The correct answer is E. This patient likely has Chrug-Struass syndrome. Chrug-Struass syndrome is a vasculitis, which is associated with eosinophilia and asthma. This patient has nephritic syndrome as evidenced by edema, hypertension, and hematuria. Asthma is suggested by his nocturnal chest tightness and shortness of breath. Laboratory results reveal elevated eosinophils, which is typical in this condition. Chrug-Strauss is associated with a positive pANCA.

Goodpastures syndrome is typically defined as a combination of nephritic syndrome and pulmonary hemorrhage, although some patients have nephritic syndrome alone. The disease is mediated by antibodies to the glomerular basement membrane (choice A) and therefore those are the laboratory results often associated with the disease.

ASO (choice B) is associated with post infectious glomerulonephritis. Patients present with oliguria, hypertension, and edema. They classically complain of Coca-Cola colored urine. These infections classically occur 1-3 weeks after infection with nephritogenic group A streptococci (step throat or cellulitis).

Wegner granulomatosis is similar to Chrug-Strauss but respiratory involvement such as nasal septal perforation or sinus problems are typical presenting signs. Wegners doesn't have an association with asthma or increased serum eosinophils. The test associated with Wegners is cANCA (choice C).

Bergers syndrome (IgA nephropathy) presents in a similar manner to post-infectious glomerulonephritis but there is no latent period between infection and kidney involvement. These patients typically have gross hematuria after a viral illness. About 50% of these patients will have an elevated IgA (choice D).

The correct answer is D. When evaluating a patient for a positive tuberculin skin you must first classify which risk category the patient belongs. Patients are divided into three groups: High risk patients are considered to have a positive skin test if the area of induration is greater than or equal to 5 mm. These are people with HIV or those at high risk for HIV (i.e. IV drug users), people who have close contact with patients with active TB, or those who have had TB or evidence of prior TB on chest x-ray. Patients with induration greater than or equal to 10 mm are considered to have a positive test if they immigrated from countries with a high prevalence of TB, are known HIV negative IV drugs users, are medically underserved populations, prisoners, mental institution residents, nursing home residents, those with some chronic medical problems, or hospital workers. All other people are considered to have a positive test if the area of induration is greater than 15 mm. Our patient has an area of induration of less than 10 mm. No further work up is needed in this patient.

Collecting sputum for acid fast bacilli (AFB) (choice A) is helpful in confirming the diagnosis of suspected tuberculosis. If this patient reported typical symptoms of tuberculosis such as fevers, night sweats, weight loss, and cough a positive AFB smear or culture would help us to make the diagnosis of TB.

Extended course of single drug therapy (choice B) would be necessary if this patient had a positive skin test with no evidence of active infection. Preventative therapy has been shown to reduce the incidence of reactivated tuberculosis.

An extended course of four-drug therapy (choice C) is the treatment of choice for active tuberculosis. A typical four-drug regimen includes isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin.

A recent converter of their skin test should get a chest x-ray (choice E) to evaluate for any evidence of active disease and to have a baseline chest x-ray that could be followed in the future. Once a patient has a positive skin test, it is no longer valuable to perform further skin tests. Rather, yearly chest x-rays for evidence of reactivated TB should be done.

The correct answer is E. Cocaine is contraindicated during breast feeding and so you need to advise the mother to stop breast feeding if she is using cocaine. Possible effects of cocaine in the breast milk include growth retardation and neurologic damage. Cocaine use during pregnancy is associated with fetal demise, spontaneous abortions, premature rupture of membranes, preterm labor and delivery, placental abruption, intrauterine growth retardation, and congenital anomalies. Other medications and drugs that are contraindicated during breastfeeding are bromocriptine, cyclophosphamide, cyclosporine, doxorubicin, lithium, ergotamine, methotrexate, amphetamines, heroin, marijuana, nicotine, and phencyclidine.

The most appropriate next step is to tell her is to discontinue breastfeeding if she is using cocaine, not to advise her to stay away from her son when she is using cocaine (choice A). This answer makes it seem like it is okay that she is using drugs, but she should just not be near her baby. This is actually not true. If she is using the cocaine to lose weight, you should recommend a healthy diet and exercise regimen.

It is incorrect to call her husband and ask if he knows that she is using drugs (choice B) or to contact the child welfare association and inform them of your findings (choice C). You should first try to reason with the patient and encourage her to discontinue using cocaine and tell her that she is not only risking her own life now, but also that of her son's because she is breast feeding.

She already admitted to you that she is using cocaine and so it is unnecessary to obtain a urine sample to test for cocaine and other illegal drugs (choice D).

The correct answer is E. This patient has the signs and symptoms most consistent with a Trichomonas vaginalis infection, which is diagnosed by finding motile, flagellated organisms on a saline wet mount smear preparation. Patients with T. vaginalis typically experience vulvar itching and burning, a "frothy" malodorous discharge, dysuria, dyspareunia, and frequency and urgency of urination. Vaginal and cervical petechiae ("strawberry cervix") may be present. The treatment is metronidazole and it is important to treat the partner because T. vaginalis can be transmitted by sex.

