The correct answer is B.

The patient in this question is presenting with acute cholecystitis. He is presenting with fever, right upper quadrant pain after a fatty meal that radiates to the right scapula, and positive Murphy sign (pain on palpation in the right upper quadrant with cessation of inspiration). Additional nonspecific findings include vomiting, leukocytosis, and mild elevation in transaminases. Acute cholecystitis usually arises from gallstone formation that obstructs the cystic duct. The symptoms occur after eating a fatty meal because the fat stimulates gallbladder contraction, and in the presence of cystic duct obstruction, this leads to colicky pain. Infection results from stasis that contributes to bacterial growth in the gallbladder.

⚠Choice A is not correct:

Alcoholic liver disease does not present with this constellation of symptoms.

⚠Choice C is not correct:

Similar to common bile duct obstruction, obstruction from a carcinoma of the head of the pancreas would cause severely elevated alkaline phosphatase levels and would normally present with weight loss and painless jaundice.

⚠Choice D is not correct:

Importantly, alkaline phosphatase is not elevated in this patient with acute cholecystitis. Assume if laboratories are not shown, they are normal. If it were elevated (in addition to total bilirubin and direct bilirubin), this might indicate common bile duct obstruction in the setting of jaundice (choledocolithiasis).

⚠Choice E is not correct:

Pancreatitis should definitely be ruled out with a lipase check, but pain typically is only epigastric in nature and radiates to the back.

Summarized Points:

acute cholecystitis presents with fever, right upper quadrant pain after a fatty meal that radiates to the right scapula, and positive Murphy sign (pain on palpation in the right upper quadrant with cessation of inspiration). Usually caused by gallstone formation that obstructs the cystic duct.

A 6-year-old girl is brought to the physician for a routine examination. She has no complaints and is enjoying first grade. Her favourite drink is orange juice, and she enjoys chips and cookies. The girl has no medical problems and takes no medications. The review of the systems is negative. Several maternal relatives are obese, but no family members have heart disease or stroke. There are no smokers in the home. Body mass index (BMI) was previously in the 80th percentile but is now in the 99th percentile. Vital signs are normal. Examination reveals central adiposity. No acanthosis nigricans is seen. Which of the following is the best next step in the management of this patient?

A. Serum lipid panel
B. 12-lead electrocardiogram
C. Liver ultrasound
D. No testing indicated at this age
E. Serum thyroid function test

The growing prevalence of overweight (body mass index [BMI] 85th–95th percentile) and obese (BMI ≥95th percentile) children has resulted in increasing rates of early dyslipidemia and metabolic syndrome. Children with a BMI ≥95th percentile should undergo fasting glucose testing to screen for diabetes mellitus, serum alanine aminotransferase (ALT) to screen for fatty liver disease, and a serum lipid panel to screen for dyslipidemia. Ideally, total cholesterol, triglycerides, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol are measured after the patient has fasted. Triglycerides in particular can remain elevated for several hours after a high-fat meal, but recent studies show that the other values may not be significantly affected by a recent meal. The first-line treatment for children with elevated LDL and triglycerides includes regular exercise, a healthy diet low in fat and cholesterol, avoiding sugary beverages, and minimizing television time to <2 hours per day. Addressing modifiable risk factors can delay, pause, or reverse the development of these complications.


⚠Choice B is not correct:

Routine electrocardiogram in asymptomatic children with no significant family history of cardiac disease is low yield and not recommended.

⚠Choice C is not correct:

If the serum ALT is elevated, a liver ultrasound can be performed to evaluate for fatty liver disease.

⚠Choice D is not correct:

Testing should be performed to identify potentially treatable complications of obesity.

⚠Choice E is not correct:

Hypothyroidism rarely causes obesity in isolation and usually manifests with other abnormalities (e.g., constipation, cold intolerance, fatigue).

Summarized Points:

Pediatric obesity is increasingly common and is associated with early complications such as dyslipidemia, fatty liver disease, and hypertension. Fasting glucose, serum alanine aminotransferase, and a lipid panel should be measured in these patients. Dietary and lifestyle modifications are the first-line treatment.

