Virginia Questions Flashcards
A 50 year old female with a ten year history of type II diabetes presents for regularly-scheduled follow up. She has no complaints, and just visited her ophthalmologist last week. Current medications include glyburide, metformin, and simvastatin. On physical exam, vital signs are virtually unchanged from previous visits, with temperature 37.1 C (99 F), HR 80, BP 140/83, RR 15, and O2 Sat 98% on room air. Neurological examination reveals diminished sensation to light touch and pinprick in a stocking distribution on the lower extremities bilaterally. Remainder of physical exam is benign. Laboratory evaluation reveals: Na+ 136, K+ 3.9 Cl- 104, HCO3- 25, BUN 15, Cr 1.0, Glucose 150; hemoglobin A1c: 7.1%; Urinalysis: negative for ketones, glucose, bilirubin, leukocyte esterase, or blood; moderate protein; Lipid profile: Total cholesterol 146, HDL 46, LDL 100. At this time, which of the following would be the most appropriate intervention?
A.Increase simvastatin
B.Increase glyburide
C.Increase metformin
D.Add hydrochlorothiazide
E.Add lisinopril
E.Add lisinopril
The patient’s lipid profile is technically at her target LDL – thus, she does not need an increase in her statin (answer A).
Key teaching point: All diabetics should be on an ACE inhibitor or ARB for cardiovascular and renal protection.
As an additional teaching point, every health maintenance visit with a diabetic patient should focus on the “Diabetic Five” – these five things, in this order: 1) Smoking cessation 2) Blood pressure control 3) Lipid control 4) Aspirin/metformin 5) Glucose control
A 55 year old female comes to the emergency department complaining of a headache for the past six hours. Her headache began abruptly after she finished eating breakfast, and quickly increased to 8/10 throbbing pain located mainly over her right temple. The pain has been associated with mild nausea but no vomiting. She denies chronic or recurrent headaches, but did have one headache similar to this one two weeks ago, which resolved after taking ibuprofen and lying in a quiet, dark room. She has smoked one pack of cigarettes daily for 38 years. On physical exam, the patient has temperature of 37.0 C (98.6 F), pulse of 99, and BP 147/95. Neurological examination is nonfocal, but mild photophobia and nuchal rigidity are noted. Fundoscopic examination reveals no papilledema. Skin exam shows no lesions. CT of the head, obtained without contrast, reveals no abnormalities. What is the most appropriate next step in the management of this patient?
A.Obtain head CT with contrast
B.Lumbar puncture
C.Administer i.m. sumatriptan
D.Administer oral ibuprofen
E.Administer i.v. ceftriaxone
B.Lumbar puncture
E.
Ceftriaxone (answer E) is the most commonly used empiric antibiotic for adults with suspected bacterial meningitis since it penetrates the CSF and covers the most likely pathogens in this age group: S. pneumoniae (60%) and N. meningitides (20%). This patient is afebrile, however, and her stiff neck and photophobia are simply signs of meningeal irritation – which in this case is caused by SAH, not a bacterial infection. Meningitis may cause headache, but not as suddenly as the headache described in the question. Even if this patient was suspected to have meningitis, you would likely want to obtain an LP before giving antibiotics so that you don’t sterilize the cultures! After obtaining an LP, antibiotic therapy with ceftriaxone (or cefotaxime) and vancomycin could be started. (The latter is used to cover the possibility of drug-resistant S. pneumoniae while you await results of the CSF culture.)
A four week old male infant is brought by his mother to the physician following one week of emesis. The patient’s mother states that the patient has been vomiting non-bilious material immediately after each feeding, but then becomes fussy and demands to be fed again. She denies ever seeing any blood in the emesis. Over the past two or three days, the infant’s vomiting has become increasingly sudden and forceful. The child is irritable, with few tears. The oropharynx is dry, the infant’s fontanelles appear sunken, and moderate skin tenting is noted. Capillary refill is approximately 2 seconds. On abdominal exam, visible peristaltic waves are observed, and a 1cm firm mass is palpated in the right upper quadrant. What is the most likely laboratory finding?
A.Na+ 130, K+ 2.9, Cl- 89, HCO3- 35
B.Na+ 138, K+ 3.8, Cl- 100, HCO3- 26
C.Na+ 150, K+ 4.0, Cl- 100, HCO3- 24
D.Na+ 140, K+ 3.8, Cl- 100, HCO3- 15
E.Na+ 130, K+ 5.8, Cl- 110, HCO3- 20
A.Na+ 130, K+ 2.9, Cl- 89, HCO3- 35
Repetitive vomiting of acidic gastric juices causes the loss of HCl – thus, the patient’s Cl- should be low. Since you’re losing H+, there will also be a metabolic alkalosis, so the HCO3- will be elevated as well. Finally, in order to maintain pH balance, the kidneys avidly reabsorb H+, but they can only do this at the expense of K+, resulting in hypokalemia.
A 30 year old female presents to her physician with a breast mass. She first noted a small “lump” in her left breast while showering about six weeks ago. She has noted no change in the size of the mass since that time, and she denies pain or nipple discharge. Family history is significant for a paternal grandmother who had breast cancer at age 79. Physical examination reveals a soft, round, mobile 1cm mass in the lower outer quadrant of the left breast. No skin changes are noted. What is the most appropriate next step in the management of this patient?
A.Mammography
B.Refer the patient for radical mastectomy
C.Begin levonorgestrel/etinyl estradiol
D.Genetic testing for BRCA1 and BRCA2
E.Ultrasound of breast mass
E.Ultrasound of breast mass
Key teaching point: Mammogram is the preferred imaging study for women over 35, while women younger than 35 should get ultrasound to evaluate a breast mass. In women younger than 35, the breast tissue is often too dense to evaluate mammographically, and the incidence of breast cancer younger women is still very low.
An otherwise healthy 8 year old girl presents with two weeks of perianal pruritis. She has two younger brothers, one of whom has had similar complaints for the past few days. Physical exam reveals perianal erythema with mild excoriations. The “scotch tape test” reveals several bean-shaped white eggs. What is the most likely diagnosis in this patient?
A.Trichuriasis
B.Enterobiasis
C.Child abuse
D.Fecal soilage
E.Atopic dermatitis
B.Enterobiasis
Whipworm or trichuriasis (choice A) is a common intestinal helminthic infection worldwide, with the highest prevalence in tropical regions. Hosts are usually asymptomatic, though the disease can cause loose stools that contain mucus or blood, resulting in a secondary anemia. Trichuriasis is also classically associated with rectal prolapse in a patient with a heavy parasite load. Heavy loads can affect a child’s growth and cognition. Diagnosis is made by stool examination for eggs, which are barrel shaped with a hyaline plug at each end.
