Question 1

A 33-year-old woman, gravida 2 para 1 aborta 1, comes to the office for preconception counseling. The patient feels well. Her first pregnancy, approximately 6 years ago, was complicated by diet-controlled gestational diabetes mellitus and by preeclampsia with severe features that required hospitalization at 32 weeks gestation and cesarean delivery at 34 weeks gestation. After delivery, the patient was discharged on antihypertensives, which were discontinued 6 weeks postpartum. She had a normal 2-hour glucose tolerance test at the same visit. Her second pregnancy 4 years ago resulted in a spontaneous abortion at 7 weeks gestation. The patient has no other chronic medical conditions and only takes a daily prenatal vitamin. She practices yoga 4 or 5 times a week. The patient does not use tobacco or illicit drugs but drinks alcohol socially once or twice a month. Blood pressure is 100/70 mm Hg. BMI is 20 kg/m². Pelvic examination is normal. In addition to continuing prenatal vitamins, which of the following is the best advice for this patient?

Accepted Answer

Explanation: 11ec2b69_c19d_61d5_8f63_818274daec62_MD0005_00 Preeclampsia, defined as new-onset hypertension and proteinuria and/or end organ damage at >20 weeks gestation, is a leading cause of pregnancy-related morbidity and mortality. Preeclampsia is hypothesized to result from abnormal increases in platelet aggregation and vasoconstriction, resulting in placental infarction and ischemia. Patients with predisposing factors, such as a history of chronic kidney disease, diabetes mellitus, chronic hypertension, autoimmune disease, and preeclampsia in a prior pregnancy (particularly severe features and/or <37 weeks gestation), are at high risk for preeclampsia development. In high-risk patients, daily aspirin initiated at 12 weeks gestation is the only therapy that has been proven to decrease the risk of preeclampsia. Aspirin inhibits platelet aggregation and helps prevent placental ischemia. (Choice A) Folic acid supplementation decreases the risk of neural tube defects (NTDs). Prenatal vitamins contain 0.4 mg of folic acid, an adequate amount for patients at average risk for a fetus with NTDs, such as this patient. High-dose folic acid, 4 mg daily, is indicated for patients at high risk for a fetus with NTDs (eg, prior NTDs, carbamazepine, valproate). neural tube defects (NTDs) (Choice C) Vaginal progesterone is indicated to decrease the risk for preterm delivery in patients found incidentally during transvaginal ultrasound to have a short cervix (<2 cm). Patients with a history of preterm delivery are treated with intramuscular hydroxyprogesterone to prevent preterm birth recurrence. (Choice D) Patients with previous gestational diabetes mellitus are at risk for recurrence in subsequent pregnancies. Obesity is associated with an increased recurrence risk; however, this patient has a normal BMI. A low-carbohydrate diet does not decrease the recurrence risk. Educational objective: Patients with a history of renal disease, diabetes mellitus, hypertension, or prior preeclampsia (particularly preterm preeclampsia with severe features) are at high risk for preeclampsia recurrence. In high-risk patients, aspirin is used for preeclampsia prevention and is started at 12 weeks gestation. References: Low-dose aspirin for preventing preeclampsia and its complications: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25833349) Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20664402)

Question 2

A 23-year-old Caucasian male presents to the emergency department with an acute onset of flushing, a throbbing headache, palpitations and abdominal cramps.  His symptoms began thirty minutes after eating fish at a local restaurant.  He says that his two friends who had the same dinner in the restaurant with him had similar but milder symptoms.  The particular fish that he ordered in the restaurant is his favorite, and he eats this dish at least twice a month, but this time it tasted unusually spicy.  His past medical history is insignificant.  Which of the following is the most likely cause of this patient's symptoms?

Accepted Answer

Explanation: The clinical scenario described is consistent with scombroid poisoning, which is caused by the ingestion of improperly stored seafood. If seafood is stored at temperatures exceeding 15C, histidine can undergo decarboxylation and form histamine. Symptoms of scombroid poisoning include flushing, a throbbing headache, palpitations, abdominal cramps, diarrhea, and oral burning. These typically begin 10-30 minutes after ingesting the fish, and are self-limited. Patients sometimes describe a bitter taste, but this is not always present. Physical findings may include skin erythema, wheezing, tachycardia and hypotension. (Choice B)Scombroid poisoning is frequently misdiagnosed as an acute allergic reaction; however, the development of similar symptoms in the patient's friends supports the former diagnosis. (Choice E)Pufferfish poisoning is less common than scombroid poisoning, and is characterized by the prominence of neurological symptoms (perioral tingling, incoordination, weakness, etc). (Choice A)Toxic shock is usually accompanied by high fever and hypotension. (Choice C)Carcinoid syndrome is an unlikely diagnosis in this patient because his symptoms are clearly associated with the fish ingestion. Educational Objective: The symptoms of scombroid poisoning include flushing, a throbbing headache, palpitations, abdominal cramps, diarrhea, and oral burning. These typically begin 10-30 minutes after ingesting the fish, and are self-limited.

Question 3

A 29-year-old woman, gravida 0 para 0, comes to the office for preconceptual counseling. The patient has been taking oral contraceptives for the past 6 years and would like to become pregnant within the next 6 months. She has no chronic medical conditions or previous surgeries. Her menses occur every 28 days and last for 4 days. Her menstrual flow is light and accompanied by mild cramping. The patient's Pap tests, the last of which was 2 years ago, have been normal. In addition to oral contraceptive pills, she takes a multivitamin daily and uses acetaminophen occasionally. She has no known drug allergies and is up to date on all vaccinations. The patient drinks socially once a week but does not use cigarettes or illicit drugs. She is an aerobics instructor and teaches for 90 minutes 5 days a week. On days the patient does not teach, she exercises with light weights. In addition, she frequently goes scuba diving on weekends. Blood pressure is 100/60 mm Hg and pulse is 62/min. BMI is 22 kg/m². Pelvic examination reveals a retroverted, normal-size uterus with no adnexal masses or tenderness, a closed cervix, and no vaginal discharge or bleeding. In addition to recommending prenatal vitamins, which of the following is the best advice for this patient?

Accepted Answer

Explanation: 11ec2b69_c19d_d706_8f63_a5dccfaac72f_MD0005_00 Aerobic exercise and strength training are important for disease prevention and health maintenance. During pregnancy, exercise decreases the risk of excessive weight gain, low back and pelvic pain, gestational diabetes mellitus, fetal macrosomia, preeclampsia, and cesarean delivery. Therefore, low-risk patients who regularly exercise prior to pregnancy are encouraged to continue; those who did not exercise previously are encouraged to start. The recommended regimen during pregnancy is 30 minutes of moderately intense aerobic exercise (the patient should be able to converse while exercising) on most or all days of the week (Choice A). Patients who are already conditioned for long-duration, high-intensity exercise can safely continue their regimen during pregnancy (Choice B). Some physical activities performed during pregnancy increase the risk of maternal and fetal morbidity and therefore are not recommended. The weight gain and progressive lumbar lordosis that occur during pregnancy cause a shift in the center of gravity, making pregnant women more susceptible to falling. Exercises associated with a high risk of falling (eg, skiing, gymnastics, horseback riding) and contact sports should be avoided due to the risk of maternal abdominal trauma and abruptio placentae. Although swimming is safe during pregnancy, scuba diving is not recommended due to the risk of fetal decompression sickness from air embolus formation (Choice D). (Choice E) Light-weight (eg, 4.5 kg [10 lb]) resistance training is considered safe during pregnancy. However, training that involves marked straining, heavy resistance, or Valsalva maneuver is not recommended as it may decrease uteroplacental blood flow temporarily. Educational objective: Healthy women with uncomplicated pregnancies are recommended to perform 30 minutes of moderately intense exercise on most days of the week. Scuba diving, exercise associated with a high risk of falling, and contact sports are not recommended during pregnancy. References: ACOG committee opinion no. 650: physical activity and exercise during pregnancy and the postpartum period. (http://www.ncbi.nlm.nih.gov/pubmed/26595585) Physical activity and pregnancy: cardiovascular adaptations, recommendations and pregnancy outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/20524714)

