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Urgent and Emergency Care
Endocrinology
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100
Which one of the following confirmed findings in a 3-year-old female is diagnostic of sexual abuse? A. Bacterial vaginosis B. Genital herpes C. Gonorrhea D. Anogenital warts E. Hepatitis
Gonorrhea The diagnosis of any sexually transmitted or associated infection in a postnatal prepubescent child should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical inquiry, and testing for other common sexually transmitted diseases. Gonorrhea, syphilis, and postnatally acquired Chlamydia or HIV are virtually diagnostic of sexual abuse, although it is possible for perinatal transmission of Chlamydia to result in infection that can go unnoticed for as long as 2–3 years. Although a diagnosis of genital herpes, genital warts, or hepatitis B should raise a strong suspicion of possible inappropriate contact and should be reported to the appropriate authorities, other forms of transmission are common. Genital warts or herpes may result from autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact. Bacterial vaginosis provides only inconclusive evidence for sexual contact, and is the only one of the options listed for which reporting is neither required nor strongly recommended.
100
An asymptomatic 3-year-old male presents for a routine check-up. On examination you notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the examination is normal. What is the most likely diagnosis? A: small VSD B: Still's murmur C: Subaortic stenosis D: PDA
Still’s murmur There are several benign murmurs of childhood that have no association with physiologic or anatomic abnormalities. Of these, Still’s murmur best fits the murmur described. The cause of Still’s murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall.
100
A 16-year-old male presents to urgent care with a severe sore throat and has been running a fever of 102 degrees F. What physical exam finding would be most specific for peritonsillar abscess? A: Difficulty opening the mouth B: voice change C: Otalgia D: Odynophagia
Difficulty opening his mouth Trismus is almost universally present with peritonsillar abscess. Voice change, otalgia, and odynophagia may or may not be present with peritonsillar abscess. Pharyngotonsillitis and peritonsillar cellulitis may also be associated with these complaints. Otalgia is common with peritonsillar abscess, otitis media, temporomandibular joint disorders, and a variety of other conditions. Peritonsillar abscess is rarely present without at least a 3-day history of progressive sore throat.
100
What medication most increases insulin sensitivity in an overweight patient with diabetes mellitus? A. Metformin (Glucophage) B. Acarbose (Precose) C. Glyburide (DiaBeta, Micronase) D. NPH insulin
Metformin (Glucophage) Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This means lower insulin levels achieve the same level of glycemic control, and may be one reason that weight changes are less likely to be seen in diabetic patients on metformin. Acarbose is an α-glucosidase inhibitor that delays glucose absorption.
100
In a 34-year-old primigravida at 35 weeks' gestation, which one of the following supports a diagnosis of MILD preeclampsia rather than severe preeclampsia? A. A blood pressure of 150/100 mm Hg B. A 24-hr protein level of 6 g C. A platelet count <100,000/mm3 D. Liver enzyme elevation with epigastric tenderness E. Altered mental status
A blood pressure of 150/100 mm Hg The criteria for severe preeclampsia is: ● blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include ● proteinuria above 5 g/24 hr ● thrombocytopenia with a platelet count <100,000/mm3 ● liver enzyme abnormalities ● epigastric or right upper quadrant pain ● alteration of mental status.
200
A 9-month-old male is seen for a routine well-baby examination. There have been no health problems and developmental milestones are normal. Review of the growth chart shows that length, weight, and head circumference have continued to remain at the 75th percentile. The examination is normal with the exception of the anterior fontanelle being closed. Proper initial management would be: A: Genetic testing B: serial head circumference measurements C: CT scan D: Referral to Neurosurgeon
Serial measurement of head circumference The anterior fontanelle in the newborn is normally 0.6–3.6 cm, with the mean size being 2.1 cm. It may actually enlarge the first few months, but the medial age of closure is 13.8 months. The anterior fontanelle closes at 3 months in 1% of cases, and by 1 year, 38% are closed. While early closure of the anterior fontanelle may be normal, the head circumference must be carefully monitored. The patient needs to be monitored for craniosynostosis (premature closure of one or more sutures) and for abnormal brain development. When craniosynostosis is suspected, a skull radiograph is useful for initial evaluation. If craniosynostosis is seen on the film, a CT scan should be obtained.
