall and

      weighs 76 kg (168 lb); BMI is 23 kg/m2. Vital signs during the previous visit were temperature 36.9°C (98.4°F), pulse 82/min, and blood pressure 130/85 mm Hg. Physical examination of the neck

      disclosed a right-sided carotid bruit. Examination of the extremities disclosed diminished pulses with associated hair loss over both legs. Hemoglobin A1c was 7.2%. Urine albumin-creatine ratio

      was 62 mg/g/24 h (N<30). Ankle-brachial index (ABI) was 0.89 on the left and 0.98 on the right; duplex carotid ultrasonography showed nonulcerated plaque with 70% stenosis in the right internal

      carotid artery. The patient was referred to an ophthalmologist, who diagnosed him with nonproliferative background diabetic retinopathy. Which of the following findings in this patient is of most

      concern?

      A

      ) 70% stenosis of the right carotid artery

      B

      ) Hemoglobin A1c of 7.2%

      C

      ) Left ABI of 0.89

      D

      ) Nonproliferative diabetic retinopathy

      E

      ) Urine albumin-creatine ratio of 62 mg/g/24 h

      25. A 25-year-old woman returns to the office because of intermenstrual spotting since beginning oral contraceptive therapy 6 months ago. This is her first attempt at oral contraceptive therapy;

      she and her partner primarily used condoms for contraception in the past. Before this current therapy her menstrual periods had always been regular. Which of the following is the most appropriate

      management?

      A

      ) Advise her to take two pills daily until the bleeding stops

      B

      ) Discontinue the oral contraceptive therapy and have her resume use of condoms for birth control

      C

      ) Reassure her that the bleeding problem will resolve in a few months

      D

      ) Switch the current oral contraceptive pill to one containing a higher estrogen dose

      E

      ) Switch to a progestin-only oral contraceptive pill

      The following vignette applies to the next 2 items.


      A 17-year-old girl is brought to the health center by her mother because the girl has had only two menstrual periods in the past 8 months. She had regular menstrual periods from menarche at age 14

      years until 18 months ago. For the past 18 months she has been training as a long-distance runner.

      Item 1 of 2

      26. The underlying mechanism of her menstrual dysfunction is best defined by an abnormality in which of the following serum concentrations?

      A

      ) Androstenedione

      B

      ) Creatine kinase

      C

      ) Luteinizing hormone

      D

      ) Testosterone

      E

      ) Thyroid-stimulating hormone (TSH)

      Item 2 of 2

      27. Which of the following is the most likely cause of the menstrual irregularity?

      A

      ) High-carbohydrate diet

      B

      ) Increased basal body temperature

      C

      ) Increased muscle mass

      D

      ) Loss of body fat

      E

      ) Repeated volume depletion


      28. A 23-year-old white nulligravid woman returns to the office for follow-up of a 2-year history of primary infertility. Menstrual periods occur at regular 28-day intervals. She has a history of

      chronic pelvic pain. Analysis of her husband's semen shows a sperm count of 40 million with 65% motility and normal morphology. Diagnostic laparoscopy with hydrotubation shows normal pelvic

      anatomy, with no evidence of endometriosis or pelvic adhesions. Both fallopian tubes spill methylene blue dye. The patient's basal body temperatures recorded during the past month are shown. Which

      of the following is the most likely cause of the patient's inability to conceive?

      A

      ) Anovulation

      B

      ) Male factor infertility

      C

      ) Old pelvic inflammatory disease

      D

      ) Polycystic ovary syndrome

      E

      ) No cause can be identified at this time

      29. In the course of routine prenatal care at the health center, a 30-year-old Hispanic woman is found to have gestational diabetes. This is her first pregnancy and she is at 20 weeks' gestation.

      She should be counseled that adequate prenatal care, including regular determination of blood glucose concentrations and adherence to a controlled dietary regimen, may reduce the possibility of

      which of the following?

      A

      ) The fetus developing macrosomia

      B

      ) Her developing essential hypertension

      C

      ) Her developing type 1 diabetes mellitus in the future

      D

      ) Intrauterine growth restriction

      E

      ) Premature delivery

      30. A 20-year-old woman returns to the office for the results of her prenatal laboratory studies. By date of her last menstrual period she is 14 weeks pregnant with her second child. Her first

      pregnancy, which you followed, resulted in an uncomplicated vaginal delivery approximately 11 months ago. Her prenatal serology screening for syphilis is positive with a titer of 1:126, and a

      fluorescent treponemal antibody absorption (FTA-ABS) test is positive. The patient denies having lesions consistent with syphilis, and her current physical examination shows no lesions. Serology

      during her first pregnancy was negative. At this time, which of the following is the most appropriate management?

      A

      ) Do an amniocentesis to obtain fluid for darkfield evaluation

      B

      ) Follow the treatment regimen recommended for primary or secondary syphilis

      C

      ) Postpone treatment until the patient is at least 20 weeks pregnant

      D

      ) Schedule a lumbar puncture before instituting treatment

      E

      ) Withhold treatment until further studies rule out a biologic false-positive

      31. A 34-year-old man comes to the office with his wife and daughter because he has had some dusky lesions on his shoulder for the past 2 months. He says that two have become larger during the

      past week. He and his wife have recently adopted an 18-month-old girl from the Ukraine who has a similar rash. He is an environmental scientist and his work requires him to travel overseas and

      work outdoors. He is concerned about the possibility of skin cancer. Vital signs are normal. Physical examination shows a cluster of six discrete papular lesions on his left shoulder that are

      slightly tender. These lesions have a central depression containing some pus-like material. There is no axillary or cervical adenopathy. His rash is shown. Which of the following is the most

      appropriate management for the patient?

      A

      ) Acyclovir

      B

      ) Scabicidal cream

      C

      ) Topical corticosteroid cream

      D

      ) Topical fluconazole

      E

      ) Topical liquid nitrogen

      32. A 25-year-old Latino man comes to the health center for a periodic health evaluation. He tells you that he has attended a day-treatment program for his schizophrenia, paranoid type, since his

      discharge from the hospital 1 year ago. The patient's most recent psychiatrist is moving away and he now wants you to refill his medications. He takes haloperidol, benztropine and valproic acid.

      He says, "The voices aren't telling me to harm myself anymore. And I know now that my food is not poisoned." The patient is 183 cm (6 ft) tall and weighs 86 kg (190 lb). Vital signs are:

      temperature 37.0°C (98.6°F), pulse 72/min, respirations 14/min and blood pressure 130/86 mm Hg. Physical examination is significant for darting and protruding movements of the tongue and some

      facial grimacing. Which of the following is the most appropriate change in pharmacotherapy?

      A

      ) Prescribe vitamin A

      B

      ) Increase the dose of benztropine

      C

      ) Increase the dose of haloperidol

      D

      ) Replace haloperidol with risperidone

      E

      ) Replace valproic acid with lithium

      33. A third-year medical student returns to the student health service for the third time because he thinks he has ulcerative colitis. After a thorough history and physical examination, he is told

      that no organic disease is present. Despite that reassurance, the student continues to test his stool for blood and continues to believe that his physicians have missed the correct diagnosis. This

      behavior is most characteristic of which of the following?

      A

      ) Conversion disorder

      B

      ) Depersonalization

      C

      ) Hypochondriasis

      D

      ) Munchausen syndrome

      E

      ) Somatization disorder

      34. A 10-year-old Asian-American boy is brought to the office for a sports physical examination. He has been healthy except for a few episodes of otitis media as an infant. He has had no shortness

      of breath, syncope or chest pain in the past. Growth has been normal. Vital signs are: temperature 36.6°C (97.8°F), pulse 80/min, respirations 16/min, and blood pressure 110/76 mm Hg. Cardiac

      examination discloses an early systolic click at the apex, a midsystolic ejection murmur at the right upper sternal border and a thrill in the suprasternal notch. The remainder of the physical

      examination is normal. The patient is referred to the cardiologist and the diagnosis of aortic stenosis is confirmed by echocardiogram. Close follow-up and graded exercise testing are recommended.

      The patient is at increased risk for which of the following?

      A

      ) Atrial arrhythmias

      B

      ) Complete heart block

      C

      ) Coronary artery disease

      D

      ) Pulmonary hypertension

      E

      ) Sudden death

      35. A 12-year-old Haitian boy is brought to the health center for the first time by his mother and maternal grandmother. The mother states, "There was a voodoo curse placed on my family and now my

      son is having problems because of that." She reports that for the past 6 months he has been talking back to his teachers, has been suspended from school for skipping class, and has been defiant

      with all adults. He is failing two subjects in school and will need to attend summer classes. His medical history is significant for an allergy to sulfa drugs, a positive PPD skin test for which

      he was treated prophylactically at age 10 years, and encopresis that resolved. He currently takes no medications. The patient is 163 cm (5 ft 4 in) tall and weighs 49 kg (108 lb). Vital signs are:

      temperature 37.0°C (98.6°F), pulse 80/min, respirations 18/min and blood pressure 90/50 mm Hg. Which of the following is the most appropriate opening statement to the mother?

      A

      ) "Do you think your son may be taking drugs?"

      B

      ) "I suggest you consult a voodoo priest for help with this problem."

      C

      ) "Tell me more about the voodoo and its effect on your son's behavior."

      D

      ) "There is no such thing as voodoo."

      E

      ) "Voodoo does not cause children to have bad behavior."

      36. You are invited to a council meeting of Native-Americans to discuss a heptavalent pneumococcal polysaccharide-protein conjugate vaccine (Prevnar7) for use in the community's children, many of

      whom are younger than age 12 months. All of the infants and children in the community are up-to-date on standard recommended vaccinations. The council spokesperson says, "We are skeptical about

      the safety of giving our sons and daughters yet another vaccine." Which of the following is the most compelling reason to recommend vaccination of all infants younger than 12 months of age?

      A

      ) Administration of the vaccine will decrease the incidence of invasive pneumococcal disease among the children in the community

      B

      ) Administration of the vaccine will decrease the likelihood of secondary pneumonia during respiratory syncytial virus (RSV) season

      C

      ) Administration of the vaccine will significantly decrease the severity of acute otitis media and prevent hearing loss

      D

      ) Native-American children make ineffective antibodies when the 23-valent pneumococcal vaccine alone is administered to them

      E

      ) The peak incidence of pneumococcal disease occurs in children younger than 12 months of age
      ================================================================================
      1. A 76-year-old woman is admitted to the hospital after a fall at her home earlier in the day. She has been followed in your practice for several years and is in generally good health. She drinks

      socially, does not smoke and has been active in senior citizen groups. She takes ibuprofen occasionally for pain, but no other medications. On admission she is alert and oriented, and complains

      only of pain in her left leg. Her temperature is 36.1°C (97.0°F), pulse is 72/min and regular, and blood pressure is 140/85 mm Hg. X-ray films taken upon arrival show a fracture of the left

      femoral shaft. Surgical repair of the fracture is done the next morning. The patient receives 2 U of packed erythrocytes during the procedure. Postoperative medications include morphine,

      prophylactic cephalothin and low-dose warfarin. On the evening of the operation, the patient becomes combative, begins to hallucinate and has a brief, generalized seizure. A fine petechial rash is

      noted on her chest. Which of the following is the most likely cause of her seizure?

      A

      ) Antibiotic allergy

      B

      ) Blood transfusion reaction

      C

      ) Fat emboli

      D

      ) Hemorrhagic stroke

      E

      ) Unrecognized cerebral concussion

      2. A 72-year-old woman with metastatic rectal cancer is admitted to the hospital because of weakness and altered mental status. She has bilateral ureteral stents due to prior obstruction from the

      cancer. She has been using a fentanyl patch for several weeks. Physical examination on admission is notable for lethargy and 3-mm reactive pupils but no focal neurologic signs. She is afebrile and

      has a blood pressure of 120/82 mm Hg. Laboratory studies show serum urea nitrogen (BUN) concentration of 60 mg/dL and a serum creatinine concentration of 6.2 mg/dL. Serum bilirubin concentration

      is normal. One week ago serum BUN concentration was 30 mg/dL and serum creatinine concentration was 3.0 mg/dL. Which of the following is the most likely explanation for her altered mental status?

      A

      ) Fentanyl intoxication

      B

      ) Hepatic encephalopathy

      C

      ) Hypercalcemia

      D

      ) Uremia

      E

      ) Urosepsis

      3. A 54-year-old African American woman has been in the intensive care unit (ICU) for the past 10 hours because she has failed to regain consciousness after passing out at a restaurant 11 hours

      ago. Upon initial arrival at the emergency department the patient's friend stated that the patient had remarked about the sudden onset of a terrible headache and neck stiffness while they were

      having lunch. A few minutes after the onset of the headache, she became confused, vomited, and lost consciousness. She regained consciousness briefly en route to the hospital, but she has been

      unconscious since admission. On arrival she was intubated and mechanically ventilated and transferred to the ICU, where intravenous fluids were started. Vital signs are: pulse 110/min and blood

      pressure 174/96 mm Hg. She exhibits no spontaneous movement and is unresponsive to verbal or painful stimuli. Lung fields are clear to auscultation. CT angiogram confirms subarachnoid hemorrhage

      from a ruptured cerebral aneurysm and impaired intracranial circulation. The family should be counseled regarding which of the following?

      A

      ) The futility of continued life support

      B

      ) The need for screening of first-degree relatives for aneurysms

      C

      ) The need for them to sustain hope

      D

      ) The need to have a guardian ad litem appointed to make informed decisions about the patient's care

      E

      ) The probability that the patient will not regain consciousness

      4. A previously healthy 3-year-old boy is admitted to the hospital through the emergency department because he has been having generalized seizures. He had a fever this morning and had one seizure

      at home and another on the way to the emergency department. While in the emergency department he had several additional seizures that were controlled with intravenous lorazepam. Vital signs on

      arrival at the emergency department were temperature 39.6°C (103.3°F), pulse 110/min, respirations 24/min, and blood pressure 85/60 mm Hg. Physical examination showed no abnormalities except for

      left otitis media and lethargy. Intravenous phenytoin was administered. Spinal fluid examination, serum electrolyte concentrations and complete blood count were normal. Now in the hospital, the

      patient has another seizure. The patient is managed appropriately and the seizure stops. When discussing this child's management and prognosis with the parents, it is most appropriate to counsel

      them about which of the following?

      A

      ) Their child has an increased risk for attention-deficit/hyperactivity disorder

      B

      ) Their child has an increased risk for developing a brain tumor

      C

      ) Their child is likely to be developmentally delayed

      D

      ) Their child will have a seizure every time he has a fever

      E

      ) Their child will probably become seizure-free as he becomes older

      5. A 21-year-old Asian-American man who sustained a closed head injury in a motorcycle accident is admitted to the hospital. He is intubated and is receiving mechanical ventilation in the

      intensive care unit. On repeat physical examinations during the next 2 days, he shows no clinical signs of cerebral activity and has no spontaneous respiration. His pupils are fixed in

      mid-position and he has no vestibulo-ocular reflexes. Electroencephalograms obtained 24 hours apart have nearly flat tracings. His driver's license indicates his desire to be an organ donor. When

      you inform his parents that he is brain dead, you remind them of his donor statement and request permission to harvest usable organs. The parents are shocked; they say they are unaware of his

      desire to be an organ donor and refuse to grant permission. Because the patient meets the clinical criteria for brain death, which of the following is most appropriate?

      A

      ) Explain how their son's death can contribute to another person's life

      B

      ) Have a potential organ recipient talk with the family

      C

      ) Obtain a court order authorizing removal of usable organs

      D

      ) Order cerebral angiography to convince the parents that their son is brain dead

      E

      ) Proceed with organ removal because the patient is an adult

      6. A 52-year-old woman is admitted to the hospital for diagnostic evaluation of a slight aphasia and change in her personality, as noted by her husband. CT scan of the head discloses a 3-cm mass

      in the left temporal lobe and a 5-cm mass in the right frontal lobe. Because she is a chronic cigarette smoker, you have been obtaining annual chest x-ray films, which have been reported as

      normal. Her chest x-ray film on admission today is reported as showing a "2-cm spiculated mass in the left subapical region." No reference is made to comparing this film with the prior films. The

      radiologist then calls you and admits to you that the lesion was present on her prior films but it was overlooked. Which of the following is the most appropriate next step?

      A

      ) Agree with the radiologist that informing the patient and her family will do more harm than good

      B

      ) Ask the radiologist to inform the patient and her family of the problem

      C

      ) Compliment the radiologist for finding what will probably be the primary lesion accounting for the two CNS lesions

      D

      ) Consult with your attorney regarding avoidance of litigation for yourself

      E

      ) Inform the radiologist of your responsibility to inform the patient and her family of the problem

      The following vignette applies to the next 2 items.


      While making rounds in a rehabilitation facility, you see a 76-year-old white woman who has been your patient for 25 years. One month ago she was diagnosed with metastatic non-small cell carcinoma

      of the lung with metastases to the other lung, liver and brain. She now has moderate left hemiparesis that limits walking. She also has multiple, asymptomatic, deep venous thrombi of both legs

      that are being treated with a vena caval filter. Despite discussion with the patient and her family about her illness, her son tells you that she is apparently unaware that her condition is

      terminal.

