Free USMLE-STEP-3 Exam Dumps Preview

This patient clearly presents with a paranoid stance, although he is not overtly psychotic. Individuals with antisocial personality disorder are usually more dishonest, aggressive, and exploitative in their attitudes. Narcissistic patients may become easily offended by interactions when not feeling as though they are being treated as "special," but they do not display as much overt mistrust. Patients with schizoid and schizotypal personality disorders appear indifferent or odd, usually with a detached attitude.
Patients with paranoid personality disorder display a pervasive suspiciousness toward others, continuously feeling slighted and bearing grudges, not unusually in the form of litigiousness

Agoraphobia is characterized by anxiety about being in places where escape might be difficult or help might not be available in the event that a panic attack occurs (e.g., crowds, bridges, standing in lines). GAD involves excessive worry about a number of events for at least 6 months. Panic disorder is diagnosed if there are recurrent, unexpected panic attacks along with concerns about having further attacks or about the consequences of having an attack (e.g., heart attack, losing control). Social phobia is characterized by a persistent dread of social or performance situations due to fears of acting in an embarrassing or humiliating way. This woman experiences symptoms consistent with a specific phobia, blood-injection- injury type (DSM IV-TR). Due to the sympathetic discharge, individuals with certain phobias, most notably social phobia, can sometimes be managed with the use of beta-blockers.

This is particularly useful when a known exposure will occur. Beta-blockers could worsen the symptoms of blood-injury phobia, however, given the vasovagal nature of the response. Insightoriented and supportive therapies are not particularly helpful with treating phobias, as phobias usually require specific behavioral techniques. SSRIs can be efficacious in certain anxiety disorders, such as social phobia, panic disorder, and GAD; however, they are not useful for phobias such as
blood-injury type. Exposure therapy is considered to be the optimal treatment for phobias in general, especially specific phobias. In this therapy, the patient is exposed to particular phobic stimuli of an increasingly anxiety-provoking nature, and certain relaxation techniques are introduced.

This patient is manifesting symptoms consistent with asthma. With the history of recently moving to a new area, along with a family history of allergies and eczema, his asthma may be further classified as allergic asthma. Episodic symptoms of cough, dyspnea, and wheezing are likely to occur. The diagnosis of asthma is made by demonstrating reversible airway obstruction. Airway obstruction is likely to be manifested by a reduction in the FEV1. An increase in the FEV1 of 15% after the use of a bronchodilator is the definition of reversibility. A CXR is most likely to be normal. Numerous cardiac conditions, such as CHF, cardiomyopathies, or pericardial effusions, may result in cardiomegaly on a CXR. Diffuse infiltrates may be seen with infections, interstitial lung disease, or other conditions. Flattened diaphragms would be consistent with prolonged obstructive lung disease, such as emphysema. The treatment of choice for the prevention of symptoms in all stages of asthma other than mild intermittent is inhaled steroid. All patients with asthma should also have a short-acting bronchodilator for acute symptomatic relief. A leukotriene modifier would be an alternative recommendation and might be a good addition to an inhaled steroid, as they also have FDA indications for patients with allergic rhinitis.

Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unclear etiology. The salient diagnostic features include fever for greater than 5 days, cervical lymph node greater than 1 cm, nonpurulent conjunctivitis, oral changes (cracking lips or "strawberry tongue"), polymorphous rash to the trunk, and changes to the hands and feet (peeling of the fingers or toes or edema of the hands or feet). This may be confused with group Abeta-hemolytic streptococcal pharyngitis, which usually is not associated with conjunctivitis. Coxsackie viral infection is commonly seen as the "hand-footmouth" disease, with shallow ulcers on the palms, soles, and in the mouth. There is nominal fever associated, and conjunctivitis is uncommon. Parvovirus B-19 (erythema infectiosum, "fifth disease") is commonly called "slapped cheek" disease because of the exanthem of bright red cheeks. Adenopathy and conjunctivitis are not features of this infection.
Acute phase reactions are often elevated late in the course of Kawasaki disease.
The most common blood test result would be a dramatically elevated platelet count. It is usually greater than 750,000 and can be greater than 1,000,000. An ESR is also likely to be elevated, not low. Apositive rapid strep test would lead one more toward acute GAS disease. The treatment of choice for Kawasaki disease is IVIG and aspirin. IVIG infusion is usually over 12 hours and will commonly result in rapid defervescence and clinical improvement. Treatment of Kawasaki disease is important as it will prevent long-term sequelae. A common side effect of IVIG is aseptic meningitis. Nearly a quarter of untreated children will develop coronary artery dilatation. This is most common cause of acquired heart disease in children younger than 5 years of age. The coronary artery dilatation can result in aneurysm formation and myocardial infarction.

From the description, the diagnosis in this patient is acute regional enteritis. The incidental finding of regional enteritis in patients operated on for the presumed diagnosis of acute appendicitis is treated medically unless there is proximal obstruction. The risk of operating on patients with regional enteritis is the formation of a fistula and/or abscess, especially if the area to be resected is involved with the disease process. However, if the cecum and the appendix are not involved, it is advisable to perform an appendectomy. In this instance, it would be safe and eliminate acute appendicitis from the differential if his symptoms recurred.

In general, women with diabetes mellitus are at increased risk for congenital abnormalities as well as spontaneous abortion, with the risk rising in direct relationship to the maternal hemoglobin A1C. The risk is particularly increased when the periconception hemoglobin A1C value exceeds 10%. In addition to congenital heart defects, which are increased approximately fivefold over the general population (2.5% vs. 0.5%), open neural defects are thought to be 10 times more common

Pharyngoesophageal (Zenker's) diverticulum is the most common diverticulum of the esophagus, and is an example of a pulsion diverticulum. It is a false diverticulum and consists of the mucosa and submucosa protruding through the esophageal musculature. A true diverticulum would involve all three layers. It is situated posteriorly just proximal to the cricopharyngeal muscle, at a weak point in the esophagus. Symptoms include dysphagia, spontaneous regurgitation of undigested food/pills, noisy swallowing, and halitosis. The most serious complication of a Zenker's diverticulum is aspiration leading to pneumonia or a lung abscess. The diagnostic test of choice is a barium swallow. Both AP and lateral views are essential to estimate the size of the diverticulum and determine the side of deviation. Treatment mandates a cricopharyngeal myotomy in order to relieve the increased pressure at the upper esophageal sphincter that is responsible for the development of the diverticulum. Surgical management of the diverticulum itself could involve a resection or a diverticulopexy, which allows the pouch to spontaneously drain. Esophagoscopy with biopsy to rule out cancer is only indicated preoperatively if there is evidence of ulcers or mass defects on the barium swallow. EGD should be considered postoperatively because of a high association of GERD with Zenker's diverticula. Complications of surgery include infection, recurrence, vocal cord paralysis secondary to injury to the recurrent laryngeal nerve, and esophagocutaneous fistulas.

The symptoms described by the patient are classic for rest pain. Patients often experience pain at night while lying in bed, and the pain improves with dependent positioning of the affected extremity. Initial evaluation of this patient should be an arterial duplex study of the vessels of the affected leg. This noninvasive test can provide great detail on the extent of the disease and the location of hemodynamically significant obstruction. Furthermore, it will help determine if inflow obstruction is present in the aorta or iliac vessels. It is crucial in these patients to determine if the arterial obstruction involves the aortoiliac vessels or is confined to the lower extremity vasculature. After determining the location of the atherosclerotic lesion, you can proceed with a traditional angiogram, CT angiogram, or even an MRI/MRA to evaluate the vessels in order to plan your intervention. The management of peripheral arterial occlusive disease is determined in part by the severity of the symptoms. Patients with limbthreatening ischemia, indicated by rest pain, tissue necrosis, and nonhealing wounds, should be considered for revascularization. On the other hand, patients with intermittent claudication, usually described as an "ache" in the calf, should first be managed conservatively. This includes institution of lifestyle modifications such as smoking cessation, walking programs, and medical therapy with pentoxifylline or cilostazol. However, patients with severe intermittent claudication that is lifestyle limiting should be considered for surgical revascularization.

In evaluating a sporadic thyroid nodule in a patient who is euthyroid, it is critical to determine whether the nodule is malignant or benign. The most diagnostic test is the fine needle aspiration. Ultrasound will only distinguish between cystic and solid structures, and most nodules have some solid component. The nuclear scan will demonstrate a photopenic area in over 85% of patients. Neither these tests nor CT scan will reliably separate benign from malignant nodules. Thyroid antibody studies do not play a role in the evaluation of a thyroid nodule in a euthyroid patient. They are sometimes used in the evaluation of thyroiditis.

Early clinical decline in a transplant patient is concerning for primary organ failure. This can be related to donor issues, technical issues, or donor organ ischemia. Signs of liver dysfunction include hypoglycemia (as the liver is unable to perform gluconeogenesis), coagulopathy with elevated prothrombin times, elevated ammonia levels, acid-base changes (unable to clear lactate via the Cori cycle), hyperkalemia, and oliguria. All liver transplant patients have an initial rise in transaminases which should decrease over the first 48 hours.

Explanations:
Understanding the concepts of sensitivity, specificity, PPV, and NPV is crucial to interpreting diagnostic test results. Sensitivity is defined as the percentage of people who have a disease who test positive for that disease. Specificity is defined as the percentage of people who are free of a disease who test negative. These two concepts are considered characteristics of the specific test in question and are independent of the prevalence of the disease in the population. The PPVs and NPVs of a test are the test's clinical characteristics and these concepts are directly related to the prevalence of the disease in the population. The PPV is the percentage of people who have a positive test result who actually have the disease. Similarly, the NPV is the percentage of people who have a negative test result who don't have the disease.

While the definitions may seem subtly different, the implications are significant. The usual way to calculate sensitivity, specificity, PPV, and NPV is with the table, using the following definitions

The definitions of sensitivity, specificity, PPV, and NPV would then be: Sensitivity = a/(a + c)
Specificity = d/(d + b)
PPV = a/(a + b)
NPV = d/(d + c)
The specific information in this question comes from an article describing a study of B-type natriuretic peptide (BNP) for the diagnosis of CHF. The data presented show that 106 persons tested positive using the BNP test. After comparison with the "gold standard," in this case, a review by expert cardiologists, 95 of these 106 were determined to truly have CHF. Therefore, 11 of the 106 were false positives and 95 were true positives. Similarly, 144 persons tested negative using the BNP test. Of these, 142 were confirmed as true negatives and 2 were determined to be false negatives.
Putting these numbers into a table reveals:

The calculations then become: Sensitivity = a/(a + c) = 95/(95 + 2) = 98%
Specificity = d/(d + b) = 142/(142 + 11) = 93%
PPV = a/(a + b) = 95/(95 + 11) = 90%
NPV = d/(d + c) = 142/(142 + 2) = 99%

Amyloidosis is caused by the deposition of an abnormal proteinaceous material between cells. The majority of the cases are idiopathic, but a small percentage is secondary to chronic infection or inflammation, plasma cell dyscrasias, or immune diseases. One of the characteristic presentations of amyloidosis is splenic infiltration and splenomegaly caused by deposition of amyloid in the follicular regions. Grossly, the spleen has a diffuse, pink, glassy, waxy appearance with obliteration of the white pulp. Amyloid infiltration can also affect the kidneys, liver, and heart. Clinical symptoms are usually due to functional impairment of the diseased organ. The diagnosis of amyloidosis is made by tissue biopsy or, more recently, by fat-pad biopsy looking for amyloid deposits. With Congo red stain, amyloid appears red; with polarization, it shows an apple-green birefringence, which is diagnostic of amyloid.

In patients who have melanoma that is confined to the skin (i.e., no evidence of metastatic disease), the most important prognostic factor is the Breslow histologic depth of the tumor. The age of the patient and location of the tumor also play a role in prognosis, but to a lesser degree. The forearm and leg tend to have a better prognosis; scalp, hands, feet, and mucous membranes have a worse prognosis. Older persons tend to have poorer prognoses, as well. Standard treatment
for melanoma involves surgical excision. Sentinel lymph node biopsy should also be performed in any patient who has a melanoma that is at least 1 mm thick. This aids in determining whether melanoma cells have metastasized to the local lymph node basin. If the sentinel lymph node biopsy is negative for melanoma cells, no further lymph node studies are necessary. However, a positive biopsy warrants complete lymph node dissection. In addition to this situation, complete lymph node dissection is indicated in the setting of clinical lymphadenopathy regardless of evident distant metastasis. High dose interferon alpha-2 therapy is aviable option for use as adjuvant therapy in patients at high risk for disease recurrence, having been shown to prolong periods of remission and possibly improve mortality. Single-agent chemotherapy is generally used in patients with stage IV melanoma and is considered more for palliative purposes.

