Question 1

A 14-year-old boy is brought to the emergency department for evaluation of severe scrotal pain.  Half an hour ago, the patient was accidentally hit in the scrotum during wrestling practice.  He applied ice and took acetaminophen, neither of which relieved the pain.  He has not tried urinating due to fear of the pain.  The patient underwent a right orchiopexy as an infant due to unilateral cryptorchidism but has no chronic medical conditions.  Temperature is 36.7 C (98.1 F), blood pressure is 114/76 mm Hg, and pulse is 108/min.  Abdominal examination is unremarkable.  There is moderate bruising on the right hemiscrotum but not on the medial thigh or perineum.  The right testis is exquisitely tender to palpation but has normal contours.  Bilateral testes retract with stroking of the medial thigh.  The penis has no blood at the meatus or open wounds.  Intravenous morphine provides significant pain relief, and the patient is able to urinate spontaneously.  Urinalysis results are as follows:  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfd7_47dd_8f63_83860cfeea88_MD0005_00 Scrotal trauma is usually due to sports, bicycle, or motor vehicle injuries and can result in significant testicular injury. Because the right spermatic cord is slightly shorter, the right testis is higher and more vulnerable to injury from compression against the pubis. Patients typically have scrotal pain, swelling, and bruising. An absent cremasteric reflex on examination is a nonspecific finding that can occur with significant testicular injury or testicular torsion or as a normal variant. However, the presence of a cremasteric reflex, as in this patient, does not exclude testicular injury. In a patient with mild, self-resolving symptoms and a normal physical examination, minor injury can be managed with oral analgesics, ice packs, and outpatient follow-up (Choice B). If significant swelling (eg, moderate bruising) or marked pain (eg, requiring intravenous morphine) are present, as in this patient, further workup is indicated. A urinalysis evaluates for hematuria, which may indicate a potential injury of the urinary tract. Scrotal ultrasound assesses the extent of injury and guides therapy. If ultrasound reveals testicular rupture, fracture, avulsion, or compression by scrotal hematoma, urgent surgical exploration and repair are required. Surgery should be performed within 72 hours of the injury to optimize testicular salvage. To prevent scrotal trauma, clinicians should counsel patients to wear a protective cup while participating in contact sports (eg, wrestling, hockey, football). (Choice A) Emergent surgical detorsion and orchiopexy are used to treat testicular torsion, which causes scrotal pain and swelling despite the lack of preceding trauma. The cremasteric reflex is typically absent. Torsion is unlikely in this case, as it rarely occurs in patients with a previous orchiopexy. (Choice C) Retrograde urethrography is indicated when urethral injury is suspected (eg, blood at the tip of the meatus, hematuria). This patient has a normal penile examination with no blood on urinalysis. (Choice E) Testicular fine-needle aspiration may be used for sperm retrieval in the evaluation of male infertility but is not used to assess scrotal trauma. Educational objective: Mild scrotal trauma is managed conservatively with analgesics. Significant scrotal pain and swelling require scrotal ultrasound to assess for testicular injury. References: Sonography of pediatric blunt scrotal trauma: what the pediatric urologist wants to know. (http://www.ncbi.nlm.nih.gov/pubmed/27112160) Role of ultrasonography for testicular injuries in penetrating scrotal trauma. (http://www.ncbi.nlm.nih.gov/pubmed/27132505) Can ultrasound help to manage patients with scrotal trauma? (http://www.ncbi.nlm.nih.gov/pubmed/27433221)

Question 2

A 76-year-old man is brought to the emergency department from a nursing home in critical condition due to fever and confusion.  His nursing home records were not transferred with him.  On initial evaluation, his temperature is 38.9 C (102 F), blood pressure is 75/50 mm Hg, and heart rate is 120/min.  The patient is obtunded and cannot provide a history.  He is immediately intubated and placed on mechanical ventilation.  An internal jugular venous central line is placed and infusion of normal saline boluses is initiated.  The covering clinician places a STAT order for cefepime and contacts the on-call pharmacist to expedite order approval.  The antibiotic is administered as soon as it arrives in the emergency department.  Shortly thereafter, the patient develops profound hypotension, skin rash, and respiratory distress.  Despite resuscitation efforts, he expires.  Retrospective review of the nursing home paperwork shows documentation of severe penicillin and cephalosporin allergy.  Which of the following interventions would improve patient safety during similar high-risk situations?

Accepted Answer

Explanation: 11ec2b69_bfe1_5a0d_8f63_97743132b21b_MD0005_00 In this scenario, the patient was given a medication to which he was allergic, resulting in a fatal anaphylactic reaction. In health care, as in other settings, errors can happen when multiple systems fail in succession. The Swiss cheese model (Figure) shows that a process has many layers of defense, but all these layers have holes. When all of the holes line up, an error can occur. In this case, the patient's nursing home records were not available, and there was no opportunity for verbal or written handoff communication of potential allergies. Given the patient's critical clinical condition, broad-spectrum antibiotics were ordered without checking for allergies. In an attempt to expedite care, these antibiotics were dispensed and administered on an emergency basis. Multiple efforts to improve patient safety have been developed to decrease the "size" of the holes in the layers of defense. One such method is to increase redundancy and double checks, especially for high-risk processes. For example, allergies can be verified multiple times by multiple providers, flagged by the electronic medical record (EMR) system, and documented in multiple locations in the medical record and on patient wristbands. (Choice B) Automating key functions can help prevent errors from occurring due to variations in patients and processes. For example, EMR systems are often set to automatically prompt clinicians to verify allergies before ordering medications on newly admitted patients or to signal possible drug-drug interactions between medication orders. (Choice C) With increasing shift work in health care, patient handoffs have become both increasingly prevalent and a source of medical errors. Standardized handoffs that use checklists and mnemonics have resulted in improved safety and decreased medical errors. These tools take the burden off clinicians to conduct handoffs purely by memory. (Choice D) Systems should be improved both retroactively and proactively. A retroactive system responding to errors that have already occurred will be less effective at finding and preventing new ones. (Choice E) Safety generally improves when multiple members of a care team participate in communication and decision making. For instance, procedural timeouts often require the involvement of surgeons, anesthesiologists, nurses, and technicians to all verify the details of a procedure. Educational objective: In the Swiss cheese model, a process has many layers of defense but all layers have holes. When the holes line up, an error can occur. Many different methods, including redundancy and double checks during high-risk processes, have been developed to reduce these holes and the likelihood of error. References: Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. (http://www.ncbi.nlm.nih.gov/pubmed/24302089)

Question 3

A 48-year-old man comes to the office for intractable lower extremity bone pain.  He has end-stage renal disease due to focal segmental glomerulosclerosis and has been on hemodialysis 3 times a week for the past 4 years.  Approximately 3 months ago, adjustments in his medications and hemodialysis regimens were made after the patient was found to have high serum calcium, phosphorus, and parathyroid hormone levels; however, these adjustments did not lead to any significant improvements in laboratory values.  Temperature is 36.9 C (98.4 F), blood pressure is 190/100 mm Hg, and pulse is 88/min.  Oral examination shows pallor of the mucous membranes.  Lungs have decreased sounds at both bases.  Cardiovascular examination shows a 2/6 systolic ejection murmur at the left upper sternal border and a palpable thrill over an arteriovenous fistula in the left forearm.  Laboratory results are as follows:  Chest x-ray reveals cardiomegaly with calcification of the ascending aorta.  Which of the following treatments would be most beneficial for this patient's current condition?

