FREE Internal Medicine Rotation Cardiovascular Practice Exam

Amphotericin B is the drug of choice in the initial treatment of cryptococcal meningitis. It is used in combination with flucytosine for 2 weeks, followed by fluconazole for 10 weeks. (Review topic: Cryptococcus)

A reaction size of greater than or equal to 5 mm in an HIV positive patient is considered a positive tuberculin skin test reaction. (Review topic: Tuberculosis)

The patient is severely dehydrated; therefore he requires immediate intravenous rehydration to prevent hypovolemic shock and to maintain circulation. (Review topic: Cholera)

Iron deficiency anemia is a microcytic, hypochromic anemia and is treated with ferrous sulfate. (Review topic: Iron deficiency)

Stable angina pectoris results when myocardial oxygen demand exceeds oxygen supply. Nitrates, the first-line therapy for acute episodes and they act principally through smooth muscle relaxation and venodilation which causes blood pooling in the peripheral vasculature with a concomitant reduction in preload. Decreased preload decreases cardiac contractility and oxygen demand. View topic

Electrophysiology studies are used to evaluate the excitability of the myocardium and to reproduce the ventricular tachycardia (VT). Catheter ablation can cure VT in 90% of cases in those without structural heart disease. Repeating the ECG when she has no symptoms and documented Holter monitor demonstrates the likely etiology of the syncope. Exercise treadmill test is not indicated as she has had multiple sustained ventricular tachycardia episodes. Transesophageal echocardiography is used most commonly to evaluate the aorta for evidence of dissection, to elucidate evidence of atrial clots, and to assess for evidence of valvular vegetation. (Review topic: Syncope)

Silicosis can occur in sandblasters and produce a CXR appearance of calcification of the hilar nodes with an "eggshell" pattern with long term exposure

This patient has classic symptoms of hematuria, pretibial edema, and hypertension indicative of nephritic syndrome. The history of an untreated sore throat is key to the diagnosis of post-streptococcal glomerulonephritis. He would have a positive ASO titer. (Review topic: Acute and chronic renal failure)

The condition is acromegaly, which often goes undiagnosed for many years. Gigantism and acromegaly are usually caused by a pituitary adenoma that secretes excessive amounts of Growth Hormone (GH); rarely, they are caused by non-pituitary tumors that secrete GHRH. Gigantism occurs if growth hormone hypersecretion begins in childhood, before the closure of the epiphyses Acromegaly involves growth hormone hypersecretion beginning in adulthood; a variety of bony and soft tissue abnormalities develop. Signs and symptoms include bone and soft tissue welling jaw protrusion, an increased spacing of teeth along with forehead and brow protrusion. Joint pain, headache, vision problems, thickened skin, excess sweating, hair growth, and pigmentation. (Review topic: Acromegaly/gigantism)

The patient has end stage renal disease and with the pericardial friction rub is in need of immediate hemodialysis. (Review topic: Acute and chronic renal failure)

Mitral valve regurgitation is defined as an incompetent closure of the mitral valve. Classically patients will present with a pansystolic heart murmur over the mitral area. Posterior myocardial infarction is the second most common cause of mitral valve regurgitation. Mitral valve regurgitation is characterized by an incompetent closure of the mitral valve. This condition causes retrograde blood flow into the left atrium during systole. The most common cause of mitral regurgitation is mitral valve prolapse, followed by a dysfunction of the posteromedial papillary muscle due to posterior myocardial infarction. Other causes may include, endocarditis or stretching of the mitral valve ring.  

The ‘click' of mitral valve prolapse, caused by the tightening of the chordae tendinae, moves closer to S2 with increased preload. Increased preload causes the left ventricle to stretch, as a result, the chordae tendinae are stretched as well. This makes it harder for the mitral valve to prolapse until the ventricles shrink enough to allow the chordae tendinae to let the mitral valve prolapse. Since there is more blood in the ventricles, it takes them longer to pump it out and shrink to a point at which MVP can occur, hence it occurs later in systole. Thus, the click will get closer to S2 with increased preload. Hand grip, rapid squatting, and inspiration all increase preload. Standing decreases preload and will cause an earlier onset of the click.

Acute interstitial nephritis (AIN) is a renal lesion that causes a decline in kidney function and is characterized by an inflammatory infiltrate in the kidney interstitium. Drugs (remembered as the 5 Ps) are the most common cause of AIN. The 5 Ps are Pee (diuretics, especially sulfa ones), Pain-free (NSAIDs), Penicillins and cephalosporins, Proton pump inhibitors, and rifamPin. Patients will present with elevated creatinine, eosinophils, WBC casts, and hematuria. (Review topic: Acute interstitial nephritis)

Renal artery stenosis is characterized by hypertension refractory to treatment with worsening kidney function. ACEIs and angiotensin II receptor blockers can be used for treatment but may lead to acute kidney failure. Thus, renal function must be closely monitored after initiating treatment with one of these agents. (Review topic: Renal vascular disease)

GERD is a common complaint at primary care offices. It classically presents with heartburn, epigastric pain, and a sour taste that occurs within an hour of consuming a meal. PPIs are the initial medical management, except in the case of alarm symptoms. Any patient with symptoms of GERD accompanied by dysphagia, recurrent vomiting, weight loss, hematemesis, anemia, melena, or age > 50 should undergo endoscopy as these are considered high risk for the presence of an upper gastrointestinal malignancy. (Review topic: Gastroesophageal reflux disease)

This patient’s GCS score is 7 (2 + 1 + 4 = 7) (Review topic: Coma)

Simple aspiration by insertion of a needle into the involved side will decompress the tension pneumothorax until a chest tube can be inserted. (Review topic: Pneumothorax)

This patient of reproductive age and ureteropelvic symptoms should be screened for pregnancy in addition to other diagnostic studies (e.g., urinalysis, urine culture, and KOH prep). (Review topic: Urinary tract infection)

Cytomegalovirus (CMV) is the most common viral infection in solid organ transplant recipients. CMV infection usually develops during the first few months post-transplantation and is associated with clinical infectious diseases and acute and/or chronic graft injury and dysfunction. It often presents with fever, fatigue, arthralgias, pneumonia, GI ulcers, and hepatitis. (Review topic: Cytomegalovirus)

If LDL-C is not at goal after 6-12 weeks the next best step for the treatment of familial hypercholesterolemia is to add ezetimibe 10 mg daily and check again in 6-12 weeks. If at that time the patient’s LDL is still not at goal (ideally < 150) refer to lipid specialist to consider adding a PCSK9 inhibitor.