This patient has tumor lysis syndrome (TLS), a group of metabolic derangements due to rapid cell turnover with release of intracellular contents, such as phosphate and potassium, and increased purine metabolism, leading to hyperuricemia.
It is usually seen after the initiation of cytotoxic chemotherapy, but occasionally occurs spontaneously in patients with bulky disease such as Burkitt's lymphoma. The uric acid crystallizes in the renal tubules and can cause oliguric renal failure.
Once renal failure has occurred, patients usually require hemodialysis until renal function recovers. Each of the other choices may be employed to prevent the development of TLS in high-risk patients prior to beginning chemotherapy

Carcinoid syndrome is seen in less than 10% of patients with metastatic carcinoid disease. It is seen in patients with elevated serotonin levels, which is metabolized by the liver. Thus, only patients with massive hepatic metastasis or with tumors that bypass the hepatic filter--such as a retroperitoneal tumor--show symptoms. 5-Hydroxyindoleacetic acid (5-HIAA) levels can be tested in the urine to give the diagnosis (urinary vanillylmandelic acid [VMA] is indicative of a pheochromocytoma). An apple core lesion on the colon is most likely to be a large adenocarcinoma, which would not be associated with carcinoid symptoms. Common symptoms of carcinoid syndrome include flushing, diarrhea, right heart failure, and asthma.
Weight loss and liver failure are uncommon symptoms.

Maternal obstetric injury remains a major cause of rectovaginal fistula in women. For this patient, it is imperative to determine the presence or absence of a concomitant injury to the anal sphincter complex along with the possibility of a fistula.
Crohn's disease can be a cause of abdominal pain, diarrhea, anal abscess formation, and fecal incontinence. It would be very unlikely, and highly coincidental, for it to present in this manner. Perianal abscesses can lead to anal fistula formation and subsequent fecal incontinence, but most commonly present with exquisite pain. Fistulas and fecal incontinence would be later complications. Neither a vaginal hematoma nor a retained vaginal foreign body would result in fecal incontinence.

Oral corticosteroids are a mainstay of firstline treatment for moderate-to-severe ulcerative colitis. Starting doses of 40 mg PO daily of prednisone, with a slow taper, are often effective in reducing colonic inflammation, although some patients are unable to wean steroids or maintain remission once achieved. The patient does not have dysplasia in any biopsy specimens, nor does he have signs of systemic toxicity, so a colectomy would be premature. Oral metronidazole is ineffective in ulcerative colitis. Cortisone enemas would be helpful if the patient had isolated left-sided disease, but it is doubtful that enema therapy would reach his hepatic flexure. Intravenous cyclosporine would be used in severe colitis as a last measure before colectomy but this patient is not yet sick enough to warrant such therapy. PSC occurs in approximately 3% of patients with ulcerative colitis and is its major liver complication. It is a chronic inflammatory condition of the biliary tree. It can typically manifest with elevated alkaline phosphatase and bilirubin levels, and results in diffuse stricturing and pruning of the biliary tree. Wilson disease, hereditary hemochromatosis and alpha-1 antitrypsin deficiency are not associated with ulcerative colitis and are not cholestatic liver diseases. Primary biliary cirrhosis could account for these laboratory findings, but is rare in both males and patients with ulcerative colitis. Patients with PSC are at increased risk of developing cholangiocarcinoma but not the other liver tumors mentioned. Patients with celiac sprue are at increased risk for small bowel cancers (adenocarcinoma, lymphoma). Patients with FAP are at increased risk to develop desmoid tumors.

Although this is the first time that your patient has been noted to have an elevated blood pressure reading, given his family history and obesity, it is important to consider the coexistence of other cardiovascular risk factors. His evaluation should include, among other things, screening for DM and dyslipidemia along with an ECG. It is reasonable to ask the patient to submit himself to a strict diet (low in fat and salt) and to increase his exercise and activity, since these lifestyle modifications will likely result in weight loss, decreased blood pressure, and improve his risk profile for cardiovascular disease. Nonetheless, it is rarely enough to normalize blood pressure in all but the earliest stages of hypertension.
Provided that no other comorbidities exist, the patient should return to clinic in no more than 2 months for a repeat blood pressure check. There is no need to consider secondary causes of hypertension, given his age and presentation.

You should not start antihypertensive medications until further evaluation is completed, and a second elevated reading confirms your diagnosis of hypertension. In the initial evaluation of hypertension (as per the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC-7], 2003), it is important to evaluate the patient for end-organ damage. This should include the heart, kidneys, eyes, and nervous system.
It is recommended to obtain a urinalysis to assess for proteinuria, glucosuria, or hematuria; to obtain an ECG to evaluate the heart for potential hypertrophy or early signs of cardiovascular disease; to obtain a fasting lipid profile, particularly after the age of 35, to assess the cardiovascular risk profile; and to check the patient's renal function to assess for damage or dysfunction. Thyroid function tests are only indicated in the workup of secondary causes of hypertension. According
to the JNC-7, this patient's blood pressure falls into the stage 2 hypertension classification in which either systolic blood pressure (SBP) is at least 160 mmHg or diastolic blood pressure (DBP) is at least 100 mmHg.

Stage 1 hypertension is characterized by a SBP of 140159 mmHg and a DBP of 9099 mmHg. Prehypertension is characterized by a SBP of 120139 mmHg and a DBP of 8089 mmHg. Normal blood pressure is characterized by a SBP of less than 120 mmHg and a DBP of less than 80 mmHg. In classifying a patient's blood pressure and determining appropriate therapy, the higher of the two categories corresponding to the SBP and DBP is the one that is used. Per JNC-7 guidelines, treatment of stage 2 hypertension should involve the consideration of a two-drug regimen initially. The goal blood pressure in patients with diabetes is a SBP less than 130 mmHg and a DBP less than 80 mmHg. An ACE inhibitor should be used as the drug class has been shown to slow the progression of diabetic nephropathy and reduce albuminuria. Thiazide diuretics, betablockers, and calcium channel blockers are appropriate choices to consider in this patient in addition to an ACE inhibitor.

Hungry bone syndrome refers to hypocalcemia following surgical correction of hyperparathyroidism in patients with severe, prolonged disease, as serum calcium is rapidly taken from the circulation and deposited into the bone. Symptoms usually occur within 2448 hours following parathyroidectomy, when calcium levels reach a nadir. Early symptoms include numbness and tingling in the perioral area, fingers, or toes. Advanced symptoms include nervousness, anxiety, and increased neuromuscular transmission evidenced by positive Chvostek's and Trousseau's signs, carpal pedal spasm, and hyperactive tendon reflexes. In severe cases, one may develop a prolonged QT interval on ECG. Patients who manifest any signs or symptoms of hypocalcemia always require intervention. In severely symptomatic patients, treatment should begin with intravenous calcium gluconate. Mildly symptomatic patients may be given oral calcium in the form of calcium lactate, calcium carbonate, or calcium gluconate. If hypocalcemia remains despite calcium supplementation, additional therapy with vitamin D may be needed. Supplemental calcium and vitamin D therapy should be continued until serum calcium levels return to normal

Senile plaques are the most conspicuous histologic lesion also known as neuritic plaque, constitute a spherical deposit of A fragments (amyloid beta fragments) of variant degree length. They are surrounded by reactive astrocytes, microglia, and display alpha-synuclein immunoreactive neuronal process.

This young woman has cervicitis, but without evidence of pelvic inflammatory disease (PID). Chlamydia is the most common bacterial cause of sexually transmitted diseases in the United States and the most likely etiology of this patient's infection. Gonorrhea would be the next most likely cause and, frequently, there will be coinfection with the two pathogens. The simplest outpatient treatment for these two would be a single 1- g oral dose of azithromycin and a 125-mg IM dose of ceftriaxone. This regimen will ensure complete compliance, which is crucial. Treatment of her sexual partners would also be recommended. Another cause of cervicitis is trichomoniasis, for which metronidazole, either for 1 week of 500 mg bid or a single 2- g oral dose, would be recommended therapy. Of the suggested answers, option Ais the only one which would cover the two most common infectious agents.

The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up. Caf?au lait spots are associated with neurofibromatosis. High arched palates are associated with fragile X syndrome.
Ambiguous genitalia are commonly seen in CAH.

Children with Down syndrome are at an increased risk for hypothyroidism. It may be hard to detect without routine laboratory screening as they will commonly have mental retardation and developmental delay as part of their syndrome.
Hypothyroidism may not be present in the immediate newborn period and requires, at a minimum, annual testing throughout the child's life. The other findings listed are not specifically associated with Down syndrome. Lens dislocation is commonly found with Marfan syndrome or homocysteinuria.

Children with Down syndrome have an increased prevalence of duodenal atresia. Pyloric stenosis is uncommon to see in the newborn period. It tends to present with nonbilious vomiting usually after 24 weeks of age. Hirschsprung disease (aganglionosis coli) presents with constipation and failure to pass stool. Infants with Hirschsprung disease commonly will not pass stool in the first days of life. Biliary atresia is a progressive cause of jaundice in an infant. It is the most common cause of a cholestatic jaundice in the newborn period. Emesis is not typically associated with biliary atresia. Milk protein allergy is a common cause of bloody stools in the first few months of life, but does not have bilious emesis associated with it.

The patient has Sheehan syndrome, necrosis of the pituitary associated with childbirth. She has panhypopituitarism, but the most urgent hormone to replace is hydrocortisone. Thyroid hormone should not be replaced until after glucocorticoids are administered. The hyponatremia will correct with glucocorticoids and saline. The patient is not deficient in mineralocorticoids, as she does not have primary adrenal insufficiency; therefore, fludrocortisone is not indicated.

Burn injuries can be very serious and very intimidating for the patient and physician alike. In an ER setting, the most efficient way to estimate the extent of the burn injury is to use the "rule of nines." In determining the percentage of the TBSA that is involved, it is important only to consider second-and third-degree burns in this calculation. In this system, the head and neck are 9%; each arm represents 9%; the anterior trunk, posterior trunk, and each lower extremity carry a value
of 18%; the genitalia are estimated to be 1%. For the patient in this question, the burns cover his anterior face and neck (4.5%), anterior trunk (18%), and bilateral upper extremities (18%) for a TBSA of approximately 40%. Having identified the extent of the thermal damage, it is critical to initiate resuscitation immediately. The thermal injury itself causes the release of many inflammatory mediators that result in a profound capillary leak. As a result of this profound increase in capillary permeability, the patient's intravascular volume and thus overall perfusion can drop rapidly and dramatically. In order to compensate, burn patients will require aggressive fluid resuscitation. Furthermore, as in any trauma situation, the fluid used in the initial resuscitation should be isotonic such as Ringer's lactate. The Parkland formula (4 mL/kg/%TBSA) is a common equation used to estimate the fluid needs in the first 24 hours for thermal injuries. Typically, one-half of this total volume is given in the first 8 hours. In this particular case, an 80-kg man with 40% TBSA burns would require 12.8 L of fluid in the first 24 hours. So for the first 8 hours, you would plan to run isotonic fluid at 800 mL/h.

The patient appears to be at risk for hereditaty nonpolyposis colon cancer (HNPCC) or Lynch syndrome. This autosomally dominant inherited cancer predisposition is characterized by colorectal cancer involving at least two generations, with one or more cases being diagnosed before age 50, and patients may have multiple primary cancers (affected women often also have endometrial or ovarian cancer). It is recommended that HNPCC family members undergo screening colonoscopy every two years beginning at age 25. The colon cancers in HNPCC often involve the proximal colon, so flexible sigmoidoscopy would be an insufficient tool for screening the at-risk bowel. HNPCC should be differentiated from familial adenomatous polyposis (FAP), another inherited colon cancer predisposition. This wellstudied and described autosomal dominant inherited condition is much less common than HNPCC. Affected patients develop thousands of adenomatous premalignant polyps, which are generally evenly distributed from cecum to anus and usually become evident between puberty and age 25. Because the polyps are so widespread and evenly distributed, proctosigmoidoscopy is usually a sufficient screening procedure for at-risk family members. When diagnosed with FAP, it is recommended that patients under prophylactic colectomy. If not treated surgically, almost all patients will develop colorectal cancer by age 40. Colonoscopy beginning at age 50 would be recommended for persons at average risk for colon cancer.

Apatient who is anovulatory due to PCOS would be expected to have normal estrogen production. However, without corpus luteum formation following ovulation there is no significant progesterone production. Therefore, the discontinuation of a period of progestin therapy would initiate menstrual flow

Pleomorphic adenoma (mixed tumor) is the most common tumor of the salivary glands. Pleomorphic adenoma is a benign neoplasm characterized by a mixture of epithelium and stromal elements. Two-thirds of all tumors of the major salivary glands and about half of those in the minor ones are pleomorphic adenomas. The tumor is nine times more frequent in the parotid than in the submandibular gland and usually arises in the superficial lobe of the parotid. It occurs most often in the middleaged people and shows a female preponderance. While it is a benign tumor, the recommended treatment is removal, as it will continue to grow and cause symptoms. Most authorities recommend wide local excisions, in an effort to reduce the risk of recurrence.

The clinical scenario described is classic for an acute MI. The patient has multiple risk factors, including smoking, hypertension, and elevated cholesterol. His symptoms of crushing chest pain radiating to the left arm is commonly seen in this setting. Often the first electrocardiographic sign of acute ischemia is the development of hyperacute T waves. The ECG will usually show S-T segment elevations in the area of the involved occluded vessel, with reciprocal S-T segment depressions in uninvolved areas. This can be followed by the eventual resolution of S-T segment abnormalities and the development of T wave inversions and Q waves. Diffuse P-R depressions are often the initial manifestation of pericarditis, a less common cause of acute chest pain. This often progresses to diffuse S-T segment elevations, the presence of which helps to distinguish pericarditis from the focal S-T elevations more classically associated with a thrombosed coronary artery. Q waves would be unlikely to occur within 1 hour of the onset of symptoms. In this clinical setting, a normal ECG, while possible, would be less likely to occur.