      Item 1 of 2

      7. Which of the following is the most appropriate next step?

      A

      ) Arranging transfer to the in-patient psychiatric ward

      B

      ) Beginning anxiolytic therapy

      C

      ) Discussing the prognosis again with the patient

      D

      ) Encouraging the family to discuss the patient's prognosis with her

      E

      ) Explaining to the son that it is inappropriate for you to speak about his mother's illness

      Item 2 of 2

      8. The patient is not in severe pain and she currently has no respiratory distress. She has chosen not to have further intervention and she probably has about 3 months to live. Her husband is an

      active 75-year-old man with recently diagnosed type 2 diabetes mellitus. Two of their three sons live 1 hour away. The patient has many concerned neighbors and friends. The patient's family asks

      for your advice regarding appropriate care for her for the remainder of her illness.


      Which of the following is the most appropriate recommendation?

      A

      ) Continued care in the rehabilitation center until she is able to ambulate on her own

      B

      ) Home health care for as long as she qualifies for skilled nursing services

      C

      ) Home hospice care with physical therapy

      D

      ) Placement under intermediate (nonskilled) care in a local nursing home

      E

      ) Placement under skilled care in a local nursing home

      9. An 18-year-old woman gave birth to a healthy neonate 72 hours ago. The woman now has the acute onset of tachypnea. Vital signs are normal. Diffuse wheezing is noted on auscultation of the

      chest. Chest x-ray film is normal. Electrocardiogram shows evidence of right heart strain. Which of the following is the most likely diagnosis?

      A

      ) Adult respiratory distress syndrome

      B

      ) Aspiration pneumonia

      C

      ) Bronchopneumonia

      D

      ) Congestive heart failure

      E

      ) Pulmonary embolism

      10. A 34-year-old woman undergoes a middle ear operation with oral intubation and general anesthesia. During the 4-hour procedure she was in a semi-lateral position with her head maximally turned

      to the right and her chin tucked on her chest. She awakens normally at the end of the procedure and is extubated without difficulty. Approximately 30 minutes later she appears anxious and is

      sitting upright. She leans forward and says, "I'm not getting enough air." Her voice is barely audible and very hoarse and she appears to be struggling to take a deep breath. Vital signs are:

      pulse 94/min, respirations 28/min and blood pressure 128/72 mm Hg. Oxygen saturation is 92% with an FIO2 of 0.4. Oxygen flow is maximally increased and O2 saturation is 93%. Auscultation of the

      chest discloses bilateral breath sounds with crowing sounds on inspiration and expiration. Which of the following is the most appropriate pharmacotherapy?

      A

      ) Midazolam

      B

      ) Naloxone

      C

      ) Nebulized racemic epinephrine

      D

      ) Neostigmine

      E

      ) Succinylcholine

      11.

      A 67-year-old man with a history of poorly controlled hypertension is admitted to the hospital because of increasing fatigue, weight loss and dyspnea on exertion for the past 6 weeks. Medical

      history includes tonsillectomy, adenoidectomy, mitral valve commissurotomy and a sigmoid colon resection for diverticulitis. Vital signs are: pulse 90/min, respirations 14/min and blood pressure

      190/100 mm Hg. The patient appears chronically ill but is in no acute distress. Laboratory studies show:


      Serum


      Urine


      Na+

      140 mEq/L

      WBC

      0/hpf

      K+

      4.5 mEq/L

      RBC

      4/hpf

      Cl-

      100 mEq/L



      HCO3-

      25 mEq/L




      Which of the following is the most likely finding on echocardiography?

      A

      ) Ejection fraction of 60%

      B

      ) Left ventricular wall thickening

      C

      ) Pericardial fluid

      D

      ) Septal dyskinesia

      E

      ) Thoracic aortic aneurysm

      he following vignette applies to the next 2 items.


      You have been treating a 5-month-old child in the neonatal intensive care unit (NICU). He was delivered at 26 weeks' gestation by cesarean delivery because of premature rupture of membranes. The

      mother is 18 years old and is unemployed. There are two other children in the home. The father is not living with them, and he has not been in contact with the mother. The mother rarely visits the

      NICU. The infant had severe respiratory distress syndrome at birth and required dopamine for blood pressure support. His condition progressed to pulmonary interstitial emphysema and

      bronchopulmonary dysplasia by 4 weeks of age. At 4 months of age he required a tracheostomy and medication for control of his blood pressure. Now, at 5 months of age, the boy has a cardiac arrest

      requiring resuscitation and placement of chest tubes. He then develops seizures that are eventually controlled with medication. The neonatologist feels that the child will always require life

      support. The mother refuses to discuss the possibility of withdrawing life support. Her insurance is Medicaid. The hospital bill for this child is now $350,000.

      Item 1 of 2

      12. To guide further treatment at this time, it is most important to assess which of the following?

      A

      ) The extent of neurologic injury

      B

      ) The financial impact on the family

      C

      ) The mother's level of understanding of the child's prognosis

      D

      ) Whether another family member is better suited to make decisions about the patient's care

      E

      ) Your state's law regarding futile care

      Item 2 of 2

      13. One week later the mother and the attending physician are unable to reach an agreement on the management plan. Which of the following is the most appropriate next step?

      A

      ) Ask the court to appoint a guardian

      B

      ) Defer major decisions until the father can be located

      C

      ) Have the social worker contact Medicaid regarding further coverage

      D

      ) Involve the hospital bioethics committee

      E

      ) Maintain the patient on a respirator but transfer him out of the NICU

      14. A 42-year-old African-American man with hepatitis C is admitted to the hospital for evaluation of a 3-day history of fever and right upper quadrant abdominal pain. The pain is steady and does

      not change with position. He has had associated nausea but has not vomited. He has a history of alcohol dependence but has not had an alcoholic beverage since being diagnosed with hepatitis C 4

      years ago. He does not take any medications. On admission, vital signs are: temperature 38.5°C (101.3°F), pulse 115/min, respirations 24/min and blood pressure 100/60 mm Hg. Physical examination

      shows scleral icterus. Abdominal examination discloses mild distention and right upper quadrant tenderness to palpation; the liver spans 25 cm. There is no rebound tenderness and bowel sounds are

      normal. Ultrasonography of the right upper quadrant shows three small gallstones, dilated right and left intrahepatic ducts and normal common bile duct. Laboratory studies show:


      Serum



      Blood



      ALT

      650 U/L

      Hematocrit

      35%

      AST

      442 U/L

      WBC

      22,000/mm3

      Alkaline phosphatase

      342 U/L

      PT

      14 sec

      Bilirubin

      7.0 mg/dL

      PTT

      28 sec

      Na+

      140 mEq/L

      INR

      1.2

      K+

      4.2 mEq/L





      Cl-

      104 mEq/L





      HCO3-

      23 mEq/L






      Fluid resuscitation is begun. Which of the following is the most appropriate next step?

      A

      ) Biopsy of the liver

      B

      ) Cholecystectomy

      C

      ) CT scan of the abdomen

      D

      ) Endoscopic retrograde cholangiopancreatography with st

      15. A 16-year-old Mexican American girl who is 28 weeks pregnant comes to the health center with her boyfriend because of epigastric pain radiating to her back. She says, "I have had pain for many

      days, especially after eating." She has been taking acetaminophen for the pain several times a day for the past week. She admits to drinking an occasional bottle of light beer. She has been

      receiving prenatal care at the health center. Vital signs today are temperature 37.5°C (99.5°F), pulse 110/min, respirations 15/min, and blood pressure 110/70 mm Hg. Height is 157 cm (5 ft 2 in)

      and weight is 90 kg (200 lb). Physical examination shows scleral icterus and epigastric and right upper quadrant tenderness. Uterus is appropriately enlarged for her gestational stage. The patient

      is admitted to the hospital for observation. Results of laboratory studies are shown:


      Serum



      ALT

      55 U/L

      AST

      58 U/L

      Alkaline phosphatase

      350 U/L

      Amylase

      3000 U/L

      Bilirubin



      Total

      7.3 mg/dL

      Direct

      5.9 mg/dL

      Lipase

      475 U/L (N=10140)


      These laboratory results are most indicative of which of the following?

      A

      ) Acetaminophen-induced hepatic necrosis

      B

      ) Alcoholic pancreatitis

      C

      ) Biliary pancreatitis

      D

      ) Hepatitis C infection

      E

      ) Mononucleosis

      16. A 22-year-old woman is in her 5th hospital day following admission for evaluation of severe right lower quadrant abdominal pain. During the previous 8 months, she has had episodes of abdominal

      pain with associated recurrent diarrhea, which sometimes contained blood. The pain and diarrhea became increasingly severe during the 5 days prior to admission. During that time, she lost 2 kg (5

      lb) and had a temperature to 39.0°C (102.0°F). Abdominal examination on admission disclosed a right lower quadrant mass. Blood hemoglobin concentration was 15.5 g/dL and leukocyte count was

      24,000/mm3. Colonoscopy showed linear ulcerations with discontinuous areas of inflammation. Biopsy of the lower intestine disclosed noncaseating granulomas. Serum antibody test to Saccharomyces

      cerevisiae was positive. Treatment with intravenous hydrocortisone therapy was begun. Today, the patient's abdominal pain and diarrhea are resolved. Vital signs are temperature 37.0°C (98.6°F),

      pulse 76/min, respirations 12/min, and blood pressure 122/74 mm Hg. The abdomen is soft and nontender to palpation; bowel sounds are normal. Which of the following is the most appropriate

      pharmacotherapy for this patient?

      A

      ) Azathioprine

      B

      ) Mesalamine

      C

      ) Metronidazole

      D

      ) Prednisone

      E

      ) Ranitidine

      The following vignette applies to the next 2 items.


      A 28-year-old man who lives in a small rural township is admitted to the hospital because of gastrointestinal bleeding. On admission the patient is pale and has orthostatic hypotension. Hemoglobin

      concentration is 8 g/dL. His condition is stabilized. Emergent upper endoscopy shows a visible gastric vessel, which is treated appropriately.

      Item 1 of 2

      17. Specific additional history should be obtained regarding which of the following?

      A

      ) Consumption of alcoholic beverages

      B

      ) Family history of cancer

      C

      ) Source of drinking water

      D

      ) Travel history

      E

      ) Use of tobacco products

      Item 2 of 2

      18. Which of the following is the most appropriate laboratory study?

      A

      ) Antibodies for Helicobacter pylori

      B

      ) Vitamin B12 (cyanocobalamin) concentration

      C

      ) Ferritin concentration

      D

      ) Gastrin concentration

      E

      ) Iron concentration


      19. A 74-year-old woman is admitted to the hospital for treatment of a hip fracture. Her only medical problem is chronic insomnia; she told the nurse, "I have taken sleeping pills for years." Two

      days after the operation she has a tonic clonic seizure. Vital signs now are: temperature 38.0°C (100.4°F), pulse 110/min and blood pressure 180/100 mm Hg. She is confused, has diaphoresis and is

      trembling. Which of the following is the most likely diagnosis?

      A

      ) Barbiturate withdrawal

      B

      ) Diphenhydramine withdrawal

      C

      ) Propoxyphene withdrawal

      D

      ) Pulmonary embolus

      E

      ) Stroke

      20. You have just returned from a trip out of town and learn that your long-time patient with end-stage chronic obstructive pulmonary disease has been hospitalized and is on a ventilator. On the

      way to the intensive care unit to visit him, you are informed that the patient has just died. On your way into the patient's room you meet the patient's 68-year-old wife. Which of the following is

      most appropriate to say to her?

      A

      ) "How do you feel?"

      B

      ) "I am sorry for your loss."

      C

      ) "I know you are upset."

      D

      ) "What happened while I was gone?"

      E

      ) "Your husband didn't suffer."

      21. A 3-day-old Latina infant is in the hospital awaiting routine physical examination. She was born to a 28-year-old woman by cesarean delivery at term because of breech presentation. She is the

      woman's first child and the pregnancy was uncomplicated. The infant weighed 3686 g (8 lb 2 oz) at birth. Physical examination discloses asymmetry in the number of thigh skin folds and uneven knee

      levels when the hips and knees are flexed. Barlow test is done and a palpable "click" is felt in the left hip. Without prompt treatment, this child is at increased risk for which of the following?

      A

      ) Dysplasia of the hip

      B

      ) Femoral head anteversion

      C

      ) Legg-Calve-Perthe disease

      D

      ) Metatarsus adductus

      E

      ) Slipped capital femoral epiphysis

      The following vignette applies to the next 2 items.


      An 83-year-old woman is admitted to a nursing home for ongoing management of Parkinson disease. Her husband can no longer care for her at home because she is moderately demented, has difficulty

      walking, has fallen several times and has urinary incontinence. She has difficulty swallowing her pills, and she needs assistance with feeding. Despite her husband's attentive care, she has lost 9

      kg (20 lb), going from 47.1 kg (104 lb) to 38 kg (84 lb) during the past 9 months. After 2 weeks in the nursing home, the nursing staff notes that the patient frequently eats and drinks very

      little and often coughs after she swallows. Her current medications include fluoxetine, selegiline, carbidopa-levodopa, trazodone, estrogen and sorbitol. Vital signs now are: temperature 36.4°C

      (97.6°F), axillary; pulse 88/min; respirations 18/min and blood pressure 102/84 mm Hg, supine. Physical examination shows a frail and thin woman. Voice is soft and low. Chest is clear to

      auscultation. Heart rate is regular without murmurs or gallops. Abdomen is soft and nontender with decreased bowel sounds. Rectal examination is normal. She is generally stiff with low amplitude

      tremors at rest. Laboratory results show:


      Serum



      BUN

      47 mg/dL

      Creatinine

      1.9 mg/dL

      Na+

      161 mEq/L

      K+

      3.9 mEq/L

      Cl-

      120 mEq/L

      HCO3-

      24 mEq/L


      When the nursing home calls you with the laboratory results, the office staff informs you that the patient's husband telephoned earlier that afternoon and "fired" you from the case. There are no

      written notes from the staff and you have not spoken to the husband yourself.

      Item 1 of 2

      22. The most appropriate next step is to contact which of the following?

      A

      ) Husband and give him the names of other physicians who attend patients in the nursing home

      B

      ) Husband and inform him of the laboratory results, their implications and management options

      C

      ) Nursing home and inform them that you are no longer the patient's physician

      D

      ) Nursing home and initiate nasogastric rehydration in the facility

      E

      ) Nursing home and order the immediate transfer of the patient to the hospital

      Item 2 of 2

      23. Which of the following complications is most likely to develop if her hypernatremia is corrected too quickly?

      A

      ) Disseminated intravascular coagulation

      B

      ) Intravascular hemolysis

      C

      ) Pontine myelinolysis

      D

      ) Pulmonary edema

      E

      ) Seizures


      24. A 68-year-old woman with stage IV ovarian cancer is in the hospital following initial staging and a debulking operation. She refuses chemotherapy and the physician agrees to follow her wishes.

      This is an example of which ethical principle?

      A

      ) Authority

      B

      ) Autonomy

      C

      ) Beneficence

      D

      ) Justice

      E

      ) Nonmaleficence

      25. You assist in the delivery of a neonate born to a couple who have been your patients for the past 7 years. The husband is 50 years old and the wife is 45 years old. The wife had been offered

      maternal serum triple-marker screening and amniocentesis during the pregnancy because of her advanced age, and she had declined the testing. At the delivery, the neonate has features suggestive of

      Down syndrome. Apgar score is 9 at 1 minute and 9 at 5 minutes. Initial physical examination demonstrates no cyanosis and no heart murmur. In the delivery room, which of the following is the best

      initial statement to make to the parents?

      A

      ) "Do you remember the tests we discussed early in your pregnancy?"

      B

      ) "I am concerned about your infant because she may have Down syndrome."

      C

      ) "I am sorry to have to tell you this, but I suspect your baby has Down syndrome."

      D

      ) "We are going to have to take the baby to the nursery for some tests."

      E

      ) "Your daughter is doing well, but I am concerned about some of her physical features."

      26. A 26-year-old primigravid woman at 38 weeks' gestation is admitted to the hospital because she is in labor; contractions occur every 3 minutes and last 60 seconds. The patient's prenatal

      course has been uncomplicated. Labor curve is now normal and fetal heart rate tracing shows good variability with an occasional mild deceleration. Her patient chart indicates that a previous

      physician thought she might have a platypellic pelvis. She is now 10-cm dilated. The fetus is at +1 station with a mentum-anterior face presentation. Which of the following is the most appropriate

      management at this time?

      A

      ) Deliver the child vaginally after manually rotating the fetus to a mentum-posterior presentation

      B

      ) Deliver the child vaginally with the aid of forceps

      C

      ) Deliver the child vaginally with the aid of vacuum extraction

      D

      ) Deliver the child vaginally without intervention

      E

      ) Deliver the child via emergency cesarean delivery

      27. A full-term, 3402-g (7-lb 8-oz) neonate aspirated meconium at delivery. Apgar score is 3 at 1 minute and 3 at 5 minutes. He is intubated and assisted ventilation is established using a

      respirator. His condition stabilizes for 30 minutes but the arterial blood gas values suddenly deteriorate. Which of the following is the most appropriate first step?

