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https://step2.medbullets.com/testview?qid=109022 | A 47-year-old man presents to the emergency department with a headache. He suddenly developed a throbbing, bitemporal headache about 5 hours ago "out of nowhere." He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines. The patient took his prescribed sumatriptan with no relief of his symptoms. He also endorses nausea and he reports that he vomited once before arrival in the emergency department. The patient denies any recent trauma to the head. His medical history is significant for migraines and hypertension. He has a 20-pack-year smoking history and a history of cocaine use. He drinks 5-6 beers per week. His temperature is 98.6°F (37°C), blood pressure is 147/91 mmHg, pulse is 62/min, and respirations are 12/min. On physical exam, he appears to be in moderate distress and has pain with neck flexion. He has no focal neurologic deficits. A head CT is performed and can be seen in Figure A. This patient’s condition affects the space in between which of the following brain layers? | Periosteum and galea aponeurosis | Arachnoid mater and pia mater | Dura mater and arachnoid mater | Skull and dura mater | B | Arachnoid mater and pia mater | This patient presents with a sudden, severe headache and a head CT showing bleeding in the subarachnoid space, which confirms a diagnosis of subarachnoid hemorrhage. The bleeding in a subarachnoid hemorrhage occurs between the arachnoid and pia mater.
Subarachnoid hemorrhages present with a sudden, severe headache referred to as a “thunderclap” headache. Patients typically complain that the headache is the "worst headache of their life." Some patients also present with symptoms of meningeal irritation such as nausea and vomiting, nuchal rigidity, or focal neurologic deficits. Although most cases of subarachnoid hemorrhage are secondary to trauma, patients with risk factors such as hypertension and cocaine use can have non-traumatic presentations. Patients with an expanding bleed or acute neurologic changes require surgical clipping or embolization of the bleeding vessels.
Macdonald and Schweizer review the evidence regarding the treatment of patients with subarachnoid hemorrhage. They discuss how survival rates have improved with early aneurysm repair, prescription of nimodipine, and advanced intensive care support. They recommend early diagnosis in order to improve outcomes in these patients.
Figure/Illustration A is an axial slice of a head CT showing hyperintensity in the basal cisterns (red circle). This finding is consistent with bleeding in the subarachnoid space.
Incorrect Answers:
Answer B: Bleeding between the dura and arachnoid mater describes a subdural hematoma. A subdural hematoma presents as a headache with progressive confusion. It appears as a crescent-shaped lesion on head CT. Patients with an expanding bleed will require surgical decompression to avoid herniation syndromes.
Answer C: Bleeding between the periosteum and galea aponeurosis describes a subgaleal hemorrhage. Subgaleal hemorrhages occur in newborns and are caused by vacuum-assisted deliveries. Treatment is usually supportive as the bleeding will resolve by itself. Some patients with severe bleeds may require transfusion due to excessive blood loss.
Answer D: Bleeding between the periosteum and skull describes a cephalohematoma. Cephalohematomas occur in newborns and are caused by rupture of the blood vessels crossing the periosteum. They are usually secondary to a prolonged second stage of labor. Treatment is supportive as the blood will resolve and be resorbed.
Answer E: Bleeding between the skull and dura mater describes an epidural hematoma. An epidural hematoma presents as a brief loss of consciousness followed by a lucid interval and then progressive confusion or somnolence. It appears as a biconvex lesion on head CT. Treatment is with urgent surgical decompression as patients will rapidly decompensate after the lucid interval.
Bullet Summary:
Subarachnoid hemorrhage classically presents as a thunderclap headache with a brief loss of consciousness and meningismus. | nan |
https://bit.ly/42Cge5V | A 16-year-old boy presents to an ophthalmologist with blurry vision. Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school. The patient is otherwise doing well in school and enjoys playing basketball. His medical history is otherwise significant for scoliosis which is managed by an orthopedic surgeon. His family history is significant for a mother with type 2 diabetes mellitus and a father who underwent aortic valve replacement last year. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, the patient is tall for his age and has long arms. He has 20 degrees of thoracic scoliosis, which is stable from previous exams. On slit-lamp examination, the patient is found to have bilateral upward lens subluxation and is prescribed corrective lenses. Which of the following is the most likely cause of this patient’s symptoms? | Extra copy of sex chromosome | Mutation of RET proto-oncogene | Defective metabolism of methionine | Mutation of chromosome 15 | D | Mutation of chromosome 15 | This patient presents with tall stature, upward lens subluxation, and a family history of aortic valve disease, which suggests a diagnosis of Marfan syndrome. Marfan syndrome is caused by an autosomal dominant mutation in the fibrillin-1 gene on chromosome 15.
The fibrillin-1 gene codes for a glycoprotein in the extracellular matrix of connective tissue. Patients with Marfan syndrome classically present with a triad of musculoskeletal, ocular, and cardiovascular symptoms. The musculoskeletal findings include tall stature, long limbs, arachnodactyly, pectus excavatum, joint hypermobility, skin hyperelasticity, and scoliosis. Patients with Marfan syndrome also often present with upward lens subluxation, and they are at increased risk of cardiac disease, including aortic regurgitation and aortic dissection. Treatment is symptomatic with avoidance of contact sports, beta-blockers, and valve repair to prevent cardiac complications.
Bitterman and Sponseller review the evidence regarding the diagnosis and treatment of Marfan syndrome. They discuss how skeletal manifestations are often the initial presentation of this condition leading to diagnosis. They recommend screening for patients who are suspected to have this disease.
Incorrect Answers:
Answer A: Defective metabolism of methionine describes homocystinuria, an autosomal recessive deficiency of cystathionine synthase. Although patients with homocystinuria may also have tall stature, arachnodactyly, and pectus deformity, the lens dislocation in homocystinuria is downward rather than upwards. Patients with homocystinuria also tend to have a fair complexion, intellectual disability, and thrombophilia. Treatment includes vitamin B6 supplementation.
Answer B: Extra copy of a sex chromosome describes Klinefelter syndrome (47,XXY). Although patients with Klinefelter syndrome classically present with tall stature, they do not have the other clinical features found in this patient, including joint hypermobility and lens subluxation. Patients with Klinefelter also present with hypogonadism and azoospermia. Treatment is supportive
Answer D: Mutation of COL5A1 or COL5A2 leads to Ehlers-Danlos syndrome, a collagen disorder that commonly presents with joint hypermobility, skin hyperextensibility, and skin fragility with easy bruising. Ehlers-Danlos would not explain this patient’s lens subluxation. Treatment may include bracing of unstable joints.
Answer E: Mutation of RET proto-oncogene describes multiple endocrine neoplasia type 2B (MEN2B). Patients with MEN2B may present with Marfanoid habitus and are predisposed to medullary thyroid cancer, pheochromocytoma, and mucosal neuromas. MEN2B would not explain lens subluxation. Treatment is with surgical resection of tumors.
Bullet Summary:
Marfan syndrome is caused by an autosomal dominant mutation in the fibrillin-1 gene on chromosome 15 and presents with a triad of musculoskeletal, ocular, and cardiovascular findings. | nan |
https://step2.medbullets.com/testview?qid=216501 | A 26-year-old man presents to his primary care physician with a 6-month history of increasing lower back pain. He first felt the pain while lifting boxes at work but thought that he had just strained a muscle. The pain appears to be worse in the mornings and after rest. Exercise and physical activity appear to temporarily make the pain better. He has taken acetaminophen and ibuprofen for the pain. He has no significant medical history and takes no medications. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. On physical exam, he is found to have limited flexion and extension of his spine as well as tenderness to palpation over the insertion of his patellar tendons bilaterally. Results from laboratory tests are shown below:
Serum:
Erythrocyte sedimentation rate (ESR): 61 mm/hr
C-reactive protein (CRP): 36 mg/L (normal <10 mg/L)
Which of the following is the most accurate test for this patient's condition? | Bone scan | Computed tomography | Magnetic resonance imaging | Radiograph | C | Magnetic resonance imaging | This young man presents with low back pain that is relieved by physical activity, decreased spinal mobility, enthesitis of his patellar tendons, and elevated ESR/CRP values most likely has ankylosing spondylitis (AS). The most accurate diagnostic test for early ankylosing spondylitis is MRI.
Multiple imaging tests can diagnose ankylosing spondylitis. Radiographs of the spine will show squaring of vertebrae with vertical or marginal syndesmophytes resulting in a "bamboo spine" appearance. The earliest radiographic sign is the erosion of the iliac side of the sacroiliac joint, but this finding is not sensitive in the early stages of the disease. MRI is sensitive in detecting sacroiliac inflammation, which makes this the best modality for early detection of ankylosing spondylitis in young patients. Initial therapy for ankylosing spondylitis includes lifestyle modifications (exercise, smoking cessation, physical therapy) and non-steroidal anti-inflammatory drugs (NSAIDs). Therapy for patients with inadequate response to NSAIDs includes tumor necrosis factor inhibitors (etanercept, infliximab, adalimumab) and interleukin 17 inhibitors (secukinumab, ixekizumab).
Jung et al. studied whether signs of inflammation on MRI are correlated with bone quality in patients with ankylosing spondylitis. The authors find that bone marrow edema is negatively correlated with the trabecular bone score. The authors recommend control of active bone inflammation to prevent osteoporosis in patients with ankylosing spondylitis.
Incorrect Answers:
Answer A: Bone scan will show inflammation in the sacroiliac joints, but this study lacks specificity for this disease compared with other inflammatory forms of arthritis.
Answer B: CT will show bony changes but not active inflammation, so it is most commonly used to diagnose cervical fractures in patients with ankylosing spondylitis. While it can support the diagnosis, it is less accurate than an MRI.
Answer D: Radiographs will show erosion of the iliac side of the sacroiliac joint, but this finding is not sensitive in the early stages of the disease when bony ankylosis has not yet occurred. Radiographs may be an appropriate initial test.
Answer E: Ultrasound is useful in evaluating muscle strains or tendon tears; however, it is not able to detect bony abnormalities and is therefore of limited use in ankylosing spondylitis.
Bullet Summary:
MRI is the most sensitive and accurate test for the early detection of ankylosing spondylitis. | Ultrasound |
https://bit.ly/3skGIMT | A 1-month-old girl presents to her pediatrician with her mother. The patient was born at 38 weeks gestation via Caesarean section for cervical incompetence. The patient’s mother has no complaints. The child had a runny nose and cough for a few days last week. The patient’s mother endorses decreased appetite during the aforementioned illness which has now returned to baseline. The patient’s family history is significant for an older brother with glucose-6-phosphate dehydrogenase (G6PD) deficiency and a maternal uncle with cirrhosis secondary to chronic hepatitis B. On physical exam, the patient has scleral icterus and dark urine staining her diaper. Laboratory testing reveals the following: Serum: Na+: 137 mEq/L Cl-: 102 mEq/L K+: 4.2 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 12 mg/dL Glucose: 96 mg/dL Creatinine: 0.36 mg/dL Alkaline phosphatase: 146 U/L Aspartate aminotransferase (AST): 86 U/L Alanine aminotransferase (ALT): 76 U/L Total bilirubin: 4.6 mg/dL Direct bilirubin: 3.8 mg/dL Which of the following is the most likely diagnosis? | Decreased metabolism of bilirubin | Increased enterohepatic circulation of bilirubin | Increased production of bilirubin | Obstruction of the extrahepatic biliary tree | D | Obstruction of the extrahepatic biliary tree | This 2-month-old patient presents with jaundice, dark urine, mild transaminitis, and conjugated hyperbilirubinemia, which suggests the diagnosis of biliary atresia. Biliary atresia is characterized by obstruction of the extrahepatic biliary tree.
Biliary atresia is a progressive, obliterative disease of the extrahepatic biliary tree. It presents in the first 8 weeks of life with jaundice, acholic stools, dark urine, hepatomegaly, mild transaminitis, and conjugated hyperbilirubinemia. The definitive diagnosis is made by a cholangiogram that will demonstrate the obliteration of these ducts. Patients who are untreated experience fatal neurological defects due to kernicterus and accumulation of bilirubin in the brain. Treatment usually involves hepatoportoenterostomy (Kasai procedure), in which the duodenum is directly anastomosed to the liver. Most patients also eventually require a liver transplant.
Hartley et al. review the evidence regarding the diagnosis and treatment of patients with biliary atresia. They discuss how researchers are trying to reverse the liver fibrosis associated with this disease. They recommend early referral for a Kasai procedure or liver transplant as needed.
Incorrect Answers:
Answer A: Decreased metabolism of bilirubin occurs with enzymatic deficiencies such as those seen in Crigler-Najjar or Gilbert syndrome. Both Crigler-Najjar and Gilbert syndromes lead to unconjugated hyperbilirubinemia (much more severe in Crigler-Najjar syndrome) rather than the conjugated hyperbilirubinemia seen in this patient.
Answer B: Increased enterohepatic circulation describes the pathophysiology underlying breast milk jaundice. Breast milk jaundice classically peaks in the first 2 weeks of life and leads to unconjugated rather than conjugated hyperbilirubinemia. Treatment is usually supportive and patients can typically continue to breastfeed.
Answer C: Increased production of bilirubin can occur in hemolytic diseases such as G6PD deficiency or hereditary spherocytosis. These conditions would similarly lead to an unconjugated hyperbilirubinemia. Treatment is with addressing the underlying anemia with possible transfusion or splenectomy.
Answer E: Obstruction of the intrahepatic biliary tree describes Alagille syndrome, in which patients have a paucity of interlobular bile ducts. Alagille syndrome is less common than biliary atresia and usually presents with other associated features, such as short stature, dysmorphic facies, ocular findings, and cardiac or renal anomalies. Treatment is with ursodiol.
Bullet Summary:
Biliary atresia presents in the first 8 weeks of life with jaundice and conjugated hyperbilirubinemia. | Obstruction of the intrahepatic biliary tree |
https://step2.medbullets.com/testview?qid=216438 | A 32-year-old man presents to the emergency department with pain upon defecation. His symptoms started a few weeks ago but have been worsening. Sometimes he notes blood on the toilet paper. He has to strain to have bowel movements and has trouble defecating secondary to pain. He is generally healthy and does not smoke. The patient is a software engineer and enjoys hiking, going to nightclubs, and dancing. His temperature is 98.1°F (36.7°C), blood pressure is 112/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam reveals a small, superficial fissure that is lateral to the anus and lateral to the midline. Which of the following is the most appropriate management for this patient? | Testing for HIV, fecal occult blood, and sexually transmitted diseases | CT scan of the abdomen and pelvis | Surgical excision | Topical lidocaine, sitz baths, and fiber supplements | A | Testing for HIV, fecal occult blood, and sexually transmitted diseases | This patient is presenting with pain upon defecation, constipation, and a fissure lateral to the midline which is suggestive of an anal fissure. Anal fissures lateral to the midline are associated with inflammatory and infectious etiologies; thus, further workup (testing for HIV, fecal occult blood testing, and sexually transmitted disease testing) is needed rather than merely symptomatic treatment.
Anal fissures present with exquisite pain upon defecation which may lead to fecal retention and constipation. Commonly, anal fissures are caused by constipation, local trauma (such as anal intercourse), or a tight anal sphincter. Anal fissures that occur secondary to trauma are usually midline. On the other hand, lateral anal fissures are a harbinger of more serious alternative diagnoses and require further workup. Lateral anal fissures can be caused by infections (HIV being one of the most concerning as well as syphilis or tuberculosis), Crohn disease, granulomatous disease, malignancy, as well as foreign bodies. For this reason, lateral anal fissures should not only be treated symptomatically but require testing for sexually transmitted diseases, inflammatory conditions, and malignancy to determine the underlying etiology based on the patient’s risk factors and associated symptoms.
Steele and Madoff review anal fissures. They note that while both operative and non-operative interventions may be indicated in the management of an anal fissure after alternative diagnoses have been ruled out, advances in medical management may spare patients sphincter-dividing surgery. They recommend considering all modalities.
Incorrect Answers:
Answer A: CT scan of the abdomen and pelvis followed by an MRI may be the most appropriate testing if a perirectal abscess is suspected. These abscesses can track very deep. For this reason, further imaging and drainage in the operating room followed by antibiotics are indicated rather than a simple bedside incision and drainage. Imaging may be indicated in this patient after medical workup fails to elucidate an etiology.
Answer B: Incision, drainage, ciprofloxacin, and metronidazole may be indicated for a perianal abscess (note, this is not a perirectal abscess), which presents with a tender, fluctuant mass right next to the anus. The diagnosis can be made clinically or supported by an ultrasound.
Answer C: Surgical excision may be performed in the management of a perianal fistula, which presents with a draining tract next to the anus that releases purulence or fecal contents causing staining of the patient’s underwear and irritation of the skin. The diagnosis is made with an exam and a CT, MRI, or fistulogram followed by a fistulotomy.
Answer E: Topical lidocaine, sitz baths, and fiber supplements are the appropriate management of an anal fissure that is midline and secondary to a clear cause such as trauma or constipation. It would be inappropriate to only treat this patient symptomatically with a lateral anal fissure as this is a sign of a more serious diagnosis.
Bullet Summary:
Anal fissures that are lateral to the midline require workup for sexually transmitted infections, cancer, and autoimmune disease. | nan |
https://bit.ly/3OGVR2b | A 57-year-old man presents to the emergency department for weight loss and abdominal pain. The patient has felt steadily more fatigued over the past month and has lost 22 pounds without effort. Today, he fainted prompting his presentation. The patient has no significant medical history. He does have a 33-pack-year smoking history and drinks 4 to 5 alcoholic drinks per day. His temperature is 99.5°F (37.5°C), blood pressure is 100/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is very thin and appears pale. Stool fecal occult blood testing is positive. A CT scan of the abdomen is performed demonstrating a mass in the colon with multiple metastatic lesions scattered throughout the abdomen. The patient is informed of his diagnosis of metastatic colon cancer. When the patient conveys the information to his family, he focuses his efforts on discussing the current literature in the field and the novel therapies that have been invented. He demonstrates his likely mortality outcome which he calculated using the results of a large multi-center study. Which of the following is this patient most likely demonstrating? | Intellectualization | Pessimism | Rationalization | Optimism | A | Intellectualization | This patient is using facts and logic to emotionally distance himself from his stressful diagnosis. This ego defense method is suggestive of intellectualization.
Intellectualization typically occurs in patients who have received a very stressful diagnosis or bad news for a close loved one. They will often focus on the science and research of their disease rather than focus on emotionally processing this stressful event. This is a way of distancing themselves from the diagnosis and their circumstances. These patients may have difficulty connecting with others because they become extremely focused on data.
Arnold reviews the evidence regarding the diagnosis of intellectualization. He discusses how this term can either refer to the isolation of affect or the general use of reason. He recommends a better understanding of how this ego defense works.
Incorrect Answers:
Answer A: Dissociation is the detachment of the mind from the emotional state/body. A more specific diagnosis for this patient would be intellectualization as he is detaching himself from the emotional state of the diagnosis and instead focusing on the science behind his condition.
Answer C: Optimism is trying to find the best in a bad situation. This patient's focus on treatment outcomes and absence of emotion suggests intellectualization as the employed defense mechanism. Patients who are optimistic will still be able to emotionally process information.
Answer D: Pessimism is finding the worst in most situations. Pessimism would be a possible answer if the patient had a very treatable disease but thought that poor outcomes would occur regardless.
Answer E: Rationalization is the use of logic or reasoning (that can be inappropriate) in order to substantiate one's behavior even when it is inappropriate. An example is justifying theft because a person was in need.
