Question 1.
A 25-year-old woman comes to the clinic for a Pap smear. She has been treated for multiple sexually transmitted infections in the past. She is sexually active and does not use contraception. Her temperature is 37.0°C (98.6°F), pulse is 80/min, and respirations are 14/min. Physical examination shows no abnormalities. Pelvic examination is normal without evidence of cervical discharge or motion tenderness. A Pap smear is obtained and shows high-grade squamous intraepithelial lesions. Colposcopy is performed and shows cervical intraepithelial neoplasia (CIN) grade 3. Which of the following is the most appropriate treatment for this patient’s condition?
Abdominal hysterectomy
Hysterectomy, either abdominal or vaginal is used in the treatment of establish cervical cancer. CIN 3 is carcinoma in situ and can be managed with less invasive procedures
High dosage of prednisone
Corticosteroid medications, such as prednisone, do not play any role in the treatment of cervical intraepithelial neoplasia which is managed either by repeat testing or procedural intervention depending on the grade.
Loop electrical excision procedure
Major takeaway
In patients who have cervical intraepithelial neoplasia (CIN) grade 3, a cervical ablativeprocedure is the next best step in management. This can be accomplished with a loop electrical excision procedure (LEEP).
Main explanation
Excisional or ablative procedures, such as a loop electrical excision procedure (LEEP), laser therapy, cryotherapy, and cervical cone biopsy are appropriate for the management of cervical intraepithelial neoplasia (CIN) grades 2 or 3.CIN 1 lesions often regress spontaneously without further management and only follow up for repeat smear or colposcopy is required. The rate of spontaneous regression of CIN 2 or 3 is lower, warranting a procedure to remove the abnormal cells. If left untreated, CIN may progress to cervical cancer.The choice of procedure should be considered carefully in women of childbearing age as these procedures may compromise cervical integrity and can be associated with a slight increase in preterm birth.
Repeat colposcopy to rule out false positive
Repeat colposcopy is unnecessary given the recent colposcopy showing cervical intraepithelial neoplasia (CIN) grade 3. Instead, active treatment is required to avoid progression to invasive carcinoma.
Vaginal hysterectomy
Hysterectomy, either abdominal or vaginal, is used in the treatment of establish cervical cancer. CIN 3 is carcinoma in situ and can be managed with less invasive procedures
Question 2.
A 51-year-old woman is seeking a psychological evaluation for a learning disability. Her mother was 45 at the time of birth, and she was told as a child that she was deprived of oxygen during delivery which caused minor brain damage. She does not think this is true. She states that she has always felt awkward and incapable in social situations, never knowing the right thing to say. She has always been clumsy. Her mood will change rapidly, especially in public, and she will withdraw into herself and only feel capable of glaring and muttering under her breath. While she has few interests, they are topics about which she has an incredible knowledge. She follows the same exact schedule every day and becomes extremely flustered when something interferes with her plans. She tends to avoid eye contact or stare blankly. Which of the following is the most likely diagnosis?
Autism spectrum disorder
Major takeaway
Autism spectrum disorder is a condition characterized by persistent impairment in social interactions and restrictive/repetitive behaviors, patterns and interests.
Main explanation
The patient in this question most likely has autism spectrum disorder which is the DSM 5 category that consolidates autistic disorder, Asperger’s disorder, and pervasive developmen¬tal disorder. Autism spectrum disorder is characterized by atypical social development, including a lack of social awareness or inability to socialize, coupled with extreme behavioral rigidity. Although the cause is largely unknown, there are multiple etiologies associated including birth complications and genetic factors. During preschool years children with autism spectrum disorder may be asymptomatic. Later children start to have delayed use of nonverbal components of communication, limited attention, and do not respond to social communication demands. They can have normal language development. Behavioral disturbances are also present, and other features include clumsiness, average or above average school performance, and comorbidity with psychiatric conditions. Clinical assessments and a formal diagnostic interview along with clinical judgement are the standard for diagnosing autism spectrum disorder.