200
You perform a health maintenance examination on a 2-year-old white male. He is asymptomatic and is meeting all developmental milestones. The only significant finding is a grade 3/6 diastolic murmur heard at the right upper sternal border. Which one of the following would be most appropriate at this time? A: Referral to Pediatric Cardiology B: Echocardiography C: Follow-up in 2 months for reassessment D: Reassurance that this is a benign finding that should resolve
Referral to a pediatric cardiologist Children who have a murmur that is diastolic or is greater than 2/6 should be referred for cardiovascular evaluation, perhaps after an echocardiogram is obtained. Other reasons for referral include cardiac symptoms, abnormal splitting of S2, a murmur that increases on standing, a holosystolic murmur, or ejection clicks. Digoxin is not indicated at this point in this asymptomatic patient.
200
When presenting with appendicitis, patients over the age of 65 are more likely than younger patients to have? A: Perforation B: elevated WBC C: Fever D: Rebound tenderness
Perforation Older patients with appendicitis are more likely to present without classic signs and symptoms. Elevated WBC counts, rebound tenderness, guarding, and fever are less reliably seen. As a result of delays in diagnosis, perforation is found in over 65% of elderly patients at the time of diagnosis.
200
A healthy 72-year-old female comes to your office for a follow-up visit. She has hypertension which is well controlled with an ACE inhibitor. Routine laboratory tests are normal except for a serum calcium level of 10.8 mg/dL (N 8.5–10.5). A repeat calcium level is 11.1 mg/dL. Which one of the following would be most appropriate at this point? A. Radiographs of the hands B. An osteocalcin level C. An intact parathyroid hormone (PTH) level D. Bone densitometry
An intact parathyroid hormone (PTH) level In primary hyperparathyroidism, hypercalcemia is the result of excessive PTH secretion by one or more abnormal, enlarged parathyroid glands. Laboratory findings in most patients with primary hyperparathyroidism reflect the mild clinical presentation of the disorder. The serum calcium level is often 1 mg/dL or more above the upper limits of normal. Bone radiographs may show the classic changes of subperiosteal bone resorption in the occasional patient with hyperparathyroidism, but in most cases they are normal or may show osteopenia. Osteocalcin is an osteoblast-specific protein. It is a marker of increased skeletal turnover, and it is usually not indicated clinically. The development of highly sensitive and specific assays for intact, largely active PTH has simplified the assessment of parathyroid activity. Bone densitometry is a test to determine the degree of osteoporosis.
200
A 25-year-old female at 36 weeks gestation presents for a routine prenatal visit. Her blood pressure is 118/78 mm Hg and her urine has no signs of protein or glucose. Her fundal height shows appropriate fetal size and she says that she feels well. On palpation of her legs, you note 2+ pitting edema bilaterally. Which one of the following is true regarding the appropriate next step in management? A: She should have daily blood pressure checks B: Her leg swelling requires no further intervention C: She should be counseled on induction of labor if she does not naturally go into labor by 38 weeks D: Consider an echo to evaluate for cardiomyopathy
Her leg swelling requires no further evaluation Lower-extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower-extremity edema with no signs of elevated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient’s presentation, as are cardiac or renal conditions.
300
A small child with failure to thrive is found to have a bone age that is markedly delayed relative to height age and chronologic age. The most likely etiology is: A: trisomy 21 B: Cystic fibrosis C: hypothyroidism D: maternal substance abuse
Hypothyroidism Hypothyroidism is associated with markedly delayed bone age relative to height age and chronologic age. In cystic fibrosis, bone age and height age are equivalent, but both lag behind chronologic age. Children with chromosomal anomalies such as trisomy 21 (Down syndrome) or XO have a height age which is delayed relative to bone age. This pattern is also seen as a result of maternal substance abuse.
300
In a patient who presents with symptoms of acute myocardial infarction, which one of the following would be an indication for thrombolytic therapy? A. New-onset ST-segment depression B. New-onset left bundle branch block C. New-onset first degree atrioventricular block D. New-onset Wenckebach second degree heart block E. Frequent unifocal ventricular ectopic beats
New-onset left bundle branch block In patients with ischemic chest pain, the EKG is important for determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads. In a patient with an MI, new left bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not infarction – they will show ST-segment depression only. Frequent unifocal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy.