Bullet Summary:
Intellectualization is the use of facts and logic to distance oneself from a stressful situation. | nan |
https://bit.ly/3DDvy7X | A 27-year-old woman presents for her first prenatal visit at an estimated gestational age of 16 weeks and 4 days by last menstrual period. She is presenting late to prenatal care due to significant anxiety about her pregnancy, as she and her husband had struggled with infertility for several years prior to conceiving. She has had nausea and vomiting for about 2 months, tender and swollen breasts, and cravings for foods she typically does not eat. She took a pregnancy test about 10 weeks ago and was too nervous to read the result immediately. After 24 hours, she saw that it was positive. The patient has a past medical history of bulimia nervosa but has not been symptomatic in 2 years. She also had an appendectomy at age 15 for appendicitis. She is a Ph.D. student and her husband is a physician. Her temperature is 98.5°F (36.9°C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min. The patient’s affect is normal and she is pleasant and excited about her pregnancy. A physical exam is notable for abdominal distension but is otherwise unremarkable. Ultrasound is shown in Figure A, and urine human chorionic gonadotropin is negative in the office. Which of the following is the most likely diagnosis? | Couvade syndrome | Delusion of pregnancy | Feigned pregnancy | Pseudocyesis | D | Pseudocyesis | This patient presents with signs and symptoms of pregnancy but a nongravid uterus on ultrasound and a negative pregnancy test. The most likely diagnosis is pseudocyesis.
Pseudocyesis, or false pregnancy, most commonly presents with abdominal distension, breast tenderness, nausea, and other typical symptoms of pregnancy. Patients truly believe they are pregnant and may report positive pregnancy tests at home (perhaps due to false positives from waiting too long before reading the result) but office testing is negative. Ultrasound will be normal and show the absence of a developing fetus. The mainstay of treatment is explaining the diagnosis in a therapeutic manner and offering counseling to help patients cope.
Small reviews the evidence regarding the diagnosis and treatment of pseudocyesis. He discusses how this disease is a heterogenous entity involving neuroendocrine changes. He recommends clearly defining the cause of this disease in patients.
Figure/Illustration A shows a transabdominal ultrasound with an empty cavity without signs of pregnancy (red circle). These findings are consistent with pseudocyesis.
Incorrect Answers:
Answer A: Couvade syndrome refers to a “sympathetic pregnancy,” in which a patient experiences pregnancy symptoms when someone close to her is pregnant. This does not apply to this patient because she believes that she is pregnant herself.
Answer B: Delusion of pregnancy is a false and fixed belief about being pregnant, despite factual evidence to suggest otherwise. Patients typically do not experience actual pregnancy symptoms and may have a history of psychotic disorders, both of which are inconsistent with this patient’s presentation. Treatment is with cognitive behavioral therapy.
Answer C: Feigned pregnancy is the intentional falsifying of symptoms for a clear external motive and is a subtype of factitious disorder or malingering. This patient does not express any desire for secondary gain and seems to truly believe that she is pregnant, which is more consistent with pseudocyesis.
Answer E: A recent miscarriage is unlikely, as urine hCG testing often takes up to a month to become negative after pregnancy loss. Furthermore, the patient reports that her symptoms have been consistently present, whereas a miscarriage would typically cause a cessation of pregnancy symptoms.
Bullet Summary:
Pseudocyesis is a somatic symptom disorder in which women believe they are pregnant and experience pregnancy symptoms without an actual pregnancy. | Recent miscarriage |
https://step2.medbullets.com/testview?qid=109241 | A 3-day-old boy is evaluated in the hospital nursery for the delayed passage of meconium. The patient is breastfed, has been feeding well every 2 hours, and is urinating over 8 times per day. He was born at 35 weeks gestation to a 27-year-old G4P4 mother. The patient is of Ashkenazi Jewish descent and the patient’s parents refused all prenatal genetic testing. The pregnancy was uncomplicated until the patient’s mother had a spontaneous rupture of membranes at 35 weeks of gestation. The patient’s 3 older siblings are all healthy. The patient’s temperature is 98.2°F (36.8°C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min. On physical exam, he appears to be in moderate distress. He has no dysmorphic features, and his abdomen is distended and non-tender. Bowel sounds are absent. Which of the following is the most appropriate next step in management? | Upper gastrointestinal series | Sweat testing | Abdominal radiograph | Abdominal CT | C | Abdominal radiograph | Delayed passage of meconium should be evaluated with an abdominal radiograph to rule out bowel perforation. Patients with a perforation require emergency surgery.
All neonates should pass meconium in the first 48 hours of life. Patients that fail do to so should be evaluated with an abdominal radiograph to exclude the possibility of bowel perforation. If free air is seen on the abdominal radiograph, patients should be taken for emergent surgery to repair the perforation. If bowel perforation is ruled out, a workup should be done to determine the etiology of the delayed passage, which would most likely include a contrast enema to differentiate between meconium ileus and Hirschsprung disease. Treatment is with meconium removal or excision of the defective segment respectively.
Adams and Stanton review the evidence regarding the diagnosis and treatment of neonatal bowel obstruction. They discuss how malrotation, jejunoileal atresia, duodenal atresia, and colonic atresia are common causes of this finding. They recommend surgical management of these conditions.
Incorrect Answers:
Answer A: An abdominal radiograph would be faster than an abdominal CT to rule out an indication for emergency surgery. The use of CT should also be restricted in the pediatric population due to the radiation exposure involved. Adult patients with unclear radiographic findings can be further assessed using a contrast CT scan.
Answer C: Contrast enema is the test of choice to differentiate meconium ileus from Hirschsprung disease, but the most important first step is to rule out bowel perforation. Patients who do not have perforation can then undergo this test to determine the etiology of failure to pass meconium.
Answer D: Sweat testing would aid in the diagnosis of cystic fibrosis, particularly in this patient who has had no prenatal screening. The first step in management should be an abdominal radiograph to rule out bowel perforation. Cystic fibrosis can be treated with pancreatic enzyme replacement and pulmonary therapy.
Answer E: Upper gastrointestinal series is used to make the diagnosis of intestinal malrotation, which more commonly presents with bilious vomiting secondary to midgut volvulus rather than the delayed passage of meconium. Treatment is with surgical derotation.
Bullet Summary:
Neonates who fail to pass meconium in the first 48 hours of life should be urgently evaluated with an abdominal radiograph to rule out bowel perforation. | nan |
https://step2.medbullets.com/testview?qid=109961 | A 37-year-old machinist presents to his primary care physician with eye problems. He has felt a mass in his eye that has persisted for the past month. The patient has a medical history of blepharitis treated with eye cleansing and squamous cell carcinoma of the skin treated with Mohs surgery. His temperature is 99.5°F (37.5°C), blood pressure is 157/102 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a firm and rubbery nodule palpable inside the patient's left eyelid. Physical exam does not elicit any pain. Which of the following is the most likely diagnosis? | Chalazion | Foreign body | Hordeolum | Meibomian cell carcinoma | A | Chalazion | This patient presenting with a painless firm and rubbery nodule has symptoms that are suggestive of a chalazion.
Chalazion presents with a hard and painless eyelid nodule. This pathology occurs secondary to granulomatous inflammation of the Meibomian gland. The lesion can be treated with simple excision; however, recurrent lesions are concerning for Meibomian cell carcinoma. The most important differential diagnosis to consider in these patients is a hordeolum which presents with a firm and painful lid nodule (in contrast to painless). Treatment is with warm compresses followed by incision and curettage in refractory cases.
Li et al. review the evidence regarding the diagnosis and treatment of chalazion. They discuss how gland loss is a possible sequelae from this disorder. They recommend using warm compresses for symptomatic relief.
Incorrect Answers:
Answer B: Foreign body is a possible diagnosis given this patient's occupation as a machinist; however, this would typically present with pain over the patient's cornea with a sudden onset of symptoms. Treatment is with removal of the foreign body.
Answer C: Hordeolum presents with a hard and painful lid nodule in contrast to a hard and painless lid nodule. Treatment is with warm compresses and possible debridement in refractory cases.
Answer D: Ingrown eyelash follicle could present with a firm lid nodule; however, it would be located near the margin of the eyelid and would likely be inflamed and tender. Treatment is with warm compresses and possible debridement in refractory cases.
Answer E: Meibomian cell carcinoma is a possible diagnosis but is epidemiologically less common than a chalazion. This diagnosis would be more likely if the lesion was recurrent despite excision. Treatment is with wide excision of the lesion.
Bullet Summary:
Chalazion presents with a firm and painless eyelid nodule. | nan |
https://step2.medbullets.com/testview?qid=217661 | A 53-year-old African-American woman presents to her primary care doctor with increasing difficulty climbing the stairs. She noticed the weakness approximately 3 months ago. It has gotten progressively worse since that time. She has also noticed increasing difficulty combing her hair, standing from a seated position, and experiences muscle aches. Her medical history is significant for hypertension treated with lifestyle modification and gastroesophageal reflux disease (GERD). Her temperature is 98.6°F (37.0°C), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 16/min. She has 3/5 strength to shoulder abduction and hip flexion bilaterally. Her strength is 5/5 to wrist extension and ankle plantar flexion. No skin rashes are noted. Which of the following is the most accurate test to confirm this patient’s diagnosis? | Electromyography | MRI | Muscle biopsy | Serum aldolase | C | Muscle biopsy | This patient with insidious, subacute, progressive, symmetric proximal muscle weakness (difficulty climbing the stairs, combing her hair, standing from a seated position) without associated skin lesions most likely has polymyositis. The most accurate diagnostic test for polymyositis is muscle biopsy.
Polymyositis is caused by an autoimmune reaction that leads to cell-mediated cytotoxicity against unidentified skeletal muscle antigens, primarily affecting the endomysium. It is more often found in women, patients between 30-60 years of age, and African-Americans. Clinical features of polymyositis include symmetric proximal muscle weakness that may be accompanied by myalgia, dysphagia (due to pharyngeal muscle weakness), restrictive lung disease (due to respiratory muscle weakness), cardiac involvement (myocarditis, heart failure), interstitial lung disease, and increased risk of malignancy. There are no accepted diagnostic criteria for polymyositis; however, diagnosis is usually secured with a combination of clinical features and other tests. Routine initial studies can include a complete blood count, complete metabolic panel, C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase, aldolase, creatine kinase, autoantibodies (anti-nuclear antibody, anti-Jo-1), and electromyography (EMG). Muscle biopsy of an affected muscle is the gold standard for diagnosis and will typically show muscle fiber damage, CD8+ T cells in the endomysium, and overexpression of MHC-I on the sarcolemma. First-line treatment of polymyositis includes glucocorticoids and a steroid-sparing agent (methotrexate, azathioprine). Subsequent treatments can include intravenous immunoglobulins, rituximab, or plasmapheresis.
Amato et al. review the evaluation and treatment of inflammatory myopathies such as polymyositis, dermatomyositis, and inclusion body myositis. They found that polymyositis typically presents in adult life with symmetric proximal leg greater than arm weakness. They recommend that a muscle biopsy be done on any patient considered to have polymyositis, preferably prior to starting immunosuppressive treatment.
Incorrect Answers:
Answer A: Electromyography (EMG) can help distinguish myopathic weakness (e.g., polymyositis) from neuropathic causes of weakness (e.g., amyotrophic lateral sclerosis, myasthenia gravis). Characteristic EMG findings include fibrillations, early recruitment of motor unit potentials, and abnormal low-amplitude motor unit potentials. EMG is not a confirmatory test and is less sensitive than muscle biopsy for diagnosing myositis.
Answer B: MRI can be used to demonstrate areas of edema, atrophy, fatty replacement, and calcification in patients with suspected polymyositis. MRI can assess large regions of muscle, thus avoiding sampling error with muscle biopsy. The findings in MRI are nonspecific and require correlation with muscle biopsy for definitive diagnosis. MRI can also be used to help select the site of muscle biopsy.
Answer D: Serum aldolase can occasionally be used in the diagnostic investigation of suspected polymyositis if creatine kinase is normal. Aldolase elevation is nonspecific and may be seen in fasciitis, drug-induced myositis, and connective tissue disease-associated interstitial lung disease.
Answer E: Serum creatine kinase (CK) is the most sensitive muscle enzyme exam and should be part of the initial diagnostic investigation of any patient with suspected polymyositis. CK elevation is nonspecific and may be seen in myriad conditions such as inflammatory insult, metabolic injury, drug-induced injury, and infection.
Bullet Summary:
Muscle biopsy is the gold standard for the diagnosis of polymyositis. | Serum creatine kinase |
https://bit.ly/3R0iH7u | A 70-year-old woman is brought to the emergency department by ambulance. She was found on the floor of her apartment after her neighbor called 911. She is confused and is unable to provide any history, but complains of generalized pain. Her temperature is 99.2°F (37.3°C), blood pressure is 129/64 mmHg, pulse is 63/min, respirations are 13/min, and oxygen saturation is 99% on room air. Physical exam reveals, a confused, ill-appearing woman. Lungs are clear to auscultation bilaterally. An electrocardiogram is obtained as shown in Figure A. Dipstick urinalysis is notable for 4+ blood and dark colored urine. Which of the following is the most appropriate next step in management? | Albuterol and IV fluid resuscitation | Calcium gluconate | Insulin, glucose, and IV fluid resuscitation | IV fluid resuscitation | B | Calcium gluconate | This patient with confusion, dark urine, and peaked T waves on electrocardiogram in the setting of a prolonged time spent down likely has developed rhabdomyolysis with associated hyperkalemia. For patients with suspected hyperkalemia and electrocardiogram changes, the most appropriate next step in management is treatment with calcium gluconate
Rhabdomyolysis occurs when muscle cells lyse and release their intracellular contents. This can occur secondary to intense athletics, seizures, stimulant drug use, or a prolonged period of immobility. Lysis of muscle cells leads to release of potassium, myoglobin, purines, and other intracellular contents. Release of large amounts of myoglobin can result in renal impairment and myoglobinuria. On dipstick urinalysis, myoglobin causes a positive result for blood. Renal impairment further increases the risk for development of hyperkalemia. On ECG, hyperkalemia manifests with a "peaked" appearance of T waves, especially in the precordial leads. As hyperkalemia worsens, electrocardiogram changes progress to loss of P waves, QRS complex widening, and eventual sine wave rhythm. For patients with suspected hyperkalemia and characteristic changes noted on the electrocardiogram, the most appropriate immediate step in management is treatment with intravenous calcium gluconate. Calcium gluconate acts to stabilize cardiac myocyte membranes and prevent development of life-threatening arrhythmias.
Gupta et. al review rhabdomyolysis. They discuss the pathophysiology, clinical manifestations and diagnosis. They further detail complications that may arise such as hyperkalemia, and discuss respective management strategies.
Figure A demonstrates an electrocardiogram with features characteristic of hyperkalemia. Note the peaked appearance of the T waves in the precordial leads.
Incorrect Answers:
Answer A: Albuterol and IV fluid resuscitation may eventually be appropriate. Albuterol (a beta agonist) will act to shift potassium to the intracellular compartment. This patient's electrocardiogram changes warrant immediate treatment with calcium gluconate in order to stabilize cardiac myocyte membranes.
Answer C: Insulin, glucose, and IV fluid resuscitation are indicated in this patient. Insulin acts to shift potassium to the intracellular compartment, and fluid resuscitation is warranted for the patient's likely renal impairment. Calcium gluconate is the more immediate priority to prevent development of arrhythmia.
Answer D: IV fluid resuscitation is indicated for this patient with likely renal impairment. However, calcium gluconate is the more immediate priority to address this patient's hyperkalemia and prevent development of arrhythmia.
Answer E: Sodium polystyrene is an oral potassium binder that increases GI excretion of potassium. It may be appropriate to treat mild hyperkalemia in some patients. It takes a prolonged amount of time to have any significant effect.
Bullet Summary:
For patients with suspected hyperkalemia and characteristic changes noted on ECG, the most appropriate immediate step in management is treatment with intravenous calcium gluconate. | Sodium polystyrene sulfonate |
https://bit.ly/3GZtkBx | A 9-year-old girl presents to the emergency department with a fever and a change in her behavior. She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection. She also was treated for a urinary tract infection 10 weeks ago. Her mother says that last night her daughter felt ill, and her condition has been worsening. Her daughter experienced a severe headache and had a stiff neck. This morning she was minimally responsive, vomited several times, and produced a small amount of dark cloudy urine. The patient was born at 39 weeks and met all her developmental milestones. She is currently up to date on her vaccinations and did not have infections during early childhood. Her parents are divorced and her father has noted she does not seem to get sick when he takes care of her. Her temperature is 99.5°F (37.5°C), blood pressure is 60/35 mmHg, pulse is 190/min, respirations are 33/min, and oxygen saturation is 98% on room air. The patient is started on intravenous fluids, vasopressors, and broad-spectrum antibiotics. Which of the following is the most appropriate underlying explanation for this patient's presentation? | Gastroenteritis | Intentional contamination | Meningitis | Urinary tract infection | B | Intentional contamination | This patient is presenting with repeat sepsis, which is uncommon in a pediatric patient with no significant medical history. This abnormal concentration of infections when the patient is with her mother suggests a diagnosis of intentional contamination.
Factitious disorder by proxy (formerly Munchausen syndrome) occurs when 1 individual creates symptoms in another for attention. Typically, this is a parent feigning or creating symptoms in a child in order to receive the psychiatric gain of attention from healthcare personnel. The patient should be treated and removed from the parents as this is considered child abuse. Factitious disorder by proxy should be suspected in any pediatric patient who has repeat infections that are atypical or not expected epidemiologically. Patients should also be evaluated for organic causes of symptoms such as immunodeficiency syndromes.
Abeln and Love review the evidence regarding the diagnosis of factitious disorder by proxy. They discuss how these disorders have high morbidity and mortality when not accurately recognized. They recommend paying attention to red flags such as abnormal constellations of symptoms.
Incorrect Answers:
Answer A: Gastroenteritis would present with nausea, vomiting, and diarrhea; however, it would not present with sepsis routinely. Gastroenteritis does not best explain the most likely underlying cause of this patient's presentation.
Answer B: Immunodeficiency such as severe combined immunodeficiency (SCID) would present with lifelong infections from birth that are bacterial, viral, and fungal. Immunodeficiency would not present with repeat infections in a pediatric patient only when they are with one patient.
Answer D: Meningitis would present with headache, altered mental status, and meningeal signs. In the setting of repeat sepsis in a healthy pediatric patient, intentional contamination is more likely. Similarly, an absence of photophobia and no further history/physical exam supporting this diagnosis suggests an alternative diagnosis.
Answer E: Urinary tract infection would present with dysuria rather than repeat episodes of sepsis. Though a urinary tract infection could lead to sepsis, this would be rare and more likely to occur in an immunosuppressed patient, the elderly, or a neonate. UTIs are a common cause of infection and fever in pediatric patients.
Bullet Summary:
Factitious disorder by proxy occurs when 1 individual feigns or creates symptoms in another. | nan |
https://step2.medbullets.com/testview?qid=216507 | A 7-year-old boy presents to the emergency department after an episode of jerking his extremities followed by confusion. This has happened in the past, but his mother thought he was fabricating his symptoms. She has taken him to a free health clinic to have him seen by a doctor who prescribed medication; however, she has been unable to fill the prescription. He has had an MRI of the brain with no acute findings in the past. The mother states this episode lasted about 3 minutes and involved full-body jerking. After the episode, the child was non-responsive but was breathing on his own. The child has a history of migraine headaches with aura that resolve with ibuprofen. He is otherwise healthy and has no medical problems or recent illness and is up to date on his vaccinations. His temperature is 97.6°F (36.4°C), blood pressure is 100/64 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 99% on room air. The patient is protecting his airway but is unable to answer questions. He is able to move the right upper and lower extremity. He initially is unable to move his left upper and lower extremity and has a left facial droop; however, after a few minutes, he has 4/5 strength in the affected side with resolution of his facial weakness. The mother notes that this is similar to his past episodes. Which of the following is the most appropriate management? | Diazepam | Observation | Sumatriptan | CT head | B | Observation | This patient is presenting after a seizure (tonic-clonic jerking of his extremities) and is currently postictal given that he is obtunded. Given that the patient is not moving the left side of his body, he is likely suffering from Todd paralysis, which can occur after seizures and resolves on its own with only observation.
