The correct answer is C. Testicular cancer is the most common cancer in men 20-40 years of age. Lifetime incidence is .4% for white male and .08% in black males. Cryptoorchidism is the biggest risk factor for testicular cancer and it increases the risk about fourfold. Nearly 95% of all malignant testicular cancers are of the germ cell type that are divided into the seminoma and nonseminoma. Various tumor markers can help distinguish between the two types of germ cell tumors. Elevated AFP is produced by embryonal and yolk sac elements which are found only in nonseminomas. HCG however, is produced by both seminomas and nonseminomas. A lactate dehydrogenase (LDH) can also be used, but is less specific. Staging is done to assess the extent of disease and to guide therapy. Stage 1 cancer is confined to the testis, epididymis, or spermatic cord. Stage 2 is limited to the retroperitoneal nodes, subclassified by the size of the nodes into < 2 cm, between 2-5 cm, and > 5 cm in diameter. Stage 3 involves metastases to the supradiaphragmatic nodes or visceral sites. Based on the above information, this patient has a seminoma type, Stage 1 process. The standard of therapy is postorchiectomy adjuvant radiotherapy. Since there is no retroperitoneal node involvement, his case is not stage 2 (choice D). If it was stage 2, radiotherapy or chemotherapy can usually cure the cancer.

Since the patient's cancer does not secrete AFP, his cancer is not of the nonseminoma type. Staging was described previously. In general, retroperitoneal lymph node dissection is the standard of care for patients with Stage 1 nonseminoma cancer (choice A). Stage 2 (choice B) and 3 disease requires early retroperitoneal lymph node dissection and either close conservative surveillance or immediate chemotherapy afterwards.

The correct answer is C. Thyroid disease, typically Graves disease, during pregnancy affects approximately 0.2% of women. Patients usually present with the usual complaints (nervousness, palpitations, diarrhea, weight loss, weakness, and a tremor) and the diagnosis is confirmed with thyroid function tests (TFTs). An increased thyroxine (T4) and triiodothyronine resin uptake and a decreased thyroid stimulating hormone (TSH) are found in a patient with hyperthyroidism. Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor.

Do nothing because these are normal values during pregnancy (choice A) is incorrect because pregnancy is associated with increased T4, decreased triiodothyronine resin uptake, and normal TSH levels. This patient has hyperthyroidism.

This patient has hyperthyroidism confirmed with TFTs and there is no reason to perform an ultrasound (choice B). An ultrasound should be performed with a fine needle aspiration if a thyroid nodule is present.

Since this patient is symptomatic and has TFTs associated with hyperthyroidism, it is inappropriate to reassure her and reevaluate her in 1 month (choice D).

Radioactive iodine therapy (choice E) is contraindicated during pregnancy because it can have a destructive effect on the fetal thyroid.

The correct answer is B. Clinically, the paucity of meconium, and the presence of abdominal distension in a neonate, are suspicious for meconium plug syndrome. The "bubbly" appearance on the left abdomen reinforces this consideration. Meconium plug syndrome is more common in infants after labor induction with magnesium sulfate. A water-soluble contrast enema will reveal a spindly plug of meconium in the colon, and often will serve also as a therapeutic enema. Differential considerations include small left colon syndrome, which may coexist with meconium plug syndrome. Also, if therapeutic contrast enema fails to resolve symptoms, Hirschprung's disease or cystic fibrosis must be considered. Do not confuse these entities with meconium ileus.

Conservative treatment such as bowel rest (choice A) is not the appropriate management. A contrast study is necessary to evaluate for meconium plug syndrome. Failure to diagnose and treat may result in perforation.

Conservative treatment such as intravenous fluid resuscitation (choice C) is not appropriate. A contrast study is necessary to evaluate for meconium plug syndrome.

A laparotomy (choice D) is not indicated for meconium plug syndrome or small left colon syndrome.

An ultrasonography (choice E) is a useful screening tool for intussusception, but not for meconium plug syndrome.

The correct answer is E. Treatment in a hyperbaric oxygen chamber is recommended in all patients with carbon monoxide poisoning with carboxyhemoglobin levels above 25% or if they have mental status changes, angina, EKG changes suggestive of ischemia, abnormal neurologic exam, pH <7.2, or if they are unconsciousness for more than 20 minutes. In pregnant patients, however, the threshold for hyperbaric oxygen is lower because of the increased fetal hemoglobin affinity to carbon monoxide. The fetal carboxyhemoglobin level is typically 10-15% higher than the mothers. Thus, in pregnant women a carboxyhemoglobin level of >15 would necessitate treatment with hyperbaric oxygen.

Administer 100% oxygen and call for an obstetric consultation for a STAT c-section (choice A) is the incorrect treatment, as the patient has no indication for a STAT c-section.

Administer 100% oxygen for 3 hours and recheck the carboxyhemoglobin level (choice B) would be the correct treatment for pregnant patients with carboxyhemoglobin levels initially of less than 10% who have complete resolution of their symptoms after treatment with oxygen. However, at discharge patients must understand that their environmental exposure must be altered.

Admit the patient for treatment with 100% oxygen for 24 hours (choice C) is the correct treatment in pregnant patients with initial carboxyhemoglobin levels of 10-15% or with persistent headache after treatment and initial levels less than 10%.

Advise them to have their heating system checked (choice D) is appropriate after treatment is initiated.

The correct answer is E. The only tests, from the ones mentioned above, that are included in the standard work-up for the differential diagnosis of panic disorder are thyroid function tests. Other tests include complete blood count, electrolytes, fasting glucose, liver function, urea, creatinine, calcium concentrations, urinalysis, urine drug screen, and electrocardiogram.

Measurement of cardiac enzymes (choice A) is justified in patients who have present risk factors for cardiovascular disease and symptoms of chest pain. Otherwise, they are not included in a routine workup.

Echocardiogram (choice B) is not indicated as a standard test, but can be ordered if there is additional suspicion of mitral valve prolapse or other cardiac condition that may present with the same symptoms.

Electroencephalogram (choice C) is indicated if there is the presence of neurological symptoms or possible temporal lobe epilepsy. It does not belong to standard tests.

Serum theophylline level (choice D) is done only if there is evidence of possible drug intoxication, which could lead to some of the symptoms described. It is not a standard test for every patient.

The correct answer is B. The patient has microscopic hematuria without evidence of a urinary tract infection. The correct work up for a painless hematuria, whether it is microscopic or gross, is a contrast study of the upper tract (CT urogram or an IVP) to look at the kidneys and ureters and a cystoscopy to look in the bladder to rule out any neoplasms.

Checking another urinalysis today (choice A) is incorrect because another urinalysis would not change the management of this patient. Even if the next urinalysis does not reveal any RBCs, the presence of blood in this current urinalysis dictates that an appropriate work up be performed. The patient may also have intermittent hematuria, which may be missed on subsequent urinalysis.

An ultrasound and referral (choice C) is incorrect. Though, a renal ultrasound can pick up abnormalities in the kidney including hydronephrosis or a tumor, it cannot be used to evaluate the ureters.

Antibiotics and repeat urinalysis (choice D) is incorrect, because the patient does not have any evidence of an infection.

Reexamining her in 1-week (choice E) is incorrect because painless hematuria needs to be worked up to rule out urological malignancies.

The correct answer is A. You should reverse the warfarin. The risk of him having a stroke from atrial fibrillation is far outweighed by the immediate goal of stopping the intracranial bleeding.

This patient requires a high blood pressure to maintain cerebral perfusion. If you drop his blood pressure with labetalol (choice B) this will cause his brain to lose oxygen. Also, subdural bleeds are venous, so the high arterial blood pressure would not be expected to increase the bleeding.

A brain MRI (choice C) will not provide additional useful information at this time.

Heparin (choice D) is contraindicated during an intracranial bleed. The goal is to reverse anticoagulation.

It is too early to predict outcome. You should not tell the family that he will die and do nothing further (choice E).

The correct answer is C. As of April 2001, the Advisory Committee on Immunizations Practices recommends that all adults over age 50 should receive the influenza vaccine annually. This change from all adults over 65 was due to the fact that there were low vaccination rates of high risk persons aged 50-64. The committee believes that if they recommend the vaccine for all adults over 50, it would increase the vaccination rate among the high-risk population. Other people who require annual influenza vaccines are younger people with chronic medical problems or the people that live them. Also, health care workers, pregnant women who expect to be in their second or third trimester during flu season, travelers to areas where there is currently influenza season, or anyone else who wishes to receive the vaccine.

