Hy 1751-1821

Hy 1751

Q) This came up as a concept on boards. A 40-year-old female, lesions on her face and neck (lesions are usually there). On examination, multiple lesions that seem to be hanging off the skin are seen. Lesion is small, soft, and pedunculated. The largest lesion is about 5 mm in diameter. The color of different lesions varies from flesh colored to slightly hyperpigmented. What is this? (Pick: Seborrheic keratoses, Acrochordons, Lentigos)


a) Acrochordons. They are very common benign lesions that can occur at any skin site, but have a predilection for the neck, axilla. Seborrheic keratoses are “warty” and Lentigos are “age spots/freckles”. All are benign. Got it?

Hy 1752 Toughie, on Boards, but can you get it?
70-year-old woman, cardiac catheterization via the right femoral artery now presents w/ cool right foot. She has a pulsatile mass over her right inguinal area, loss of her distal pulses, bruit over the point at which the right femoral artery was entered. What is the disease? (Pick Femoral pseudoaneurysm OR Retroperitoneal hematoma.)
a) Femoral pseudoaneurysms tis a common vascular complication of cardiac catheterization. The combination of a pulsatile mass, femoral bruit, and compromised distal pulses-- nail this for Step 1. The diagnosis can be confirmed by ultrasound.
Hy 1753
Baby is delivered vaginally following a breech presentation. There is bilateral subluxation (dislocation) of the hips. There is decreased abduction of both hips. Besides breech presentation, which of the following infants are most at risk for developmental dysplasia of the hip? Pick: African American infants, Female infants, Premature infants…
a) Female infants! Developmental dysplasia of the hip generally includes subluxation (partial dislocation) of the femoral head, and complete dislocation of the femoral head from the acetabulum. The disorder is more common in females than in males—in many series, as much as five times more common.


Hy 1754 Another Fat Concept
A 65-year-old man, w/ 50-pack-year smoking history, worsening of shortness of breath. He has a change in his chronic daily cough w/ blood tinged sputum. On physical examination, he has rhonchi in the right posterior mid-lung field w/ soft scattered rhonchi in both lung fields with a prolonged expiratory phase. There is a 7-cm, irregularly shaped mass in the right middle lobe with associated lobar consolidation. Which would most suggest that the patient has surgically incurable lung cancer? (Pick from: Worse hoarseness of the voice, Worse hemoptysis, Dyspnea.)
a) hoarseness! A patient with chronic obstructive pulmonary disease (COPD) and suspected lung carcinoma who becomes hoarse likely has metastatic disease to the recurrent laryngeal nerve. LISTEN, a lung cancer is BAD BAD. Surgical cure is only of the only hopes, and if you have signs of metastasis outside, surgery cannot be and then the patient also cannot be…prayer is now warranted here.
Hy 1755
I forgot to mention, can you POINT to the recurrent laryngeal nerve on radiograph? Oh, someone just also asked me if you can POINT to the nasolacrimal duct on a coronal section of the face that is at the level of the demonstration of the superior, middle, and inferior turbinates.
Hy 1756
A 55-year-old female w/ osteoporosis. She has hypertension and diabetes mellitus. She smokes 1 pack of cigarettes per day. She hit menopause and asks about osteoporosis prevention. She should be told that independent of side effects, the best therapy currently available for prevention is which of the following? Pick from: bisphosphonates, estrogens, flouride, calcium. Also, what cells do bisphosphonates directly act on?
a)Pick estrogens. The other meds are used, but estrogen is the mainstay. They will help her HDL levels and coronary artery disease. Bisphosphonates are agents that inhibit osteoclastic bone resorption. Early intervention can prevent osteoporosis. Later intervention can halt its progression, but it is not currently possible to reverse established disease. All current therapies for osteoporosis are directed at inhibiting bone resorption. Bone loss is greatest within the first year of menopause.

Hy 1757
A 50 yr old male has heart disease. The patient is very concerned about a massive infarction. The patient reports that he eats well, exercises regularly, and "normal" cholesterol levels. He reports that he had previously smoked one and a half packs per day for about 20 years but quit 2 years ago. Around how many years must this patient have stopped smoking before his tobacco use no longer counts as a risk factor? Take a good guess.


a) Listen, the major cardiac risk factors are family history, age, tobacco use, hypertension, diabetes, and low HDL. Tobacco use counts, even if it is no longer current, for around 15 years.

Hy 1758
(Picture shown) A 6-week-old boy w/ rash involving the diaper area. There are erythematous, slightly scaly patches covering the buttocks and the lower abdomen. There is no lymphadenopathy, fever. What is the most common cause? Pick: (Candidiasis, contact dermatitis, Langerhans cell histiocytosis, Psoriasis)



a) contact dermatitis. KNOW what this most common looks like.

Hy 1759
These are easy points. Do you know the difference between Conversion disorder, Hypochondriasis, Malingering, Munchausen, and Somatization disorder?
Conversion disorder: Conversion disorder is the development of specific, usually dramatic, physical complaints in response to psychologic stress
Hypochondriasis: Hypochondriasis is much more common than somatization disorder and is usually not as severe. It is often tested as a “lesser” form of Somatization disorder.
Malingering: We all kinda did this to get out of a duty or school, etc. by saying we were sick.
Munchausen: involves more elaborate and deliberate mimicking of medical conditions. Sometimes it involves hurting one’s own children. Recall that rapper “Slim Shady” Eminem complained about this regarding his mother.
Somatization disorder. The physical complaints are usually vague and not adequately explained by a physical disorder. Formal criteria for the diagnosis have been defined and include onset before age 30, symptoms involving at least four different body parts, two or more gastrointestinal symptoms, at least one reproductive or sexual symptom, and at least one neurologic symptom.
They seem easy to differentiate, but students complained that it was a hairline difference.

