ID
A 33-year-old woman is evaluated after sustaining a needlestick puncture in an infusion clinic, where she works as a nurse. The needle was being placed for intravenous therapy and had blood on it; it is from a patient at the clinic who is known to have HIV infection and is taking antiretrovirals, but the recent viral load is unknown. The nurse has already cleaned her wound. Medical history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal, and other examination findings are noncontributory.
What is the most appropriate next step?
A. Begin tenofovir, emtricitabine
B. Begin tenofovir, emtricitabine, dolutregavir
C. Begin tenofovir, emtricitabine, ritonavir boosted darunavir
D. Determine the patients viral load
B. Begin tenofovir, emtricitabine, dolutregavir
Preferred HIV postexposure prophylaxis regimens include tenofovir disoproxil fumarate, emtricitabine, and either dolutegravir or raltegravir and are appropriate whether the exposure was occupational or nonoccupational.
A two-drug regimen for postexposure prophylaxis (compared with pre-exposure prophylaxis) is no longer recommended.
Protease inhibitors such as darunavir, whether boosted or not, are not recommended for prophylaxis because of their higher rates of adverse effects.
Because postexposure prophylaxis must begin promptly to be most effective, it would not be appropriate to wait for results of the source patient's viral load before determining therapy. The source patient should also be tested for other blood-borne pathogens, such as hepatitis B and C.
A 56-year-old man is seen during a routine evaluation for stage G4 chronic kidney disease (CKD). History is also significant for hypertension. Medications are losartan, labetalol, furosemide, and amlodipine. He has no symptoms and remains physically active.
On physical examination, blood pressure is 129/76 mm Hg, and pulse rate is 68/min; other vital signs are normal. The physical examination is otherwise unremarkable.
Laboratory studies:
Hemoglobin 11 g/dL (110 g/L)
Bicarbonate 19 mEq/L (19 mmol/L)
Creatinine 3.1 mg/dL (274 µmol/L)
Phosphorus 5.7 mg/dL (1.8 mmol/L)
Potassium 5.1 mEq/L (5.1 mmol/L)
Which of the following will most likely slow the progression of this patient's CKD?
A. ACE inhibitor
B. Erythropoeisis-stimulating agent
C. Phosphate binder
D. Sodium bicarbonate
D. Sodium bicarbonate
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend treatment of metabolic acidosis with alkali therapy in patients with chronic kidney disease when the serum bicarbonate is chronically <22 mEq/L (22 mmol/L). Untreated metabolic acidosis can lead to muscle loss and bone loss. In early CKD, metabolic acidosis is typically a normal anion gap hyperchloremic metabolic acidosis. As glomerular filtration rate (GFR) declines, organic and inorganic anions are retained, and an anion gap metabolic acidosis develops. Large observational studies have shown a strong association between lower serum bicarbonate levels and both increased progression of CKD and mortality.
Blood pressure control, particularly with renin-angiotensin system agents, has been shown to slow progression of proteinuric renal diseases and especially diabetes mellitus.
As the estimated GFR declines below 30 mL/min/1.73 m2 (stages G4-G5), anemia can become symptomatic. Erythropoiesis-stimulating agents (ESAs) are highly effective in raising hemoglobin concentrations and alleviating symptoms but have not been shown to slow progression of CKD.
Although poorly controlled hyperphosphatemia is associated with a greater risk of CKD progression, optimizing mineral metabolism parameters with a phosphate binder has not been shown to slow progression of CKD.
A 41 year old female comes to the office with an 8 month history of amenorrhea. Multiple home pregnancy tests have been consistently negative. She has mild dyspareunia and blurred vision but no headaches, galactorrhea, hot flashes or weight change. PMH and FH are unremarkable. Physical exam is unremarkable. She takes no medications. She does not use alcohol, tobacco or IV drugs. Labs show a prolactin level of 50 ng/ml (normal 5-20). Serum LH is undetectable. FSH is low normal and the alpha subunit is markedly elevated. TSH, testorone, insulin-like growth factor 1 are normal. MRI shows a 2-cm pituitary tumor with suprastellar extension.
What is the most appropriate next step?
