wikidoc - User contributions [en]

WBR278

2013-09-17T19:59:32Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular
|Prompt=A 68-year-old male is seen in the office for recurrent chest pain. He reports that he is getting substernal chest pain, without radiation, when he goes for a walk. The pain resolves with 12–15 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 130/68, pulse 86, and respiratory rate 14. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be the most appropriate test to order?
|Explanation=EXPLANATION: Aortic stenosis is one of the most common valvular abnormalities found in adults. It can be congenital—such as a unicuspid or bicuspid valve—or acquired. In young adults, acquired aortic stenosis is often seen as a consequence of rheumatic fever. This is becoming less common in developed nations. In adults over the age of 65, the most common cause of aortic stenosis is age-related degenerative, calcific aortic stenosis. The valvular cusps are immobilized and the stenosis caused by calcium deposits along the flexion lines of the valves. Acquired aortic stenosis typically has a prolonged asymptomatic period. During this time the stenosis may be found incidentally by auscultation of the characteristic harsh, holosystolic murmur in the aortic valve area that radiates to the carotid arteries. There may also be a slow, small, and sustained arterial pulsation (pulsus parvus and tardus) due to the relative outflow obstruction.
When considering the diagnosis of aortic stenosis, the initial diagnostic test of choice would be echocardiography. It would provide information on both the structure (bicuspid, tricuspid, and the like) and the function (valve area, pressures) of the valve. The size and function of the left ventricle can also be determined.

EDUCATIONAL OBJECTIVE: Aortic stenosis is one of the most common valvular abnormalities found in adults. The initial diagnostic test of choice would be echocardiography.
|AnswerA=Cardiac catheterization
|AnswerAExp=Incorrect- If aortic stenosis is found on echocardiogram and the patient is symptomatic, the next test would be cardiac catheterization. This would allow for direct measurement of the pressure gradient across the valve. It would also allow for evaluation of the status of the coronary arteries in order to determine whether CABG would need to be performed along with valve replacement.
|AnswerB=Electrophysiologic studies
|AnswerBExp=Incorrect- Electrophysiologic studies would not play a role in the typical evaluation of aortic stenosis.
|AnswerC=Exercise stress test
|AnswerCExp=Incorrect- Exercise stress testing is relatively contraindicated in the setting of symptomatic aortic stenosis.
|AnswerD=Echocardiogram
|AnswerDExp=Correct- see explantion.
|AnswerE=24-hour Holter monitor
|AnswerEExp=Incorrect- Holter monitoring would only be useful if there were a concomitant arrhythmia.
|RightAnswer=D
|WBRKeyword=Aortic stenosis
|Approved=Yes
}}

WBR278

2013-09-17T19:58:53Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|Prompt=A 68-year-old male is seen in the office for recurrent chest pain. He reports that he is getting substernal chest pain, without radiation, when he goes for a walk. The pain resolves with 12–15 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 130/68, pulse 86, and respiratory rate 14. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be the most appropriate test to order?
|Explanation=EXPLANATION: Aortic stenosis is one of the most common valvular abnormalities found in adults. It can be congenital—such as a unicuspid or bicuspid valve—or acquired. In young adults, acquired aortic stenosis is often seen as a consequence of rheumatic fever. This is becoming less common in developed nations. In adults over the age of 65, the most common cause of aortic stenosis is age-related degenerative, calcific aortic stenosis. The valvular cusps are immobilized and the stenosis caused by calcium deposits along the flexion lines of the valves. Acquired aortic stenosis typically has a prolonged asymptomatic period. During this time the stenosis may be found incidentally by auscultation of the characteristic harsh, holosystolic murmur in the aortic valve area that radiates to the carotid arteries. There may also be a slow, small, and sustained arterial pulsation (pulsus parvus and tardus) due to the relative outflow obstruction.
When considering the diagnosis of aortic stenosis, the initial diagnostic test of choice would be echocardiography. It would provide information on both the structure (bicuspid, tricuspid, and the like) and the function (valve area, pressures) of the valve. The size and function of the left ventricle can also be determined.

EDUCATIONAL OBJECTIVE: Aortic stenosis is one of the most common valvular abnormalities found in adults. The initial diagnostic test of choice would be echocardiography.

|AnswerA=Cardiac catheterization
|AnswerAExp=Incorrect- If aortic stenosis is found on echocardiogram and the patient is symptomatic, the next test would be cardiac catheterization. This would allow for direct measurement of the pressure gradient across the valve. It would also allow for evaluation of the status of the coronary arteries in order to determine whether CABG would need to be performed along with valve replacement.
|AnswerB=Electrophysiologic studies
|AnswerBExp=Incorrect- Electrophysiologic studies would not play a role in the typical evaluation of aortic stenosis.
|AnswerC=Exercise stress test
|AnswerCExp=Incorrect- Exercise stress testing is relatively contraindicated in the setting of symptomatic aortic stenosis.
|AnswerD=Echocardiogram
|AnswerDExp=Correct- see explantion.
|AnswerE=24-hour Holter monitor
|AnswerEExp=Incorrect- Holter monitoring would only be useful if there were a concomitant arrhythmia.
|RightAnswer=D
|WBRKeyword=Aortic stenosis
|Approved=Yes
}}

WBR278

2013-09-17T19:46:01Z

Sapan Patel: Created page with "{{WBRQuestion |QuestionAuthor={{Sapan}} |ExamType=USMLE Step 3 |MainCategory=Community Medical Health Center, Primary Care Office |SubCategory=Cardiovascular |MainCategory=Com..."

WBRCurrentQuestion

2013-09-17T19:42:02Z

Sapan Patel:

279

WBR277

2013-09-17T19:39:10Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|Prompt=Physician is called to see a newborn in the nursery because the nurse is concerned that the baby have single crease in the palm of the hand, small ears, small mouth, upward slanting eyes, wide space between the first and second toes, short hands with short fingers. Which of the following sign is most likely associated in this newborn?
|Explanation=
EXPLANATION: The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up.

EDUCATIONAL OBJECTIVE: The most common finding in a newborn with Down syndrome is hypotonia which should prompt close evaluation and follow-up.

|AnswerA=Café au lait spots
|AnswerAExp=Incorrect- This newborn is showing signs of Down syndrome. Café au lait spots are associated with neurofibromatosis.
|AnswerB=High arched palate
|AnswerBExp=Incorrect- This newborn is showing signs of Down syndrome. High arched palates are associated with fragile X syndrome.

|AnswerC=Ambiguous genitalia
|AnswerCExp=Incorrect- This newborn is showing signs of Down syndrome. Ambiguous genitalia are commonly seen in CAH.
|AnswerD=Hypotonia
|AnswerDExp=Correct- See explanation.
|AnswerE=Club feet
|AnswerEExp=Incorrect- This newborn is showing signs of Down syndrome.
|RightAnswer=D
|WBRKeyword=Down syndrome
|Approved=Yes
}}

WBR277

2013-09-17T19:38:32Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Pediatrics
|Prompt=Physician is called to see a newborn in the nursery because the nurse is concerned that the baby have single crease in the palm of the hand, small ears, small mouth, upward slanting eyes, wide space between the first and second toes, short hands with short fingers. Which of the following sign is most likely associated in this newborn?
|Explanation=
EXPLANATION: The most common finding in a newborn with Down syndrome is hypotonia. Other common findings include single palmar crease, flat facial profile, macroglossia, and wide space between the first and second toes. Hypotonia in the newborn period should prompt close evaluation and follow-up.