Accepted Answer

Explanation: 11ec2b69_bfdd_6268_8f63_c7f2279b1e5a_MD0005_00 This patient with chronic kidney disease (CKD), bone pain, vascular calcifications, and elevated calcium, phosphorus, and parathyroid hormone (PTH) levels has tertiary hyperparathyroidism. CKD affects parathyroid metabolism due to several factors: CKD causes phosphate retention due to a decrease in the filtered phosphate load. Binding of calcium by phosphate can lower free serum calcium levels, leading to a compensatory rise in PTH. CKD decreases renal conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, leading to decreased calcium absorption in the intestine. 1,25-dihydroxyvitamin D production is also suppressed by fibroblast growth factor 23, which is produced by osteocytes in response to hyperphosphatemia and falling free calcium concentrations. The net result is secondary hyperparathyroidism characterized by elevated PTH levels, low/low-normal calcium levels, and low 1,25-dihydroxyvitamin D levels (despite adequate 25-hydroxyvitamin D stores). Over time, this can lead to autonomous PTH secretion unresponsive to rising calcium levels, resulting in hypercalcemia with very high PTH levels. This tertiary hyperparathyroidism can be associated with metabolic bone disease with bone pain and an elevated bone-specific alkaline phosphatase (due to high bone turnover). Indications for parathyroidectomy in tertiary hyperparathyroidism include: Persistently elevated calcium (eg, >10.5 mg/dL), phosphorus, or PTH (eg, >800 pg/mL) levels Soft tissue calcification or calciphylaxis (vascular calcification with skin necrosis) Intractable bone pain or pruritus (Choice A) Bisphosphonates are generally not recommended in end-stage renal disease as they reduce bone turnover, leading to osteomalacia, mixed uremic osteodystrophy, and adynamic bone disease. They can also cause a worsening of hyperparathyroidism. (Choice B) Intravenous hydration is used for the acute treatment of severe hypercalcemia. However, it is not helpful in patients with end-stage renal disease and tertiary hyperparathyroidism as it is less effective in increasing urinary calcium excretion and can lead to fluid overload. (Choice D) Tertiary hyperparathyroidism is neither an indication nor a contraindication to renal transplantation. However, parathyroidectomy is recommended before renal transplantation when PTH levels are >800 pg/mL as hyperparathyroidism is unlikely to improve following transplantation. (Choice E) Peritoneal dialysis is effective in controlling calcium, phosphorus, and PTH levels in early secondary hyperparathyroidism. However, in severe secondary or tertiary hyperparathyroidism, peritoneal dialysis is not superior to hemodialysis. Educational objective: Chronic kidney disease is associated with phosphate retention, reduced free serum calcium levels, and decreased 1,25-dihydroxyvitamin D levels. This leads to a compensatory rise in parathyroid hormone (PTH) levels (secondary hyperparathyroidism). Over time, this can lead to autonomous PTH secretion (tertiary hyperparathyroidism). Indications for parathyroidectomy in tertiary hyperparathyroidism include persistent hypercalcemia or hyperphosphatemia, very high PTH levels, soft tissue calcification or calciphylaxis, and intractable bone pain. References: Secondary hyperparathyroidism: pathogenesis, disease progression, and therapeutic options. (http://www.ncbi.nlm.nih.gov/pubmed/21454719)

Question 4

A 35-year-old man comes to the office for evaluation of an enlarged testicle. His partner first noticed the enlargement 2 weeks ago. The patient feels well and has had no fever, dysuria, urethral discharge, or scrotal trauma. He has a history of HIV infection and has been on antiretroviral therapy for 2 years. His most recent CD4 count was 550/mm³, and he has never had an HIV-related infection. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 72/min. No lymphadenopathy is present. The lungs are clear to auscultation, and heart sounds are normal. The abdomen is soft, nontender, and nondistended with no masses or hepatosplenomegaly. Testicular examination reveals a diffusely enlarged and hard right testicle with no distinct nodules and negative transillumination. The left testis is normal. Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfd6_ab9b_8f63_2b2b85e0c38a_MD0005_00 This patient has a firm, uniformly enlarged testicle that does not transilluminate, raising concern for testicular cancer. Testicular cancer is the most common solid tumor in men age 15-35. Risk is greatest in those with cryptorchidism, but individuals with HIV are at slightly elevated risk. Most patients have painless, unilateral testicular enlargement. Examination usually reveals a firm, hard testicle, with or without nodules, that does not transilluminate. The initial test of choice for evaluating a testicular mass is bilateral scrotal ultrasound. If ultrasound reveals a solid lesion, further work-up with serum tumor markers (eg, alpha-fetoprotein, β-hCG) and screening CT scans is typically required. Most patients then undergo radical inguinal orchiectomy to establish a tissue diagnosis. Radical orchiectomy plus chemotherapy is usually curative; 5-year survival rates are approximately 95%. (Choice A) Varicocele is a common condition of young men that can be treated with venous embolization. Although varicocele can cause testicular enlargement and does not transilluminate, it feels like a bag of worms on examination (unlike cancer, which is typically hard and firm). (Choice B) Patients with suspected testicular cancer who receive trans-scrotal biopsy are at increased risk for lymphatic spread and recurrence. As such, radical orchiectomy is preferred for both tissue diagnosis and treatment. However, scrotal ultrasound should be performed prior to either invasive procedure in order to determine if the mass is solid or cystic. (Choices C and E) Infectious epididymo-orchitis can be treated with a dose of intramuscular ceftriaxone and 10 days of doxycycline. Diagnosis is typically confirmed with urinalysis and urine testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Although infectious epididymo-orchitis can cause testicular enlargement, most cases are very painful and accompanied by scrotal wall erythema. Educational objective: Scrotal ultrasound is the initial test of choice for evaluating a testicular mass. If ultrasound shows a solid mass, further workup with serum tumor markers and screening CT scans is required. Patients with suspected testicular cancer then usually require radical inguinal orchiectomy for both tissue diagnosis and initial treatment. References: Ultrasound of the scrotum. (http://www.ncbi.nlm.nih.gov/pubmed/15602220)

Question 5

You are the current "on call physician" for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times.  This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer's dementia. Her daily medications are amlodipine, metformin, calcium - vitamin D, and donepezil. You are concerned that something is not right with the patient.
The nurse calls you back in twenty minutes.  She states that she gave a dose of prn (as needed) medication which was ordered by a physician before.  She arranged an ambulance to transfer the patient to a nearby hospital.  Her temperature is 36.7 C (98 F), blood pressure is 116/78 mmHg, pulse rate is 76/min, and respiratory rate is 18/min.  She is still agitated, and she is now disoriented to place and person.  She gets easily distracted, and she is having auditory hallucinations.  In the hospital, her physical examination is unremarkable.  What is the most appropriate next step in the management of her condition?