A 77-year-old woman was admitted from home because of syncope. Her daughter reports that the patient has been losing weight and rarely eating since the death of her husband about one year ago. In addition, the daughter states that her mother's urine has a dark colour to it and that she is very concerned. He laboratory results are the following:

 Serum chemistry
    Creatinine  247µmol/L (50-90)
    Albumin 21 g/L (35-50)
 Urinalysis
    Blood positive
 

Urine microscopy shows 0-2 WBC and 0-2 RBC. The patient does not have a significant cardiac history, but she has diabetes and takes metformin 1000 mg twice a day. What is the next best step in determining the etiology of her acute kidney injury?

A. Creatinine kinase level
B. Renal ultrasound
C. CT scan with IV contrast
D. Glycated hemoglobin
E. Lactate dehydrogenase level

The correct answer is A.

This patient is suffering from an acute kidney injury (AKI) due to pigment nephropathy from rhabdomyolysis. A urine dipstick test for blood with positive findings in the absence of red blood cells (RBCs) indicates myoglobinuria. This should automatically suggest rhabdomyolysis. A creatine kinase (CK) level can confirm that the patient has rhabdomyolysis from protein/calorie malnutrition. She has been losing weight and is weak, and her albumin level is low, which confirms a decreased oral intake. CK levels rise within 12 hours of muscle injury, peak in 24-36 hours, and decrease at a rate of 30-40% per day. The serum half-life of CK is approximately 36 hours. Total CK elevation is a sensitive but nonspecific marker for rhabdomyolysis. CK levels 5 times the reference range suggest rhabdomyolysis, although CK levels in rhabdomyolysis are frequently 100 times the reference range or even higher.

⚠ Choice B is not correct:

Several studies have shown the benefits of ultrasound in the diagnosis of rhabdomyolysis. However, most consistent data is needed to rely on it as a diagnostic tool.

⚠ Choice C is not correct:

Imaging studies in rhabdomyolysis may show signs of muscle edema and/or hemorrhage. Edematous muscles on CT scan are usually hypodense and possibly enlarged.

⚠ Choice D is not correct:

Glycated hemoglobin, also known as HbA1c, can be used to check the blood sugar levels of prediabetics and monitor blood sugar control in patients with diabetes mellitus. Some studies have shown that elevated HbA1c levels predict acute kidney injury after coronary artery bypass grafting in non-diabetic patients.

⚠ Choice E is not correct:

Aside from creatinine kinase, other muscle enzymes, such as aldolase, aminotransferases, lactate dehydrogenase, may be elevated in rhabdomyolysis. Their presence is not necessary to make the diagnosis.

Summarized Points:

The diagnostic hallmark of rhabdomyolysis is an elevation in serum creatinine kinase (CK) levels. These levels can range from about 1500 to over 100,000 international units/L and usually begin to rise within 2-12 hours following muscle injury and reach a peak within 24-72 hours. Another characteristic finding of rhabdomyolysis is reddish-brown urine from myoglobinuria, which may only be seen 50% of the time.

A 41-year-old woman is evaluated for a 9-month history of Raynaud phenomenon. She reports no difficulty swallowing, dyspnea on exertion, or hand stiffness. She has recently developed gastroesophageal reflux disease. On physical examination, vital signs are normal. The skin between the distal and proximal interphalangeal joints of the fingers is difficult to tent. Three telangiectasias on the right hand and four on the left are noted. She also has two small telangiectasias on the face and one on the inside bottom lip. No digital pitting is seen. Laboratory evaluation reveals a positive antinuclear antibody titer (1:320) and positive anticentromere antibody titer (1:160). Which of the following is the most likely diagnosis?

A. Eosinophilic fasciitis
B. Limited cutaneous systemic sclerosis
C. Diffuse cutaneous systemic sclerosis
D. Mixed connective tissue disease

The correct answer is B.

Anticentromere antibodies (titer of 1:80 or higher) are rare in healthy people. The finding of anti-centromere antibodies (ACAS) in the setting of Raynaud phenomenon is 60% sensitive and 98% specific for limited cutaneous systemic sclerosis (LcSSc), which was previously known as the CREST syndrome. Patients with LcSSc have manifestations that can include calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST); all five conditions may not be present. The presence of anticentromere antibodies increases the risk for pulmonary hypertension, which occurs in 20% of these patients. Patients who have only Raynaud phenomenon and ACA must be followed for development of LcSSc This patient with recent onset of Raynaud phenomenon is showing features of LcSSc. Although gastroesophageal reflux disease is common in the general population, the recent onset of telangiectasias and sclerodactyly suggests LcSSc. The telangiectasias seen in LcSSc are matted; these clusters of dilated vessels appear as small pink or red macules that blanch on light pressure. They are most commonly seen on the face, mucous membrane, and hands.