EDUCATIONAL OBJECTIVE: The most common finding in a newborn with Down syndrome is hypotonia which should prompt close evaluation and follow-up.

|AnswerA=Café au lait spots
|AnswerAExp=Incorrect- This newborn is showing signs of Down syndrome. Café au lait spots are associated with neurofibromatosis.
|AnswerB=High arched palate
|AnswerBExp=Incorrect- This newborn is showing signs of Down syndrome. High arched palates are associated with fragile X syndrome.

|AnswerC=Ambiguous genitalia
|AnswerCExp=Incorrect- This newborn is showing signs of Down syndrome. Ambiguous genitalia are commonly seen in CAH.
|AnswerD=Hypotonia
|AnswerDExp=Correct- See explanation.
|AnswerE=Club feet
|AnswerEExp=Incorrect- This newborn is showing signs of Down syndrome.
|RightAnswer=D
|WBRKeyword=Down syndrome
|Approved=Yes
}}

WBR277

2013-09-17T19:31:39Z

WBRCurrentQuestion

2013-09-17T19:22:52Z

Sapan Patel:

278

WBRCurrentQuestion

2013-09-10T14:11:06Z

Sapan Patel:

274

WBR271

2013-09-09T20:54:48Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|Prompt=A 6-year-old child is brought to office because of a sudden onset of irritability, weakness, and pallor. The father provides history that both of his children have been experiencing episodes of vomiting and diarrhea. His physical examination reveals a blood pressure of 116/82, dry mucus membranes, petechiae, and diffuse abdominal pain. The following laboratory work is obtained:

*Urinalysis: microscopic hematuria and proteinuria
*Blood urea nitrogen (BUN)/creatinine (Cr): 20/1.0 mg/dL
*Hemoglobin: 7 g/dL
*Peripheral blood smear: fragmented RBCs
*Prothrombin time (PT), partial thromboplastin time (PTT): normal
*Coombs' test: negative

What is the most likely diagnosis?
|Explanation=HUS (Hemolytic Uraemic Syndrome) is the combination of a microangiopathic hemolytic anemia and acute renal failure. It is commonly associated with E. coli O157/H7 gastroenteritis. HUS is one of the most common causes of acquired renal failure in children.

EDUCATIONAL OBJECTIVE: HUS is triad of gastroenteritis, microangiopathic hemolytic anemia and acute renal failure.
|AnswerA=Idiopathic thrombocytopenic purpura
|AnswerAExp=Incorrect- Idiopathic thrombocytopenic purpura is a bleeding disorder in which the immune system destroys platelets, which are necessary for normal blood clotting. Persons with the disease have too few platelets in the blood. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerB=Henoch Schonlein Purpura
|AnswerBExp=Incorrect- Purpura, arthritis and abdominal pain are known as the "classic triad" of Henoch–Schönlein purpura. But finding of acute renal failure are more suggestive of HUS.
|AnswerC=Evans syndrome
|AnswerCExp=Incorrect- Evans syndrome is an autoimmune disease in which an individual's antibodies attack their own red blood cells and platelets. Both of these events may occur simultaneously or one may follow on from the other. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerD=Meningococcemia
|AnswerDExp=Incorrect- Meningococcemia, like many gram-negative blood infections, can cause disseminated intravascular coagulation (DIC), which is the inappropriate clotting of blood within the vessels. DIC can cause ischemic tissue damage when upstream thrombus obstructs blood flow and haemorrhage because clotting factors are exhausted. But normal PT and PTT findings exclude this as a possibility.
|AnswerE=Hemolytic Uraemic Syndrome
|AnswerEExp=Correct- See explanation
|RightAnswer=E
|Approved=Yes
}}

WBR271

2013-09-09T20:53:35Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|Prompt=A 6-year-old child is brought to office because of a sudden onset of irritability, weakness, and pallor. The father provides history that both of his children have been experiencing episodes of vomiting and diarrhea. His physical examination reveals a blood pressure of 116/82, dry mucus membranes, petechiae, and diffuse abdominal pain. The following laboratory work is obtained:

*Urinalysis: microscopic hematuria and proteinuria
*Blood urea nitrogen (BUN)/creatinine (Cr): 20/1.0 mg/dL
*Hemoglobin: 7 g/dL
*Peripheral blood smear: fragmented RBCs
*Prothrombin time (PT), partial thromboplastin time (PTT): normal
*Coombs' test: negative

What is the most likely diagnosis?
|Explanation=HUS (Hemolytic Uraemic Syndrome) is the combination of a microangiopathic hemolytic anemia and acute renal failure. It is commonly associated with E. coli O157/H7 gastroenteritis. HUS is one of the most common causes of acquired renal failure in children.

EDUCATIONAL OBJECTIVE: HUS is triad of gastroenteritis, microangiopathic hemolytic anemia and acute renal failure.
|AnswerA=Idiopathic thrombocytopenic purpura
|AnswerAExp=Incorrect- Idiopathic thrombocytopenic purpura is a bleeding disorder in which the immune system destroys platelets, which are necessary for normal blood clotting. Persons with the disease have too few platelets in the blood. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerB=Henoch Schonlein Purpura
|AnswerBExp=Incorrect- Purpura, arthritis and abdominal pain are known as the "classic triad" of Henoch–Schönlein purpura.But finding of acute renal failure are more suggestive of HUS.
|AnswerC=Evans syndrome
|AnswerCExp=Incorrect- Evans syndrome is an autoimmune disease in which an individual's antibodies attack their own red blood cells and platelets. Both of these events may occur simultaneously or one may follow on from the other. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerD=Meningococcemia
|AnswerDExp=Incorrect- Meningococcemia, like many gram-negative blood infections, can cause disseminated intravascular coagulation (DIC), which is the inappropriate clotting of blood within the vessels. DIC can cause ischemic tissue damage when upstream thrombus obstructs blood flow and haemorrhage because clotting factors are exhausted. But normal PT and PTT findings exclude this as a possibility.
|AnswerE=Hemolytic Uraemic Syndrome
|AnswerEExp=Correct- See explanation
|RightAnswer=E
|Approved=Yes
}}

WBR271

2013-09-09T20:52:48Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Genitourinary, Hematology, Pediatrics
|Prompt=A 6-year-old child is brought to office because of a sudden onset of irritability, weakness, and pallor. The father provides history that both of his children have been experiencing episodes of vomiting and diarrhea. His physical examination reveals a blood pressure of 116/82, dry mucus membranes, petechiae, and diffuse abdominal pain. The following laboratory work is obtained:

*Urinalysis: microscopic hematuria and proteinuria
*Blood urea nitrogen (BUN)/creatinine (Cr): 20/1.0 mg/dL
*Hemoglobin: 7 g/dL
*Peripheral blood smear: fragmented RBCs
*Prothrombin time (PT), partial thromboplastin time (PTT): normal
*Coombs' test: negative

What is the most likely diagnosis?
|Explanation=HUS (Hemolytic Uraemic Syndrome) is the combination of a microangiopathic hemolytic anemia and acute renal failure. It is commonly associated with E. coli O157/H7 gastroenteritis. HUS is one of the most common causes of acquired renal failure in children.

