A 32-year-old G1P0 woman presents to her obstetrician for a prenatal visit. She is 30 weeks pregnant. She reports some fatigue and complains of urinary urgency. Prior to this pregnancy, she had no significant medical history. She takes a prenatal vitamin and folate supplements daily. Her mother has diabetes, and her brother has coronary artery disease. On physical examination, the fundal height is 25 centimeters. A fetal ultrasound shows a proportional reduction in head circumference, trunk size, and limb length. Which of the following is the most likely cause of the patient’s presentation?
Q2
A 24-year-old woman, gravida 1, para 0, at 39 weeks' gestation, is admitted to the hospital in active labor. She currently has contractions occurring every 3–5 minutes. For the past 3 days, she has had burning pain in the vulvar area associated with intense itching. Her pregnancy has been uneventful. She has a history of genital herpes at the age of 16, which was treated with acyclovir. Her vital signs are within normal limits. Genital examination shows grouped vesicles on an erythematous base over the vulvar region. Pelvic examination shows rupture of membranes and that the cervix is 3 cm dilated. Which of the following is the most appropriate next step in management?
Q3
An investigator studying patients with symptoms of arthritis detects a nonenveloped virus with a single-stranded DNA genome in the serum of a pregnant patient. Fetal infection with this pathogen is most likely to cause which of the following manifestations?
Q4
A 3175-g (7-lb) female newborn is delivered at 37 weeks to a 26-year-old primigravid woman. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. The pregnancy had been uncomplicated. The mother had no prenatal care. She immigrated to the US from Brazil 2 years ago. Immunization records are not available. One day after delivery, the newborn's temperature is 37.5°C (99.5°F), pulse is 182/min, respirations are 60/min, and blood pressure is 82/60 mm Hg. The lungs are clear to auscultation. Cardiac examination shows a continuous heart murmur. The abdomen is soft and nontender. There are several discolored areas on the skin that are non-blanchable upon pressure application. Slit lamp examination shows cloudy lenses in both eyes. The newborn does not pass her auditory screening tests. Which of the following is the most likely diagnosis?
Q5
A 3-day-old female newborn delivered vaginally at 36 weeks to a 27-year-old woman has generalized convulsions lasting 3 minutes. Prior to the event, she was lethargic and had difficulty feeding. The infant has two healthy older siblings and the mother's immunizations are up-to-date. The infant appears icteric. The infant's weight and length are at the 5th percentile, and her head circumference is at the 99th percentile for gestational age. There are several purpura of the skin. Ocular examination shows posterior uveitis. Cranial ultrasonography shows ventricular dilatation, as well as hyperechoic foci within the cortex, basal ganglia, and periventricular region. Which of the following is the most likely diagnosis?
Q6
A 23-year-old man comes to the physician for frequent and painful urination. He has also had progressive painful swelling of his right knee over the past week. He is sexually active with two female partners and uses condoms inconsistently. His mother has an autoimmune disease that involves a malar rash. Examination shows conjunctivitis bilaterally. The right knee is warm, erythematous, and tender to touch; range of motion is limited. Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h. Urinalysis shows WBCs. Further evaluation of this patient is most likely to reveal which of the following?
Q7
A 28-year-old man presents to the office complaining of a sore throat, difficulty swallowing, and difficulty opening his mouth for the past 5 days. He states that he had symptoms like this before and "was given some antibiotics that made him feel better". He is up to date on his immunizations. On examination, his temperature is 39.5°C (103.2°F) and he has bilateral cervical lymphadenopathy. An oropharyngeal exam is difficult, because the patient finds it painful to fully open his mouth. However, you are able to view an erythematous pharynx as well as a large, unilateral lesion superior to the left tonsil. A rapid antigen detection test is negative. Based on this clinical presentation, what is a serious complication of the most likely diagnosis?