A. Cabergoline
B. Cyclical estrogen-progesterone
C. Octreotide
D. Pituitary radiation
E. Refer to surgery for trans-sphenoidal pituitary resection
E. Refer to surgery
This patient has amenorrhea and hypogonadism with suppressed LH and FSH levels but increased alpha subunits. This is strongly suggestive of a nonfunctioning pituitary adenoma. The clinical symptoms of a nonfunctioning adenoma are usually minimal and the diagnosis is not apparent until it is large enough to cause headaches or visual disturbances. The preferred therapy is trans-sphenoidal surgery.
Dopaminergic agents are preferred for prolactin-secreting adenomas, but have no effect on gonadotropin-secreting adenomas. Prolactin levels are usually >200 ng/ml in patients with prolactinomas.
A 55-year-old woman is evaluated after screening colonoscopy showed three polyps at the rectosigmoid junction. The three polyps were 3 mm, 5 mm, and 6 mm in size. All three polyps were completely excised and pathology showed them to be hyperplastic. Colonoscopy preparation was excellent and the procedure was complete to the cecum. Family history is significant for colon cancer diagnosed in her paternal grandfather at age 80 years.
All physical examination findings, including vital signs, are normal.
When should this patient next undergo colonoscopy?
A. 1 year
B. 3 years
C. 5 years
D. 10 years
D. 10 years
This patient should undergo colonoscopy in 10 years. Serrated polyps are classified into three histologic types: hyperplastic polyps, sessile serrated polyps, and traditional serrated adenomas. Hyperplastic polyps are the most common type of serrated polyp. They are non-neoplastic and are composed of normal mucosal elements; small hyperplastic polyps, often found in the rectosigmoid colon, are believed to have no clinical significance. As a result, the interval until the next screening examination is 10 years, the same as for patients who do not have polyps found on baseline examination.
1-year surveillance interval is not appropriate for this patient. It is indicated in patients with more than 10 adenomas found on colonoscopy, those with a diagnosed polyposis syndrome, or those with Lynch syndrome.
A 3-year surveillance interval is recommended for patients who have three or more adenomas (or sessile serrated polyps) found on baseline colonoscopy, one adenoma larger than 10 mm in size, or an adenoma with any degree of villous or high-grade dysplasia.
A surveillance interval of 5 years is recommended for patients with two or fewer adenomas (or sessile serrated polyps) found on baseline colonoscopy and for patients with a first-degree relative with colon cancer diagnosed at an age younger than 60 years.
Reaching 19,340 feet, this mountain is the tallest in Africa. In what country is it located?
A. Angola
B. Ghana
C. Nigeria
D. Tanzania
E. Egypt
D. Tanzania
Kilimanjaro's majestic glacial cap of 11,000-year-old ice has long captured imaginations the world over, but the ice-capped peak is melting at an alarming rate. Within several decades, scientists predict, the glaciers will have completely disappeared.
A 45-year-old man is evaluated for a 3-day history of fever, myalgia, headache, and nonproductive cough. He works as a large-animal veterinarian. Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs are normal except for a temperature of 38.2 °C (100.8 °F). Oxygen saturation is 94% breathing ambient air. The examination is otherwise unremarkable.
A chest radiograph shows a patchy right lower lobe interstitial infiltrate.
What is the most likely organism?
A. Bacillus anthracis
B. Coxiella burnetti
C. Chlamydia psittaci
D. Francisela tularensis
E. Yersinia pestis
B. Coxiella burnetti
Community-acquired pneumonia not requiring hospitalization, is most frequently caused by atypical bacteria, Streptococcus pneumoniae, or a viral pathogen. Many zoonotic organisms can potentially cause pulmonary infection, but they can usually be differentiated based on illness severity and animal reservoir. In this patient, the relatively mild infection coupled with exposure to livestock makes C. burnetii the most likely culprit. C. burnetii, which causes Q fever pneumonia, is most frequently associated with exposure to farm animals, parturient animals in particular.
Bacillus anthracis is the causative agent of anthrax. Cutaneous anthrax is the most common naturally occurring form of the disease. In the United States, inhalation anthrax is almost exclusively of concern as an agent of bioterrorism.
Chlamydia psittaci is the causative agent of psittacosis, which typically presents as pneumonia associated with abrupt onset of fever, severe headache, and dry cough. This organism is associated with inhalation of dried bird droppings.