Branching hyphae and spores (choice A) are associated with an infection with Candida albicans, which is characterized by intense pruritus and a thick, white ("cottage-cheese") discharge. This patient's discharge is not consistent with a Candida infection.

Epithelial cells with clumps of bacteria and "ground-glass" cytoplasm (choice B) are associated with an infection with Gardnerella vaginalis, which is characterized by gray-white, "fishy" discharge. Irritation of the vaginal epithelium is not usually seen. This patient's discharge is not consistent with a Gardnerella infection.

Giant multinucleated cells with intranuclear inclusions (choice C) are associated with an infection with herpes simplex virus, which is characterized by vesicular lesions, ulcers, paraesthesia, and dysuria. The diagnosis is confirmed with viral cultures and scrapings. Giant multinucleated cells with eosinophilic intranuclear inclusions are seen when stained with Wright's stain. A saline wet mount smear preparation is not used to diagnose herpes infections. Also, this patient's discharge is not consistent with a herpes infection.

Koilocytes (choice D) are associated with an infection with the human papilloma virus (HPV) which is characterized by soft, fleshy lesions on the genital region (condyloma acuminata). The diagnosis is established with a biopsy of the lesions. A Pap smear may show "koilocytes", which are cytologic changes associated with HPV. A saline wet mount smear preparation is not used to diagnose HPV. This patient's signs and symptoms are inconsistent with HPV.

The correct answer is B. Although this patient is presenting with many of the classic signs of chronic plaque psoriasis, it is best to document it clearly in the chart with a representative biopsy at least once in a patient with this chronic disease. The easiest place to do a biopsy in this patient is either the scalp or the elbow (not a given choice). The results of a nail biopsy in psoriasis is not as classic (choice A) and a tongue biopsy is difficult compared to other easily accessible skin areas,(choice C). The classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles. Psoriasis of the tongue is a migratory glossitis, which is a thickened area of the tongue that is transient. One day it will be in one area of the tongue, the next day, it will move, thus "migratory", to another area on the tongue. Psoriasis of the nails consists of distal onycholysis (distal lifting of the nail plate), subungual debris (scale underneath the nail), total nail dystrophy, oil-spots (again, scale under the nail), and pitting. Pitting can be seen in one or 2 other dermatologic conditions but more often represents psoriasis. Psoriasis is an inherited disease whose exact chromosomal location and mechanism is still under debate. Psoriasis has not been directly linked to substance abuse problems. This patient most likely inherited the psoriasis and perhaps even the substance abuse problems from his father, albeit separately.

There are other forms of psoriasis which include erythrodermic psoriasis which is total body erythema and scaling, which can occur as the first onset of psoriasis or as an exacerbation of existing psoriasis, pustular psoriasis which are crops of sterile pustules, which erupt and can form lakes of pus, and inverse psoriasis which is psoriasis of the groin and intertriginous areas. Because the plaques are constantly moist, they do not have the typical silvery, heaped-up scale of psoriasis. They are still very well-defined and may have some scale on the outer edge of each plaque. Guttate psoriasis is an eruption of "rain-drop" like scaly plaques often seen in children after a group A streptococcal infection.

Although tinea of the skin and nails is in the differential in psoriasis, this patient with so many classic psoriasis findings does not need a KOH or fungal culture of the nails (choice D) or skin from the ear (choice E). Diagnostic tests for fungus are only performed if the lesions are not classic, and the clinical picture is hazy between psoriasis and tinea. The major diagnoses that can cause scaling in the ear are psoriasis and discoid lupus, but rarely fungus.

The correct answer is B. Critical aortic stenosis is suggested by the patient's physical exam (late peaking ejection murmur at the base, prominent apical impulse) and clinched by the echocardiogram showing an aortic valve area of 0.6 cm² (a valve area less than 0.7 cm² is considered critical).

Congestive failure (choice A) is unlikely given that there is no mention of the classic physical stigmata (S3, elevated jugular venous pressure, crackles on the lung exam).

Hypertensive cardiomyopathy (choice C) is unlikely given that the patient has no history of preexisting hypertension, and is not hypertensive on exam.

Idiopathic hypertrophic subaortic stenosis (choice D) is unlikely given that there is no mention of outflow obstruction on the echocardiogram.

Ischemic heart disease (choice E) is less likely given the absence of any history of coronary disease, minimal coronary disease risk factors, and the absence of wall motion abnormalities or scar on the echocardiogram.

The correct answer is B. This patient's symptoms are consistent with a facial nerve palsy that may be caused by Lyme disease (from his camping trip). To test the facial nerve, you should ask the patient to show you his teeth. If the left side of his face is drawn to the right, he most likely has a left-sided facial palsy. Other facial nerve tests include asking him to wrinkle his forehead, puff out his cheeks, and hold his eyes shut as tightly as possible as you try to carefully pry them open.

If this patient had a trigeminal nerve palsy, you should ask him to clench his teeth while you palpate the masseter muscle (choice A). During this maneuver, his jaw would deviate to the same side as the lesion. Also, he would complain of sensory abnormalities on his forehead, cheek, and jaw and paroxysms of pain on his chin, lips, cheeks, and gums.

