A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. Testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix.
What should be the next step in her work-up?
A. human papillomavirus testing virus typing
B. CT scan of the pelvis
C. ultrasound of the uterus and ovaries
D. cone biopsy of the cervix
E. colposcopy and directed cervical biopsy
Correct Answer: E Section: (none)
Explanation:
Human papillomavirus has been associated with the development of multiple squamous cell malignancies, including cervical cancer (HPV types 16, 18, 31, 45, and 5153), as well as anal, penile, and vulvar cancers. Recent evidence has also linked some oropharyngeal squamous cell cancers to HPV infection as well. The risk for HPV-associated cancer is increased in patients with HIV co-infection. HPV type 11 may cause genital warts but is not a likely cause of cervical cancer. The presence of other sexually transmitted diseases, such as Chlamydia or hepatitis B, may help to identify women at high risk for cervical cancer, but they are not direct causes of cervical cancer. Following the abnormal pap smear findings, the next step in the diagnosis of this patient would be a colposcopy with biopsy of any visualized cervical abnormalities. At this point, HPV testing and typing would not add to or change the work-up, so they would not be necessary. HPV testing and typing can be helpful in the evaluation of women with lower grade cervical cytological abnormalities, such as ASCUS. The other tests noted may be performed later in the diagnostic work-up, after the results of the biopsies are known.
Question 602:
A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. Testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix.
Infection with which of the following agents is most likely to have resulted in her cancer?
A. human papillomavirus type 16
B. hepatitis C virus
C. hepatitis B virus
D. Chlamydia trachomatis
E. human papillomavirus type 11
Correct Answer: A Section: (none)
Explanation:
Human papillomavirus has been associated with the development of multiple squamous cell malignancies, including cervical cancer (HPV types 16, 18, 31, 45, and 5153), as well as anal, penile, and vulvar cancers. Recent evidence has also linked some oropharyngeal squamous cell cancers to HPV infection as well. The risk for HPV-associated cancer is increased in patients with HIV co-infection. HPV type 11 may cause genital warts but is not a likely cause of cervical cancer. The presence of other sexually transmitted diseases, such as Chlamydia or hepatitis B, may help to identify women at high risk for cervical cancer, but they are not direct causes of cervical cancer. Following the abnormal pap smear findings, the next step in the diagnosis of this patient would be a colposcopy with biopsy of any visualized cervical abnormalities. At this point, HPV testing and typing would not add to or change the work-up, so they would not be necessary. HPV testing and typing can be helpful in the evaluation of women with lower grade cervical cytological abnormalities, such as ASCUS. The other tests noted may be performed later in the diagnostic work-up, after the results of the biopsies are known.
Question 603:
A previously healthy 34-year-old man, a lifelong nonsmoker, sought medical care at an Urgent Care Center for an upper respiratory infection. A chest x-ray was obtained, which revealed a peripherally located right lower lobe lung nodule. A follow-up CT of the chest showed the 1.8 cm nodule with multiple nonspecific calcifications, and no associated hilar or mediastinal adenopathy.
What is the most appropriate next step?
A. Refer the patient to a thoracic surgeon to evaluate for wedge resection for suspected malignancy.
B. Repeat the CT chest in 3 months to assess for stability of the nodule.
C. Refer the patient for a percutaneous needle biopsy of the lesion to rule out malignancy.
D. Refer the patient to a pulmonologist to evaluate for possible bronchoscopy with transbronchial biopsy.
E. Treat with empiric antibiotics for possible pneumonia and repeat the chest x-ray in6 weeks to see if the nodular opacity has resolved.
Correct Answer: B Section: (none)
Explanation:
This patient has a solitary pulmonary nodule. Overall, 35% of these lesions are malignant, usually primary lung cancers. In patients under 35 years of age without a smoking history, <1% of such lesions are malignant. Certain patterns of calcification within the nodule suggest a benign cause ("bulls-eye" pattern in granulomas, and "popcorn ball" in hamartomas), but these features alone cannot exclude malignancy. For low-risk patients such as this man, if the lesion remains stable on serial imaging studies (such as serial CT every 36 months) for 2 years, then no biopsy is deemed necessary to exclude malignancy.