This is a classic case of enterobiasis (answer B) or “pinworm.” The most common presenting symptom is intense anal itching or pruritus ani. Other symptoms (such as abdominal pain/fullness or nausea and vomiting) may occur if the worm burden is high.
A seven year old female is brought to the physician by her mother because of facial swelling and dark, cola-colored urine. These symptoms began abruptly two days ago and have been associated with anorexia and malaise. There have been no known sick contacts. Her mother states that the child is up to date with her immunizations and has been in good health except for a runny nose and sore throat around two weeks ago, which resolved after a few days without treatment. Vital signs are temperature 37.2 C (98.9 F), heart rate 95, and blood pressure of 148/86. There is diffuse edema of the lower extremities, face, and eyelids. Lungs and heart are clear to auscultation. Urinalysis shows moderate hematuria and proteinuria, and dysmorphic RBCs and occasional RBC casts are noted on microscopic examination. Based on these findings, what is the most likely diagnosis?
A.IgA nephropathy
B.Alport syndrome
C.Thin basement membrane nephropathy
D.Postinfectious glomerulonephritis
E.Henoch-Schonlein purpura
D.PSGN
the key features of post-streptococcal GN were all there. These include the patient’s age (<7 years old), dark brown colored urine (representing hematuria), and periorbital and peripheral edema. There is also a latent period of around 10 days following pharyngitis before symptoms of glomerulonephritis occur, although for glomerulonephritis following streptococcal impetigo, the latent period can be as long as 3-4 weeks. One diagnostic finding not mentioned was the anti-streptolysin O titer, which you would expect to be positive (indicating recent exposure to Group A strep). Finally, the finding of RBC casts is an important one. When you see casts in the urine sediment - whether WBC, RBC, or granular - you have glomerular disease.
A 30 year old female comes to her physician’s office for a routine health examination. She has been in good health recently and is up to date with her gynecological examinations. Her only medication is loratadine for seasonal allergies and ibuprofen for occasional headaches. Physical examination shows temperature 37.1 C (98.8 F), pulse 80, BP 170/92, RR 14, oxygen saturation of 99% on room air. A 3/6 mid-systolic ejection murmur is present. Abdomen is nontender with a soft systolic-diastolic bruit that lateralizes to the left side. The patient is grossly intact neurologically, and fundoscopic examination shows sharp optic disc margins. Laboratory evaluation shows Na+ 141, K+ 3.9, Cl- 106, HCO3- 27, BUN 18, Cr 1.0, glucose 98. Urinalysis shows trace proteinuria and no casts. What is the most likely pathological mechanism causing this patient’s hypertension?
A.Fibromuscular dysplasia
B.Oversecretion of aldosterone
C.Exogenous administration of corticosteroids
D.Atherosclerotic disease
E.Catecholamine-producing tumor
A.Fibromuscular dysplasia
This is a case of secondary hypertension caused by renal artery stenosis. They key clues are the markedly elevated blood pressure in an otherwise healthy young person and the presence of an abdominal bruit. In a patient without vascular risk factors, the stenosis is likely to be caused by fibromuscular dysplasia of the vessel wall (answer A) instead of atherosclerotic disease. Two quick teaching points: 1) This patient is a textbook example of fibromuscular dysplasia, which typically occurs in females under 50 years old. To confirm the diagnosis requires imaging – typically renal ultrasound with Doppler or CT or MR angiography. 2) Although the vast majority of patients with hypertension have essential hypertension, elevated blood pressure can be a sign of a more serious underlying disorder. You should always consider the diagnosis of secondary hypertension in patients who have a known onset of hypertension before age 30, patients whose blood pressure remains elevated despite multiple medications, patients who have severe (>160/100 mm Hg) hypertension above age 55, or patients with a sudden increase in their blood pressure from a stable baseline.
Atherosclerotic disease (answer D) is certainly a cause of renal artery stenosis, and would explain her abdominal bruit. The tip off in this question was that the patient was a young, previously-healthy woman - just the kind of patient who gets fibromuscular dysplasia. Atherosclerotic plaques are more likely to cause stenosis in older patients with vascular risk factors such as smoking, diabetes, or hyperlipidemia.
A 23 year old male presents with syncope. He reports that while walking briskly to his car, he felt his heart “racing” in his chest, and shortly thereafter passed out. The patient denies any prior syncopal episodes, but does note occasional episodes of palpitations that occur after moderate activity or during periods of increased stress. There is no family history of neurological disease, cardiac disease, or sudden cardiac death. On physical examination, pulse is 85 and regular, BP is 124/74, respiratory rate is 16, and oxygen saturation is 98% on room air. Cardiac examination reveals pulsation at the fifth intercostal space at the left parasternal area in the midclavicular line. S1 is within normal limits, and S2 is heard to split on inspiration. The remainder of the physical exam is unremarkable. EKG taken in the office shows the following tracing in lead II. Which of the following would be the most appropriate treatment for this patient’s disorder?
A.Radiofrequency ablation of pre-excitation pathway
B.Urgent DC cardioversion
C.Heart transplant
D.Biventricular pacemaker placement
E.Coronary angioplasty
A.Radiofrequency ablation of pre-excitation pathway
This question describes a classic presentation of Wolff-Parkinson-White (WPW) syndrome, a rare disease that is frequently tested on the USMLE. This disorder is caused by the presence of an “accessory pathway,” an abnormal conduction pathway that allows electrical impulses from the SA node to reach the ventricle without having to conduct through the AV node. Normal conduction through the AV node is slower than conduction through this accessory or “pre-excitation” pathway, so the ventricle gets activated at different times by the two different pathways. At rest, this produces the pathognomonic EKG finding of a delta wave, seen above. However, this pre-excitation pathway can lead to a number of cardiac arrhythmias, ranging from atrial fibrillation or flutter with a rapid ventricular response to ventricular tachycardia or fibrillation. Patients may experience a range of symptoms, from mild palpitations, to syncope, to sudden cardiac death. Although you may attempt to control the arrhythmias pharmacologically, the ultimate treatment for Wolff-Parkinson-White is radiofrequency ablation of the abnormal accessory conduction pathway (answer A). To answer this question correctly, you had to diagnose WPW from the EKG.