Dissociative identity disorder
Dissociative identity disorder is a complex and chronic posttraumatic psychopathology related to early and severe child abuse. Dissociation is the disruption of normal integrative processes of perception, memory, consciousness, and identity.
Generalized anxiety disorder
Generalized anxiety disorder is characterized by excessive, uncontrollable and irrational worry about events and activities and interferes with daily functioning.
Neonatal asphyxia
Neonatal asphyxia occurs due to deprivation of oxygen during birth, which can be caused by a variety of reasons. Neurodevelopmental abnormalities are possible depending on severity and duration of hypoxia.
Schizoid personality disorder
Schizoid personality disorder is characterized by a lack of interest in social relationships, a solitary lifestyle, secretiveness, emotional coldness, and apathy.
Question 3.
A 35 year-old woman comes to the office because of loss of vision in her right eye for 3 days. She says that two days before the loss of vision, she had pain within the right orbital region, exacerbated by eye movement. The pain also worsened with palpation of the area around her eye. Visual Examination shows she has diminished pupillary responses to light, but the pupil is not dilated in ambient light. She also has consensual light reflex from the non affected eye. Which of the following is the most likely diagnosis?
Horner's syndrome
Horner’s syndrome is a combination of symptoms that arises the sympathetic trunk is damaged. Symptoms occur on the same side as the lesion of the sympathetic trunk. It is characterized by miosis (a constricted pupil), ptosis (a weak, droopy eyelid), apparent anhidrosis (decreased sweating), with or without enophthalmos (inset eyeball).
Idiopathic intracranial hypertension
Idiopathic intracranial hypertension is characterized by headache, nausea, and vomiting, as well as pulsatile tinnitus, and double vision. If untreated, it may lead to swelling of the optic disc in the eye, which can progress to vision loss.
Optic neuritis
Major takeaway
Multiple sclerosis (MS) commonly presents with optic neuritis, which is characterized by visual loss which may be accompanied by pain particularly with eye movement or direct palpation. Diminished pupillary response accompanies severe vision loss.
Main explanation
25% of patients with Multiple Sclerosis (MS) present as initial manifestation an episode of optic neuritis. The patients have (over a period of several days) a partial or total loss of vision in one eye. Before the visual loss, the patients may experience pain within the orbit of the affected eye, exacerbated by eye movement or palpation of the globe.
In cases where there is substantial visual loss, there is normally a diminished pupillary response to light (afferent pupillary paralysis) and the pupil is not dilated in ambient light. If the optic neuritis is unilateral, the consensual light reflex from the normal eye is retained.
Half of patients with optic neuritis recover completely. More than one half of patients with optic neuritis will develop other signs of MS.
Remember that MS is chronic disease characterized by selective demyelination of the CNS with a classic location of plaques at the angles of the lateral ventricles. It is clinically characterized by episodes of focal disorders of the optic nerves, spinal cord, and brain, which remit to a varying extent and recur over a period of years.
Temporal lobe stroke
A lesion in the temporal lobe that results in damage to Meyer’s loop causes a characteristic loss of vision in a superior quadrant (quadrantanopia or “pie in the sky” defect.)
Giant-cell arteritis
Giant-cell arteritis is an inflammatory disease of blood vessels most commonly involving large and medium arteries of the head, predominantly the branches of the external carotid artery. The most serious complication is occlusion of the ophthalmic artery, which can cause painless, permanent loss of vision.
Question 4.
An 8-year-old girl comes to the emergency department because she is a victim of physical abuse. After the case was notified to the authorities by one of their neighbors, she was removed from home and taken into the custody of child protection services. Which of the following disorders is this patient most at risk for in adulthood?
Asperger syndrome
Asperger syndrome is a developmental disorder characterized by difficulties in social interaction and nonverbal communication. The cause is unknown, but thought to be partly inherited.
Attention deficit hyperactivity disorder
Attention deficit hyperactivity disorder is a psychiatric disorder of the neurodevelopment type. Symptoms include problems paying attention, excessive activity, and difficulty controlling behavior.
