1-1. The answer is b. (Behrman, 16/e, p 35. McMillan, 3/e, pp 756-761. Rudolph, 21/e, pp 121-128.) Infants who are developing normally should be able to smile and coo when smiled at or talked to by 8 wk of age. By 3 mo of age, infants should be able to follow a moving toy not only from side to side but also in the vertical plane. When placed on his or her abdomen, a normal 3-mo-old infant can raise his or her face 45 degrees to 90 degrees from the horizontal. Not until 6 to 8 mo of age should an infant be able to maintain a seated position.

1-2. The answer is d. (Sadock, 7/e, pp 1505-1511.) Conversion disorder is characterized by the sudden appearance of one or more symptoms simulating an acute neurological illness in the context of severe psychological stress. The symptoms with which conversion disorder manifests conform to the patient's own understanding of the medical condition and are not associated with the usual diagnostic signs. Contrary to malingering and factitious disorder, conversion disorder is nonvolitional. Conversion disorder is more frequent in women, with a female-to-male ratio of 2-5 to 1. In childhood, both sexes are equally represented. Prevalence is highest in rural areas and among the underprivileged, the undereducated, and the cognitively delayed. The sudden onset and the temporal relation to a severe stress help differentiate conversion disorder from more chronic conditions such as somatization disorder and personality disorders.

1-3. The answer is a. (Fauci, 13/e, p 518.) Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. The swelling and inflammation of the external auditory meatus strongly suggests this diagnosis. This infection usually occurs in older diabetics and is almost always caused by Pseudomonas aeruginosa. Haemophilus influenzae and Moraxella catarrhalis frequently cause otitis media but not external otitis.

1-4. The answer is c. (Schwartz, 7/e, pp 64-66.) Magnesium deficiency is common in malnourished patients and patients with large gastrointestinal fluid losses. The neuromuscular effects resemble those of calcium deficiency—namely, paresthesia, hyperreflexia, muscle spasm, and ultimately tetany. The cardiac effects are more like those of hypercalcemia. An electrocardiogram therefore provides a rapid means of differentiating between hypocalcemia and hypomagnesemia. Hypomagnesemia also causes potassium wasting by the kidney. Many hospital patients with refractory hypocalcemia will be found to be magnesium deficient. Often this deficiency becomes manifest during the response to parenteral nutrition when normal cellular ionic gradients are restored. A normal blood pH and arterial PCO2 rule out hyperventilation. The serum calcium in this patient is normal when adjusted for the low albumin. Hypomagnesemia causes functional hypoparathyroidism, which can lower serum calcium and thus result in a combined defect.

1-5. The answer is e. (Behrman, 16/e, pp 797-798, 865-867, 910-914, 922-925. McMillan, 3/e, pp 717-718, 898-902, 951-953, 1012, 1017-1021, 1137-1140, 2160-2162. Rudolph, 20/e, pp 582-583, 626-628, 689-692, 2010-2011.) The incubation period for Rocky Mountain spotted fever (RMSF) has a range of 1 to 14 days. A brief prodromal period consisting of headache and malaise is typically followed by the abrupt onset of fever and chills. A maculopapular rash starts on the second to fourth day of illness on the flexor surfaces of the wrists and ankles before moving in a central direction. Typically, the palms and soles are involved. The rash can become hemorrhagic within 1 or 2 days. Hyponatremia and thrombocytopenia may be seen.

Tularemia has a variable presentation, including abrupt onset of fever, chills, malaise, weakness, and headache, and also a variety of skin rashes. Children often have fever, pharyngitis, hepatosplenomegaly, and nonspecific constitutional symptoms.

In the differential diagnosis of RMSF are a number of other diseases. A morbilliform eruption can precede a petechial rash caused by Neisseria meningitidis. Viral infections, particularly by the enteroviruses, can cause a severe illness that resembles RMSF. Atypical measles is seen primarily in persons who received the killed measles vaccine before 1968. After exposure to wild-type measles, such a person can develop a prodrome consisting of fever, cough, headache, and myalgia. This is usually followed by the development of pneumonia and an urticarial rash beginning on the extremities. Toxic shock syndrome (TSS) is a disease characterized by sudden onset of fever, diarrhea, shock, inflammation of mucous membranes, and a diffuse macular rash resulting in desquamation of the hands and feet. Lyme disease is seen with an early period of localized disease including erythema migrans, possibly with flulike symptoms, followed by a distinctive period of erythema migrans, arthralgia, arthritis, meningitis, neuritis, and carditis.