Hy 1760
A 60 year old male who smoked and drank most of his life describes progressive dysphagia that began 3 months ago. He first noticed difficulty swallowing meat; it then progressed to other solid foods, then to soft foods, and now to liquids as well. He locates the place where the food "sticks" at the lower end of the sternum. He has lost 30 pounds. You do a barium swallow and find what disease?




a) Likely esophageal cancer, squamous cell type.

Hy 1761
A 20-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes with a gush of fluid. Sterile speculum examination shows fluid is nitrazine. The fetal heart rate is in the 150s (normal) and is in breech. A cesarean delivery is performed. During the operation, the physician, who has received no recent immunizations, is stuck with a syringe from the pt. What is this physician at greatest risk of contracting? (Pick from: HIV, Hep B, Hep C)

a) Hep B. The risk of acquiring hepatitis B is significantly higher than the risk for HIV. KNOW that there is no immunization for hepatitis C available yet!!


Hy 1762
KNOW this key point: The complete blood count (or alternatively the hematocrit or hemoglobin) cannot be used to assess the size of an acute blood loss!!!!!!!!! This comes up over and over on Boards…The reason is that the hematocrit or red cell count will drop only as fluid from other body sources (mostly extracellular fluid, with a smaller shift of intracellular fluid to extracellular) enters the capillary beds in response to a decreased intracapillary blood pressure. This takes at least a few hours to happen. Don’t let yourself get tricked. If someone goes into shock from acute blood loss, the CBC could be within normal limits initially!!! The blood pressure will be the first thing to drop fast in a patient in shock fr. Blood loss양식의 맨 위




Hy 1770

KNOW this: Esophageal pH monitoring would be used for gastroesophageal reflux.

Hy 1771

Also KNOW this: Manometry would be called for if the history suggested a motility problem.

Hy 1772
If you get a common question regarding esophageal tumor, will you do an endoscopy first or a Barium swallow?

a) Barium swallow. The tumor will eventually be seen and biopsied by endoscopy, but the endoscopist will first want to know the exact location of the tumor and the degree to which the lumen is occluded. Otherwise, there is a high risk of instrumental perforation of the esophagus. The best way to obtain that information is to do a barium swallow to see a cancer of the esophagus.


Hy 1773
A female infant is born vaginal at 39 weeks' gestational age with no problems. There is no sig. Family history. She has a port-wine stain on the right side of her face 4 cm by 3 cm. What is the tx? Pick: Cryosurgery OR Pulsed dye laser OR topical steroids.
a- This is a port-wine stains are vascular malformations Pulsed dye laser reduces the size of most port-wine stains. Remember the question! If it is a “small port wine lesion, it may spontaneously regress, but the large ones need more attention.

Hy 1774
A 71-year-old male complains of increasing calf pain when walking uphill. The symptoms have gradually increased 2 months. He had an MI 2 years ago. His blood pressure has been controlled with diltiazem, hydrochlorothiazide, and propranolol. There is right carotid bruit and diminished pulses at the dorsalis pedis. Which of the three drugs should have the dosage lowered?




a) propranolol. It is contraindicated in patients with peripheral claudication, as we see in this poor patient.





Hy 1775
2 1/2-year-old child has difficulty walking. She has ataxia and mental retardation. You see telangiectasias involving the conjunctiva, ears, and antecubital fossae. She also has a history of multiple respiratory tract infections. Immunoglobulin studies would most likely show an absence of … ? (Pick IgA and IgE OR IgE and IgG)



ans is IgA and IgE. The child's condition is the autosomal recessive disease, ataxia-telangiectasia. Choreoathetoid movements, slurred speech, ophthalmoplegia, and progressive mental retardation characterize the disease at it advances. Telangiectasias, are a helpful diagnostic clue.


Hy 1776
A 40 year old automobile mechanic has new onset of wheezing. He is otherwise healthy. He has a history of chronic heartburn, for which he takes ranitidine nightly. He also has a history of hypertension taking propranolol, enalapril, and hydrochlorothiazide. He uses occasional pseudoephedrine for allergic rhinitis. His blood pressure is 134/88 mm Hg, pulse is 68/min, and respirations are 18/min. On lung examination, soft expiratory wheezes are heard throughout both lung fields. Which med that he is using is most likely contributing to his wheezing?


a) Propranolol! Remember this may cause bronchospasm by blocking the beta receptors in the lungs and propranolol is contraindicated in patients with known asthma or chronic obstructive pulmonary disease. Be CAREFUL, some may have picked enalapril, due to the association with cough, but it is not usually associated with wheezing!

Hy 1777
A 40-year-old man has 1-day history of increasing nausea, vomiting, lethargy. He has an extensive smoking history and has lung cancer. His skin shows eroding calcium deposits. Lab results indicate a serum calcium level of 13.4 mg/dL. What drug do you reach for? Pick Etidronate OR Hydrochlorothiazide OR IV saline?




a) Recall that Hypercalcemia can be treated with IV saline and furosemide, not with a hydrochlorothiazide (common mistake).