Hemophilia A is the genetic deficiency of factor VIII. The best primary treatment for this condition is replacement with recombinant factor VIII, which reduces exposure to blood products. (Review topic: Clotting factor disorders)

Endoscopic intestinal mucosal biopsy of the proximal duodenum (bulb) and distal duodenum is the standard method for confirmation of the diagnosis in patients with a positive serologic test (IgA endomysial antibody) for celiac disease

Multiple myeloma is a monoclonal plasma cell cancer that arises in the bone marrow. It often leads to numerous lytic bone lesions, as well as anemia, thrombocytopenia, hypercalcemia, and renal insufficiency. (Review topic: Multiple myeloma)

Cisapride is a prokinetic agent. It’s not used in the treatment of anal fissure.

This patient has signs and symptoms consistent with bronchiectasis including CXR findings of dilated and thickened bronchi that may appear as tram-tracks or as ring-like markings.

The patient in this vignette has both Cushing syndrome (hypercortisolism) and Cushing disease (hypercortisolism due to a pituitary adenoma). Symptoms of hypercortisolism include muscle breakdown, striae, hyperglycemia, hypertension, moon-facies, and a buffalo hump. (Review topic: Cushing disease)

The most likely diagnosis in this patient is polymyositis. This is supported by the finding of a gradual progressive proximal muscle weakness and elevation of creatinine phosphokinase level. The finding of lymphoid inflammatory infiltrates on muscle biopsy confirms the diagnosis. Initial treatment of choice in this condition is the use of a corticosteroid (prednisone). Patients who do not respond to prednisone may then benefit from the use of methotrexate or azathioprine. Both intravenous immune globulin and hydroxychloroquine are effective for the treatment of patients with dermatomyositis that is resistant to prednisone therapy. (Review topic: Polymyositis)

In addition to smoking cessation, patients with COPD may benefit from vaccination against both influenza and pneumococcal disease. (Review topic: COPD)

Sickle cell disease can lead to avascular necrosis, most frequently involving the acetabulum, head of the femur, and head of the humerus. Patients will report pain with different characteristics than the one associated with their sickle cell crises, which should raise concern. (Review topic: Sickle cell anemia)

Chronic hypertension in pregnancy can be treated with some medications and labetalol is recommended as a first-line therapy for treatment of hypertension during pregnancy. Angiotensin-converting enzymes (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should be avoided.

Diphtheria spreads by direct or droplet infection. Clinical manifestations include sore throat, low-grade fever, and a grayish-white pseudomembrane on the posterior pharynx. (Review topic: Diphtheria)

Hypercalcemia (greater than 10.5 mg/dL) is the hallmark of primary hyperparathyroidism. (Review topic: Hyperparathyroidism)

IV fluids are the first treatment for diabetic ketoacidosis, as these patients typically present with a 5-10% volume deficit. Intravenous fluid can also help to correct the acidemia and hyperglycemia before insulin therapy is initiated

Shigella is a gram-negative bacteria that causes watery diarrhea or dysentery (the frequent and often painful passage of small amounts of stool that contains blood, pus, and mucus). The illness starts abruptly with diarrhea, lower abdominal cramps, and tenesmus accompanied by fever, chills, anorexia, headache, and malaise Stools are loose and mixed with blood and mucus. The abdomen is tender; dehydration is common. Transmission is via direct person-to-person contact and contaminated foods and water. The stool is positive for leukocytes and red blood cells; culture yields Shigella spp. (Review topic: Shigellosis)

Small cell lung cancer is very aggressive with a median survival (untreated) of 6-18 weeks.

This patient has acute pancreatitis can be associated with significant morbidity and mortality. It ranges from mild to severe depending on the degree of organ dysfunction. An elevated leukocyte count is a poor prognostic factor in acute pancreatitis. There are several prognostic scoring systems available to predict the risk of mortality in patients with acute pancreatitis. The Ranson criteria is a well-known scoring system. The APACHE II Scoring System is cited by Medscape as being the best validated. These systems use various combinations of clinical and biochemical data. Although necessary for diagnosis, serum amylase, and lipase concentrations do not correlate with the severity of pancreatitis. (Review topic: Acute/chronic pancreatitis)

When at least 2 patients are ill within 72 hours of each other and at least one resident has laboratory-confirmed influenza, the facility should promptly initiate antiviral chemoprophylaxis with oral oseltamivir to all non-ill residents living on the same unit as the resident with laboratory-confirmed influenza (outbreak affected units), regardless of whether they received influenza vaccination during the current season. Consideration may be given for extending antiviral chemoprophylaxis to residents on other unaffected units or wards in the long-term care facility based upon other factors (e.g. unavoidable mixing of residents or healthcare personnel from affected units and unaffected units). Oseltamivir is the recommended antiviral drug for chemoprophylaxis of influenza in long-term care settings. Baloxavir is not approved for chemoprophylaxis of influenza and is not recommended for chemoprophylaxis of influenza in long term care facility residents. Amantadine and rimantadine are NOT recommended for use because of high levels of antiviral resistance to these drugs among circulating influenza A viruses. (Review topic: Influenza )

Acute bronchitis is defined by a cough that persists for more than five days. The most common cause of acute bronchitis is a viral infection (90% of cases). Therefore, supportive therapy such as increased fluids (cough results in increased fluid loss) and ibuprofen (antipyretic) is the most appropriate approach.

This patient most likely has autosomal dominant polycystic kidney disease (ADPKD) given his bilateral flank masses/pain, hypertension, and hematuria. Ultrasound is the best method to screen family members of patients with ADPKD to see if they are affected. (Review topic: Polycystic kidney disease)

Peripheral vascular disease with intermittent claudication and signs of decreased perfusion should be examined using Doppler ultrasound and the ankle-brachial index (ABI). An ABI of <0.41 is grounds for the immediate surgical consultation.

TMP-SMX is the drug of choice for all forms of pneumocystis. Prophylaxis is provided for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection. Daily Bactrim is the prophylaxis antibiotic of choice.

The PH is low so you know it is acidosis and the PCO2 is not normal, in this case it is high so you know it has a RESPIRATORY cause. This is Respiratory acidosis. (Review topic: Acid/base disorders)

Diverticulitis presents with left lower quadrant abdominal pain, systemic symptoms (such as fever), nausea, vomiting, and leukocytosis on lab values. It typically occurs in a patient with a history of diverticulosis. The most accurate test for diverticulitis is a CT scan. Colonoscopy is contraindicated as it could cause rupture. Further management is keeping the patient NPO and administering ciprofloxacin, metronidazole, and IV fluids. Patients who can not tolerate oral antibiotics should be started on IV antibiotics. (Review topic: Diverticular disease)

Testicular torsion occurs in the 10-20 year age group and is characterized by acute onset of severe pain and swelling of the testis. Physical examination will reveal a tender high-riding testis. (Review topic: Testicular torsion)

This person has increasing respiratory failure as indicated by the raising PaCO2 levels. Intubation is required at this time.