Hepatitis A vaccine (choice A) is recommended for some travelers (except to Western Europe, New Zealand, Australia, Canada, and Japan), people with chronic liver disease, IV drug users, homosexual men, etc.

Hepatitis B vaccine (choice B) is recommended for all adolescents, sexual partners of people with hepatitis, people who are high risk for STDs (including patients with recently diagnosed STDs), hemodialysis patients, health care workers, correctional facility inmates, etc.

No vaccinations (choice D) would be required had this woman been less than 50 years old, although influenza vaccination could be offered to any interested person.

Pneumococcal vaccine (choice E) would be recommended for adults over 65 years old, patients with certain chronic diseases, immunosuppressed patients, asplenic patients, and certain populations such as Alaska natives.

These recommendations are from the ACIP, April 2001.

The correct answer is D. The presence of unilateral edema without evidence of infection (fever, chills, warmth over the affected area, elevated white blood cell count) in the setting of a recent history of decreased activity (long airplane ride) all suggests this diagnosis. The presence of a positive Homan sign (calf pain with dorsiflexion of the foot) is also suggestive of a deep vein thrombosis.

An arterial thrombus (choice A) is unlikely given that the pulses on the affected limb are not diminished, there is no evidence of pallor or coolness of the affected limb, and there is no history of pain or paresthesias of the limb.

Cellulitis (choice B) is less likely given that there is no history of fever or chills, and the affected limb is without any increase in warmth despite the slight erythema, and the white blood cell count is not elevated.

Congestive heart failure (choice C) is unlikely since there is no history of congestive failure or coronary artery disease, and the patient has unilateral edema (the edema associated with congestive failure is typically bilateral).

Lymphangitis (choice E) is unlikely since there is no evidence of infection on physical exam (including streaking over the affected limb which would be classic for lymphangitis) or laboratory evaluation.

The correct answer is B. The risk of contracting meningococcal disease among household members and childcare and nursery school contacts is considered high enough to warrant chemoprophylaxis. Rifampin, ceftriaxone, and ciprofloxacin are the 3 recommended agents used as chemoprophylaxis for invasive meningococcal disease.

A serogroup-specific quadrivalent meningococcal vaccine (choice A) is used to prevent cases of invasive meningococcal disease. It is given routinely to all military recruits and recommended for children with asplenia and other immunodeficiencies. Some groups also advise college students to receive this vaccine. The vaccine may be useful as an adjunct to chemoprophylaxis during an outbreak, but it is not routinely recommended, as chemoprophylaxis is.

It is unnecessary to admit her to the hospital for careful observation (choice C). This patient should be given chemoprophylaxis and her father should be advised to observe her carefully for the development of a febrile illness. Medical evaluation should be sought immediately if an illness occurs, but hospitalization at this time in this asymptomatic patient is not indicated.

Throat and nasopharyngeal culture to decide if treatment is indicated (choice D) is incorrect. Throat and nasopharyngeal cultures are not useful in determining the risk of contracting this disease. Chemoprophylaxis for invasive meningococcal disease is indicated for this high-risk contact.

It is inappropriate to recommend careful observation and schedule a follow-up visit in 1 week (choice E). This patient is a high-risk contact and therefore requires chemoprophylaxis. Careful observation is important too.

The correct answer is D. The single best test for establishing and quantifying the amount of reflux is a 24-hour pH monitoring test. The pH probe is placed 5-cm proximal to the lower esophageal sphincter as determined by manometry. The probe is connected to a computer and the data is recorded continuously at 1-second intervals throughout the 24-hour period. The number of reflux episodes with a pH below 4, the total time the pH is below 4, and the longest duration of the pH below 4 in the lower esophagus, is analyzed from this data. Also, the number of reflux episodes longer than 5 minutes is analyzed from this data. This data is used to interpret the presence of gastroesophageal reflux disease and to quantify its severity. Patients with a pH of less than 4 more than 9% of the time are highly likely to benefit from an antireflux procedure. Under normal circumstances, no reflux episode should last longer than 5 minutes.

An acid infusion test, (Bernstein test), is an older test (choice A), where saline or one-tenth normal hydrochloric acid is infused into the lower esophagus to see whether the symptoms were reproduced. This test is no longer performed.

An endoscopy and biopsy (choice B) are important to detect Barrett's esophagus, but not essential in the detection of gastroesophageal reflux.

Esophageal manometry (choice C) is helpful prior to the correction of esophageal reflux because it quantifies peristalsis within the body of the esophagus and quantifies the strength, length, and location of the lower esophageal sphincters. This is not essential as a first step in the diagnosis of gastroesophageal reflux, although, it is essential before surgical correction.

Upper gastrointestinal series (choice E) is useful to demonstrate a hiatus hernia, paraesophageal hernia, or an esophageal stricture associated with reflux disease. A substantial number of patients who don't actually have clinically significant reflux will have reflux on the upper gastrointestinal series and hence, this test is not very specific.

The correct answer is A. Tetanus prone wounds are any wounds that are over 6 hours old, deep, crushed or penetrated, contaminated with soil, associated with compound fractures, partial or full thickness burns, or human or animal bites. Patients who received 3 doses of tetanus toxoid in the last 5 years do not need further therapy for a tetanus prone wound or for a clean wound. Patients who received a tetanus toxoid between 5-10 years ago and have a tetanus prone wound need booster tetanus toxoid injections, whereas those with a clean wound would need no further therapy. When the last dose of tetanus toxoid was more than 10 years ago, then both clean wounds and tetanus prone wounds need tetanus toxoid booster injections. In addition, those with a tetanus prone wound, whose last dose was more than 10 years ago, need to have human immunoglobulin (choice C) administered.

When the tetanus toxoid vaccination history is not available or the tetanus toxoid injections were administered more than 10 years ago, then an individual with a tetanus prone wound would need tetanus toxoid and human immunoglobulin (choice B). Whereas in a clean wound, a tetanus toxoid complete course is essential. In this case, the farmer received a tetanus toxoid booster 8 years ago and the wound described is a tetanus prone wound. Hence, one booster dose of tetanus toxoid is indicated in this patient.

No therapy (choice D) is not the correct option in this patient, as the wound is tetanus prone, and the last toxoid booster was given more than 5 years ago.

Surgical debridement is indicated in crushed wounds. Wherever there is a soft tissue injury from crushed wounds, and when there is some devitalized tissue, surgical debridement is indicated, even if it is old. In a clean, penetrating wound, surgical debridement (choice E) is not indicated.

The correct answer is C. Ordering a thyroid function test is correct, because this patient demonstrates not only physiological hyperthyroid changes (i.e. increased heart rate), but also cutaneous findings classic for Graves disease. Skin changes are distinctive in hyperthyroidism. The cutaneous surface is warm, moist, and smooth textured. Palmar erythema or facial flushing may be seen. The hair is thin and has a downy texture and nonscarring alopecia may be observed. Graves disease has a female to male ratio of 7:1. Thyroid acropachy is characterized by digital clubbing and diaphyseal proliferation of the periosteum in acral and distal long bones (tibia, fibula, ulna, and radius). Pretibial myxedema consists of bilateral localized, cutaneous accumulations of glycosaminoglycans and occurs in 4% of patients who have or have had Graves disease. Improvement in plaques of pretibial myxedema have resulted from intralesional injections of triamcinolone acetonide and with clobetasol solution under Duoderm occlusion, applied once weekly for 4-6 weeks. Systemic steroids are of no benefit.

Checking testosterone level (choice A) is incorrect, because an elevated testosterone level would only account for hair thinning, but not her other physiologic and cutaneous changes.

Giving her aluminum chloride (choice B) is incorrect, because this solution will only alleviate sweaty palms and soles for this patient, but does not help to diagnose and treat the underlying issue.

Referring her to ophthalmology (choice D) is incorrect, because eventually this patient may need to see an ophthalmologist for severe exophthalmos, but diagnosing Graves disease is the more appropriate first step for this patient.

Despite her family history of psychiatric illnesses, referral to psychiatry (choice E) is incorrect, because this patient's manic appearance is most likely secondary to thyroid hormone imbalance.

The correct answer is A. Hematospermia, the presence of blood in the seminal fluid, is usually the result of nonspecific inflammation of the urethra, prostate, or seminal vesicles. It is almost always self-limiting and resolves within several weeks. Occasionally, hematospermia may be associated with infection, particularly tuberculosis, cytomegalovirus, and schistosomiasis, but rarely is it associated with malignancy. All patients with this complaint should undergo careful physical exam to exclude hypertension which may cause hematospermia, a rectal exam, and a PSA test to exclude prostatic carcinoma, and a urine cytology to rule out the possibility of transitional cell carcinoma of the prostate. This patient has had a complete work-up for initial presentation of hematospermia. There is no need to do anything but reassure the patient that his condition is almost always self-limiting.