Borderline personality disorder
Major takeaway
Borderline personality disorder is a pattern of abnormal behavior with extreme fear of abandonment, and unstable relationships with other people. This pattern of behavior typically begins in early adulthood. Victims of child abuse are at risk of developing borderline personality disorder.
Main explanation
Borderline personality disorder is a pattern of abnormal behavior with extreme fear of abandonment, and unstable relationships with other people. This pattern of behavior typically begins in early adulthood. Substance abuse, depression, and eating disorders often co-exist with borderline personality disorder. Although the specific causes for Borderline personality disorder are unknown, several studies have shown that victims of child abuse are at risk of developing this condition. Furthermore, research has shown that there may be a genetic predisposition that associates child abuse with an increased risk for borderline personality disorder in adulthood: Tryptophan Hydroxylase I Polymorphisms. Borderline personality disorder consists of variable mood shifts, self-mutilation, impulsiveness, and a sense of emptiness.
Childhood disintegrative disorder
Childhood disintegrative disorder is a rare condition with late onset of developmental delays in social function, motor skills, and language. The cause for this disorder is unknown, but has been linked to autism spectrum disorder.
Delusional disorder
Delusional disorder is a mental illness characterized by delusions with no prominent hallucinations, thought disorder, or mood disorder. The delusions cannot be the effects of a drug, medication, or general medical condition to be considered a delusional disorder.
Question 5.
A 5-year-old boy is brought to his pediatrician because of anal itching, nocturnal restlessness, and irritability for the past two days. Upon examination of the rectal area, small (approximately 8-10 millimeters in length) thread-like, white specimens can be seen near the anus (see image below). The pediatrician performs a cellophane-tape test and sends the tape to the laboratory for microscopic examination. Which of the following is the most likely diagnosis?
Bedbug bite
Bedbugs are ectoparasites of the Cimicidae family whose blood-sucking bites can cause intense itching, among other skin reactions, in mammals or birds. Their activities also tend to occur at night as they are nocturnal. However, the insects are a reddish-brown color unlike the white organism in the image above.
Crohn disease
Crohn disease is a chronic inflammatory condition that affects any part of the gastrointestinal tract, including the anus. Inflammation in the anus could cause itching as seen in this patient. However, this patient does not present with other characteristic symptoms of Crohn disease such as abdominal pain and diarrhea.
Louse infestation
Lice are blood-sucking ectoparasites. A louse infestation, such as body or pubic lice, would cause similar symptoms as seen in this patient. Lice can also be examined with the cellophane-tape test; however, examination with the naked eye would show an arthropod-like insect, not the thread-like worms in the image above.
Pinworm infection
Major takeaway
A pinworm infection is an infestation of the nematode Enterobius vermicularis. The pinwormis a white, threadlike organism that resides in the cecum, appendix, and ascending colon. Females may lay egg in the anal area. The movement of the worm causes intense anal pruritus. It is most common in children.
Main explanation
A pinworm infection is caused by the nematode Enterobius vermicularis which is just visible to the naked eye (about 10 millimeters in length). The primary symptom of intense itchiness in the perianal area is due to the pregnant female pinworm’s movement and tail insertion by which she deposits her ova, usually at night. Other symptoms include prickling pain in the anal area, abdominal discomfort, and loss of appetite. Many cases of infection are asymptomatic. The infection is commonly a pediatric condition. The female pinworm may or may not lay her eggs, resulting in patients being egg-positive or egg-negative, respectively. Because the female will usually lay her eggs at night, the cellophane-tape test will show best results in the early morning. The cellophane-tape examination can be used to garner the eggs for microscopic viewing and differential diagnosis.
Scabies
Scabies is a skin infestation caused by the mite Sarcoptes scabiei hominis that causes pruritus. It can affect the anal area with intense itching. However, patients with scabies will present with a linear burrow caused by the mite’s movement which is not seen in this patient.
Question 6.
A 70-year-old man comes to the office because he has had increasing frequency of urination. He says that he has to get out of bed about five times per night to go to the bathroom. Further examination is performed and he is diagnosed with benign prostatic hyperplasia. Which of the following is the most appropriate management for this patient?