Question 604:
A 72-year-old previously healthy woman was diagnosed with Stage II breast cancer and was initiated on FAC chemotherapy (5-fluorouracil, doxorubicin, cyclophosphamide) 3 months ago. She now presents to the emergency room complaining of exertional dyspnea, orthopnea, and lower extremity edema. Her vital signs are normal, her EKG is normal, and her chest x-ray shows cardiomegaly and pulmonary vascular congestion.
What is the most likely cause of the patient's new symptoms?
A. malignant pericardial effusion with cardiac tamponade
B. acute pericarditis due to viral infection
C. anthracycline-induced cardiomyopathy
D. valvular aortic stenosis
E. acute myocardial infarction
Correct Answer: C Section: (none)
Explanation:
This patient has clinical signs of congestive heart failure. Cardiomyopathy may be a complication of chemotherapy containing anthracyclines (doxorubicin, daunorubicin, idarubicin, epirubicin). The cumulative anthracycline dose is the most widely recognized risk factor for this problem, although it is more common in patients over 70, patients with any other history of heart disease, or those with a history of thoracic radiation treatment. Other reversible causes of heart failure such as ischemic cardiomyopathy should be investigated. Patients with anthracycline cardiomyopathy frequently have recovery of systolic function with standard medical heart failure therapy. Lack of chest pain and a normal EKG make acute pericarditis or acute myocardial infarction unlikely. Pericardial effusion with tamponade might cause dyspnea and edema, but not pulmonary vascular congestion or pulmonary edema.
Question 605:
A 32-year-old man who is HIV-positive was found to have Burkitt's lymphoma with diffuse bulky abdominal disease. He now reports to the hospital and is scheduled to begin chemotherapy. Admission laboratory studies show elevations of his uric acid at 15 mg/dL, serum phosphorus at 8.5 mg/dL, creatinine at 2.9 mg/ dL, and potassium at 6.1 mEq/L.
What therapy is most likely to reverse the patient's metabolic abnormalities?
A. administration of intravenous saline with mannitol to try to keep urine output >2.5 L/day
B. allopurinol 300 mg/day
C. administration of intravenous sodium bicarbonate to keep urinary pH >7.0
D. hemodialysis
E. administration of the recombinant uricase enzyme rasburicase to lower uric acid levels
Correct Answer: D Section: (none)
Explanation:
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
Question 606:
A 25-year-old woman with acute myelocytic leukemia is undergoing induction chemotherapy and presents to the Emergency Center complaining of a 1-day history of fever to 102ยบ F with no other symptoms. Other than having a fever, her vital signs and physical examination are normal. Laboratory evaluation reveals pancytopenia, with a WBC count of 0.3 k/L, hemoglobin concentration of 9.2 mg/dL, and platelet count of 23,000/L. What is the most appropriate initial management?
A. Obtain blood cultures, urine culture, a chest x-ray, and discharge patient to home with follow-up in 12 days to review culture results.
B. Obtain blood cultures, urine culture, a chest x-ray, and admit the patient to the hospital for observation with plan to institute antibiotics if any culture becomes positive.
C. Obtain blood culture, urine culture, a chest x-ray, and admit the patient to the hospital for empiric broad-spectrum antibiotics with Gram-negative coverage.
D. Obtain blood culture, urine culture, a chest x-ray, and admit the patient to the hospital for empiric antibiotics with Gram-positive coverage.
E. Forego cultures and admit the patient to the hospital for empiric antibiotics with both Gram-positive and Gram-negative coverage.
Correct Answer: C Section: (none)
Explanation:
This patient has neutropenia (neutrophil count <500/L) with fever. For high-risk patients, such as patients with leukemia, the standard of care is to obtain cultures and a chest radiograph, perform any other studies as indicated by the patient's clinical presentation, and initiate empiric antibiotic therapy. Guidelines from the Infectious Disease Society of America recommend empiric broad-spectrum coverage for Gram-negative organisms, including anti-pseudomonal coverage. Antibiotics such as vancomycin, for Gram-positive infection, are added if there is hypotension, suspicion for a central venous catheter-related infection, or recent or current evidence for Gram-positive infection (such as MRSA colonization, or positive culture for Gram-positive cocci).
Question 607:
A64-year-old man with a long history of smoking but no significant past medical history presents to his physician's office complaining of a 12 week history of worsening dyspnea, facial swelling, and discoloration. He has also had swelling and discomfort of his right arm. Physical examination reveals edema with plethora of the face and right arm, with prominent collateral veins over the chest wall.