Question 4

A 6-month-old boy is brought to the emergency department due to poor feeding.  His mother says, "My son normally nurses every 3 hours, but for the past 24 hours, he hasn't been latching or sucking when I offer him the breast.  A few days ago, his eyelids started to appear droopy, and they don't open fully today.  He also was previously able to roll and sit by himself, but today he is only lying down and not doing anything."  The infant normally stools 2-3 times per day but has not stooled for 7 days, despite the family giving him small amounts of prune juice.  He was born at 40 weeks gestation by vaginal delivery after an uncomplicated pregnancy.  Immunizations are up to date, and he takes no medications.  He lives on a large rural farm with his parents and grandfather.  Temperature is 36.7 C (98 F), pulse is 128/min, respirations are 30/min, and pulse oximetry is 99% on room air.  Physical examination demonstrates a hypotonic infant lying with arms and legs splayed outward on the examination table.  He has bilateral ptosis and poor suck.  Gag reflex is intact. 
Which of the following is the most likely mechanism of this patient's condition?

Accepted Answer

Explanation: 11ec2b69_c198_a6d8_8f63_c9dfbd7e7d41_MD0005_00 Infant botulism is a flaccid neuropathy that occurs in children age <1 following the ingestion of Clostridium botulinumspores. These spores are typically found in honey as well as environmental dust/soil, particularly in rural or farm areas where the soil is frequently disturbed. Although ingestion of the spores is unlikely to harm a healthy adult, infants have an immature digestive system that lacks protective enteric microbiota. Therefore, the spores are able to colonize the gastrointestinal tract and produce toxin in situ. This neurotoxin inhibits presynaptic acetylcholine release into the neuromuscular junction, causing dysfunction of the skeletal and smooth muscles. Nonspecific early manifestations include constipation and poor feeding, as seen in this infant. Over time patients develop oculobulbar weakness, which may result in ptosis, impaired pupillary constriction, poor suck, and/or absent gag reflex. Muscle weakness can progress to descending paralysis and respiratory failure. Neurologic examination reveals symmetric hypotonia, diminished or absent deep tendon reflexes, and decreased strength. (Choice A) Acetylcholine receptor antibodies in the neuromuscular junction are implicated in myasthenia gravis. Ptosis is a common presenting symptom; however, constipation is not associated, and a slow progression of fluctuating muscle weakness and fatigue is characteristic. (Choice B) Degeneration of anterior horn cells describes spinal muscular atrophy, which causes flaccid paralysis, hyporeflexia, and fasciculations. It is unlikely in this infant who was developing appropriately until a week prior to presentation. (Choice C) Demyelination of peripheral nerve axons occurs with Guillain-Barré syndrome, which is rare in infants and characterized by ascending paralysis. Ptosis is an uncommon concurrent finding. (Choice E) A traumatic injury to the spinal cord could result from nonaccidental trauma, which should be considered in an infant with altered mental status. However, this patient has no red flags for child abuse, and upper motor neuron findings (eg, hypertonia) are expected with spinal cord lesions. Educational objective: Infant botulism is caused by ingestion of Clostridium botulinum spores, which produce a neurotoxin that inhibits presynaptic acetylcholine release at neuromuscular junctions. Classic findings include constipation, oculobulbar weakness, and descending flaccid paralysis in a previously healthy infant. References: Acute muscular weakness in children. (http://www.ncbi.nlm.nih.gov/pubmed/28489146) Clinical mimics of infant botulism. (http://www.ncbi.nlm.nih.gov/pubmed/17403857)

Question 5

A 44-year-old man is rescued from a house fire and brought to the emergency department with nausea, headache, and altered mental status.  The fire likely began due to the stove accidently being left on overnight.  He has no chronic medical problems and takes no medications.  The patient had smoked a pack of cigarettes a day for 10 years but quit several years ago.  He does not use illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 28/min.  Pulse oximetry is 97% on room air.  The patient has soot around the mouth and oropharynx, flushed cheeks, pink palmar skin, and breath that smells strongly of smoke.  He is lethargic but has spontaneous movement in all extremities.  Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds with occasional ectopic beats.  Laboratory results are as follows:  Chest-x ray reveals no infiltrates.  ECG shows T-wave inversions in leads I, aVL, V5, and V6 that were not present on previous ECGs.  Which of the following is most likely to confirm the underlying diagnosis?

Accepted Answer

Explanation: 11ec2b69_c199_b84d_8f63_8f1b1c79018b_MD0005_00 This patient who was rescued from a burning house has headache, nausea, altered mental status, and significant lactic acidosis suggesting carbon monoxide (CO) poisoning. CO binds heme with a much greater affinity than oxygen, forming carboxyhemoglobin. As carboxyhemoglobin levels increase above 10%-15%, impaired peripheral oxygen delivery and peripheral oxygen use may lead to acute symptoms. Mild cases manifest with headache, malaise, nausea, and dizziness; more severe cases often present with seizure, syncope, coma, and/or myocardial ischemia. Significant lactic acidosis and elevated cardiac enzymes are frequently present. Pulse oxymetry cannot differentiate carboxyhemoglobin from oxyhemoglobin and is typically normal. Diagnosis requires arterial blood gas analysis with measurement of carboxyhemoglobin level by co-oximetry. Mild cases are typically treated with high-flow 100% oxygen; more severe cases may require mechanical ventilation or hyperbaric oxygen therapy. (Choice A) Coronary artery catheterization can diagnose coronary atherosclerosis and is often used in patients thought to have acute coronary ischemia from an unstable atherosclerotic plaque. Although this patient has evidence of cardiac ischemia (troponinemia, ECG abnormalities), the underlying etiology is almost certainly CO poisoning (not atherosclerosis). (Choice B) Arterial blood PO₂ reflects the amount of oxygen dissolved in blood and is typically unchanged by CO exposure (unlike oxyhemoglobin, which is severely reduced). (Choice D) Methemoglobinemia is due to the oxidation of iron molecules in hemoglobin, which prevents oxygen binding. The most common causes are medications (eg, dapsone, benzocaine) and toxins (eg, aniline dyes). Manifestations are due to impaired oxygen delivery and include headache, nausea, lethargy, and cyanosis. This patient who was rescued from a burning house is far more likely to have CO poisoning. (Choice E) Urine toxicology may be useful for patients with alterations in mental state following suspected drug exposure, and some illicit stimulants (eg, cocaine) can cause altered mental status and ischemia. However, this patient who was rescued from a burning house is far more likely to have CO poisoning. Educational objective: Acute carbon monoxide poisoning often causes headache, malaise, nausea, and dizziness; more severe cases may present with seizure, syncope, coma, and/or myocardial ischemia. Diagnosis requires arterial blood gas analysis with carboxyhemoglobin level measured by co-oximetry. Pulse oxymetry cannot diagnose carbon monoxide poisoning (no differentiation between carboxyhemoglobin and oxyhemoglobin). References: Carboxyhemoglobin levels in carbon monoxide poisoning: do they correlate with the clinical picture? (http://www.ncbi.nlm.nih.gov/pubmed/18606318)

Question 6

A 44-year-old man comes to the office for an annual physical examination.  The patient's history includes hypertension and gastroesophageal reflux disease, for which he takes enalapril and ranitidine.  The patient also has a history of depression in his early 20s that responded well to sertraline.  He currently has no depressive symptoms.  The patient works as a real estate agent and has been employed at the same company for many years.  He is married with two children ages 17 and 15.  He says, "Things are okay at work and at home, but I'm a little worried about paying for college."  The patient has a 15-pack-year smoking history and drinks socially but does not use illicit drugs.  There is a family history of hypertension and coronary artery disease, and the patient describes both his father and brother as recovering alcoholics.  Blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 16/min.  Examination shows no abnormalities.  Which of the following questions is most appropriate to screen this patient for unhealthy alcohol use?

