var killers_step2 = new Array( //1 "A 42-year-old woman presents to her physician because of recent urinary tract infections (UTIs). She has been on an unknown oral antibiotic chronically. She has a temperature of 99 F, and costovertebral angle tenderness is noted on the left side. A plain film of the abdomen reveals a radiopaque density filling the left renal pelvis and calyces. Which of the following is the most likely pathogen? $$Bacteroides fragilis%%Clostridium difficile^^Escherichia coli&&Proteus mirabilis##Streptococcus bovis", //2 "A 35-year-old woman has developed marked thickening of the skin of her hands, particularly her fingers. This thickening is accompanied by hyperpigmentation and is so marked as to limit the range of motion of her fingers. If this patient goes on to develop gastrointestinal problems, which of the following is most likely? $$ Carcinoid tumor%%Duodenal peptic ulcer^^Esophageal dysfunction&&Pneumatosis cystoides intestinalis##Sacculations of the colon", //3 "A 23-year-old man presents with a 3-month history of cough with blood-tinged sputum, shortness of breath, and gross hematuria. His temperature is 37.5 C (99.5 F), blood pressure is 158/94 mm Hg, pulse is 87/min, and respiratory rate is 22/min. Examination reveals bilateral crackles at the lung base and mild edema of the palpebrae and feet. A chest x-ray film shows scattered pulmonary infiltrates in a distribution different from that present on a film taken 2 months ago. Examination of the sputum shows hemosiderin-laden macrophages but no microorganisms. Laboratory investigations show modest iron-deficiency anemia and no evidence of ANCA-type antibodies. Urinalysis shows gross hematuria and modest proteinuria. A renal biopsy demonstrates the presence of glomerulonephritis with linear deposition of IgG and complement components along the glomerular basement membrane. Which of the following is the most likely diagnosis?$$Churg-Strauss syndrome%%Goodpasture syndrome^^Idiopathic pulmonary hemosiderosis&&Postinfectious glomerulonephritis##Wegener granulomatosis", //4 "A 67-year-old man comes to the physician because of insomnia, irritability, and palpitations for 3 months. He is currently taking amiodarone for cardiac arrhythmias, fluoxetine for depression, and enalapril for hypertension. His blood pressure is 130/70 mm Hg, and his pulse is 90/min and regular. Which of the following is the most appropriate next step?$$ Measurements of thyroxine and TSH%% Administration of propranolol^^ Referral for psychiatric consultation&& Substitution of antidepressant drug ## Substitution of antihypertensive drug", //5 "An unconscious 35-year-old man is brought to the emergency department by his wife. She explains that the patient takes phenytoin for chronic epilepsy. An hour ago, the patient had a seizure but did not regain consciousness. Physical examination reveals that his blood pressure is 92/40 mm Hg, temperature is 38.5 C (101.3 F), pulse is 110/min, and respiratory rate is 20/min. During the examination, the physician observes the sudden onset of tonic-clonic convulsions. Which of the following is the most common precipitating cause of this emergency?$$ Alcohol withdrawal%% Drug noncompliance^^ Head trauma&& Hypoxia## Intracranial infection", //6 "A 26-year-old librarian presents with chronic daytime somnolence, which has frequently caused him to fall asleep at work. He does not smoke but drinks 1-2 glasses of wine daily. He says he frequently awakens at night but denies any visual or auditory hallucinations on falling asleep. His height is 186 cm (73 in), and his weight is 60% greater than expected. Chest examination reveals no specific findings other than distant breath sounds. Arterial blood gas analysis during normal ventilation shows:
PaO282 mm Hg
PaCO255 mm Hg
After the patient voluntarily hyperventilates for 1 minute, blood gas analysis returns within normal limits. Which of the following will have the greatest benefit on this patient\'s symptoms?$$ Benzodiazepines at bedtime%% Daily acetazolamide^^ Morning administration of dextroamphetamine && Supplemental oxygen at night## Weight loss", //7 "A 35-year-old man with history of chronic heroin abuse comes to the physician because of progressive swelling of his feet and hands. His blood pressure is 155/90 mm Hg. Laboratory studies show:
Blood, serum
Creatinine 1.2 mg/dL
BUN 20 mg/dL
Urinalysis
Protein 3+
Erythrocytes 10/hpf
The amount of protein measured in a 24-hour urine collection is 4.5 g. Which of the following is the most likely diagnosis?$$ Acute proliferative glomerulonephritis%% Crescentic glomerulonephritis^^ Focal segmental glomerulosclerosis&& Minimal change disease## Nodular glomerulosclerosis (Kimmelstiel-Wilson disease)", //8 "A 61-year-old man presents for an elective surgical incision and drainage procedure. The patient has an 8-year history of hepatitis C infection with well-documented cirrhosis and portal hypertension. He has a large hematoma on his thigh that is suspected to have necrotic tissue underlying it and therefore requires debridement. On preoperative screening, his prothrombin time is noted to be 17.4 seconds. Transfusion of which of the following is the most appropriate next step in management of this patient prior to his procedure?$$ Cryoprecipitate%% Fresh frozen plasma^^ Packed red blood cells&& Platelets## Whole blood", //9 "A 55-year-old woman with long-standing diabetes mellitus and a 2-year history of progressive renal failure comes to medical attention because of chest pain for 12 hours. The pain is substernal and continuous, with radiation to the neck. She is on a strict dietary regimen with protein, fluid, and salt restriction. Her temperature is 37.2 C (99 F), blood pressure is 150/85 mm Hg, pulse is 82/min and regular, and respirations are 16/min. There is no jugular vein distention or pitting edema. Auscultation reveals a rubbing sound in the precordial region and slightly distant but normal heart sounds. Lungs are clear to auscultation. The patient is admitted, and laboratory studies show:
Hematocrit 33%
Hemoglobin 11.2 g/dL
Leukocyte count 12,500/mm3
Serum
Urea nitrogen 102 mg/dL
Glucose 128 mg/dL
Na 142 mEq/L
K 5.3 mEq/L
Cl 103 mEq/L
Arterial blood
pH 7.38
PO2 92 mm Hg
PCO2 39 mm Hg
chest x-ray film shows a normal cardiac outline, and an electrocardiogram shows nonspecific ST changes. Echocardiogram reveals mild fluid collection within the pericardial sac. Which of the following is the most appropriate next step in management?$$ Water and salt intake reduction%% Antibiotic treatment^^ Antihypertensive treatment&& Anti-inflammatory treatment##Hemodialysis", //10 "A 26-year-old black gravida 2, para 1, at 32 weeks\' gestation presents to the physician for a prenatal visit. Her prenatal course has been remarkable for hyperemesis gravidarum in the first trimester. She also had a urine culture in the first trimester that grew out Group B Streptococcus. She has had type 1 diabetes for the past 2 years and has had good control of her blood glucose levels during this pregnancy. Her first pregnancy resulted in a low transverse cesarean section for dystocia. Other than insulin, she takes no medicines and has no known drug allergies. After a routine prenatal visit, the physician sends her to the antepartum fetal testing unit to undergo a nonstress test (NST). Which of the following characteristics makes this patient a good candidate for antepartum fetal testing with an NST?$$ Black race%% Diabetes mellitus^^ Group B Streptococcus urine culture&& History of cesarean section## Hyperemesis gravidarum", //11 "A 19-year-old gravida 2, para 1 woman presents at her first prenatal visit complaining of a rash, hair loss, and spots on her tongue. Her temperature is 37 C (98.6 F), blood pressure is 112/74 mm Hg, pulse is 68/min, and respirations are 14/min. Physical examination is significant for a maculopapular rash on her trunk and extremities, including her palms and soles. She has \"moth-eaten\" alopecia and white patches on her tongue. Her uterus is 10-week size, which is consistent with her dating by last menstrual period. The rest of her examination is unremarkable. RPR and MHA-TP are positive. Which of the following is the most appropriate pharmacotherapy?$$ Clindamycin%% Gentamicin^^ Nitrofurantoin&& Penicillin## Tetracycline", //12 "A 34-year-old woman with breast cancer presents to her physician complaining of increased weakness, lower back pain, and urinary incontinence. She was diagnosed with breast cancer 2 years ago and is undergoing radiation and chemotherapy. Her back pain developed 2 days ago. Physical examination shows lower extremity weakness and hyporeflexia. Which of the following is the most appropriate next step in this patient\'s care?$$ Obtain a neurologic consultation%% Obtain an emergency spinal MRI^^ Administer narcotics for pain relief&& Administer high-dose steroids## Perform a lumbar puncture", //13 "An otherwise healthy, 65-year-old woman comes to the physician because of bloody discharge from the right nipple for 2 weeks. On examination, no retraction, erosion, or other abnormal change is present. Palpation reveals an ill-defined, 1-cm nodule located deep in the right areola. Which of the following is the most appropriate next step in diagnosis?$$ Cytologic examination of nipple discharge%% Mammography alone^^ Ultrasonography&& Biopsy under mammographic localization## Mammography followed by fine-needle cytology", //14 "A 34-year-old woman, gravida 3, para 2, at 16 weeks\' gestation comes to the physician concerned that she may have been exposed to an infectious disease. Yesterday, she and her 5-year-old son spent a day at the beach with one of his classmates. This morning, the classmate was sent home from school with a fever and rash that the teacher thought was suspicious for chickenpox. The patient is unsure whether she had chickenpox as a child. Her temperature is 37 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 88/min, and respirations are 16/min. Her examination is unremarkable. An inquiry made by the physician confirms that the classmate has chickenpox. Which of the following is the most appropriate next step in management?$$ Check an IgG varicella serology%% Wait to see whether a rash develops^^ Administer IV acyclovir&& Administer oral acyclovir## Administer varicella vaccine", //15 "A 26-year-old primigravid woman at 10-weeks\' gestation comes to the physician for a routine prenatal appointment. Her dating is based on a 6-week ultrasound. She has sickle-cell anemia. She has no past surgical history, takes prenatal vitamins, and has no known drug allergies. She tells the physician that she recently learned that the father of the baby has sickle-cell trait. On examination, her uterus is appropriate for a 10-week gestation and fetal heart tones are heard. Her hematocrit is 37%. What is the most appropriate next step in the management of this patient?$$ Genetic counseling%% Obstetric ultrasound^^ Hydroxyurea&& IV hydration## Blood transfusion", //16 "A 23-year-old woman, gravida 1, para 0, at 25 weeks\' gestation comes to the physician because of right upper quadrant pain, nausea and vomiting, and malaise for the past 2 days. Her temperature is 37 C (98.6 F), blood pressure is 104/72 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals right upper quadrant tenderness to palpation. The cervix is long, closed, and posterior. There is generalized edema. Laboratory values are as follows:
Leukocyte count 10,500/mm3
Platelet count 62,000/mm3
Hematocrit 26%
Sodium 140 mEq/L
Chloride 100 mEq/L
Potassium 4.5 mEq/L
Bicarbonate 26 mEq/L
peripheral blood smear reveals hemolysis. Which of the following laboratory findings would be most likely in this patient?$$ Decreased fibrin split products%% Decreased lactate dehydrogenase^^ Elevated AST&& Elevated fibrinogen## Elevated glucose", //17 "A 17-year-old woman, gravida 1, para 0, at 38 weeks\' gestation comes to the labor and delivery ward because of contractions. Her dating was determined by a 7-week ultrasound. Her prenatal course was complicated by gestational diabetes. Her past surgical history is significant for shoulder surgery. She takes insulin and prenatal vitamins. She has no known drug allergies. She smokes 3-4 cigarettes per day. She is initially found to be 4 cm dilated and is contracting every 2-3 minutes. She is admitted to the labor and delivery ward and, over the next 4 hours, progresses to full dilation. After pushing for 2 hours, she delivers the fetal head but has great difficulty delivering the fetal shoulders. Eventually, the fetus is delivered by the posterior arm. In the process of delivery the newborn\'s humerus is fractured. Which of the following factors contributed the most to the difficult delivery of the fetus?$$ Cigarette smoking%% Gestational age^^ Gestational diabetes&& Maternal age## Maternal shoulder surgery", //18 "A 1-year old child is brought in for a well check-up. His parents report that he has been of good health and began walking a few weeks earlier. They are concerned that he tends to bump into things and falls more than his older sister did. Family history is significant for retinoblastoma. On examination, the pediatrician notes leukocoria of the left eye. No significant lymphadenopathy is present, and there is no enlargement of the liver or spleen. The child\'s height and weight are normal for age. Which of the following is the most appropriate next step in management?$$ Explain to parents what leukocoria is and reassure them that it is temporary%% Return visit in 1 month ^^ Refer to neurologist && Refer to ophthalmologist## Treat the eye with erythromycin ophthalmic ointment for 10 days", //19 "A 4-day-old female infant presents to the emergency department with vomiting and abdominal distention. The mother states that the vomitus was green in color. The infant also has had difficulty feeding and has been hard to console. The mother had an uncomplicated pregnancy. The infant passed meconium within 12 hours after birth. She also had several small, seedy, yellowish stools each day since birth. On physical examination, she is very irritable. Her anterior fontanel is slightly depressed. Her abdomen is distended. Which of the following is the most likely diagnosis?$$ Allergic reaction to formula%% Gastroesophageal reflux disease^^ Hirschsprung disease&& Meconium ileus## Midgut volvulus", //20 "A 24-year-old, unemployed man is brought to the hospital by police after he was found sleeping on chairs at a departure gate in the airport. When awakened by the police and asked to leave the premises, the man insisted that he be allowed to stay in that specific location, since he was able to pick up on \"special radiowave signals\" emanating from that airline\'s planes arriving between 1 PM and 3 PM. He spoke of being part of a secret mission with spies from an unidentified foreign country and stated that he was concerned that the police were working with his enemy. The police were able to calmly bring the man into the nearest psychiatric emergency department, where he was evaluated. He was taking no medications at the time, and a urine toxicology screen was negative. Which abnormality is most consistently seen in CT scans of the brains of persons who have the disorder suggested by the history and findings?$$ Atrophic changes in the cerebellar vermis%% Bilateral hypodensities in the orbitofrontal region^^ Hydrocephalus&& Increased ventricle-to-brain ratio## Significant sulcal widening", //21 "A 59-year-old woman is brought to a psychiatrist because her family has been worried about her worsening behavior. The family reports prominent changes in personality and in the way in which she has recently been relating to others. They report that she has recently become sexually provocative in her attire and demeanor, she does not know how to hold socially appropriate conversations anymore, and she lacks the insight that she once had. She has a new grandchild and has recently become indifferent to him, and occasionally sits still, stares ahead, and seems mute. She is found to have mild memory and cognitive dysfunction, perseveration, and an inability to plan and organize. She has a positive glabellar sign. This patient most likely has dysfunction of which of the following regions of the brain?$$ Basal ganglia%% Frontal lobe^^ Hypothalamus&& Temporal lobe## Ventricular obstruction", //22 "A 34-year-old Caucasian woman presents to the emergency department with thoughts of suicide. She states that she was feeling \"fine\" until a week ago, when she began to feel very depressed. In addition, she states that she has not slept very much in the past few days and she has been experiencing rapidly shifting extremes of mood, one day feeling \"on top of the world\" and the next feeling \"tired and down in the dumps.\" She claims that she has thoughts of jumping in front of a train to kill herself. When asked about illicit drug use, she becomes rather indignant, stating that she is being accused of being a drug addict. A urine drug screen is positive for cocaine metabolites. Which of the following is the most likely diagnosis?$$ Bipolar disorder, manic%% Dysthymic disorder^^ Histrionic personality disorder&& Major depressive disorder## Substance-induced mood disorder", //23 "A 24-year-old woman develops moderate, generalized abdominal pain of sudden onset and shortly thereafter faints. At the time of evaluation in the emergency department, she has regained consciousness, is pale, and has a blood pressure of 95/70 mm Hg and a faint pulse rate of 90/min. The abdomen is mildly distended and tender, with normal bowel sounds. Her hemoglobin is 7 g/dL. There is no history of trauma, but it is suspected that she might be bleeding into her abdomen, and a diagnostic peritoneal lavage is performed. The study shows that there is free blood in the peritoneal cavity. She denies the possibility of pregnancy because she has been on birth control pills since the age of 14 and has never missed taking them. Pelvic examination is normal, and a pregnancy test is negative. At laparotomy, the surgeons are likely to find which of the following?$$ Bleeding ovarian follicle%% Ruptured abdominal aortic aneurysm^^ Ruptured ectopic pregnancy&& Ruptured hepatic adenoma## Ruptured hepatic artery aneurysm", //24 "A 56 year-old man presents to his urologist for continued evaluation of hypertension and hematuria. The patient has a 10-year history of hypertension and recent onset of painless hematuria for which he sought the attention of an urologist 3 months ago. The patient also has a long-standing history of hypertension for which he has been treated with multiple medications, all with minimal benefit. On detailed questioning, the man states that he has been having severe headaches that are refractory to narcotic analgesics. Three days ago, a renal ultrasound was obtained that demonstrated bilaterally enlarged kidneys with multiple cysts. Which of the following is the most appropriate next step in diagnosis?$$ CT scan of the pelvis%% CT scan of the thorax^^ MRI of the brain&& Intravenous pyelography (IVP) ## Magnetic resonance angiogram (MRA) of the brain", //25 "A 53-year-old man is brought to the emergency department by his wife because of headache and visual changes. Approximately 3 hours ago, he had the acute onset of an extremely severe posterior headache that was non-radiating but was associated with nausea and vomiting. This headache subsided, but over the past hour he has developed mild neck stiffness and pain on flexion of his neck. The patient is not cooperative, so no additional history is known; however, his wife states that he was feeling well until recently and has no allergies. The patient appears moderately uncomfortable and is complaining of the worst headache he has ever experienced. Which of the following is the most likely cause for his symptoms?$$ Arteriovenous malformation%% Cerebellar bleed^^ Putamenal bleed&& Ruptured berry aneurysm## Thalamic bleed"); var answers_step2 = new Array('D','C','B', 'A', 'B', 'E', 'C', 'B', 'E', 'B', 'D', 'D', 'E', 'A', 'A', 'C', 'C', 'D', 'E', 'D', 'B', 'E', 'D', 'D', 'D'); var description_step2 = new Array( //1 "The correct answer is D. The patient is experiencing recurrent UTIs associated with the presence of kidney stones (the radiopaque density in the renal pelvis and calyces). Urease-producing organisms, such as Proteus mirabilis, create a high urinary pH, contributing to the development of struvite kidney stones. The stone may cause obstruction and urinary stress, leading to infection. These stones are relatively soft and are usually amenable to percutaneous nephrostomy. Acetohydroxamic acid is an effective urease inhibitor. Pseudomonas and Providencia are less common urease-producing organisms that may cause struvite calculi. Bacteroides fragilis (choice A) is associated with peritonitis in patients with an intra-abdominal abscess