Clostridium difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C. difficile, and the release of toxins that cause mucosal inflammation. Antibiotic therapy is the key factor that alters the colonic flora. (Review topic: Gastroenteritis)

Myocarditis in the United States is most commonly caused by a viral infection, typically adenovirus, coxsackie B, parvovirus B19, or others. It often presents with systemic symptoms such as fatigue and chest pain, but may cause sudden death. (Review topic: Myocarditis)

Candidal esophagitis is a condition most commonly seen in the immunocompromised and those with esophageal motility disorders. Diagnosis of Candida esophagitis is made by demonstration of yeast or hyphal forms in plaque smears and exudate stained with periodic acid– Schiff or Gomori silver stains. The characteristic endoscopic finding is diffuse, linear, yellow-white plaques adherent to the mucosa. (Review topic: Esophagitis)

The diagnosis of IBS can reasonably be made using the Rome criteria as long as patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology. Patients with one of these red flag findings require further imaging studies and/or colonoscopy. (Review topic: Irritable bowel syndrome)

Mycobacterium avium complex (MAC) should be considered in HIV positive patients with CD4 counts <50 presenting with cough, fever, right upper quadrant abdominal pain, fatigue, and weight loss. (Review topic: HIV infection)

This patient’s presentation with headache, palpitations, warm skin, hyperhidrosis, tachycardia, hyperreflexia, and a high-frequency tremor in the setting of an elevated TSH and free T4 concentration is indicative of a TSH-secreting pituitary adenoma. The next step in management is an MRI of the pituitary with gadolinium to evaluate for the presence of an adenoma. (Review topic: Pituitary adenoma)

Rheumatoid arthritis's early signs include soft tissue swelling, osteopenia, erosions, and joint space narrowing. Later changes include subluxation causing ulnar deviation, z- thumb, boutonniere, and swan neck deformities, and ankylosis. (Review topic: Rheumatoid arthritis)

This patient has Crohn’s disease which is characterized by a transmural inflammation of the GI tract. It may affect any part of the GI tract but is usually associated with the terminal ileum, the colon, or both. On colonoscopy, areas of ulceration and submucosal thickening give the bowel a cobblestone appearance, with some skipped areas of normal bowel. In addition to the transmural inflammation, there are granulomas, abscesses, fissures, and fistula formation. Symptoms include fever, weight loss, abdominal pain (usually the right-lower quadrant), diarrhea (rarely with associated blood), and growth retardation in children. Complications include intestinal obstruction; toxic megacolon, which is usually more common in ulcerative colitis; malabsorption, particularly associated with fat-soluble vitamins and especially vitamin B12; intestinal perforation; fistula formation; and development of gall and kidney stones. (Review topic: Crohn disease)

The diagnostic procedure of choice in this patient is abdominal ultrasonography. Gallstones will be demonstrated in approximately 95% of cases, and the specificity of the procedure is high. Ultrasound examination should be done after 8 hours of fasting because gallstones are visualized better in a distended, bile-filled gallbladder. Ultrasound findings that suggest acute cholecystitis are pericholecystic fluid, gallbladder thickening, and sonographic Murphy sign. CT scan and MRI is more sensitive in diagnosis of choledocholithiasis; however, they are expensive and offer no more sensitivity in the diagnosis of gallstones or acute cholecystitis. The HIDA scan is expensive and reserved for cases in which the ultrasound study or CT scan is nondiagnostic but there is a high suspicion of cholecystitis.

This patient of reproductive age and ureteropelvic symptoms should be screened for pregnancy in addition to other diagnostic studies (e.g., urinalysis, urine culture, and KOH prep). (Review topic: Urinary tract infection)

The additive effect of sildenafil on nitrates can amplify cardiac preload reduction and hypotension. Sildenafil is contraindicated in patients taking nitrates. (Review topic: Erectile dysfunction)

Rabies virus is part of the Rhabdoviridae family, a zoonosis of certain mammal species and endemic in all continents. Infection usually results from inoculation of virus in an animal's saliva through the skin or onto mucous membranes. The virus spreads via peripheral nerves to the central nervous system. The time between inoculation and the onset of symptoms is usually between 20-90 days (the nearer the bite to the head, the shorter the incubation period). The prodromal symptoms are fever, headache, myalgia, fatigue, sore throat, irritability, anxiety, and insomnia. The disease progresses to either furious or paralytic rabies encephalitis, usually within a week. Furious rabies is the most common type with symptoms of hydrophobia, aerophobia, contraction of the facial muscles, opisthotonos, autonomic instability, dysarthria, dysphagia, agitation, and combativeness. The other form is paralytic rabies where the patient develops a flaccid paralysis, more prominent in the bitten limb. There is no treatment for rabies, but the Milwaukee protocol can be followed. (Review topic: Rabies)

This patient is suffering from megaloblastic anemia secondary to folic acid deficiency. Medications commonly associated with this condition include methotrexate, phenytoin, and trimethoprim. Folic acid deficiency leads to a decreased production of DNA synthesis, resulting in megaloblastic anemia. Folic acid deficiency differs from vitamin B12 deficiency in 2 ways: 1) Neurologic symptoms (demyelination and subacute combined degeneration of the spinal cord) are seen with vitamin B12 deficiency but not with pure folate deficiency; 2) Folic acid deficiency is associated with normal serum methylmalonic acid (MMA) and increased homocysteine, whereas vitamin B12 deficiency leads to increases in both MMA and homocysteine. It is important to always obtain a TSH level to rule out hypothyroidism in the setting of megaloblastic anemia. Additionally, folic acid levels are of particular importance in pregnant patients, who have a higher folic acid requirement; low folic acid during pregnancy can lead to fetal neural tube defects. (Review topic: Folic acid deficiency anemia)

Involvement of the tip of the nose with herpes virus is known as Hutchinson’s sign. It is suggestive of involvement of the cornea with herpes and urgent referral to an ophthalmologist is recommended. The patient has shingles (herpes zoster) which follows dermatomes and is generally unilateral. Involvement of the tip of the nose or lid margins should lead one to suspect corneal involvement. (Review topic: Varicella zoster)

The next best step in the management of this patient is to infuse 5% dextrose solution as it is the fluid of choice in treating hypernatremia that has been symptomatic for >48hr. It is important to ensure a gradual decline in serum sodium. Ideally, aim for a rate less than 10 mEq/L /day (about .4mEq/L/h). Decreasing serum sodium too quickly increases the risk of cerebral edema. (Review topic: Hypernatremia)

Acute myelogenous leukemia (AML) is a leukemia that presents in adults with a cell lineage of the immature granulocytic cells seen in the peripheral blood e.g. myeloblasts, promyelocytes. Auer rods are commonly seen in this condition. (Review topic: Acute/chronic leukemia)

