In a patient with atrial fibrillation, which one of the following confers the greatest risk for stroke?
Correct Answer C: It is well established that atrial fibrillation is associated with a heightened risk of stroke. Anticoagulant therapy is not without risk, and for this reason a risk-scoring system has been developed to aid the clinician in deciding on therapy. Points are assigned using the acronym “CHADS2”. One point each is given for a history of Congestive heart failure, Hypertension (both treated and untreated), Age greater than 75, and Diabetes mellitus, and 2 points for a previous history of Stroke or TIA.
An elderly man presents with a skin lesion on his arm. He states that it has been growing in the last few months. The lesion is asymmetric, has no distinct border, varies in color and is greater than 6mm.
What is the most likely diagnosis?
Correct Answer C:
The ABCD criteria is used to diagnose a malignant melanoma. ABCD is an abbreviation for asymmetry, border, color and diameter. Malignant melanoma arises from melanocytes in a pigmented area: skin, mucous membranes, eyes, and CNS. Metastasis is correlated with depth of dermal invasion. With spread, prognosis is poor. Diagnosis is by biopsy. Wide surgical excision is the rule for operable tumors. Metastatic disease requires chemotherapy but is difficult to cure.
A chronic smoker presents with cough, dyspnea and swelling in the face and neck. You suspect superior vena cava obstruction.
What is your next step?
Correct Answer A:
Superior vena cava syndrome (SVCS) is a collection of symptoms caused by the partial blockage or compression of the superior vena cava, the major vein that carries blood from the head, neck, upper chest, and arms to the heart. Nearly 95% of SVCS cases are caused by cancer.
The most common symptoms are these: problems breathing, coughing and swelling in the face, neck, upper body, and arms.
Approximately 90% of cases are associated with a cancerous tumor that is compressing the superior vena cava. A chest xray usually shows a mediastinal mass (tumor) that is compressing the superior vena cava.
A 43-year-old woman with severe abdominal pain that radiates to her back is found to have high amylase and lipase levels.
Which of the following is generally not part of the treatment of this illness?
Correct Answer B:
Acute pancreatitis is inflammation of the pancreas (and, sometimes, adjacent tissues) caused by the release of activated pancreatic enzymes. The most common triggers are biliary tract disease and chronic heavy alcohol intake.
The condition ranges from mild (abdominal pain and vomiting) to severe (pancreatic necrosis and a systemic inflammatory process with shock and multiorgan failure).
Diagnosis is based on clinical presentation and serum amylase and lipase levels. Initial management of a patient with acute pancreatitis consists of supportive care with fluid resuscitation, pain control, and nutritional support. Patients with acute pancreatitis should be monitored closely in the first 24 to 48 hours.
Antibiotics are generally not indicated. Antibiotics, usually drugs of the imipenem class, should be used in any case of pancreatitis complicated by infected pancreatic necrosis. However, they should not be given routinely for fever, especially early in the disease course, because this symptom is almost universally secondary to the inflammatory response and typically does not reflect an infectious process.
A 50-year-old man presents to the emergency room with severe epigastric pain, low-grade fever, tachycardia, and mild hypotension. The patient relates a history of moderate to heavy social drinking. The chief resident suspects acute pancreatitis.
Which one of the following laboratory findings is generally considered diagnostic of acute pancreatitis?
Acute pancreatitis is inflammation of the pancreas (and, sometimes, adjacent tissues) caused by the release of activated pancreatic enzymes. The most common triggers are biliary tract disease and chronic heavy alcohol intake. The condition ranges from mild (abdominal pain and vomiting) to severe (pancreatic necrosis and a systemic inflammatory process with shock and multiorgan failure).
Serum amylase and lipase levels are typically elevated in persons with acute pancreatitis. However, these elevations may only indicate pancreastasis. In research studies, amylase or lipase levels at least 3 times above the reference range are generally considered diagnostic of acute pancreatitis.
Treatment is supportive, with IV fluids, analgesics, and fasting.
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