.Clostridium difficile (choice B) is associated with pseudomembranous colitis.

Escherichia coli (choice C) is the most common cause of UTI.

Streptococcus bovis (choice E) is a nonenterococcal type of group D streptococcus.", //2 "The correct answer is C. The changes seen are those of scleroderma; if other organs become involved, the term systemic sclerosis is appropriate. This disease is characterized by diffuse fibrosis, degenerative changes, and vascular abnormalities. The most common significant internal involvement in these patients is esophageal dysfunction (which may predispose for reflux disease with risk of Barrett\'s esophagus and cancer of the esophagus), which occurs as a result of replacement of the muscle of the esophagus by densely fibrotic, scar-like tissue. Other gastrointestinal complications include pneumatosis cystoides intestinalis (see below), sacculations of the colon and ileum (see below), biliary cirrhosis, and malabsorption secondary to bacterial overgrowth in the poorly functional small bowel.

Carcinoid tumor (choice A) does not have an increased incidence in systemic sclerosis.

Duodenal peptic ulcer (choice B) does not have an increased incidence in systemic sclerosis, although esophageal peptic ulcer, secondary to reflux problems, does.

Pneumatosis cystoides intestinalis (choice D) is an uncommon intestinal complication of systemic sclerosis in which degeneration of the muscularis mucosa allows the entry of air into the intestinal wall.

Sacculations of the colon (choice E) and ileum are broad outpouchings (very fat diverticula) that can sometimes complicate systemic sclerosis as a result of smooth muscle atrophy. ", //3 "The correct answer is B. Goodpasture syndrome is an autoimmune disease mediated by autoantibodies against a domain of type IV collagen in the basement membranes of both glomerular capillaries and alveolar capillaries. Consequently, the lungs develop hemorrhagic interstitial pneumonia manifesting with hemoptysis, whereas the kidneys develop necrotizing glomerulonephritis leading to nephritic syndrome (responsible for hematuria, pitting edema, and hypertension in this case). Linear deposition of IgG and complement along the basement membrane of the alveolar and glomerular capillaries is the pathognomonic feature. The latter alone is sufficient to support a diagnosis of Goodpasture syndrome. Corticosteroids and immunosuppressants are necessary to treat this serious condition. Churg-Strauss syndrome (choice A) must be considered in the differential diagnosis. This condition is associated with blood and tissue eosinophilia and, frequently, with circulating ANCA, ie, antineutrophil cytoplasmic antibodies (specifically p-ANCA).

