ORTHOPAEDICS 1

A 16-year-old boy was playing soccer and fell on his outstretched hand. He felt a crunch sound and intense pain in his left shoulder area. He then presented to the ER with complaints of pain in his left shoulder and hand. On exam he was holding his left arm with his right hand. There was a bruise around the clavicle area and a palpable gap was felt in the middle of the clavicle. Auscultation revealed a loud bruit just beneath the clavicle. X-ray revealed that the middle of the clavicle was fractured and displaced. The next step in his management is:

A. CT chest for pneumothorax
B. Nerve conduction studies
C. Angiogram
D. Open reduction of clavicle
E. Closed reduction with figure of eight brace

Explanation:

This boy presents with a fracture of his clavicle and had both left shoulder and hand pain. A bruit is heard and one has to rule out arterial injury with a clavicle fracture. Clavicle fractures, which are displaced, can injure the subclavian artery. On examination, one may find diminished radial pulse but an angiogram is necessary to rule out an injury to the vessel.

Choice A: The patient already has a chest x-ray and one can always look for a pneumothorax. Pneumothorax can occur with a clavicle fracture and easily identified with a chest x-ray.

Choice B: Clavicle injuries are also notorious for injuring the brachial plexus. Usually the patient will complain of pain in his arm, hand and shoulder. Brachial plexus injury can be ruled out with nerve conduction studies.

Choice D: Distal third clavicle injuries are usually unstable and may require open reduction and internal fixation. Cosmetically the results are not good but the results are acceptable.

Choice E: The treatment of clavicle injuries depends on where the clavicle is fractured. Proximal and middle third clavicle injuries can be treated with closed reduction with figure of eight brace or sling for one-to-two weeks. Early range of motion and strengthening are recommended.

NEUROLOGY 02

A 66-year-old female is brought to you by her concerned son. She has increasing confusion with loss of mobility and stiff limbs. She does not have any problems with her joints. She tends to cry out for no reason. She often screams and says that she is seeing a lion roaring in the backyard. In addition, she often sees cats in her room, even though there are none. She was treated with haloperidol, but that aggravated her rigidity. She also has significant memory loss. She is a non-smoker. She has no significant past psychiatric history. She is alert, but disoriented and quite agitated. On examination, increased tone and normal reflexes with coarse resting tremors are noted in the extremities. Her visuospatial abilities are quite impaired. Her vitals are, BP: 136/72 mm of Hg; PR: 98/min; RR: 16/min. Her CBC, electrolytes, creatinine, glucose, LFTs, TSH and B12 levels are within normal range. Serology for syphilis is negative. Based on this history and examination what is the most likely diagnosis?
A. Lewy body dementia
B. Alzheimer’s disease
C. Multi infarct dementia
D. Neurosyphilis
E. Pick’s disease

Explanation:
Dementia with Lewy body (DLB) is characterized by fluctuating cognitive impairment. Parkinsonism is also seen with poor response to dopaminergic agonist therapy. Hallucinations are visual and bizarre. The central feature required for the diagnosis of dementia with Lewy bodies (DLB) is progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function. Prominent or persistent memory impairment may not necessarily occur in the early stages but is usually evident with progression. Deficits on tests of attention and of frontal-subcortical skills and visuospatial ability may be especially prominent.

Two of the following core features are essential for a diagnosis of probable DLB, and one is essential for possible DLB:
a.Fluctuating cognition with pronounced variations in attention and alertness
b.Recurrent visual hallucinations that are typically well formed and detailed
c.Spontaneous motor features of Parkinsonism

Features supportive of the diagnosis are:
1.Repeated falls
2.Syncope
3.Transient loss of consciousness
4.Neuroleptic sensitivity
5.Systematized delusions

Alzheimer’s disease is a progressive dementia with associated risk factors including: age; female gender; positive family history; head trauma; Down’s syndrome. Typical first symptoms are: subtle memory loss; language difficulties; apraxia; followed by impaired judgment; and personality changes. Treatment is specifically targeted to specific symptoms and includes psychosocial intervention and pharmacological therapy.

Multi infarct dementia accounts for 15-20% cases of dementia. There is cognitive dysfunction with motor and sensory neurological dysfunction. Risk factors are: older age, male sex, black race, cigarette smoking, hypertension, diabetes and vasculitis. Treatment is generally directed towards the risk factors.

