Test 65

Question 1

Perianal abscess

Answer 1

Anal abscesses should be treated with prompt incision and drainage. Antibiotics should also be prescribed in those patients who have DM, immunosuppression, extensive cellulitis, or valvular heart dx.
Fifty percent of patients with anal abscesses will go on to develop a chronic fistula from the involved anal gland to the overlying skin. Such fistulas require surgical repair.

Question 2

Hypothyroidism

Answer 2

Newborn screening can identify congenital hypothyroidism before symptoms develop. Low T4 and elevated TSH levels are confirmatory. Levothyroxine should be started as soon as possible to prevent permanent neurological injury.

Question 3

Kidney transplantation

Answer 3

The immediate and long-term complications of donor nephrectomy are low. Patients have an increased risk of gestational complications after donor nephrectomy compared to pregnancies before the procedure. However, the rate is similar to that of the general population. The risk of end-stage renal disease and overall mortality following kidney donation are the same as in the general population.

Question 4

DM

Answer 4

Patients with type 1 DM are at increased risk for other autoimmune conditions, most commonly autoimmune thyroiditis and celiac dx. All patients should be screened at diagnosis with antibodies against thyroglobulin, thyroid peroxidase, and tissue transglutaminase.

Question 5

Hepatic encephalopathy (HE)

Answer 5

HE is usually triggered by elevated ammonia levels due to an underlying precipitating event. A common trigger of HE is excessive diuresis, which reduces intravascular volume and results in hypokalemia and metabolic alkalosis. Tx includes volume and electrolyte repletion and using medications (lactulose) to reduce ammonia levels.

Question 6

Urinary tract infection

Answer 6

Patients with suspected acute, uncomplicated cystitis are often treated empirically with nitrofurantoin or trimethoprim-sulfamethoxazole without additional testing (urine culture) or evaluation.

Question 7

Reactive arthritis

Answer 7

Reactive arthritis presents with asymmetric oligoarthritis, usually with a hx of genitourinary or gastrointestinal infection. Enthesitis and dactylitis may also be seen. Extra-articular sx such as uveitis, urethritis, keratoderma blennorrhagica, and circinate balanitis occur in a minority of patients. Synovial fluid has a high white blood cell count but is culture negative.

Question 8

Reactive arthritis

Answer 8

The incidence of reactive arthritis after infection with Chlamydia or a predisposing gram-negative rod is higher in individuals who are HLA-B27 positive.

Question 9

Hepatorenal syndrome

Answer 9

Hepatorenal syndrome is a common cause of acute renal failure in patients with cirrhosis but should be considered a diagnosis of exclusion. A fluid bolus is needed to confirm that the renal failure is not secondary to intravascular volume depletion. A combination of midodrine and octreotide along with albumin is the tx of choice after dx is confirmed.

Question 10

CNS lymphoma

Answer 10

The degree of immunosuppression seems to be the major determinant of the survival in the patients with primary CNS lymphoma.

Question 11

Hand injury

Answer 11

In digital injuries, tendons are more likely to be injured than arteries, veins, or nerves due to their relative, vulnerable, anatomic location.

Question 12

Myotonic dystrophy

Answer 12

Congenital myotonic dystrophy is the most severe form and typically presents at birth with profound hypotonia, poor feeding, and respiratory distress. An inverted V-shaped upper lip, contractures, and cataracts are also common. Genetic testing identifying a trinucleotide (CTG) repeat expansion is diagnostic.

Question 13

Cardiac tamponade

Answer 13

Subacute cardiac tamponade is characterized by progressive dyspnea, fatigue, jugular venous distension, and lower extremity edema. Echocardiography showing early diastolic collapse of the RV and RA is the most specific diagnostic finding for tamponade physiology.