var killers_step3 = new Array( //1 "A 63-year-old man comes to the office because of \"problems seeing.\" He says that his wife is making him \"get some help\" because he got into a minor car accident last night, and it was his fault because he has difficulty seeing. His vision is \"fine\" during the day, but he is basically \"blind as a bat\" when it is dark. He admits to an \"occasional bottle of vodka.\" He has dry skin with multiple, diffuse areas of hyperkeratosis. His condition would most likely have been prevented by supplementation with: $$niacin %%vitamin A ^^vitamin B1 &&vitamin B12 ##vitamin C ", //2 "Three months after witnessing her best friend being shot to death by another classmate in school, a 14-year-old girl is brought to the office by her parents because her teacher says the she seems to be having trouble concentrating. Ever since that \"awful day\" she has been very \"sad\" and withdrawn, often sitting on her bed, staring at the wall \"for hours.\" She has frequent crying spells and refuses to play with friends or participate in her normal after-school activities. Her appetite has \"dwindled down to nothing\" and she feels very guilty that she survived the shooting. On further questioning, she reluctantly admits that she has constant thoughts of \"joining her friend.\" She did not receive any counseling after the incident.
The most likely diagnosis is $$adjustment disorder %%brief psychotic disorder ^^dysthymic disorder &&major depressive disorder ##normal grief", //3 "Three months after witnessing her best friend being shot to death by another classmate in school, a 14-year-old girl is brought to the office by her parents because her teacher says the she seems to be having trouble concentrating. Ever since that \"awful day\" she has been very \"sad\" and withdrawn, often sitting on her bed, staring at the wall \"for hours.\" She has frequent crying spells and refuses to play with friends or participate in her normal after-school activities. Her appetite has \"dwindled down to nothing\" and she feels very guilty that she survived the shooting. On further questioning, she reluctantly admits that she has constant thoughts of \"joining her friend.\" She did not receive any counseling after the incident.
The most vital question to ask at this time is: $$\"Are you hearing voices?\" %%\"Do you have any friends that you feel comfortable talking to at school?\" ^^\"Do you wear a helmet when you ride your bicycle?\" &&\"Can you describe your typical weekly alcohol intake?\" ##\"Have you thought of the means by which you can \'join your friend\'?\"", //4 "A 46-year-old woman comes to the office for a periodic health maintenance examination. She says that she feels \"great\", exercises daily, eats a low-fat diet, takes her calcium, and gets regular mammograms and pap smears. Her physical examination is entirely normal. You notice that she has become fidgety as you turn to leave the room. You ask her if there is anything bothering her and she tells you that she is concerned about her 15-year-old son, who is also your patient. She says that she has walked in on her son masturbating six times in the past 2 weeks, and she found a \"heterosexual adult magazine\" under his mattress. She is worried about this \"behavior\". She says that he is doing well in school, plays on the varsity basketball team, and hangs out with friends on the weekends. The most appropriate response to this patient is:$$\"From what you have told me, this seems like completely normal behavior for an adolescent boy.\" %%\"He will regret it later on in life; masturbation causes infertility.\" ^^\"I wish I could help you, but it seems that you need to take him to a psychiatrist for evaluation.\" &&\"It sounds like there is more to this story than you are telling me; he must have been sexually abused as a child.\" ##\"You should make him an appointment to see me as soon as possible; I need to evaluate him for a paraphilia\"", //5 "A 28-year-old woman comes to the office because of a 4-day history of \"itching, burning, and an awful-smelling vaginal discharge\". She says that she and her boyfriend had similar symptoms a few months ago, which resolved after treatment by his physician. Now, she believes that he is \"fooling around,\" because this \"disease\" has returned. On physical examination her vulva is erythematous and there are patches of petechiae in the upper vagina and on the cervix. There is a copious amount of yellowish-green, \"frothy\", malodorous vaginal discharge. Examination of the discharge on a saline wet mount will most likely reveal:$$branching hyphae and spores %%epithelial cells with clumps of bacteria and \"ground-glass\" cytoplasm ^^giant multinucleated cells with intranuclear inclusions &&koilocytes ##motile, flagellated organisms", //6 "A 16-year-old girl is brought to the office by her mother because she \"never got her period.\" She is very upset and constantly feels \"left-out\" of her girlfriend\'s conversations. They all tell her that she is so lucky that she does not have to worry about using birth control with her boyfriend. She takes no medications and denies strenuous exercise or excessive dieting. Physical examination shows mature, adult breasts, a scanty amount of axillary and pubic hair, a normal clitoris, and a blind-ending vagina. Laboratory studies show a male level of serum testosterone. The patient\'s mother asks about the severity of this condition and the long-term effects. The most appropriate response is:$$\"She is similar to many teenage girls who do not menstruate until they are 16 and they go on to have normal reproductive lives.\" %%\"This condition is very serious and she will require a bilateral mastectomy because of her increased risk of breast cancer.\" ^^\"Your daughter will begin menstruating after receiving hormonal therapy and she may be able to become pregnant in the future.\" &&\"Your daughter will begin menstruating after receiving hormonal therapy but she will not be able to conceive.\" ##\"Your daughter will probably require surgery and estrogen replacement, and she will not be able to conceive.\"", //7 "A 43-year-old has been coming to you for 5 years for management of his HIV infection. Over past few years he has had Pneumocystis carinii pneumonia, Kaposi\'s sarcoma, oral candidiasis, and \"everything else under the sun.\" He has been with the same partner for 6 years, who is also HIV positive. They have both been on a variety of \"cocktails\" and have suffered through many adverse side effects. You notice that he looks healthier and ask him how he was able to bulk up so well. He replies, \"I have finally found a cure for the nausea and lack of appetite- marijuana! My partner and I have been growing it in our yard and we smoke it a couple of times a day. We feel great!\" His partner is also a patient of yours. The best response is:$$\"Are you aware that marijuana use has been associated with respiratory problems?\" %%\"I am sorry, but I am going to have to call the police and turn you in.\" ^^\"I can provide you with a medication that will also alleviate these symptoms, instead of using marijuana\" &&\"I have read about other patients doing that; however, do you really think that using an illegal drug is a good idea?\" ##\"That is against the law, and you must stop at once!\"", //8 "28. A 48-year-old woman is brought to the emergency department by her husband because of an \"excruciatingly painful left eye.\" They were at the movies when she began to complain of blurry vision and a severe headache, and she had to run to the restroom to throw-up. The pain \"settled into her eye\" on the ride over to the hospital. She is now complaining of seeing \"halos\" around lights. Her ophthalmologic history is significant for several dendritic herpetic ulcers over the past few years. Physical examination shows conjunctival hyperemia with an edematous left eyelid. The cornea appears \"steamy\" and the pupil is fixed and mid-dilated. The left eye is tender and firm on palpation. Tonometric testing reveals an intraocular pressure (IOP) of 67mm Hg. The most appropriate immediate action is to $$order a CT scan of the head %%perform a lumbar puncture ^^perform a peripheral iridotomy &&treat the patient with corticosteroids, topically ##treat the patient with mannitol, intravenously", //9 "A married 64-year-old man comes to the office because of a purple lesion on his nose. He says that the lesion started out as a \"small dot\" about 3 months ago, and it has been \"growing exponentially\" ever since. He is a retired physician who has been married to his high school sweetheart for 42 years. Physical examination shows a 3-cm reddish-purple nodule on the right side on his nose and generalized lymphadenopathy. You suspect that the lesion is Kaposi\'s sarcoma and the lymphadenopathy is due to an HIV infection. You gently approach the issue and he reluctantly admits to \"visits\" with prostitutes. After a long discussion he finally consents to HIV testing. The results of the ELISA and Western Blot, which return in 2 weeks, show that he is infected with HIV. His CD4 count is 158/ml. He comes in to the office to discuss the results and begs you not to tell his wife, who is also your patient. He says that hearing what he has been in involved in \"will kill her.\" You remind him that HIV may also \"kill her.\" The most appropriate first step is to $$contact his wife anonymously and tell her that she has been exposed to HIV %%contact the appropriate government health agency and report your findings ^^promise him that as his doctor you will respect his privacy and maintain confidentiality &&promise him that you will keep the results confidential if he agrees to use condoms with his wife ##try to persuade him to voluntarily discuss the issue with his wife", //10 "A 4-year-old boy is admitted to the hospital earlier in the day because of fever, irritability, and erythema of the hands and feet for the past week. His mother has been giving him aspirin to reduce his temperature. His physical examination on admission showed a temperature of 39.7 C (103.4 F), bilateral conjunctival injection, an enlarged right-sided cervical lymph node (1.8-cm), fissured lips, a red tongue with red papillae, pharyngeal hyperemia, erythematous and edematous palms and soles, and a confluent, blanching erythematous rash on the trunk. Intravenous fluids were started, the aspirin therapy was continued, and laboratory studies were ordered. These laboratory studies finally return and show an erythrocyte sedimentation rate of 28mm/h and a platelet count of 490,000/mm3. The patient is extremely uncomfortable and now shows desquamation of the fingers and toes. The most appropriate therapy at this time is $$corticosteroids %%ibuprofen ^^intravenous gammaglobulin &&oxacillin ##penicillin V", //11 "A 28-year-old woman comes to the office because she is \"finally ready for the big guns\" to get rid of her acne. She has been a patient of yours since childhood, and over the years you have treated her with benzoyl peroxide gel, topical tretinoin, topical erythromycin, and oral tetracycline, minocycline, and erythromycin. She has never been satisfied with the results of these agents, and you have discussed isotretinoin with her in the past, but she always said \"next time.\" Physical examination shows multiple large and inflamed cysts and nodules on her face, back, and chest. The most appropriate next step is to $$check her records for previous lipid, CPK, and glucose levels and liver function tests; if normal give her a prescription for isotretinoin %%do a urine pregnancy test; if negative give her a prescription for isotretinoin ^^do a urine pregnancy test; if negative tell her to take another pregnancy test on the second day of her next period or 11 days after her last unprotected intercourse, and then you will prescribe isotretinoin &&obtain lipid, CPK, and glucose levels and liver function tests ; if normal give her a prescription for isotretinoin ##order pelvic ultrasonography; if no visible fetus, give her a prescription for isotretinoin", //12 "A 28-year-old woman comes to the office because she is \"finally ready for the big guns\" to get rid of her acne. She has been a patient of yours since childhood, and over the years you have treated her with benzoyl peroxide gel, topical tretinoin, topical erythromycin, and oral tetracycline, minocycline, and erythromycin. She has never been satisfied with the results of these agents, and you have discussed isotretinoin with her in the past, but she always said \"next time.\" Physical examination shows multiple large and inflamed cysts and nodules on her face, back, and chest.

