E.N.T 1

A 64-year-old female with history of type II DM with end stage renal disease on hemodialysis was recently discharged from the hospital after treating for sepsis with Methicillin Resistant Staphylococcus Aureus (MRSA). During the hospitalization she received renal adjusted dose of vancomycin and ceftriaxone. She also developed severe muscle cramps during dialysis and was started on quinine. Her other medications include insulin for DM and hydrochlorothiazide plus metoprolol for hypertension. Since the time of discharge she has been complaining of a perception of an internal noise in her left ear. The most likely medication responsible for her condition is:
A. Ceftriaxone
B. Quinine
C. Vancomycin
D. Hydrochlorothiazide
E. Metoprolol

Explanation:
Tinnitus can sometimes occur in patients taking aspirin, quinine, and even in patients who are depressed. It may be a feature of Ménière’s disease and acoustic neuroma. It can cause disruption of sleep, concentration and depression. Tricyclic anti-depressants have been found to be effective for this condition. For decades quinine is being used for treating cramps in dialysis patients. Only one double-blind placebo controlled trial of nine hemodialysis patients has shown its beneficial affect.

Choice A: Ceftriaxone does not produce tinnitus.

Choice C: Vancomycin can cause nephrotoxicity and the red man syndrome (due to histamine release from mast cells), but does not cause tinnitus.

Choice D: Hydrochlorothiazide is a diuretic agent, which does not cause tinnitus.

Choice E: Metoprolol is a beta-blocker, which does not cause tinnitus.

ETHICS 1

A 25-year-old Caucasian male presents with a 1 week history of headaches, runny nose, nausea, fever and general discomfort. Physical examination reveals mild meningeal irritation without other findings. His Temperature is 38.3C(100.9F). You recommend admission to hospital and lumbar puncture, to exclude meningitis. The patient refuses to undergo the procedure. What would you do?
A. Let him go home
B. Force him to stay in hospital against his will
C. Counsel him properly about the risks of having untreated meningitis, let him go and state he can always come back
D. Have him sign a paper that he understands he can die if he has bacterial meningitis and it is left untreated
E. Explain him everything over and over until he understands, stays in hospital and allows you to do a lumbar tap on him

Explanation:

There is a very high probability that this young man has meningitis. You have to counsel him properly, and say you would treat him appropriately if he would be back. You cannot let him just go without counseling or force him to do something against his will. Choices (D) and (E) are also inappropriate.

ONCOLOGY

A 54-year-old male comes to the ER with complaints of cough and bloody sputum. He used to smoke 2packs/day for 22 years, but quit last month. He is having weight loss, anorexia, constipation, increased thirst, and easy fatigability, which he thinks is due to his depression. His wife died 4 months ago and “life never felt same after that”. On examination, he is a slim man who appears pale. The vitals are stable though he appears a little irritable and short of breath. You order a complete blood work and chest x-ray and the results are:
Sodium 144 mEq/dL
Potassium 4.3 mEq/dL
Chloride 98 mEq/dL
Bicarbonate 21 mEq/dL
Calcium 11.5 mg/dL
BUN 28 mg/dL
Creatinine 0.8 mg/dL
Chest X Ray Hilar mass in the left lung
What is the most probable diagnosis?

A. Tuberculosis
B. Squamous cell carcinoma of lung
C. Oat cell carcinoma of lung
D. Sarcoidosis
E. Adenocarcinoma of the lung

Explanation:
This patient’s symptoms are suggestive of hypercalcemia, which is confirmed by the laboratory results. Hypercalcemia is usually associated with Squamous Cell Carcinoma of Lungs (Remember sCa++mous) (Choice B) not Oat Cell Carcinoma (Choice C). Hypercalcemia usually develops as a late complication of cancer, and its appearance is very serious. Even though hypercalcemia is frequently due to metastatic involvement of the bone, it is also because of parathormone-related protein (PTHrP). PTHrP is similar to PTH in the receptor binding area. Binding to PTH results in increased calcium resorption from the bones and increased renal calcium resorption in the distal tubule.