Semen analysis (choice B) evaluates semen for volume and sperm concentration, quantity, motility, and morphology. Its utility is in the evaluation of infertility.

Transrectal ultrasonography (choice C) can evaluate the prostate, seminal vesicles, or ejaculatory ducts. It may be utilized for persistent hematospermia. It does not play a role in evaluation of a single episode of hematospermia.

Cystoscopy, or cystourethroscopy (choice D), allows for visualization of the pendulous, bulbar and prostatic urethra and bladder, and is not indicated unless hematospermia persists and there is concern for the underlying pathology.

Antibiotics (choice E) can be utilized in the treatment of prostatitis. There is no evidence that reveals utility of such agents in the current clinical scenario. When treating prostatitis, antibiotics should be used for at least 21 days. Patients with prostatitis normally have a soft, boggy, and tender prostate on rectal exam and have associated urinary complaints (dysuria and frequency).

Prostate specific antigen (PSA) (choice F) is a useful screening tool for prostate cancer. In general, a normal PSA is any value less than 4. Some urologists also believe in age-adjusted PSA with a normal value being slightly lower for younger patients. A repeat exam is not necessary in light of this patient's normal level.

Prostate biopsy (choice G) is an invasive procedure that is performed in patients who have a clinical suspicion of prostate cancer (i.e., abnormal digital rectal exam or elevated PSA). This patient has neither, and subjecting him to an unnecessary invasive test is not indicated.

The correct answer is B. Recurrent otitis media in an adult leads to the suspicion for cholesteatoma, which is a congenital or acquired epidermoid inclusion cyst of the middle ear. The physical exam confirms this diagnosis given “white, amorphous debris in the right middle ear,” which is desquamated epithelial debris. It often destroys the external auditory canal bone and leads to a perforation of the tympanic membrane. It typically requires surgical therapy.

Preoperatively, most surgeons obtain a detailed temporal bone CT to evaluate the cholesteatoma. A bone scan with SPECT images of the skull (choice A) is useful to look for osteomyelitis, but osteomyelitis would be low on the differential diagnosis in this patient given the lack of fever.

Antibiotics such as erythromycin (choice C) may treat the current infection, but will not treat the underlying cholesteatoma leading to the infection.

Antibiotics such as imipenem (choice D) may treat the current infection, but will not treat the underlying cholesteatoma leading to the infection.

Prednisone (choice E) would not be helpful in this patient. Workup for cholesteatoma should commence with a CT of the temporal bones.

Myringotomy (choice F) is indicated for recurrent ear infections, but the physical exam findings in this patient suggests cholesteatoma.

The correct answer is B. This patient has Trisomy 21, which is commonly known as Down's syndrome. Numerous medical problems are associated with this syndrome including ligamentous laxity, mental retardation, hypotonia, hypothyroidism, and diabetes. The ligamentous laxity increases the risk for many musculoskeletal problems including patellar dislocations, hip instability, planovalgus feet, and atlantoaxial (AA) instability. Nearly 20% of Downs patients with AA instability are asymptomatic. However, neurologic consequences with normal dynamic cervical x-rays, i.e., flexion and extension views, is rare. General indications for cervical spine surgery are AA instability greater than 5mm with neurologic signs or prophylactic fusion for instability greater than 1 cm. Soft cervical collars do not improve stability. Scoliosis is not a contraindication to sports participation for any patient. A normal physical exam, negative neurological exam, and a letter from orthopaedics documenting a stable spine essentially clears this patient for non-contact sports.

After repeat cervical spine reevaluation by the orthopaedic surgeon in 6 months. If the cervical spine is still stable then there can be clearance for full sports participation but contact sports are prohibited (choice A) is incorrect. Contact sports are always prohibited. Orthopedic follow-up in 6 months is recommended, but to wait until then for clearance is unnecessary.

Immediately, no further studies or consultations indicated; a soft cervical collar during sporting activities only and contact sports are prohibited (choice C) is incorrect. Many patients with Down's syndrome participate in sports. The Special Olympics is the most notable example. These patients do not wear soft cervical collars because they are not indicated and they provide no additional stability.

Never, because clearance for sports is contraindicated for this patient as the history is consistent for generalized ligamentous laxity. Although physical exam is unremarkable, the patient is at risk for significant musculoskeletal injury. Of greatest concern is the atlantoaxial (AA) joint. A fall from running may result in a complete spinal cord injury and paraplegia (choice D) is incorrect. Atlantoaxial instability is the greatest concern. To prohibit athletic activities in an asymptomatic Down's patient with normal dynamic cervical spine studies would be overcautious. Sports have inherent risks to all participants. There are many social, physical, emotional, and other benefits that should not be deprived from Down's patients.

Never, because clearance for sports is contraindicated for this patient as the history is consistent for generalized ligamentous laxity. Although physical exam is unremarkable the patient is at risk for significant musculoskeletal injury. Of greatest concern is the scoliosis. A fall from running may result in a complete spinal cord injury and paraplegia (choice E) is incorrect. Scoliosis is not a contraindication to sports participation in any patient, especially patients with stable spines, no history of surgery, and no indication for surgery. Many patients with scoliosis play on contact sports teams with permission from their physicians.

The correct answer is E. In premenopausal women, simple cystic masses are usually benign, functional ovarian cysts that resolve spontaneously. Functional ovarian cysts are thought to be formed when an ovarian follicle fails to rupture during maturation. Reassurance and reexamination in 2-3 months are recommended.

Since this cyst is most likely a functional ovarian cyst that will probably resolve spontaneously, it is inappropriate to aspirate the mass under ultrasound guidance (choice A). If the mass happens to be malignant and you aspirate it, this can lead to leakage, peritonitis and seeding of the peritoneal cavity with the tumor.

Germ cell ovarian tumors are associated with elevated levels of α-fetoprotein and human chorionic gonadotropin (choice B). This patient most likely has a functional ovarian cyst rather than a rare, germ cell tumor.

It is unnecessary to order serum CA-125 (choice C) because this adnexal mass is most likely a functional ovarian cyst, as opposed to an ovarian malignancy. If the cyst does not resolve, this test may be indicated in the future.

Oral contraceptive pills (choice D) are often prescribed for a functional ovarian cyst that does not resolve spontaneously. It may be appropriate after reevaluating this patient in a few months if the cyst is still present.

At this time, a laparoscopy (choice F) for an asymptomatic simple cyst in a premenopausal woman is too aggressive since this is most likely benign. This may be the last resort if the cyst does not resolve spontaneously after a trial of oral contraceptive pills.

The correct answer is B. The patient likely has tuberculosis. Virtually all M. tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter. The symptoms of tuberculosis are protean and nonspecific and can be classified as either systemic or organ-specific. Classic systemic symptoms include fever, night sweats, anorexia, weight loss, and weakness. However, since tuberculosis is associated with other illnesses that have similar symptoms, this lack of specificity can result in a delayed diagnosis or even a misdiagnosis. Organ-specific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and hemoptysis. The requirement for diagnosis is the presence of the organism that appears by acid-fast staining in a sputum sample.

In patients with primary tuberculosis, chest radiographs (choice A) often show infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy. These findings are non-specific and are not used for confirmation of the diagnosis.

A sputum culture (choice C) is not useful in this case since the organism responsible for TB is fastidious and is difficult to culture, and certainly does not grow rapidly.

The organism responsible for TB does not stain with traditional Gram stain dyes (choice D) and therefore requires special staining such as acid-fast in order to detect it.

Although it is imperfect, the gold standard for diagnosing latent tuberculosis infection remains the intradermal injection (choice E) of purified protein derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux method). The test has no role in the diagnosis of active infection.

The correct answer is D. The shortness of breath, diminished heart sounds, low voltage on electrocardiogram, enlarged heart on x-rays and chest CT (fluid attenuation in the pericardium without pericardial thickening) all support a pericardial effusion. Pericardial effusions may be idiopathic or infectious in patients with AIDS.

Bacterial endocarditis (choice A) would present with a fulminant course of high fever, septic emboli, sepsis, and possibly heart failure.

Bacterial pneumonia (choice B) presents with fever, sepsis, and focal lung consolidation.

A myocardial infarction (choice C) would be unusual in a 49-year-old without severe coronary artery disease. AIDS itself is not a predisposing factor. The electrocardiogram did not demonstrate any evidence of ischemia or infarct.

A pneumothorax (choice E) may present spontaneously. There is no pneumothorax on the chest x-rays or the chest CT.