Ventricular arrhythmias, both tachycardia and fibrillation, are recognized complications of acute MI. The presence of ventricular fibrillation or pulseless ventricular tachycardia should lead to the primary "ABCD" survey, as outlined in the American Heart Association's ACLS protocols. The mnemonic stands for airway, breathing, circulation, and defibrillation. Epinephrine, lidocaine, or amiodarone are reserved for the setting where defibrillation is ineffective. Synchronized cardioversion would be used in efforts to convert a patient's rhythm in the setting of a stable tachycardia.

This is a case of dementia, vascular type (multiinfarct dementia), caused by poorly controlled hypertension. Atrophy of the caudate nucleus is seen in Huntington chorea, which accounts for the movement disorder and dementia that are seen in that illness. Dilated ventricles without atrophy are characteristic of normal pressure hydrocephalus (NPH), one of the potentially reversible causes of dementia. The triad seen in NPH consists of dementia, gait disturbance, and urinary incontinence. Pick's disease is a gradually progressing dementia, displaying marked but preferential atrophy of the frontal and temporal lobes of the brain. Generalized atrophy can often be seen with neuroimaging in Alzheimer dementia.
Vascular dementia classically will show lacunar infarcts of the white matter on MRI. With the exception of reversible causes (e.g., NPH, metabolic causes, or heavy metal toxicity), improvement is unusual in dementing illnesses. A rapid decline is common in dementias due to prion infection, such as Creutzfeldt-Jakob disease. Stable dementias are also unusual, most notably seen in dementia due to a head injury. Both Alzheimer's and Pick's dementias demonstrate a steady worsening of the illness over many years. The multiple small infarcts causing vascular dementia correspond to a stepwise deterioration in functioning of the patient

The most common infectious cause of blindness in the world is trachoma. Trachoma is the chronic effect of a C. trachomatis infection acquired in the perinatal period. The most common cause of blindness in the world is noninfectious

This toddler has developed pica, the eating of nonnutritive substances. Decreased levels of folate may be associated with depression and dementia in adults but is not seen in cases of pica. Iron deficiency, a potential cause of pica, may present with eating of dirt. A lead level would be necessary to determine if the child were eating lead-based paint. Manganese levels have not been shown to be abnormal in pica. As zinc deficiency is another cause of pica, assessment of a zinc level is essential in children who consume clay (as is being done by the child in this case)

Teriparatide is a recently approved recombinant form of parathyroid hormone that stimulates bone formation, rather than inhibiting resorption, and which is associated with a marked reduction in the incidence of bone fractures. Estrogen and the estrogen receptor modulator raloxifene, alendronate, and calcitonin all inhibit bone resorption and increase BMD, but the percent increase in bone density is less than occurs with teriparatide

Explanations:
This case is a characteristic presentation for malingering. Consciously producing symptoms in order to assume the sick role is the motivation behind factitious disorder. There is no evidence of psychotic symptoms as would be seen in delusional disorder. Hypochondriasis involves the preoccupation with fears of having a serious illness rather than the focus on complaints of pain. The unconscious production of symptoms due to unconscious conflict is the hallmark of conversion disorder, which presents with a neurologic deficit. Malingering, which is not considered a mental illness, is defined as the intentional production of symptoms motivated by external incentives. These incentives may include such things as avoidance of work, military duty, and jail, or the acquisition of drugs (which is seen in the above case) (DSM IV-TR). In cases of suspected malingering, accusations or law enforcement involvement will likely result in further hostility and harm to any therapeutic alliance. Referral for admission to a mental health facility or to a psychiatrist may also have the same effect and is not warranted unless another mental illness or safety concerns are present. While limit setting is absolutely necessary with these individuals, a professional demeanor must be maintained. Gentle confrontation coupled\ with a focus on understanding their underlying problems (leading to their feigning illness) are the most helpful approaches. Amore complete evaluation may be necessary to determine whether or not there is an additional mental illness or substance dependence that will need to be treated.

The incidence of adenocarcinoma of the lung has increased significantly in the last two decades and is now the most common form of lung cancer in women and, in some studies, also in men. There may be mixtures of histologic patterns in the same cancers and, therefore, the finding of squamous cell carcinoma is not infrequent. A recent classification that is more common for clinical use has been developed in response to the necessity for the different therapies. These two large groups are divided into small cell versus nonsmall cell carcinomas. On histologic examination, the adenocarcinomas can be divided into bronchial-derived adenocarcinoma and bronchioloalveolar carcinoma. This classification is based on histologic findings alone. The lesions, in general, are peripherally located and tend to be smaller. Adenocarcinoma, including the bronchioloalveolar variant, is the least frequently associated with a history of cigarette smoking. Special stains for mucin are frequently positive.

The actions of the resident who reviewed the patient's chart were unethical. He is not involved in the case and the fact that he is a physician and colleague of the patient does not free him of the requirements that protect patient confidentiality, backed by federal regulations (see discussion of HIPAA above). He should not have pulled her chart. He would only be making matters worse by further violating the patient's right to confidentiality in sharing her results with the other resident.
The attending clinicians involved in the case are the only people who should have privileged access to the patient's sensitive health information.

Hirschsprung disease usually manifests in the immediate neonatal period by failure to pass meconium, followed by obstructive constipation. Abdominal distention develops and, in general, a large segment of the colon is involved and distended. The incidence of Hirschsprung disease is 1 in 5000 live births, with an 80% male predominance in nonfamilial cases. There is no apparent difference in occurrence among races. A number of abnormalities have been associated with Hirschsprung disease, including Down syndrome (2- 3% of the cases), congenital heart disease, colonic atresia, and malrotation. The tissue diagnosis is made on the basis of an absence of ganglion cells in the submucosa and the myenteric plexus on a full-thickness rectal biopsy. Some surgeons prefer suction biopsy to full-thickness biopsy because it is easy to obtain the specimen and they can avoid scarring and fibrosis in the area. The other four choices are not applicable and can be ruled out on the basis of clinical history and an extremely low incidence of other pathologic conditions at the perinatal age. When suction biopsies are performed, the tissue sample for acetyl cholinesterase stain should be frozen as soon as possible. All of the other stains would not be helpful to identify ganglion cells. As soon as the diagnosis is confirmed with the rectal biopsy, a surgical procedure should be undertaken that consists of a resection of the aganglionic section of colon. All the other options are not the treatment of choice for this disease.

Encounters with persons traveling to other countries are common in primary care or community health settings. The advice and interventions provided are dependent on where the person is going, what he or she will be doing, and for how long he or she will be there. The most accessible and up-to-date source of this information in the United States is at the Centers for Disease Control web site, which provides detailed recommendations on vaccinations, health, and safety risks involved in overseas travel. In this series of questions, the travelers are going to the region of central Africa and, more specifically, to a rural area of Cameroon. This is an area of the world where polio remains a risk. As most Americans have not been vaccinated against polio since childhood, booster immunization against polio is recommended. The injectable polio vaccine is recommended as it does not carry with it the risk of vaccine-induced disease that the oral (live virus) vaccine does. Smallpox has been eliminated as a naturally occurring disease, although it remains of importance in bioterrorism discussions. The smallpox vaccine is not necessary for travel to any part of the world, but is used by the military or medical first responders who may be exposed in the event of a biowarfare attack. The traveling couple is up-to-date on their dT status with boosters within the past 2 years. They have completed a series of both MMR and hepatitis B, which is felt to confer lifetime immunity. Malaria prevention is an important consideration for travel to many areas of the developing world. Different regimens may be used depending on the area to which the travel will occur. All regimens, however, require the institution of prophylaxis prior to travel and the continuation of prophylaxis for up to 4 weeks after completion of travel. This is due to the life cycle of organisms that cause the disease. Prevention of malaria also involves attempts to reduce one's risk of exposure to the Ixodes mosquito which can transmit the disease. This mosquito tends to be more active early in the morning and at dusk, and less active in the middle of the day. Wearing long sleeved clothing, using mosquito nets, and insect repellent is important. DEET-containing insect repellents are recommended as the most effective products available and are safe when used appropriately. The most common cause of injury during travel is motor vehicle accidents. The risk of injury is higher in many developing countries than in the United States due to poor roads, poor vehicle maintenance, lack of seat belts, and other issues. Very cautious driving and avoidance of driving after dark may help to reduce the risk somewhat. While swimming is an ideal exercise in such hot climates as central Africa, freshwater lake swimming should be avoided due to the risk of exposure to schistosomiasis. The Schistosoma species that cause this disease are endemic in standing freshwater bodies. Swimming or bathing in salt water or chlorinated swimming pools is safer. Traveler's diarrhea and exposure to foodborne pathogens is a common cause of illness during travel to developing countries. The guideline with food is to cook it, peel it, purify it, or forget it. Fruits that can be peeled, such as oranges or bananas, are generally safe to eat. Carbonated beverages are also safe. However, ice cubes made from local water supplies are a common, and sometimes ignored, source of infection. Water purification can be accomplished by boiling or by filtering through an absolute 1 m filter and then purifying with iodine. Filtering alone does not provide adequate protection. Salads that are not made of carefully cleaned vegetables should be avoided and salad dressings may also be contaminated. Meats that are well cooked and served hot would be considered less likely to transmit an infection. Finally, brushing one's teeth with unpurified water carries a significant risk of transmission of waterborne illness and should be avoided. Purified water or bottled water should be used instead.

Explanations:
The NNT is calculated by first determining the ARR for a specific outcome between two groups in a study. The ARR, or risk difference, is calculated by subtracting the percentage of subjects who develop an The outcome in the treatment group from the percentage who develop the outcome in the control group. outcome considered is the development of prostate cancer. This occurred in 24% of the control group and 18% of the finasteride group. The ARR is calculated as 24% - 18% = 6% or 0.06. The NNT is calculated as: NNT = 1/ARR. In this example, the NNT = 1/0.06 = 16.67, approximately 17. This suggests that for every 17 men who took finasteride there was one fewer case of prostate cancer. The NNH is calculated in exactly the same manner as the NNT. The only difference is that the outcome is adverse. In this study, highgrade prostate cancers occurred more often in the finasteride group than the placebo group; 6.4% of men who took finasteride and 5.1% who took a placebo developed high-grade prostate cancer. The risk difference, in this case an absolute risk increase, is 6.4% - 5.1% = 1.3% or 0.013.
The NNH = 1/absolute risk increase
= 1/0.013 = 77

This patient is presenting with subclavian steal syndrome, which is caused by subclavian stenosis proximal to the take off of the verterbral artery. Exertion of the extremity causes blood to be shunted away from the brain to the arm resulting in vertigo or even syncope. These patients usually have diminished radial pulses on the affected side and also have other evidence of atherosclerotic disease. A carotidsubclavian bypass is the operation of choice for these patients.

The pregnancy risk factor category assists the physician and patient to understand the safety of the use of a medication during pregnancy. The summary of the categories is as follows: category A-- controlled human studies demonstrate no risk to a fetus. Category B--animal-reproduction studies have not demonstrated fetal risk but there are no controlled human studies to assess the risk. Category C-- animal-reproduction studies have demonstrated risk to a fetus and no controlled human studies are available. Category D--evidence of human teratogenic risk exists but in some cases the known risks may be outweighed in serious situations, such as lifethreatening disease. Class X--this drug should never be used by a pregnant female under any circumstances. The principle of autonomy states that the patient has the right and capability to control the course of her medical care and to participate in the decision-making process.

Polyuria in a prepubertal female may indicate the presence of a UTI. AUTI must be excluded as the first step. Polyuria may also indicate vulvovaginitis. Vulvovaginitis in a prepubertal female is usually irritation and hygiene related. The presence of dysuria with the polyuria would make the utility of checking fingerstick glucose, as a screening test for diabetes, low yield. The nightly use of bubble baths makes chemical urethritis the most likely cause of this girl's polyuria and dysuria. Diabetes mellitus would present typically with polyuria, polydipsia, weight loss, and decrease in energy. There would also be no dysuria unless there were a concomitant UTI. Diabetes insipidus is a very rare disease in childhood and would be unlikely in an otherwise healthy girl. The presence of a retained foreign body (typically toilet paper) is usually seen in conjunction with a vaginal odor and discharge as well.

Aminoglycosides such as gentamicin accumulate in the proximal tubular cells of the kidney, resulting in a defect in renal concentrating ability and reduced glomerular filtration after several days. This renal impairment is almost always reversible. Of all the aminoglycosides, gentamicin and tobramycin are the most nephrotoxic. Aminoglycosides may also cause ototoxicity in the form of irreversible auditory or vestibular damage. There is a direct relationship between aminoglycoside dosage and the risk for development of ototoxicity, so doses should be adjusted according to a patient's baseline renal function. Complicated UTIs involve metabolic or hormonal abnormalities such as those seen in M or during pregnancy; the presence of foreign bodies such as calculi, tumors, or catheters; the presence of strictures causing turbulent urine flow or vesicoureteral reflux; incomplete voiding such as that seen in neurogenic bladder, prostate
hyperplasia or cancer; and, the presence of unusual infecting microorganisms. A history of recurrent UTI does not in itself lead to the classification of subsequent infections as complicated. Due to anatomic differences in urethral length between males and females, any UTI in a male is considered complicated. A history of recent surgery does not correlate with development of a complicated UTI unless the surgical procedure resulted in the creation of some anatomic
abnormality which increased the risk of infection; examples of such abnormalities include adhesions or strictures.
Apostvoid residual volume greater than 50100 mL suggests abnormal bladder emptying, which would predispose an individual to development of UTIs.