1-6. The answer is c. (Stobo, 23/e, p 744.) Chronic lymphocytic leukemia is the most common of all leukemias with an increasing incidence with age. Patients are usually asymptomatic, but may complain of weakness, fatigue, or enlarged lymph nodes. The diagnosis is made by peripheral blood smear, as mature small lymphocytes constitute almost all the white blood cells seen. No other process produces a lymphocytosis of this morphology and magnitude.

1-7. The answer is d. (Schwartz, 7/e, pp 1156-1158.) Perforation of the esophagus in the chest is a surgical catastrophe that requires aggressive intervention in virtually all circumstances. While that intervention can usually consist of efforts to patch the perforation and drain the mediastinum, concomitant obstructive esophageal disease, whether inflammatory stenosis or cancer, mandates removal or bypass of the obstruction if control of the leak and its consequent persisting mediastinal and pleural contamination is to be accomplished. For distal esophageal cancers, many thoracic surgeons would use the classic Ivor-Lewis operation, which consists of mobilizing the stomach in the abdomen and then performing a right thoracotomy with mediastinal cleanout, esophagectomy, and esopha-gogastrostomy. In some circumstances, and by some surgeons' preference, a left thoracotomy approach might be used. The transhiatal approach would probably be avoided in this situation where an unknown amount of mediastinal contamination has taken place.

1-8. The answer is c. (DSM-IV, pp 669-673.) The essential feature of obsessive-compulsive personality disorder is a preoccupation with perfection, orderliness, and control. Individuals with this disorder lose the main point of an activity and miss deadlines because they pay too much attention to rules and details and are not satisfied by anything less than "perfec tion." As in other personality disorders, symptoms are ego-syntonic and create considerable interpersonal, social, and occupational difficulties. Obsessive-compulsive disorder is differentiated from obsessive-compulsive personality disorder by the presence of obsessions and compulsions. Paranoid personality disorder is characterized by suspiciousness and distrust of others. Individuals with narcissistic personality disorder are preoccupied with perfection, but usually they are convinced of having already reached it. Individuals with obsessive-compulsive personality disorder, instead, are rarely satisfied with themselves. Passive-aggressive personality disorder is characterized by a passive resistance to perform in occupational and social settings, manifested by forgetfulness, procrastination, and intentional lack of efficiency.

1-9. The answer is b. (Ingelfinger, 3/e, ch 9, pp 198-202.) Although hypertension can resolve spontaneously, this is an unlikely explanation for resolution over a 2-wk period in 35% of the subjects. A much more likely explanation is regression toward the mean. Because of random fluctuations, any one measurement of blood pressure may be far from a person's normal blood pressure. If patients are referred for the study based on a single measurement, those in whom the measurement was high (which proved later not to reflect the actual blood pressure) are much more likely to be referred than those in whom the measurement was too low. Thus, in any group selected based on a characteristic with substantial day-to-day variation, many will have values closer to the population mean when the measurement is repeated, and the "worst patients" will improve. Neither baseline drift (which occurs with measurements on certain machines that require frequent calibration) nor measurement error is as likely an explanation. The Hawthorne effect refers to a tendency among study subjects to change simply because they are being studied. It is much more likely to affect studies of behavior or attitudes than a study of blood pressure.

1-10. The answer is d. (USPSTF, 2/e, pp 251-252.) Venipuncture is the best way to accurately measure blood lead levels. Capillary blood is often contaminated, which results in falsely elevated levels. It is more cost effective to collect venous blood initially than to do so only if the capillary blood level is high. Although many infants with lead poisoning also have iron deficiency anemia, the complete blood count will not identify all cases of lead poisoning. The erythrocyte protoporphyrin is no longer recommended for screening as it will not identify lead levels below 25 ^g/dL. It may be used for the detection of iron deficiency. Testing for ferritin is used to estimate body iron stores.

1-11. The answer is a. (Fauci, 14/e, pp 1955-1956.) The patient's multiple trigger points, associated sleep disturbance, and lack of joint or muscle findings make fibromyalgia a possible diagnosis. The diagnosis hinges on the multiple tender points. Complete blood count (CBC) and erythrocyte sedimentation rate (ESR) are characteristically normal. Tricyclic antidepressants restore sleep; aspirin and anti-inflammatory drugs are not helpful. Biofeedback and exercise programs have been partially successful. The clavicle, medial malleolus, and forehead are never trigger points for the process.