Q8
A 65-year-old man is brought to the emergency department after coughing up copious amounts of blood-tinged sputum at his nursing home. He recently had an upper respiratory tract infection that was treated with antibiotics. He has a long-standing history of productive cough that has worsened since he had a stroke 3 years ago. He smoked a pack of cigarettes daily for 40 years until the stroke, after which he quit. The patient appears distressed and short of breath. His temperature is 38°C (100.4°F), pulse is 92/min, and blood pressure is 145/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Physical examination shows digital clubbing and cyanosis of the lips. Coarse crackles are heard in the thorax. An x-ray of the chest shows increased translucency and tram-track opacities in the right lower lung field. Which of the following is the most likely diagnosis?
Q9
A 9-month-old boy is brought to the physician because of abnormal crawling and inability to sit without support. A 2nd-trimester urinary tract infection that required antibiotic use and a spontaneous preterm birth via vaginal delivery at 36 weeks’ gestation both complicated the mother’s pregnancy. Physical examination shows a scissoring posture of the legs when the child is suspended by the axillae. Examination of the lower extremities shows brisk tendon reflexes, ankle clonus, and upward plantar reflexes bilaterally. When encouraged by his mother, the infant crawls forward by using normal reciprocal movements of his arms, while his legs drag behind. A brain MRI shows scarring and atrophy in the white matter around the ventricles with ventricular enlargement. Which of the following is most likely associated with the findings in this child?
Q10
You are called to the bedside of a 75-year-old woman, who is post-op day 4 from a right total hip replacement. The patient appears agitated; she is trying to pull out her IV, and for the past 4 hours she has been accusing the nursing staff of trying to poison her. Her family notes that this behavior is completely different from her baseline; she has not shown any signs of memory loss or behavioral changes at home prior to the surgery. You note that she still has an indwelling catheter. She continues on an opioid-based pain regimen. All of the following are potential contributors to the patient’s presentation EXCEPT:
Congenital TORCH infections US Medical PG Practice Questions and MCQs
Question 1: A 32-year-old G1P0 woman presents to her obstetrician for a prenatal visit. She is 30 weeks pregnant. She reports some fatigue and complains of urinary urgency. Prior to this pregnancy, she had no significant medical history. She takes a prenatal vitamin and folate supplements daily. Her mother has diabetes, and her brother has coronary artery disease. On physical examination, the fundal height is 25 centimeters. A fetal ultrasound shows a proportional reduction in head circumference, trunk size, and limb length. Which of the following is the most likely cause of the patient’s presentation?
A. Gestational diabetes
B. Antiphospholipid syndrome
C. Rubella infection (Correct Answer)
D. Pre-eclampsia
E. Cigarette smoking
Explanation: **Rubella infection**
- The **reduced fundal height** (25 cm at 30 weeks) and **symmetrically small fetus** (proportional reduction in head, trunk, and limbs) are characteristic findings of **intrauterine growth restriction (IUGR)** due to a congenital infection like rubella.
- Maternal symptoms like **fatigue** and **urinary urgency** are non-specific but, in the context of fetal findings, point towards a systemic process affecting both mother and fetus.
*Gestational diabetes*
- Fetal growth in gestational diabetes is typically characterized by **macrosomia** (large for gestational age), not IUGR.
- Clinical findings would usually include a **fundal height larger than expected** for gestational age due to a larger fetus.
*Antiphospholipid syndrome*
- This condition is associated with **recurrent pregnancy loss**, **thrombosis**, and **placental insufficiency**, which can lead to IUGR.
- However, the IUGR associated with antiphospholipid syndrome is typically **asymmetric**, meaning the head circumference is spared while the abdomen and other body parts are disproportionately small.
*Pre-eclampsia*
- Pre-eclampsia can cause **IUGR** due to placental insufficiency, but it is primarily characterized by **new-onset hypertension** and **proteinuria** after 20 weeks of gestation, which are not mentioned in this case.
- While fatigue and urgency can be present, the absence of hypertension and proteinuria makes pre-eclampsia less likely as the primary cause.