      A

      ) Auscultate the chest

      B

      ) Check the respirator settings

      C

      ) Increase the oxygen flow

      D

      ) Recheck the arterial blood gas values

      E

      ) Reposition the endotracheal tube

      28. A 56-year-old man who is alcohol-dependent is admitted to the hospital because of fever, encephalopathy and increasing abdominal girth. The patient has no family and has been living on the

      street. An abdominal paracentesis is consistent with spontaneous bacterial peritonitis, which is treated with antibiotic therapy. During the next 10 days, the patient's renal function deteriorates

      and his serum creatinine concentration increases to 11.3 mg/dL, with a serum urea nitrogen (BUN) concentration of 144 mg/dL. He becomes progressively more obtunded, develops respiratory failure

      and is intubated. He requires vasopressors to maintain his blood pressure. There is general agreement from the gastrointestinal and renal services that he will not recover and that further

      treatment, including dialysis, is futile. The patient is thrashing about in bed, moaning and grimacing periodically. Which of the following is the most appropriate next step in management?

      A

      ) Do a liver biopsy to identify the cause of the patient's liver failure

      B

      ) Initiate lactulose treatment to reduce his encephalopathy

      C

      ) Initiate analgesic therapy to palliate the patient's apparent discomfort

      D

      ) Stop all antibiotic therapy to reduce the chance of further renal toxicity

      E

      ) Stop all medical treatment

      The following vignette applies to the next 2 items.


      A 38-year-old woman is admitted to the hospital for an elective breast-reduction operation. She is in good health and has never been admitted to the hospital or had previous operations. Her only

      medication is an oral contraceptive pill. Shortly after the administration of general anesthesia she develops muscular rigidity, temperature increases to 40.6°C (105.0°F), pulse increases to

      130/min and blood pressure decreases from 110/70 mm Hg to 80/40 mm Hg. Arterial blood gas values show:


      PO2

      60 mm Hg

      PCO2

      40 mm Hg

      pH

      7.12

      Total CO2

      18 mm Hg

      O2 saturation

      88%

      Item 1 of 2

      29. Which of the following is the most appropriate intravenous pharmacotherapy to administer at this time?

      A

      ) Dantrolene

      B

      ) Diazepam

      C

      ) Epinephrine

      D

      ) Magnesium sulfate

      E

      ) Succinylcholine

      Item 2 of 2

      30. Which of the following is the most likely cause of this reaction?

      A

      ) Abnormal increase in intracellular calcium

      B

      ) Hypothalamic dysfunction

      C

      ) Hypovolemia

      D

      ) Inability to sweat

      E

      ) Inhibition of protein synthesis

      The following vignette applies to the next 2 items.


      You are asked to see a 63-year-old woman who is in the hospital after undergoing an operation 4 days ago for a displaced tibia-fibula fracture. The operation was uncomplicated. Preoperative chest

      x-ray film was normal. She has a transurethral urinary catheter, which was placed during the operation 4 days ago. Today she has a temperature of 37.9°C (100.2°F). Laboratory studies disclose mild

      leukocytosis. Urinalysis shows greater than 100 WBC/hpf and many bacteria. You suspect that she has a urinary tract infection.

      Item 1 of 2

      31. Which of the following would have been the most appropriate method of preventing a urinary tract infection in this patient?

      A

      ) Cleaning the perineum twice daily with povidone-iodine

      B

      ) Irrigating the bladder every 8 hours

      C

      ) Removing the catheter immediately post-operation

      D

      ) Treating the patient with prophylactic antibiotics

      E

      ) Using only silver-coated urinary catheters

      Item 2 of 2

      32.

      Incidence of Bacteruria Related to Catheter Use

      Study Randomized Suprapubic Catheter Transurethral Catheter Odds Ratio +95% CI

      A No 2/25 21/31 0.04(0.01-0.24)

      B Yes 10/48 20/44 0.32(0.11-0.86)

      C Yes 2/32 16/34 0.08(0.01-0.41)

      D Yes 8/32 5/40 1.87(0.48-8.01)

      *CI=confidence interval


      A Colleague suggests to you that suprapubic catheters can decrease a patient's risk for bacterial colonization. You identify four studies in the medical literature that compare the incidence of

      bacteruria in patients with a transurethral catheter versus patients with a suprapubic catheter. The study results are shown. Which of the following is the most important criterion related to the

      validity of these data?

      A

      ) Confidence interval

      B

      ) The number of patients with bacteriuria

      C

      ) Odds ratio

      D

      ) Sample size

      E

      ) Study design


      The following vignette applies to the next 2 items.


      A 67-year-old woman with a 2-month history of cough was admitted to the hospital after chest x-ray film and CT scan showed a lung mass with suspected mediastinal extension. Biopsies obtained

      during bronchoscopy and mediastinoscopy showed poorly differentiated squamous cell carcinoma in the peritracheal lymph nodes. A pulmonary consultant has determined that the tumor is inoperable,

      and that the only available treatment is palliative radiation therapy. The patient has been informed of the diagnosis by you and others, but when you see her now in your office she seems unclear

      about what she has been told.

      Item 1 of 2

      33. Given the patient's uncertainty about the details of her diagnosis, which of the following is the most appropriate next step?

      A

      ) Ask the pulmonologist to explain the diagnosis to her

      B

      ) Assume that she is depressed and begin antidepressant pharmacotherapy

      C

      ) Give her the phone number for the American Cancer Society

      D

      ) Recommend that she bring family members with her to her visit next week

      E

      ) Recommend that she obtain a second opinion

      Item 2 of 2

      34. The patient returns to the office for follow-up 2 weeks later. She requests copies of her medical records and angrily states, "Doctor, I think you're wrong. I've been praying and I know I

      don't have cancer." Which of the following is the most appropriate response?

      A

      ) "I told you that all of your years of smoking would put you at risk for lung cancer."

      B

      ) "I would be happy to go over all of the reports with you; I appreciate that this is a difficult diagnosis to accept."

      C

      ) "The request for medical records can only come through your attorney."

      D

      ) "The sooner you accept this diagnosis, the sooner we can get on with appropriate therapy."

      E

      ) "We are having a case conference later today with the pulmonary and radiation therapy specialists; maybe you would like to attend to hear their opinions about your disease."

      35. A 45-year-old homeless man is admitted to the hospital because of myalgias and jaundice. He has no known past medical history and denies alcohol or drug abuse. Vital signs are: temperature

      37.1°C (98.8°F), pulse 90/min, respirations 18/min and blood pressure 117/75 mm Hg. On examination he appears malnourished. Pupils are round and reactive with scleral icterus. Dentition is poor.

      Gums are swollen and friable. Neck is supple without adenopathy or bruits. No jugular venous distention is noted. Lungs are clear. Cardiac examination demonstrates a normal S1 and S2 with a 2/6

      systolic murmur at the left sternal border. Abdomen is distended, but otherwise normal. Examination of the skin discloses diffuse perifollicular hemorrhages on the legs with purpura and

      ecchymosis. There is no clubbing or cyanosis of the hands, but splinter hemorrhages of the nail beds are noted. Neurologic examination shows normal cranial nerves. Sensation to touch in the legs

      is decreased, bilaterally. Laboratory studies show:


      Serum



      Blood



      AST

      120 U/L

      Hemoglobin

      9.2 g/dL

      Bilirubin

      4.2 mg/dL

      WBC

      5500/mm3




      MCV

      82 μm3




      Platelets

      234,000/mm3




      PTT

      23 sec




      PT

      12 sec




      INR

      1.05


      Which of the following is the most likely underlying cause for this patient's symptoms and laboratory findings?

      A

      ) Acute viral hepatitis

      B

      ) Endocarditis

      C

      ) Vitamin C deficiency

      D

      ) Hemochromatosis

      E

      ) Vitamin K toxicity

      36. An 8-hour-old neonate, who was born via cesarean delivery at 38 weeks' gestation, is in the neonatal unit. The cesarean delivery was done due to fetal distress. The mother is a healthy

      25-year-old woman and this was her first pregnancy. There were no complications during the pregnancy, but bloody amniotic fluid was noted at the time of delivery. The neonate's Apgar score was 8

      at 1 minute and 9 at 5 minutes; points were taken off for color only. At 30 minutes of age the infant was noted to have some mild grunting and tachypnea. These symptoms resolved spontaneously

      during approximately a 40-minute period, but the on-call physician ordered a complete blood count and blood culture for suspected sepsis. Because the symptoms resolved so quickly, no antibiotic

      therapy was started. You are now satisfied that further pursuit of infectious problems is not indicated. The neonate appears normal, and the mother's initial attempts at breast-feeding seem

      successful. Laboratory studies on the neonate return and are normal except for a hematocrit of 40% (N=4565). Maternal and infant blood type are both O, Rh-positive. The best course of action at

      this time is to do which of the following?

      A

      ) Obtain hematology consultation

      B

      ) Obtain serum iron studies, including total iron-binding capacity

      C

      ) Order an Apt test on the neonate's stool

      D

      ) Order hemoglobin electrophoresis

      E

      ) Repeat the hematocrit determination
      ================================================================================
      1. A 60-year-old white woman comes to the office because of a 6- to 12-month history of weakness. She initially noted the weakness in her right hand, and it has now become generalized and is

      associated with muscle cramps. She is not taking any medications. Past medical history is unremarkable. On physical examination there is marked muscle wasting of the hands and arms bilaterally

      (left greater than right). There is less muscle wasting in the legs. Sensation to touch remains intact. Muscle fasciculation of the arms and hands is noted and deep tendon reflexes are decreased.

      Speech and mentation are intact. Which of the following studies is most likely to be abnormal in this patient?

      A

      ) Edrophonium chloride test

      B

      ) Electromyography

      C

      ) Serum protein electrophoresis

      D

      ) Urine lead levels

      E

      ) Urine mercury levels

      2. A 23-year-old primigravid woman comes to the office to begin prenatal care. She and her husband had been having unprotected sexual intercourse for 8 months prior to becoming pregnant. The

      patient is excited about the pregnancy. She is at 10 weeks' gestation based on the date of her last menstrual period. Medical history is significant for a 6-year history of intermittent left-sided

      seizures that began following a motor vehicle accident during high school. The patient has taken valproic acid therapy for the past 4 years with good control of the seizures. Vital signs today are

      temperature 36.7°C (98.0°F), pulse 80/min, respirations 20/min, and blood pressure 110/60 mm Hg. Which of the following is the most appropriate modification to the patient's pharmacotherapy?

      A

      ) Discontinue the valproic acid until after pregnancy

      B

      ) Switch the valproic acid to diazepam

      C

      ) Switch the valproic acid to phenobarbital

      D

      ) Switch the valproic acid to phenytoin

      E

      ) No modification is indicated

      3. A 32-year-old secretary comes to the office for a periodic health evaluation and Pap smear. She says, "I've been doing fine except that for the past 2 months my right hand sometimes has been

      tingling and feels numb, especially at night. I'm always dropping things, too." She takes oral contraceptive pills and thyroid replacement medication for hypothyroidism. She is right-hand

      dominant. She has no history of acute trauma. On physical examination, she has numbness and tingling in the thumb and first two digits of her right hand after 15 seconds of a wrist flexion test.

      The remainder of the examination is normal. Which of the following studies is most likely to establish a diagnosis?

      A

      ) Cervical spine x-ray films

      B

      ) MRI of the brain

      C

      ) Nerve conduction studies

      D

      ) Serum thyroid-stimulating hormone (TSH) concentration

      E

      ) X-ray film of the right hand and wrist

      4. A 48-year-old Iranian American man comes to the office because of chronic dry cough, weight loss and intermittent temperatures to 38.3°C (101.0°F) for the past 2 months. He has lost 3.5 kg (8

      lb) during this time. Today vital signs are: temperature 38.3°C (100.9°F), pulse 90/min, respirations 18/min and blood pressure 120/78 mm Hg. Auscultation of the lungs discloses fine crackles

      throughout the lung fields. The remainder of the physical examination is normal. Chest x-ray film is shown. Therapy with isoniazid, rifampin, pyrazinamide and ethambutol is begun. Your office

      staff ask you whether they should be evaluated for exposure to tuberculosis. Which of the following is the most appropriate next step?

      A

      ) Do nothing for office staff because the patient is unlikely to be infectious

      B

      ) Monitor the staff during the next few weeks for development of cough or fever, and base further treatment on this information

      C

      ) Obtain chest x-ray films in 4 weeks of each staff member who came into contact with the patient

      D

      ) Place a 5-TU PPD skin test in 4 weeks on each staff member who came into contact with the patient

      E

      ) Prescribe prophylactic isoniazid therapy to all office staff

      5. A 67-year-old man comes to the office for an initial visit. He says his daughter, who is a patient in your practice, "made me come" because of a lesion in his mouth under his tongue. He is a

      farmer from the South who is visiting his daughter, and he is not concerned about the lesion. He says, "It has been present for a couple of months, and although I can feel it with the tip of my

      tongue and it is slightly sore, it doesn't give me any trouble." He has always been healthy and takes no medication. He drinks alcohol in small amounts on weekends, and he uses tobacco in a

      variety of forms. On physical examination, a 2H2-cm, raised, roughened gray lesion on the oral mucosa of the left side of the floor of the mouth is noted extending to the base of the tongue. You

      decide the lesion is highly suggestive of a malignancy and that a biopsy should be obtained. Based on the patient's history and incidence of lesions in this location, the lesion is most likely

      which of the following?

      A

      ) Adenocarcinoma

      B

      ) Basal cell carcinoma

      C

      ) Leukoplakia

      D

      ) Lymphoma

      E

      ) Squamous cell carcinoma

      6. A 52-year-old African-American man returns to the health center for a follow-up visit 1 week after he was discharged from the hospital after being diagnosed with acute pneumonia. Discharge

      medications included inhaled bronchodilators, oral antibiotics and a tapering course of oral corticosteroids. The antibiotic and corticosteroid therapies were completed yesterday. He has no

      previous hospital admissions for respiratory disease. He has a nonproductive, chronic, daily cough. He smoked one to two packs of cigarettes per day since age 13 years, but he has not smoked since

      admission to the hospital. Vital signs today are: temperature 36.8°C (98.2°F), pulse 92/min, respirations 10/min and blood pressure 120/80 mm Hg. On physical examination he appears well. There are

      markedly diminished, but clear, breath sounds with no wheezing or rhonchi; there is a prolonged expiratory phase. There is no digital clubbing. Which of the following is the most likeley

      diagnosis?

      A

      ) Asthma

      B

      ) Bronchiectasis

      C

      ) Chronic bronchitis

      D

      ) Emphysema

      E

      ) Pulmonary fibrosis

      The following vignette applies to the next 3 items.


      Patient History

      Sex: Male

      Age: 53 years

      Sociodemographic information: African-American high school teacher, married, no tobacco use, history of heavy alcohol use but not for the past 10 years

      Medical history: Hypertension; peptic ulcer disease 15 years ago; pneumonia-related hospitalization 15 years ago; no known drug allergies

      Family history: Mother died of renal failure due to diabetes and hypertension at age 69 years; father died of heart failure and hypertension; two sisters have hypertension

      Current medications/drug information: One aspirin tablet daily

      Today's Visit

      Height: 185 cm (6 ft 1 in)

      Weight: 87 kg (192 lb)

      Vital signs:

      Temperature 36.8°C (98.2°F) Respirations 16/min

      Pulse 88/min, regular Blood pressure 150/95 mm Hg

      Physical examination: Blood pressure is equal in both arms, fundi show arteriolar narrowing; remainder of physical examination is normal


      Laboratory studies: Electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy


      The patient whose chart is shown comes to the office for the first time because he has been transferred to your managed care organization. He had been taking a blood pressure medication but

      explains that he ran out of it 8 months ago. He did not make an appointment until now because, he says, "I just never got to it." His wife persuaded him to seek care now. He tells you that he

      requested his previous records be sent to you but they have not arrived.

      Item 1 of 3

      7. Which of the following is the most appropriate pharmacotherapy for this patient?

      A

      ) Clonidine

      B

      ) Enalapril

      C

      ) Hydrochlorothiazide

      D

      ) Nifedipine

      E

      ) Terazosin

      tem 2 of 3

      8. The patient returns to the office in 1 week for a follow-up visit. He says he has a cold with cough, nasal congenstion and a scratchy throat. Blood pressure in now 140/85 mm Hg. On physical

      examination lungs are clear and there is no peripheral edema. Regarding over-the-counter medications for this patient's cold, he should be cautioned to avoid which of the following?

      A

      ) Chlorpheniramine

      B

      ) Dextromethorphan

      C

      ) Guaifenesin

      D

      ) Oxymetazoline

      E

      ) Pseudoephedrine

      Item 3 of 3

      9. Regarding his blood pressure, which of the following is the most appropriate management?

      A

      ) Add a second antihypertensive medication to the regimen

      B

      ) Add potassium chloride supplements to the medication

      C

      ) Change the antihypertensive medication

      D

      ) Continue with the current regimen

      E

      ) Increase the dose of the prescribed medication


      10. A family of two adults and two school-aged children comes to the office because each family member has had intermittent nausea and diarrhea during the past 4 to 6 weeks. They are at increased

      risk for giardiasis if which of the following is true?

      A

      ) A close family friend has AIDS

      B

      ) Their water supply is a shallow well

      C

      ) They frequently consume uncooked vegetables

      D

      ) They recently adopted a new pet dog

      E

      ) They recently returned from a trip to Mexico

      11. A 61-year-old Dutch businessman comes to the office to discuss the results of screening flexible sigmoidoscopy done 1 week ago. He has hypertension and hypercholesterolemia, for which he takes

      hydrochlorothiazide and pravastatin. His grandmother died of colon cancer, but no other family members have had colon cancer or polyps. During the sigmoidoscopy, the colon was well visualized to

      60 cm and a 1-cm polyp was removed. On pathologic examination, the polyp was found to be adenomatous. Which of the following is the most appropriate diagnostic study at this time?