The appropriate steps are taken. You should explain to her that while she is taking isotretinoin she should$$avoid all physical activity %%be cautious when driving or operating any vehicle at night ^^make sure to use 1 form of birth control; it should be an effective one, such as an injectable/implantable contraceptive product &¬ donate blood until 3 weeks following discontinuation of the drug ##take a multivitamin with vitamin A", //13 "A 28-year-old woman is brought to the office by her husband who says that the police were called to their house last night because she \"brandished a knife at the neighbor.\" He says that his wife has been \"pretty crazy\" for the past 8 months. It all started with her \"believing that the neighbor\'s son, who has been dead for years, has been communicating with her through the shower faucet, and telling her to kill his parents.\" At first, he thought that this was just a joke, but then he began to realize that something has to be \"off\" because she began to see faces of other dead acquaintances in the refrigerator. She stopped her daily showers, started wearing dirty cloths from the hamper, and cut off all communication with friends and relatives. She was constantly so disheveled and \"out there\" that she was fired from her job as a grocery store clerk. Approximately 5 months ago, there was a 3-week period where she had difficulty sleeping, a 15-pound weight loss, and there was a generalized \"sadness about her.\" During this period, she repeatedly expressed feelings of worthlessness, and rarely got out of bed to watch television, which up until then had been her most exciting activity. The husband says that she has recently begun to complain about sleeping \"troubles\" again, and she has had difficulty getting out of bed. She now says that she \"needs to get out of the office to kill those people once and for all.\" She does not take any medications, use any drugs, or drink alcohol. The most likely diagnosis is $$brief psychotic disorder %%delusional disorder ^^major depressive disorder &&schizoaffective disorder ##schizophrenia", //14 "A 66-year-old woman comes to the office because of difficulty sleeping, a decreased appetite, fatigue, an inability to concentrate, and a general \"down\" mood for the past 2½ weeks. She states that she and her husband are going on a 3-week trip to Italy and France next month, and she \"wants to get to the bottom of this\" before they go. She has been coming to you since her first child was born, and over the years you have treated her for gastroenteritis, several yeast infections, and most recently, high blood pressure. She has always been a very compliant patient. You notice in her chart that you prescribed propranolol for her hypertension 1 month ago, after trying to control it with weight reduction, smoking cessation, alcohol elimination, salt and fat reduction, and aerobic exercise. Her blood pressure at 3 previous visits was 150/90 mm Hg and today it is 135/80 mm Hg. She does not take any other medications. At this time you should$$advise her to start a \"gentle\" walking routine to \"lift her spirits\" %%advise her to stop taking propranolol and give her a prescription for hydrochlorothiazide ^^explain to the patient that she is stressed about her trip, and these symptoms will pass &&give her a prescription for tranylcypromine ##increase the dose of propranolol and prescribe phenelzine", //15 "A 27-year-old man comes to the emergency department because an \"exquisitely painful\" scrotum. He says that he was walking to lunch with friends when the pain hit him \"like a thunderclap.\" He says that he has a steady girlfriend and they have an \"active sex life.\" He is \"very healthy\" and has never experienced pain like this before and he regularly checks himself \"there\" after that young comedian underwent testicular surgery on television. His temperature is 37 C (98.6 F), blood pressure is 130/85 mm Hg, pulse is 86/min, and respirations are 19/min. Physical examination shows severe scrotal tenderness that is not relieved when the scrotum is elevated. The right testes is high in the scrotum and riding in a horizontal position. The cord above the testes is not tender. A urinalysis shows:
Color straw/lightMicroscopic 
Specific gravity1.020WBC4/hpf
pH 5.8 Glucose absent
Protein absent Bacteria absent