Accepted Answer

Explanation: 11ec2b69_c19f_5da9_8f63_a370fd119a76_MD0005_00 Unhealthy alcohol use (that can result in medical consequences and/or features of DSM-5 substance use disorder) is prevalent and under-recognized in primary care. This patient admits to social drinking, but this is a nonspecific term that could indicate anything from infrequent consumption of small amounts to heavy drinking. All adult primary care patients should be screened for unhealthy alcohol use. Studies support the use of single-item screening. The single-item screening question, "How many times in the past year have you had 5 (4 for women) or more drinks in a day?" efficiently identifies unhealthy use. A response >1 is considered positive. Patients who are positive on the single-item screen should subsequently be assessed further for symptoms of DSM-5 substance use disorder (eg, evidence of withdrawal, tolerance, craving, functional impairment). Other screening tests to identify unhealthy use in primary care include the 10-item Alcohol Use Disorders Identification Test (AUDIT) and the 3-item AUDIT-C, which are widely validated but more time-intensive (appropriate for settings with additional staff and time). Both the AUDIT-C and AUDIT require scoring, with specific cutoffs screening positive for unhealthy drinking and higher scores suggestive of alcohol dependence. A brief counseling intervention is recommended for patients identified as having unhealthy alcohol use. This consists of a nonjudgmental, empathic discussion about the patient's personal risks of continued alcohol use with the goal of decreasing consumption or achieving abstinence. (Choices A, C, and D) Questions from the 4-item CAGE questionnaire are no longer recommended as an initial screen because they fail to identify the full spectrum of unhealthy use (ie, patients with a mild alcohol use disorder may respond negatively to all CAGE questions). CAGE questions can be used to quickly detect more severe alcohol problems indicative of a moderate to severe DSM-5 alcohol use disorder. For example, a positive response to drinking in the morning to steady one's nerves suggests the presence of alcohol withdrawal. (Choice B) Although psychiatric conditions are commonly comorbid with alcohol use disorders, and this patient has a previous diagnosis of depression, the first step is to identify the extent of his alcohol use. Questions to assess the relationship of his alcohol use to depression would be indicated if the patient were currently having depressive symptoms. Educational objective: Asking how many times in the past year a patient has had 5 (4 for women) or more drinks in a day is an effective screening tool to identify unhealthy alcohol use. The Alcohol Use Disorders Identification Test-C is also a widely validated instrument that can be used for assessment. References: Validation of self-administered single-item screening questions (SISQs) for unhealthy alcohol and drug use in primary care patients. (http://www.ncbi.nlm.nih.gov/pubmed/25986138) The ability of single screening questions for unhealthy alcohol and other drug use to identify substance dependence in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/24411807) Primary care validation of a single-question alcohol screening test. (http://www.ncbi.nlm.nih.gov/pubmed/19247718)

Question 7

A 22-year-old woman comes to the office due to feeling depressed over the last 10 days.  She says, "The other day, I just started crying for no reason.  I really should feel good because I work out in the gym every day.  But I just don't feel like doing anything else.  I can't shake this feeling."  The patient has also felt more irritable in the past week.  "I almost got into a fight with a woman in the gym.  I can be sad one minute and angry the next; it's weird."  She has a history of an eating disorder as a teenager as well as attention-deficit/hyperactivity disorder.  The patient has no other medical problems except for acne, which recently worsened.  She has 4 or 5 alcoholic drinks a week.  Her only medication is methylphenidate, and the prescribed dose has remained stable over the past few years.  The patient has a family history of depression.  Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 16/min.  Mental status examination shows no abnormalities.  Physical examination is notable for facial acne and mild hirsutism.  Chemistries and complete blood count are within normal limits except for mildly elevated hematocrit and hemoglobin.  Which of the following is the most likely explanation for this patient's symptoms?

Accepted Answer

Explanation: This patient's changes in mood, worsened acne, and hirsutism suggest the likelihood of anabolic-androgenic steroid abuse. Anabolic steroids (eg, testosterone, trenbolone, boldenone, stanozolol, nandrolone) are popular among young people and athletes looking to improve physical appearance and performance. In women, they may also be associated with eating disorder symptoms; in addition, women may exhibit clitoromegaly, bilateral temporal hair loss, and an irreversible deepening of the voice. Mood symptoms may occur in both women and men. Increased aggressive behavior can also be seen (more notably in men). Other adverse effects include impaired endogenous testicular function, decreased testicular size and sperm count, and gynecomastia in men, as well as ovarian dysfunction in women. Hepatic dysfunction may occur, HDL levels can decrease, and high doses can cause cardiac dysfunction. In addition, patients can develop erythrocytosis due to androgen-stimulated erythropoiesis; erythropoietin used to enhance athletic performance can also increase erythropoiesis but does not cause androgenic hormonal changes (Choice C). (Choices B and D) Primary mood disorders are not diagnosed if symptoms are attributable to substances (eg, anabolic steroids). Cyclothymic disorder is characterized by numerous periods of hypomanic and depressive symptoms that occur over at least 2 years. A major depressive episode involves >2 weeks of persistently depressed mood and associated depressive symptoms (eg, sleep and appetite disturbance, decreased energy and concentration, suicidality). This patient's mood changes have been present for 10 days. (Choice E) Methylphenidate is a central nervous system stimulant used for attention-deficit/hyperactivity disorder. It is associated with hypertension and tachycardia and, when misused, may result in agitation, aggressiveness, and psychosis. However, this patient's hirsutism (virilization) and depressed mood are more likely explained by anabolic steroid abuse. Educational objective: Anabolic-androgenic steroids are used to improve physique and athletic performance but are associated with numerous adverse effects, including mood and behavior changes. Findings may include acne, hirsutism, bilateral temporal hair loss, voice deepening, gynecomastia, clitoromegaly, testicular failure, ovarian dysfunction, hepatic dysfunction, altered lipid profiles, and erythrocytosis. References: Mechanisms in endocrinology: medical consequences of doping with anabolic androgenic steroids: effects on reproductive functions. (http://www.ncbi.nlm.nih.gov/pubmed/25805894) Effects of anabolic androgenic steroids on the reproductive system of athletes and recreational users: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/28258581)

Question 8

A 19-year-old woman, gravida 1 para 0, comes to the office at 28 weeks gestation for a routine prenatal visit.  Her prenatal course was complicated by vaginal bleeding at 8 weeks gestation due to a subchorionic hematoma.  At that time, laboratory evaluation in the emergency department showed that she was Rh(D) negative, and she received anti-D immune globulin.  The vaginal bleeding resolved, and the patient has had no other problems during this pregnancy.  She has no chronic medical problems or previous surgeries.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 110/70 mm Hg and heart rate is 80/min.  Fundal height is 28 cm and fetal heart rate is 145/min.  Laboratory evaluation today shows a negative anti-D antibody screen.  The patient is no longer in contact with the father of her child, and his Rh(D) status is unknown.  Which of the following is the best next step concerning Rh(D) alloimmunization in this patient?

