Correct Answer: C Section: (none)

Explanation:

The presence of headache, eye pain, nausea, and vomiting should prompt the consideration of the diagnosis of acute angle closure glaucoma. This is a rare but serious condition in which the aqueous outflow is obstructed, and the intraocular pressure abruptly rises. Susceptible eyes have a narrow anterior chamber and when the pupil becomes dilated, the peripheral iris blocks the outflow via the anterior chamber angle. Edema of the cornea occurs, resulting in cloudiness on examination. Diagnosis is made by measuring the intraocular pressure during an acute attack. Treatment includes medications to induce miosis in an effort to relieve the blockage or, if that fails, surgical intervention. In some patients, the headache or GI symptoms can overshadow the ocular symptoms, resulting in a delay in diagnosis and unnecessary workup for other conditions. In this case, the lack of findings on abdominal examination makes appendicitis or perforated bowel unlikely. DKA can present with primary GI symptoms, but would not explain the ocular symptoms. Similarly, cerebellar or other brain tumors may cause headache, nausea, and vomiting, but would not be causes of a painful, red eye.

Correct Answer: D Section: (none)

Explanation:

Above shows a pustule or furuncle with a necrotic center. With the patient having a history of boils under his arms and groin, a S. aureus infection should be suspected. Communityacquired methicillin-resistant S. aureus (MRSA) infection has been described to present as an appearance similar to a spider bite. Brown recluse spider bites have necrotic centers, but do not usually form pustules. TMP-SMZ is the best oral agent available for MRSA. Benadryl and topical steroids would not be indicated. Surgical debridement is not indicated. If there is a large pustule, incision and drainage of the wound may be useful. Alternatively, a needle aspirant of drainage could be sent for culture. Patients should be instructed not to press on these lesions to express puss. This causes bacterimia and can later lead to serious systemic infections due to S. aureus. If a patient with S. aureus infection becomes febrile, he should be admitted to the hospital for systemic antibiotics. Blood cultures should be taken. S. aureus easily forms abscesses in the skin and in other tissues. Blood-borne infection causes endocarditis, renal furuncles, and osteomyelitis.

Correct Answer: E Section: (none)

Explanation:

In all likelihood, this patient is presenting with a systemic inflammatory arthritis. Clearly, treatment will need to be initiated. In order to effectively and promptly treat her, you will need to understand the current state of her physiology. Therefore, basic laboratory studies including blood count, full chemistries, and urinalysis should be obtained. At this point, the most likely diagnosis is RA, and the rheumatoid factor and sedimentation rate may be helpful. Theoretically, sarcoidosis can present in this way but, epidemiologically, this is much less likely. Because of this and because the ACE level is fairly nonspecific, it should not be part of the initial workup. Neither joint fluid aspiration nor uric acid levels are likely to be diagnostic. The elevation of serum transaminase in the face of elevated sedimentation rate, moderate or low positive ANA, and rheumatoid factors raise the question about hepatitis C.

About 50% of patients with active hepatitis C will have cryoglobulinemia. Cryoglobulins can produce low moderate positive rheumatoid factors. Therefore, it is extremely important in this circumstance to be certain that hepatitis C is not present. With such a low positive ANA, the likelihood that this is classical Lupus is low, and double-stranded DNA antibodies are not likely to be revealing. C-reactive protein may confirm the presence of inflammation, but it won't provide additional information over the sedimentation rate. Syphilis, "the great imitator," again may occasionally have arthritis as a manifestation--but rarely without other features. The remaining studies while they might be useful later but are unlikely to be helpful as the next most important test obtained. The probable source of the patient's symptoms is RA. Osteoarthritis can produce articular swelling, but on physical examination, there is rarely bogginess in the synovium. Anti-CCP antibody is an antibody directed against the citrullinated portion of fillagen. It has the highest specificity for RA of any antibody known. It is usually present early and may predict more severe disease.

Correct Answer: D Section: (none)

Explanation:

Crohn's disease is a chronic inflammatory disease of the GI tract of unknown etiology. Both medical and surgical treatments are palliative in nature--there is no known "cure." pproximately 70% of patients with Crohn's disease will require an operation during their lifetime. The most common indication for surgery is recurrent bowel obstruction, followed by perforation with abscess and fistula formation.