EDUCATIONAL OBJECTIVE: HUS is triad of gastroenteritis, microangiopathic hemolytic anemia and acute renal failure.
|AnswerA=Idiopathic thrombocytopenic purpura
|AnswerAExp=Incorrect- Idiopathic thrombocytopenic purpura is a bleeding disorder in which the immune system destroys platelets, which are necessary for normal blood clotting. Persons with the disease have too few platelets in the blood. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerB=Henoch Schonlein Purpura
|AnswerBExp=Incorrect- Purpura, arthritis and abdominal pain are known as the "classic triad" of Henoch–Schönlein purpura.But finding of acute renal failure are more suggestive of HUS.
|AnswerC=Evans syndrome
|AnswerCExp=Incorrect- Evans syndrome is an autoimmune disease in which an individual's antibodies attack their own red blood cells and platelets. Both of these events may occur simultaneously or one may follow on from the other. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerD=Meningococcemia
|AnswerDExp=Incorrect- Meningococcemia, like many gram-negative blood infections, can cause disseminated intravascular coagulation (DIC), which is the inappropriate clotting of blood within the vessels. DIC can cause ischemic tissue damage when upstream thrombus obstructs blood flow and haemorrhage because clotting factors are exhausted. But normal PT and PTT findings exclude this as a possibility.
|AnswerE=Hemolytic Uraemic Syndrome
|AnswerEExp=Correct- See explanation
|RightAnswer=E
|Approved=Yes
}}

WBR271

2013-09-09T20:50:49Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|SubCategory=Genitourinary, Hematology
|SubCategory=Genitourinary, Hematology
|SubCategory=Genitourinary, Hematology
|SubCategory=Genitourinary, Hematology
|SubCategory=Genitourinary, Hematology
|SubCategory=Genitourinary, Hematology
|SubCategory=Genitourinary, Hematology
|SubCategory=Genitourinary, Hematology
|Prompt=A 6-year-old child is brought to office because of a sudden onset of irritability, weakness, and pallor. The father provides history that both of his children have been experiencing episodes of vomiting and diarrhea. His physical examination reveals a blood pressure of 116/82, dry mucus membranes, petechiae, and diffuse abdominal pain. The following laboratory work is obtained:

*Urinalysis: microscopic hematuria and proteinuria
*Blood urea nitrogen (BUN)/creatinine (Cr): 20/1.0 mg/dL
*Hemoglobin: 7 g/dL
*Peripheral blood smear: fragmented RBCs
*Prothrombin time (PT), partial thromboplastin time (PTT): normal
*Coombs' test: negative

What is the most likely diagnosis?
|Explanation=HUS (Hemolytic Uraemic Syndrome) is the combination of a microangiopathic hemolytic anemia and acute renal failure. It is commonly associated with E. coli O157/H7 gastroenteritis. HUS is one of the most common causes of acquired renal failure in children.

EDUCATIONAL OBJECTIVE: HUS is triad of gastroenteritis, microangiopathic hemolytic anemia and acute renal failure.

|AnswerA=Idiopathic thrombocytopenic purpura
|AnswerAExp=Incorrect- Idiopathic thrombocytopenic purpura is a bleeding disorder in which the immune system destroys platelets, which are necessary for normal blood clotting. Persons with the disease have too few platelets in the blood. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerB=Henoch Schonlein Purpura
|AnswerBExp=Incorrect- Purpura, arthritis and abdominal pain are known as the "classic triad" of Henoch–Schönlein purpura.But finding of acute renal failure are more suggestive of HUS.
|AnswerC=Evans syndrome
|AnswerCExp=Incorrect- Evans syndrome is an autoimmune disease in which an individual's antibodies attack their own red blood cells and platelets. Both of these events may occur simultaneously or one may follow on from the other. But findings of gastroenteritis and acute renal failure are more suggestive of HUS.
|AnswerD=Meningococcemia
|AnswerDExp=Incorrect- Meningococcemia, like many gram-negative blood infections, can cause disseminated intravascular coagulation (DIC), which is the inappropriate clotting of blood within the vessels. DIC can cause ischemic tissue damage when upstream thrombus obstructs blood flow and haemorrhage because clotting factors are exhausted. But normal PT and PTT findings exclude this as a possibility.
|AnswerE=Hemolytic Uraemic Syndrome
|AnswerEExp=Correct- See explanation
|RightAnswer=E
|Approved=Yes
}}

WBR271

2013-09-09T19:57:28Z

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Genitourinary, Hematology, Pediatrics
|Prompt=A 5-year-old child is brought to office because of a sudden onset of irritability, weakness, and pallor. The father provides history that both of his children have been experiencing episodes of vomiting and diarrhea. His physical examination reveals a blood pressure of 115/80, dry mucus membranes, petechiae, and diffuse abdominal pain. The following laboratory work is obtained:

*Urinalysis: microscopic hematuria and proteinuria
*Blood urea nitrogen (BUN)/creatinine (Cr): 20/1.0 mg/dL
*Hemoglobin: 7 g/dL
*Peripheral blood smear: fragmented RBCs
*Prothrombin time (PT), partial thromboplastin time (PTT): normal
*Coombs' test: negative

What is the most likely diagnosis?

|AnswerA=Idiopathic thrombocytopenic purpura

|AnswerB=Henoch Schonlein Purpura

|AnswerC=Evans syndrome

|AnswerD=Meningococcemia
|AnswerE=Hemolytic Uraemic Syndrome
|RightAnswer=E
|Approved=Yes
}}

WBRCurrentQuestion

2013-09-09T19:53:01Z

Sapan Patel:

272

WBR269

2013-09-09T19:48:21Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Cardiovascular, Preventive Medicine
|Prompt=A 42-year-old female presents to your office for elevated blood pressure (BP). She has been having headaches for the last 2 weeks. She checks her BP at pharmacy and she presents with readings ranging between 162/106 and 154/92. After some research she did on her own, she has been exercising and following the "DASH (Dietary Approaches to Stop Hypertension)" diet for the past 2 months. Her BP in the office after more than 10 minutes of resting was 152/88 in her left arm and 146/92 in her right. She tells you that both her mother and father have hypertension. She denies chest pain, shortness of breath, dizziness, or blurred vision. She denies tobacco use, drinks 3–4 beers on weekends, and uses no recreational drugs. Your physical examination should include documentation of which of these?
|Explanation=The seventh report of the Joint National Committee on the prevention, detection, evaluation, and treatment of high blood pressure (JNC 7) key recommendations classify this patient in hypertension stage 1, as most of her BP readings are systolic blood pressure (SBP) in the 140–159 range and diastolic blood pressure (DBP) between 90 and 99.

*Category: SBP and/or DBP
*Normal: <120 and <80
*Prehypertension: 120–139 or 80–90
*Hypertension stage 1: 140–159 or 90–99
*Hypertension stage 2: >160 or >100

The primary purpose of the initial physical examination is to look for causes of secondary hypertension and for early organ damage due to untreated hypertension. In physical examination for a newly diagnosed patient with hypertension, there are recommendations to include BP measurement in both arms, examination of the optic fundi, BMI calculation, auscultation for carotid, abdominal and femoral bruits, palpation of the thyroid gland, examination of the heart and lungs, and examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation.

Educational objective: The primary aim of the initial physical examination is to look for causes of secondary hypertension and for early organ damage due to untreated hypertension.
|AnswerA=Cranial nerve examination
|AnswerAExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|AnswerB=Peripheral nerve examinations
|AnswerBExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|AnswerC=Auscultation for carotid, abdominal, and femoral bruits
|AnswerCExp=Correct- See explanation
|AnswerD=Palpation of the abdomen for hepatosplenomegaly
|AnswerDExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|AnswerE=Mental status examination
|AnswerEExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|RightAnswer=C
|Approved=Yes
}}

WBR269

2013-09-09T19:46:15Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|Prompt=A 42-year-old female presents to your office for elevated blood pressure (BP). She has been having headaches for the last 2 weeks. She checks her BP at pharmacy and she presents with readings ranging between 162/106 and 154/92. After some research she did on her own, she has been exercising and following the "DASH (Dietary Approaches to Stop Hypertension)" diet for the past 2 months. Her BP in the office after more than 10 minutes of resting was 152/88 in her left arm and 146/92 in her right. She tells you that both her mother and father have hypertension. She denies chest pain, shortness of breath, dizziness, or blurred vision. She denies tobacco use, drinks 3–4 beers on weekends, and uses no recreational drugs. Your physical examination should include documentation of which of these?
|Explanation=The seventh report of the Joint National Committee on the prevention, detection, evaluation, and treatment of high blood pressure (JNC 7) key recommendations classify this patient in hypertension stage 1, as most of her BP readings are systolic blood pressure (SBP) in the 140–159 range and diastolic blood pressure (DBP) between 90 and 99.