Idiopathic pulmonary hemosiderosis (choice C) may appear similar to Goodpasture syndrome in its pulmonary manifestations-hemoptysis and pulmonary infiltrates-but this condition does not involve the kidneys nor is it associated with linear IgG deposition along basement membranes.

Postinfectious glomerulonephritis (choice D) most commonly follows a streptococcal infection and manifests with nephritic syndrome.

Pulmonary manifestations are not present. Immunofluorescence of kidney biopsies reveals granular deposition of IgG and complement in the mesangium and glomerular basement membrane.

Wegener granulomatosis (choice E) enters the differential diagnosis of any condition manifesting with concomitant involvement of lungs and kidneys. It is characterized by a necrotizing granulomatous vasculitis and frequent presence of circulating c-ANCA.", //4 "The correct answer is A. Insomnia, irritability, and palpitations are nonspecific symptoms that may be caused by a variety of diseases and drugs, but they are frequent manifestations of hyperthyroidism. Furthermore, the fact that the patient takes amiodarone should prompt investigations for hyperthyroidism. Amiodarone causes symptomatic hyperthyroidism in a small percentage of patients (2% to 3%) and asymptomatic elevation of T3 and T4 with much greater frequency. Thus, thyroid hormone measurements should be combined with measurement of TSH, which is suppressed in the presence of significant thyroid hyperfunction.Administration of propranolol (choice B) is effective in relieving symptoms of hyperthyroidism due to abnormal sympathetic activation, namely tachycardia, excessive sweating, anxiety, and tremor. It should be used for temporary relief until hyperthyroidism has resolved, but is not adequate treatment in this case. Amiodarone withdrawal is the most appropriate option if hyperthyroidism is confirmed.

Referral for psychiatric consultation (choice C) implies that the symptoms are due to an underlying psychiatric etiology, which is a plausible explanation in a patient with history of depression. However, hyperthyroidism should be ruled out first.

Substitution of a different antidepressant drug (choice D) would be justified if the symptoms were due to fluoxetine administration. Treatment with fluoxetine, as well as other serotonin-selective reuptake inhibitors (SSRI), may cause insomnia and nervousness. Again, amiodarone-related hyperthyroidism should be ruled out before attributing the symptoms to the SSRI side effects.

Substitution of a different antihypertensive drug (choice E) would not be justified in this case. Enalapril, as any other angiotensin-converting enzyme (ACE) inhibitors, is a remarkably safe drug with few and rare adverse effects. Hypotension is one of these, but the patient in this example has a blood pressure within a fairly normal range.", //5 "The correct answer is B. Status epilepticus is a life-threatening emergency that should be treated promptly. It is diagnosed when a generalized convulsive seizure lasts longer than 10 minutes or when a seizure episode is followed by another episode without recovery of consciousness. There are two types of status epilepticus, convulsive and nonconvulsive. The convulsive type is the most dangerous. It can lead to metabolic and cardiovascular disturbances, including hypoxemia, hypoglycemia, hypotension, and hyperthermia, that may cause death or permanent brain damage. About 50% of patients presenting with status epilepticus do not have history of epilepsy. The most frequent precipitating factor in adults with a diagnosis of epilepsy is drug noncompliance. Alcohol withdrawal (choice A), head trauma (choice C), hypoxia (choice D), intracranial infection are other precipitating factors for status epilepticus. Of these, infection is the most common in childhood.", //6 "The correct answer is E. The clinical picture and results of blood gas analysis before and after hyperventilation are characteristic of obesity-hypoventilation syndrome (also known as Pickwickian syndrome, after a character in Charles Dickens\' The Pickwick Papers). Hypoventilation results from a combination of reduced drive on respiratory centers and physical impediment on respiration imposed by obesity. Improvement of hypoxemia and hypercapnia following voluntary hyperventilation differentiates this condition from chronic obstructive pulmonary disease. Most patients with Pickwickian syndrome also have obstructive sleep apnea and consequent daytime sleepiness. Weight loss is the single most effective therapeutic intervention.

Benzodiazepines at bedtime (choice A) are contraindicated, as are any other hypnotic agents. Alcohol should also be avoided.

Treatment with daily acetazolamide (choice B) has been tried in obstructive sleep apnea but with disappointing results.

Morning administration of dextroamphetamine (choice C) is used for the treatment of narcolepsy. This disease is hereditary and manifests with sudden sleep attacks, cataplexy (abrupt loss of muscle tone), and hypnagogic hallucinations. None of these symptoms are present in this case.

Supplemental oxygen at night (choice D) has been found to have some benefit in reducing the severity of nocturnal episodes of hypoxemia in obstructive sleep apnea, but it may also increase the duration of apneic episodes.", //7 "The correct answer is C. The clinical presentation is consistent with nephrotic syndrome, since proteinuria is within a nephrotic range, ie, >3 g/day. The history of heroin abuse makes focal segmental glomerulosclerosis (FSG) the most likely diagnosis. FSG may occur in idiopathic form or in association with three conditions: morbid obesity, HIV infection, and heroin abuse. A renal biopsy will reveal sclerosis occurring in some, but not all, glomeruli (focal), with each glomerulus showing partial involvement (segmental). Electron microscopy shows detachment of epithelial podocytes from the glomerular basement membrane, an alteration also seen in minimal change disease. Note in this clinical case, the coexistence of nephrotic features (marked proteinuria and edema) with nephritic signs (hypertension and microhematuria), which is often present in FSG.

Acute proliferative glomerulonephritis (choice A) is characterized by proliferation of endothelial and mesangial cells with influx of leukocytes. The glomeruli are hypercellular, and immune deposits are epimembranous in location. This pattern is associated with nephritic syndrome, ie, proteinuria < 3 g/day, hematuria, hypertension, pedal and periorbital edema. The prototype of this glomerular disease is postinfectious glomerulonephritis.

Crescentic glomerulonephritis (choice B) owes its designation to the crescent-shaped masses of cells (epithelial and inflammatory) that accumulate within the urinary space of Bowman capsule, obliterating the glomerular tuft. This results in a rapidly progressive renal failure, requiring aggressive immunosuppressive therapy.

Minimal change disease (choice D) is a mostly a disease of childhood. It manifests with full-blown nephrotic syndrome. On light microscopy, the glomeruli appear normal, only to reveal detachment of epithelial podocytes on electron microscopy.

Nodular glomerulosclerosis (Kimmelstiel-Wilson disease; choice E), is pathognomonic of diabetic nephropathy. Round PAS-positive (ie, glycoprotein-rich) globules are seen within the glomeruli. This feature, along with diffuse mesangial sclerosis due to accumulation of altered glycoproteins of plasma origin, constitutes the pathologic substrate of diabetes-related renal dysfunction.", //8 "The correct answer is B. A basic understanding of blood product and blood component replacement is crucial. The use of such products is extremely common, and there is misuse. Patients with liver disease have a deficiency of one or more clotting factors produced by the liver. A blood product that specifically raises such factors is indicated for treatment. Fresh frozen plasma (FFP) generally increases plasma anticoagulation factors by 30%. Like all blood products it is type specific. There is a correlation for prothrombin times greater than 15 and the risk of bleeding with invasive procedures such as paracentesis. For this reason, FFP is usually indicated in such patients prior to undergoing their procedure. Cryoprecipitate (choice A) is prepared from FFP and contains concentrated factor VIII, factor XIII, fibrinogen, and von Willebrand\'s factor. Indications for use are hypofibrinogenemia (DIC), von Willebrand\'s disease, and hemophilia A.

