60 Question Interactive Exam 1

Hidradenitis suppurativa (hi-drad-uh-NIE-tis sup-yoo-ruh-TIE-vuh) is a chronic skin condition that features pea-sized to marble-sized lumps under the skin. Also known as acne inversa, these deep-seated lumps typically develop where skin rubs together — such as the armpits, groin, between the buttocks and under the breasts. The lumps associated with hidradenitis suppurativa are usually painful and may break open and drain foul-smelling pus. In many cases, tunnels connecting the lumps will form under the skin. Hidradenitis suppurativa tends to start after puberty, persist for years and worsen over time. Early diagnosis and treatment of hidradenitis suppurativa can help manage the symptoms and prevent new lesions from developing.

Barrett's esophagus is a disorder in which the lining of the esophagus (the tube that carries food from the throat to the stomach) is damaged by stomach acid and changed to a lining similar to that of the stomach.

Spina bifida is a condition that affects the spine and is usually apparent at birth. It is a type of neural tube defect (NTD). Spina bifida can happen anywhere along the spine if the neural tube does not close all the way. The backbone that protects the spinal cord does not form and close as it should. This often results in damage to the spinal cord and nerves.

Hyphema is blood in the front area (anterior chamber) of the eye. The blood collects behind the cornea and in front of the iris.

This patient is presenting with a sudden decline in cognitive function in the setting of hypertension, which is suggestive of vascular dementia. Vascular dementia is the second most common cause of dementia. It typically occurs in patients with risk factors such as hypertension, atherosclerosis, and vasculitis. Typically, there is a multifocal infarction that leads to the subsequent injury. The presentation of vascular dementia is unique in that there is a stepwise decline in cognitive ability with discrete events in contrast to Alzheimer's dementia which is a gradual decline. There is no treatment for vascular dementia other than treating the underlying etiology, which would involve interventions such as treatment of hypertension and dyslipidemia and smoking cessation.

Auer rods are clumps of azurophilic granular material that form elongated needles seen in the cytoplasm of leukemic blasts. They can be seen in the leukemic blasts of acute myeloid leukemia with maturation and acute promyelocytic leukemia (known as acute myeloid leukemia M2 and M3, in the FAB classification, respectively) and in high grade myelodysplastic syndromes and myeloproliferative syndromes. They are composed of fused lysosomes/primary neutrophilic granules and contain peroxidase, lysosomal enzymes, and large crystalline inclusions. Morphologically, the Auer "rods" come in all sizes and shapes. They have been described as needle-shapes with pointed ends (most common), comma-shapes, and diamond-shapes; others were long and rectangular. Occasional corkscrew forms and rare granular Auer bodies were also noted. More appropriately, they can be referred to as Auer bodies.

Osteoporosis is a progressive bone disease that is characterized by a decrease in bone mass and density which can lead to an increased risk of fracture. In osteoporosis, the bone mineral density (BMD) is reduced, bone microarchitecture deteriorates, and the amount and variety of proteins in bone are altered. Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy X-ray absorptiometry; the term "established osteoporosis" includes the presence of a fragility fracture. You will usually have normal serum calcium, normal urinary calcium and normal serum alkaline phosphatase.

It is caused primarily by precipitation of calcium soaps in the abdominal cavity,when the pancreas is damaged, free fatty acids are generated by the action of pancreatic lipase. Insoluble calcium salts are present in the pancreas, and the free fatty acids avidly chelate the salts, resulting in calcium deposition in the retroperitoneum. In the other way glucagon-stimulated calcitonin release and decreased PTH secretion may play a role. In addition, hypoalbuminemia may be a part of the clinical picture, resulting in a reduction in total serum calcium. In patients with concomitant alcohol abuse, a poor nutritional intake of calcium and vitamin D, as well as accompanying hypomagnesemia, may predispose those with pancreatitis to hypocalcemia. Some studies shows that systemic endotoxin exposure and extraskeletal sequestration of calcium appears to play a significant role in the development of hypocalcemia in patients with acute pancreatitis. Learn More

Mitral valve prolapse may be preceded by a systolic click. It usually occurs in mid or late systole and lasts until the beginning of the S2. Listen to mitral valve prolapse Classification of Murmurs Chart: classification of murmurs

A systolic crescendo-decrescendo murmur (one that rises in intensity and then falls) is heard with aortic stenosis. Radiates to the neck, often heard with a loud thrill, harsh heard while the patient is sitting and leaning forward. The review of valvular disorders can be found here:valvular disorders

Venous return increases when a person squats and so does peripheral vascular resistance. The volume of blood in the left ventricle, arterial blood pressure, and stroke volume increase. The increase in the left ventricle volume decreases the prolapse of a mitral valve and the intensity of the murmur. If the patient is asked to stand, all of the above information may be found reversed.