Accepted Answer

Explanation: This patient is still exhibiting the classic signs and symptoms of delirium. Cognitive and perceptual disturbances including hallucinations are very common in delirious patients. As described above, virtually any acute medical condition can precipitate delirium in an older demented patient. It is important to perform a complete physical examination and obtain basic laboratory studies to identify or rule out the potential causes of delirium, especially the reversible causes, which include: dehydration, hypo/hypernatremia, infections, hypoglycemia, hypercalcemia, uremia, and liver failure. (Choices A and B) The use of psychotropic medications to calm this patient is not recommended at this time. It is prudent to rule out the reversible medical causes of delirium before prescribing psychotropic medications or obtaining a psychiatric consultation. (Choice D) There is no history of head trauma or any focal neurological signs and symptoms; therefore, a head CT scan is not indicated at this point. (Choice E) Physical restraints should be used only as a last resort in an agitated and delirious patient. They frequently increase confusion and agitation. Constant observation, preferably by someone familiar to the patient, is more helpful in such situations. Educational objective: Focused history, physical examination and basic laboratory work-up should be performed early in the initial evaluation of delirium in any patient.

Question 6

A 68-year-old man comes to the office due to recurrent episodes of dizziness.  His medical problems include hypertension, coronary artery disease, asthma, type 2 diabetes mellitus, and hypercholesterolemia.  He is retired and lives alone.  He does not use tobacco, alcohol, or drugs.  Medications include aspirin, enalapril, isosorbide mononitrate, simvastatin, glyburide, and metformin.  Temperature is 36.7 C (98 F), blood pressure is 125/80 mm Hg in the decubitus position and 100/70 mm Hg in the standing position, pulse is 86/min in the decubitus position and 92/min in the standing position, and respirations are 14/min.  Examination shows no abnormalities.  Which of the following is the most effective strategy to manage this patient's symptoms?

Accepted Answer

Explanation: Polypharmacy is defined as the use of multiple (generally ≥5) drugs in a single patient, typically to manage different medical conditions. Polypharmacy is common in the elderly. Knowledge of drug interactions and adverse effects is essential to the primary care provider. For instance, although beta blockers are usually included as part of the treatment of coronary artery disease, they were not prescribed to this patient, likely due to his diabetes and asthma. This patient takes the following medications: aspirin, enalapril, isosorbide mononitrate, simvastatin, glyburide, and metformin. He has orthostatic hypotension-given the significant drop in blood pressure (eg, systolic blood pressure drop >20 mm Hg) and increase in pulse when he moved from the decubitus to the standing position-associated with dizziness. These findings are classically associated with the use of diuretics, alpha blockers, or nitrates. Isosorbide mononitrate use has been associated with dizziness (in 4% of patients) and orthostatic hypotension (in 1% of patients). Therefore, it should be stopped in this patient. (Choice A) Enalapril is an antihypertensive drug that has not been associated with orthostatic hypotension as frequently as the drugs mentioned above. Side effects include renal failure, hyperkalemia, cough, and angioedema. (Choice C) Simvastatin can cause myalgias, rhabdomyolysis, and liver function test abnormalities. Its use is not associated with orthostatic hypotension. (Choice D) As the patient's findings are likely due to polypharmacy and he has no focal neurologic deficits, there is no need for further studies (eg, CT scan, MRI) or neurologic consultation. (Choice E) Meclizine may offer symptomatic benefit in cases of dizziness due to vestibular disease, not those associated with orthostatic hypotension. Educational objective: Polypharmacy is frequent in the elderly. Orthostatic hypotension is common in this setting and is usually related to the use of diuretics, alpha blockers, or nitrates.

Question 7

A 76-year-old female is seen in the clinic with numerous medical complaints.  She is scheduled to undergo elective surgery for right hip replacement.  She says she is tired, has a very poor appetite, and does not sleep well at night.  She denies any fevers, chills, chest pain, or shortness of breath.  Her ECG and chest x-ray are normal.  She cannot remember which medications she takes.  What is the most important factor in perioperative adverse drug reaction in the elderly population?

Accepted Answer

Explanation: Multiple medications are the most common factor in predisposing elderly patients to an increased incidence of adverse drug reactions. Patients over age 65 take an average of two to six prescribed drugs and one to three non-prescription drugs daily. These patients are at an increased risk preoperatively for anesthetic and operative drug reactions. The most common medications associated with adverse drug reactions include anti-psychotics, anti-hypertensives, sedatives, diuretics, NSAIDs, corticosteroids, and digoxin. (Choice D)Most elderly patients have an increased gastric pH, which tends to increase the absorption of drugs, thereby adding to the circulating levels of antagonistic compounds. (Choices C and E)The gradual reduction in the glomerular filtration rate in the elderly also adds to the circulating drug levels. This is further compounded by the fact that elderly patients have reduced levels of total body water. (Choice A)Age, itself, does not increase the risk of a perioperative adverse drug reaction. Educational Objective: Multiple medications are a major cause of adverse drug reactions in the elderly.

Question 8

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath. Two days ago, she choked while having tea and doughnuts and almost lost consciousness. Her son performed the Heimlich maneuver. The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care. Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence. She is allergic to penicillin (anaphylaxis). Her temperature is 38.9 C (102 F), blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen. Auscultation of the chest shows crackles at the right lung base. The heart sounds are regular. There is no jugular venous distension. The abdomen is soft, nontender, and nondistended. There is no peripheral edema. Laboratory results are as follows: A portable chest x-ray shows a right lower-lobe infiltrate. During the last 4 days of hospitalization, the patient has received 6 L of 0.9% saline. Her urine output has been 400 mL in the last 24 hours. She has been afebrile for the past 2 days. Her blood cultures are negative, and her urine culture grew budding yeast. The patient is currently receiving 150 mL/hr of 0.9% saline, nasogastric tube feedings, and antibiotics. Her temperature is 36.7 C (98 F), blood pressure is 140/70 mm Hg, pulse is 82/min, respirations are 18/min, and oxygen saturation is 96% on 2 L O₂ by nasal cannula. Her mucous membranes are moist. The lungs still have crackles at the right base. There is no pericardial rub, peripheral edema, or asterixis. The results of her recent basic metabolic panel are as follows: An ECG shows no abnormal intervals and no peaked T waves. What is the most appropriate course of action at this time?