Essential tremor is the most common movement disorder. This postural tremor may have its onset anywhere between the second and sixth decades of life, and its prevalence increases with age. It is slowly progressive over a period of years. An essential tremor is characterized by a rapid, fine tremor that is made worse with sustained positions. The frequency of essential tremor is 4 to 11 Hz, depending on which body segment is affected. Proximal segments are affected at lower frequencies, and distal segments are affected at higher frequencies. Although typically a postural tremor, essential tremor may occur at rest in severe and very advanced cases. It most commonly affects the hands but can also affect the head, voice, tongue, and legs. It usually affects patients older than 50 years. The tremor may be intensified by stress, anxiety, excessive fatigue, drugs (e.g., caffeine, alcohol withdrawal, steroids), or thyroid disorders. In many cases, the patient may report relief with alcohol use and a positive family history of tremors. Senile tremors tend to increase with age. Parkinson’s disease is differentiated by the presence of a pill-rolling tremor at rest, masked face, bradykinesias, and rigidity. Parkinson’s also shows a favorable response to the administration of L-dopamine and does not improve with the use of alcohol. Treatment of essential tremors involves the treatment of the underlying disorder and the use of propranolol (Inderal), or primidone (Mysoline). Primidone may be preferred because of the exercise intolerance associated with the high-dose β-blockers. Some data suggest antiseizure agents (topiramate, gabapentin) have efficacy. Patients who have a very-low-amplitude rapid tremor are generally more responsive to these agents than those who have a slower tremor with greater amplitude. Patients who have a tremor of the head and voice may also be more resistant to treatment than do patients with an essential tremor of the hands. In severe cases, surgery may be considered. (Review topic: Essential tremor)

Cirrhosis of the liver can cause elevated circulating estrogens, leading to features such as palmar erythema, gynecomastia, spider angiomas, and testicular atrophy. (Review topic: Cirrhosis)

The diagnostic procedure of choice in this patient is a total colonoscopy to confirm a mass lesion, to determine the location of that lesion, and to obtain a biopsy specimen of the lesion if possible. (Review topic: Cancer of rectum, colon, esophagus, stomach)

An asymptomatic patient of Mediterranean origin presenting with isolated, microcytic anemia is most likely due to beta thalassemia minor. This patient would present with increased levels of hemoglobin A on gel electrophoresis. (Review topic: Thalassemia)

This patient has a right ventricular myocardial infarction leading to right-sided heart failure, which explains the increase in the jugular venous pressure. The external jugular vein pulsation should normally be <3 cm vertical height above the sternal angle.

This patient presents with H. pylori gastritis complicated by a peptic ulcer. Treatment for H. pylori is with triple or quadruple therapy. Omeprazole, metronidazole, tetracycline, and bismuth are appropriate quadruple therapy. (Review topic: Esophagitis)

This patient has nephrogenic diabetes insipidus. This has resulted from the lack of renal response to antidiuretic hormone (ADH); in this case, the diabetes insipidus is of the nephrogenic subtype and caused by the drug lithium carbonate. Typically the first step is to discontinue the offending drug, however at this point discontinuing lithium is not acceptable to the patient based on her difficulty with managing her mood disorder. As a result, thiazide diuretics are the most appropriate next step because they are the first-line pharmacological therapy for nephrogenic diabetes insipidus. By causing volume depletion through sodium and chloride loss in the distal renal tubule, thiazides can significantly decrease urine loss. This is caused by inducing greater reabsorption of sodium and water in the proximal convoluted tubule in physiologic response to a transient thiazide -induced hypovolemia. (Review topic: Diabetes insipidus)

The PH is high which means this is an alkalosis, the PCO2 is normal so it's not respiratory and the bicarb (HCO3) is high so you know it is metabolic. This is METABOLIC ALKALOSIS. (Review topic: Acid/base disorders)

This patient most likely has Graves' disease. The thyroid studies would demonstrate elevated levels of T4, free T4, and T3 with a decrease in TSH. (Review topic: Hyperthyroidism)

Encephalitis may present similar to meningitis but the key differentiator is altered mental status. In meningitis there will be no altered mental status (at least on your exam). (Review topic: Encephalitis)

Clostridium tetani infection is a vaccine-preventable disease that results in approximately 50 cases per year in the United States. Even with modern medical resources, 20% to 25% of patients with generalized tetanus die. Treatment includes airway protection, benzodiazepines for muscle spasm, tetanus immune globulin immediately, and three doses of tetanus toxoid given by the standard schedule. Metronidazole or penicillin is also administered to destroy the organism and prevent toxin production. (Review topic: Tetanus)

Anemia of chronic disease is associated with chronic renal failure. (Review topic: Acute and chronic renal failure)

The patient presents with a deep venous thrombosis (DVT) given her swollen and tender lower extremity. The most common inherited form of hypercoagulability is factor V Leiden. It is caused by a mutation in factor V which prevents it from being inactivated by protein C. This leads to unregulated prothrombin activation and an increase in thrombotic events. Epidemiologically, factor V Leiden is the most common heritable cause of a hypercoagulable state. Patients who have presented with multiple DVTs or pulmonary embolisms may require lifelong anticoagulation. (Review topic: Hypercoagulable state)

This clinical presentation is consistent with thrombotic thrombocytopenic purpura (TTP), which is associated with a pentad of signs and symptoms including fever, microangiopathic hemolytic anemia, thrombocytopenia (with associated petechiae), renal dysfunction, and neurological or mental status changes. Physical exam demonstrates petechiae, a result of thrombocytopenia, and his peripheral blood smear is positive for schistocytes (RBC fragments), which are seen in microangiopathic hemolytic anemias such as TTP. (Review topic: Thrombotic thrombocytopenic purpura)

Complex regional pain syndrome (CRPS) is defined as a disorder of the extremities characterized by regional pain that is disproportionate in time or degree to the usual course of any known trauma or other lesion. The pain is not restricted to a specific nerve territory or dermatome and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings. For patients with early CRPS who require treatment for pain, one (or more) of the following agents is appropriate: NSAIDs (Ibuprofen or Naproxen), sn adjunctive medication for neuropathic pain (such as gabapentin, amitriptyline, or nortriptyline), topical lidocaine cream (2 to 5 percent) or topical capsaicin cream 0.075 percent, and a short-term bisphosphonate course for patients with early CRPS who have pain and abnormal uptake on bone scan.