The absence, or malabsorption, of zinc from the diet will result in zinc deficiency. The clinical entity is called acrodermatitis enteropathica. Symptoms may manifest during the transition from breast milk to cow's milk. The typical dermatologic manifestations of this are symmetrically distributed perianal and perioral (in a horseshoe pattern) dermatitis. The skin lesions are eczematous, dry, scaly, or psoriasiform. Children with vitamin C deficiency present with petechial hemorrhages of the skin and mucus membranes. Hypocalcemia does not include specific dermatologic changes. Tetany is a classic manifestation of hypocalcemia. Skin pallor is the most important sign of iron deficiency. Children with inadequate iodine in their diet may develop hypothyroidism.

This woman likely suffers from a major depressive episode. While asking about substance abuse, current medications, medical problems, and a past history of depression are very important in a complete psychiatric evaluation, assessment of suicidality is essential. The risk of suicide in patients with major depressive disorder is about 20 times higher than those without the illness. The estimated lifetime risk of suicide is approximately 15% in those individuals with major depressive disorder. The choice of a specific antidepressant may be influenced by many factors, including prior response in the patient or a family member and comorbid medical problems or substance abuse in the family (and, therefore, potentially the patient). If a patient or family member has a history of manic symptoms or bipolar disorder, consideration should be given to beginning a mood stabilizer prior to initiating antidepressant therapy, as antidepressants can cause a switch into mania in those individuals.

At the initial prenatal visit, a complete history and physical examination is performed along with a panel of laboratory studies. Routinely, a complete blood count, blood type, and Rh group with antibody screen, rubella antibody, rapid plasma reagin (RPR), HIV, pap smear, cervical swab for gonorrhea and chlamydia, urinalysis, and urine culture are performed. Pregnancy is one of the few conditions in which treatment of asymptomatic bacteruria would be recommended. Neither a basic metabolic panel nor a TSH measurement would be indicated unless the patient had an underlying medical condition that warranted further evaluation. Screening for gestational diabetes with a glucose measurement after ingestion of 50 g of glucose is performed in many pregnancies, but not until 2428 weeks' gestation. Routine screening for vaginal or rectal colonization with group B Streptococcus is also performed, but not until 34 weeks of gestation or later. It is recommended that all pregnant women be screened for hepatitis B at their initial prenatal visit by obtaining a hepatitis B surface antigen. This helps to determine if the woman has hepatitis B that could put her baby at risk for the infection.
Hepatitis B surface antibody may be a sign of previous infection or of previous vaccination with the hepatitis B vaccine. The presence of core antibody and e antibody may be signs of previous infection.
Testing for the e antigen is not useful for initial screening purposes but may be warranted if the patient were found to have chronic hepatitis B infection.
If the mother tests positive for hepatitis B surface antigen during her pregnancy then the neonate should receive both hepatitis B immune globulin and the initial dose of the hepatitis B vaccine series. This combination has been shown to reduce risk of perinatal transmission from approximately 10% if the woman is surface antigen positive to less than 3%. There are currently no data to show that delivering a baby by caesarian section will reduce the risk of perinatal transmission of the infection. Breastfeeding has not been shown to increase the rate of transmission of infection to a nursing infant.

Screening for HIV should be offered to all pregnant women as part of routine prenatal care. Screening for HIV infection is done using an enzyme immunoassay (EIA). If the screening test is positive, it may be repeated. Once the screening test is determined to be positive, a Western blot assay or immunofluorescent antibody assay (IFA) is done as a confirmatory test. If the confirmatory test is positive, the patient is then considered to be infected with HIV. Pregnant patients should be treated for HIV by the same standards as any other adult with HIV, though some consideration is given to selection of antiretroviral medications that are safest in pregnancy. Appropriate HIV-related care should not be deferred because of pregnancy. For patients with significant HIV disease, the combination of elective scheduled cesarean and antiretroviral therapy has been shown to be more effective than antiretrovirals alone at reducing perinatal transmission of HIV. In the absence of any therapy, the risk of vertical transmission is estimated at 25%. With zidovudine therapy, the risk is decreased to approximately 58%. When zidovudine is given in combination with elective cesarean for appropriate patients, the risk is decreased to approximately 2%. In a recent meta-analysis, perinatal transmission occurred in only 1% of treated women with RNA viral loads less than 1000 copies/ mL. Given the low risk of transmission in this group, it is unclear whether cesarean delivery would provide additional benefit. After reviewing this data, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice has issued a Committee Opinion concerning route of delivery, recommending consideration of scheduled cesarean delivery for HIV-1-infected pregnant women with HIV- 1 RNA levels >1000 copies/mL near the time of delivery.

When pelvic organs prolapse occurs beyond the level of the hymen, anatomic obstruction of urine occurs in approximately 30% of patients. Over time, urinary stasis from obstruction can lead to UTIs. Detrusor hypocontractility, not overactivity, can be another long-term sequela of chronic urinary retention, enhanced by a stretch injury to the postsynaptic parasympathetics in the bladder wall. Menopause alone is not a risk factor for retention, and a spinal cord tumor is not likely in this patient without specific neurologic complaints or findings on physical examination. Due to urinary stasis, she is at risk for a UTI. Left untreated, she could develop obstructive uropathy and/or pyelonephritis. Surgery is an option, but not without the prior consideration of nonsurgical options such as a pessary or intermittent clean, self-catheterization (if the problem were to persist). In the event of chronic retention, radiographic imaging would help to assess for upper tract obstruction (i.e., hydronephrosis). Oxybutynin is not appropriate, as it could compound urinary retention. Urodynamic studies could be helpful in the future to ascertain the exact cause of her retention (obstruction from the prolapse vs. chronic detrusor insufficiency vs. neurogenic bladder), but is not the first action to consider.

The fetal monitoring strip in these questions shows the presence of early decelerations. Early decelerations are characterized by a gradual decrease in the fetal heart rate and gradual return to the baseline in association with a contraction.
The onset and recovery of the heart rate are coincident with the onset and recovery of the contraction. These are thought to be due to vagal stimulation due to fetal head compression. They are not associated with fetal hypoxia or acidosis and no intervention, other than continued careful labor monitoring, is indicated. Variable decelerations are caused by umbilical cord compression. They are characterized by the abrupt decrease in heart rate. The onset of the deceleration frequently varies in successive contractions, and they generally last less than 2 minutes. Late decelerations are gradual decreases in heart rate that begin at or after the peak of the contraction and return to baseline after the contraction has ended. It is often the first fetal heart rate abnormality seen in uteroplacental-induced hypoxia. Any process that causes maternal hypotension, excessive uterine activity, or placental dysfunction can induce late decelerations. Fetal tachycardia is defined as a baseline fetal heart rate of >160 bpm and is considered severe if the rate is >180 bpm. The most common cause of this is maternal fever, but it can also be due to fetal compromise, arrhythmias, or certain medications.
Hyperstimulation is a nonreassuring heart rate pattern caused by the presence of frequent uterine contractions. This occurs most commonly in labors that are being augmented with oxytocin. The initial management includes reduction in the dose, or discontinuation, of the oxytocin

This patient exhibits the criteria for conduct disorder. Antisocial personality disorder can only be diagnosed in a person who is over age 18. In fact, the diagnosis of antisocial personality disorder requires evidence of conduct disorder prior to age 15 (DSM IV-TR). Children with autism, schizophrenia, and mental retardation may display aggressive or disruptive behavior, but these illnesses do not necessarily predict future conduct disorder. Patients with ADHD and learning disorders are at an increased risk of developing conduct disorder as they get older.

It is not uncommon for patients with conduct disorder to have a history of oppositional defiant disorder as a younger child. Indeed, the disorders are often thought of as being on a spectrum, with oppositional defiant disorder early on, followed by conduct disorder and eventually antisocial personality disorder. Having conduct disorder does not by itself predict panic disorder, schizoid personality disorder, or the development of schizophrenia. If left untreated, there is a significantly increased risk of developing a substance use disorder, which also predicts a worse prognosis

The most common cause of anorectal fistula and abscess is infection of the anal glands, which empty into the anal canal at the level of the dentate line. Classification of anal fistula is based upon the relationship of the epithelialized tract to the anal sphincter muscle and can be intersphincteric (most common), transsphincteric, suprasphincteric, and extrasphincteric (least common). A symptomatic fistula is an indication for surgery because it rarely heals spontaneously. Despite popular teaching, there is little use for antibiotics in the primary treatment of anal abscess. As a rule, surgical drainage is required and antibiotics are only indicated if cellulitis is present. However, those patients who are immunocompromised, have valvular heart disease, or poorly controlled diabetes should always be considered for antibiotics.

Kawasaki disease (mucocutaneous lymph node syndrome) is a disease of unclear etiology. The salient diagnostic features include fever for greater than 5 days, cervical lymph node greater than 1 cm, nonpurulent conjunctivitis, oral changes (cracking lips or "strawberry tongue"), polymorphous rash to the trunk, and changes to the hands and feet (peeling of the fingers or toes or edema of the hands or feet). This may be confused with group Abeta-hemolytic streptococcal pharyngitis, which usually is not associated with conjunctivitis. Coxsackie viral infection is commonly seen as the "hand-footmouth" disease, with shallow ulcers on the palms, soles, and in the mouth. There is nominal fever associated, and conjunctivitis is uncommon. Parvovirus B-19 (erythema infectiosum, "fifth disease") is commonly called "slapped cheek" disease because of the exanthem of bright red cheeks. Adenopathy and conjunctivitis are not features of this infection.
Acute phase reactions are often elevated late in the course of Kawasaki disease.
The most common blood test result would be a dramatically elevated platelet count. It is usually greater than 750,000 and can be greater than 1,000,000. An ESR is also likely to be elevated, not low. Apositive rapid strep test would lead one more toward acute GAS disease. The treatment of choice for Kawasaki disease is IVIG and aspirin. IVIG infusion is usually over 12 hours and will commonly result in rapid defervescence and clinical improvement. Treatment of Kawasaki disease is important as it will prevent long-term sequelae. A common side effect of IVIG is aseptic meningitis. Nearly a quarter of untreated children will develop coronary artery dilatation. This is most common cause of acquired heart disease in children younger than 5 years of age. The coronary artery dilatation can result in aneurysm formation and myocardial infarction.

At the initial prenatal visit, a complete history and physical examination is performed along with a panel of laboratory studies. Routinely, a complete blood count, blood type, and Rh group with antibody screen, rubella antibody, rapid plasma reagin (RPR), HIV, pap smear, cervical swab for gonorrhea and chlamydia, urinalysis, and urine culture are performed. Pregnancy is one of the few conditions in which treatment of asymptomatic bacteruria would be recommended. Neither a basic metabolic panel nor a TSH measurement would be indicated unless the patient had an underlying medical condition that warranted further evaluation. Screening for gestational diabetes with a glucose measurement after ingestion of 50 g of glucose is performed in many pregnancies, but not until 2428 weeks' gestation. Routine screening for vaginal or rectal colonization with group B Streptococcus is also performed, but not until 34 weeks of gestation or later. It is recommended that all pregnant women be screened for hepatitis B at their initial prenatal visit by obtaining a hepatitis B surface antigen. This helps to determine if the woman has hepatitis B that could put her baby at risk for the infection.
Hepatitis B surface antibody may be a sign of previous infection or of previous vaccination with the hepatitis B vaccine. The presence of core antibody and e antibody may be signs of previous infection.
Testing for the e antigen is not useful for initial screening purposes but may be warranted if the patient were found to have chronic hepatitis B infection.
If the mother tests positive for hepatitis B surface antigen during her pregnancy then the neonate should receive both hepatitis B immune globulin and the initial dose of the hepatitis B vaccine series. This combination has been shown to reduce risk of perinatal transmission from approximately 10% if the woman is surface antigen positive to less than 3%. There are currently no data to show that delivering a baby by caesarian section will reduce the risk of perinatal transmission of the infection. Breastfeeding has not been shown to increase the rate of transmission of infection to a nursing infant.

This patient's presentation and laboratory data are consistent with nephrotic syndrome. Nephrotic syndrome is typically associated with proteinuria of greater than 3.5 g/day, hypoalbuminemia, edema, and hyperlipidemia. Abnormalities commonly seen in nephrotic syndrome include hypocalcemia (due to vitamin D deficiency), low thyroxine levels (due to loss of thyroxine-binding globulin [TBG]), and microcytic, hypochromic anemia (due to transferring loss).
Hypocomplementemia may be found in some forms of nephrotic syndrome, but this is not a typical finding. Hematuria is one of the components found in nephritic syndrome.