A 74 year old man presents with double vision. He first noticed this several months ago, and although his symptoms wax and wane, he now experiences daily episodes of “seeing double,” most frequently in the evenings. He also reports increased generalized fatigue and notes that he sometimes gets so tired at dinner that he “can hardly chew” his food. Past medical history includes osteoarthritis, hypertension, and abdominal aortic aneurysm repair. Physical examination reveals a comfortable, age-appropriate elderly gentleman with mild dysarthria. Cardiac auscultation reveals both an S4 and a 2/6 holosystolic murmur heard best at the left upper sternal border with radiation to the carotids. On neurologic exam, the patient has 5/5 strength proximally and distally. Sensation is intact and reflexes are 2+ throughout. Ocular movements are sluggish but intact in all directions. The patient has mild bilateral ptosis, which is noted to increase with sustained upward gaze. Stroking the bottom of the foot results in downward deflection of the great toe bilaterally. Which of the following is the most appropriate next step in diagnosis?
A.Administer i.v. edrophonium
B.CT of chest
C.MRI/MRA of brain and cerebral vessels
D.Temporal artery biopsy
E.CSF examination for oligoclonal bands
A.Administer I.V. edrophonium
This is a presentation of oculobulbar myasthenia gravis. The easiest way to confirm the diagnosis in a patient such as this one with overt ptosis is to administer i.v. edrophonium (answer A). Edrophonium is an acetylcholinesterase inhibitor with a short onset of action and half life. If you give the medication and the patient’s symptoms immediately improve, you have essentially confirmed the diagnosis. Edrophonium’s trade name is Tensilon, so you may hear neurologists talk about giving a patient the “Tensilon Test” to confirm MG.
Alternately, EMG can diagnose MG if you see a decremental response to repetitive nerve stimulation.
Here are some additional teaching points about myasthenia gravis: 1) The key feature of MG is fatigable muscle weakness. Patients will typically report that their symptoms worsen throughout the day. Oculobulbar myasthenia gravis is the most common type, resulting in the signs and symptoms presented in the question stem: double vision, ptosis, dysarthria, and difficulty chewing.
2) Myasthenia gravis has a bimodal age distribution, so there are two classic groups of patients who get MG: young women in their 20s or 30s with autoimmune disorders (RA, SLE, hyperthyroidism, etc.), and men in their 70s or 80s.
3) MG is caused by autoantibodies that bind to postsynaptic ACh receptors. A commonly tested point is distinguishing myasthenia gravis from Lambert-Eaton syndrome, which is a paraneoplastic disorder (usually associated with small cell lung cancer) in which antibodies are produced against the pre-synaptic Ca2+ channels.
4) The treatment of myasthenia gravis begins with anticholinesterase drugs like neostigmine or pyridostigmine, which increase the amount of ACh in the synapse, overcoming the antibody blockade. Prednisone or other immunosuppressive drugs are also used, and i.v. Ig or plasmaphresis are used for refractory cases to more directly target the responsible autoantibodies.
5) Myasthenia gravis almost always have some abnormality of the thymus: 75% will have thymic hyperplasia, and 15% will have an overt thymoma. Since the disease is mediated by T cells, removal of the thymus can be curative in patients who fail medical therapy. Regardless, once the diagnosis of MG has been established, it is reasonable to rule out thymoma via CT scan.
On routine examination, a five year old child is noted to have a loud S1 with a fixed and widely split S2 that does not vary with respiration. A soft, mid-systolic ejection murmur is heard best on the left in the second intercostal space. Remainder of physical exam is otherwise unremarkable. There is no nail clubbing, hepatomegaly, or jugular venous distension. The child is healthy and active and her mother has no health concerns. Which of the following is the most likely diagnosis in this patient?
A.Mitral valve prolapse
B.Pulmonic regurgitation
C.Tetralogy of Fallot
D.Atrial septal defect
E.Ventricular septal defect
D.ASD
1) ASDs, can remain asymptomatic for a long time – they are frequently picked up on routine exam. Because the pressure in the left atrium is slightly higher than the pressure in the right atrium, there is a net movement of blood from left-to-right. Over time, this overloads the pulmonary circulation and leads to pulmonary hypertension. Eventually, the pressure in the pulmonary vascular bed gets so high that the shunt reverses, causing a right-to-left shunt. This is the dreaded Eisenmenger syndrome, in which a left-to-right shunt reverses flow and turns into right-to-left shunt.
2) ASDs are silent! The murmur that is heard in this case is NOT blood flow through the ASD. Remember that to hear a murmur, you have to have turbulent blood flow. The difference in pressures between the right and left atria is so small that the blood flows easily, without turbulence. However, since there is a net left-to-right movement of blood, there is an increased volume of blood coursing across the pulmonary valve. This leads to a flow or ejection murmur heard best in the listening area for the pulmonic valve
A 64 year old male presents for routine health evaluation. He has been feeling well and has no complaints. Past medical history includes hypertension, osteoarthritis, and generalized anxiety disorder. Medications include hydrochlorothiazide, ibuprofen, atenolol, and paroxetine. Physical exam shows temperature 37.9 C (99.3 F), pulse 61, blood pressure 131/70, and respirations 15/min. Laboratory evaluation shows: Na+ 141; K+ 3.9; Cl- 103; HCO3- 25; BUN 18; Creatinine 1.2; WBC 9.7; Hemoglobin 10.1; Platelets 179; MCV 73 fL. Which of the following is the most appropriate next step in the management of this patient?
A.Add lisinopril
B.Measure reticulocyte count
C.Test B12 and folate levels
D.Endoscopy
E.Indirect and direct Coombs’ tests
D.Endoscopy
Key teaching point: Iron deficiency anemia in a male is colorectal cancer until proven otherwise. This patient presents with a microcytic anemia: his hemoglobin and MCV are both low. The differential diagnosis of microcytic anemias is fairly broad, and includes a number of “zebras.” (A useful mnemonic to remember the differential of microcytic anemias is “TAILS” – Thalassemias, Anemia of chronic disease (which can sometimes be normocytic), Iron deficiency anemia, Lead poisoning, and Sideroblastic anemia)
Far and away the top cause of a microcytic anemia is iron deficiency anemia brought about by blood loss. Any male or postmenopausal woman who presents with iron deficiency anemia should be evaluated for an occult GI source of their bleeding, preferably with upper and lower endoscopy (answer D). This patient could have an ulcer related to his NSAID use – or he could have colorectal carcinoma. Either case deserves further evaluation.
A 36 year old African-American male comes to the clinic complaining of fatigue and dark, cola-colored urine for the past five days. He denies fever, nausea or vomiting, recent travel, and i.v. drug use. Past medical history includes ulcerative colitis. Medications include sulfasalazine as well as trimethoprim/sulfamethoxazole which the patient began taking one week ago for a presumed Staphylococcal skin infection. Vital signs are temperature 36.8 C (98.2 F), pulse 78, blood pressure 118/72, respirations 14/min. Physical examination shows scleral icterus and a nontender abdomen without organomegaly. Laboratory evaluation shows: WBC 8.6; Hgb 9.1; Hct 27.3; Platelets 212; MCV 88 fL; Na+ 144; K+ 4.8; Cl- 101; HCO3- 26; BUN 14; Creatinine 1.0; Glucose 101; LDH 410 U/L; Haptoglobin 8 mg/dL. Which of the following is the most appropriate next step in management of this patient?
