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<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="02c285a1erlcgo.png"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>usmle med 6</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="usmle med 6"><U><B>home</B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="pearls 1"><U>pearls 1</U></A>   |   <A HREF="id20.htm" TARGET="_top" TITLE="pearls 2"><U>pearls 2</U></A>   |   <A HREF="id21.htm" TARGET="_top" TITLE="pearls 3"><U>pearls 3</U></A>   |   <A HREF="id22.htm" TARGET="_top" TITLE="pearls 4"><U>pearls 4</U></A>   |   <A HREF="id24.htm" TARGET="_top" TITLE="pearls 5"><U>pearls 5</U></A>   |   <A HREF="id18.htm" TARGET="_top" TITLE="qcm"><U>qcm</U></A>   |   <B>answers</B>   |   <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="02ad2c00dkelyh.png"> <div>   <a href="http://counter.mycomputer.com/"><img alt="Counter" src="http://counter.mycomputer.com/c.count?u=DHAMMOUD&c=1" border=0></a>   </div> <bR> <div> <A HREF="id23.htm" TARGET="_top" TITLE="pearls 1"><U>pearls 1</U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="pearls 2"><U>pearls 2</U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="pearls 3"><U>pearls 3</U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="pearls 4"><U>pearls 4</U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="pearls 5"><U>pearls 5</U></A></div> <div> <A HREF="id18.htm" TARGET="_top" TITLE="qcm"><U>qcm</U></A></div> <div> answers</div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>answers</I></div> <div> ANSWER: Question 1.1</div> <div> <B>A. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Hypercalciuria</B></FONT></div> <div> <B>(Nephrology; renal stones)</B></div> <div> This patient has renal colic secondary to a renal stone. Renal colic characteristically has an abrupt onset in the flank, with radiation of the pain toward the abdomen and into the groin. It is associated with urinary frequency, dysuria, and hematuria. Men are more frequently affected than women.</div> <div> The most common metabolic abnormality in stone-formers is idiopathic hypercalciuria. Calcium oxalate stones account for the majority of stones (60%). There is an increased incidence of these stones in patients on megadoses of vitamin C and in Crohn's disease, the latter due to increased reabsorption of oxalate in the damaged mucosa of the terminal ileum. Other factors that predispose to stones are low urine citrate levels, because citrate is necessary to bind stone constituents; reduced urine volume; and incomplete distal renal tubular acidosis (phosphate stones in children). The recurrence rate for stone-formers is 75%.</div> <div> Only stones that contain calcium, such as cal-cium oxalate or calcium phosphate, are radiopaque. However, uric acid, xanthine, and ammonium nitrate stones are radiolucent on x-ray and show up as a filling defect.</div> <div> The laboratory workup for stones involves:</div> <div> ¥ urinalysis, which checks urine pH</div> <div> ¥ urine culture, if pyuria is present; urease splitters increase stone formation</div> <div> ¥ serum calcium and serum phosphate to rule out primary hyperparathyroidism</div> <div> ¥ serum uric acid to rule out hyperuricemia</div> <div> ¥ electrolytes to identify metabolic acidosis due to distal renal tubular acidosis</div> <div> ¥ serum creatinine to evaluate renal function status</div> <div> ¥ a flat plate of the abdomen, which identifies radiopaque stones or locates filling defects</div> <div> ¥ an intravenous pyelogram to rule out stones (staghom calculi) in the renal pelvis and medullary sponge kidney, which is commonly associated with stones</div> <div> ¥ a 24-hour urine for calcium to detect hypercal-ciuria</div> <div> ¥ a 24-hour urine for uric acid to detect urico-suria</div> <div> ¥ a 24-hour urine for citrate, because low levels predispose to stones</div> <div> ¥ a 24-hour urine for sodium, because increased levels contribute to increased calcium excretion</div> <div> ¥ a 24-hour urine for phosphates, which are an indirect measure of dairy product ingestion</div> <div> Urine should always be strained to identify the stones, which must be submitted for analysis, so that appropriate treatment modalities can be employed. X-ray diffraction is the gold standard for stone analysis.</div> <div> The mainstay of therapy is increased water intake (2.5-3 L/day). Hydrochlorothiazide is the treatment of choice for hypercalciuria, because volume contraction increases calcium reabsorption. Alkalinizing the urine pH is useful in the treatment of uric acid, oxalate, and cystine stones.</div> <div> The best overall management of stones is waiting for spontaneous passage. Extracorporeal shock wave lithotripsy is most useful for stones that are less than 2 cm. A combination of percutaneous lithotripsy and shock wave therapy is used for larger stones. Staghorn calculi (struvite stones) in the renal pelvis are best removed by surgery.