Hy 1778
A 25-year-old woman has scaling skin since childhood. You see fine scaling of the back and extensor surfaces of the extremities. Involved areas also show horny plugs in the orifices of hair follicles. Cracking of the skin is prominent on the palms and soles. The patient has what dx? Pick Ichthyosis vulgaris OR Xeroderma.
a) This is ichthyosis vulgaris. It has an autosomal dominant inheritance, very very common. Bathing limited to 10-minute periods (to hydrate the stratum corneum), followed by immediate application of petrolatum jelly, can help to control scaling.

Hy 1779
12-month-old infant has bilious vomiting and abdominal distention for 10 hours. He has been constipated since birth and failed to pass meconium during the 1st two days. His length and weight are below the 5th percentile. His abdomen is distended. After a digital rectal examination, a fair amount of stool ejects out from the anus. What is the dx?
a) Hirschsprung disease

Hy 1780
KNOW that Endometrial cancer is the most common gynecologic cancer in women ages 45 and older. The main factor that predisposes to endometrial cancer is exposure to unopposed estrogen. Endogenous factors include, early menarche, late menopause, chronic anovulation, estrogen-secreting ovarian tumors, and MOST COMMONLY, obesity.









Hy 1781
7-year-old boy in acute distress. PMH of generalized fatigue and mild, mid-abdominal pain that have become steadily worse over 3 days. He has a maculopapular rash on his thighs and feet with spread to buttocks. The rash does not blanch. He has high temp and stomach pain. He is nauseated and vomited. Stool is guaiac-positive. He is dehyrated. What is the disease? Pick: Henoch-Schönlein Purpura or Rocky Mountain Spotted Fever or Nephrotic Syndrome.
a) Henoch-Schönlein Purpura. This is VERY common, thus, it will be on your examination with the same presentation.

Hy 1782
Recall if you picked Rocky Mountain Spotted Fever/RMSF in the last concept, KNOW it is one of the most common tick-borne diseases. The typical rash of RMSF appears within a week of the tick bite. It begins on the palms, soles, and extremities and spreads centrally. Severe headache and photophobia are common complaints. Also, even though nephrotic syndrome frequently follows an infectious illness, there was no edema and protein in the urine (This concept will be tested! Do you know what color urine nephrotic syndrome shows on regular visual inspection?)

Hy 1783
24-year-old female has crampy periumbilical pain. This lasted 9 months along with constipation lasting 4-5 days monthly. These are typically followed by 3-4 days of frequent loose bowel movements. She denies any bloody stools, fever, weight loss.Her physical examination is normal. What dx? Pick Crohn’s, or Giardia, or Peptic Ulcer, or Irritable bowel syndrome.
a) This is classic for Irritable bowel syndrome. A LARGE percent of the American population has this.

Hy 1784
29-year-old woman is seen in the emergency department for a broken ankle. She describes a fall down her stairs at home earlier that day. She denies any alcohol or drugs. She has no significant PMH, but she has been admitted to the hospital many times for previous fractures. The patient explains that all these visits are due to her "active lifestyle" and her frequent home repair projects. The patient has been married, she claims happily, for 2 years. She is employed as a manager at a local restaurant; her husband is unemployed and on disability pay for back problems. Domestic abuse is suspected. Do you know how to approach this “common” scenario, i.e. what you say? Pick: Confront the husband OR Refer to social services OR Ask her to talk about the relationship more openly.




a) First, try not to pick the answer choices that says “Refer to”. Don’t confront the husband. Rather, ask her non judgmentally to talk to her about her husband.

Hy 1785
A previously healthy, normal weight 22-year-old woman has mild jaundice, low-grade fever, arthralgia, malaise, amenorrhea for 3 months. There is no alcohol or smoking. She has an elevated AST and ALT levels, hypergammaglobulinemia, and high titers of circulating antinuclear and anti-smooth muscle autoantibodies. There is a liver biopsy w/ lymphocytic portal inflammation with early bridging necrosis. Is this an autoimmune hepatitis OR Nonalcoholic steatohepatitis OR Primary biliary cirrhosis?




a) This is autoimmune hepatitis, not Nonalcoholic steatohepatitis which is more involved in obese women. Primary biliary cirrhosis has a predilection for middle-aged women. It manifests with progressive signs of cholestasis, in which pruritus and xanthomas are often the earliest signs along with anti mitochondrial antibodies.

Hy 1786
Know everything about Parkinson disease (PD), a neurodegenerative condition caused by degeneration of the dopaminergic neurons in the substantia nigra that normally project to the striatum (you must be able to point to the substantia nigra and the striatum on a brain stem slide). Resting tremor, rigidity, and akinesia are the principal manifestations. Levodopa is a precursor of dopamine and the most effective drug for the symptomatic treatment of PD. Anticholinergic drugs (e.g., benztropine, procyclidine), MAO-B inhibitors (selegiline), dopamine releasers (amantadine), dopamine agonists (e.g., bromocriptine, pergolide), and muscle relaxants (diazepam) are additional options frequently used instead of or in association with levodopa.










Hy 1787

1-month-old baby male w/ bloody diarrhea. No infectious agent is identified, baby is found to be thrombocytopenic. The baby has skin rash, eczema. By three months of age, the baby begins to develop recurrent respiratory infections. Dx?: Pick from: CHF, Lymphoma, Rheumatoid arthritis.











a) Lymphoma. Baby has Wiskott-Aldrich syndrome, which is an X-linked recessive immunodeficiency disease characterized by the triad of thrombocytopenia (hemorrhage may be the presenting complaint), eczema, respiratory infections. Survivors past age 10 have a 10% incidence of cancer, particularly lymphoma and acute lymphoblastic leukemia. Modern treatment consists of splenectomy, continuous antibiotic therapy, IV immunoglobulin, and bone marrow transplantation.