1-12. The answer is e. (Behrman, 16/e, pp 169-171. McMillan, 3/e, p 1472. Rudolph, 20/e, pp 1005-1006, 1015-1016.) The syndrome of kwash-iorkor is caused by a diet that is deficient in protein, leading to low serum albumin, which causes decreased plasma volume and increased interstitial fluid or edema. The term marasmus refers to a combined inadequacy of protein and energy in which the deficiency is dominated by the lack of food in general. The minimum requirement for protein is 8% of the total daily calories when the protein provided is from high-quality animal sources. These patients have a high death rate from intercurrent infections.

1-13. The answer is c. (Sabiston, 15/e, pp 131-133.) Whenever significant bleeding is noted in the early postoperative period, the presumption should always be that it is due to an error in surgical control of blood vessels in the operative field. Hematologic disorders that are not apparent during the long operation are most unlikely to surface as problems postop-eratively. Blood transfusion reactions can cause diffuse loss of clot integrity; the sudden appearance of diffuse bleeding during an operation may be the only evidence of an intraoperative transfusion reaction. In the postoperative period, transfusion reactions usually present as unexplained fever, apprehension, and headache—all symptoms difficult to interpret in the early postoperative period. Factor VIII deficiency (hemophilia) would almost certainly be known by history in a 65-year-old man, but if not, intraoperative bleeding would have been a problem earlier in this long operation. Severely hypothermic patients are not able to form clots effectively, but clot dissolution does not occur. Care should be taken to prevent the development of hypothermia during long operations through the use of warmed intravenous fluid, gas humidifiers, and insulated skin barriers.

1-14 through 1-15. The answers are 1-14 b, 1-15 b. (LaDou, 2/e, pp 320-321.) Silicosis, a pneumoconiosis, is caused by respiratory exposure to silica, a major component of rock and sand. Patients with silicosis are at risk of mycobacterium infection, both atypical and typical. A positive purified protein derivative (PPD) in a patient with chronic silicosis warrants preventive tuberculosis therapy. Such a patient is also at higher risk for fungal infections such as cryptococcosis. Asbestos increases the risk of lung cancer and mesothelioma. Byssinosis is an occupational form of asthma due to inhalation of cotton dust. Caplan syndrome may occur in coal miners who have rheumatoid arthritis and is characterized by rapidly evolving rounded densities on chest x-rays.

1-16. The answer is b. (Wyllie, 1993, p 895.) Most rhythmic to-and-fro movements of the eyes are called nystagmus. Nystagmus has a fast component in one direction and a slow component in the opposite direction. Nystagmus with a fast component to the right is called right-beating nystagmus. Phenytoin (Dilantin) may evoke nystagmus at levels of 20 to 30 mg/dL. The eye movements typically appear as a laterally beating nystagmus on gaze to either side; this type of nystagmus is called gaze-evoked. If the patient has nystagmus on looking directly forward, he or she is said to have nystagmus in the position of primary gaze. Therapeutic levels for pheny-toin are usually 10 to 20 mg/dL, and some patients develop asymptomatic nystagmus even within that range. Ataxia, dysarthria, impaired judgment, and lethargy may also occur at toxic levels of phenytoin. Many other drugs also evoke nystagmus. Weakness of abduction of the left eye, or abducens palsy, is due either to injury to the sixth cranial nerve or to increased intracranial pressure. Impaired convergence can occur normally with age or may be a sign of injury to the midbrain. Papilledema is a sign of increased intracranial pressure. Impaired upgaze may occur in many conditions, and would not be expected to occur with a toxic phenytoin level.

1-17 through 1-18. The answers are 1-17 e, 1-18 a. (Greenfield, 2/e, p 1970.) The significant observation in this question is the description of lymphangitic inflammatory streaking up the inner aspect of the patient's leg. This is highly suggestive of a streptococcal infection, and the presumptive therapy should be high doses of a bactericidal antibiotic. Penicillin remains the mainstay of therapy against presumed streptococcal infections. Most streptococcal cellulitis is adequately treated by penicillin, elevation of the infected extremity, and attention to the local wound to ascertain adequate local drainage and absence of any persisting foreign body. However, the clinician must be alert to the possibility of a more fulminant and life- or limb-threatening infection by clostridia, microaero-philic streptococci, or other potentially synergistic organisms that can produce rapidly progressive deep infections in fascia or muscle. Smears and cultures of drainage fluid or aspirates should be taken. Close observation of the wound is essential, and aggressive debridement in the operating room is mandatory at the slightest suggestion that fasciitis or myonecrosis may be ensuing.