The correct answer is D. With an abnormal bleeding pattern in a woman over 35, the most important thing to rule out is endometrial hyperplasia or cancer. The first step in a workup for endometrial hyperplasia is to perform an easy office Pipelle biopsy of the endometrium and send it for pathologic evaluation. If this returns as normal, you can consider other reasons for her bleeding, which may include submucosal fibroids, polyps, anovulation, or perimenopause.

Once you rule out other reasons for her bleeding, such as endometrial hyperplasia, fibroids, or a polyp, you can cycle her on OCPs to regulate her bleeding (choice A). Many perimenopausal women are cycled on low-dose contraceptive pills as well.

Altered FSH and LH levels (choice B) may indicate that she is perimenopausal; however, abnormal bleeding in a patient her age should be evaluated with a biopsy. Menopause is associated with elevated levels of FSH and LH.

An ultrasound evaluation (choice C) would be reasonable to evaluate her uterus for any fibroids, and a saline infused sonogram would show polyps.

Clearly this woman also needs a Pap smear (choice E), but as a physician the most important thing to do is rule out cancer with a biopsy. A mammogram is not routinely recommended by the United States Preventive Services Task Force until age 40.

The correct answer is D. Uterine atony is the most likely etiology of this patient's postpartum bleeding. The likelihood of uterine atony increases with prolonged labor, difficult delivery, and prolonged pregnancy. Initial management of the patient should include a thorough pelvic examination for lacerations and signs of atony, such as a boggy uterus. Uterine massage should be initiated immediately, if atony is suspected. Occasionally, appropriate uterine contractions are stimulated with uterine massage and oxytocics alone.

Hypogastric artery ligation (choice A) is not the appropriate initial management of this patient. Surgical measures are reserved for those patients who do not respond to medical therapy first.

Selective arterial embolization (choice B) is an interventional radiology procedure which involves an angiogram to localize the specific vessel or vessels that are bleeding. Metallic coils or other materials are then used to embolize these selective vessels. It is not the appropriate initial management of this patient. Invasive procedures are reserved for those patients who do not respond to medical therapy first.

Uterine artery ligation (choice C) is not the appropriate initial management of this patient. Surgical measures are reserved for those patients who do not respond to medical therapy first.

Uterine packing (choice E) is not the most appropriate initial management of this patient. If uterine massage and oxytocics do not adequately stimulate uterine contractions, packing the uterine cavity with gauze can be performed. This is a temporizing measure while the patient waits for more definitive therapy.

The correct answer is B. This patient is most likely being physically abused and an open-ended statement such as "Tell me about the fall" will allow her to tell the story spontaneously. It will encourage her to speak freely and does not carry any negative or accusatory tones, and it is not a leading or biased question.

"Is that a black eye that you are attempting to cover-up?" (choice A) is a terrible opening remark. The main goal of the initial question/remark is to establish a relationship and allow the patient to speak freely. This question carries an accusatory tone and it will only make her more uncomfortable and defensive.

"You did not really fall, did you?" (choice C) is a bad question too, because it is biased, leading and will make her defensive. It is not a good way to start an interview and establish a doctor-patient relationship.

"You seem to be very accident prone, what did you do now?"(choice D) is a judgmental, sarcastic question that is inappropriate. The main goal is to establish a relationship in which the patient feels comfortable and trusting. You may think that this is a "cute and funny" way to warm up to the patient, but this is not the proper setting for sarcasm. This question will only make her angry, upset, and defensive.

While she probably does need marriage counseling, opening the interview with the statement, "You should probably get some marriage counseling" (choice E) is inappropriate. You need to allow her the opportunity to tell you what happened (preferably with an open-ended question/statement), and if you feel that there are inconsistencies between her response and her body language, it may be appropriate to say something like, "you seem to be unhappy about the circumstances under which you fell." Being judgmental right from the start will not be good in the long run.

"Your husband does not hit you, does he?" (choice F) is a terrible question to ask her. It is leading, biased and she will try to give you the response that she thinks that you want to hear ("No, of course he doesn't hit me."). It is best to ask an open-ended question that allows her to tell you what happened. If this does not lead in the direction that you think is appropriate, you may ask, "does your husband ever hit you?", but this is not the best way to start out.

The correct answer is C. In acute psychiatric emergencies, a neuroleptic agent (haloperidol) and a benzodiazepine (diazepam) are typically given to control the patient and aid in sedation. An anticholinergic agent, such as benztropine, should be added to prevent parkinsonian-like symptoms (rigidity and akinesia) that may occur in patients treated with high-potency antipsychotic agents (haloperidol).

In this acute situation, it is inappropriate to begin psychosocial treatment with behavior skills training (choice A). Psychosocial treatment, including behavior skills training, multi-family groups, vocational training, and workshops, is very important in the long-term management of schizophrenia. During the patient's hospitalization, after the patient is stabilized, the treatment plan should focus on practical issues, and set the stage for outpatient psychosocial issues.

Dantrolene is the treatment for neuroleptic malignant syndrome (choice B), which may be caused by high-potency antipsychotic agents (haloperidol). It is not routinely given to prevent this condition. NMS is associated with a high fever, autonomic instability, rigidity, behavioral changes, and laboratory abnormalities such as elevated white blood cell count, creatine kinase, and abnormal liver function tests.

Clozapine (choice D) is used as a second-line antipsychotic agent for patients who do not respond to the typical antipsychotic medications and have prominent negative symptoms (flat affect, poverty of speech, and asociality). It is not typically the first agent given in an acute psychiatric emergency. It is associated with agranulocytosis (1%) and requires weekly monitoring of the white blood cell count.

Electroconvulsive therapy (choice E) may be used in cases of non-responsive catatonia. It is not often used to treat an acute psychiatric emergency with a wild and out of control patient.

The correct answer is A. The diagnosis and treatments for rapidly progressive glomerulonephritis, in this case, are woefully inadequate. In adults, where the disease is much less common, and the outcome much worse, early initiation of high-dose steroids has been associated with improved mortality and more rapid return of renal function. Even this therapy, however, has benefits for at most, 40% of patients.

For this reason, lower dose steroids (choice B) are not adequate therapy.

Intravenous penicillin (choice C) or oral penicillin (choice E) presume that treatment of the inciting infection will alter the course of the renal failure. This has not been the case in clinical practice and the severity of the precipitating illness and its duration are not correlated with the course of the glomerulonephritis.

Oral high-dose cyclophosphamide (choice D) is often reserved for more dramatic immune suppression in patients with more severe disease, but its efficacy and applicability to all RPGN patients is far from clear and therefore the risks associated with its use are not offset by any benefit.

The correct answer is A. This patient probably has a subarachnoid hemorrhage. She must be evaluated for an aneurysm and a neurosurgical consult must be obtained.

Sumatriptan (choice B) is a treatment for migraine. The history and cerebrospinal fluid results do not support a diagnosis of migraine.

Intravenous acyclovir (choice C) would be used to treat herpes encephalitis. Although there are often red blood cells in the spinal fluid of such patients, the overall history is more consistent with a subarachnoid hemorrhage than herpes encephalitis.

This does not appear to be bacterial meningitis. It is not emergent that ceftriaxone (choice D) be given in this case.

Repeating the lumbar puncture (choice E) is not going to help with the diagnosis or treatment.

The correct answer is B. One of the most important aspects of the evaluation of older patients is observing them performing activities of daily life. Greeting them in the waiting room allows you to note their cognitive and affective responses, their ability to rise from the chair, and follow directions to the examining room. Observing them provides you with information about their balance, coordination, cognition and judgment.

While it may allow you to help them into the examining room quicker so you can see more patients per day (choice A), this is not necessarily medically beneficial to geriatric patients. You should do this so you can observe them in a everyday type situation, evaluating their cognitive and affective responses, their ability to rise from the chair and follow directions to the examining room.

It is not medically beneficial to check the weather outside so you can talk about it with the patient because this is one of their favorite topics (choice C). While it may seem that a lot of older people like to discuss the weather, this is probably because it is one of the few topics that affects people in the same way, no matter what your age or education level is.

While you may see who brought the patient to your office by greeting them in the waiting room (choice D), this is not the best answer. You should talk to the patient first, since they are your main priority and should be made to feel that way. If the patient is able to follow you into the room alone, and would like to be examined alone, you can ask them if you can speak to the caregivers if you believe that it will provide you with relevant information. Since this patient lives alone and may be able to comprehend and communicate with you, you should first try to obtain a history from him, before seeking it out from caregivers or relatives.