Accepted Answer

Explanation: 11ec2b69_c19e_e878_8f63_f1da1bfb06b1_MD0005_00 Rh(D) alloimmunization occurs when an Rh(D)-negative mother develops antibodies against Rh(D) antigen. Alloimmunization can lead to hemolytic disease of an Rh(D)-positive newborn and/or fetus; maternal IgG anti-D antibodies cross the placenta and destroy fetal red blood cells. When severe anemia develops in the fetus, it can lead to heart failure and subsequent hydrops fetalis (eg, pleural or pericardial effusion, ascites). Rh(D) alloimmunization Therefore, antibody screening is performed in all pregnant women at the first prenatal visit and at 28 weeks gestation to identify antibodies that increase the risk of hemolytic disease (typically anti-D). Positive antibody screening indicates that alloimmunization has already occurred, and anti-D immune globulin is not administered. Negative anti-D antibody screening confirms a lack of antigen exposure and is an indication to proceed with anti-D immune globulin prophylaxis at 28 weeks gestation (Choice E). This prophylactic anti-D immune globulin neutralizes any occult Rh(D) antigen exposure that may occur between the third trimester and delivery. The postpartum dose of anti-D immune globulin, administered <72 hours after delivery, reduces the risk of alloimmunization from fetomaternal hemorrhage associated with delivery. The postpartum dose, with the addition of the antenatal dose at 28 weeks gestation, reduces the risk of alloimmunization to <1% (Choice B). (Choice C) Anti-D immune globulin has a short half-life, and the dose administered at 8 weeks gestation is no longer effective after 28 weeks gestation. Therefore, even when an early dose of anti-D immune globulin has been given, another dose is still indicated to protect against possible fetomaternal hemorrhage that may occur between 28 weeks gestation and delivery. (Choice D) Anti-D immune globulin is not required in patients with an Rh(D)-negative partner because there is no risk of Rh incompatibility; anti-D immune globulin should be given when paternal Rh(D) status is unknown. Educational objective: Anti-D immune globulin is administered at 28 weeks gestation to all Rh(D)-negative women with a negative anti-D antibody screen; a repeat dose is given <72 hours after delivery if the infant is Rh(D) positive. References: Appropriate provision of anti-D prophylaxis to RhD negative pregnant women: a scoping review. (http://www.ncbi.nlm.nih.gov/pubmed/25491600)

Question 9

A 3-hour-old girl is evaluated in the newborn nursery due to fussiness.  The patient breastfed immediately after birth but afterward has been difficult to console.  The father says, "Every time I pick her up she screams."  The neonate was born at 41 weeks gestation via spontaneous vaginal delivery to a 30-year-old primigravida.  The mother has type 1 diabetes mellitus, which was diagnosed at age 11 and is well controlled.  She had unremarkable serologic testing in the first trimester and a negative rectovaginal culture for group B Streptococcus at 35 weeks gestation.  The delivery was complicated by prolonged rupture of membranes of 21 hours.  The neonate was vigorous at birth with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.  She weighs 3.6 kg (7 lb 15 oz).  Vital signs are within normal limits.  Physical examination shows a quiet, alert girl in no distress.  Auscultation of the chest is normal.  Palmar grasp reflex is present and symmetric.  The patient cries with passive movement of the left arm, and there is crepitus with edema over the left mid-clavicle.  The presumed diagnosis is discussed with the parents.  The mother says, "I can't believe this happened.  I'm so worried.  What is the next step?"  Which of the following is the most appropriate response regarding management of this patient?

Accepted Answer

Explanation: 11ec2b69_c19d_13b4_8f63_8f6a5295e4fb_MD0005_00 This patient has signs of a clavicle fracture (eg, pain with upper extremity movement, crepitus over clavicle). The clavicle is the most commonly fractured bone in newborns. Risk factors include macrosomia, shoulder dystocia, and device-assisted delivery (eg, forceps, vacuum). As in this case, however, many newborns with clavicle fracture do not have risk factors. Examination findings include pain with passive movement of the ipsilateral upper extremity and crepitus or swelling over the clavicle. The Moro reflex may be asymmetric due to clavicular fracture or a concomitant brachial plexus injury. Brachial plexus palsy is diagnosed clinically by the presence of arm weakness in a given cervical nerve distribution, which is not present in this patient (Choice A). brachial plexus injury A plain radiograph confirms the diagnosis of a fracture. Management includes gentle handling and parental reassurance. To prevent painful movement, the affected arm should be flexed 90 degrees at the elbow and pinned to the neonate's shirt. The fracture heals spontaneously over several weeks without sequelae. Surgery, physical therapy, and casting are therefore not indicated (Choices C, D, and E). Educational objective: Neonatal clavicular fractures can present with localized crepitus and irritability with passive motion of the ipsilateral upper extremity. Management is supportive, and there are no long-term sequelae. References: Neonatal clavicular fracture: recent 10 year study. (http://www.ncbi.nlm.nih.gov/pubmed/25203556)

Question 10

A 6-month-old boy is brought to the emergency department due to poor feeding.  His mother says, "My son normally nurses every 3 hours, but for the past 24 hours, he hasn't been latching or sucking when I offer him the breast.  A few days ago, his eyelids started to appear droopy, and they don't open fully today.  He also was previously able to roll and sit by himself, but today he is only lying down and not doing anything."  The infant normally stools 2-3 times per day but has not stooled for 7 days, despite the family giving him small amounts of prune juice.  He was born at 40 weeks gestation by vaginal delivery after an uncomplicated pregnancy.  Immunizations are up to date, and he takes no medications.  He lives on a large rural farm with his parents and grandfather.  Temperature is 36.7 C (98 F), pulse is 128/min, respirations are 30/min, and pulse oximetry is 99% on room air.  Physical examination demonstrates a hypotonic infant lying with arms and legs splayed outward on the examination table.  He has bilateral ptosis and poor suck.  Gag reflex is intact. The patient is admitted to the intensive care unit for close observation.  On admission, his temperature is 36.8 C (98.2 F), blood pressure is 88/45 mm Hg, pulse is 135/min, respirations are 28/min, and pulse oximetry is 99% on room air.  His examination is otherwise unchanged from initial evaluation.  Arterial blood gas on room air is as follows:
 Which of the following is the most appropriate immediate step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c199_431b_8f63_8f50e138828c_MD0005_00 Intravenous botulism immune globulin (BIG-IV) is the treatment for infant botulism and should be administered as early as possible in the course of the illness to reduce the severity and duration of symptoms. It is given once the diagnosis is suspected and should not be delayed while awaiting confirmatory stool studies. Close monitoring of respiratory status is also required and is typically performed in an intensive care setting in case of any sudden deterioration. Supportive care includes laxatives for constipation and nasogastric feeds for poor suck. Infants often require hospitalization for a few months; however, a full recovery is expected with BIG-IV. (Choice A) Although many patients require intubation for airway protection and poor respiratory effort, immediate intubation is not required in this case as the infant has an intact gag reflex and normal vital signs and blood gas. (Choice B) Antibiotics (especially aminoglycosides) are avoided as they can cause colonic C botulinum to lyse, increasing toxin absorption. Empiric antibiotics are indicated for suspected neonatal meningitis, which would present with neurologic decline, fever, and tachycardia. (Choice D) Pooled human immune globulin is the preferred therapy for Guillain-Barré syndrome. However, specific immune globulins are indicated for infant botulism. (Choice E) Pyridostigmine is an anticholinesterase inhibitor used in the treatment of myasthenia gravis. This drug potentiates the effects of acetylcholine in the neuromuscular junction but is ineffective for botulism because acetylcholine release is inhibited. Educational objective: Intravenous botulism immune globulin should be provided as soon as possible for infant botulism while awaiting the confirmatory stool studies. References: Medical treatment for botulism. (http://www.ncbi.nlm.nih.gov/pubmed/24558013)

Question 11

A 79-year-old female nursing home resident is brought to the clinic by a nurse from the facility.  Three years ago, the patient was diagnosed with dementia, and her memory and behavior have gradually worsened.  Staff members report that she has been exhibiting increased aggression and paranoia over the last few weeks.  She has pushed staff members and tried to rush out of the nursing facility.  The patient does not recall these episodes.  Gabapentin, valproate, citalopram, and trazodone were tried but did not improve her worsening symptoms.  She has a history of hypertension and diabetes, which are well controlled with medication.  She had a myocardial infarction approximately 10 years ago with no cardiac symptoms since then.  The patient's vital signs are within normal limits, and on examination there are no abnormal findings except for areas of ecchymosis on her upper extremities.  ECG is normal, and QTc interval is 430 msecs.  The physician recommends low-dose risperidone.  The patient's daughter, who is her guardian, is notified of the treatment plan and is concerned as she heard there is an increased risk of death associated with antipsychotics.  She asks the physician about the safety of the medication.  Which of the following is the most appropriate response regarding the potential safety risks of this class of medications?