1-19. The answer is a. (Silberstein, p 78.) This patient has common migraine. Of the agents listed, only ergotamine tartrate is generally considered of use in treatment to abort a headache. Verapamil and amitriptyline may be used as prophylactic, or preventative, therapy. Phenobarbital is an anticonvulsant and is not typically used to treat migraine. Nitroglycerine can actually precipitate headaches in susceptible individuals. Nausea is a frequent accompaniment of migraine, and metoclopramide (Reglan) may be effective in relieving the nausea. It also reduces gastric stasis, which can retard absorption of oral medications. Certain antiemetics, such as pro-chlorperazine, may relieve nausea and also provide relief from the headache itself. Additional agents that might be of benefit in abortive therapy include ibuprofen (which this patient has already tried without relief), aspirin, acetaminophen, isometheptene (Midrin), ergotamine, or a triptan. The triptans are a group of medications that act as agonists at serotenergic receptors (specifically, 5HT-1 receptors), and they have been found to be very effective at stopping migraine headaches.

1-20. The answer is d. (Silberstein, p 78-80.) Several medications are effective as prophylactic agents in the treatment of migraine. These include amitriptyline, propranolol, verapamil, and valproate. Most experts recommend initiating prophylactic therapy only when headaches occur at least one to two times per month. Metoclopramide, sumatriptan, and ergota-

mine tartrate are appropriately used to treat an acute attack of migraine, and should not be prescribed on a daily basis. Daily use of these medications can establish a rebound syndrome that results in a daily headache. Oral contraceptives (OCPs) may be associated with either an increase or decrease in the frequency of migraines, but are not generally used as a treatment for migraine. Some experts recommend not prescribing OCPs for patients with migraine for fear of increasing the risk of a stroke, although OCPs are probably safe to use in most patients with common migraine.

1-21. The answer is c. (Stein, 5/e, p 504.) Warfarin is the principal agent recommended for the prophylaxis of acute pulmonary embolus in patients who receive total hip replacement. Warfarin is started preoperatively, and the daily dose is adjusted to maintain an international normalized ratio (INR) of 2 to 3. The value of aspirin in this setting is unclear. Early ambulation and elastic stockings are also important in preventing thromboem-bolism, but are not adequate in themselves in this high-risk situation.

1-22 through 1-23. The answers are 1-22 e, 1-23 b. (Behrman, 16/e, pp 1704-1705. McMillan, 3/e, pp 1808-1809. Rudolph, 20/e, pp 1762-1763.) Lymphocytic (Hashimoto's) thyroiditis is a typical organ-specific autoimmune disease characterized by lymphocytic infiltration of the thyroid gland with or without goiter. It is the most common cause of juvenile hypothyroidism, peaking in adolescence and affecting as many as 1% of school children. The condition is four to seven times more prevalent in girls than in boys and may persist for many years without symptoms. Patients are initially euthyroid, but with the eventual atrophy of the gland, they become hypothyroid. Spontaneous remission can occur in one-third of the affected adolescents. Hashimoto's thyroiditis is not related to endemic goiter caused by iodine deficiency.

Autoimmune thyroiditis is associated with many other autoimmune disorders; its association with Addison's disease and insulin-dependent diabetes mellitus is called type II polyglandular autoimmune disease (Schmidt syndrome). Family clusters of autoimmune thyroiditis are common; nearly 50% of the patients have siblings with antithyroid antibodies.

In Hashimoto's thyroiditis, thyroid function tests are often normal, although an elevated thyroid-stimulating hormone (TSH) level may be seen in a euthyroid child. With progressive thyroid failure, T3 and T4 levels drop and TSH level rises. Most patients have titers of thyroid antimicrosomal antibodies; elevated antithyroglobulin titers occur infrequently. Blocking TSH antibodies are thought to be related to development of hypothy-roidism. Congenital rubella infection can cause late-onset thyroiditis and hypothyroidism on an autoimmune basis. Antirubella antibodies cannot be used for diagnostic purposes in this 13-year-old child because she has probably been immunized with the attenuated vaccine or may have had rubella in childhood.