Packed red blood cells (choice C) are prepared from all the red cell mass in a pint of donated blood.

It has no plasma or buffy coat and therefore no proteins (coagulation factors) or platelets. It is used to restore red cell mass.

Platelets (choice D) are a blood component therapy used to restore platelet count. One unit of platelets increases the platelet count by 5000-10,000 cells/mm3, assuming no ongoing destruction or sequestration. Platelets are usually transfused as a \"six-pack.\" Each unit is the product of one unit donated whole blood; thus, a \"six-pack\" represents pooled platelets from multiple donors.

Transfusion of whole blood (choice E) is not a current practice. Whole blood is the content of 1 pint of donated blood. It is unfiltered and contains plasma, platelets, white cells, and red cells. This product is usually processed so that each of these components are removed (except white cells) and used for transfusions in specific clinical situations. ", //9 "The correct answer is E. A friction rub on auscultation indicates that the patient\'s chest pain is due to acute fibrinous pericarditis. Electrocardiographic changes in this condition are often nonspecific, but echocardiography is a sensitive diagnostic tool. Renal failure is one of the most common causes of acute pericarditis (uremic pericarditis), which usually occurs when BUN exceeds 100 mg/dL (often earlier in diabetic patients). Fever is usually absent in uremic pericarditis. Institution of hemodialysis (or more aggressive hemodialysis) promptly leads to resolution of pericarditis. Indeed, the onset of acute pericarditis is an absolute indication to start hemodialysis treatment.

Further reduction of water and salt intake (choice A) would not be sufficient to treat uremic pericarditis and might be counterproductive in this specific case.

Antibiotic treatment (choice B) is useful in cases of infective (purulent) pericarditis, but uremic pericarditis is the result of circulating toxins, not infection.

Antihypertensive treatment (choice C) is often necessary in renal failure but has no effect on uremic pericarditis. In this case, the blood pressure is within \"borderline\" values.

Anti-inflammatory treatment (choice D) is helpful in reducing symptoms but does not affect the natural course of the process. Indomethacin or corticosteroids may be used.

Erythropoietin administration (choice E) is used to treat anemia of renal failure. It is usually started when hematocrit falls below 30% to 35%. Pericardial biopsy (choice H) is advisable when the etiology is not clear, which is not the case in the presence of an obvious clinical picture of renal failure.

Partial pericardiectomy (\"pericardial window\"; choice I) and pericardiocentesis (choice G) are used to treat pericardial tamponade, which is an accumulation of large amounts of pericardial fluid (inflammatory or hemorrhagic) that impairs diastolic filling and causes acute heart failure. In this case, the amount of exudate within the pericardium and the hemodynamic conditions do not warrant such therapy.", //10 "The correct answer is B. Women with diabetes mellitus are at increased risk for sudden intrauterine death. In the past, antepartum fetal death occurred in as many as 20% to 30% of patients with type 1 (insulin requiring) diabetes. Now, with improved maternal care and fetal surveillance, sudden intrauterine death is rare. Fetal surveillance usually begins at 28-32 weeks\' gestation and consists of twice weekly nonstress tests (NST) until the mother delivers. An NST is reactive if there are two accelerations of the fetal heart rate (an increase of 15/min for 15 seconds) in 20 minutes. If the NST is not reactive, uteroacoustic stimulation should be performed, followed by a contraction stress test or biophysical profile. Management would then be based on the outcome of those tests.

Many obstetric outcomes vary according to race. However, black race (choice A) would not be an indication for antepartum fetal testing. In this patient, her diabetes mellitus makes her a candidate for such testing, not her race.

A urine culture positive for Group B Streptococcus (choice C) is an indication for antibiotic prophylaxis during labor and delivery to prevent GBS invasive disease in the newborn. A positive GBS urine culture is not an indication for antepartum fetal testing.

History of cesarean section (choice D) is an important aspect of the patient\'s past obstetric history. However, in the absence of diabetes mellitus, a prior c-section is not an indication for antepartum fetal testing.

Hyperemesis gravidarum (choice E) is a condition of pregnancy characterized by persistent nausea and vomiting. It is most often limited to the first trimester and usually resolves by 16 weeks\' gestation. Although hyperemesis gravidarum can be a difficult condition for the patient, it is not an indication for antepartum fetal testing.", //11 "The correct answer is D. This patient has syphilis, a disease caused by Treponema pallidum, a spirochete, as evidenced by the positive rapid plasma reagin (RPR) test and microhemagglutination assay for antibodies to T. pallidum (MHA-TP). Primary syphilis is characterized by a painless ulcer, called a chancre, typically found on the vagina or cervix. Untreated primary syphilis can progress to secondary syphilis, which is characterized by \"moth-eaten\" alopecia, a maculopapular skin rash involving the palms and soles, and white patches on the tongue. Tertiary syphilis is characterized by gumma formation, cardiac lesions, and CNS abnormalities. Syphilis in pregnancy is associated with increased rates of preterm delivery, intrauterine growth retardation, and fetal demise. However, the most devastating complication of syphilis in pregnancy is congenital infection of the fetus, which can lead to severe effects on fetal morbidity and mortality. The key to preventing congenital infection is adequate treatment of the mother. The drug of choice for syphilis is penicillin. Clindamycin (choice A) is effective for some gram-positive and anaerobic infections. It does not treat syphilis and would not be indicated for this patient.

Gentamicin (choice B) is mostly used for gram-negative infections. It does not treat syphilis and would not be indicated.

Nitrofurantoin (choice C) is often used in pregnancy to treat urinary tract infections. However, it does not treat syphilis and therefore would not be indicated for this patient.

Tetracycline (choice E) should not be used in pregnancy, as it is known to cause discoloration of deciduous teeth and it can be deposited into fetal long bones. It is considered a second-line treatment of syphilis in the nonpregnant patient. ", //12 "The correct answer is D. This patient probably has breast cancer metastases to the spine and is in danger of spinal cord compression, which is an emergency. It is essential to administer steroids immediately to help decrease the swelling and relieve some compression. She might ultimately need surgical intervention or radiation. A neurologic consultation (choice A) will help localize the lesion; however, this is an emergency and must be treated immediately.

An MRI (choice B) will localize the lesion but should not delay emergent intervention. Narcotics (choice C) would provide only symptomatic relief. A lumbar puncture (choice E) might reveal malignant cells on cytologic evaluation but would not contribute to her immediate management.", //13 "The correct answer is E. Nipple discharge in the nonlactating breast may be the presenting sign of a number of diseases, the most common of which are intraductal papilloma, carcinoma, and fibrocystic changes. Carcinoma is more likely in women older than 50. Regardless of whether this sign is present, a clinically malignant palpable mass in a postmenopausal woman should be investigated with mammography followed by fine-needle cytology (or excisional biopsy). The features suspicious for malignancy in this case include ill-defined margins of the mass and the hemorrhagic nature of the discharge.

