Study Guide Exam for ROSH REVIEW
QUESTIONS AND ANSWERS UPDATED
68-year-old woman with no previous medical problems presents to the emergency
department for diverticulitis. An abdominal computed tomography scan is performed,
and she is found to have a 2 cm mass on her right adrenal gland. Which of the following
is the most likely etiology of the mass?
ABenign cortisol-secreting mass
BBenign nonfunctioning mass
CPheochromocytoma
DPrimary adrenal carcinoma - CORRECT ANSWER-B
An adrenal incidentaloma is most often a benign nonfunctioning mass. The incidental
discovery of an adrenal gland mass during an imaging study performed for another
reason is very common. Findings can be unilateral or bilateral, and the pathologic
diagnosis can be different on each side. Imaging characteristics on computed
tomography and magnetic resonance imaging can help to differentiate between the
possible benign and malignant etiologies. If initial imaging suggests a benign etiology,
follow-up scans should be done after six to 12 months to monitor for growth and
changes in imaging characteristics.
The most common functional adrenal incidentaloma is a benign cortisol-secreting mass
(A), which can cause subclinical Cushing syndrome. Pheochromocytoma (C) is a less
common diagnosis of adrenal incidentaloma. All patients with adrenal incidentalomas
should be tested for pheochromocytoma with measurement of 24-hour urinary
fractionated metanephrines and catecholamines. Primary adrenal carcinoma (D) is rare.
A mass greater than 4 cm in diameter is more likely to be malignant.
A 10-year-old boy presents to the clinic because he has recently been too tired to play
with his friends and has had a backache. His mother reports he had a fever yesterday of
100.9°F, and last week she noticed some bruises on his arms that she thought were
from the dog jumping on him. On physical examination, he appears fatigued and pale.
His temperature is 101.1°F. He has cervical lymphadenopathy and hepatomegaly, as
well as scattered new and resolving bruises on his extremities. Which of the following is
the most appropriate initial diagnostic test?
AComplete blood count
BComprehensive metabolic panel
CCytomegalovirus titer
DHeterophile antibodies for mononucleosis - CORRECT ANSWER-A
Acute lymphoblastic leukemia is the most common malignancy in childhood.
Lymphoblastic lymphoma represents an overlapping clinical presentation of the same
disease. Its nonspecific symptoms may make it difficult to distinguish from other
,common childhood illnesses, such as infectious mononucleosis due to Epstein-Barr
virus or cytomegalovirus. Signs and symptoms may include bruising, fever, hematologic
abnormalities, lymphadenopathy, musculoskeletal pain, pallor, and palpable liver or
spleen. The diagnostic evaluation should begin with a complete blood count with
differential, along with a peripheral smear. Findings may include a low, normal, or high
white blood cell count. Anemia and thrombocytopenia are also common. Lymphoblasts
are often seen on peripheral smear. If lymphadenopathy is a prominent finding, lymph
node biopsy should be considered. Prompt referral to a pediatric hematologist-
oncologist for bone marrow biopsy and further testing and management is necessary.
Additional diagnostic modalities may include cytochemistry and cytogenetic testing, flow
cytometry with immunophenotyping, and molecular testing. Treatment decisions are
usually based on risk stratification according to prognostic factors at the time of
presentation. Prognosis varies, but the cure rate may be ≥ 85%.
A comprehensive metabolic panel (B) could detect hepatic injury, which is common in
infectious mononucleosis, but is less likely than a complete blood count to identify the
cause of this patient's pallor and bruising. Cytomegalovirus titer (C) and heterophile
antibodies for mononucleosis (D) are useful for diagnosing infectious mononucleosis,
which usually presents with fatigue, fever, lymphadenopathy, pharyngitis, and
sometimes splenomegaly. When cytomegalovirus is the cause of infectious
mononucleosis, the illness is usually milder, w
A 17-year-old adolescent is brought to the emergency department by his parents with
fever and altered mental status for several hours. You have a strong suspicion for
meningitis, so you perform a lumbar puncture. Which of the following results from the
cerebrospinal fluid analysis would most support a diagnosis of aseptic meningitis?