Category: SBP and/or DBP
Normal: <120 and <80
Prehypertension: 120–139 or 80–90
Hypertension stage 1: 140–159 or 90–99
Hypertension stage 2: >160 or >100

The primary purpose of the initial physical examination is to look for causes of secondary hypertension and for early organ damage due to untreated hypertension. In physical examination for a newly diagnosed patient with hypertension, there are recommendations to include BP measurement in both arms, examination of the optic fundi, BMI calculation, auscultation for carotid, abdominal and femoral bruits, palpation of the thyroid gland, examination of the heart and lungs, and examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation.

Educational objective: The primary aim of the initial physical examination is to look for causes of secondary hypertension and for early organ damage due to untreated hypertension.
|AnswerA=Cranial nerve examination
|AnswerAExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|AnswerB=Peripheral nerve examinations
|AnswerBExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|AnswerC=Auscultation for carotid, abdominal, and femoral bruits
|AnswerCExp=Correct- See explanation
|AnswerD=Palpation of the abdomen for hepatosplenomegaly
|AnswerDExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|AnswerE=Mental status examination
|AnswerEExp=Incorrect- It is not an essential part of physical examination for a newly diagnosed patient with hypertension.
|RightAnswer=C
|Approved=Yes
}}

WBR269

2013-09-09T19:18:04Z

WBRCurrentQuestion

2013-09-09T19:14:58Z

Sapan Patel:

270

WBR268

2013-09-09T19:09:01Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|SubCategory=Infectious Disease, Surgery
|Prompt=A 60-year-old male on total parenteral nutrition (TPN) for 10 days following development of a postoperative enterocutaneous fistula has developed high, spiking temperatures up to 102.3°F over the last 7 hours. The only abnormal finding on physical examination is redness and induration around his central line. The most appropriate step is which of the following?
|Explanation=A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever. The catheter site may have redness, induration, tenderness, and purulent discharge extruding from the skin. Often, however, the skin appears normal. A thorough search for other possible sources of fever including pulmonary, intraabdominal, urinary, and wound infections is always prudent. Catheter sepsis can be life threatening and early intervention is essential. Peripheral and central blood cultures should be obtained and the catheter must be removed promptly.

Educational objective- A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever.
|AnswerA=Begin broad-spectrum antibiotics and observe for 48 hours
|AnswerAExp=Incorrect- It is not mandatory to treat with antibiotics unless the fever persists or signs of sepsis are present.

|AnswerB=Blood cultures through the central line, begin broadspectrum antibiotics and await culture results
|AnswerBExp=Incorrect- As the catheter must be removed promptly to control infection.
|AnswerC=Catheter removal, send tip for culture and replace with a new central line over the guide wire
|AnswerCExp=Incorrect- It is contraindicated to replace the catheter over a guide wire because the skin tract is infected.
|AnswerD=Catheter removal, send tip for culture and establish central line at another site
|AnswerDExp=Correct- See explanation
|AnswerE=Catheter removal, send tip for culture and establish peripheral intravenous line
|AnswerEExp=Incorrect- It is right to remove the catheter but for TPN, establishing central line at another site is more appropiate action than establishing peripheral intravenous line.
|RightAnswer=D
|Approved=Yes
}}

WBR268

2013-09-09T19:05:11Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|SubCategory=Infectious Disease, Surgery
|Prompt=A 60-year-old male on total parenteral nutrition (TPN) for 10 days following development of a postoperative enterocutaneous fistula has developed high, spiking temperatures up to 102.3°F over the last 7 hours. The only abnormal finding on physical examination is redness and induration around his central line. The most appropriate step is which of the following?
|Explanation=A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever. The catheter site may have redness, induration, tenderness, and purulent discharge extruding from the skin. Often, however, the skin appears normal. A thorough search for other possible sources of fever including pulmonary, intraabdominal, urinary, and wound infections is always prudent. Catheter sepsis can be life threatening and early intervention is essential. Peripheral and central blood cultures should be obtained and the catheter must be removed promptly.

Educational objective- A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever.
|AnswerA=Begin broad-spectrum antibiotics and observe for 48 hours
|AnswerAExp=Incorrect- It is not mandatory to treat with antibiotics unless the fever persists or signs of sepsis are present.

|AnswerB=Blood cultures through the central line, begin broadspectrum antibiotics and await culture results
|AnswerBExp=Incorrect- As the catheter must be removed promptly to control infection.
|AnswerC=Catheter removal, send tip for culture and replace with a new central line over the guide wire
|AnswerCExp=Incorrect- It is contraindicated to replace the catheter over a guide wire because the skin tract is infected.
|AnswerD=Catheter removal, send tip for culture and establish central line at another site
|AnswerDExp=Correct- See explanation
|AnswerE=Catheter removal, send tip for culture and establish peripheral intravenous line
|AnswerEExp=Incorrect- It is right to remove catheter but for TPN, establishing central line at another site is more appropiate than establishing peripheral intravenous line.
|RightAnswer=D
|Approved=Yes
}}

WBR268

2013-09-09T19:04:45Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|SubCategory=Infectious Disease, Infectious Disease, Surgery
|Prompt=A 60-year-old male on total parenteral nutrition (TPN) for 10 days following development of a postoperative enterocutaneous fistula has developed high, spiking temperatures up to 102.3°F over the last 7 hours. The only abnormal finding on physical examination is redness and induration around his central line. The most appropriate step is which of the following?
|Explanation=A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever. The catheter site may have redness, induration, tenderness, and purulent discharge extruding from the skin. Often, however, the skin appears normal. A thorough search for other possible sources of fever including pulmonary, intraabdominal, urinary, and wound infections is always prudent. Catheter sepsis can be life threatening and early intervention is essential. Peripheral and central blood cultures should be obtained and the catheter must be removed promptly.

Educational objective- A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever.
|AnswerA=Begin broad-spectrum antibiotics and observe for 48 hours
|AnswerAExp=Incorrect- It is not mandatory to treat with antibiotics unless the fever persists or signs of sepsis are present.

|AnswerB=Blood cultures through the central line, begin broadspectrum antibiotics and await culture results
|AnswerBExp=Incorrect- As the catheter must be removed promptly to control infection.
|AnswerC=Catheter removal, send tip for culture and replace with a new central line over the guide wire
|AnswerCExp=Incorrect- It is contraindicated to replace the catheter over a guide wire because the skin tract is infected.
|AnswerD=Catheter removal, send tip for culture and establish central line at another site
|AnswerDExp=Correct- See explanation
|AnswerE=Catheter removal, send tip for culture and establish peripheral intravenous line
|AnswerEExp=Incorrect- It is right to remove catheter but for TPN, establishing central line at another site is more appropiate than establishing peripheral intravenous line.
|RightAnswer=D
|Approved=Yes
}}

WBR268

2013-09-09T19:03:16Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Infectious Disease, Surgery
|Prompt=A 60-year-old male on total parenteral nutrition (TPN) for 10 days following development of a postoperative enterocutaneous fistula has developed high, spiking temperatures up to 102.3°F over the last 7 hours. The only abnormal finding on physical examination is redness and induration around his central line. The most appropriate step is which of the following?
|Explanation=A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever. The catheter site may have redness, induration, tenderness, and purulent discharge extruding from the skin. Often, however, the skin appears normal. A thorough search for other possible sources of fever including pulmonary, intraabdominal, urinary, and wound infections is always prudent. Catheter sepsis can be life threatening and early intervention is essential. Peripheral and central blood cultures should be obtained and the catheter must be removed promptly.

