#32 Rosh Review

A 14-year-old woman presents to clinic with some frustration over never having a menstrual period. She is short in stature and has Tanner stage 2 breast development. As you begin a gynecological exam, you realize that you cannot pass a speculum into the vagina. Which of the following is the most likely diagnosis? Dysfunctional uterine bleeding Primary amenorrhea Secondary dysmenorrhea Sheehan's syndrome

Correct Answer ( B ) Explanation: Primary amenorrhea, seen in approximately 2.6% of the population, is defined as absence of menarche by age 16 in a woman with normal growth and secondary sexual development, or age 14 in a woman without normal growth and secondary sexual development. Secondary amenorrhea, in women who have previously menstruated, is defined as absence of menses for more than 3 cycles or 6 months. The most common cause of primary amenorrhea is caused by gonadal dysgenesis due to a chromosome abnormality, while other causes include hypothalamic disease, pituitary disease, abnormal hymen (as in the patient above) or vagina development or uterine agenesis. The patient may have a family history significant for sexual development abnormalities. The most common cause of secondary amenorrhea is pregnancy, followed by abnormalities of the hypothalamic-pituitary-ovary axis, thyroid disease, and ovarian or uterine disorders. Dysfunctional uterine bleeding (A) is defined as nonpathologic, excessive and noncyclic bleeding mainly due to anovulation.Secondary dysmenorrhea (C) is abnormal uterine bleeding associated with non-midline pelvic pain, which can be due to endometriosis, uterine fibroids or pelvic inflammatory disease. Sheehan's syndrome (D) is a rare cause of amenorrhea in the complicated postpartum setting, in which severe hemorrhage and/or hypotension results in pituitary gland necrosis.

You are called to the emergency department to examine a two-year-old girl for possible ingestion. She was accompanied by her grandparents who found her with an opened bottle of pills. There were two pills found in her mouth although the caretakers are not certain as to how many pills are missing. In transit to the ED, the girl was asymptomatic. Your examination at the ED reveals an alert girl with bradycardia, hypotension, normal pupillary size and reaction. You perform an ECG that shows sinus bradycardia. Blood glucose is normal. Which of the following medications could the girl most likely have ingested? Clonidine Metoprolol Nortriptyline Phenobarbital

Correct Answer ( B ) Explanation: The findings on the girl are most consistent with beta-blocker toxicity like metoprolol. Beta-blockers competitively inhibit the action of catecholamines at the β receptor. Toxicity results in decreased chronotropy and inotropy in addition to slowing conduction through AV nodal tissue. These effects are manifested as bradycardia, hypotension, and heart block. Patients with reactive airways disease can experience bronchospasm due to blockade of β2-mediated bronchodilation. Beta-blockers interfere with glycogenolysis and gluconeogenesis, which can lead to hypoglycemia. Evaluation after an overdose should include an ECG and frequent reassessments of hemodynamic status. Blood glucose should be measured in all patients as hypoglycemia may be seen. Treatment involves supportive care and gastrointestinal decontamination as indicated. Glucagon and high-dose insulin are the the antidotes of choice for beta-blocker toxicity. Clonidine (A) poisoning may cause lethargy, miosis, and bradycardia. In severe cases there can be hypotension, respiratory depression, and apnea. Nortriptyline (C) is a tricyclic antidepressant, and toxicity can lead to anticholinergic toxidrome that includes delirium, mydriasis, dry mucous membranes, tachycardia, hyperthermia, mild hypertension, urinary retention, and slow GI motility. CNS toxicity can include lethargy, coma, myoclonic jerks, and seizures. Cardiovascular manifestations include sinus tachycardia, widening of the QRS complex, premature ventricular contractions, and ventricular arrhythmias. Phenobarbital (D) is a barbiturate and toxicity may lead to respiratory depression, hypotension, and psychosis.

A 10-year-old boy presents with increased lethargy and vomiting. Mom states the patient has had 3 days of cough, rhinorrhea, sore throat, and fever. The nanny has been giving the patient an appropriate dose of over-the-counter cold medicine. The physical exam is remarkable for lethargy, mild icterus, and hepatomegaly. Laboratory results are remarkable for markedly elevated AST and ALT. Which medication is most likely responsible for this patient's presentation? Acetaminophen Aspirin Guaifenesin Ibuprofen

Correct Answer ( B ) Explanation: The patient's presentation is consistent with Reye's syndrome. Reye's syndrome is an uncommon, rapidly progressive, noninflammatory encephalopathy associated with altered mental status, cerebral edema, and hepatic dysfunction. Clinically, patients present with a respiratory or gastrointestinal prodrome followed by an encephalopathic picture marked by behavioral changes and deteriorating level of consciousness. It is a multisystem disease, but the mechanism of injury is not fully elucidated. Salicylate ingestion (aspirin) during a viral illness, particularly with chicken pox or influenza, is associated with the condition. In overdose, acetaminophen (A) can cause similar symptoms, but given appropriate weight-based dosing, acetaminophen-induced liver toxicity is unlikely. Guaifenesin (C) is an expectorant commonly found in over-the-counter cough medications, which can cause vomiting and drowsiness as a side effect, but is not associated with liver toxicity. Ibuprofen (D) is a nonsteroidal anti-inflammatory medication, which has been implicated in rare cases of Reye's syndrome involving juvenile rheumatoid arthritis or other connective tissue diseases. Given this rare association, aspirin is much more likely to be the cause.

A 17-month-old boy presents with bilious vomiting, fever, and abdominal distention for the past three days. The mother states she noticed blood in the last diaper she changed. What is the most likely diagnosis? Anal fissure Intussusception Milk protein allergy Pyloric stenosis

Correct Answer ( B ) Explanation: The presence of bilious vomiting should always raise concern for intestinal obstruction such as intussusception. Intussusception is commonly caused by a pathological lead point. This is a lesion or variation in the intestine that is trapped by peristalsis and dragged into a distal segment of intestine. This causes bowel obstruction and ischemia. The most common location is when the terminal ileum telescopes into the right colon. It is usually diagnosed via ultrasound, which shows a "coiled spring" or "target lesion" representing layers of intestines within the intestine. Surgery is indicated in patients who are acutely ill or have evidence of perforation. Otherwise, patients are treated with non-operative reduction using hydrostatic or pneumatic pressure by enema. Anal fissure (A) does not present with abdominal distention or vomiting. Milk protein allergy (C) is not associated with bilious vomiting and improves when feeding is changed to a hypoallergenic formula. Pyloric stenosis (D) typically presents with projectile vomiting and palpation of an olive shaped mass in the abdomen.

A 23-year-old man presents with burning and itching of the penis. On physical examination, the patient is uncircumcised. There is erythema and inflammation of the distal foreskin and superficial layer of the glans. With retraction of the foreskin there is scant white discharge. What is the appropriate treatment? Ceftriaxone IM Clotrimazole cream Doxycycline Mupirocin ointment

Correct Answer ( B ) Explanation: This patient has balanoposthitis, inflammation of the glans penis (balanitis) as well as the distal foreskin (posthitis). There are multiple causes of balanoposthitis. In younger patients, local irritation from bubble baths is a common cause as well as from soaps and detergents. These cases are treated with topical steroids like hydrocortisone. The etiology may also be infectious with candida as the most common organism. With Candidal infections, a whitish discharge with some eroded plaques may be present. This patient's presentation is suggestive of a Candida infection which is treated with topical antifungal agents such as clotrimazole. Other infectious organisms include anaerobic organisms (treated with topical metronidazole) as well as streptococcal infections. It is uncommon for sexually transmitted infections to cause balanoposthitis. By far the most common contributing factor is poor hygiene. Ceftriaxone administered intramuscularly (A) is the treatment of gonococcal infections. The dose for all gonococcal infections is 250 mg IM. Since sexually transmitted infections are an uncommon cause of balanoposthitis, this medication is not indicated. Doxycycline (C) is used in the treatment of chlamydial infections. A course of doxycycline is prescribed for pelvic inflammatory disease or epididymitis. An uncomplicated urethritis or cervicitis secondary to chlamydia is treatment with a single dose of 1gm of azithromycin. Mupirocin ointment (D) is a topical antibiotic that is used primarily in the treatment of community-associated methicillin resistant Staph aureus infections, a common cause of purulent skin and soft tissue infections in patients presenting to the emergency department.

A 64-year-old man with a history of hypertension presents to the Emergency Department requesting medication refills. He states that he has not taken his medications for the last 2 weeks. His blood pressure is 190/100. He has no complaints at this time. He has prescription bottles for atenolol and hydrochlorothiazide. What management is indicated? Change his medications to a calcium-channel blocker Give the patient a prescription for his medications and refer to his primary doctor in 48 hours Start intravenous labetalol and admit to the floor Start intravenous labetalol and admit to the intensive care unit

Correct Answer ( B ) Explanation: This patient presents with asymptomatic hypertension in the setting of medical non-compliance and should be restarted on his medications and scheduled for follow up with a primary care provider. Accelerated hypertension is defined as markedly elevated blood pressure in the absence of symptoms. This is in contrast with hypertensive emergency where the patient has symptoms or evidence of end organ system dysfunction or both as a result of elevated blood pressure. Accelerated hypertension has a poor long-term prognosis if not controlled but does not pose an immediate threat. As such, it should not be aggressively treated with parenteral medications. Rapid lowering of blood pressure in patients with chronic elevated blood pressure can cause organ hypoperfusion, particularly brain hypoperfusion, and lead to serious sequelae. These patients should be restarted on their medications (if appropriate) and sent for follow up with a primary care physician to monitor and treat the elevated blood pressure. There is no reason to change the patient's medications (A) since he has not been taking them. Starting an intravenous medication (C and D) is required in the treatment of hypertensive emergency but may be dangerous in patients with asymptomatic elevated blood pressure.

An eight-year-old girl is seen in your office with abdominal pain, bloody diarrhea, and weight loss for the past few weeks. Her family just returned from Africa. You obtain a stool sample and find Schistosome eggs. Which of the following medications is the treatment of choice for this infection? Albendazole Ivermectin Praziquantel Prednisone

Correct Answer ( C ) Explanation: Schistosoma organisms infect humans via contaminated water in endemic areas. The parasite is carried by snails and is capable of penetrating intact human skin. There are many different species of Schistosome. Children with Schistosoma mansoni present with intestinal symptoms such as abdominal pain and bloody diarrhea. Once in the bloodstream S. mansoni spread hematogenously to the inferior mesenteric veins. The diagnosis is made by microscopic stool examination for eggs. The treatment of choice is praziquantel 40 mg/kg/day twice daily for one day. Albendazole (A) is the treatment of choice for Ascariasis (round worm) and Trichuriasis. Ivermectin (B) is the treatment of choice of Strongyloidiasis infection. Prednisone (D) is not usually used in the treatment of parasitic infections.

A 65-year-old man presents to the ED with sudden onset of chest pain that began 2 hours prior to arrival. He has a history of hypertension treated with hydrochlorothiazide, hyperlipidemia treated with simvastatin, erectile dysfunction treated with sildenafil, and takes a daily aspirin. An ECG demonstrates an anterior wall myocardial infarction. Which of the patient's home medications serves as a contraindication for the use of nitroglycerin to treat this his chest pain? Aspirin Hydrochlorothiazide Sildenafil Simvastatin

Correct Answer ( C ) Explanation: Sildenafil is an inhibitor of cyclic guanosine monophosphate (cGMP) specific phosphodiesterase type 5. It leads to an increased release of nitric oxide resulting in smooth muscle relaxation and vasodilation. Sildenafil is a commonly used medication in men for erectile dysfunction. The combination of sildenafil and nitroglycerin can result in profound hypotension. Therefore, the use of nitrates is contraindicated in patients who also take sildenafil. The use of aspirin (A), hydrochlorothiazide (B), and simvastatin (D) are not contraindications to the use of nitroglycerin.

During a round-table discussion with your ophthalmology team, you are asked to describe the mechanism of action of certain glaucoma medications. Which of the following correctly matches the drug to its action? Brimonidine : carbonic anhydrase inhibitor Dorzolamide : prostaglandin analog Lantanoprost : selective alpha-2-agonist Timolol : nonselective beta-2-adrenergic antagonist

Explanation: There are several classes of medications used in the treatment of open-angle (chronic) glaucoma. Once diagnosed, most glaucoma can be successfully managed to prevent the onset or progression of vision loss. The nonselective ß-2-adrenergic antagonists decrease aqueous humour production. Common medications in this group are timolol and betaxolol. Brimonidine (A) is a selective alpha-2-agonist that decreases aqueous humour production and increases its drainage through the trabecular meshwork. Dorzolamide (B) is a carbonic anhydrase inhibitor that decreases production of aqueous humour. Lantanoprost (C) is a prostaglandin analog that increases drainage of aqueous humour.