Hy 1788
14-year-old boy dives into the shallow end of a swimming pool and hits his HEAD hard! When he is rescued, he shows a complete lack of neurologic function below the neck. He is still breathing on his own, but he cannot move or feel his arms and legs. What med in the ER will be of immediate help? Pick: high dose antibiotics or high dose corticosteroids or high dose Hyperbaric oxygen.
a) Give IV corticosteroids.

Hy 1789
65-year-old man w/ increasing urinary frequency. He has no past medical history and is on no medications. A digital rectal exam reveals a normal-sized prostate. The prostate-specific antigen (PSA) level is elevated. What should you do first? Pick: Give Leuprolide OR Biopsy?





a) Biopsy first. Metastatic prostate cancer can be treated with leuprolide, but let’s see if the prostate is undergoing BPH and hypertrophy.


Hy 1790
28-year-old man, post an appendectomy, w/severe lower abdominal-suprapubic pain. He has not urinated since the procedure. He is tachycardic. What do you do? Pick one: give metaprolol. OR give doxazosin. OR give cipro. OR straight catheterization of the bladder.







a) straight catheterization of the bladder. KNOW that post-surgical patients often have urinary retention as part of their normal, immediate postoperative course; therefore, indwelling catheters are often placed. You may be tricked by Boards to pick a beta blocker. Listen, tachycardia is most likely a sinus tachycardia related to severe pain. Recall 1000 posts ago our discussion of how inflammation increases fever and heartrate?

Hy 1791
KNOW that placing a nasogastric tube (NGT) has a role in the treatment of intestinal obstruction and pancreatitis, not urinary obstruction, common mistake.


Hy 1792
An inner city family has been using a DAYCARE for their 3-year-old child while the parents work. The neighbor is diagnosed with pulmonary tuberculosis. PPD test of the 3-year-old is negative. What drug do you give? Pick from: Ethambutol, Isoniazid, Rifampin, Streptomycin.
a) Pick isoniazid. It is the standard. KNOW that chemoprophylaxis is indicated in the following groups: 1) persons whose tuberculin skin test has converted from negative to positive within the previous 2 years; all small children (<4 years of age) who are either exposed by known close contact to a person with untreated tuberculosis or who have a positive PPD; all HIV patients with positive PPD; elderly patients with a definite conversion of PPD; PPD positive persons with apical scars; and PPD positive persons.
Hy 1793
44-year-old obese w/ 3 hours of severe abdominal pain. She has also had multiple episodes of vomiting. She describes the pain as "worse than labor," and it radiates to the interscapular region. She has fever and RUQ pain. What is the dx. And the part of body affects (arrow is pointing to location). (Hint: is it the cystic duct or the common bile duct?)





a) She has a gallstone, in the CYSTIC DUCT, not the common bile duct. acute cholecystitis has multiple risk factors, including female gender, obesity, and a classic history of prolonged biliary colic in association with fevers. The presentation illustrated is typical and results from obstruction of the cystic duct, which drains the gallbladder. This is a Boards FAVORITE. KNOW that obstruction of the common bile duct or the pancreatic duct will produce acute bacterial cholangitis, which would be demonstrated by Charcot's triad, i.e., right upper quadrant pain, fever, and jaundice.


Hy 1794
A week after an upper respiratory infection, pt. develops conjunctival hyperemia, watery discharge, ocular irritation. On the morning of the doctor's visit, the patient had difficulty opening his eyelids on awakening as they were "glued shut". No purulent fluid is seen. The preauricular lymph node on one side is enlarged. What is the bug? Adenovirus OR Herpes II OR Neisseria?







a) Adenovirus. Neisseria would produce a more “purulent” discharge.





Hy 1795
62-year-old woman is brought to the emergency department by her daughter, who is concerned her mother had a "stroke." According to the daughter, the woman woke up that morning not knowing where she was. She recently saw her primary care physician, who started her on a new medication. Which of the following medications would most likely cause cognitive impairment? Pick either Alprazolam OR Bupropion OR Sertraline






A) Alprazolam, KNOW this.



Hy 1796
An 8-year-old male presents to the emergency department with decreased mental status. His mother states that she has noticed he has been drinking and urinating more frequently over the past several weeks. He was hard to wake up this morning and complained of abdominal pain. Guys and Gals, the pt is a drowsy male with clear airways and mild tachycardia. Mucous membranes are dry and his lips are cracked. His abdomen is mildly tender to palpation diffusely, but there is no rebound or guarding. Laboratory evaluation reveals a glucose of 560 mg/dL and potassium of 5.9 mEq/L.An arterial blood gas analysis reveals a pH of 7.18. A urinalysis is positive for ketones and glucose. CT scan of the abdomen is normal. A chest x-*** film is clear. Two hours after initiation of treatment the physician adds potassium to the patient's IV fluids. Which of the following best explains this therapeutic decision?