      A

      ) Colonoscopy

      B

      ) Determination of serum α-fetoprotein concentration

      C

      ) Determination of serum carcinoembryonic antigen concentration

      D

      ) Double-contrast lower gastrointestinal barium study

      E

      ) No further study is indicated

      12. A 52-year-old woman is brought to the office by her husband for evaluation of increasing tearfulness, restlessness, difficulty sleeping and weight loss for 1 month. During the visit, the

      patient appears restless and upset. She acknowledges her husband's account of her symptoms, but she does not volunteer any additional information. They have been married for 15 years and have a

      good relationship. Both the patient and her husband are teachers and they have a healthy 13-year-old son. She was previously healthy. Physical examination today is normal. The most appropriate

      initial management of her symptoms is to do which of the following?

      A

      ) Prescribe haloperidol

      B

      ) Prescribe lithium

      C

      ) Prescribe lorazepam

      D

      ) Prescribe sertraline

      E

      ) Refer them for couples therapy

      13. A 14-year-old white girl is brought to the health center by her mother. The mother is in tears and states, "My daughter has been suspended from school for cursing at a teacher in class. Last

      night she came home 2 hours after her curfew. When I confronted her she yelled at me and pushed me into the wall. I don't know what is wrong with her." The girl states, "There is nothing wrong

      with me. I just want to be with my friends and do what I want. I don't feel I need a curfew. I didn't do anything wrong at school. The teacher mouthed off at me. She should have been suspended

      instead of me." The girl has been your patient since age 10 years when the family moved from another state. She has a history of allergies to mold and dust for which she uses loratadine as needed.

      She takes no other medications. Her menses began at age 12 years. Vital signs now are: temperature 37.0°C (98.6°F), pulse 90/min, respirations 12/min and blood pressure 106/60 mm Hg. Physical

      examination is normal. Which of the following is the most appropriate opening question to the patient when you are speaking alone with her?

      A

      ) "Are you using drugs or alcohol?"

      B

      ) "How do you want your parents to react to your violating their rules?"

      C

      ) "What seems to be bothering you the most?"

      D

      ) "Why aren't you showing your parents any respect?"

      E

      ) "Why did you push your mother?"

      14. A 7-year-old white boy is brought to the health center by his mother because of stomach pain for the past 3 months. The mother says that the pain typically comes on soon after waking and is

      not relieved by antacids. She says his symptoms never occur late in the day, but only in the mornings. There has been no vomiting, diarrhea or weight loss. The child has been generally healthy and

      is up-to-date with vaccinations. He lives with both parents. His height and weight are at the 75th percentile. Physical examination, including developmental assessment, is normal. Specific

      additional history should be obtained regarding which of the following?

      A

      ) Days of the week in which the patient is most symptomatic

      B

      ) Family history of milk allergy

      C

      ) Quantity of food intake

      D

      ) Recent travel history

      E

      ) The source of water at home

      15. A 49-year-old man, who is accompanied by his son, comes to the office for the first time for follow-up of mild depression. He recently moved to the area and he tells you that his previous

      physician initiated fluoxetine therapy 4 weeks ago. He has a history of stage I malignant melanoma, which was treated with wide, local excision 2 years ago. He mentions that he was adopted as a

      young child and his family history is unknown. The patient is friendly and engaging, seems to be full of energy and calls you by your first name. He reports that he has been unusually productive

      at work recently and is able to "get by" on 1 to 2 hours of sleep nightly. His son says, "Dad isn't acting like himself. He talks about weird things and he's become religious in a creepy way." On

      physical examination the patient is well developed and well nourished. Vital signs are: temperature 37.0°C (98.6°F), pulse 95/min, respirations 14/min and blood pressure 135/90 mm Hg. There is a

      mild, nonpainful increase in tactile sensory acuity. He says, "My skin is really sensitive." The remainder of the physical examination, including neurologic examination, is normal. Which of the

      following is the most likely precipitant of this episode?

      A

      ) Family conflict

      B

      ) Fluoxetine

      C

      ) Recurrence of melanoma in his central nervous system

      D

      ) Stress

      E

      ) Unknown; this cannot be determined

      16. A 62-year-old man returns to the office to discuss findings of x-ray films of the lumbosacral spine obtained 2 months ago following an office visit for evaluation of chronic low back pain.

      Physical examination at that time was normal. He was instructed to take aspirin as needed for pain and to await notification from the office regarding when he should return to discuss the x-ray

      films. The office staff failed to schedule a return visit for the patient; today's visit was scheduled by the patient. The patient says, "I've been extremely anxious about the potential results of

      the x-ray film, and I'm angry that nobody from the office called me to schedule a follow-up visit." The radiologist's report accompanying the x-ray film notes the presence of a lytic lesion at the

      L1 vertebra consistent with metastatic cancer and the recommendation that a CT scan be obtained. In addition to apologizing to the patient for neglecting to contact him to schedule follow-up,

      which of the following is the most appropriate approach to informing the patient of the x-ray film findings?

      A

      ) Inform him of the findings and emphasize that the responsibility to schedule a follow-up appointment was his

      B

      ) Inform him of the findings and emphasize the need for further evaluation

      C

      ) Inform him of the findings and tell him that the radiologist is as much to blame for not informing him of the urgency of his condition

      D

      ) Inform him that the findings are nonspecific and that further studies are needed to identify a diagnosis

      E

      ) Tell him that the radiologist's report is likely overstated and that additional x-ray films will need to be obtained

      17. A 21-year-old woman who is a varsity basketball player comes to the student health center because of left knee pain for the past month. She says the pain has progressively worsened and has not

      been relieved with ibuprofen. The pain occurs when she descends stairs or is in class for long periods. She says, "My knee pops a lot." Physical examination today shows knee crepitus, and weakness

      and atrophy of the vastus medialis muscle. Which of the following is the most appropriate treatment at this time?

      A

      ) Anterior cruciate ligament reconstruction

      B

      ) Arthroscopic meniscectomy

      C

      ) Immobilization of the knee

      D

      ) Nonweight-bearing on crutches for 2 weeks

      E

      ) Quadriceps-strengthening exercises

      18. A 39-year-old African-American woman is brought to the health center at 7:00 PM by her children because of weakness and numbness in her right leg. She also says, "I have an odd feeling in my

      left leg." The symptoms started several days ago and gradually have increased. She also experienced low back pain about 10 days ago, which responded until recently to oral morphine and ibuprofen

      prescribed by her primary care physician, whom she could not reach tonight. She has had no problems with bowel or bladder function. She was treated 4 months ago with mastectomy, chemotherapy and

      radiation therapy for infiltrating ductal carcinoma of the left breast. Neurologic examination today discloses weakness of all muscle groups in the right leg and thigh, with normal strength in the

      left leg. There is marked decrease in sensation to pinprick and temperature up to the area of the inguinal ligament on the right, and decreased perception of position and vibration sense in the

      left lower extremity. The patellar and Achilles reflexes are hyperactive on the right and those on the left are normal. Rectal sphincter tone is normal. Diagnostic studies show metastatic disease

      to L2 with minimum invasion of the spinal canal. Which of the following is the most appropriate method to control her pain?

      A

      ) Chemotherapy

      B

      ) Dorsal rhizotomy

      C

      ) Long-acting oral morphine therapy

      D

      ) Radiation therapy

      E

      ) Surgical decompression

      19. A 55-year-old man comes to the office because of a 1-month history of right knee pain. He reports no recent trauma to his knee but says that he has recently increased his weekly running

      distance from 12 miles to 30 miles. On physical examination he has aching knee pain with squatting. The rest of the physical examination is normal. Which of the following factors in the patient's

      history , if present, would indicate the patellofemoral joint as the source of the pain?

      A

      ) Associated thigh pain

      B

      ) Buckling of the knee

      C

      ) Increased pain with stair climbing

      D

      ) Locking of the knee

      E

      ) Prominent knee swelling

      20. A 24-year-old professional gardener comes to the office because of a generalized, maculopapular, itchy rash that developed a few days ago. The itching is keeping him awake at night. Three

      weeks ago he began treatment for a seizure disorder with 400 mg of phenytoin, daily. Physical examination now shows a generalized maculopapular rash with excoriations. The most appropriate

      management at this time is discontinuation of the drug and addition of which of the following?

      A

      ) Oral hydroxyzine

      B

      ) Oral prednisone

      C

      ) Topical betamethasone

      D

      ) Topical emollients

      E

      ) Topical hydrocortisone

      21. A 58-year-old white man comes to the office because of a mass in his neck for the past 2 months. He says, "My voice is bad and sometimes I can't catch my breath." He is a construction worker

      and has a long history of alcohol abuse and cigarette smoking. Vital signs are normal. Physical examination shows a large mass in the floor of the mouth, extending to the tonsillar fossa. A 4H5-cm

      mass is noted in the right anterior triangle of the neck. The greatest immediate risk to the patient is which of the following?

      A

      ) Airway obstruction

      B

      ) Aspiration

      C

      ) Bleeding

      D

      ) Sepsis

      E

      ) Stroke

      22. A 15-year-old girl comes to the office because of a 2-day history of an itchy rash on her right ankle. The rash occurred 1 day after she took a school field trip to a local park while wearing

      a new pair of sandals. She has moderate to severe asthma, for which she takes zafirlukast, salmeterol, and albuterol by metered-dose inhaler as needed. She has been tapering off oral prednisone

      for the past 2 months. Vital signs are temperature 37.5°C (99.5°F), pulse 86/min, respirations 16/min, and blood pressure 125/80 mm Hg. Auscultation of the lungs discloses mild, diffuse expiratory

      wheezing. Her right ankle is shown. Which of the following is the most likely diagnosis?

      A

      ) Chigger infestation

      B

      ) Contact dermatitis

      C

      ) Herpes zoster

      D

      ) Poison ivy dermatitis

      E

      ) Scabies

      The following vignette applies to the next 2 items.


      A 29-year-old truck driver comes to the health center for advice regarding his serum cholesterol concentration, which was determined recently at a shopping mall health fair. He had the test at the

      request of his wife, who is pregnant with their first child. The test result read "high," with advice to see a physician. The patient has a family history of premature coronary artery disease. Two

      uncles had myocardial infarctions (MI), one at age 41 years and the other at age 45 years. His father died of an MI at age 47 years. He tells you that his 34-year-old brother takes "some type of

      cholesterol pill." The patient has no significant medical history. He denies smoking cigarettes but admits to drinking a few beers in the evenings at home. Two to three times per week he meets his

      friends at a local tavern before driving home. He is currently taking no medications, and his physical examination is normal except for mild obesity. A fasting serum lipid profile was done 2 days

      ago at the suggestion of the nurse who took his history by phone. Results are available today and show:


      Serum



      Cholesterol



      Total

      171 mg/dL

      HDL

      29 mg/dL

      LDL

      117 mg/dL

      Triglycerides

      156 mg/dL

      Item 1 of 2

      23. To evaluate his risk for cardiac disease, in addition to his serum lipid concentrations it is appropriate to obtain which of the following serum laboratory studies?

      A

      ) Angiotensin II concentration

      B

      ) Apolipoprotein B concentration

      C

      ) Endothelin concentration

      D

      ) Homocysteine concentration

      E

      ) Lipoprotein lipase concentration

      Item 2 of 2

      24. With respect to his alcohol intake, it is most appropriate to do which of the following?

      A

      ) Determine if his uncles and father drank and whether it affected their lipid levels

      B

      ) Encourage him to continue drinking in moderation given his lipid analysis

      C

      ) Investigate the risk of his drinking while driving his truck

      D

      ) Recommend that he switch from beer to red wine

      E

      ) Recommend that he switch to a low-calorie beer

      25. A 50-year-old African-American woman returns to the office for follow-up of diabetes mellitus, which has been treated with diet; extended-release glipizide, 10 mg daily; and metformin, 500 mg

      twice a day. She says, "I do the best I can adhering to my diet." She tests her blood glucose concentration daily. For the past month her fasting blood glucose concentrations have averaged 170

      mg/dL. Hemoglobin A1c 1 week ago was 8.4%. The patient is 167.5 cm (5 ft 6 in) tall and weighs 86 kg (190 lb). Which of the following is the most appropriate change in therapy?

      A

      ) Add chlorpropamide

      B

      ) Add insulin

      C

      ) Increase the metformin dosage

      D

      ) Stop the glipizide and metformin and start insulin

      E

      ) No change is indicated

      26. A 36-year-old African-American woman with hypertension comes to the office because of a 3-day history of intermittent, painless, gross hematuria. Symptoms started spontaneously, and she has

      not had fever, chills, flank pain or dysuria. Her only medication is hydrochlorothiazide. Vital signs are: temperature 37.0°C (98.6°F), pulse 72/min and blood pressure 128/84 mm Hg. Physical

      examination is normal; there is no costovertebral angle tenderness. Laboratory studies show:


      Serum



      Urine



      Electrolytes

      Normal

      Protein

      3+

      Glucose

      78 mg/dL

      Blood

      Positive

      BUN

      8 mg/dL

      Microscopic

      RBCs too numerous to count

      Blood





      No WBCs, bacteria or casts

      CBC

      Normal

      Nitrite

      Negative

      Partial thromboplastin time

      Normal

      Urine culture

      Pending

      Platelet count

      268,000/mm3





      Prothrombin time

      Normal






      Which of the following is the most appropriate next step?

      A

      ) Cystoscopy

      B

      ) Determination of protein excretion in a 24-hour urine sample

      C

      ) Initiation of antibiotic therapy

      D

      ) Renal biopsy

      E

      ) Transvaginal ultrasonography of the uterus

      The following vignette applies to the next 2 items.


      A 15-year-old girl is brought to the office for the first time by her mother, who has been your patient for many years. The mother is concerned because her daughter, who had menarche at age 11

      years, has not had a period in the past 6 months. Both mother and daughter have kept a record of the girl's periods. The first three periods were irregularly spaced and not painful. Subsequent

      periods were regularly spaced and were accompanied by severe cramping on the first day. The cramping subsided 1 year ago. The mother insists that you interview her and her daughter together. She

      says that her daughter is not sexually active. She tells you that her daughter gets straight A grades and that she is very active in sports. The girl is also a cheerleader and is taking a night

      course for college credit at the local community college through the school's gifted child program. The mother tells you that her daughter has a good appetite for healthy food and does not eat

      junk food. She asks you what is causing her daughter's amenorrhea.

      Item 1 of 2

      27. Which of the following is the most appropriate initial response?

      A

      ) "In young women, missing a few periods is not unusual, and we should wait a while longer before becoming concerned."

      B

      ) "It is a well-known fact that the most likely cause of amenorrhea in young women is pregnancy. How can you be certain she has not been sexually active?"

      C

      ) "Many things can cause missed periods. After I examine your daughter, I may be able to provide more insight into the problem."

      D

      ) "Over-involvement in some athletic activities can cause menstrual periods to cease."

      E

      ) "Your daughter is involved in a lot of activities and may be under stress. That can certainly be a factor in causing cessation of periods."

      Item 2 of 2

      28. After responding to the mother's question, you ask the mother to wait outside while you speak privately with the girl and do a physical examination. No additional information is obtained.

      Vital signs are: temperature 37.0°C (98.6°F), pulse 110/min and blood pressure 90/50 mm Hg. Height is 165 cm (5ft 5 in) and weight is 49 kg (105 lb). Physical examination shows some eroding of the

      enamel on the girl's rear teeth. Sexual maturation is complete. Abdomen is soft and nontender. Which of the following is the most likely diagnosis?

      A

      ) Athletic amenorrhea

      B

      ) Bulimia

      C

      ) Hypothyroidism

      D

      ) Pregnancy

      E

      ) Stress-induced amenorrhea


      29. A 39-year-old white homemaker comes to the office because of abnormal vaginal bleeding. You provide routine medical care for her and her family. She says her menstrual periods always have been

      regular and that her last normal regular period was about 10 weeks ago. She has had spotting for 1 week. She tells you that she and her husband use "withdrawal" as their birth control method.

      Urine pregnancy test is positive. Vital signs now are: temperature 37.4°C (99.3°F), pulse 88/min and blood pressure 110/72 mm Hg. Pelvic examination discloses a small amount of blood in the

      vagina. Cervix is closed. Uterus is soft, nontender and anteverted. Adnexae are nontender. Additional history reveals that she had a first trimester elective abortion at age 20 years and she has

      genital herpes that recurs about twice each year. Her husband is age 40 years and has Crohn disease. Her children are ages 7 and 9 years. The 7-year-old was born by cesarean delivery at 32 weeks'

      gestation after placental abruption. This couple's greatest risk factor for miscarriage is which of the following?