A generalized tonic-clonic seizure may present with full-body tonic-clonic activity with altered mental status. After a generalized tonic-clonic seizure, patients can be postictal and appear to be obtunded. Other than ensuring adequate oxygenation/ventilation and evaluating for the cause of the seizure, there is no further intervention needed as this postictal state will improve with time. After seizures, some patients present with Todd paralysis, which is a focal paralysis after a seizure. This may mimic a stroke, and thus the patient’s risk factors and known seizure history should be factored into the decision. Todd paralysis does not require any intervention and will improve with time and observation only.
Xu et al. review Todd paralysis. They note that Todd paralysis is characterized by temporary limb weakness or hemiplegia and usually occurs following a seizure. They recommend that it can be difficult to differentiate Todd paralysis from a stroke in certain patient populations.
Bullet Summary:
Answer A: Alteplase is a thrombolytic that could be used in an acute ischemic stroke if given within 4.5 hours of symptom onset without any contraindications to its use. It would only be given after the CT scan of the head has been performed and other reversible causes have been addressed in the setting of acute ischemic stroke. Alteplase is not given when neurologic symptoms are thought to be secondary to Todd paralysis. In fact, seizure and Todd paralysis would be a contraindication to thrombolytic use in stroke.
Answer B: CT head, in addition to a fingerstick blood glucose, should immediately be performed in all patients with sudden onset focal neurologic deficits thought to be secondary to a stroke. A stroke would present with sudden onset focal neurologic deficits. However, it is common for patients to be obtunded and have focal neurologic deficits after a seizure and this would not warrant a stroke workup unless clinical suspicion exists. This patient has no risk factors for stroke and his improving strength suggests against a stroke. Moreover, he has a history of a normal MRI of the brain.
Answer C: Diazepam would only be given for a patient who is actively seizing as it is a benzodiazepine with a long half-life. Note that it is not indicated in a postictal patient as there is no ongoing seizure. Benzodiazepines are not given as preventive measures for seizures.
Answer E: Sumatriptan may be indicated to treat a migraine, which presents with a pulsatile, unilateral headache and is more common in women. Hemiplegic migraine can cause focal neurologic deficits, and it would be reasonable to treat a migraine headache if a patient had focal neurologic deficits and a history of known hemiplegic migraines. Patients will either have a frequent history of hemiplegic migraines themselves or in their family.
Bullet Summary:
Focal neurologic deficits (Todd paralysis) can be seen after a seizure and will resolve with observation. | nan |
https://step2.medbullets.com/testview?qid=215182 | A 68-year-old man presents for evaluation by a neurologist for an involuntary hand tremor that started approximately 3 months ago. The shaking improves when he reaches for objects but returns when he is not using his hand. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. His left hand exhibits a 4-6 Hz tremor when resting on his lap. The tremor extinguishes with voluntary movement. In addition, his left upper extremity has increased tone with passive range of motion. Which of the following is the most likely diagnosis? | Cerebellar stroke | Essential tremor | Huntington disease | Lacunar stroke | E | Parkinson disease | This patient who presents with a low amplitude, 4-6 Hz resting tremor that resolves with voluntary movement and associated rigidity most likely has Parkinson disease.
Parkinson disease is caused by degeneration of dopaminergic neurons in the substantia nigra pars compacta of the basal ganglia. This neurodegenerative process leads to movement abnormalities such as bradykinesia, “cogwheel” muscle rigidity (intermittently increased muscle tone with passive range of motion), shuffling gait, postural instability, and a resting tremor sometimes referred to as “pill-rolling” in quality. Parkinson disease usually presents with unilateral symptoms and subsequently progresses to bilateral involvement. First-line treatment involves dopaminergic drugs such as carbidopa-levodopa. Antimuscarinic agents can also be used for symptom control.
Zhong et al. review the role of the cerebellum in tremor in Parkinson disease. The authors find that the cerebellum may modulate tremor amplitude via cerebello-thalamo-cortical circuits. The authors recommend further study of the cerebellum as an alternative therapeutic target in Parkinson patients with dopamine-resistant tremors.
Incorrect Answers:
Answer A: Cerebellar stroke can manifest as an intention tremor, which presents as an oscillatory tremor that increases in amplitude at the endpoint of visually goal-directed movement. Intention tremors are best exhibited in the finger-nose-finger test in which the patient repeatedly touches their nose and then extends their arm to touch the examiner's finger. Patients would also have more severe symptoms including ataxia, nausea, vomiting, and nystagmus.
Answer B: Essential tremor is a condition that is often familial and presents as a high frequency (4-9 Hz) tremor that occurs with sustained posture and is worsened with movement. Treatment includes propranolol and primidone.
Answer C: Huntington disease is an autosomal dominant trinucleotide repeat disorder that leads to neurodegeneration of the caudate and putamen. Chorea is a hallmark movement abnormality associated with Huntington disease and presents with spontaneous, jerking, purposeless involuntary movements.
Answer D: Lacunar stroke can result in ischemia to the subthalamic nucleus and produce hemiballismus. This presents as spontaneous unilateral explosive movements of an upper extremity and occasionally the ipsilateral lower extremity. Other motor deficits are also expected when there is a lacunar infarct.
Bullet Summary:
Resting tremor is a hallmark of Parkinson disease and presents with low amplitude, 4-6 Hz oscillatory rhythmic movements that temporarily extinguish with voluntary movement. | Parkinson disease |
https://step2.medbullets.com/testview?qid=217241 | A 72-year-old man with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia presents to his primary care provider for concerns about his cognitive decline. His wife has noticed that he has a worsening ability to organize, plan, and exhibit impulse control over the last month. The patient states that he is able to complete his activities of daily living without assistance, but has some weakness of his left upper and lower extremities that began 3 months prior. He needs reminders from his wife about daily tasks to complete. He enjoys spending time with his spouse, playing cards with his friends, and taking daily walks around his neighborhood. His temperature is 98.2°F (36.8°C), blood pressure is 149/87 mmHg, pulse is 87/min, and respirations are 12/min. Physical exam reveals an elderly man who is oriented to person, place, and time. He has 4/5 left-sided weakness of the upper and lower extremities and associated pronator drift of the left upper extremity. A mini-mental status exam reveals he is able to remember 2 out of 3 words after 4 minutes. He is able to appropriately draw a clock. A magnetic resonance imaging study of the brain is shown in Figure A. Which of the following is the most likely diagnosis? | Alzheimer disease | Mild cognitive impairment | Normal aging | Pseudodementia | E | Vascular dementia | This patient with cardiovascular risk factors (hypertension, type 2 diabetes mellitus, hyperlipidemia) who presents with sudden cognitive decline of executive function and neurologic symptoms consistent with vasculopathy and possible prior stroke given his neurologic exam likely has vascular dementia, which can be corroborated with magnetic resonance imaging revealing white matter focal involvement consistent with vascular infarcts.
Vascular dementia is a form of dementia that results from compromise of blood supply to the brain, such as minor strokes or microinfarcts to the white matter. These insults lead to worsening cognitive abilities and presents classically as a stepwise decline (sudden/sharp declines in cognitive function that occur at distinct periods of time, not gradually) in cognitive function (thinking, planning, self-control, flexibility in thought). This is often associated with neurologic deficits as byproducts of these strokes. Unlike other forms of dementia, this presentation is step-wise. Treatment involves optimizing medical management to treat underlying medical comorbidities (managing cardiovascular risk factors such as hypertension, type 2 diabetes mellitus, hyperlipidemia), physical therapy/rehab for stroke symptoms, and caregiver support at home. Magnetic resonance imaging reveals focal white matter changes consistent with small vascular infarcts.
Khan et al. review the diagnosis and management of vascular dementia while including commentary on recent updates in the literature. They found that risk factors for vascular diseases such as stroke, high blood pressure, high cholesterol, and smoking also raise the risk of vascular dementia. They thus recommend medical management of underlying medical comorbidities such as hypertension, diabetes mellitus, or hyperlipidemia as treatments for vascular dementia.
Figure/Illustration A shows magnetic resonance imaging with white matter small vessel ischemic changes (red arrows) characteristic of vascular dementia within a background of diffuse generalized atrophy.
Incorrect Answers:
Answer A: Alzheimer disease is a form of dementia that presents with progressive forgetfulness as the first and most jarring clinical symptom, followed by worsening visual/spatial recognition, and then worsening behavioral function. It is most common in patients over the age of 75. It is not associated with focal deficits or weakness on neurological exam.
Answer B: Mild cognitive impairment is a stage between the expected cognitive decline of normal aging and forms of dementia. Patients and family members may notice problems with memory, thinking, or judgment, but they are not significant enough to cause interference with activities of daily living.
Answer C: Normal aging does not involve a noticeable decline in cognition and does not involve neurologic deficits. Declines are present, but are infrequent and do not impede activities of daily living.
Answer D: Pseudodementia is the result of untreated depression, which can present as forgetfulness in the elderly. This etiology can be distinguished by screening for signs or symptoms of depression, which might include sleep disturbance, anhedonia, lack of energy, increased or decreased appetite, fatigue, and/or loss of concentration. These symptoms are absent in this case.
Bullet Summary:
Vascular dementia presents with a step-wise decline in executive cognitive function and neurologic deficits in a patient with cardiovascular risk factors and is associate with MRI findings including white matter changes consistent with vascular infarcts. | Vascular dementia |
https://bit.ly/3DkrY2C | A 54-year-old man presents to the clinic with 4 weeks of persistently worsening back pain. The pain is localized to 1 spot in his lower back and is worse with physical activity. His medical history is pertinent for intravenous drug use. He has no past surgical history. His temperature is 36.8°C (98.2°F), blood pressure is 118/90 mmHg, pulse is 92/min, respirations are 13/min, and oxygen saturation is 99% on room air. On physical exam, he has midline back tenderness to palpation at L2-L3. Laboratory workup reveals an erythrocyte sedimentation rate of 112 mm/h and C-reactive protein of 10 mg/dL. Which of the following is the most likely diagnosis? | Ankylosing spondylitis | Osteomyelitis | Degenerative spine disease | Metastatic tumor | B | Osteomyelitis | This patient with a history of intravenous drug use who presents with worsening focal back pain and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) most likely has vertebral osteomyelitis.
Vertebral osteomyelitis typically occurs via three routes: hematogenous spread from a distant site (the most common mechanism), direct inoculation from spinal surgery or trauma, or contiguous spread from adjacent soft tissue infection. Patients usually present with back or neck pain, with or without fever, and the most common clinical finding is local tenderness to percussion over the involved posterior spinous process. Risk factors include injection drug use, degenerative spine disease, prior spinal surgery, infective endocarditis, diabetes mellitus, corticosteroid therapy, and other immunocompromised states. Vital signs may be normal, and laboratory evaluation commonly reveals an elevated white blood cell count, ESR, and CRP. An MRI of the spine is the most appropriate diagnostic test. In stable patients, antimicrobial therapy should be withheld until a microbiological diagnosis is confirmed; once the diagnosis is confirmed, pathogen-directed therapy should then be administered.
Beronius et al. conducted a retrospective study on vertebral osteomyelitis in pursuit of diagnostic criteria to simplify the diagnosis and classification of vertebral osteomyelitis. The authors found that elevated ESR and CRP are found in most patients with vertebral osteomyelitis. The authors recommend clinicians have a high index of suspicion for vertebral osteomyelitis in order to avoid delayed diagnosis.
Incorrect Answers:
Answer A: Ankylosing spondylitis is an inflammatory arthritis of the spine and is often associated with one or more articular or periarticular extraspinal features, including synovitis, dactylitis, and enthesitis. Patients typically present with chronic back pain and loss of mobility before the age of 45.
Answer B: Degenerative spine disease involves osteoarthritis of the spine and is associated with increasing age, presenting commonly as sharp or chronic pain in the neck or back. It typically does not result in radiculopathy, defined as irritation or injury of a nerve root, causing pain, weakness, numbness, or tingling in specific distributions depending on the location of the affected nerve root. Though it is certainly on the differential for this patient, his elevated ESR and CRP make osteomyelitis a more likely diagnosis.
Answer C: Herniated disc can cause a variety of symptoms depending on the position and size of the herniation. If the herniated disk impinges on a nerve, patients may have radiculopathy.
Answer D: Metastatic tumor is typically suspected in patients with back pain in the setting of a known malignancy. The most common primary cancers that metastasize to bone include breast, prostate, thyroid, lung, and renal cancer.
Bullet Summary:
Vertebral osteomyelitis typically presents as focal back pain, with or without fever, with an elevated erythrocyte sedimentation rate and C-reactive protein. | nan |
https://step2.medbullets.com/testview?qid=109242 | A 7-week-old boy presents to the pediatrician for vomiting. Three weeks ago, the patient began vomiting after meals. The vomitus appears to be normal stomach contents without streaks of red or green. His parents have already tried repositioning him during mealtimes and switching his formula to eliminate cow’s milk and soy. Despite these adjustments, the vomiting has become more frequent and forceful. The patient is voiding about 4 times per day and his urine appears dark yellow. He has fallen 1 standard deviation off of the growth curve. The patient's mother reports that the pregnancy was uncomplicated other than an episode of sinusitis in the 3rd trimester, for which she was treated with azithromycin. The patient's temperature is 98.7°F (37.1°C), blood pressure is 58/41 mmHg, pulse is 166/min, and respirations are 16/min. On physical exam, the patient looks small for his age. His abdomen is soft, non-tender, and non-distended. Which of the following is the most appropriate next step in management? | Abdominal ultrasound | Intravenous hydration | MRI of the head | Pyloromyotomy | B | Intravenous hydration | This patient presents with nonbilious, forceful vomiting, poor weight gain, signs of dehydration, and a history of exposure to azithromycin, which suggests a diagnosis of pyloric stenosis. The most appropriate next step in management is intravenous hydration.
Pyloric stenosis classically presents in a male infant between 4 to 6 weeks of age with nonbilious, projectile vomiting after meals. Risk factors for pyloric stenosis include bottle feeding and exposure to macrolide antibiotics in the patient or mother. Protracted vomiting frequently leads to hypochloremic, hypokalemic metabolic alkalosis. Patients should be resuscitated with intravenous hydration and evaluated for electrolyte abnormalities that require repletion. After a patient is adequately resuscitated, patients can undergo an ultrasound to confirm the diagnosis and then be treated surgically for definitive therapy.
Adams and Stanton review the evidence regarding the diagnosis and treatment of neonatal bowel obstruction. They discuss how malrotation, jejunoileal atresia, duodenal atresia, and colonic atresia are common causes of this finding. They recommend surgical management of these conditions.
Incorrect Answers:
Answer A: Abdominal ultrasound is the test of choice to diagnose pyloric stenosis, but evaluation for electrolyte derangements and subsequent intravenous hydration and electrolyte repletion should be initiated first in this patient with signs of dehydration and malnutrition. Further evaluation is reserved after a patient is adequately resuscitated.
Answer B: MRI of the head would be appropriate if this patient had additional signs of a mass in the head, such as neurological changes or worsening of the vomiting in the morning. In the absence of these signs and the presence of a mass in the epigastrium, this patient is more likely to have pyloric stenosis.
Answer C: Pyloromyotomy is the definitive management of pyloric stenosis, but this patient should undergo fluid replacement and have any electrolyte derangements detected and managed before undergoing surgery. Surgical intervention can carry significant risks if patients are not adequately resuscitated.
Answer E: Thickening feeds are one of the techniques used to manage gastroesophageal reflux. In the setting of this patient’s epigastric mass and clinical picture, pyloric stenosis is the more likely etiology of his vomiting. Reflex presents with non-projectile vomiting that is dependent on position.
Bullet Summary:
Patients with pyloric stenosis should first undergo intravenous rehydration and electrolyte repletion, as protracted vomiting may lead to severe hypochloremic, hypokalemic metabolic alkalosis. | Thickening feeds |
https://step2.medbullets.com/testview?qid=216626 | A 55-year-old man presents to the emergency department after feeling lightheaded then fainting while he was carrying boxes upstairs. The patient works on a farm and does not see a doctor often. He has a history of hypertension but does not take medications routinely. He has not had any chest pain, dyspnea, or weakness during this time frame and currently feels at his baseline. He smokes cigarettes occasionally. His temperature is 98.1°F (36.7°C), blood pressure is 152/93 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable and the patient walks with a stable gait and no focal weakness. An ECG is performed as seen in Figure A. Laboratory studies are ordered as seen below.
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 197,000/mm^3
Serum:
Na+: 140 mEq/L
Cl-: 102 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 139 mg/dL
Creatinine: 1.1 mg/dL
Troponin: < 0.01 ng/mL
Which of the following is the most likely diagnosis? | Wolff Parkinson White syndrome | ST elevation myocardial infarction | Torsades des pointes | Left ventricular hypertrophy | D | Left ventricular hypertrophy | This patient with chronic untreated hypertension is presenting with syncope and an ECG demonstrating large voltages in leads V1-V6 and a left ventricular strain pattern (ST depressions in V5/V6 and aVL), which are concerning for left ventricular hypertrophy.
Left ventricular hypertrophy occurs secondary to chronic hypertension or conditions that increase afterload such as aortic stenosis. This leads to an increase in the mass of the left ventricle. There are many possible criteria on ECG for left ventricular hypertrophy including left axis deviation, large R waves, a large S wave in aVR, or ST segment depression and T wave inversion in the left heart leads (referred to as left ventricular strain). A more simple method of recalling left ventricular hypertrophy is very large voltages in the ECG leads that serve the left ventricle. Left ventricular hypertrophy should be considered in presentations such as syncope. Note that while ECG findings suggest left ventricular hypertrophy, the diagnosis must be supported with echocardiography. Management involves treating the underlying cause (most commonly, this is hypertension).
Artham et al. discuss left ventricular hypertrophy. They note that it is a risk factor for future cardiac events and increased mortality. They recommend early diagnosis and management to improve outcomes.
Figure/Illustration A is an ECG with very large voltages (red arrows) and ST segment depressions/T wave inversions (blue arrows, a more classic left ventricular strain pattern), concerning for left ventricular hypertrophy.
Incorrect Answers:
Answer B: Non-ST elevation myocardial infarction would present with nonspecific ST segment and T wave changes with an elevated troponin. While this patient does demonstrate ST depressions in the lateral leads, the troponin level is normal.
Answer C: ST elevation myocardial infarction would present with ST elevation in a vascular distribution on ECG in the setting of chest pain, diaphoresis, and an elevated troponin level. Note that this patient’s lack of symptoms (pain) and normal troponin in the setting of the ST elevation in leads V1-V3 make this unlikely to be ST elevation myocardial infarction and more likely to be left ventricular hypertrophy.
Answer D: Torsades des pointes occurs in patients with a prolonged QT interval that evolves into twisting of the QRS complexes around an isoelectric baseline. It may cause syncope or cardiac arrest. Note there is no QT prolongation on this patient’s ECG that would predispose him to this condition.
Answer E: Wolff Parkinson White syndrome presents with a delta wave on ECG (a slurred upstroke into the QRS complex) and may undulate with supraventricular or ventricular tachycardia. There is no delta wave in this patient’s ECG supporting this diagnosis. Ablation is the most effective long-term treatment.
