Correct Answer: D Section: (none)

Explanation:

In evaluating a sporadic thyroid nodule in a patient who is euthyroid, it is critical to determine whether the nodule is malignant or benign. The most diagnostic test is the fine needle aspiration. Ultrasound will only distinguish between cystic and solid structures, and most nodules have some solid component. The nuclear scan will demonstrate a photopenic area in over 85% of patients. Neither these tests nor CT scan will reliably separate benign from malignant nodules. Thyroid antibody studies do not play a role in the evaluation of a thyroid nodule in a euthyroid patient. They are sometimes used in the evaluation of thyroiditis.

Correct Answer: D Section: (none)

Explanation:

This patient is manifesting symptoms consistent with asthma. With the history of recently moving to a new area, along with a family history of allergies and eczema, his asthma may be further classified as allergic asthma. Episodic symptoms of cough, dyspnea, and wheezing are likely to occur. The diagnosis of asthma is made by demonstrating reversible airway obstruction. Airway obstruction is likely to be manifested by a reduction in the FEV1. An increase in the FEV1 of 15% after the use of a bronchodilator is the definition of reversibility. A CXR is most likely to be normal. Numerous cardiac conditions, such as CHF, cardiomyopathies, or pericardial effusions, may result in cardiomegaly on a CXR. Diffuse infiltrates may be seen with infections, interstitial lung disease, or other conditions. Flattened diaphragms would be consistent with prolonged obstructive lung disease, such as emphysema.

The treatment of choice for the prevention of symptoms in all stages of asthma other than mild intermittent is inhaled steroid. All patients with asthma should also have a short-acting bronchodilator for acute symptomatic relief. A leukotriene modifier would be an alternative recommendation and might be a good addition to an inhaled steroid, as they also have FDA indications for patients with allergic rhinitis.

Correct Answer: B Section: (none)

Explanation: Because there is a smoking history, it is appropriate to order a spiral CT scan to better delineate whether the mass is a tumor, an infectious process, or both. Tumor blocking a bronchus can frequently be associated with a pneumonia involving lung behind the compressed bronchus; therefore, the evaluation should include collecting the appropriate cultures along with the further imaging. The full staging of small cell lung cancer is very important both for prognosis to relate to the patient and his family and to define the most appropriate therapy. Therefore, it is appropriate to order the MRI studies of the head along with CT scans with contrast of the abdomen and pelvis, a bone scan and a bone marrow aspirate and biopsy to determine if the disease is limited to the thorax or has metastasized to other organs. Small cell lung cancer limited to the thorax is potentially a disease that can achieve complete, long-term remissions with appropriate therapy. Small cell lung cancer metastatic beyond the chest can be well palliated but, at this time, our current treatments are unable to induce a long-term disease-free remission. Surgery alone is not an appropriate treatment for small cell lung cancer. Even with a successful complete tumor resection, without systemic therapy (chemotherapy), the small cell lung cancer recurs in 100% of cases within months to several years.

Correct Answer: A Section: (none)

Explanation:

The patient has symptoms of spinal cord compression and needs an urgent MRI to establish the diagnosis. Spinal cord compression usually develops when patients have metastases to the vertebral body with epidural extension of the tumor, displacing the underlying thecal sac, and causing cord edema and injury. Patients with cord compression usually experience new or worsening pain symptoms days or weeks before the development of motor weakness below the level of compression. Loss of sensation and loss of bowel or bladder control occur even later. Clues that the pain symptoms may represent cord injury include pain that is worse with recumbency or Valsalva and the occurrence of Lhermitte's sign, an electric sensation down the back and into the extremities with extension or flexion of the neck or spine.

Initiation of therapy, such as radiation therapy or neurosurgical intervention, might be necessary later but would be premature before the diagnosis is established with an imaging study. If the patient's history or physical exam suggests spinal cord compression, initiation of corticosteroids should be started immediately while diagnostic imaging is pending. Pain control with adequate narcotic analgesia is important and may be instituted while the appropriate diagnostic studies are being obtained. Delay of 1 week would be inappropriate due to the urgent nature of the problem and risk of neurological compromise. The patient's neurological status at the time of diagnosis is the most important prognostic factor: 7580% of patients who are ambulatory at the time of diagnosis will retain locomotion. But, if already paraplegic, only 10% will regain the ability to walk. While this patient appeared neurologically intact, the development of neurological deficits can progress over a period of days, making rapid diagnosis and institution of appropriate therapy such as corticosteroids and radiotherapy an urgent consideration. Other factors such as age, presence of co-morbid medical conditions, functional status, and tumor androgensensitivity are important to the patient's overall cancer prognosis.