The most appropriate next step is to $$administer ciprofloxacin, intravenously %%apply ice packs and observe in the emergency department ^^measure serum HCG and AFP &&perform a trans-scrotal testicular biopsy ##request a urology consultation, STAT", //16 "A 58-year-old man comes to the office 7 weeks after his wife died from complications during breast cancer surgery. He says that he \"misses her like crazy\" and it is so hard for him because he did not expect to \"ever lose her.\" He often finds himself crying in the bathroom at work; however it is the weekends that are especially difficult. He goes out for dinner and to the movies with their 2 children and his friends, but he typically feels a little detached. It is \"really hard to handle\" seeing other men with their wives. He is very \"sad\" and wants to know if he is going to be \"okay\". The most appropriate response to this patient is: $$\"It seems like you are experiencing a major depressive episode that we can treat with fluoxetine\" %%\"Let\'s see how you feel in a few weeks and we will discuss the most appropriate treatment then\" ^^\"You are experiencing grief, which is completely normal and expected reaction to the loss of your wife\" &&\"You have an adjustment disorder that should be treated with psychotherapy\" ##\"You should have your friends set you up with a widowed woman who will understand you\"", //17 "A 49-year-old woman comes to the office for a periodic health maintenance examination. She is in good health and has no complaints; however she has a \"very important question.\" She says that one of her best friends recently passed away from ovarian cancer, and she is very worried because the woman never experienced any symptoms and did not have a family history of the disease. She wants to know if you can review her history and tell her if there is anything that will affect her risk for developing the disease. You flip through her chart and notice that she had menarche at age 11 and is still menstruating. She and her husband were trying unsuccessfully to conceive for 7 years, she took oral contraceptive pills for 18 years, and she has always been about 60-70 pounds overweight. The most accurate statement concerning this patient\'s risk for developing ovarian cancer is that she$$decreased her risk by taking oral contraceptive pills (OCPs) %%needs to have periodic pelvic sonograms because oral contraceptive pills put her at an increased risk ^^needs to have periodic pelvic sonograms because she never had kids and is overweight, which increases her risk for developing the disease &&should consider having a hysterectomy and bilateral oophorectomy because there is a good chance that she will develop the disease due to the fact that she took OCPs, never had children, and is overweight ##should take hormonal replacement therapy when she reaches menopause to decrease her risk of developing the disease", //18 "A 42-year-old woman comes to the office for a periodic health maintenance examination. She has no specific complaints. She has been a patient of yours since she was 23 years of age and she comes for a \"check-up\" every few years. Her last Pap smear, which was normal, was 1 year ago. She does not have a family history of breast cancer, and she has never had a mammogram. She wants to know what she is \"due for\" today, and since you follow the recommendations of the U.S. Preventive Services Task Force, you make sure that you$$advise her to floss daily and brush her teeth with a fluoride-containing toothpaste %%ask her about suicidal intent ^^perform fecal occult blood testing &&schedule a mammogram ##tell her to take a low-dose aspirin daily", //19 "A 33-year-old woman comes to the office because of an \"itchy rash\" on the ring finger of her left hand. She says that she began to notice it about 3 weeks ago, after her son was born and she started washing her hands \"every minute\" and began pushing the baby carriage. It started out as a \"red itchy area\" under her wedding band, and it progressed to \"scaly bumps that sometimes burst.\" It is itchy all day long, and not especially worse at night or after a hot shower. She is very upset because she can no longer wear her wedding band. She does not suffer from allergies and has never had any similar episodes in the past. Nobody else in her household has similar symptoms. Physical examination shows an area of localized erythema, vesicles, scales, and thickened skin on the proximal part of her left index finger. It is difficult for her to stop scratching her finger for long enough for you to examine it. A full-body skin examination does not reveal any other lesions.
The most likely mechanism for this reaction is $$antibody-mediated cytotoxic reaction to cell surface antigens %%antigen-antibody complexes formed in the vessels in response to an antigen ^^fixation of complement results in osmotic lysis of antibody-coated cell &&release of histamine from basophils after antigen interaction with Fc-receptor bound IgE ##release of lymphokines from sensitized lymphocytes reacting with antigens", //20 "A 33-year-old woman comes to the office because of an \"itchy rash\" on the ring finger of her left hand. She says that she began to notice it about 3 weeks ago, after her son was born and she started washing her hands \"every minute\" and began pushing the baby carriage. It started out as a \"red itchy area\" under her wedding band, and it progressed to \"scaly bumps that sometimes burst.\" It is itchy all day long, and not especially worse at night or after a hot shower. She is very upset because she can no longer wear her wedding band. She does not suffer from allergies and has never had any similar episodes in the past. Nobody else in her household has similar symptoms. Physical examination shows an area of localized erythema, vesicles, scales, and thickened skin on the proximal part of her left index finger. It is difficult for her to stop scratching her finger for long enough for you to examine it. A full-body skin examination does not reveal any other lesions.
The most appropriate treatment at this time is $$a high-potency fluorinated topical glucocorticoid %%oral prednisone ^^a topical coal tar preparation &&a topical salicylic acid preparation ##0.5% permethrin cream", //21 "A 69-year-old man is on your ward surgical service one day after having a gastric tube placed. The patient has a long history of dementia secondary to Alzheimer\'s disease and was admitted to the hospital for failure to thrive (FTT). A full evaluation revealed only severe dementia but no obvious cause for the FTT. A swallowing study was performed that indicated likely aspiration of all oral foods. After discussion with the family, a decision was made to place a gastric tube for the purposes of feeding. The surgery was uneventful and the patient appears to be doing well during a routine postoperative check.
The most accurate statement about this surgical procedure is that it $$allows the patient to take oral as well as tube-based foods %%eliminates the risk of aspiration ^^has no effect on the risk of aspiration &&will improve the patient\'s long-term mortality ##will improve the patient\'s near-term morbidity", //22 "A 69-year-old man is on your ward surgical service one day after having a gastric tube placed. The patient has a long history of dementia secondary to Alzheimer\'s disease and was admitted to the hospital for failure to thrive (FTT). A full evaluation revealed only severe dementia but no obvious cause for the FTT. A swallowing study was performed that indicated likely aspiration of all oral foods. After discussion with the family, a decision was made to place a gastric tube for the purposes of feeding. The surgery was uneventful and the patient appears to be doing well during a routine postoperative check.

Later that evening you are called to see the patient after he is found severely obtunded. The patient is 34 hours post-operative. The patient had been getting tube feedings for the past 5 hours and had minimal gastric residuals at the 2 hour check time. On arrival the patient is cyanotic with labored breathing. His pulse oximeter reads 85% on 100% non-rebreathing mask. On inspection of the patient\'s mouth and oropharynx, there are tube feedings visible. The most likely etiology of this patient\'s respiratory distress is $$inadvertent oral consumption and aspiration of tube feedings %%oropharyngeal obstruction and hypoventilation ^^over-sedation &®urgitation and aspiration of gastric-tube infused tube feedings ##residual anesthesia", //23 "A 47-year-old woman was admitted to the hospital for severe abdominal pain. She has a long history of vague abdominal complaints and has been hospitalized three times in the previous 12 months for similar complaints. She has a past medical history that is also significant for hypertension and diet-controlled diabetes mellitus. Three days ago she experienced the onset of severe abdominal pain, mid-epigastric, radiating to her back. She vomited once and then slept, albeit with much discomfort overnight. The following morning she had tremendous abdominal pain after eating her breakfast, and once again vomited brown-black fluid. She called 911 and was brought to the hospital emergency department by ambulance. She reports that she has had similar symptoms in the past but other hospitals have failed to find any etiology for her pain. On exam, she is an obese woman who appears to be in mild distress. Her vital signs are unremarkable except for a temperature of 99.1 degrees F. Her abdomen is diffusely tender to palpation with guarding.

The most appropriate diagnostic intervention at this time is $$abdominal CT scan %%HIDA-scan ^^liver function tests with amylase and lipase levels &&no study is indicated based upon her previous abdominal history ##right upper quadrant ultrasound", //24 "A 47-year-old woman was admitted to the hospital for severe abdominal pain. She has a long history of vague abdominal complaints and has been hospitalized three times in the previous 12 months for similar complaints. She has a past medical history that is also significant for hypertension and diet-controlled diabetes mellitus. Three days ago she experienced the onset of severe abdominal pain, mid-epigastric, radiating to her back. She vomited once and then slept, albeit with much discomfort overnight. The following morning she had tremendous abdominal pain after eating her breakfast, and once again vomited brown-black fluid. She called 911 and was brought to the hospital emergency department by ambulance. She reports that she has had similar symptoms in the past but other hospitals have failed to find any etiology for her pain. On exam, she is an obese woman who appears to be in mild distress. Her vital signs are unremarkable except for a temperature of 99.1 degrees F. Her abdomen is diffusely tender to palpation with guarding.