Hy 1797
A previously healthy 45-year-old woman is in a motor vehicle accident. She suffers multiple internal and external injuries from which she is still actively bleeding when reached by an ambulance. Her blood pressure is 50/20 mm Hg. This is a GREAT FAMOUS concept. What would her labs show on a CBC? Low, OR normal, OR elevated counts?








a) NORMAL!!! The body takes sometimes over an hour to change the WBC counts. But the Blood Pressure will be normal. Red cell count 4.5 million per microliter; white cell count 6000 per microliter.


Hy 1798
A 11-year old boy presents with a fever and vomiting for 4-5 days. Initially, the emesis was clear, but now it contains streaks of bright red blood. Findings on a physical examination, complete blood count, and serum electrolytes are within normal limits. Which of the following is the most likely cause of the hematemesis? Pick either Mallory Weiss Tear OR Esophageal varices.





a) Mallory Weiss Tear. A Mallory-Weiss tear occurs in the lower (stress LOWER) esophagus after forceful or protracted vomiting. In most cases, the bleeding is painless and resolves once the insulting incident (i.e., vomiting) resolves. Also, what kind of muscle type is in the lower esophagus?


Hy 1799
A medicine consult is requested on a 32-year-old woman with paranoid schizophrenia. Several days after the patient's admission, she developed polyuria, vomiting, stupor, diarrhea, and restlessness. She is currently taking risperidone, 10 mg given at bedtime, but no other medications. Which of the following is the most likely diagnosis? Pick between Anticholinergic crisis OR Water intoxication OR Serotonin syndrome.







a) Tricky question. Answer is Water intoxication. The patient is showing the symptoms of psychogenic polydipsia, which is the excessive intake of water as a result of a psychiatric disorder. The symptoms of excessive water intake include polyuria, vomiting, and diarrhea. As the patient is on a closed psychiatric unit, the chances of reactions to excessive medications are rare, given the careful monitoring of medication intake on most psychiatric units.






Hy 1800
A 62-year-old woman has bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman. Pelvic examination is normal. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. What do you do? Pick either cone biopsy OR hysterectomy.









a) HYSTERECTOMY! Endometrial cancer is the most common gynecologic cancer in women ages 45 and older. The main factor that predisposes a woman to the development of endometrial cancer is exposure to unopposed estrogen, whether endogenous or exogenous. Endogenous factors include, early menarche, late menopause, chronic anovulation, estrogen-secreting ovarian tumors, and obesity. Exogenous factors include the ingestion of unopposed estrogen (as with estrogen replacement therapy). Hypertension and diabetes have also been associated with endometrial cancer, though this relationship may likely be related to obesity. This patient has endometrial cancer on the basis of her endometrial biopsy result. The correct management for this patient is with total abdominal hysterectomy, bilateral adnexectomy, and possible lymph node sampling. Recall Cone biopsy is used in the diagnosis and management of cervical cancer. It would not be used for this patient with an endometrial biopsy showing endometrial cancer.





Hy 1801
A 45-year-old man, alcoholic cirrhosis, bleeding from a duodenal ulcer. He has required 6 units of blood over 8 hours, and all conservative measures to stop the bleeding, including irrigation with cold saline, IV vasopressin, and endoscopic use of the laser have failed. Laboratory studies showed a bilirubin of of 4.5 mg/dL, a prothrombin time of 22 seconds, and a serum albumin of 1.8 g/dL. He was mentally clear when he came in, but has since then developed encephalopathy and is now in a coma. Which of the following best describes his operative risk? Pick from: Acceptable, Acceptable only if infused with vit K, Acceptable if dialysis is done to remove bili, Not acceptable at all. (Hint: Look at the bili level)







a) Not acceptable at all! The studies show extremely marginal liver function, which would be tipped into overt liver failure by an anesthetic and an operation. He is not a surgical candidate. Recall that Vitamin K works only when there is a functioning liver that can use it. In the absence of adequate liver function, it will not correct the prothrombin time


Hy 1802
Pt is a mentally retarded 10-year-old boy presents with arthritis, nephrolithiasis, and progressive renal failure. Since his first years of life, he manifested peculiar neurologic abnormalities consisting of self-mutilative biting of the lips and fingers, choreoathetosis, and spasticity. Two male relatives on mother’s side had the same dx and died young. What is the dx? Is it Fragile X OR Lesch-Nyhan syndrome OR Lead poisoning?



a) aLesch Nyhan syndrome. Lesch-Nyhan syndrome was described in 1964 in two brothers who manifested self-mutilative behavior, choreoathetosis, and mental retardation beginning in their first year of life. This X-linked hereditary disorder is due to complete deficiency of hypoxanthine phosphoribosyltransferase (HPRT), an enzyme that catalyzes the "salvage" pathway of purines. A salvage pathway deficiency results in increased "de novo" synthesis of purines, with consequent overproduction of uric acid. This is why patients with deficient HPRT develop hyperuricemia, with secondary uric acid stones, renal impairment, and gouty arthritis. Lesch-Nyhan syndrome is also characterized by self-mutilative behavior, choreoathetosis, and mental retardation, which manifestations are still largely unexplained. Renal failure is the most frequent cause of death. Chronic lead intoxication affects the nervous, gastrointestinal, and hematopoietic systems. Behavioral anomalies, hypochromic microcytic anemia, and peripheral neuropathies are the most common manifestations. Children are particularly vulnerable to lead intoxication.





