Test 61

Question 1

Hyperthyroidism

Answer 1

TSH is the recommended initial screening test in pregnant patients with suspected hyperthyroidism. If TSH is suppressed below trimester-specific norms, free or total T4 is used for confirmation. If TSH is suppressed but T4 is normal or equivocal, a total T3 level may be useful.

Question 2

Hyperthyroidism

Answer 2

During pregnancy, hCG directly stimulates TSH receptors on thyroid follicles, increasing the release of thyroid hormone. Very high hCG levels (multiple gestation, hyperemesis gravidarum) can cause gestational transient thyrotoxicosis. This condition is generally self-limited and resolves as hCG levels fall by 14-16 weeks gestation.

Question 3

Caustic ingestion

Answer 3

In patients with evidence of respiratory distress (tachypnea) or severe oropharyngeal damage after a caustic ingestion, laryngoscopy should be performed first to assess the likelihood of impending airway compromise.

Question 4

Informed consent

Answer 4

Second-stage labor arrest occurs when there is no fetal descent (no change in fetal station) after nulliparous patients push for greater than or equal to 3 hours without an epidural (or greater than or equal to 4 hours with an epidural). Management is via cesarean delivery. In most states, adolescents can provide their own consent for pregnancy-related care.

Question 5

Precocious puberty

Answer 5

Central precocious puberty is the onset of secondary sexual characteristics in girl age <8 and boys age <9 with advanced bone age and elevated LH and FSH levels. Treatment for central precocious puberty is gonadotropin-releasing hormone agonist that down regulates LH and FSH, thereby slowing the progression of pubertal development.

Question 6

Kidney transplantation

Answer 6

The optimal kidney donor for a child with end-stage renal disease is a living, related donor with an identical blood type. Donors must be adults who are capable of making informed decision and must be free of major medical contraindications. Compared with deceased kidney donation, living donated kidneys have longer graft survival.

Question 7

Genetic inheritance

Answer 7

Hemophilia A is an X-linked recessive disorder that occurs almost exclusively in males. Daughters born to an affected father and a normal mother will be carriers. Sons born to a carrier mother have a 50% chance of having hemophilia.

Question 8

Sickle cell

Answer 8

An aplastic crisis in sickle cell disease is a transient failure of erythropoiesis most commonly due to parvovirus B19. Presentation includes a sudden drop in hemoglobin and a very low reticulocyte count (<1%).

Question 9

Venous thromboembolism

Answer 9

Under-anticoagulation can lead to worsening of thrombotic disease, and such patient should be started on intravenous heparin (or subcutaneous low molecular weight heparin) until a therapeutic INR is achieved with warfarin. Such cases should not be considered anticoagulation failures that warrant placement of an IVC filter.

Question 10

Health insurance

Answer 10

Federal law mandates that insurance plans cover 100% of costs associated with preventive health care services (screening mammogram), so that patients incur zero out-of-pocket spending (no copay).

Question 11

Euthyroid sick syndrome

Answer 11

Euthyroid sick syndrome is often characterized by low T3 levels with normal TSH and T4 in patients with acute illness. It is primarily due to decreased peripheral conversion of T4 to T3. Treatment is not recommended unless abnormal thyroid function persists after the patient has returned to baseline health.

Question 12

VSD

Answer 12

Patients with a VSD typically have a harsh holosystolic murmur with maximal intensity over the left 3rd and 4th intercostal spaces accompanied by a thrill. Small restrictive VSDs are associated with a louder murmur, but large nonrestrictive VSDs have a softer and early systolic murmur.

Question 13

Community acquired pneumonia

Answer 13

An obstructing endobronchial malignancy should be suspected in patients with an extensive smoking history who have nonresolution of a pneumonia. A chest CT can help to diagnose such a malignancy as well as other causes of a nonresolving pneumonia such as an abscess or empyema.

Question 14

Colorectal cancer screening

Answer 14

Patients at average risk for colon cancer should start colon cancer screening at age 45. For those with a first-degree relative with colon cancer or advanced adenoma, screening colonoscopy is recommended beginning at age 40 or 10 years before the relative’s age at diagnosis, whichever comes first.

Question 15

Renal cell carcinoma

Answer 15

Renal cell carcinoma is typically associated with smoking, obesity, and hypertension. Patients usually have hematuria, abdominal mass, and/or flank pain. Paraneoplastic syndromes (erythropoietin secretion) are common. Diagnosis requires a CT scan of the abdomen.
Renal cell carcinoma is usually diagnosed by CT scan of the abdomen, which reveals an enhancing kidney mass with thickened, irregular wall or septa. If the tumor is localized within the kidney, nephrectomy is often curative.

Question 16

Osteoporosis

Answer 16

Exercise-induced amenorrhea is due to a decrease in the pulsatile secretion of LH, which leads to a decline in estrogen production. It can lead to osteopenia, osteoporosis, breast and vaginal atrophy, mild hypercholesterolemia, and infertility.

Question 17

Uterine fibroids

Answer 17

Uterine sarcoma typically presents in postmenopausal patients with a history of previous tamoxifen use or pelvic radiation. Presenting symptoms can include new-onset pelvic pressure or pain, a uterine mass, ascites, and symptoms of metastasis (pleural effusion). Treatment is with hysterectomy. Adjuvant chemotherapy and/or radiation therapy may be indicated.

Question 18

Hyperthyroidism

Answer 18

Toxic thyroid nodules are characterized by increased radioiodine uptake in the nodule and suppressed uptake in the remainder of the gland. Definitive treatment with surgery or radioactive iodine ablation is recommended for patients with overt hyperthyroidism; surgery is preferred for those with large goiters, obstructive symptoms, or suspected thyroid cancer. Patients should be treated with antithyroid drugs to achieve euthyroidism prior to surgery; methimazole is preferred over propylthiouracil for most patients. PTU is preferred if hyperthyroidism is dx in the first trimester of pregnancy as methimazole is associated with more severe teratogenic effects.