A.Quantitative IgM for hepatitis A virus
B.Begin darbopoietin injections
C.Begin methylprednisolone
D.Discontinue trimethoprim/sulfamethoxazole
E.Immediate transfusion of packed red blood cells
D.Discontinue TMP/SMX
This is a case of glucose-6-phosphate dehydrogenase (G6PD) deficiency, an X-linked recessive disease that tends to affect men of Mediterranean or African descent. G6PD is an enzyme in glycolysis that is responsible for the production of NADPH, which maintains glutathione in its reduced state and protects cells from oxidative stress. Since red blood cells are dependent on glycolysis and thus G6PD to produce their NADPH and glutathione, deficiency of G6PD results in RBCs that are exquisitely susceptible to oxygen radicals. Anything that increases oxidative stress results in hemolysis and an acute hemolytic anemia. The most common culprits include: viral or bacterial infections, fava beans, nitrofurantoin, quinine, dapsone, and sulfonamides. Here, the culprit was sulfamethoxazole, so that drug should be discontinued (answer D).
The disease is typically self limiting, and treatment is supportive. The key diagnostic findings in this patient are the elevated LDH and decreased haptoglobin, both of which indicate that RBCs are being lysed and are releasing their contents into the serum. The patient’s total and indirect (unconjugated) bilirubin are also likely elevated, given his clinical presentation of jaundice.
A 65 year old female with diabetes is found on routine screening to have a total serum cholesterol concentration of 198 mg/dL, with a serum HDL cholesterol of 58 mg/dL and serum LDL cholesterol of 128 mg/dL. Triglycerides are 78 mg/dL, and last hemoglobin A1c is 6.5%. The patient has no known history of coronary artery disease, does not smoke, and exercises daily. Current medications include rosuvastatin, fosinopril, glyburide, and metoprolol. Blood pressure is 129/78. Urinalysis shows no protein. Which of the following is the best management plan and treatment goal for this patient?
A.Add niacin to increase HDL to >80 mg/dL
B.Increase rosuvastatin to target LDL <100 mg/dL
C.Add gemfibrozil to decrease triglycerides to <70 mg/dL
D.Discontinue fosinopril and add hydrochlorothiazide to decrease blood pressure to <120/80
E.Begin insulin therapy to target Hgb A1c <6.0%
B.Increase rosuvastatin to target LDL <100 mg/dL
Key teaching point: Patients with diabetes are considered to have known coronary artery disease for purposes of lipid goals, and need the lowest possible LDL. This question involves lipid management. Presently, we tend to focus most of our efforts on a patient’s LDL (or “bad”) cholesterol, since there is the greatest amount of evidence linking elevated LDL to adverse cardiovascular events and death.
In general, to figure out a patient’s lipid goal, you first count up their risk factors. Cigarette smoking, a family history of premature cardiovascular disease, low “good” cholesterol (HDL <40 mg/dL), and hypertension (BP >140/90) all count as risk factors. Patients with two or more risk factors have a target LDL goal of <130 mg/dL, while patients with zero or one risk factor have an LDL goal of <160 mg/dL.
However, there’s a catch: patients with KNOWN coronary artery disease (previous MI, angina, etc.) need a lower LDL of <100 mg/dL. Also, a number of other diseases count as “coronary heart disease equivalents” and earn the same lower target LDL of less than 100. Patients with cerebrovascular disease, an abdominal aortic aneurysm, or peripheral arterial disease are assumed to have diseased coronary vessels as well. Patients with diabetes also fit into this category, so even though the patient in the question stem has no other risk factors, she still needs the most stringent LDL goal of less than 100.
An 84 year old woman has experienced three weeks of diffuse myalgias. In addition to worsening fatigue, she has stiffness upon awakening in her shoulders, hip girdles, neck, and torso. The stiffness usually resolves after several hours. She has also had occasional low-grade fevers and a 6 pound weight loss since her symptoms began. Physical examination shows decreased active range of motion of the shoulders and neck, but no muscle tenderness. Neurological exam shows normal sensation and reflexes. No abnormal findings are noted on skin examination. Which of the following is the most likely associated finding in this patient’s disease?
A.Anti-centromere antibodies positive at 1:640
B.Absolute neutrophil count of 950/mm3 (Normal: >1800 mm3)
C.Karyotyping showing t(9,22) chromosomal rearrangement
D.Erythrocyte sedimentation rate (ESR) of 96 mm/h (Normal: <20 mm/h)
E.X-rays demonstrating expansion of the bony cortex in a mosaic pattern
D.ESR of 96 mm/h (Normal: <20 mm/h)
Key teaching point: A markedly elevated ESR is the hallmark of polymyalgia rheumatica. This is polymyalgia rheumatica, one of the all-time favorites of shelf exams. Patients present with the symptoms above, though they will have few findings on physical examination. The erythrocyte sedimentation rate is usually markedly elevated (answer D) and is usually above 70-80 mm/h, but sometimes over 100 mm/h. The treatment for polymyalgia rheumatica is corticosteroids – patients will usually feel MUCH better after just a few doses of prednisone!
Another key teaching point about polymyalgia rheumatica is its association with giant cell arteritis or temporal arteritis. Patients with temporal arteritis will have temporal artery tenderness, headache, jaw pain, or evidence of ischemia (such as arm claudication or TIAs). The most ominous finding is transient visual loss, as temporal arteritis can occlude the arteries leading to the eye. This can lead to permanent blindness if the patient is not treated immediately.
An 18 year old female presents to her family physician to discuss options for birth control. Menarche was at age 12. Her menses occur at regular 28 day intervals, but she does have moderate abdominal cramping, bloating, and occasional nausea that sometimes prevent her from going to school. She is interested in becoming sexually active but her boyfriend, who has had other sexual partners in the past, doesn’t like to use condoms. Her family history is significant for her mother having had ovarian cancer at age 40. The patient does not smoke and is otherwise healthy. What would be the most appropriate initial step in the management of this patient?