Threatened: Sometimes a woman will experience vaginal bleeding in the early months of pregnancy. This bleeding is usually mild and may be accompanied by cramps or backaches. But the cervix remains closed and, as the name suggests, the miscarriage is not successful. In fact, the majority of pregnancies continue successfully after a threatened miscarriage.

Almost everyone has PVCs at some time, from childhood through adulthood. In a study of healthy members of the military, the incidence of PVCs was 0.5% among those under the age of 20 and 2.2% in those over the age of 50. This study shows the rise in PVCs – as in all types of abnormal heart rhythms – that occurs with age. PVCs occur more commonly in older people and in individuals with underlying heart disease, including a history of heart attack. People with a family history of cardiac arrhythmia (abnormal heart rhythm) also have a higher risk for PVCs.

De Quervain tenosynovitis is an entrapment tendinitis of the tendons contained within the first dorsal compartment at the wrist; it causes pain during thumb motion.

The classic presentation of pulmonary embolism is the abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia. However, most patients with pulmonary embolism have no obvious symptoms at presentation. Rather, symptoms may vary from sudden catastrophic hemodynamic collapse to gradually progressive dyspnea. The diagnosis of pulmonary embolism should be suspected in patients with respiratory symptoms unexplained by an alternative diagnosis, especially those with classic risk factors. Surgery is one of the leading causes of problem blood clots, especially joint replacements of the hip and knee. During the preparation of the bones for the artificial joints, tissue debris may enter the bloodstream and contribute to causing a clot. Simply being immobile during any type of surgery can lead to the formation of clots. The risk increases with the length of time you are under general anesthesia. For this reason, most people undergoing the type of surgery predisposing them to DVT will receive medication before and after surgery to prevent clot formation and continued after surgery.

Occult bleeding, as evidenced by the patient's history of black stools, is initially verified by a positive fecal occult blood test.

Melanoma risk tracks with low constitutive pigmentation: skin that burns rather than tans is the strongest phenotypic risk factor. Other risk factors include fair skin, red or blond hair, light eye color, many or atypical nevi, a personal or family history of melanoma, and intense intermittent sun exposure or blistering sunburns. Melanoma is more common in women before age 50 and in men after age 50.

BCCs are the most frequently occurring form of skin cancer. They are abnormal, uncontrolled growths or lesions that arise in the skin’s basal cells, which line the deepest layer of the epidermis (the outermost layer of the skin). BCCs often look like open sores, red patches, pink growths, shiny bumps, or scars. Usually caused by a combination of cumulative UV exposure and intense, occasional UV exposure, BCC can be highly disfiguring if allowed to grow, but almost never spreads (metastasizes) beyond the original tumor site. Only in exceedingly rare cases can BCC spread to other parts of the body and become life-threatening. There are an estimated 2.8 million cases of BCC diagnosed in the US each year. In fact, it is the most frequently occurring form of all cancers. More than one out of every three new cancers are skin cancers, and the vast majority are BCCs. It shouldn’t be taken lightly: this skin cancer can be disfiguring if not treated promptly. Are you at risk? We have the information you need about the prevention, detection, and treatment of basal cell carcinoma.

Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel.

Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored. Azotemia has three classifications, depending on its causative origin, but all three types share a few common features. All forms of azotemia are characterized by a decrease in the glomerular filtration rate (GFR) of the kidneys and increases in blood urea nitrogen (BUN) and serum creatinine concentrations. The BUN-to-creatinine ratio (BUN:Cr) is a useful measure in determining the type of azotemia. A normal BUN:Cr is equal to 15. Learn More

Primary aldosteronism (PA) is one of the most common causes of secondary hypertension in adults, along with obstructive sleep apnea, chronic kidney disease, and renal artery stenosis, and it is found in roughly 1 in 5 patients with resistant hypertension (uncontrolled on 3 drugs including a diuretic). Clues are resistant hypertension and spontaneous or diuretic-induced hypokalemia, but most patients with PA have a normal potassium, so per AHA/ACC everyone with resistant hypertension should be screened regardless of potassium. Screen with a morning plasma aldosterone-to-renin ratio, confirm, then use adrenal CT and adrenal vein sampling to separate an aldosterone-producing adenoma (laparoscopic adrenalectomy) from bilateral adrenal hyperplasia (spironolactone or eplerenone). Learn More

An infant will triple birth weight within the first year of life. A newborn that weighs 8 pounds at birth will weigh approximately 24 pounds at 1 year of age.