This patient has history, physical, and laboratory findings that suggest possible multiple myeloma. For example, his history is pertinent for lower back pain and headaches. Moreover, Bence-Jones protein is not usually detected by urine dipstick but will be detected during a 24-hour urine collection. This would explain why there is relatively little urine protein detected on dipstick but over 5 g on the 24-hour urine. Lastly, multiple myeloma should be considered in an older patient with unexplained anemia. Given these findings, a serum and urine protein electrophoresis would be the best test to order next. A kidney biopsy would usually be diagnostic, but is unnecessary if the electrophoresis is positive.
Complement levels and anti-GBM titer would not be of any use at the present time. Checking glycosylated Hgb will inform you of the adequacy of glucose control, but will be of little use with regard to the workup of the nephrotic syndrome.
This patient has a low anion gap due to the presence of unmeasured cations in the blood. In this case, they arise from circulating immunoglobulins. The fractional excretion of sodium and urea can be helpful in differentiating prerenal causes from other etiologies of acute renal failure. A split 24-hour urine for protein is helpful in determining the presence of orthostatic proteinuria. Initiation of ACE inhibitors or angiotensin receptor blockers is the best option in patients with diabetic nephropathy, as these medications have been shown to slow the progression of kidney disease. The other medications listed may be used adjunctively, with an ACE inhibitor or angiotensin receptor blocker, if adequate blood pressure control could not be achieved with monotherapy. HIV-associated nephropathy is typically associated with a collapsing glomerulopathy, a variant of focal segmental glomerulosclerosis. Membranous nephropathy is associated with a number of other infections, including syphilis, hepatitis B, and hepatitis C virus. Membranoproliferative glomerulonephritis has also been associated with hepatitis C virus.

The patient has clinical and biochemical evidence of gallstone pancreatitis including epigastric pain, a history suggestive of prior biliary colic, elevated transaminases and bilirubin (suggestive of an obstructing common bile duct stone), and an elevated amylase and lipase. Gastroenteritis would not be expected to alter liver chemistries. Drug-induced pancreatitis is possible as furosemide has been shown to cause pancreatitis, but would not result in the abnormal liver chemistries.
Acute cholecystitis and cholangitis would likely be associated with an elevated leukocyte count, right upper quadrant abdominal pain, and fever. An abdominal ultrasound could assess the gallbladder for the presence of stones and signs of cholecystitis, such as gallbladder wall thickening or pericholecystic fluid. It could also look for a dilated biliary tree or an obstructing stone in the common bile duct. An abdominal x-ray could reveal a localized ileus ("sentinel loop") or calcifications suggestive of chronic pancreatitis, but would be of significantly lesser yield. A CT or MRI of the abdomen would provide images of the pancreas and liver, but are often clinically unhelpful early in the course of acute pancreatitis.
An ERCP is not indicated at this point, as only one set of liver chemistries is available. Should the bilirubin rise or fail to fall, an ERCP might be warranted to decompress the biliary tree. The patient has a common bile duct stone causing biliary obstruction. This stone likely caused the patient's acute pancreatitis as well. Papillotomy (also known as sphincterotomy) will allow endoscopic removal of the stone. The stone cannot be removed through the native papilla, as the sphincter of Oddi musculature would not allow such a large stone to pass. Thus, sphincterotomy must be performed to disrupt the sphincter musculature. Papillary balloon dilation is possible but is associated with an increased risk of pancreatitis. Abiliary stent is a viable option to provide drainage, but is inferior to sphincterotomy and stone extraction. No manipulation of the pancreatic duct is warranted. The stone should not be left in place as it could lead to recurrent pancreatitis or cholangitis.

Any infant or child that presents with bilious emesis should be evaluated immediately for malrotation with midgut volvulus. This is a surgical emergency since the volvulus can compromise the vascular supply to the intestine. Malrotation is a congenital disorder wherein the normal prenatal rotation of the midgut is incomplete and results in the cecum remaining in the epigastrium with a narrow superior mesenteric artery (SMA) pedicle. When this happens, bands form between the cecum and the abdominal wall ("Ladd's bands"). Avolvulus may result around the shortened mesentery, cutting off the vascular supply to the midgut and causing obstruction. In volvulus, patients present with acute onset of bilious emesis and later with bloody stools or hemodynamic instability. The diagnosis of malrotation can be best made with an upper GI contrast study, which will show the duodenojejunal junction displaced to the right of midline. Sometimes this can also reveal volvulus. Patients with volvulus must be taken emergently to the OR to reduce the volvulus. If intestinal ischemia is advanced, a significant portion of small bowel may have to be removed, resulting in "short gut syndrome." In this patient presenting with bilious emesis, malrotation with volvulus must be considered and addressed early. The correct answer is to get an upper GI contrast study to evaluate for malrotation and obtain a surgical consultation. Observation (choice C) may result in intestinal ischemia or death. Pyloric stenosis (choice B) presents with nonbilious emesis. Choice D refers to intussusception, which often presents with bloody stools but bilious emesis is unlikely. Necrotizing enterocolitis (choice E) can also present with bloody stools, but usually occurs in premature infants as they approach full enteral feeds.

This woman likely suffers from major depressive disorder. Treatment with a SSRI is considered to be first-line therapy. Although the neurovegetative symptoms of depression (e.g., insomnia, change in appetite, anergia, poor concentration) can sometimes improve after several days of initiating pharmacotherapy, the feelings of depression and hopelessness may take up to 46 weeks to significantly improve. As long as she is tolerating the SSRI, the urge to quickly increase the dose should be avoided so as to minimize side effects. Upon initiation of a SSRI, education and reassurance should be provided to the patient regarding the expected time until remission. Although there are characteristic side effects, most patients tolerate treatment with SSRIs. Many of these side effects, such as headaches, gastrointestinal disturbances, and vivid dreams, transpire at the start of treatment and may resolve over days to weeks. Sexual dysfunction, such as impotence or inhibited orgasm, not uncommonly occurs after several weeks to months of treatment with SSRIs and can continue with ongoing treatment.

Toxic nodular goiter, also known as Plummer's disease, is a consequence of one or more thyroid nodules secreting inappropriately high levels of thyroid hormone independently of thyroid-stimulating hormone (TSH) control. Hyperthyroidism in patients with toxic nodular goiter is milder than in those with Graves' disease, and the condition is not accompanied by extrathyroidal manifestations such as ophthalmopathy, pretibial myxedema, vitiligo, or thyroid acropathy. Patients with toxic multinodular goiter are older at presentation than those with Graves' disease. The thyroid gland characteristically has one or more nodules on palpation. Local symptoms of compression, such as dysphagia and dyspnea, may occur. The diagnosis is suggested by a thorough history and physical examination and confirmed by documenting suppressed serum TSH level and raised serum thyroid hormone level.

Relative immaturity of the lacrimal drainage system can result in the accumulation of debris in the nasolacrimal duct. This will manifest as a swelling inferior to the middle canthus. Dermoid cysts in children are commonly found as a subcutaneous nodule on the lateral portion of the eyebrow. Mucoceles are usually found as fleshy papules on the inner portion of the lower lip. Frontal encephaloceles are midline in location.

RA is primarily a clinical diagnosis. The history and physical examination are crucial to confirming the diagnosis and ruling out differential diagnosis. No one laboratory analysis can make the diagnosis, however using laboratory analysis in conjunction with a detailed history and examination can help to confirm the clinical suspicion. Some findings that may suggest RA include: morning stiffness (LR 1.9), symmetric arthralgias (LR 1.2), rheumatoid nodules (LR 3.0), positive serum rheumatoid factor (LR 8.4), and radiographic changes of hands/wrists that demonstrate erosions or hypodensity adjacent to the joints (LR 11). Rheumatoid factor is present in about 70% of patients with the diagnosis at some point in the course, however in less than 30% of patients with early RA. ANAmay be positive in 2040% of RA patients but may also be positive in many other disease states. Anti-CCP antibodies have been reported to have a sensitivity of 4070% and specificity of 95%. The presence of both RF and anti-CCP is very highly specific for the diagnosis of RA

Current American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for treating a pap smear consistent with HGSIL is to perform colposcopy with directed biopsies if a lesion is seen. Routine pap smear in 1 year is an unacceptable option for this patient given her increased risk for developing cervical cancer. Random biopsies have a high false negative rate if there is no visible lesion to biopsy, thus, are not helpful. The pap smear is a screening test of the cervix, not the endometrium. There is no reason to suspect that this patient has endometrial pathology, therefore, an endometrial biopsy is not warranted. HPV testing is not recommended for high-grade pap smears. All high-grade pap smears require further investigation with colposcopy regardless of HPV status. If colposcopy is unsatisfactory, meaning no lesion is identified, the full transformation zone is not visualized or the full extent of the lesion is not identified, then a diagnostic excisional procedure is warranted. A loop excisional electrocautery procedure (LEEP) would be appropriate. However, note that if your suspicion for cancer is high, the cauterized edges from a LEEP procedure can complicate the pathologic assessment of positive margins. A cold knife cervical conization can be performed in the operating room as an outpatient surgery and provides the best surgical specimen for pathologic evaluation. In this case, a TVUS, endometrial dilation, and curettage, and ECC are all inappropriate options since they do not accurately evaluate the cervix, which is the primary site of concern. This patient has, by definition, microinvasive cervical cancer. Approximately 1015% of patients in the United States with stage I cervical cancer will have a microinvasive cancer. Microinvasive cancer is defined as stage IA with invasion limited to a depth of 5 mm with lateral extent not to exceed 7 mm. Stage IA is further subdivided into stage IA1 with stromal invasion less than 3 mm and IA2 with invasion 35 mm in depth. Young patients with microinvasive squamous cell carcinoma of the cervix who desire future fertility can be treated with conization alone, provided that certain strict criteria are met. The cone specimen should be properly excised and then evaluated by an experienced pathologist. The tumor must meet the criteria for stage IA1 disease with invasion less than 3 mm and a lateral extent less than 7 mm. The cone margins must be negative, and there should be no lymphvascular space invasion.

This patient's presentation is consistent with Graves' disease. Infiltrative ophthalmopathy is a common finding in this condition. Approximately 2040% of patients with Graves' disease possess clinically evident eye disease. Complaints include photophobia, diplopia, reduced visual acuity, and easy tearing; and, signs of corneal or conjunctival irritation are oftentimes present. Periorbital edema, chemosis, lid retraction with restricted ocular movement, proptosis, and upward gaze
impairment may also be found. Optic nerve compression may also arise, leading to decreased visual acuity, visual field defects, impaired color vision, and papilledema. Macroglossia, hyperkeratosis, cerebellar ataxia, and pericardial effusion are all findings in hypothyroidism. (Ceci Textbook of Medicine, pp. 13961400) Free T3 levels are elevated in all patients with Graves' disease. Most patients also have elevated free T4 levels, but occasionally this level will remain within the normal reference range in a state known as T3 toxicosis. This generally occurs during the initial phases of Graves' disease or at the onset of a relapse. TSH levels are suppressed by the elevated thyroid hormone levels.

Although antidepressant treatment may be appropriate if the patient is suffering from a depressive illness, further questioning would have to be made prior to that determination. Postpartum depressive symptoms are not uncommon and they may not require treatment. If there is felt to be immediate danger to the child, calling child protective services would certainly be indicated. Having intrusive thoughts does not equate with acting on the thoughts, and thoughts similar to those in this case are not unusual given the stress of a newborn. Again, more information would need to be obtained. On the other hand, premature reassurance regarding the thoughts of harm without knowing additional facts might be dangerous if the patient is harboring a plan or intent to harm her child. Hospitalization may be necessary if the patient is suffering from postpartum psychosis or is suicidal. Only by gathering further history and symptoms, especially focusing on a support system and possible psychotic symptoms, can the clinician determine if there is significant cause for concern. Postpartum psychosis is considered a psychiatric emergency because of the risk of harm to the infant and usually requires immediate hospitalization (DSM IV-TR).

The patient has diffuse interstitial infiltrates on CXR that correspond in time and presentation to acute inhalation histoplasmosis. This would be seen in a patient, such as an amateur spelunker, who has been in a cave with bats. It is the act of crawling through the cave that disturbs the spores of histoplasmosis that grow in the bat guano. The incubation period for influenza is 12 days. It is passed primarily by secretions from the nose spread by hands. The other members of the expedition were not sick, as they might be with influenza. Disseminated aspergillosis occurs in immunocompromised patients who have defects in both cell-mediated and humoral immunity. This patient does not have this. While the CXR could mimic military tuberculosis, the association with caving 14 days before would make tuberculosis less likely and histoplasmosis more likely. There is no history that the patient is immunocompromised with HIV and would be at risk for
P. jiroveci pneumonia. Fungal serologies would establish the diagnosis, but acute and convalescent serologies would take 3 weeks for results. These are only useful in outbreak investigations. The other choices do not fit due to the reasons above. Treatment of acute respiratory histoplasmosis is based on severe hypoxia and would require arterial blood gases to establish the need for therapy. None of the fungal infections mentioned are transmissible person to person, therefore respiratory isolation would not be necessary. Histoplasmosis is a dimorphic fungus that grows as a yeast at body temperature and a mold at room temperature. The mold produces the spores that are infectious. A similar situation occurs for Cryptococcus neoformans.
C. immitis and aspergillosis are not transmitted from person to person.