Accepted Answer

Explanation: Multiple studies have demonstrated an overall increased risk of death from the use of antipsychotics in patients with dementia. Both first- and second-generation antipsychotics can increase mortality. Increased risk of death may be due to increased cardiac events, as well as from complications of stroke, falls, and aspiration pneumonia, and from other causes. These and other risks of medication use in the elderly highlight the importance of informed consent, patient and family education, and the physician's need to be educated about benefits and risks. These medications can be considered for use in elderly patients in certain situations in the context of potential benefits, risk of harm from not treating (ie, short-term safety risk), and viability of other management options. The presence of psychotic symptoms in the elderly (or the presence of dangerous behaviors that have not responded to other medications) often indicates a need for judicious use of antipsychotics to decrease the risk of harm. Minimization of dosage and duration of treatment plus continuous reevaluation of symptoms are indicated. (Choices A, B, D, and E) There is an increased risk of mortality with the use of antipsychotics in patients with dementia, and the risks are not limited to those with pre-existing cardiovascular disease. Mortality risks are not eliminated by monitoring for ECG changes, given that there are multiple noncardiac causes of death possible with the use of these medications. Educational objective: Antipsychotics increase the risk of mortality in patients with dementia and should be used with caution. Short-term benefits may outweigh long-term risks when other measures fail and the behavior poses safety risks. When antipsychotic drugs are deemed necessary, low-dose antipsychotics can be recommended after informing families of the increased mortality risk. References: Atypical antipsychotic use in patients with dementia: managing safety concerns. (http://www.ncbi.nlm.nih.gov/pubmed/22952071) A review of adverse outcomes associated with psychoactive drug use in nursing home residents with dementia. (http://www.ncbi.nlm.nih.gov/pubmed/27812994) Use of antipsychotics for the treatment of behavioral symptoms of dementia. (http://www.ncbi.nlm.nih.gov/pubmed/26953213)

Question 12

A 48-year-old man comes to the office for his yearly follow-up visit.  The patient's medical history includes hypercholesterolemia, hypertension, and alcohol use disorder.  He says, "I am going through a divorce, and it has been hard not to drink.  It's depressing to come home to an empty house, and I usually end up in a bar on my way home from work."  The patient consumes 2 pints of vodka daily and admits that he keeps a bottle of vodka at work so that he can drink during the day.  He has a history of blackout episodes during intoxication.  Last year, the patient was hospitalized after having a seizure and was treated for alcohol withdrawal.  Following discharge, he was referred to an outpatient substance abuse program but did not attend because, "I thought I could stop on my own."  The patient has lived alone since his wife moved out of the house and works in insurance sales.  His longest period of sobriety is 3 weeks.  He does not use illicit drugs but has smoked a pack of cigarettes daily for 20 years.  The patient says, "I want to stop drinking, but the cravings are just too strong."  In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy?

Accepted Answer

Explanation: This patient has a history of alcohol use disorder and has required treatment for withdrawal in the past. He is actively drinking, and his consumption has likely increased under the stress of his divorce. He has been unable to stop on his own for more than a few weeks at a time and experiences strong cravings. Pharmacotherapy for alcohol use disorder is underused and should be considered in patients, such as this one, who have moderate to severe alcohol use disorder and who are unable to achieve abstinence with psychosocial treatment alone. Pharmacologic treatments target the reinforcing effects of alcohol by modulating the function of opioids and glutamate. First-line pharmacotherapy for alcohol use disorder includes naltrexone, a mu opioid receptor antagonist, and acamprosate, a glutamate modulator. Naltrexone has been shown to decrease alcohol cravings, reduce heavy drinking days (defined as >5 drinks/ for men and >4 for women), and increase days of abstinence. It can be initiated while the patient is still drinking. It is contraindicated in patients taking opioids and in those with acute hepatitis or liver failure. A depot form of naltrexone can be used when there are concerns regarding nonadherence. (Choice A) Bupropion is used to treat depression and aid smoking cessation. It is not effective in alcohol use disorder. In addition, bupropion is associated with an increased risk of seizures and is contraindicated in patients with a predisposition to seizures. (Choice B) Benzodiazepines (eg, chlordiazepoxide) are used to treat moderate to severe alcohol withdrawal. They have no role in the treatment of alcohol use disorder and carry risks of abuse and dependence. (Choice C) Disulfiram is an aversive agent reserved for patients who are abstinent. It inhibits aldehyde dehydrogenase, which causes an unpleasant physiologic reaction when alcohol is consumed. Candidates for disulfiram must be highly motivated or take the medication in a supervised setting as a patient may skip a dose to avoid the medication's aversive reaction when alcohol is desired. It would not be preferred in this patient who is actively drinking and lives alone. (Choice E) Varenicline is a first-line pharmacotherapy for smoking cessation. It would not treat this patient's alcohol use disorder. Educational objective: Naltrexone is a first-line treatment for moderate to severe alcohol use disorder. It decreases cravings and heavy drinking and can be initiated in opioid-free patients who are still drinking. References: Review article: pharmacotherapy for alcohol dependence - the why, the what and the wherefore. (http://www.ncbi.nlm.nih.gov/pubmed/28220511) Reductions in alcohol craving following naltrexone treatment for heavy drinking. (http://www.ncbi.nlm.nih.gov/pubmed/27402770) Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24825644)

Question 13

A 32-year-old woman comes to the emergency department for double vision that started several hours ago.  Objects appear blurry, which she has never experienced before.  Four weeks ago, the patient had a sore throat with enlarged, tender glands and was treated with azithromycin.  She ate home-canned fish yesterday at a friend's house.  The patient does not use tobacco, alcohol, or illicit drugs.  Her family history is insignificant.  Temperature is 36.6 C (98 F), blood pressure is 132/73 mm Hg, and heart rate is 59/min.  Oral mucosa is dry.  She has mild bilateral ptosis and facial muscle weakness, but no sensory loss or muscle weakness of the extremities.  Pupils are dilated with sluggish reactivity to light, and mild dysarthria is seen.  Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: 11ec2b69_c198_0a96_8f63_cb7961213ac9_MD0005_00 This patient, with bulbar weakness, impaired pupillary response, and preserved sensory function after eating home-canned food, has clinical features of acute botulism. Botulism is a serious presynaptic neuromuscular junction disorder caused by botulinum toxin produced by Clostridium botulinum. This is a widespread, anaerobic organism found frequently in improperly canned and preserved foods. Botulinum toxin acts at peripheral nerve endings to inhibit release of acetylcholine into the synaptic cleft. This leads to the inability to achieve a threshold end-plate postsynaptic potential (action potential). Botulinum toxicity leads ultimately to neuromuscular junction failure and subsequent weakness (limb and/or bulbar). It also leads to autonomic dysfunction (eg, blurry vision due to accommodation failure and impaired pupillary responses). Other botulism syndromes include infant botulism due to intestinal colonization, adult enteric botulism, and botulism associated with contaminated wounds. Diagnosis of botulism depends on early awareness and recognition of possibly contaminated food sources. On examination, sensory function is normal, multiple cranial nerve distributions may become weak, and reflexes are usually diminished or absent. Electromyography results may also suggest the diagnosis, which is confirmed by assay of the serum for botulinum toxin. (Choice B) Brainstem stroke can cause oculomotor dysfunction with associated dysarthria/dysphagia and pupillary abnormalities (eg, Weber syndrome/Benedikt syndrome). Additional deficits that may be diagnosed include contralateral hemiparesis/plegia and sensory dysfunction. The presence of bilateral deficits in this patient, absence of vascular risk factors, and young age make a brainstem stroke less likely. (Choice C) Guillain-Barré syndrome is an acute, autoimmune, demyelinating polyradiculoneuropathy that is usually preceded by a respiratory or gastrointestinal illness (eg, Campylobacter jejuni). It typically presents as ascending weakness and mild sensory symptoms (acral numbness/paresthesia) with later bulbar/diaphragmatic involvement and autonomic disturbances. (Choice D) Infectious mononucleosis is caused most commonly by the Epstein-Barr virus. Symptoms are generalized fatigue, headache, fever, sore throat, and swollen lymph nodes. Focal neurological deficits/bulbar symptoms are not found. (Choice E) Myasthenia gravis (MG) is an autoimmune, postsynaptic, neuromuscular junction disorder caused by antibodies against the acetylcholine receptor. It clinically presents with fatigable, fluctuating weakness (arms > legs), ptosis, diplopia, dysarthria, and dysphagia. Patients can develop purely bulbar variants of MG; however, autonomic dysfunction is rare and reflexes as well as sensory functions are usually normal. Educational objective: Botulism is an acute, presynaptic, neuromuscular junction disorder caused by infection with Clostridium botulinum. Botulinum toxin inhibits release of acetylcholine into the synaptic cleft in both the autonomic and somatic nervous systems. Clinically, patients develop acute bulbar and descending limb weakness with absent reflexes and autonomic dysfunction but preserved sensation. References: Neuromuscular junction disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23524069) Botulism, where are we now? (http://www.ncbi.nlm.nih.gov/pubmed/21171845)

