A 69-year-old male presents with a 2-week history of fever, fatigue, weight loss, and mild diarrhea. He is found to have a mildly tender mass in the left lower quadrant of the abdomen.
The most likely diagnosis is:
Correct Answer D: Diverticulitis commonly affects the left lower quadrant in the elderly and may present as an abscess.
→ Crohn’s disease primarily affects the distal small intestine (regional enteritis), most typically in a young person, and usually in the second or third decade of life.
→ Ulcerative colitis usually presents with a longer history and does not typically present with a mass.
→ Celiac disease does not cause a palpable left lower quadrant mass.
→ A 2-week history of a palpable mass is not a typical presentation for lymphoma.
A 45-year-old white male undergoes a health screening at his church. He has a carotid Doppler study, abdominal ultrasonography, heel densitometry, and a multiphasic blood panel. He receives a report indicating that all of the studies are normal, but a 0.7-cm thyroid nodule was noted. The TSH level is normal. He schedules a visit with you and brings you the report. A neck examination and ENT examination are normal, and you do not detect a nodule. His past medical history and family history are unremarkable. You recommend:
Correct Answer C: This is a classic incidentaloma. Nodules are detected in up to 50% of thyroid sonograms and carry a low risk of malignancy (< 5%). If the TSH level is normal, nuclear scanning and further thyroid studies are not necessary. Nodules smaller than 1 cm are difficult to biopsy and thyroid surgery is not indicated for what is almost certainly benign disease. It is reasonable to follow small nodules with clinical examinations and periodic sonograms.
Note:
A 42-year-old female is found to have a thyroid nodule during her annual physical examination. Her TSH level is normal. Ultrasonography of her thyroid gland shows a solitary nodule measuring 1.2 cm.
Which one of the following would be most appropriate at this point?
Correct Answer B: All patients who are found to have a thyroid nodule on a physical examination should have their TSH measured. Patients with a suppressed TSH should be evaluated with a radionuclide thyroid scan; nodules that are “hot” (show increased isotope uptake) are almost never malignant and fine-needle aspiration biopsy is not needed. For all other nodules, the next step in the workup is a fine-needle aspiration biopsy to determine whether the lesion is malignant.
Endocarditis in an I.V. drug user:
Correct Answer D: Infective endocarditis is infection of the endocardium, usually with bacteria (commonly, streptococci and staphylococci) or fungi. It produces fever, heart murmurs, petechiae, anemia, embolic phenomena, and endocardial vegetations. Vegetations may result in valvular incompetence or obstruction, myocardial abscess, or mycotic aneurysm.
Infective endocarditis occurs most often on the left side (eg, mitral or aortic valve). About 10 to 20% of cases are right sided (tricuspid or pulmonic valve). IV drug abusers have a much higher incidence of right-sided endocarditis (about 30 to 70%).
Diagnosis requires demonstration of microorganisms in blood and usually Echocardiography. Treatment consists of prolonged antimicrobial treatment and sometimes surgery.
A 27-year-old man comes to the office because of a week history of right knee pain. He says he jogs 3 miles a day and that the pain in his knee worsens during his run. On physical examination his gait appears to be normal. Examination of the right knee reveals tenderness and fullness over the medial collateral ligament.
On physical examination there is most likely to be:
Correct Answer D: This is a classic description of injured medial collateral ligaments (MCL), which results from constant stress in valgus position.The patient is in the supine position with the knee flexed 25-30 degrees. The examiner places one hand on the lateral knee and grasps the medial ankle with the other hand. Then the knee is abducted. Pain and excessive laxity indicate stretching or tearing of the MCL. Abduction with the opening of the joint line more than 5 mm and associated pain usually indicates rupture of the medial collateral ligament.
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