Educational objective- A high index of suspicion is warranted for catheter sepsis in any patient who has had a central line for several days and suddenly spikes a high fever.
|AnswerA=Begin broad-spectrum antibiotics and observe for 48 hours
|AnswerAExp=Incorrect- It is not mandatory to treat with antibiotics unless the fever persists or signs of sepsis are present.

|AnswerB=Blood cultures through the central line, begin broadspectrum antibiotics and await culture results
|AnswerBExp=Incorrect- As the catheter must be removed promptly to control infection.
|AnswerC=Catheter removal, send tip for culture and replace with a new central line over the guide wire
|AnswerCExp=Incorrect- It is contraindicated to replace the catheter over a guide wire because the skin tract is infected.
|AnswerD=Catheter removal, send tip for culture and establish central line at another site
|AnswerDExp=Correct- See explanation
|AnswerE=Catheter removal, send tip for culture and establish peripheral intravenous line
|AnswerEExp=Incorrect- It is right to remove catheter but for TPN, establishing central line at another site is more appropiate than establishing peripheral intravenous line.
|RightAnswer=D
|Approved=Yes
}}

WBR268

2013-09-09T18:48:38Z

Sapan Patel: Created page with "{{WBRQuestion |QuestionAuthor={{Sapan}} |ExamType=USMLE Step 3 |MainCategory=Inpatient Facilities |SubCategory=Dermatology, Infectious Disease, Surgery |MainCategory=Inpatient..."

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Dermatology, Infectious Disease, Surgery
|Prompt=A 60-year-old male on total parenteral nutrition (TPN) for 10 days following development of a postoperative enterocutaneous fistula has developed high, spiking temperatures up to 102.3°F over the last 7 hours. The only abnormal finding on physical examination is redness and induration around his central line. The most appropriate step is which of the following?

|AnswerA=Begin broad-spectrum antibiotics and observe for 48 hours

|AnswerB=Blood cultures through the central line, begin broadspectrum antibiotics and await culture results

|AnswerC=Catheter removal, send tip for culture and replace with a new central line over the guide wire

|AnswerD=Catheter removal, send tip for culture and establish central line at another site

|AnswerE=Catheter removal, send tip for culture and establish peripheral intravenous line
|RightAnswer=D
|Approved=Yes
}}

WBRCurrentQuestion

2013-09-09T18:45:21Z

Sapan Patel:

269

WBR266

2013-09-09T18:34:23Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|Prompt=The police bring a 22-year-old male into the emergency room after a disruption at the local college campus. According to his medical chart, he has been treated for a depressive episode in the past. He describes his mood as "great" but claims to have been awake for 4 days due to working on several inventions. He admits to rapid thoughts and believes that God has chosen him to be the next Messiah. In fact, angels have commanded him to steal from the student union in order to begin a new church.
Which of the following drugs should be given to treat symptoms of this patient?
|Explanation=This patient displays criteria for bipolar disorder, manic with psychotic features. Individuals intoxicated with cocaine classically show signs similar to mania. Frank psychotic symptoms can occur in up to 50% of individuals.

Cocaine is a powerful nervous system stimulant. Its effects can last from 15–30 minutes to an hour, depending on dosage and the route of administration.

Cocaine increases alertness, feelings of well-being and euphoria, energy and motor activity, feelings of competence and sexuality. Athletic performance may be enhanced in sports where sustained attention and endurance is required. Anxiety, paranoia and restlessness can also occur, especially during the comedown. With excessive dosage, tremors, convulsions and increased body temperature are observed.With excessive or prolonged use, the drug can cause itching, tachycardia, hallucinations, and paranoid delusions. Overdoses cause hyperthermia and a marked elevation of blood pressure, which can be life-threatening.

Educational Objective: Lorazepam is used to treat manic symptoms associated with cocaine intoxication and it has relatively rapid course of action.
|AnswerA=Divalproex sodium
|AnswerAExp=Incorrect- It is an appropriate treatment for mania but it may take several days to weeks before significant therapeutic effects are achieved.
|AnswerB=Lamotrigine
|AnswerBExp=Incorrect- Lamotrigine is efficacious in bipolar depression and in the maintenance phase, but it is not particularly effective in treating the manic phase.
|AnswerC=Lithium
|AnswerCExp=Incorrect- It is an appropriate treatment for mania but it may take several days to weeks before significant therapeutic effects are achieved.
|AnswerD=Mirtazapine
|AnswerDExp=Incorrect- An antidepressant such as mirtazapine may worsen mania in a bipolar patient.
|AnswerE=Lorazepam
|AnswerEExp=Correct- Lorazepam or other high potency benzodiazepines are useful in the acute management of manic patients as the sedative effects are relatively rapid.
|RightAnswer=E
|Approved=Yes
}}

WBR266

2013-09-09T18:14:48Z

Sapan Patel: Created page with "{{WBRQuestion |QuestionAuthor={{Sapan}} |ExamType=USMLE Step 3 |MainCategory=Emergency Room |SubCategory=Psychiatry |MainCategory=Emergency Room |SubCategory=Psychiatry |MainC..."

WBRCurrentQuestion

2013-09-09T16:32:22Z

Sapan Patel:

265

WBR262

2013-09-09T16:30:22Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Psychiatry
|Prompt=The police bring a 22-year-old male into the emergency room after a disruption at the local college campus. According to his medical chart, he has been treated for a depressive episode in the past. He describes his mood as "great" but claims to have been awake for 4 days due to working on several inventions. He admits to rapid thoughts and believes that God has chosen him to be the next Messiah. In fact, angels have commanded him to steal from the student union in order to begin a new church.
Urine toxicology performed in order to rule out a substance of abuse as a cause of his symptoms would most likely reveal which substance?
|Explanation=This patient displays criteria for bipolar disorder, manic with psychotic features. Individuals intoxicated with cocaine classically show signs similar to mania. Frank psychotic symptoms can occur in up to 50% of individuals.

Cocaine is a powerful nervous system stimulant. Its effects can last from 15–30 minutes to an hour, depending on dosage and the route of administration.

Cocaine increases alertness, feelings of well-being and euphoria, energy and motor activity, feelings of competence and sexuality. Athletic performance may be enhanced in sports where sustained attention and endurance is required. Anxiety, paranoia and restlessness can also occur, especially during the comedown. With excessive dosage, tremors, convulsions and increased body temperature are observed.With excessive or prolonged use, the drug can cause itching, tachycardia, hallucinations, and paranoid delusions. Overdoses cause hyperthermia and a marked elevation of blood pressure, which can be life-threatening.