Hy 1803
A front-seat passenger in a car involved in a head-on collision relates that he hit the dashboard with his knees, however, he is specifically complaining of severe pain in his right hip, rather than knee pain. He lies in the stretcher in the emergency department with the right lower extremity shortened, adducted, and internally rotated. Point to the injury on a radiograph. Choose either Surgical Neck of the Femur, Shaft of the femur, OR Posterior dislocation of the hip.







a) The mechanism of injury is classic. As the knee hits the dashboard in the sitting position, the femoral head is driven backward and out of the socket. The position of the injured extremity is also typical, with the internal rotation produced by the posteriorly dislocated femoral head. This injury is an orthopedic emergency.

Hy 1804
A 26-year-old woman comes because of a lump in her vagina. The lump is nontender but is uncomfortable. She states that for the last 6 years this lump has come and gone once a yr. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. What do you do? Pick either Surgical drainage/Bartholin procedure OR IV antibiotics.
















a) Surgical drainage! This is a Bartholin cyst and a type of abscess. They secrete mucus into the vagina. Bartholin's cysts occur when the opening to the duct becomes occluded and the gland swells from a buildup of mucus secretions. If the cyst becomes infected, the result is a Bartholin's abscess. These Bartholin's cysts and abscesses are the most common vulvar cysts. Some of these cysts are small and asymptomatic and do not require treatment. This patient, however, is uncomfortable when she walks and she also has continued recurrences. Therefore, surgical intervention is indicated. Often a catheter is used to drain the cyst and create an ostium to allow future drainage. However, as in this patient's case, once the catheter is removed the cyst may form once again. Consequently, this patient would be best served with a Bartholin's cyst marsupialization procedure, ie surgical drainage. This is a surgical procedure in which the Bartholin's cyst wall is opened and the cyst itself is sewn open to the vaginal mucosa medially and the skin of the introitus laterally. This should allow free egress of the cyst fluid and prevent re-formation of the cyst. A portion of the cyst wall can be removed at the time of surgery and sent for pathologic evaluation to rule out malignancy, which, while highly unlikely in a young woman, is still a small possibility.




Hy 1805
4-year-old boy falls from the jungle gym. He sustains minor abrasions and contusions, and is taken care of by the school nurse. His parents take him that same afternoon to his regular pediatrician and demand "a thorough check-up" for possible internal injuries. The pediatrician complies, and a complete physical examination is normal. His hemoglobin is 14 g/dL, and a urinalysis shows the presence of microhematuria. What do you do now? Pick from CT scan of the abdomen and pelvis OR Reassurance OR Urologic workup, starting with a sonogram.






a) Urologic workup, starting with a sonogram.

Hy 1806
72-year-old African American woman is being readied for discharge from the hospital 2 weeks after a stroke affecting her right occipital cortex. A psychiatric consultation is called to evaluate the patient for depression, as she has had decreased appetite, some crying spells, and insomnia. After determining that the patient is not suffering from delirium, which of the following medications would be most appropriate to treat her depressive symptoms? Pick from: Phenelzine, Nortriptyline, OR Sertraline.
















a) Sertraline. In a patient with complications from a stroke, a selective serotonin reuptake inhibitor (SSRI), such as sertraline, has been demonstrated to be the safest and most effective medication for the treatment of clinical depression.

Hy 1807
You care for a family w/ a 45-year old husband, 43-year-old wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal grandmother who lived with them died after a prolonged respiratory infection. Autopsy subsequently confirms that she had active pulmonary tuberculosis at the time of death. The organism tested sensitive to all anti-tuberculosis drugs. What do you give to the family? Pick from: PPD from all members, OR Get CBC, OR Get sputum cultures.





a) PPD from all members. The immediate step is to screen the family for TB exposure. The most effective manner in which to accomplish this is by placing PPDs on all members and working up those with a positive test.







Hy 1808
A front-seat passenger in a car involved in a head-on collision relates that he hit the dashboard with his knees, however, he is specifically complaining of severe pain in his right hip, rather than knee pain. He lies in the stretcher in the emergency department with the right lower extremity shortened, adducted, and internally rotated. Point to the injury on a radiograph. Choose either Surgical Neck of the Femur, OR Shaft of the femur, OR Posterior dislocation of the hip.









a) The mechanism of injury is classic. As the knee hits the dashboard in the sitting position, the femoral head is driven backward and out of the socket. The position of the injured extremity is also typical, with the internal rotation produced by the posteriorly dislocated femoral head. This injury is an orthopedic emergency.




Hy 1809
A 26-year-old woman comes because of a lump in her vagina. The lump is nontender but is uncomfortable. She states that for the last 6 years this lump has come and gone once a yr. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. What do you do? Pick either Surgical drainage/Bartholin procedure OR IV antibiotics.








b) Surgical drainage! This is a Bartholin cyst and a type of abscess. They secrete mucus into the vagina. Bartholin's cysts occur when the opening to the duct becomes occluded and the gland swells from a buildup of mucus secretions. If the cyst becomes infected, the result is a Bartholin's abscess. These Bartholin's cysts and abscesses are the most common vulvar cysts. Some of these cysts are small and asymptomatic and do not require treatment. This patient, however, is uncomfortable when she walks and she also has continued recurrences. Therefore, surgical intervention is indicated. Often a Word catheter is used to drain the cyst and create an ostium to allow future drainage. However, as in this patient's case, once the catheter is removed the cyst may form once again. Consequently, this patient would be best served with a Bartholin's cyst marsupialization procedure. This is a surgical procedure in which the Bartholin's cyst wall is opened and the cyst itself is sewn open to the vaginal mucosa medially and the skin of the introitus laterally. This should allow free egress of the cyst fluid and prevent re-formation of the cyst. A portion of the cyst wall can be removed at the time of surgery and sent for pathologic evaluation to rule out malignancy, which, while highly unlikely in a young woman, is still a small possibility.