Liver function tests reveal the following:
Alkaline phosphatase 450 IU/L
Direct bilirubin 3.4 mg/dL
Serum glucose180 mg/dL
Amylase267 mg/dL
Serum calcium8.8 mmol/L
Lipase101 mg/dL
SGOT 45 IU/L
SGPT33 IU/L
A right upper quadrant ultrasound shows a distended common bile duct and an abdominal CT scan reveals stranding and inflammatory changes in the pancreatic head. The most appropriate management at this time is $$continuous infusion of intravenous opioids %%daily abdominal CT scans to evaluate for pancreatic necrosis ^^intravenous antibiotics &&intravenous fluids and nil per os status ##surgical debridement", //25 "A 47-year-old woman was admitted to the hospital for severe abdominal pain. She has a long history of vague abdominal complaints and has been hospitalized three times in the previous 12 months for similar complaints. She has a past medical history that is also significant for hypertension and diet-controlled diabetes mellitus. Three days ago she experienced the onset of severe abdominal pain, mid-epigastric, radiating to her back. She vomited once and then slept, albeit with much discomfort overnight. The following morning she had tremendous abdominal pain after eating her breakfast, and once again vomited brown-black fluid. She called 911 and was brought to the hospital emergency department by ambulance. She reports that she has had similar symptoms in the past but other hospitals have failed to find any etiology for her pain. On exam, she is an obese woman who appears to be in mild distress. Her vital signs are unremarkable except for a temperature of 99.1 degrees F. Her abdomen is diffusely tender to palpation with guarding.

Liver function tests reveal the following:
Alkaline phosphatase 450 IU/L
Direct bilirubin 3.4 mg/dL
Serum glucose180 mg/dL
Amylase267 mg/dL
Serum calcium8.8 mmol/L
Lipase101 mg/dL
SGOT 45 IU/L
SGPT33 IU/L
A right upper quadrant ultrasound shows a distended common bile duct and an abdominal CT scan reveals stranding and inflammatory changes in the pancreatic head.

That evening, the patient is noted to have a temperature of 103.4 degrees F. Her blood pressure and heart rate are within normal range. Her physical examination is unchanged. The most appropriate management at this time is to $$draw blood cultures and await results %%draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy ^^draw blood, urine, and sputum cultures and await results &&obtain an urgent abdominal CT scan ##start ampicillin, gentamicin, and metronidazole therapy"); var answers_step3 = new Array('B','D','E', 'A', 'E', 'E', 'C', 'E', 'E', 'C', 'C', 'B', 'D', 'B', 'E', 'C', 'A', 'A', 'E', 'A', 'E', 'D', 'C', 'D', 'B'); var description_step3 = new Array( //1 "The correct answer is B. This patient most likely has a vitamin A (retinoic acid) deficiency, which is characterized by night blindness and dry, hyperkeratotic skin. It can progress to conjunctival dryness, corneal ulceration, and necrosis. It occurs in patients with malabsorption or proteinuria, liver disease, alcoholics, and those receiving total parenteral nutrition (TPN).

Niacin (choice A) deficiency, which is often called pellagra, is characterized by diarrhea, dementia, and dermatitis. It occurs in individuals with a high intake of maize (corn). It is not associated with night blindness.

Vitamin B1 (thiamine) deficiency (choice C), which is often called beri-beri, is characterized by high output heart failure and central nervous system disturbances (Wernicke-Korsakoff\'s syndrome). Wernicke-Korsakoff\'s syndrome occurs in alcoholics and is associated with nystagmus, ataxia, confabulation, and retrograde amnesia. It is not associated with night blindness.

A deficiency of vitamin B12 (choice D) is associated with megaloblastic anemia and peripheral neuropathy. It is not associated with night blindness. It occurs in individuals with pernicious anemia, postgastrectomy, and those with intestinal organisms or ileal abnormalities.

A deficiency of vitamin C (choice E), which is often called scurvy, is characterized by easy bruising, perifollicular hemorrhages, purpura, poor wound healing, bone lesions, and emotional changes. It is not commonly associated with night blindness. It occurs in individuals with diets devoid of citrus fruits and vegetables.

", //2 "The correct answer is D. This patient most likely has major depressive disorder. To meet the criteria for this disorder a patient must exhibit a 2-week history of a distinct change in mood or a loss of interest or pleasure, along with at least 4 of the following: a decreased appetite and weight loss, difficulty sleeping, psychomotor retardation or agitation, fatigue, feelings of worthlessness or guilt, an inability to concentrate, and suicidal ideation. The symptoms must cause functional impairment.

This patient\'s suicidal ideation and marked functional impairment make it incorrect to diagnose her with adjustment disorder (choice A). An adjustment disorder, which may develop in response to a stressor, is characterized by a depressed mood and other symptoms that are similar, but less severe than in major depressive disorder. If a patient meets the criteria for a major depressive disorder (as stated in the explanation above), you cannot diagnose her with an adjustment disorder. Also, individuals with an adjustment disorder typically return to baseline functioning within 3 months.

A brief psychotic disorder (choice B) is characterized by delusions, hallucinations, disorganized speech, or grossly disorganized behavior lasting for more than a day but less than a month. This patient does not fit this description.

Dysthymic disorder (choice C) is characterized by a depressed mood for more than 2 years. This patient has only been symptomatic for 3 months.

Normal grief (choice E) is an expected reaction to the loss of a loved one. It is characterized by feelings of loss, sadness, and decreased enjoyment. Individuals with normal grief may experience frequent crying spells and possibly minor dysfunction. It typically lasts a few months, but may last longer. Major depressive disorder is diagnosed when there is suicidal ideation and feelings of worthlessness and guilt.", //3 "The correct answer is E. Since she has already told you that she has suicidal ideation (\"joining her friend\"), it is very important to ask if she has \"thought of the means by which\" she can \"join her friend\" or has made any preparatory actions.

It may be important to ask the patient if she is hearing voices (choice A) to determine if her depression is associated with psychotic features; however this will not change the immediate management. You have already found out that she \"constantly\" thinks about \"joining her friend,\" so now you need to question her about a plan.

While is important to find out if she has friends that she can confide in, asking her, \"Do you have any friends that you feel comfortable talking to at school?\" (choice B) is not vital at this time. You already know that she has thoughts about \"joining her friend,\" now you need to find out if she has a plan.

It is important to counsel patients to wear helmets when riding their bicycle (choice C), however this is not the most vital question to ask a patient with suicidal ideation.

All adolescents should be asked to describe their use of alcohol and other drugs (choice D), however this is not the most vital question to ask a patient with suicidal ideation.", //4 "The correct answer is A. Masturbation is completely normal. The mother should be told to respect her son\'s privacy at this time and try not to make him feel like he is doing anything wrong. Many adolescent boys hide pornographic magazines in their rooms, and as long as this \"behavior\" does not involve children or anything illegal and is not causing functional impairment, there is no need for concern.

It is inappropriate to say, \"\"He will regret it later on in life; masturbation causes infertility.\" (choice B) because this statement is not true.

It is inappropriate to say, \"I wish I could help you, but it seems that you need to take him to a psychiatrist for evaluation.\" (choice C) because masturbation is a completely normal and does not require any evaluation.