Cytologic examination of nipple discharge (choice A) may reveal malignant cells but is associated too frequently with false negative results to be reliable. Mammography alone (choice B) is adequate if the breast mass appears benign on clinical grounds. Biopsy or fine-needle aspiration may then be carried out depending on the mammographic findings.

Ultrasonography (choice C) is mainly used to differentiate between solid and cystic masses. However, it does not allow any inference on the malignant versus benign nature of a lesion. If a lesion is cystic, the fluid should be aspirated and examined cytologically.

Biopsy under mammographic localization (choice D), i.e., a \"stereotactic\" biopsy, is not necessary in this case because the lesion is palpable and can be easily sampled by fine-needle aspiration or conventional biopsy.", //14 "The correct answer is A. The varicella-zoster virus, the virus that causes the clinical manifestations that are commonly referred to as \"chickenpox,\" can have severe consequences for a mother and her fetus during pregnancy. Fortunately, most pregnant women have already been exposed. And, of those pregnant women who are not sure whether they had chickenpox, the overwhelming majority will also have already been exposed and be immune to infection. The ideal time to screen for immunity to varicella is preconceptionally. If a pregnant women thinks she has been exposed, then the first step is to verify that the infected person truly has varicella. The next step is to check the mother\'s IgG serology. If her serology is positive, then she has immunity and there is no risk to her or her fetus. If the serology is negative, she should be given varicella-zoster immune globulin (VZIG), which is about 75% effective in preventing an infection if given within 96 hours of exposure.

Administration of IV acyclovir (choice C) would be inappropriate. First, the mother most likely has already had varicella infection and is therefore immune. Second, the mother has no evidence of being infected. Finally, even in the case of a confirmed maternal infection, IV acyclovir is used only when serious complications of varicella infection (e.g., pneumonia or encephalitis) develop.

Administration of oral acyclovir (choice D) would be inappropriate for the above listed reasons.

Administration of the varicella vaccine (choice E) would be contraindicated because it is an attenuated live-virus vaccine. These vaccines are not recommended for pregnant women.

Waiting to see whether a rash develops (choice B) would not be appropriate. The incubation period for the virus is 10-14 days. VZIG is most effective if given within 96 hours of exposure. Therefore, this patient may not develop a rash for 10 or more days, and by that time it would be too late for VZIG.", //15 "The correct answer is A. Sickle-cell anemia results from a single A - T substitution that leads to valine being substituted for glutamic acid on the beta-chain of the hemoglobin molecule. This change in the configuration of the hemoglobin molecule makes the erythrocyte sickle when it becomes deoxygenated. Patients with sickle-cell anemia have a number of maladies, including severe pain crises, pulmonary infarction, bony abnormalities, cerebrovascular accidents, and an increased likelihood of infection with gram-positive organisms. This patient has sickle-cell anemia (SS), and the father of the baby has sickle-cell trait (AS). This gives the fetus a 50% likelihood of having sickle-cell disease and a 50% likelihood of having sickle-cell trait. Amniocentesis and chorionic villus sampling can be used to determine the genotype of the fetus. This patient should at least be offered the option of having genetic counseling to better understand the inheritance of the disease and the fetus\' likelihood of having each outcome.

Obstetric ultrasound (choice B) is a very useful diagnostic modality to examine the fetus, umbilical cord, placenta, amniotic fluid, and maternal pelvic structures. This patient, however, does not have an indication for an ultrasound at this time. This patient already had a 6-week ultrasound, which is especially useful for dating the pregnancy. The best time to do a \"screening\" ultrasound to look for fetal anomalies is during the second trimester. This patient, at 10-weeks\' gestation with an ultrasound done 4 weeks ago, would have no indication for another ultrasound at this time.

Hydroxyurea (choice C) is a drug used to increase the production of hemoglobin F in patients with sickle-cell anemia who are not pregnant. It is considered a class D drug, and its use in pregnancy is limited.

IV hydration (choice D) is frequently used in patients with sickle-cell anemia during pain crises. This patient has no evidence of having a pain crisis; therefore, IV hydration would not be indicated during a prenatal visit.

Blood transfusion (choice E) during pregnancy for the patient with sickle-cell anemia is an area of controversy. Some argue for routine transfusion to maintain the hematocrit above 25% and the level of hemoglobin A above 40%. This patient is asymptomatic, with a hematocrit of 37% at 10-weeks\' gestation. Therefore, blood transfusion would not be indicated as the next step in management.", //16 "The correct answer is C. This patient has the findings consistent with HELLP syndrome. HELLP stands for hemolysis, elevated liver enzymes, and low platelets, and is related to preeclampsia. A patient with HELLP typically presents with complaints of abdominal pain and nausea and vomiting, as well as a history of malaise or flu-like symptoms. The patients are usually afebrile and often have normal vital signs. Although HELLP is related to preeclampsia, hypertension and proteinuria may be absent or minimal. Examination usually reveals right upper quadrant or epigastric tenderness. Laboratory values show evidence of hemolysis (e.g., abnormal peripheral blood smear, elevated lactate dehydrogenase, and increased bilirubin), elevated liver enzymes (e.g., elevated AST and ALT), and low platelets (<100,000/mm3). The treatment is essentially the same as for severe preeclampsia.

Decreased fibrin split products (choice A) would not be consistent with HELLP syndrome. Up to 40% of patients with HELLP syndrome will develop disseminated intravascular coagulation (DIC). In DIC, fibrin split products are elevated.

Decreased lactate dehydrogenase (choice B) would also not be consistent with HELLP syndrome. As noted above, lactate dehydrogenase rises as hemolysis takes place and as the liver is damaged.

Elevated fibrinogen (choice D) would also not usually be seen in HELLP syndrome. In the up to 40% of patients with HELLP who develop DIC, the fibrinogen level would be decreased.

Elevated glucose (choice E) would not usually be seen in HELLP syndrome.", //17 "The correct answer is C. Gestational diabetes is defined as glucose intolerance that develops or is first recognized during pregnancy. To diagnose gestational diabetes, a 50-g oral glucose tolerance test (OGTT) is given between 24 and 28 weeks. Any woman with a plasma glucose value above 140 mg/dL on the 50-g OGTT is then sent for a 100-g, 3-hour OGTT, in which a 100-g glucose load is given and plasma glucose levels are checked at 1, 2, and 3 hours. Any woman with two or more abnormal values is considered to have gestational diabetes. A class A1 gestational diabetic does not have fasting hyperglycemia (glucose >105 mg/dL) and can usually be treated with diet alone. A class A2 gestational diabetic has fasting hyperglycemia and needs insulin treatment. Gestational diabetics are at increased risk for fetal macrosomia. Fetal macrosomia is a risk factor for shoulder dystocia, a condition in which the fetus\' anterior shoulder becomes impacted against the mother\'s pubic symphysis. This fetus had a shoulder dystocia that was relieved only with delivery of the posterior arm. In the process, the humerus was fractured. The shoulder dystocia was likely the result of the fetal macrosomia, which was most likely caused by the mother\'s gestational diabetes.

Cigarette smoking (choice A) has not been shown to be related to shoulder dystocia.