Sensory abnormalities can be elicited by having him close his eyes and tell you when you are touching his cheek with gauze (choice C). He does not have these sensory symptoms.

If he had a left-sided spinal accessory nerve palsy, you should have him turn his head to the right against your hand (choice D). The dysfunction would manifest with the patient being unable to do this, or weakness on this side as opposed to the other side. He does not complain of weakness in the head, neck, or shoulder.

The gag reflex of the glossopharyngeal nerve is tested by touch the posterior pharyngeal wall with an applicator stick (choice E). Symptoms of glossopharyngeal nerve lesions are sensory dysfunction of the pharynx, loss of taste on the posterior third of the tongue, and a partially dry mouth.

The correct answer is B. This patient most likely has performance anxiety, which is a form of social phobia. The treatment usually involves beta-blockers before a performance to decrease the symptoms. However, a patient with severe asthma should avoid beta-blockers because they can cause bronchoconstriction and precipitate into an asthmatic attack.

A pulmonary function test (choice A) and a chest x-ray (choice D) are not indicated at this time. You already know that she has asthma that has required hospitalizations and the results of these tests are unlikely to change your management.

A referral to a psychiatrist (choice C) may be helpful in treating her performance anxiety, but she is in your office for propranolol, so it is your responsibility to first try to explain to her that her asthma makes her a bad candidate for this treatment.

You should not prescribe propranolol for her to take before her performances (choice E) because she has severe asthma, which makes beta-blockers a dangerous medication for her. Beta-blockers can cause airway obstruction, which may lead to worsening asthma.

The correct answer is D. Infertility is usually defined as the failure to conceive after a year of unprotected intercourse and it affects up to 15% of reproductive-aged couples. 60% of the time there is a female factor such as ovulation disorders or anatomical defects in the genital tract and the other 40% of the time it is due to male disorders of spermatogenesis. The initial work-up of an infertile couple usually includes a complete history and physical examination, a basal body temperature chart, laboratory studies, and semen analysis obtained by masturbation. The semen analysis evaluates the sperm count, volume, viscosity, motility, and differential. A hysterosalpingogram, which is an x-ray of the female genital tract after an opaque dye is injected into the uterine cavity, is useful in evaluating the anatomy and is sometimes included in the initial work-up. However, many OB-GYNs will order this study only after the results of the previously mentioned studies are normal.

The most appropriate next step is to obtain a semen sample for analysis, not to advise him to stop bicycling so often (choice A). While some believe that the pressure and heat generated by sitting on a bicycle seat can affect sperm count, you must first order a semen analysis to determine if the infertility is due to a male factor.

Determining his testosterone concentration (choice B) is not a typical part of the evaluation of infertility. Semen analysis is important to determine the sperm count, volume, viscosity, motility, and differential.

It is incorrect to inform them that she is not ovulating (choice C) because she has regular menstrual cycles with menstrual symptoms and the results of the basal body temperature recording are completely normal and indicate that she is most likely ovulating. Also, the mid luteal progesterone is normal.

It is inappropriate to schedule a hysteroscopy (choice E) at this time. A hysteroscopy allows the physician to directly evaluate the endometrial cavity through an endoscope and to possibly biopsy or remove any lesions that are present. A semen analysis should be performed before an invasive procedure, such as this, is ordered.

The correct answer is A. The screening tests for prostate cancer are digital rectal exam and serum PSA levels. If either one of these is abnormal then the patient needs to undergo transrectal ultrasound with prostate biopsy. This procedure can be done as an outpatient without anesthesia. Utilizing transrectal ultrasound allows for visualization of the prostate at the time of biopsy so that each specimen is from a different anatomic location within the prostate. In general, normal PSA levels are <4 ng/mL. Some investigators believe in "age-adjusted PSA." In that case, the upper limits of normal PSA for men ages 40-49 is 2.5 ng/mL, ages 50-59 is 3.5 ng/mL, ages 60-69 is 4.5 ng/mL, and ages 70-79 is 6.5 ng/mL. Under either system, this patient's PSA of 7.4 ng/mL is abnormal and warrants further investigation. The fact that this patient has both an abnormal rectal exam and an elevated PSA are even stronger indications for prostate biopsy. The urologic literature is filled with a variety of blood tests/imaging studies that may be performed in an attempt to limit the number of men undergoing transrectal ultrasound and prostate biopsy. To date none of these have been uniformly accepted. This leaves only the digital rectal exam and serum PSA levels as the initial screening tools for prostate cancer.

Elevated PSA (choice B) and nodule of the prostate (choice I ) are both indications for prostate biopsy. As stated, if either is abnormal then the patient is a candidate for biopsy. However, (choice A) is the correct answer because it acknowledges that both are abnormal in this patient.

This patient's history of tobacco use (choices G and H) and exposure while working in a textile factory (choice C) are risk factors for development of transitional cell carcinoma of the urinary tract (ureter/bladder). Neither of these are indications for prostate biopsy.

The fact that this patient's father has prostate cancer (choices D, E, J) is concerning. This patient is eligible for earlier and perhaps more frequent screening tests. However, a family history of prostate cancer is not an indication to perform prostate biopsy. In choice J, the presence of a nodule on DRE is indication for biopsy; however, the family history is not an indication.