Bladder training
Bladder training is a first line behavioral modification in patients with urge or stress incontinence. Patients with BPH benefit from medical management.
Cyproterone acetate
Cyproterone acetate is used for its properties as an androgen receptor antagonist blocking testosterone and dihydrotestosterone. It is also a progesterone agonist and glucocorticoid antagonist. Although it may be used to treat benign prostatic hyperplasia (BPH) and hyperandrogenism, it has been replaced by other, more selective medications.
Finasteride
Major takeaway
Benign prostatic hyperplasia is DHT-dependent. Finasteride is a 5α-reductase enzyme inhibitor that decreases the formation of DHT thus relieving the symptoms of obstruction and urinary retention by reducing the size of the prostate.
Main explanation
When symptomatic, BPH can lead to increased frequency of urination, nocturia, urinary hesitancy, urgency, and weak stream. Treatment is only implemented in symptomatic cases and usually begins with medical therapy (patients with bladder outlet obstruction might require more invasive management). Alpha-1-adrenergic antagonists and 5-alpha-reductase inhibitors are two classes of drugs used in the medical management of BPH. Finasteride and dutasteride are 5α-reductase inhibitors that inhibit the conversion of testosterone into DHT (dihydrotestosterone). Six to twelve months of treatment are generally required before the prostate volume, which is DHT dependent, decreases enough to provide improvement of symptoms. This class of medication is more effective in men with larger prostates. Alpha-1-adrenergic antagonists have the advantage of reducing blood pressure, but this might lead to adverse side effects of hypotension.
Partial prostatectomy
Prostatectomy may be indicated in cases such as prostate cancer or renal insufficiency secondary to chronic bladder outlet obstruction, but it is not indicated for benign prostatic hyperplasia
Self retaining catheter
A self retaining catheter (e.g. Foley) may be indicated chronically in cases of urinary incontinence due to bladder outlet obstruction or neurogenic bladder.
Question 7.
A 47-year-old man comes to the office because of a 1-week history of right knee pain and limited lower limb movement. His medical history is relevant to previous knee trauma and a recently diagnosed rheumatoid arthritis. The patient currently works as a football coach. Physical examination shows well-circumscribed swelling, tenderness, and increased volume in the posterior region of the right knee and limited 90-degree angle extension/in flexion of his right knee. Additionally, the increased volume in the right knee posterior region disappears with a 45-degree flexion. His temperature is 36.4°C (97.5°F), pulse is 80/min, respirations are 14/min, blood pressure is 110/60 mmHg. Which of the following is the most likely cause of this patient’s condition?
Aneurysmal bone cyst
An aneurysmal bone cyst is a benign bone neoplasm that consists of several sponge-like blood or serum filled non-endothelialized spaces. This tumor commonly affects the proximal humerus, femur, tibia, and pelvis. However, patients with aneurysmal bone cyst would not have the lesion disappear with a 45-degree angle on physical examination.
Baker's cyst
Major takeaway
Baker’s cyst is a benign popliteal fluid collection in the gastrocnemius-semimembranosus bursa. This fluid collection commonly communicates with the synovial space. Physical examination classically reveals the Foucher’s sign, which is the evanescence of the cyst with a 45-degree knee flexion.
Main explanation
The patient in the vignette is experiencing a Baker’s cyst. A Baker’s cyst is a benign poplitealfluid collection in the gastrocnemius-semimembranosus bursa. This fluid collection commonly communicates with the synovial space, therefore the pathogenesis is caused by a valve-like connection between the knee joint and the gastrocnemius-semimembranosus bursa, resulting in fluid being squeezed into a single direction.
Baker cyst has a bimodal age distribution since it most commonly affects young children and middle-aged adults. In the majority of cases, this condition is caused by chronic joint disease(i.e., athletes), degenerative arthropathy, and rheumatoid arthritis.
Physical examination classically reveals the Foucher’s sign, which is the evanescence of the cyst with a 45-degree knee flexion. Other findings may show increased volume on popliteal fossa and a rounded, mobile mass, with a sensation of fluid content of well-definededges.