A.Recommend condom use because of the patient’s family history of ovarian cancer
B.Prescribe an OCP after a work-up of her cyclical abdominal cramping
C.Start a progestin-only pill to limit the patient’s intake of estrogen
D.Prescribe a combined oral contraceptive
E.Recommend an intrauterine device (IUD)
D.Prescribe a combined oral contraceptive
1) Primary dysmenorrhea is caused by the inflammatory response (mediated by prostaglandins and leukotrienes) at menstruation that causes uterine contractions. Pain may be due to a temporary endometrial ischemic process. Combination OCPs make the endometrial lining thin, meaning that there are less inflammatory products produced at the time or menses, which in turn reduces menstrual flow and uterine contractions.
2) Questions sometimes come up regarding OCPs and cancer. Data support the assertion that OCPs help to PREVENT ovarian cancer. Currently, however, the literature does not clearly support or refute the idea that OCPs could cause breast cancer. Any patient with a family history of breast cancer should be made aware of the current uncertainty about the relationship, but advised that years of studies have shown no increased cancer risk with the more moden low-estrogen formulation pills that are prescribed today. Remember, of course, that estrogen-only supplementation should never be used in pre-menopausal women with a uterus because excessive estrogen exposure has been linked to endometrial hyperplasia and carcinoma.
A 55 year old woman has had four days of a cough productive of dark yellow sputum. She has also experienced occasional shaking chills and has sharp chest pain that is worst on inspiration. She denies recent travel history, known sick contacts, or recent hospitalization. Past medical history is significant for osteoarthritis and hypertension. Temperature is 38.0 C (100.4 F), pulse 85, blood pressure 132/80, respirations 22/min, oxygen saturation 97% on room air. The patient is alert, oriented, and interactive. Heartbeat is regular with normal S1 and S2. There is no JVD. There are decreased breath sounds as well as egophony and positive tactile fremitus at the right lung base. Abdomen is obese, nondistended, and nontender. There are no petechiae or rashes noted on skin exam. Which of the following is the most appropriate therapy for this patient?
A.Enoxaparin
B.Vancomycin and meropenem
C.Cefepime and gentamicin
D.Azithromycin
E.Immediate needle thoracostomy
D.Azithromycin
Because there is no history of the patient being hospitalized, this is community acquired pneumonia (CAP).
This patient is under age 65 with stable vital signs and no serious underlying medical illnesses – she is an ideal candidate for outpatient therapy. Once you’ve decided that a patient can be managed as an outpatient, you should select a drug regimen that covers the likely causative agents. In this setting, the most likely bug is S. pneumoniae, with the next most likely bugs being H.influenzae and Moraxella catarrhalis. You also need to consider the “atypical” causes of pneumonia like Mycoplasma, Chlamydia, and Legionella. (In fact, the CXR shown was taken from a patient with Mycoplasma.)
A significant number of S.pneumoniae strains are resistant to beta-lactams, as are many H.flu strains and almost all Moraxella strains.
Atypical pneumonias are also impervious to beta-lactams and cephalosporins, so your antibiotic choices are limited to macrolides, quinolones, and tetracyclines. Although erythromycin or tetracycline could work, macrolides like clarithromycin or azithromycin (answer D) cover H.flu better and would be the best choice among those listed.
Doxycycline or a “respiratory” fluoroquinolone like levofloxacin or moxifloxacin are reasonable outpatient monotherapies, as well.
A 15 year old girl is referred from her dentist after she bled excessively following extraction of her wisdom teeth. She also reports prolonged menses lasting 8-10 days and recurrent epistaxis. Her mother experienced lengthy postpartum bleeding after the delivery of all three of her children. Physical examination reveals scattered petechiae. Laboratory analysis shows: WBC 7.6; Hemoglobin 9.8; Hematocrit 29.1; Platelets 229; PT 12 s (normal 11-15s); aPTT 35 s (normal 20-35s); Bleeding time 13 min (normal 2-7 min). Which of the following is the most appropriate treatment for this patient’s disorder?
A.Plasmaphresis
B.Desmopressin
C.Factor VIII concentrate
D.Hydroxyurea
E.Splenectomy
B. Desmopressin
Plasmaphresis (answer A) is the treatment for thrombocytopenic thrombotic purpura or TTP. The classic pentad of TTP is microangiopathic hemolytic anemia, thrombocytopenia, mental status changes or neurological abnormalities, fever, and renal dysfunction.
This is von Willebrand’s disease, the most common hereditary bleeding disorder. This is an autosomal dominant disease that results in deficient or defective von Willebrand factor, a large glycoprotein that functions as a carrier protein for Factor VIII and also aids in platelet adhesion. To make the diagnosis, look for a positive family history and a personal history of easy bruising, mucosal bleeding, bleeding after dental procedures or tonsillectomy, or heavy menstrual bleeding. Laboratory analysis will show a normal PT, a normal or increased aPTT (depending on the degree of Factor VIII deficiency), and an increased bleeding time. The treatment for mild disease is desmopressin (answer B), which increases the production and release of von Willebrand factor from the endothelium. More severe bleeding episodes may require treatment with cryoprecipitate.
“Petechiae suggest Platelet deficiency; Cavity or joint bleeding suggests Clotting factor deficiency.”
The family history here also distinguishes between hemophilias and von Willebrand’s. Both hemophilia A (deficiency of Factor VIII) and hemophilia B (deficiency of Factor IX, also known as Christmas disease) are X linked disorders. Finding them in females would be very rare. Von Willebrand’s disease, however, is autosomal dominant, and should appear in every generation of the family regardless of sex.
Hydroxyurea (answer D) is the treatment of choice for sickle cell disease, where it increases the production of hemoglobin F. It has no role in the treatment of von Willebrand’s disease.
Splenectomy (answer E) can be used to treat refractory cases of idiopathic thrombocytopenic purpura (ITP) if initial medical treatment with drugs like corticosteroids fails. Of course, to diagnose ITP requires thrombocytopenia, and this patient’s platelet count is normal.
A 27 year old male has had a sore throat for two weeks. The pain has now become so great that he has great difficulty swallowing and has only been able to eat and drink small amounts over the past few days. He has had occasional fevers, but denies cough or coryza. Prior to this, the patient had been very healthy and had not been to a physician for fifteen years. Vital signs on presentation include temperature 38.0 C (100.4 F), pulse 90, blood pressure 118/75, and respirations 14/min. On physical exam, no tonsillar exudates are seen, but there are numerous soft, fluffy white plaques in the patient’s tongue and oropharynx. The lesions bleed slightly when they are scraped. Which of the following is the most appropriate next step in the management of this patient?