Which of the following conditions most clearly results in symptomatic hemorrhoids? Pancreatitis Peptic ulcer disease Pregnancy Ulcerative colitis

Correct Answer ( C ) Explanation: Swollen lower rectum vessels are called hemorrhoids. This area contains several vessels which tend to engorge and prolapse, and as such, hemorrhoids are one of the most common causes of any anorectal complaint. However, hemorrhoids are frequently misdiagnosed by many medical practitioners. They do not represent true varicosities, but rather, are comprised of arteries, veins, smooth muscle and connective tissue, all of which are covered by anal canal epithelium. They occur normally in asymptomatic individuals, but are hence called "hemorrhoids" when they cause symptoms. The most likely associated etiology is pregnancy. Other potential etiologies include anorectal varices and poor venous return, which commonly occurs during prolonged sitting on the toilet. Other risk factors include genetic predisposition, colon cancer, inflammatory bowel disease, hepatic disease, rectal surgery, chronic diarrhea and spinal cord injury. Pancreatitis (A) is not a direct risk factor to developing symptomatic hemorrhoids. However, hepatic causes of pancreatitis may be an indirect risk factor for symptomatic hemorrhoids.Peptic ulcer disease (B) is not directly linked to symptomatic hemorrhoids. Although constipation can be seen in cases of ulcerative colitis (D), ulcerative colitis is not directly associated with symptomatic hemorrhoids. In contrast, Crohn disease is more commonly associated with the development of symptomatic hemorrhoids.

Question: At what age is foreign body aspiration most common?

Answer: 3 years old. Rapid Review Foreign Body Aspiration Patient will be a child Complaining of a sudden episode of coughing, wheezing, or stridor Comments: most common is the right main bronchus

Question: What is the classic physical sign associated with tricuspid regurgitation?

Answer: A large, bounding v wave is seen during jugular vein inspection. Also, a pulsatile liver may be palpable. Rapid Review Tricuspid Regurgitation Causes: tricuspid ring stretching > pulmonary HTN, endocarditis, rheumatic heart disease Pansystolic murmur at left sternal border JVP: giant c-v wave Atrial fibrillation

Question: What is the Jarisch-Herxheimer reaction?

Answer: A systemic, inflammatory response caused by dying spirochetes when syphilis is treated.

Question: When should abscesses associated with diverticulitis be surgically treated?

Answer: Abscesses over 5 cm in diameter should either be drained percutaneously or surgically. Rapid Review Diverticulitis Patient will be complaining of abdominal pain that is localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits PE will show localized guarding, rigidity, and rebound tenderness Diagnosis is made by CT scan Treatment is abx

Question: What is the most common reason sick sinus syndrome occurs?

Answer: Age and replacement of SA node with fibrous tissue. Rapid Review Sick Sinus Syndrome (SSS) SA node dysfunction Tachycardia-bradycardia syndrome: sinus rate varies from fast to slow and back again Syncope, palpitations Definitive rx: pacemaker placement + rate control medication Untreated SSS → sinus block or sinus arrest

Question: What antibiotics are associated with the development of a morbilliform rash in a patient with infectious mononucleosis?

Answer: Ampicillin and amoxicillin. Rapid Review Infectious Mononucleosis Patient will be complaining of low-grade fever, headache, malaise, severe fatigue PE will show mildly tender lymphadenopathy involving the posterior cervical chain, hepatosplenomegaly Diagnosis is made by heterophile antibody test (monospot test), generalized maculopapular rash following administration of amoxicillin Most commonly caused by Epstein-Barr virus Treatment is self-limiting, refrain from contact sports for four weeks post-infection

Question: Upon which chromosome is the gene responsible for Huntington disease located?

Answer: An expanded and unstable CAG trinucleotide repeat in the huntingtin gene on chromosome 4 is responsible for this disease. Rapid Review Huntington's Disease Autosomal dominant, CAG trinucleotide repeats Age 35-40 Atrophy of caudate nucleus, putamen, globus pallidus Chorea + dementia + labile mood

Question: In patients with aortic dissection, what is the recommended blood pressure goal?

Answer: Antihypertensives should be titrated to a systolic blood pressure of 110 mm Hg. Rapid Review Asymptomatic Hypertension MC causes of BP elevation: pain, anxiety No workup indicated Outpatient follow-up

Question: What is alcohol withdrawal delirium (delirium tremens)?

Answer: Delirium and clouded consciousness that occurs as part of alcohol withdrawal. Rapid Review Ethanol Withdrawal Autonomic hyperactivity (↑ HR, ↑ BP, diaphoresis) Visual, tactile hallucinations Seizures Delirium tremens: autonomic hyperactivity, psychosis, peaks 2-5 days after cessation Tremulousness → hallucinations → seizures → delirium tremens Rx: BZDs

Question: What medication should be administered to help reduce the vasospasm associated with subarachnoid hemorrhage?

Answer: Nimodipine. Rapid Review Subarachnoid Hemorrhage Sudden onset, thunderclap headache Ruptured berry aneurysm Polycystic kidney disease Head CT/LP Xanthochromia Nimodipine

Question: Is rhythm control superior to rate control in atrial fibrillation?

Answer: No, rate- and rhythm-control strategies improve symptoms, but neither has been conclusively shown to improve survival compared to the other.

Question: Do childhood vaccinations protect against Coxsackieviruses?

Answer: No.

Question: What is the best marker of immunosuppression in HIV-positive patients?

Answer: The CD4 cell count is the best predictor of susceptibility to opportunistic infection and immunologic dysfunction. Rapid Review HIV Clinical course: exposure --> acute HIV syndrome --> seroconversion --> asymptomatic period- -> symptomatic period Dx: ELISA followed by HIV-1/HIV-2 differentiation immunoassay or Western blot Dx tests become positive during seroconversion (3-12 weeks after exposure) Chronic watery diarrhea: Cryptosporidium White cottage cheese lesions: Candida Irremovable white lesions on lateral tongue: hairy leukoplakia (EBV) Pneumonia, CD4 <200: PCP TB: CD4 <200, may have negative CXR/PPD Ring-enhancing intracranial lesions + focal neurologic deficits: Toxoplasma gondii Ring-enhancing intracranial lesions + AMS: primary CNS lymphoma Meningitis, CD4 <100: Cryptococcus Focal neurologic deficits, non-enhancing white matter lesions, CD4 <50: PML (JC virus) Retinitis, cotton-wool spots: CMV Dark purple skin/mouth nodules: Kaposi's sarcoma Cutaneous: HSV, zoster reactivation

Question: What can be used as an adjunct tool to augment manual disimpaction?

Answer: The Hill-Ferguson retractor.

Question: Although overall fat decreases with age, where does the distribution of fat tend to accumulate?

Answer: The abdomen; visceral fat predilection causes an increase in waist circumference with age. Rapid Review Aging Changes ↓ Hearing, vision ↓ Immune response ↓ Bladder control ↓ Pulmonary, renal, GI function ↑ Fat/muscle ratio ↑ Suicide risk Sleep: ↓ REM sleep ↑ Sleep onset latency, ↑ Early awakenings Sexual changes: Males: ↑ refractory period, slower erection/ejaculation Females: vaginal dryness, thinning, shortening

Question: Angina may be associated with which psychological disorders?

Answer: The anxiety disorders, such as panic disorder and generalized anxiety disorder. Rapid Review Prinzmetal's Angina Intermittent coronary artery vasospasm Risk factors: smoking, cocaine ​ST elevations Negative cardiac biomarkers Rx: nitrates, CCBs

Question: When is the greatest risk of sudden death after a myocardial infarction?

Answer: The first few hours after secondary to ventricular tachycardia, ventricular fibrillation or cardiogenic shock. Rapid Review Pericardial Tamponade Patient will be complaining of dyspnea and chest pain PE will show muffled heart sounds, JVD, hypotension (Beck's triad), pulsus paradoxus ECG will show low voltage QRS, electrical alterans Echocardiography will show diastolic collapse of RV Treatment is pericardiocentesis

Question: Which antibiotic is first line for endocarditis prophylaxis prior to a dental procedure?

Answer: Two grams of Amoxicillin 1 hour prior to procedure. Rapid Review Endocarditis Patient will be complaining of fever, rash, cough and myalgias PE will show Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE) Diagnosis is made by echocardiography and Duke's criteria Most commonly caused by: IVDA: S. aureus, tricuspid Native valve: Streptococci, mitral Treatment is antibiotics Comments: GI malignancy: S. bovis

Question: What type of Salter-Harris fracture is present in slipped capital femoral epiphysis?

Answer: Type 1. Rapid Review Slipped Capital Femoral Epiphysis (SCFE) Patient will be an obese male 12 - 16 years old Complaining of a progressive limp and knee pain PE will show loss of hip internal rotation X-ray will show "scoop of ice cream slipping off an ice cream cone" Diagnosis is made by AP and frog-lateral X-rays Treatment is non-weight bearing and urgent orthopedic consultation

Question: What other clinical entity is associated with thiamine deficiency?

Answer: Wet beriberi (high output cardiac failure). Rapid Review Wernicke Encephalopathy Patient will be a chronic alcoholic Complaining of ataxia and confusion PE will show nystagmus Most commonly caused by thiamine (B1) deficiency Treatment is aggressive thiamine repletion Comments: replace thiamine BEFORE glucose

A 19-year-old man presents with a maculopapular rash. Three weeks ago, he noticed an ulcer on his penis, but he did not seek medical attention because it resolved spontaneously. He reports associated malaise and arthralgias. He denies penile discharge and dysuria. Skin examination reveals a maculopapular rash which includes his palms and soles. His genital examination is normal. Which of the following is the most appropriate treatment regimen? A single dose of intramuscular ceftriaxone A single dose of oral azithromycin A single intramuscular injection of benzathine penicillin G Weekly intramuscular injections of benzathine penicillin G for 3 weeks

Correct Answer ( C ) Explanation: This patient has secondary syphilis, an infection caused by the spirochete Treponema pallidum. Syphilis infection proceeds in different stages, each with different signs and symptoms, as well as recommended treatment regimens. Secondary syphilis is characterized by a maculopapular, copper-colored rash and associated fever, malaise, and myalgias. Primary syphilis precedes this stage and is characterized by a painless ulcer in the genital area without systemic signs or symptoms. Primary, secondary, and early latent syphilis (< 1 year from inoculation) are treated with a single intramuscular injection of benzathine penicillin G. Doxycycline, tetracycline, and erythromycin can be used in penicillin allergic patients. Patients with tertiary (characterized by gummas, neurological deficits, and cardiovascular effects) or late latent (> 1 year from inoculation) syphilis, are treated with weekly intramuscular injections of benzathine penicillin G for 3 weeks (D). This patient does not have signs or symptoms of these more progressed stages of disease. A single dose of oral azithromycin (B) and a single dose of intramuscular ceftriaxone (A) are the recommended treatments for cervicitis and urethritis due to Chlamydia trachomatis and Neisseria gonorrhoeae, respectively.

A 55-year-old man with a history of alcoholism presents with an unsteady gait. He is slightly confused with ophthalmoplegia noted on neurologic examination. Which of the following is the primary treatment of this syndrome? Dextrose Folic acid Magnesium Vitamin B1

Correct Answer ( D ) Explanation: Wernicke-Korsakoff syndrome is actually made up of two individual syndromes that often occur simultaneously and are both caused by thiamine deficiency (vitamin B1). Wernicke's encephalopathy is the classic triad of ataxia (cerebellar dysfunction), ophthalmoplegia (or nystagmus) and acute confusion. This is a clinical diagnosis treated with thiamine (vitamin B1) replacement therapy. Korsakoff's syndrome is the permanent memory and learning disturbance. Patients with Korsakoff's syndrome are unable to learn new information or to recall previously known information and frequently confabulate in an attempt to hide their memory deficits. Wernicke-Korsakoff syndrome is truly a medical emergency with mortality rates between 10 and 20%. Dietary deficiency in vitamin B1 (likely combined with some genetic factors) leads to development of the syndrome. Dextrose (A) is indicated in the treatment of hypoglycemia. However, hypoglycemia does not play a role in the development of Wernicke-Korsakoff. When administering dextrose to alcoholics, there is a theoretical risk of precipitating Wernicke-Korsakoff if thiamine is not given in close proximity to the sugar solution. Folic acid (B) is another vitamin frequently deficient in alcohols with poor nutritional status. While important for multiple metabolic functions in the body, folic acid deficiency does not cause an acute clinical syndrome. Magnesium (C) is an important co-factor in many enzyme systems of the body, including transketolase which is the thiamine-dependent enzyme affected in Wernicke-Korsakoff. Alcoholics are frequently magnesium deficiency because of poor dietary intake and its repletion is indicated if below the normal range when measured.

A 20-year-old man presents complaining of a painful swollen finger. On examination, you note the findings seen in the image above. Which of the following is true regarding this condition and its treatment? An 11-blade scalpel or 18-gauge needle should be inserted into the eponychium and paronychium parallel to the nail until pus begins to drain Incision should be made on the palmar aspect of the finger pulp and then the wound should be packed with gauze It is caused by herpes simplex virus and therefore incision and drainage should be avoided to prevent spread, secondary infection and delayed healing The nail must always be removed to allow appropriate abscess drainage

Correct Answer ( A ) Explanation: A paronychia is an infection of the soft tissues surrounding of the nail root of a finger or toe. Initially a mild cellulitis develops that ultimately progresses to an abscess under the eponychium. Standard therapy includes incision and drainage, packing and possibly oral antibiotic therapy. Drainage is performed by insertion of an 11-blade scalpel or 18-gauge needle into the eponychium and parinychium parallel to the nail until pus begins to drain. The abscess cavity should be opened completely with hemostats or small scissors. The cavity is then packed and the patient is discharged with 48-hour follow-up. If not treated early, a subungual abscess can form and purulent matter accumulates under the nail itself. Only when a subungual abscess develops does the proximal nail need to be trephined or removed to allow adequate drainage of the abscess (D). This is not required for uncomplicated paronychia. A felon is an infection of the distal pulp of the finger, which often starts after trauma to the finger and can be associated with a small foreign body. If a large abscess is present incision and drainage on the palmar aspect of the finger (B) is necessary with wound packing. Herpetic whitlow (C) is an infection of the finger secondary to herpes simplex virus 1 or 2. This can be caused by autoinoculation from herpetic lesions in other locations (mouth, genitals) or can be seen in health care workers who are exposed to infected patients. Oral antiviral therapy can shorten the duration of symptoms if started early. Incision and drainage is not advised as this can lead to further spread, secondary infection and delayed healing.