The most common symptoms of hypercalcemia are feeling tired, difficulty thinking clearly, lack of appetite, pain, frequent urination, increased thirst, constipation, nausea, and vomiting. Most patients do not experience all of the symptoms of hypercalcemia, and some patients may not have any symptoms at all.

Sarcoidosis (Choice D) does cause hypercalcemia but usually patients have bilateral hilar adenopathy, evidence of erythema nodosum. However, hilar mass in a smoker is most likely a cancer, than anything else.

Hypercalcemia is not normally associated with Tuberculosis (Choice A). TB is very unlikely in USA unless patient has some kind of immunosuppression.

Adenocarcinoma is usually a peripheral lesion and usually not associated with hypercalcemia.

PSYCHIATRY 1

A 26-year-old lady is brought in by her husband with complaints of crying spells, since 1 month. She also has decreased appetite and has lost 15lbs(6.8kg)in the above span of time. In addition to these symptoms, she has disturbed sleep and easy fatigability. She has developed these symptoms after the death of their 2-year-old son. Although she continues to go to work, she does not feel as enthusiastic about it anymore. She denies any suicidal thoughts, but does admit to passive thoughts of death “in order to be with her son”. The diagnosis most likely in this case is:


A. Major depressive episode
B. Cyclothymia
C. Dysthymic disorder
D. Normal bereavement
E. Adjustment disorder


Explanation:

Bereavement is a normal reaction to the death of a loved one. Some grieving individuals present with classic symptoms of Major depression but the symptoms are not as pronounced as in Major depression. Besides, Normal bereavement rarely lasts beyond 2 months, though a Major depressive epiosde can. Also, bereavement does not cause as much functional impairment, as a depressive episode.

Choice A. According to DSM-1V criteria, Major depressive episode require the presence of 5 or more of the following symptoms for at least 2 weeks:
1. Depressed mood most of the day
2. Markedly diminished interest in all activities
3. Insomnia or hypersomnia
4. Significant weight loss or weight gain
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Decreased concentration
9. Recurrent thoughts of death or suicidal ideations

Although, this patient does have some of the symptoms of Major depression, the presence of her symptoms, in the setting of recent loss of a loved one, make Bereavement a more likely diagnosis.


Choice B. Cyclothymia is the presence of numerous episodes of hypomanic symptoms and numerous episodes of depressive symptoms (that do not meet the criteria for Major depression) for a period of at least 2 years.

Choice C. Dysthymia is the presence of depressed mood for most of the time, for at least 2 years. In addition, it also includes the presence of 2 or more of the following: 1. Poor appetite or overeating, 2. Insomnia or hypersomnia, 3. Low self-esteem, 4. Low energy, 5. Feelings of hopelessness, 6. Poor concentration.

Choice E. Adjustment disorder is the development of behavioral symptoms in response to a stressor occurring within 3 months of the onset of the stressor. The distress is usually in excess to what would be expected from exposure to the stressor. It usually causes significant impairment in social or occupational functioning.

GASTROENTEROLOGY 1

A 45-year-old white male comes to your office for evaluation of diarrhea of 8-months duration. He says that he has lost almost 15 lbs during the past 8 months. He denies any blood in the stools. 24-hour stool collection reveals fecal fat of 10 gm/day. Stool microscopy reveals no pathogens and no leucocytes. D-xylose test was performed which shows that less than 2 grams of D-xylose is excreted in urine in 5 hours. D-xylose test was re-performed after treatment with antibiotics but excretion is still less than 2 grams in 5 hours. Based on these findings, what is the most likely diagnosis in this patient?

A.  Lactose intolerance
B.  Bacterial overgrowth
C.  Pancreatic insufficiency
D.  Whipple’s disease
E.  Terminal ileal disease


The answer is D.
Whipple’s disease

Explanation:

Lactose intolerance may result in chronic diarrhea, but fecal fat will not be high in such causes (Option A).