*Cigarette smoking*
- Maternal cigarette smoking is a known risk factor for **IUGR**, particularly **symmetrical IUGR**.
- However, the patient's medical history states "no significant medical history" and does not mention smoking, making an infection a more likely explanation given the context.
Question 2: A 24-year-old woman, gravida 1, para 0, at 39 weeks' gestation, is admitted to the hospital in active labor. She currently has contractions occurring every 3–5 minutes. For the past 3 days, she has had burning pain in the vulvar area associated with intense itching. Her pregnancy has been uneventful. She has a history of genital herpes at the age of 16, which was treated with acyclovir. Her vital signs are within normal limits. Genital examination shows grouped vesicles on an erythematous base over the vulvar region. Pelvic examination shows rupture of membranes and that the cervix is 3 cm dilated. Which of the following is the most appropriate next step in management?
A. Tocolytic therapy until lesions are crusted
B. Oral acyclovir therapy and vaginal delivery
C. Topical acyclovir and vaginal delivery
D. Oral acyclovir therapy and cesarean delivery (Correct Answer)
E. Topical acyclovir and cesarean delivery
Explanation: ***Oral acyclovir therapy and cesarean delivery***
- The presence of **active genital herpes lesions** at the time of labor poses a high risk of **neonatal herpes simplex virus (HSV) infection** during vaginal delivery, which can be severe or fatal for the neonate.
- **Acyclovir therapy** aims to reduce viral shedding and transmission, but given the active lesions and rupture of membranes, a **cesarean delivery** is indicated to prevent vertical transmission to the newborn.
*Tocolytic therapy until lesions are crusted*
- **Tocolytic therapy** is used to inhibit uterine contractions and delay labor, but it is not indicated for managing active herpes lesions in a term pregnancy as it would only delay an inevitable delivery.
- Waiting for lesions to crust would prolong labor unnecessarily and still carry a risk of transmission, especially with ruptured membranes.
*Oral acyclovir therapy and vaginal delivery*
- While **oral acyclovir** can help suppress viral shedding, a **vaginal delivery** is contraindicated when active genital herpes lesions are present at the onset of labor due to the significant risk of **neonatal HSV infection**.
- Ruptured membranes further increase the risk of ascending infection and direct contact during passage through the birth canal.
*Topical acyclovir and vaginal delivery*
- **Topical acyclovir** is generally less effective than oral antivirals in suppressing systemic viral replication and does not adequately prevent viral shedding from active lesions during labor.
- A **vaginal delivery** would still expose the neonate to the virus, making this an inappropriate choice given the high risk of neonatal herpes.
*Topical acyclovir and cesarean delivery*
- While a **cesarean delivery** is the correct mode of delivery in this scenario, **topical acyclovir** is not the optimal antiviral treatment for active genital herpes during labor.
- **Oral acyclovir** provides better systemic viral suppression and is the preferred antiviral agent in such cases, though the urgency of active lesions still necessitates a cesarean.
Question 3: An investigator studying patients with symptoms of arthritis detects a nonenveloped virus with a single-stranded DNA genome in the serum of a pregnant patient. Fetal infection with this pathogen is most likely to cause which of the following manifestations?
A. Hydrops fetalis (Correct Answer)
B. Notched teeth
C. Microcephaly
D. Chorioretinitis
E. Vesicular rash
Explanation: ***Hydrops fetalis***
- The description of a nonenveloped virus with a **single-stranded DNA genome** is characteristic of **Parvovirus B19**. This virus commonly causes hydrops fetalis due to **fetal anemia** and subsequent heart failure.
- Parvovirus B19 infection in pregnant women can lead to severe complications for the fetus, primarily due to tropism for **erythroid progenitor cells**, resulting in anemia.
*Notched teeth*
- **Hutchinson's teeth**, characterized by notches, are a classic manifestation of **congenital syphilis**, caused by the bacterium *Treponema pallidum*, not a virus.
- Syphilis is a spirochete and not a single-stranded DNA virus.