Neurosyphilis appears in 15-20% of late syphilis cases. There are four types. In general paresis type, there is general involvement of cerebral cortex. There is usually decrease in concentrating power, memory loss, dysarthria, tremors of finger and lips, irritability, mild headaches. In addition, there are personality changes with the patient becoming slovenly, irresponsible, confused and psychotic.

Pick’s disease is one of the groups of diseases labeled as Fronto temporal dementia. Patients manifest personality change (euphoria, disinhibition, apathy) and compulsive behaviors such as peculiar eating habits or hyperorality. Memory is impaired with visual-spatial functions usually intact.

PAEDIATRICS 1

A 5-year-old female child is brought to the ER for fever, chills and abdominal pain. Her parents report that she has been complaining of burning micturition and abdominal pain for the last 2 days. On examination, her vitals are; T: 102 F (38.9C); RR: 20/min; PR: 130/min and BP: 90/60 mm of Hg. Physical examination reveals costovertebral angle tenderness. Urine analysis shows pyuria, significant bacteriuria, WBC casts and is positive for nitrites and esterase. What is the most likely cause of this condition in children?

A. Hydronephrosis
B. Wilm’s tumor
C. Vesicoureteral reflux
D. Ureteral duplication
E. Renal stones

Explanation:
This patient has clinical presentation suggestive of acute pyelonephritis. Vesicoureteral reflux is the most likely cause of acute UTI in this age group. It is more commonly seen in girls.

Vesicoureteral reflux is the retrograde flow of urine from the bladder to the ureter and renal pelvis. Normally, the ureter is attached to the bladder in an oblique fashion, leading to a flap-valve mechanism that prevents reflux, however reflux occurs when the submucosal portion of ureter between the mucosa and detrusor muscle is short or absent. Vesicoureteral reflux is generally congenital and seen in approximately 1% of children.

Reflux is a risk factor for UTI as it facilitates the transport of bacteria from bladder to the upper urinary tract. Reflux is present in 35-40 % of children with UTI and is the most common cause of UTI in this age group. Diagnosis is made with voiding cystourethrogram (VCUG) followed by renal imaging.

Option B: Wilm’s tumor is generally seen in children but is not a common cause of acute UTI.

Option D: Ureteral duplication can lead to vesicoureteral reflux and acute UTI, but most of the vesicoureteral reflux are congenital, run in the families and is due to the anomalous intravesical portion of ureter.

Option A and E: Renal stones and hydronephrosis are not common in this age group.

TRAUMA 1

A 34-year-old male patient is brought to you after his friend’s car was involved in a collision. The patient was in front passenger seat, wearing a seat belt, and complains of epigastric pain since the event. He is hemodynamically stable with no obvious injury or complaint, other than epigastric pain. X-ray of the abdomen shows retroperitoneal air. Which of the following is the investigation of choice to confirm the suspected diagnosis?
A. Plain CT scans of abdomen
B. Diagnostic peritoneal lavage
C. Exploratory laparotomy
D. CT scans of abdomen with oral contrast
E. USG of abdomen

Explanation:
Twenty to thirty percent of duodenal injuries follow blunt trauma, when the duodenum is compressed between the spine and an external solid structure like a steering wheel, lap belt (as in this case), etc. The second portion of the duodenum, being retroperitoneal and the least mobile, is most commonly injured.

Isolated duodenal injuries can be easily missed. Patient may complain of epigastric or right upper quadrant pain, with or without peritoneal signs; however, presentation may be very subtle and requires a high degree of suspicion for diagnosis. Retroperitoneal air or obliteration of right psoas margin on abdominal x-ray is very suggestive. CT scan of the abdomen, with administration of oral contrast material, confirms the diagnosis of duodenal injury. If CT scan is not available, upper GI study with gastrograffin, and if negative, with barium can be used.

(Choice A, E) Plain CT scan of the abdomen and USG are not sensitive for duodenal injuries, though they would diagnose the associated injuries.

(Choice B) DPL is not sensitive for duodenal injuries, as the second part of the duodenum is the most commonly injured portion and is retroperitoneal.

(Choice C) The patient is hemodynamically stable with no signs of penetrative abdominal injury; so, exploratory laparotomy is not warranted.