</div> <div>  <A NAME="answer_2_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 2.1</div> <div> <B>B. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Adhesions from previous surgery</B></FONT></div> <div> <B>(General surgery; small bowel obstruction)</B></div> <div> The patient has a small bowel obstruction, which is most commonly caused by adhesions from a previous surgery. Characteristic physical findings in small bowel obstruction are vomiting, colicky midabdominal pain, abdominal distention, hyper peristalsis, obstipation (i.e., absence of stool and flatus), and a lack of rebound tenderness. Abdominal x-rays show distended loops of bowel with a stepladder pattern of differential air-fluid levels. In some cases, intestinal incubation relieves the entrapped gas and fluids, causing the obstruction to subside. Other cases require surgical intervention.</div> <div> Torsion of the bowel around the mesenteric root is referred to as a volvulus. It produces obstruction and strangulation of bowel. Intussusception is uncommon in adults and produces a combination of obstruction and infarction. Small bowel infarction resulting from thrombosis of the superior mesenteric artery causes a bloody diarrhea. "Thumb printing" from submucosal edema is noted on abdominal films.</div> <div>  <A NAME="answer_3_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 3.1</div> <div> <B>D. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio</B></FONT></div> <div> <B>(General surgery; preoperative pulmonary function testing)</B> </div> <div> Patients with lung disease prior to operation are at increased risk for atelectasis, pneumonia, and hypoxemia [i.e., a low arterial O2 tension (PO2)]. Chest x-rays, electrocardiograms, and arterial blood gases are all useful preoperative screens, but pulmonary function studies provide the best preoperative screen, because they reflect dynamic measurements of pulmonary function in the patient. The forced expiratory volume in I second (FEVER) indicates how much air can be expelled from the lungs in 1 second after a maximal inspiration (normally 4 liters). The forced vital capacity (FVC) represents the entire amount of air that can be expelled (normally S liters). The ratio of the FIVE to the FVC (normally 80%) is considered the best overall screen. Values less than 50% of predicted outcome correlate with a high risk for postoperative pulmonary complications.</div> <div> Arterial blood gas measurements reflect primary acid-base disorders (e.g., acidosis or alkalosis), but they do not predict pulmonary complications in the postoperative state. Respiratory acidosis secondary to retention of CO2 is the main reason for evaluating arterial blood gases, because acidosis is always associated with hypoxemia. In addition, treatment with high-flow oxygen could potentially cause respiratory arrest and further retention of CO2, because the low arterial O2 tension (PO2), which serves as a stimulus for breathing, is lost.</div> <div>  <A NAME="answer_4_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 4.1</div> <div> <B>A. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Haemophilus influenza B vaccine is recommended for those patients with recurrent otitis media or a history of acute epiglottitis. </B></FONT></div> <div> <B>(Pediatrics; specialized vaccines)</B></div> <div> Haemophilus influencee B vaccine is indicated for the prevention of invasive diseases such as meningitis and epiglottitis. The majority of otitis media caused by Haemophilus is due to nontypable strains. Influenza vaccine is recommended for children at risk of serious pulmonary complications, such as children with congenital heart disease, severe asthma, bronchopulmonary dysplasia, cystic fibrosis, renal disease, diabetes, and sickle cell anemia. Pneumococcal vaccine is much more effective after 2 years of age. It is currently recommended that all newborns be immunized against hepatitis B virus (HBV). Newborns of HBV-anti-gen-positive mothers should also receive hepatitis B immune globulin at birth, but it should be administered at a separate site from the vaccine.</div> <div>  <A NAME="answer_5_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 5.1</div> <div> <B>D. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Meckel's diverticulum</B></FONT></div> <div> <B>(Pediatrics; Meckel's diverticulum)</B></div> <div> Meckel's diverticulum is the most common congenital anomaly of the tract. It is a true diverticulum because it consists of all three layers. It usually presents as painless rectal bleeding. The condition is best remembered as the disease of twos; it affects two percent of the population, occurs in the first two years of life, is a sacculation two feet proximal to the ileocecal junction and is two inches long. While iron deficiency is the most common cause of anemia overall, in this age bracket, the most common cause of iron deficiency is G.I. bleeding from Meckel's diverticulum. The diverticulum usually consists of ectopic gastric tissue. Diagnosis is made by technetium scan. Excision is the treatment of choice.