*Microcephaly*
- **Microcephaly** is a severe neurological abnormality often associated with congenital infections like **Zika virus** or **cytomegalovirus (CMV)**, which are RNA and double-stranded DNA viruses, respectively.
- While viral infections can cause microcephaly, Parvovirus B19 is primarily known for causing fetal anemia and hydrops, not typically microcephaly.
*Chorioretinitis*
- **Chorioretinitis** is a common ocular manifestation of congenital infections such as **toxoplasmosis**, **CMV**, and **rubella**, but it is not a hallmark of Parvovirus B19 infection.
- These pathogens have different genomic structures and disease presentations.
*Vesicular rash*
- A **vesicular rash** is characteristic of infections caused by **herpesviruses**, such as **varicella-zoster virus (VZV)** or herpes simplex virus.
- These are **double-stranded DNA viruses**, not single-stranded DNA viruses like Parvovirus B19.
Question 4: A 3175-g (7-lb) female newborn is delivered at 37 weeks to a 26-year-old primigravid woman. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. The pregnancy had been uncomplicated. The mother had no prenatal care. She immigrated to the US from Brazil 2 years ago. Immunization records are not available. One day after delivery, the newborn's temperature is 37.5°C (99.5°F), pulse is 182/min, respirations are 60/min, and blood pressure is 82/60 mm Hg. The lungs are clear to auscultation. Cardiac examination shows a continuous heart murmur. The abdomen is soft and nontender. There are several discolored areas on the skin that are non-blanchable upon pressure application. Slit lamp examination shows cloudy lenses in both eyes. The newborn does not pass her auditory screening tests. Which of the following is the most likely diagnosis?
A. Congenital CMV infection
B. Congenital syphilis
C. Congenital parvovirus B19 infection
D. Congenital toxoplasmosis
E. Congenital rubella infection (Correct Answer)
Explanation: ***Congenital rubella infection***
- The constellation of **congenital cataracts** (cloudy lenses), **patent ductus arteriosus** (continuous murmur), **sensorineural hearing loss** (failed auditory screening), and **blueberry muffin rash** (discolored, non-blanchable skin areas) is highly characteristic of congenital rubella syndrome.
- The mother's lack of prenatal care and unknown immunization status, coupled with immigration from Brazil where rubella might be more prevalent, increases the likelihood of an unvaccinated mother acquiring the infection during pregnancy.
*Congenital CMV infection*
- While CMV can cause **sensorineural hearing loss**, it typically presents with **periventricular calcifications** on neuroimaging, **microcephaly**, and often **hepatosplenomegaly** and **thrombocytopenia**, which are not mentioned here.
- Although CMV can cause chorioretinitis and cataracts, the classic cardiac and skin findings of rubella are absent.
*Congenital syphilis*
- Congenital syphilis can present with a wide range of manifestations, including **hepatosplenomegaly**, **snuffles**, **bone lesions** (e.g., periostitis), and a **rash**, but the specific combination of cataracts, patent ductus arteriosus, and blueberry muffin rash is not typical.
- Eye involvement in syphilis is usually interstitial keratitis, not cataracts, and cardiac defects are less common or different.
*Congenital parvovirus B19 infection*
- Parvovirus B19 is primarily associated with **hydrops fetalis**, severe **anemia**, and sometimes myocarditis.
- It does not typically cause **cataracts**, **patent ductus arteriosus**, or the characteristic rash seen in this case.
*Congenital toxoplasmosis*
- Congenital toxoplasmosis classically presents as a triad of **hydrocephalus**, **intracranial calcifications**, and **chorioretinitis**.
- It does not typically cause **congenital cataracts**, **patent ductus arteriosus**, or the "blueberry muffin" rash.
