Correct Answer: D

Cancer of the cervix that has not invaded cervical stroma is stage 0 carcinoma in situ. Cancer that has invaded the cervical stroma but has not spread beyond the cervix is stage I. Involvement of the upper vagina or parametria (but not to the pelvic sidewall) is stage II. Stage III is involvement of the lower third of the vagina (IIIA) or parametria to the pelvic sidewall (IIIB). Extension outside the reproductive tract is stage

IV.

Correct Answer: A

Epidemic typhus (classical typhus fever, or louse-borne typhus) has disappeared from most areas of the world but might reappear in conditions of famine, war, or other disasters. There are small areas where it is endemic. The responsible organism, a rickettsia, is conveyed from case to case by the human body louse,

P. humanus corporis. Malaria, in its various forms (Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae), is spread from human to human by females of the various Anopheles group of mosquitoes. Dengue fever has a worldwide distribution in tropical and subtropical areas. In addition to producing the classical fever with severe myalgia (breakbone fever), it can also cause a hemorrhagic fever. The causative agent, a group B arbovirus with four distinct serogroups, is virus-conveyed from case to case by the A aegypti mosquito. Colorado tick fever occurs mainly in mountainous areas of the United States within the range of its vector, D. andersoni. The highest incidence is in May and June. Several hundred cases are recorded annually, but it is likely that the actual incidence is much higher. Avoidance of tick bites is the principal control measure. Yellow fever, the prototypical viral hemorrhagic fever, is African in origin but has spread to and remains endemic in equatorial regions of Central and South America. The vector, A. aegypti, has also spread worldwide, but surprisingly, cases have not been reported in India and Southeast Asia. The illness varies in severity from a mild, nonspecific fever to a more severe condition with hemorrhagic, hepatic, and renal manifestations.

Correct Answer: G

Complaints involving both psychological and medical conditions are difficult to diagnose and treat. At times, medically identifiable causes are present, but the psychological factors contributing to the discomfort complicate the diagnosis and treatment and lead to frustration in both physician and patient. At other times, no identifiable cause for pain or other physical symptoms can be found; nevertheless, the patient still has the symptoms. Questions arise:

Is the patient lying? Is there some deep psychological problem? Could there be a medical disorder in the early stages of development that gives rise to physical symptoms but no clear physical signs to make the diagnosis? One group of psychiatric disorders addresses some of these issues--the somatoform disorders. Somatization disorder is an axis I psychiatric disorder where a patient complains of multiple somatic complaints involving multiple organ systems, but which cannot be explained by physical and/or laboratory findings. Conversion disorder is another axis I disorder where there is a disturbance of bodily function that does not conform to anatomic or neurologic concepts, and it is due to psychological factors. Body dysmorphic disorder is a pervasive subjective feeling/belief that some aspect of the patient's appearance is ugly or deformed. Hypochondriasis is a persistent belief in the presence of one or two serious physical diseases despite medical assurance that one does not have the disease/illness. Pain disorder (somatoform pain disorder) is a disorder with the presence of severe, distressing and persistent pain which cannot be explained adequately by evidence of a physiologic process or physical disorder. Panic disorder is a kind of anxiety disorder. Discrete periods of extreme sympathetic nervous system symptoms occur, including tachycardia, sweating, shortness of breath, and others, during which time a person experiences extreme fear. Malingering is the deliberate manufacture of false or exaggerated symptoms for financial gain or to avoid an unpleasant situation such as jail time or military duty. In a factitious disorder, there is the deliberate production of signs and symptoms of illness in order to assume the sick role.

Correct Answer: E

Acute appendicitis initially presents with periumbilical pain secondary to obstruction of the appendiceal lumen. This is mediated through visceral pain fibers, and because the appendix is from the embryologic midgut, the pain is referred to the umbilicus. With obstruction of a hollow viscus, there may be associated nausea. As the inflammatory process progresses to involve the visceral and parietal peritoneal surfaces, the pain becomes localized directly over the appendix in the right lower quadrant. Fever and leukocytosis are nonspecific signs of an inflammatory process. Gastroenteritis may be associated with nausea, anorexia, and lowgrade fever. Periumbilical pain is colicky and secondary to increased peristalsis. Localized pain and signs of peritoneal irritation are uncommon. Aruptured right ovarian cyst may mimic appendicitis. Patients may exhibit right lower abdominal peritoneal irritation. However, the onset of pain is usually sudden, and the pain is initially felt in the right lower quadrant.

These patients do not have anorexia or other gastrointestinal symptoms. The clinical picture of regional enteritis (Crohn's disease) is one of a chronic illness, often associated with weight loss, intermittent cramps, and diarrhea. Fever, tenderness, and a palpable right lower quadrant inflammatory mass may result from complications of ileal involvement. Sigmoid diverticulitis is more common in older patients, often with a prodromal history of irregular bowel habits. There may be left lower quadrant pain and tenderness, with a palpable left-sided inflammatory mass. A cecal volvulus presents with sudden onset of colicky abdominal pain and signs and symptoms of a bowel obstruction, including bilious emesis and abdominal distention. Alcohol-related acute pancreatitis presents with pain referred to the epigastrium, with radiation to the back mediated through the celiac ganglia. The patient may develop abdominal distention secondary to the associated paralytic ileus. Hyperamylasemia and an elevated serum lipase, in this clinical setting, are suggestive of pancreatitis. Perforated peptic ulcer and acute cholecystitis may also present with epigastric pain, and elevations of both serum lipase and amylase. Pain from a perforated ulcer, however, is sudden in onset and may be associated with shoulder-tip pain from diaphragmatic irritation. About 75% of patients with perforated duodenal ulcers have pneumoperitoneum on chest and abdominal radiographs.

Acute cholecystitis will usually commence after a large meal and initially presents as colicky epigastric pain, progressing to pain localized in the right upper abdomen when transmural inflammation of the gallbladder wall produces peritoneal irritation. Acute mesenteric occlusion presents with sudden onset of severe but poorly localized periumbilical abdominal pain, associated with acidosis. There may be elevation of serum amylase and lipase. A ruptured abdominal aortic aneurysm will present with sudden onset of midabdominal pain, back pain, and hemodynamic instability.

Correct Answer: F

Pancreatic carcinoma occurs in the head of the gland in 75% of cases. About 75% of the patients with carcinoma in the head of the pancreas present with obstructive jaundice, weight loss, and, in the presence of advanced disease, abdominal pain.