⚠Choice A is not correct:

Eosinophilic fasciitis is associated with orange peel induration (peau d'orange) of proximal extremities, with sparing of hands and face, and the presence of peripheral eosinophilia. The presence of Raynaud phenomenon and the positive ACA result make eosinophilic fasciitis an unlikely diagnosis.

⚠Choice C is not correct:

Patients with diffuse cutaneous systemic sclerosis (DcSSc) have skin involvement that is more extensive than that found in LcSSc and additionally includes the arms, trunk, and lower extremities. Anti-Scl-70 antibodies are generally associated with DcSSc, with a prevalence approaching 30%, and these antibodies are associated with a higher risk for interstitial lung disease. ACM are uncommon in DcSSc.

⚠Choice D is not correct:

Mixed connective tissue disease is a specific overlap syndrome that includes clinical manifestations of at least two of the following: systemic lupus erythematosus, polymyositis, and systemic sclerosis. Positive results for anti-U1-ribonucleoprotein antibodies are the primary laboratory feature in many patients. The absence of findings associated with another connective tissue disease and a positive ACA titer support the diagnosis of LcSSc rather than mixed connective tissue disease.

Summarized Points:

The finding of anticentromere antibodies in the setting of Raynaud phenomenon is 60% sensitive and 98% specific for the development of limited cutaneous systemic sclerosis. Anti-Scl-70 antibodies are generally associated with diffuse cutaneous systemic sclerosis, with a prevalence approaching 30%, and these antibodies are associated with a higher risk for interstitial lung disease.

An 79-year-old woman experiences the sudden onset of lower extremity weakness and collapse on getting out of bed. She has been previously healthy and has not taken any medications. She has no history of back pain. On examination, she is alert and oriented to time, place and date. Her upper extremity sensation and strength are intact. Her legs are weak bilaterally, with loss of pain and temperature sensation and areflexia. Her bladder is distended. Which of the following is the most likely diagnosis?

A. Anterior cerebral artery occlusion
B. Anterior spinal artery occlusion
C. Cauda equina syndrome
D. Guillain-Barré syndrome
E. Thoracic spinal cord compression

The correct answer is B:

The perfusion territory of the anterior spinal artery includes the anterior horn cells and part of the pain and temperature pathways. Thrombosis of this artery causes flaccid paralysis, loss of bowel and bladder function and loss of pain and temperature sensation.


⚠ Choice A is not correct:

Anterior cerebral artery occlusion can cause leg weakness but there should be no sensory loss. Upper motor neuron signs are present in the leg.

⚠ Choice C is not correct:

Cauda equina syndrome can cause flaccid paraplegia but somatic sensation should be compromised since sensory nerve roots are involved in the disease process.

⚠ Choice D is not correct:

Guillain-Barré syndrome rarely develops this acutely. If loss of pain and temperature sensation occurs, it presents with concurrent loss of position and vibration sense.

⚠ Choice E is not correct:

Thoracic cord compression is associated with low back pain and produces upper motor neuron dysfunction in the legs.

Summarized Points:

These patients, typically abruptly present with Anterior Spinal Artery(ASA) syndrome consisting of flaccid paralysis, bowel/bladder dysfunction, sexual dysfunction, possible hypotension, and loss of tendon reflexes. Spasticity and hyperreflexia develop over the subsequent days to weeks. Vibratory and proprioceptive sensation is preserved because posterior circulation of the spinal cord is not affected This patient needs emergent MRI for diagnosis and treatment with supportive care and lumbar drains to reduce spinal pressure.

A 27-year-old farmer presents with a linear vesicular rash on his hands and face, particularly around his left eyelid. He describes the rash as highly itchy. He has no fever, headaches, or nausea. He has had a similar rash as a child but doesn't recall it. He mentioned he was pulling out weeds around the edge of his farm before the rash occurred. Given the suspected diagnosis, which of the following is the most appropriate treatment option for this patient?