Question 5: A 3-day-old female newborn delivered vaginally at 36 weeks to a 27-year-old woman has generalized convulsions lasting 3 minutes. Prior to the event, she was lethargic and had difficulty feeding. The infant has two healthy older siblings and the mother's immunizations are up-to-date. The infant appears icteric. The infant's weight and length are at the 5th percentile, and her head circumference is at the 99th percentile for gestational age. There are several purpura of the skin. Ocular examination shows posterior uveitis. Cranial ultrasonography shows ventricular dilatation, as well as hyperechoic foci within the cortex, basal ganglia, and periventricular region. Which of the following is the most likely diagnosis?
A. Congenital parvovirus infection
B. Congenital Toxoplasma gondii infection (Correct Answer)
C. Congenital Treponema pallidum infection
D. Congenital cytomegalovirus infection
E. Congenital rubella infection
Explanation: ***Congenital Toxoplasma gondii infection***
- **Ventricular dilatation** with widespread **hyperechoic foci** (calcifications) in the brain, along with **posterior uveitis**, highly suggests congenital toxoplasmosis.
- Other features like **generalized convulsions**, **icterus**, **purpura**, and **microcephaly** (indicated by 5th percentile weight/length vs 99th percentile head circumference discrepancy suggesting hydrocephalus with macrocephaly) are also consistent with this diagnosis.
*Congenital parvovirus infection*
- Primarily causes severe **anemia**, **hydrops fetalis**, and **myocarditis**; it does not typically present with extensive cerebral calcifications or uveitis.
- While it can lead to neurological issues, the specific brain imaging findings and ocular involvement described are not characteristic.
*Congenital Treponema pallidum infection*
- Characterized by rhinitis (**snuffles**), **hepatosplenomegaly**, **bone abnormalities** (e.g., osteochondritis), and **rash**.
- While it can cause CNS involvement and developmental delays, the distinct pattern of brain calcifications and uveitis is not typical.
*Congenital cytomegalovirus infection*
- Can cause **periventricular calcifications**, but the widespread, diffuse calcifications (cortex, basal ganglia, periventricular) are less typical than with toxoplasmosis, which often shows more diffuse parenchymal calcifications.
- While it shares features like small for gestational age, icterus, and purpura, **posterior uveitis** is more strongly associated with toxoplasmosis.
*Congenital rubella infection*
- Classic triad includes **cataracts** (or glaucoma), **sensorineural hearing loss**, and **congenital heart defects** (e.g., PDA, pulmonary artery stenosis).
- While CNS involvement (e.g., intellectual disability, microcephaly) can occur, the widespread cerebral calcifications and posterior uveitis are not characteristic.
Question 6: A 23-year-old man comes to the physician for frequent and painful urination. He has also had progressive painful swelling of his right knee over the past week. He is sexually active with two female partners and uses condoms inconsistently. His mother has an autoimmune disease that involves a malar rash. Examination shows conjunctivitis bilaterally. The right knee is warm, erythematous, and tender to touch; range of motion is limited. Laboratory studies show an erythrocyte sedimentation rate of 62 mm/h. Urinalysis shows WBCs. Further evaluation of this patient is most likely to reveal which of the following?
A. Hiking trip two months ago
B. Recent norovirus gastroenteritis
C. Chondrocalcinosis of the left knee
D. Positive anti-dsDNA antibodies
E. HLA-B27 positive genotype (Correct Answer)
Explanation: ***HLA-B27 positive genotype***
- The patient's symptoms (urethritis, conjunctivitis, and arthritis) constitute the classic triad of **Reiter's syndrome**, a form of **reactive arthritis**.
- **Reactive arthritis** is strongly associated with the **HLA-B27 genotype**, which is found in a significant majority of affected individuals.
*Hiking trip two months ago*
- This information is vague and does not directly link to a specific pathogen or trigger for reactive arthritis.
- While some bacterial infections can be acquired through environmental exposure, there is no direct evidence provided in the stem to support a connection.
*Recent norovirus gastroenteritis*
- **Norovirus** typically causes acute, self-limiting gastroenteritis and is not commonly associated with the development of **reactive arthritis**.
- Reactive arthritis is primarily triggered by certain **genitourinary** or **gastrointestinal bacterial infections** (e.g., Chlamydia, Shigella, Salmonella, Campylobacter).