A bulging tympanic membrane is the single most specific otoscopic finding for acute otitis media (AOM), because it shows a middle ear effusion under pressure with acute inflammation. Per the American Academy of Pediatrics (AAP), AOM is diagnosed by moderate to severe bulging of the tympanic membrane, new-onset otorrhea not caused by otitis externa, or mild bulging with recent (less than 48 hours) ear pain or intense TM erythema. Bulging of the TM is the most specific sign because it shows an effusion under pressure with acute inflammation. Decreased mobility on pneumatic otoscopy confirms a middle ear effusion, but it does not distinguish AOM from otitis media with effusion (OME). Redness alone is unreliable because crying and fever can redden the TM.

Hordeolum (stye) is a staphylococcal infection characterized by a localized red swollen and acutely tender abscess of the upper or lower eyelid.

Growth of the lobules and alveoli is under the influence of progesterone. Prior to menses, the breast swelling that women notice is a result of the progesterone which is secreted from the corpus luteum. During menses, the swelling subsides.

The posterior column affects proprioception (position sense) and vibration sense.

Cryptococcus is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients. Learn More

Low output heart failure occurs secondary to ischemic heart disease, hypertension, dilated cardiomyopathy, and valvular and pericardial disease. High output heart failure generally occurs due to hyperthyroidism, anemia, pregnancy, av fistulas beriberi and Paget's disease. What is beriberi?

Per the ACC/AHA valvular heart disease guideline, warfarin for a mechanical mitral valve targets an INR of 3.0 (range 2.5 to 3.5), because the mitral position carries a higher risk of valve thrombosis. A mechanical aortic valve targets an INR of 2.5 (range 2.0 to 3.0), or 3.0 if the patient has thromboembolic risk factors (atrial fibrillation, prior thromboembolism, left ventricular dysfunction, a hypercoagulable state) or an older-generation valve. Direct oral anticoagulants (DOACs) should not be used in patients with mechanical valves.

An aneurysm that is 5.5 cm in size requires surgical intervention. Patients who have an aneurysm between 4 and 5 cm require surgical intervention but only if their co-morbidities are low.

Varicose veins develop when individuals spend a prolonged amount of time on their feet.

Rest chest pain with transient ST elevation that resolves promptly with nitroglycerin, with normal troponins, is the signature of vasospastic (Prinzmetal) angina. Prinzmetal angina occurs in younger patients at rest, with no preceding angina. It is associated with ECG changes and is thought to be related to transient coronary vasospasm rather than atherosclerosis. Classic features are chest pain at rest (often at night or early morning) with transient ST elevation that is rapidly relieved by nitrates. The diagnosis is confirmed by coronary angiography showing no significant fixed obstruction, with spasm that can be provoked and then relieved with intracoronary nitroglycerin. Treatment is a calcium channel blocker with or without a long-acting nitrate, plus smoking cessation; avoid nonselective beta-blockers.

At 20-22 weeks, the fundal height is typically at the level of the umbilicus.

Viral croup is characterized by a history of upper respiratory tract symptoms followed by onset of a barking cough and stridor.  

Bronchiectasis has numerous etiologies. Most commonly, cultures reveal normal oral flora from the lower respiratory tract: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa.

Evidence suggests that aspirin in a patient with acute ischemia is beneficial. There is no need to get further tests to confirm this patient's condition until the patient gets to the hospital. Call the ambulance, time delay should be minimized. I would also begin treatment with sub-lingual nitroglycerin assuming there are no contraindications.

A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

A patient with ambivalence toward sexual relationships, no close contacts, and no desire for either, along with anhedonism and flat affect are typical for this disorder.

Bipolar 1 disorder is a mood disorder in which patients experience manic and major depressive episodes. Lithium is the first-line treatment for bipolar disorder.

Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future.