</div> <bR> <div>  <A NAME="answer_6_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 6.1</div> <div> <B>E. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Preceding viral illness---Guillain-Barre syndrome</B></FONT></div> <div> <B>(Neurology; Guillain Barre' syndrome)</B></div> <div> Many cases of Guillain Barre syndrome are preceded by a virus or vaccination. Multiple sclerosis is believed to be an autoimmune disorder, not posttraumatic. Parkinson's disease might easily arise from neurotoxins affecting the cells of the substantia nigra, but aluminum is not currently suspected (although it has been suspected in the past as contributing to Alzheimer's disease). Infantile spasms are generally associated with acquired central nervous system injury; they are not genetic. Finally, Huntington's disease is clearly a genetic trait, the autosomal dominant gene localized to chromosome 4. </div> <bR> <div>  <A NAME="answer_7_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 7.1</div> <div> <B>D. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Hypophosphatemia</B></FONT></div> <div> <B>(Endocrinology; hypophosphatemia and respiratory failure)</B> </div> <div> In diabetic ketoacidosis (DKA), glucosuria results in the loss of significant amounts of sodium, potassium, and phosphate in the urine. When insulin is used in the treatment of DKA, phosphorus is normally transported along with glucose into muscle and adipose cells so that glucose can be phosphorylated and used for glycolysis. However, the presence of insulin also enhances glycolysis in the liver. The liver begins to remove massive amounts of glucose and phosphorus from the blood, thereby depleting the already low blood concentration of phosphate. This depletion of phosphate decreases the amount of phosphorus available to accompany glucose into the muscle, which causes a depletion of adenosine triphosphate (ATP) within the muscle, leading to paralysis of the respiratory muscles and death of the patient. This sequence is the rationale for providing phosphate supplementation in the treatment of DKA.</div> <div> Glucose toxicity refers to the effect of hyperglycemia in reducing the sensitivity of tissues to insulin therapy in both type I and type II diabetes mellitus.</div> <div> Although hyperkalemia is commonly seen in the setting of DKA, it is not due to an excess of potassium stores but is the result of a transcellular shift of potassium out of cells as excess hydrogen ions in ketoacidosis are buffered intracellularly. This transcellular shift often disguises the marked deficits in total body potassium that these patients have because of loss of potassium in the urine, resulting from the osmotic effect of glucosuria. Therefore, potassium supplementation is extremely important in the treatment of DKA and can be given as potassium phosphate rather than as potassium chloride.</div> <bR> <div>  <A NAME="answer_8_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 8.1</div> <div> <B>D. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Leave out the pertussis component of the vaccine, and give diphtheria-tetanus toxoid on the next immunization.</B></FONT></div> <div> <B>(Pediatrics; diphtheria-tetanus-pertussis immunization)</B> </div> <div> Most of the reactivity of diphtheria-tetanus-pertussis (DTP) is due to the pertussis component. Serious reactions, such as seizures, contraindicate the further use of the pertussis vaccine. This reaction, however, does not contraindicate the further use of the tetanus and diphtheria toxcids.</div> <bR> <div>  <A NAME="answer_9_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 9.1</div> <div> <B>C. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Pelvis</B></FONT></div> <div> <B>(Orthopedics; pelvic fractures and blood loss)</B></div> <div> Pelvic fractures have the greatest potential for blood loss (> 1 L) of all fractures because of a large venous and arterial blood supply. This underscores why most trauma centers are prepared to place external fixators to tamponade pelvic bleeding in the emergency room. Bladder injury and transection of the urethra are also common injuries associated with pelvic fractures. The femur is the second most common fracture site associated with massive blood loss. Closed fractures in the spine, humerus, tibia and fibula, and other sites are usually associated with a blood loss of less than 450 ml.</div> <bR> <div>  <A NAME="answer_10_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 10.1</div> <div> <B>B. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Analysis of variance</B></FONT></div> <div> <B>(Biostatistics; analysis of variance)</B></div> <div> The question relates to assessing group differences of a continuous variable, which in this question is age. If the comparison were between two groups with a continuous variable, a Student's t test would be correct. With more than two groups, it is necessary to use analysis of variance. A correlation coefficient assesses the strength of association, not the differences among groups. The chi squared test assesses differences among groups of categorical variables. Logistic regression is used to assess a categorical outcome for a continuous predictor.</div> <bR> <div>  <A NAME="answer_11_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 11.1</div> <div> <B>C. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Diverticular disease</B></FONT></div> <div> <B>(General surgery; colovesi cal fistula secondary to diverticular disease)</B></div> <div> Fistulas are abnormal communications between two hollow organs or between a hollow organ and the exterior. The most common fistulas in the gastrointestinal tract are colovesical fistulas and the most common cause is diverticular disease complicated by diverticulitis. Colovesical fistulas are more common in men. Air and fecal material in the urine suggest the diagnosis. Methylene blue instilled into the rectum or bladder can identify these fistulas. Surgery is required if they persist.</div> <div> Rectovaginal fistulas are most commonly caused by trauma secondary to childbirth. Anorectal fistulas can be associated with inflammatory bowel disease. Small intestine fistulas are common in Crohn's disease. Gastrocolic fistulas can occur after peptic ulcer surgery. </div> <bR> <div>  <A NAME="answer_12_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 12.1</div> <div> <B>D. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Acute myocardial infarction</B></FONT></div> <div> <B>(General surgery; complications associated with carotid endarterectomy)</B></div> <div> The most common complication following a carotid endarterectomy is an acute myocardial infarction. Endarterectomy is the standard treatment for atherosclerosis involving the bifurcation of the common carotid artery. Overall, there is approximately a 4% incidence of complications following this procedure. In addition to acute myocardial infarction, complications include stroke (uncommon), numbness beneath the chin, and palatal palsy. Pulmonary embolus is not a common complication of carotid endarterectomy.</div> <div> Air embolism is a potential problem in surgery or trauma in the head and neck area. Venous injury can result in air being sucked into the right atrium from the negative intrathoracic pressure associated with inspiration. Air mixed with blood in the right heart produces a frothy material that blocks the blood entering the pulmonary artery. This can be prevented by keeping the patient supine and applying digital pressure to the injured vessel. Treatment involves placing the patient on the left side and keeping the head lower than the feet, thus trapping the air in the right ventricle. This is followed by administration of 100% oxygen.</div> <bR> <div>  <A NAME="answer_13_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 13.1</div> <div> <B>E. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Normal</B></FONT></div> <div> <B>(Psychiatry; sexual issues)</B></div> <div> This man is showing normal behavior. In order to qualify as a paraphilia, a person must not only have an unusual object of sexual desire but must also have acted on the fantasy or have problems forming relationships because of it. Paraphilias include exhibitionism, in which an individual exposes his genitals to others; fetishism, in which sexual pleasure is gained from inanimate objects; frotteurism, in which sexual pleasure is gained by rubbing the penis against a clothed woman; and voyeurism, in which a person secretly observes people dressing or engaging in sexual activity.</div> <bR> <div>  <A NAME="answer_14_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 14.1</div> <div> <B>A. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Dementia.</B></FONT></div> <div> <B>(Psychiatry;psychosis)</B></div> <div> This patient's symptoms consist of delusions. Delusions always indicate the presence of psychosis. Of the choices, only dementia can present with psychosis, often consisting of persecutory delusions. Other disorders with similar psychotic symptoms include schizophrenia and delusional disorder.</div> <bR> <div>  <A NAME="answer_15_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 15.1</div> <div> <FONT SIZE="4" COLOR="#800000" FACE="Arial" ><B>C. </B></FONT><B>Dissociative fugue</B>.</div> <div> <B>(Psychiatry; cognitive disorder)</B></div> <div> Dissociative fugue is characterized by sudden travel away from home, inability to recall one's past, and a disturbance of identity. It often occurs during the course of severe stress. Memory impairment may or may not be present with organic psychoses, conversion disorder, or delirium. Subjective memory problems sometimes occur during major depression.