300
A 67-year-old Hispanic male comes to your office with severe periumbilical abdominal pain, vomiting, and diarrhea which began suddenly several hours ago. His temperature is 37.0 degrees C (98.6 degrees F), blood pressure 110/76 mm Hg, and respirations 28/min. His abdomen is slightly distended, soft, and diffusely tender; bowel sounds are normal. Other findings include clear lungs, a rapid and irregularly irregular heartbeat, and a pale left forearm and hand with no palpable left brachial pulse. Right arm and lower extremity pulses are normal. Urine and stool are both positive for blood on chemical testing. His hemoglobin level is 16.4 g/dL (N 13.0–18.0) and his WBC count is 25,300/mm3 (N 4300–10,800). The diagnostic imaging procedure most likely to produce a specific diagnosis of his abdominal pain is: A. Intravenous pyelography (IVP) B. Sonography of the abdominal aorta C. A barium enema D. Celiac and mesenteric arteriography E. Contrast venography
Celiac and mesenteric arteriography The sudden onset of severe abdominal pain, vomiting, and diarrhea in a patient with a cardiac source of emboli and evidence of a separate embolic event makes superior mesenteric artery embolization likely. In this case, evidence of a brachial artery embolus and a cardiac rhythm indicating atrial fibrillation suggest the diagnosis. Some patients may have a surprisingly normal abdominal examination in spite of severe pain. Microscopic hematuria and blood in the stool may both occur with embolization. Severe leukocytosis is present in more than two-thirds of patients with this problem. Diagnostic confirmation by angiography is recommended. Immediate embolectomy with removal of the propagated clot can then be accomplished and a decision made regarding whether or not the intestine should be resected. A second procedure may be scheduled to reevaluate intestinal viability.
300
A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central hypothyroidism secondary to a pituitary adenoma. The nurse practitioner in your office orders a TSH level, which is found to be 0.1 mIU/mL (N 0.5-5.0). She asks you what you would you recommend? A: Adjust her Synthroid dosing B: Order a free T4 C: Repeat head imaging to ensure that the adenoma has not expanded D: TRH stimulation test
Order a free T4 level before adjusting the dose of Levothyroxine Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory findings are a low serum free T4 and a low TSH. A free T4 level is needed to evaluate the proper dosage of replacement therapy in secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in secondary hypothyroidism since the pituitary is malfunctioning. In the initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to stimulation. It is not necessary in this case, since the diagnosis has already been made.
300
A 32-year-old white female at 16 weeks' gestation presents to your office with right lower quadrant pain. Which one of the following imaging studies would be most appropriate for initial evaluation of this patient? A: Ultrasound B: CT scan C: Imaging is not safe for this patient
Ultrasonography of the abdomen CT has demonstrated superiority over transabdominal ultrasonography for identifying appendicitis, associated abscess, and alternative diagnoses. However, ultrasonography is indicated for the evaluation of women who are pregnant and women in whom there is a high degree of suspicion for gynecologic disease.
400
The mother of a 5-day-old white male brings the infant to your office because of profuse bleeding from his circumcision site. A plastibell technique was used, and the bell is partially on. The mother reports that there was some scrotal bruising after the procedure. The remainder of the pre- and postnatal history is unremarkable. The infant appears healthy and vigorous. There is no heart murmur. Capillary refill is good. There is no bruising and no petechiae. Laboratory Findings Hematocrit 54% (N 41–65) Hemoglobin 18.0 g/dL (N 13.4–19.8) WBCs 14,000/mm3 (N 6000–17,500) Platelets 278,000/mm3 (N 150,000–400,000) Prothrombin time 12 sec (N 10–16) Activated partial pro- thrombin time 87 sec (N 31–54) Which one of the following is most likely to be deficient? A: Factor IX B: Factor VIII C: Antithrombin III deficiency D: Protein C
Factor VIII level Hemophilia is X-linked and occurs in approximately 1 in 5000 male births, with 85% having factor VIII deficiency (hemophilia A) and the remaining 15% having factor IX (hemophilia B) and factor XI (hemophilia C) deficiency. Because factor VIII does not cross the placenta, bleeding symptoms may be present from birth, with the most dreaded manifestation being intracranial hemorrhage. About 30% of affected male infants will bleed from the circumcision site. The only “routine” laboratory test that is affected by a reduced level of factor VIII is the activated partial thromboplastin time. Once hemophilia is suspected, the specific assay for factor VIII will confirm the diagnosis. Factor VIII levels in affected persons vary from less than 1% to approximately 25% of normal activity. Clinical severity of the disease varies with the degree of deficiency of factor VIII activity. Recently developed recombinant factor VIII for treating patients with hemophilia can help prevent transfusion-related infections. Deficiencies of antithrombin III, protein S and protein C, and mutations of the gene for factor V (factor V Leiden) are associated with thrombotic conditions, not bleeding.