Gestational age (choice B) is related to shoulder dystocia when the patient is post-dates (>40 weeks). This patient, however, is at 38 weeks\' gestation.

There is some evidence that advanced maternal age (choice C) may be related to shoulder dystocia. This patient is 17; therefore, advanced maternal age is not a factor.

Maternal shoulder surgery (choice E) is not related to the occurrence of shoulder dystocia. ", //18 "The correct answer is D. Leukocoria is a white pupillary reflex (the so-called cat\'s eye reflex). Its detection warrants a prompt consultation with the ophthalmologist. It may indicate a diagnosis of cataract, tumor, retinal detachment, retinopathy of prematurity, or chorioretinitis. When the pediatrician reviewed this patient\'s family history, there was a history of retinoblastoma. Children with the inherited form of retinoblastoma usually present at an earlier age (median 11 months) and have bilateral tumors. The sporadic type of retinoblastoma is usually unilateral and occurs later in infancy. Children with retinoblastoma usually present with leukocoria, but parents may also bring a child to the physician because they noted strabismus or loss of vision. The standard treatment for retinoblastoma is enucleation.

Reassurance that leukocoria is a normal or temporary condition (choice A) or arranging a return visit in 1 month (choice B) will only delay the diagnosis of a serious eye condition. A thorough funduscopic exam is required and may need to be done under anesthesia. A consultation with a neurologist (choice C) is not required; cerebrospinal fluid examination for tumor cells is usually not necessary.

Erythromycin ophthalmic ointment is (choice E) commonly used for conjunctivitis.", //19 "The correct answer is E. In the neonatal period, midgut volvulus is the most common cause of abdominal obstruction due to malrotation. Green-colored vomitus represents bilious vomiting, which is caused by obstruction of the small bowel. The infant typically has normal feeding and appears to be well in the first few days of life. As the malrotation worsens, the infant starts to develop abdominal fullness, especially in the right upper quadrant. Bilious vomiting soon develops as the small bowel is completely obstructed. If the volvulus is not diagnosed and treated early, intestinal ischemia and necrosis may develop. This can lead to bowel perforation and shock. Volvulus is the most common type of malrotation in newborns. It is caused by failure of the cecum to move into the right lower quadrant. The usual location of the cecum is in the subhepatic area. Because the cecum fails to rotate properly, it does not form the normal broad-based adherence to the posterior abdominal wall. A midgut volvulus is formed when the mesentery, which includes the superior mesenteric artery, is tethered by a narrow stalk and is twisted around itself. In addition, bands of adhesive tissue (Ladd bands) may extend from the cecum to the right upper quadrant, obstructing the duodenum. Midgut volvulus is an emergency in neonates. When an infant is suspected of having this condition, he or she should be stabilized immediately by IV fluids, antibiotics, and nasogastric suctioning. Abdominal radiographs should be taken as soon as possible to evaluate for bowel obstruction. Radiologic findings of volvulus include small bowel dilatation, paucity of air in the intestine, and a corkscrew-like appearance of the duodenum. Emergent surgery is needed to relieve the obstruction. Adhesive tissues should be resected, and the entire intestine should be inspected for anomalies. If segments of ischemic bowel are present, they should be removed. If the viability of the bowel cannot be determined during the surgery, a second surgery 12-36 hours later may be necessary to inspect and remove any ischemic bowel segment. Short bowel syndrome is a dreaded complication if a significant portion of the bowel was nonviable, and thus removed. Allergic reaction to formula (choice A) typically presents between 4 and 6 weeks of age. Reactions rarely present in the neonatal period. Bilious vomiting is also not consistent with an allergic reaction to formula.

Gastroesophageal reflux disease (choice B) happens commonly in infants. In fact, the lower gastroesophageal sphincter is poorly developed during infancy. Most cases of reflux are of normal variant and need not be worried. However, when reflux causes significant problems, such as poor weight gain or apnea, it then needs to be treated. The vomiting in gastroesophageal reflux disease is never bilious.

Hirschsprung disease (choice C) results from partial or complete absence of ganglion cells in the colon. It is the most common cause of neonatal obstruction of the colon. Hirschsprung disease is suspected when the infant fails to pass meconium in the first 24 hours of life. Diagnosis becomes more likely when barium enema shows the appearance of a megacolon proximal to the aganglionic segment. It is confirmed with punch biopsy.

Meconium ileus (choice D) is most commonly associated with cystic fibrosis. It typically presents at birth or within the first 48 hours. Symptoms include failure to pass meconium, abdominal distention, and vomiting, which may be bilious.", //20 "The correct answer is D. Schizophrenia occurs in 1% of the population, equally affecting males and females. It is characterized by psychosis and disruption in one\'s ability to function socially. Presenting complaints may include auditory hallucinations, strange belief systems, paranoia, lack of motivation, decrease in self-care and peculiar mannerisms. In schizophrenia, neuropathologic volumetric analyses suggest a loss of brain weight, specifically of gray matter. CT studies may show a compensatory enlargement of the lateral and third ventricles, thereby increasing the ventricle-to-brain ratio. The temporal lobes appear to lose the most volume when compared with those of persons without schizophrenia. The frontal lobes may likewise have abnormalities; however, these are not related to the volume of the lobes but rather to the level of activity detected by functional MRIs.

Atrophic changes in the cerebellar vermis (choice A) are not typical for CT scans of patients with schizophrenia. The cerebellum is responsible for the regulation and control of muscular tone, the coordination of movement, and the control of posture and gait. Specifically, the vermis is the narrow middle zone between the two hemispheres of the cerebellum; it is unrelated to any dysfunction related to schizophrenia.

Bilateral hypodensities in the orbitofrontal region (choice B) are not typically seen in schizophrenic patients. Damage to the orbitofrontal region of the brain usually results in impaired social judgment. One criterion for the diagnosis of schizophrenia is social/occupational dysfunction. Often this is characterized by a disturbance in interpersonal relations. This is not thought to be due to an error in social judgment; likewise, it is not due to abnormalities in the orbitofrontal region of the brain.

Hydrocephalus (choice C) is a condition marked by an excessive accumulation of fluid, which leads to dilation of the ventricles and elevated intracranial pressure. There are several types of hydrocephalus, including but not limited to communicating, noncommunicating, normal pressure, and congenital. This condition is not related to schizophrenia.

Significant sulcal widening (choice E) is often seen as a result of atrophic changes consistent with aging and the dementias. Mild sulcal widening may be seen in scans of patients with schizophrenia, but significant changes are not characteristic.", //21 "The correct answer is B. Frontal lobe dementia is characterized by damage to the frontal lobes and includes marked personality and behavioral changes as described in the question. The age of onset is most often between 50 and 60, and the condition is often progressive. Frontal lobe dementia is usually characterized by disproportionate impairment in tasks related to frontal lobe function, such as deficiency in abstract thinking, attentional shifting, or set formation. Disinhibition is also a key finding. CT or MRI reveals atrophy of the frontal lobe, especially early in the disease process. At present, the definitive diagnosis of any degenerative dementia is based on postmortem neuropathologic examination. Only one type of frontal lobe dementia, Pick disease, is associated with distinctive histopathologic abnormalities that allow for certain diagnosis. The patient\'s glabellar sign is one of several signs elicited in a neurologic exam of a patient with frontal lobe dysfunction. The basal ganglia (choice A) consist of deep subcortical nuclei responsible for movement disorders. The basal ganglia is composed of the caudate nucleus, putamen, globus pallidus, subthalamic nucleus, and substantia nigra. Certain movement disorders that result from basal ganglia dysfunction include Parkinson disease and hemiballism. The basal ganglia is not the area involved in this woman\'s symptoms.