Question 14

A 25-year-old woman, gravida 2 para 1, comes to the office at 28 weeks gestation for her initial prenatal visit.  She is known to be Rh(D)-negative, and her husband is Rh(D)-positive.  Her previous pregnancy was uncomplicated, with no episodes of bleeding prior to delivery.  The patient's labor was complicated by a significant intrapartum abruptio placentae, although she ultimately had a vaginal delivery.  She received the same standard dose of anti-D immune globulin at 28 weeks gestation and immediately postpartum.  She did not require a blood transfusion and recovered with iron supplementation.  Prior to this visit, the patient came to the emergency department due to cramping without bleeding, and a transvaginal ultrasound at that time was consistent with 8 weeks gestation.  Today, she has no vaginal bleeding, leakage of fluid, or contractions; fetal movements are occasional.  She has no chronic medical problems and no surgical history.  Temperature is 36.7 C (98 F), blood pressure is 100/70 mm Hg, and pulse is 80/min.  Fundal height is 30 cm.  Fetal heart rate is 145/min.  Routine blood work shows that anti-D antibody titers are 1:32.  Which is the most likely explanation for the positive antibody results in this patient?

Accepted Answer

Explanation: 11ec2b69_c19e_7347_8f63_1b8fae5170db_MD0005_00 An inadequate dose of anti-D immune globulin postpartum is the most likely cause of anti-D alloimmunization (eg, positive antibody screen) in this patient. Typically, a standard 300 µg anti-D immune globulin dose is administered at 28 weeks gestation and again <72 hours postpartum in an Rh(D)-negative mother with a Rh(D)-positive infant. However, pregnancies complicated by massive fetomaternal hemorrhage (eg, abruptio placentae) may require adjustments in the anti-D immune globulin dose, as the standard dose of anti-D immune globulin prevents maternal sensitization only up to 30 mL of fetal blood. In cases of fetomaternal hemorrhage, the amount of fetomaternal transfusion is calculated, so that an adequate dose of anti-D immune globulin can be administered within the 72-hour timeframe. The rosette test is a qualitative screening that determines the presence of fetomaternal hemorrhage. If negative, the standard dose of anti-D immune globulin is administered. If positive, the amount of hemorrhage can be determined using a Kleihauer-Betke test or flow cytometry, and the dose of anti-D immune globulin is increased based on the percentage of fetal red blood cells in the maternal circulation. Kleihauer-Betke test (Choice A) A standard dose of anti-D immune globulin is administered at 28 weeks gestation in uncomplicated pregnancies to neutralize occult fetomaternal hemorrhage. This patient's first pregnancy was uncomplicated at 28 weeks gestation and did not require an adjusted anti-D immune globulin dose. (Choice C) Early prophylaxis with anti-D immune globulin is indicated in patients with vaginal bleeding or trauma prior to 28 weeks gestation, conditions not seen in this patient. (Choice D) Prophylaxis between pregnancies is rarely indicated (eg, after accidental transfusion of Rh-positive blood). (Choice E) Delayed administration (eg, >72 hours postpartum), as opposed to early administration, of anti-D immune globulin postpartum may result in failure of effective anti-D immune globulin prophylaxis. Educational objective: Failure to adjust the dose of anti-D immune globulin after massive fetomaternal hemorrhage (eg, abruptio placentae) may result in maternal alloimmunization. References: Detection of fetomaternal hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/22231030)

Question 15

A 32-year-old man comes to the emergency department due to a throbbing frontal headache that began during the night and slowly worsened.  The patient has also had nausea with lightheadedness.  "It's the oddest thing.  It seemed like a migraine at first, but when my wife began having similar symptoms, I realized it must be the flu or something."  The patient has no medical problems and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.  He and his wife are renovating their older home.  They recently retiled the bathrooms and are now considering replacing some of the major appliances as they are quite old.  Temperature is 36.7 C (98.1 F), blood pressure is 120/76 mm Hg, pulse is 90/min, and respirations are 18/min.  Pulse oximetry is 97% on ambient air.  Mucous membranes are moist, and pupils are equal and reactive to light.  Auscultation of the heart and lungs is normal.  No neck rigidity or meningeal signs are present.  Neurologic examination is normal.  Diagnostic tests, including complete blood count, metabolic panel, and arterial blood gas with co-oximetry, are ordered.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c19a_7b9e_8f63_f7ecbf131fad_MD0005_00 This patient and his wife developed concurrent headaches, nausea, and lightheadedness while in a home with older appliances, raising suspicion for carbon monoxide (CO) poisoning. CO is a colorless, odorless gas that binds heme with a much greater affinity than oxygen and interferes with oxygen offloading at the tissue level. Toxic exposure largely occurs in the setting of poorly functioning heating systems or improperly vented fuel-burning devices (eg, kerosene heaters). Mild cases are marked by flu-like symptoms (eg, headache, malaise, nausea, dizziness); more severe cases often present with seizure, syncope, coma, and/or myocardial ischemia. CO poisoning is often suspected when several people in a shared environment develop symptoms of the disorder. Confirmation is generally made when arterial blood gas analysis shows elevated carboxyhemoglobin levels (pulse oxymetry cannot differentiate between oxyhemoglobin and carboxyhemoglobin and cannot be used for diagnosis). Initial treatment with high-flow oxygen through a nonrebreathing face mask typically resolves the symptoms, but hyperbaric oxygen may be required for those with severe toxicity. (Choice B) CO poisoning is life-threatening, and the treatment is low risk. Treatment should not be delayed while awaiting confirmation of the diagnosis. (Choice C) Acute migraines often cause headaches, nausea, and dizziness and are frequently treated with sumatriptan. This patient who has no history of migraine and who developed symptoms simultaneously with his wife is more likely to have CO poisoning. (Choice D) Acute meningitis is usually diagnosed with lumbar puncture and treated with antibiotics. Although meningitis can cause headaches, fatigue, and nausea, most patients also have fever, altered mental status, and/or nuchal rigidity. (Choice E) Influenza can be treated with oseltamivir. Although many cases are associated with headache and fatigue, most patients also have fever, cough, rhinorrhea, sore throat, and myalgias. Educational objective: Symptoms of carbon monoxide poisoning include headache, nausea, malaise, and dizziness. Suspicion should be raised when several people who share a common environment develop concurrent symptoms. Diagnosis is confirmed by arterial blood gas analysis with carboxyhemoglobin level; treatment with high-flow oxygen through a nonrebreathing mask is generally curative, but patients with severe toxicity may require hyperbaric oxygen.