1-24. The answer is b. (Mehta, pp 296-297.) A Baker's cyst occurs in the midline of the popliteal fossa and is often a complication of rheumatoid arthritis. The cyst represents a diverticulum of the synovial sac that protrudes through the joint capsule of the knee. The knee is composed of 12 different bursae. Anserine bursitis occurs with inflammation of the bursa on the medial side of the proximal tibia. There is localized tenderness and swelling over the knee. Prepatellar bursitis is called housemaid's knee (i.e., from scrubbing floors) and is characterized by inflammation of the bursa anterior to the patella. Usually, the history supports the diagnosis. Inflammation of the infrapatellar bursa is called clergyman's or carpet-layer's knee. Deep venous thrombosis (DVT) is due to partial or complete occlusion of a vein by a thrombus and may be characterized by a painful, swollen calf or thigh. Occasionally, there will be a positive Homan sign (pain with dorsi-flexion of the foot), but often a DVT will be asymptomatic.

1-25. The answer is c. (Rock, 8/e,pp 485-497.) Surgical abortion is among the safest procedures in medicine, with a serious complication rate in the first trimester of less than 1% and a mortality of only one-twentieth that of term delivery. In the first trimester, suction dilatation and curettage is the method of choice. The oral agent RU-486 followed by injection of prostaglandin has been shown to be highly effective and safe in European trials, but as of 2000 this medication was not yet available for clinical use in the United States. It is effective up to about 9 wk of gestation. 15-methyl a-prostaglandin can be used as an intramuscular abortifacient, as can pros-taglandin E2 suppositories or intraamniotic prostaglandin F2a for second-trimester induction of preterm labor. Intraamniotic injection of hypertonic saline is no longer considered appropriate because it has a much higher incidence of serious complications including death, hyperosmolar crisis, cardiac failure, peritonitis, hemorrhage, and coagulation abnormalities. There are far better medicines available, and saline should no longer be used.

1-26. The answer is b. (Wallace, 14/e, pp 1031-1035.) Cataract is the main cause of visual loss globally and is the most common eye problem associated with age in the United States. It can be treated surgically. Risk factors include hypertension, diabetes, exposure to ultraviolet radiation, and corticosteroid therapy. Diabetic retinopathy is less likely to occur in recent-onset diabetes, particularly if the diabetes is well controlled. Xerophthalmia refers to blindness due to vitamin A deficiency. Age-related macular degeneration is the leading cause of blindness for persons over the age of 65 in the United States. Prevalence is estimated to be from 6% to 16%. Its pathophysiology is not well understood.

1-27. The answer is d. (Fauci, 14/e, pp 2120, 2192-2193. Goldman, 21/e, p 1102.) Persons with Marfan syndrome have arm spans that are greater than their height and an above-average crown-to-heel height. Joints are hyperextensible and patients have long, spiderlike, slender fingers (arach-nodactyly). The Steinberg sign or thumb sign is positive when the fingers are clenched over the thumb and the thumb protrudes beyond the ulnar margin of the hand. These patients often have a high-arched palate, kyphoscoliosis, subluxation of the lens, and a murmur of mitral valve prolapse. Aortic regurgitation and dissection of the aorta may complicate Mar-fan syndrome. Patients with Lesch-Nyhan syndrome (X-linked disorder) present with self-mutilation, choreoathetosis, spasticity, gout, and mental retardation. Patients with gonadal dysgenesis or Turner syndrome are 45,X; the syndrome is characterized by primary amenorrhea, short stature, webbed neck with low posterior hairline, and multiple congenital abnormalities. Patients with Ehlers-Danlos syndrome (EDS) present with hyper-elasticity of the skin ("rubber man" syndrome) and hypermobile joints. Noonan syndrome is an autosomal dominant disorder characterized by webbed neck, short stature, and congenital heart disease. Patients have normal karyotypes and normal gonads.

1-28. The answer is c. (Behrman, 16/e, pp 1650-1651. McMillan, 3/e, pp 1555-1556. Rudolph, 20/e, pp 1404-1405.) At 1 year of age, 0.7% of boys born at term still have cryptorchidism. In adults with cryptorchidism, the risk of testicular malignancy is much higher than in unaffected men. Orchiopexy does not eliminate this risk, but repositioning the testes makes them accessible for periodic examinations. Whether the testes are brought into the scrotum or not, the sperm count can be reduced. The failure of the testes to develop, and their subsequent atrophy, can be detected by 6 mo of age. Torsion of the testis is a potential risk because of the excessive mobility of the undescended testis. Orchiopexy helps to eliminate this problem.