Explanations:
Pregestational diabetes is associated with numerous risks to both the mother and the fetus. Stillbirths are more common in pregnancies to diabetic women and stillbirths without an identifiable cause, called "unexplained" stillbirths, are a well-described phenomenon. Similarly, preterm births are more common in diabetics than nondiabetics. While congenital malformations are more common in pregnancies to diabetic women, fetal chromosomal abnormalities are not more common.
Children of women with diabetes have an approximately 13% incidence of developing type 1 diabetes. While earlier obstetrical teaching suggested that maternal diabetes delayed fetal lung maturation, more recent studies do not support this.
Gestational age is likely the most significant factor in the development of respiratory distress. While there are significant maternal risks from the interaction of diabetes and pregnancy, with the possible exception of diabetic retinopathy, the long-term course of diabetes does not appear to be affected by pregnancy.

Pregnancy neither exacerbates nor modifies diabetic nephropathy and the development of diabetic peripheral neuropathy during pregnancy is uncommon. While preeclampsia is a significant risk and the perinatal mortality rate is 20 times higher in preeclamptic diabetic women compared to normotensive women, the occurrence of preeclampsia does not appear to be related to diabetic control. Diabetic ketoacidosis is a serious complication with an approximately 20% rate of fetal loss. However, it is estimated to occur in 1% of pregnancies of diabetic women. Infections occur in approximately 80% of pregnancies in insulin-dependent diabetics, with candida vaginitis, urinary tract infections, and respiratory infections being common. Preconception counseling in diabetic women who desire to become pregnant is a critical issue that often is best served by a team that includes the obstetrician, primary care physician, endocrinologist, and diabetic educators.
When possible, attempts should be made to attain optimal diabetic control. Women with good diabetic control have been shown in observational studies to have a lower rate of having infants with congenital anomalies than women with poorer diabetic control. Optimal diabetic control has been defined as glycated hemoglobin levels within or near the upper limit of the normal range. This can be obtained with multiple daily insulin injections or, in selected patients, a continuous infusion via an insulin pump. All women--diabetic or not should be counseled to take folic acid prior to conception in order to lower the rate of neural tube defects. ACE inhibitors are contraindicated during pregnancy and should, whenever possible, be discontinued prior to conception.

Hashimoto thyroiditis is a very common cause of hypothyroidism in the parts of the world where iodine levels are insufficient. The clinical picture is characterized by a gradual enlargement of the thyroid gland with autoimmune destruction.
There is a great female to male predominance, with ratio of 10 20:1. Clusters of families are seen which are associated with HLA-DR5 on the major histocompatibility complex (MHC). A few cases are also characterized by HLA-DR3. The pathogenesis is attributed to cellular and humoral immunity which produces thyroid tissue injury. The morphology of the thyroid gland is characterized by typical destruction of the thyroid parenchyma with dense lymphocytic infiltrate and many secondary germinal centers. Occasional scattered Hurthle cells are also seen. Depending on the stage of the disease, extensive areas of fibrosis may also be present. The clinical course of Hashimoto thyroiditis is usually an initial period of time in which the patient may be euthyroid followed by hypothyroidism.

This patient has OCD. Benzodiazepines such as alprazolam may be helpful for the acute anxiety associated with OCD, but they are not a first-line medication to reduce the obsessions or compulsions. Although antipsychotics such as olanzapine are sometimes used in conjunction with other psychotropics in patients with severe, intractable OCD, they are not recommended as monotherapy given their significant side effects. Antidepressants that mostly affect norepinephrine, such as bupropion and desipramine, are not particularly effective in treating OCD. Serotonergic drugs, such as citalopram and the tricyclic clomipramine, have been proven to improve both obsessions and compulsions.

Because of this fact, OCD is thought to involve the serotonergic system. EMDR is a treatment used specifically for posttraumatic stress disorder (PTSD). Although psychoanalysis and psychodynamic (or insight-oriented) psychotherapies may be beneficial for some individuals with OCD, there have not been enough studies to document their effectiveness. Supportive psychotherapy can be useful in helping the patients to cope with their severe anxiety and limitations, but it does not particularly address the obsessions and compulsions themselves. Behavioral therapy has consistently demonstrated success in treating OCD, and studies have shown it to be as efficacious as pharmacotherapy.

This patient is exhibiting signs and symptoms of an anaphylactic reaction, likely to one of the medications that she recently took. Angioedema is occurring (swelling of the lips and tongue). Her dyspnea may be a manifestation of laryngeal edema or of bronchospasm. She is at high risk for respiratory compromise and, therefore, of the options listed, having her activate the emergency medical system is the most appropriate. Calling 911 from your office would be another option.
Of the interventions listed, epinephrine would provide the most benefit in correcting the underlying problem. The alpha-and betaadrenergic effects result in vasoconstriction, bronchial smooth-muscle relaxation, and reduction on vascular permeability. Oxygen may be required if the patient is hypoxic, IV fluids may be necessary for persistent hypotension and albuterol may benefit the treatment of bronchospasm, but epinephrine would most immediately address the multiple systemic effects of anaphylaxis

Reactive arthritis consists of a triad of nonspecific urethritis, conjunctivitis, and asymmetric arthritis, usually involving the large joints of the lower extremities. Genitourinary causes of reactive arthritis include Chlamydia or Ureaplasma. GI infections due to Salmonella, Shigella, Yersinia, Klebsiella, and Campylobacter can also cause reactive arthritis. Gout attacks are typically monoarticular and begin abruptly with the affected joint being exquisitely painful, warm, red, and swollen. These attacks often spontaneously resolve in 310 days. While the symptoms from pseudogout may mimic those of gout, they tend to be less painful and take longer to reach peak intensity. Gonococcal arthritis is seen more often in females, is associated with migratory arthralgia, tends to favor the upper limbs and knees and may be associated with cutaneous lesions (pustules). The absence of attacks and joint distribution makes gout and pseudogout less likely. The history of conjunctivitis and association with diarrhea makes the diagnosis of reactive arthritis more likely than resistant gonococcal arthritis. His clinical symptoms do not suggest ankylosing spondylitis, although if he was HLA-B27 positive he would be at increased risk of developing spondylitis. This patient has the classic symptoms and exposure risk (GI infection) to suggest reactive arthritis. For the articular symptoms, reduction of inflammation and restoration of function can be achieved with nonsteroidal antiinflammatories alone. A sufficient number of patients with reactive arthritis will not be HLA-B27 positive, thus rendering this test useless as a screening test. However, it may be useful when the clinical picture is incomplete (such as absence of antecedent infection or lack of extraarticular features). Once an antecedent infection has triggered reactive arthritis, it is unlikely that antibiotics will affect the course of the illness (except in the case of chlamydiaassociated urogenital disease where a trial of prolonged antibiotic therapy may be reasonable).

Systemic corticosteroids are usually ineffective in reactive arthritis, but may be tried for resistant disease or conditions such as AIDS in which cytotoxic therapy is contraindicated. Given the absence of skin lesions, penile discharge, or urogenital symptoms, one would be hard-pressed to challenge the patient's statement that he has not engaged in unprotected sex at the risk of jeopardizing the physicianpatient relationship. Reactive arthritis may be the first manifestation of HIV infection. Therefore, HIV antibody status should be determined when the appropriate risk factors and/or clinical features are present. As mentioned previously, systemic steroids are usually ineffective for reactive arthritis and, with the possibility of joint infection, would necessitate ruling out infection by arthrocentesis of the affected joints. Joint infection cannot be ruled out based on his presentation, and joint sepsis must be excluded prior to corticosteroid injection. The clinical presentation is classic for reactive arthritis, and the absence of systemic symptoms makes the likelihood of disseminated bacterial infection low. Indomethacin, at a dose of 150200 mg/day, is the prototypic NSAID medication for treatment of reactive arthritis. Doses higher than this are associated with significant GI complications and do not improve efficacy in a patient resistant to the standard dose. In the event that the patient does not respond to 200 mg of indomethacin or alternative NSAIDs, disease-modifying antirheumatic drugs (DMARD) such as methotrexate, azathioprine, or sulfasalazine may be used, provided that HIV test results are negative, as these immunosuppressants have been reported to precipitate the onset of AIDS in HIV-positive patients.

On September 30, 1978, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research submitted the report "Ethical Principles and Guidelines for the Protection of Human Subjects of Research," named after the Belmont Conference Center in the Smithsonian Institution. The three ethical principles emphasized in this report include justice, beneficence, and respect for persons. Justice is the equitable distribution of research burdens and benefits. Beneficence is the mechanism to maximize benefits and minimize harm to research subjects. Respect for persons is the ethical principle which prioritizes the respect for individual autonomy and the protection of individuals with reduced autonomy. The principle of respect emphasizes the protection of subjects' privacy, maintenance of confidentiality, informed consent, and the utilization of additional safeguards for the protection of vulnerable populations. Health and Human Service (HHS) regulations delineate additional mechanisms to protect human subjects, which include (1) institutional assurances of compliance, (2) Institutional Review Board (IRB) review, and (3) informed consent. An institutional assurance of compliance is documentation that the institution will follow HHS regulations for the protection of human subjects. An IRB is a committee that has been established to protect human subjects involved in research activities. These committees must have at least five members of varying backgrounds who possess the professional competence to review research activities.
Informed consent is the voluntary choice of an individual to participate in research activities. To be truly informed consent, the individual must have a clear and accurate understanding of the purpose of the research, the risks involved, the potential benefits, the procedures to be performed and the alternative modalities of treatment available. Typically, these are in a written consent form. The legal arguments for informed consent emphasize the right of self determination. This is in contrast to the ethical basis of individual autonomy. Therefore, a mere signature by the individual participant does not fulfill the ethical requirements of the informed consent process. Any research study must have scientific validity, a fair selection of individual subjects for populations, protection of vulnerable populations, fair access to the benefits of medical research, acceptable risk-benefit ratios, appropriate informed consent, and independent review of the study. In addition, Data Safety Monitoring Boards are being utilized to further monitor the safety of research protocols and participation.

The patient exhibits the typical features of the nonthyroidal illness syndrome. The total thyroxine level is low, but TBG is also low (based on the elevated T3 resin uptake), so that the free thyroid index is still in the normal range. The low TBG is related to the patient's nutritional deficiency. The low T3 and TSH levels are related to his illness and the use of both glucocorticoids and dopamine, which decrease TSH. The reverse T3 level is high because of the blockade of T4 to T3 conversion caused by the illness.
This finding excludes hypopituitarism as an underlying cause. There is no specific therapy for this problem other than treating the underlying illness.

Gingival hyperplasia is a common side effect of chronic phenytoin administration. This will resolve with cessation of the medication. None of the other anticonvulsants listed will result in this problem.

Finding a conduit for use in coronary artery bypass grafting can sometimes be a challenge since these patients often have diffuse atherosclerotic disease. The left internal mammary artery is most commonly used. Bilateral internal mammary arteries can be used, however this increases the chances of sternal healing problems. Saphenous vein grafts are used in patients with multivessel disease, although this may not be an option in patients with deep vein thrombosis (DVT), venous insufficiency, or arterial insufficiency to the legs (because they will not heal the harvest wound). Radial arteries, the right gastroepiploic artery, and inferior epigastric arteries have also been used.

Psoriasis is a benign chronic, inflammatory skin disorder with a genetic basis that affects approximately 2% of the population in the United States. The condition varies in its presentation from person to person, with some having only local involvement and others having a severe generalized involvement. The incidence occurs in a bimodal distribution, with peaks persons in their 20s and 50s. Those with earlier onset generally will have a more severe disease over the course of their lifetime. Psoriasis has several variants, or subtypes, including plaque type (most common), eruptive (guttate), generalized pustular, and erythrodermic psoriasis. Some patients may be asymptomatic or may have only minor itching.
Others may have involvement of most of their body, with severe disfigurement and poor quality of life. Psoriasis may involve any skin area; however, areas such as the scalp, extensor surfaces, palms, soles, and nails should always be examined. The typical lesions are described as erythematous, well-demarcated plaques with overlying scales. Fine stippling (pitting) of the nails is highly suggestive of psoriasis. In addition to the skin findings, patients may also have arthritis.
The lesions can be reactivated with local injury or irritation of normal skin (Koebner phenomenon). The diagnosis is predominantly clinical, based on the history and examination. There are no laboratory measures that will diagnose psoriasis.
Skin biopsy, although not pathognomonic, would show features consistent with psoriasis and would help to rule out other similar appearing conditions.

This patient is demonstrating acute peritoneal signs that require surgical intervention. Adding additional testing, either with radiology or more laboratory assessment would not alter the management at this point in time. Although some patients with chronic pelvic pain have a history of sexual or physical abuse, an assessment in the acute emergent setting does not take initial priority. Although ovarian torsion can be enigmatic in its presentation, this patient demonstrates classic signs of intermittent pelvic pain and an ovarian cyst with a solid component. The 8-cm increase in ovarian size is likely due to vascular congestion from occlusion of the blood supply. Early intervention is more likely to result in salvaging viable tissue before the onset of irreversible tissue necrosis. The absence of fever and other GI symptoms, along with a left lower quadrant mass on ultrasound goes against the possibility of appendicitis or pancreatitis. Her pregnancy test is negative which generally excludes an ectopic pregnancy.

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.