A 52-year-old business executive presents to the ED with diaphoresis, tachycardia, visual hallucinations, and recent seizure. The patient states that he drinks alcohol daily but he is trying to quit. His last drink was one day ago. Which of the following is the most appropriate medication at this time? Chlordiazepoxide Haloperidol Phenytoin Quietiapine

Correct Answer ( A ) Explanation: Abrupt cessation of alcohol intake in a chronic alcoholic can lead to alcohol withdrawal syndrome. A history and physical is usually all that is necessary to make a diagnosis. Ethanol withdrawal is characterized by a autonomic hyperactivity (diaphoresis, tachycardia), hand tremor, insomnia, nausea, vomiting, hallucinations (visual), anxiety psychomotor agitation and seizures. Treatment includes monitoring, serial Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) testing and long acting benzodiazepines like chlordiazepoxide or diazepam. Haloperidol (B) can be used to treat agitation and hallucinations of alcohol withdrawal syndrome, however, it can lower the seizure threshold. This would not be prudent in a patient with possible recent seizure activity. Phenytoin (C) does not treat alcohol withdrawal syndrome seizures, however, it may be considered as adjuvant therapy in a patient with a documented seizure disorder. The atypical antipsychotic quietiapine (D) is not used in the treatment of alcohol withdrawal hallucinations.

A 26-year-old woman complains of sneezing, nasal congestion and ocular pruritus. She just moved into an apartment that was previously inhabited by pet owners. You prescribe intranasal corticosteroids, but two weeks later, she returns with no improvement. Which of the following is the most appropriate treatment option at this time? Azelastine (Astelin®) Dust mite-proof pillowcases In-room air filtration Montelukast (Singulair®)

Correct Answer ( A ) Explanation: Allergic rhinitis is an IgE mediated illness. It usually occurs after exposure to allergens such as pollen, mold, dust mites and animal dander. Symptoms include nasal congestion, rhinorrhea, sneezing and nasal and ocular pruritus. Treatment is multifold, and should be based on age and symptom severity. Avoidance of known allergens is crucial. First-line therapy is intranasal corticosteroids. Patients who are refractory, or have initial moderate to severe symptoms, should be treated with intranasal irrigation, decongestants, intranasal or oral antihistamines, such as azelastine, cromolyn or leukotriene receptor antagonists. Immunotherapy is considered in those who do not respond to pharmacologics. Air-filters (C) and mite-proof pillowcases (B) have not been shown to be effective in allergic rhinitis. Large metanalyses have shown leukotriene receptor antagonists, like montelukast (D), are not as effective as intranasal corticosteroids or intranasal antihistamines. As such, leukotriene receptor antagonists are considered second or third line therapy.

A previously healthy 62-year-old woman presents to your office with a complaint of dizziness. For the past two weeks, she has been experiencing an occasional spinning sensation that lasts approximately 20-30 seconds. She first noticed it while tilting her head back in the shower and also had symptoms when rolling over in bed. Which of the following is the most likely diagnosis? Benign paroxysmal positional vertigo Labyrinthitis Ménière disease Orthostatic hypotension

Correct Answer ( A ) Explanation: Benign paroxysmal positional vertigo (BPPV) is the most common type of vertigo in the United States. It is caused by loose calcium debris in the posterior semicircular canal of the ear. BBPV typically has a sudden onset and individuals notice it in connection with positional changes of the head, such as rolling over in bed, while showering, or sitting up quickly. The incidence is higher in women and BBPV generally occurs in individuals older than 50 years of age. Most cases of BBPV are either idiopathic or due to head trauma. Symptoms include recurrent episodes of vertigo that last less than one minute and resolve with positional changes of the head. Some individuals also experience nausea and vomiting. Diagnosis is based on history and physical exam, including nystagmus seen during provoking maneuvers. First-line treatment is with canalith repositioning maneuvers including the Epley maneuver. Patients with labyrinthitis (B) have nystagmus which is persistent, spontaneous, and not affected by position of the head. Individuals with BPPV will have positional nystagmus with the Dix-Hallpike maneuver, a physical exam technique used to diagnose BPPV. Patients are often mistakenly diagnosed with Ménière disease (C) when they have BPPV, however the vertigo seen in Ménière disease is not positional like in BPPV. Orthostatic hypotension (D) occurs when blood pressure changes cause hypoperfusion of the brain and patients experience dizziness symptoms with positional change from supine to sitting or standing.

While performing a routine physical examination, a provider notices a distinct decrease in the strength of the patient's radial pulse during inspiration. Which of the following conditions does this patient likely have? Constrictive pericarditis Diabetes mellitus Subclavian steal syndrome Tietze syndrome

Correct Answer ( A ) Explanation: Pulsus paradoxus is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. When the drop is more than 10 mm Hg, it is referred to as pulsus paradoxus. Pulsus paradoxus has nothing to do with pulse rate or heart rate. As a breath is taken in, the negative intrathoracic pressure within the chest increases venous return to the right side of the heart (increases right ventricular volume). Under normal circumstances, the right ventricle is able to expand into the pericardial space and has very little impact on the left ventricle. Pulsus paradoxus is a sign that is indicative of several conditions, including cardiac tamponade, constrictive pericarditis, chronic sleep apnea, croup, and obstructive lung disease. The paradox in pulsus paradoxus is that, on clinical examination, one can detect beats on cardiac auscultation during inspiration that cannot be palpated at the radial pulse. It results from an accentuated decrease of the blood pressure (due to reduced stroke volume), which leads to the radial pulse not being palpable and may be accompanied by an increase in the jugular venous pressure height (Kussmaul's sign). As is usual with inspiration, the heart rate is slightly increased, due to decreased left ventricular output. Diabetes mellitus (B), subclavian steal syndrome (C), and Tietze syndrome (D) are not associated with pulsus paradoxus.

A 43-year-old woman comes to the emergency department with a 5-hour history of right upper quadrant pain, fever, nausea, vomiting, and anorexia. She says she began experiencing these symptoms shortly after eating at her favorite fast food restaurant. Her temperature is 38.8°C (101.8°F). Palpation of the abdomen shows voluntary guarding. Laboratory studies shows leukocytosis with a left shift. Which of the following is the most likely diagnosis? Acute cholecystitis Acute pancreatitis Appendicitis Peptic ulcer disease

Correct Answer ( A ) Explanation: Right upper quadrant pain (+/- radiating to the shoulder or back), fever, nausea, vomiting, and anorexia most likely suggests acute cholecystitis. Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis (with a left shift) associated with gallbladder inflammation that is usually related to gallstone disease. Onset of symptoms generally occurs following ingestion of a fatty meal (as in this case). Although, most patients with active gallstones are asymptomatic and do not go on to develop cholecystitis, cholecystitis occurs most commonly due to blockage of the cystic duct with gallstones. This blockage results in buildup of bile and increased pressure within the gallbladder which leads to right upper quadrant abdominal pain. Definitive treatment is typically surgical removal of the inflamed gallbladder (ie, cholecystectomy). Acute pancreatitis (B) is sudden inflammation of the pancreas and typically presents with severe epigastric pain (usually radiating to the back), nausea, vomiting, and hemodynamic instability (eg, shock). Laboratory studies will show elevated serum amylase and lipase levels. Appendicitis (C) is inflammation of the appendix and typically presents with right lower quadrant pain, nausea, vomiting, and decreased appetite (ie, anorexia). Peptic ulcer disease (PUD) (D) presents with epigastric pain that worsens with eating. These patients can also present with iron deficiency anemia due to gastrointestinal blood loss.

Which of the following statements is true regarding the diagnosis of Epstein-Barr virus infection? Guillain-Barré syndrome is a possible complication Neutrophilia predominates Splenomegaly occurs in 10% of patients The virus is transmitted via respiratory droplets

Correct Answer ( A ) Explanation: The Epstein-Barr virus (EBV) is implicated in a variety of human illnesses. It is associated with infectious mononucleosis, B-cell lymphoma, Hodgkin disease, Burkitt lymphoma, and nasopharyngeal carcinoma. EBV can affect nearly all organ systems. Neurologic complications such as encephalitis, meningitis, and Guillain-Barré have been reported. EBV is associated with lymphocytosis (B) with >50% lymphocytes. Atypical lymphocytes are found on examination of the peripheral blood smear. Splenomegaly (C) occurs in >50% of patients. Therefore, patients should be advised to avoid all contact sports for a minimum of four weeks after illness onset to avoid splenic injury. EBV is transmitted via salivary secretions (D) and requires close contact for transmission (hence lay application of the term "kissing disease"). The infection is usually contracted from an asymptomatic individual who sheds the virus. After infecting the oropharyngeal epithelium, it disseminates through the blood stream. The virus infects B lymphocytes and causes an increase in T lymphocytes, which results in enlargement of lymphoid tissue. In immunocompromised patients with decreased T-cell function, B cells continue to proliferate, and proliferation may lead to neoplastic transformation.

A 42-year-old woman presents with severe facial pain. The patient reports she has had episodes of severe, shooting pain on the lower half of the left side of her face. Her neurologic examination is normal. She cannot identify any triggers for the episodes of pain. Which of the following is the appropriate next step? Carbamazepine prescription CT scan of the head Prednisone prescription Referral for EEG

Correct Answer ( A ) Explanation: Trigeminal neuralgia is manifested by intermittent episodes of severe pain in the distribution of the fifth cranial nerve. The maxillary and mandibular branches of the trigeminal nerve are most commonly affected. Trigeminal neuralgia is thought to be idiopathic although there may be some component of vascular compression as this has been found on surgical exploration of the trigeminal nerve root. Patients will often describe physical triggers that lead to an episode of severe pain. These include: chewing, shaving, brushing the teeth or touching the involved area of the face. In the absence of any neurologic deficit, no imaging is necessary. The antiepileptic carbamazepine is the medical treatment of choice for this condition. Other medications that have been tried but not shown to have more effectiveness include gabapentin, phenytoin, valproic acid, baclofen, lamotrigine and levetiracetam. If medical therapy fails, surgical procedures aimed at the destruction of the trigeminal ganglion may be attempted. A CT scan of the head (B) is not indicated unless a neurologic deficit is identified. Structural lesions including tumors, vascular malformations and aneurysms could cause the neuralgia. Prednisone (C) is not part of the treatment regimen for trigeminal neuralgia. Prednisone is used as therapy in the treatment of Bell's palsy, which is a paralysis of the peripheral facial nerve. The underlying pathology of Bell's palsy is thought to be due to inflammation of the nerve and prednisone is effective at improving paralysis when compared to placebo. A referral for EEG (D) is not part of the work-up for trigeminal neuralgia. Although antiepileptic medication is used in the treatment of the syndrome, seizures themselves do not play a role in causing the neuralgia.

A 24-year-old sexually active man presents with complaints of the "flu" for the past three weeks. Specifically, he complains of generalized weakness, malaise, myalgias, a low-grade fever, and anorexia. He denies URI symptoms or a cough. He has intercourse with men and does not always use condoms. He is concerned that he may have contracted HIV. His vital signs are significant for a blood pressure of 128/62 mm Hg, a heart rate of 82 beats per minute, an oxygen saturation of 99% on room air, and a temperature of 38.5°C. Your physical exam reveals a well-appearing male who is in no acute distress with no thrush or abnormal findings. Laboratory values reveal WBC of 6.2 with 3% bands, hemoglobin of 15.6 g/dl, and platelets of 120. Chest radiograph and urinalysis are normal. Which of the following statements best describes the next management step? You suspect acute HIV syndrome, obtain an oral swab for rapid HIV testing, and admit the patient for confirmatory studies if positive You suspect acute HIV syndrome, obtain an oral swab for rapid HIV testing, and confirm with blood specimen if positive You suspect acute HIV syndrome, obtain an oral swab for rapid HIV testing, and discharge and reassure the patient if negative You suspect acute HIV syndrome, obtain an oral swab for rapid HIV testing, and make the diagnosis of HIV if positive

Correct Answer ( B ) Explanation: Acute HIV syndrome (also known as acute seroconversion syndrome) may follow primary exposure by two to four weeks and cause nonspecific symptoms, including fever, chills, malaise, myalgias, pharyngitis, diarrhea, or other neurologic or immunologic complaints. These symptoms are generally mild with spontaneous resolution and are often mistaken for a benign viral illness. As a result, many patients do not seek medical care during this phase. When testing for HIV, positive oral swab results should be considered preliminary pending confirmation (required) with serum testing via HIV-1/HIV-2 differentiation immunoassay or Western blot. Oral swab testing has the advantage of being highly sensitive, relatively inexpensive, rapid, and noninvasive, and can detect antibodies for both HIV-1 and HIV-2. However, oral testing has a lower positive predictive value in low-prevalence populations than blood testing and may have a higher false positive rate. Therefore, positive results (D) should be confirmed with HIV-1/HIV-2 differentiation immunoassay or Western blot prior to diagnosis. Admission is not required (A) for a new diagnosis of HIV in the asymptomatic or nontoxic patient when proper outpatient follow-up can be arranged. Patients will generally develop detectable antibodies between two and eight weeks following initial infection. Therefore, during this period, antibody-based testing may yield falsely negative (C) results. Patients should be instructed to repeat the test in two to three months.