Correct Answer: A Section: (none)

Explanation: The hallmark of immune (also known as idiopathic) thrombocytopenia purpura (ITP) is the otherwise healthy appearing child with isolated thrombocytopenia. ITP is the most common cause of isolated thrombocytopenia in childhood. It occurs with equal frequency in both boys and girls. The presence of thrombocytopenia in a patient with otherwise normal cell lines, and a normal physical examination is enough to make the diagnosis, so further evaluation, such as a bone marrow biopsy, is unnecessary. Which children to treat and which treatment to use are areas of controversy in the management of ITP. Most acute ITP will resolve spontaneously, so many will recommend observation for children who appear well, are asymptomatic, and have platelet counts above 30,000. Platelet transfusions should be reserved only in the instance of ongoing or imminent bleeding. When a decision is made to treat, usually when the platelet count falls below 20,000, there are several options available. Treatment involves using IVIG, steroids, anti-D immunoglobulins, or combinations thereof. Combinations of medications may work synergistically. Prednisone is often used initially, as it can be given orally and is inexpensive. Typically, it will be tapered over 2 weeks to 3 months. By using combination therapy when needed, splenectomy can be avoided in the vast majority of cases. When it is necessary, it should be delayed, if at all possible, for at least a year after diagnosis.

Correct Answer: E Section: (none)

Explanation:

This woman likely suffers from a major depressive episode. While asking about substance abuse, current medications, medical problems, and a past history of depression are very important in a complete psychiatric evaluation, assessment of suicidality is essential. The risk of suicide in patients with major depressive disorder is about 20 times higher than those without the illness. The estimated lifetime risk of suicide is approximately 15% in those individuals with major depressive disorder. The choice of a specific antidepressant may be influenced by many factors, including prior response in the patient or a family member and comorbid medical problems or substance abuse in the family (and, therefore, potentially the patient). If a patient or family member has a history of manic symptoms or bipolar disorder, consideration should be given to beginning a mood stabilizer prior to initiating antidepressant therapy, as antidepressants can cause a switch into mania in those individuals.

Correct Answer: D Section: (none)

Explanation:

The patient has chronic schizophrenia with an acute exacerbation consisting of disorganization, paranoia, persecutory delusions, and command hallucinations to kill his landlord. Although all of the choices may be indicated, this patient appears to be at significant risk of harm to others, namely his landlord. Therefore, only admission to the hospital for treatment (either voluntary or involuntary) would adequately protect the landlord. The Durham rule refers to criminal responsibility, that one is not criminally responsible if the illegal act was a product of a mental disease or defect. The M'Naghten rule was established by the British courts and posits that one is not guilty by reason of insanity if, due to a mental disease, one was unaware of the nature of the act or was incapable of realizing the act was wrong. Testamentary capacity refers to one's competence to make a will. The Tarasoff I and Tarasoff II rulings refer to the duty to warn others of danger and duty to protect others from danger, respectively

Correct Answer: C Section: (none)

Explanation: The patient has likely developed tardive dyskinesia (TD), a late-occurring movement disorder associated with chronic antipsychotic use. Adding an anticholinergic agent like benztropine would be indicated for treating an acute dystonia but is not effective for TD. Continuing the current dose of his antipsychotic will not lessen his movements, and increasing it will more than likely worsen them over time. Discontinuing his psychotropic will not reduce his dyskinesia, and it will provide a high risk for relapse of his psychosis. Once an individual has TD, reducing the dose (if clinically indicated) may minimize the progression or even improve the abnormal movements. The patient displays features consistent with neuroleptic malignant syndrome (NMS), a life-threatening condition associated with antipsychotic therapy. Adding benztropine will not treat NMS. Immediate discontinuation of the antipsychotic is recommended. Initiation of dantrolene, a muscle relaxant, as well as bromocriptine, a dopamine receptor agonist, may also be used to manage the patient.

Correct Answer: B Section: (none)

Explanation: Explanations: This case is a characteristic presentation for malingering. Consciously producing symptoms in order to assume the sick role is the motivation behind factitious disorder. There is no evidence of psychotic symptoms as would be seen in delusional disorder. Hypochondriasis involves the preoccupation with fears of having a serious illness rather than the focus on complaints of pain. The unconscious production of symptoms due to unconscious conflict is the hallmark of conversion disorder, which presents with a neurologic deficit. Malingering, which is not considered a mental illness, is defined as the intentional production of symptoms motivated by external incentives. These incentives may include such things as avoidance of work, military duty, and jail, or the acquisition of drugs (which is seen in the above case) (DSM IV-TR). In cases of suspected malingering, accusations or law enforcement involvement will likely result in further hostility and harm to any therapeutic alliance. Referral for admission to a mental health facility or to a psychiatrist may also have the same effect and is not warranted unless another mental illness or safety concerns are present. While limit setting is absolutely necessary with these individuals, a professional demeanor must be maintained. Gentle confrontation coupled\ with a focus on understanding their underlying problems (leading to their feigning illness) are the most helpful approaches. Amore complete evaluation may be necessary to determine whether or not there is an additional mental illness or substance dependence that will need to be treated.

Correct Answer: B Section: (none)

Explanation:

In this case, the patient most likely has rheumatoid arthritis, an autoimmune chronic relapsing disorder that mostly affects the joints. The disease is usually seen in Western European and North American White females between the ages of 30 and 50. The clinical hallmark of the disease is symmetric swelling of the small joints of the hands and feet, particularly the proximal and interphalangeal joints. Swelling, pain, and stiffness are most severe in the morning. Pathologically, a pannus, or hypertrophic inflamed synovium, is produced that may eventually erode into the articular cartilage, with subsequent fibrosis, restriction of movements, and deformity.