Accepted Answer

Explanation: Although the patient seems to be improving clinically, she continues to be oliguric despite intravenous fluids. Her physical examination findings do not indicate hypovolemia, and she has no ongoing volume losses. Therefore, there is no indication for volume expansion with intravenous saline. Excess saline infusion can worsen her clinical status by causing volume overload (pulmonary edema) and hyperchloremic non-anion gap metabolic acidosis (in addition to her existing anion gap acidosis from her kidney failure). Her tube feeds should compensate for daily obligatory fluid losses. In a patient with acute kidney injury (AKI), the goals of care include maintaining adequate renal perfusion (intravenous saline or vasopressors), avoiding nephrotoxic agents, and close monitoring of volume status and any acid-base and electrolyte disturbances. (Choice A) In some patients with AKI, dialysis is indicated for intractable hyperkalemia, hypervolemia, severe metabolic acidosis (eg, pH <7.1), and marked uremic symptoms. This patient might require dialysis if her acidosis worsens, or if she develops significant hyperkalemia or progressive volume overload. She has none of these urgent indications at this time, and it is possible she may soon recover from AKI as her volume status (and renal perfusion) is adequate and her sepsis has resolved. (Choice B) Loop diuretics may improve urine output in a patient with AKI; however, they do not hasten recovery of renal function. A trial of loop diuretics is generally indicated if there is evidence of fluid overload (such as pulmonary edema). The doses required to achieve diuresis in AKI are usually high. (Choice C) Patients with indwelling urinary catheters may grow Candida on urine culture, but they do not require treatment with antifungals unless there is evidence of a systemic infection or tissue invasion. (Choice E) Intravenous colloids (albumin) can expand intravascular volume. Clinical trials have demonstrated no clinical or survival benefit of colloids over crystalloids. Intravenous albumin is used for volume expansion in cirrhotic patients with hepatorenal syndrome or spontaneous bacterial peritonitis, as they are at risk for third spacing of fluid. Educational objective: Fluid overload can occur in patients who are oliguric or anuric. Indications for dialysis include uremia, intractable hyperkalemia, hypervolemia, and metabolic acidosis. References: Fluid management in adults and children: core curriculum 2014. (http://www.ncbi.nlm.nih.gov/pubmed/24332766) Bicarbonate therapy in severe metabolic acidosis. (http://www.ncbi.nlm.nih.gov/pubmed/18322160)

Question 9

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath. Two days ago, she choked while having tea and doughnuts and almost lost consciousness. Her son performed the Heimlich maneuver. The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care. Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence. She is allergic to penicillin (anaphylaxis). Her temperature is 38.9 C (102 F), blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen. Auscultation of the chest shows crackles at the right lung base. The heart sounds are regular. There is no jugular venous distension. The abdomen is soft, nontender, and nondistended. There is no peripheral edema. Laboratory results are as follows: A portable chest x-ray shows a right lower-lobe infiltrate. Item 1 of 4 Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfd9_6ac4_8f63_ab1c77ed21c1_MD0005_00 The patient's clinical features and the chronology of events are highly suggestive of aspiration pneumonia. This condition is due to an infection of the lung parenchyma by microbes from the oral cavity, commonly gram-positive cocci, gram-negative rods, and anaerobes (polymicrobial). Patients typically present 1-5 days following an aspiration episode with respiratory difficulty, cough, sputum, fever, and chills. Clindamycin has excellent activity against gram-positive cocci and anaerobes; it is usually the first-line drug as it is inexpensive, widely available, and associated with a low rate of methicillin-resistant Staphylococcus aureus superinfection. A combination beta-lactam and beta-lactamase inhibitor would be another option, but this patient has a penicillin allergy. Given her age, hypoxia, and comorbidities, she needs to be admitted to the hospital for management. It is important to differentiate aspiration pneumonitis from aspiration pneumonia. Aspiration pneumonitis is a chemical injury with inflammation of lung parenchyma due to the inhalation of foreign materials such as gastric contents (Mendelson's syndrome). Patients usually have a history of depressed level of consciousness and a witnessed vomiting or aspiration event. Respiratory distress occurs 2-5 hours after an aspiration event, and there are generally no features of infection. Treatment is supportive (without antibiotics). (Choice B) Corticosteroids are not indicated in aspiration pneumonia. In addition, this patient is not wheezing and has no asthma or any other chronic respiratory condition for which steroids would be indicated. (Choice C) There is no evidence of endocarditis suggesting the need for an echocardiogram at this point. Blood cultures are sometimes obtained in patients with pneumonia but are not always necessary. They are recommended if the patient is being admitted to the intensive care unit or in the setting of cavitary lesions, pleural effusions, leukopenia, severe liver disease, or certain immune deficiencies. endocarditis (Choice D) CT scan could be performed to further evaluate the lung infiltrates, but it is not required in this patient at this stage as the clinical presentation and chest x-ray are sufficient to diagnose and initiate treatment for her condition. (Choice E) Azithromycin is not effective in the treatment of aspiration pneumonia, and adequate sputum samples are difficult to obtain and not always indicated in elderly, demented patients. Educational objective: Aspiration pneumonia should be suspected in any patient with a recent history of foreign body aspiration, cough, sputum, and fever. The treatment is clindamycin or combination beta-lactam with beta-lactamase inhibitor. Aspiration pneumonitis should be suspected in patients with depressed level of consciousness, a history of vomiting, and respiratory distress shortly after an aspiration event. There are generally no features of infection, and treatment is supportive (without antibiotics). References: Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. (http://www.ncbi.nlm.nih.gov/pubmed/17278083) Reappraisal of clindamycin IV monotherapy for treatment of mild-to-moderate aspiration pneumonia in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/15821205)

Question 10

A 62-year-old man is hospitalized for an elective coronary artery bypass graft surgery.  The patient has been having exertional chest pain and was found to have a left main coronary artery disease.  Other medical issues include hypertension, hyperlipidemia, and stage 3 chronic kidney disease.  The patient is a retired financial advisor with a 50-pack-year smoking history.  He undergoes the surgery without operative complications and is successfully extubated the next day.  Postoperative medications include atorvastatin, metoprolol, and morphine.  On the third postoperative day, the patient is found to be progressively drowsy, lethargic, and difficult to rouse.  Temperature is 36.1 C (97 F), blood pressure is 110/68 mm Hg, pulse is 112/min and irregular, and respirations are 9/min and shallow.  Examination shows flat neck veins and mild bibasilar lung crackles.  Pupils are 1 mm and equal.  The patient withdraws all extremities equally to pain.  ECG shows atrial fibrillation with rapid ventricular response.  Fingerstick glucose level is 125 mg/dL.  Laboratory results are as follows:  The laboratory findings are not significantly changed compared to preadmission values.  Which of the following is the most appropriate next step in management of this patient's altered mental status?