A.Peripheral blood smear for atypical lymphocytes
B.Rapid antigen detection test for Group A beta-hemolytic Streptococcus
C.Antibody assay for measles virus IgM (MVIgM)
D.Lateral neck radiographs
E.ELISA for HIV-1 antibodies
E.ELISA for HIV-1 antibodies
This is a description of candidal thrush. Fungi like candida do not typically infect normal, healthy patients. Patients who are taking immunosuppressive drugs (including steroids), who are receiving hemodialysis, or have diabetes or cancer may get candidal infections, so a good history should first seek for these factors. In their absence, you need to search out causes of acquired immunodeficiency, and the most likely of those is HIV (answer E). This patient’s history is concerning for esophageal candidiasis, so evaluation should probably also include EGD.
A 15 year old otherwise healthy female presents to her family physician with right lower quadrant abdominal pain. Although the pain waxes and wanes, it reaches a 7/10 on the pain scale, and ibuprofen has been ineffective. Menarche occurred at age 10 and her menses have always been regular at 26 day cycles. The patient is not sexually active. LMP was 2 weeks ago. Bimanual exam appreciates normal size ovaries, but the patient experiences pain on palpation of the right adnexae. An abdominal ultrasound reveals a 5 cm smooth, thin walled, unilocular cystic structure on the right ovary. Urine pregnancy test is negative and WBC is normal. What is the most likely diagnosis?
A.Polycystic ovarian syndrome
B.Dermoid tumor
C.Endometriosis
D.Physiological ovarian cyst
E.Tubo-ovarian abscess
D.Physiological ovarian cyst
Physiological cysts are usually asymptomatic initially, but as they get larger they can cause a feelings of pelvic fullness, constipation, and urinary frequency. Ultrasound is the appropriate test to confirm the diagnosis. A few additional teaching points… 1) Regarding management, if a fluid-filled cyst increases in size, is greater than 6 cm, or causes symptoms, a laparoscopic cystectomy is indicated. The cyst wall should be sent for pathological evaluation. Asymptomatic simple cysts less than 6 cm can be observed.
In order to obtain a job at a prison, a 34 year old man undergoes a required chest x-ray to screen for tuberculosis. A 14mm rounded opacity is noted, surrounded by normal lung tissue. There are small calcifications within the opacity, but no adenopathy or atelectasis is seen radiographically. The patient has never smoked and has no known exposures to tuberculosis. There is no family history of lung cancer or other malignancy. On physical exam, the patient has temperature 37.0 C (98.6 F), pulse 76, blood pressure 130/83, respirations 14/min. Lungs are clear to auscultation and percussion. No nail clubbing is seen. Which of the following is the most appropriate next step in the management of this patient?
A.Repeat chest x-ray in 3 months
B.Begin rifampin, isoniazid, pyrazinamide, and ethambutol
C.Bronchoscopy
D.CT guided needle biopsy
E.Thoracotomy
A.Repeat CXR in 3 mo
There are a number of factors that increase the likelihood that a SPN is malignant, and for a patient to be considered low risk, he or she must lack ALL of them. Having one or more of these characteristics places the individual into the moderate or high risk for malignancy and demands further workup or a tissue diagnosis.
1) Age: The risk of malignancy increases with age: only 3% of SPNs are malignant for patients 35-40, while >50% are malignant for patients over 60. Only individuals less than 35 years old are considered “low risk” for malignancy.
2) Size: Larger lesions (>3cm) are more likely malignant. Only SPNs less than 2cm can be considered low risk.
3) Radiographic appearance: Benign lesions tend to have smooth, well-circumscribed borders, while malignant nodules have irregular or spiculated borders. Calcifications are more often seen with benign lesions, although the pattern of calcification is important.
4) Rate of change: The very slowest growing lung cancers have a doubling time of around 400 days. Thus, if a lesion has been stable when compared to prior imaging for two years, it is likely benign.
5) Smoking history: Smoking is obviously far and away the #1 risk factor for lung cancer. Only non-smokers can be considered to have a low risk SPN.
In short, then, only nonsmokers under 35 years old who have an SPN less than 2cm (or one that has been radiographically stable for two years) can be considered low risk for SPN. These patients can be managed with follow up imaging, either CXR or CT, every 3-6 months initially (answer A).
A 7 year old girl is brought to her physician because her parents are concerned that she is shorter than all of her classmates. The patient’s past medical history is benign, and she is otherwise healthy and thriving at home and at school. Her mother is 61 in. (155 cm) and her father is 67 in. (170 cm) tall. In reviewing her old records, it appears that her growth velocity is normal. Physical examination shows the child to be in the 3rd percentile for her age for both height and weight. The patient is Tanner stage 1 and is otherwise developmentally appropriate. The remainder of physical exam is normal. What is the most appropriate next step in the management of this patient?
A.Reassurance
B.Bone age
C.HIV testing
D.Serum IGF-1
E.Serum growth hormone level
B. Bone age
Short stature is defined as 2 standard deviations below normal the mean height for children of the same sex and age, so this child fits the bill. The most important initial factor to consider is whether the growth velocity is normal or not. If a child has a very low growth velocity (<5th percentile) or “falls off” the growth curve, you should investigate causes for short stature like endocrinopathies, growth hormone deficiency, malnutrition or abuse, or malignancy.
the two most common causes of short stature are familial short stature and constitutional delay of growth, and both of these present with a normal growth velocity. The best test to differentiate familial short stature from constitutional delay is bone age (answer B), and that is the most appropriate next step for this patient. For familial short stature, bone age should match chronological age, while in constitutional delay, bone age will lag behind chronological age.
A couple of additional teaching points…
1) Bone age is obtained by taking radiographs of the hand and wrist, and may be described as such on the USMLE, so don’t be thrown off!
2) A child that has small stature but is overweight for their height may have growth hormone deficiency. Conversely, a child that is underweight for their height may have malnutrition.
A 26 year old G2P1 is at 28 weeks gestation of an uncomplicated pregnancy. The patient denies decreased fetal movement, dysuria, urinary frequency or urgency, vaginal bleeding or discharge, and nausea and vomiting. Medications include a prenatal vitamin and folate and iron supplements. Physical exam shows uterine fundal height 29 cm with fetal heart rate in the 150s. Laboratory testing shows: Fasting serum glucose 115mg/dL; Maternal blood type B+. The patient’s urinalysis shows the following. Color: yellow; Specific gravity: 1.020 (normal: 1.002 – 1.030); pH: 5.2; Glucose: negative; Ketones: negative; Protein: 1+; RBC: negative; Leukocyte esterase: trace; Nitrite: 2+; Urobilinogen: 0.3 EhrU/dL (normal: 0.2-1.0 EhrU/dL). Urine culture grows 25,000 cfu/mL Gram negative rods. Cervical cultures for N.gonnorheae and Chlamydia are negative. Which of the following is the most appropriate next step in the management of this patient?