Hy 1810
4-year-old boy falls from the jungle gym. He sustains minor abrasions and contusions. His parents take him that same afternoon to his regular pediatrician and demand "a thorough check-up" for possible internal injuries. The pediatrician complies, and a complete physical examination is normal. His hemoglobin is 14 g/dL, and a urinalysis shows the presence of microhematuria. What do you do now? Pick from CT scan of the abdomen and pelvis OR Reassurance OR Urologic workup, starting with a sonogram.




b) Urologic workup, starting with a sonogram.



Hy 1811
Just know that a pt with many spider angiomas on his trunk should suggest chronic liver disease.



Hy 1812
54-year-old obese man w/ burning retrosternal pain and heartburn, brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets relief antacids or H2 blockers. The problem has been present for many years and seems to be progressing. Should you do a Barium swallow or an Endoscopy w/Biopsy or give a Proton Pump Inhibitor?






a) Endoscopy and Biopsy. The clinical picture is fairly convincing for long-standing gastroesophageal reflux. The main concern is the degree of peptic esophagitis that he may have developed, and the possibility of Barrett's esophagus and premalignant changes. Endoscopy and biopsies will provide the answer.

Hy 1813
41-year-old man is brought to the emergency department by paramedics after being found conscious at the scene of a motor vehicle accident. He had been the passenger in a high-speed collision and was thrown a distance of 20 feet through the front windshield. An evaluation reveals fractures of both femurs, the pelvis, the left tibia, and the left humerus. The patient is admitted to the intensive care unit for observation. Twenty-four hours later he becomes confused and markedly dyspneic; 100% oxygen is administered via face mask, but he remains with a pO2 of 54 mm Hg. Numerous petechiae also have developed diffusely on all four extremities and on his trunk. Which of the following is the most likely cause of his clinical condition? Pulmonary Embolism OR Fat Embolism?







a) Fat embolism! The findings of petechiae, alteration in mental status, and refractory hypoxemia in a patient with multiple bone trauma should suggest the diagnosis of fat embolism. This is usually seen 1-3 days after the initial trauma. Fat globules will be released from the fractured bones and obstruct pulmonary vessels. An altered sensorium and petechiae are also typical of fat embolism.









Hy 1814
A 45-year-old man presents to a physician with complaints of weakness, fatigue, and feeling near fainting when he stands up quickly. Screening chemistry studies demonstrate sodium, 125 mEq/L; potassium, 5.5 mEq/L; bicarbonate, 15 mEq/L; and urea nitrogen, 45 mg/dL. The physician is considering Addison disease in his differential diagnosis. Which of the following features on physical examination would be most suggestive of this diagnosis? A large furrowed tongue OR Black spots on his shoulders.







a) Black spots on his shoulders… While there is some variation in the usage of the term, Addison disease is usually taken to mean adrenocortical insufficiency related to disease that destroys the adrenal gland. Most authors separate out secondary adrenocortical insufficiency due to pituitary failure and recent or current exogenous steroid therapy. True Addison disease, which is not related to inadequate pituitary secretion of ACTH, frequently has stigmata of hyperpigmentation relating to a melanocyte-stimulating hormone (MSH) effect seen with high ACTH levels. The biochemical basis of this is a homology between part of the ACTH molecule and the MSH molecule. Typical hyperpigmentation features include black freckles of the shoulders, head, and neck; bluish-black discoloration of areolas and mucous membranes (both oral and anogenital); and diffuse tanning, specifically including non-sun-exposed skin. The pattern of laboratory screening studies illustrated in the question stem is also very suggestive, with very low serum sodium, high potassium, low bicarbonate, and high serum urea nitrogen.





Hy 1815
Recall that Small glistening bumps on the lips suggests the mucosal neuromas of MEN Iib. KNOW how they look like.






Hy 1816
MRI studies reveal the following congenital malformations in the CNS of a 6 month-old baby presenting with intractable vomiting: small posterior fossa, downward displacement of the cerebellar vermis and medulla through the foramen magnum, syringomyelia, and myelomeningocele. Which of the following is the most likely diagnosis? Pick either Arnold-Chiari type 1 malformation OR Arnold-Chiari type II malformation.OR Dandy Walker.





a) Arnold-Chiari malformations are among the most frequent congenital anomalies of the CNS. The small posterior fossa is a crucial diagnostic feature of Arnold-Chiari type 2. This change is probably responsible for downward displacement of the cerebellar vermis and medulla through the foramen magnum. This leads to obstruction of the CSF flow and hydrocephalus. Important associated abnormalities include lumbar myelomeningocele and syringomyelia


Hy 1817
What IS Dandy Walker syndrome?



a) Dandy-Walker malformation refers to a constellation of anomalies that include an abnormally large posterior fossa, absence of cerebellar vermis, and development of a large ependyma-lined cyst that represents an expanded 4th ventricle





Hy 1818
16-month-old is taken to the emergency room after falling while learning to walk. The toddler has an enlarging, swollen bruise on his forehead, which is now over two inches across. The parents say that the bruise is noticeably larger than it was when they entered the emergency room an hour earlier. A blood sample is drawn, and the child oozes blood at the puncture site for 25 minutes. Clotting studies on the blood sample show a prolonged PTT and a normal PT. Follow-up studies show very low levels of factor VIII. Which of the following is the most likely diagnosis? Pick either Von Willebrand’s Dx OR Hemophilia A








a) Hemophilia A. Hemophilia is an X-linked clotting disorder that occurs in two forms: hemophilia A due to deficient factor VIII and hemophilia B due to deficient factor IX. Some individuals with hemophilia have levels of these factors that are 5% of normal or even higher, and have relatively mild disease, only requiring replacement therapy during surgical procedures or other situations in which significant bleeding might occur. In contrast, individuals with factor levels less than 1% of normal have severe bleeding problems throughout life that usually become apparent (as in this case) by 18 months of age. In these individuals, excessive bleeding into joints and tissues may cause crippling musculoskeletal disorders.