Accepted Answer

Explanation: 11ec2b69_bfdf_d36c_8f63_9358cc7f9e70_MD0005_00 This patient has the triad of depressed respiratory rate with shallow breaths, small pupils, and depressed mental status, consistent with acute opioid intoxication. Reduced bowel sounds are also common. The best predictor of acute toxicity is a respiratory rate <12/min as opioids act directly on brainstem respiratory centers to produce respiratory depression, resulting in decreased depth and frequency of breaths (leading to respiratory acidosis). Opioids also decrease both the hypercapnic and hypoxic respiratory drive through interaction with central and peripheral chemoreceptors. In the setting of kidney disease, morphine carries a particularly high risk of opioid toxicity compared to many other opioids. Morphine undergoes a 2-step metabolic process to form the metabolites morphine-3-glucuronide and morphine-6-glucuronide (which is a more potent opioid receptor agonist than morphine); these metabolites are then eliminated by the kidney. Renal dysfunction allows morphine-6-glucuronide to accumulate and can potentially lead to acute toxicity; patients in the postoperative period are at particular risk for this clinical scenario. Immediate management of opioid toxicity involves the administration of intravenous naloxone, an opioid receptor antagonist, as well as ventilatory support in patients with apnea or extremely low respiratory rates. (Choice B) Atrial fibrillation (AF) is common after cardiac surgery, and AF with rapid ventricular response (eg, pulse >100/min) may result in hemodynamic instability and cerebral hypoperfusion. However, this patient's heart rate is only slightly above the acceptable range and significant hypotension is not present; in addition, although AF in general can be treated with diltiazem, calcium channel blockers may be ineffective in AF after cardiac surgery. (Choice C) Noncontrast head CT scan or other neuroimaging is an important consideration for patients with acute mental status changes, but in a patient with multiple signs and symptoms of opioid intoxication it should not delay the administration of naloxone. (Choice D) Coronary angiography will detect bypass graft closure, which can occur within 30 days after surgery and presents with postoperative ischemia and possible hemodynamic instability. ECG would be expected to show ventricular arrhythmia or evidence of ischemia. (Choice E) Symptomatic uremia can manifest with nausea, vomiting, neuropathy, pericarditis, lethargy, seizures, and coma, and is an indication for urgent hemodialysis. However, it usually occurs in the setting of end-stage renal disease or acute renal failure and is less likely in this patient with stable chronic kidney disease. Educational objective: Opioid intoxication presents with the triad of respiratory depression, miosis, and depressed mental status. Renal dysfunction can increase the risk of opioid toxicity, especially with morphine. Immediate management involves the administration of intravenous naloxone as well as ventilatory support when needed. References: What do we know about opioids and the kidney? (http://www.ncbi.nlm.nih.gov/pubmed/28117754)

Question 11

You are the current "on call physician" for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times.  This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer's dementia. Her daily medications are amlodipine, metformin, calcium - vitamin D, and donepezil. You are concerned that something is not right with the patient.
A CT scan of the patient's head is normal. Initial lab studies reveal the presence of a urinary tract infection with mild prerenal azotemia. You start the patient on empiric antibiotic therapy and intravenous fluids; however, the patient's mental status remains unchanged. You provide a bedside sitter for the patient for constant supervision. The sitter reports that the patient is very combative now. She has been trying to get out of bed and has twice attempted to pull her IV line out. She resisted the physical restraints that the nurse was trying to apply. Frequent orientation and reassurance has not improved her behavior. Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: The patient is exhibiting behavior that could harm herself and the healthcare staff. Initial supportive measures such as reassurance, orienting her to the environment, and having constant supervision has not been successful in managing her disruptive behavior. Low-dose haloperidol may be useful in controlling her symptoms, preventing harm, and allowing for the safe continuation of her treatment. Antipsychotics are associated with a variety of side effects. These include sedation, orthostatic hypotension, anticholinergic side effects, tardive dyskinesia, and extrapyramidal symptoms. Thus, the patient should be started at lower doses and the dose is then titrated upwards to achieve the desired effects. (Choice B) Benzodiazepines have a more rapid onset of action, but these can worsen confusion and sedation. They can be used as an adjunct to antipsychotics to reduce extrapyramidal side effects. (Choice C) Physical restraints should be only used as a last resort in a combative patient. They frequently lead to worsening of confusion. They are used when medications fail to act, and the patient remains a significant threat to his/her and the healthcare staff's safety. (Choice D) Sitters are helpful in providing orientation and constant supervision for a confused patient. Once a patient becomes combative, other modalities including chemical and physical restraints are frequently necessary. (Choice E) Performing a lumbar puncture is only indicated if the patient has unexplained fever, altered mental status, and nuchal rigidity. Change in mental status alone is not an indication for lumbar puncture. Educational objective: Physical and chemical restraints should be used judiciously in a combative and disruptive patient. These help prevent injuries and falls, and allow for the continuation of medical therapy. Always give haloperidol (antipsychotics) before you apply restraints.

Question 12

You are the current "on call physician" for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times. This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer's dementia. Her daily medications are amlodipine, metformin, calcium - vitamin D, and donepezil. You are concerned that something is not right with the patient. Item 1 of 3 Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: This patient is suffering from an acute confusional state, also known as delirium. Delirium is extremely common in old nursing home patients. It manifests as a change in the level of awareness, easy distractibility, cognitive and perceptual disturbances including memory loss, disorientation, and even agitation. It typically develops over hours to days, and this acute onset distinguishes it from dementia. Delirium is a multifactorial disorder. The factors that increase the risk of delirium are subdivided into those that increase the susceptibility to delirium and those that precipitate delirium. The most common factors that increase the patient's susceptibility to delirium include advanced age and an underlying brain disorder (i.e., dementia, Parkinson's disease, and history of prior stroke). The factors that precipitate delirium include multiple medication use (polypharmacy), infections (i.e., urinary tract infections and pneumonia), fluid and electrolyte disturbances (dehydration, hyponatremia, or hypernatremia), malnutrition, immobility (including the use of restraints), use of bladder catheters, and a wide variety of other medical conditions. In fact, delirium may be the only presenting complaint in an older demented patient suffering from an acute medical illness; therefore, checking this patient's vital signs should be the first step to rule out early infections and fluid and electrolyte disturbances. (Choice A) Transferring this patient to a hospital may be necessary for further evaluation of the cause of the delirium; however, this should not be the first step in the management of this patient. (Choices B and D)Misuse of antipsychotics and benzodiazepines is very common in managing behavioral problems in demented nursing home patients. It leads to frequent adverse effects and worsening of the cognitive status; therefore, it is important to rule out any medical, environmental, or psychosocial causes before prescribing any psychotropic medications. (Choice E) As explained above, the use of physical restraints can precipitate and even worsen the delirium, and should therefore be avoided. Educational objective: Delirium can be the only finding of an acute medical condition in older demented individuals. Use of psychotropic medications as a first line therapy for behavioral problems is not recommended.

Question 13

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath.  Two days ago, she choked while having tea and doughnuts and almost lost consciousness.  Her son performed the Heimlich maneuver.  The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care.  Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence.  She is allergic to penicillin (anaphylaxis).  Her temperature is 38.9 C (102 F), blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min.  Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen.  Auscultation of the chest shows crackles at the right lung base.  The heart sounds are regular.  There is no jugular venous distension.  The abdomen is soft, nontender, and nondistended.  There is no peripheral edema.  Laboratory results are as follows:  A portable chest x-ray shows a right lower-lobe infiltrate.
During the night, the patient deteriorates and becomes more hypoxic, requiring 100% oxygen by facemask.  Her son refuses to have her intubated.  She has several episodes of hypotension.  Aggressive intravenous fluid therapy is given, and a Foley catheter is placed.  Her blood pressure normalizes.  Over the course of the next 12 hours, her urine output drops to 5 mL/hr.  On the 4th day of hospitalization, her temperature is 37.3 C (99.1 F), blood pressure is 122/70 mm Hg, and pulse is 78/min.  Despite receiving intravenous fluids, her urine output remains low.  Laboratory results are as follows:
 Further evaluation of this patient would most likely show which of the following?