Question 16

A 22-year-old man is brought to the emergency department by his family for cough and shortness of breath.  The patient was found an hour ago in a barn on the family's property.  He was observed to have severe, frequent coughing episodes with copious sputum production.  The patient also vomited several times with no visible blood.  He reports feeling severely short of breath but has no fever, pain, headache, or confusion.  He has a history of major depression treated with paroxetine.  Family members reveal that the patient recently ended a long-term relationship with his girlfriend.  He does not have a history of using tobacco, alcohol, or illicit drugs, although his younger brother, who lives nearby, uses heroin.  The patient and his parents work in agriculture.  Temperature is 36.6 C (97.9 F), blood pressure is 105/65 mm Hg, pulse is 48/min, and respirations are 28/min.  Pulse oximetry shows 87% while breathing ambient air.  Physical examination reveals an alert, diaphoretic patient in respiratory distress.  Mucous membranes are moist and pupils are pinpoint bilaterally.  Coarse breath sounds with bilateral wheezing are heard on lung auscultation, and heart sounds are normal.  The patient's clothes are soiled with stool and urine.  He is intubated for progressive respiratory distress, and his soiled clothes are removed.  Copious airway secretions are noted as mechanical ventilation is initiated.  Laboratory studies and imaging are ordered.  Which of the following is the most likely mechanism of this patient's condition?

Accepted Answer

Explanation: 11ec2b69_c19b_8d11_8f63_0536851e820d_MD0005_00 This man with diaphoresis, bowel and bladder incontinence, bronchospasm with copious sputum production, and hypoxemic respiratory failure has signs of cholinergic toxicity suggestive of organophosphate exposure. Organophosphate toxicity typically occurs after exposure to or ingestion of agricultural pesticides; organophosphates are unfortunately also used as chemical warfare agents (eg, sarin). Organophosphates are potent acetylcholinesterase (AChE) inhibitors, allowing for excessive buildup of acetylcholine within the synapses, which leads to cholinergic toxicity. Patients classically develop diarrhea, urination, miosis, bradycardia, emesis, lacrimation (tearing), and salivation (DUMBELS: muscarinic effects). Nicotinic activation leads to muscle weakness and paralysis. Patients may develop central nervous system depression which, in conjunction with bronchospasm and bronchorrhea, often leads to respiratory failure requiring intubation. Sudden onset of symptoms and garlic-like odor from clothing (possibly due to the composition of the organophosphate or the petroleum base used) are also characteristic. Treatment includes resuscitation (fluids, oxygen), intubation as needed for respiratory failure, decontamination (eg, removal of clothing), and administration of atropine (a competitive inhibitor of acetylcholine) and pralidoxime (a cholinesterase-reactivating agent) as reversal agents. (Choice A) An overdose of paroxetine (which has anticholinergic activity) or excess atropine (a competitive inhibitor of acetylcholine at muscarinic receptors) would cause anticholinergic toxicity. This is characterized by dry mucous membranes, flushing, mydriasis, urinary retention, and decreased bowel motility, the opposite of which is noted in this patient. (Choice B) Asthma exacerbations and anaphylactic reactions are due to IgE antibody-mediated mast cell activation leading to bronchoconstriction. These patients would not be expected to have bowel or bladder incontinence, emesis, or bradycardia. (Choice D) Hypersensitivity pneumonitis is caused by pulmonary immune system activation in response to an inhaled antigen (eg, poultry, mold); it may cause shortness of breath and cough, but would not cause bowel/bladder incontinence, emesis, bradycardia, or pinpoint pupils. (Choice E) Heroin toxicity is due to stimulation of opioid receptors in the central and peripheral nervous system and can cause pinpoint pupils and respiratory depression; however, it does not cause excessive bowel and bladder output, cough, secretions, or diaphoresis. Educational objective: Organophosphate poisoning typically occurs after exposure to or ingestion of agricultural pesticides; acetylcholinesterase inhibition causes a cholinergic toxidrome. Treatment includes resuscitation, decontamination, and administration of atropine and pralidoxime as reversal agents.

Question 17

A 52-year-old woman comes to the office for follow-up of hypertension.  The patient's blood pressure has been stable over the past 8 years on treatment with hydrochlorothiazide and amlodipine.  However, recent home blood pressure readings have been higher than usual.  The patient has had no changes in sleep quality, caffeine intake, or dietary sodium, but she has been drinking an herbal tea, which her son brought back from a trip to Asia, several times a day.  She also takes black cohosh for occasional menopausal hot flashes.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.5 C (97.7 F), blood pressure is 152/88 mm Hg, pulse is 70/min, and respirations are 14/min.  Physical examination reveals normal jugular venous pressure, clear lung fields, and normal S1 and S2.  Femoral pulses are 2+ bilaterally, and no abdominal bruits are noted.  Laboratory results are as follows:  Additional testing shows a supine morning plasma renin activity of 0.15 ng/mL per hour (normal: 0.3-1.9) and a serum aldosterone level of 0.9 ng/dL (normal: 2-5).  Which of the following is the most likely cause of this patient's uncontrolled hypertension?

Accepted Answer

Explanation: 11ec2b69_c19a_f0d0_8f63_e12001843042_MD0005_00 This patient noticed a significant increase in her blood pressure after she began drinking an herbal tea every day. In addition, she has mild hypokalemia, low aldosterone, and low plasma renin activity (PRA), suggestive of licorice root intoxication. Licorice root is available as an ingredient in herbal teas and as a flavoring in various food products. However, it contains glycyrrhetinic acid, which inhibits 11-beta-hydroxysteroid dehydrogenase, thereby preventing conversion of cortisol to cortisone. The excess cortisol binds to mineralocorticoid receptors and causes hypertension, hypokalemia, and metabolic alkalosis. Due to feedback inhibition, production of aldosterone and renin is suppressed. (Choice A) Black cohosh has been promoted for treatment of menopausal symptoms. It is generally safe, although it has been associated with possible hepatotoxicity. In addition, it may cause hypotension (rather than hypertension) and adverse estrogenic effects. (Choice B) Ginkgo has been marketed as an antioxidant and advocated for the treatment of mild memory loss, dementia, macular degeneration, and peripheral vascular disease. Potential adverse effects include increased risk of bleeding, especially in patients who take aspirin or other antiplatelet drugs. (Choice D) The clinical manifestations of licorice intoxication are mediated via mineralocorticoid receptors and resemble primary aldosteronism. However, this patient's serum aldosterone level is low. (Choice E) Renal artery stenosis leads to an elevation in serum aldosterone level due to activation of the renin-angiotensin-aldosterone system. This patient's aldosterone and PRA are low, and the absence of abdominal bruits makes renal artery stenosis even less likely. Educational objective: Compounds in licorice root can inhibit the conversion of cortisol to cortisone. The excess cortisol binds to mineralocorticoid receptors and causes hypertension, hypokalemia, and metabolic alkalosis. References: Bioactive candy: effects of licorice on the cardiovascular system. (http://www.ncbi.nlm.nih.gov/pubmed/31615045)

Question 18

A 30-year-old woman, gravida 2 para 1 aborta 1, comes to the office for preconception counseling. The patient's first pregnancy 10 years ago ended in a term cesarean delivery due to fetal malpresentation. That pregnancy was otherwise uncomplicated. She is now with a new partner and recently had a first-trimester spontaneous abortion. The patient has no chronic medical conditions and has had no surgeries other than the cesarean delivery. She has no history of sexually transmitted infections. Her last Pap test, 2 years ago, was normal. She takes a prenatal vitamin daily. The patient does not use cigarettes or illicit drugs but drinks a glass of wine on the weekend. She drinks 3 cups of coffee each morning. The patient participates in a 30-minute aerobics class 3 times a week and plays tennis every weekend. Blood pressure is 110/60 mm Hg and pulse is 68/min. BMI is 22 kg/m². Physical examination reveals a small, nontender, retroverted uterus; no adnexal masses or tenderness; and a cervix with no visible lesions or discharge. The patient wants to know what she can do to prepare for her next pregnancy. Which of the following is the most appropriate response regarding this patient's risk for another spontaneous abortion?

