Preguntas y

Respuestas 4

 A 33-year-old woman gives birth to a baby girl. The next

day, she begins to bleed from her vagina and from
venipuncture sites. Laboratory studies demonstrate
decreased platelets, prolonged prothrombin time (PT) and
partial thromboplastin time (PTT), and increased fibrin split
products. These features are most consistent with which of
the following?
A. Disseminated intravascular coagulation
B. Hemophilia A
C. Severe liver disease
D. Vitamin K deficiency
E. Von Willebrand's disease

 The correct answer is A.

The patient is experiencing disseminated intravascular
coagulation (DIC), a feared, and often life-threatening
complication of many other disorders, including amniotic
fluid embolism, infections (particularly gram-negative
sepsis), malignancy, and major trauma. The diagnosis is
suspected when both a decrease in platelets and a
prolongation of PT and PTT times are observed. The
observed hematologic abnormalities are due to
consumption of platelets and clotting factors, caused by
extensive microclot formation with accompanying
fibrinolysis (reflected by the increased fibrin split products).
The D-dimer assay measures cross-linked fibrin derivatives,
and is a specific test for fibrin degradation products.

 A 40-year old man complains of increasing difficulty in swallowing

over the past 3 years. He reports a feeling of pressure in his chest
occurring 2-3 seconds after swallowing a solid bolus. He also
experiences regurgitation of undigested food eaten hours
previously. A radiograph taken after swallowing barium shows a
distended esophageal body with a smooth tapering at the lower
esophageal sphincter. Manometry shows the absence of esophageal
peristalsis with swallowing and a lower esophageal sphincter that
fails to relax. What is the most likely diagnosis?
A. Achalasia
B. Diffuse esophageal spasm
C. Incompetent lower esophageal sphincter
D. Oropharyngeal dysphagia
E. Scleroderma

 The correct answer is A.

Achalasia is an acquired esophageal motility disorder that slowly
develops. The motility is abnormal due to the loss of inhibitory enteric
neurons of the esophageal body and lower esophageal sphincter. Both
vasoactive intestinal peptide and nitric oxide function as inhibitory
neurotransmitters here, and the presence of both is decreased in
achalasia. Radiographs typically show a dilated esophagus that tapers at
the lower esophageal sphincter, producing a so-called "bird's beak."
Because of the poor motility, ingested food is regurgitated and can lead
to aspiration symptoms. Heartburn can occur due to production of lactic
acid in the esophagus as the retained ingestate is fermented. Manometric
demonstration of absent peristalsis in the esophageal body and poor
relaxation of the lower esophageal sphincter with a swallow confirm the
diagnosis.

 A 29-year-old woman with a history of irregular menses becomes

amenorrheic. She had no problems conceiving her first child at the
age of 23, but she has been trying unsuccessfully to become
pregnant for the past two years. She also notes a weight gain of
about 3 kg, increasing fatigue, puffy face and marked cold
intolerance. A complete blood count (CBC) reveals a Hb of 11.1
and an MCV of 90. Physical exam reveals a moderate-sized diffuse
enlargement of the thyroid gland. Which of the following thyroid
profiles would most likely be seen in this woman?

A. Low T3, low T4, high TSH

B. Low T3, low T4, low TSH
C. Low T3, high T4, low TSH
D. High T3, low T4, low TSH
E. High T3, high T4, low TSH

 The correct answer is A.

This woman is experiencing signs and symptoms of hypothyroidism,
the most common cause of which is chronic thyroiditis, or Hashimoto's
thyroiditis. It is an autoimmune disorder, mostly affecting women, in
which antithyroid antibodies are produced. The immune response
results in autoimmune destruction of the thyroid gland, rendering it
less able to produce thyroid hormone, causing hypothyroidism. Some
other symptoms of hypothyroidism are weakness, fatigue, coarse hair,
constipation, hoarseness, and hearing loss. Since the thyroid cannot
produce thyroid hormone, both T3 and T4 would be low. In trying to
compensate for low thyroid hormone levels, the pituitary gland
releases excess TSH to stimulate the thyroid gland to make more
thyroid hormone.