Accepted Answer

Explanation: 11ec2b69_bfd8_0b30_8f63_e9e6806d1a8b_MD0005_00 This patient has most likely developed acute tubular necrosis (ATN), which is responsible for most cases of acute renal failure in hospitalized patients. The etiopathology generally involves a perfusion deficit due to hypovolemia, hypotension, shock, sepsis, or low cardiac output states. The typical presentation is oliguria following a hypotensive episode, with elevated blood urea nitrogen and creatinine levels (though the ratio is typically normal) and anion gap acidosis. Examination of the urinary sediment usually shows characteristic "muddy brown" casts. "muddy brown" casts (Choice A) Prerenal azotemia is associated with decreased fractional excretion of sodium; however, once ATN sets in, the fractional excretion of sodium increases (usually >2). Response to a fluid challenge is the gold standard in distinguishing prerenal azotemia (which responds to a fluid challenge with improved urine output) from ATN. This patient's low urine output and elevated creatinine despite receiving continuous intravenous hydration and showing no signs of hypovolemia (normotension, no tachycardia) suggest ATN. (Choice B) In patients with oliguria, it is always important to consider obstructive uropathy. This diagnosis is more likely if there is a history of such conditions as renal colic, pelvic or retroperitoneal malignancy, or history of radiation. Benign prostatic hyperplasia is the most common cause of obstructive uropathy. This diagnosis is less likely in women, particularly those with a Foley catheter in place. (Choice C) Eosinophils are seen in the urine of patients with drug-induced allergic interstitial nephritis (AIN). This patient's clinical picture is not consistent with AIN, which is usually seen 3-5 days (and rarely in the first 2 days) after the administration of antibiotics. (Choice E) Red cell casts in the urine are indicative of glomerulonephritis. Educational objective: Acute tubular necrosis should be suspected in patients with oliguria following a hypotensive episode. Muddy brown casts and high fractional excretion of sodium differentiate acute tubular necrosis from prerenal azotemia. References: Diagnostic value of urine microscopy for differential diagnosis of acute kidney injury in hospitalized patients. (http://www.ncbi.nlm.nih.gov/pubmed/18784207)

Question 14

A 7-year-old boy is brought to the emergency department due to rash, abdominal pain, and nausea.  The rash first appeared 2 days ago.  According to his father, a few initial red, round lesions on the back of both thighs now seem to have "merged together" and spread "all over his legs and buttocks."  The rash is not itchy or painful.  The abdominal pain and nausea began today and have been intermittent.  The boy's appetite is decreased but he has no vomiting or diarrhea.  His last bowel movement was yesterday and appeared normal.  Other than an upper respiratory infection last week, the patient has been healthy and takes no medications.  He went to a family barbeque last week and ate a hamburger and hot dog.  Vaccinations are up to date and he has no allergies.  His temperature is 36.7 C (98 F), blood pressure is 110/65 mm Hg, and pulse is 105/min.  On physical examination, his abdomen is soft, nondistended, and mildly tender to palpation in the periumbilical region.  Skin examination shows a non-blanching purple rash on his lower extremities and buttocks.  Stool guaiac is positive.  Which of the following is the most likely diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_bfde_25b9_8f63_5d26de3960e9_MD0005_00 This patient's presentation is highly suggestive of Henoch-Schönlein purpura (HSP). HSP is primarily a pediatric vasculitis that results from systemic IgA deposition. The presentation varies in severity but most patients have a rash that begins as erythematous macules that coalesce into palpable purpura. The purpura is non-blanching and non-pruritic and is distributed symmetrically across gravity-dependent body parts (eg, legs, buttocks). Intermittent abdominal pain and nausea are usually due to small-bowel intussusception. Edema and hemorrhage in the small bowel serve as the pathological lead points. Involvement of the joints and kidneys is also common and usually manifests later. Some boys have scrotal pain/swelling. An antecedent upper respiratory infection is present in 50% of patients. HSP is diagnosed clinically, especially when the presentation is classic and involves lower-extremity purpura, as in this patient. Laboratory findings that support the diagnosis include a normal platelet count and coagulation studies and elevated inflammatory markers (eg, white blood cell count, erythrocyte sedimentation rate). Urinalysis may show casts, hematuria, pyuria, and proteinuria. HSP resolves spontaneously in most patients; some require nonsteroidal anti-inflammatory drugs or corticosteroids. (Choice A) Acute urticaria is characterized by pruritic, raised, erythematous wheals. Each lesion usually fades within 24 hours. This patient's rash is not itchy and has worsened after 24 hours, making this diagnosis unlikely. (Choice B) Hemolytic uremic syndrome consists of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure that typically occurs in patients age <5 after an acute bloody diarrheal illness. This patient has had no preceding diarrhea, making this diagnosis unlikely. (Choice D) Idiopathic thrombocytopenic purpura (ITP) presents as petechiae or purpura that develop in any skin area spontaneously or with low impact. Although it often follows a viral upper respiratory infection, the abdominal pain and extensive distribution of the purpura on this patient's legs are more consistent with HSP than ITP. (Choice E) Thrombotic thrombocytopenic purpura is a serious disorder characterized by the pentad of fever, microangiopathic hemolytic anemia (pallor), thrombocytopenia, renal failure, and neurologic impairment (eg, confusion). This patient is afebrile and neurologically intact, making this diagnosis unlikely. Educational objective: Henoch-Schönlein purpura commonly presents with purpura in gravity-dependent areas (eg, legs, buttocks) and abdominal pain from small-bowel intussusception. Arthralgias and IgA nephropathy are also common but usually manifest later. The diagnosis is based primarily on the clinical presentation. References: Clinical practice: diagnosis and management of Henoch-Schönlein purpura. (http://www.ncbi.nlm.nih.gov/pubmed/20012647) Henoch-Schönlein purpura. (http://www.ncbi.nlm.nih.gov/pubmed/19817340)

Question 15

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath.  Two days ago, she choked while having tea and doughnuts and almost lost consciousness.  Her son performed the Heimlich maneuver.  The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care.  Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence.  She is allergic to penicillin (anaphylaxis).  Her temperature is 38.9 C (102 F), blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min.  Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen.  Auscultation of the chest shows crackles at the right lung base.  The heart sounds are regular.  There is no jugular venous distension.  The abdomen is soft, nontender, and nondistended.  There is no peripheral edema.  Laboratory results are as follows:  A portable chest x-ray shows a right lower-lobe infiltrate.
With the appropriate treatment, the patient's kidney function recovers.  She is afebrile with mild persistent cough and is ambulating without difficulties.  She is now ready to be discharged.  Which of the following is most important to perform before discharging the patient?