Multiple factors influence the initial dose of levothyroxine when used for thyroid replacement therapy, including age, the duration and severity of hypothyroidism , and the presence of certain underlying conditions. Thyroid hormones are known to elevate heart rate and increase cardiac contractility, both of which demand more oxygen utilization by the heart. In hypothyroid patients with a history of chronic stable angina, initial levothyroxine doses are typically smaller and then titrated upward. This regimen prevents a more immediate increase on the heart's workload that could occur with usual doses and minimizes the chances of an exacerbation of angina.

Hypochondriacs feels there is something wrong with their body. Patients seek reassurance and make frequent visits for medical care. Hypochondriacs can mimic obsessive compulsive disorder obsessions. The difference between the two diagnoses is that hypochondriacs limit their obsessions to their body.

Brainstem auditory-evoked potentials evaluate the sensory pathway and identify the site of any anatomical disruption. The test does not require any active response from the patient and is useful in the evaluation of suspected hearing loss in an infant.

Studies confirm the association of asbestos exposure to the development of mesothelioma.

The mental status exam is able to evaluate appearance, affect, mood, speech, activity, and behavior, thought processes, cognition, fund of knowledge, judgment, content of thought, and insight. You can obtain a basic knowledge of the level of intelligence based on information provided by the patients and their behavior. Intelligence quotient is measured through IQ tests.

Chloroquine is a standard prophylaxis for the prevention of malaria. The Dominican Republic is a country with a high risk for malaria; it is also a chloroquine-susceptible region as are most parts of Central America and Mexico. It is safe, efficacious, and has few major side effects. It is ideal for short visits to endemic regions. Learn More

Rh-negative women who are exposed to Rh-positive blood through pregnancy, delivery, threatened or spontaneous hemorrhage, surgery for ectopic pregnancy, or amniocentesis may become sensitized and require anti-D immunoglobulin (RhoGAM). Patients who are Rh-negative should be administered RhoGAM in threatened or spontaneous abortions. Rh-negative women in the setting of ectopic pregnancies, threatened abortions, and/ or complete abortions should be given 50 μg if they are at less than 12 weeks’ gestation and 300 μg if they are at 12 or more weeks’ gestation.

Metabolic acidosis is characterized by increased production of acids, decreased excretion of acids, or loss of bicarbonate. The etiology of metabolic acidosis is divided into those with a normal anion gap and those associated with an increased anion gap. Metabolic acidosis with an increased anion gap includes lactic acidosis, ketoacidosis, and renal failure. Lactic acidosis, the most common cause of nonhospitalized, nondiabetic metabolic acidosis is due to decreased oxygen delivery to tissues and associated anaerobic metabolism, which results in an increased production of lactate. This lactate production accompanies severe metabolic acidosis. Low tissue perfusion, characteristic of lactic acidosis, may include shock and sepsis. Metabolic acidosis with a normal anion gap is known as hyperchloremic metabolic acidosis. The primary causes of normal anion gap acidosis include renal loss of bicarbonate through proximal tubular acidosis, distal tubular acidosis, hyperkalemic renal tubular acidosis, renal insufficiency, or carbonic anhydrase inhibition and gastrointestinal loss of alkali through diarrhea, pancreatic fistulas, or ureterosigmoidostomy.

The definition of hypernatremia is a serum sodium level more than 145 mEq/ L. Hypernatremia is classified as isovolemic (diabetes insipidus, skin loss through hyperthermia, and iatrogenic), hypervolemic (administration of hypernatremic solutions, mineralocorticoid excess as in Conn or Cushing syndrome, and salt ingestion), and hypovolemic (renal losses through diuretics or glycosuria, GI, respiratory, or skin losses, and adrenal deficiencies). Water deficit in hypernatremic patients is calculated by the following formula: In Women: Water deficit (L) = [0.5 (body weight, kg)] × (measured serum sodium/ normal serum sodium) − 1 Water deficit = 0.5 (60) = 30 [( 180/ 140) − 1] = 30 (0.2857) = 8.6 L. (Gibbs and Tavel, 2006, pp. 1935-1937) Make it easy with MedCalc

A primary spontaneous pneumothorax is thought to result from a rupture of subpleural apical blebs secondary to high negative intrapleural pressures. Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse. A person with this condition may feel chest pain on the side of the collapsed lung and shortness of breath. Blebs may be present on an individual's lung (or lungs) for a long time before they rupture. Many things can cause a bleb to rupture, such as changes in air pressure or a very sudden deep breath. Often, people who experience a primary spontaneous pneumothorax have no prior sign of illness; the blebs themselves typically do not cause any symptoms and are visible only on medical imaging. Affected individuals may have one bleb to more than thirty blebs. Once a bleb ruptures and causes a pneumothorax, there is an estimated 13 to 60 percent chance that the condition will recur.