Guaiac-positive stool (choice F) is an important finding on this patient's physical exam. It will warrant further investigation but is not an indication for prostate biopsy.

The correct answer is C. This patient has asthma, and the most crucial step in the management of asthma is avoidance of the triggering factors, e.g., allergens. Unfortunately, it is difficult to avoid specific types of allergens, such as pollens. Specific measures to eliminate or reduce exposure to dust mites and animal dander at home lead to a reduced frequency of attacks and hospitalization rates. Regardless of the allergens involved, elimination of respiratory irritants, especially cigarette smoke, is of crucial importance. The bronchial tree of asthmatic patients is highly reactive to any form of chemical or physical irritation. Thus the avoidance of passive smoke is important. The mother should ask her boyfriend to go smoke outside alone if he needs to, but he should not be allowed to smoke in the house.

It is not practical to administer immunotherapy against identified allergens (choice A) in this case because he is allergic to multiple airborne allergens, and it seems like he is especially responsive to cigarette smoke. Immunotherapy is of some benefit when a single allergen is identified. The most important step is to try to reduce exposure to avoidable allergens (smoke).

Avoidance of all exercise (choice B) is not appropriate because even though exercise triggers asthmatic attacks in some patients, this does not seem to be his main trigger.

Humidifiers and air cleaners (choice D) at home is not the appropriate management. Humidifiers favor the growth of dust mites, and air cleaners have not been shown to be uniformly effective in getting rid of dust mites.

It is inappropriate to prescribe inhaled sodium cromoglycate, oral corticosteroids, and oral theophylline (choice E) for this patient because the fewest number of drugs at the lowest effective doses should be used. Typically, a one drug regimen (a bronchodilator or an inhaled corticosteroid) for mild to moderate asthma or two drugs for more severe cases is sufficient to control asthma exacerbations. Oral corticosteroids are indicated in cases of severe asthma and are therefore, not for this patient.

The correct answer is C. Autoimmune thrombocytopenic purpura of childhood (childhood ITP) is a disorder that usually occurs after a viral illness. The pathophysiology involves antibody (IgG or IgM) binding to platelets. These antibody- coated platelets are subsequently destroyed in the spleen. Thrombocytopenia ensues and most often resolves spontaneously within 6 months. Persistent thrombocytopenia is treated with 2 weeks of prednisone 2-4 mg/kg/day or IVIG 1g/kg/day. Cases refractory to medical therapy in which severe thrombocytopenia persists are treated with splenectomy to prevent further destruction of platelets. An extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients.

One month of penicillin prophylaxis and influenza vaccine (choice A) is an inappropriate choice. Patients should remain on penicillin prophylaxis due to the continued risk of infection. Asplenic patients are susceptible to infection with encapsulated organisms including Pneumococcus and H. influenza, thus vaccination against influenza is unnecessary.

One month of prednisone with concomitant IVIG therapy (choice B) is not indicated at this point. This patient has already failed these therapies and her condition has improved after the splenectomy.

Permanent prednisone therapy and influenza vaccine (choice D) is an inappropriate choice. Permanent prednisone would act to chronically suppress this patient's immune system making her more susceptible to an infection. Once again, influenza vaccination is not warranted in asplenic patients.

Two weeks of prednisone therapy (choice E) is inappropriate at this point. As stated before, prednisone therapy has already failed and the patient has improved post splenectomy.

The correct answer is B. This patient has dilated cardiomyopathy, which in this case is most likely due to his heavy alcohol consumption. Ceasing alcohol consumption may reverse his disease or at least halt its progression. Other treatments include salt restriction, diuretics, ACE inhibitors, digitalis, and the consideration of anticoagulation to decrease the risk of embolization.

Cardiac catheterization will show decreased cardiac output, not increased cardiac output (choice A) because of systolic dysfunction.

Immediate cardiac transplantation (choice C) is usually only indicated for advanced disease that is refractory to medical therapy.

Spontaneous improvement occurs in 50% of patients with this disease (choice D) is incorrect. While most people with dilated cardiomyopathy suffer progressive heart failure and death, about 25% of patients have a spontaneous improvement or stabilization.

Because of systolic dysfunction and the development of mural thrombi, systemic embolization is a serious concern for patients with dilated cardiomyopathy and therefore anticoagulation is often recommended. Systemic embolization is not associated with his disease (choice E) is incorrect.

The correct answer is D. The United Stated Preventive Services Task Force (USPSTF) recommends that all women planning to become pregnant take a daily multivitamin supplement containing folic acid. It is recommended that they start taking it at least 1 month prior to conception and continue through the first trimester to reduce the risk of neural tube defects. According to the USPSTF, taking a daily multivitamin containing folic acid is also recommended for all women capable of becoming pregnant. This is to reduce the risk of neural tube defects in unplanned pregnancies.

A urine pregnancy test (choice A) is unnecessary at time because this patient's last menstrual period was only 10 days ago and she has not missed a period. It is very unlikely that she is pregnant at this time.