Question: What is the treatment for iron poisoning?

Question: What is the treatment for iron poisoning? Answer: Deferoxamine. Rapid Review ß-Blocker Toxicity: PE will show hypotension, bradycardia, and heart block Labs will show hypoglycemia Treatment is glucagon

Question: Can a woman with complete placenta previa undergo a vaginal delievery?

Answer: No, Cesarean delivery is indicated for all patients with sonographic evidence of complete placenta previa. Rapid Review Placenta Previa Patient will be a pregnant women in her third trimester Complaining of painless vaginal bleeding Diagnosis is made by transabdominal ultrasound Comments: Do not do a digital vaginal exam

Question: At which gestational age should Rhogram be administered to an Rh neg woman?

Answer: 28 weeks.

Question: What is the leading cause of cardiac death among the young in developing countries?

Answer: Acute rheumatic fever. Rapid Review Rheumatic Fever Patient with a history of GAS infection Complaining of fever, red skin lesions on the trunk and proximal extremities, and small, non-tender lumps located over the joints PE will show JONES criteria: Joints, Oh, no carditis!, Nodules, Erythema marginatum, Sydenham's chorea Labs will show anti-streptolysin O, anti-DNase B, positive throat culture, or positive rapid antigen test Treatment is antibiotics, NSAIDs Comments: Modified Jones Criteria for a first episode of acute rheumatic fever: need 2 major or 1 major and 2 minor

Question: What common viral infection is associated with intussusception?

Answer: Adenovirus. Rapid Review Intussusception (Telescoping Bowel) Patient will be a child 5 months - 3 years old Complaining of colicky abdominal pain, vomiting and bloody stools (currant jelly) Diagnosis is made by ultrasound ("target sign") Most commonly caused by a tumor or meckel's diverticulum Treatment is air/contrast enema

Question: How does one differentiate a pulmonary versus cardiac source of cyanosis?

Answer: Administration of oxygen to cyanotic infants with pulmonary disease typically raises pulse oximetry to 95% whereas in cardiac disease the oxygen saturation will likely remain below 90%. Rapid Review Ductal Dependent Lesions Transposition of the great vessels (most common cause in newborns) Tetralogy of Fallot (most common in children >1 year old) Tricuspid atresia Interrupted aortic arch Coarctation of the aorta Hypoplastic left heart syndrome Shock, "gray baby" within hours to days after birth PGE1

Question: Name 3 substances that contain salicylates?

Answer: Aspirin, Pepto-Bismol, oil of wintergreen (methyl salicylate) Rapid Review Reye's Syndrome Child with viral illness treated with aspirin Fatty liver Encephalopathy → delirium, seizures Vomiting Hypoglycemia Avoid aspirin in children (except in Kawasaki disease)

Question: What is the treatment of choice for pertussis?

Answer: Azithromycin.

Question: What is the initial work-up of a patient with primary amenorrhea?

Answer: Breast and pelvic examination, pregnancy test, pelvic ultrasound and serum follicle-stimulating hormone. Rapid Review Primary Amenorrhea Definition: lack of menarche by 16 with normal 2° sexual characteristics or by 14 with no 2° sexual characteristics Etiologies: Hypothalamic/pituitary Ovarian Uterine Pseudohermaphroditism Lab workup: FSH, LH, prolactin, TFTs, testosterone, hCG Rx: treat underlying cause

Question: Pilocarpine is another glaucoma medication. What is its mechanism of action?

Answer: Cholinergic (causes miosis, increased aqueous humour drainage). Rapid Review Acute Angle-Closure Glaucoma Patient will be entering a dark room or movie theater Complaining of acute unilateral painful vision loss, vomiting, and seeing halos around lights PE will show cloudy cornea and fixed mid-dilated pupil Labs will show ↑ IOP ( > 21 mm Hg) Treatment is topical ßBs, carbonic anhydrase inhibitors, steroids, miotics

Question: What are some examples of antibiotics effective against Pseudomonas aeruginosa?

Answer: Fluoroquinolones, aminoglycosides, carbapenems, certain 3rd generation cephalosporins (ceftazidime) and 4th generation cephalosporins are usually effective against Pseudomonas aeruginosa. Rapid Review Otitis Externa Patient with a history of swimming or moisture exposure Complaining of malodorous discharge and pruritus PE will show pain with palpation of tragus/pinna Most commonly caused by Pseudomonas aeruginosa Treatment is topical antimicrobials with or without steroids Comments: Necrotizing otitis externa - a complication seen in diabetics/immunocompromised

Question: What is the most common type of major joint dislocation?

Answer: Glenohumeral joint (shoulder). Rapid Review Anterior Shoulder Dislocation Subcoracoid most common Arm abducted, externally rotated Complications: axillary nerve damage, Bankart lesion, Hill-Sachs deformity

Question: What is the name of a localized herpes simplex virus infection of the fingers or toes?

Answer: Herpetic whitlow. Rapid Review Hand, Foot, Mouth Disease (HFMD) Patient will be a child younger than 5 years of age Complaining of decreased appetite and fever PE will show an oral exanthem plus a macular, maculopapular, or vesicular rash on the hands and feet Most commonly caused by Coxsackievirus A Treatment is supportive

Question: What is the first line antibiotic treatment for uncomplicated acute otitis media?

Answer: High-dose amoxicillin at 80-90 mg/kg/day. Rapid Review Acute Otitis Media Viral > bacterial (S. pneumoniae most common) Middle ear effusion ↓ TM mobility with pneumatic otoscopy Bulging, cloudy TM Amoxicillin

Question: What are some common electrolyte abnormalities found with hydrochlorothiazide?

Answer: Hypokalemia, hyponatremia, hypomagnesemia, and hypercalcemia. Rapid Review PDE-5 Inhibitors Mechanism: inhibits PDE-5 → corpus cavernosum smooth muscle relaxation + ↑ blood flow → erection Headache, dyspepsia ("Hot and heavy, but then headache, heartburn, hypotension") Nitrates + PDE-5 inhibitor use → refractory hypotension

Question: What is the treatment of last resort for severe and uncontrolled postpartum hemorrhage?

Answer: Hysterectomy. Rapid Review Postpartum Hemorrhage Patient will be a woman who has just given birth PE will show > 500 cc loss of blood and an enlarged "boggy" uterus Most commonly caused by uterine atony Treatment is uterine massage, oxytocin, prostaglandins, or surgery

Question: Which is less sedating, fexofenadine or diphenhydramine?

Answer: In general, first-generation oral antihistamines, like diphenhydramine, cause much more sedation than second-generation oral antihistamines, like fexofenadine. Rapid Review Allergic Rhinitis Patient with a history of asthma, atopic dermatitis and sinusitis Complaining of sneezing, rhinorrhea, and nasal congestion PE will show infraorbital edema and darkening, transverse nasal crease, cobblestoning of the posterior pharynx Labs will show elevated serum IgE Treatment is glucocorticoid nasal spray Comments: nasal polyps, asthma, and aspirin-sensitivity (Samter's triad)

Question: When is hydronephrosis expected and relatively considered normal?

Answer: In up to 80% of second trimester pregnancies, dilation of the ureters and renal pelvis commonly occurs. Rapid Review Ultrasound: Hydronephrosis Mild: distention of collecting system Moderate: dilation of collecting system, rounding of calyces, and renal papillae obliteration ("bear claw") Severe: calyceal dilation with cortical thinning

Question: What is the culprit lesion in patients with acute ST elevation in lead aVR?

Answer: Left main coronary artery. Rapid Review Myocardial Infarction ECG Patterns Anterior: ST elevations in V3, V4 Septal: ST elevations in V1, V2 Lateral: ST elevations in V5, V6, I, aVL Inferior: ST elevations in II, III, aVF Right ventricular: ST elevations in V4R, V5R Posterior: ST depressions in V1, V2, large R waves

Question: What intraneuronal inclusions are associated with Parkinson's disease?

Answer: Lewy bodies. Rapid Review Parkinson's Disease Lewy bodies, substantia nigra dopaminergic neuron loss TRAP: Tremor (resting, "pill rolling"), Rigidity, Akinesia, Postural instability Carbidopa/levodopa, anticholinergic drugs Avoid antipsychotics

Question: What is the name of the non-infectious endocarditis that presents with sterile vegetations on both sides of the involved valve?

Answer: Libman-Sacks endocarditis. Rapid Review Endocarditis Patient will be complaining of fever, rash, cough and myalgias PE will show Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE) Diagnosis is made by echocardiography and Duke's criteria Most commonly caused by: IVDA: S. aureus, tricuspid Native valve: Streptococci, mitral Treatment is antibiotics Comments: GI malignancy: S. bovis

Question: What trio of physical exam findings might be present in a patient with Pericardial Tamponade?

Answer: Muffled Heart Sounds, JVD, Narrowing Pulse Pressure/Hypotension (Beck's Triad).

Question: In children, what is the most common cause of paronychia development?

Answer: Nail biting or finger sucking. Rapid Review Incision and Drainage MRSA 60-75% Simple cutaneous abscesses: ABX not indicated Small abscesses: packing not indicated Complications: bleeding, extension, neurovascular injury

Question: Which ethnicity is known for having the greatest risk for developing gallstones and acute cholecystitis?

Answer: Native Americans. Rapid Review Cholecystitis Patient will be complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy's sign, Boas' sign Diagnosis is made by: Initial: US, Gold standard: HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy

Question: A teenage male complains of a hard lump in his scrotum. Can this be monitored with reassurance?

Answer: No! He must undergo further diagnostic testing with an ultrasound.

Question: Where is McBurney's point located?

Answer: One-third of the distance between the anterior superior iliac spine and the umbilicus. Rapid Review Cholecystitis Patient will be complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy's sign, Boas sign Diagnosis is made by: Initial: US, Gold standard: HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy

Question: How soon after removal of an infected pacemaker can another permanent pacemaker be placed?

Answer: Only after 4-6 weeks of intravenous antibiotics.

Question: Which type of malignancy is often associated with dermatomysoitis in women?

Answer: Ovarian cancer. Rapid Review Polymyositis Patient will be complaining of muscle pain and progressive weakness of 3 months duration PE will show diffuse tenderness of proximal muscles in the shoulder girdle and pelvic girdle, without rash or joint swelling and neurologic examination yields normal results Labs will show (+) Anti-Jo, (+) Anti-SRP, (+) Anti-Mi-2 Treatment is corticosteroids

Question: Where is the most common location to find ectopic endometrial tissue in endometriosis?

Answer: Ovaries. Rapid Review Endometriosis Patient will be a woman Complaining of pre or midcycle dysmenorrhea, dyspareunia, dyschezia (painful bowel movement) PE will show uterosacral nodularity or a fixed or retroverted uterus Diagnosis is made by laparoscopy Most common site is ovaries

Question: What is the name of the inability to retract foreskin?

Answer: Phimosis. Rapid Review Balanoposthitis Patient will be an uncircumcised male Complaining of burning and itching of the penis PE will show erythema and inflammation with scant white discharge Most commonly caused by Candida Treatment is topical antifungal Comments: Recurrent balanitis is seen in diabetics

Question: Which schistosoma species primarily presents with urinary symptoms?

Answer: Schistosoma haematobium.

Question: What is the best diagnostic test for adrenal insufficiency?

Answer: Serum cortisol level. Rapid Review Primary Adrenal Insufficiency (Addison's Disease) Patient will be complaining of abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE will show hyperpigmentation of skin and mucus membranes and hypotension Labs will show hyponatremia and hyperkalemia Most commonly caused by autoimmune Treatment is hydrocortisone

Question: How common is short-term relapse in asthmatic patients discharged from the Emergency Department?

Answer: Short-term relapse (within 3 days) is fairly common at around 11%. Rapid Review Asthma Asthma: airway inflammation + bronchial hyperresponsiveness + reversible airflow obstruction PEF <50%: severe exacerbation Treatments: O2: maintain SpO2 > 88% ß-agonists: ↑ cAMP → bronchodilation Anticholinergics: ↓ bronchoconstriction Corticosteroids: ↓ inflammation, administer early Mg: severe exacerbations Non-invasive ventilation: ↓ work of breathing Mechanical ventilation: Objective: maximize expiratory time Low respiratory rate High inspiratory flow rate Maintain plateau pressure <30 cm H2O Permissive hypercapnia to avoid breath stacking

Question: Weakening of the anorectal support structures, which also leads to hemorrhoid symptoms, can begin as early as which age bracket?