A.Administer RhoGAM
B.Measure maternal serum alpha feto-protein (MSAFP)
C.Begin insulin therapy
D.Begin cephalexin
E.Reassurance and routine follow-up
D.Begin cephalexin
Key teaching point: Bacteruria of pregnancy, even if asymptomatic, should be treated with antibiotics to reduce the risk of pyelonephritis.
A 72 year old man comes to his physician because he has been feeling sad and “thinks he needs help.” For the past several weeks, he has noted decreased appetite and an 8 lb weight loss, and he has seldom left his house, even to participate in his weekly bowling league. While he is able to fall asleep normally, he awakens after 3-4 hours and is unable to fall asleep again. He has also had increasing difficulty balancing his checkbook and writing his Christmas cards, and believes that he just can’t stay focused enough to complete these tasks. Six months ago, his wife of fifty years died, and he often feels guilty that he did not treat her as kindly as he should have. When he thinks about his wife, he thinks that he would rather be dead than without her, although he denies having a plan to harm himself. Past medical history includes coronary artery disease and gout. Medications include lisinopril, allopurinol, metoprolol, furosemide, and aspirin. Which of the following is the most likely diagnosis in this patient?
A.Adjustment disorder
B.Bereavement
C.Major depressive disorder
D.Dysthymic disorder
C. Major depressive disorder
SIG: E CAPS 25 mnemonic. S – Sleep disturbance, either hypersomnia or insomnia; I – loss of Interest in usually pleasurable activities; G – feelings of Guilt or worthlessness; E – decreased Energy; C – decreased Concentration; A – Appetite disturbance, either increased or decreased; P – Psychomotor retardation; S – Suicidal ideation; 2 – symptoms must be present for at least a 2 week period; 5 – five symptoms required from the list above to make the diagnosis (and at least one of them must be either depressed mood or anhedonia).
A 54 year old man presents with acute knee pain which began last night while he was sleeping. He is now in 9/10 pain and says that he is hardly able to walk secondary to his inability to flex his left knee. Past medical history includes hypertension, nephrolithiasis, and two similar episodes of pain that have occurred over the past 16 months, one in his toe and another in his left knee. On physical exam, the patient is visibly uncomfortable and is holding his leg perfectly still. There is marked erythema and soft tissue swelling surrounding the knee. Passive range of motion is severely diminished secondary to the patient’s pain. Analysis of joint aspirate shows a WBC of 60,000 and abundant needle shaped crystals that show negative birefringence under a polarizing filter. Treatment is initiated with colchicine, prednisone, and indomethacin. What is the next most appropriate step in the management of this patient?
A.24 hour urine collection for uric acid
B.Measurement of serum uric acid
C.Plain film x-rays of knee
D.Begin therapy with allopurinol
E.Begin therapy with probenecid
A.24 hour urine collection for uric acid
Patients with gout can loosely be grouped into two categories: those who produce excessive amounts of uric acid (“overproducers”) and those who have reduced urinary excretion of uric acid (“undersecreters”). If you collect a 24 hour urine sample and find less than 600 mg of uric acid, the person is an undersecreter, and would benefit from uricosuric therapy like probenecid (answer E) or sulfinpyrazone. These medications block the reabsorption of uric acid in the renal tubule and cause increased clearance of uric acid in the urine. However, if there is greater than 600 mg of uric acid, the patient is more likely an overproducer and would likely benefit from allopurinol (answer D) to reduce the production of uric acid. Allopurinol is a xanthine oxidase inhibitor and results in decreased production of purines and uric acid. Starting either allopurinol or probenecid in an acute flare of gout is contraindicated, however, since sudden changes in the serum uric acid concentration often cause another attack.
A 36 year old G1P0A0 at 18 weeks gestation presents for routine prenatal care. She has no complaints and has felt the baby moving normally. Her only medication is a prenatal vitamin. Family history is significant for mental retardation in a nephew. Physical examination shows a fundal height of 17 cm and a fetal heart rate in the 160s by Doppler ultrasonography. Laboratory analysis shows alpha fetoprotein to be elevated to 3.5 multiples of the median (MoM). Unconjugated estriol and beta-hCG are within normal limits. This woman’s fetus is most likely to have which of the following conditions?
A.Fragile X syndrome
B.Cystic fibrosis
C.Anencephaly
D.Trisomy 18
E.Trisomy 21
C.Anencephaly
Alpha fetoprotein (AFP) is a plasma protein that is normally produced in the fetal liver. Since it crosses the placenta from the fetal circulation, measurement of the alpha fetoprotein in the maternal serum (the MSAFP) is a useful screening test for fetal abnormalities. Grossly, you can think of an increased AFP as being caused by any defect in which the fetal body cavity is left open. These include neural tube defects like anencephaly (answer C) or myelomeningocele and abdominal wall defects like gastroschisis or omphalocele
A 3 year old male is brought to the physician by his mother after she noted multiple bruises on his body. She denies any recent trauma. Two weeks ago, the patient had three days of cough and low-grade fever that resolved without antibiotic therapy, but since that time he has been well. Past medical history is otherwise unremarkable. The patient is up-to-date on all required immunizations. On physical exam, the patient is afebrile and playing happily at his mother’s feet in the examination room. There are no peritonsillar exudates. Tympanic membranes are clear. There is no abdominal tenderness or organomegaly. Examination of the skin shows diffuse and numerous petechiae and purpura. Laboratory analysis reveals the following: WBC 7.5 k/mcL; hemoglobin 12 g/dL; hematocrit 36%; platelets 27 k/mcL; total bilirubin 0.7 mg/dL; AST 22 U/L; ALT 18 U/L; alkaline phosphatase 120 U/L; LDH 186 U/L; PT 11 s (normal 11-13s); PTT 22 s (normal 20-30s). Which of the following is the most appropriate initial treatment for this patient’s disorder?
A.Prednisone
B.Ceftriaxone
C.Vincristine
D.Cyclophosphamide
E.Immediate platelet transfusion
A. Prednisone
This patient has idiopathic thrombocytopenic purpura (ITP). ITP is a diagnosis of exclusion made by finding low platelets and ruling out other diseases and toxic exposures that result in decreased platelet counts. It is an autoimmune disease caused by antibody-mediated destruction of platelets, so first line therapies are high-dose corticosteroids like prednisone (answer A) as well as intravenous immunoglobulin (IVIg). Patients refractory to these treatments may require more high-powered immunosuppressant drugs or splenectomy.
There are two groups of patients who get ITP: children from 2-4, and adults (usually women) in their 20s-40s. Children in general do much better with the disease: over 80% of children will have a spontaneous remission of their disease, while only 20% of adults have a sustained remission.