It is unnecessary to obtain chlamydial and gonorrheal cultures (choice B) because this patient is asymptomatic and is not considered at high risk for these infections. The USPSTF recommends that the routine screening of asymptomatic persons for these infections should typically be limited to sexually active adolescents and people that fall into high-risk groups, including those with a prior sexually transmitted disease, multiple partners, inconsistent barrier contraception usage, being unmarried, and being under 25 years of age. High-risk pregnant women should be screened. They say that the routine screening of asymptomatic adults for chlamydia and gonorrhea is not recommended.

The USPSTF concludes that there is insufficient evidence to recommend for or against routine clinical breast examinations (choice C) alone to screen for breast cancer. They recommend screening mammography, with or without clinical breast examination, every 1–2 years for women aged 40 and older. According to these guidelines, this asymptomatic 30-year-old woman does not need a CBE at this time.

The USPSTF recommends that pregnant women be tested for hepatitis B surface antigen (choice E) at their first prenatal visit. Since she is most likely not pregnant yet (her last menstrual period was 10 days ago), this test is unnecessary at this time.

The correct answer is D. Abnormal liver function is one of the main side effects associated with HMG-CoA reductase inhibitors, which are one of the most common classes of drugs prescribed for elevated cholesterol. While this side effect is relatively uncommon (1-2%), it can be very serious. It is important to monitor cholesterol and liver function tests at 6 weeks and 12 weeks after the initiation of therapy or when the dosage is increased, and then every 4-6 months.

It is important to order liver function tests and to remind her to call you if she develops any side effects from the medication, before you let her go pick up her children (choice A).

There is no apparent reason to measure uric acid levels (choice B) in this patient at this time. Niacin, not HMG CoA reductase inhibitors, is associated with elevated uric acid levels. Even though this patient has a history of gout, she does not have symptoms now and she is specifically at the office for a follow-up examination after starting lovastatin.

Myositis is one of the other side effects of HMG CoA reductase inhibitors, but this too is relatively uncommon. Myositis occurs more frequently when combined with other cholesterol lowering agents. Discontinuation of the medication is important if these symptoms occur because rhabdomyolysis with renal failure and death can occur. The routine measurement of creatine kinase levels (choice C) is not recommended. It is usually done when patients complain of muscle aches and cramps.

While it is important to remind her to call you if she develops any side effects from the medication (choice E), such as muscle aches, you first need to order liver function tests.

The correct answer is B. It is important to realize that a pelvic examination is an uncomfortable procedure for women to go through, and the position may make them feel nervous, embarrassed, and helpless. Helping women to relax and feel comfortable makes the whole experience easier for both the physician and the patient. The best statement at this time is, "Please try to relax as much as you can. I know that is easier said than done." It may help her relax, and also make her realize that you understand that this is a difficult situation.

"How many times have you and your boyfriend had sexual intercourse?" (choice A) is not a relevant question, because no matter what the answer is, it will not change your management. Also, you need to recognize that her "clenched teeth" probably means that she is nervous, and needs reassurance at this time.

"Relax! This is not going to hurt." (choice C) is almost like a command, and it may make her even more nervous. "Please try to relax as much as you can. I know that is easier said than done," is a much better way to get a similar message across.

"Why are you clenching your teeth? I'm not going to hurt you," (choice D) is inappropriate because it may make her even more nervous. Also, "why" questions like this one have the possibility of making the patient defensive and uncomfortable.

"Why are you so nervous? You've already had sex so this shouldn't hurt." (choice E) is completely inappropriate, because you should realize that a pelvic examination is an uncomfortable situation, especially the first one, and your main goal at this time should be to help her relax. Also, the second part, "You've already had sex so this shouldn't hurt," is a terrible thing to say, because you may think that you are being friendly or funny, but your job is to be a professional, and not make inappropriate statements. It seems a bit judgmental and may be seen as sexual harassment. Another point is that you do not know if this is going to hurt her, whether or not she has had sex already. It is best to avoid these types of statements all together, and say something that will help put her at ease.

The correct answer is C. The nephrotic syndrome is defined by a urinary protein level exceeding 3.5 g per 1.73 m2 of body-surface area per day. Diabetic nephropathy is the most common cause of nephrotic proteinuria. Five primary glomerular diseases account for the great majority of cases of the nephrotic syndrome in persons who do not have diabetes. In adults, the most common cause is membranous glomerulonephropathy. A common clinical triad of the nephrotic syndrome is hypertension, hyperlipidemia, and proteinuria. Although the exact mechanism whereby edema formation occurs in these patients is uncertain, the loss of urinary protein leads to total body edema formation. Regardless of the magnitude of the urinary protein loss, initiating ACE inhibitor therapy has been shown to be beneficial in terms of both decreasing the urinary protein content and prolonging survival.

Adding a loop diuretic (choice A) or increasing the thiazide dosage (choice B) fails to address the etiology of the edema. This patient has new onset edema and simply trying to manage the symptom by increasing an existing diuretic dosage or adding a second diuretic class agent fails to address the underlying etiology of this patient's edema.