Pneumonic tularemia occurs either after direct inhalation or through secondary spread of Francisella tularensis into the lungs. Pneumonic tularemia is characterized by a nonproductive cough, dyspnea, and substernal or pleuritic chest pain.
Yersinia pestis infection of the lung causes pneumonic plague. Rodents serve as the primary reservoir for plague. Pulmonary infection occurs through droplet transmission from an infected host or secondary spread from an extrapulmonary source.
A 32 year old woman with SLE comes to the office for a follow up. She was diagnosed with SLE 3 years ago during evaluation of a skin rash, and joint pain. Symptoms are well controlled with hydroyxchloroquine. She takes no other medications, has no other medical conditions, no bad habits. BP is 150/90 mmHg. Temperature is 99 F, pulse is 78/min, and respirations are 14/min. There is a faint malar rash, but no mucosal ulcers, joint tenderness, or swelling. Lungs are clear. Heart sounds are normal. Abdomen soft without tenderness or organomegaly. There is mild b/l pitting edema of the lower extremities.
Labs:
Hb 10.8 g/dL
Platelets 140,000
Leukocytes 8,200
BUN 36 mg/dL
Creatinine 2 mg/dL
Urinalysis showed 2+ protein, 1-2 WBC's, 20-30 RBCs and red blood cell casts. BMP and UA were normal 2 months ago. Renal U/S shows no abnormalities.
What is the best next step in management?
A. Advise antihypertensives and close observation
B. Discontinue hydroxychloroquine and repeat labs
C. Perform ultrasonography-guided renal biopsy
D. Prescribe slow-tapering glucocorticoid therapy
E. Recommend intensive immunosuppressive therapy
C. Perform ultrasonography-guided renal biopsy
The presence of lower extremity edema, renal dysfunction, proteinuria, and active sediment in a patient with SLE raises concern for lupus nephritis. Categorized into 6 classes based on pathologic findings on biopsy. Therapy is guided by disease classification; therefore renal biopsy is indicated prior to treatment in all patients with evidence of marked proteinuria, active urinary sediment or declining renal function.
A 38-year-old woman is seen in follow-up to discuss the findings of an abdominal and pelvic CT scan done to evaluate renal colic, which has since resolved. The abdominal CT scan showed two small nonobstructing renal calculi in the right kidney and a 1.6-cm left adrenal mass with a density of 21 Hounsfield units (indeterminate for adrenal adenoma). Other than nephrolithiasis, the remainder of the medical history is unremarkable, and she takes no medications.
On physical examination, vital signs and the remainder of the examination are unremarkable.
Laboratory studies show normal serum electrolytes.
Which of the following is the most appropriate test to perform next?
A. 24 hour urine free cortisol
B. 24 hour urine free metanephrines
C. Plasma aldosterone-renin ratio
D. Serum DHEA
B. 24 hour urine free metanephrines
Biochemical testing for pheochromocytoma should be undertaken in all patients with an adrenal mass, even in the absence of typical symptoms or hypertension.
An alternative screening test for pheochromocytoma is measuring the fractionated free plasma metanephrine level.
The 24-hour urine free cortisol test is not sensitive enough to diagnose subclinical autonomous cortisol secretion from an adrenal mass.
The patient does not require screening for primary aldosteronism with a plasma aldosterone-plasma renin ratio (ARR) as she does not have hypertension.
In women, rapid onset of hirsutism, menstrual irregularities, and virilization should raise suspicion for tumoral hyperandrogenism. Measurement of dehydroepiandrosterone sulfate (DHEAS) is not indicated in this patient, as she did not show signs of hyperandrogenism (hirsutism, deep voice, male pattern balding, clitoromegaly).
A 60-year-old man is evaluated for epigastric pain that occurs intermittently after eating. He was hospitalized twice in the preceding year for idiopathic recurrent acute pancreatitis. He is a former smoker and reports no alcohol use.
On physical examination, vital signs are normal, as is the remainder of the examination.
Contrast-enhanced CT of the abdomen shows a diffusely dilated main pancreatic duct with normal intrahepatic and extrahepatic bile ducts and a normal gallbladder. No tumor is seen in the pancreas or liver, and there is no peripancreatic inflammation or necrosis. Endoscopic ultrasonography confirms no evidence of a tumor or gallstone, but the main pancreatic duct appears dilated throughout the pancreas. Mucin is seen exuding from the ampulla of Vater during the endoscopy.