A. Skin patch testing
B. Antibiotic treatment targeted at Staph aureus
C. Treatment with jewelweed extract
D. Topical corticosteroid therapy
E. Systemic corticosteroid therapy

Poison ivy causes allergic contact dermatitis due to a type IV hypersensitivity reaction to the plant Toxicodendron radicans, with similar reactions caused by poison oak and poison sumac. The compound urushiol is present in poison ivy and causes a Type IV hypersensitivity reaction in up to 50% of exposed individuals. Although exposure to intact plant parts does not usually cause dermatitis, the toxic oil will contact skin, clothing, pets, or tools through bruised or broken pieces of plants. Urushiol oil passes through the epidermis to be processed by Langerhans cells, activating T lymphocytes to trigger the hypersensitivity reaction. Clinical features include pruritic, erythema, and formation of vesicles, bullae, or plaques presentation in linear arrangement where exposure to urushiol has occurred. Although the rash usually occurs within 4 to 96 hours after exposure in previously sensitized patients, it may develop in some cases up to 3 weeks after exposure. Treatment with systemic corticosteroids is indicated for severe symptoms and when the rash is on the face or genitalia. In other cases, high-potency topical corticosteroids and antihistamines may provide some relief.

⚠ Choice A is not correct:

Skin patch testing isn't as useful clinically at this time as it would look for hypersensitivity reactions to particular triggers. In the story, the clinical history is adequate to diagnose based on the stem and the physical exam findings to proceed with treatment.

⚠ Choice B is not correct:

While there may be secondary infections due to bacteria in areas of skin exposure and damage, of which staph aureus may be a culprit, the clinical stem does not suggest impetigo, so antibiotics are not indicated.

⚠ Choice C is not correct:

Jewelweed extract is not efficacious for treating contact dermatitis due to poison ivy.

⚠ Choice D is not correct:

Treatment with high potency topical corticosteroids is generally appropriate for limited exposure areas. However, given the lesions around his face, particularly around his eyes, systemic steroids are indicated for this patient.

Summarized Points:

Contact dermatitis due to poison ivy, poison oak, and poison sumac are caused by a type IV hypersensitivity reaction to urushiol exposure. While the reaction will dissipate on its own, treatment with steroids can be helpful, and systemic steroids are indicated when areas involved include the face or genitalia

A 55-year-old woman, gravida 1 para 1, comes to the office due to leakage of urine. The patient first noticed intermittent loss of urine a few years ago. The leakage has progressively worsened and now she is constantly leaking a small amount of urine. The patient soaks through a thin incontinence pad 2 or 3 times a day. She has no dysuria, hematuria, or urge to void. The patient has type 1 diabetes mellitus managed with an insulin pump. Her last hemoglobin A1c was 11.6%. At age 30 she had an operative vaginal delivery complicated by a large perineal laceration. Vital signs are normal. Pelvic examination reveals leakage of urine that increases with Valsalva. Postvoid residual volume is increased. There is decreased sensation to light touch and pinprick involving the perineum and both feet. Laboratory results are as follows:

 Urinalysis
  Protein  trace
  Blood  trace
  Urine culture negative
 

Which of the following is the best next step in the management of this patient?


A. Intermittent self-catheterization
B. Pelvic floor muscle exercises
C. Placement of midurethral sling
D. Placement of suprapubic catheter
E. Tolterodine therapy

The correct answer is 🅰.

Patients with overflow incontinence often have poor urine stream, dribbling, sensation of incomplete emptying, and nocturia. This is due to continuous leakage of urine from persistent urinary retention caused by either:

Outflow obstruction - incomplete bladder emptying due to compression of the urethra, often by uterine fibroids or severe pelvic organ prolapse
Poor detrusor function - decreased bladder contractility due to advancing age, medications (e.g., anticholinergics), spinal pathology (e.g., spinal stenosis), and neuropathy (e.g., diabetes mellitus)
Patients with poorly controlled diabetes develop neuropathies (e.g., decreased pinprick sensation), causing loss of the sensation of bladder fullness and incomplete voiding that in turn leads to urinary retention. Chronic urinary retention increases the risk for urinary tract infection and renal damage; therefore, patients require intermittent self-catheterization. Additional treatment includes cholinergic agonists (e.g., bethanechol) and correction of underlying causes (e.g., optimization of hemoglobin A1c, correction of prolapse).