There is no role for a high-protein diet (choice D) in managing these patients. Contrary to previously held opinions that the protein needed to be replaced by high-protein diets, it is now clear that such diets exacerbate kidney damage and accelerate protein loss. Low-protein diets are recommended for these patients.

There is no indication for hemodialysis (choice E) at this time. The five indications for HD are refractory hyperkalemia, volume overload, acidosis, uremia, or uremic pericarditis.

The correct answer is D. Gynecomastia (puberal hypertrophy) is very common in adolescents during puberty and is frequently asymmetric and tender. It is important to reassure this patient that it affects approximately 50–60% of adolescent boys at around Tanner stage III. It usually regresses before age 20. Surgery is rarely indicated. The open and closed comedones (also known as "blackheads" and "whitehead") are part of acne vulgaris, which is another common problem that affects adolescents.

Evaluation for liver disease (choice A) is unnecessary at this point because gynecomastia is very common during adolescence. He has no other signs of liver disease.

An ultrasound (choice B) is often used to distinguish cystic from solid masses. It is not indicated at this time in this case because this patient most likely has puberal hypertrophy of the breast (gynecomastia).

It is completely inappropriate to prescribe testosterone to give him a more "masculine" body-type (choice C) because testosterone often causes gynecomastia. Testosterone is converted to estradiol in extraglandular tissues and leads to feminization.

Fine needle aspiration (choice E) and mammography (choice F) are used to evaluate a dominant breast mass or possibly gynecomastia in a patient who is not going through puberty, has a negative drug history, or a rapidly growing, large (>4cm) mass. This patient's gynecomastia is most likely due to puberty, making further work-up too aggressive at this time.

The correct answer is A. Acne rosacea is a chronic inflammatory skin condition that has a predisposition to affect the central "flush" areas of the face, the central cheeks, nose, brow, and chin. This condition most frequently takes the form of flushing erythema which appears to be triggered by the consumption of alcohol, spicy food, or hot foods and beverages. Environmental factors that exacerbate flushing are sun exposure, heat, cold, and wind. The second main component to this disorder is acneiform papules and pustules, furuncles, and cysts. Treatment of rosacea includes avoiding exogenous factors, as mentioned above, and the use of a variety of topical and oral antibiotics. The most common topical antibiotic used by dermatologists is metronidazole gel, which is applied to affected areas twice a day. If the patient experiences moderate to severe inflammatory papules and pustules, the addition of an oral antibiotic is indicated, most commonly one in the tetracycline family.

Contact allergic dermatitis (choice B) is incorrect because usually contact dermatitis to makeup will result in generalized erythema over the surface that comes in contact with the culprit agent as well as numerous small, pinpoint vesicles. It is not usually exacerbated by foods, drinks, or the sun.

Cystic acne (choice C) is incorrect because the woman is described as having inflammatory papules and pustules, not deep-seated cysts. Also, cystic acne is usually not triggered by foods or drinks. Also, this is the classic description of acne rosacea.

Drug allergy to ibuprofen (choice D) is incorrect because drug allergies tend to involve the entire body, beginning at trunk then spreading to the extremities with the face being affected last.

Perioral dermatitis (choice E) is incorrect because perioral dermatitis is a discrete eruption consisting of grouped erythematous papules, vesicles, or pustules located around the mouth with marked sparing of the skin immediately surrounding the vermilion border. It often occurs on the nasolabial folds, on the chin, and around the eyelids.

The correct answer is B. This patient has Meniere's syndrome (endolymphatic hydrops). Meniere's syndrome is characterized but intermittent vertigo lasting about 1-8 hours with associated hearing loss, aural pressure, and tinnitus. Symptoms tend to wax and wane. It differs from benign positional vertigo in that the symptoms do not necessarily worsen with positional changes. In addition, positional vertigo doesn't have the same associated factors as Meniere's syndrome does. The treatment is a low salt diet and HCTZ. If the patient is resistant to medical therapy, surgery to decompress the endolymphatic sac can be a last resort.

Diazepam (choice A) is a useful treatment to ablate an acute episode of acute vertigo but is not a first line therapy for Meniere's syndrome.

Meclizine (choice C) is an antihistamine, which is useful in the management of less severe attacks of vertigo.

Scopolamine (choice D) is sometimes used in a transdermal preparation to be beneficial in the management of chronic vertigo. The anticholinergic side effects can limit its usefulness.

Physical therapy (choice E) is becoming more important in the management of vertigo. It is thought to help the enhance CNS ability to compensate for labyrinthine dysfunction. Recently, use of specific head maneuvers has been incorporated into the management of vertigo.

The correct answer is D. The mother has tuberculosis disease and the newborn has no evidence of infection or disease. According to the American Academy of Pediatrics and the Report of the Committee on Infectious Diseases, a newborn infant should be given prophylaxis with isoniazid if a recent contact has active disease. This is true even if they have a negative tuberculosis skin test (TST) and chest x-ray. The newborn should be reevaluated with a skin test in 3 months and if negative the isoniazid can be discontinued, but if positive the isoniazid should be continued for 6 more months (9 months total).