It is inappropriate to say, \"It sounds like there is more to this story than you are telling me; he must have been sexually abused as a child.\" (choice D) because there is no indication that he was sexually abused. Masturbation is a completely normal and typically is unrelated to previous sexual abuse. If you are concerned that there is something she is not telling you, it would be better to say, \"It sounds like there is more than you are telling me, maybe we should discuss it.\"

It is inappropriate to say, \"You should make him an appointment to see me as soon as possible; I need to evaluate him for a paraphilia\" (choice E) because masturbation is a completely normal behavior and there is no need to evaluate him for a paraphilia. It is very common for a teenage boy to have a \"heterosexual adult magazine\" hidden in his room; and since there is no functional impairment and it does not seem like he is involved abnormal behavior (such as inanimate objects or prepubescent children), there does not seem to be any cause for concern.

You should not tell her to\" reprimand him the next time you walk in on him masturbating\" (choice F). Masturbation is completely normal. The mother should be told to respect her son\'s privacy at this time and try not to make him feel like he is doing anything wrong.", //5 "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 and 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.", //6 "The correct answer is E. This patient most likely has testicular feminization, which is a syndrome caused by either a dysfunction or total absence of the testosterone receptor and results in a phenotypic female with 46,XY chromosomes and a male level of serum testosterone. Patients with this disorder will have normal breast development but a paucity of axillary and pubic hair. Pelvic ultrasound would reveal agenesis of the vagina and uterus. These patients have undescended testes (in the abdomen, inguinal canal, or labia majora) that need to be removed to prevent tumor development. They may also require surgery to create a vagina for sexual function. Estrogen therapy is usually provided to prevent osteoporosis and hot flashes and to maintain feminization. Because they do not have ovaries or a uterus, these patients will never be able to become pregnant.

It would be appropriate to say, \"She is similar to many teenage girls who do not menstruate until they are 16 and they go on to have normal reproductive lives\"(choice A) if the diagnosis is physiologic pubertal delay. Physiologic pubertal delay is characterized by primary amenorrhea, which is defined as the absence of menses by the age of 16, or 4 years after the onset of breast development. Girls with this condition have appropriate sexual maturation, normal XX chromosomes, and a normal pelvic ultrasound. The patient in this case has normal breast development, abnormal pubic hair development, male chromosomes and hormone levels, and a blind-ending vagina. She most likely has testicular feminization and will not go on to have a normal reproductive life.

It is inappropriate to say, \"This condition is very serious and she will require a bilateral mastectomy because of her increased risk of breast cancer\"(choice B) because this patient most likely has testicular feminization, which is not typically associated with an increased risk of breast cancer.

It is inappropriate to say, \"Your daughter will begin menstruating after receiving hormonal therapy and she may be able to become pregnant in the future\" (choice C) because this patient most likely has testicular feminization and will never menstruate or be able to become pregnant because she does not have a uterus.

It is inappropriate to say, \"Your daughter will begin menstruating after receiving hormonal therapy but she will not be able to conceive\" (choice D) because she most likely has testicular feminization, and will never be able to menstruate because she does not have a uterus. Hormonal therapy is indicated to prevent osteoporosis and hot flashes and to maintain feminization. Because they do not have ovaries or a uterus, these patients will never be able to become pregnant.", //7 "The correct answer is C. As a general rule, when a patient tells you that they are using an illegal drug or a questionable alternative treatment, it is best to dissuade them by recommending a better alternative, rather than criticizing them. Simply put, don\'t argue with their practice, instead, suggest something better.

\"Are you aware that marijuana use has been associated with respiratory problems?\" (choice A) and \"I have read about other patients doing that; however, do you really think that using an illegal drug is a good idea?\" (choice D) are not the best responses because they are both a bit critical and argumentative. Ideally, you should try to dissuade patients from questionable practices, not by criticizing the practices, but by recommending better alternatives.

\"I am sorry, but I am going to have to call the police and turn you in.\" (choice B) and \"That is against the law, and you must stop at once!\" (choice E) are not the best responses because while marijuana is illegal, it is not the physician\'s responsibility to enforce the law. The patient\'s comfort is most important and his/her interest comes first. Also, being combative will typically alienate the patient, which is not a good way to maintain a physician-patient relationship. If you are critical and combative your patients will be reluctant to tell you about their use of these practices (if they come back to you at all).", //8 "The correct answer is E. This patient most likely has acute angle-closure glaucoma, which is an ocular emergency that requires immediate treatment to prevent blindness. It is characterized by a rapid increase of IOP, often occurring when the pupil is dilated (such as in a dark movie theater). The symptoms include severe eye pain, blurry vision, a headache, and nausea and vomiting. The physical examination usually shows a tender, firm eye with conjunctival hyperemia, lid edema, a hazy cornea, and a fixed, mid-dilated pupil. Immediate treatment includes mannitol (to reduce vitreous volume), acetazolamide and topical beta-blockers, such as timolol (to block aqueous production), and pilocarpine (to facilitate aqueous outflow). Ophthalmologic consultation should be sought as soon as possible. A peripheral laser iridectomy is the definitive procedure and is usually performed after the IOP is controlled.

A CT scan of the head (choice A) is indicated in the evaluation of papilledema, not acute angle-closure glaucoma. Papilledema, which is optic disc swelling caused by elevated intracranial pressure, typically presents with a headache, nausea and vomiting, and transient visual obscurations.

A lumbar puncture (choice B) is performed after a CT scan of the head as part of the evaluation of papilledema, not acute angle-closure glaucoma. If the CT scan is normal and the opening pressure is elevated the most likely diagnosis is pseudotumor cerebri. This typically affects young, obese women and is treated with weight reduction and acetazolamide.

A peripheral iridotomy (choice C) is the definitive procedure for acute angle-closure glaucoma, but it is usually performed after the IOP is controlled with mannitol, acetazolamide, timolol, and pilocarpine.

Corticosteroids (choice D) are not typically included in the initial management of acute angle-closure glaucoma and they are contraindicated in patients with dendritic herpetic ulcers.", //9 "The correct answer is E. Physicians must violate confidentiality and warn third persons about the danger of HIV infection if the patient is unwilling to inform the person himself. Before informing third parties, the physician should try to do everything possible to persuade the patient to voluntarily discuss the issue with their partner. If the physician believes that an individual may really be saved from a deadly infection, confidentiality should be violated.

It is inappropriate to contact his wife anonymously and tell her that she has been exposed to HIV (choice A). First, it is best to try to persuade him to voluntarily discuss the issue with his wife. If this is unsuccessful, the physician has the duty to violate confidentiality.

It is necessary to contact the appropriate government health agency and report your findings (choice B) so that they can track patient contacts; however, it is best to first try to persuade the patient to voluntarily discuss the issue with his partners himself. It is still necessary to notify the appropriate health agency, even if the patient agrees to tell his wife.

You cannot promise him that as his doctor you will respect his privacy and maintain confidentiality (choice C) or promise him that you will keep the results confidential if he agrees to use condoms with his wife (choice D) because you have the duty to warn third parties about the HIV infection. HIV and AIDS are infectious diseases designated as notifiable at the national level.", //10 "The correct answer is C. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin. The disease is characterized by a high fever for longer than 5 days, bilateral

conjunctival injection, fissured lips, a \"strawberry tongue\", mucosal change in the oral pharynx, erythematous and edematous palms and soles with desquamation, a polymorphous rash, cervical lymphadenopathy, an elevated erythrocyte sedimentation rate, and thrombocytosis. The most important complication is coronary artery aneurysms, which may be prevented by early treatment with aspirin and intravenous gammaglobulin. An echocardiogram is necessary to evaluate cardiac involvement.