Parkinson's disease results from a depletion of dopamine in neurons located in the substantia nigra pars compacta and results in characteristic movement disorders of pill-rolling tremor, bradykinesia, gait instability, and rigidity. Dementia may develop as the disease progresses. Histologically, Parkinson's disease features Lewy bodies: intraneuronal aggregates of alpha-synuclein. (Review topic: Parkinson disease)

Features of delirium include a fluctuating level of consciousness, the presence of hallucinations, disorientation, and abnormal vital signs. Delirium involves a waxing and waning course and is caused by reversible entities such as infections, medications, postoperative periods, alcoholism, electrolyte imbalances, and other medical conditions. In dementia, the level of consciousness is usually preserved. There are usually no hallucinations or abnormal vital signs. The course is usually insidious and progressive, and symptoms are typically reversible. This patient is exhibiting signs and symptoms of delirium, and therefore, hallucinations are the most likely to be present because all the other choices are features of dementia. (Review topic: Delirium)

Bell's palsy, referring to an idiopathic cranial nerve VII palsy, should be suspected in patients who present with unilateral drooping of the mouth and inability to wrinkle the brow. (Review topic: Bell's palsy)

Patients with community-acquired pneumonia who require hospitalization on the general medical ward are treated with an extended-spectrum beta-lactam antibiotic, such as ceftriaxone, with a macrolide, such as azithromycin. The addition of a macrolide is also recommended due to the patient's smoking history and the possible involvement of Haemophilus influenzae.

Electrocardiogram is the gold standard for diagnosing myocardial infarction within the first 6 hours of symptom onset. Electrocardiogram changes will include ST-segment elevation (signifying transmural infarct), ST-segment depression (signifying subendocardial infarct), and Q waves (signifying transmural infarct).

Persistently low platelet counts (less than 20,000) require effective long-term treatment, and splenectomy is the treatment of choice. (Review topic: Idiopathic thrombocytopenic purpura )

Sjögren syndrome is an autoimmune disorder that commonly presents with dryness of the eyes, mouth, and other areas of the body covered by mucous membrane. Because of the chronic dysfunction of the exocrine glands and the chronicity of dryness of the eyes and the mouth, patients should be counseled to avoid decongestants and atropine drugs. The use of these medications can further exacerbate their symptoms. Penicillins, antihistamines, corticosteroids, and fluoroquinolones are not directly associated with encouraging exocrine dysfunction. (Review topic: Sjögren syndrome)

Patients with all of these conditions may be diaphoretic and complaining of dyspnea. Marked hypotension in acute coronary syndrome occurs when the right coronary artery is affected. Acute coronary syndromes do not usually present with systolic murmurs, but patients will complain of angina and the ECG changes will include ST-segment changes. Patients who have severe heart failure will have similar symptoms but also have pulsus alternans and pulmonary rales. Finally, patients with pulmonary embolus may have hemodynamic changes but usually have a low PaO2 and a normal PaCO2. ECG may show right-axis deviation in a pulmonary embolus as well.

Tonic-clonic seizures comprise two phases, the tonic phase, and the clonic phase. During the tonic phase, the patient will quickly lose consciousness, and the skeletal muscles will suddenly tense. Next, during the clonic phase, the patient's muscles will start to contract and relax rapidly, causing convulsions. (Review topic: Seizure disorders)

This patient is presenting with signs and symptoms consistent with complicated acute pyelonephritis. The next best step in management, whether complicated or uncomplicated pyelonephritis, is to obtain a urine analysis and urine culture. (Review topic: Pyelonephritis)

Primary syphilis is characterized by Chancre (painless superficial ulcer with a clean base and firm, indurated margins) and regional lymphadenopathy. (Review topic: Syphilis)

This patient's presentation is consistent with a varicocele. Right-sided varicocele, bilateral varicocele, and failure of a varicocele to disappear upon lying supine are signs suggestive of inferior vena cava (IVC) obstruction and warrant further investigation with a CT scan of the abdomen. (Review topic: Varicocele)

Esophageal cancer occurs in the elderly population. Presents as dysphagia initially to solids then weeks later to liquid. Prolonged histories of tobacco use, and alcohol ingestion are strong risk factors for esophageal cancer. (Review topic: Cancer of rectum, colon, esophagus, stomach)

Toxoplasmosis occurs commonly in the immunocompromised (AIDS) and presents with symptoms of encephalitis etc. Brain imaging CT Scan/MRI) usually shows multiple ring-enhancing lesions. Pyrimethamine plus sulfadiazine is the standard therapy for the treatment of toxoplasmosis. (Review topic: Toxoplasmosis)

A clinical diagnosis of polyarteritis nodosa (PAN) is suspected based upon the presence of characteristic symptoms, physical findings, and compatible laboratory test results. However, because of the relative rarity of this disease and the potentially severe adverse effects related to treatment, the diagnosis should be confirmed by biopsy whenever possible. In the absence of an obvious site for biopsy, angiography sometimes reveals microaneurysms of blood vessels in the renal, hepatic, or mesenteric circulations. (Review topic: Polyarteritis nodosa)

The correct answer is dilated cardiomyopathy. Left ventricular dilation (as seen in the radiograph) and systolic dysfunction (shortness of breath, murmur) must be present for diagnosis. Most cases are idiopathic. The two most common causes of secondary dilated cardiomyopathy are ischemia and long-standing hypertension. An S3 gallop signifies the end of rapid ventricular filling in the setting of fluid overload and is often associated with dilated cardiomyopathy. (Review topic: Cardiomyopathy)

The most abundant plasma protein found in the human fetus is alpha-fetoprotein (AFP). AFP is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP in both the bloodstream and in the amniotic fluid. In adults, high blood levels (over 500 nanograms/milliliter [or ng/ml]) of AFP are seen in hepatocellular carcinoma. (Review topic: Hepatic cancer)

This patient has Raynaud phenomenon secondary to limited scleroderma. Treatment involves stress management and cold avoidance. Calcium channel blockers (CCB), such as oral nifedipine or amlodipine, are the first-line option. Topical nitrates and phosphodiesterase type 5 inhibitors (e.g. sildenafil) can be used in patients with contraindications to CCBs or who have failed prior CCB treatment. (Review topic: Systemic sclerosis)

The patient has carcinoid syndrome, a disease which features a neuroendocrine cell tumor which secretes a large amount of serotonin in an episodic manner. Many neuroendocrine tumors originate in the GI tract and release their active products into the portal venous system. Serotonin is metabolized by the liver before they reach the systemic circulation. Thus, patients usually remain asymptomatic until the tumors metastasize to the liver, allowing their vasoactive products to bypass hepatic metabolism. Serotonin causes the patient's symptoms of flushing, wheezing, diarrhea, and hypotension. In addition, carcinoid syndrome patients often have right-sided heart valve defects, most commonly tricuspid regurgitation. Symptoms of carcinoid syndrome can be memorized using the mnemonic FDR (flushing, diarrhea, and right-sided heart valves).

Hypertension in the setting of diabetes should be treated, with a goal systolic blood pressure of <130 mm Hg. The best first choice of medication is an angiotensin-converting enzyme inhibitor (ACEi).