The American Academy of Pediatrics recommends that household contacts (younger than 4 years old) of patients with active disease should be treated if they have a negative skin test and chest x-ray. Doing nothing (choice A) and reevaluating the newborn in 3 months (choice E) are incorrect.

If the TST and the chest x-ray are negative and the patient is asymptomatic, it is unnecessary to obtain a sputum sample by bronchoscopy from the baby (choice B).

Isoniazid, rifampin, pyrazinamide, and ethambutol (choice C) are treatment for tuberculosis disease (positive TST, signs and symptoms of disease, and an abnormal chest x-ray and sputum). The newborn does not have the disease and should not be given all of these drugs.

The correct answer is B. IgA nephropathy, also called Berger disease, is a major cause of recurrent glomerular hematuria. The hematuria typically lasts for a few days, and then subsides, only to recur every few months. The total picture is that of a nephrotic syndrome, with hyperlipidemia, proteinuria, and hypoalbuminemia. Most patients have an initial benign course, but up to 50% develop chronic renal failure by 20 years.

Focal segmental glomerulosclerosis (choice A) is a rare cause of idiopathic glomerular disease, usually characterized by hypertension, hematuria, renal insufficiency, and nephrosis. Compared to Berger disease, this entity in its primary form is quite rare.

Membranoproliferative glomerulonephritis (choice C) exhibits a variety of presentations ranging from asymptomatic proteinuria to full nephrotic syndrome. The diagnosis should be suspected when renal disease is accompanied by low serum complement levels. Hepatitis C virus accounts for most of the cases of MPGN.

Rapidly progressive glomerulonephritis (choice D) presents with rapidly declining renal function, an active urinary sediment including RBC casts, as well as oliguria or anuria.

Systemic lupus erythematosus (choice E) may involve the kidney and can have a variety of renal presentations; from benign progressive azotemia to rapidly progressive nephritis. The kidneys are involved in nearly all cases of SLE, but rarely without involvement of other organs.

The correct answer is B. This patient most likely has conjunctivitis due to a bacterial infection. Conjunctivitis is a common condition in children that is usually bacterial or viral. Bacterial infections are usually purulent, while viral infections are not. Topical antibiotic therapy is typically given for bacterial infections. Conjunctivitis is contagious and it usually spreads by direct contact. Respiratory spread may occur. Children should be excluded from childcare settings until they are examined, given treatment if indicated, and approved for readmission.

It is incorrect to tell the mother that careful hand washing does not affect the spread of this condition (choice A) because the spread of infection is minimized by hand washing.

It is inappropriate to tell the mother that she should take her daughter for a CT scan before the appointment to rule out orbital cellulitis (choice C). A CT scan is used to evaluate a patient with suspected orbital cellulitis, which presents with proptosis, decreased visual acuity, and pain with movement. It is unlikely that the patient in this case has orbital cellulitis, and if the symptoms that the mother reported were consistent with orbital cellulitis, you would want to evaluate her before sending her for diagnostic studies.

Since the condition is most likely due to a self-limited virus, the appointment is for reassurance and not to administer therapy (choice D) is incorrect. The "thick yellow discharge" that the mother described is consistent with a bacterial infection, not a viral infection. The appointment is for evaluation and the administration of antibiotic therapy if indicated.

Topical corticosteroids are indicated if the patient has a herpetic dendritic ulcer (choice E) is incorrect. Corticosteroids are contraindicated in patients with a herpetic dendritic ulcer because they can worsen the condition. Individuals with a dendritic ulcer often have a painful, red eye, with visual blurring. Discharge may be present.

The correct answer is C. The history is typical of that for neurogenic claudication, which is caused by lumbar stenosis. The lower extremity weakness is also typical of bilateral L4/L5 radiculopathies. You would want to do an MRI to confirm the diagnosis and make sure that other pathology such as a spinal tumor was not responsible.

There is no reason to suspect brain pathology in this case (choice A). If there were cranial nerve or mental status abnormalities it should be considered.

His gait disorder is being caused primarily by pain, which is secondary to neurogenic claudication of the lumbar spine. He has known cervical spine problems, which may be contributing by impairing balance. It would also cause weakness of deltoids and biceps by C5 root compression. He may need a cervical spine MRI (choice B) at some point, but it is not primarily causing his walking troubles.

There is no indication for electromyography or nerve conduction (choice D) as the history and exam are sufficient to make this diagnosis. An MRI should be ordered to confirm the diagnosis and rule out other pathology.

An angiogram of the lower extremities might be indicated if you suspected vascular claudication (choice E). More commonly this would involve the calves and distal pulses would not be palpable.

The correct answer is D. When performing a complete pelvic examination, the Pap smear is the first specimen to collect to avoid contamination. Both endocervical and ectocervical specimens should be obtained during a Pap smear. However, the ectocervix should be sampled first, to avoid contamination with the endocervical cells, and therefore, get an accurate sample. Lubricant should not be used until after collecting cervical cells with a Pap smear.

A bimanual examination (choice A), should be performed after the Pap smear. This is to make sure that the Pap smear specimen is not contaminated by lubricants and cells, (or bacteria), from other areas.