Accepted Answer

Explanation: 11ec2b69_c19c_5062_8f63_6985c7faeb70_MD0005_00 A spontaneous abortion, a pregnancy loss (miscarriage) at <20 weeks gestation, is the most common early pregnancy complication. Risk factors include advanced maternal age (eg, >35), a history of prior spontaneous abortion, extremes in BMI, and substance abuse. The most common cause of spontaneous abortion is a fetal chromosome abnormality (eg, aneuploidy, trisomy 16). Other common etiologies include congenital anomalies (eg, teratogens), uterine structural anomalies (eg, uterine septum, uterine leiomyoma), infection (eg, toxoplasmosis), and chronic maternal disease (eg, thrombophilia, thyroid disorder, diabetes mellitus). There is no way to prevent a spontaneous abortion, but its risk factors can be minimized. uterine septum leiomyoma (Choices A, B, and E) Caffeine, moderate exercise, and prior cesarean delivery are not associated with an increased risk for spontaneous abortion. (Choice C) Spontaneous abortions are frequently due to chromosomal abnormalities (eg, aneuploidy). These abnormalities usually result from spontaneous errors in meiosis rather than inherited defects. Inherited chromosomal anomalies (eg, mosaicism, Robertsonian translocation) are uncommon causes. However, as the number of spontaneous abortions in a patient increases, so does the likelihood that an inherited chromosomal abnormality is the underlying cause. For this reason, parental karyotyping is indicated in patients with a history of recurrent pregnancy loss (>3 spontaneous abortions). Robertsonian translocation Educational objective: Spontaneous abortion is pregnancy loss at <20 weeks gestation. Risk factors include prior spontaneous abortion, advanced maternal age, extremes in BMI, and maternal substance abuse. References: Miscarriage and its associations. (http://www.ncbi.nlm.nih.gov/pubmed/18825607)

Question 19

A 34-year-old woman, gravida 3 para 2, at 12 weeks gestation comes to the office for a routine prenatal visit. The patient reports no nausea, vomiting, abdominal pain, or vaginal bleeding. The patient's 2 previous pregnancies were complicated by poorly controlled type 2 diabetes mellitus and resulted in term cesarean deliveries for fetal macrosomia. Both children are healthy. The patient has no other chronic medical conditions. She takes a prenatal vitamin daily, and her glucose levels are controlled with an insulin regimen. She does not use tobacco, alcohol, or illicit drugs. Family history is noncontributory. Blood pressure is 120/70 mm Hg and pulse is 68/min. BMI is 30 kg/m². Bedside Doppler examination reveals a fetal heart rate of 164/min. The patient requested a first-trimester combined test, and the results revealed normal-range nuchal translucency thickness, low pregnancy-associated plasma protein A, and an elevated β-hCG level. The results are discussed and the patient desires further management of these results. Which of the following is the best recommendation in management of this patient's laboratory findings?

Accepted Answer

Explanation: 11ec2b69_c19c_9e83_8f63_63d381a3a4d5_MD0005_00 The first-trimester combined test is a screening test for aneuploidy and has a higher detection rate than second-trimester quadruple screening, with the additional advantage of an earlier diagnosis. It is comprised of ultrasound measurement of nuchal translucency thickness at 9-13 weeks gestation combined with measurement of first-trimester serum markers, β-hCG, and pregnancy-associated plasma protein A (PAPP-A). Although a positive result on a screening test (eg, low PAPP-A, elevated β-hCG) is concerning for aneuploidy (eg, trisomy 21), a definitive diagnosis can be made only by examining the fetal karyotype, which requires either chorionic villus sampling at 10-13 weeks gestation or amniocentesis after 15 weeks gestation. (Choice A) Diabetes mellitus does not affect the sensitivity or specificity of the first-trimester combined test; therefore, abnormal results require further evaluation. Although women with diabetes mellitus and elevated hemoglobin A1c values are at increased risk for congenital malformations (eg, neural tube defects), they are not at increased risk for aneuploidy. (Choice C) Repeating the first-trimester combined test does not increase sensitivity. (Choice D) This patient's first-trimester combined test results are suggestive of an increased risk of aneuploidy. However, the diagnosis of aneuploidy should be confirmed with karyotype analysis prior to pregnancy termination. Educational objective: The first-trimester combined test screens for aneuploidy by measuring nuchal translucency, β-hCG, and pregnancy-associated plasma protein A values. A positive result is confirmed by a diagnostic procedure, either chorionic villus sampling or amniocentesis, to evaluate fetal karyotype. References: Practice bulletin no.162: Prenatal diagnostic testing for genetic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/26938573) Practice bulletin no. 163: Screening for fetal aneuploidy. (http://www.ncbi.nlm.nih.gov/pubmed/26938574)

Question 20

A 75-year-old man with a recent diagnosis of metastatic pancreatic cancer is admitted to the hospital due to dehydration.  The patient admits that he was trying to hasten his death by refusing food and water despite his family's disagreement with this plan.  He is a documentary filmmaker who has made multiple films on the subject of bravery, frequently interviewing firemen and wartime pilots.  He says that "being brave means not being afraid of death and leaving this suffering behind."  The patient's wife recently filed for divorce.  She says that she is an observant Buddhist and has been "fed up with his atheism for a long time; it's just so negative.  He doesn't believe that anything has a point, when really everything is purposeful if he would only just look.  He can't even see the people around him who love and support him."  The patient occasionally has pain despite taking morphine regularly.  He has experienced severe constipation as a result of the pain medication and has received minimal relief from stool softeners.  His wife says that prior to his hunger strike his appetite was poor and that he frequently spends much of the day doing nothing other than lying on the couch watching television due to fatigue.  After his wife leaves the room, the patient pleads with the physician to "give me something to end my life in peace with dignity." 
Which of the following factors is most closely associated with this type of request?

Accepted Answer

Explanation: Requests for euthanasia (in which a physician ends a patient's life through the administration of a lethal substance) or physician-assisted suicide (in which the physician provides only the prescription for the lethal medication) are common in patients with terminal illnesses, most frequently cancer. The factors most often associated with requests for euthanasia include a loss of autonomy and control of the dying process, loss of dignity, and loss of ability to engage in pleasurable activities. Although pain should be routinely assessed as a potential factor, it is not as consistently correlated with requests for euthanasia (Choice E). Requests for euthanasia are more closely associated with fears of future suffering rather than actual pain in the moment. Psychological factors (eg, significant depressive symptoms) should also be considered; psychiatric consultation may be indicated to assess for the presence of clinical depression as well as the potential for treatment. (Choice A) Absence of religious beliefs has not been shown to be consistently associated with requests for euthanasia or assisted suicide. (Choice B) Divorced or separated marital status is a risk factor for suicide, but it is not consistently associated with requests for euthanasia or assisted suicide among the terminally ill. (Choice C) Fear of becoming a burden is less commonly identified with requesting euthanasia or assisted suicide than loss of autonomy. Educational objective: Requests for euthanasia and physician-assisted suicide are most common in patients with terminal cancer. A loss of sense of autonomy and dignity and the fear of future suffering are the factors most consistently associated with these requests. References: Implementing a Death with Dignity program at a comprehensive cancer center. (http://www.ncbi.nlm.nih.gov/pubmed/23574120) Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in "vulnerable" groups. (http://www.ncbi.nlm.nih.gov/pubmed/17906058)

Exam 2: Foundations of Independent Practice