Hy 1819
36-year-old woman comes to a psychiatrist for an initial appointment after relocating. She is on lithium for bipolar disorder, and has been stable for several years after two manic episodes in her early 30's. She was previously seen by a psychiatrist every two months and had blood drawn for routine monitoring related to her lithium treatment every six months. Since it has been about eight months since her last appointment, the psychiatrist decides to order lab-work and to see the patient back in one week to finish gathering history, to review the lab results, and to provide the patient with another prescription. What laboratory studiy would be most appropriate for the physician to order?, U/A OR TSH?





a) TSH, Lithium affects thyroid function and thyroid-stimulating hormone (TSH) levels should be monitored every 6-12 months. Lithium often causes a generally benign and often transient decrease in the concentration of thyroid hormones. About 30% of patients receiving long-term treatment with lithium will have elevated TSH levels. If symptoms of hypothyroidism emerge, treatment with levothyroxine may be indicated. During routine monitoring of lithium maintenance treatment, lithium plasma concentration and serum creatinine should also be measured periodically.









Hy 1820
21-year-old woman, gravida 2, para 1, at 28 weeks' gestation comes to the physician because of spotting after intercourse and a foul-smelling vaginal discharge. Her prenatal course has, up to now, been uncomplicated, and she has no medical problems. Speculum examination shows inflammation of the cervix with a mucopurulent cervical discharge. A gonorrhea and Chlamydia test is performed which comes back positive for chlamydia. Which of the following is the most appropriate pharmacotherapy? Azithromycin OR Doxycycline?








a) Azithromycin. This patient has Chlamydia cervicitis. Chlamydia is the most common sexually transmitted bacterial organism in the United States. It is essential to detect and treat chlamydial infection during pregnancy because maternal chlamydial infection is associated with several complications of pregnancy including preterm premature rupture of the membranes (PPROM) and preterm labor. Chlamydial infection is also associated with neonatal conjunctivitis, which results from the fetus passing through an infected birth canal. The partner of the patient must be treated as well as the patient herself in order to prevent reinfection. A test of cure (TOC) should be performed 4 to 6 weeks after treatment is given to ensure that the organism has been completely eradicated from the patient and her partner or partners. Azithromycin has a prolonged tissue half-life and therefore it can treat chlamydia in a single dose. This single dose treatment allows far greater compliance than the multiple doses that are required if erythromycin or amoxicillin is used. The single dose treatment with azithromycin also allows the treatment to be "observed" (i.e., the patient can be watched taking the medication). While the safety and effectiveness of azithromycin during pregnancy has not been as well proven as that of erythromycin or amoxicillin, it is believed to be safe and its single dose quality makes it the drug of choice.


Hy 1821
71-year-old woman is being treated for a severe chronic obstructive pulmonary disease (COPD) flare. The patient presented 3 days ago with cough, fever, and pleuritic chest pain. She had been feeling fatigued and, on the day of admission, was persistently febrile. She has had more severe shortness of breath, often at rest and with mild exertion, and moderate dyspnea. A chest radiograph revealed a left lower lobe infiltrate, and she was started on antibiotics. The patient has a long smoking history with a forced expiration in 1 second (FEV1) of 1.1 L. Which of the following therapies is most beneficial with respect to long-term morbidity and mortality in this patient? Inhaled steroids, OR Systemic steroids, OR LT Oxygen Therapy?






a) Long Term Oxygen Therapy. Tricky, eh? Not everything is treated with meds.

[aaaaaaaaaa]

Thank you so much with helping us through this tough time, you have helped me tremendously. I wanted to know if you can possibly help me with trying to access goljan's high yield 100 pages. I have given my email to diff people on this site and no one has emailed it to me and my exam is in 2 weeks. If you can, can you email it to me at:
Usmleaaaaa@yahoo.com and may g-d bless u!

[tommyk]

the free download section of ValueMD. A lot of stuff is actually Dr. Goljan's Notes there.

Sincerely,

Tommy

check monsoonrain's post from today...he posted his ftp with username and password so that you can download Goljan photolist and all of his high yield documents...so do a search for posts today by user monsoonrain

hope this helps

[aaaaaaaaaa]

thanks for getting back to me. For some reason I was unable to acccess that site, I don't know if it is because my computer is not good, it is an old one i must say. I tried again but could not do it. If someone can maybe email it to me? or any other suggestions for me? Thank you again for getting back to me.

He really really is a great man. 100 times greater than me or anyone in this area. May he live 1000 years.

[aaaaaaaaaa]

thank you guys for getting back to me once again, hopefully we can figure this out.

As I said before, there are some prior posts missing. Does anyone have them?