1-29. The answer is e. (CDC, MMWR 1999;48, pp 5-7.) Two doses of vaccine intramuscularly, one immediately and one 3 days later, are recommended for those who were previously immunized. A primary course of vaccination consists of three doses of one of the three approved vaccines at 0, 7, and 21 or 28 days. It is recommended for persons in high-risk groups, such as veterinarians, animal handlers, and certain laboratory personnel.

1-30. The answer is e. (Schwartz, 7/e, pp 1681-1684.) This patient has cytologic evidence of a papillary lesion, possibly papillary carcinoma. Papillary carcinoma is a relatively nonaggressive lesion with long-term survival (>20 years) of more than 90%. The lesion is frequently multicentric, which argues for more complete resection. Metastases, when they occur, are usually responsive to surgical resection or radioablation therapy. Removal of the involved lobe, and possibly the entire thyroid gland, is appropriate. Central and lateral lymph node dissection is performed for clinically suspect lymph nodes. Papillary carcinoma is frequently multifocal. Bilateral disease mandates total thyroidectomy. The use of radioactive 131I, however, is contraindicated in pregnancy and should be used with caution in women of childbearing age.

1-31. The answer is a. (Ludman, pp 33, 42-45.) Acute sinusitis is predominantly due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis infection that occurs when the cleaning mechanism— namely, the ciliary activity through the sinuses into the nasal passages— fails. Patients often complain of headache, facial pain, nasal congestion, and purulent discharge. Facial pain is worsened with percussion of the affected sinus and cloudiness of the sinus may be seen with transillumination. Computed tomography (CT) films of the sinuses (air-fluid levels) are the best method of making a definitive diagnosis but should only be done if the patient fails to respond to a 2-wk course of antibiotic therapy aimed at the common bacteria. Chronic sinusitis occurs after adequate treatment of acute sinusitis has failed to eradicate the symptoms. Common organisms for chronic sinusitis include anaerobes and Staphyloccocus aureus. Ludwig's angina is a rare accumulation of pus in the floor of the mouth (cellulitis) and causes induration of the neck. Orbital cellulitis may follow ethmoid or maxillary sinusitis and causes the upper eyelid to become swollen, red, and tender. Vincent's angina is a necrotizing ulcerative gingivitis (trench mouth).

1-32. The answer is b. (Fauci, 14/e, pp 713-717.) Definitive diagnosis is made by demonstrating greater than 10% plasma cells in bone marrow. None of the other findings are specific enough for definitive diagnosis. Renal biopsy would not be helpful.

1-33. The answer is e. (Bradley, 3/e, p 1905.) Butyrophenones, the most commonly prescribed of which is haloperidol, routinely produce some signs of parkinsonism if they are used at high doses for more than a few days. This psychotic young woman proved to be less sensitive to the parkinsonian effects of the phenothiazine thioridazine than she was to those of haloperidol. Adding the anticholinergic trihexyphenidyl may also have helped to reduce the patient's parkinsonism. Another commonly used medication that can cause parkinsonism, in addition to tardive dyskinesia, is metoclopramide (Reglan).

1-34. The answer is e. (DiSaia, 5/e, pp 153-160.) Women who have invasive vulvar carcinoma are usually treated surgically. If the lesion is unilateral, is not associated with fixed or ulcerated inguinal lymph nodes, and does not involve the urethra, vagina, anus, or rectum, then treatment usually consists of radical vulvectomy and bilateral inguinal lymphadenectomy. If inguinal lymph nodes show evidence of metastatic disease, bilateral pelvic lym-phadenectomy is usually performed. Radiation therapy, though not a routine part of the management of women who have early vulvar carcinoma, is employed (as an alternative to pelvic exenteration with radical vulvectomy) in the treatment of women who have local, advanced carcinoma.

1-35. The answer is a. (Hales, 3/e, p 573.) The symptoms experienced by this patient are classical symptoms of hyperventilation, which commonly is associated with panic disorder and other anxiety states. Hyperventilation causes a drop in blood CO2 and alkalosis, which in turn causes a decrease in the ionized fraction of the serum calcium and constriction of the cerebral vessels. Dizziness, lightheadedness, and feelings of derealization follow the cerebral hypoxia. The lower ionized calcium level causes signs of tetany, such as painful muscle spasms in the hands, perioral tingling, and paresthesias. Breathing into a paper bag reverses the symptoms because the recycled air has a higher concentration of carbon dioxide than does normal air.