A20 white blood cells/µL, 60% neutrophils, normal glucose levels, protein 60 mg/dL
B200 white blood cells/µL, 10% neutrophils, low glucose levels, protein 60 mg/dL
C50 white blood cells/µL, 20% neutrophils, low glucose levels, protein 200 mg/dL
D600 white blood cells/µL, 90% neutrophils, low glucose levels, protein 300 mg/dL -
CORRECT ANSWER-A
Meningitis is an inflammation of the meninges and can range from mild self-limited
cases to severe disease associated with significant morbidity and mortality. The most
common form of meningitis is aseptic meningitis, meaning that the cerebrospinal fluid
cultures do not show evidence of bacterial growth. These cases are typically viral in
nature, with enterovirus being the most common pathogen. The incidence of
enterovirus-associated meningitis is highest in the summer and early fall. Children and
young adults have a higher risk of Neisseria meningitidis, and older adults are at a
higher risk of Streptococcus pneumoniae meningitis. Listeria monocytogenes meningitis
is more common in immunocompromised patients. Regardless of the culprit, the
presentation is usually the same. Patients present with headache, fever, neck stiffness,
and altered mental status. Younger patients may present with lethargy, poor oral intake,
and irritability. All patients in which there is a concern for meningitis should undergo
prompt lumbar puncture with cerebrospinal fluid analysis. Aseptic meningitis will
commonly show a mildly elevated white blood cell count with a higher neutrophil
,predominance early in the disease (but a lymphocytic predominance later on), normal to
slightly elevated protein, and a normal glucose level. Normal C-reactive protein and
procalcitonin levels are more common in aseptic meningitis as well.
Fungal meningitis will reveal a white blood cell count of 50 to 500/µL, less than 30%
neutrophils, low glucose levels, and variable amounts of protein (B). Cryptococcus has
a high likelihood of growing on cerebrospinal fluid cultures. Meningitis caused by
Mycobacterium tuberculosis will reveal white blood cells in the range of 50 to 500/µL,
with less than 30% neutrophils, low glucose level, and protein greater than 100 mg/
A 2-week-old male infant is brought to the clinic by his parents with concerns about his
enlarged head and short extremities. He seems to be well otherwise. On physical exam,
he has macrocephaly with a prominent forehead and large anterior fontanelle, a low
nasal bridge, shortened extremities, and a trident deformity of the hands. Which of the
following is the best diagnostic method to confirm his condition?
AGenetic testing
BPhysical exam
CRadiographic skeletal survey
DThyroid-stimulating hormone - CORRECT ANSWER-A
Achondroplasia is the most common cause of dwarfism and one of the most common
causes of a large anterior fontanelle in infants. Achondroplasia can be inherited in an
autosomal dominant manner, but most cases occur as de novo mutations. It presents in
infancy with macrocephaly, prominent forehead, enlarged anterior fontanelle, low nasal
bridge, shortened extremities, and a trident deformity of the hands. X-rays typically
demonstrate narrowed interpedicular distance of the lumbosacral vertebral bodies,
shortened long bones with abnormal metaphyses, a short narrow chest, and shortened
metacarpals and phalanges. Almost all cases are due to a mutation in nucleotide 1138
of the fibroblast growth factor receptor 3 gene (FGFR3). Genetic testing for a mutation
in the FGFR3 gene can confirm the diagnosis. Hypochondroplasia is a similar disorder
with milder manifestations and is often associated with mutations at nucleotide 1620 of
FGFR3. Children with achondroplasia typically have delayed motor development that
generally resolves by the age of 3 years. Intellectual development is normal.
Complications may include cervical medullary compression, leg bowing, obesity,
obstructive sleep apnea, recurrent otitis media, and spinal stenosis. Management is
directed at maximizing function and preventing, monitoring for, and treating
complications.
Physical exam (B) and radiologic skeletal survey (C) are important in supporting the
diagnosis of achondroplasia, but they are not confirmatory. Thyroid-stimulating hormone
(D) is appropriate for diagnosing congenital hypothyroidism, which is also associated
with an enlarged anterior fontanelle. Other causes of enlarged anterior fontanelle
include Down syndrome, increased intracranial pressure, familial macrocephaly, and
rickets. These are all less likely diagnoses in this patient who has t
, A 21-year-old man presents to the clinic with a sudden onset of moderate pain in his
intergluteal region two days ago. Symptoms are worse while sitting and when doing sit-
ups. He also reports swelling and purulent drainage in the area. He denies fever or
malaise. Physical examination reveals a tender mass in his intergluteal region with a
sinus draining purulent fluid. What is the most likely diagnosis?