The hypothalamus (choice C) helps to maintain homeostasis through the secretion of hormones, central control of the autonomic nervous system and the development of emotional and motivational states. The hypothalamus also interacts with limbic structures and the reticular formation for the maintenance of arousal. Temporal lobe dysfunction (choice D) can occur in several ways; however, the resultant problems would be different. Temporal lobe seizures include simple partial seizures characterized by olfactory and gustatory hallucinations and complex partial seizures characterized by impairment of consciousness, repetitive psychomotor movements, and automatic behavior. Tumors in the temporal lobe may cause memory disturbances, superior quadrantanopsia, and, if the dominant temporal lobe is involved, aphasia. Disruption of the temporal lobe can involve limbic structures and tends to cause psychosis. Further, mania can be associated with temporal lobe lesions, especially on the right side.

Ventricular obstruction (choice E) results in hydrocephalus, which is an increase in the volume of cerebrospinal fluid within the skull. It can occur with or without an increase in pressure. Most commonly, there is an increase in pressure; this type of hydrocephalus can be divided into obstructive and communicating hydrocephalus. Many types of pathology can cause obstructive hydrocephalus, including brain tumors, inflammatory processes, and developmental abnormalities. Increased intracranial pressure may not be present in normal pressure hydrocephalus, which can cause a reversible dementia, but the characteristics of this dementia are not congruent with this woman\'s symptoms.", //22 "The correct answer is E. The key to this case is that the patient\'s mood was \"fine\" until 1 week prior to presentation. Thereafter, her symptoms of mood lability and dysphoria with suicidal thoughts can be attributable to cocaine use and/or withdrawal. Once cocaine use stops, the mood symptoms generally improve within a few days, and suicidal ideation often resolves. In bipolar disorder, manic (choice A), elevated or irritable mood states generally last for days on end, even in so-called \"rapid cyclers.\" It would be difficult to make the diagnosis of bipolar disorder in this patient because of the positive urine drug screen and the fact that all of her symptoms can be ascribed to cocaine use. Dysthymic disorder (choice B) is characterized by the presence of depressive symptoms that do not meet the full criteria for major depression, with a duration of at least 2 years. Rapidly shifting extremes of mood and acute suicidal impulses are not characteristic. Although individuals with histrionic personality disorder (choice C) have rapidly shifting expressions of emotion and may have chronic dysphoria, the key feature of this disorder is the need and constant quest for attention from others. Major depressive disorder (choice D) requires at least a 2-week history of a constellation of depressive symptoms. This diagnosis cannot be reliably made when symptoms can be otherwise explained, such as in this case of drug use.", //23 "The correct answer is D. A known complication of long-standing use of birth control pills is the development of hepatic adenomas that may rupture and bleed. A bleeding ovarian follicle (choice A) can give mild abdominal pain right at the midpoint of the menstrual cycle, but it would not produce bleeding of this magnitude.

An abdominal aortic aneurysm (choice B) would be very rare at this age, and bleeding typically begins retroperitoneally with excruciating back pain. Once the aneurysm ruptures into the peritoneal cavity, complete vascular collapse ensues.

An ectopic pregnancy (choice C) is the first thought when a sexually active young woman has spontaneous intra-abdominal bleeding, but in this case it has been ruled out by the history, the pelvic examination, and the pregnancy test.

Other visceral aneurysms (choice E) can indeed bleed, and have a tendency to do so during pregnancy. They are very rare and favor the splenic artery. They can also occur in the hepatic artery, but the odds are extremely low.", //24 "The correct answer is D. This patient has adult onset polycystic kidney disease (APKD). APKD is an autosomal dominant disease that presents with hypertension, renal cysts, hematuria, and possible renal failure, usually after age 30. There is a 10% to 20% incidence of berry aneurysms in these patients, and they need to be screened with angiography to determine the presence or absence of these malformations. A magnetic resonance angiogram of the brain (MRA) is the standard option for such imaging in most medical centers. CT scan of the pelvis (choice A) is not indicated since clinical history and renal ultrasound alone can make the diagnosis of APKD. The concern here is to screen for the concomitant presence of intracranial pathology. CT scan of the thorax (choice B) is incorrect. Unless these lesions were mistaken for renal cell carcinoma, there is no indication to scan a distant site like the lungs as this disease has no malignant potential. Intravenous pyelography (IVP; choice C) is used to evaluate the collecting system of the urinary tract and is not indicated in this case, as the diagnosis of APKD is almost certainly based on the ultrasound and clinical presentation. This study adds no diagnostic information to the results of the ultrasound already obtained.

MRI of the brain (choice E) is not useful for detecting circulatory malformations without the aid of the angiographic contrast material.", //25 "The correct answer is D. This is a classic presentation of a ruptured berry aneurysm. There must be a high suspicion for this diagnosis, since failure to make it will likely result in the death of the patient. Although the diagnosis of headache is quite common, the classic pattern is that of a sentinel bleed followed by meningismus and agitation that herald a re-bleed in more than 70% of subarachnoid hemorrhage (SAH) patients within 48 hours. Once the SAH is identified (usually with a CT scan), neurosurgical intervention to stop the bleeding can be begun, and the patient thereafter has a normal life expectancy. The most common nontraumatic cause for SAH is a berry aneurysm in the anterior portion of the circle of Willis. Arteriovenous malformation (choice A) is a rare cause of a SAH and intracranial bleeds in general.

The cerebellum (choice B) is an uncommon site for bleeds. When they do occur, they are generally due to severe hypertension. Such bleeds are urgent because they can cause brain stem compression or obstructive hydrocephalus if not promptly evacuated.

The putamen (choice C) and thalamus (choice E) are the most common sites for hypertensive bleeds. Such bleeds do not produce meningismus, only mental status changes and focal neurologic deficits."); var cate_step2 = new Array("IM", "IM", "IM", "IM", "IM", "IM", "IM", "SURGERY", "IM", "OB/GYN", "OB/GYN", "IM", "SURGERY", "OB/GYN", "OB/GYN", "OB/GYN", "OB/GYN", "PED", "PED", "PSYCH", "IM", "PSYCH", "SURGERY", "IM", "IM"); var cateSub_step2 = new Array("NEPH", "RHEUM", "NEPH", "ENDO", "NEURO", "PULM", "NEPH", "", "CARDIO", "", "", "NEURO", "", "", "", "", "", "MULTI", "GASTRO", "", "NEURO", "", "", "NEPH", "NEURO"); //SPECIALTIES var baseSpecs_step2 = new Array ("IM","PED","PSYCH","OB/GYN","SURGERY"); //SUBSPECIALTIES var baseSubSpecs_step2 = new Array ("MULTI","GASTRO", "HEM", "NEPH","NEURO","DER","CARDIO", "RHEUM","PULM","ENDO");