Answer: The 20s. Rapid Review Hemorrhoids Internal Proximal to dentate line Painless bleeding External Below dentate line Visible Painful Initial rx: WASH (Water (sitz bath), Analgesics, Stool softeners, High fiber diet) Thrombosed hemorrhoid rx: excision with elliptical incision

Question: In von Willebrand disease is the patient's platelet count depressed, normal or increased?

Answer: The platelet count will be normal in von Willebrand disease. Rapid Review von Willebrand Disease Patient with a history of a parent with similar symptoms Complaining of mucosal hemorrhage or bleeding that is difficult to control Labs will show decreased factor VIII, prolonged bleeding time Treatment is desmopressin (DDAVP) Comments: Most common inherited bleeding disorder, autosomal dominant

Question: For how long after the insertion of an IUD is the risk of developing pelvic inflammatory disease increased?

Answer: Three weeks. Rapid Review Pelvic Inflammatory Disease (PID) Patient will be a Female With a history of multiple sexual partners or unprotected sex or both Complaining of lower abdominal pain, cervical motion tenderness, painful sexual intercourse PE will show mucopurulent cervical discharge, "Chandelier sign" Most commonly caused by Chlamydia Treatment is ceftriaxone + doxycycline Comments: Fitz-Hugh-Curtis syndrome: perihepatitis + PID

Question: What is the other name of trigeminal neuralgia?

Answer: Tic douloureux. Rapid Review Trigeminal Neuralgia Sudden unilateral paroxysms of pain in gums, cheek, chin, temporal forehead Pain in V2 and V3 distributions, not V1 Right side > left side Triggers: chewing, brushing teeth, touching face, hot/cold exposure Carbamazepine

Question: True or false: Medical providers should counsel their patients to include 40-minute sessions of moderate to high-intensity aerobic activity 3-4 times per week as part of a healthy lifestyle?

Answer: True.

Question: True or false: Recurrence of benign paroxysmal positional vertigo is common?

Answer: True. Rapid Review Benign paroxysmal positional vertigo (BPPV) Patient will be complaining of sudden onset sensation of room spinning in connection with positional changes of the head, lasting seconds to minutes Diagnosis is made by Dix-Hallpike Most commonly caused by the presence of an otolith in the labyrinth system Treatment is Eply maneuver

A 62-year old man presents complaining of crushing substernal chest pain for the last two hours associated with diaphoresis, nausea, and lightheadedness. His pain improved with sublingual nitroglycerin. Electrocardiogram obtained in triage shows deep Q waves and ST segment elevation in leads V1-V4, with ST depression in leads III and aVF. This pattern on electrocardiogram represents infarction of which area of myocardium? Anterior Inferior Lateral Posterior

Correct Answer ( A ) Explanation: Anterior wall myocardial infarction is characterized by ST elevation in leads V1-V4, with reciprocal changes in the inferior leads (III and aVF). Septal involvement is reflected by changes in V1 and V2. The left anterior descending artery serves the anterior wall. Inferior wall infarctions (B) are characterized by ST elevation in leads II, III, and aVF. The inferior wall of the heart and the AV node are served by the right coronary artery in approximately 90% of cases (right dominant). The remaining 10% are served by the left circumflex artery (left dominant). Lateral wall infarctions (C) are frequently seen in conjunction with anterior (anterolateral) or inferior infarctions (inferolateral). Various vessels—including the left anterior descending, right coronary, and left circumflex coronary arteries—serve the lateral wall of the heart. Isolated lateral involvement is characterized by ST elevation in leads V5-V6 with ST elevations in I and aVL in high lateral infarctions. Posterior wall infarctions (D) are characterized by ST depressions in leads V1 and V2. Posterior leads can be placed on the patient's back which will then reveal elevations.

A 23-year-old woman delivers her first child. Her family history is positive for three uncles who needed early-in-life surgery for "heart defects." You are asked to assess her 1-day-old infant who does not "appear well" according to the nursing staff. During your examination, which of the following findings most suggests the presence of congenital heart disease? Basilar crackles and peripheral edema Fever Symmetric brachial and femoral pulses Systolic murmur

Correct Answer ( A ) Explanation: Congenital cardiac defects occur in 8 out of 1000 live births. Up to one third of infants born with a congenital cardiac defect develop life-threatening symptoms within the first few days of life, with 80% of infants presenting with congestive heart failure (pulmonary or peripheral edema or both). The mortality rate in this critical period is 90%. The majority of these defects can be screened for in the prenatal period with four-chamber echocardiography. Consider screening in women with diabetes, a family history of congenital heart disease, indomethacin exposure or rubella exposure. Fever (B) is less likely present as a sign of congenital heart disease and is more common in the setting of sepsis. Any 1-day-old infant with a fever should be worked up for sepsis including CBC, blood cultures, lumbar puncture, and should be started empirically on antibiotics. The presence or absence of cardiac murmur (D) is an unreliable sign of congenital heart disease, as many subtypes, even in their severe forms, are not associated with murmur. Examples include coarctation of the aorta and transposition of the great vessels. Normally, brachial and femoral pulses should be symmetric (C). Furthermore, the pulsation force should be similar in the brachial arteries as compared to the femoral arteries. However, in some congenital cardiac abnormalities, such as obstructive left-sided disease, left-to-right brachial pulses are commonly asymmetric.

A 3-year-old girl presents with painful vesicles on her buccal mucosa and posterior pharynx and vesiculopapular lesions on the hands and feet. Which of the following is the most likely cause of her symptoms? Coxsackie A 16 Herpes simplex virus 1 Human herpes virus 6 Varicella zoster virus

Correct Answer ( A ) Explanation: Coxsackie A 16, an enterovirus, is the most frequent cause of Hand-Foot-and-Mouth disease (H-F-M). Hand, foot, mouth disease is characterized by several days of fever (often high and acute in onset), irritability, and decreased appetite. On physical exam, the oropharynx is inflamed with vesicles that can be present on the tongue, buccal mucosa, lips, palate, posterior pharynx and gingiva which can ulcerate leaving 4-5 mm shallow lesions with surrounding erythema. Lesions typically resolve in about one week. Its distinctive presentation also includes a vesiculopapular skin rash typically on the dorsum of the hands and feet but may also present on the palms and soles and buttocks and groin. The skin lesions are usually tender and approximately 3-7 mm in size. Complications are rare but include myocarditis and pericarditis. Treatment is supportive with cool fluids and pain relievers to prevent dehydration from poor oral intake due to pain. Herpes gingivostomatitis is an acute oropharyngeal infection and is the most common presentation of primary herpes simplex virus 1 (B) infection in children six months to five years. It is sudden in onset and is associated with high fever, mouth pain, drooling, and food and drink refusal. The gums become swollen and vesicles develop throughout the oral cavity and are usually more extensive than that of those with H-F-M and are limited to the anterior oral cavity unlike the posterior involvement of coxsackie. There is no skin rash associated with herpes simplex virus 1 infection. Human herpes virus 6 (C) is associated with roseola infantum (sixth disease). This self-limited disease occurs in infancy and early childhood. It begins with the abrupt onset of high fever usually lasting 72 hours. Upon defervescence, a 2-3 mm morbilliform rash develops on the trunk. Varicella zoster virus (D) is associated with both varicella (chicken pox) and zoster (shingles). Varicella is associated with skin lesions that typically present first on the scalp and face and spread downward to the trunk. They are pruritic and evolve from erythematous macules to papules to form a clear, fluid filled vesicle. This occurs over a 24-48 hour period then lesions begin to crust over as new vesicles are appearing. Zoster is associated with a vesicular rash in a dermatomal distribution.

A 29-year-old woman presents with cyclic pelvic pain that has been increasing over the last 7 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis? Endometriosis Functional ovarian cyst Ovarian cancer Pelvic inflammatory disease

Correct Answer ( A ) Explanation: Endometriosis is abnormal growth of endometrium outside the uterus, particularly in the pelvis and ovaries. Retrograde menstruation is the most widely accepted cause; however its pathogenesis is not clearly understood. The "3 Ds," dysmenorrhea, dyspareunia, and dyschezia, as well as abnormal uterine bleeding are among the well-recognized manifestations. With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or "chocolate cyst." Imaging is of limited value and is only useful in the presence of pelvic or adnexal mass. Ultimately, a definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery. Functional ovarian cysts (B) occur from ovulation and form as a normal part of the menstrual cycle. They are usually not symptomatic. It is important to consider ovarian cancer in a patient with a pelvic mass however, ovarian cancer (C) usually occurs in older women over age 55 and patients are often asymptomatic until the disease is more advanced. With Pelvic inflammatory disease (PID) (D) the patient will have abdominal tenderness, adnexal tenderness, cervical motion tenderness and an elevated temperature.

A 10-month-old girl is brought to the ED by parents because they noted her to be tugging her right ear. On otoscopy, you note the finding seen in the image above. Which of the following is most closely associated with acute otitis media? Bulging tympanic membrane Erythema of the ear canal and erythematous tympanic membrane Low-grade fever and tugging at the ear Opacification of the tympanic membrane

Correct Answer ( A ) Explanation: Otitis media is a general term for middle ear inflammation; acute otitis media (AOM) is associated with an infection, whereas otitis media with effusion (OME) is associated with fluid behind the tympanic membrane without an infection. The incidence of AOM is bimodal, with a 1st peak between the ages of 6 and 18 months and the 2nd, smaller peak at 5 years. A bulging tympanic membrane is the single finding most closely associated with acute otitis media. Bulging of the tympanic membrane has the highest predictive value for the presence of middle ear effusion. Erythema of the ear canal and tympanic membrane (B) suggest increased vascularity from inflammation but is not sufficient for a diagnosis of AOM. Low-grade fever and tugging at the ear (C) are parts of a constellation of symptoms (ear pain, ear tugging, sleeplessness, irritability, decreased oral intake) commonly associated with AOM but have been confirmed by a 2009 study (Shaikh et al.) that none of these symptoms were predictive without controlling for the presence of URI. Opacification of the tympanic membrane and air-fluid levels behind the tympanic membrane (D) are findings not specific to AOM and can also be found in children with otitis media with effusion.

Which of the following patients in the setting of a known subarachnoid hemorrhage has the worst prognosis? A 39-year-old woman who is confused and has mild right lower extremity weakness A 55-year-old man with a severe headache and oculomotor nerve palsy A 65-year-old man with a mild headache, nausea, and an episode of vomiting A 70-year-old woman with headache, neck stiffness, and an episode of vomiting

Correct Answer ( A ) Explanation: The Hunt and Hess scale is one of several schemes used to classify the severity of a subarachnoid hemorrhage based on the patient's clinical condition at presentation. It is used as a predictor of outcome; higher grades correlate with lower survival rates. The patient who is confused with mild right lower extremity weakness is classified as Grade III and has a projected survival of 50%. A 55-year-old man with a severe headache and oculomotor nerve palsy (B) is a Grade II and has a 60% survival rate. A 65-year-old man with a mild headache, nausea, and an episode of vomiting (C) and a 70-year-old woman with headache, neck stiffness, and an episode of vomiting (D) are both Grade I and have a survival rate of 70%.

The shoulder is most vulnerable to an anterior glenohumeral dislocation when in which of the following positions? Abduction and external rotation Abduction and internal rotation Adduction and external rotation Adduction and internal rotation

Correct Answer ( A ) Explanation: The shoulder is most vulnerable when abducted and externally rotated. A fall or tackle with the arm in this position can cause an anterior shoulder dislocation. Posterior shoulder dislocations are less common and are associated with grand mal seizures and electric shock. Abduction and internal rotation (B), adduction and external rotation (C), adduction and internal rotation (D) are not associated with increased risk of anterior shoulder dislocation.

A 9-year-old boy is brought to the ED by his mom for bizarre behavior. She states that he has had intermittent fevers for the past week and is now complaining of joint pain and swelling. Most concerning for Mom is the writhing, purposeless, and uncontrollable movements of her son's hands that she observed this morning. On exam, a diastolic murmur is noted at the right upper sternal border. Which of the following tests is most likely to confirm the diagnosis? Antistreptolysin O titer (ASO) CBC ECG Echocardiogram Myocardial biopsy

Correct Answer ( A ) Explanation: This patient has acute rheumatic fever (ARF), a systemic disease triggered by a complex hyperimmune response to group A streptococcal (GAS) pharyngitis. The American Heart Association has developed and modified the Jones criteria to enable physicians to identify patients with ARF. To fulfill the criteria, the patient must exhibit evidence of recent streptococcal disease and have either two major criteria or one major and two minor criteria. This patient has three of the major criteria: chorea (writhing, purposeless, and uncontrollable movements of the hands); carditis (diastolic murmur suggestive of aortic insufficiency); and arthritis. Evidence of recent streptococcal infection is required to confirm the diagnosis. This can be accomplished by detecting an elevated or rising ASO titer or by obtaining a positive throat culture or rapid Strep antigen test. Thrombocytosis in a CBC (B) may be seen in ARF because platelets are an acute phase reactant. However, this will not confirm the diagnosis of ARF. Thrombocytosis is also seen in Kawasaki syndrome. An ECG (C) may be abnormal in this patient, possibly showing evidence of strain due to underlying aortic insufficiency, but would not confirm the diagnosis. At some point, this patient will require an echocardiogram (D), but this will not aid in determining or confirming the underlying diagnosis of ARF. Myocardial biopsy (E) is an invasive procedure that is not required to make the diagnosis of acute rheumatic fever. It is sometimes used in the diagnosis of myocarditis.