Corticosteroids (choice A) are not used to treat Kawasaki disease. They may be used to treat some of the symptoms in severe Henoch-Schonlein purpura (HSP), which is a vasculitis involving kidneys, gastrointestinal tract, skin, and joints. Individuals with HSP typically have a rash on the lower extremities and buttocks.

Ibuprofen (choice B) is not the most appropriate therapy at this time. This patient most likely has Kawasaki disease, which is treated with aspirin and intravenous gammaglobulin.

Oxacillin (choice D) is used to treat staphylococcal scalded skin syndrome (SSSS), not Kawasaki disease. SSSS is characterized by fever, malaise, periorbital edema, and a generalized, fine, erythematous rash. With gentle rubbing, the epidermal layer of the skin may exfoliate. It is usually preceded by an upper respiratory infection. Thrombocytosis is generally not present.

Penicillin V (choice E) is the treatment for scarlet fever, not Kawasaki disease. Scarlet fever usually presents with an erythematous sandpaper-like rash with fever and a \"strawberry\" tongue. It is typically associated with streptococcal pharyngitis. Desquamation may occur. It is usually not associated with bilateral conjunctivitis, fissured lips, or thrombocytosis.", //11 "The correct answer is C. Since isotretinoin (Accutane) is teratogenic, before prescribing it to a female patient, the patient must have 2 negative pregnancy tests, 1 in the physician\'s office and 1 on the second day of her next period or 11 days after her last unprotected intercourse, whichever is later. A prescription for isotretinoin can be given only after these 2 separate tests. The patient must also be using 2 types of birth control methods for 1 month before starting treatment and for at least 1 month following discontinuation of the medication. Isotretinoin is only indicated in cases of severe recalcitrant nodular acne.

It is inappropriate to check her records for previous lipid, CPK, and glucose levels and liver function tests; if normal give her a prescription for isotretinoin (choice A). First of all, the most important test is the pregnancy test. And while isotretinoin has been observed to effect lipids, CPK, LFTs, and glucose, it is probably best to obtain current pretreatment values.

It would be wrong to do a urine pregnancy test and if negative give her a prescription for isotretinoin (choice B). Patients must have 2 negative pregnancy tests before starting isotretinoin.

You must get 2 negative pregnancy test, in addition to obtaining normal lipid, CPK, and glucose levels and liver function tests before giving her a prescription for isotretinoin (choice D).

A pelvic ultrasound (choice E) is not performed before starting isotretinoin. Two negative urine pregnancy tests are enough.", //12 "The correct answer is B. Decreased night vision has been reported by patients taking isotretinoin. It is important to tell patients to be cautious when driving or operating any vehicle at night.

Some patients taking isotretinoin have had elevated CPK levels after vigorous physical activity. Also, up to 16% of patients have experienced musculoskeletal symptoms, such as arthralgia. However, it is not appropriate to tell her to avoid all physical activity (choice A). It is best if she informs you of any planned vigorous physical activity, and you can make management decisions based on the specifics.

Patients must use 2 separate and effective forms of contraception when taking isotretinoin, therefore it is inappropriate to tell her to make sure to use 1 form of birth control; it should be an effective one, such as an injectable/implantable contraceptive product (choice C).

Patients taking isotretinoin cannot donate blood during treatment and for 1 month after discontinuing the drug. Telling her that she can donate blood at 3 weeks after discontinuation (choice D) is incorrect. This rule is to make sure that if a pregnant woman needs a blood transfusion, her fetus is not exposed to the drug.

Patients taking isotretinoin should be advised not to take vitamin-A containing supplements because of the additive toxic effects that can occur because of the drugs relationship to vitamin A. It is incorrect to tell her to take a multivitamin with vitamin A (choice E).

To avoid scarring, patients taking isotretinoin should be advised not to wax or have any skin resurfacing procedures done during and up to 6 months after treatment. Telling her to wax instead of shaving her legs and underarms (choice F) is incorrect. ", //13 "The correct answer is D. This patient most likely has schizoaffective disorder, which is characterized by a mood disorder and separate psychotic symptoms. The individual must have at least 2 weeks of delusions or hallucinations in the absence of prominent mood symptoms. Mania or depression may be present. This patient has hallucinations, delusions, and disorganized behavior, which are suggestive of schizophrenia; however the presence of the depressive symptoms makes schizoaffective disorder the diagnosis.

A brief psychotic disorder (choice A) is characterized by delusions, hallucinations, disorganized speech and behavior for more than 1 day but less than 1 month. This patient\'s symptoms have been present for longer than a month and she has intermittent and prominent depressive symptoms.

Delusional disorder (choice B) is the presence of non-bizarre delusions for more than a month. The belief that one is being followed is a common symptom. The patient in this case is having bizarre delusions.

Major depressive disorder (choice C) is characterized by a major depressive episode, which is associated with a depressed mood, sleep disturbances, feelings of guilt, fatigue, a change in appetite, psychomotor agitation or retardation, and suicidal thoughts. Psychotic features may be present, however they resolve when the mood disorder has resolved. The patient in this case has the psychotic symptoms in the absence of the depressive symptoms.

Schizophrenia (choice E) is characterized by the presence of psychotic symptoms and functional impairment for at least 6 months. Unusual thoughts, perceptions, and behaviors are called positive symptoms, while social withdrawal, a flat affect, and lack of energy are called negative symptoms. The presence of positive and negative symptoms for 6 months in the absence of a mood episode is schizophrenia. The patient is this case has positive and negative symptoms but also has major depressive episodes, which is consistent with schizoaffective disorder.

Schizophreniform disorder (choice F) is characterized by the presence of delusions, hallucinations, disorganized speech and behavior, without a mood episode, that lasts between 1 month and 6 months. This patient has had these symptoms for longer than 6 months and had depressive episodes.", //14 "The correct answer is B. The symptoms of change in appetite, fatigue, insomnia, lack of concentration, and worthlessness for greater than 2 weeks are consistent with depression. Propranolol is one of the most common pharmacological agents to cause depression. Other side effects of propranolol include dizziness, bronchospasm, nausea, vomiting, diarrhea, and constipation. It may also precipitate asthma, congestive heart failure, and hypoglycemia in susceptible patients. The patient should be switched to another antihypertensive agent.

Just advising her to start a \"gentle\" walking routine to \"lift her spirits\" (choice A) is inappropriate because she is having real depressive symptoms that are most likely due to the propranolol.

It is inappropriate to explain to the patient that she is stressed about her trip, and these symptoms will pass (choice C). She is obviously having real symptoms that require serious attention, and in this case the depressive symptoms are most likely due to propranolol.

It is inappropriate to give her a prescription for tranylcypromine (choice D) because her depressive symptoms are most likely due to propranolol. Also, tranylcypromine, which is an MAOI, is not the best first choice for an antidepressive agent due to the necessary dietary restrictions and the risk of orthostatic hypotension. If you were going to give her an antidepressant, an SSRI or a tricyclic, such as nortriptyline, is better because of the relatively low risk of orthostatic hypotension or anticholinergic effects.

Since propranolol is most likely causing her depressive symptoms, it is incorrect to increase the dose of propranolol and prescribe phenelzine (choice E). Also, phenelzine, which is an MAOI, is not the best first choice for an antidepressive agent due to the necessary dietary restrictions and the risk of orthostatic hypotension", //15 "The correct answer is E. This patient has the classic presentation of testicular torsion, which is a surgical emergency, and therefore requires an immediate urologic consultation. He requires surgical intervention to reverse the spermatic cord torsion and restore blood flow.