ACarbuncle
BFuruncle
CPerianal abscess
DPilonidal disease - CORRECT ANSWER-D
Pilonidal disease involves the skin and subcutaneous tissue at or the near the upper
part of the intergluteal cleft of the buttocks and typically manifests as an infection. The
intergluteal cleft forms the groove between the buttocks, which extends from the sacrum
to the perineum lying just superior to the anus. Although intergluteal pilonidal cavities
are not true cysts, the lining of the sinus tracts associated with them may be
epithelialized. Symptoms usually manifest in early adulthood, and men are affected
more than women. Risk factors for pilonidal disease include sedentary lifestyle or
prolonged sitting, obesity, local trauma or irritation, family history, and a deep
intergluteal cleft. Pilonidal disease is a clinical diagnosis based upon findings of a pit or
sinus in the region of the intergluteal cleft. Commonly, there is a series of noninflamed
pilonidal pits in the midline that extend posteriorly. Patients typically present with mild to
severe pain with or without drainage in the intergluteal region. No laboratory or imaging
studies are needed for diagnosis. The likelihood of an infected pilonidal cyst is
extremely high when a patient presents with an acutely inflamed mass near the top of
the natal cleft. Patients with acute pilonidal abscess should be treated with incision and
drainage, and the wound should be debrided of all hair. For patients with recurrent or
chronic pilonidal disease, an excision of the pilonidal sinus and all tracts is
recommended. The role of antibiotics is generally limited to the clinical setting of
cellulitis, although patients with concurrent systemic illness, underlying
immunosuppression, methicillin-resistant Staphylococcus aureus, or those at high risk
for endocarditis should be considered for adjunctive antimicrobial treatment.
Carbuncle (A) refers to a coalescence of seve
A 23-year-old man on a ski vacation presents to the emergency department stating he
awoke with a moderate headache, lightheadedness, decreased appetite, nausea, and
fatigue. He reports ascending 3000 meters yesterday. Physical examination reveals that
his lungs are clear to auscultation without rales, rhonchi, or crackles. Cardiac exam is
also normal. The patient is treated with supplemental oxygen at 2 L/minute. Which of
the following is the best treatment option for this patient's condition?
AAcetazolamide
BAspirin
CGinkgo biloba
DHyperbaric therapy - CORRECT ANSWER-A
QUESTIONS AND ANSWERS UPDATED
68-year-old woman with no previous medical problems presents to the emergency
department for diverticulitis. An abdominal computed tomography scan is performed,
and she is found to have a 2 cm mass on her right adrenal gland. Which of the following
is the most likely etiology of the mass?
ABenign cortisol-secreting mass
BBenign nonfunctioning mass
CPheochromocytoma
DPrimary adrenal carcinoma - CORRECT ANSWER-B
An adrenal incidentaloma is most often a benign nonfunctioning mass. The incidental
discovery of an adrenal gland mass during an imaging study performed for another
reason is very common. Findings can be unilateral or bilateral, and the pathologic
diagnosis can be different on each side. Imaging characteristics on computed
tomography and magnetic resonance imaging can help to differentiate between the
possible benign and malignant etiologies. If initial imaging suggests a benign etiology,
follow-up scans should be done after six to 12 months to monitor for growth and
changes in imaging characteristics.
The most common functional adrenal incidentaloma is a benign cortisol-secreting mass
(A), which can cause subclinical Cushing syndrome. Pheochromocytoma (C) is a less
common diagnosis of adrenal incidentaloma. All patients with adrenal incidentalomas
should be tested for pheochromocytoma with measurement of 24-hour urinary
fractionated metanephrines and catecholamines. Primary adrenal carcinoma (D) is rare.
A mass greater than 4 cm in diameter is more likely to be malignant.
A 10-year-old boy presents to the clinic because he has recently been too tired to play
with his friends and has had a backache. His mother reports he had a fever yesterday of
100.9°F, and last week she noticed some bruises on his arms that she thought were
from the dog jumping on him. On physical examination, he appears fatigued and pale.
His temperature is 101.1°F. He has cervical lymphadenopathy and hepatomegaly, as
well as scattered new and resolving bruises on his extremities. Which of the following is
the most appropriate initial diagnostic test?
AComplete blood count
BComprehensive metabolic panel
CCytomegalovirus titer
DHeterophile antibodies for mononucleosis - CORRECT ANSWER-A
Acute lymphoblastic leukemia is the most common malignancy in childhood.