A 65-year-old woman presents to the emergency department in atrial fibrillation with rapid ventricular response for an unknown duration of time. She was started on heparin and no atrial thrombus was seen on transesophageal echocardiogram. She underwent successful direct current cardioversion and is now back in normal sinus rhythm. What is the minimum period of time she must she remain on anticoagulation after cardioversion? Five days Four weeks One year Three months

Correct Answer ( B ) Explanation: At least four weeks of anticoagulation is recommended post-cardioversion in patients with atrial fibrillation lasting more than 48 hours or for an unknown duration of time. Although electrical atrial activity is normalized following cardioversion, atrial mechanical stunning and a higher risk of stroke may persist for up to four weeks, and warfarin with a goal INR of 2.0-3.0 must be continued during this time. The risk of thromboembolism after cardioversion can be diminished to less than 1% during the four weeks after cardioversion by the use of a month of therapeutic anticoagulation. For patients who have been in atrial fibrillation for less than 48 hours, anticoagulation is not mandatory because clot formation during that time is unlikely. Five days (A) is not enough time to reduce the risk of cardioversion related thromboembolism. Three months (D) and one year (C) of anticoagulation are not recommended. However, lifelong anticoagulation may be recommended depending on the patient's CHADS2 or CHADSVASc score.

A 2-year-old girl presents to the Emergency Department with her parents for a rash. She has lesions on her palms and on the soles of her feet, as well as in her oral cavity as shown above. Which of the following indicates that the child is no longer contagious and can safely return to daycare? Ability to tolerate oral intake Active skin lesion resolution Antibiotic therapy is complete Fever resolution

Correct Answer ( B ) Explanation: An oral exanthem plus a macular, maculopapular, or vesicular rash on the hands and feet suggests a diagnosis of hand, foot, and mouth disease (HFMD) caused by an enterovirus, most commonly Coxsackievirus A serotypes. This is a clinical diagnosis. Outbreaks are seen in daycare centers, schools, summer camps, hospital wards, and military installations. The most common age group affected are children less than five years of age. The virus is usually transmitted from person to person by the fecal-oral route. However, transmission can occur by contact with oral, respiratory, and vesicular secretions. The incubation period may last from 2-7 days. Patients may present with throat or mouth pain or refusal to eat. Fever is rare and is usually below 38.3ºC. Management is largely supportive with hydration and pain control. Infants and children with active skin lesions should be excluded from daycare. Once the active skin lesions resolve the child can return to daycare. It is also important to practice strict hand hygiene as enteroviruses are spread through stool for weeks following infection. Hand, foot, and mouth disease is caused by an enterovirus and is not bacteriologic. Therefore, antibiotic therapy (C) is not necessary for management. Fever is rare with this condition. Fever resolution (D) itself does not indicate that the child is no longer contagious and should not be used to determine ability to return to daycare. Because patients may experience pain with eating, proper pain management will improve oral intake. Patient's ability to tolerate oral intake (A) may signify that they are improving, but does not necessarily mean that they are no longer contagious.

A 31-year-old man presents with 10/10 flank pain that radiates to his testicle. He has no significant past medical history. Temperature and vital signs are normal. Examination reveals no edema or skin lesions. Urinalysis is positive for a microhematuria. Further evaluation would most likely reveal which of the following abnormalities? Calcium deposition in the renal parenchyma Enlarged renal pelvis and proximal ureter Glomerular capillary angiopathy Parenchymal hemorrhage, neutrophil casts and suppurative necrosis

Correct Answer ( B ) Explanation: Hydronephrosis is the distension of the renal calyces and pelvis due to obstruction of distal urinary flow which commonly accompanies hydroureter. It can occur in both acute and chronic forms, and can affect one or both kidneys. Major childhood causes include congenital ureteropelvic junction abnormalities, urethral valves and urethral stricture. Major adult causes include urolithiasis, benign prostatic hyperplasia and other bladder outlet obstruction, prostate carcinoma, bladder prolapse and retroperitoneal or pelvic neoplasms. Acute hydronephrosis leads to changes in renal function and acute renal failure, while chronic forms cause infection and sepsis, renal scarring, permanent nephron loss and calculous formation. Acute cases typically present with pain (renal or ureteral colic), which alludes to the level of obstruction. Renal pelvic or superior urethral obstruction causes flank pain, while inferior urethral obstruction refers pain to the ipsilateral testicle or labia. Severe pain usually is the result of acute complete or partial bilateral stone obstruction, or acute fluid overload in previously asymptomatic and undiagnosed ureteropelvic junction abnormality. Leukocytosis and pyuria suggests an infectious etiology. Hematuria suggests urolithiasis as the cause. Renal ultrasonography is the initial test of choice to diagnose the level of urinary tract obstruction. If unremarkable, intravenous pyelography or CT scanning may be necessary. Treatment is geared at treating the underlying etiology. Nephrocalcinosis (A), most common in premature infants, is a disorder of serum or urine hypercalcemia (hyperparathyroidism) that leads to diffuse, fine calcium deposition in the renal parenchyma. It is related to, but different than, nephrolithiasis. Nephrotic syndrome is the result of some type of glomerular abnormality. In adults, the most common primary cause is focal segmental glomerulosclerosis (glomerular scarring), while one of the most common secondary causes is diabetic nephropathy (glomerular inflammation, angiopathy (C) and scarring). Nephrotic syndrome is characterized by proteinuria, hypoalbuminemia, hyperlipidemia and (typically facial) edema. Pyelonephritis is inflammation of the renal parenchyma, calyces and pelvis commonly due to urinary tract or serum bacterial infection. Patients present with fever, tachycardia, dysuria, nausea and costovertebral angle tenderness. Histopathological samples typically consist of hemorrhage, neutrophil casts and suppurative necrosis (D).

A 34-year-old man presents to the psychiatric clinic because his wife thinks he has become more irritable, reckless, and paranoid over the past year. During the patient interview, he appears unable to prevent occasional, jerking movements of his arms and torso. He says his father developed the same problem in his 40's and died alone in a psychiatric hospital about 15 years later. Which of the following tests will most definitively diagnose this patient's likely condition? Brain MRI Genetic testing Lumbar puncture Positive emission tomography (PET) scan

Correct Answer ( B ) Explanation: Genetic testing is the most definitive method of diagnosing Huntington disease, the most likely disease in this patient. Huntington disease is a genetically-passed neurologic disorder with an autosomal dominant inheritance pattern. Patients usually present with symptoms between 30 and 50 years of age and typically first notice mild abnormal movements or intellectual changes. Irritability, personality changes, and antisocial behaviors are common. In the initial stages, the abnormal movements may merely be slight fidgeting or restlessness. However, over the next 15-20 years, the disorder will progress to cause obvious dementia and the stereotypic dystonic posturing and choreiform ("dance-like") movements that are hallmarks of the disease. Huntington disease may be suggested by cerebral atrophy of the caudate nucleus on CT or MRI scanning of the brain. A positive emission tomography (PET) scan might show a reduced striatal metabolic rate. However, genetic testing under the guidance of a licensed genetic counselor is diagnostic. There is no cure for Huntington disease and no treatments exist to slow its progress. Tetrabenazine is usually used to manage the dyskinesia. Phenothiazines or haloperidol may be recommended to provide additional control of movements and to palliative any behavioral disturbances. Clozapine is occasionally needed to manage severe psychiatric effects. All patients with Huntington disease should be given the option to have their offspring referred for genetic counseling to aid in informed reproductive planning. A brain MRI (A) may show atrophy of the caudate nucleus in patients with Huntington disease. However, it is not the best test to definitively diagnose the underlying genetic cause of the patient's symptoms. A lumbar puncture (C) is not useful for diagnosing Huntington disease. This test may be helpful if an acute infectious etiology, such as meningitis or encephalitis, were responsible for the patient's symptoms. A positive emission tomography scan (D) can indicate a reduced striatal metabolic rate, but this is non-specific and not able to establish the diagnosis of Huntington disease.

A 32-year-old woman is diagnosed with Prinzmetal's angina. She presents to clinic 2 weeks after being discharged from the hospital. She complains of 3 episodes of angina since discharge. She is concerned about future attacks. Long-term prophylaxis to reduce these attacks is best accomplished with which of the following medications? Atorvastatin Nifedipine Propranolol Warfarin

Correct Answer ( B ) Explanation: Prinzmetal's angina is a condition of cyclical chest pain secondary to coronary vasospasm. Any acute angina must be evaluated and empirically treated with an anti-ischemic regimen of antihypertensive, antiplatelet and antithrombotic medications. Once the diagnosis of coronary vasospasm is made, long term management of the anginal attacks include calcium channel blockers, namely nifedipine, and long-acting nitrates like isosorbide dinitrate. Statin medications (A) do play a role in the overall management of patients with Prinzmetal's angina, as there is some correlation with atherosclerosis. However, statins do not work at decreasing vasospasm, and as such, they would not be a viable choice in decreasing the chest pain attacks. Nonselective beta-blockers like propranolol (C) are contraindicated in the treatment of Prinzmetal's angina. Anticoagulants like warfarin (D) play no role in decreasing the vasospasm and subsequent angina associated with Prinzmetal's.

A 39-year-old woman presents to the office with painless vaginal bleeding in the third trimester (32 weeks) of pregnancy. She has had no prenatal care and a history of tobacco use. She denies any lower extremity edema, and her vital signs are normal. She has five other children, all of whom were delivered via Cesarean section. Which of the following conditions should you be most concerned about? Labor Placenta previa Placental abruption Preclampsia

Correct Answer ( B ) Explanation: Painless third-trimester bleeding was a common presentation for placenta previa in the past; however, now most cases of placenta previa are detected antenatally with ultrasound before the onset of significant bleeding. This patient has had no prenatal care and is at increased risk for complications. Placenta previa is characterized by placental tissue that overlies or is adjacent to the cervical os. Placenta previa typically presents as painless vaginal bleeding in the second or third trimester. Between 70% and 80% of patients with placenta previa will have at least one bleeding episode. Patients at risk of placenta previa include increasing parity or maternal age, cigarette smoking, and prior uterine surgery. About 10% to 20% of patients present with uterine contractions before bleeding, and fewer than 10% remain asymptomatic. Of patients with bleeding, one third will present before 30 weeks' gestation, one third between 30 and 36 weeks' gestation, and one third after 36 weeks' gestation. Patients with early-onset bleeding (<30 weeks' gestation) have the greatest risk for blood transfusion and associated perinatal morbidity and mortality. The bleeding is believed to occur from disruption of placental blood vessels in association with the development and thinning of the lower uterine segment. Patients with placenta previa who present preterm with vaginal bleeding require hospitalization and immediate evaluation to assess maternal-fetal stability. In at least 50% of women who present with asymptomatic previa, delivery can be delayed for more than 4 weeks, including patients with initial bleeding episodes greater than 500 mL. If the patient were in labor (A) she would be having painful contractions and not painless vaginal bleeding. Preeclampsia (D) is associated with lower extremity edema, proteinuria and elevated blood pressure, none of which are present in this scenario. Placental abruption (C) occurs when the placenta seperates from the uterus. The condition is associated with painful bleeding. Risk factors for abruption include hypertension, advanced maternal age, and cocaine use.

A 30-year-old woman, who had an uncomplicated pregnancy, delivered a healthy newborn a few minutes ago. She just now delivered a placenta with absent cotyledons. Copious amounts of blood begin to flow from the vaginal orifice. Within minutes, the patient becomes lightheaded but maintains consciousness. You attempt manual extraction but the bleeding continues and the blood pressure decreases to 98/68 mmHg. Which of the following is the next best step in management of postpartum hemorrhage? Blood type and cross-match Suction curettage Uterine artery ligation Uterine packing with gauze

Correct Answer ( B ) Explanation: Postpartum hemorrhage can be a serious, and sometimes fatal, situation. One of the causes is retention of placental tissue, which is usually due to abnormal placental implantation or an abnormal separation process. Delivery of an incomplete placenta, for example one that is abnormally shaped or missing some of its normal septations (cotyledons), may prevent normal postpartum uterine contractions. This can lead to improper constriction of the spiral arteries (uterine atony), and ultimately, excessive bleeding. If retained placenta is a highly suspected cause of postpartum hemorrhage, immediate digital extraction should be performed by inserting fingers thru the cervix and into the uterus, then using them to direct and maneuver any remaining intrauterine tissue out through the vagina. If this is unsuccessful, and bleeding continues or the patient decompensates, curettage with a suction device or sharp curette is recommended. Adjuvant interventions include establishing large-bore intravenous access, uterine massage, oxytocin, methylergonovine maleate and alerting the operating room. Obtaining a blood type (A) and alerting the blood bank is wise in managing any patient with hemorrhage. However, in this case, it should not supersede a definitive treatment like curettage. If curettage fails, then one should consider a more advanced hemostatic treatment like uterine artery or hypogastric artery ligation (C) or arterial embolization. Packing the uterine cavity with gauze (D), once commonplace, is seldom used today as it is only a temporizing maneuver.