Accepted Answer

Explanation: This patient's problem initially began with aspiration of food. Given her advanced dementia, a swallowing dysfunction is very probable. Therefore, before discharging this patient, it is advisable to ensure that a speech therapist has performed a speech and swallow evaluation. Diet modification is typically required and is preferred over continuation of the same type of food under supervision. (Choice A) The patient appears to have a reasonable support system at home with her son and husband. (Choice B) The patient must be evaluated for swallowing dysfunction before consideration of percutaneous endoscopic gastrostomy (PEG) tube placement. Furthermore, it is unclear whether PEG tubes prevent future aspiration episodes or improve long-term survival for patients with swallowing difficulties. (Choice C) The patient is ambulating without difficulty and likely does not need intensive inpatient rehabilitation. Physical therapy is important for the assessment of gait and balance and prevention of falls; however, it will not help prevent aspiration episodes. (Choice E) Home safety assessment is designed to help reduce accidents at home in elderly patients, particularly accidents due to falls. This patient's illness was due to aspiration. Educational objective: Speech and swallowing evaluation, followed by diet modification, is performed in high-risk patients to prevent future episodes of aspiration. It is unclear whether percutaneous endoscopic gastrostomy tube placement prevents aspiration episodes or improves long-term survival of patients with swallowing difficulties. References: Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. (http://www.ncbi.nlm.nih.gov/pubmed/21069702)

Question 16

A 15-month-old boy is brought to the office for a well-child visit.  His parents are concerned that he is not yet walking.  He can pull himself up to stand and take steps while holding on to furniture but has not yet taken any steps unassisted.  The patient says 5 words and can follow simple commands, such as "Clap your hands!" or "Wave bye-bye!"  He is also able to pick up small items and food with his thumb and pointer finger and tries to use a spoon when feeding.  The boy is up to date with all vaccinations.  He has no known allergies and takes no medications.  He was born via uncomplicated vaginal delivery at 37 weeks gestation.  The patient was breastfed exclusively, with vitamin D supplementation, until age 6 months and has since had a varied diet.  Gross motor milestones include rolling over at age 6 months and sitting unassisted at age 8 months.  Height and weight are at the 40th percentile.  Physical examination shows a nondysmorphic and active boy.  He pulls himself up to stand and cruises around the examination room while holding on to chairs or his mother.  During the examination, he cries and clings to his mother.  The remainder of the examination is unremarkable.  What is the best next step in management of this patient?

Accepted Answer

Explanation: Developmental milestones are typically described by a mean age at which most children achieve them. All milestones, however, have an age range of normal acquisition. Walking is typically acquired around age 12 months but is considered normal at age 9-16 months. If no other delays (eg, fine motor, language, social) are present and physical examination is otherwise normal, close follow-up is appropriate until age 16 months. In addition to achieving previous gross motor milestones at appropriate ages (eg, rolling over by 6 months), this patient is showing appropriate fine motor coordination (eg, feeding with a spoon) and social interaction (eg, stranger anxiety). Reassurance should be provided, and follow-up in a month is recommended. (Choices A and B) Duchenne muscular dystrophy is an X-linked disorder characterized by proximal muscle weakness and cardiomyopathy. Although delayed walking can be a presenting sign, almost all patients also have cognitive delays, which this child does not have. Screening with a creatine kinase level, which is elevated in this condition, would be reasonable if the child were not walking by age 16 months. If evaluation and examination are otherwise normal, referral to early intervention services and physical therapy would be appropriate. (Choice C) In vitamin D-dependent rickets, patients have decreased vitamin D and calcium levels; the disease can present with delayed gross motor milestones. Physical examination would reveal bowing of the radius/ulna and tibia, delayed closure of fontanelles, and frontal bossing. This child has a varied diet and examination is normal. (Choice D) Bilateral hip radiographs are obtained for suspected developmental dysplasia of the hip in older infants and toddlers. Clinical findings include limited hip abduction and asymmetric leg creases but no delays in motor milestones. This condition is also less likely in nonbreech boys. Educational objective: Walking is a gross motor milestone that normally occurs at age 9-16 months. Evaluation and treatment should be considered if a child is not walking by age 16 months or delays are present in multiple developmental categories. References: Evidence-based milestone ages as a framework for developmental surveillance. (http://www.ncbi.nlm.nih.gov/pubmed/24294064)

Question 17

A 4-month-old boy is brought to the office by his parents for a well-child visit.  Their only concern is that the infant spits up a few times a day after breastfeeding.  These episodes are occurring less frequently than before, and the emesis is not bilious or projectile.  He is sometimes fussy after spitting up but is easily consolable.  The patient was born at 37 weeks gestation by spontaneous vaginal delivery and has no chronic medical conditions.  Vaccinations are up to date.  His weight and length growth charts are shown in image 1, and the head circumference growth chart is shown in image 2.  On physical examination, the patient is alert and smiling.  The anterior fontanelle is soft and flat, and there are no craniofacial anomalies.  Cardiac examination is normal.  The abdomen is soft and nontender.  He is able to roll from his stomach to his back and hold his head steady without support.  Which of the following is the best next step in the management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfdf_5e3a_8f63_3b677864786a_MD0005_00 Head circumference (HC) is measured routinely from birth to age 2 or 3 years, the period of greatest brain growth. Macrocephaly, defined as HC ≥98th percentile for age, may be familial (eg, benign familial macrocephaly) or may signify an underlying genetic syndrome or life-threatening intracranial process. Neuroimaging is required to evaluate for a pathologic intracranial process in the following circumstances: Rapidly expanding HC (eg, >2 cm/month in infant <6 months) Neurologic abnormalities (eg, seizures) Developmental delay This infant with macrocephaly is feeding and growing normally; has a soft, flat fontanelle with no dysmorphic features to suggest an underlying genetic syndrome; and is meeting 4-month milestones (eg, holding head steady, rolling over). However, his HC is rapidly expanding (5 cm in 2 months), and he therefore requires imaging. A head ultrasound is the best study in infants with an open anterior fontanelle. It is fast, involves no radiation, and requires no sedation. If the ultrasound is normal, reassurance and observation are appropriate (Choice D). (Choices A and E) Evaluation with chromosomal analysis for syndromic macrocephaly (eg, Sotos syndrome) and a screen for metabolic macrocephaly (eg, organic acidurias) may be considered in a patient with developmental delay/regression and dysmorphic features, neither of which are seen in this patient. (Choice B) Plain radiographs of the head can detect skeletal dysplasias but have little use in the evaluation of macrocephaly. Educational objective: Infants with macrocephaly (head circumference ≥98th percentile) who have an open anterior fontanelle and rapidly expanding head circumference should have a head ultrasound to evaluate for pathologic intracranial processes. References: Fifteen-minute consultation on the infant with a large head. (http://www.ncbi.nlm.nih.gov/pubmed/23793045)

Question 18

A 74-year-old Caucasian female is brought to the physician's office by her daughter because she has been coughing a lot for the past four weeks.  Her cough is present throughout the day, and is most prominent at nighttime.  She easily gets "out of breath" while walking around the house.  She denies fevers, rigors, or sputum production.  She has a past medical history of hypertension, atrial fibrillation, congestive heart failure with an ejection fraction of 35%, history of ventricular tachycardia, hypothyroidism, and vascular dementia.  Her daily medications include aspirin, metoprolol, furosemide, levothyroxine, amiodarone, and multivitamins.  She is allergic to ACE inhibitors and penicillin.  On examination, her temperature is 37.2C (99F), blood pressure is 110/82 mmHg, heart rate is 82/min, and respiratory rate is 20/min.  Her mucous membranes are moist.  There is no evidence of jugular venous distention.  The lung examination reveals equal and normal air entry on both sides, with fine end inspiratory crackles heard at both the lung bases.  Cardiovascular examination reveals a regular heart rhythm with no evidence of S3 gallop or murmurs.  The rest of her physical examination is unremarkable.  An initial chest x-ray reveals the presence of a normal cardiac silhouette.  There is no evidence of pleural effusions.  There are diffuse interstitial opacities seen bilaterally in the lower lung fields.  Which of the following is the most appropriate next step in her management?