⚠ Choice B and C are not correct:

Patients with stress urinary incontinence have increased leakage of urine with Valsalva; however, they do not have an associated elevated post residual volume. Stress urinary incontinence is treated with lifestyle modifications (e.g., weight loss, smoking cessation), pelvic floor muscle exercises (e.g., Kegel exercises), and midurethral slings. Strengthening the pelvic floor prevents urethral hypermobility and decreases leakage with Valsalva (e.g., sneezing, coughing). Midurethral slings are reserved for patients who fail lifestyle modifications and pelvic floor therapy.

⚠ Choice D is not correct:

Suprapubic catheters can be used in cases of severe urinary retention; however, indwelling catheters increase the risk of urinary tract infection and antibiotic resistance.

⚠ Choice E is not correct:

Tolterodine is an antimuscarinic that inhibits bladder contractions and is used to treat urgency incontinence. Patients with urgency incontinence have a sudden need to urinate (e.g., overactive bladder) followed by immediate involuntary loss of urine.

Summarized Points:

Overflow incontinence presents with continuous leakage of urine secondary to urinary retention caused by underactive detrusor function (e.g., diabetes mellitus) or outflow obstruction (e.g., pelvic organ prolapse). Treatment focuses on correcting reversible causes, cholinergic agonists, and intermittent self-catheterization.

A 27-year-old woman presents with complaints of daily nosebleeds and heavy menstrual cycles. She says she has had a history of easy bruising but no other medical problems. She states her father, sister, and brother also bruise easily. The patients mother does not share these symptoms, and further questioning reveals no bleeding or coagulation disorders in any of her relatives. Physical examination reveals ecchymoses on the arms and gingival bleeding. No petechiae or hemarthrosis are noted. The remainder of the physical examination is noncontributory. Laboratory tests show:

  White blood cells 9 x 109/L (3.5–10.5)
  Hemoglobin 125 g/L
  Platelet 205 x 109/L (130–380)
  Bleeding time 9 minutes (1–9)
  Prothrombin time 12 seconds (10–14)
  Mixing study prothrombin time 15 seconds 
  Partial thromboplastin time 47 seconds (22–30)
  Mixing study partial thromboplastin time 37 seconds 
  Factor VIII coagulant activity low
 

Which of the following is the most likely diagnosis?


A. Factor VIII inhibitor
B. Hemophilia type A
C. Hemophilia type B
D. Medication adverse effect
E. von Willebrand’s disease

The correct answer is E.

von willebrand's disease (vWD) is a coagulation disorder due to a deficiency in von Willebrand’s factor (vWF). vWF is necessary for platelet-to-platelet adhesion and platelet adhesion to epithelial surfaces. In addition, vWF stabilizes coagulation factor VIII in the circulation and prevents its degradation. Patients with vWD may present with easy bruising or mucosal bleeding (oral, gastrointestinal, or menstrual bleeding). These patients do not develop petechiae or hemarthrosis, as may be seen with other coagulation disorders.

vWD is usually inherited through an autosomal dominant pattern. The laboratory findings show a normal platelet count with increased bleeding time, as would be expected in a case of vWD. In addition, the patient has low factor VIII activity and a prolonged partial thromboplastin time, which is due to increased factor VIII degradation as seen with vWF deficiency.


⚠Choice A is not correct:

Factor VIII inhibitor is a common condition that can mimic hemophilia. In patients with a factor VIII inhibitor, the partial thromboplastin time will not correct, as it did in this patient. Therefore, a factor VIII inhibitor is unlikely.

⚠Choice B and C are not correct:

Hemophilia type A and B are associated with deficiencies or impaired function of coagulation factor VIII and IX respectively. These patients present with an increased partial thromboplastin time. It is expected that hemophilia patients would have a normal bleeding time because their platelet function is not altered. In addition, these patients may present with hemarthrosis. Hemophilia is an x-inked recessive disease that does not typically affect female patients.

⚠Choice D is not correct:

Given this patients presentation and family history of bleeding, a medication adverse effect is unlikely. Thrombocytopenia is a common adverse effect of medications such as methotrexate, valproic acid, histamine blockers (H2), and more. However, this patient has a normal platelet count. Dysfunction of platelet function and the coagulation profile is possible, but a young patient with no medical history is unlikely on a medication like aspirin.