Bacterial overgrowth, pancreatic insufficiency, Whipple’s and Crohn’s disease all result in chronic diarrhea with increased fecal fat content. D-xylose is a simple sugar. It does not need to undergo any digestive process before it can be absorbed. Its absorption requires an intact mucosa only.

In normal individuals, after ingestion of 25 grams of D-xylose, its urinary excretion will be greater than 4.5 grams in 5 hours. In pancreatic insufficiency, there is deficiency of pancreatic enzymes, which lead to impaired digestion of fats. D-xylose absorption remains unimpaired, as there is no damage to small intestinal mucosa.

In terminal ileal disease, bile salts are decreased due to impaired enterohepatic circulation, and as a result absorption of fats will be impaired. In bacterial overgrowth there will be both impaired fat absorption due to bacterial de-conjugation of bile salts as well as decreased excretion of xylose due to bacterial consumption of the simple sugar. In such cases, urinary excretion of xylose returns to normal after treatment with antibiotics. In the above case, urinary exertion of D-xylose does not increase after treatment with antibiotics and bacterial overgrowth is therefore ruled out. Whipple’s disease damages small intestinal mucosa, thus impairing D-xylose absorption (Option D).

CARDIOLOGY 1

60-year-old white male presents to the ER with sudden onset of chest pain, nausea, vomiting, and diaphoresis. He describes this chest pain as a squeezing sensation, it started 2 hours ago at rest, radiates to jaw, and is partially relieved by sublingual nitroglycerin. He has a history of 30 pack/year of cigarette smoking. He is a known hypertensive for the past 10 years and suffered a hemorrhagic stroke 6 months ago. His medications include aspirin, atenolol, and hydrochlorothiazide. On examination, PR: 76/min; BP: 139/79 mmHg; RR: 13/min; Temperature: 37.3C(99F). On auscultation, lungs are clear and heart sounds are normal. Chest x-ray is normal. EKG shows ST segment elevation of 2mm in leads V3 to V6. These ST changes persist after sublingual nitroglycerin. Which of the following steps is the most appropriate regarding the management of this patient?

A. IV tissue plasminogen activator, IV heparin, and aspirin

B. IV tissue plasminogen activator and aspirin

C. IV heparin, IV nitroglycerin, and aspirin

D. IV amiodarone and IV magnesium

E. Immediate coronary angiography and PTCA


The answer is E.
Immediate coronary angiography and PTCA


Explanation:

The above patient is likely to benefit from thrombolytic therapy, but he has a history of a relatively recent hemorrhagic stroke (less than 1 year ago). Thrombolytic therapy would put him at a tremendous risk for intracranial bleeding and is therefore contraindicated. In such circumstances, immediate coronary angiography and PTCA or stent is the procedure of choice.

Thrombolytic therapy is indicated when the chest pain is suggestive of MI and there is ‘ST’ segment elevation greater than 1 mm in two contiguous leads after sublingual nitroglycerin administration to rule out coronary vasospasm. Another indication for thrombolytic therapy is a new or presumably new left bundle branch block. Thrombolytic therapy is not indicated for an MI with ‘ST’ segment depression and it is also not indicated for unstable angina. In these settings, no proven benefit has been shown for thrombolytic therapy. Thrombolytic therapy can be given when ‘ST’ depression shows a posterior MI, especially in the setting of an inferior wall MI.

Absolute contraindications to thrombolytic therapy include: active internal bleeding; history of hemorrhagic stroke anytime, or an ischemic stroke within past year; known intracranial neoplasm; current systolic BP greater than 180 or diastolic BP greater than 110; or suspected aortic dissection.

Thrombolytic therapy with tissue plasminogen activator requires co-administration of heparin and aspirin for greater benefit. Tissue plasminogen activator is slightly more effective than streptokinase but it has a slightly more risk of intracranial bleeding. For streptokinase, co-administration of heparin is not required.