Following the establishment of a diagnosis, what is the most appropriate initial therapy?
A. elevation of the head and monitoring for airway obstruction
B. urgent radiation therapy
C. administration of glucocorticoids
D. empiric chemotherapy for suspected lung cancer
E. surgical evaluation for resection of the obstructing mass
Correct Answer: A Section: (none)
Explanation:
The patient's most likely diagnosis is superior vena cava syndrome (SVCS), which is usually due to external compression of the SVC by tumor or lymph nodes, sometimes associated with intraluminal thrombosis. The diagnosis is established by CT of the chest with intravenous contrast, which can demonstrate the level and extent of obstruction, as well as the presence of any caval thrombus. Plain chest radiography may show some mediastinal widening, but yields much less information. Echocardiography would be appropriate if the patient had suspected pericardial effusion with tamponade, but that would not produce unilateral arm edema and discoloration. Doppler studies of the deep veins of the arm would be useful if the problem were isolated to the upper extremity. In this case, the cerebral venous drainage is also involved, so the obstruction is more proximal, i.e. at the level of the SVC. Arteriogram would not be indicated, since the issue in this case is venous obstruction, not arterial insufficiency. Unless the patient has cerebral edema with mental status changes or upper airway compromise due to tracheal obstruction, the diagnosis of SVCS is not immediately life-threatening, and emergent therapy is not usually indicated. The majority of patients with SVCS present with this as the initial presentation of their malignancy, before a tissue diagnosis has been established. This is problematic, since therapy is guided by the underlying malignancy (radiation therapy for non-small cell lung cancers, chemotherapy +/-radiation for small cell lung cancers or lymphomas), but empiric initiation of radiation or glucorticoids (if the underlying diagnosis is lymphoma) may obscure the histologic diagnosis. The most important initial step is to try to obtain a biopsy to establish the cancer type before initiating therapy. If symptoms are severe, placement of intravascular stents may provide rapid symptomatic relief without compromising subsequent diagnostic or therapeutic efforts. Surgical intervention is rarely indicated, and usually only for benign causes of SVCS.
Question 608:
A64-year-old man with a long history of smoking but no significant past medical history presents to his physician's office complaining of a 12 week history of worsening dyspnea, facial swelling, and discoloration. He has also had swelling and discomfort of his right arm. Physical examination reveals edema with plethora of the face and right arm, with prominent collateral veins over the chest wall.
What test is most likely to establish the cause of the patient's symptoms?
A. PA and lateral chest radiograph
B. echocardiogram
C. CT of the chest with intravenous contrast
D. ultrasound with Doppler flow studies of the right arm
E. arteriogram of the carotid and axillary arteries
Correct Answer: C Section: (none)
Explanation:
The patient's most likely diagnosis is superior vena cava syndrome (SVCS), which is usually due to external compression of the SVC by tumor or lymph nodes, sometimes associated with intraluminal thrombosis. The diagnosis is established by CT of the chest with intravenous contrast, which can demonstrate the level and extent of obstruction, as well as the presence of any caval thrombus. Plain chest radiography may show some mediastinal widening, but yields much less information. Echocardiography would be appropriate if the patient had suspected pericardial effusion with tamponade, but that would not produce unilateral arm edema and discoloration. Doppler studies of the deep veins of the arm would be useful if the problem were isolated to the upper extremity. In this case, the cerebral venous drainage is also involved, so the obstruction is more proximal, i.e. at the level of the SVC. Arteriogram would not be indicated, since the issue in this case is venous obstruction, not arterial insufficiency. Unless the patient has cerebral edema with mental status changes or upper airway compromise due to tracheal obstruction, the diagnosis of SVCS is not immediately life-threatening, and emergent therapy is not usually indicated. The majority of patients with SVCS present with this as the initial presentation of their malignancy, before a tissue diagnosis has been established. This is problematic, since therapy is guided by the underlying malignancy (radiation therapy for non-small cell lung cancers, chemotherapy +/-radiation for small cell lung cancers or lymphomas), but empiric initiation of radiation or glucorticoids (if the underlying diagnosis is lymphoma) may obscure the histologic diagnosis. The most important initial step is to try to obtain a biopsy to establish the cancer type before initiating therapy. If symptoms are severe, placement of intravascular stents may provide rapid symptomatic relief without compromising subsequent diagnostic or therapeutic efforts. Surgical intervention is rarely indicated, and usually only for benign causes of SVCS.