Summarized Points:

von willebrand's disease (vWD) is a coagulation disorder generally inherited through an autosomal dominant pattern that presents with easy bruising or mucosal bleeding. Laboratory findings in this disorder show a normal platelet count with increased bleeding time

A 72-year-old woman comes to the office due to 2 days of malaise, fatigue, and fleeting joint pains in her neck and shoulders. She is retired and frequently travels with her ornithology club to view birds along Lake Erie beach. Temperature is 37.9 C (100.2 F), blood pressure is 128/68 mm Hg, and pulse is 102/min. Palpation of the patient's cervical spine and paraspinous muscles reveals no reproducible tenderness. There is a flat, erythematous, 4-cm lesion with a pale center on her right thigh. Which of the following is the most appropriate next step in the management of this patient?

A. Borrelia burgdorferi serology
B. Intravenous ceftriaxone
C. Low-dose prednisone
D. Viral respiratory panel
E. Oral doxycycline

This patient traveled to a Lyme endemic area and subsequently developed systemic symptoms and a rash with central clearing, raising strong suspicion for early localized Lyme disease. Lyme disease is a spirochetal illness caused by Borrelia burgdorferi and is transmitted during blood feeding by the bodes scapular's tick. Although patients may not recall a tick bite, symptoms of early localized Lyme disease typically occur 7-14 days after inoculation, including:

Erythema migrans (EM), a macular rash that slowly spreads outward and eventually forms areas of central clearing (leading to a "bull's eye" appearance)
Nonspecific systemic manifestations such as headache, malaise, low-grade fever, and myalgia
Because the humoral antibody response is not yet formed at this early stage of disease, serologic testing should not be performed. Patients are diagnosed clinically, primarily based upon residence/travel to a Lyme endemic area and the presence of the hallmark lesion of EM.

Empiric treatment with 14 days of oral doxycycline is the preferred therapy for patients of all ages (including children) due to high efficacy and activity against possible coinfection with Anaplasia (also transmitted by / scapular's). Oral amoxicillin is also effective but is generally reserved for pregnant patients or those with allergies to doxycycline.


⚠Choice A is not correct:

IgM antibodies for Lyme disease may take 2-6 weeks after infection to appear in the blood. Patients (such as this patient) presenting initially with EM do not require serologic testing and should be treated for Lyme disease with antibiotics (e.g., doxycycline, cefuroxime, or amoxicillin).

⚠Choice B is not correct:

Intravenous ceftriaxone is effective against B burgdorferi but is reserved for patients with more serious complications who need to be hospitalized (e.g., meningitis, carditis). Oral agents are preferred for early localized Lyme disease and for most patients who can be treated as outpatients.

⚠Choice C is not correct:

Low-dose prednisone often rapidly reverses symptoms in patients with polymyalgia rheumatica, an autoimmune disease marked by symmetric muscle pain and limited movement in the shoulder and pelvic girdles. Although systemic symptoms can sometimes occur, a rash with central clearing would be atypical.

⚠Choice D is not correct:

Viral respiratory infections often cause nonspecific systemic symptoms, but most patients would have some manifestations linked to the upper airways (e.g., cough, rhinorrhea). The presence of a single macular lesion with central clearing makes viral upper respiratory infection less likely than Lyme disease.

Summarized Points:

Early localized Lyme disease should be suspected in any patient who recently visited or resides in a Lyme endemic area and presents with the hallmark rash of erythema migrans. Serology should not be performed at this early stage of illness due to a lack of full humoral response. The diagnosis is made clinically, and oral doxycycline is the treatment of choice for all nonpregnant patients.

A 14-year-old boy is brought to the office due to right eye pain. Yesterday, she developed swelling on the right upper eyelid. Examination shows a tender, 3 mm area of swelling and erythema along the margin of the right upper eyelid. There is no conjunctival injection or discharge. Extraocular movements are intact and her visual acuity is 20/20 bilaterally. Which of the following is the most appropriate management of this patient's condition?


A. Incision and drainage of the lesion
B. Oral antibiotics
C. Topical antibiotics
D. Topical corticosteroids
E. Application of warm compresses