The diagnosis is initially established with a knee ultrasound. Further imaging assessment can be performed with a knee MRI. The most common complication of Baker’s cyst is cyst rupture into the popliteal fossa. Treatment usually depends on the presence of complications or symptomatic presentation. Aspiration and local injection of corticosteroids are commonly practiced to relieve symptoms caused by the cyst.
Popliteal aneurysm
A popliteal aneurysm is a common type of peripheral aneurysm characterized by bulging of the popliteal artery. This condition is usually an incidental finding, since, patients are normally asymptomatic. Here, however, the patient has a history of knee trauma and rheumatoid arthritis, both conditions are predisposing for Baker’s cyst.
Popliteal artery entrapment syndrome
Popliteal artery entrapment syndrome is a rare condition which results in claudication and chronic leg ischemia. Patients often present with right-calf claudication, coldness, and leg numbness. Here, however, none of this symptoms or signs are present in this patient.
Synovial sarcoma
Synovial sarcoma is a malignant soft tissue neoplasm of the synovial membrane. This condition is more common among adolescents and young adults. Patients often present with asymptomatic swelling or a growing mass. Here, however, the patient circumcised mass that disappears with a 45-degree flexion.
Question 8.
A 26-year old man comes to the office because of unexplained sadness, suicidal thoughts, and agitation. He appears preoccupied and engages in face-picking and nail biting. The symptoms have been ongoing, causing severe deterioration in the student’s grades at graduate school and motivation to participate in intramural sports, previously one of his favorite past-times. Which of the following medications is the most appropriate first-line treatment for this patient?
Bupropion
Bupropion is an atypical antidepressant that acts as a dopamine and norepinephrine reuptake inhibitor. It is also indicated for smoking cessation.
Levominalcipran
Levominalcipran is a serotonin-norepinephrine reuptake inhibitor (SNRI). Should the patient fail a trial of a SSRI, augmentation or transition to an SNRI is an appropriate next step of management.
Mirtazapine
Mirtazapine is a tetracyclic antidepressant used to treat atypical depression by antagonizing presynaptic α2 adrenergic receptorsand postsynaptic serotonin 5-HT2 and serotonin 5-HT3 receptors. An atypical antidepressant is not a first-line treatment for depression.
Sertraline
Major takeaway
In the pharmacological management of major depressive disorder, a selective serotonin reuptake inhibitors such as sertraline and fluoxetine is the drug of choice.
Main explanation
The monoamine hypothesis of depression states that depression in a patient of the anxiousand obsessive-compulsive type, serotonin is likely the neurotransmitter of malfunction. As such, a selective serotonin reuptake inhibitor (SSRI) would be the drug of choice. This patient also displays symptoms of an anxiety disorder with his face picking and nail biting. Of the SSRI drug group, sertraline is reputedly one of the more anxiolytic SSRIs, and has a milder side effect profile and a low price due to the size of its market and the existence of generics.
Should the patient fail a trial of a SSRI, augmentation or transition to an SNRI (e.g. venlafaxineand levomilnacipran), or less preferably a tricyclic antidepressant, monoamine oxidase inhibitor, or atypical antidepressant (e.g. trazodone, mirtazapine, bupropion, and vortioxetine) could be attempted as symptoms and conditions warrant.
Venlafaxine
Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI). Should the patient fail a trial of a SSRI, augmentation or transition to an SNRI is an appropriate next step of management.
Question 9.
A 23 year-old man comes to the psychiatry clinic, accompanied by his mother, because she is concerned after seeing cut marks on his arms. His mother says that his life is chaotic and unstable. He often brings nice girls home whom he “likes a lot” to meet his family, only to come home days later, slam his bedroom door shut, and yell that he “hates all of them” and “just wants to be alone”. He has difficulty keeping jobs because of his angry outbursts, but also has no trouble finding a new one because he can be very friendly and professional in interviews. Which of the following is the most likely diagnosis?
Antisocial personality disorder
Characterized by disregard for and violation of rights of others, often including criminal behavior. These patients must have a history of conduct disorder before age 18. They often have an uncanny ability to charm and deceive for personal gain.