1-36. The answer is c. (Seidel, 4/e, pp 476-478.) Coarctation of the aorta is narrowing of the aorta usually just distal to the origin of the ductus arteriosus and subclavian artery. Patients may complain of epistaxis, headache, cold peripheral extremities, and claudication. Absent, delayed, or markedly diminished femoral pulses may also be found. The low arterial pressure in the legs in the face of hypertension in the arm is also a clue to the diagnosis. Chest radiograph in coarctation shows rib notching secondary to the dilated collateral arteries. Patent ductus arteriosus (PDA) is associated with a loud continuous murmur. Tetralogy of Fallot consists of ventricular septal defect (VSD), pulmonic stenosis (PS), dextroposition of the aorta, and right ventricular hypertrophy (RVH).

1-37. The answer is c. (Seidel, 4/e, pp 382, 392-393.) This patient has a pleural effusion most likely due to tuberculosis. Chest examination of a pleural effusion will reveal distant or absent breath sounds, a pleural friction rub, decreased fremitus, and flatness to percussion. A pleural friction rub is a raspy, grating sound heard on both inspiration and expiration due to inflamed surfaces rubbing against each other. Occasionally, exaggerated bronchial breath sounds are audible at the area of the effusion.

1-38. The answer is a. (Schatzberg, 2/e, p 710.) Tricyclic antidepressants such as clomipramine and amitriptyline and selective serotonin reuptake inhibitors (SSRIs) such as paroxetine and sertraline, as well as monoamine oxidase inhibitors (MAOIs), can cause erectile dysfunction, delayed ejaculation, anorgasmia, and decreased libido. Bupropion, mirtazapine, trazodone, and nefazodone, in contrast, do not affect sexual functions in a negative way.

1-39. The answer is a. (Fauci, 14/e, p 487.) Symptoms of chronic toxicity of vitamin A (25,000 U or more for a protracted period) include bone pain, hyperostosis, hair loss, dryness and fissures of the lips, and weight loss. High doses of vitamin C for long periods can cause an increase in the risk of oxalate kidney stones and uricosuria. Vitamin E excess is present in persons receiving anticoagulants and in premature infants, and can prolong prothrombin time. Vitamin D excess results in hypercalcemia. Excess of vitamin Bx or thiamin has not been described. Vitamin K excess results in blockage of the effect of anticoagulants. Excess most frequently occurs in the fat-soluble vitamins (A, D, E, K).

1-40. The answer is c. (Behrman, 16/e, pp 52-57. McMillan, 3/e, pp 531-536. Rudolph, 20/e, pp 39-45.) Adolescence is a time of major physical, cognitive, and emotional changes. The tasks of the adolescent are directed toward determining his or her ultimate adult self. He or she must become independent of his or her parents, and in so doing, take responsibility for his or her own welfare and start preparing for his or her future work or career. He or she must define himself or herself sexually and move toward lasting attachments. The range of normality is broad and the variations numerous. Evaluation of the adolescent requires weighing the normal and abnormal tendencies to determine where the balance lies. To neglect schoolwork and have no vision or plan for the future suggests either immaturity or depression. A certain degree of concern for appearance is a healthy adolescent phenomenon. On the other hand, excessive concern for physical well-being and physical symptoms suggests an abnormal level of anxiety or depression. Constant quarreling with friends indicates a lack of flexibility and accommodation. Close friends help in the separation from parents and the achievement of independence by providing mutual support and self-justification. Bickering with siblings, on the other hand, is a holdover from childhood and, if not excessive, may be considered normal. Brief superficial romantic attractions fueled more by fantasy than reality start in early to middle adolescence. These are rehearsals for the more serious attachments to come.

1-41. The answer is c. (Fauci, 14/e, pp 1334-1335.) The patient's chest pain is most likely due to pericarditis. An enlarged cardiac silhouette without other chest x-ray findings of heart failure suggests pericardial effusion. Echocardiography is the most sensitive, specific way of determining whether or not pericardial fluid is present. The effusion appears as an echofree space between the moving epicardium and stationary pericardium. It is unnecessary to perform cardiac catheterization for the purpose of evalu-

ating pericardial effusion. Radionuclide scanning is not a preferred method for demonstrating pericardial fluid.