OBSTETRICS 1

A 28-year-old woman comes to your office for the first time for antenatal checkup, after having recently moved into your community. Her antenatal records show ultrasound performed at 16-weeks gestation, which was consistent with the date of last menstrual period. Now she is at 42-weeks gestation. On examination, fundal height is consistent with dates and the cervix is not favorable. Repeat ultrasonogram reveals a fetal weight of 3500g(7.7lb), and an amniotic fluid index of 10. Fetal heart tracing is reassuring. What is the most appropriate next step in management of this patient?
A. Twice weekly non-stress test and biophysical profile
B. Immediate induction of labor
C. Amnioinfusion and wait for spontaneous delivery
D. Cesarian section
E. Steroid administration and serial testing of fetal lung indices

Explanation:
Post-term pregnancy is defined as a pregnancy age more than 42-weeks gestation. Perinatal mortality is 2-3 times higher in post-term pregnancies and it is related most commonly to post-maturity syndrome, which occurs consequently to aging and infarction of the placenta. Post-mature infants typically have a loss of subcutaneous fat, long fingernails, dry and peeling skin, and abundant hair. In 70-80% of cases, fetuses are not affected by placental insufficiency and continue to grow past 42-weeks gestation, resulting in macrosomia. The cause of post-term pregnancy is unknown; however, some associated syndromes have been noted such as anencephaly and trisomy 18.

In terms of diagnosis of post-term pregnancy, the importance of accurate dating cannot be stressed enough. In fact 20-30% of pregnancies have uncertain dates, which may mislead to another diagnosis or cause it to be overlooked.

The management of post term pregnancy is principally based on the well being of the fetus. The non-stress test and biophysical profile should be performed twice weekly and if there is oligohydramnios or if spontaneous decelerations are noted, delivery has to be accomplished. If on the contrary, those parameters are reassuring, as in this case, labor should not be induced unless the cervix is favorable, the infant is macrosomic or in the presence of obstetrical indications for delivery. If the pregnancy is more than 43 weeks, delivery is mandated. If the pregnancy is more than 42 weeks, the cervix is favorable and fetal head is into the pelvis labor should be induced. Patients with uncertain dates should be managed expectantly as long as fetal assessment is reassuring, and the possibility of preterm pregnancy should be considered as much as that of post-term pregnancy.

Choice (B): Expectant management is more appropriate since fetal heart tracing is reassuring and there is no oligohydramnios. Moreover, the cervix is not favorable for induction of labor.

Choice (C): The patient does not have oligohydramnios (AFI of 5 or more), so amnioinfusion is not necessary.

Choice (D): C. Section is indicated in the presence of signs of fetal distress. The fetal heart activity of this fetus is normal.

Choice (E): Fetal lung maturity is not a concern here since it occurs in preterm not post-term infants. The respiratory condition most frequent in post term fetuses is meconium aspiration.

PSYCHIATRY 2

A middle-aged divorced woman brings Rebecca, her 19-year-old daughter to your office and says, “Rebecca seems abnormal to me”. She’s concerned that she hardly has any friends and does not indulge in any activities that girls her age normally do, i.e. dating or going out with friends. She always keeps to herself, stays locked in her room for most of the day, or goes out hiking in the woods by herself. Other than that, she attends college regularly and is good in her academics. You notice that she makes minimal eye contact when you speak to her. Her thought process seems devoid of any delusions or hallucinations. On directly questioning her about the reason for her preference for keeping aloof, she says, “I just don’t enjoy being in the company of others. People don’t interest me much and I’d rather be to myself”. From the above information you come to the conclusion that she belongs to which one of the following personality types?
A. Schizotypal
B. Dependent
C. Schizoid
D. Avoidant
E. Borderline

Explanation:
Schizoid personality disorder is characterized by detachment from relationships and inability to express emotions. These patients do not enjoy close relationships and prefer keeping aloof and isolated. They rarely indulge in any pleasurable activities and appear indifferent to praise or criticism from others. They always choose solitary activities.

Choice A. Patients with Schizotypal personality disorder show a pattern of odd and eccentric behavior and reduced capacity for close relationships. These patients usually exhibit “magical thinking” like bizarre fantasies, belief in sixth sense, telepathy, superstitions or clairvoyance. They often have paranoid ideation and unusual perceptual experiences.

Choice B. Patients with Dependant personality disorder have an excessive need to be taken care of and tend to be clinging and submissive with their close ones. They tend to be extremely indecisive and avoid taking initiative with any new activities, due to feelings of inadequacy. They have difficulty expressing disagreement with others, for fear of losing support. They fear being "left alone" to take care of themselves.