The most common bacterial infection in the newborn period is GBS. GBS is commonly cultured in the adult vaginal tract, and its vertical transmission can be interrupted with maternal antimicrobial treatment prior to delivery of the infant.
Mothers are commonly treated in labor with penicillin, ampicillin, clindamycin, or azithromycin in an attempt to interrupt transmission to the infant while passing through the birth canal. If antimicrobial prophylaxis is initiated greater than 4 hours prior to delivery, the rate of early-onset GBS disease is dramatically decreased. The current recommendation for term infants of GBS-positive women who have received antibiotics in labor (at least two doses or =4 hours prior to delivery) is observation without testing or antibiotics. (American Academy of Pediatrics, 2003, pp. 584591) Classic hemophilia is an X-linked recessive bleeding diathesis. Hemophilia is inherited on the maternal lineage from carrier (or affected) mothers.
This infant, being a male, would receive his X chromosome from his mother. He is, therefore, not at risk for having hemophilia. Further, being an X-linked trait, there cannot be a male "carrier" state.

A fever in the first 46 weeks of life needs to be treated very aggressively. There are no reliable clinical or laboratory findings currently available that can discriminate between a nominal viral illness and a serious bacterial infection. In the newborn period, fever may be the only indicator of bacteremia or meningitis. Any rectal temperature greater than 100.5 should trig ger a full sepsis workup. This should include cultures of the blood, urine, and spinal fluid. In this age range, empiric antimicrobials should be initiated that should cover for GBS, E. coli, and Listeria monocytogenes. A commonly used regimen is ampicillin and gentamicin. Many would also include empiric acyclovir in this age range. In infants, the routine use of antipyretics should be discouraged. A blood culture alone is not an adequate screening tool for meningitis. While a urinary tract infection (UTI) is a common cause of infection in infants, a more complete evaluation would be warranted.

Goodpasture syndrome is characterized by antibasement antibodies, with the lungs and kidneys bearing the brunt of the damage. Antibodies against platelet surface antigens, parietal cells, antigens, receptors, and colonic mucosal cells are seen in autoimmune thrombocytopenia, pernicious anemia, myasthenia gravis, and ulcerative colitis, respectively.

The Halsted radical mastectomy involves removal of all breast tissue, lymphadenectomy, and removal of the pectoralis major. The modified radical mastectomy preserves the pectoralis major muscle thus decreasing the morbidity of the surgery with the same survival. The modified radical mastectomy does include a lymph node dissection. The anatomic limits of the modified radical mastectomy include the sternum medially, the subclavius muscle superiorly, the inframammary fold inferiorly, and the latissimus dorsi muscle laterally. The surgeon must identify the thoracodorsal nerve and the long thoracic nerve, which innervate the latissimus dorsi muscle and the serratus anterior muscle, respectively.
Damage to the long thoracic nerve results in a "winged scapula." After a complete dissection of level I, II, and III lymph nodes, the use of radiation therapy needs to be critically evaluated because of the long-term morbidity of lymphedema.

This patient has a markedly supratherapeutic INR and clinical evidence of bleeding. Discontinuation or dosage reduction of warfarin is an appropriate intervention by itself in patients with an INR less than 5.0 or in patients without signs of bleeding. In patients with bleeding or with an INR greater than 5.0, however, further interventions are indicated. Vitamin K1 administration provides a more rapid reversal of the anticoagulation caused by warfarin, but it takes 68 hours to begin having an effect and up to 24 hours to achieve its maximal effect. Immediate reversal may be obtained by the administration of fresh frozen plasma intravenously in addition to vitamin K1

The presence of headache, eye pain, nausea, and vomiting should prompt the consideration of the diagnosis of acute angle closure glaucoma. This is a rare but serious condition in which the aqueous outflow is obstructed, and the intraocular pressure abruptly rises. Susceptible eyes have a narrow anterior chamber and when the pupil becomes dilated, the peripheral iris blocks the outflow via the anterior chamber angle. Edema of the cornea occurs, resulting in cloudiness on examination. Diagnosis is made by measuring the intraocular pressure during an acute attack. Treatment includes medications to induce miosis in an effort to relieve the blockage or, if that fails, surgical intervention. In some patients, the headache or GI symptoms can overshadow the ocular symptoms, resulting in a delay in diagnosis and unnecessary workup for other conditions. In this case, the lack of findings on abdominal examination makes appendicitis or perforated bowel unlikely. DKA can present with primary GI symptoms, but would not explain the ocular symptoms. Similarly, cerebellar or other brain tumors may cause headache, nausea, and vomiting, but would not be causes of a painful, red eye.

This patient is suffering from bulimia nervosa, categorized by recurrent episodes of binge eating associated with compensatory behaviors including self-induced emesis, diuretic, or laxative abuse. Because of the repeated vomiting of gastric fluids, patients are prone to develop various electrolyte abnormalities, such as hypochloremic alkalosis or hypokalemia. Hypernatremia and leukopenia are not commonly seen. Anticonvulsants, such as valproic acid and carbamazepine, as well as mood stabilizers such as lithium, may be helpful for treating comorbid bipolar disorder but are not in and of themselves efficacious in the treatment of bulimia nervosa. Similarly, antipsychotics and benzodiazepines may be used in co-occurring psychotic or anxiety disorders, but do not help with binging or purging. Antidepressants, especially the SSRIs, have been shown to be successful in decreasing both the binging and purging behaviors.

Spontaneous pneumothorax is usually found in young males. A tall, thin habitus is common. Eighty-five percent of patients are found to have pulmonary blebs on the affected side. The correct management is placement of a chest tube, pain control, oxygen supplementation, and serial chest x-rays to monitor resolution. Thoracotomy is required if the pneumothorax does not resolve with a chest tube or if there is a persistent air leak. Bleb resection and pleurodesis is usually performed at the time of operation to prevent future bleb rupture and to promote adhesion of the lung to the chest wall. Thoracotomy is also offered to patients after a recurrence to prevent future episodes. Fifty percent of patients will have a recurrence on the ipsilateral side after a spontaneous pneumothorax.

Crohn's disease is a chronic inflammatory disorder of unknown etiology that has the potential to involve the different portions of the gastrointestinal (GI) tract from the mouth to the anus. It is characterized by a transmural inflammation with skipped areas in which the intestinal wall is not affected. Frequently, the presence of noncaseating epithelioid granulomas is seen.

This patient has a gastrinoma, seen in Zollinger-Ellison syndrome, and should also be evaluated for possible MEN I. Gastrin is a GI hormone that is released from the antral G cells of the stomach to regulate acid secretion by the gastric parietal cells. It is released when the stomach gets the signal that is needed to initiate the digestion process, and also acts to stimulate chief cells to secrete pepsinogen and to increase gastric mucosal blood flow. Known stimulants for the release of gastrin include: vagal stimulation, calcium, alcohols in the stomach, proteins/amino acids in the stomach, antral distention, and gastric pH greater than 3. Antral pH less than 2 inhibits gastrin release, as does somatostatin. Secretin has no effect or decreases gastrin levels in healthy patients, but it increases gastrin release in patients with Zollinger-Ellison syndrome.
Glucagon has little or no effect on gastrin release.

This patient appears to be suffering from a major depressive episode and is exhibiting acute suicidal ideation with a definitive plan and intent to overdose on a potentially lethal substance. She clearly poses an increased risk of self-harm and requires immediate hospitalization. As she refuses a voluntary admission, involuntary admission (commitment) is warranted. Autonomy is the right of a patient to self-determination. Confidentiality is not a core ethical principle. Nonmaleficence is the duty to "first, do no harm." The concept of justice involves social, political, legal, and religious considerations. The important code of beneficence (preventing harm) is illustrated in the above case, where an immediately suicidal patient is admitted involuntarily.

This woman likely suffers from a major depressive episode. While asking about substance abuse, current medications, medical problems, and a past history of depression are very important in a complete psychiatric evaluation, assessment of suicidality is essential. The risk of suicide in patients with major depressive disorder is about 20 times higher than those without the illness. The estimated lifetime risk of suicide is approximately 15% in those individuals with major depressive disorder. The choice of a specific antidepressant may be influenced by many factors, including prior response in the patient or a family member and comorbid medical problems or substance abuse in the family (and, therefore, potentially the patient). If a patient or family member has a history of manic symptoms or bipolar disorder, consideration should be given to beginning a mood stabilizer prior to initiating antidepressant therapy, as antidepressants can cause a switch into mania in those individuals.

Menstrual disorders, primarily oligo-and amenorrhea, are particularly common among women with eating disorders and are thought to be the result of hypothalamic hypoestrogenism. This patient demonstrates estrogen deficiency (decreased breast size, urogenital atrophy). Her dental caries, oral sores, and hand sores might be a result of self-induced vomiting. Hyperthyroidism would be considered in the differential diagnosis of a young woman with weight loss and menstrual irregularities. In contrast to persons with a medical condition that causes weight loss, those with an eating disorder express a disordered body image and, often, a desire to be underweight. This patient requires additional investigation to assess for the possibility of inpatient admission. Patients with a prolonged, severe eating disorder are at risk for developing dehydration, electrolyte imbalance (especially hypokalemia), cardiac dysrhythmias, and hypothermia. Hospitalization would be considered for those who are severely dehydrated, who have marked electrolyte abnormalities who are <75% of their ideal body weight, or who have a comorbid condition that would require hospitalization, such as a severe
psychiatric disorder. Although weight-bearing exercise favors bone formation, when excessive exercise and/or an eating disorder results in amenorrhea, estrogen levels fall. Subsequently, bone mineral density decreases. Persons with eating disorders are at increased risk for comorbid psychiatric conditions including depression, anxiety, obsessive-compulsive disorder, and personality disorders.

The term CHARGE is a mnemonic standing for Coloboma, Heart malformations, Atresia choanae, Retarded (growth and mental),Genital anomalies, and Ear anomalies. The colobomas are usually seen in the iris, but can be seen in the eyelids and the nasolabial folds as well. The heart anomalies of CHARGE association are usually ventricular septal defects and tetralogy of Fallot.

In patients with liver failure, the source of an upper GI bleed is esophageal varices in 50%, gastritis in 30%, and duodenal ulcers in only about 10%. Esophageal variceal bleeding is a potentially fatal complication of portal hypertension. The initial management should include fluid resuscitation and replacement of blood and clotting factors as needed. The second step is to control the source of bleeding. Medical management may include vasopressin or octreotide. Once the patient is stabilized, endoscopic evaluation of the bleeding is crucial. It can be both diagnostic and therapeutic. Endoscopic techniques for controlling hemorrhage can include sclerotherapy, banding, or balloon tamponade. If these methods are ineffective, or the patient has numerous recurrences, portal shunts can be considered. TIPS have increased in popularity as a method for portal decompression. This can be performed in the acute setting. Surgical shunts are also an option, but are primarily reserved for stable patients with recurrent bleeding episodes and not performed in an acutely unstable patient. Mesocaval shunts connect the SMV to the IVC in a variety of manners. Splenorenal shunts are actually the most common type of shunt. Nonselective shunts that completely divert portal blood flow from the liver can actually increase hepatic encephalopathy. Most surgeons prefer selective shunts, which preserve a component of hepatic blood flow and thus function. Synthetic graft material can be safely used to create the shunts.
Postoperative mortality is directly related to the patient's preprocedure medical condition and degree of hepatic failure.

This patient has sickle cell anemia. This is evident from sickle cells forms on the peripheral blood smear in Figure 1-13. Pain medication is an important initial concern. It is often difficult to determine whether a patient in sickle cell crisis has an ongoing infection. Infections can precipitate sickle cell crisis. With respect to community-acquired pneumonia, the diagnosis is difficult. A patient with sickle cell crisis can have fever as a result of the sickle crisis. They can have an increased respiratory rate, physical examination, and CXR findings which suggest pneumonia as a result of pulmonary infarctions. A white blood count can be elevated due to marrow stimulation. In the presence of the acute chest syndrome, characterized by chest pain, hypoxia, and CXR infiltrates, antibiotics would be indicated. Without further information, it is hard to decide to empirically start broad-spectrum antibiotics for community-acquired pneumonia. Transfusions should generally be avoided in patients with sickle cell anemia who are not symptomatic due to the anemia. Since patients in sickle cell crisis have intravascular hemolysis, their reticulocyte counts are usually high and they can replace their blood quickly. Repeated small transfusions will lead to autoantibodies that will make further transfusions difficult. Arterial blood gas determination should not be the first step, given the above information. A CT scan of the abdomen is not indicated given the nonspecific nature of the patient's abdominal findings. Parvovirus B19 can cause aplastic crisis in patients with hemoglobinopathies, including sickle cell disease. A tip to this diagnosis is the decreased reticulocyte count in a patient who normally would have a high reticulocyte count. Given the information listed above, there is no indication for broad-spectrum antibiotics. Splenectomy is not a reasonable alternative at this point. Patients with sickle cell disease have autosplenectomy by the time they are adults. A bone marrow biopsy maybe indicated because of the low platelet count, but not initially. GnCSF is not indicated because the patient does not have neutropenia.
Patients with sickle cell disease typically have isosthenuria.

This is due to repeated infarction of the renal papilli. This causes destruction and interference with the counter current mechanism that causes urine concentration. As a result, patients with sickle cell anemia have the inability to concentrate their urine. This results in fluid and electrolyte abnormalities. Patients in sickle cell crisis are usually fluid depleted. This and the sickled blood cells cause hyperviscosity and microinfarctions. There is no evidence that the patient has diabetes insipidus, which usually has a urine specific gravity less than 1.005. Patients with UTIs do not have isosthenuria due to RBCs and WBCs that increase the urine specific gravity. Sickle cell patients may have zinc deficiency, but this is not a cause of isosthenuria.