Bullet Summary:
Left ventricular hypertrophy can be associated with syncope and presents with large voltages in the leads that serve the left ventricle and a left ventricular strain pattern. | nan |
https://step2.medbullets.com/testview?qid=216637 | A 55-year-old man presents to the emergency department after fainting while moving furniture. He states that he has been working in a hot, humid attic all day and forgot his water bottle. He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute. He awoke at his neurologic baseline afterwards. The patient has a history of hypertension being managed by his primary care doctor. His temperature is 98.7°F (37.1°C), blood pressure is 149/82 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals a diaphoretic man. He demonstrates an unremarkable cardiopulmonary exam. The patient walks with a steady gait and his neurologic exam is non-focal. An ECG is performed as seen in Figure A. The patient is given 2 liters of oral fluids and feels back to his baseline. Which of the following conditions is most likely to occur in this patient based on his current history and ECG? | Atrial fibrillation | Torsades des pointes | Stroke | Complete heart block | D | Complete heart block | This patient is presenting with dizziness and syncope in the setting of likely dehydration (working in a hot/humid environment without water) and feels better after rehydration, suggesting a diagnosis of orthostatic hypotension. An ECG is performed and incidentally demonstrates a bifascicular block, which is at high risk of progressing to a complete heart block.
Bifascular block is a conduction abnormality in 2 of the 3 fascicles that conduct electricity from atria to ventricles. This leaves conduction to the ventricles via the single remaining fascicle. There are different possibilities that may present on ECG. One possibility is a right bundle branch block with a left anterior fascicular block; the other is a right bundle branch block with a left posterior fascicular block. Note that the pathophysiology of complete heart block is an inability to conduct electricity from the atria to the ventricles. If there is only 1 fascicle left to conduct electricity, the patient would be in complete heart block if this fascicle were to no longer work, which is a common outcome in patients with bifascicular block. Treatment of complete heart block involves the placement of a pacemaker.
Wiberg et al. discuss bifascicular block. They note the possible outcome of a complete heart block. It is recommended to look for this finding on ECG and appropriately workup patients to prevent progression of disease.
Figure/Illustration A is an ECG demonstrating bifascicular block. Note the left axis deviation as suggested by the net upward deflection of the QRS in lead I and net downward deflection in lead II (blue arrows). Then, note the appearance of a right bundle branch block with the RSR pattern in aVR (black arrow) and upward R’ in lead V1 (green arrow). This is a classic pattern for bifascicular block. Contrast this to the other pattern of bifascicular block which would present with a right bundle branch block and right axis deviation (upward QRS in lead II and downward in lead I), which was not seen in this case.
Incorrect Answers:
Answer A: Atrial fibrillation may occur secondary to aging, hypertension, or ischemia and presents with an irregularly irregular rate and rhythm with an absence of P waves. It may cause complications such as stroke. Management typically involves rate control agents such as beta-blockers or calcium channel blockers.
Answer C: Myocardial infarction is a likely outcome in individuals with risk factors such as obesity, hypertension, smoking, and dyslipidemia, in particular, without proper preventive measures and medical therapy including statins, beta blockers, and ACE inhibitors. This patient may be at risk of a myocardial infarction with his hypertension, and his underlying bifascicular block could suggest undiagnosed cardiac ischemia; however, it is more likely this patient progresses to complete heart block in the setting of his bifascicular block.
Answer D: Stroke is a possible complication of atrial fibrillation. For this reason, most patients with atrial fibrillation are on blood thinners to prevent this complication. It occurs secondary to stasis of blood in the fibrillating left atrium. Patients are often risk stratified prior to starting blood thinners with tools such as CHADS2VASC and HASBLED. Isolated syncope is a rare manifestation of stroke.
Answer E: Torsades des pointes is a progression from QT prolongation which may occur secondary to genetic conditions, medications, and/or infection. It presents on ECG with QRS complexes that twist in amplitude around the electrical baseline. Treatment involves the administration of magnesium sulfate and, if needed, electrical cardioversion.
Bullet Summary:
A bifascicular block can progress to complete heart block. | nan |
https://bit.ly/448sWLu | A 25-year-old man presents to his primary care physician with anxiety and fatigue. During this past week, he has been unable to properly study and prepare for final exams because he is exhausted. He has been going to bed early but is unable to get a good night’s sleep. He admits to occasional cocaine and marijuana use. Otherwise, the patient has no significant medical history and is not taking any medications. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, the patient is a tired and anxious appearing young man. His neurological exam is within normal limits. The patient states that he fears he will fail his courses if he does not come up with a solution. Which of the following is the most appropriate initial step in management? | Polysomnography | Sleep hygiene education | Alprazolam | Melatonin | B | Sleep hygiene education | This patient is presenting with trouble sleeping without a known organic cause, for which the most appropriate initial step in management is to discuss sleep hygiene with the patient.
In any patient that presents with a chief complaint of fatigue, it is always best to assess how they are sleeping. After a physical exam is performed in order to rule out signs or symptoms of a severe organic cause (neurologic deficits), the most appropriate initial step in management is to discuss sleep hygiene with the patient. Sleep hygiene includes discussing the patient’s exposure to light (eliminate exposure to blue light at night), altering diet (no large meals or caffeine before bed), and behavioral modification (only using the bed for sleep). Once a trial of proper sleep hygiene has been tried, then it would be appropriate to potentially move on to other interventions including pharmacological interventions.
Horne presents evidence regarding the best sleep hygiene practices. He discusses how exercise and avoidance of caffeine near bedtime is beneficial to helping with insomnia. He recommends using these interventions prior to pharmacologic treatment.
Incorrect Answers:
Answer A: Alprazolam is a benzodiazepine that could be used to help with this patient’s anxiety and could help them sleep. However, benzodiazepines are potent drugs with addictive properties and would not be used as first-line treatment for insomnia. Lifestyle modifications should be tried first to determine if these will be effective in helping the patient sleep.
Answer B: Melatonin is a supplement that is often used to improve sleep quality. Starting the patient on a supplement is plausible as an initial step in management, but it would not take precedence over educating the patient regarding sleep hygiene. These interventions often are very effective and have no side effects.
Answer C: Polysomnography could be the most appropriate initial step in management if an organic cause for this patient’s sleep problems (such as obstructive sleep apnea) is suspected. There is nothing suggesting an organic cause for this patient’s sleep issues and it is highly likely that a college-age student near finals period would benefit from a discussion on sleep hygiene prior to an expensive diagnostic test such as polysomnography.
Answer E: Zolpidem is a muscle relaxant and hypnotic with a similar mechanism of action to a benzodiazepine. Zolpidem has the potential to be addicting and would not be tried prior to sleep hygiene interventions. Some patients who are refractory to other interventions may benefit from the use of Zolpidem.
Bullet Summary:
Any patient that presents with fatigue and trouble sleeping without a clear organic cause should first be counseled in sleep hygiene habits prior to any other interventions or diagnostic tests. | nan |
https://bit.ly/3s3wiAZ | A 67-year-old man is seen on the surgical floor after a transplant procedure. The previous day, the patient had a renal transplant from a matched donor. He is currently recovering and doing well. The patient has a medical history of IV drug use, diabetes mellitus, oral cold sores, hypertension, renal failure, and dyslipidemia. The patient's current medications include lisinopril, atorvastain, insulin, and aspirin. Prior to the procedure, he was also on dialysis. The patient is started on cyclosporine. The patient successfully recovers over the next few days. His temperature is 98.5°F (36.9°C), blood pressure is 121/76 mmHg, pulse is 70/min, and respirations are 13/min. Which of the following medications should be started in this patient? | Azithromycin | Low dose acyclovir | Penicillin | TMP-SMX | D | TMP-SMX | This patient is presenting status post renal transplant and is currently on immunosuppressive therapy. This patient should be started on TMP-SMX as prophylaxis against Pneumocystis jiroveci pneumonia (PJP).
After a transplant procedure, patients are started on immunosuppressive therapy in order to avoid rejection of the transplanted organ. The most important interventions for a patient after a transplant procedure are to receive all of their vaccinations and to receive TMP-SMX as prophylaxis against PJP. Other appropriate but less dire measures include giving ganciclovir as prophylaxis against cytomegalovirus (CMV). Patients should be closely monitored to avoid transplant rejection as well as infection.
Weyant et al. review the evidence regarding the treatment of patients with PJP. They discuss how TMP-SMX has been the classic prophylaxis and treatment for this disease. They recommend considering echinocandins for patients who experience significant side effects.
Incorrect Answers:
Answer A: Azithromycin is appropriate prophylaxis for patients with HIV with CD4 counts < 50. Patients on immunosuppressive drugs should receive some of the same prophylactic medications but they do not require azithromycin upon initiation of immunosuppressive medications.
Answer B: Low-dose acyclovir would be an inappropriate intervention in this patient after a transplant procedure. Ganciclovir and high-dose acyclovir are the appropriate options for prophylaxis of CMV.
Answer C: Penicillin can be used as prophylaxis for patients with rheumatic heart disease or asplenia; however, it would not be the most appropriate initial measure in a transplant patient.
Answer E: Valacyclovir is the treatment for herpes simplex virus (HSV). It is not routinely indicated as prophylaxis in transplant patients. HSV will present with vesicular rashes developing on the affected areas.
Bullet Summary:
Patients on immunosuppressive therapy after a transplant should be vaccinated (pneumovax, hepatitis A and B, influenza, and tetanus-diphtheria) and started on TMP-SMX. | Valacyclovir |
https://step2.medbullets.com/testview?qid=216264 | A 69-year-old man passes away after a 3-week hospitalization for liver failure, complicated by a myocardial infarction. A medical student rotating in the intensive care unit asked if she can practice performing intubations during her rotation. The resident suggests performing one on the deceased patient, as the student cannot harm him. Which of the following is the most appropriate course of action for the medical student? | Ask the resident if the patient’s family or the patient has been consented for this procedure | Consult the hospital ethics committee | Contact the patient's family to ask for permission to perform the procedure | Intubate the patient with the resident's supervision | A | Ask the resident if the patient’s family or the patient has been consented for this procedure | This medical student wants to perform a procedure on a deceased patient for educational purposes. Before proceeding, the student should ensure that permission has been obtained from the patient's family or the patient when he was alive.
Performing procedures on deceased patients is ethically permissible with appropriate consent and consideration of risks and benefits for patients, families, learners, staff, and the field of medicine. Supervising physicians must obtain informed consent from the patient while alive and with capacity or from a newly deceased patient’s healthcare proxy or family. During the consent process, the supervisor should outline the patient's and family's rights, wider educational and societal benefits, potential risks, and ensure that performing the procedure would be consistent with the patient's values and wishes. Additionally, the supervising physician has a responsibility to ensure that a medical examiner has cleared the patient and that the patient is not an organ donor before proceeding. Finally, the procedure should be documented in the patient's chart.
Berger and Cassell review the ethics of practicing procedures on deceased patients. They note that some ethical norms may suggest this practice is not appropriate. They recommend performing procedures when consent is obtained and it is ethically acceptable to do so.
Incorrect Answers:
Answer B: Consulting the hospital ethics committee is not necessary, for with proper permission, trainees may perform procedures on deceased patients for educational purposes. The ethics committee should only be consulted when there is no clear course of action (an example may be no advanced directive with family members disagreeing on what the patient's wishes would have been for a critically ill patient).
Answer C: Contacting the patient's family to ask for permission to perform the procedure is incorrect, as the supervising physician needs to verify and document consent. Medical students cannot consent patients and family members. Moreover, the family should not be contacted if the patient has already approved or refused this when he had capacity.
Answer D: Intubating the patient with the resident's supervision is incorrect because proper permission must be ensured prior to performing educational procedures on deceased patients.
Answer E: Reporting the resident to hospital administration is incorrect because it is ethically permissible to perform an intubation on a deceased patient provided there is proper permission. The resident is not asking the medical student to do anything illegal or against hospital policy. Reporting the resident may be indicated if the resident was performing procedures against the patient's will.
Bullet Summary:
Trainees may perform procedures for educational purposes on deceased patients if permission is obtained from the patient prior to death, the patient's family, or a healthcare proxy. | Report the resident to hospital administration |
https://step2.medbullets.com/testview?qid=108987 | A 71-year-old woman arrives to clinic with sudden vision loss. She was in her usual state of health until waking up this morning unable to see out of her right eye. She denies pain, but reports her right eye “feels funny.” The patient’s medical history is significant for a previous myocardial infarction, hypertension, and osteoporosis. Her current medications include aspirin, metoprolol, rosuvastatin, lisinopril, and alendronate. Her temperature is 98°F (36.7°C), blood pressure is 145/86 mmHg, pulse is 62/min, and respirations are 12/min with an oxygen saturation of 98% on room air. The patient's pupils are symmetric in size and equally reactive to light with accommodation. A fundoscopic exam of the right eye is shown in Figure A. The left optic fundus is unremarkable. Which of the following is the most likely diagnosis? | Papilledema | Retinal vein occlusion | Retinal detachment | Closed angle glaucoma | B | Retinal vein occlusion | This patient is presenting with sudden, painless, unilateral vision loss with a fundoscopic exam positive for venous dilation and retinal hemorrhage. These findings are consistent with the diagnosis of retinal vein occlusion.
Retinal vein occlusion can occur in either central or branch retinal veins and is often caused by compression from nearby arterial atherosclerosis. It presents as acute onset, painless vision loss, normally in one eye. On fundoscopic exam, classic findings of this disease include venous engorgement, retinal hemorrhage, cotton wool exudates, and edema/swelling of the optic disk can be seen. There is no definitive treatment for this disorder but symptomatic treatment includes intravitreal glucocorticoid injections and retinal laser photocoagulation. Retinal vein occlusion may resolve spontaneously or progress to permanent vision loss.
Robinson and Halpern present evidence regarding the treatment of retinal vein occlusion. They discuss how the treatments for the acute phase of this disease have been disappointing. They recommend managing long-term complications such as neovascularization with phototherapy.
Figure/Illustration A is a fundoscopic exam showing engorged retinal veins, optic disk swelling, and widespread retinal hemorrhages (red circle). These findings are characteristic of central retinal vein occlusion.
Incorrect Answers:
Answer A: Central retinal artery occlusion can present as sudden onset, unilateral vision loss. Fundoscopic exam will show a “cherry-red” spot at the fovea and a “fuzzy” retina with attenuated vessels. Embolic sources may include carotid artery atherosclerosis or cardiac vegetation. Treatment is with risk factor control.
Answer B: Closed-angle glaucoma presents as sudden, painful, vision loss caused by increased intraocular pressure. The eye will appear red and often feel “hard.” The optic disc will show characteristic cupping. Intraocular pressure will be levated and treatment is with acetazolamide, steroids, timolol, bromidine, and pilocarpine. Irodotomy is reserved for refractory cases.
Answer C: Papilledema may present as an enlargement in the blind spot and is usually bilateral, as it is caused by increased intracranial pressure. On fundoscopic exam, there will be bilateral optic disk swelling, seen as an elevated optic disk and blurred margins. Patients should undergo a neurologic evaluation to determine the etiology of the papilledema.
Answer D: Retinal detachment presents as monocular loss of vision, often described as a “curtain pulled down,” and preceded by “flashers” and “floaters.” On fundoscopic exam, crinkling of the retinal tissue and abrupt changes in vessel direction can be seen. Surgical reattachment of the retina is required to prevent loss of vision.
Bullet Summary:
Retinal vein occlusion presents with a sudden, monocular, painless loss of vision with optic disk swelling, dilated veins, cotton wool spots, and retinal hemorrhages. | nan |
https://bit.ly/3BSwAMD | An 18-year-old man presents to his primary care provider with his parents for a sports physical. He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD). He was started on methylphenidate at that time and the patient now reports improvement in his ability to concentrate in school and at home. He hopes to play baseball in college and has begun lifting weights daily in preparation for baseball season. The patient has a healthy diet to fuel his exercise regimen. His parents have no concerns and are pleased with the recent improvement in his grades. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, the patient has tall stature with average muscle mass for his age. He has no dysmorphic features. His chest has a normal appearance other than mild gynecomastia. The patient has sparse facial hair and a moderate amount of coarse pubic hair that extends across the pubis and spares the medial thighs. His testes are small and firm. Laboratory testing is performed and reveals the following:
Follicle-stimulating hormone (FSH): 42 mIU/mL
Luteinizing hormone (LH): 38 mIU/mL
Which of the following is the most likely etiology of this patient’s presentation? | CGG trinucleotide repeat disorder | Anabolic steroid use | Failure of neuronal migration | Meiotic nondisjunction | D | Meiotic nondisjunction | This patient presents with tall stature, gynecomastia, and small testes with elevated FSH and LH, which suggests a diagnosis of Klinefelter syndrome. Klinefelter syndrome is usually caused by meiotic nondisjunction that results in a 47,XXY genotype.
Klinefelter syndrome is the most common cause of primary hypogonadism. Patients with Klinefelter syndrome present with tall stature, neurocognitive difficulties (ADHD), and features of hypogonadism including gynecomastia, small testes, small phallus, hypospadias, underdeveloped secondary sex characteristics, and cryptorchidism. Patients without hypospadias or cryptorchidism are often not diagnosed until after puberty when the symptoms of gynecomastia and small testes become more prominent. Because the hypogonadism in Klinefelter syndrome is caused by testicular fibrosis, laboratory results demonstrate low testosterone and elevated FSH and LH levels. Treatment for this condition includes androgen replacement therapy.
Lanfranco et al. review the evidence regarding the treatment of Klinefelter syndrome. They discuss how modern fertility augmentation therapy has allowed some of these patients to produce viable offspring. They recommend having a detailed discussion with these patients and their partners regarding possible outcomes.
Incorrect Answers:
Answer A: Anabolic steroid use causes decreased levels of FSH and LH due to the suppression of GnRH release by the hypothalamus. This results in decreased FSH and LH release by the pituitary gland. Anabolic steroid use would not present with signs of hypogonadism.
Answer B: The CGG trinucleotide repeat disorder characterizes fragile X syndrome. Fragile X presents with macroorchidism rather than hypogonadism and patients typically have dysmorphic features of a long, narrow face with large ears, a prominent forehead, and a prominent chin. Fragile X is the most common cause of inherited intellectual disability.
Answer C: The CTG trinucleotide repeat disorder characterizes myotonic dystrophy. Although myotonic dystrophy presents with hypogonadism, patients would also present with symptoms of progressive weakness, such as facial weakness, dysphagia, or hand grip weakness. Treatment is with cardiac pacemakers and ventilatory support.
Answer D: Failure of neuronal migration characterizes Kallmann syndrome. Kallmann syndrome presents with the classic symptoms of anosmia and hypogonadism, but patients with Kallmann syndrome have a low FSH and LH. Treatment is with hormone replacement therapy.
Bullet Summary:
Klinefelter syndrome results in primary hypogonadism and presents with tall stature, gynecomastia, small testes, a small phallus, hypospadias, and cryptorchidism. | nan |
https://bit.ly/3LoaHJF | A 28-year-old woman presents to her primary care provider with a headache. Every few weeks she has an episode of a right-sided, throbbing headache. The episodes began several years ago and are accompanied by nausea and bright spots in her vision. The headache usually subsides if she lies still in a dark, quiet room for several hours. The patient denies any weakness, numbness, or tingling during these episodes. Her medical history is significant for acne, hypothyroidism, obesity, and endometriosis. Her home medications include levothyroxine, oral contraceptive pills, and topical trans-retinoin. Her temperature is 98.6°F (37°C), blood pressure is 125/81 mmHg, pulse is 64/min, and respirations are 11/min. She has 2 glasses of wine with dinner several nights a week and has never smoked. She works as a receptionist at a marketing company. On physical exam, the patient has no focal neurologic deficits. A CT of the head is performed and shows no acute abnormalities. Which of the following is the most appropriate treatment for this patient during these episodes? | Topiramate | Sumatriptan | Acetazolamide | High-flow oxygen | B | Sumatriptan | This patient presents with episodic, unilateral throbbing headaches with photophobia, which suggests a diagnosis of migraine. The most appropriate treatment during these episodes is an abortive medication such as sumatriptan.