Infective endocarditis (IE) is an infection of the endocardial surfaces of the heart, most commonly the heart valves. IE occurs when a microorganism begins to invade the heart valves causing an inflammatory reaction that damages the valve - sometimes leading to stenosis and sometimes leading to regurgitation. This patient developed a new cardiac murmur in recent weeks that is described as a faint systolic murmur heard over the lower left sternal border. This is most consistent with tricuspid regurgitation. She also has distended neck veins and hepatomegaly, both of which suggest right-sided heart failure which can result from tricuspid regurgitation. Small infectious emboli can break away from the primary lesion on the tricuspid valve and go into the pulmonary vasculature causing shortness of breath and pleuritic chest pain. Most cases of IE are caused by Staphylococcus aureus and Viridans streptococci, and diagnosis is confirmed by obtaining multiple blood cultures that show that there is continuous bacteremia.

Vitamin B12 deficiency can cause megaloblastic anemia and peripheral neuropathy. Patients with a vegan diet are prone to vitamin B12 deficiency as it can only be obtained through animal sources. (Review topic: Vitamin B12 deficiency )

Heart failure with reduced ejection fraction is typically characterized by dyspnea, orthopnea, and peripheral edema. Medications that have been demonstrated to reduce mortality are angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), β-blockers, spironolactone, and hydralazine (in African American patients).

Primary adrenal insufficiency commonly presents with shock, and symptoms are consistent with decreased aldosterone levels. Pertinent laboratory values include hypoglycemia, hyperkalemia, and metabolic acidosis. Proper diagnosis includes confirmation of low levels of cortisol and aldosterone levels in the early morning (typically around 6 AM) when they should be at their highest. Additional testing could include a cosyntropin stimulation test, which involves administering a dose of cosyntropin, a synthetic form of ACTH. Cortisol levels are measured when the cosyntropin is given, 30 minutes after administration, and sometimes 60 minutes after administration. An increase of less than 9 μg/dL after cosyntropin administration indicates primary adrenal insufficiency, while higher levels would suggest secondary adrenal insufficiency. A dexamethasone suppression test is used with patients who have elevated cortisol. Dexamethasone suppresses ACTH production, which then suppresses cortisol production. As cortisol increases vascular tone, the patient's hypotension should indicate low cortisol levels. Further suppressing them would not yield additional diagnostic insight. (Review topic: Addison’s disease)

Salmonella infection presents with bloody diarrhea, abdominal pain, vomiting, and headache. Poultry and eggs are the vehicles of infection. It is estimated that 1 in 10,000 egg yolks is infected with Salmonella enteritidis. (Review topic: Salmonellosis)

PSA measurement correlates well with volume and stage of disease and is the recommended examination for monitoring disease progression. It is recommended that serial PSA testing be performed no more often than every six months and repeat digital rectal examination (DRE) no more often than every 12 months unless clinically indicated. (Review topic: Prostate cancer)

Hashimoto thyroiditis is the result of an autoimmune-mediated lymphocytic inflammation and destruction of the thyroid tissue. Diagnosis is based on thyroid function tests, as well as the presence of certain antibodies, such as anti-thyroid peroxidase (anti- microsomal) and anti-thyroglobulin. (Review topic: Hypothyroidism)

The cerebrospinal fluid of a patient with bacterial meningitis will exhibit a high leukocyte count, high protein concentrations, and reduced glucose concentrations compared with serum glucose content. (Review topic: Meningitis)

Rocky Mountain spotted fever (RMSF) is a tick-borne febrile illness characterized by a maculopapular rash starting on the extremities, involving the soles and palms, and progressing to the trunk. Doxycycline is the agent of choice for the treatment of RMSF. Doxycycline is used in treating Rocky Mountain spotted fever. All others are not used in treating Rocky Mountain spotted fever. (Review topic: Rocky Mountain spotted fever)

The patient most likely has vulvovaginal candidiasis which is usually characterized by whitish, curdy vaginal discharge, vaginal pH <4.5, and presence of yeast cells, hyphae or pseudohyphae on wet mount with 10% KOH. Oral fluconazole is the appropriate for vulvovaginal candidiasis. (Review topic: Candidiasis)

This patient presents with possible lymphoma. Diagnosis is made by lymph node biopsy. Bone marrow biopsy and CT scan of the chest are used for staging of the disease. (Review topic: Lymphoma)

Myasthenia gravis is often diagnosed using the Tensilon test. However, it is most definitively diagnosed with single fiber electromyography which shows a decremental response to motor nerve stimulation. (Review topic: Myasthenia gravis)

In the absence of old x-rays in a nonsmoking individual less than 35 years old, CT scan of the chest is the next step in the evaluation of a solitary pulmonary nodule.

Sarcoidosis is most common in African Americans. Typical radiographic features include bilateral hilar lymphadenopathy. Also, ACE levels are elevated in as many as 50-60% of patients. (Review topic: Sarcoidosis)

A high PH means this is alkalosis. Next look at the PCO2 it is not normal and is low. Therefore this is a RESPIRATORY ALKALOSIS. (Review topic: Acid/base disorders)

All SSRIs and SNRIs, as classes, can cause hyponatremia. The mechanism of action is believed to be syndrome of inappropriate antidiuretic hormone (SIADH). The hyponatremia can be profound with an incidence of 9% of all SSRIs prescribed with a higher incidence of hyponatremia in the elderly and those with compromised kidney function. (Review topic: Hyponatremia)

Anemia of chronic disease is characterized by anemia in the setting of a chronic illness such as systemic lupus erythematosus and rheumatoid arthritis. Lab values will show decreased serum iron levels, decreased total iron-binding capacity, and increased ferritin. (Review topic: Anemia of chronic disease)

Guillain-Barre syndrome is typified by progressive symmetrical, distal to proximal spread of weakness, and areflexia without fever or sensory deficits. CSF analysis shows elevated protein due to axonal demyelination but no glucose disturbances and no significant or sustained pleocytosis. (Review topic: Guillain-Barré syndrome)

This patient has nephrogenic diabetes insipidus. This has resulted from the lack of renal response to antidiuretic hormone (ADH); in this case, the diabetes insipidus is of the nephrogenic subtype and caused by the drug lithium carbonate. Therefore the urine will have low specific gravity, low osmolality, high plasma osmolality, and high serum sodium. (Review topic: Diabetes insipidus)

When testing is indicated, a two-tier conditional strategy should be used to support the diagnosis of Lyme disease. Serologic testing has traditionally been performed using an initial enzyme-linked immunosorbent immunoassay (ELISA) or immunofluorescence assay, followed by a Western blot. (Review topic: Lyme disease)

Esophageal varices occur as a result of portal hypertension due to chronic liver disease. History of prolonged excessive alcohol ingestion is a risk factor for alcoholic liver cirrhosis which is a chronic liver disease. When they hemorrhage, treatment focuses on hemostasis, replacing lost blood volume, and prevention of complications. (Review topic: Esophageal varices)