*Chondrocalcinosis of the left knee*
- **Chondrocalcinosis** (calcium pyrophosphate deposition disease or pseudogout) primarily affects older individuals and typically presents with acute, severe arthritis.
- While it can affect the knee, it is not consistently associated with the extra-articular manifestations (urethritis, conjunctivitis) seen in this patient, and its etiology is distinct from reactive arthritis.
*Positive anti-dsDNA antibodies*
- **Positive anti-dsDNA antibodies** are a hallmark of **systemic lupus erythematosus (SLE)**, an autoimmune disease.
- While SLE can cause arthritis and sometimes conjunctivitis, it does not typically cause urethritis in the manner described, nor does it fit the overall clinical picture as well as reactive arthritis.
Question 7: A 28-year-old man presents to the office complaining of a sore throat, difficulty swallowing, and difficulty opening his mouth for the past 5 days. He states that he had symptoms like this before and "was given some antibiotics that made him feel better". He is up to date on his immunizations. On examination, his temperature is 39.5°C (103.2°F) and he has bilateral cervical lymphadenopathy. An oropharyngeal exam is difficult, because the patient finds it painful to fully open his mouth. However, you are able to view an erythematous pharynx as well as a large, unilateral lesion superior to the left tonsil. A rapid antigen detection test is negative. Based on this clinical presentation, what is a serious complication of the most likely diagnosis?
A. Infectious mononucleosis
B. Acute rheumatic fever
C. Lemierre syndrome (Correct Answer)
D. Whooping cough
E. Diphtheria
Explanation: ***Lemierre syndrome***
- The patient's symptoms (sore throat, dysphagia, trismus), fever, unilateral peritonsillar lesion, and cervical lymphadenopathy are highly suggestive of a **peritonsillar abscess**.
- **Lemierre syndrome** is a severe complication of oropharyngeal infections, especially peritonsillar abscesses, involving thrombophlebitis of the internal jugular vein and septic emboli.
*Infectious mononucleosis*
- While mononucleosis can cause severe pharyngitis and lymphadenopathy, it typically presents with **bilateral tonsillar enlargement** and exudates, not a unilateral peritonsillar lesion.
- Furthermore, a history of recurrent strep-like symptoms and effective antibiotic response makes streptococcal infection (and its complications) more likely.
*Acute rheumatic fever*
- This is a non-suppurative complication of untreated **Group A Streptococcus (GAS)** pharyngitis.
- The patient's unilateral peritonsillar lesion points to a localized suppurative infection (abscess), making acute rheumatic fever less likely as a direct complication of the *current* presentation.
*Whooping cough*
- Also known as **pertussis**, this is a respiratory infection characterized by severe, **paroxysmal coughing fits** followed by a characteristic "whoop."
- The patient's symptoms of sore throat, difficulty swallowing, and a peritonsillar lesion are inconsistent with whooping cough.
*Diphtheria*
- Diphtheria causes a severe sore throat and the formation of a **thick, grey pseudomembrane** on the tonsils and pharynx.
- While serious, the patient's symptoms and the absence of a pseudomembrane make diphtheria less likely, especially with an updated immunization status.
Question 8: A 65-year-old man is brought to the emergency department after coughing up copious amounts of blood-tinged sputum at his nursing home. He recently had an upper respiratory tract infection that was treated with antibiotics. He has a long-standing history of productive cough that has worsened since he had a stroke 3 years ago. He smoked a pack of cigarettes daily for 40 years until the stroke, after which he quit. The patient appears distressed and short of breath. His temperature is 38°C (100.4°F), pulse is 92/min, and blood pressure is 145/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Physical examination shows digital clubbing and cyanosis of the lips. Coarse crackles are heard in the thorax. An x-ray of the chest shows increased translucency and tram-track opacities in the right lower lung field. Which of the following is the most likely diagnosis?