A 57-year-old woman with a history of type 2 diabetes mellitus has had two weeks of worsening erythema and edema of the ear canal with deep otalgic pain. Copious granulations are present in the canal and a foul aural odor is noted. Which of the following organisms most likely caused this infection? Haemophilus influenza Pseudomonas aeruginosa Staphylococcus aureus Streptococcus pyogenes

Correct Answer ( B ) Explanation: Pseudomonas aeruginosa is the typical organism responsible for malignant otitis externa, of which this patient is showing classic signs and symptoms. In addition to the ear canal edema and erythema seen in common otitis externa, patients with malignant otitis externa will complain of deep otalgia and a persistent, malodorous aural odor. Granulations will be seen in the canal and deficits of cranial nerves VI, VII, and IX-XII may be seen depending on the severity of progression. The medical history of a patient with malignant otitis externa often includes diabetes mellitus or another immunocompromising condition. Any suspicion of malignant otitis externa should prompt clinicians to order a CT of the auditory canal and head with radionuclide scanning. The presence of osseous lesions on imaging confirms the diagnosis of malignant otitis externa. Prolonged antipseudomonal antibiotics are often necessary for several months to allow for infection resolution. Antibiotics should not be discontinued until a gallium scan is performed that indicates a reduction in the inflammatory process. Haemophilus influenza (A), Staphylococcus aureus (C), and Streptococcus pyogenes (D) are generally not implemented in the development of malignant otitis externa. Rather, these are more likely to cause acute otitis media, which generally presents with otalgia, decreased hearing, and fever, often following a recent upper respiratory infection.

A 79-year-old woman complains of increasing fatigue and general weakness. She has never fallen in her life before, but, in the past six months, she has had three falls. When considering your differential diagnosis, which of the following age-related body composition changes would you explain to the patient? Bone demineralization Myofibrosis Neuroregeneration Presbycusis

Correct Answer ( B ) Explanation: The aging process can be summarized by describing the "Senescent Phenotype", which includes the four physiological processes of body composition change, neurodegeneration, homeostatic dysregulation and altered energy dynamics. Concerning body composition, a person's weight will change over life, increasing from birth to about 65 years of age, at which point it decreases, mainly due to an overall decrease in protein and fat. However, the ratio of fat to protein increases due to fatty infiltration. One main target of this process is muscle tissue: non-collagenous protein gets replaced with fat. But, the muscle protein that does remain becomes more fibrotic, with an overall increase in fibro-collagenous tissue, a process known as fibrosis. Increased muscle fat and fibrosis, and decreased functional muscle protein, leads to decreased muscle function which manifests as weakness. Bone demineralization (A) does occur with aging, however, it's main effect is an increase in fractures, not a decrease in strength. We are born with all the neurons we'll ever have; i.e., we do not regenerate nerves (C). Presbycusis (D) is the age-related decrease in hearing.

A 75-year-old woman with a history of sick sinus syndrome status post pacemaker implantation 2 weeks ago presents with pain over the pacemaker site and fever. Examination reveals erythema, warmth, fluctuance and tenderness over the pacemaker site. What management should be pursued? Incision and drainage of the site Intravenous antibiotics, cardiology consultation and admission Needle aspiration of the site Oral antibiotics and follow up with cardiology

Correct Answer ( B ) Explanation: The patient presents with a subcutaneous pacemaker "pocket" infection, which requires intravenous antibiotics, specialist consultation and admission. As with all surgical procedures, pacemaker implantation carries a risk for infection. This risk is small; about 2% for local wound infection and 1% risk for bacteremia or sepsis. Unfortunately, bacteremia is unlikely to respond to conservative management with antibiotics alone and replacement is often necessary. When either local infection or bacteremia is suspected, blood cultures should be obtained and intravenous antibiotics should be initiated. Staphylococcus aureus and Staphylococcus epidermidis are the most commonly isolated bacteria (60-70%). Thus, empirical antibiotics should include vancomycin. It is difficult to distinguish local infection from systemic infection and 20-25% of those with local infections will have positive blood cultures. Although it is tempting to attempt local incision and drainage (A) of a likely abscess, this approach is contraindicated as the scalpel may inadvertently sever the pacemaker leads. Oral antibiotics (D) may be adequate for the management of a mild cellulitis but it is difficult to distinguish cellulitis from a pocket infection. Additionally, the presence of fever and fluctuance suggests a more advanced infection. A hematoma at the pacemaker site can mimic a pocket infection and needle aspiration (C) can differentiate these two processes. However, needle aspiration should only be performed under fluoroscopy because the needle may cut insulation surrounding the pulse generator or pacemaker leads leading to malfunction of the device.

A 14-year-old otherwise healthy boy presents to your clinic with his father. He is concerned because his breasts are enlarged. Appropriate management includes which of the following? BRCA gene testing Reassurance Serum estrogen level Ultrasound

Correct Answer ( B ) Explanation: The patient has gynecomastia, a common finding in males during early pubertal changes (occurs in half of men at some point during adolescence, most commonly between ages 13-14 years or tanner stage 3-4). Gynecomastia results from relative imbalance between estrogen and testosterone levels. Generally, males reach adult levels of testosterone production after estrogen levels rise, resulting in a relative imbalance between the two hormones. Additionally, estrogen is produced in extragonadal tissue (particularly adipose) by the aromatization (aromatase is the enzyme that converts androstenedione into estrogen). Gynecomastia in males and asymmetric breasts in females are a normal aspect of pubertal development and is a normal finding. Therefore, reassurance is all that is required. Further evaluation of the breast tissue for causes of pathologic gynecomastia is indicated when gynecomastia has persisted beyond 2 years or over 17 years of age. Serum estrogen level (C) is not elevated in physiologic gynecomastia, rather 24 hour testosterone and 24 hour estradiol can be abnormal, though these levels need not be obtained to diagnose physiologic gynecomastia. Pathologic gynecomastia can occur due to chronic renal disease, cirrhosis, hyperthyroidism, and underlying adrenal and testicular malignancy. Ultrasound (D) of the breast tissues is not indicated unless there is suspicion for malignancy or infection. In patients with suspicious breast masses, a thorough testicular exam should also be performed. BRCA (A), a gene that is associated with increased risk of breast cancer, is not associated with either physiologic or pathologic gynecomastia.

A 43-year-old woman with a history of von Willebrand disease presents with epistaxis. Vital signs are normal and examination reveals oozing from the right nares despite applying pressure. Which treatment is indicated in this patient's management? Cryoprecipitate Desmopressin Factor VIII concentrate Fresh frozen plasma

Correct Answer ( B ) Explanation: This patient presenting with mild bleeding with a history of von Willebrand disease should have desmopressin (DDAVP) administered. von Willebrand disease is a common inherited bleeding disorder. von Willebrand factor (vWF) is involved in factor VIII activity in supporting platelet adhesion. Platelets have normal morphology but in the absence of factor VIII/vWF complex their ability to adhere is impaired. There are three types of von Willebrand disease: Type I - mild to moderate decrease in vWF, Type II - dysfunctional vWF, Type III - absolute lack of vWF. Patients predominantly present with mucosal surface bleeding including epistaxis and bleeding from the gums. Menorrhagia and gastrointestinal bleeding are common but hemarthrosis is rare. Diagnosis is classically made with an abnormal bleeding time. A reduction in vWF activity will also be seen. In patients with mild mucosal bleeding, desmopressin or DDAVP is sufficient for treatment. Desmopressin acts by increasing circulating levels of factor VIII and vWF. It can be administered intravenously or nasally. Cryoprecipitate (A) contains factor VIII, XIII, von Willebrand factor (vWF), fibrinogen and fibronectin and can be used in patients with severe bleeding. Fresh frozen plasma (D) should only be used in severe bleeding when factor VIII concentrate is not available. Factor VIII concentrate (C) is first line therapy in patients with vWF and severe bleeding if available.

A patient with a complete C5 spinal cord injury presents to the ED with dysautonomia. He has not passed stool for the last 48 hours. Due to his quadriplegia, his nursing aide performs digital rectal stimulation and disimpaction. However, he has been unable to remove any stool as of late. An abdominal radiograph shows a significant amount of stool in the lower rectum. Which of the following is the next best step in managing this patient's fecal impaction? Balloon tamponade with a Sengstaken-Blakemore device Colonoscopy Enema washout Phrenic nerve stimulation

Correct Answer ( C ) Explanation: Fecal impaction is a common gastrointestinal problem. Prompt identification is key. Settings in which this morbid condition is common are patients on opioids, antacids, calcium channel blockers and anticholinergics, spinal cord injury patients, laxative dependency and abuse and patients with Chagas' or Hirschsprungs's disease. Symptoms include constipation, rectal discomfort, anorexia, nausea, vomiting, paradoxical diarrhea and overflow urinary incontinence. Disimpaction may be necessary. Steps to perform this procedure are double-gloving, use of copious amounts of anal lubricant, asking the patient to concentrate on deep breathing, telling the patient what you are going to do before you do it, inserting the index finger into the rectum and then moving it to dislodge, fragment or extract as much stool as possible. When this procedure fails, an enema washout can be tried. One common enema solution is docusate syrup, water and sorbitol. The solution is introduced through a rubber catheter and rubber seal-ball. Flow rate and volume are adjusted to maintain patient comfort. Balloon tamponade (A) with a Sengstaken-Blakemore device is used to stop the bleeding of esophageal varices, not to relieve fecal impaction. Colonoscopy (B) is used after all impacted stool has been removed to search for reasons why a patient has impaction. Used in high cervical spinal cord patients who cannot self-ventilate, a phrenic nerve stimulator (D) is implanted to stimulate the phrenic nerve to activate the diaphragm for successful ventilation.

An 84-year-old woman is recovering in the hospital from an acute anterior ST elevation myocardial infarction four days ago without complication. The patient suddenly develops chest pain, tachypnea and dyspnea. Her pulse is 115 beats per minute, respiratory rate is 26 breaths per minute, blood pressure is 85/50 mm Hg in both arms. She has elevated jugular venous pulsations and distant heart sounds. Her lungs are clear to auscultation bilaterally and no new murmur is appreciated. What is the most likely etiology of her acute decompensation? Acute aortic dissection Acute mitral regurgitation Left ventricular free wall rupture Post infarction ventricular septal defect

Correct Answer ( C ) Explanation: Left ventricular free wall rupture usually leads to hemopericardium with cardiac tamponade, characterized by the classic triad of jugular venous distention, hypotension and muffled heart sounds. The presence of rupture is first suggested by the development of sudden profound right heart failure and shock, often progressing rapidly to pulseless electrical activity and death. Survival depends primarily upon the rapid recognition and immediate therapy. Patients displaying suggestive symptoms, signs, and ECG changes require a bedside echocardiogram for diagnosis. Treatment is emergent pericardiocentesis and hemodynamic support. Risk factors include first myocardial infarction, anterior location of the infarction, elderly age and female sex. The incidence of myocardial rupture after an MI is about 1% in patients. In about one-half of cases, myocardial rupture occurs within the first five days after a myocardial infarction and in over 90% of cases within two weeks. Acute aortic dissection (A), acute mitral regurgitation (B) and post infarction ventricular septal defect (D) are all major mechanical complications of acute myocardial infarction that can cause hemodynamic collapse. Acute aortic dissection is associated with inferior wall ST elevation myocardial infarction. Common clinical findings are asymmetric blood pressures and an early diastolic murmur of aortic regurgitation. Acute mitral regurgitation is another complication of myocardial infarction and presents with a new holosystolic murmur heard best at the left sternal border and apex that may radiate to the axilla. Post infarction ventricular septal defect is characterized by a new holosystolic murmur at the left sternal border associated with a thrill. Both acute ischemic mitral regurgitation and post infarction ventricular septal defect can result in acute pulmonary edema with respiratory distress. The diagnosis must be confirmed by echocardiography.

A 59-year-old man presents to your office with a resting tremor, rigidity, and bradykinesia. You note that his handwriting is small and difficult to read when you look at the registration form he completed upon check-in. Which of the following is the most likely diagnosis? Cerebellar tremor Multiple sclerosis Parkinson disease Primary writing tremor

Correct Answer ( C ) Explanation: Parkinson disease is a progressive neurodegenerative disorder. Individuals with Parkinson disease often exhibit a characteristic tremor, a shuffling gait, and a masked facial expression. However, the effects of Parkinson disease are much more widespread. Although the cardinal features of Parkinson disease are described as resting tremor, rigidity, bradykinesia, akinesia, postural instability, flexed posture, and "freezing" episodes, these do not all manifest at once. Early motor signs may be subtle and nonspecific. Often they are recognized only in retrospect. A decrease in arm swing or stride length on one side while walking can lead to pain in the shoulder, upper back, low back, or hip. Decreased fine motor coordination can cause difficulty with buttons and clasps. Thus, getting dressed in the morning may become a slower process. Additional movements may slow and decrease in amplitude. For example, handwriting often becomes smaller and more difficult to read. When tremors first appear, they often are intermittent and most obvious during stressful situations. As the disease progresses, physical signs become more obvious. Tremor often is more constant. However, it may be absent altogether in some people, especially older individuals. Parkinsonian tremor usually is present only at rest. Some people learn to control the tremor by keeping their hands active. As walking becomes more difficult, people with Parkinson disease tend to become more sedentary. Difficulty with initiating movement, in combination with worsening balance, can make rising from soft chairs and car seats an arduous process. As the disease advances, akinesia (lack of movement) and bradykinesia (slowness of movement) continue to become more prominent. Posture may become more stooped. People with Parkinson disease may attribute these signs to weakness or stiffness of their limbs and body. Cerebellar tremor (A) is a slow tremor that is absent during rest but appears and progressively increases in amplitude with movement, particularly with fine adjustments required for a precise movement. It is associated with cerebellar disease. Multiple sclerosis (B) patients often exhibit incoordination, dysarthria, and intention tremor along with weakness in one or more limbs and visual blurring due to optic neuritis. Primary writing tremor (D) is a rare condition characterized by a 4- to 7-Hz tremor in the hand while assuming a writing posture or during the writing task itself. Most patients are men. About one-third have a positive family history of writing tremor, and a similar number give a history of improvement after ethanol ingestion.