      A

      ) History of abruptio placenta

      B

      ) History of genital herpes

      C

      ) History of premature delivery

      D

      ) Maternal age

      E

      ) Paternal history of auto-immune disease

      30. A 30-year-old woman who is 28 weeks pregnant with her first child comes to the office for a routine prenatal visit. She has been a strict vegetarian for many years. At each prenatal visit she

      has insisted that she is eating well. However, she has gained only 0.9 kg (2 lb) since her initial prepregnancy weight of 54 kg (120 lb); she is 165 cm (5 ft 5 in) tall. She says that she has been

      taking her prenatal vitamins and iron as instructed. She has a regular exercise routine but has decreased this activity significantly during the past 4 weeks because, she says, "I've been too

      tired." Pulse is 90/min and blood pressure is 110/60 mm Hg. Physical examination shows a reddened, malar rash. Laboratory studies at this visit show:


      Hematocrit 25%

      Hemoglobin 7.5 g/dL

      WBC 3500/mm3

      MCV 105 μm3

      Platelet count 89,000/mm3


      Which of the following is most appropriate to prescribe orally at this time?

      A

      ) Corticosteroid therapy

      B

      ) Vitamin Bl2 (cyanocobalamin) supplementation

      C

      ) Folate supplementation

      D

      ) Iron supplementation

      E

      ) Vitamin E (tocopherol) supplementation

      31. A 36-year-old African-American woman with hypertension comes to the office because of a 3-day history of dysuria, hematuria, and urinary frequency and urgency. Symptoms started the day after

      she returned from a weekend visit with her boyfriend in another city. She has no prior history of urinary tract infections and she denies fever, chills, flank pain, nausea or vomiting. Her only

      medication is hydrochlorothiazide. Vital signs at today's visit are: temperature 37.6°C (99.6°F), pulse 90/min and blood pressure 126/84 mm Hg. Physical examination is normal. Laboratory studies

      show:


      Urine

      Blood Positive

      WBC 15-20/hpf

      RBC 15-20/hpf

      Bacteria Moderate

      Casts Negative

      Nitrate Positive

      Protein 1+


      Which of the following is the most appropriate next step?

      A

      ) Increase oral intake of fluids and order a urine culture

      B

      ) Order cystoscopy

      C

      ) Order intravenous urography

      D

      ) Repeat the urinalysis in 3 to 4 days

      E

      ) Start antibiotic therapy

      32. A 54-year-old white man comes to the office because of increasingly severe nosebleeds for the past 10 days. He says initially his nosebleeds resolved spontaneously, but over the past week they

      have become more frequent and have had a heavier flow. He says his nose has been bleeding almost constantly for the past 48 hours. There is no history of trauma or previous nosebleeds. His only

      medication is quinidine, which was started 6 weeks ago for restless legs. Medical history is otherwise unremarkable and he takes no other medications. Vital signs are: temperature 36.5°C (97.7°F),

      pulse 75/min, respirations 18/min, and blood pressure 132/85 mm Hg. His nose is packed with tissue paper and he has blood stains on his shirt. Examination of the nose shows no active bleeding or

      nasal lesions, but there is dried blood on his nares. Petechiae are noted inside the oral cavity. Examination of the skin shows scattered ecchymoses over the lower extremities. The remainder of

      the physical examination is noncontributory. Results of laboratory studies show:


      Serum Blood

      ALT 32 U/L Hematocrit 37%

      AST 43 U/L Hemoglobin 11.7 g/dL

      WBC 6500/mm3

      PTT 22 seconds

      INR 1.0

      Platelet count 32,500/mm3


      Which of the following is the most appropriate initial management?

      A

      ) Bone marrow biopsy

      B

      ) Determination of bleeding time

      C

      ) Discontinuation of quinidine

      D

      ) Platelet transfusion

      E

      ) Vasopressin therapy

      33. At an annual company examination, a 40-year-old man has an elevated mean corpuscular volume. Hemoglobin concentration is normal. This finding is most suggestive of which of the following?

      A

      ) Alcohol abuse

      B

      ) Hemosiderosis

      C

      ) Hepatitis B infection

      D

      ) Schistosomiasis

      E

      ) Vitamin B6 (pyridoxine) deficiency

      34. A 15-year-old white girl is brought to the health center by her mother for a periodic health evaluation and refill of tetracycline for acne. Upon entering the examination room, the patient's

      mother asks to speak alone with you. In private, she says, "My daughter has been like a different person for the past 4 months. She used to be on the honor roll and is now failing school. She

      received detention six times for truancy and for talking back to teachers. She argues with her brother and me over everything. She quit the tennis team and doesn't see any of her friends." The

      mother can think of no explanation for these changes. When you interview the patient alone, she becomes angry and says, "Mom should mind her own business and stop talking about me behind my back."

      She denies use of drugs or alcohol. She tells you, "I don't want to go out of the house because my acne makes me feel ugly. Plus, I've put on ten pounds." Today she weighs 54 kg (120 lb); she is

      165 cm (5 ft 5 in) tall. Which of the following is the most appropriate advice to the mother?

      A

      ) Her daughter is just going through a normal adolescent phase

      B

      ) Her daughter would benefit from a diet program

      C

      ) Her daughter would benefit from a trial of antidepressant medication

      D

      ) She should use a behavior-modification program to control her daughter

      E

      ) No advice is indicated because it would violate patient confidentiality

      35. A 17-year-old African-American girl comes to the health center because she wants contraception. She has been sexually active for the past 2 years. She has never taken oral contraceptive

      therapy. She says that her boyfriends use condoms some of the time. Past medical history is unremarkable. She takes no medication and has no allergies. She does not drink alcoholic beverages. She

      smokes one-half pack of cigarettes per day. Her last menstrual period, which was normal, was 3 weeks ago. She has had no vaginal symptoms. The patient is 165 cm (5 ft 5 in) tall and weighs 62 kg

      (137 lb). Pulse is 62/min and blood pressure is 106/64 mm Hg. Physical examination, including pelvic examination, is normal. Which of the following is the most appropriate recommendation for

      contraception in this patient?

      A

      ) Combination oral contraceptive therapy

      B

      ) Diaphragm

      C

      ) Intrauterine device (IUD)

      D

      ) Levonorgestrel

      E

      ) Spermicidal jelly

      36. A 20-year-old white woman comes to the office because of increasing fatigue for the past 3 weeks. She is 24 weeks pregnant with her first pregnancy. She says she has noted increased difficulty

      maintaining her usual pace in the local factory where she works packing boxes. Prior to pregnancy, she had no health problems and was considered an above-average worker. Other than the fatigue and

      an occasional backache, she has had an uneventful pregnancy. Results of initial prenatal laboratory studies were normal, and she has attended all of her prenatal office appointments. Complete

      blood count is obtained at this visit and a peripheral blood smear, also obtained during this visit, is shown. At this time, the most likely explanation for the patient's fatigue is that she has

      which of the following?

      A

      ) Iron-deficiency anemia

      B

      ) Vitamin B12 (cyanocobalamin) deficiency

      C

      ) Folate deficiency

      D

      ) Leukemia

      E

      ) Physiologic anemia of pregnancy
      ================================================================================
      1. A 75-year-old retired landscape architect is brought to the emergency department after the police found him wandering around the city. He was unable to tell them who he was or where he lived.

      He has a long history of poorly controlled hypertension. He had two strokes several months ago from which he partially recovered. He can walk but his left arm remains weak. Pertinent family

      history indicates that his father, a successful businessman, committed suicide at age 72 years. Which of the following is the most likely diagnosis?

      A

      ) Bipolar disorder, manic episode

      B

      ) Major depressive disorder

      C

      ) Vascular dementia

      D

      ) Dementia, Alzheimer type

      E

      ) Schizophrenia

      2. A 37-year-old woman comes to the emergency department because of a 2-day history of weakness in her left foot which has caused her to accidentally stub the toes of her left foot several times.

      She reports no other symptoms and is otherwise generally healthy. Medical history is unremarkable except for an episode of blurred vision 1 year ago that resolved on its own. She takes no

      medications and does not smoke cigarettes or drink alcoholic beverages. Physical examination shows a left footdrop but is otherwise noncontributory. Neurologic examination shows hyperreflexia of

      the deep tendon reflexes in all extremities. CT scan of the head shows no abnormalities. Lumbar puncture is done. Examination of this patient's cerebrospinal fluid is most likely to show which of

      the following?

      A

      ) Elevated glucose

      B

      ) Elevated IgG

      C

      ) Elevated neutrophil count

      D

      ) Elevated protein

      E

      ) Positive VDRL

      3. A 55-year-old African-American woman is transported to the emergency department by paramedics. She was sitting at the dinner table, and suddenly said to her husband, "I have a terrible

      headache." She then dropped her fork and slumped in her chair. The husband went to her aid, and she said, "I can't move my right side." He then called emergency medical services. On arrival the

      patient is alert and oriented. She is holding her head and is in obvious distress. Vital signs are: pulse 101/min, respirations 28/min and blood pressure 190/118z mm Hg. The patient's husband

      tells you that she has been treated for hypertension for the past 10 years and that she has a 25-year history of simple migraines that occur every 3 to 4 months. On physical examination the

      patient has an obvious right hemiparesis with an associated hemisensory deficit and hyperreflexia. Blood is drawn for laboratory studies, electrocardiography is done and CT scan of the head is

      ordered. Her husband asks, "What do you think happened, Doctor?" Based on her clinical presentation and past medical history, which of the following is the most likely cause?

      A

      ) Cerebellar hemorrhage

      B

      ) Complicated migraine

      C

      ) Embolic cerebral infarct

      D

      ) Intracerebral hemorrhage

      E

      ) Subarachnoid hemorrhage

      4. A 36-year-old firefighter is trapped in a burning building when his air supply runs out. When the rescuers find him 15 minutes later, he is breathing spontaneously and has a pulse, but he is

      unresponsive. There is no evidence of acute traumatic injury. He is resuscitated with 100% oxygen via a nonrebreathing face mask. He gradually becomes conscious, and by the time he reaches the

      emergency department, he is awake, alert and complains only of a headache. On arrival in the emergency department arterial blood gas values while breathing 100% oxygen show:


      PO2

      493 mm Hg

      PCO2

      29 mm Hg

      pH

      7.53

      Carboxyhemoglobin

      30%


      Which of the following is the most appropriate management at this time?

      A

      ) Admit the patient for careful monitoring of his airway

      B

      ) Begin phenytoin therapy by intravenous loading

      C

      ) Have the patient rebreathe 100% oxygen at 10 L/min

      D

      ) Intubate the patient in order to allow controlled mechanical ventilation

      E

      ) Measure the concentration of carbon monoxide in his blood

      5. A 23-year-old rugby player is brought to the emergency department by his teammates after sustaining blunt trauma to the left infra-orbital area during a game. The patient complains of

      significant periorbital pain and says, "I'm seeing flashing lights." Physical examination discloses periorbital swelling. Pupils are equal and reactive. Visual acuity is 20/20 in the right eye and

      20/40 in the left eye. Which of the following is the most appropriate step?

      A

      ) Discharge and follow-up with an ophthalmologist within 24 hours

      B

      ) Discharge with a nonsteroidal anti-inflammatory drug (NSAID) and an eye patch

      C

      ) Discharge with corticosteroid eyedrops and a nonsteroidal anti-inflammatory drug (NSAID)

      D

      ) Discharge with pain medication and application of ice packs

      E

      ) Immediate consultation with an ophthalmologist

      6. A 19-year-old white college student is brought to the emergency department by her two roommates because of shortness of breath. The roommates tell you that her symptoms came on suddenly about

      one hour after they picked her up at the airport where she had arrived after a 6-hour flight from visiting her parents. The patient has rapid and shallow breathing, and with difficulty she tells

      you, "I can't get my breath and I'm having pains in my chest. My face is numb. I think I'm dying. Do something. Do something!" She says she has never had an experience like this before. She always

      has been healthy and she takes no medications except for combination oral contraceptive therapy. Physical examination is normal except for tachypnea and tachycardia. Electrocardiogram shows sinus

      tachycardia but is otherwise normal. Arterial blood gas values while breathing room air show:


      PO2

      99 mm Hg

      PCO2

      30 mm Hg

      pH

      7.44


      Which of the following is the most appropriate long-term pharmacotherapy?

      A

      ) Bupropion

      B

      ) Gabapentin

      C

      ) Lorazepam

      D

      ) Metoprolol

      E

      ) Paroxetine

      The following vignette applies to the next 2 items.


      A 58-year-old white man comes to the emergency department because of chest heaviness for the past 45 minutes associated with shortness of breath and a sense of doom. He has not seen a physician

      since he was 18 years old. He smokes approximately two packs of cigarettes per day. He takes no prescription medications. He has had increasing heartburn recently and he has been taking eight to

      twelve antacid tablets daily during the past 3 weeks. He is mildly nauseated and diaphoretic. Vital signs are: temperature 37.2°C (99.0°F), pulse 98/min, respirations 20/min and blood pressure

      160/96 mm Hg. Electrocardiogram shows that ST-T segment changes are indeterminate. You are aware of a new blood test, CQ, that can diagnose an acute myocardial infarction (MI) more quickly than

      the creatine kinase isoenzymes. The receiver operating characteristic (ROC) curve for CQ is shown in the exhibit for four cut-off points. You believe the likelihood of an acute MI is high in this

      patient and you want to minimize the chance of a false negative.

      Item 1 of 2

      7. Which of the following is the most appropriate cut-off point on the ROC curve?

      A

      ) A

      B

      ) B

      C

      ) C

      D

      ) D

      E

      ) It cannot be determined with the data provided

      Item 2 of 2

      8.

      The cut-off point at which the test performance for CQ is most accurate in the detection of an acute MI is which of the following?

      A

      ) A

      B

      ) B

      C

      ) C

      D

      ) D

      E

      ) It cannot be determined from an ROC curve

      End of Set

      9. A 67-year-old man is brought to the emergency department in ventricular fibrillation. His rectal temperature is 26.7°C (80.0°F). Among the following criteria, the patient should be declared

      dead when defibrillation fails after which of the following?

      A

      ) Rapid endotracheal intubation and administration of 100% oxygen

      B

      ) Restoration of a normal core temperature

      C

      ) Restoration of a normal oral temperature

      D

      ) 1 hour of core rewarming

      E

      ) 20 minutes of warming, externally

      10. A 19-year-old white woman is brought to the emergency department by her mother because of intractable emesis. She has a past history of bulimia and according to her mother has been under the

      care of a psychiatrist. She apparently was well until 1 day ago when she developed emesis and an inability to tolerate liquid and solid foods. Although she takes no medications other than oral

      contraceptives, she admits to occasional use of both laxatives and ipecac. She denies the use of alcohol or of illicit drugs and says she has experienced no previous symptoms of chest pain,

      heartburn, hematemesis or fever. Physical examination shows a well-nourished woman with normal vital signs. No lesions are evident on inspection of the skin, but turgor is poor. The thyroid is

      flat, nontender and without masses. On auscultation of the lungs, moist rales are present at the bases bilaterally. The point of maximal impulse of the heart on the chest wall is 7 cm from the

      lower left sternal margin in the sixth intercostal space. There is no evidence of an S4 although an S3 is heard. A soft systolic murmur is heard at the apex without a diastolic component.

      Jugulovenous distention is present 3 cm above the suprasternal notch at 45 degrees' elevation of the chest. The abdomen is soft and a tender liver edge extends 3 cm below the right costal margin.

      Pitting edema is present in both legs to the mid-calf bilaterally. Laboratory studies show a serum creatinine concentration of 4.2 mg/dL and serum urea nitrogen (BUN) of 88 mg/dL. Urinalysis shows

      renal tubular epithelial cell casts. Chest x-ray film shows cardiomegaly, central hilar vascular congestion and cephalization of blood flow. Which of the following is the most likely explanation

      for cardiac decompensation and renal failure in this patient?

      A

      ) Bulimic cardiomyopathy

      B

      ) Cocaine intoxication

      C

      ) Hypothyroidism

      D

      ) Myocardial ischemia

      E

      ) Myocarditis

      11. A 73-year-old recently widowed African-American woman comes to the emergency department because of abdominal pain, nausea and constipation for the past 3 days. She says the pain has been

      intermittent and she has had severe nausea and left-sided stomach cramps. She alternates between being constipated and having diarrhea but she has not had a bowel movement in the past 36 hours.

      She admits to smoking one pack of cigarettes per day, and she has diabetes mellitus that is poorly controlled with diet and glyburide. Vital signs now are: temperature 37.8°C (100.8°F), pulse

      100/min, respirations 28/min and blood pressure 180/90 mm Hg. Abdomen is distended and tender; rectal examination is positive for occult blood. X-ray film is shown. Which of the following is the

      most appropriate management at this time?

      A

      ) Discharge home with clear fluids

      B

      ) Exploratory laparotomy

      C

      ) Nasogastric tube

      D

      ) Oral antibiotics

      E

      ) Rectal tube

      12. A 10-day-old female neonate with Down syndrome is brought to the emergency department by her mother because she has been vomiting for the past 2 days. The vomitus is bile-stained. She was

      initially breast-fed, but she has been drinking cow milk-based formula for the past week. Physical examination shows slight fullness in the left upper quadrant without obvious tenderness. Test of

      the stool for occult blood is negative. Which of the following is the most likely diagnosis?

      A

      ) Allergy to cow milk protein

      B

      ) Duodenal obstruction

      C

      ) Hypertrophic pyloric stenosis

      D

      ) Peptic ulcer with pyloric obstruction

      E

      ) Small-bowel volvulus

      The following vignette applies to the next 2 items.