Whenever you are with a patient, you are in a physician-patient situation. It is unlikely that patients may feel more comfortable discussing issues in the hallway because they can feel as if you are on the "same level" and not in a doctor-patient situation (choice E). The most medically relevant information that you can obtain by greeting them in the waiting room is about their balance, coordination, cognition and judgment.

The correct answer is B. This patient is in congestive heart failure as evidenced by her jugular venous distension, bibasilar lung crackles, and dyspnea on exertion. The reasoning for the new onset CHF could be chemotherapy associated cardiotoxicity, infiltrative cardiac disease from her breast cancer, acute myocardial disease, pulmonary embolism, pericardial effusion, or radiation induced cardiac disease. The most appropriate initial test to perform should be an electrocardiogram. An ECG may show signs of acute myocardial ischemia (ST segment changes), pericardial effusion (electrical alternans, low voltage QRS), or right heart strain.

An ABG (choice A) isn't necessary at this point since the patient isn't desaturating or hypoxemic.

A chest x-ray (choice C) would better elucidate the degree of pulmonary effusions, whether the heart is globular and enlarged (supportive of pericardial effusion), or if there are signs of pulmonary embolism (Hamptons hump, Westermark sign). However, to determine whether this is an acute cause of cardiac failure, an ECG should be performed first

An echocardiogram (choice D) would better evaluate cardiac structures and visualize any pericardial effusion. It may also assist in the diagnosis of myocardial ischemia and pulmonary embolism. However, prior to obtaining an echocardiogram, an ECG should be performed to determine whether this patient has an acute cardiac problem.

Bronchoscopy (choice E) would be appropriate if this was a primary pulmonary disease, such as an atypical pneumonia. However, it would not be an appropriate initial test in this case.

The correct answer is B. This patient's girlfriend most likely has human papillomavirus (HPV) infection, which is associated with dysplastic changes and cervical cancer. This patient should be evaluated for an HPV infection, and if there are no visible lesions, acetic acid (vinegar) should be applied to the anogenital region to detect the presence of the virus. Invisible lesions typically turn white when acetic acid is applied. This is thought to occur because the acetic acid causes maceration and swelling of virally induced epithelial hyperplasia, which usually has an increased glycogen content and enhanced permeability. Even though this is not specific for HPV and false-positives can occur, it may enhance the detection of an HPV infection.

If no lesions are found when acetic acid is applied, you should advise him to return if he develops any lesions (choice A) and recommend that he use condoms during all sexual activity (choice C). Condoms will probably not completely prevent the spread of infection, but they should theoretically reduce transmission.

Since his sexual partner most likely has an HPV infection and he is sexually active with many partners, syphilis screening may be appropriate, but the VDRL (Venereal Disease Research Laboratory) and RPR (rapid plasma reagin) tests are used for screening, not the FTA-ABS (choice D). The FTA-ABS is more specific, but it is usually not considered a screening test because it is more expensive and remains reactive in patients with a prior, treated syphilis infection.

Taking random biopsies of the penis (choice E) is completely inappropriate, and it will make a patient very unhappy. Acetic acid should be applied to help see invisible lesions and biopsies can be taken from suspicious areas.

Since many patients infected with HPV have no visible signs and symptoms, it is inappropriate to tell him that he is healthy (choice F) before further evaluation (application of acetic acid).

The correct answer is B. Lower gastrointestinal bleeding in a child with a negative endoscopy is suspicious for a Meckel's diverticulum (MD). A MD occurs in 2% of the population and 2% are symptomatic. They occur 2 feet from the ileocecal valve, are usually 2 inches in length, and contain 2 types of mucosa (gastric and pancreatic). A MD is a true diverticulum from the antimesenteric border of the small bowel, and is the most common congenital abnormality of the gastrointestinal tract. It is usually asymptomatic, but may develop symptoms, usually before the age of 12. Bleeding may either be pronounced, as in this case, or present as a subtle anemia. A technetium-99m pertechnetate scan is about 90% accurate in its diagnosis. Presentation may be bleeding (50%) or obstruction (25%).

Abdominal angiography (choice A) is only useful in the unstable patient with a rising pulse and potentially, falling blood pressure. In this case, the patient is hemodynamically stable, and a nuclear medicine technetium scan is appropriate.

Sigmoidoscopy (choice C) is not necessary, as it will offer no more information than the previously performed colonoscopy.

A small bowel follow through (choice D) sometimes reveals a Meckel's diverticulum in asymptomatic patients. It is not the study of choice in this symptomatic patient.

Upper gastrointestinal endoscopy (choice E) would not be appropriate as this patient is having lower gastrointestinal bleeding.

The correct answer is B. Wire loss during insertion of a central venous line is a relatively common occurrence with an estimated incidence of about 1%. Once lost, the issue becomes where the wire will become lodged. The most common location is in the distal pulmonary artery such that the proximal tip of the wire is in the right ventricle. When this occurs, it is not uncommon, in fact it is quite normal to see arrhythmia. The problem is when these rhythms are ventricular tachycardias. The wire must be removed by an interventional radiologist or cardiac surgeon.

Unless the wire lodges in the atrium and it is somehow "pushed" during extraction, atrial-septal perforations (choice A) are uncommon.

A pneumothorax (choice C) is not a complication of wire loss, but of placing subclavian central lines.

Again, unless some force is applied to the wire during attempted extraction, tissue damage to the tricuspid valve (choice D) is not very common.

A ventricular perforation (choice E) could occur if the wire is coiled in the ventricle. The force of ventricular contraction could force the tip of the wire through the membranous septum. Although this is possible, the most common, in fact, routine complication from wire loss is cardiac arrhythmia.

The correct answer is D. This patient has hypernatremia as a consequence of insensible free water losses. He needs free water repletion with one half the free water deficit being given in the first 12 hours and the remaining half over the next 24 hours. The serum sodium should fall by no more than 0.5mEq/L/hour (12 mEq/day).

Intravenous half-normal saline repletion (choice A) will worsen the condition. Although there is more free water in this preparation, the added sodium will likely worsen this patient's condition.

There is no role for intravenous lactated ringers repletion (choice B) in correcting hypernatremia since it has a similar sodium content as normal saline.

Intravenous normal saline repletion (choice C) will aggravate the condition by providing only some free water and the remainder sodium. This is used to replete some forms of hyponatremia.

Oral thiazide diuretics (choice E) are often a treatment for hypernatremia when salt sodium excess is the primary problem. This can occur with hypertonic dialysis solutions.

The correct answer is D. This patient is suffering from a paraphimosis. This occurs in uncircumcised males who have their foreskin retracted beyond the coronal sulcus, so that it is not subsequently reduced. This has the potential to become an emergency, as the retracted foreskin will act as a tourniquet around the penis, leading to pain, edema, and possibly, vascular compromise. With time the penis will appear as though there is a ring around the distal aspect of it. Important components to the diagnosis of this condition include history and physical. A high level of suspicion is necessary and asking the patient about a history of circumcision is very important. Treatment of this urologic emergency involves attempted manual reduction. This is done with manual compression of all edema out of the glans followed by reduction of the foreskin. If this cannot be accomplished, then the patient will need surgical correction with either a dorsal slit or circumcision.

This scenario is a perfect example of why a physical exam is so important. While Foley catheters may be uncomfortable, they should not be excruciatingly painful once in appropriate position. Changing antibiotics (choice A) does not address the emergent issue. Urinary tract infection may cause urinary retention as this patient had. If one is concerned for UTI, then a urinalysis and urine culture (choice G) would be appropriate after reduction of the foreskin.

The mild epididymal pain, the patient has, may be a bout of epididymitis, which can happen in patients with an in-dwelling catheter. Obtaining a scrotal ultrasound (choice B) will help in this diagnosis but plays no role in evaluation and treatment of a paraphimosis.

A PSA (choice C) and prostate biopsy (choice F) are both utilized in the work-up of prostate cancer. A hard nodule on prostate exam, does raise the suspicion for prostate cancer. However, these tests can be performed at a later date.

Removing this patient's catheter (choice E) is the wrong management for paraphimosis. The foreskin can be reduced with the catheter in place. Physical exam is so important in this case, or else the diagnosis will be missed. Besides, it is unlikely that this patient will be able to void on his own so soon after his bladder was allowed to distend with 900 cc of urine.

The correct answer is D. Herpes simplex keratitis should be suspected in patients with recurrent symptoms of unilateral pain, redness, and photophobia in the presence of an epithelial staining defect. Under slit lamp biomicroscopy these staining defects often take on a "dendritic" appearance, but without a slit lamp they may appear as just fluoroscein uptake. These patients should be referred to an ophthalmologist for treatment. Never prescribe topical corticosteroids for patients with suspected herpes simplex keratitis.