Lymphoblastic lymphoma represents an overlapping clinical presentation of the same
disease. Its nonspecific symptoms may make it difficult to distinguish from other
,common childhood illnesses, such as infectious mononucleosis due to Epstein-Barr
virus or cytomegalovirus. Signs and symptoms may include bruising, fever, hematologic
abnormalities, lymphadenopathy, musculoskeletal pain, pallor, and palpable liver or
spleen. The diagnostic evaluation should begin with a complete blood count with
differential, along with a peripheral smear. Findings may include a low, normal, or high
white blood cell count. Anemia and thrombocytopenia are also common. Lymphoblasts
are often seen on peripheral smear. If lymphadenopathy is a prominent finding, lymph
node biopsy should be considered. Prompt referral to a pediatric hematologist-
oncologist for bone marrow biopsy and further testing and management is necessary.
Additional diagnostic modalities may include cytochemistry and cytogenetic testing, flow
cytometry with immunophenotyping, and molecular testing. Treatment decisions are
usually based on risk stratification according to prognostic factors at the time of
presentation. Prognosis varies, but the cure rate may be ≥ 85%.
A comprehensive metabolic panel (B) could detect hepatic injury, which is common in
infectious mononucleosis, but is less likely than a complete blood count to identify the
cause of this patient's pallor and bruising. Cytomegalovirus titer (C) and heterophile
antibodies for mononucleosis (D) are useful for diagnosing infectious mononucleosis,
which usually presents with fatigue, fever, lymphadenopathy, pharyngitis, and
sometimes splenomegaly. When cytomegalovirus is the cause of infectious
mononucleosis, the illness is usually milder, w
A 17-year-old adolescent is brought to the emergency department by his parents with
fever and altered mental status for several hours. You have a strong suspicion for
meningitis, so you perform a lumbar puncture. Which of the following results from the
cerebrospinal fluid analysis would most support a diagnosis of aseptic meningitis?
A20 white blood cells/µL, 60% neutrophils, normal glucose levels, protein 60 mg/dL
B200 white blood cells/µL, 10% neutrophils, low glucose levels, protein 60 mg/dL
C50 white blood cells/µL, 20% neutrophils, low glucose levels, protein 200 mg/dL
D600 white blood cells/µL, 90% neutrophils, low glucose levels, protein 300 mg/dL -
CORRECT ANSWER-A
Meningitis is an inflammation of the meninges and can range from mild self-limited
cases to severe disease associated with significant morbidity and mortality. The most
common form of meningitis is aseptic meningitis, meaning that the cerebrospinal fluid
cultures do not show evidence of bacterial growth. These cases are typically viral in
nature, with enterovirus being the most common pathogen. The incidence of
enterovirus-associated meningitis is highest in the summer and early fall. Children and
young adults have a higher risk of Neisseria meningitidis, and older adults are at a
higher risk of Streptococcus pneumoniae meningitis. Listeria monocytogenes meningitis
is more common in immunocompromised patients. Regardless of the culprit, the
presentation is usually the same. Patients present with headache, fever, neck stiffness,
and altered mental status. Younger patients may present with lethargy, poor oral intake,
and irritability. All patients in which there is a concern for meningitis should undergo
prompt lumbar puncture with cerebrospinal fluid analysis. Aseptic meningitis will
commonly show a mildly elevated white blood cell count with a higher neutrophil
,predominance early in the disease (but a lymphocytic predominance later on), normal to
slightly elevated protein, and a normal glucose level. Normal C-reactive protein and
procalcitonin levels are more common in aseptic meningitis as well.
Fungal meningitis will reveal a white blood cell count of 50 to 500/µL, less than 30%
neutrophils, low glucose levels, and variable amounts of protein (B). Cryptococcus has
a high likelihood of growing on cerebrospinal fluid cultures. Meningitis caused by
Mycobacterium tuberculosis will reveal white blood cells in the range of 50 to 500/µL,
with less than 30% neutrophils, low glucose level, and protein greater than 100 mg/
A 2-week-old male infant is brought to the clinic by his parents with concerns about his
enlarged head and short extremities. He seems to be well otherwise. On physical exam,
he has macrocephaly with a prominent forehead and large anterior fontanelle, a low
nasal bridge, shortened extremities, and a trident deformity of the hands. Which of the
following is the best diagnostic method to confirm his condition?