A 36 year old construction worker is brought to the emergency room after a house frame collapsed on him. His upper thighs were trapped under a heavy wooden beam for almost two hours while his co-workers worked to free him. Vital signs are temperature 37.2 C (99.0 F), pulse 90, blood pressure 136/82, respirations 16/min. The patient is alert and oriented, but obviously in pain. There are occasional superficial abrasions on the face and arms, but no large lacerations are noted. Breath sounds are present and equal bilaterally. There is a normal S1 and S2. Abdomen is nontender, nondistended, and atraumatic. The patient’s legs show bilateral ecchymoses and tenderness at the upper thigh. Dorsalis pedis and posterior tibial pulses are 2+, and distal leg sensation to light touch and pinprick is intact. Laboratory analysis shows the following Na+ 145; K+ 5.3; Cl- 101; bicarbonate 22; BUN 17; creatinine 1.1; glucose 106. Dipstick urinalysis is unremarkable except for 4+ blood. Microscopic urinalysis shows 2 WBCs/hpf, 0 RBCs/hpf, 3 epithelial cells/hpf, and no casts. What is the most appropriate next step in the management of this patient?
A.Intubation and mechanical ventilation
B.Bolus with 2 L i.v. 0.9% NaCl solution
C.Cystoscopy
D.Intravenous pyelogram
E.Abdominal and pelvic CT
B.Bolus with 2 L i.v. 0.9% NaCl solution
Key teaching point: When you find blood on a dipstick urinalysis but there are no RBCs microscopically, think of myoglobinuria. This patient has rhabdomyolysis, a common complication of crush injuries. The two most serious complications of rhabdomyolysis are renal failure induced by myoglobinuria and electrolyte abnormalities (like hyperkalemia, hypocalcemia, and metabolic acidosis) caused by the release of massive amounts of intracellular ions.
At the moment, this patient’s electrolytes do not demand immediate intervention – but the finding of large blood on urine dipstick but no RBCs on microscopic analysis shows that the patient does have myoglobinuria (myoglobin cross reacts with hemoglobin on the urine dipstick).
The most important intervention at this time is giving i.v. fluid (answer B) to prevent myoglobin-induced ATN. Patients with myoglobinuria may require massive amounts of fluid in order to maintain good urine output because of fluid sequestration at the site of injury.
A 37 year old teacher has had three months of non-productive cough. The cough seems to be worst at night and upon awakening in the morning. She denies fevers, dyspnea, chest pain, wheezing, purulent nasal discharge, or heartburn. Past medical history includes IBS and hypertension. Medications include candesartan and an oral contraceptive pill. She has never smoked or traveled outside of the United States. Physical examination reveals an afebrile, well-nourished, healthy appearing female. The oropharynx is moist and without erythema or exudates. Nasal mucosa is pink and slightly edematous. Breath sounds are clear to auscultation bilaterally. First and second heart sounds are within normal limits, and no additional heart sounds or murmurs are noted. There is no peripheral edema. Chest x-ray shows normal lung fields. Which of the following is the most appropriate intervention at this time?
A.Stop candesartan
B.Begin antihistamine and decongestant
C.Amoxicillin/clavulanate
D.Place tuberculin purified protein derivative (PPD)
E.Chest CT
B.Begin antihistamine and decongestant
This patient presents with a chronic cough, defined as any cough lasting >3 weeks. The most likely culprits in an otherwise healthy person are, in order, postnasal drip, asthma, and GERD. Since this patient has no findings that suggest GERD, asthma, or any other of the numerous other pathological causes of chronic cough, it is reasonable to treat her empirically for postnasal drip with an antihistamine and decongestant (answer B). This course of action is the most likely to both provide a diagnosis and ameliorate the patient’s symptoms. In the appropriate setting, chronic cough can be a sign of CHF or intrinsic lung disease. Smokers can have chronic cough related to emphysema, chronic bronchitis, or the irritation of the tobacco smoke itself.
A 57 year old male presents with three weeks of fatigue. He denies depressed mood, palpitations, changes in bowel habits, syncope, or new medications. On physical examination, the patient’s temperature is 36.7 C (98.6 F), pulse 100, and blood pressure 126/82. Peripheral pulses are 2+, but are noted to be irregularly irregular. Breath sounds are equal bilaterally, and there is no peripheral edema. Initial troponin I is not elevated. The patient is started on intravenous diltiazem, and an EKG is obtained. The patient’s EKG is seen here. Which of the following is the most appropriate next step in the management of this patient?
A.Heparin and warfarin
B.Cardiac catheterization
C.Cardiac defibrillator implantation
D.Ibutilide
E.Electrical conversion
A.Heparin and warfarin
This patient presents with what is likely chronic atrial fibrillation. At this point, the most appropriate intervention among those listed is to begin anticoagulation with heparin and warfarin (answer A). This question raises a number of important issues regarding the treatment of atrial fibrillation. 1) When the atrium isn’t squeezing blood out appropriately, thrombus formation can result. If the atrium suddenly starts squeezing again, that thrombus can embolize, causing organ damage or stroke. For this reason, before electrical or pharmacological cardioversion is attempted, the patient should be adequately anticoagulated. (The exception to this is in a severely hemodynamically unstable patient – in that case, the risk of doing nothing is much greater than the risk of causing a stroke.) Even if you’re not going to attempt cardioversion, a patient with either chronic or paroxysmal atrial fibrillation should be anticoagulated to reduce their stroke risk, which is why the best answer among those listed is answer
At the insistence of his wife, a 71 year old farmer presents to have a “bump” on his shoulder evaluated. The bump has been there for several years, and though it is not painful, it does itch from time to time. The patient does report many years of sun exposure while working on his farm. Physical examination reveals a comfortable, fair-skinned gentleman. On the patient’s left shoulder, there is a smooth, 3cm by 4cm papular lesion with numerous dilated blood vessels throughout. A photo of this lesion is seen here. Which of the following is the most appropriate therapy for this patient?
A.Podophillin resin
B.Shave biopsy
C.Local excision
D.Topical tacrolimus
E.Excision, lymph node biopsy, and radiation
C.Local excision
This is a basal cell carcinoma, the single most common cancer in humans. Note the smooth, pearly appearance and multiple telangiectasias. Fortunately, basal cell carcinomas rarely metastasize. However, they can grow and become locally destructive (especially in a cosmetically-sensitive location such as the face.) For that reason, the gold standard of therapy is removal of the tumor through some type of local therapy such as cryosurgery, local radiation, topical 5-fluorouracil, or surgical excision (answer C).