      A 49-year-old homeless white man comes to the emergency department and says, "I began vomiting 2 to 3 hours ago, and then started to throw up blood." He reports vomiting "about half a cup" of red

      blood. He had epigastric discomfort after several episodes of emesis, but no preceding abdominal pain. The patient says that he drinks about a half pint of bourbon per day, and he does not use

      aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). He has no previous history of similar symptoms. Vital signs now are: temperature 37.0°C (98.6°F), pulse 105/min and blood pressure 150/77

      mm Hg. On physical examination he is alert, oriented and disheveled, and he has the odor of alcohol on his breath. No scleral icterus is present. Abdomen is soft, with mild epigastric tenderness.

      Liver edge is palpated 2 cm below the right costal margin and is nontender. Bowel sounds are present. Stool is negative for occult blood. An intravenous line is started. Endoscopy confirms a tear

      of the gastroesophageal junction. Laboratory studies show:


      Serum



      Amylase

      135 U/L

      BUN

      10 mg/dL

      Creatinine

      0.7 mg/dL

      Na+

      137 mEq/L

      K+

      3.3 mEq/L

      Cl-

      97 mEq/L

      HCO-3

      22 mEq/L

      Blood



      Hematocrit

      37%

      Hemoglobin

      12 g/dL

      WBC

      12,100/mm3

      Platelet count

      317,000/mm3

      Item 1 of 2

      13. The patient says, "What are you going to do, Doc?"


      Which of the following is the most appropriate next step?

      A

      ) Cimetidine, intravenously

      B

      ) Observation and supportive care

      C

      ) Octreotide, intravenously

      D

      ) Sclerotherapy

      E

      ) Selective arterial vasopressin

      Item 2 of 2

      14. After 1 hour the patient's condition has stabilized. Despite your urging him to stay for further evaluation, he insists on leaving.


      At this time which of the following is most appropriate to tell the patient?

      A

      ) An elective operation should be scheduled

      B

      ) He is at immediate risk for major gastrointestinal hemorrhage

      C

      ) His symptoms might indicate severe alcoholic liver disease

      D

      ) Omeprazole would help prevent further episodes

      E

      ) The risk for rebleeding from this episode is relatively small


      The following vignette applies to the next 2 items.


      A 17-year-old African-American boy is brought to the emergency department by his mother and two of his friends at 2:00 AM on Sunday morning. His friends had taken him home from a party after he

      began to act strangely. They were aware that the patient had recently been treated for marijuana abuse, and they believe that he has significantly cut back on his drug use. His friends began to

      worry when he insisted that several peers at the party were talking about him behind his back and were plotting to harm him. On the way to the hospital, he was adamant that the same individuals

      were following them and that they were all in great danger. Now, the patient is unable to walk a straight line, and his speech is slurred. Vital signs are: temperature 38.1°C (100.5°F), pulse

      130/min, respirations 20/min, and blood pressure 150/105 mm Hg. Physical examination discloses vertical and horizontal nystagmus. The remainder of the physical examination and neurologic

      examination is normal.

      Item 1 of 2

      15. The most likely cause of the patient's current symptoms is intoxication with which of the following?

      A

      ) Alcohol

      B

      ) Cannabis

      C

      ) Heroin

      D

      ) Nitrous oxide

      E

      ) Phencyclidine

      Item 2 of 2

      16. Which of the following is the most appropriate pharmacotherapy?

      A

      ) Diphenhydramine

      B

      ) Fluoxetine

      C

      ) Haloperidol

      D

      ) Hydroxyzine

      E

      ) Phentolamine


      The following vignette applies to the next 2 items.


      A 4-year-old girl is brought to the emergency department by her mother because of severe wrist pain. The girl was playing with her friends in her backyard and fell, breaking the fall with her

      outstretched hand. On physical examination there is slight swelling over the dorsal aspect of the wrist. X-ray films of the wrist are shown.

      Item 1 of 2

      17. The findings are most consistent with which of the following?

      A

      ) Carpal navicular fracture

      B

      ) Cortical fracture of the radius

      C

      ) Fracture of the distal radius and ulnar growth plates

      D

      ) Fracture of the distal radius growth plate

      E

      ) Perilunate dislocation of the wrist

      Item 2 of 2

      18. Which of the following is the most appropriate management?

      A

      ) Apply an elastic bandage and apply ice packs to the wrist

      B

      ) Do closed reduction of the fracture

      C

      ) Do closed reduction of the fracture and report the case to child protective services

      D

      ) Immobilize the forearm and hand in situ in a cast

      E

      ) Prepare for open reduction and internal fixation


      The following vignette applies to the next 3 items.


      A 10-year-old boy is brought to the emergency department because he developed hives and shortness of breath 10 minutes after being stung by an insect. His father tells you that he had a similar

      episode of dyspnea and urticaria 2 years ago. Physical examination now shows a frightened child who appears out of breath, has generalized urticaria and asks for help in a hoarse voice. Vital

      signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 36/min and blood pressure 70/40 mm Hg.

      Item 1 of 3

      19. Which of the following is the most important first step in managing this patient?

      A

      ) Administer diphenhydramine, orally

      B

      ) Administer epinephrine, subcutaneously

      C

      ) Administer oxygen via face mask

      D

      ) Establish intravenous access

      E

      ) Obtain arterial blood gas values

      Item 2 of 3

      20. After 10 minutes there is no change in his condition.


      At this time, the most appropriate next step is to administer which of the following?

      A

      ) Diphenhydramine, orally

      B

      ) Dopamine, intravenously

      C

      ) Epinephrine, subcutaneously

      D

      ) Prednisone, orally

      E

      ) Ranitidine, orally

      Item 3 of 3

      21. The patient improves with treatment. In 30 minutes his urticaria, dyspnea and hoarseness are resolved and his vital signs are normal. As you prepare to discharge the patient you recommend that

      he be evaluated by an allergist.


      The patient's mother asks you what should be done until he can be seen by the allergist. Which of the following is the most appropriate recommendation?

      A

      ) Avoid all outdoor activity

      B

      ) Take diphenhydramine, orally, every 4 hours while awake

      C

      ) Take oral prednisone once daily

      D

      ) Use an albuterol metered-dose inhaler after any insect sting

      E

      ) Use an epinephrine autoinjector if he is stung again

      22. A 3-year-old girl is brought to the emergency department by her father because of vomiting. He reports that her medical history is unremarkable except for a viral infection 1 month ago, during

      which she had a mild fever and was irritable for 2 days. She recovered quickly and was well until 3 days ago, when she seemed more thirsty than usual and did not eat as much solid food as she had

      before. She began vomiting last night and was lethargic today. She is afebrile, pulse is 180/min and respirations are 40/min and deep. On physical examination she is lethargic but responds to

      touch. Which of the following abnormalities is most likely on further physical examination?

      A

      ) Acetone-smelling breath

      B

      ) Hepatomegaly

      C

      ) Multiple bruises of various stages of healing

      D

      ) Nuchal rigidity

      E

      ) An olive-sized mass in the right upper abdominal quadrant

      23. A 71-year-old retired oil refinery worker comes to the emergency department at 2:00 AM because of inability to urinate for the past 6 hours. He says he is having abdominal discomfort and that

      he has had a decreased urinary stream and urinary dribbling for the past 4 months. Vital signs are: temperature 36.5°C (97.7°F), pulse 103/min and blood pressure 140/90 mm Hg. His lower abdomen is

      mildly tender and the urinary bladder can be percussed at 2 cm below the umbilicus. Rectal examination shows an enlarged, firm, smooth prostate. Neurologic examination is normal. Which of the

      following is the most appropriate initial management?

      A

      ) Admit the patient to the short-stay unit for observation

      B

      ) Do a suprapubic cystostomy and drain the bladder

      C

      ) Insert an indwelling urinary catheter

      D

      ) Order pelvic ultrasonography

      E

      ) Order retrograde cystourethrography

      24. A 15-year-old girl is brought to the emergency department by her sister. The patient is 36 weeks pregnant and is very upset. She says, "I don't feel the baby move like I used to. Something's

      wrong!" She has had no prenatal care. A fetal nonstress test is obtained and is nonreactive. Which of the following is the most appropriate first step?

      A

      ) Assess biophysical profile

      B

      ) Determine her hemoglobin concentration

      C

      ) Determine her serum glucose concentration

      D

      ) Induce labor

      E

      ) Order amniocentesis to determine fetal maturity

      he following vignette applies to the next 2 items.


      A 56-year-old white executive is admitted to the hospital from the emergency department following a severe nosebleed. One month ago he had a brief viral illness after being exposed to an exanthem

      eruption of one of his grandchildren. At that time the patient was also referred to a urologist because of fatigue, low back pain, and urinary frequency. He was diagnosed with prostatitis, for

      which he has been taking sulfamethoxazole-trimethoprim for the past 12 days. He does not take any other medications. On arrival in the emergency department vital signs were: temperature 36.8°C

      (98.2°F), pulse 100/min, respirations 16/min, and blood pressure 120/66 mm Hg. The patient appeared pale with scattered areas of bruising on his limbs and body and a few petechiae. No

      lymphadenopathy or organomegaly was found. Results of laboratory studies obtained in the emergency department are shown:

      Blood

      Urine

      Hematocrit 21%

      WBC 0/hpf

      Hemoglobin 5.6 g/dL

      RBC 10-20/hpf

      WBC 2000/mm3

      MCV 102 μm3

      Partial thromboplastin time 26 sec

      Platelet count 20,000/mm3

      Prothrombin time 12.8 sec

      INR 1.3

      Bone marrow biopsy shows marked hypocellularity.

      Item 1 of 2

      25. Which of the following is the most appropriate management?

      A

      ) Administer granulocyte colony-stimulating factor

      B

      ) Administer high-dose short-term corticosteroids

      C

      ) Administer parenteral broad-spectrum antibiotics

      D

      ) Begin transfusion with whole blood

      E

      ) Discontinue sulfamethoxazole-trimethoprim

      Item 2 of 2

      26. Supportive measures are provided for the patient.


      Which of the following is the most appropriate treatment recommendation for this patient at this time?

      A

      ) Chemotherapy

      B

      ) Follow-up evaluation in 1 week

      C

      ) Glucocorticoid therapy

      D

      ) Hematopoietic growth factor therapy

      E

      ) Stem cell transplant


      27. An 87-year-old woman is brought to the emergency department by ambulance. Her friend found her lying in bed in her home about one-half hour ago. She had been incontinent of urine and had also

      vomited. The patient has a history of degenerative joint disease, hypertension and chronic obstructive pulmonary disease. The paramedics brought in her medications, which include felodipine,

      naproxen, albuterol inhaler, ipratropium inhaler, prednisone, theophylline and ciprofloxacin. On questioning the woman she says she has a headache and nausea, but she is not able to give a more

      coherent history. She appears restless, tremulous and agitated. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 26/min and blood pressure 110/65 mm Hg. Physical

      examination is normal except for mild expiratory wheezing. Chest x-ray film is normal. Which of the following is the most likely cause of her symptoms?

      A

      ) Exacerbation of chronic obstructive pulmonary disease

      B

      ) Gastroenteritis

      C

      ) Migraine

      D

      ) Stroke

      E

      ) Theophylline toxicity

      28. A 53-year-old white man is brought to the emergency department by emergency medical services after he crashed his car into a tree. He was not wearing a seatbelt. Upon arrival in the emergency

      department the patient is clearly drunk but he is cooperative during the examination. Vital signs are: temperature 37.0°C (98.6°F), pulse 110/min, respirations 18/min and blood pressure 110/75 mm

      Hg. Physical examination shows generalized tenderness over the lower abdomen and pelvis. Neurologic examination is normal. X-ray films of the cervical spine, chest and pelvis are normal, as is CT

      scan of the head. On reexamination 3 hours later, no urinary output has been recorded. The patient is unable to produce a urine sample. He has received 1400 mL of lactated Ringer solution since

      the accident. Foley catheter is placed and yields 5 mL of bloody urine. X-ray film obtained after placement of the Foley catheter is shown. Which of the following is the most appropriate next

      step?

      A

      ) Foley catheter drainage for 10 days

      B

      ) Observation only

      C

      ) Percutaneous nephrostomy

      D

      ) Suprapubic catheter drainage

      E

      ) Surgical repair

      29. A 17-year-old white girl is brought to the emergency department after she was struck by a car while riding her bicycle. She was wearing a helmet. She is awake, alert, and oriented. Vital signs

      are temperature 37.0°C (98.6°F), pulse 100/min, respirations 18/min, and blood pressure 107/60 mm Hg. Pulse oximetry shows an oxygen saturation of 96% while breathing room air. Physical

      examination shows no cervical spine tenderness. Breath sounds are clear. Abdominal, pelvic, and neurologic examinations are normal. Screening x-rays of the lateral cervical spine and pelvis are

      normal. Chest x-ray is shown. Which of the following is the most likely diagnosis?

      A

      ) Aortic rupture

      B

      ) Flail chest

      C

      ) Hemothorax

      D

      ) Perforated viscus

      E

      ) Pulmonary contusion

      The following vignette applies to the next 3 items.


      You are notified that your patient, a 26-year-old pregnant woman, has been brought by ambulance to the emergency department after she was in an automobile accident. The vehicle in which she was a

      passenger was broad-sided by another car. She was in the front passenger seat and was wearing a lap/shoulder belt. You have known the patient for 10 years. She is at 34 weeks' gestation with her

      second pregnancy; she has one child. The nurses attach an external fetal monitor immediately upon the patient's arrival. When you arrive, the patient's vital signs are: pulse 110/min, respirations

      18/min and blood pressure 120/80 mm Hg. The fetal heart rate is 150/min with occasional accelerations to 160/min and no decelerations. The monitor shows uterine contractions about every 7 minutes.

      The patient states that her only discomfort is from the contractions. She says, "They feel like the hard ones from the end of labor with my other baby." On physical examination, the abdomen is

      very tender to palpation. On speculum examination, there is a small amount of bright red blood oozing from the cervix, which is long and closed. The patient asks you how long she will have to stay

      in the hospital.

      Item 1 of 3

      30. Which of the following is the most appropriate response at this time?

      A

      ) "We need to monitor both you and the baby and do some additional tests before I can answer your question."

      B

      ) "You are in preterm labor from the accident. We will try to stop the contractions with medication, and you can go home later today."

      C

      ) "You seem a little shaken up, but the baby is fine. I want you to go home but remain in bed the rest of the day."

      D

      ) "You seem a little shaken up. Even though the baby seems fine, I would like to keep you overnight for observation."

      E

      ) "You will need to stay here until the baby is delivered."

      Item 2 of 3

      31. While you are talking with the patient, she has a severe contraction that lasts for 5 minutes. Fetal heart tones decrease to 60/min. Which of the following is the most appropriate action at

      this time?

      A

      ) Determine fetal scalp pH

      B

      ) Give the mother oxygen by face mask and magnesium sulfate by slow intravenous push

      C

      ) Prepare for immediate cesarean delivery

      D

      ) Place an internal fetal scalp electrode

      E

      ) Rupture the membranes artificially for vaginal delivery

      Item 3 of 3

      32. The appropriate action is undertaken. The patient asks you if she would have been better off if she had not been wearing a seatbelt. Which of the following is the most appropriate answer?

      A

      ) "If your car has an air bag, you should not use the seat belt when you are pregnant. But if your car does not have an air bag, we still recommend you use the seat belt."

      B

      ) "We prefer that pregnant women not wear seat belts because, in case of accidents, the belt can cause more harm than it prevents."

      C

      ) "Pregnant women should use seat belts until about 28 weeks' gestation. After that, the abdomen is so large that the belt can cause the kind of problem you experienced."

      D

      ) "The problem you had was caused from the forces of the accident. You might have been injured more seriously without a seat belt."

      E

      ) "Your problem was that you were sitting in the front passenger seat, which is the most dangerous seat in the car. If you had sat in a different seat, this would not have happened."


      33. A 47-year-old man is brought to the emergency department because of the sudden onset of chest pain. On cardiac examination, which of the following physical findings is suggestive of ischemia?

      A

      ) Early diastolic murmur at the base

      B

      ) A late systolic murmur at the apex

      C

      ) Mid-systolic click

      D

      ) Pericardial knock

      E

      ) Pulsus paradoxus

      34. A 23-year-old woman comes to the emergency department because of fever. She was diagnosed with acute lymphoblastic leukemia 2 weeks ago, and chemotherapy was initiated 3 days later. She has

      received all of the chemotherapy as an outpatient. Several hours prior to admission she developed a single episode of shaking chills, which spontaneously resolved. Vital signs are temperature

      38.4°C (101.1°F), pulse 108/min, respirations 16/min, and blood pressure 120/80 mm Hg. She is in mild distress. Partial alopecia is noted, and a Hickman catheter is in place. Results of stat

      complete blood count are obtained and shown:


      Blood



      Hemoglobin

      8.5 g/dL

      WBC

      950/mm3

      Platelet count

      80,000/mm3


      Urinalysis shows no abnormalities. Two sets of blood cultures are obtained. Which of the following is the most appropriate next step?

      A

      ) Administer a single dose of antibiotics and discharge with oral antibiotics

      B

      ) Admit her to the hospital

      C

      ) Discharge her on G-CSF (filgrastim)

      D

      ) Monitor vital signs in the emergency department

      E

      ) Remove the Hickman catheter and discharge with oral antibiotics

      The following vignette applies to the next 2 items.


