United States Medical Licensing Step 3

Cholelithiasis is much more common in women than men. In addition to gender, the development of gallstones can also be affected by age, weight, family history, and pregnancy. Gallstones often remain asymptomatic, but they can cause symptoms when they cause obstruction of the cystic duct. The result of this obstruction is biliary colic, which is experienced as epigastric pain radiating to the back and can be associated with nausea and vomiting. The presence of tenderness to palpation in the right upper quadrant, fever, and leukocytosis would suggest acute cholecystitis, a complication of gallstones. In a patient suspected of having complications of gallstones, the best test for evaluation is ultrasonography.
Ultrasonography is highly sensitive in detecting gallstones and also provides details about the thickness of the gallbladder wall, the presence of pericholecystic fluid, and also the presence or absence of tenderness over the gallbladder during the examination (sonographic Murphy's sign). A two-way roentgenogram of the abdomen is much less sensitive, detecting only 20% of gallstones. A CT scan of the abdomen with IV and PO contrast can be sensitive in detecting the inflammatory changes associated with acute cholecystitis, but it is much more expensive and time consuming when compared to ultrasound. A HIDA scan, although sensitive and specific in the right setting, is generally reserved for more complicated cases where the diagnosis is unclear. Failure to visualize the gallbladder with HIDA scan in 1 hour indicates either partial or complete cystic duct obstruction and confirms the diagnosis of acute cholecystitis. However, this should not be the first-line test in evaluating a patient for acute cholecystitis. Finally, an MRCP can be very useful in evaluating the biliary tree and the presence of choledocholithiasis in a patient with cholecystitis and an elevated bilirubin, but does not have a role in the diagnosis of acute cholecystitis.

Informing a patient of a new diagnosis of cancer can be a very challenging and emotional experience for both the patient and the physician. It is important to maintain composure and not to rush. Certainly in the setting of a terminal cancer, the news can be devastating. The discussion that will follow this kind of information will often be lost as the patient copes with the news. In these situations, it is important to give the patient time to grieve. It is also important to be prepared to spend adequate time with the patient and family in order to review any questions. Finally, it is not unreasonable, if the patient is in agreement, to give them time to process this information and to discuss the diagnosis with their family before presenting them with management options. It is poor practice to avoid these confrontations, and a new diagnosis of cancer should be presented to the patient by a physician in a face-toface manner if possible. It is also important to have information for the patient to take home in the form of handouts, pamphlets, or Internet resources, in order to help them continue to come to terms with the diagnosis and the current management options that are available.

Papilledema is optic disc swelling and implies raised intracranial pressure. Headache is a common associated symptom. The initial evaluation of papilledema should involve imaging, either by MRI or CT scan with and without contrast, to exclude mass lesions. If these studies are negative, then the subarachnoid opening pressure should be measured by lumbar puncture. An ESR is unlikely to be diagnostic in this case. It would be more important in the evaluation of vision loss or headache in a person over the age of 50. Neither a pregnancy test nor a glucose tolerance test would provide information on the cause of increased intracranial pressure. Pseudotumor cerebri is a condition of idiopathic intracranial hypertension. It is a diagnosis of exclusion that would be made in the presence of papilledema, normal imaging studies, and elevated opening pressure on lumbar puncture with normal CSF studies. The majority of patients with pseudotumor cerbri are young, female, and obese. This condition is treated with a carbonic anhydrase inhibitor, such as acetazolamide, which lowers intracranial pressure by reducing the production of CSF. Weight reduction, while important, is often unsuccessful in improving the condition by itself. Steroids, tetracycline, pregnancy, and oral contraceptives are not associated with the development of pseudotumor cerbri. Pseudotumor cerebri may ultimately resolve spontaneously, but there is a significant risk for development of impaired vision or even blindness if left untreated. The goal of treatment is the reduction of intracranial pressure. This may be accomplished in a number of ways. Use of medications such as acetazolamide or furosemide is considered a first-line therapy, with the aim of reducing CSF production. If pharmacologic treatment proves unsuccessful, alternative treatment options include surgical options such as optic nerve fenestration or creation of a ventricular-peritoneal shunt. Performing serial lumbar punctures is also possible but carries a number of associated risks including development of infections or headaches

This patient's presentation is consistent with gout. Aspiration of his first MTP joint is likely to reveal the presence of needle-shaped, negatively birefringent crystals. Rhomboid-shaped, positively birefringent crystals are characteristic of calcium pyrophosphate deposition disease, or pseudogout, with the knee being the joint most commonly affected. Nonbirefringent crystals are found in hydroxyapatite crystal deposition disease. The synovial fluid from joints affected by gout typically show evidence of inflammation in the form of leukocytosis with a predominance of polymorphonuclear neutrophils. The presence of bacteria in synovial fluid is characteristic of infection rather than gout, although gout and infectious arthritis may coexist. (Cecil Textbook of Medicine, pp. 17031708) Acute gouty arthritis usually presents in a monoarticular or oligoarticular distribution, with the first MTP joint most commonly affected. The diagnostic gold standard is detection of urate crystals within the synovial fluid of affected joints.
It most commonly affects adult men with a peak incidence in the fifth decade of life. While patients with gout typically also have hyperuricemia, only a small fraction of the people with hyperuricemia actually have or will develop gout.