Antibiotics, such a ciprofloxacin (choice A) are necessary to treat epididymitis, which typically presents with scrotal pain, fever, pyuria, a tender cord, and a normally positioned testes. Elevation of the testes may somewhat relieve the pain. Ice packs, bed rest, antiinflammatory agents, and scrotal support are typically used in conjunction with the antibiotics.

Applying ice packs and observing in the emergency department (choice B) is inappropriate management of testicular torsion, which requires immediate urologic consultation.

Measuring serum HCG and AFP (choice C) is part of the evaluation for testicular cancer, which typically presents as a painless mass. If tenderness is present, it is often dull and aching, rarely acute and \"exquisitely painful.\"

Performing a trans-scrotal testicular biopsy (choice D) is not useful in testicular torsion, which is a surgical emergency, and therefore requires an immediate urologic consultation. A trans-scrotal testicular biopsy, which some may use in testicular cancer, is often avoided to prevent potential tumor contamination of the lymphatics. ", //16 "The correct answer is C. This patient is most likely experiencing a normal and expected grief reaction to the loss of his wife. It is normal to have intense feelings of loss, a decreased enjoyment of activities, frequent crying spells, and a \"sad\", depressed mood. Minor dysfunction may occur, but it is not pronounced or persistent. It often diminishes with time and is not associated with suicidal ideation or psychotic symptoms.

It is inappropriate to say, \"It seems like you are experiencing a major depressive episode that we can treat with fluoxetine\" (choice A) because he is experiencing normal grief. A major depressive episode would be the diagnosis if he has marked functional impairment, psychomotor retardation, a preoccupation with worthlessness, suicidal ideation, or psychotic symptoms.

It is inappropriate to say, \"Let\'s see how you feel in a few weeks and we will discuss the most appropriate treatment then\" (choice B) because he needs reassurance right now, not in few weeks.

\"You have an adjustment disorder that should be treated with psychotherapy\" (choice D) is wrong because he is most likely having a normal grief reaction, not an adjustment disorder. An adjustment disorder is an abnormal, maladaptive response to a stressor that leads to significant functional impairment and extreme sadness and stress. It is similar to depression, but it does not meet the criteria for a major depressive episode. The patient in this case is \"sad\" and has normal feelings of loss. He is able to go to work and go out with friends and family and therefore, does not have an adjustment disorder.

You should not say to him, \"You should have your friends set you up with a widowed woman who will understand you\" (choice E). It is not the physician\'s place to give advice as to when he should start dating again; that should happen when he is ready. Support groups, family, and friends may be helpful during these difficult times.", //17 "The correct answer is A. Numerous studies demonstrate that the use of oral contraceptive pills (OCPs) decreases a woman\'s likelihood of developing ovarian cancer. One theory to explain the decreased ovarian cancer risk is that the OCPs provide hormones that inhibit the hormonal suppression by the pituitary, which then decreases the amount of gonadotropins that are produced and helps to suppress monthly ovarian germinal capsule disruptions caused by ovulation. Some other studies suggest that factors that increase the risk of developing ovarian cancer are nulliparity and the use of postmenopausal replacement therapy and ovulation-inducing drugs. These findings are controversial.

Periodic pelvic sonograms (choice B and C) are not recommended to screen asymptomatic women for ovarian cancer. Also, OCPs have been shown to decrease a woman\'s risk for ovarian cancer. Nulliparity may be associated with an increased risk, and obesity is not typically associated with ovarian cancer.

She should not consider having a hysterectomy and bilateral oophorectomy because there is a good chance that she will not develop the disease due to the fact that she took OCPs, never had children, and is overweight (choice D). A prophylactic hysterectomy and bilateral oophorectomy is not indicated in this woman with no family history of disease. OCPs have been shown to decrease a woman\'s risk for ovarian cancer. Nulliparity may be associated with an increased risk, and obesity is not typically associated with ovarian cancer.

She should not take hormonal replacement therapy when she reaches menopause to decrease her risk of developing the disease (choice E) because hormonal replacement therapy does not decrease the risk. ", //18 "The correct answer is A. This asymptomatic 42-year-old woman should be advised to floss daily and brush her teeth with a fluoride-containing toothpaste. Recommended screening tests include measurement of blood pressure and BMI, and a Pap smear for all women who are or have been sexually active, every 1-3 years until 65, if consistently normal. Counseling about smoking, alcohol, exercise, and fat consumption is recommended. Measurement of total serum cholesterol may be prudent. .

The U.S. Preventive Services Task Force states that there is insufficient evidence to recommend for or against the routine screening for suicidal intent (choice B) in asymptomatic patients. Physicians should definitely ask depressed patients about suicidal ideation, however, not asymptomatic patients at a periodic health maintenance examination

A flexible sigmoidoscopy (every 2-3 years) and/or annual fecal occult blood testing (choice C) is recommended for all patient beginning at age 50.

A mammogram (choice D) is recommended for women beginning at age 50. Women at high risk for breast cancer may begin mammography at an earlier age.

The U.S. Preventive Services Task Force states that there is insufficient evidence to recommend for or against routine aspirin (choice E) prophylaxis for the primary prevention of myocardial infarction (MI) in asymptomatic persons. It may be considered in men over 40 who are at an increased risk for developing a myocardial infarction and who lack contraindications for aspirin use.", //19 "The correct answer is E. This patient has allergic contact dermatitis, which is a type IV hypersensitivity reaction that is characterized by the release of lymphokines from sensitized lymphocytes reacting with antigens. It is a cell-mediated reaction that does not require antibody formation. The antigen in this case is the nickel in her wedding band. The nickel is typically drawn out of the ring by water, sweating, or detergent. Even good quality rings may contain nickel.

Antibody-mediated cytotoxic reaction to cell surface antigens (choice A) is the mechanism for pernicious anemia, not contact dermatitis.

Antigen-antibody complexes formed in the vessels in response to an antigen (choice B) is the mechanism for autoimmune diseases, such as rheumatoid arthritis and lupus, not contact dermatitis.

Fixation of complement results in osmotic lysis of antibody-coated cell (choice C) is the mechanism for autoimmune-hemolytic anemia, not contact dermatitis.

Release of histamine from basophils after antigen interaction with Fc-receptor bound IgE (choice D)

is the mechanism for atopy and asthma, not contact dermatitis.", //20 "The correct answer is A. This patient has contact dermatitis, which should be treated with a high-potency fluorinated topical glucocorticoid. Since she already stopped wearing her ring, which is the most likely offending agent, a topical steroid will help to relieve the symptoms.

Oral prednisone (choice B) is used for widespread allergic contact dermatitis, or if it involves the face or genitals. It should not be used as a first-line treatment for localized disease.

Topical coal tar (choice C) and/or salicylic acid (choice D) are used to treat seborrheic dermatitis, not allergic contact dermatitis. Seborrheic dermatitis is characterized by erythema and greasy yellow-brown scales. The scalp and eyebrow are the most common sites.

0.5% permethrin cream (choice E) is the treatment for scabies, which is an ectoparasitic infestation that causes a rash and itching that is worse at night and after a hot shower. Burrows are typically present and appear as wavy lines that end in a pearly bleb. Scraping the burrows and examining the scrapings under the microscope reveals the mite, its eggs, or pellets. It is highly contagious and often involves other members of the household.", //21 "The correct answer is E. This procedure will most likely improve the patient\'s near term morbidity. The larger issue of providing tube feeding for severely demented patients is currently a topic under much debate. In addition to this patient\'s dementia, he has objective evidence that he aspirates when taking oral food. Patients such as this are one of the most common groups of patients given gastric or jejunal feeding tubes. Because this patient\'s primary problem is upper esophageal dysmotility and/or poor airway reflexes, a feeding tube placed in the stomach will only be of benefit if the patient does not regurgitate. If food travels retrograde through the lower esophageal sphincter and makes it to the mouth, the patient will be at the same risk of aspiration. However regurgitation is less frequent when food is given via a gastric tube, therefore this patient\'s short-term prognosis is improved.