Choice D. Avoidant personality disorder is characterized by a pattern of hypersensitivity to criticism, social inhibition, and feelings of inadequacy. These individuals AVOID (as the name suggests) intimate relations in an attempt to escape from being ridiculed. They also view themselves as inferior to others and are reluctant to engage in new activities or take any risk, due to fear of being embarrassed.

Choice E. As per DSM IV criteria, patients with Borderline personality disorder show a pattern of instability of interpersonal relationships and marked impulsivity. They swing wildly between devaluing and idealizing people (people are either "all good or all bad", popularly known as “splitting”). These patients often demonstrate suicidal or self- mutilating behavior. They also exhibit instability of mood and often find it difficult to control their anger. They tend to have chronic feelings of emptiness.

OPHTHALMOLOGY 1

A 65-year-old African American man comes to the emergency department with sudden loss of vision in his right eye. He is a diabetic, on treatment with metformin and glyburide for the past 10 years. Examination reveals visual acuity reduced to light perception in his right eye and normal in his left. Ophthalmoscopy reveals loss of fundus details, floating debris and dark red glow. His vital signs are normal. What is the likely diagnosis?
A. Retinal detachment
B. Diabetic retinopathy
C. Vitreous hemorrhage
D. Central retinal vein occlusion
E. Age related macular degeneration

Explanation:
In vitreous hemorrhage, patients present with sudden, acute loss of vision and sudden onset of floaters, as in this patient. Diabetic retinopathy is the most common cause of vitreous hemorrhage. The important clue to diagnosis is the fact that the fundus will be hard to visualize and even if visualized details may be obscured. Immediate ophthalmoscopic consultation is required. In patients with underlying medical condition conservative treatment with upright positioning for sleep to enhance settling of hemorrhage is advised.

Choice A: Retinal detachment refers to separation of the inner layers of the retina. It may be associated with metabolic disorders such as diabetes mellitus, trauma including ocular surgery, vascular disease, myopia, or degeneration. These patients complain of photopsia accompanied with showers of floaters.

Choice B: Diabetic retinopathy patients are usually asymptomatic even though changes in fundoscopy are seen. The symptoms of sudden acute onset of visual loss with numerous floaters are suggestive of vitreous hemorrhage, which frequently occurs in patients with proliferative diabetic retinopathy.

Choice D: Central retinal vein occlusion, presents with sudden, painless, unilateral loss of vision. It is also noted in patients with a history of hypertension. Ophthalmoscopic signs are disk swelling, venous dilation and tortuosity, retinal hemorrhages, and cotton wool spots.

Choice E: Patients with macular degeneration typically present with painless progressive blurring of central vision, which can be acute or insidious. It occurs bilaterally.

CARDIOLOGY 2

A 38-year-old Asian immigrant presents for the evaluation of exertional dyspnea with minimal activity. His past medical history is significant for acute rheumatic fever. He denies any fever, chest pain, cough, malaise or weight loss. His PR: 70/min and regular; BP: 126/76mmHg; Temperature: 37.2C(99F). His apex beat is tapping and non-displaced. Auscultation of his lungs shows crepitations in both lower lung fields. Auscultation of heart reveals a loud first heart sound, mid-diastolic rumbling and a low-pitched murmur at the apex with an opening snap. The murmur is accentuated by mild exercise. Chest X-ray shows straightening of the left border of the heart and presence of Kerley B lines. EKG shows left atrial enlargement. Which of the following findings is a hallmark of the suspected disease?
A. Left atrial enlargement
B. Elevated left atrioventricular pressure gradient
C. Wide pulse pressure
D. Elevated left ventricular diastolic pressure
E. Atrial fibrillation

Explanation:
The hallmark finding of MS is elevated left atrioventricular pressure gradient that ultimately leads to left atrial enlargement. The elevated left atrial pressures are transmitted to the pulmonary veins, capillaries, and arteries. These phenomena are responsible for the exertional dyspnea and later, pulmonary hypertension and right heart failure. Enlargement of the left atrium predisposes to the development of atrial fibrillation which is quite common in mitral stenosis but is not the hallmark finding.

The left ventricular diastolic pressure is normal in pure mitral stenosis. These pressures become elevated when there is coexistent mitral regurgitation, aortic valve disease, systemic hypertension, or coronary artery disease.

A wide pulse pressure is not a feature of mitral stenosis. It occurs in aortic insufficiency and other conditions in which circulation is hyperdynamic.