Tophi are primarily seen in patients with long-standing hyperuricemia and is considered a finding of chronic gouty arthritis. As the disease progresses, acute attacks become more frequent and last longer if left untreated. Indomethacin inhibits the prostaglandin synthesis that facilitates the inflammation of acute gout and inhibits the phagocytosis of urate crystals by leukocytes. This inhibits the cell lysis and release of cytotoxic factors that initiate the inflammatory cascade. Allopurinol (an inhibitor of urate synthesis) and probenecid and sulfinpyrazone (promoters of urate excretion) are useful for preventing gout but are not effective during an acute gout attack. Aspirin is inappropriate in the treatment of gout since it can inhibit urate elimination and, therefore, increase hyperuricemia.

Mortality from cervical carcinoma has been considerably falling throughout the years and that is secondary to multiple factors, such as cytologic screenings (pap smears), early detection, and treatment of dysplasia.

Ewing sarcoma is a malignant neoplasm of the bone that originates in the medullary canal and is composed of small uniform round cells. This tumor belongs to the primitive neuroectodermal tumors (PNET) of childhood. Approximately, 85% of these tumors show the C-MYC oncogene expression and there is a reciprocal transformation of chromosomes 11 and 22.

Polycystic ovary syndrome is characterized by clinical manifestations related to the secretions of excess of androgen hormones. There is usually a persistent anovulation, resulting clinically in irregular or absent menstruation. The ovaries are moderately enlarged and contain many small cysts located in the cortex.

Malignant melanoma is a malignant neoplasm of the melanocyte. Most melanomas arise in the basal layer of the epidermis and remain confined to the epidermis in a radial growth phase for sometime. Later in the tumor development, it will grow down into the dermis (vertical growth phase) and gain access to the lymphatics. Clinically, most melanomas display a variegated brown, tan, pink, or black appearance. Irregular edges, enlargement, and central nodular ulceration may be noted. The microscopic appearance is characterized by nests of cells and single cells with eccentrically located nuclei and prominent eosinophilic macronucleoli. Melanin is present in the cytoplasm. Squamous cell carcinomas are not pigmented and they are rare on the back. Basal cell carcinomas can sometimes be confused with the melanomas when they are the pigmented variety. (This was not a selection given.) Generally, those happen in the sunexposed areas. The prognosis of melanoma is related to the depth of invasion measured by either the Clark level or Breslow thickness. Deeply invading tumor and thicker tumors are associated with poor prognosis.

Sinus histiocytosis represents hyperplasia of the endothelial lining of the sinusoids, which become dilated and contain many histiocytes. This reaction, which is also called reticular hyperplasia, becomes very prominent in lymph nodes when they are draining a cancerous process. This is particularly common in the axillary nodes when cancer of the breast has been detected. It is thought to represent an immune response to the host against the tumor products.

Multiple myeloma is a plasma cell dyscrasia that is characterized by involvement of the skeleton in multiple sites. The characteristic x-ray shows punched-out bone lesions that are very easily seen in the calvarium. Extension of the disease to lymph nodes and extranodal sites, such as skin, can be seen. The bone marrow biopsy and smears reveal an increased number of plasma cells, which usually constitute greater than 20% of all of the cells. The cells either diffusely infiltrate and replace the marrow elements or can be seen scattered throughout the hematopoietic elements. The neoplastic plasma cells have a perinuclear hof and an eccentrically placed nucleus which allows the recognition. In 99% of patients with multiple myeloma, electrophoretic analysis reveals increased levels of IgG in the blood, light chains (Bence-Jones proteins) in the urine, or both. The monoclonal IgG produces a high spike when seen in the serum or in the urine, subject to electrophoresis. In general, the quantitative analysis of the monoclonal IgG is more than 3 g. The clinicopathologic diagnosis of multiple myeloma rests on radiographic and laboratory findings. Marrow examination may reveal increased plasma cells or sheet-like aggregates that may completely replace the normal elements. The prognosis for this condition is variable, but generally poor.