Angle closure glaucoma (choice A) could be consistent with recurrent episodes, but not with this clinical presentation. Patients with angle closure glaucoma will present with poorly reactive pupils, marked decrease in visual acuity, and corneal edema making the cornea unclear.

Allergic diseases (choice B) are most commonly bilateral and are associated with a mucoid discharge and are less likely to cause pain, photophobia, and epithelial defects.

Bacterial conjunctivitis (choice C) rarely produces an epithelial defect, is often associated with copious mucoid discharge, and would not be expected to be recurrent.

Subconjunctival hemorrhage (choice E) is a benign clinical finding. In this case, it would not explain pain, photophobia, tearing, or decreased visual acuity.

The correct answer is E. Using of non-latex gloves is correct because this child has developed a latex allergy. 3-10% of spina bifida patients eventually develop sensitization to latex, hypothesized to be secondary to the increased exposure to surgical procedures in their early life. The history of using latex gloves to clean him regularly for bowel movements as well as erythematous plaques in groin and abdominal areas should raise the suspicion for latex allergy. Half of these patients will have concomitant fruit allergies to banana, avocado, kiwi, chestnut, and passion fruit. The best treatment is to avoid latex material and treat flares with strong topical steroids.

Oral antibiotics (choice A) and topical antibiotics (choice D) are incorrect, because while these two treatment options may decrease the chance of superinfection, they will not treat the primary lesions.

Oral antifungal agents(choice B) and topical antifungal (choice C) are incorrect because the lesions are not classic for tinea. Tinea generally presents as erythematous bordered plaques with central clearance and superficial scaling. Occasionally, tinea cruris may not have scaling secondary to the moist environment, but the lesions on his thighs and abdomen would have the classic scales.

The correct answer is B. Any fetus exposed to alcohol, especially during the first trimester, is at risk for fetal alcohol syndrome (FAS). Cardiac malformations, especially ventricular septal defect (VSD), are noted with increased frequency among infants exposed to excessive levels of alcohol in utero. Additional characteristics of children with FAS may include CNS impairments such as microcephaly, mental retardation, and attention deficit disorders. For women with "moderate" alcohol intake, defined as 1-2 oz of absolute alcohol per day (i.e., 2-4 drinks per day), the risk of FAS is 10%. This woman consumes 4-6 drinks per day and thus places her fetus at risk for some component of FAS.

Bowel obstruction (choice A) is incorrect because it is not found in FAS. Bowel obstruction, which can occur with duodenal atresia, is found with increased frequency in a fetus with Down's syndrome, not FAS.

Cleft lip and palate (choice C) is incorrect. Facial dysmorphia found in FAS includes low-set ears, smooth philtrum, and short palpebral fissures.

Macrosomia (choice D) is incorrect. Growth restriction (not macrosomia or tall stature) is found either prenatally or postnatally in FAS.

Tall stature (choice E) is also incorrect. Children with FAS are small for gestational age and growth restricted.

The correct answer is C. This patient has interstitial fibrosis. Clues to the diagnosis include a history of mildly progressive shortness of breath with a non-productive cough. Physical exam findings of late crackles with inspiration, and the lack of signs of CHF or reactive airway disease such as wheezing suggest interstitial fibrosis. A chest x-ray revealing a ground glass pattern or a reticular nodular pattern also suggests the diagnosis. Pulmonary function tests reveal decreased lung volume with decreased forced vital capacity and FEV1. The ratio of FEV1/FVC might be normal or increased. Diffusion capacity should be decreased.

Patients with asthma have a similar PFT pattern to patients with other obstructive lung disease such as emphysema or bronchitis (choice A) but should have a good bronchodilator response since the pathology of asthma involves bronchospasm. Patients with COPD with bronchospasm will have similar PFTs.

Patients with restriction secondary to obesity or kyphosis have PFTs which show a restrictive pattern (choice B) similar to a patient with interstitial lung disease. The two etiologies can be differentiated by either history or physical exam findings or by examination of the diffusion capacity. In obesity/kyphosis, the diffusion capacity is normal while in interstitial lung disease, the diffusion capacity is decreased.

Emphysema (choice D) patterns on PFT look identical to other obstructive patterns (e.g., asthma, chronic bronchitis) with two exceptions. First, the diffusion capacity in emphysema is decreased. Second, there should not be a significant bronchodilator response in pure emphysema. The caveat of this is that very often chronic bronchitis and emphysema coexist so that some bronchodilator response is possible.

This patient does have underlying lung disease so it would be unlikely for her to have normal PFTs (choice E).

The correct answer is A. AST is less specific for liver than ALT. AST is found in multiple organs and will be elevated with any muscle injury. In fact, before the advent of assays for the MB fraction or troponin, AST was used to assess for myocardial infarction. The patient was recently placed on simvastatin (an HMG Co-A reductase inhibitor). While these cholesterol-lowering drugs are generally benign, myositis is a complication that the prescribing physician must be aware of. The patient's presentation of fatigue and muscle aches fits the diagnosis of myositis. In addition, an elevated AST with an otherwise completely normal liver panel should heighten suspicion that the AST is not coming from the liver. The patient's dark urine is classic for myoglobinuria. The patient should be treated with intravenous fluids to maintain renal perfusion, therefore avoiding renal tubular injury from the myoglobin. Depending on the level of the creatinine kinase, alkalinizing the urine may also help protect the kidney from injury in this setting. There is no definitive treatment for the myositis itself. Typically, the myositis resolves after the offending agent (simvastatin in this case) is discontinued.

An erythrocyte sedimentation rate (choice B) is incorrect. While an erythrocyte sedimentation rate may be useful as a sensitive marker of inflammation, it is not specific for any disease process. As this case illustrates, recently prescribed medicines should always be considered at the top of your differential diagnosis as the etiology of a new disease process. The erythrocyte sedimentation rate would not help make the diagnosis, nor would the result change management.

An elevated AST to ALT ratio may be suggestive of alcoholic liver injury. This is thought to be due to the fact that ethanol decreases ALT synthesis. In addition, ethanol is thought to cause mitochondrial damage in the liver, where AST lives. However, the ratio of AST to ALT in alcoholic hepatitis is more frequently closer to 2:1. The extremely high ratio in this case (again, with a normal ALT) points to an extrahepatic process. An elevated GGT can reflect alcoholic liver damage, but again, this is unlikely in the face of completely normal bilirubin and alkaline phosphatase. Therefore, ordering a GGT level and a serum alcohol level (choice C) is not correct.

Hepatitis A, B, and C serologies (choice D) are incorrect because the viral hepatitides should not cause an isolated level in AST.

A right upper quadrant ultrasound (choice E) is incorrect mainly for the same reasons as elucidated above. A right upper quadrant ultrasound is useful for evaluating suspected structural disease. Typically, structural disease of the liver is suspected when there are clues of hepatic obstruction. Elevated bilirubin and alkaline phosphatase are typically elevated in hepatic obstruction, and both are normal in this case.

The correct answer is B. This patient meets the criteria for irritable bowel syndrome (IBS), which include at least 12 weeks in the preceding 12 months of abdominal discomfort or pain that has 2 of the following features: relieved by defecation, associated with a change in the form of stool, or associated with a change in the frequency of stool. However, IBS is still a diagnosis of exclusion and it is therefore necessary to first rule out an organic cause for her symptoms such as inflammatory bowel syndrome, celiac sprue, endocrine tumors (e.g. carcinoid syndrome),or villous adenoma.

It is doubtful that this patient would have an indolent bacterial infection (choice A) for the past year without a history that better suggests bacterial infection, e.g., Entamoeba histolytica, Salmonella, Campylobacter, or Yersinia infection.

IBS is considered to be a functional bowel disorder characterized by hyperalgesia and altered motility of the gut. IBS-type symptoms can be exacerbated by psychosocial stressors, but it is not the root cause of this condition (choice C).

There is no effective medication to offer this patient for symptomatic relief (choice D) is incorrect. IBS is often thought of as an untreatable condition that requires psychiatric intervention. However, there are many different medications that may alleviate this patient's complaints. Antidiarrheals and bulking agents may relieve her diarrhea and anticholinergics and tricyclic antidepressants may improve her abdominal discomfort.

The is NO increased risk of adenocarcinoma (choice E) with irritable bowel syndrome, though inflammatory bowel disease (e.g., ulcerative colitis) does increase risk for colon cancer.