      An 81-year-old Chinese-American woman is brought to the emergency department by her husband because of back pain. She says, "My back hurts and the pain is getting worse." The patient tells you

      that 2 days ago, an epidural block was done by a staff anesthesiologist because of a chronic, painful left L5 radiculopathy. She obtained temporary relief immediately after the procedure, but

      about 24 hours ago she began having midline low back pain without radiation that has increased in severity. She was unsuccessful today in contacting the orthopedist who arranged the procedure.

      Vital signs now are: temperature 38.5°C (101.3°F), pulse 101/min and blood pressure 140/85 mm Hg. On physical examination there is tenderness over the L3-5 area in the midline, which is slightly

      swollen. Straight leg-raising test is negative bilaterally. Anal sphincter tone is normal. There is decreased sensation over the left lateral calf, an absent left ankle reflex and moderate

      weakness of left great toe extension. The remainder of the neurologic examination of the leg is normal.

      Item 1 of 2

      35. Which of the following is the most accurate statement?

      A

      ) An epidural abscess has developed

      B

      ) The epidural block has worn off

      C

      ) The original injection was subdural

      D

      ) A radiculopathy has developed at a different level

      E

      ) She is having a reaction to the anesthetic

      Item 2 of 2

      36. Which of the following is the most appropriate next step?

      A

      ) Administer an analgesic and diphenhydramine

      B

      ) Administer an analgesic, intravenously, and arrange myelography

      C

      ) Contact the anesthesiologist about repeating the epidural block

      D

      ) Reassure the patient and have her make an appointment with the orthopedist for tomorrow

      E

      ) Request an emergency MRI of the spine
      ================================================================================
      1. A 76-year-old retired plumber comes to the office with his wife because he has had progressive memory loss during the past year. His wife tells you that he has recently gotten lost in his home

      at night. He has also had urinary incontinence, about which he says, "It must be because of my big prostate." The patient's wife is concerned that he walks differently and often staggers, but he

      has not fallen. He now uses a cane. He tells you that he has recently used his wife's lorazepam for insomnia. One of his four siblings has significant memory loss. Vital signs are normal. Physical

      examination shows good orientation. During the mental status examination, he recalls only one of three items after 3 minutes, he is unable to do serial threes or sevens, and there is evidence of

      impaired judgment. He has mild ataxia with a tendency to fall to the left if he does not have support. Which of the following is the most likely presumptive diagnosis?

      A

      ) Dementia, Alzheimer type

      B

      ) Normal-pressure hydrocephalus

      C

      ) Parkinson dementia

      D

      ) Pseudodementia due to depression

      E

      ) Reversible drug-induced dementia

      2. A 52-year-old woman comes to the office because of difficulty falling asleep. She says that she retires to her bedroom at 7:00 PM and watches television while lying on her bed. She turns out

      the light and the TV at 11:00 PM but lies awake until at least 2:00 AM. She then sleeps soundly until 7:00 AM when she gets up to go to work. She is divorced and lives alone. She takes no

      medications. Her physical examination is normal. Which of the following is the most appropriate management?

      A

      ) Advise her to avoid watching TV in bed

      B

      ) Advise her to drink a warm beverage before going to bed

      C

      ) Advise her to exercise lightly at 9:00 PM

      D

      ) Prescribe flurazepam

      E

      ) Prescribe temazepam

      3. A 7-year-old girl is brought to the office by her mother because the girl has been awakening regularly at night in considerable distress about 1 hour after falling asleep. The mother describes

      her as being extremely fearful and inconsolable during these episodes. Her mother says, "She cries out something about a figure in a dark cape who is chasing after her and wants to turn her into

      stone. A few minutes later, she is able to go back to sleep and remembers little of what has happened the next morning." She has been in excellent health and has achieved appropriate developmental

      milestones. She is doing well in school and has a number of friends and playmates. She is 121 cm (4 ft) tall and weighs 22 kg (48 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 60/min,

      respirations 18/min and blood pressure 100/70 mm Hg. Physical examination shows a normally developed and well-nourished girl. Physical and neurologic examinations are normal. Which of the

      following is the most likely diagnosis?

      A

      ) Cataplexy

      B

      ) Central sleep apnea

      C

      ) Major depressive disorder

      D

      ) Nightmares

      E

      ) Night terrors

      4. An 8-year-old boy is brought to the health center by his parents because of a 2-day history of sore throat and fever. Temperature is 38.3°C (101.0°F) and pulse is 88/min; other vital signs are

      normal. Physical examination shows erythema of the posterior pharynx; the tonsils are enlarged and there are a few spots of whitish exudate on the left tonsil. A few small, nontender posterior

      cervical lymph nodes are palpable. There is no rash. Rapid streptococcal test is negative. Which of the following is the most appropriate next step?

      A

      ) Administer intramuscular penicillin

      B

      ) Obtain a throat culture

      C

      ) Obtain acute-phase serum for antistreptolysin-O titer

      D

      ) Prescribe azithromycin

      E

      ) Reassure the patient's parents that he has a viral illness

      5. A 16-year-old Latino boy comes to the health center because of ear pain for the past 2 days. He has been working at a local restaurant 30 to 40 hours per week through a school-sponsored

      vocational education program. His father left his family when the patient was a young child, and his mother died 1 year ago of breast cancer. He was declared an emancipated minor by the court

      after his mother's death, and he now rents a room in a home in his neighborhood. He has received care at the health center in the past for episodic illnesses and vaccinations before his mother

      died. Which of the following is the most accurate statement regarding obtaining consent for treatment today?

      A

      ) Can be seen because he is likely to have an infectious disease and signed consent is not necessary

      B

      ) Can be seen because his deceased mother gave signed consent for services in the past

      C

      ) Can be seen if he signs a consent for services

      D

      ) Cannot be seen because he has a living parent whose signed consent is required

      E

      ) Cannot be seen without consent of the court that awarded emancipated minor status

      6. A 67-year-old man comes to the office because of a 1-week history of increasing cough productive of small amounts of clear sputum and shortness of breath on exertion. He has smoked one and

      one-half packs of cigarettes per day for the past 40 years. He quit smoking 14 months ago when he was told that he had severe lung disease. He appears to be in no acute distress. He cannot speak

      in full sentences without taking a breath, and he purses his lips when exhaling. The patient is 170 cm (5 ft 7 in) tall and weighs 57 kg (125 lb); BMI is 20 kg/m2. The physical examination is most

      likely to show which of the following?

      A

      ) Accessory muscle use

      B

      ) An audible, right-sided S3

      C

      ) Cyanosis of the extremities

      D

      ) Lower extremity edema

      E

      ) Wide splitting of S2

      7. A 32-year-old African-American woman with a history of major depressive disorder comes to the health center because of palpitations and dizziness for the past week. She has been taking

      fluoxetine for the past 3 years and had been doing well until her mother died several months ago. At that time she became despondent with frequent crying and inability to sleep at night. Six weeks

      ago her psychiatrist increased the dose of fluoxetine but she did not think it helped. A friend recommended St. John's wort, which she began taking several weeks ago. She also takes calcium

      carbonate daily, occasional antihistamines for seasonal allergies, and amoxicillin-clavulanate, which was prescribed 10 days ago by another physician for a sinus infection. Vital signs now are:

      temperature 37.2°C (99.0°F), pulse 90/min, respirations 18/min and blood pressure 140/90 mm Hg. On physical examination she is somewhat tremulous. Thyroid is normal and chest is clear.

      Cardiovascular examination discloses a regular rhythm with slight tachycardia. Abdominal and neurologic examinations are normal. Which of the following is the most likely cause of her symptoms?

      A

      ) Anxiety reaction due to her mother's death

      B

      ) Hyperthyroidism

      C

      ) Interaction between fluoxetine and amoxicillin-clavulanate

      D

      ) Interaction between fluoxetine and antihistamines

      E

      ) Interaction between fluoxetine and St. John's wort

      8. A 54-year-old African-American dispatcher comes to the office because of hip and leg pain. You have treated the patient for diabetes mellitus, emphysema and obesity. His diabetes is controlled

      with diet and insulin therapy and is managed by his wife who is a registered nurse. He has a 30-year history of smoking two packs of cigarettes per day and he does not want to stop. For the past 4

      months he has been taking aspirin with each meal to relieve his hip and leg pain. His wife drops him off at work in the morning; he walks to the hospital to ride home with his wife. He states he

      has no pain at rest but walking for a few blocks causes his whole left leg to ache. Which of the following is the most likely cause of his symptoms?

      A

      ) Osteoarthritis

      B

      ) Peripheral neuropathy

      C

      ) Peripheral vascular insufficiency

      D

      ) Sciatic nerve radiculopathy

      E

      ) Spinal stenosis

      9. A 74-year-old woman comes to the office because of constipation and blood-streaked stools for the past 3 days. She has had a 4.5-kg (10-lb) weight loss and anorexia for the past few months. She

      has a temperature of 37.0°C (98.6°F). Abdominal examination is normal. Rectal examination is normal except for the presence of occult blood on examination of the stool. Leukocyte count is

      9000/mm3. Which of the following is the most likely diagnosis?

      A

      ) Carcinoma of the cecum

      B

      ) Carcinoma of the sigmoid colon

      C

      ) Ischemic colitis

      D

      ) Pseudomembranous enterocolitis

      E

      ) Ulcerative colitis

      10. A 46-year-old white woman returns to the office for follow-up of abdominal pain. Two weeks ago, she came to the office because of constipation and passing two to three loose stools with mucus

      per day. Physical examination at that time was normal. Her weight has remained the same and temperature has been normal. She has never had an abdominal operation. Lower gastrointestinal barium

      study and flexible sigmoidoscopy are normal. Complete blood count is normal. Today, you review the results with the patient. Which of the following is the most appropriate recommendation to the

      patient?

      A

      ) Antianxiety medication

      B

      ) Antispasmodic medication

      C

      ) Consultation with a gastroenterologist

      D

      ) Consultation with a psychiatrist

      E

      ) Fiber supplementation

      11. A 10-year-old boy is brought to the office by his mother for a periodic health evaluation. He has been your patient for several years. Recently his teachers and his school counselor have

      recommended that he be treated with methylphenidate because of his disruptive behavior in the classroom. He has no past history of behavioral problems. Which of the following is the most

      appropriate advice to the mother?

      A

      ) "Children with this problem may not have a very high IQ."

      B

      ) "Children with this problem usually grow out of it by puberty."

      C

      ) "I don't think he has attention-deficit disorder because he has not had problems in the past."

      D

      ) "Let's get more information from the school."

      E

      ) "Methylphenidate treatment will probably improve his grades."

      12. A 24-year-old woman comes to the office for an initial prenatal visit. A home pregnancy test was positive 2 weeks ago. Her last menstrual period was 10 weeks ago. She has been healthy and has

      no significant medical history. She takes no medications. During the interview she becomes tearful and says, "My husband hit me several times 6 weeks ago and I'm afraid that it may happen again.

      He's become very loving now since he found out about the baby, but I'm still worried." Vital signs now are: temperature 36.9°C (98.4°F), pulse 80/min, respirations 20/min and blood pressure 110/70

      mm Hg. Pelvic examination shows a 10-week size uterus and is otherwise normal. Ultrasonography confirms a 10-week gestation. Which of the following strategies is most appropriate?

      A

      ) Provide her with the name and phone number of a shelter for battered women

      B

      ) Reassure the patient that abusive behavior is less likely now that she is pregnant

      C

      ) Recommend marital counseling

      D

      ) Schedule an appointment with the husband to discuss his abusive behavior

      E

      ) Tell her that you will report this to the police if it happens again

      13. A 16-year-old boy and his mother come to the office because the mother is concerned that her son may have a drug problem. You have treated him in the past for mild intermittent asthma, and he

      currently uses an albuterol inhaler prior to exercise. You last saw him 1 year ago for a sports physical examination. At that time, he admitted to drinking alcohol on the weekends. He also

      admitted to marijuana use but had planned to quit using both before track season started. The mother says that her son now seems disinterested in school and other activities in which he was

      previously engaged. He has quit the track team, has become irritable, and he has a new set of friends whom his mother dislikes and describes as "druggies." She acknowledges that the boy's father,

      from whom she is divorced, has an alcohol abuse problem. The boy's older brother abused cocaine for 2 years but is now in a drug rehabilitation program. Prior to interviewing and examining the

      patient, the mother pulls you aside and asks you to test her son for drugs without informing him. Which of the following is the most appropriate response?

      A

      ) Agree to do toxicologic screening but review the test results with the patient before giving the results to the mother

      B

      ) Agree to do toxicologic screening only if, after discussing it with the patient, he agrees to the test

      C

      ) Agree to do toxicologic screening without the patient's knowledge per his mother's request

      D

      ) Decline to do toxicologic screening stating that you do not want to get caught between her and her son

      E

      ) Decline to do toxicologic screening unless under a court order

      The following vignette applies to the next 2 items.


      A 75-year-old woman whom you treat for obstructive lung disease comes to the office because of thoracic back pain, which has been troubling her for several weeks. There is no specific history of

      trauma. Her current medications include ipratropium and inhaled albuterol. She no longer smokes cigarettes and she does not use alcohol. She underwent a mastectomy 10 years ago for breast cancer.

      Today, vital signs are normal. Her weight is unchanged from 1 year ago. On physical examination breath sounds are diminished in intensity but normal in quality. There is no tenderness over the

      spinous processes. Laboratory studies in the office show a normal complete blood count and erythrocyte sedimentation rate. A compression fracture of the thoracic spine is seen on a lateral chest

      x-ray film. After further discussion, the patient agrees to a trial of alendronate to prevent further fractures.

      Item 1 of 2

      14. Regarding alendronate therapy, the patient should be told which of the following?

      A

      ) The medication should be chewed, rather than swallowed

      B

      ) The medication should be taken at bedtime

      C

      ) The medication should be taken with a full glass of water

      D

      ) The medication should be taken with meals

      E

      ) She should lie down immediately after taking the medication

      Item 2 of 2

      15. Four days later, the patient returns to the office complaining of chest pain, odynophagia and dysphagia. You decide to discontinue the alendronate. In addition, which of the following is the

      most appropriate diagnostic study?

      A

      ) Electrocardiography

      B

      ) Esophagoscopy

      C

      ) Laryngoscopy

      D

      ) MRI of the thoracic spine

      E

      ) X-ray film of the lateral neck

      16. A 69-year-old woman comes to the office because of left knee pain. She says, "For the past several years my left knee has been bothering me a bit but I have been getting by. However, for the

      past few days it has been killing me. I was at the outlet mall 2 days ago and I was fine, but yesterday I woke up with such knee pain that I could hardly walk." She denies injuring the knee. No

      other joints bother her this much although she notes that her right knee occasionally hurts. The pain does not improve with ibuprofen. She has hypertension controlled with hydrochlorothiazide and

      a β-blocking medication, and she has mild chronic renal failure. Serum creatinine concentration 3 months ago was 2.1 mg/dL. She is 168 cm (5 ft 6 in) tall and weighs 106 kg (233 lb). Physical

      examination today discloses moderate effusion of the left knee. The left knee is warm to touch compared with the right knee. Range of motion is normal but there is crepitus. There is no rash or

      erythema of the skin. X-ray films of both knees are shown. Arthrocentesis shows:


      WBC 850/mL

      Gram stain Negative

      Microscopic No crystals seen under polarized light


      Which of the following is the most likely diagnosis?

      A

      ) Gout

      B

      ) Osteoarthritis

      C

      ) Osteoporosis

      D

      ) Pseudogout

      E

      ) Septic arthritis

      17. A 46-year-old man with diabetes mellitus well controlled by diet alone returns to the office for a follow-up visit for migraines. You have been seeing him for the past year for the migraines,

      and about 2 months ago you prescribed a calcium-channel-blocking medication. His previous medications included ergotamine and propranolol, but they were discontinued because of lack of full

      effect. At today's visit he complains of ankle swelling. Physical examination is normal except for 2+ pitting edema. Which of the following is the most appropriate step at this time?

      A

      ) Determine serum albumin concentration

      B

      ) Discontinue his calcium-channel-blocking medication

      C

      ) Order determination of protein excretion in a 24-hour urine sample

      D

      ) Order echocardiography

      E

      ) Prescribe a diuretic agent

      18. A 27-year-old woman comes to the clinic because of chronic dermatitis involving both ear lobes. She has pierced ears and the rash is most marked around the insertion of her earrings. She

      should be advised to do which of the following?

      A

      ) Avoid skin sensitizing soaps while wearing earrings

      B

      ) Discontinue the use of metallic earring posts

      C

      ) Have her ears repierced

      D

      ) Soak her earrings in 70% alcohol for 24 hours before using them

      E

      ) Wear clip-on earrings only

      19. A 46-year-old woman whom you are treating for hypertension and hypothyroidism returns to the office for a follow-up visit. She denies dyspnea, orthopnea, nocturia or exertional chest

      discomfort. She states, "Doctor, I've recently found that my feet are swollen. It's becoming hard to get my shoes on. My feet don't really bother me, except that they look funny and make me feel

      self-conscious." The patient has no other medical problems. She has no allergies. She does not smoke cigarettes and she drinks a glass of wine every evening. Her medications are levothyroxine,

      extended-release nifedipine and enalapril. Blood pressure is 128/78 mm Hg. On physical examination there are no abnormalities of the skin. Neck veins are not distended. Pulmonary and cardiac

      examinations are normal. Liver and spleen are not palpable. She has 2+ pitting edema of both legs. The remainder of the examination is normal. Which of the following is the most likely explanation

      for the edema?