A. Aspiration pneumonia
B. Pulmonary embolism
C. Lung cancer
D. Bronchiectasis (Correct Answer)
E. Emphysema
Explanation: ***Bronchiectasis***
- The patient's history of **chronic productive cough**, **hemoptysis** (blood-tinged sputum), **digital clubbing**, and recent respiratory infection suggests bronchiectasis. The chest X-ray finding of **tram-track opacities** is highly characteristic of this condition, indicating bronchial wall thickening and dilation. The history of stroke placing him at risk for aspiration, and prior smoking also contribute to the risk of chronic lung damage.
- **Bronchiectasis** is defined by **permanent dilation of the bronchi** due to chronic inflammation and infection, leading to impaired mucociliary clearance and recurrent infections. The description perfectly fits the clinical and radiological picture.
*Aspiration pneumonia*
- While the patient's history of **stroke** increases his risk for **aspiration**, the chronic nature of his symptoms (long-standing productive cough worsening since stroke) and the presence of **digital clubbing** are less consistent with acute aspiration pneumonia.
- **Aspiration pneumonia** typically presents as an acute illness with fever and cough, and while it could explain some symptoms, it doesn't fully account for the chronic changes (clubbing, tram-track opacities).
*Pulmonary embolism*
- **Pulmonary embolism** usually presents with **acute onset dyspnea** and **pleuritic chest pain**, often without a history of chronic productive cough or digital clubbing. Hemoptysis can occur but is not typically copious and is associated with infarction.
- The chest X-ray findings of **increased translucency** and **tram-track opacities** are not characteristic of pulmonary embolism, which might show an area of opacification (Westermark sign, Hampton hump) or be normal.
*Lung cancer*
- While **lung cancer** can cause cough, hemoptysis, and shortness of breath, and the patient's smoking history is a risk factor, the description of **tram-track opacities** on chest X-ray is not characteristic of lung cancer. **Digital clubbing** can be seen, but the chronic productive cough for years is more indicative of a chronic inflammatory process.
- The typical X-ray findings for lung cancer would be a **mass lesion**, nodule, or atelectasis, not diffuse bronchial wall thickening.
*Emphysema*
- **Emphysema** is characterized by **shortness of breath** and a **chronic cough**, often related to a smoking history, and the X-ray might show **increased translucency** due to hyperinflation. However, copious **blood-tinged sputum** and **digital clubbing** are not typical features of emphysema.
- The classic X-ray finding for emphysema is **hyperinflation** with flattened diaphragms, and while increased translucency is mentioned, **tram-track opacities** are not seen; these indicate bronchial wall thickening, not alveolar destruction.
Question 9: A 9-month-old boy is brought to the physician because of abnormal crawling and inability to sit without support. A 2nd-trimester urinary tract infection that required antibiotic use and a spontaneous preterm birth via vaginal delivery at 36 weeks’ gestation both complicated the mother’s pregnancy. Physical examination shows a scissoring posture of the legs when the child is suspended by the axillae. Examination of the lower extremities shows brisk tendon reflexes, ankle clonus, and upward plantar reflexes bilaterally. When encouraged by his mother, the infant crawls forward by using normal reciprocal movements of his arms, while his legs drag behind. A brain MRI shows scarring and atrophy in the white matter around the ventricles with ventricular enlargement. Which of the following is most likely associated with the findings in this child?
A. Antenatal injury
B. Genetic defect
C. Postnatal head trauma
D. Intrapartum asphyxia
E. Preterm birth (Correct Answer)
Explanation: ***Preterm birth***
- The combination of **abnormal crawling**, **inability to sit without support**, **scissoring posture**, **spasticity**, and **periventricular white matter scarring** (periventricular leukomalacia, PVL) are classic signs of **spastic cerebral palsy**.
- **Preterm birth** is the most significant risk factor for **PVL** and the subsequent development of spastic cerebral palsy, particularly spastic diplegia.