Borderline personality disorder
Major takeaway
Borderline personality disorder is characterized by instability of interpersonal relationships, self-image, and emotions, as well as by impulsivity across a wide range of situations, causing significant impairment or subjective distress.
Main explanation
Borderline personality disorder is a pattern of abnormal behavior characterized by extreme fear of abandonment, or feelings of emptiness. Symptoms may be triggered by seemingly normal events, and typically begin to appear in early adulthood, although they can sometimes be observed in children. People with borderline personality disorder often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment. Substance abuse, impulsive relationships, and self harm are classic for borderline personality disorder. About 6% of these patients die by suicide. This disorder is typically treated with cognitive behavioral therapy or dialectical behavior therapy. Haloperidolmay be used to reduce anger, and flupenthixol may reduce the likelihood of suicidal behavior.
While this patient’s ability to charm in interviews could point to antisocial personality disorder, and his emotional outbursts could point to histrionic personality disorder, the constellation of symptoms (self-mutilation, mood instability, and splitting with regard to girls) point to borderline personality disorder.
Histrionic personality disorder
Characterized by attention-seeking behavior, excessive emotionality and excitability, sexual provocation, and excessive concern with appearance. These patients are lively, dramatic, vivacious, and flirtatious.
Schizotypal personality disorder
Characterized by eccentric appearance, odd beliefs or magical thinking, and interpersonal awkwardness. Thee patients feel extreme discomfort with maintaining close relationships with people because they think their peers have negative thoughts towards them.
Avoidant personality disorder
Characterized by hypersensitivity to rejection, social inhibition and timidity, and feelings of inadequacy. These patients often describe themselves as uneasy, anxious, lonely, and unwanted.
Question 10.
A 65-year-old woman comes to the office because of a vulvar mass that has been present for the past several months. She has had intense pruritus and the mass has increased in size progressively. She had experienced vaginal itching in the past that was relieved with topical estrogen treatment, but the cream seems to have no effect on this mass. She has smoked one pack of cigarettes per day for the past 50 years. Medical history is significant for a history of abnormal Pap smears that were treated with a cold knife cone biopsy. Vaginal examination shows a unifocal plaque with ulceration on the labia majora. No signs of active infection are noted. Which of the following is the most likely diagnosis in this patient?
Bartholin duct abscess
A Bartholin duct abscess will present with a chief complaint of severe pain and swelling. Examination will reveal a warm,tender mass in the lower medial labia majora or lower vestibular area surrounded by erythema and edema.
Hidradenoma
Hidradenomas are found in patients with hidradenitis suppurativa. The onset is typically during puberty and a single lesion can last seven days. The lesions are painful and can develop into abscesses. Given this patient’s new onset of symptoms and lack of resolution, it is unlikely to be a hidradenoma.
Normal anatomy
The symptoms of pruritus, ulcerated plaques, and enlargement of a mass are not seen in the absence of pathology.
Seborrheic keratosis
Seborrheic keratoses are benign lesions. They appear as stuck on, warty, well-circumscribed, and often scaly hyperpigmentedlesions that are typically an annoyance for patients.
Vulvar carcinoma
Major takeaway
Vulvar pruritus is the most common symptom of vulvar cancer. Diagnosis should be achieved with a vulvar biopsy taken from the center of the lesion.
Main explanation
Vulvar cancer is the fourth most common gynecologic cancer. The mean age at diagnosis is 65. Risk factors for vulvar cancer include cigarette smoking, vulvar dystrophy (i.e. lichen sclerosus), vulvar or cervical intraepithelial neoplasia, human papillomavirus (HPV) infection, immunodeficiency syndromes, a history of cervical cancer, and northern European ancestry. This patient is in the appropriate age group, and likely has a history of HPV infection given the history of abnormal pap smears.
Most patients will present with a unifocal vulvar plaque, ulcer, or mass on the labia majora. Pruritus is a common complaint, however, many patients are asymptomatic at the time of diagnosis. Definitive diagnosis is based upon histologic examination of a vulvar biopsy.