LCIS is a benign diagnosis and alone does not have a risk of progression to an invasive cancer. However, a diagnosis of LCIS does increase the risk for development of future breast cancer at a rate of about 1% per year. It is important to remember that the risk is increased for both breasts. It has been shown that chemoprevention with tamoxifen can decrease the incidence of breast cancer by 49%. It is also sufficient to follow this population closely with annual mammograms and semiannual clinical examinations. Prophylactic bilateral mastectomies are an option and result in a 90% decrease in the risk of subsequent breast cancer. Since a diagnosis of LCIS increases the risk of cancer in both breasts, a mastectomy of the affected side is insufficient treatment

Encounters with persons traveling to other countries are common in primary care or community health settings. The advice and interventions provided are dependent on where the person is going, what he or she will be doing, and for how long he or she will be there. The most accessible and up-to-date source of this information in the United States is at the Centers for Disease Control web site, which provides detailed recommendations on vaccinations, health, and safety risks involved in overseas travel. In this series of questions, the travelers are going to the region of central Africa and, more specifically, to a rural area of Cameroon. This is an area of the world where polio remains a risk. As most Americans have not been vaccinated against polio since childhood, booster immunization against polio is recommended. The injectable polio vaccine is recommended as it does not carry with it the risk of vaccine-induced disease that the oral (live virus) vaccine does. Smallpox has been eliminated as a naturally occurring disease, although it remains of importance in bioterrorism discussions. The smallpox vaccine is not necessary for travel to any part of the world, but is used by the military or medical first responders who may be exposed in the event of a biowarfare attack. The traveling couple is up-to-date on their dT status with boosters within the past 2 years. They have completed a series of both MMR and hepatitis B, which is felt to confer lifetime immunity. Malaria prevention is an important consideration for travel to many areas of the developing world. Different regimens may be used depending on the area to which the travel will occur. All regimens, however, require the institution of prophylaxis prior to travel and the continuation of prophylaxis for up to 4 weeks after completion of travel. This is due to the life cycle of organisms that cause the disease. Prevention of malaria also involves attempts to reduce one's risk of exposure to the Ixodes mosquito which can transmit the disease. This mosquito tends to be more active early in the morning and at dusk, and less active in the middle of the day. Wearing long sleeved clothing, using mosquito nets, and insect repellent is important. DEET-containing insect repellents are recommended as the most effective products available and are safe when used appropriately. The most common cause of injury during travel is motor vehicle accidents. The risk of injury is higher in many developing countries than in the United States due to poor roads, poor vehicle maintenance, lack of seat belts, and other issues. Very cautious driving and avoidance of driving after dark may help to reduce the risk somewhat. While swimming is an ideal exercise in such hot climates as central Africa, freshwater lake swimming should be avoided due to the risk of exposure to schistosomiasis. The Schistosoma species that cause this disease are endemic in standing freshwater bodies. Swimming or bathing in salt water or chlorinated swimming pools is safer. Traveler's diarrhea and exposure to foodborne pathogens is a common cause of illness during travel to developing countries. The guideline with food is to cook it, peel it, purify it, or forget it. Fruits that can be peeled, such as oranges or bananas, are generally safe to eat. Carbonated beverages are also safe. However, ice cubes made from local water supplies are a common, and sometimes ignored, source of infection. Water purification can be accomplished by boiling or by filtering through an absolute 1 m filter and then purifying with iodine. Filtering alone does not provide adequate protection. Salads that are not made of carefully cleaned vegetables should be avoided and salad dressings may also be contaminated. Meats that are well cooked and served hot would be considered less likely to transmit an infection. Finally, brushing one's teeth with unpurified water carries a significant risk of transmission of waterborne illness and should be avoided. Purified water or bottled water should be used instead.

Cystic fibrosis is the most common hereditary condition in Whites with a carrier frequency of 1 in 25. The American College of Obstetricians and Gynecologists, the American College of Medical Genetics, and the National Institutes of Health have recommended that cystic fibrosis carrier screening be offered to all White couples either pregnant or considering a pregnancy, and that the availability of screening be discussed with members of other ethnic groups who have a lower frequency of cystic fibrosis carrier state. Cystic fibrosis is inherited in an autosomal recessive fashion, so for a couple in which both mother and father are carriers the risk of having an affected child is 25% or 1 in 4. In the case presented, in which the husband's sister has cystic fibrosis, his likelihood of being a carrier is 2 in 3 (since he has an affected sibling, both of his parents are obligate carriers, and since he is not affected, he is either a noncarrier [1 in 3] or a carrier [2 in 3]).
This pattern is true for all autosomal recessive disorders.

The pelvic ultrasound is the most reliable measurement of fetal gestational age in the absence of accurate dating by LMP. A first trimester sonogram is thought to be reliable ? days. Given the patient's history, she is likely at least 2 months pregnant. hCG level at this gestation can be variable and is not a useful method of pregnancy dating. A pelvic examination is useful to help confirm likely dating, but is not a reliable means of determining EDD. FSH and LH levels have no role in determining pregnancy dating.

The risk of postpartum major depression is estimated at 820% in all postpartum patients. In those with a previous history of postpartum depression, the risk is thought to be 50100%. In patients who have had previous depression not associated with pregnancy, the risk of postpartum depression is 2030%. Maternity blues is a milder psychological reaction that can occur in the early postpartum period and is thought to occur in 70+ % of all postpartum patients. Patients with a history of bipolar disease have a igher risk of recurrence in the postpartum period, and these patients often present with postpartum psychosis symptoms.

This clinical vignette describes an adolescent female with PCOS. PCOS is commonly seen in obese adolescent females with anovulatory menstrual cycles, hirsutism, and generalized virilization (acne). Commonly, PCOS patients will have glucose insensitivity and manifest features of type II diabetes mellitus. The diagnosis of PCOS may be difficult to ascertain. A pelvic ultrasound demonstrating "polycystic ovaries" (the string of pearls sign) may be quite helpful. Girls with PCOS will typically have elevated triglycerides, low HDL cholesterol, and a suppressed prolactin. As indicated above, PCOS girls also often have glucose insensitivity and an abnormal glucose tolerance test. The most effective therapy in PCOS involves lifestyle alterations (weight loss and exercise) and hormonal regulation of ovulation. The hypoglycemic agent metformin is now being used to assist in the management of PCOS. Occasionally, subcutaneous insulin may be effective in controlling hyperglycemia, but this will not prevent diabetes mellitus.

Vasospasm severe enough to reduce flow and produce cyanosis after exposure to cold is called Raynaud phenomenon. Some make a further distinction between Raynaud syndrome when the phenomenon is associated with another systemic disorder and Raynaud disease when there is no established systemic process. Similarly, Raynaud phenomenon in the absence of a systemic illness may also be referred to as primary Raynaud phenomenon, and Raynaud in the presence of another systemic illness may be termed secondary Raynaud phenomenon. In this case, there is no evidence of another systemic illness. Clinical features suggesting SLE or RA are absent. Subacute bacterial endocarditis likewise would be expected to be associated with fever, which is absent in this patient. In addition, one would expect to see areas of necrosis either in the soft tissue (Janeway spots) or under the fingernails (splinter hemorrhages) were any kind of embolic phenomenon is present. (Harrison's Principles of Internal Medicine, 15th ed., pp. 1438- 1439)
Given the patient's age, it is reasonable to explore the possibility of an associated systemic illness. If one were present, basic laboratories such as blood count, urinalysis, and chemistries are important. ANAis a reasonable screening study in this case. It does have a prognostic value increasing the likelihood of the development of a systemic process in the future.

If positive, further serologic studies might then be helpful in establishing a more specific diagnosis. The arterial Doppler with cold stimulation can be a useful test in showing a marked drop in blood flow with cold exposure. Still, with such a classical description, it is hard to imagine how this test would be helpful either diagnostically or therapeutically. Antidouble-stranded DNA antibodies would establish the diagnosis of SLE. Likewise, the antiscleroderma antibodies (anti-Scl-70) would be a very important prognostic marker once the ANA is positive and certainly would occasion a rheumatic disease consultation. Patients with hypercoagulable states, including those with positive cardiolipin antibodies, can often mimic Raynaud's. Given that the patient wants to become pregnant, this would be an important study to obtain. Sjren antibodies, both SSA and SSB, are important in this case because of the contemplated pregnancy. Sjren antibodies can cross the placenta and create the syndrome of neonatal lupus (complete heart block, thrombocytopenia, and rash).

Vasospasm severe enough to reduce flow and produce cyanosis after exposure to cold is called Raynaud phenomenon. Some make a further distinction between Raynaud syndrome when the phenomenon is associated with another systemic disorder and Raynaud disease when there is no established systemic process. Similarly, Raynaud phenomenon in the absence of a systemic illness may also be referred to as primary Raynaud phenomenon, and Raynaud in the presence of another systemic illness may be termed secondary Raynaud phenomenon. In this case, there is no evidence of another systemic illness. Clinical features suggesting SLE or RA are absent. Subacute bacterial endocarditis likewise would be expected to be associated with fever, which is absent in this patient. In addition, one would expect to see areas of necrosis either in the soft tissue (Janeway spots) or under the fingernails (splinter hemorrhages) were any kind of embolic phenomenon is present. (Harrison's Principles of Internal Medicine, 15th ed., pp. 1438- 1439)
Given the patient's age, it is reasonable to explore the possibility of an associated systemic illness. If one were present, basic laboratories such as blood count, urinalysis, and chemistries are important. ANAis a reasonable screening study in this case. It does have a prognostic value increasing the likelihood of the development of a systemic process in the future.

If positive, further serologic studies might then be helpful in establishing a more specific diagnosis. The arterial Doppler with cold stimulation can be a useful test in showing a marked drop in blood flow with cold exposure. Still, with such a classical description, it is hard to imagine how this test would be helpful either diagnostically or therapeutically. Antidouble-stranded DNA antibodies would establish the diagnosis of SLE. Likewise, the antiscleroderma antibodies (anti-Scl-70) would be a very important prognostic marker once the ANA is positive and certainly would occasion a rheumatic disease consultation. Patients with hypercoagulable states, including those with positive cardiolipin antibodies, can often mimic Raynaud's. Given that the patient wants to become pregnant, this would be an important study to obtain. Sjren antibodies, both SSA and SSB, are important in this case because of the contemplated pregnancy. Sjren antibodies can cross the placenta and create the syndrome of neonatal lupus (complete heart block, thrombocytopenia, and rash).

This is a clinical presentation of West Nile virus infection. The tongue fasciculations go along with an inflammation at the base of the brain. The patient is at the right age for West Nile virus infection and he is immunocompromised due to diabetes. The diagnosis can be made by performing a West Nile virus IgM titer on the CSF. Diabetics can have cryptococcal meningitis. Lumbar puncture in this setting is usually normal with increased opening pressure, and rhabdomyolysis is not a feature of this disease. Diabetics are more at risk for candidiasis. However, the patient has no history of instrumentation, IV catheters, or other situations that would lead to disseminated candidiasis. Diabetics are at increased risk for
C. immitis infection, but we have no history of the patient living in an area endemic for this organism. Diabetics are at increased risk for rhinocerebral mucormycosis. An MRI of the head might have shown involvement of the sinus. However,
this patient's presentation is not consistent with rhinocerebral mucormycosis.

Osteoporosis is generally defined as a T score of -2.5 SD or greater on assessment of BMD. Osteopenia is generally defined as a T score between 1 and 2.5 SD below the peak BMD for a healthy young person of the same gender.
Osteoporosis screening with an assessment of BMD should be offered to the following groups: ?All women 65 years old or older
?All adult women with a history of a fracture (or fractures) not caused by severe trauma (such as a motor vehicle accident)
?Younger postmenopausal women who have clinical risk factors for fractures ?Modifiable risk factors:
current cigarette smoking, low body weight (<127 lbs), estrogen deficiency, premature menopause, excessive thyroid hormone replacement, chronic corticosteroid therapy, low calcium intake (life-long), alcoholism, uncorrected visual impairment, inadequate physical activity, recurrent falls ?Nonmodifiable risk factors: personal or family history of fragility, family history of osteoporosis, White or Asian race, age, gender, poor health/frailty, dementia, hypogonadism in males, fracture without substantial trauma Serial assessments for BMD may be useful but one must remember the precision error among the tests. Using DEXA, a BMD must have a 35% difference to be clinically significant. Patients who are on pharmacologic treatment with bisphosphonates may only show this much change in 1 year. Therefore, static BMD or slight reduction should not be regarded as treatment failure. At present, there are no hard evidencebased guidelines for the most efficient use for BMD monitoring. However, the following guidelines are generally accepted:
?For patients with";norma"; baseline BMD (T score more than -1.0), consider a followup measurement every 35 years. Patients whose bone density is well above the minimal acceptable level may not need further bone density testing.
?For patients in an osteoporosis prevention program, perform a follow-up measurement every 12 years until bone mass stability is documented. After BMD has stabilized, perform follow-up measurements every 23 years.
?For patients on a therapeutic program, perform a follow-up measurement yearly for 2 years. If bone mass has stabilized after 2 years, perform a follow-up measurement every 2 years. Otherwise, continue with annual follow-up measurements until stability of bone mass is achieved.