Dysphagia to solids that is only gradually progressive is suggestive of an esophageal stricture, which may be related to acid reflux, radiation therapy, or eosinophilic esophagus. GERD accounts for approximately 70-80% of all cases of esophageal stricture. (Review topic: Esophageal strictures)

Hypocalcemia is defined as a decrease in total plasma calcium concentration < 8.8 mg per dL in the presence of normal plasma protein concentration. Causes include hypoparathyroidism, vitamin D deficiency, renal tubular disease, magnesium depletion, acute pancreatitis, hypoproteinemia, septic shock, hyperphosphatemia, and drugs, including phenytoin, phenobarbital, and rifampin. Most patients are asymptomatic. Symptoms, when present, include muscle cramps involving the legs and back, mental status changes, dry skin, depression, and psychosis. Papilledema may occasionally occur, and cataracts may develop after prolonged hypocalcemia. Severe hypocalcemia (< 7 mg per dL) may cause tetany, laryngospasm, or generalized seizures. With hypocalcemia giving rise to latent tetany, the patient may exhibit a positive Chvostek’s sign (involuntary twitching of the facial muscles caused by a light tapping of the facial nerve just anterior to the exterior auditory meatus) or a positive Trousseau’s sign (carpopedal spasm caused by reduction of the blood supply to the hand with a blood pressure cuff inflated to 20 mm Hg above the systolic BP applied to the forearm after 3 minutes). (Review topic: Hypoparathyroidism)

Hydronephrosis, dilation of the collecting ducts, may be present due to a stone or other source of obstruction. (Review topic: Hydronephrosis)

Selected antinuclear antibodies (ANAs), including anti-double-stranded deoxyribonucleic acid (dsDNA) and anti-Sm, are highly specific for the diagnosis of systemic lupus erythematosus (SLE). The ANA test is positive in virtually all patients with SLE at some time in the course of their disease. If the ANA is positive, one should test for other specific antibodies, such as anti-dsDNA, anti-Smith (anti-Sm), Ro/SSA, La/SSB, and U1 ribonucleoprotein (RNP). (Review topic: Systemic lupus erythematosus)

Cluster headaches are a neurological disorder characterized by severe, recurrent headaches that are focused on one side of the head, typically around the eye. Recommended primary prevention is verapamil. Inhalation of 100% oxygen at 6–12 L/min for 15 minutes via a nonrebreathing mask provides relief within 15 minutes but it does not help prevent future episodes. Subcutaneous sumatriptan (6 mg) is beneficial (ie, pain-free within 20 minutes) in about 75 percent of patients. (Review topic: Cluster headaches)

This patient presents with blurry vision and vertical diplopia after prodromal gastrointestinal symptoms following ingestion of home-canned foods, most consistent with foodborne botulism. The underlying mechanism is decreased acetylcholine release in the presynaptic terminal of the motor neuron. (Review topic: Botulism)

Chronic lymphocytic leukemia presents with a WBC count greater than 20,000/microliter and an absolute lymphocyte count of greater than 5000/microliter. (Review topic: Acute/chronic leukemia)

Hepatomegaly is not a component of Charcot’s triad which consists of Fever + Jaundice + Right upper abdominal pain. The full triad present in only 70% of cases. Reynolds' pentad, which occurs in severe suppurative cholangitis consists of Charcot's triad plus altered mental status and hypotension.

This patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency is experiencing an episode of hemolysis triggered by drug exposure (glipizide, a sulfonylurea). (Review topic: G6PD deficiency)

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 49-year-old with a cold nodule and follicular architecture is suspicious for follicular adenoma or adenocarcinoma. Surgical excision is necessary to determine whether the neoplasm exhibits signs of capsular or vascular invasion for this determination. (Review topic: Thyroid cancer)

Calcium pyrophosphate deposition (CPPD), more commonly known as pseudogout, commonly presents as sudden onset, severe pain of a joint, much like gout. However, aspiration of the synovial fluid in pseudogout demonstrates rhomboid-shaped, weakly positively birefringent crystals. The pathogenesis of CPPD is similar to that of gout. Calcium pyrophosphate crystals cause joint synovial cells to secrete proinflammatory cytokines such as IL-1, which recruits neutrophils and macrophages, further promoting the inflammatory process. Colchicine is an inhibitor of microtubule assembly. It is therefore hypothesized that the drug inhibits crystal endocytosis and/or presentation to intracellular inflammasomes, which helps prevent the propagation of the inflammation process. Daily, low-dose colchicine, therefore, will help reduce future episodes of pseudogout attacks. (Review topic: Pseudogout)

A resident of Ohio River Valley with pulmonary symptoms and radiographic features would most likely have histoplasmosis as it is endemic in this area. All other options can present with similar symptoms but are not endemic in this region. Histoplasmosis is an AIDS-defining illness, associated with soil containing birds and bat droppings. A CD4+ cell count of < 150 cells/mm3 is associated with opportunistic Histoplasma capsulatum infections in HIV patients. Coccidioidomycosis is endemic in California’s San Joaquin Valley and southern parts of Arizona, Utah, and Nevada. (Review topic: Histoplasmosis)

Huntington's disease is an Inherited autosomal dominant neurodegenerative disease characterized by a clinical triad that includes progressive dementia, chorea, and a pattern of inheritance. The disease is caused by excessive dopamine signaling due to the degeneration of inhibitory neurons in the striatum of the basal ganglia. It is believed that this excessive dopaminergic activity causes the chorea seen in Huntington disease patients, so they are typically treated with drugs that either decrease monoamine levels or block dopamine receptors. Tetrabenazine was the first drug approved for the management of Huntington's disease in the US; it manages chorea and is believed to reversibly decrease levels of dopamine, serotonin, histamine, and norepinephrine. (Review topic: Huntington Disease)

This patient has chronic tension-type headache. Chronic tension-type headaches are often described as a steady, aching, vise-like sensation that encircles the entire head. Chronic tension-type headaches are often accompanied by tight and tender muscles at the site of maximal pain, often in the posterior cervical, frontal, or temporal musculature. Chronic tension-type headache is defined as tension-type headache occurring more than 15 days a month. Chronic daily tension-type headaches are usually related to causal factors that include stress and worry, depression, overwork, lack of sleep, incorrect posture, and marital and family dysfunction. (Review topic: Tension headaches)

This is a Grade IV permanently prolapsed hemorrhoid. (Review topic: Hemorrhoids)

Rheumatic heart disease is caused by autoimmune cross-reactivity following a Streptococcal infection. Development of antibody-mediated mitral valve damage is common. Long-term penicillin is suitable for acute treatment and prophylaxis from complications.

Blood pressure in the lungs is usually very low < 15 mm HG. In pulmonary hypertension, the pressure increases > 25 mmHg at rest!