AGenetic testing
BPhysical exam
CRadiographic skeletal survey
DThyroid-stimulating hormone - CORRECT ANSWER-A
Achondroplasia is the most common cause of dwarfism and one of the most common
causes of a large anterior fontanelle in infants. Achondroplasia can be inherited in an
autosomal dominant manner, but most cases occur as de novo mutations. It presents in
infancy with macrocephaly, prominent forehead, enlarged anterior fontanelle, low nasal
bridge, shortened extremities, and a trident deformity of the hands. X-rays typically
demonstrate narrowed interpedicular distance of the lumbosacral vertebral bodies,
shortened long bones with abnormal metaphyses, a short narrow chest, and shortened
metacarpals and phalanges. Almost all cases are due to a mutation in nucleotide 1138
of the fibroblast growth factor receptor 3 gene (FGFR3). Genetic testing for a mutation
in the FGFR3 gene can confirm the diagnosis. Hypochondroplasia is a similar disorder
with milder manifestations and is often associated with mutations at nucleotide 1620 of
FGFR3. Children with achondroplasia typically have delayed motor development that
generally resolves by the age of 3 years. Intellectual development is normal.
Complications may include cervical medullary compression, leg bowing, obesity,
obstructive sleep apnea, recurrent otitis media, and spinal stenosis. Management is
directed at maximizing function and preventing, monitoring for, and treating
complications.
Physical exam (B) and radiologic skeletal survey (C) are important in supporting the
diagnosis of achondroplasia, but they are not confirmatory. Thyroid-stimulating hormone
(D) is appropriate for diagnosing congenital hypothyroidism, which is also associated
with an enlarged anterior fontanelle. Other causes of enlarged anterior fontanelle
include Down syndrome, increased intracranial pressure, familial macrocephaly, and
rickets. These are all less likely diagnoses in this patient who has t
, A 21-year-old man presents to the clinic with a sudden onset of moderate pain in his
intergluteal region two days ago. Symptoms are worse while sitting and when doing sit-
ups. He also reports swelling and purulent drainage in the area. He denies fever or
malaise. Physical examination reveals a tender mass in his intergluteal region with a
sinus draining purulent fluid. What is the most likely diagnosis?
ACarbuncle
BFuruncle
CPerianal abscess
DPilonidal disease - CORRECT ANSWER-D
Pilonidal disease involves the skin and subcutaneous tissue at or the near the upper
part of the intergluteal cleft of the buttocks and typically manifests as an infection. The
intergluteal cleft forms the groove between the buttocks, which extends from the sacrum
to the perineum lying just superior to the anus. Although intergluteal pilonidal cavities
are not true cysts, the lining of the sinus tracts associated with them may be
epithelialized. Symptoms usually manifest in early adulthood, and men are affected
more than women. Risk factors for pilonidal disease include sedentary lifestyle or
prolonged sitting, obesity, local trauma or irritation, family history, and a deep
intergluteal cleft. Pilonidal disease is a clinical diagnosis based upon findings of a pit or
sinus in the region of the intergluteal cleft. Commonly, there is a series of noninflamed
pilonidal pits in the midline that extend posteriorly. Patients typically present with mild to
severe pain with or without drainage in the intergluteal region. No laboratory or imaging
studies are needed for diagnosis. The likelihood of an infected pilonidal cyst is
extremely high when a patient presents with an acutely inflamed mass near the top of
the natal cleft. Patients with acute pilonidal abscess should be treated with incision and
drainage, and the wound should be debrided of all hair. For patients with recurrent or
chronic pilonidal disease, an excision of the pilonidal sinus and all tracts is
recommended. The role of antibiotics is generally limited to the clinical setting of
cellulitis, although patients with concurrent systemic illness, underlying
immunosuppression, methicillin-resistant Staphylococcus aureus, or those at high risk
for endocarditis should be considered for adjunctive antimicrobial treatment.
Carbuncle (A) refers to a coalescence of seve
A 23-year-old man on a ski vacation presents to the emergency department stating he
awoke with a moderate headache, lightheadedness, decreased appetite, nausea, and
fatigue. He reports ascending 3000 meters yesterday. Physical examination reveals that
his lungs are clear to auscultation without rales, rhonchi, or crackles. Cardiac exam is
also normal. The patient is treated with supplemental oxygen at 2 L/minute. Which of
the following is the best treatment option for this patient's condition?
AAcetazolamide
BAspirin
CGinkgo biloba
DHyperbaric therapy - CORRECT ANSWER-A