Question 609:
A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sleeping 1214 hours per day, and at times she seems confused. CT scan of the brain reveals no abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL. What is the most likely cause of her hypercalcemia?
A. widespread osteolytic metastases
B. ectopic production of a parathyroid hormone-related protein
C. excessive administration of oral calcium and Vitamin D supplementation to prevent osteoporosis
D. undiagnosed primary hyperparathyroidism
E. side effect of medications such as thiazide diuretics
Correct Answer: B Section: (none)
Explanation:
The patient is hypercalcemic and has laboratory features suggesting dehydration, as do most patients with symptomatic hypercalcemia. Initial management would include saline rehydration, which replaces volume deficits, dilutes the elevated serum calcium, and promotes urinary calcium excretion. The addition of loop diuretics such as furosemide can also increase calciuresis, but should only be added after the patient has had adequate volume repletion. Administration of bisphosphanates, such as pamidronate or zoledronate, provide more powerful reduction of serum calcium by inhibiting bone resorption and liberation of calcium. Their effects may last for several weeks, but their onset of action does not occur for 12 days. Subcutaneous calcitonin can provide a faster onset of action to inhibit bone resorption within a few hours, but patients develop tachyphylaxis and become unresponsive to the drug effect within 2448 hours. Most cancer patients with hypercalcemia develop this problem as a paraneoplastic phenomenon, due to the production of a parathyroid hormone-related protein (PTHrP).
This problem, called humoral hypercalcemia of malignancy (HHM), is very common, affecting 510% of all cancer patients. The diagnosis is usually straightforward, as there is a readilyavailable laboratory assay for PTHrP. Other cancer patients develop HHM due to the production of an enzyme that converts 25hydroxyvitamin D to the more active 1,25-hydroxyvitamin D, similar to the hypercalcemia seen in patients with granulomatous diseases. Severe hypercalcemia solely due to the presence of osteolytic metastases is much less common. Hyperparathyroidism and medications such as thiazide diuretics can also cause elevations of serum calcium, but usually not to the severe levels seen in HHM.
Question 610:
A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sleeping 1214 hours per day, and at times she seems confused. CT scan of the brain reveals no abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL.
What is the most appropriate initial therapy for the patient's hypercalcemia?
A. volume resuscitation with normal saline
B. administration of furosemide every 6 hours
C. subcutaneous calcitonin
D. intravenous zoledronate
E. treatment of the patient's underlying malignancy with chemotherapy
Correct Answer: A Section: (none)
Explanation:
The patient is hypercalcemic and has laboratory features suggesting dehydration, as do most patients with symptomatic hypercalcemia. Initial management would include saline rehydration, which replaces volume deficits, dilutes the elevated serum calcium, and promotes urinary calcium excretion. The addition of loop diuretics such as furosemide can also increase calciuresis, but should only be added after the patient has had adequate volume repletion. Administration of bisphosphanates, such as pamidronate or zoledronate, provide more powerful reduction of serum calcium by inhibiting bone resorption and liberation of calcium. Their effects may last for several weeks, but their onset of action does not occur for 12 days. Subcutaneous calcitonin can provide a faster onset of action to inhibit bone resorption within a few hours, but patients develop tachyphylaxis and become unresponsive to the drug effect within 2448 hours.
Most cancer patients with hypercalcemia develop this problem as a paraneoplastic phenomenon, due to the production of a parathyroid hormone-related protein (PTHrP).
This problem, called humoral hypercalcemia of malignancy (HHM), is very common, affecting 510% of all cancer patients. The diagnosis is usually straightforward, as there is a readilyavailable laboratory assay for PTHrP. Other cancer patients develop HHM due to the production of an enzyme that converts 25hydroxyvitamin D to the more active 1,25-hydroxyvitamin D, similar to the hypercalcemia seen in patients with granulomatous diseases. Severe hypercalcemia solely due to the presence of osteolytic metastases is much less common. Hyperparathyroidism and medications such as thiazide diuretics can also cause elevations of serum calcium, but usually not to the severe levels seen in HHM.
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