Correct Answer: E Section: (none)

Explanation:

The indications for surgery for duodenal ulcers include intractability, hemorrhage, obstruction, and perforation. Initial management includes dietary and behavior modification, H2 blockade, proton pump inhibitors, and treatment for H. pylori. Duodenal ulcers are rarely secondary to a malignancy and are related to acid production, unlike gastric ulcers, which have a higher incidence of association with malignant processes. Surgical approaches include: vagotomy (truncal, selective, highly selective), vagotomy combined with antrectomy, or subtotal gastrectomy. There are varying rates of perioperative morbidity and effectiveness reported in the literature. Recurrence rates after vagotomy and pyloroplasty alone approach 30%, in long-term followup. The complication of dumping after a highly selective vagotomy is significantly lower than truncal vagotomy. A drainage procedure after highly selective vagotomy is unnecessary, and vagal denervation of the proximal stomach reduces receptive relaxation.

Correct Answer: A Section: (none)

Explanation:

Carcinoma of the gallbladder accounts for 24% of GI malignancies. Fewer than 1% of patients undergoing biliary tract operations have carcinoma either as an anticipated diagnosis or as an incidental finding. The calcified "porcelain" gallbladder is associated with a 20% incidence of gallbladder carcinoma. Signs and symptoms of carcinoma of the gallbladder are generally indistinguishable from those associated with cholecystitis and cholelithiasis. They include abdominal discomfort, right upper quadrant pain, nausea, and vomiting. Most long-term survivors are patients who underwent cholecystectomy for cholelithiasis and in whom the malignancy was an incidental finding on the pathology report. The management of these patients is based on the depth of tumor penetration into the wall of the gallbladder

Correct Answer: D Section: (none)

Explanation:

The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Café au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome. Ambiguous genitalia are commonly seen in CAH.

Children with Down syndrome are at an increased risk for hypothyroidism. It may be hard to detect without routine laboratory screening as they will commonly have mental retardation and developmental delay as part of their syndrome. Hypothyroidism may not be present in the immediate newborn period and requires, at a minimum, annual testing throughout the child's life. The other findings listed are not specifically associated with Down syndrome. Lens dislocation is commonly found with Marfan syndrome or homocysteinuria.

Children with Down syndrome have an increased prevalence of duodenal atresia. Pyloric stenosis is uncommon to see in the newborn period. It tends to present with nonbilious vomiting usually after 24 weeks of age. Hirschsprung disease (aganglionosis coli) presents with constipation and failure to pass stool. Infants with Hirschsprung disease commonly will not pass stool in the first days of life. Biliary atresia is a progressive cause of jaundice in an infant. It is the most common cause of a cholestatic jaundice in the newborn period. Emesis is not typically associated with biliary atresia. Milk protein allergy is a common cause of bloody stools in the first few months of life, but does not have bilious emesis associated with it.

Correct Answer: E Section: (none)

Explanation:

Sheehan syndrome describes damage to the pituitary gland classically resulting from hypotension following a postpartum hemorrhage. The clinical picture is variable due to the fact that the damage may involve one or more of the various cellular subtypes in the pituitary gland that secrete either adrenocorticotropic hormone (ACTH), GH, prolactin, TSH, or LH/FSH. An amenorrheic patient with a history of Sheehan's syndrome would not be expected to have functional pituitary gonadotropes so a GnRH pump or clomiphene citrate would not be useful because they both rely on a functional pituitary gland. Replacement of gonadotropins (LH and FSH) would be the best treatment option

Correct Answer: E Section: (none)

Explanation:

The pelvic ultrasound is the most reliable measurement of fetal gestational age in the absence of accurate dating by LMP. A first trimester sonogram is thought to be reliable ±7 days. Given the patient's history, she is likely at least 2 months pregnant. hCG level at this gestation can be variable and is not a useful method of pregnancy dating. A pelvic examination is useful to help confirm likely dating, but is not a reliable means of determining EDD. FSH and LH levels have no role in determining pregnancy dating.

The risk of postpartum major depression is estimated at 820% in all postpartum patients. In those with a previous history of postpartum depression, the risk is thought to be 50100%. In patients who have had previous depression not associated with pregnancy, the risk of postpartum depression is 2030%. Maternity blues is a milder psychological reaction that can occur in the early postpartum period and is thought to occur in 70+ % of all postpartum patients. Patients with a history of bipolar disease have a igher risk of recurrence in the postpartum period, and these patients often present with postpartum psychosis symptoms.

Correct Answer: C 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.