1-42. The answer is c. (Fauci, 14/e, pp 1336-1337.) The patient has developed cardiac tamponade, a condition in which pericardial fluid under increased pressure impedes diastolic filling, resulting in reduced cardiac output and hypotension. On exam there is elevation of jugular venous pressure. The jugular venous pulse shows a sharp x descent, the inward impulse seen at the time of the carotid pulsation. In contrast to pulmonary edema, the lungs are usually clear. Neither a strong apical beat nor an S3 gallop is expected in tamponade.

1-43. The answer is c. (Cunningham, 20/e, pp 718-725. DeCherney, 8/e, pp 380-386.) Preeclampsia is defined as hypertension, proteinuria (>300 mg/24 h), and/or nondependent edema of the face and hands. Risk factors for preeclampsia include black race, nulliparity, multiple gestations, extremes of age (<15 or >35 years), chronic hypertension, and a family history positive for preeclampsia. Eclampsia is defined as seizures in a patient with preeclampsia. The cure for preeclampsia/eclampsia is delivery. Magnesium sulfate is often used for seizure prophylaxis and management.

The HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a variant of preeclampsia.

1-44. The answer is d. (Schwartz, 7/e, pp 169, 204.) Most pelvic fractures are the result of automobile-pedestrian accidents, and these fractures are a frequent cause of death. The pelvis is extremely vascular with a diffuse blood supply that makes hemorrhage common and surgical control of bleeding difficult. This patient has a type II fracture (single break in pelvic ring) through a non-weight-bearing portion of the pelvis. These fractures are best treated by bed rest until hemodynamic stability is assured and thereafter by gentle ambulation as pain permits. The clinician must watch carefully for associated injuries to the bladder, urethra, and colon and must be alert to the many other possible concurrent injuries to an elderly patient who has suffered a collision, even a low-velocity attack from a pizza man.

1-45. The answer is c. (Bradley, 3/e, pp 1552-1554.) Although papil-ledema must be considered evidence of a potentially life-threatening intracranial process, optic nerve bulging in this young woman is most likely from pseudotumor cerebri. This is a relatively benign condition that occasionally develops in obese or pregnant women. Cerebrospinal fluid (CSF) pressure is markedly elevated in these patients, but they are not at risk of herniation. The condition is presumed to arise from hormonal problems. Without treatment, the increased intracranial pressure will produce optic nerve damage with loss of visual acuity.

1-46. The answer is a. (Bradley, 3/e, pp 1552-1554.) With pseudotumor cerebri, removal of some of the CSF produces a protracted lowering of the intracranial pressure. This pressure reduction is desirable because persistent pressure elevations will damage the optic nerve. Pseudotumor cerebri in the pregnant woman usually abates soon after the fetus leaves its mother, but this condition is not serious enough to justify termination or acceleration of a pregnancy. Vitamin excess may cause pseudotumor in some persons. Diuretics are sometimes used to manage patients who are not pregnant, but they are usually less effective than repeated lumbar puncture when that is practical.

1-47 through 1-48. The answers are 1-47 b, 1-48 d. (Holmes, 3/e, ch 79, p 1081.) Chlamydia trachomatis is the most frequently reported bacterial sexually transmitted disease (STD) in the United States. Infections of the cervix may present as a friable cervix, but are most often without signs or symptoms. Pelvic inflammatory disease (PID) caused by chlamydia often presents with milder symptoms than when gonorrhea is the cause. Prompt treatment reduces the occurrence of long-term sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain. The risk of infertility appears to be higher for chlamydial infections compared to any other STD. Screening women is important to reduce the risk of PID and its sequelae.

1-49. The answer is b. (Freedberg, 5/e, pp 636-643.) Erythema multiforme is often caused by drugs. It is most important to identify the offending agent. Phenytoin can induce erythema multiforme, so this information is critical. Sulfa drugs, barbiturates, and penicillin can also cause the rash. The rash with its target lesions should not be confused with toxic shock or measles. The sore throat is likely to be a symptom from the process itself, suggesting involvement of the oral mucosa.

1-50. The answer is d. (Stein, 5/e, p 1861.) Episodic hypoglycemia at night is followed by rebound hyperglycemia. This response, called the Somogyi phenomenon, develops in response to excessive insulin administration. An adenergic response to hypoglycemia results in increased glycogenolysis, gluconeogenesis, and diminished glucose uptake by peripheral tissues. After hypoglycemia is documented, the insulin dosages are slowly reduced.

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