Educational objective: Individuals intoxicated with cocaine classically show signs similar to mania. Frank psychotic symptoms can occur in up to 50% of individuals.
|AnswerA=Alcohol 
|AnswerAExp=Incorrect- While alcohol can present with psychotic symptoms, it more commonly creates a depressed picture.
|AnswerB=Benzodiazepines
|AnswerBExp=Incorrect- Benzodiazepine intoxication rarely causes manic or psychotic symptoms.
|AnswerC=Cannabis 
|AnswerCExp=Incorrect- Although cannabis use is not infrequently associated with paranoia, it rarely displays frank psychosis.
|AnswerD=Cocaine 
|AnswerDExp=Correct- See explanation
|AnswerE=Opiates
|AnswerEExp=Incorrect- Opiate intoxication will appear more as a depressed syndrome.
|RightAnswer=D
|Approved=Yes
}}

WBR262

2013-09-09T16:25:13Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|Prompt=The police bring a 22-year-old male into the emergency room after a disruption at the local college campus. According to his medical chart, he has been treated for a depressive episode in the past. He describes his mood as "great" but claims to have been awake for 4 days due to working on several inventions. He admits to rapid thoughts and believes that God has chosen him to be the next Messiah. In fact, angels have commanded him to steal from the student union in order to begin a new church.
Urine toxicology performed in order to rule out a substance of abuse as a cause of his symptoms would most likely reveal which substance?
|Explanation=This patient displays criteria for bipolar disorder, manic with psychotic features. Individuals intoxicated with cocaine classically show signs similar to mania. Frank psychotic symptoms can occur in up to 50% of individuals.

Cocaine is a powerful nervous system stimulant. Its effects can last from 15–30 minutes to an hour, depending on dosage and the route of administration.

Cocaine increases alertness, feelings of well-being and euphoria, energy and motor activity, feelings of competence and sexuality. Athletic performance may be enhanced in sports where sustained attention and endurance is required. Anxiety, paranoia and restlessness can also occur, especially during the comedown. With excessive dosage, tremors, convulsions and increased body temperature are observed.With excessive or prolonged use, the drug can cause itching, tachycardia, hallucinations, and paranoid delusions. Overdoses cause hyperthermia and a marked elevation of blood pressure, which can be life-threatening.

Educational objective: Individuals intoxicated with cocaine classically show signs similar to mania. Frank psychotic symptoms can occur in up to 50% of individuals.
|AnswerA=Alcohol 
|AnswerAExp=Incorrect- While alcohol can present with psychotic symptoms, it more commonly creates a depressed picture.
|AnswerB=Benzodiazepines
|AnswerBExp=Incorrect- Benzodiazepine intoxication rarely causes manic or psychotic symptoms.
|AnswerC=Cannabis 
|AnswerCExp=Incorrect- Although cannabis use is not infrequently associated with paranoia, it rarely displays frank psychosis.
|AnswerD=Cocaine 
|AnswerDExp=Correct- See explanation
|AnswerE=Opiates
|AnswerEExp=Incorrect- Opiate intoxication will appear more as a depressed syndrome.
|RightAnswer=D
|Approved=Yes
}}

WBR262

2013-09-09T16:17:43Z

Sapan Patel:

WBR262

2013-09-09T16:01:55Z

WBRCurrentQuestion

2013-09-09T15:58:04Z

Sapan Patel:

263

WBR261

2013-09-09T15:48:00Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Psychiatry
|Prompt=The patient is a 72-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia).
Further history, cognitive examinations, physical examination, and laboratory/radiographic studies are obtained. The results are consistent with Alzheimer's dementia. While the family had been able to take care of him initially, they have since returned to the clinic stating that they can no longer keep him at home. They feel that he is becoming much more agitated. He is staying up at night. Lately he has been rearranging the furniture, claiming to look for "the little people who are teasing me." They have noticed that he has difficulty walking, often moving slowly and dropping items. The family has pursued nursing home placement, but they wish to have something prescribed in order to help him sleep and keep him calm.
Which of the following medications should be avoided in this patient?
|Explanation=This patient displays characteristics of Lewy body disease, a dementia that may be related to [[Alzheimer dementia]]. The classic triad of Lewy body dementia is a fluctuating course, peduncular hallucinations (visual hallucinations of small people, animals, or objects), and parkinsonian features. These patients tend to be very sensitive to extrapyramidal side effects and, therefore, antipsychotics such as [[risperidone]] should be avoided or sparingly used.

Educational objective:In patients with Lewy body dementia, antipsychotics such as [[risperidone]] should be avoided or sparingly used as they tend to be very sensitive to extrapyramidal side effects.
|AnswerA=Buspirone
|AnswerAExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerB=Donepezil
|AnswerBExp=Incorrect- This drug should not be avoided as he has [[Alzheimer's disease]]. It is treatment of choice.
|AnswerC=Lorazepam
|AnswerCExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerD=Trazodone
|AnswerDExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerE=Risperidone
|AnswerEExp=Correct- See expanation
|RightAnswer=E
|Approved=Yes
}}

WBR261

2013-09-09T15:47:30Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|MainCategory=Community Medical Health Center, Primary Care Office
|MainCategory=Community Medical Health Center, Primary Care Office
|SubCategory=Neurology, Neurology, Psychiatry
|Prompt=The patient is a 72-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia).
Further history, cognitive examinations, physical examination, and laboratory/radiographic studies are obtained. The results are consistent with Alzheimer's dementia. While the family had been able to take care of him initially, they have since returned to the clinic stating that they can no longer keep him at home. They feel that he is becoming much more agitated. He is staying up at night. Lately he has been rearranging the furniture, claiming to look for "the little people who are teasing me." They have noticed that he has difficulty walking, often moving slowly and dropping items. The family has pursued nursing home placement, but they wish to have something prescribed in order to help him sleep and keep him calm.
Which of the following medications should be avoided in this patient?
|Explanation=This patient displays characteristics of Lewy body disease, a dementia that may be related to [[Alzheimer dementia]]. The classic triad of Lewy body dementia is a fluctuating course, peduncular hallucinations (visual hallucinations of small people, animals, or objects), and parkinsonian features. These patients tend to be very sensitive to extrapyramidal side effects and, therefore, antipsychotics such as [[risperidone]] should be avoided or sparingly used.

Educational objective:In patients with Lewy body dementia, antipsychotics such as [[risperidone]] should be avoided or sparingly used as they tend to be very sensitive to extrapyramidal side effects.
|AnswerA=Buspirone
|AnswerAExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerB=Donepezil
|AnswerBExp=Incorrect- This drug should not be avoided as he has [[Alzheimer's disease]]. It is treatment of choice.
|AnswerC=Lorazepam
|AnswerCExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerD=Trazodone
|AnswerDExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerE=Risperidone
|AnswerEExp=Correct- See expanation
|RightAnswer=E
|Approved=Yes
}}

WBR261

2013-09-09T15:47:03Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|SubCategory=Neurology, Neurology, Psychiatry
|SubCategory=Neurology, Neurology, Psychiatry
|SubCategory=Neurology, Neurology, Psychiatry
|SubCategory=Neurology, Neurology, Psychiatry
|SubCategory=Neurology, Neurology, Psychiatry
|SubCategory=Neurology, Neurology, Psychiatry
|SubCategory=Neurology, Neurology, Psychiatry
|SubCategory=Neurology, Neurology, Psychiatry
|Prompt=The patient is a 72-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia).
Further history, cognitive examinations, physical examination, and laboratory/radiographic studies are obtained. The results are consistent with Alzheimer's dementia. While the family had been able to take care of him initially, they have since returned to the clinic stating that they can no longer keep him at home. They feel that he is becoming much more agitated. He is staying up at night. Lately he has been rearranging the furniture, claiming to look for "the little people who are teasing me." They have noticed that he has difficulty walking, often moving slowly and dropping items. The family has pursued nursing home placement, but they wish to have something prescribed in order to help him sleep and keep him calm.
Which of the following medications should be avoided in this patient?
|Explanation=This patient displays characteristics of Lewy body disease, a dementia that may be related to [[Alzheimer dementia]]. The classic triad of Lewy body dementia is a fluctuating course, peduncular hallucinations (visual hallucinations of small people, animals, or objects), and parkinsonian features. These patients tend to be very sensitive to extrapyramidal side effects and, therefore, antipsychotics such as [[risperidone]] should be avoided or sparingly used.