The correct answer is B. This patient is presenting with low back pain and regular menstrual-like cramping, which are signs of preterm labor. After the history is taken the physician should evaluate the cervix to assess for rupture of membranes, vaginal bleeding, presentation, cervical dilation, effacement and station. Preterm labor is defined as a patient between 20-36 weeks with uterine contractions occurring 4 per 20 minutes or 8 contractions in 60 minutes that are accompanied by premature rupture of membranes, cervical dilation greater than 2cm, effacement exceeding 50% or a change in cervical dilation or effacement detected by serial exams.

Magnesium sulfate (choice A) is a final step in the management of preterm labor. The initial step should be to confirm the diagnosis of preterm labor by palpating the abdomen and determining contraction frequency.

It is important to document fetal well-being during preterm labor with a non-stress test (choice C), but the initial step should be to confirm the diagnosis of preterm labor by palpating the abdomen and determining contraction frequency.

Palpating the abdomen to determine the strength of contractions (choice D) is incorrect because the strength of the uterine contractions can only be determined with an intrauterine pressure catheter and not by external palpation. Also, at this point it is important to know the status of the cervix to see if the patient is in preterm labor or is having preterm contractions.

The first step should be to confirm the diagnosis of preterm labor by determining the frequency of contractions. Ultrasonography (choice E) can and should be done later during the management of preterm labor. Ultrasonography is useful in estimating gestational age, as well as in evaluation for placental abruption or placenta previa.

The correct answer is D. The most important recommendation for this patient is to wear a seat belt at all times in a car, whether he is a driver or passenger. This is true whether the car has airbags or not. Use of safety belt restraints has been shown to reduce the risk of motor vehicle injury and death. Studies have shown that lap and shoulder belts can decrease the risk of moderate to serious injury to front seat occupants by up to 55% and can reduce crash mortality by 40-50%. Motor vehicle accident victims who are wearing seat belts at the time of the crash are less likely to require hospital admission and have lower hospital charges. Multiple studies that evaluated mandatory seat belt laws report significant reductions in motor vehicle related injuries, hospital admissions, and fatalities after implementation of such laws.

Buying a car with driver's side airbags (choice A) is not the most important recommendation for this patient. He was not wearing a seat belt at the time of his accident and this is a good opportunity to encourage him to do so at all times while in a car. Although it is not mandatory to drive a car with airbags, it is mandatory to wear safety belts in 49 states. Forty-nine states (all except New Hampshire) and the District of Columbia have mandatory safety belt laws. In most states, these laws cover front-seat occupants only. Beginning with the model year 1998, all new passenger cars in the U.S. are required to have driver and passenger side air bags. A review by the National Highway Traffic Safety Administration estimated that air bags increase the effectiveness of safety belts by about 5-10%.

Buying a car with both driver side and passenger side airbags (choice B) is not the most important recommendation for this patient.

Wearing a seat belt only while driving and not as a passenger (choice C) is inappropriate counseling. It is important to advise the patient to wear a seat belt at all times while in a car as a driver or passenger.

It is inappropriate to advise the patient to only wear a seat belt if the car does not have airbags (choice E). Airbags are designed as a safety supplement to seat belts and are not meant to be used as a substitute. .

The correct answer is F. This patient is most likely a victim of spousal abuse and it is important to call attention to the inconsistencies between her response and her body language by saying, "You seem really upset about the circumstances under which you got those bruises." It is usually good to start out the conversation with an open-ended question, like "tell me about these bruises." When she got visibly upset and made up an unlikely excuse, it is appropriate to confront her (to point out that there is a discrepancy with her statement and behavior). You can tell that she is upset because she is looking down at the floor, speaking quietly, and obviously crying (wet cheeks and sniffling). Spousal abuse is very common and women typically seek medical attention for headaches, abdominal pain, pelvic pain, or depression. It is rare that they come in complaining of spousal abuse. The physician must be able to recognize the signs and symptoms of abuse.

It is not correct to ask her, "How long has your husband been abusing you?" (choice A), "I believe that your husband has been abusive for a while. Why would you stay with him?" (choice B) or "You need to leave your husband as soon as possible" (choice E) because she has not yet told you that she has been abused. To maintain a good doctor-patient relationship it is important to allow the patient to feel comfortable and share information with you, without feeling like you are jumping to conclusions. It is best to try to get her to talk to you, rather than you automatically "blurting out" your opinions and putting her on the defensive. A direct question, such as "does your husband ever hit you?" may be necessary, but it is best to start out by allowing the patient to describe the situation and speak freely.

From the physical examination and her body language, it seems more likely that she is a victim of spousal abuse than a coagulopathy. Therefore it is incorrect to tell her that "Those bruises are caused by a clotting abnormality that is common during pregnancy" (choice C). Also, it is not normal to have multiple bruises in various stages of healing on the breasts during pregnancy.

It is inappropriate to ask her, "Why haven't you told me that your husband is abusive during our previous appointments?" (choice D), because this automatically puts her on the defensive. You should never "accuse" a patient of not acting in the way which you think is best. She is obviously very upset about the situation, and you will only make her feel worse by this statement. Patients should not be criticized about their decisions. This will only alienate them and destroy the doctor-patient relationship that is built on trust and confidence.

The correct answer is A. This patient has a radio-opaque renal calculi. Calcium oxalate containing stones account for approximately 60% of all kidney stones. These stones are radio-opaque, (visible on plain x-ray films). Hypercalciuria is the direct precursor to most calcium stone formations. This increase of calcium levels in the urine can occur from increased intestinal absorption, decreased renal absorption, or increased bone resorption. Oxalate is either produced endogenously from the enzymatic cleavage of glyoxylate to oxalic acid and glycine or via intestinal absorption.

Cystine stones (choice B) form from cystinuria. Cystinuria is the result of an inherited autosomal recessive defect in the renal tubular reabsorption of 4 amino acids, which include cystine, ornithine, lysine, and arginine (COLA). They occur in acidic urine and are very rare. Patients frequently provide a family history of kidney stones.

Indinavir (choice C) is a protease inhibitor used in the treatment of HIV. Patients taking this medication are at an increased risk of forming renal stones. These stones are very difficult to treat, as they cannot be seen on plain x-ray or CT scans.

Struvite stones are composed of magnesium ammonium phosphate (choice D). These stones are infectious in etiology and are formed by urea-splitting organisms. The most common organisms are the Proteus species, Pseudomonas, and Klebsiella. They are sometimes called "triple phosphate" stones and occur in the setting of persistently high urinary pH (>7.2). These stones have a high association with neurogenic bladders and foreign bodies in the urinary tract. Because the stones contain numerous infective bacteria, which the antibiotics cannot penetrate, the stone must be removed for the infection to be cleared.

Uric acid stones (choice E) account for approximately 10% of renal stones. They are not visible on plain films. Uric acid is a product of purine metabolism and is excreted in the urine. These stones form in the face of low urine volume, low pH (acid urine), and high levels of urinary uric acid. The etiology of uric acid stones include hyperuricuria, gouty diathesis, myeloproliferative diseases, malignancy, and Crohns disease.

The correct answer is A. The differential diagnosis is rather broad at this point. You should look for an infectious or malignant mass with a contrast enhanced CT or MRI.

A non-contrast head CT (choice B) is less sensitive for abscess or tumor.

A lumbar puncture (choice C) should only be done after you are sure that there is not significant mass effect.

This patient has an acute problem which should be addressed now. Antiretroviral therapy (choice D) will help him in the long term, but does not need to be initiated in the emergency department.

Intravenous heparin (choice E) is a treatment for embolic stroke. Embolic stroke is unlikely in this case and he needs further evaluation before considering treatment with intravenous heparin.

The correct answer is C. Children with a personal or family history of seizures are at a slightly increased risk of having a seizure after immunization with the MMR vaccine. However, the child should be vaccinated anyway because the risks outweigh the benefits. Since the MMR causes a fever in up to 15% of recipients, simple febrile seizures do occur. However, as with most febrile seizures, it does not seem to greatly increase the risk for epilepsy. Parents should be made aware of the increased risk of fever within 12 days of being immunized and be told to treat the fever as it arises.

It is inappropriate to advise her to see a neurologist if she is this concerned about her child's risk of seizures (choice A) because you should be able to explain the risks and benefits of the vaccine as they relate to seizures.

Phenobarbital (choice B) is inappropriate for this infant who has no personal history of seizures because therapeutic concentrations may not be reached within the few days that this patient is at greatest risk.

It is incorrect to tell her that a febrile episode within 12 days after immunization is not associated with an increased risk of seizures (choice D). Up to 15% of MMR vaccine recipients develop a fever, and it seems as if these individuals are at risk for having a simple febrile seizure.