- The **periventricular white matter** in preterm infants (especially <34 weeks, but also late preterm at 34-37 weeks) is highly vulnerable to ischemic injury due to immature vascular development and susceptibility to hypoxic-ischemic insults during the perinatal period.
- This infant was born at **36 weeks (late preterm)**, which is a known risk factor for PVL and cerebral palsy.
*Antenatal injury*
- While brain injury can occur in the antenatal period, the specific finding of **periventricular leukomalacia** is most characteristically associated with **prematurity** and perinatal/early postnatal events rather than purely antenatal injury.
- The term "antenatal injury" is too vague and doesn't capture the specific pathophysiology of PVL, which occurs around the time of birth in vulnerable preterm infants.
*Genetic defect*
- While some forms of cerebral palsy can have a genetic component, the clinical picture here, especially the MRI findings of **periventricular leukomalacia**, strongly points to an acquired brain injury rather than a primary genetic defect.
- Genetic conditions typically present with more widespread or specific neurodevelopmental abnormalities, often without the focal periventricular white matter scarring seen in PVL.
*Postnatal head trauma*
- **Postnatal head trauma** would typically present with a history of injury and more acute neurological deficits or focal lesions on imaging (e.g., subdural hematoma, contusions), rather than the characteristic **periventricular white matter scarring** observed here.
- The presentation is consistent with a developmental disorder from perinatal brain injury, not an acute traumatic event from infancy.
*Intrapartum asphyxia*
- **Intrapartum asphyxia** (hypoxic-ischemic encephalopathy) in term infants characteristically leads to damage in the **deep grey matter** (e.g., basal ganglia, thalamus) and cortex, not primarily **periventricular white matter** as seen here.
- The MRI findings of **periventricular leukomalacia** are pathognomonic for **prematurity-related injury**, not term asphyxia.
Question 10: You are called to the bedside of a 75-year-old woman, who is post-op day 4 from a right total hip replacement. The patient appears agitated; she is trying to pull out her IV, and for the past 4 hours she has been accusing the nursing staff of trying to poison her. Her family notes that this behavior is completely different from her baseline; she has not shown any signs of memory loss or behavioral changes at home prior to the surgery. You note that she still has an indwelling catheter. She continues on an opioid-based pain regimen. All of the following are potential contributors to the patient’s presentation EXCEPT:
A. Volume depletion
B. Infection
C. Electrolyte abnormalities
D. Amyloid accumulation (Correct Answer)
E. Polypharmacy
Explanation: ***Amyloid accumulation***
- **Amyloid accumulation** is associated with **Alzheimer's disease** and other forms of **dementia**, which are chronic neurodegenerative conditions.
- The patient's acute onset of confusion and agitation, despite no prior history of cognitive decline, makes **amyloid accumulation** an unlikely immediate contributor to her current presentation.
*Volume depletion*
- **Dehydration** or **hypovolemia** can lead to reduced cerebral perfusion, altered mental status, and delirium in elderly patients.
- Post-operative patients, especially those with pain and limited mobility, are at increased risk for **volume depletion** if fluid intake is inadequate or fluid losses are excessive.
*Infection*
- **Urinary tract infections (UTIs)** are common in elderly patients, particularly those with indwelling catheters, and can present as acute delirium or altered mental status without typical fever or dysuria.
- The presence of an **indwelling catheter** makes a UTI a strong possibility for precipitating delirium in this patient.
*Electrolyte abnormalities*
- Disturbances in **electrolytes**, such as **hyponatremia** or **hypernatremia**, **hypokalemia**, or **hypercalcemia**, can profoundly affect brain function and lead to acute confusion, agitation, and delirium.
- Post-operative fluid shifts, medication effects, and underlying medical conditions can predispose elderly patients to **electrolyte imbalances**.
*Polypharmacy*
- The use of multiple medications, particularly sedatives, analgesics (like **opioids**), and anticholinergics, is a significant risk factor for **delirium** in older adults.
- Her current **opioid-based pain regimen** contributes to **polypharmacy** and poses a risk for drug-induced delirium.
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