400
Which one of the following is a risk factor for perioperative arrhythmias? A. Supraventricular tachycardia B. Congestive heart failure C. Age >60 D. Premature atrial contractions E. Past history of hyperthyroidism
Congestive heart failure Significant predictors of intraoperative and perioperative ventricular arrhythmias include preoperative ventricular (not supraventricular) ectopy, a history of congestive heart failure, and a history of cigarette smoking. Age and a history of hyperthyroidism are not significant predictors of perioperative ventricular arrhythmias.
400
What medication is contraindicated in the treatment of patients with cocaine-induced arrhythmias? A: Verapamil B: Metoprolol C: Lidocaine D: Sodium bicarbonate
Metoprolol (Lopressor) When treating arrhythmias related to cocaine toxicity, hypertonic sodium bicarbonate and benzodiazepines may be given when the distinction between sodium channel blockade–induced QRS-complex widening and ischemia-induced ventricular tachycardia is unclear. Lidocaine may subsequently be utilized if necessary. Verapamil has been shown to reverse cocaine-induced coronary vasospasm. Beta-adrenergic blocking drugs have been shown to exacerbate coronary vasospasm by resulting in unopposed alpha-adrenergic activity. Beta-blockers are therefore contraindicated in the treatment of cocaine-induced cardiac problems.
400
An asymptomatic 55-year-old male visits a health fair, where he has a panel of blood tests done. He brings the results to you because he is concerned about the TSH level of 12.0 µU/mL (N 0.45-4.5). His free T4 level is normal. Which one of the following is most likely to be associated with this finding? A: Abnormal fasting blood sugars B: Elevated LDL C: Thyroid enlargement D: History of conspitation
elevated LDL level With subclinical thyroid dysfunction, TSH is either below or above the normal range, free T3 or T4 levels are normal, and the patient has no symptoms of thyroid disease. Subclinical hypothyroidism (TSH >10 µU/mL) is likely to progress to overt hypothyroidism, and is associated with increased LDL cholesterol. Subclinical hyperthyroidism (TSH <0.1 µU/mL) is associated with the development of atrial fibrillation, decreased bone density, and cardiac dysfunction. Neither type of subclinical thyroid dysfunction is associated with diabetes mellitus. There is insufficient evidence of benefit to warrant early treatment of either condition
400
A 28-year-old gravida 2 para 1 presents to the emergency department at 16 weeks' gestation. She has noted the sudden onset of dyspnea, pleuritic chest pain, and mild hemoptysis. Both calves are mildly edematous and somewhat tender. A lung scan shows a high probability of pulmonary emboli. Which one of the following would be appropriate management at this time? A: IVC filter placement B: Start Lovenox for bridging to warfarin C: Aspirin therapy D: IV heparin followed by subcutaneous heparin for the remainder of the pregnancy
Intravenous heparin for 5–10 days followed by subcutaneous heparin for the duration of the pregnancy The risk of pulmonary embolism is five times higher in pregnant women than in non-pregnant women of similar age, and venous thromboembolism is a leading cause of illness and death during pregnancy. Warfarin, which readily crosses the placenta, should be avoided throughout pregnancy. It is definitely teratogenic during the first trimester, and extensive fetal abnormalities have been associated with exposure to warfarin in any trimester. Because heparin does not cross the placenta, it is considered the safest anticoagulant to use during pregnancy. Initially, patients with venous thromboembolism during pregnancy should be managed with heparin given according to the recommendations for nonpregnant patients. These women should receive intravenous heparin for 5–10 days followed by subcutaneous heparin for the duration of the pregnancy. Warfarin can be given after delivery, since it is not present in breast milk. The indications for placement of an inferior vena cava filter are not changed by pregnancy, and include any contraindication to anticoagulant therapy, the occurrence of heparin-induced thrombocytopenia, and recurrence of pulmonary embolism in a patient receiving adequate anticoagulant therapy. There are no data to support the use of aspirin for treatment or prophylaxis of pulmonary embolism either during or after pregnancy.
500
A 16-year-old female cross-country runner has pain around both ankles. On examination, pain is elicited on foot inversion and there is decreased motion of the hind foot and peroneal tightness. A rigid flat foot also is observed. What is the most likely diagnosis? A: Navicular stress fracture B: Os trigonum C: Tarsal coalition D: Sever's apophysitis E: Plantar fasciitis
Tarsal coalition Tarsal coalition is the fusion of two or more tarsal bones. It occurs in mid-to late adolescence and is bilateral in 50% of those affected. Pain occurs around the ankle, and there is decreased range of motion of the hindfoot and pain on foot inversion on examination. Os trigonum results from non-ossification of cartilage. It usually is unilateral and causes palpable tenderness of the heel. Sever’s apophysitis is inflammation of the calcaneal apophysis, and causes pain in the heel. Plantar fasciitis causes tenderness over the anteromedial heel. Navicular stress fractures are tender over the dorsomedial navicular.