Educational objective:In patients with Lewy body dementia, antipsychotics such as [[risperidone]] should be avoided or sparingly used as they tend to be very sensitive to extrapyramidal side effects.
|AnswerA=Buspirone
|AnswerAExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerB=Donepezil
|AnswerBExp=Incorrect- This drug should not be avoided as he has [[Alzheimer's disease]]. It is treatment of choice.
|AnswerC=Lorazepam
|AnswerCExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerD=Trazodone
|AnswerDExp=Incorrect- This drug should not be avoided as it does not have extrapyramidal side effects.
|AnswerE=Risperidone
|AnswerEExp=Correct- See expanation
|RightAnswer=E
|Approved=Yes
}}

WBR261

2013-09-09T15:27:28Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|Prompt=The patient is a 72-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia).
Further history, cognitive examinations, physical examination, and laboratory/radiographic studies are obtained. The results are consistent with Alzheimer's dementia. While the family had been able to take care of him initially, they have since returned to the clinic stating that they can no longer keep him at home. They feel that he is becoming much more agitated. He is staying up at night. Lately he has been rearranging the furniture, claiming to look for "the little people who are teasing me." They have noticed that he has difficulty walking, often moving slowly and dropping items. The family has pursued nursing home placement, but they wish to have something prescribed in order to help him sleep and keep him calm.
Which of the following medications should be avoided in this patient?
|Explanation=This patient displays characteristics of Lewy body disease, a dementia that may be related to [[Alzheimer dementia]]. The classic triad of Lewy body dementia is a fluctuating course, peduncular hallucinations (visual hallucinations of small people, animals, or objects), and parkinsonian features. These patients tend to be very sensitive to extrapyramidal side effects and, therefore, antipsychotics such as [[risperidone]] should be avoided or sparingly used.

Educational objective:In patients with Lewy body dementia, antipsychotics such as [[risperidone]] should be avoided or sparingly used as they tend to be very sensitive to extrapyramidal side effects.
|AnswerA=Buspirone
|AnswerAExp=Incorrect
|AnswerB=Donepezil
|AnswerBExp=Incorrect
|AnswerC=Lorazepam
|AnswerCExp=Incorrect
|AnswerD=Trazodone
|AnswerDExp=Incorrect
|AnswerE=Risperidone
|AnswerEExp=Correct- See expanation
|RightAnswer=E
|Approved=Yes
}}

WBR261

2013-09-09T15:22:20Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor={{Sapan}}
|ExamType=USMLE Step 3
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|SubCategory=Neurology
|Prompt=The patient is a 72-year-old man brought to the primary care clinic by his family over concerns that he has Alzheimer's disease. They have noticed a worsening of his memory over the past 6 months. He does not seem to want to get out of bed, and he appears to have difficulty providing for his basic needs such as cleaning, dressing, and cooking for himself. He is hesitant when talking, but it is unclear whether he is unable or unmotivated to speak. His family has also noticed that he appears depressed and is often seen crying. A MSE of the patient is performed to help determine whether he is suffering from a dementing illness or a depressive illness (pseudodementia).
Further history, cognitive examinations, physical examination, and laboratory/radiographic studies are obtained. The results are consistent with Alzheimer's dementia. While the family had been able to take care of him initially, they have since returned to the clinic stating that they can no longer keep him at home. They feel that he is becoming much more agitated. He is staying up at night. Lately he has been rearranging the furniture, claiming to look for "the little people who are teasing me." They have noticed that he has difficulty walking, often moving slowly and dropping items. The family has pursued nursing home placement, but they wish to have something prescribed in order to help him sleep and keep him calm.
Which of the following medications should be avoided in this patient?
|Explanation=This patient displays characteristics of [[Lewy body disease]], a dementia that may be related to [[Alzheimer's dementia]]. The classic triad of Lewy body dementia is a fluctuating course, peduncular hallucinations (visual hallucinations of small people, animals, or objects), and parkinsonian features. These patients tend to be very sensitive to extrapyramidal side effects and, therefore, antipsychotics such as [[risperidone]] should be avoided or sparingly used.

Educational objective:In patients with Lewy body dementia, antipsychotics such as [[risperidone]] should be avoided or sparingly used as they tend to be very sensitive to extrapyramidal side effects.
|AnswerA=Buspirone
|AnswerAExp=Incorrect
|AnswerB=Donepezil
|AnswerBExp=Incorrect
|AnswerC=Lorazepam
|AnswerCExp=Incorrect
|AnswerD=Trazodone
|AnswerDExp=Incorrect
|AnswerE=Risperidone
|AnswerEExp=Correct- See expanation
|RightAnswer=E
|Approved=Yes
}}

WBR261

2013-09-09T15:06:44Z

WBRCurrentQuestion

2013-09-09T14:53:39Z

Sapan Patel:

262

WBR0130

2013-08-26T20:56:54Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|Prompt=A 67-year-old man presents with a 2-day history of severe dizziness. The symptoms are exacerbated by turning his head and relieved by lying still. He reports nausea and vomiting for the first day of his illness, but successfully eats breakfast on the day he is seen in clinic. He denies hearing loss and tinnitus. His past medical and surgical histories are unremarkable. He has no previous exposure to ototoxic drugs and denies further neurologic symptoms. Physical examination reveals an obviously uncomfortable white male in a wheelchair.Otologic examination is without abnormality. Weber testing with a 512 Hz tuning fork is to midline. Romberg testing indicates right-sided pathology. Cranial nerve examination is normal except left beating nystagmus. Vertigo is experienced after the Dix-Hallpike maneuver. Nystagmus is observed after a few seconds of lying down during the maneuver.The patient is treated with diazepam, which, on follow up, has relieved his symptoms.

What is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often have positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0136

2013-08-26T20:56:43Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|Prompt=A 72-year-old white female visits her physician in outpatient clinic with symptoms of vertigo. During the physical examination the physician maneuvers the patient from a sitting position to a lying position, with her shoulders and head slightly off the edge of the table. Upon rotating the head to one side, the physician observes horizontal nystagmus. Upon repetition of this maneuver, the nystagmus becomes less prominent.

Which of the following is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often have positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0130

2013-08-26T20:55:49Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|Prompt=A 67-year-old man presents with a 2-day history of severe dizziness. The symptoms are exacerbated by turning his head and relieved by lying still. He reports nausea and vomiting for the first day of his illness, but successfully eats breakfast on the day he is seen in clinic. He denies hearing loss and tinnitus. His past medical and surgical histories are unremarkable. He has no previous exposure to ototoxic drugs and denies further neurologic symptoms. Physical examination reveals an obviously uncomfortable white male in a wheelchair.Otologic examination is without abnormality. Weber testing with a 512 Hz tuning fork is to midline. Romberg testing indicates right-sided pathology. Cranial nerve examination is normal except left beating nystagmus. Vertigo is experienced after the Dix-Hallpike maneuver. Nystagmus is observed after a few seconds of lying down during the maneuver.The patient is treated with diazepam, which, on follow up, has relieved his symptoms.