If you are going to obtain chlamydia and gonococcal cultures, (choice B), it should be done after the Pap smear. This is to make sure that the Pap smear specimen is not contaminated by lubricants and cells, (or bacteria) from other areas. Routine screening for chlamydia in asymptomatic individuals is recommended for high risk women, and sexually active women, and adolescents age 25 and younger. As of 2001, the USPSTF makes no recommendation for or against the routine screening of asymptomatic low-risk women in the general population for chlamydial infection. Routine screening for gonorrhea in asymptomatic individuals is recommended for high risk women.

The endocervical specimen (choice C), should be obtained after the ectocervical specimen. When performing a Pap smear, it is important to obtain an accurate sample and to be certain as to exactly where the cells are taken from. If you obtain the endocervical cells first, there is a chance, that some of these cells will be deposited on the exocervix, and then when the ectocervical sample is taken, the endocervical cells, with be mixed with the ectocervical cells and the pathology reading will not be accurate, (as to the site).

A lubricant (choice E), should not be used on the Pap smear spatula. It may contaminate the specimen.

The correct answer is B. Constipation is a common problem in formula-fed infants, and it is best treated by increasing the amount of fluids in the diet, especially with fruit juices that contain sorbitol, such as prune and pear, which help to relieve constipation. It is often caused by a diet that is too low in fluids or deficient of bulk.

It is not recommended to give mineral oil (choice A) to infants because of the risk of aspiration and severe lipoid pneumonia.

Determining TSH levels (choice C) is not appropriate at this time because this is a common problem in formula-fed infants that is related to diet. Hypothyroidism is associated with constipation, however, newborns born in United States hospitals are routinely screened for this disorder, which can also lead to mental retardation. It is unlikely that she has hypothyroidism.

A barium enema (choice D), rectal manometry and a rectal biopsy (choice E) are all part of the evaluation of patients with suspected Hirschprung's disease, which is a lack of ganglion cells in the distal colon. It is very unlikely that this infant has this relatively rare (1 in 5000) disease that is often suspected if a newborn does not have stool in the first 24 hours of life. Infants with this disease often have a distended abdomen and a rectum that is devoid of stool. It is more likely that this formula-fed infant has diet-related constipation.

Reassurance (choice F) is incorrect in this case because formula-fed infants this age should be having 1-2 bowel movements a day. You can reassure him that this is very common and she will most likely be fine once they adjust her diet.

The correct is answer is C. A chest pain that is pleuritic and improves with sitting up and leaning forward is a classic description of the chest pain associated with pericarditis, as is the precordial rub auscultated on physical exam. Diffuse ST elevations with diffuse PR depressions and PR elevation in lead aVR is also the classic description of the EKG findings associated with pericarditis.

Angina (choice A) or myocardial infarction (choice B) are less likely given that the patient has no risk for coronary artery disease (hypertension, hyperlipidemia, diabetes, tobacco). He also describes a very active lifestyle without symptoms, suggestive of no cardiac pathology prior to the onset of these symptoms. The ST changes on EKG, that alone would suggest ischemia, become more consistent with pericarditis since they are associated with PR segment changes that are classically associated with this particular disease process.

Pneumonia (choice D) is unlikely since there is no history of cough or dyspnea, and there is no mention of findings on the chest exam consistent with such a process (e.g., findings suggesting a consolidative process such as decreased breath sounds, increased fremitus, and egophony over the affected area).

Pulmonary embolism (choice E) is less likely, given that there are no apparent risk factors such as a history of hypercoagulability or poor activity. The EKG findings are also not consistent with a pulmonary embolism, where one would classically see an S wave in lead I, Q wave and T wave inversion in lead III, or ST-T wave changes in leads V1 through V4.

The correct answer is B. This patient is presenting with symptoms of depression. However, major organ disease must be ruled out before the diagnosis is made. Laboratory studies should be ordered, including thyroid function tests, a biochemical profile, and a complete blood count. Diseases such as hypothyroidism, anemia, diabetes mellitus, and disorders of the kidney, liver, and cardiovascular systems are all associated with depressive symptoms.

Some patients say that taking St. John's Wort (SJW) and getting plenty of exercise and exposure to daylight (choice A) are helpful in treating depressive symptoms, but before you make any recommendations for his symptoms, he should be evaluated to rule out an organic disease. SJW is an herbal medication that inhibits the uptake of serotonin, dopamine, and norepinephrine. There is some clinical data to support its use for depression, but this is not widely accepted.

It is inappropriate to order a CT scan of the abdomen (choice C) to evaluate this patient's depressive symptoms because it is too expensive and most likely unnecessary. Pancreatic cancer has been associated with depression, but this patient does not have any other symptoms that are suggestive of pancreatic cancer (jaundice, pain, weight loss). Laboratory studies are appropriate at this time.

After laboratory studies rule out any abnormalities, it is appropriate to prescribe fluoxetine and ask him to return for a reexamination in 2 weeks (choice D). It is not the next step at this time.

Referral to a psychiatrist (choice E) may be necessary in the future, but at this time laboratory studies should be ordered and if they are all normal, a trial of antidepressant therapy should be started. If he does not respond or if you (and the patient) think that he may benefit from mental health care, he should be referred.