Treatment with IV heparin, aspirin, and IV nitroglycerin is indicated in cases of unstable angina and non-Q wave infarcts. In those cases, thrombolytic therapy has not been shown to be associated with a proven benefit.

IV amiodarone and IV magnesium are not useful in the setting of MI unless arrhythmias or low serum magnesium levels complicate it.

RESPIRATORY 1

A 35-year old male presents to the office with complaints of wheezing and tightness of the chest for the past 3 months. The patient also complains of hoarseness of voice. He has no history of bronchial asthma, hypertension or diabetes. He is a non-smoker but occasionally drinks alcohol. On examination, he is not in any distress. His vitals are, Pulse rate: 84/min, Blood Pressure: 130/80 mmHg, Respiratory rate: 18/min, and afebrile. Examination of the upper respiratory tract reveals a red and inflamed larynx. Chest is clear to auscultation and percussion. Based on the above scenario, what is the most appropriate initial treatment for this patient?

A.	Daily salbutamol inhalations
B.	Salbutamol 2 puffs only at bed time
C.	Oral theophylline
D.	Omeprazole before break fast
E.	Oral prednisone

the answer is

D.	Omeprazole before break fast

Explanation:

Any nocturnal, newly diagnosed asthma in a middle-aged patient should raise a suspicion for gastroesophageal reflux disease (GERD). The characteristic features of GERD such as the associated laryngitis are due to acid reflux. In this patient, hoarseness of voice and inflammation of larynx point towards a laryngitis. Therefore, with all these features it is better to give a trial of proton pump inhibitors (omeprazole), which would be both therapeutic and diagnostic.

Daily inhalation of salbutamol (Choice A) is the treatment when GERD is not suspected as an etiology or as an add-on therapy with Proton Pump Inhibitors (PPI).

Salbutamol at bedtime (Choice B) would be a good treatment for mild nocturnal asthma.

Oral theophylline (Choice C) is not indicated in this patient or for that matter as a first line drug in any newly diagnosed case of bronchial asthma.

Again, oral prednisone is not a medication of choice here because of two reasons. Steroids cause worsening of the GERD symptoms. Even if you use steroids in the treatment of bronchial asthma, inhaled steroids are more efficacious and have less systemic effects.

INFECTIOUS DISEASE 1

A 54-year-old male comes to you with complaints of fever, exertional dyspnea and a non-productive cough for one week. He was diagnosed with HIV infection three years ago; however he has been asymptomatic. His vitals are, T: 38.9C(102F), RR: 28/min, PR: 100/min, and BP: 120/80 mm Hg. He is hypoxic at 80% saturation on room air; using a 100% non-rebreather mask, his oxygen saturations increased to 92%.
Lab results are:

Hb: 11.5 g/dL
WBC: 7,000/cmm; no band forms
Platelets: 130,000/cmm
ABG on room air:
pH: 7.46
PO2: 60 mm Hg
PCO2: 32 mm Hg
The chest-x ray shows a diffuse bilateral interstitial infiltration. His CD4 count is 190/µL and the LDH is 400 U/L. What is the most appropriate next step in this patient?

A. Initiation of antiretroviral (HAART) treatment
B. Intravenous ceftriaxone
C. Intravenous pentamidine and steroids
D. Trimethoprim-sulfamethoxazole and steroids
E. Trimethoprim-sulfamethoxazole alone

the answer is D. Trimethoprim-sulfamethoxazole and steroids

Explanation:

PCP (pneumocystis carinii pneumonia) is a hallmark manifestation of AIDS. It is one of the most common opportunistic infection seen in AIDS, mostly associated with CD4 count < 200/µL. The diagnosis should be considered in any HIV patient who presents with dry cough, exertional dyspnea and fever. Chest x- ray usually shows bilateral interstitial infiltrates. PCP is also indicated by the symptom of hypoxia, which may be more severe than expected from radiographic findings. Serum LDH levels are frequently elevated and diagnosis is confirmed by demonstration of organism in sputum or BAL aspirate. The bacterial pneumonia should be considered if the patient has a productive cough, hemoptysis (also TB), a focal infiltrate on the chest-x ray, and an elevated white count with left shift. A chest-x ray finding of hilar adenopathy with diffuse pulmonary infiltrates suggests histoplasmosis, cryptococcosis, mycobacterial infection, or neoplasm. Trimethoprim-sulfamethoxazole is the initial drug of choice in PCP irrespective of the severity of the pneumonia. Steroids have been shown to decrease mortality in cases of severe PCP. Indication of steroid use in PCP includes:
1. PaO2 < 70mm Hg.
2. A-a gradient > 35.
This patient has a PaO2 < 70 mm Hg, and thus steroid use is indicated in this patient.
(Choice A) Though initiation of antiretroviral treatment is indicated in this patient, it is important to start TMP-SMX with steroid first to deal with the PCP and prevent mortality. Failure to start PCP treatment is associated with almost 100% mortality.
(Choice B) Ceftriaxone can be given if this patient has evidence of bacterial pneumonia. His white count is normal. He has a non-productive cough. His chest-x ray is not suggestive, either. Even if this is a bacterial infection, ceftriaxone alone is not sufficient. This, however, is often used, along with azithromycin, to cover the atypical organisms, especially if the patient has community-acquired pneumonia.
(Choice C) Pentamidine is the drug of choice for severe cases of PCP in patients with intolerance to TMP-SMX; however, there is no evidence of intolerance to TMP-SMX in this patient. Pentamidine is comparatively less effective than TMP-SMX.

RHEUMATOLOGY 1

A 48-year-old female presents with a rash over her face for the past few weeks. She also complains of recent onset difficulty in rising from seated position and climbing stairs. On examination, you notice a dusky malar rash and a purplish periorbital edema. There is no ocular or facial weakness. Her proximal muscles of both extremities show symmetrical weakness. Which of the following is commonly associated with this presentation?

A. Inflammatory bowel disease.
B. Anti-Scl-70 antibodies.
C. Gottron’s sign.
D. HLA-B27 association.
E. Esophageal smooth muscle dysfunction.
F. Acetyl choline receptor antibodies
G. Positive Anti-DsDNA antibodies.

the answer is C Gottron’s sign.

Explanation:

In dermatomyositis, patients can have a classic malar rash, like systemic lupus erythematosus (SLE). Periorbital edema with a purplish suffusion is called the heliotrope rash. Scaly patches over the dorsum of proximal interphalangeal and metacarpophalangeal joints (Gottron’s sign) are fairly unique to dermatomyositis. Unlike myasthenia facial or ocular muscle weakness is uncommon. Unlike scleroderma, which affects the lower smooth muscle of esophagus, it involves striated muscle of the upper pharynx and can make deglutition difficult. Suspected patients should have measurement of serum creatine kinase and aldolase levels. Specific diagnosis is usually made by muscle biopsy. These patients should have a complete metastatic workup to rule out malignancy. It includes PAP smear, mammogram, CT chest / abdomen / pelvis, and colonoscopy.

Choice (A): Inflammatory bowel disease is usually associated with ankylosing spondylitis.

Choice (B): Anti-Scl-70 antibodies are positive in scleroderma. Rheumatoid factor is positive in few patients with dermatomyositis. Majority of theses patients have positive anti nuclear antibody.

Choice (D): HLA B27 is negative and is usually positive in seronegative spondyloarthropathies such as ankylosing spondylitis, Reiter’s arthritis etc.

Choice (E): Esophageal smooth muscle dysfunction is not a feature of dermatomyositis. The striated muscles of the pharynx are affected leading to difficulty in the initial phase of swallowing.