HAEMATOLOGY 1

An 80-year-old female is brought to your office, by her son, because of severe fatigue. She lives alone and is suffering from severe degenerative joint disease, which puts her in a house arrest-type state. Her son usually helps with getting grocery. Her only other medical problem is hypertension. She takes hydrochlorothiazide and acetaminophen. Her vitals are stable. On examination, she has pallor, and evidence of severe degenerative joint disease. Which of the following is the most likely cause of pallor in this patient?

A. Vitamin D deficiency
B. Vitamin C deficiency
C. Iron deficiency
D. Folate deficiency
E. Chronic hemolysis
F. Anemia of chronic disease
G. Vitamin B12 deficiency
H. Copper deficiency

Explanation:
The following points are to be noted in this clinical vignette. This is a geriatric patient with pallor and fatigue. Her medical history is significant for severe degenerative joint disease and HTN. With the given information, it is obvious that her fatigue is most likely due to anemia. Iron deficiency is the most common cause of anemia in elderly patients; the iron deficiency is most likely secondary to a nutritional deficiency, in this case. Other very common cause of IDA in elderly patients is chronic blood loss; however this patient has no complaints suggestive of chronic blood loss (such as gastritis, PU, diverticulitis, etc.).

Choice F: Anemia of chronic disease (ACD) is seen in patients with chronic illnesses. This is usually seen with infectious, inflammatory, or neoplastic diseases. Also, more recently, this has been noted in patients with severe trauma, heart disease, and diabetes mellitus. This patient has chronic degenerative joint disease, but it should be noted that inflammatory joint disease and not degenerative joint disease cause ACD. The pathophysiology involves defective utilization of the iron by the RBC precursors, secondary to inflammatory mediators.

Choice A: Vitamin D deficiency can occur in a patient who does not go out of the house, or is in a house arrest state; however, this would cause osteomalacia, and not anemia.

Choice B: Vitamin C deficiency is also common among elderly patients who consume a diet poor in vitamin C, and it would cause scurvy. This patient has no clinical features suggestive of scurvy.

Choices D and G: A diet poor in green leafy vegetables and meat can cause folate or vitamin B-12 deficiency, respectively, which could lead to megaloblastic anemia. No information on the patient's diet is given in this vignette. It is also important to note that IDA is the most common anemia in the elderly.

Choices E and H: This patient does not have any clinical features suggestive of copper deficiency or chronic hemolysis. Chronic hemolysis and copper deficiency can also cause IDA.

ONCOLOGY 1

Ms. Stern is a 57-year-old female diagnosed with stage II Hodgkin’s lymphoma 4 weeks ago. She is put on combination chemotherapy of ABVD regimen (Doxorubicin, Bleomycin, Prednisone, and Procarbazine). She complains of severe nausea and vomiting. She does not want to continue with her medicine, as they are making her life even more miserable. She is also having some general malaise, and then had a bit of a sore throat. She has lost 30 lb(12.6kg) in a month. Her vitals are, Temperature: 38.5C(101.3F); PR: 88/min; RR: 18/min; BP: 109/68mm of Hg. The patient is on 92% pulse oximetry on room air. On examination the mouth is dry and she looks significantly cachectic with enlarged cervical lymph nodes and hepatomegaly. How can her vomiting be best managed?
A. Stop the chemotherapy drugs
B. Ondansetron
C. Metoclopramide
D. Tell patient that her nausea will get better with time
E. Prochlorperazine

Explanation:
Nausea and vomiting is one of the major undesirable effects of chemotherapy. It is the major reason for non-compliance and failure of chemotherapy regimes. Patients should be thoroughly educated about nausea and vomiting before the chemotherapy begins. As far as pharmacological treatment is concerned, a 5-HT3 receptor antagonist Ondansetron is very promising in reducing chemotherapy-induced emesis and is available in a tablet form also. The other steps that should be taken in such patients include small frequent meals, avoiding bland foods, appropriate food presentation, and giving patient what he wants to eat.

Nausea and vomiting is a major hindrance to patient's compliance to chemotherapy so telling him to bear it is not the best option.

Metoclopramide and prochlorperazine are the classical agents that can be give to such patients either alone or in combination with ondansetron though they are not the best drugs for chemotherapy-induced emesis.

Expected side effects like nausea and vomiting are not the indications to stop chemotherapy.