Migraines present with unilateral, "throbbing" pain and are associated with nausea and vomiting, photophobia, and phonophobia. Migraines can occur after exposure to specific triggers or they can occur idiopathically. Patients may also endorse visual auras such as bright lines or shapes in the visual field and sensory auras such as paresthesias. Medications like NSAIDs or sumatriptan are usually used as abortive treatment during acute episodes of migraine. Patients with recurrent migraines can be managed with prophylactic medications like topiramate, beta-blockers, or amitriptyline.
Mayans and Walling present evidence regarding the treatment of migraines. They discuss how acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, antiemetics, ergot alkaloids, and combination analgesics are effective against this disease. They recommend providing these treatments in order to mitigate symptoms.
Incorrect Answers:
Answer A: Acetazolamide is used to treat idiopathic intracranial hypertension (IIH). IIH is most commonly seen in obese women of childbearing age and can be caused by medications such as oral isotretinoin (not topical tretinoin, as in this case) and tetracyclines. The initial symptom is usually a pulsatile headache that worsens with lying down and improves upon standing.
Answer B: High-flow oxygen is an abortive treatment for cluster headaches. Cluster headaches typically present in male patients with unilateral pain around the eye that is worse at night. Associated symptoms include spasms of the unilateral face as well as tearing and visual abnormalities in the eye.
Answer D: Topiramate can be used as prophylaxis for migraines but is not commonly used as an abortive medication. Chronic prophylactic medications generally function by decreasing spasms of the cranial blood supply in order to prevent a migraine from developing. They have minimal effectiveness after a migraine has already developed.
Answer E: Verapamil is a prophylactic medication used for cluster headaches. In addition to presenting in the peri-orbital region, cluster headaches are typically accompanied by lacrimation, rhinorrhea, and focal findings such as ptosis. It would not be effective in terminating a migraine.
Bullet Summary:
Triptans are used as an abortive treatment for migraines, which present as unilateral, throbbing headaches that may be associated with nausea and/or vomiting, photophobia, phonophobia, and aura. | nan |
https://bit.ly/3Qj2QR9 | A 27-year-old woman presents to her primary care physician with pain in her hands, shoulders, and knees. The pain has lasted for several months but seems to have worsened recently. Any activity such as opening jars, walking, or brushing her teeth is painful. The patient has a medical history of a suicide attempt in college, constipation, anxiety, depression, and a sunburn associated with surfing which was treated with aloe vera gel. Her temperature is 99.5°F (37.5°C), blood pressure is 137/78 mmHg, pulse is 92/min, respirations are 14/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below. Hemoglobin: 9 g/dL Hematocrit: 33% Leukocyte count: 2,500/mm^3 with normal differential Platelet count: 107,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 102 mEq/L K+: 4.4 mEq/L HCO3-: 24 mEq/L BUN: 21 mg/dL Glucose: 90 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L Which of the following findings is the most likely to be positive in this patient? | Anti-cyclic citrullinated peptide antibodies | Degenerated cartilage in weight bearing joints | Anti-dsDNA antibodies | Anti-histone antibodies | C | Anti-dsDNA antibodies | This patient is presenting with arthralgias, pancytopenia, possible malar rash, and a history of depression/abnormal behavior. Epidemiologically, the most likely diagnosis is systemic lupus erythematosus (SLE) which is associated with anti-dsDNA antibodies.
SLE is an autoimmune disorder that most commonly occurs in young adult women. It presents with at least 4 criteria from SOAP BRAIN MD - Serositis, Oropharyngeal ulcers, Anti-nuclear antibodies, Photosensitivity, Blood disorders (pancytopenia and hemolytic anemia), Renal abnormalities (proteinuria), Arthralgias, Immune disease (hemolytic anemia and anti-dsDNA), Neurologic (psychosis, stroke, and seizure), Malar rash, and Discoid rash. The most common presenting symptoms for SLE can often be just arthralgias/arthritis with vague other symptoms suggestive of a rheumatologic disorder. Anti-nuclear antibodies are very sensitive for this pathology and anti-dsDNA antibodies are very specific. Treatment may include hydroxychloroquine as well as other immunomodulators and management of end-organ dysfunction.
Wang and Xia review the evidence regarding double stranded DNA in patients with SLE. They discuss how these antibodies are a very specific finding in this disease. They recommend measuring these levels.
Incorrect Answers:
Answer A: Anti-cyclic citrullinated peptide is associated with rheumatoid arthritis which is a possible diagnosis in this patient, but it is less likely epidemiologically given her age and other symptoms of pancytopenia and a history of sunburn (which is likely a malar rash or photosensitivity). Treatment is with methotrexate.
Answer C: Anti-histone antibodies would be found in drug-induced lupus. This patient's medication history is not known; however, this is a less likely diagnosis compared to SLE. Treatment is with discontinuation of the offending medication.
Answer D: Degenerated cartilage in weight bearing joints describes osteoarthritis which tends to affect the knees and hips in older patients. Treatment is with conservative management or with total joint replacement.
Answer E: IgM against parvovirus B19 describes a parvovirus B19 infection which commonly presents with arthralgias; however, her other symptoms point towards a diagnosis of SLE. Treatment is supportive.
Bullet Summary:
Arthritis/arthralgias are often the most common presenting symptom for SLE. | nan |
https://step2.medbullets.com/testview?qid=216403 | A 59-year-old man presents to the emergency department after a sudden onset of slurred speech and right upper extremity weakness. His symptoms lasted 20 minutes but by the time he arrived at the emergency department he was symptom-free. The patient denies any preceding symptoms. He has a history of diabetes, obesity, and hypertension but does not see a physician for his underlying conditions. His temperature is 99.2°F (37.3°C), blood pressure is 140/85 mmHg, pulse is 82/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam reveals normal vision, strength, and sensation with a stable gait. Finger-nose testing and tandem gait are unremarkable. A CT scan of the head is performed and is unremarkable. Which of the following is the most appropriate next step in management? | CTA head/neck | MRI brain | Labetalol | Aspirin | D | Aspirin | This patient is presenting with a transient episode of neurologic dysfunction (slurred speech and right upper extremity weakness) that has completely resolved, which is concerning for a transient ischemic attack. In the setting of his normal head CT, aspirin should be administered next.
A transient ischemic attack (TIA) is a brief episode of focal neurologic dysfunction that completely resolves without any residual deficits. Patients with a TIA are at high risk for future TIAs and stroke. For this reason, management is immediately centered on a thorough neurological exam followed by a CT scan of the head to rule out a hemorrhage. Subsequently, aspirin should immediately be administered which reduces the incidence of future stroke. Patients will subsequently be discharged on aspirin in addition to other morbidity-lowering agents including a statin and tight blood pressure and glycemic control as well as a second antiplatelet agent in appropriate patients. Further workup for a TIA may include a CTA head/neck, an MRI brain, and an echocardiogram. Modification of risk factors is also critical in these patients including weight loss, smoking cessation, exercise, glycemic control, and blood pressure control.
Clissold et al. review transient ischemic attacks. They note that transient ischemic attacks (TIA), if untreated, carry a high risk of early subsequent stroke. They recommend, after appropriate diagnostic workup, early administration of an antiplatelet agent.
Incorrect Answers:
Answer B: Atorvastatin is an important initial intervention in the management of patients who have TIA/stroke. However, this intervention takes weeks of consistent therapy in order to have a significant effect on morbidity, thus it would not be the most important next step in management when compared to aspirin, which is more important in reducing acute stroke risk. Further, a lipid panel is generally performed first to determine if a statin is needed.
Answer C: CTA head/neck is a part of the workup of a TIA to rule out carotid stenosis/dissection/atherosclerosis as the cause of the patient's symptoms. It is more important to give aspirin early in TIA/stroke prior to obtaining further imaging (though this study would still be performed).
Answer D: Labetalol and other blood pressure medications are important in risk factor modification to prevent future strokes/TIAs. Patients with diabetic nephropathy should be on an ACE inhibitor or angiotensin-receptor blocker which are nephroprotective. Of note, his blood pressure currently is not very elevated nor is it causing end-organ dysfunction.
Answer E: MRI brain should be performed to further characterize whether there was any ischemic injury to the brain; however, this usually will occur after a CTA head/neck and certainly after the patient receives an aspirin. It can more accurately characterize if a stroke occurred, and the extent of the injury.
Bullet Summary:
The workup of a transient ischemic attack should be centered on a thorough neurological exam, a non-contrast CT scan of the head, and administration of aspirin assuming there is no intracranial bleed. | nan |
https://bit.ly/3Mv8f5p | A 59-year-old woman presents to her primary care physician for trouble sleeping. When she goes to bed at night, she has an urge to get up out of bed and walk around. The patient often wakes her husband when she does this which irritates him. There is a perpetual uneasiness and feeling of a need to move at night which is relieved by getting up and walking around. The patient denies symptoms during the day. She works as a mail carrier and is nearing retirement. She has a medical history of anxiety, depression, irritable bowel syndrome, and dysmenorrhea. She is not currently taking any medications. Her temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals 5/5 strength in the upper and lower extremities, 2+ reflexes in the upper and lower extremities, a stable gait pattern, and normal sensation. Cardiopulmonary and abdominal exams are within normal limits. Which of the following is the most appropriate initial step in management? | Alprazolam | Ferrous sulfate | Iron studies | Pramipexole | C | Iron studies | This patient is presenting with the need to get up and walk around at night, which is suggestive of restless leg syndrome. The most appropriate initial step in management is collecting iron studies to assess for iron deficiency.
Restless leg syndrome presents with a sustained sense of restlessness and a feeling of a need to move one's legs. Symptoms typically occur at night and are relieved by activities such as walking. Iron deficiency can be a precipitating factor in restless leg syndrome as iron is a cofactor in the production of dopamine. Prior to administering iron, it is important to first confirm or rule out the diagnosis of iron deficiency with laboratory values which should include a CBC and iron studies. If iron deficiency exists, iron should be administered. If iron deficiency is not present, then dopamine agonists such as pramipexole or ropinirole can be administered.
Gossard et al. review the evidence regarding the diagnosis and treatment of restless leg syndrome. They discuss how iron deficiency is associated with the development of this disorder. They recommend iron repletion in deficient patients.
Incorrect Answers:
Answer A: Alprazolam could be an appropriate step in management if the patient suffers from episodic panic attacks/anxiety. It is not an optimal long-term therapy for anxiety or depression. Benzodiazepines are not first-line in treating restless leg syndrome.
Answer B: Ferrous sulfate would not be indicated until iron deficiency is confirmed. Iron deficiency is associated with restless leg syndrome as iron is a cofactor in the production of dopamine.
Answer D: Pramipexole is a dopamine agonist that is an effective therapy for restless leg syndrome. However, it is more important to treat any underlying causes for restless leg syndrome such as iron deficiency prior to starting a dopamine agonist.
Answer E: Supportive therapy and an exercise routine ignore the potential underlying pathology and do not offer any specific treatment for this patient's restless leg syndrome. Exercise can improve symptoms of restless leg syndrome but iron deficiency must still be ruled out.
Bullet Summary:
Patients with restless leg syndrome should be assessed for iron deficiency and treated if they are iron deficient. | Supportive therapy and an exercise routine |
https://step2.medbullets.com/testview?qid=217097 | A 62-year-old woman is brought to a physician by her husband for fluctuating changes in behavior and hallucinations over the past 2 years. On occasion, she becomes difficult to understand and her speech becomes disorganized. She also frequently sees "small people" and animals on the dining room table, which is disturbing to her. Her medical problems include hypertension and chronic obstructive pulmonary disease for which she takes amlodipine, albuterol, ipratropium, and a fluticasone inhaler. She was formerly an executive at a software company but had to retire due to frequent memory lapses. Her temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 12/min. Physical exam is notable for slowed movements and difficulty with balance at rest, which were not present at her wellness visit 1 year ago. Which of the following pathological findings (Figures A-E) would most likely be seen if a brain biopsy were performed? | Figure A | Figure B | Figure C | Figure D | C | Figure C | This patient with fluctuating changes in behavior and cognition, visual hallucinations, memory loss, and extrapyramidal symptoms (bradykinesia, postural instability) most likely has Lewy body dementia. Lewy body dementia is characterized histologically by Lewy bodies, which are intracytoplasmic eosinophilic inclusions of alpha-synuclein (shown in Figure C).
Alpha-synuclein is normally abundantly present in its unfolded form in neurons. Abnormal folding of alpha-synuclein leads to aggregation into insoluble fibrils. These intracytoplasmic aggregates (Lewy bodies) are seen in Parkinson disease, Lewy body dementia, and multiple system atrophy, which are collectively referred to as alpha-synucleinopathies. Lewy body dementia is the second most common degenerative dementia and presents with fluctuating cognition, visual hallucinations, parkinsonism (bradykinesia, postural instability, rigidity, and a resting tremor), rapid eye movement (REM) sleep disorder, autonomic dysfunction, and sensitivity to antipsychotics. Lewy body dementia can be distinguished from Parkinson disease with dementia by the timing of symptoms. In Lewy body dementia, cognitive symptoms begin at the same time as or 1 year prior to the onset of movement symptoms whereas in Parkinson disease the cognitive symptoms classically occur over 1 year after motor symptoms. There is no cure for Lewy body dementia, and treatment is aimed at alleviating symptoms.
Arnaoutoglou et al. reviewed the epidemiology, pathology, treatment, and future directions for research of Lewy body dementia. The authors found potential genetic bases for Lewy body dementia, including mutations in the GBA gene. They recommended that further research be conducted on the therapeutic implications of these genetic findings.
Figure/Illustration A shows a hematoxylin and eosin (H&E) stained brain biopsy of a patient with Creutzfeldt-Jakob disease. Characteristic spongiform changes in neurons (yellow boxes) and agglomerated prions (orange arrows) are seen in this slide.
Figure/Illustration B shows an H&E stained brain biopsy of a patient with a small lacunar infarct on low magnification. A central area of tissue loss (yellow outline) and surrounding residual gliosis (orange arrows) are seen in this slide.
Figure/Illustration C shows a brain biopsy of a patient with Lewy body dementia stained with mouse anti-alpha-synuclein antibody and counterstained with hematoxylin. Lewy bodies (intracytoplasmic eosinophilic inclusions of alpha-synuclein) are indicated by orange arrows. Note that Lewy bodies are always found intracellularly (neurons highlighted by blue boxes).
Figure/Illustration D shows an H&E stained brain biopsy of a patient with Alzheimer disease. Extracellular neurofibrillary tangles found in Alzheimer disease are indicated by black arrows.
Figure/Illustration E shows an H&E stained brain biopsy of a patient with frontotemporal dementia. A characteristic Pick cell (red box), or ballooned neuron, with dissolved chromatin (yellow arrow), is seen in this slide.
Incorrect Answers:
Answer A: Figure A shows an H&E stained brain biopsy of a patient with Creutzfeldt-Jakob disease. Creutzfeldt-Jakob disease is a rapidly progressive dementia that manifests with poor concentration, declining executive function, startle myoclonus, 14-3-3 protein on lumbar puncture, and synchronous sharp wave complexes on electroencephalogram (EEG). Clinical decline occurs over the course of weeks and months, culminating in death within a year. Creutzfeldt-Jakob disease shows spongiform vacuolation due to the accumulation of abnormal prion protein (PrPsc).
Answer B: Figure B shows an H&E stained brain biopsy of a patient with a small lacunar infarct. Lacunar infarcts may be asymptomatic or cause focal neurologic deficits such as motor hemiparesis, pure sensory stroke, ataxic hemiparesis, or dysarthria-clumsy hand syndrome depending on the territory involved. Lacunar strokes will show diffuse eosinophilia of the affected area, followed by liquefactive necrosis with neutrophilic infiltration, followed by macrophages with surrounding reactive gliosis, finally leading to an area of tissue loss with residual gliosis.
Answer D: Figure D shows an H&E stained brain biopsy of a patient with Alzheimer disease. Alzheimer disease presents with a gradual cognitive decline with difficulty completing activities of daily living. Memory is the most prominently affected domain. Visual hallucinations, fluctuating levels of cognition, and extrapyramidal symptoms are not common in Alzheimer disease. Amyloid plaques and neurofibrillary tangles may be seen on brain biopsy.
Answer E: Figure E shows an H&E stained brain biopsy of a patient with frontotemporal dementia (Pick disease). The behavioral variant of frontotemporal dementia is associated with early-onset personality and behavioral changes, and it may be associated with extrapyramidal symptoms. Unlike Lewy body dementia, memory is usually not affected in frontotemporal dementia until late in the disease course. frontotemporal dementia is characterized by Pick cells (ballooned neurons with dissolved chromatin) and Pick bodies, round intracellular aggregates of hyperphosphorylated tau protein.
Bullet Summary:
Lewy body dementia presents with alterations in consciousness, disorganized speech, visual hallucinations, extrapyramidal symptoms, early compromise of executive functions, and eosinophilic intracytoplasmic inclusions of alpha-synuclein (Lewy bodies) on biopsy. | Figure E |
https://step2.medbullets.com/testview?qid=109573 | A 25-year-old woman presents for a new patient physical exam. Aside from occasional shin splints, she has a relatively unremarkable medical history. She takes oral contraceptive pills and a multivitamin daily. All of her age appropriate immunizations are up to date. Her periods have been regular, occurring once every 28 to 30 days with normal flow. She is sexually active with 2 partners, who use condoms routinely. Her prior pap smear was performed last year and was normal. Her mother has diabetes and coronary artery disease, and her father passed away at age 45 after being diagnosed with colon cancer at age 40. Her grand-aunt underwent bilateral mastectomies after being diagnosed with breast cancer at age 60. Her temperature is 36.7°C (98°F), blood pressure is 115/80 mmHg, pulse is 65/min, respirations are 12/min, and oxygen saturation is 100% on room air. Her physical exam is within normal limits. Which of the following is the most appropriate recommendation for this patient? | Colonoscopy in 5 years | Colonoscopy in 10 years | Mammogram now | Pap smear in 5 years | A | Colonoscopy in 5 years | This patient is presenting for a health evaluation with a family history significant for her father's death due to colon cancer at age 45. She should thus get a colonoscopy when she reaches the age 10 years prior to her father's age of diagnosis or in 5 years (at age 30).
The age threshold for colon cancer screening varies based on the patient's risk factors, including family history of colon cancer, inflammatory bowel disease, and/or genetic disorders. In the absence of significant risk factors, colonoscopies can be used for screening starting at age 45 and repeated every 10 years if results are normal. If there is family history of colon cancer (one or more first degree relatives, including parent, sibling, or child), colonoscopies should be recommended starting at age 40 or 10 years prior to the age of the family member's diagnosis, whichever is earlier. Polyps or grossly abnormal colon tissue may be biopsied for grading and guide further diagnostic imaging workup.
Aasma et al. review the clinical guidelines for colorectal cancer screening. They found that recent epidemiological data shows an increase in the incidence of colorectal cancer in individuals younger than 50 years. They recommend starting colonoscopy screening at 45 years of age in the average-risk adult population.
Incorrect Answers:
Answer B: Colonoscopy in 10 years is reasonable, but it is not the earlier of the 2 age thresholds mentioned above.
Answer C: Pap smear with HPV DNA screening for cervical cancer is indicated every 5 years for women aged 30 to 65 who wish to extend the screening interval from the 3 year interval for pap smear alone.
Answer D: Pap smear alone is indicated every 3 years for women of ages 21 to 65.
Answer E: Mammogram to screen for breast cancer is recommended every 2 years for women aged 50 to 74.