Women diagnosed with symptomatic, moderate to severe hyperthyroidism during the first trimester of pregnancy should take PTU. Patients may continue PTU for the remainder of pregnancy or switch to methimazole at 16 weeks. Women diagnosed with symptomatic, moderate to severe hyperthyroidism after the first trimester should take methimazole.

Hypercalcemia associated with malignancies is commonly due to increased bone resorption through osteoclastic factors, parathyroid hormone (PTH) factors, prostaglandins, peptides, steroids , and direct erosion by tumor cells. Common neoplasms include multiple myeloma, lymphosarcoma, adult T-cell lymphoma, and Burkitt lymphoma. Symptoms of hypercalcemia are variable depending on the degree elevation. Typical symptoms include constipation, anorexia, vomiting, confusion, obtundation, psychosis, nephrolithiasis, renal insufficiency, myopathy, back pain, weakness, and hypertension.

Renal tubular acidosis is an example of a normal anion gap acidosis in which there is an increase in chloride and a loss of bicarbonate. The other choices of diagnoses are associated with a high anion gap metabolic acidosis or a metabolic alkalosis.

Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining.

Long-standing hypertension causes concentric left ventricular hypertrophy (LVH), which is the classic electrocardiographic sign of hypertensive heart disease and a marker of target-organ damage. The pressure-overloaded left ventricle thickens, producing increased QRS voltage (for example, an S wave in V1 plus an R wave in V5 or V6 of 35 mm or more, or an R wave in aVL of 11 mm or more), often with a strain pattern of asymmetric ST depression and T-wave inversion in the lateral leads. LVH on ECG independently predicts heart failure, arrhythmia, and cardiovascular death, and its presence should prompt tighter blood pressure control; echocardiography is more sensitive for confirming it. Right-sided findings (right bundle branch block, right ventricular hypertrophy) point to pulmonary or right-heart disease, and ST-segment elevation indicates acute injury rather than chronic pressure overload.

Periodic measurements of blood pressure should be part of routine preventive health assessments beginning at the age of 3 years.

A single normal troponin drawn early after symptom onset does not rule out myocardial infarction, because troponin takes time to rise into the bloodstream. The diagnosis of non-ST-elevation myocardial infarction rests on a rise and/or fall of cardiac troponin on serial measurements. With high-sensitivity assays, the ACC/AHA-endorsed rapid protocols repeat the troponin 1 to 2 hours after the first draw (the 0/1-hour or 0/2-hour algorithm); with conventional assays, the repeat is drawn at 3 to 6 hours. A rising value confirms acute myocardial injury, while two normal values in a low-risk patient make infarction very unlikely. This patient has ischemic-quality pain, diaphoresis, and ST depression, so he is managed as an acute coronary syndrome while the serial troponin is pending. Aspirin, anticoagulation, and risk stratification should not wait for the second troponin. Older markers such as myoglobin and CK-MB rise and fall on their own schedules but add nothing to high-sensitivity troponin, which is the preferred biomarker. (Review PANCE/PANRE Blueprint Topic: Acute myocardial infarction)

This patient has clinical features suggestive of scleroderma or CREST syndrome. Manometry in these patients commonly shows absence of peristaltic waves in the lower 1/3 of the esophagus and a significant decrease in lower esophageal sphincter (LES) tone. The components of CREST syndrome include calcinosis, Raynaud's, esophageal dysmotility (secondary to LES sclerosis), sclerodactyly, and telangiectasias; it is a form a systemic scleroderma (sclerosis). The disease involves excessive deposition of collagen and is most common in females between the ages of 30-50. Raynaud's is typically the fist symptom to present, followed by finger puffiness that later progresses to thickening of the skin of the fingers.

Opioid overdose is a significant public health problem in the United States, with mortality now exceeding that from motor vehicle collisions. In the past 10 years, deaths from opioid overdoses has more than quadrupled. Opioid overdose typically presents with depressed respiratory rate, depressed consciousness, miosis, hypotension, and bradycardia. Furthermore, in those patients who are heroin users track marks will often be observed in the antecubital fossa, wrists, or feet from injection drug use. The treatment is naloxone, an inexpensive and effective antidote, which causes immediate reversal and can precipitate immediate and uncomfortable withdrawal.