This patient is presenting with toxic megacolon secondary to ulcerative colitis (UC). The first-line treatment for patients with toxic megacolon from UC is IV glucocorticoids to reduce inflammation and the need for surgical intervention. (Review topic: Ulcerative colitis)

Troponin I is an enzyme that's useful in evaluating a myocardial infarction (MI). Troponin I levels begin to rise within 2-3 hours post-MI, peak at about 2 days, and continue to stay elevated for about 7 days. (Review topic: Myocardial infarction)

Given the patient’s presentation (flank pain, hematuria) and history of smoking, the most likely diagnosis is renal cell carcinoma. Renal cell carcinoma most commonly presents with a combination of hematuria, an abdominal mass, and flank discomfort, although many patients are asymptomatic and are diagnosed incidentally. Patients may also have an elevated hematocrit from elevated erythropoietin production. Risk factors for renal cell carcinoma include smoking, hypertension, obesity, acquired cystic kidney disease, and genetic factors such as von Hippel Lindau. (Review topic: Renal cell carcinoma)

Pericardial effusions are associated with a variety of causes, including autoimmune disorders and infectious pericarditis. If pericardial effusion leads to cardiac tamponade, patients may have pulsus paradoxus, or a decrease in systolic blood pressure during inspiration of more than 10 mm Hg. Certain ECG findings are characteristic for pericardial effusion. In particular, electrical alternans (shown by arrows) is highly specific for pericardial effusion (usually in association with cardiac tamponade) but not particularly sensitive. This pattern, characterized by beat-to-beat changes in the QRS axis in the limb and precordial leads, is caused by swinging of the heart within the accumulated pericardial fluid. Other common findings on ECG include sinus tachycardia and low QRS voltage.

A monoarticular arthritis should raise the question of a septic versus a crystalline arthritis. Septic arthritis and crystalline arthritis can be notoriously similar in their clinical presentations, so clearly establishing the diagnosis, particularly in a patient with no known history of crystalline disease, is of great advantage before initiating definitive therapy. Crystal-induced and septic-induced joint can coexist in the same joint. An arthrocentesis is the most appropriate choice and allows examination of fluid for WBCs, crystals, and bacteria. Colchicine (choice A), NSAIDs (choice B), and antibiotics (choice C) are all inappropriate before the arthrocentesis. If diagnosis of a septic joint is missed, the joint can be destroyed from the bacteria. (Review topic: Septic Arthritis)

IV tissue plasminogen activator ( tPA ) is given in patients presenting within 4.5 hours of the symptoms of an acute stroke without contraindications. Is necessary to be aware of the risk of symptomatic intracranial hemorrhage. (Review topic: Cerebral vascular accident)

The patient is presenting with dyspareunia and dental caries suggesting a diagnosis of Sjogren’s syndrome. Sjogren’s syndrome is an autoimmune disorder that targets salivary and lacrimal glands. The most common symptoms that patients present with are dry eyes (keratoconjunctivitis sicca), dry mouth (xerostomia), arthritis, and dyspareunia. Biomarkers that are indicative of the disease include anti-Ro (anti-SSA) and anti-La (anti-SSB). Anti-nuclear antibodies (ANA) and rheumatoid factor (RF) may also be positive. (Review topic: Sjogren’s syndrome)

Polymyalgia rheumatica affects patients greater than 50 years of age and causes proximal bilateral aching and morning stiffness, along with elevated erythrocyte sedimentation rate. This inflammatory condition can be treated with low-dose glucocorticoids. (Review topic: Polymalgia Rheumatica)

Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly.

Prolonged uncontrolled glycemic control predisposes patients to develop autonomic dysfunction that can affect multiple organ systems. These include cardiovascular, gastrointestinal, pupillary, and genitourinary systems such as neurogenic bladder than can lead to overflow incontinence. 45% of patients with diabetes and 75-100% of patients with diabetic peripheral neuropathy will develop bladder dysfunction, specifically urinary retention. (Review topic: Peripheral neuropathies)

Pulmonary fibrosis presents with ground-glass infiltrates on CXR and is often associated with certain medication use. In this case, amiodarone.

The most common pattern or clinical category of MS is the relapsing-remitting category. In relapsing-remitting MS, episodes of acute worsening are followed by recovery and a stable course between relapses. In the secondary progressive category, gradual neurologic deterioration occurs with or without superimposed acute relapses in patients who previously had relapsing-remitting MS. In primary progressive MS, gradual continuous deterioration occurs from the onset of symptoms. In progressive relapsing MS, gradual neurologic deterioration occurs from the onset of symptoms but with subsequent superimposed relapses. A small fraction of patients has a relatively benign form that never becomes debilitating. The patient described most likely has relapsing-remitting MS. (Review topic: Multiple sclerosis)

Ceftriaxone is an effective treatment for acute epididymitis caused by Neisseria gonorrhea and is given with doxycycline for patients under the age of 35 who are at risk for sexually transmitted infections. (Review topic: Epididymitis)

The heterophile test (AKA Monospot) is used for the diagnosis of infectious mononucleosis in children and adults. (Review topic: Epstein-Barr infection)

This patient is suffering from temporal (giant cell) arteritis. For a patient with suspected temporal arteritis, the first step in management should be immediate administration of high-dose steroids. (Review topic: Giant cell arteritis)

Fibromyalgia is the most likely diagnosis in this patient. It is most frequently seen in women between the ages of 20 and 50. Patients complain of chronic musculoskeletal pain commonly associated with fatigue and sleep disturbances as well as headaches and numbness. Physical examination is normal except for the presence of multiple “trigger points.” (Review topic: Fibromyalgia)

Bladder cancer is associated with smoking and presents with painless hematuria. Transitional cell, squamous cell, and adenocarcinoma of the bladder are the 3 types of malignancies that can arise from the bladder. They often present in later stages with the patient having microscopic or gross hematuria. It is unlikely that a mass will be palpated, however, abdominal pain and dysuria can be associated with a large mass. Smoking is associated with the development of transitional cell carcinoma. Treatment varies based on the extent of the disease. (Review topic: Bladder cancer)

This patient is presenting with blood in his vomitus after forceful vomiting suggesting a diagnosis of a Mallory-Weiss tear. A Mallory-Weiss tear occurs secondary to a mucosal laceration at the gastroesophageal junction. (Review topic: Mallory-Weiss tear)

This patient most likely has asbestosis, which is supported by his occupation as a shipbuilder and clinical presentation as noted above. Chest x-ray findings include interstitial fibrosis, pleural thickening, and calcified pleural plaques on the diaphragm or lateral chest wall.

Suspect bordetella pertussis in an elderly patient or an infant with cough for greater than two weeks with no clear cause and a paroxysmal cough, inspiratory whoop, or post-tussive emesis should be treated with a macrolide, which may cause QT prolongation. (Review topic: Pertussis)