Malingering → siMulation of Sx for secondary gain (Money, drugs, absents of work,”cold feet” = afraid to get Married). It’s not a disorder.
FAKtitious disorder → FAKing of Sx w/o secondary gain. These patients just want to be sick (they love the sick role and the attentions they got in a hospital). It’s a disorder, as the name shows.
A 62-year-old woman is evaluated in the stroke unit for a 2-day history of difficulty speaking and right arm weakness. She has a history of hypertension and dyslipidemia and a 35-pack-year smoking history. Medications are lisinopril, atenolol, simvastatin, and aspirin.
On physical examination, blood pressure is 148/78 mm Hg, pulse rate is 84/min and regular, and respiration rate is 12/min. Other general medical examination findings are normal. Neurologic examination shows mild sensory aphasia and right arm drift.
An MRI of the brain shows an acute infarct in the left middle cerebral artery distribution that appears embolic. A magnetic resonance angiogram of the head and neck is normal. An electrocardiogram shows sinus rhythm and is normal. Telemetry performed over the next 3 days shows occasional premature ventricular complexes. A transesophageal echocardiogram shows no intracardiac thrombus, normal left atrial appendage velocities, and a patent foramen ovale with an atrial septal aneurysm. No evidence of deep venous thrombosis is found.
Which of the following is the most appropriate next step in management?
A Percutaneous patent foramen ovale closure
B Prolonged cardiac rhythm monitoring
C Surgical closure of the patent foramen ovale
An 82-year-old man is evaluated for recurrent obscure gastrointestinal bleeding. He has experienced four episodes of melena in the past 6 months. Results of a colonoscopy and upper endoscopy 3 months ago were unremarkable. There is no family history of bleeding diathesis. His only medication is iron sulfate for anemia.
On physical examination, vital signs are normal. BMI is 32. There is no abdominal tenderness. Digital rectal examination is normal.
Laboratory studies reveal a hemoglobin level of 10.1 g/dL (101 g/L); platelet count, complete metabolic panel, and INR are normal.
Which of the following is the most appropriate diagnostic test to perform next?
A 72-year-old man is evaluated in the emergency department for a severe headache, nausea, vomiting, and change in consciousness of 1 hour’s duration that developed after he fell earlier today. He has atrial fibrillation for which he takes warfarin and metoprolol.
On physical examination, temperature is normal, blood pressure is 160/90 mm Hg, pulse rate is 50/min, and respiration rate is 26/min. The patient is obtunded but responds to verbal commands and is able to follow simple instructions and swallow. No focal neurologic findings are present.
The INR is 12.
A CT scan of the head shows a subdural hematoma with a mass effect.
Which of the following is the most appropriate treatment?
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