Bullet Summary:
For patients with a family history of colon cancer, screening should start at age 40 or 10 years prior to the age of the family member's diagnosis, whichever is earlier. | Pap smear with human papillomavirus (HPV) DNA testing now |
https://bit.ly/44zO6BC | A 4-day-old neonate is brought to the pediatrician with vaginal discharge for the last 2 days. Her daughter has been feeding and voiding well. The neonate was delivered at 39 weeks gestation via an uncomplicated vaginal delivery and was discharged home after 2 days. The prenatal course was complicated by chlamydia in the mother during the first trimester, for which she and the partner were both treated with a confirmatory test of cure. The biological father is no longer involved in the patient's life, but her mother’s boyfriend has been caring for the baby whenever the mother rests. The neonate’s temperature is 98.5°F (36.9°C), blood pressure is 56/35 mmHg, pulse is 138/min, and respirations are 51/min. She appears comfortable, and cardiopulmonary and abdominal exams are unremarkable. There are no bruises or marks on her skin. Examination of the genitals reveals no vulvar irritation or skin changes but there is scant pink mucoid discharge at the introitus. Which of the following is the most appropriate next step in management? | Reassurance | Vaginal culture | Warm water irrigation of the vagina | Report to child protective services | A | Reassurance | This neonate presents with bloody vaginal discharge soon after birth without vulvar irritation, which is most consistent with physiologic neonatal vaginal discharge. Reassurance is the most appropriate next step in management.
Vaginal discharge in a neonate that is bloody and/or mucoid is most commonly due to the rapid withdrawal of maternal hormones that cross the placenta. This results in a pink discharge that may be observed as “menses” in the perinatal period. This most commonly presents several days to 1 week after birth and will self-resolve. Without concerning red flags such as genital trauma, mucopurulent discharge, or surrounding skin changes, there is no need for work-up or treatment. Additional concerning findings should prompt a work-up for child abuse.
Guritzky and Rudnitsky review the evidence regarding the work-up of a bloody neonatal diaper. They discuss how using an Apt test can be helpful in distinguishing between maternal and fetal blood. They recommend being aware of neonatal conditions that can cause bleeding to avoid missing pathologies.
Incorrect Answers:
Answer B: Reporting the case to child protective services would be necessary if child abuse were suspected. Although having an unrelated adult as a caregiver is traditionally a risk factor, there is no evidence that this neonate is being abused. Risk factors include vaginal trauma and bruising.
Answer C: Vaginal culture may be indicated if an infectious etiology such as chlamydia or group A streptococcus is suspected; however, this would more commonly present with bloody and mucopurulent discharge with or without surrounding skin inflammation. Furthermore, the patient’s mother was successfully treated for chlamydia during pregnancy, making chlamydial infection unlikely.
Answer D: Vaginal exam under anesthesia would be appropriate if a foreign body or trauma is suspected because prepubescent children should not undergo exams while awake. In a neonate with physiologic discharge, an exam is unnecessary. Foreign bodies would present with bloody discharge, pain, and potential purulence.
Answer E: Warm water irrigation of the vagina may be helpful in locating a foreign body, which is the most common cause of vaginal bleeding and discharge in a prepubertal girl. This is unlikely in a neonate and there is no evidence of trauma or irritation in the perineum.
Bullet Summary:
Vaginal discharge in a neonate is most commonly due to the withdrawal of maternal hormones and will self-resolve. | nan |
https://bit.ly/45zXPbW | A 35-year-old G0P0000 woman presents to her gynecologist with complaints of irregular menstruation. She has had only 2 periods in the last year. She feels flushed without provocation and is experiencing occasional dyspareunia with post-coital spotting. She has also had more frequent headaches than usual. The patient has a medical history of Hashimoto thyroiditis and takes levothyroxine daily. Her mother has type 1 diabetes mellitus. Her temperature is 98.5°F (36.9°C), pulse is 70/min, blood pressure is 118/76 mmHg, and respirations are 13/min. Cardiopulmonary and abdominal exams are unremarkable. The patient has Tanner 5 breasts and pubic hair. A pelvic exam reveals a normal cervix, an anteverted uterus without tenderness, and no adnexal masses. The following laboratory studies are performed: Serum: Thyroid stimulating hormone (TSH): 28 µIU/mL (9-30 µIU/mL) Cycle day 3 follicle stimulating hormone (FSH): 49 mIU/mL (4.7-21.5 mIU/mL) Cycle day 3 estradiol: 8 pg/mL (27-123 pg/mL) Prolactin: 14 ng/mL (4-23 ng/mL) Testosterone: 42 ng/dL (15-70 ng/dL) Which of the following is the most appropriate next step in management? | Brain MRI | Combined oral contraceptive | Estradiol patch with oral medroxyprogesterone | Increase levothyroxine dose | C | Estradiol patch with oral medroxyprogesterone | This patient presents with oligomenorrhea, hot flashes, and dyspareunia, and her labs are notable for a high FSH and low estradiol, most consistent with premature ovarian insufficiency/failure (POI). The most appropriate next step in management is an estradiol patch with oral medroxyprogesterone.
POI is defined by the depletion or dysfunction of ovarian follicles, resulting in oligomenorrhea or amenorrhea with symptoms of menopause (hot flashes, vaginal atrophy and dryness, mood swings, etc.) in women under age 40. The cause is unclear and thought to be autoimmune. The main diagnostic markers are a high FSH and low estradiol at the start of the follicular phase. Patients require estrogen supplementation until around age 50, as low estrogen increases the risk of coronary artery disease, osteoporosis, and sexual dysfunction. Vaginal gel or a transdermal patch is the first-line option, but both must be used in conjunction with medroxyprogesterone to avoid unopposed estrogen and the risk of endometrial hyperplasia.
Tsiligiannis et al. review the evidence regarding the outcomes of patients with POI. They discuss how this diagnosis is made in patients younger than the age of 40. They recommend closely managing the cardiovascular risk factors associated with this disease.
Incorrect Answers:
Answer A: Brain MRI would be useful for evaluating for the presence of a prolactinoma, which could cause the headaches and oligomenorrhea seen in this patient. However, her prolactin level is normal, and she has no visual disturbances (e.g., bitemporal hemianopsia), making this study less relevant.
Answer B: The combined oral contraceptive has both estrogen and progesterone, but the doses are higher than those needed for hormone replacement. For this reason, it is generally not considered first-line for the treatment of POI.
Answer D: Increasing this patient’s levothyroxine dose is unnecessary, as her TSH level is within the normal range. Furthermore, while hypothyroidism may cause menstrual irregularities and temperature dysregulation, it is unlikely to cause vaginal dryness and subsequent dyspareunia.
Answer E: Vaginal estradiol gel is an effective method of estrogen replacement in women with POI. However, used alone it may increase the risk of endometrial hyperplasia and cancer, so it should only be used in combination with a systemic progesterone.
Bullet Summary:
Premature ovarian insufficiency should be treated with estrogen and progesterone replacement. | Vaginal estradiol gel |
https://bit.ly/3Qj2QR9 | A 27-year-old woman presents to her primary care physician with pain in her hands, shoulders, and knees. The pain has lasted for several months but seems to have worsened recently. Any activity such as opening jars, walking, or brushing her teeth is painful. The patient has a medical history of a suicide attempt in college, constipation, anxiety, depression, and a sunburn associated with surfing which was treated with aloe vera gel. Her temperature is 99.5°F (37.5°C), blood pressure is 137/78 mmHg, pulse is 92/min, respirations are 14/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below. Hemoglobin: 9 g/dL Hematocrit: 33% Leukocyte count: 2,500/mm^3 with normal differential Platelet count: 107,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 102 mEq/L K+: 4.4 mEq/L HCO3-: 24 mEq/L BUN: 21 mg/dL Glucose: 90 mg/dL Creatinine: 1.0 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L Which of the following findings is the most likely to be positive in this patient? | Anti-cyclic citrullinated peptide antibodies | Anti-dsDNA antibodies | Anti-histone antibodies | Degenerated cartilage in weight bearing joints | B | Anti-dsDNA antibodies | This patient is presenting with arthralgias, pancytopenia, possible malar rash, and a history of depression/abnormal behavior. Epidemiologically, the most likely diagnosis is systemic lupus erythematosus (SLE) which is associated with anti-dsDNA antibodies.
SLE is an autoimmune disorder that most commonly occurs in young adult women. It presents with at least 4 criteria from SOAP BRAIN MD - Serositis, Oropharyngeal ulcers, Anti-nuclear antibodies, Photosensitivity, Blood disorders (pancytopenia and hemolytic anemia), Renal abnormalities (proteinuria), Arthralgias, Immune disease (hemolytic anemia and anti-dsDNA), Neurologic (psychosis, stroke, and seizure), Malar rash, and Discoid rash. The most common presenting symptoms for SLE can often be just arthralgias/arthritis with vague other symptoms suggestive of a rheumatologic disorder. Anti-nuclear antibodies are very sensitive for this pathology and anti-dsDNA antibodies are very specific. Treatment may include hydroxychloroquine as well as other immunomodulators and management of end-organ dysfunction.
Wang and Xia review the evidence regarding double stranded DNA in patients with SLE. They discuss how these antibodies are a very specific finding in this disease. They recommend measuring these levels.
Incorrect Answers:
Answer A: Anti-cyclic citrullinated peptide is associated with rheumatoid arthritis which is a possible diagnosis in this patient, but it is less likely epidemiologically given her age and other symptoms of pancytopenia and a history of sunburn (which is likely a malar rash or photosensitivity). Treatment is with methotrexate.
Answer C: Anti-histone antibodies would be found in drug-induced lupus. This patient's medication history is not known; however, this is a less likely diagnosis compared to SLE. Treatment is with discontinuation of the offending medication.
Answer D: Degenerated cartilage in weight bearing joints describes osteoarthritis which tends to affect the knees and hips in older patients. Treatment is with conservative management or with total joint replacement.
Answer E: IgM against parvovirus B19 describes a parvovirus B19 infection which commonly presents with arthralgias; however, her other symptoms point towards a diagnosis of SLE. Treatment is supportive.
Bullet Summary:
Arthritis/arthralgias are often the most common presenting symptom for SLE. | IgM against parvovirus B19 |
https://bit.ly/3D2V2LR | A 4-week-old boy presents with his parents to the pediatrician for a well-child visit. His mother reports he was eating well until 1 week ago when he began vomiting after breastfeeding. His mother has tried increasing the frequency of feeds and decreasing the amount of each feed, but the vomiting seems to be getting worse. The patient now vomits after every feed. The vomitus looks like breast milk. The patient’s mother is exclusively breastfeeding and would prefer not to switch to formula but worries that the patient is not getting the nutrition he needs. Two weeks ago, the patient was in the 75th percentile for weight and 70th for height. He is now in the 60th percentile for weight and 68th percentile for height. His temperature is 98.2°F (36.8°C), blood pressure is 58/37 mmHg, pulse is 144/min, and respirations are 34/min. On physical exam, the patient has dry mucous membranes. His abdomen is soft and non-distended. Which of the following is the most appropriate next step in management? | Abdominal ultrasound | Trial of empiric proton pump inhibitor | Abdominal radiograph | Supplement breastfeeding with formula | A | Abdominal ultrasound | This patient presents with a history of nonbilious, forceful vomiting, poor weight gain, and signs of dehydration, which is consistent with pyloric stenosis. The most appropriate next step in management is abdominal ultrasound to confirm the diagnosis.
Pyloric stenosis presents in 4- to 6-week-old infants with nonbilious, post-prandial projectile vomiting. Although pyloric stenosis classically presents with an “olive-shaped” mass in the epigastrium, the mass cannot be palpated in some patients. Any infant who develops new, persistent vomiting in the first 2 months of life and has associated dehydration or failure to thrive should undergo an abdominal ultrasound to evaluate for pyloric stenosis. Patients should undergo resuscitation prior to the definitive treatment, which is a pyloromyotomy.
Adams and Stanton review the evidence regarding the diagnosis and treatment of neonatal bowel obstruction. They discuss how malrotation, jejunoileal atresia, duodenal atresia, and colonic atresia are common causes of this finding. They recommend surgical management of these conditions.
Incorrect Answers:
Answer A: Abdominal radiograph is not helpful in evaluating for pyloric stenosis. It is more useful in the workup of bilious vomiting, as several etiologies of bilious vomiting (such as duodenal atresia and Hirschsprung disease) can be seen on an abdominal radiograph. Treatment of these conditions is surgical excision of the defective segment of colon.
Answer C: Supplementing breastfeeding with formula would not be appropriate for this patient as his failure to thrive is driven by gastric outlet obstruction. In the case of pyloric stenosis, formula would cause vomiting just as breastmilk does.
Answer D: A trial of a dairy-free diet is used to improve gastroesophageal reflux, but in the setting of this patient’s age and the description of vomiting, he should undergo an abdominal ultrasound to evaluate for pyloric stenosis. Treatment of reflux also involves positional changes during feeding.
Answer E: A trial of empiric proton pump inhibitor is indicated for patients with gastroesophageal reflux disease, but it would not address this patient’s pyloric stenosis. Patients can also undergo conservative treatments such as changing positioning during feeding.
Bullet Summary:
The diagnostic test of choice for pyloric stenosis in infants is an abdominal ultrasound. | nan |
https://step2.medbullets.com/testview?qid=108604 | A 24-year-old woman with no significant medical history presents to the emergency department for progressive shortness of breath. She endorses decreased exercise tolerance as well as intermittent palpitations. She returned from a recent missionary trip to South America 12 months prior where she endorsed eating a local delicacy as well as a period of fevers and eyelid swelling during her stay. Her temperature is 99.1°F (37.3°C), pulse is 95/min, blood pressure is 130/85 mmHg, respirations are 15/min, and oxygen saturation is 97% on room air. Physical exam is notable for a laterally displaced point of maximal impulse as well as a 2/6 diastolic murmur radiating to the axilla. A blood smear is shown in Figure A. Her laboratory results are:
Leukocyte count and differential:
Leukocyte count: 10,000/mm^3
Neutrophils: 57%
Lymphocytes: 30%
Monocytes: 3%
Eosinophils: 9%
Basophils: 1%
Hemoglobin: 13.1 g/dL
Platelet count: 420,000/mm^3
Which of the following is the most appropriate treatment? | Benznidazole | Ganciclovir | Praziquantel | Amphotericin B | A | Benznidazole | This patient presents with symptoms of heart failure, eosinophilia, trypanosomes on peripheral smear, and a history of recent travel to South America consistent with the diagnosis of Chagas disease. Treatment options for Chagas disease include benznidazole and nifurtimox.
Chagas disease is caused by the parasite Trypanosoma cruzi and is most commonly transmitted by the reduvvid (kissing) bug. The disease is endemic to South America and presents in an acute and chronic phase. The acute phase is characterized by fever, headaches, myalgias, and unilateral eyelid swelling (Romaña’ sign) where the infectious agent has been rubbed into the eye. The chronic phase of the disease is characterized by dilated apical cardiomyopathy leading to conduction abnormalities and valvular dysfunction, megacolon, and megaesophagus. Laboratory testing reveals a peripheral eosinophilia and a peripheral blood smear may reveal the infectious trypanosomes. Treatment is with benznidazole and/or nifurtimox.
Perez-Molina and Molina present the data surrounding the diagnosis and treatment of Chagas disease. They discuss how many cases progress to a chronic state characterized by cardiomyopathy, arrhythmias, and organomegaly. They recommend prompt treatment of the disease to avoid end organ damage.
Figure/Illustration A shows a peripheral blood smear with the trypomastigote form of Trypanosoma cruzi (red circle). Note the anterior location of the dense basophilic nucleus.
Incorrect Answers:
Answer A: Amphotericin B is a potent antifungal that has application in the treatment of multiple fungal infections. It is used as a first-line agent for mucormycosis and cryptococcal meningitis (in addition to flucytosine). Amphotericin B with sodium stibogluconate is used to treat visceral leishmaniasis, a protozoal infection most commonly caused by Leishmania donovani. Side effects can include nausea, vomiting, rigors, fever, hypertension or hypotension, renal dysfunction, and hypoxia.
Answer C: Erythromycin is a macrolide antibiotic that is used in the treatment of bacterial infections. It has a pro-motility effect and can also be used as a gastric pro-motility agent. Potential side effects include gastrointestinal upset, prolonged QT interval, inhibition of the P450 system, and pyloric stenosis in infants.
Answer D: Ganciclovir is a synthetic nucleoside analogue that is mainly used in the treatment of cytomegalovirus (CMV) infections. The most common side effects are bone marrow suppression (granulocytopenia, thrombocytopenia, and anemia) and gastrointestinal upset.
Answer E: Praziquantel is an anti-helminthic used in the treatment of tapeworms and flukes including Echinococcus, Taenia solium (cysticerosis), Schistosoma sp., Clonorchis sinensis (liver fluke), and Paragonimus westermani (lung fluke). Side effects of praziquantel develop due to release of contents from dead parasites and can include gastrointestinal upset, elevated liver enzymes, and dizziness.
Bullet Summary:
Treatment of Chagas disease is with benznidazole or nifurtimox. | nan |
https://step2.medbullets.com/testview?qid=108601 | A 38-year-old man presents to the emergency department with nasal congestion, blurry vision, and diplopia. His nasal congestion started about 1 week ago and he noticed the blurry vision this morning when he struggled to read the words on his television screen. His medical history is significant for IV drug use, HIV (CD4: 47/mm^3), hypertension, hyperlipidemia, diabetes mellitus, and seasonal allergies. His home medications include hydrochlorothiazide, atorvastatin, metformin, cetirizine, darunavir, tenofovir, and emtricitabine. He denies recent IV drug use. His temperature is 100.8°F (38.2°C), blood pressure is 127/85 mmHg, pulse is 78/min, and respirations are 12/min. He has injected conjunctiva and rhinorrhea. His cranial nerves are intact, and his motor and sensory neurologic exam is normal. A MRI of the brain is performed and can be seen in Figure A. Which of the following is the most appropriate next step in management? | Brain biopsy | Empiric treatment with pyrimethamine-sulfadiazine | Empiric treatment with dexamethasone | Lumbar puncture | B | Empiric treatment with pyrimethamine-sulfadiazine | This patient with a past medical history of immunosuppression due to HIV (CD4 < 100/mm^3), new focal neurologic findings, and ring-enhancing lesions on head MRI should be treated empirically with pyrimethamine-sulfadiazine for 10-14 days.
The differential diagnosis for ring-enhancing lesions in patients with HIV is determined by the degree of immunosuppression. For patients with CD4 counts > 200/mm^3, the most likely diagnoses include primary brain tumors and metastases. In patients with CD4 counts < 200/mm^3, the differential includes toxoplasma encephalitis, primary CNS lymphoma, progressive multifocal leukoencephalopathy (PML), and other infections. Patients with CD4 counts < 100/mm^3 should have empiric treatment for toxoplasma encephalitis with pyrimethamine-sulfadiazine with follow-up head imaging after 10-14 days. If the patient fails to improve clinically or the size of the lesion does not change, the next step would be a biopsy of the lesion.
Robert-Gangneux and Darde present a review of toxoplasmosis diagnosis and treatment. They discuss how the incidence of these infections has increased dramatically since the advent of organ transplantation and HIV. They recommend increasing vigilance and prophylaxis for this disease.
Figure/Illustration A is an MRI of the brain that demonstrates a ring-enhancing lesion (red circle) in the right occipital lobe. This lesion is likely causing the patient's visual complaints and is consistent with toxoplasmosis.
Incorrect Answers:
Answer A: Brain biopsy should be performed if the patient has no response clinically or on follow-up head imaging to empiric treatment with pyrimethamine-sulfadiazine for 10-14 days. Biopsy in these cases may reveal a CNS lymphoma or other neoplastic process.
Answer C: Empiric treatment with dexamethasone is indicated for patients with substantial mass effect on imaging and severely depressed mental status, neither of which is present in this patient.
Answer D: Lumbar puncture is contraindicated in patients with focal neurologic findings due to the risk of transtentorial herniation. Lumbar puncture would be indicated in the diagnosis of meningitis which presents with fever, headache, photophobies, and meningeal signs.
