Test 66

Question 1

Seborrheic dermatitis

Answer 1

Seborrheic dermatitis is characterized by pruritic, erythematous plaques with greasy scales and typically affects the scalp, central face, and ears. It usually occurs as an isolated condition but has an increased incidence in association with Parkinson disease and HIV infection, in which it may be a presenting feature.

Question 2

Ischemic stroke

Answer 2

Perioperative patients with new neurologic deficits should receive a full stroke evaluation, including an emergency noncontrast CT scan of the head. Those with perioperative stroke may be eligible for time-dependent reperfusion therapies.

Question 3

Ethical principles in healthcare

Answer 3

Unilateral termination of the physician-patient relationship by the physician may be warranted for nonpayment. However, for the termination to not constitute patient abandonment, the patient must have no immediate medical need and should be given reasonable time to find an alternate provider.

Question 4

Hearing loss

Answer 4

The decreased ability to discriminate speech in patients with presbycusis is especially obvious in a noisy, distracting environment.

Question 5

Rheumatic fever

Answer 5

The benefits of a 10-day course of penicillin for streptococcal pharyngitis include decreased sx severity and duration, prevention of spread to close contacts, and prevention of acute rheumatic fever.

Question 6

Sickle cell

Answer 6

Patients with sickle cell disease who have a severe vaso-occlusive episode and are hemodynamically stable should be treated promptly with intravenous opioids.

Question 7

Contrast nephropathy

Answer 7

AKI occurring 24-48 hours following arterial contrast administration (coronary angiography, ventriculography) is consistent with contrast-associated AKI. The diagnosis is clinical (biopsy typically not required), with supporting features that include a fractional excretion of sodium <1% and muddy brown casts on urine microscopy.

Question 8

Contrast nephropathy

Answer 8

Most patients with contrast-associated acute kidney injury experience complete recovery to baseline renal function within 3-7 days after contrast exposure.

Question 9

Multifocal atrial tachycardia

Answer 9

Multifocal atrial tachycardia most commonly occurs in elderly patients who are hospitalized with an exacerbation of underlying pulmonary disease (COPD). The dx is made by ECG demonstrating P waves of at least 3 different morphologies and an atrial rate >100/min. Tx involves appropriate management of the underlying inciting illness.

Question 10

Multifocal atrial tachycardia

Answer 10

The initial management of multifocal atrial tachycardia (MAT) is directed toward correction of underlying disturbances (exacerbation of pulmonary disease, hypokalemia). Calcium channel blockers or beta blockers can be used for rate control in patients for whom MAT persists despite correction of potential underlying causes.

Question 11

COPD

Answer 11

After adjusting for age, FEV1 remains as the single most important factor in determining the prognosis of patients with COPD.

Question 12

Chronic kidney disease

Answer 12

Mixed concentric and eccentric left ventricular hypertrophy (LVH) is common in patients with chronic kidney disease (CKD), largely related to the high prevalence of systemic hypertension and anemia. Treatment of severe anemia (hemoglobin <10 g/dL) with erythropoiesis-stimulating agents has been shown to improve quality of life and reduce LVH in patients with CKD.

Question 13

Ectopic pregnancy

Answer 13

An ectopic pregnancy can be managed medically with methotrexate or surgically. Contraindications to methotrexate include hepatic disease, renal disease, immunodeficiency, and a ruptured ectopic pregnancy.

Question 14

Bell’s palsy

Answer 14

Peripheral facial neuropathy (CN VII) can be the presenting sign of early disseminated Lyme disease. Any patient with facial weakness and risk factors for Lyme disease should undergo serologic testing. In contrast to Bell palsy, in Lyme disease, glucocorticoids do not seem to speed recovery. Most patients recover facial nerve function in approximately a month.

Question 15

Hypoglycemia

Answer 15

Iatrogenic hypoglycemia can occur following treatment for hyperkalemia. Patients with end-stage renal disease are particularly susceptible due to impaired renal gluconeogenesis and reduced renal insulin clearance. Frequent blood glucose testing should be performed.

Question 16

Sensitivity, specificity, NPV, PPV

Answer 16

Highly sensitive tests are useful for screening; highly specific tests are useful for confirmation.

Question 17

Prostatitis

Answer 17

Chronic prostatitis is a common condition that usually presents with >3 months of dysuria, pelvic pain, and/or pain during ejaculation. Patients with suspected chronic prostatitis should receive a urinalysis and urine culture before and after prostate massage.

Question 18

Prostatitis

Answer 18

Chronic prostatitis/chronic pelvic pain syndrome is characterized by >3 months of dysuria and pelvic pain. Urine studies following prostate massage usually show pyuria (>20 leukocytes/hpf) with no microorganisms.

Question 19

Prostatitis

Answer 19

The underlying cause of chronic prostatitis/chronic pelvic pain syndrome is unknown. Patients are generally treated with a combination of therapies including medications for prostate enlargement (alpha blockers), antibiotics, anti-inflammatories, and/or psychotherapy.

Question 20

Opioids

Answer 20

Opioid intoxication presents with the triad of respiratory depression, miosis, and depressed mental status. Renal dysfunction can increase the risk of opioid toxicity, especially with morphine. Immediate management involves the administration of intravenous naloxone as well as ventilatory support when needed.

Question 21

Pituitary apoplexy

Answer 21

Pituitary apoplexy (pituitary hemorrhage or infarction, usually in a large adenoma) presents with headache and cranial nerve compression symptoms (opthalmoplegia, hemianopsia). It is a life-threatening disorder that requires immediate evaluation. CT scan of the had usually obtained initially; MRI is highly sensitive and specific.

Question 22

Prerenal azotemia

Answer 22

Acute kidney injury (AKI) due to unilateral urinary obstruction is rare in the presence of a functioning contralateral kidney. Prerenal azotemia should be the suspected cause of AKI in patients with unilateral obstruction, particularly if there is evidence of volume depletion (vomiting, elevated blood urea nitrogen/creatinine ratio).