Which of the following is the most appropriate next step in management?
A. Endoscopic ultrasound in 6 weeks
B. MRI abdomen
C. Oral prednisone
D. Pancreatic resection
E. RUQ ultrasound
D. Pancreatic resection
Pancreatic cysts are classified as pancreatic cystic neoplasms (the most common), nonneoplastic pancreatic cysts, and pseudocysts. The two most common pancreatic cystic neoplasms are mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs), which involve the main duct, branch ducts, or both. Most pancreatic cysts are branch-duct IPMNs. Main-duct IPMNs can be diagnosed based on diffuse dilation of the main pancreatic duct and the characteristic feature of mucin exuding from the ampulla during endoscopic visualization. Main-duct IPMNs carry a greater than 65% risk for malignant transformation. Surgical resection is the only option for treatment of these high-risk cystic lesions of the pancreas in patients who are appropriate surgical candidates.
Which country has a unicorn as its national animal?
A. Finland
B. Sweden
C. Scotland
D. Germany
E. Norway
A 19-year-old man is evaluated in the emergency department for fever, cough producing blood-tinged sputum, shortness of breath, and headache. He attended a political rally on his college campus 4 days ago. Six other people have been hospitalized with similar symptoms. Medical history is unremarkable, and he takes no medications.
On physical examination, the patient is alert and oriented. Temperature is 39.1 °C (102.4 °F), blood pressure is 98/58 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. Oxygen saturation is 92% breathing oxygen 2 L/min by nasal cannula. Neurologic examination is nonfocal, and no meningeal signs are present. Dyspnea, bilateral pulmonary rhonchi, and tubular breath sounds are noted on pulmonary examination. No rash is present, and the abdomen is nontender.
Sputum Gram stain reveals many polymorphonuclear cells and abundant gram-negative coccobacilli demonstrating bipolar staining.
A chest radiograph shows bilateral patchy infiltrates.
Most appropriate treatment?
A. Ceftriaxone and azithromycin
B. Ciprofloxacin
C. Gentamicin
D. TMP-SMX and levofloxacin
C. Gentamicin
This patient most likely has pneumonic plague caused by the bacteria Yersinia pestis, one of the biologic agents classified as an A-list bioterrorism pathogen because of its high potential lethality and ease of dissemination. Sputum Gram stain (and possibly blood smear) may identify gram-negative coccobacilli demonstrating the classic bipolar staining or “safety pin” shape shown. The most appropriate treatment is gentamicin.
A 52-year-old woman was hospitalized 3 days ago for laparoscopic resection of the sigmoid colon secondary to recurrent diverticulitis. Diet has been advanced to a full diet. She has a 20-year history of hypertension, stage G3 chronic kidney disease, and migraine headaches. Medications are amlodipine, heparin, topiramate, and as-needed intravenous morphine.
On physical examination, vital signs are normal. Mild incisional tenderness is present. The remainder of the physical examination is unremarkable.
Creatinine
Adm: 1.6 mg/dL (141.4 µmol/L)
Today: 1.9 mg/dL (168 µmol/L)
Sodium
Adm: 140 mEq/L (140 mmol/L)
Today: 138 mEq/L (138 mmol/L)
Potassium
Adm: 4.9 mEq/L (4.9 mmol/L)
Today: 5.6 mEq/L (5.6 mmol/L)
Chloride
Adm: 102 mEq/L (102 mmol/L)
Today: 110 mEq/L (110 mmol/L)
Bicarbonate
Adm: 25 mEq/L (25 mmol/L)
Today: 20 mEq/L (20 mmol/L)
Glucose
Adm: 116 mg/dL (6.4 mmol/L)
Today: 128 mg/dL (7.1 mmol/L)
Urine output during the past 24 hours is 1400 mL.
What is the most likely cause of hyperkalemia?
A. Acute kidney injury
B. Heparin
C. Hyperglycemia
D. Metabolic acidosis
E. Topiramate
B. Heparin
Hypoaldosteronism caused by heparin, inhibitors of the renin-angiotensin system, type 4 renal tubular acidosis, or primary adrenal disease can cause hyperkalemia. Both unfractionated and low-molecular-weight heparin use is associated with a decrease in aldosterone synthesis. This occurs more frequently in patients with chronic kidney disease or diabetes mellitus, or in those taking an ACE inhibitor or angiotensin receptor blocker.