It is incorrect to tell her that no seizure events have been reported after the measles mumps rubella vaccine (choice E). Seizures have been associated with the MMR vaccine, typically simple febrile seizure.

The correct answer is D. This patient is having cardiac ischemia in the setting of increased myocardial oxygen demand. She has known coronary disease and her vital signs at the time of her angina episode show hypertension and tachycardia. The patient must have her blood pressure lowered acutely to the goal of terminating the angina with nitroglycerin.

Verapamil (choice A) is a calcium channel blocker that is used most often to slow the ventricular rate in patients with atrial fibrillation. These drugs are generally contraindicated in an acute myocardial ischemia as they tend to be associated with worse outcome.

Furosemide (choice B) may work to relieve some pulmonary congestion that this patient has as a result of her ischemia and increased left-sided filling pressures. It however fails to address the primary problem of her increased demand.

Morphine (choice C) is usually given to relieve pain, but nitroglycerin is more important at this time because it can relieve pain and also reduce the underlying ischemia.

A chest radiograph (choice E) would not be without benefit in this emergent situation, it has no role in altering any decision making or therapeutic intervention. This patient must have her blood pressure and heart rate lowered.

The correct answer is D. The clinical picture in this patient is consistent with Trichomonas vaginalis. Although the infection is often asymptomatic, men may develop urethritis, and women may complain of a frothy vaginal discharge that is greenish-yellow in color that may have a fishy odor. Women may also have some lower abdominal tenderness with more severe symptoms just before or just after menstruation. On exam, the vaginal mucosa may be erythematous with an inflamed and friable cervix. Women may also have a "strawberry cervix", a term used when there are multiple petechiae on the cervix. Although a wet prep is positive in only 40-80% of the cases, and therefore not necessary for diagnosis, seeing the trichomonads with their flagella and jerky motility is diagnostic.

Bacterial vaginosis (BV) (choice A) is a syndrome seen in sexually active females which is usually asymptomatic but often presents with a thin, white, foul smelling discharge which people often describe as "fishy". BV is usually not associated with pruritus, dysuria, or abdominal pain. BV is the most prevalent vaginal infection in sexually active females. Although not completely clear, causes are thought to include Gardnerella vaginalis, Mycoplasma hominis, and anaerobic bacteria. In order to diagnose BV, a woman must have at least 3 of the following: a whitish gray non-inflammatory vaginal discharge that adheres to the vaginal wall, a vaginal fluid pH greater than 4.5, a "fishy" odor to the vaginal fluid either before or after mixing with 10% potassium hydroxide, and a wet mount that shows "clue" cells, which are epithelial cells with smudged borders due to bacteria adherent to the cell membrane

Yeast infections are caused by overgrowth of Candida albicans(choice B) often due to factors such as pregnancy, antibiotic use, diabetes, and oral contraceptive use. Some women report predisposition to yeast infections immediately preceding menstruation. These women usually present with complaints of intense pruritus and burning accompanied by a thick white "cottage cheese"-like vaginal discharge. In a woman with a yeast infection, you would expect to see yeast and pseudohyphae on a wet mount.

Normal vaginal discharge (choice C) is usually a scant to moderate amount of clear-white colored discharge. There is usually no strong odor present. There are many lactobacilli and normal epithelial cells.

The correct answer is E. The most important recommendation for this patient is a surveillance colonoscopy every year in an effort to detect colon cancer early. Although the risk of colon cancer in Crohn's disease is much less than in ulcerative colitis, the risk increases significantly with involvement of the colon, and if the disease has been present for more than 10 years. This patient is at increased risk for colon cancer because he has had Crohn's disease for at least 15 years and has evidence of colon involvement. A colonoscopy is recommended because it is superior at detecting small lesions and biopsy of suspicious lesions can also be performed simultaneously.

An increase in prednisone dosage (choice A) is not indicated in this patient at this time. He reports feeling well and has only rare episodes of diarrhea. Medication adjustments should be made based on the patient's symptoms.

An increase in sulfasalazine dosage (choice B) is not indicated in this patient at this time. He reports feeling well and has only rare episodes of diarrhea. Medication adjustments should be made based on the patient's symptoms.

Prophylactic colectomy (choice C) is not indicated or recommended for this patient. Many patients with Crohn's disease who have extensive colitis undergo colectomy early in the course of disease to relieve persistent symptoms. This patient does not have severe symptoms nor does he have prior colonoscopy findings of dysplasia to warrant a colectomy. Prophylactic colectomy is often recommended for patients with ulcerative colitis with long standing colitis due to the increased risk of colon cancer.

Surveillance barium enema (choice D) is not the best recommendation for this patient. He has had Crohn's disease for over 10 years and is at increased risk for developing colon cancer. A barium enema is not as sensitive or specific for the detection of early colon cancer. Colonoscopy is recommended because it is superior at detecting small lesions and biopsy of suspicious lesions can also be performed simultaneously.

The correct answer is C. Crush injuries such as the one suffered by this patient often result in massive release of muscle contents. In the blood, creatine phosphokinase or CPK is an enzyme released by dead or damaged muscle. By itself it is harmless. It is however a marker for a substance not measured by conventional assay that is also released after damage to muscle. This substance, myoglobin is directly nephrotoxic. Much data exists that shows early intervention with copious alkalinized intravenous crystalloid prevents renal damage.

An echocardiogram (choice A) is indicated in the case of blunt chest wall trauma. However, in the case of a lower extremity crush injury, this is not immediately indicated.

A 12-lead electrocardiogram (choice B) may be useful, but given the nature of the injuries and the fact that there are no clinical signs or symptoms suggesting myocardial ischemia, this intervention is not the most useful.

Because there is no reason to suspect that the heart is the source of the elevated CPKs, fractionated CPK levels (choice D) would not be expected to be useful. A concern in trauma patients is always liver damage in the form of contusion or avulsion. This patient has relatively normal liver function tests and hematocrit.

This makes a right upper quadrant ultrasound (choice E) not very useful in terms of yield for a suspected intraabdominal process.

The correct answer is D. Nervousness, tremor, heat intolerance, and weight loss are classic signs and symptoms of hyperthyroidism. Hyperthyroidism is a well known cause of atrial fibrillation. This arrhythmia will respond to the treatment of the underlying endocrine abnormality. A serum thyroid stimulating hormone (TSH) level will be abnormally low in patients with hyperthyroidism and is a very specific test for this disorder.

A chest x-ray (choice A) is not a useful study in the evaluation of atrial fibrillation in the setting of hyperthyroidism. There is no reason to suspect other primary lung diseases in an otherwise healthy young male to warrant a chest x-ray.

A CT of the head (choice B) will not provide information about the etiology of the patient's atrial fibrillation. He has a distant history of surgical resection of a benign brain tumor and there is no reason to suspect metastatic disease. There is no association between primary brain pathology and atrial fibrillation.

An exercise tolerance test (choice C) is an examination to evaluate for cardiac ischemia or past infarct. This study is performed by having a patient exercise on a treadmill while wearing the electrocardiogram leads. A continuous EKG is performed during exercise to monitor for signs of ischemia. Cardiac ischemia is a very common cause of atrial fibrillation. However, there is no reason to suspect an ischemic etiology of this arrhythmia in a young, otherwise healthy patient.

A ventilation/perfusion scan (choice E) is a good diagnostic study for the evaluation of a pulmonary embolism. A pulmonary embolism is a known cause of atrial fibrillation. Although recent surgery and hospitalization does put the patient at increased risk for thromboembolic disease, he does not have shortness of breath, chest pain, or other classic symptoms of a pulmonary embolism. Young and healthy patients do develop thromboembolic disease in the setting of pelvic and lower extremity trauma, and prolonged hospitalization or bedrest.

The correct answer is B. Many patients who are volume overloaded for various reasons, whether it is due to massive volume resuscitation or congestive heart failure, will develop some degree of scrotal edema. Often times, it can be very impressive and can also cause the patient pain. This patient definitely has signs of heart failure and has likely been heavily volume loaded, because of his sepsis. The only real treatment is to optimize the patient's volume status and let the body reabsorb the fluid with diuresis as tolerated.

There are no signs of infection mentioned in the clinical scenario, thus treatment with an antibiotic is not necessary (choice A). Occasionally these patients will get some cellulitic type symptoms in the scrotum, but the treatment of choice for that would be something other than ciprofloxacin.

No specific treatment would help (choice C) is incorrect as he should be treated with diureses to improve his volume status.

The hydroceles seen in this patient are not likely to be contributing to the markedly increased size of the testicles, and percutaneous aspiration (choice D) is not necessary. Placing a drainage tube in the scrotum (choice E) is completely unnecessary and not done.