500
A 75-year-old Hispanic male presents with dyspnea on exertion which has worsened over the last several months. He denies chest pain and syncope, and was fairly active until the shortness of breath slowed him down recently. You hear a grade 3/6 systolic ejection murmur at the right upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis, with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 0.6 cm2. Left ventricular function is normal. Which one of the following is appropriate management for this patient?
Aortic valve replacement Since this patient’s mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis.
500
A 72-year-old white male presents with a complaint of headache, blurred vision, and severe right eye pain. His symptoms began acutely about 1 hour ago. Examination of the eye reveals a mid-dilated, sluggish pupil; a hazy cornea; and a red conjunctiva. What is the most likely diagnosis? A: Central retinal artery occlusion B: Retinal detachment C: Acute angle-closure glaucoma D: Mechanical injury to the globe
Acute angle-closure glaucoma This patient presents with acute angle-closure glaucoma, manifested by an acute onset of severe pain, blurred vision, halos around lights, increased intraocular pressure, red conjunctiva, a mid-dilated and sluggish pupil, and a normal or hazy cornea. Findings with retinal detachment include either normal vision or peripheral or central vision loss; absence of pain; increasing floaters; and a normal conjunctiva, cornea, and pupil. Central retinal artery occlusion findings include amaurosis fugax, a red conjunctiva, a pale fundus, a cherry-red spot at the fovea, and “boxcarring” of the retinal vessels. In patients with mechanical injury to the globe, findings include moderate to severe pain, normal or decreased vision, subconjunctival hemorrhage completely surrounding the cornea, and a pupil that is irregular or deviated toward the injury (SOR B).
500
What is a cause of thyrotoxicosis characterized by a decreased radioactive iodine uptake? A: Grave's disease B: toxic multinodular goiter C: Subacute thyroiditis D: molar pregnancy
Subacute thyroiditis Thyrotoxicosis with a high 24-hour radioactive iodine uptake (RAIU) is caused by Graves’ disease, toxic multinodular goiter, a solitary hot nodule, a TSH-secreting pituitary tumor, molar pregnancy, and choriocarcinoma. Thyrotoxicosis with a low 24-hour RAIU may be the result of subacute thyroiditis, sporadic silent thyroiditis, postpartum lymphocytic thyroiditis, radiation-induced thyroiditis, iodine-induced thyroiditis, thyrotoxicosis factitia, metastatic follicular thyroid cancer, and struma ovarii.
500
A 34-year-old African-American female presents to you for preconception counseling regarding the management of her chronic hypertension. Her blood pressure has been well controlled on benazepril (Lotensin), 20 mg/day, without any side effects. The patient’s blood pressure was 145/95 mm Hg prior to beginning benazepril. She has been pregnant once before, and her physician switched her to methyldopa (Aldomet) during that pregnancy, but she suffered from drowsiness and a dry mouth during much of that time. The pregnancy and delivery were otherwise uncomplicated. She has no history of diabetes mellitus, renal insufficiency, or asthma. She is a nonsmoker. Which one of the following would you do when she becomes pregnant? A: Continue Benazepril since this has been well tolerated B: Switch to Atenolol C: Stop the Benazepril and monitor mom and baby closely off of medications during the pregnancy D: Advise her that getting pregnant again would be dangerous because of her persistent hypertension
Discontinue the benazepril and monitor closely throughout the pregnancy for signs of preeclampsia or fetal growth restriction Most women with mild, uncomplicated essential hypertension are at minimal risk for cardiac complications within the short time frame of pregnancy. There is no evidence available that treatment of mild essential hypertension during pregnancy provides any benefit to the mother. Given the potential for short- and long-term risk to the fetus from antihypertensive treatment, it is advisable to discontinue antihypertensive treatment, monitor the mother for signs of preeclampsia, and monitor fetal growth and development. Medication is not necessary as long as the systolic blood pressure remains below 160 mm Hg, the diastolic blood pressure remains below 105–110 mm Hg, and there are no signs of preeclampsia or fetal growth restriction. Should the mother develop severe hypertension, treatment can be initiated with long-acting nifedipine, labetalol, a thiazide diuretic, or methyldopa. Atenolol has been associated with reduced fetal growth, and ACE inhibitors are contraindicated in the second and third trimesters.