Accepted Answer

Explanation: The patient has a clinical presentation consistent with the development of amiodarone-induced pulmonary toxicity. Amiodarone is a commonly used antiarrhythmic drug for the treatment of ventricular and supraventricular tachyarrhythmias. Prolonged treatment with amiodarone is associated with a variety of adverse effects including photosensitivity, skin discoloration, bone marrow suppression, thyroid dysfunction, abnormal liver function tests, and pulmonary toxicity. Of all the above, pulmonary toxicity is the most serious adverse effect that is responsible for most of the deaths associated with amiodarone therapy. Pulmonary toxicity with amiodarone can be seen in the form of chronic interstitial pneumonitis, organizing pneumonia, acute respiratory distress syndrome, and rarely with a solitary pulmonary mass. Chronic interstitial pneumonitis is the most common presentation of amiodarone-induced pulmonary toxicity. It is characterized by the presence of nonproductive cough, fever, pleuritic chest pain, weight loss, dyspnea on exertion and a focal or diffuse interstitial opacity on the chest radiograph. It is usually seen after months to years of amiodarone therapy, especially in patients who are on higher maintenance doses (more than 400 mg/day). It is a cumulative dose effect, and the serum amiodarone levels are usually within the normal range in these patients. The chest radiograph may reveal the presence of diffuse or focal interstitial or alveolar opacities. Discontinuation of amiodarone is the mainstay of treatment for amiodarone-induced pulmonary toxicity. Corticosteroids can be used in patients with severe or life-threatening pulmonary disease. The prognosis is usually good in most cases, and majority of patients either stabilize or improve after the complete withdrawal of the drug. (Choices B and C) Based on the clinical presentation and chest radiographic findings, the patient's symptoms are unlikely to be from congestive heart failure exacerbation (absence of cardiomegaly, cephalization of pulmonary vessels, and pleural effusions on the chest radiograph). Therefore, increasing the dose of Lasix or reducing the dose of beta-blocker is not indicated at this point. (Choice D) Increasing the dose of metoprolol would have no effect on the course of amiodarone-induced pulmonary toxicity or chronic interstitial pneumonitis. Educational Objective: Prolonged therapy with amiodarone can cause a serious and potentially fatal pulmonary disease. Its treatment primarily consists of complete withdrawal of amiodarone. Corticosteroids can be used in patients with severe or life-threatening pulmonary disease.

Question 19

A 35-year-old man is brought to the emergency room after sustaining gunshots to the head.  After initial hemodynamic stabilization, the patient is transferred to the intensive care unit.  The following day, after consultations with the neurosurgeons, it is concluded that the patient is brain dead and there is no chance of meaningful recovery.  While searching for a contact address, the nurse finds an organ donation card in the patient's clothing.  Family members are contacted and they confirm that the patient had always wanted to donate his organs.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: Most organs for transplantation are obtained from brain dead donors. The successful recovery of viable organs depends on appropriate identification and medical care of brain dead patients. These donors should ideally be managed in an intensive care unit (ICU) with continued hemodynamic support. Brain death leads to hypotension (loss of sympathetic tone), volume depletion (eg, secondary to central diabetes insipidus) and systemic infections. Adequate intravenous volume resuscitation (Choice C) and pressor support (if necessary) (Choice B) maintain a normotensive, euvolemic state with adequate urine output, helps improve the viability of the organs. Endocrinologic abnormalities after brain death are being increasingly recognized. Diabetes insipidus can cause severe volume depletion and adrenal insufficiency contributes to hypotension. Combined administration of corticosteroids (methylprednisolone), thyroxine (triiodothyronine or levothyroxine) and vasopressin (or desmopressin) is routinely used in most centers but the absolute efficacy of this therapy is yet unknown. (Choice A) One of the goals of care in the intensive care unit is to provide optimal ventilator support to prevent hypoxia and hypercapnia. Hypercapnia causes acidosis, which has deleterious effects on multiple organ systems and should be avoided. (Choice E) Cardiac arrest in brain death signifies complete loss of sympathetic tone, making it more difficult to maintain organ perfusion with supportive measures. Also, a shorter time interval between brain death and organ recovery improves the chances of viable organ recovery. Therefore, organs should be procured by the transplant surgery team immediately. Educational objective: Brain dead organ donors should be managed in the intensive care unit to maintain hemodynamic support with intravenous fluids and pressors if needed. Mechanical ventilation should be continued to prevent hypoxia and hypercapnia. Hormone replacement therapy (methylprednisolone, thyroid hormone, and vasopressin) should be administered. References: Organ protective management of the brain-dead donor. (http://www.ncbi.nlm.nih.gov/pubmed/15546816) Brain death and management of a potential organ donor in the intensive care unit. (http://www.ncbi.nlm.nih.gov/pubmed/25257743)

Question 20

An asymptomatic 48-year-old Caucasian female with a history of hypothyroidism is being evaluated for abnormal liver function tests.  She has no other medical problems.  She takes thyroxine for the hypothyroidism.  She takes no herbal medication.  She never smoked or used IV drugs, and rarely drinks alcohol.  Her family history is unremarkable.  Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7C (98F) and respirations are 14/min.  The physical examination is normal, except for mild, painless hepatomegaly.  The initial lab test results are as follows:
 What is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: Autoimmune hepatitis causes progressive parenchymal liver damage. Its course is variable, and severe cases can progress to cirrhosis and liver failure in 6 months. Most cases occur in young to middle-aged women. Autoimmune manifestations such as arthritis, erythema nodosum, thyroiditis, pleurisy, pericarditis, anemia and sicca syndrome are common. Common findings include elevated AST and ALT levels, a normal or near-normal alkaline phosphatase level, and a normal bilirubin level. Autoantibodies are common, and the most typical are antinuclear antibodies (in a homogeneous staining pattern, hence the term "lupoid hepatitis") and anti-smooth muscle antibodies (against actin). (Choice C) Antimitochondrial antibodies are sensitive and specific for primary biliary cirrhosis (PBC), which is rather unlikely in this patient. PBC is characterized by an elevated alkaline phosphatase level rather than elevated aminotransferase levels. (Choice A) The usual cause of high gamma-glutamyl transferase (GGT) is cholestasis. GGT is useful to differentiate whether the elevated alkaline phosphatase level is from liver or bone. Checking GGT will not contribute to this patient's diagnosis. (Choice E) Alpha-1 antitrypsin deficiency causes progressive liver failure and emphysema without signs of autoimmunity. Liver abnormalities are usually seen during the first two decades of life, and patients develop clinical features of emphysema. (Choice D) ERCP is used in cases that have more of a cholestatic picture. It is the gold standard for the diagnosis of sclerosing cholangitis, which is usually seen in patients with ulcerative colitis. ERCP has a better resolution than MR cholangiography, and is therefore more sensitive in the detection of damaged small bile ducts. Educational Objective: Autoimmune hepatitis is a disease of young to middle-aged women. Common findings include elevated AST and ALT levels, a normal or near-normal alkaline phosphatase level, and a normal bilirubin level. The most specific tests are antinuclear antibodies (homogeneous staining pattern) and anti-smooth muscle antibodies.

Exam 1: Advanced Clinical Medicine