 A 74-year-old woman, in otherwise good health, tripped and

injured her right leg 2 days previously and has been bedridden
since the accident. Two hours ago, she became delirious. On
physical examination, her temperature is 99 F, blood pressure
is 120/70 mm Hg, heart rate is 110, and respiratory rate is 32.
Pulse oximetry shows an oxygen saturation of 80%, and a chest
x-ray film is normal. Which of the following is the most likely
diagnosis?

A. Acute cerebral hemorrhage

B. Acute cerebral infarction
C. Myocardial infarction
D. Pulmonary infarction
E. Pulmonary thromboembolism

 Explanation: The correct answer is E.

Hip fracture and prolonged bed rest are classic risk
factors for the development of pulmonary
thromboemboli (PE). Common clinical manifestations of
PE are hypoxia (due to ventilation/perfusion mismatch)
despite a normal chest x-ray, tachycardia, and delirium
in older patients.

 A 65-year-old man with hyperlucent lung fields develops

extreme shortness of breath over a period of about 15
minutes. Chest x-ray shows a shift of the mediastinum to
the right, and the lung field on the left appears even more
hyperlucent than before, with the exception of a white
shadow near the heart border. Which of the following is the
most probable cause of the patient's current problem?

A. Bronchogenic carcinoma
B. Pleural effusion
C. Pulmonary embolism
D. Rupture of an emphysematous bulla
E. Tuberculosis

 Explanation: The correct answer is D.

The patient's initial hyperlucent lung fields strongly suggest
the presence of
emphysema. The radiologic findings
after the increase in shortness of breath are consistent with
free air in the
chest, which has collapsed the left lung
and caused a shift in the location of the mediastinum. Such
air might
have been introduced by rupture of a bulla.
Small pneumothoraces are usually well tolerated, but larger
ones may require decompression (the needle from a
syringe is sometimes used), or even surgical correction if
bullae continue to leak air.

 Which of the following conditions would mostly likely be

associated with chronic gastritis (Type A) resulting from
autoimmune destruction of parietal cells?

carcinoma

blood cells

A. Decreased growth of luminal bacteria

B. Decreased likelihood of developing gastric
C. Decreased plasma concentration of gastrin
D. Increased production of macrocytic red

E. Increased secretion of pancreatic

bicarbonate

 Explanation: The correct answer is D.

Autoimmune destruction of parietal cells would lead to
decreased secretion of gastric acid and intrinsic factor.
The diminished availability of intrinsic factor would
result in poor absorption of dietary vitamin B12. Over
time, the vitamin B12 deficiency could lead to
pernicious anemia, which is characterized by
increased production of macrocytes (megaloblasts) by
the bone marrow.

 A 55-year-old hypertensive man develops sudden onset of

excruciating pain beginning in the anterior chest, and
then radiating to the back. Over the next 2 hours, the pain
moves downward toward the abdomen. Which of the
following is the most probable diagnosis?

A. Aortic dissection
B. Aortic valve stenosis
C. Atherosclerotic aneurysm
D. Myocardial infarction
E. Syphilitic aneurysm

 Explanation: The correct answer is A.

This patient has an aortic dissection (formerly called
dissecting aneurysm), a
potentially fatal condition
that is too often confused clinically with myocardial
infarction. The most important clinical clue is that the
pain shifts with time. Non-invasive techniques such as
transesophageal echocardiography, computed
tomography (CT), and magnetic resonance imaging
(MRI) are increasingly useful in making this diagnosis.

 A 30-year old male complains of fatigue and diffuse skeletal

pain. He has a history of Crohn's disease, which led to
resection of the terminal ileum 3 years previously. Steatorrhea
and diarrhea have continued since the surgery. Laboratory
tests show that serum calcium is 7.5 mg/dL, serum phosphate
is 2.5 mg/dL, and serum parathyroid hormone (N-terminal) is
750 pg/mL. Which of the following is the most likely cause of
these findings?

A. Osteoporosis
B. Paget's disease
C. Primary hypoparathyroidism
D. Renal failure
E. Vitamin D deficiency

 Explanation: The correct answer is E.

Whenever serum calcium and phosphate are both
decreased, vitamin D deficiency should be considered.
In this case, the vitamin D deficiency is due to fat
malabsorption, including the fat-soluble vitamin D,
subsequent to ileal resection. If more than 100 cm of
the ileum are removed, primary bile acid production by
the liver cannot keep up with bile salt loss in the stool.
The total bile salt pool decreases and fat absorption,
including the fat-soluble vitamins is poor.