</div> <bR> <div>  <A NAME="answer_16_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 16.1</div> <div> <FONT SIZE="4" COLOR="#800000" FACE="Arial" ><B>E. </B></FONT><FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>S</B></FONT><B>light increase in hemoglobin concentration</B>.</div> <div> <B>(Laboratory medicine; laboratory values in geriatric patients)</B></div> <div> A mild glucose intolerance is normal in the elderly because of the increase in adipose tissue, which decreases the number of insulin receptors available for glucose. Alkaline phosphatase is increased in the elderly because of an increase in degenerative arthritis. Reactive bone formation occurs at the margins of the joints (osteophytes) in response to wear and tear of the articular carti lage. An increase in auto antibodies with age is secondary to a decrease in CD8 T suppressor cells. The creatinine clearance decreases as age increases, primarily as a result of a decrease in the glomerular filtration rate. The hemoglobin concentration in elderly men is in the range of the hemoglobin concentration in adult women (12 16 g/dl). This decrease is due to a decrease in testosterone, which decreases the stimulation of erythropoietin, leading to a slight decrease in ery thropoiesis in the bone marrow. </div> <bR> <div>  <A NAME="answer_17_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 17.1</div> <div> <B>C. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Calcium gluconate</B></FONT></div> <div> <B>(Cardiology; treatment of hyperkalemia)</B></div> <div> The electrocardiogram (ECG) reveals tall, slen der, tented T waves in leads I, II, aVF, and V2-6. In general, the serum potassium levels correlate well with the ECG findings, but the ECG more accurately reflects the gradient between the myocardial intracellular and extracellular potas sium. Peaking of the T waves is a more important criterion of hyperkalemla than is the wave amplitude.</div> <div> Hyperkalemia is common in end stage renal disease, because potassium is normally excreted in the kidney. Hyperkalemia is associated with dangerous cardiac arrhythmias and, if high enough, stops the heart in diastole. Calcium antagonizes cardiac conduction abnormalities and specifically reverses the effect of hyper kalemia on cardiac muscle. Sodium bicarbonate and insulin plus glucose increase the uptake of potassium into cells. Sodium bicarbonate also produces metabolic alkalosis, which shifts potas sium into cells in exchange for hydrogen ions coming out of the cells. Furosemide is a loop diuretic that increases the distal exchange of sodium ions for potassium ions, therefore losing significant amounts of potassium in the urine. Cation exchange resins given as enemas also remove potassium from the body.</div> <bR> <div>  <A NAME="answer_18_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 18.1</div> <div> <B>C. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Mania</B></FONT></div> <div> <B>(Psychiatry; mania)</B></div> <div> Mania is a syndrome characterized by an irritable, elevated, or euphoric mood, coupled with increased psychomotor activity, decreased need for sleep, grandiosity, and deterioration of judgment. It is seen in the manic phase of bipolar disorder and certain drug-induced mood disorders resulting from psychostimulants or steroids.</div> <bR> <div>  <A NAME="answer_19_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 19.1</div> <div> <B>A. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Narrow </B></FONT><B>hymen</B></div> <div> <B>(Gynecology; dyspareunia)</B></div> <div> Although most sexual problems are psychological, organic causes must still be ruled out. Of the options listed, the most likely cause of painful vaginal entry with intercourse in a virginal woman is a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >narrowed</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >hymen</FONT>. This situation can be easily treated by surgical incision in the office. Endometriosis and pelvic inflammatory disease (PID) can be causes of deep, not superficial, dyspareunia. Atrophic vaginitis is unlikely in a premenopausal woman.</div> <bR> <div>  <A NAME="answer_20_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> ANSWER: Question 20.1</div> <div> <B>E. </B><FONT SIZE="4" COLOR="#000000" FACE="Arial" ><B>Accidental poisoning-7 years old</B></FONT></div> <div> <B>(Pediatrics; accidents)</B></div> <div> Any self-poisoning in a child older than 5 years should be considered self-inflicted or abuse. Suffocation is more common in the first year of life, sometimes in infants who sleep with their parents. One in three infants who use walkers will have an accidental fall, usually a fall down stairs. The majority of drownings occur in the 1 to 4-year age-group. Pool drownings are most common in children 1 to 3 years of age. Most of these children are unsupervised in a pool with no fence around it. Pedestrian injuries are most common in the 3-to 7-year age-group.</div> <bR> <bR> </td> </tr></table></body>