What is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often have positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0136

2013-08-26T20:54:56Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|Prompt=A 72-year-old white female visits her physician in outpatient clinic with symptoms of vertigo. During the physical examination the physician maneuvers the patient from a sitting position to a lying position, with her shoulders and head slightly off the edge of the table. Upon rotating the head to one side, the physician observes horizontal nystagmus. Upon repetition of this maneuver, the nystagmus becomes less prominent.

Which of the following is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often have positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0136

2013-08-26T20:53:27Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|Prompt=A 72-year-old white female visits her physician in outpatient clinic with symptoms of vertigo. During the physical examination the physician maneuvers the patient from a sitting position to a lying position, with her shoulders and head slightly off the edge of the table. Upon rotating the head to one side, the physician observes horizontal nystagmus. Upon repetition of this maneuver, the nystagmus becomes less prominent.

Which of the following is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often havea positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0136

2013-08-26T20:53:14Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|Prompt=A 72-year-old white female visits her physician in outpatient clinic with symptoms of vertigo. During the physical examination the physician maneuvers the patient from a sitting position to a lying position, with her shoulders and head slightly off the edge of the table. Upon rotating the head to one side, the physician observes horizontal nystagmus. Upon repetition of this maneuver, the nystagmus becomes less prominent.

Which of the following is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often havea positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0136

2013-08-26T20:52:09Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.

|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0136

2013-08-26T20:49:53Z

Sapan Patel: Created page with "{{WBRQuestion |QuestionAuthor=Sapan Patel, M.B.B.S. |ExamType=USMLE Step 3 |MainCategory=Primary Care Office, Emergency Room |SubCategory=Head and Neck, Neurology |MainCatego..."

WBR0130

2013-08-26T18:40:16Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|MainCategory=Primary Care Office, Emergency Room
|MainCategory=Primary Care Office, Emergency Room
|SubCategory=Head and Neck, Neurology
|Prompt=A 67-year-old man presents with a 2-day history of severe dizziness. The symptoms are exacerbated by turning his head and relieved by lying still. He reports nausea and vomiting for the first day of his illness, but successfully eats breakfast on the day he is seen in clinic. He denies hearing loss and tinnitus. His past medical and surgical histories are unremarkable. He has no previous exposure to ototoxic drugs and denies further neurologic symptoms. Physical examination reveals an obviously uncomfortable white male in a wheelchair.Otologic examination is without abnormality. Weber testing with a 512 Hz tuning fork is to midline. Romberg testing indicates right-sided pathology. Cranial nerve examination is normal except left beating nystagmus. Vertigo is experienced after the Dix-Hallpike maneuver. Nystagmus is observed after a few seconds of lying down during the maneuver.The patient is treated with diazepam, which, on follow up, has relieved his symptoms.

What is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often havea positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}

WBR0130

2013-08-26T18:38:57Z

Sapan Patel:

{{WBRQuestion
|QuestionAuthor=Sapan Patel, M.B.B.S.
|ExamType=USMLE Step 3
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|SubCategory=Head and Neck, Neurology
|Prompt=A 67-year-old man presents with a 2-day history of severe dizziness. The symptoms are exacerbated by turning his head and relieved by lying still. He reports nausea and vomiting for the first 2 days of his illness, but successfully eats breakfast on the day he is seen in clinic. He denies hearing loss and tinnitus. His past medical and surgical histories are unremarkable. He has no previous exposure to ototoxic drugs and denies further neurologic symptoms. Physical examination reveals an obviously uncomfortable white male in a wheelchair.Otologic examination is without abnormality. Weber testing with a 512 Hz tuning fork is to midline. Romberg testing indicates right-sided pathology. Cranial nerve examination is normal except left beating nystagmus. Vertigo is experienced after the Dix-Hallpike maneuver. Nystagmus is observed after a few seconds of lying down during the maneuver.The patient is treated with diazepam, which, on follow up, has relieved his symptoms.

What is the most likely diagnosis?
|Explanation=EDUCATIONAL OBJECTIVE: In benign positional vertigo (BPV), Patients presents with brief episodes of vertigo with positional changes, typically when turning over in bed. They often havea positive response to the Dix-Hallpike maneuver, which confirms the diagnosis.
|AnswerA=Meniere's disease
|AnswerAExp=Incorrect. The presence of episodes of vertigo along with fluctuating hearing loss are consistent with the diagnosis of Meniere's disease, which is also characterized by tinnitus or a ringing sound in the ear. Some patients also experience a pressure sensation in the ear. Episodes occur at regular intervals for years, and may also be marked by periods of remission. The cause is an increase in the volume of endolymph.
|AnswerB=Acoustic neuroma
|AnswerBExp=Incorrect. Acoustic neuroma (sometimes termed a neurolemmoma or schwannoma) is a benign (noncancerous) tissue growth that arises on the eighth cranial nerve leading from the brain to the inner ear. Acoustic neuromas usually grow slowly over a period of years. They expand in size at their site of origin, and when large, can displace normal brain tissue. The brain is not invaded by the tumor, but the tumor pushes the brain as it enlarges. The slowly enlarging tumor protrudes from the internal auditory canal into an area behind the temporal bone called the cerebellopontine angle. Since the balance portion of the eighth nerve is where the tumor arises, unsteadiness and balance problems may occur during the growth of the neuroma. The most common presentation is unilateral hearing loss.
|AnswerC=Benign positional vertigo
|AnswerCExp=Correct. Benign positional vertigo (BPV) is the most likely cause of this patient’s vertigo. BPV is not typically associated with hearing loss. Patients have brief episodes of vertigo with positional changes, typically when turning over in bed. This patient had a positive response to the Dix-Hallpike maneuver, which confirms the diagnosis. BPV is due to deposition of calcium debris in the semicircular canals. Medications such as diazepam or meclizine as well as canalith repositioning (Epley’s maneuver) are used to treat the condition. The latter is a series of head rotational positions intended to relocate free floating particles in the semicircular canals.
|AnswerD=Viral labyrinthitis
|AnswerDExp=Incorrect. Labyrinthitis is an inflammation or dysfunction of the vestibular labyrinth, which is a system of intercommunicating cavities and canals in the inner ear. The syndrome is defined by the acute onset of vertigo that commonly is associated with head or body movement. Nausea, vomiting, and malaise often accompany the vertigo. The pathophysiology of this syndrome is not completely understood. However, a dysfunction of the vestibular apparatus is clearly present when labyrinthitis occurs. Many cases of labyrinthitis are associated with systemic or viral-like illnesses. Suppurative or bacterial labyrinthitis is rare, but it should be considered in patients with acute or chronic otitis media. Cases are reported in association with meningitis, but the presentation of the meningitis often overwhelms the vestibular symptoms.
|AnswerE=Vestibular neuronitis
|AnswerEExp=Incorrect. Vestibular neuronitis presents as acute onset of vertigo, nausea, and vomiting lasting for several days. As this condition is not clearly inflammatory in nature, neurologists often refer to it as vestibular neuropathy. The etiology is unknown, but it appears to be a sudden disruption of afferent neuronal input from the left and right inner ears. This imbalance in vestibular neurologic input to the central nervous system causes symptoms of vertigo. Besides the unilateral caloric weakness, electronystagmography reveals a directional preponderance and beating nystagmus away from the affected side. Work-up of patients with vestibular neuronitis begins with thorough history and physical examination. Audiometry and vestibular testing are the cornerstones of diagnosis, with imaging and laboratory studies being guided by findings on examination. Bedside examination includes Doll's eye test, head shaking nystagmus, dynamic visual acuity, caloric testing, rotational testing, past pointing, Romberg and Fukuda tests, and tandem walking. Patients with this condition do not generally have auditory symptoms.
|RightAnswer=C
|Approved=Yes
}}