Answer E: There is no role for serology for anti-John Cunningham (JC) virus antibodies in the workup of ring-enhancing lesions. If it were safe to perform a lumbar puncture (if the patient had no focal findings and no evidence of mass effect on head imaging), it would be reasonable to perform PCR of the CSF for JC virus.
Bullet Summary:
For patients with a past medical history of HIV with CD4 <100 cells/µL, focal neurologic findings, and ring-enhancing lesions on head imaging, the next step in management is empiric treatment for toxoplasma encephalitis with pyrimethamine-sulfadiazine for 10-14 days. | Serology for anti-John Cunningham (JC) virus antibodies |
https://step2.medbullets.com/testview?qid=109092 | A 69-year-old man presents to his primary care provider for a general checkup. He has a medical history of type 2 diabetes mellitus, hypertension, depression, obesity, and a myocardial infarction 7 years ago. The patient's prescribed medications are metoprolol, aspirin, lisinopril, hydrochlorothiazide, fluoxetine, metformin, and insulin. The patient has not been filling his prescriptions regularly and can not remember what medications he has been taking. His temperature is 99.5°F (37.5°C), pulse is 96/min, blood pressure is 180/120 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air. Laboratory values are obtained and the results are shown below:
Serum:
Na+: 139 mEq/L
K+: 4.3 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
BUN: 7 mg/dL
Glucose: 170 mg/dL
Creatinine: 1.2 mg/dL
Which of the following cardiac findings would be expected on physical exam? | Heart sound after S2 | Holosystolic murmur at the apex | Heart sound before S1 | Fixed splitting of S1 and S2 | C | Heart sound before S1 | This patient who presents with poorly managed hypertension over a long period of time most likely has compensatory hypertrophy of the heart. The most likely heart sound in this patient is an S4 gallop that occurs immediately before S1.
Chronic hypertension that is poorly controlled can lead to concentric hypertrophy of the heart. This adaptive mechanism creates a stiff and non-compliant left ventricle. When blood enters this stiff ventricle, the typical sound heard is an S4 heart sound which is heard right before S1. This sound represents the atrial kick that pushes blood against a non-compliant left ventricle in the last phase of diastole. Treatment is by meticulous control of the underlying cardiac pathophysiology such as hypertension.
Kino et al studied the relationship between the S1 and S4 heart sounds in aging patients. They found that an S4 heart sound can be missed in cases of prominent S1 splitting. They recommend studying heart sounds in order to not accidentally miss an S4 finding.
Incorrect Answers:
Answer A: Fixed splitting of S1 and S2 describes an atrial septal defect. The atrial septic defect allows blood to communicate between both sides of the heart and equalizes atrial pressures. Asymptomatic patients may not need treatment but surgical repair of the defect should be performed in symptomatic cases.
Answer B: A heart sound after S2 suggests a S3 heart sound which would be found in fluid-overloaded states such as heart failure. This post-systolic gallop is the result of incomplete emptying of the ventricle prior to the start of diastole so that the blood from the atria falls against an already full chamber. Treatment is with diuresis and treatment of the underlying heart failure.
Answer D: A holosystolic murmur heard at the apex describes mitral valve regurgitation. This would be possible if a papillary muscle had ruptured in an acute myocardial infarction. Treatment is with mitral valve replacement in symptomatic patients.
Answer E: A normal S1 and S2 is possible but is less likely given this patient's long-standing history of poorly managed hypertension. Hypertension usually causes concentric hypertrophy of the ventricle and thereby leads to increased resistance to diastolic filling.
Bullet Summary:
An S4 heart sound is created by blood entering a stiff and non-compliant left ventricle and is often heard in patients with long-standing hypertension. | nan |
https://bit.ly/44GDl0l | A 53-year-old man presents to the clinic with a non-tender mass in his right anterior neck. The mass has been slowly enlarging over the past 1 year. He reports no dysphagia, difficulty breathing, or changes to his voice. He also denies heat intolerance, palpitations, tremors, or diarrhea. He has hypertension and hyperlipidemia, for which he takes lisinopril and atorvastatin. He has never smoked cigarettes. His temperature is 37.1°C (98.8°F), blood pressure is 130/84 mmHg, pulse is 86/min, respirations are 12/min, and oxygen saturation is 99% on room air. Bedside ultrasound reveals a 1x2 cm hypoechogenic nodule with microcalcifications in the right thyroid lobe, which is biopsied. Pathology results are shown in Figure A. Which of the following is the most appropriate next step in management? | Repeat ultrasound in 6 months | Thyroidectomy followed by radioactive iodine | Methimazole | Radioactive iodine | B | Thyroidectomy followed by radioactive iodine | This patient who presents with a slowly enlarging neck mass has ultrasound (hypoechogenic nodule with microcalcifications) and histology findings (concentrically laminated calcifications called psammoma bodies) consistent with papillary thyroid carcinoma. The most appropriate next step in management would be thyroidectomy followed by radioiodine ablation.
Papillary thyroid carcinoma represents the majority of malignant thyroid cancers. They are slow-growing and are found in the hormone-producing follicular cells of the thyroid. Typically, these tumors are found incidentally on imaging. Risk factors for thyroid malignancy include a history of radiation exposure, female sex, and positive family history. Nodules with minimal uptake on radioactive iodine scan, firm and immobile solitary nodules, and rapidly growing nodules with associated hoarseness are more suggestive of thyroid malignancy. Findings on histology include empty-appearing nuclei with central clearing, psammoma bodies, and nuclear grooves. The treatment is thyroidectomy followed by radioactive iodine ablation of any remaining thyroid cells. Long-term care should include levothyroxine at a dose sufficient to suppress thyroid-stimulating hormone (TSH) release that may stimulate any remaining malignant cells.
Oakley et al. studied if relatives of patients diagnosed as having papillary thyroid carcinoma are at increased risk using a retrospective cohort study. The authors found first-degree relatives were at a 5-fold increased risk, and second-degree relatives were at a 2-fold increased risk. The authors recommend more research into optimal approaches to screening for thyroid cancers.
Figure/Illustration A is a histology section showing a psammoma body (blue circle), which are round, concentrically laminated calcifications that are formed after necrosis of papillary structures. Psammoma bodies and nuclei with central clearing (yellow circle) and nuclear grooves are common histology findings for papillary thyroid carcinoma.
Incorrect Answers:
Answer A: Levothyroxine would be the treatment of choice in hypothyroidism and is important in the long-term care of papillary thyroid carcinoma to suppress the TSH release that may stimulate any remaining malignant cells after treatment (thyroidectomy and radioactive iodine).
Answer B: Methimazole is an agent that blocks thyroid peroxidase, thus inhibiting the synthesis of thyroid hormones. It is used in the treatment of hyperthyroidism and does not have a role in the treatment of papillary thyroid carcinoma.
Answer C: Radioactive iodine is used as an adjunct after thyroidectomy in the treatment of papillary thyroid carcinoma in order to target any thyroid cells that may remain even after surgical excision. Surgery is the primary therapy for papillary thyroid carcinoma. Radioactive iodine is the primary method of therapy in cases of Grave disease, toxic adenoma, or multinodular goiter.
Answer D: Repeating an ultrasound in 6 months to assess the growth of the nodule or the development of suspicious characteristics is appropriate in cases where the ultrasound and biopsy findings are consistent with a benign thyroid nodule. The ultrasound findings of hypoechogenicity, microcalcifications, hypervascularity, and taller-than-wide nodules suggest malignancy, and together with a biopsy consistent with thyroid malignancy would warrant surgical treatment with subsequent radioactive iodine ablation.
Bullet Summary:
Papillary thyroid carcinoma is managed with thyroidectomy followed by radioactive iodine ablation and long-term levothyroxine to suppress thyroid-stimulating hormone stimulation of any remaining malignant cells. | nan |
https://bit.ly/460v5JM | A 23-year-old woman presents with a 7-day history of abdominal pain, and now bloody diarrhea that brings her to her primary care physician. Review of systems is notable for a 12-pound unintentional weight loss and intermittent loose stools. She has a family history notable for a father with coronary artery disease and a mother with primary sclerosing cholangitis. Her temperature is 37.2°C (98.9°F), blood pressure is 100/72 mmHg, pulse is 72/min, respirations are 12/min, and oxygen saturation is 100% on room air. Her abdomen is soft, mildly diffusely tender to deep palpation, and non-distended. She is found to have the finding on colonoscopy in Figure A. Serum perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) are positive. Which of the following is most likely to be present in this patient? | Cobblestoning and skip lesions | Continuous lesion beginning in the rectum | Fistulae and stricture formation | Perianal disease | B | Continuous lesion beginning in the rectum | This patient presents with features suggestive of inflammatory bowel disease (IBD), and her colonoscopic and serologic studies suggest ulcerative colitis (UC). UC typically begins in the rectum and progresses proximally towards the ileocecal valve in a continuous fashion.
The diagnosis of IBD should always prompt further investigation to better delineate between UC, Crohn disease, or indeterminate colitis. Further delineation guides treatment and informs prognosis. UC has a peak incidence in the second and third decades of life. It is characterized by disease extending from the rectum proximally towards the ileocecal valve in a continuous fashion. UC presents as mucosal and submucosal inflammation, with characteristic crypt distortion and presence of crypt abscesses. P-ANCA is positive in most individuals with UC. Repeated mucosal injury can induce pseudopolyp formation, and pancolitis or disease in the descending colon warrants screening colonoscopy due to increased risk of colon cancer. On imaging, the colon can be dilated by edema, losing its haustral markings and giving it a "lead pipe" appearance.
Gajendran et al. review the pathophysiology, diagnosis, and treatment of UC. They found that colonoscopy with biopsy is the best way to make a definitive diagnosis of UC. They recommend the Mayo scoring system as a commonly used method of assessing disease severity, guiding treatment options, and monitoring patients during therapy.
Figure A is a colonoscopy image showing continuous colonic mucosal inflammation typical of ulcerative colitis.
Incorrect Answer:
Answer A: Cobblestoning and skip lesions refer to the patchy areas of inflammation noted in Crohn disease. In contrast, the inflammation seen in UC involves continuous stretches of colon mucosa.
Answer C: Fistulae and stricture formation are features of Crohn disease, not UC. Fistulizing and stricture formation can affect the entire gastrointestinal tract in Crohn disease.
Answer D: Perianal disease is a feature of Crohn disease. Although UC commonly affects the rectum, it tends to spare the anus.
Answer E: Worse disease severity near the ileocecal valve is a feature of Crohn disease and not UC. UC tends to be characterized by more uniform disease severity spanning in continuous fashion from rectum towards the cecum.
Bullet Summary:
Ulcerative colitis is characterized by disease extending from the rectum proximally towards the ileocecal valve in a continuous fashion. | Worse disease severity near the ileocecal valve |
https://bit.ly/43nVOhs | A 25-year-old man presents to his primary care physician with a chief complaint of "failing health." He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise, he is not currently taking any medications. The patient lives alone and works in a health food store. He states that his symptoms have persisted for the past 8 months. When obtaining the patient's medical history, there are several times he attempts to telepathically connect with the animals in the vicinity. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, you note a healthy young man who is dressed in an all-burlap ensemble. Which of the following is the most likely diagnosis? | Brief psychotic disorder | Schizoid personality disorder | Schizotypal personality disorder | Schizophrenia | C | Schizotypal personality disorder | This patient has several odd and eccentric beliefs without frankly psychotic features and he is able to function in society. This suggests a diagnosis of schizotypal personality disorder.
Schizotypal personality disorder presents with eccentric behavior, magical thinking, odd beliefs, and perceptual disturbances. These patients may seem to have symptoms of schizophrenia; however, they do not respond to internal stimuli and do not experience visual or auditory hallucinations. They are able to function in society and care for themselves. Patients with schizotypal personality disorder typically struggle in maintaining close relationships or making friends. Patients are typically not distressed about their thought patterns but can undergo treatment with psychotherapy if they seek to change their behaviors.
Sher reviews the evidence regarding the treatment of patients with schizotypal personality disorder. He discusses how this disorder often goes undiagnosed and is difficult to treat. He recommends providing suicide prevention measures as this disease is associated with suicidal ideation.
Incorrect Answers:
Answer A: Brief psychotic disorder presents with either visual or auditory hallucinations with symptoms that have lasted for less than 1 month. Patients have frankly psychotic features and should be closely monitored for the development of schizophrenia.
Answer B: Schizoid personality disorder presents with social isolation. These patients are alone but do not desire social contact and are content in their isolation. A typical example is an individual who works in a solitary job on the graveyard shift. Patients do not have strange or magical beliefs.
Answer C: Schizophrenia presents with either visual or auditory hallucinations with symptoms that have lasted for 6 months or longer. These patients typically have trouble caring for themselves and struggle to function in society. Though this patient is attempting to connect/communicate with animals, this likely represents an odd belief rather than responding to internal stimuli. Schizophrenia should be treated with antipsychotic medications.
Answer D: Schizophreniform disorder presents with either visual or auditory hallucinations with symptoms that have lasted for 1-6 months. Patients have symptoms with frankly psychotic features and should be treated with antipsychotic medications.
Bullet Summary:
Schizotypal personality disorder presents with eccentric behavior, magical thoughts, and odd beliefs but patients are able to function within society. | nan |
https://bit.ly/48MbdvT | A 55-year-old man presents with a 2-day history of mono-articular joint pain. He is otherwise healthy and denies fever, chills, or recent trauma. His medical history is notable for a kidney stone 6 months ago. He underwent a dental procedure to extract an infected wisdom tooth 3 weeks ago. The patient does not take any medications. He is a non-smoker and does not drink alcohol or use recreational drugs. His family history is significant for osteoarthritis in his father who is 78. His temperature is 98.6°F (37°C), blood pressure is 133/84 mmHg, pulse is 84/min, and respirations are 15/min. His body mass index is 27 kg/m^2. Physical examination shows a swollen and tender joint with overlying erythema. Diagnostic arthrocentesis is performed and shows a leukocyte count of 30,000/mm^3 with 85% neutrophils. Polarized microscopy of the synovial fluid is shown in Figure A. Which of the following would most likely be found on this patient’s radiograph? | Tophi | Heberden nodes | Juxta-articular osteoporosis | Chondrocalcinosis | D | Chondrocalcinosis | This patient is presenting with a joint aspiration positive for calcium pyrophosphate dehydrate crystals, suggesting a diagnosis of pseudogout, which may show chondrocalcinosis on radiography.
Pseudogout presents classically with mono- or oligo-articular arthritis that most often affects the knee and proximal joints of elderly patients (> 60 years of age). The disease can be associated with hyperparathyroidism, Gitelman syndrome, familial hypocalciuric hypercalcemia, and hemochromatosis. The patient will have a leukocyte count < 50,000/mm^3 on joint aspiration and positively birefringent, rhomboid-shaped cells on microscopy, which represent calcium pyrophosphate dehydrate (CPPD) crystals. On radiography, chondrocalcinosis can be found, which is the calcification of adjacent cartilaginous structures. Treatment is with indomethacin.
Sidari and Hill review the evidence regarding the diagnosis and treatment of gout and pseudogout. They discuss how diagnosis can be made with fluid microscopy. They recommend treatment with non-steroidal anti-inflammatory drugs.
Figure/Illustration A is polarized microscopy of joint fluid showing rhomboid-shaped crystals that are positively birefringent (red circles). These represent calcium pyrophosphate dehydrate crystals seen in pseudogout.
Incorrect Answers:
Answer A: Boutonniere deformity is characterized by proximal interphalangeal (PIP) joint flexion and distal interphalangeal (DIP) joint extension and is a common hand deformity of rheumatoid arthritis. Rheumatoid arthritis is characterized by insidious onset of morning stiffness and pain that usually affects symmetric PIP and metacarpophalangeal (MCP) joints first. On joint aspiration, leukocyte count ranges from 5,000-50,000/mm^3, but rheumatoid arthritis would not explain the CPPD crystals. Treatment may include methotrexate.
Answer C: Heberden nodes are bony protuberances in the DIP joints, which are characteristic of osteoarthritis. Osteoarthritis presents with insidious onset of joint pain that worsens with activity and weight-bearing. On joint aspiration, the leukocyte count is < 2,000/mm^3.
Answer D: Juxta-articular osteoporosis is decreased bone density of the bone surrounding the joint space. It is a nonspecific sign that can be seen with many inflammatory joint diseases such as rheumatoid arthritis or septic arthritis. Septic arthritis presents with mono-articular joint pain, erythema, and swelling. Joint aspiration will show a leukocyte count > 50,000/mm^3 and Gram stain may be positive.
Answer E: Tophi are deposits of urate crystals in the soft tissue, which are nearly pathognomonic for gout. Gout presents as acute, mono-articular joint pain with physical examination showing a red, inflamed joint (usually the first metatarsophalangeal, knee, or ankle joint). Needle-shaped, negatively birefringent urate crystals are seen in the joint fluid aspirate. Prevention may include allopurinol.
Bullet Summary:
Pseudogout is associated with positively birefringent, rhomboid-shaped crystals and chondrocalcinosis. | nan |
https://bit.ly/3GZtkBx | A 9-year-old girl presents to the emergency department with a fever and a change in her behavior. She presented with similar symptoms 6 weeks ago and was treated for an Escherchia coli infection. She also was treated for a urinary tract infection 10 weeks ago. Her mother says that last night her daughter felt ill, and her condition has been worsening. Her daughter experienced a severe headache and had a stiff neck. This morning she was minimally responsive, vomited several times, and produced a small amount of dark cloudy urine. The patient was born at 39 weeks and met all her developmental milestones. She is currently up to date on her vaccinations and did not have infections during early childhood. Her parents are divorced and her father has noted she does not seem to get sick when he takes care of her. Her temperature is 99.5°F (37.5°C), blood pressure is 60/35 mmHg, pulse is 190/min, respirations are 33/min, and oxygen saturation is 98% on room air. The patient is started on intravenous fluids, vasopressors, and broad-spectrum antibiotics. Which of the following is the most appropriate underlying explanation for this patient's presentation? | Gastroenteritis | Immunodeficiency | Intentional contamination | Meningitis | C | Intentional contamination | This patient is presenting with repeat sepsis, which is uncommon in a pediatric patient with no significant medical history. This abnormal concentration of infections when the patient is with her mother suggests a diagnosis of intentional contamination.
Factitious disorder by proxy (formerly Munchausen syndrome) occurs when 1 individual creates symptoms in another for attention. Typically, this is a parent feigning or creating symptoms in a child in order to receive the psychiatric gain of attention from healthcare personnel. The patient should be treated and removed from the parents as this is considered child abuse. Factitious disorder by proxy should be suspected in any pediatric patient who has repeat infections that are atypical or not expected epidemiologically. Patients should also be evaluated for organic causes of symptoms such as immunodeficiency syndromes.
Abeln and Love review the evidence regarding the diagnosis of factitious disorder by proxy. They discuss how these disorders have high morbidity and mortality when not accurately recognized. They recommend paying attention to red flags such as abnormal constellations of symptoms.
Incorrect Answers:
Answer A: Gastroenteritis would present with nausea, vomiting, and diarrhea; however, it would not present with sepsis routinely. Gastroenteritis does not best explain the most likely underlying cause of this patient's presentation.
Answer B: Immunodeficiency such as severe combined immunodeficiency (SCID) would present with lifelong infections from birth that are bacterial, viral, and fungal. Immunodeficiency would not present with repeat infections in a pediatric patient only when they are with one patient.
Answer D: Meningitis would present with headache, altered mental status, and meningeal signs. In the setting of repeat sepsis in a healthy pediatric patient, intentional contamination is more likely. Similarly, an absence of photophobia and no further history/physical exam supporting this diagnosis suggests an alternative diagnosis.