Although some patients get gastric tubes to augment nutritional intake, most, like this patient do because of the inability to take oral food. Therefore it will not the patient to take oral as well as tube-based foods (choice A).

Based on the above discussion, feeding via the gastric tune tube does not eliminate the risk of aspiration (choice B). Once particulate matter makes it into the oropharynx, aspiration will likely occur.

Also as discussed above, since food is not being given orally, the only way in which a patient can aspirate with a gastric tube is to have regurgitation . Therefore, this mode of feeding does reduce the risk of aspiration, making the statement that it will have no effect on the risk of aspiration incorrect (choice C).

Because nutrition is such a fundamental component of long-term prognosis, this patient will only worsen with time since gastric feedings are no substitute for intake a variety of foodstuffs. Therefore, long-term mortality continues to be unaltered with tube feedings (choice D).", //22 "The correct answer is D. This patient\'s respiratory distress is most likely due to regurgitation and aspiration of gastric-tube infused tube feedings. As discussed above, a gastric tube does not eliminate the risk of aspiration. Because this patient\'s primary problem is upper esophageal dysmotility and/or poor airway reflexes, a feeding tube placed in the stomach will only be of benefit if the patient does not regurgitate. If food travels retrograde through the lower esophageal sphincter and makes it to the mouth, the patient will be at the same risk of aspiration.

Although this patient is demented, inadvertent oral consumption and aspiration of tube feedings (choice A) is unlikely given that the tube feedings are not dispensed in a manner that patients can consume them orally.

There is no evidence that this patient had previous upper airway difficulty. Therefore oropharyngeal obstruction and hypoventilation (choice B) is unlikely.

Even if the patient had obstructed, it would not explain his ongoing hypoxia and respiratory distress. Although frequently invoked to explain altered mental status in elderly demented patients, there is no evidence that this patient was a victim of over-sedation (choice C).

The time elapsed since the operation (34+ hours) makes residual hypnosis or sedation from general anesthesia (choice E) very unlikely. Again, even if this was a cause of initial apnea or hypoventilation, it does not explain the patients continued hypoxia on 100% oxygen.

Items 8-10

A 47-year-old woman was admitted to the hospital for severe abdominal pain. She has a long history of vague abdominal complaints and has been hospitalized three times in the previous 12 months for similar complaints. She has a past medical history that is also significant for hypertension and diet-controlled diabetes mellitus. Three days ago she experienced the onset of severe abdominal pain, mid-epigastric, radiating to her back. She vomited once and then slept, albeit with much discomfort overnight. The following morning she had tremendous abdominal pain after eating her breakfast, and once again vomited brown-black fluid. She called 911 and was brought to the hospital emergency department by ambulance. She reports that she has had similar symptoms in the past but other hospitals have failed to find any etiology for her pain. On exam, she is an obese woman who appears to be in mild distress. Her vital signs are unremarkable except for a temperature of 99.1 degrees F. Her abdomen is diffusely tender to palpation with guarding. ", //23 "The correct answer is C. The most appropriate diagnostic intervention at this time is to order liver function tests with amylase and lipase levels. This patient presented with the classic signs and symptoms of pancreatitis. This entity is very common on general surgical services and the presentation of the disease is actually quite varied. For this patient, her vomitus, abdominal pain, age, and recent history all suggest gallstones or gallstone pancreatitis. Therefore, a full set of liver function tests with amylase and lipase levels is indicated. One of the gravest errors that can be made in medical practice is that of \"labeling\" This patient has had multiple previous visits to the hospital with no diagnosis made.

An abdominal CT scan (choice A) may be indicated depending on the results of the screening chemistries.

HIDA-scan (choice B) is a quick and effective method for determining whether a patient has gallstones or gallbladder disease. Again, very useful if the chemistries point towards the gallbladder as the etiology for this patient\'s pain.

The tendency is to ascribe her visits to some psychological issue rather than to medically evaluate her. Therefore, offering no diagnostic intervention (choice D) is incorrect.

If chemistries suggest a hepatic or cystic cause for the pain, right upper quadrant ultrasound (choice E) would be an excellent modality to evaluate the ducts and gallbladder. ", //24 "The correct answer is D. The most appropriate management at this time is intravenous fluids and nil per os status. This patient has gallstone pancreatitis. Her amylase and lipase are elevated and a RUQ ultrasound shows stones. The standard therapy for this entity is bowel rest, hydration, and pain control as needed

A continuous infusion of intravenous opioids (choice A) is not indicated since, although the patient will have pain, it can easily be controlled with an \"on demand\" or \"as needed\" method. Continuous opiate infusions promote bowel immotility and constipation.

A daily abdominal CT scan to evaluate for pancreatic necrosis (choice B) is not routinely done. At most institutions, a CT scan is obtained a few days after diagnosis to evaluate for a worsening phlegmon or necrosis.

Intravenous antibiotics (choice C) are only indicated if there is evidence of pancreatic necrosis or the patient develops a fever after the diagnosis pancreatitis is made. There is a substantial amount of clinical literature validating this approach to treating pancreatitis.

Surgical debridement (choice E) is indicated in cases of very severe necrosis that is worsening or is suspected to be a focus for bacteremia and sepsis. ", //25 "The correct answer is B. The most appropriate management at this time is to draw blood cultures and initiate ampicillin, gentamicin, and metronidazole therapy. Intravenous antibiotics are only indicated if there is evidence of pancreatic necrosis or if the patient develops a fever after the diagnosis of pancreatitis is made. There is a substantial amount of clinical literature validating this approach to treating pancreatitis. The appropriate sequence of events is to draw blood cultures prior to initiating therapy in order to maximize chances of detecting an organism.

Drawing blood cultures and awaiting results (choice A), although partially correct, fails to address the key issue of instituting some type of therapy. The same is true for drawing blood, urine, and sputum cultures (choice C). Sending lab tests is not the same as a therapeutic intervention and a patient with pancreatitis that spikes a temperature requires intervention.

Although obtaining an abdominal CT scan (choice D) is important and should be done to assess any necrosis or progression of the phlegmon, it should not come prior to initiating antibiotic therapy.

Starting ampicillin, gentamicin, and metronidazole therapy (choice E) prior to drawing blood cultures may sterilize the blood and therefore make treatment more difficult." ); var cate_step3 = new Array("INT", "PSYCH", "PSYCH", "PSYCH", "OB/GYN", "OB/GYN", "INT", "SURGERY", "INT", "PED", "INT", "INT", "PSYCH", "PSYCH", "SURGERY", "PSYCH", "OB/GYN", "INT", "INT", "INT", "SURGERY", "SURGERY", "INT", "INT", "INT"); var cateSub_step3 = new Array("MULTI", "", "", "", "", "", "MULTI", "", "MULTI", "MULTI", "DER", "DER", "", "", "", "", "", "MUL", "DER", "DER", "", "", "GASTRO", "GASTRO", "GASTRO"); //SPECIALTIES var baseSpecs_step3 = new Array ("IM","PED","PSYCH","OB/GYN","SURGERY"); //SUBSPECIALTIES var baseSubSpecs_step3 = new Array ("MULTI","GASTRO", "HEM", "NEPH","NEURO","DER","CARDIO", "RHEUM","PULM","ENDO");