In patients with metabolic acidosis caused by mineral acids (such as hydrochloric acid), buffering of intracellular hydrogen ions leads to potassium movement into the extracellular fluid to maintain electroneutrality. This does not occur with organic acids such as lactate or ketoacids. In most cases of hyperchloremic metabolic acidosis, hyperkalemia typically does not develop because there is concomitant urinary and/or gastrointestinal potassium loss.
Topiramate is a carbonic anhydrase inhibitor. Carbonic anhydrase inhibition results in proximal bicarbonate, sodium, and chloride urinary loss. The increased sodium loss causes hypovolemia and triggers secondary hyperaldosteronism, promoting potassium loss and hypokalemia.
Major underlying causes of persistent hyperkalemia are disorders in which urine potassium excretion is impaired. This can be due to a marked decrease in glomerular filtration rate, decreased sodium delivery to the distal potassium secretory sites, and hypoaldosteronism. This patient is not oliguric.
Extreme elevations in glucose by increasing serum osmolality can directly cause hyperkalemia by pulling water from the intracellular space into the extracellular space, dragging potassium with it. This patient's glucose is only mildly elevated and would have little effect on osmolality and hyperkalemia.
A 20 year old female is referred to your office by her pediatrician who followed her for idiopathic hypoparathyroidism for 4 years. She takes vitamin D 50,000 units with 1.5 g of elemental calcium daily. She denies any symptoms. Physical exam is unremarkable, including a negative Chvosteks signs. Labs show a calcium level of 7.8 mg/dL, and phosphorous is 5.2 mg/dL. 24 hour urinary calcium is 680 mg.
What is the next best step in the management of this patient?
A. Change vitamin D (calciferol) to 1,25-dihydroxyvitamin D (calcitriol)
B. Decrease elemental calcium to 500 mg/day
C. Add a thiazide diuretic
D. Continue the same management
E. Increase calcium supplementation to 3 g/day
C. Add a thiazide diuretic
Patients with chronic hypoparathyroidism are managed by giving them high doses of vitamin D and calcium. The usual dose of vitamin D varies from 25,000 units to 100,000 units per day. High doses are required due to defective conversion of 25-hydroxyvit D to 1,25-dihydroxyvit D in the kidneys resulting from low PTH levels. Those dose of vit D and calcoum ia adjusted to keep calcium between 8.5-9. However, many patients will have an increase in urinary calcium due to low PTH. In patients with borderline low serum calcium and high urinary calcium, thiazide diuretics are added to decrease urinary calcium and increase serum levels.
A 62-year-old man comes to the office due to a 2 month history of progressive exertional dyspnea and fatigue. He consumes a balanced diet and does not use tobacco, alcohol or illicit drugs. Physical exam shows mucosal pallor. Stool testing for occult blood is positive. Labs are as follows:
Hemoglobin 8.6 g/dL
MCV 70
Platelets 400,000
Leukocytes 8,200
Colonoscopy reveals several small, flat, cherry-red lesions in the right colon but is otherwise normal. EGD and capsule endoscopy are normal.
The likely cause of this patient's anemia is most strongly associated with which of the following?
A. Dermatomyositis
B. End-stage renal disease
C. Primary sclerosing cholangitis
D. Seronegative spondyloarthritis
E. Tricuspid valve regurgitation
B. End-stage renal disease
Angiodysplasias are vascular anomalies composed of aberrant blood vessels in the GI tract. A frequent cause of occult GI bleeding, angiodysplasias are most common in patients age >60 and are often discovered incidentally on endoscopy, appearing as small, cherry-red lesions.
Only a small percentage of angiodysplasias bleed; however bleeding rates are higher with end-stage renal disease, aortic stenosis and von Willebrand disease as these conditions most likely cause a bleeding diathesis that leads to more frequent GI bleeding from malformed vessels.
Which country invented bread?
A. Mexico
B. France
C. Spain
D. Egypt
E. Turkey
D. Egypt
Bread was invented in Egypt around 8,000 BC. The first examples of it were flat and unleavened, most closely resembling what we know today as chapatis in India or tortillas in Latin America.