      A

      ) The patient has deep venous thrombosis

      B

      ) The patient has misreported her use of alcohol

      C

      ) The patient has not been taking levothyroxine

      D

      ) Use of enalapril

      E

      ) Use of nifedipine

      20. A 45-year-old man comes to the office because he has noted a lesion on his chest. He has been generally healthy and you last saw him 5 years ago for an insurance physical examination that was

      normal. Medical chart notes from that visit report that his skin examination was "normal." You do not recall a lesion being present in the area that he indicates. He is unaware of when the lesion

      first occurred, but it was noted by a friend at a health club who saw a television report about skin cancer. Physical examination shows a well-appearing man with brown eyes and fair complexion.

      Vital signs are normal. Skin examination is normal except for the 1-cm lesion on his lateral abdominal wall as shown. The factor that is the best predictor of this patient's prognosis is which of

      the following?

      A

      ) Degree of variation in the color of the lesion

      B

      ) Diameter of the lesion

      C

      ) His complexion

      D

      ) His eye color

      E

      ) Measurement of lesion depth

      21. A 34-year-old primigravid woman at 24 weeks' gestation returns to the office to discuss results of a fasting serum glucose study and hemoglobin A1c obtained during a visit 2 weeks ago. Medical

      history is significant for infertility, oligomenorrhea, and hirsutism. She conceived 3 months after starting treatment with metformin; she discontinued metformin at 10 weeks' gestation. She

      currently takes only a prenatal multivitamin supplement. Her mother, a maternal aunt, and a paternal aunt have type 2 diabetes mellitus. The patient is 168 cm (5 ft 6 in) tall and weighs 118 kg

      (260 lb); BMI is 42 kg/m2. Vital signs are: temperature 37.0°C (98.6°F), pulse 82/min, respirations 15/min, and blood pressure 112/64 mm Hg. Fasting serum glucose concentration is 120 mg/dL and

      hemoglobin A1c is 7.5%. Which of the following is the most appropriate management?

      A

      ) 1200-Calorie American Diabetes Association diet

      B

      ) Glyburide therapy

      C

      ) Insulin therapy

      D

      ) Reinitiating metformin therapy

      E

      ) Rosiglitazone therapy

      22. A 28-year-old African-American woman comes to the office because of low back pain and decreased urine output. She is a semiprofessional basketball player and she is married. She had one

      pregnancy 12 years ago that was uncomplicated and resulted in vaginal delivery of a term female neonate. Medications include oral contraceptive pills and a corticosteroid inhaler for asthma. She

      is 182 cm (6 ft) tall and weighs 88 kg (195 lb). Physical examination is normal except for a palpable lower abdominal mass that extends to the umbilicus. Speculum examination discloses a 3-cm

      ulcerative lesion circumferentially around the external cervical os. Bimanual examination shows a firm, nodular, central pelvic mass filling the pelvis and extending cephalad to the umbilicus.

      Rectovaginal examination confirms these findings. Stool is negative for occult blood. Which of the following is the most appropriate recommendation?

      A

      ) Arrange for laparoscopy

      B

      ) Do a cervical biopsy

      C

      ) Do an endometrial biopsy

      D

      ) Increase Pap smear screening to every 3 months

      E

      ) Obtain pelvic ultrasonography

      The following vignette applies to the next 3 items.


      A 61-year-old woman comes to the office because of a 3-month history of urinary incontinence. You have been providing care for her and her husband since they moved to your area 2 years ago. She

      has a history of diabetes mellitus that was first diagnosed 2 years ago and has been very well managed by diet alone. She currently takes lorazepam at night for sleep and calcium and vitamin D

      supplements to prevent osteoporosis. She has declined hormone replacement therapy in the past because of a concern about breast cancer. She denies dysuria or problems with incontinence after

      sneezing or laughing, but she says, "When I try to pass urine, there usually isn't much, but I have to go again a few minutes later. And then, at other times, I just lose control and wet myself. I

      recently saw a television program on this and I think I have stress incontinence." Vital signs are: temperature 36.9°C (98.4°F), pulse 64/min, respirations 16/min and blood pressure 158/72 mm Hg.

      She weighs 93 kg (205 lb) and is 163 cm (5 ft 4 in) tall. Physical examination is normal except for moderate vaginal mucosal atrophy. Urinalysis done in the office shows no signs of infection.

      Item 1 of 3

      23. Which of the following factors in this patient's history or physical examination suggests a diagnosis other than stress incontinence as the cause for this patient's symptoms?

      A

      ) Absence of dysuria

      B

      ) Diabetes mellitus

      C

      ) Increased body mass index

      D

      ) Pattern of urination

      E

      ) Vaginal mucosal atrophy

      Item 2 of 3

      24. The most appropriate next step in management is to suggest which of the following?

      A

      ) Increased fluid consumption at night

      B

      ) Referral for bladder ultrasonography

      C

      ) Replacement of lorazepam with diphenhydramine at night for sleep

      D

      ) Scheduled voiding

      E

      ) Use of a pessary

      Item 3 of 3

      25. The patient follows your suggestion. She returns to the office in 3 weeks and reports that she was recently incontinent while shopping with friends. She states, "I've never been so embarassed

      in my life! Frankly, I don't think I'm better off than when I saw you last time, and now I'm afraid to leave the house." Which of the following is the most appropriate response to the patient's

      comment?

      A

      ) "Are you ready to use estrogen therapy now?"

      B

      ) "Have you ever thought of using adult disposable diapers? They are very effective."

      C

      ) "I understand your concern. Let's discuss this further and develop a plan."

      D

      ) "I'm sorry to hear this. I'll refer you to a urologist right away."

      E

      ) "These things happen. I'm sure you can understand you're growing older."


      26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She states that despite bathing

      frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time and is taking no

      medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical examination shows no

      abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no masses. In addition to

      obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?

      A

      ) Determine serum estrogen concentration

      B

      ) Order antibody studies for syphilis and HIV

      C

      ) Prescribe an oral anti-trichomonal medication and antifungal cream

      D

      ) Question the patient regarding the circumstances surrounding her recent break-up

      E

      ) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge

      27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of

      diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for

      the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and

      oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist

      extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful

      sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic

      examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?

      A

      ) CT scan of the head

      B

      ) Electromyography and nerve conduction studies of the left upper extremity

      C

      ) Measurement of serum B12 (cobalamin) concentration

      D

      ) MRI of the cervical spine

      E

      ) Radionuclide bone scan

      28. A 32-year-old woman, gravida 3, para 2, who is at 38 weeks' gestation, is brought to the office by her coworker 15 minutes after the patient appeared to have had a seizure at work. The

      coworker says the patient was working at her computer when she suddenly fell to the floor, began shaking, and had incontinence of urine. She was unresponsive to voice until approximately 5 minutes

      after the episode. The patient has received routine prenatal care throughout her pregnancy. She has a history of mild, persistent asthma treated with corticosteroid inhalers. Vital signs on

      arrival are temperature 36.7°C (98.0°F), pulse 100/min, respirations 22/min, and blood pressure 160/110 mm Hg. The patient is alert but disoriented to time and place. She has no recollection of

      the episode. Physical examination shows bruising of her left arm and a bite on the lower lip. Which of the following is the most accurate statement regarding the risk of harm to the fetus?

      A

      ) The fetus is at risk for developing intrauterine hypoxia

      B

      ) The fetus will die unless it is delivered immediately

      C

      ) The risk to the fetus depends on any coexisting respiratory condition

      D

      ) The risk to the fetus is minimal because the seizure was short-lived

      E

      ) The risk to the fetus will not be increased if the seizure does not recur

      29. A 30-year-old African-American w26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She

      states that despite bathing frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time

      and is taking no medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical

      examination shows no abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no

      masses. In addition to obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?

      A

      ) Determine serum estrogen concentration

      B

      ) Order antibody studies for syphilis and HIV

      C

      ) Prescribe an oral anti-trichomonal medication and antifungal cream

      D

      ) Question the patient regarding the circumstances surrounding her recent break-up

      E

      ) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge

      27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of

      diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for

      the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and

      oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist

      extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful

      sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic

      examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?

      A

      ) CT scan of the head

      B

      ) Electromyography and nerve conduction studies of the left upper extremity

      C

      ) Measurement of serum B12 (cobalamin) concentration

      D

      ) MRI of the cervical spine

      E

      ) Radionuclide bone scan

      28. A 32-year-old woman, gravida 3, para 2, who is at 38 weeks' gestation, is brought to the office by her coworker 15 minutes after the patient appeared to have had a seizure at work. The

      coworker says the patient was working at her computer when she suddenly fell to the floor, began shaking, and had incontinence of urine. She was unresponsive to voice until approximately 5 minutes

      after the episode. The patient has received routine prenatal care throughout her pregnancy. She has a history of mild, persistent asthma treated with corticosteroid inhalers. Vital signs on

      arrival are temperature 36.7°C (98.0°F), pulse 100/min, respirations 22/min, and blood pressure 160/110 mm Hg. The patient is alert but disoriented to time and place. She has no recollection of

      the episode. Physical examination shows bruising of her left arm and a bite on the lower lip. Which of the following is the most accurate statement regarding the risk of harm to the fetus?

      A

      ) The fetus is at risk for developing intrauterine hypoxia

      B

      ) The fetus will die unless it is delivered immediately

      C

      ) The risk to the fetus depends on any coexisting respiratory condition

      D

      ) The risk to the fetus is minimal because the seizure was short-lived

      E

      ) The risk to the fetus will not be increased if the seizure does not recur

      29. A 30-year-old African-American woman returns to the office for a second prenatal visit. She is 12 weeks pregnant and this is her first pregnancy. Results of laboratory studies that were

      ordered at her first visit show:


      Blood

      Hematocrit 28%

      Hemoglobin 9.2 g/dL

      Hemoglobin electrophoresis

      Hemoglobin A1 64%

      Hemoglobin S 32%

      Hemoglobin A2 4%

      Mean corpuscular hemoglobin (MCH) 26 pg/cell

      Mean corpuscular hemoglobin concentration(MCHC) 32% Hb/cell

      Mean corpuscular volume (MCV) 74 μm3


      Which of the following is the most likely cause of her anemia?

      A

      ) α-thalassemia trait

      B

      ) β-thalassemia trait

      C

      ) Iron deficiency

      D

      ) Physiologic anemia of pregnancy

      E

      ) Sickle cell trait

      30. A 17-year-old girl brings her 4-day-old neonate to the health center 1 day after discharge from the hospital. She says, "I don't think my baby is getting enough milk. He wants to nurse every 2

      hours and my nipples are sore and cracked. I feel miserable." The neonate was born via vaginal delivery without complications, following a normal pregnancy. His birth weight was 3317 g (7 lb 5

      oz). Physical examination shows a vigorous, active neonate with a strong sucking reflex. He has a wet diaper on arrival and has had two stools since this morning. There is jaundice of the face. In

      order to support this new mother during this early stage of breast-feeding, which of the following is the most appropriate advice to the patient?

      A

      ) Feed the neonate on only one breast at each feeding to ensure complete emptying of the breast

      B

      ) Insert as much of the areola as possible into the neonate's mouth to improve latching

      C

      ) Not feed the neonate more than every 3 hours to allow for better milk production

      D

      ) Offer formula after each feeding to ensure that the neonate is getting enough milk

      E

      ) Switch to formula for 5 days to assist with healing of her nipples

      31. A 19-year-old African-American college student comes to the student health center because of pain in her right knee and fever. She says the pain began about 4 days ago, and she does not recall

      injuring her knee. Her only medication is an oral contraceptive pill. She is generally healthy. Vital signs are: temperature 37.7°C (99.8°F), pulse 96/min, respirations 20/min and blood pressure

      120/72 mm Hg. She appears uncomfortable. Physical examination is normal except for her right knee, which is red, swollen and tender with a tense effusion. Which of the following tests is most

      likely to support the diagnosis?

      A

      ) Cervical cultures

      B

      ) MRI of the knee

      C

      ) Plain x-ray film of the knee

      D

      ) Serum antinuclear antibody titer

      E

      ) Serum uric acid concentration

      32. A 62-year-old woman who was discharged from the hospital several hours ago following evaluation of optic neuritis now has swelling of her ankles. Prior to admission, the patient had a 3-day

      history of loss of vision and poor color perception in her right eye. Visual acuity on admission was less than 20/200 in her right eye and was 20/40 in her left eye. The remainder of the physical

      examination was noncontributory. Blood pressure on admission was 140/80 mm Hg. The patient had been otherwise healthy and had been taking no medications. She has never worn corrective lenses.

      Family history is significant for thyroid disorder. During her hospital stay, the patient received intravenous methylprednisolone therapy for the past four days. Vital signs today are temperature

      37.2°C (99.0°F), pulse 100/min, respirations 14/min, and blood pressure 150/95 mm Hg. Physical examination shows ankle edema but is otherwise unchanged from physical examination done on admission.

      Laboratory studies are obtained. Which of the following serum laboratory study results is most likely in this patient?

      A

      ) Decreased magnesium concentration

      B

      ) Decreased sodium concentration

      C

      ) Increased calcium concentration

      D

      ) Increased glucose concentration

      E

      ) Increased potassium concentration

      33. A 30-year-old white woman comes to the office for a periodic health evaluation. At this visit she asks you about a DNA test that she has heard about that can detect the presence of the adult

      polycystic kidney disease (APKD) gene in asymptomatic carriers. She has a family history of APKD. She has had no symptoms. Her blood pressure is normal, and renal ultrasound 2 months ago was

      normal. Serum creatinine concentration obtained 2 months ago was 0.9 mg/dL. Before obtaining blood for this test, it is important to explain to this patient that a positive test result would mean

      which of the following?

      A

      ) She is certain to develop renal failure

      B

      ) She may be eligible for disability

      C

      ) She may have difficulty obtaining life insurance in the future

      D

      ) She should avoid becoming pregnant

      E

      ) She should be monitored for development of liver disease

      34. A pharmaceutical representative regularly comes to your office about once a month. Her company has introduced a new prescription nonsteroidal anti-inflammatory drug (NSAID) and she has brought

      samples today. You overhear your receptionist ask the representative to leave some samples for her own use. If the representative leaves the samples for the receptionist, the most significant

      concern regarding this situation is that it does which of the following?

      A

      ) It constitutes practicing medicine without a license

      B

      ) It diverts samples intended for use by patients

      C

      ) It may constitute a liability risk

      D

      ) It promotes the use of a more expensive drug over available alternative medications

      E

      ) It provides the representative the opportunity to exert undue influence

      35. A 54-year-old woman comes to the office for her annual health maintenance examination. At her last visit 11 months ago she reported hot flushes but says they have now resolved. She takes no

      medications. She is employed as an executive for a computer manufacturing company. Her stress level has increased during the past 9 months because of her company's financial difficulties and she

      now smokes two packs of cigarettes daily. She is 170 cm (5 ft 7 in) tall and weighs 63 kg (140 lb), which is an increase of 4 kg (9 lb) since her last visit. She plans to begin an intensive

      aerobics program to stop her weight gain. The patient should be advised that initiation of this exercise program will put her most at risk for which of the following?

      A

      ) Arthritis

      B

      ) Exercise-induced asthma

      C

      ) Gastroesophageal reflux disease

      D

      ) Stress fractures

      E

      ) Stroke

      36. A 78-year-old retired autoworker from Puerto Rico is brought to the office by his son because of a 4- to 7-kg (9- to 15-lb) weight loss in the past few months. You have been treating this

      patient for hypertension with hydrochlorothiazide for the past 3 years. Today he reports that he eats only one or two bites of food and feels full and that he has a low energy level. He feels he

      is just "too old." He has never smoked cigarettes and rarely drinks alcoholic beverages. Which of the following is the most appropriate question to elicit further history that would be helpful in

      the differential diagnosis of this patient?

      A

      ) "Are you having headaches?"

      B

      ) "Did you stop taking your medication?"

      C

      ) "Have you had a change in bowel habits?"

      D

      ) "Have you had any visual changes lately?"

      E

      ) "What has been going on in your life recently?"
      ================================================================================
      Report Abuse

      * Re:All Step 3 NBME qtns.
      #498890
      moona - 10/10/06 23:45

      3. e
      4. c
      Report Abuse

      * Re:All Step 3 NBME qtns.
      #498875
      moona - 10/10/06 23:36

      1. a
      2. a
      Report Abuse

      * Re:All Step 3 NBME qtns.
      #497575
      ss - 10/10/06 11:56

      These ans are for block 1 NBME.

      Report Abuse

      * Re:All Step 3 NBME qtns.
      #497568
      ss - 10/10/06 11:54

      Newboy these are my answers.
      Do you wanna compare with yours. We can discuss those ans we think vary.
      1.c
      2.a
      3.e
      4.c
      5.d
      6.a
      7.e
      8.b
      9.e
      10.b
      11.d
      12.b
      13.c
      14.b
      15.b
      16.d
      17.d
      18.e
      19.d
      20.b
      21.a
      22.b
      23.e
      24.a
      25.d
      26.c
      27.d
      28.a
      29.a
      30.b
      31.e
      32.d
      33.d
      34.e
      35.c
      36.a




      The most common valvular abnormalities associated with ankylosing spondylitis include aortic regurgitation and mitral valve prolapse.
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