Answer E: Urinary tract infection would present with dysuria rather than repeat episodes of sepsis. Though a urinary tract infection could lead to sepsis, this would be rare and more likely to occur in an immunosuppressed patient, the elderly, or a neonate. UTIs are a common cause of infection and fever in pediatric patients.
Bullet Summary:
Factitious disorder by proxy occurs when 1 individual feigns or creates symptoms in another. | Urinary tract infection |
https://bit.ly/3n1kBse | A 32-year-old man presents to his primary care provider for a headache. He reports that he has headaches at night several times a week. He first developed these headaches over 1 year ago, but they started up again 3 weeks ago. The episodes start suddenly and feel like a stabbing, electrical pain over his left eye. He also reports tearing of the left eye during these episodes. The headaches self-resolve over the course of 2-3 hours, but the patient complains that he is avoiding going to sleep for fear of waking up in pain. His medical history includes type 1 diabetes mellitus and an episode of herpes zoster on his right flank 1 year ago. His only home medication is insulin. His temperature is 98.6°F (37°C), blood pressure is 112/69 mmHg, pulse is 61/min, and respirations are 14/min. On physical exam, his extraocular muscles are intact and his eyes are not injected. A CT of the head and sinuses shows no acute abnormalities. Which of the following is most likely to prevent future episodes of headache in this patient? | Verapamil | Sumatriptan | Carbamazepine | High-flow oxygen | A | Verapamil | This patient presents with an episodic, stabbing pain in the periorbital region that occurs at night, which is consistent with a diagnosis of cluster headaches. Verapamil is used as prophylaxis against cluster headaches.
Cluster headaches usually occur at night and may wake patients out of sleep. Cluster headaches may occur several times a week to multiple times daily and the attacks may be followed by a period of remission. Cluster headaches also typically involve the periorbital region and are unilateral. Patients also classically describe their headaches as “stabbing”. Tension-type headaches are more commonly described as dull and migraines are usually described as pulsating or throbbing. Treatment is with high-flow oxygen during acute episodes and prophylaxis against long-term headaches includes calcium channel blockers such as verapamil.
Hoffman and May review the evidence regarding the treatment of cluster headaches. They discuss how high-flow oxygen and triptans are the most effective abortive treatment for acute attacks. They recommend using chronic prophylactic medications such as verapamil.
Incorrect Answers:
Answer A: Carbamazepine is the treatment of choice for trigeminal neuralgia, which presents as shooting pain in the face. They have exquisite tenderness to palpation over the affected neurologic distribution.
Answer B: High-flow oxygen is an abortive treatment for cluster headaches. Cluster headaches typically present in men with unilateral pain around the eye that is worse at night. Associated symptoms include spasms of the unilateral face as well as tearing and visual abnormalities in the eye. This treatment is not effective for long-term prophylaxis.
Answer C: Sumatriptan is used as an abortive treatment for cluster headaches and migraines, but it is not used as prophylaxis for either. Migraines present as unilateral, throbbing headaches that may be associated with nausea and/or vomiting, photophobia, phonophobia, and aura.
Answer D: Topiramate is used as prophylaxis for migraines rather than cluster headaches. Migraines present as unilateral, throbbing headaches that may be associated with nausea and/or vomiting, photophobia, phonophobia, and aura.
Bullet Summary:
Cluster headaches classically present as sharp or stabbing periorbital headaches that occur at night, with verapamil being the prophylactic treatment of choice and high-flow oxygen being the most effective abortive treatment. | nan |
https://bit.ly/3v12XZt | A 6-month-old girl is brought to the pediatrician by her father for a scheduled check-up. She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia. She received amoxicillin and had a resolution of her symptoms. Her father reports that she seems “back to normal.” She can roll over by herself and can sit up without support. She often babbles but sometimes does make identifiable sounds like “dada” and “baba.” They recently started feeding her mushy cereal, which she seems to like but occasionally spits up. She has started teething and sometimes becomes “fussy.” Vital signs are within normal limits. A physical examination is unremarkable. The patient’s father brought a 4-week follow-up chest radiograph taken at the hospital, as shown in Figure A. Which of the structures labeled in Figure A would be most likely to change in response to another infectious illness? | A | B | C | D | A | A | The thymus gland (labeled in A) is visible on a chest radiograph in infants and will change in response to illness due to its immunologic role.
The thymus gland is the site of T-cell maturation. The thymus is visible on a chest radiograph in infants and continues to grow throughout childhood. It is located in the anterior part of the superior mediastinum. On a chest radiograph, the thymus may appear as a “widened mediastinum,” continuous with the superior border of the heart (Figure A) or as a triangular-shaped opacity known as the thymic “sail sign," located towards the right of the mediastinum. At puberty, the gland will decrease in size and eventually be replaced by fatty tissue.
Askin and Young review the evidence regarding the history and function of the thymus. They discuss how this structure is involved in immune function. They recommend monitoring for the absence of this structure in immunodeficient patients.
Figure A shows a normal chest radiograph of an infant with a normal cardiothymic contour.
Incorrect Answers:
Answer B: B points to the trachea. Deviation of this structure can be seen in patients with tension pneumothorax. Treatment is with needle thoracostomy followed by chest tube placement.
Answer C: C points to the apex of the heart. This structure can be enlarged in congenital heart conditions. Treatment is with surgical correction of these conditions.
Answer D: D points to the stomach. This structure can be abnormal in patients with pyloric stenosis. Treatment is with pyloromyotomy.
Answer E: E points to the diaphragm. This structure can be abnormal in patients with diaphragmatic hernias. Treatment is with surgical closure of the defect.
Bullet Summary:
The thymus is normally visible on a pediatric chest radiograph, but it is replaced by fatty tissue after puberty. | E |
https://step2.medbullets.com/testview?qid=216244 | A 67-year-old man presents to the emergency room reporting sudden-onset abdominal and back pain that began 3 hours ago. He was eating dinner when he started feeling severe pain in his abdomen that made him lose his appetite. He denies any diarrhea or hematochezia and says the pain is not affected by movement. He has a history of hypertension, hyperlipidemia, and depression. He currently takes amlodipine and atorvastatin and is compliant with his medications. He has a 45-pack-year smoking history, but he does not drink alcohol or use any illicit drugs. His temperature is 98.6°F (37°C), his blood pressure is 110/64 mmHg, pulse is 97/min, and respirations are 15/min. Physical exam is notable for diffuse abdominal tenderness without rigidity or guarding. During evaluation, the patient becomes diaphoretic and pale and reports that he feels fatigued. Repeat blood pressure is 87/50 and pulse is 127. Intravenous fluid boluses are administered. Which of the following is the most likely diagnosis? | Ischemic colitis | Ruptured abdominal aortic aneurysm | Aortic dissection | Acute pancreatitis | B | Ruptured abdominal aortic aneurysm | This patient who presents with sudden-onset abdominal pain, hemodynamic instability (symptomatic hypotension with tachycardia), and significant history of hypertension and smoking most likely has a ruptured abdominal aortic aneurysm (AAA).
Abdominal aortic aneurysms are dilations in the vessel wall that can predispose to rupture. Risk factors for AAA include advanced age (> 60 years), smoking history, male sex, and history of atherosclerosis. AAA can be asymptomatic or mildly symptomatic until it markedly expands or ruptures, leading to abdominal pain, back pain, or flank pain. The evaluation of suspected AAA depends on the hemodynamic stability of the patient and prior knowledge (or lack thereof) of the existence of an AAA. A hemodynamically unstable patient with a known history of AAA should be assumed to have a ruptured AAA and undergo surgical intervention without further workup (though bedside ultrasound can support the diagnosis). In an unstable patient without a known history, a bedside ultrasound to confirm the diagnosis should precede surgical intervention. In a hemodynamically stable patient with or without a known AAA history, an abdominal CTA is appropriate.
Sakalihasan et al. present a review of the presentation and treatment of abdominal aortic aneurysms. They discuss how patients are often asymptomatic until catastrophic rupture occurs. They recommend immediate surgical repair of the aneurysm during ruptures to prevent death.
Incorrect Answers
Answer A: Acute pancreatitis also presents with abdominal pain and can present with hemodynamic instability in severe cases of hemorrhagic conversion of pancreatitis. This is a rare entity and is less likely in this patient. Treatment is immediate transcatheter arterial embolization for unstable patients with hemorrhagic pancreatitis.
Answer B: Aortic dissection has similar risk factors to AAA (history of hypertension, advanced age) and also presents with acute onset back pain. Dissection normally occurs in the setting of hypertension. This diagnosis is possible but less likely in this man with a history of smoking.
Answer C: Ischemic colitis can also present with abdominal pain in a patient with risk factors for atherosclerotic disease. It is associated with hematochezia and diarrhea and is unlikely to cause the level of hypotension in this patient. Treatment is with restoration of blood flow to the ischemic bowel segment or resection if this is not possible. Management is usually centered on medical optimization.
Answer D: Perforated viscus is a surgical emergency that can also present acutely with hemodynamic instability and severe abdominal pain. However, signs of peritoneal irritation are usually present (guarding, rigidity). Treatment is with immediate surgical exploration and repair or resection.
Bullet Summary:
Patients with new-onset back and abdominal pain and a positive smoking history that progresses to hemodynamic instability should be suspected of having a ruptured abdominal aortic aneurysm. | nan |
https://step2.medbullets.com/testview?qid=216474 | A 57-year-old man is brought to the emergency department by his wife with confusion. He was seen in the emergency department 2 days ago for profuse epistaxis. His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation. However, his bleeding resolved with pressure and nasal packing. Upon presentation to the ED today, his temperature is 97.6°F (36.4°C), blood pressure is 64/33 mmHg, pulse is 160/min, respirations are 32/min, and oxygen saturation is 100% on room air. Physical exam reveals an obtunded man who cannot answer questions. A dark, purpuric rash is noted on his torso and extremities. The patient’s nasal packing is removed with no further bleeding. The patient is given IV fluids and blood cultures are drawn. Which of the following should be administered first? | Penicillin | Piperacillin-tazobactam | Meropenem | Clindamycin | D | Clindamycin | This patient is presenting with nasal packing, hypotension, tachycardia, a dark, purpuric rash, and confusion, which are concerning for toxic shock syndrome. The most important initial step in management is to administer clindamycin.
Toxic shock syndrome is a life-threatening diagnosis caused by Streptococcus pyogenes or Staphylococcus aureus and occurs commonly secondary to retained tampons or nasal packing. Patients are critically ill and require immediate management with fluids, vasopressors, and blood cultures. Source control is imperative, and the foreign body causing the infection must be removed. Next, broad-spectrum antibiotics should be started immediately. Clindamycin is often preferred as the first agent as this lincosamide antibiotic not only covers Staphylococcus aureus and Streptococcus pyogenes, but also has the theoretical benefit of suppressing toxin production. Further management is centered on fluid administration, vasopressors, and monitoring and care in an ICU setting as these patients are typically critically ill.
Russell and Pachorek review the treatments for toxic shock syndrome. They note that clindamycin is particularly important in toxic shock syndrome that is complicated by toxin production. They recommend that administration may reduce toxin production and could improve outcomes.
Incorrect Answers:
Answer B: Meropenem is a broad-spectrum antibiotic that covers most organisms except for MRSA. It is generally not used as a first-line agent unless the patient has allergies to other antibiotics or the infectious organism is only sensitive to this agent. Even in toxic shock syndrome, it would not be used as a first-line agent.
Answer C: Penicillin may be used for infections such as streptococcal pharyngitis, which presents with a sore throat, fever, and tonsillar exudates. It is a relatively weaker antibiotic and would not be used in a critically ill patient with toxic shock syndrome.
Answers 4 & 5: Piperacillin-tazobactam and vancomycin represent a powerful broad-spectrum regimen of antibiotics that covers gram-positives, gram-negatives, Pseudomonas aeruginosa, and anaerobes (piperacillin-tazobactam) as well as further gram-positive coverage and MRSA (vancomycin). Though this is a potent antibiotic combination, neither of these takes priority over clindamycin given the possible benefit of toxin suppression from clindamycin. In this patient, clindamycin and piperacillin-tazobactam would be an appropriate antibiotic regimen.
Bullet Summary:
Clindamycin may suppress toxin production and should be given early in toxic shock syndrome. | nan |
https://step2.medbullets.com/testview?qid=216360 | A 55-year-old man with a history of polysubstance abuse is found down in his home acutely obtunded. Emergency medical services administered naloxone which immediately woke the patient up and improved his oxygen saturation from 40% to 90%. However, they noted subsequently that the patient demonstrated increased work of breathing and had crackles and wheezing on pulmonary exam. The patient arrives alert and oriented claiming he feels short of breath. He denies any chest pain or other symptoms aside from shortness of breath. He has a history of cocaine-induced cardiomyopathy and myocardial infarction from cocaine use 2 years ago. The patient has a 40 pack-year smoking history. His temperature is 96.0°F (35.6°C), blood pressure is 120/68 mmHg, pulse is 102/min, respirations are 26/min, and oxygen saturation is 88% on room air. Physical exam reveals increased work of breathing, pulmonary crackles, and wheezing. A chest radiograph is performed as seen in Figure A. Which of the following is the most likely etiology of this patient's current symptoms? | Medication administration | Community acquired pneumonia | Atypical pneumonia | Poor cardiac function | A | Medication administration | This patient is presenting after administration of naloxone with respiratory distress, wheezing, crackles, and pulmonary edema on chest radiography, suggesting acute pulmonary edema. Given the presence of symptoms immediately following naloxone administration, the cause of the pulmonary edema is likely the naloxone (medication-induced) that was administered.
Opioid use disorder is a common problem in the United States and can lead to overdose, which is life-threatening if not treated. Patients with symptoms of opioid intoxication including miosis, bradypnea, and altered mental status should be empirically given naloxone, as it may be life-saving and is relatively benign. Naloxone should only be given for patients with unstable vitals or who are failing to ventilate/oxygenate or protect their airway. Naloxone commonly precipitates withdrawal and may cause nausea, vomiting, diarrhea, and pain. It is possible for naloxone to cause pulmonary edema (via a poorly elucidated mechanism). Pulmonary edema presents with wheezing, tachypnea, and pulmonary crackles. The most important intervention when treating pulmonary edema is to address the underlying cause and start the patient on positive pressure ventilation. Diuretics may be administered if the patient is volume overloaded. An echogardiogram can rule out poor cardiac function as the underlying etiology as well.
Lassen et al. review naloxone use and pulmonary edema. They note that naloxone administration can cause non-cardiogenic pulmonary edema and that the mechanism is not well elucidated. They recommend that naloxone should only be used at the lowest dose possible to stabilize the patient.
Figure A is a chest radiograph demonstrating "fluffy" interstitial infiltrates throughout both lung fields suggestive of pulmonary edema.
Incorrect Answers:
Answer A: Atypical pneumonia may present with a dry cough, fever, hypoxia, and increased interstitial markings on chest radiograph. These patients are usually well appearing, and the opacities are not as "fluffy" as pulmonary edema. A common cause is Mycoplasma pneumoniae.
Answer B: Chronic obstructive pulmonary disease (COPD) presents with a flattened diaphragm and increased number of visible ribs on chest radiography as a result of air accumulation in the chest. Pneumonia may be present on chest radiograph and is a common cause of COPD flares. A COPD flare may present with wheezing, poor air movement, hypoxia, and hypercarbia.
Answer C: Community-acquired pneumonia presents with a fever, cough, hypoxia, and a lobar consolidation on chest radiograph. This infiltrate is usually confined to one lobe and is thus often called "lobar pneumonia." Streptococcus pneumoniae is the most common cause.
Answer E: Poor cardiac function can cause pulmonary edema via increased hydrostatic pressure backing up into the lungs causing fluid leakage. Though the appearance of pulmonary edema would be the same, naloxone causes non-cardiogenic pulmonary edema. In this patient with a previous myocardial infarction, a low ejection fraction may plausibly be contributing to this patient's pulmonary edema; however, the association of symptoms with naloxone administration makes this a less likely etiology for this case.
Bullet Summary:
Naloxone can cause non-cardiogenic pulmonary edema. | nan |
https://step2.medbullets.com/testview?qid=214961 | A 51-year-old man presents to the emergency department complaining of fever and a cough with yellow-green sputum for the past 3 days. He denies any hemoptysis, facial pain, rhinorrhea, or night sweats. The patient reported similar symptoms 2 months ago. Chest radiograph performed at the time was notable for a right middle lobe consolidation. He was diagnosed with lobar pneumonia and completed a 7-day course of antibiotics with complete resolution of his symptoms. He has no other significant medical history and does not take any medications. He has smoked 1 pack of cigarettes a day for 35 years and drinks 3 beers per week. He is sexually active with his wife. His temperature is 101.7°F (38.7°C), blood pressure is 127/85, pulse is 102/min, and respirations are 22/min. Physical exam is notable for decreased breath sounds on the right side without wheezing and increased dullness to percussion on the right side. A chest radiograph is ordered and reveals a consolidation in the right middle lobe. Which of the following is the most appropriate next step in management? | Interferon-gamma release assay | CT of the chest without contrast | Barium swallow | Serum immunoglobulin levels | B | CT of the chest without contrast | This patient's presentation with recurrent pneumonia in the same anatomical location is concerning for an anatomic abnormality. Given his history of heavy smoking, lung cancer should be ruled out with a chest CT with possible subsequent bronchoscopy for tissue biopsy.
Recurrent pneumonia can be classified either as those confined to 1 anatomical location of the lung or those involving different portions of the lung. If recurrent pneumonia is limited to a single region, the patient should be evaluated for an anatomic obstruction, such as a mass or mucous plug. Obstruction will hinder mucociliary clearance and allow for the proliferation of bacteria, leading to recurrent infections. The most concerning etiology of such an obstruction is a tumor causing external bronchial compression. Thus, patients should be screened with a chest CT to rule out lung cancer in these cases. If lesions are identified on CT, subsequent bronchoscopy or CT-guided biopsy may be warranted. Treatment may involve radiotherapy, chemoimmunotherapy, or surgery depending on the underlying malignancy. Other causes of recurrent pneumonia limited to an anatomical region include recurrent aspiration secondary to tracheoesophageal disorders or seizures.
Purysko et al. discuss the role of contrast enhancement in chest CTs. The authors find common indications for contrast-enhanced chest CTs include investigation for pulmonary embolism, pleural pathology, or hilar pathology. The authors recommend against the regular use of contrast enhancement in chest CTs outside of selected indications as they rarely provide additional diagnostic benefits while subjecting the patient to the risk of adverse effects with contrast agents.
Incorrect Answers:
Answer A: Barium swallow is often done to investigate anatomical abnormalities of the upper gastrointestinal tract such as tracheoesophageal fistula or Zenker diverticulum. These can increase the risk of aspiration and lead to recurrent pneumonia. In a patient with positive risk factors for cancer, chest CT to rule out malignancy would be the most appropriate next step.
Answer C: Human immunodeficiency virus (HIV) can cause secondary immunodeficiency, which can predispose patients to recurrent infections. These recurrent pneumonias would be expected to be in different regions of the lung and not anatomically confined.
Answer D: Interferon-gamma release assay can be used to diagnose tuberculosis (TB). Reactivation of TB will present clinically with fever, cough, hemoptysis, and night sweats. Chest radiography will commonly reveal an upper lobe infiltrate.
Answer E: Serum immunoglobulin levels would be an appropriate next step to diagnose primary immunodeficiencies such as common variable immunodeficiency or other antibody defects. This would present with multiple lung infections in different regions of the lung. Moreover, these patients would be expected to have other infections such as sinusitis, otitis, and gastrointestinal infections.
Bullet Summary:
Recurrent pneumonia in the same anatomical region should be worked up with a CT with subsequent bronchoscopy and biopsy to rule out malignancy. | nan |
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