Which of the following is true regarding diverticulitis? All patients should have CT imaging performed Complicated diverticulitis can be treated with oral antibiotics Oral antibiotics should be given for 7-10 days in uncomplicated diverticulitis Ultrasound is the imaging modality of choice

Correct Answer ( C ) Explanation: Patients who present with uncomplicated diverticulitis should be treated with oral antibiotics for 7-10 days. Diverticulitis is an inflammation of the diverticulum in the large intestine. In uncomplicated cases of diverticulitis, patients present with abdominal pain typically in the left lower quadrant with tenderness to palpation in the same area. Patients should not have peritoneal signs or masses on examination. Complicated diverticulitis is defined as the presence of either extensive inflammation or complications such as abscess, peritonitis or obstruction. Patients with uncomplicated diverticulitis can be empirically treated with antibiotics (typically as an outpatient) for 7-10 days. Patients with uncomplicated diverticulitis typically do not require CT imaging (A). Patients with complicated diverticulitis should be treated with intravenous antibiotics (B) and admitted to the hospital. Ultrasound (D) has shown promise in diagnosing diverticulitis but CT is the imaging modality of choice.

Which of the following physical exam findings is suggestive of the diagnosis of acute cholecystitis? Kehr's sign Markle's sign Murphy's sign Rovsing's sign

Correct Answer ( C ) Explanation: Physical exam for suspected cholecystitis should include a complete abdominal exam including instructing the patient to take a deep inspiration while palpating the right costal margin just beneath the edge of the liver. A positive Murphy's sign occurs when the patient experiences discomfort and catches their breath on the inspiration. This occurs because of the gallbladder descending and pressing against the examiner's fingers, causing the patient to feel increased pain. A sonographic Murphy's sign can also occur during abdominal ultrasound when the ultrasound transducer palpates the right costal margin. Kehr's sign (A) is referred pain to the left shoulder that worsens with inspiration in patients with splenic injuries. Markle's sign (B) and Rovsing's sign (D) are both seen in patients with appendicitis. Markle's sign occurs when pain is elicited while standing on toes and dropping quickly to the heels. Rovsing's sign is when palpation of the left lower quadrant elicits pain in the right lower quadrant.

What is the recommended treatment for polymyositis? Antibiotics NSAIDs Prednisone Radiation therapy

Correct Answer ( C ) Explanation: Polymyositis is an inflammatory myopathy that is classified by patient age at onset or by coexisting diseases, such as myositis associated with neoplasia or myositis associated with collagen vascular diseases (e.g., systemic scleroderma, systemic lupus erythematous). They have a bimodal distribution and are seen most often between age 10 to 15 and 45 to 60 years. Myositis is most common after age 50. The cause of inflammatory myopathies is unknown, but evidence suggests a genetic predisposition (associated with certain HLA markers) combined with an environmental insult, such as viruses, thereby initiating an autoimmune process. Patients usually experience progressive, symmetric, proximal muscle weakness with fatigue, malaise, and morning stiffness. Muscles often affected are those of the shoulder, neck, and pelvic girdle. Pulmonary (interstitial pneumonitis or fibrosis), cardiac (cardiomyopathy, congestive heart failure, arrhythmias), pharyngeal (dysphagia), and musculoskeletal (myalgias, arthralgias) symptoms might occur, although most patients do not experience synovitis. CK as well as aldolase, ALT, AST, and lactate dehydrogenase (LDH) levels might be elevated. ESR is elevated only half the time. Muscle biopsy can also be helpful in diagnosis. Prednisone, 1 mg/kg/day for up to several months, is the drug of choice; the earlier started in the disease process, the more effective it is. If prednisone is not sufficient, methotrexate, azathioprine, or another immunosuppressant is added. Antibiotics (A), NSAIDs (B) and radiation treatment (D) are not recommended in the primary treatment of polymyositis.

Which one of the following is recommended for routine prenatal care? Cystic fibrosis carrier testing Hepatitis C antibody testing HIV screening Parvovirus antibody testing

Correct Answer ( C ) Explanation: Standard elements of prenatal care include a routine physical examination at the initial visit, maternal weight and blood pressure at all visits, fetal heart rate auscultation after 10 to 12 weeks, fundal height after 20 weeks, and fetal lie by 36 weeks. All pregnant women should be offered screening for asymptomatic bacteriuria, syphilis, rubella, and hepatitis B and human immunodeficiency virus infection early in pregnancy. Women at increased risk for HIV infection should be retested in the third trimester of pregnancy. All pregnant women should be screened by urine culture for asymptomatic bacteriuria between 12 and 16 weeks' gestation and be offered GBS screening by vaginorectal culture at 35 to 37 weeks' gestation. Standard prenatal care also includes screening for anemia, blood type, and serum marker screening for neural tube defects and aneuploidy. Genetic counseling and testing should be offered to couples with a family history of genetic disorders, a previously affected fetus or child, or a history of recurrent miscarriage. Counseling about cystic fibrosis carrier testing is recommended, but not routine testing (A). Women at increased risk should be tested for hepatitis C infection (B), gonorrhea, and Chlamydia. Routine screening for toxoplasmosis, cytomegalovirus, or parvovirus (D) infection is not recommended.

A 3-year-old boy is eating with his brother in the other room when his mother hears coughing and choking. His brother reports that he had just eaten a handful of peanuts before the symptoms began. In the Emergency Room, the child has moderate respiratory distress with a respiratory rate of 30 breaths per minute and a saturation of 93% on room air. He is placed on oxygen by facemask with improvement in saturations to 96%. Faint expiratory wheezes are noted over the left lobe. The remainder of the examination is unremarkable. A chest radiograph is normal. Which of the following is indicated? Administration of intramuscular epinephrine Administration of nebulized albuterol Emergent bronchoscopy Endotracheal intubation

Correct Answer ( C ) Explanation: The onset of acute respiratory distress following consumption of peanuts should prompt consideration of both foreign body aspiration and anaphylaxis. This child's focal wheezing, especially located over the left lobe, make foreign body aspiration most likely. Notably, chest radiography visualizes only ten percent of foreign bodies, as the majority are radiolucent. Chest radiography may also reveal focal air trapping, mediastinal shift with expiration, or focal atelectasis. However, these findings are not sufficiently sensitive to rule out a foreign body aspiration. In fact, chest radiography may be normal in up to two thirds of cases. If foreign body aspiration is suspected based on history and physical examination, emergent bronchoscopy should be performed. In fact, delayed bronchoscopy has been shown to increase morbidity and mortality in children with foreign body aspiration. Administration of nebulized albuterol (B) is an appropriate intervention for status asthmaticus. Albuterol is a short-acting bronchodilator with a rapid onset of action and therefore an effective rescue treatment for lower airway obstruction in asthma. However, it will not relieve obstruction that is caused by a foreign object. Administration of intramuscular epinephrine (A) is necessary for the treatment of anaphylaxis. Indeed, acute respiratory distress following peanut ingestion should raise concern for anaphylaxis. However, physical examination reveals focal lung findings and no other signs of anaphylaxis. Therefore, foreign body aspiration is more likely. Endotracheal intubation (D) is not necessary in this patient who is awake and alert with an improved oxygen saturation on supplemental oxygen. While awaiting bronchoscopy, however, his respiratory status requires close monitoring.

A 43-year-old man with asthma presents with wheezing. After 6 inhaled albuterol treatments he feels better and his lungs are clear. Which of the following is true regarding further management? Intravenous corticosteroid is indicated Intravenous magnesium sulfate is indicated Oral corticosteroid is indicated Oral respiratory antibiotic is indicated

Correct Answer ( C ) Explanation: The patient presents with a moderate asthma exacerbation that has resolved with beta-agonists and should have oral corticosteroids added to his treatment. Corticosteroids inhibit the release of inflammatory mediators and cytokines and decrease recruitment of inflammatory cells in asthma. This results in decreased airway inflammation and secondarily limits induced bronchoconstriction. The effect of steroids begins within hours in an acute asthma exacerbation and reduces both the rate of relapse and rate of admission in severe attacks. In general, patients with moderate to severe reactions should have short-course corticosteroids added to their treatment regimens in the Emergency Department. Oral prednisone or prednisolone are appropriate interventions. Intravenous corticosteroids (A) have not been found to be superior to oral steroids in patients with moderate asthma exacerbations but should be considered in patients who cannot tolerate oral intake or have impaired gastrointestinal motility or absorption. Intravenous magnesium sulfate (B) has been shown to be beneficial in preventing admission in severe asthmatics but does not have a role in mild or moderate exacerbations. The vast majority of asthma exacerbations are not caused by bacterial pathogens obviating the need for oral antibiotics (D).

Which of the following patients requires endocarditis prophylaxis for a dental procedure that requires manipulation of the gingival tissue? A 14-year-old boy with a Still's murmur A 25-year-old man with a grade 3/6 systolic ejection murmur A 35-year-old man with a prosthetic mitral valve A 45-year-old man with aortic stenosis

Correct Answer ( C ) Explanation: To prevent adverse complications from infective endocarditis, recent guidelines indicate that only high-risk cardiac patients should receive bacterial endocarditis prophylaxis when undergoing dental procedures that involve manipulation of gingival tissue or periapical teeth or perforation of oral mucosa. The routine use of infective endocarditis prophylaxis before gastrointestinal or genitourinary tract manipulation is not recommended, except in patients with active GI or GU infections.The high-risk cardiac patients include those with prosthetic cardiac valves or prosthetic material used for cardiac valve repair, prior history of infective endocarditis, unrepaired congenital heart disease, or repaired congenital heart defect with a prosthesis during the first 6 months after the procedure. Heart murmurs do not require prophylaxis for dental procedures unless they fall in high-risk category described above. Therefore a 3/6 systolic ejection murmur (B), Still's murmur (A) and aortic stenosis (D), do not require antibiotic prophylaxis.

You discover a blowing, holosystolic murmur in a newborn boy, heard loudest at the left sternal border. A pediatric cardiologist diagnoses Ebstein's anomaly. In addition to a malformed right atrium and ventricle, which of the following abnormalities would you most expect to see on this patient's echocardiogram? Left ventricular hypertrophy Overriding aorta Tricuspid insufficiency Tricuspid stenosis

Correct Answer ( C ) Explanation: Tricuspid regurgitation (or incompetence, or insufficiency) manifests as a blowing, pansystolic murmur. It is commonly associated with a thrill. It is most intense in the left, fourth intercostal space, however, it can radiate to the apex, making it difficult to differentiate from a mitral regurgitation murmur. Like tricuspid stenosis, it is quite rare, affecting only 1% of the US population. Causes include rheumatic heart disease, right ventricular dilation, myxomatous degeneration and varied connective tissue disorders. It is part of Ebstein's anomaly, a congenital heart defect in which the tricuspid leaflets attach to the right ventricular wall, leading to a larger than normal right atrium and smaller than normal right ventricle. Ebstein's anomaly is also commonly associated with an atrial septal defect, patent foramen ovale and the pre-excitation, re-entrant conduction defect of Wolff-Parkinson-White syndrome. Diuretics are the mainstay of treatment, and valvuloplasty or valve repair, if necessary, is far more common than valve replacement. Left ventricular hypertrophy (A) is not associated with Ebstein's anomaly. It is commonly due to chronic systemic hypertension. An overriding aorta (B) is one of the four congenital cardiac malformations of Tetralogy of Fallot, not Ebstein's anomaly. Tricuspid stenosis (D) does not produce a systolic murmur.

Which of the following vaccinations is considered safe in pregnancy? Live attenuated influenza Measles, mumps, rubella Tdap Varicella

Correct Answer ( C ) Explanation: Vaccinations have long been a mainstay in preventing serious disease. No evidence exists of risk to the fetus from immunizing a pregnant woman with inactivated vaccinations. Pertussis is one of the most common vaccine-preventable diseases in the US and can cause serious illness in newborns. Pregnant women should be given Tdap (tetanus, diphtheria, and pertussis) during pregnancy, preferably between 27 and 36 weeks gestation (regardless of previous history of receiving Tdap). Live vaccinations pose a theoretical risk to the fetus and are contraindicated in pregnant women. While live attenuated influenza vaccine (A) administered intranasally is contraindicated, inactivated influenza vaccine is recommended to any woman who is or will be pregnant (any trimester) during influenza season. Measles, mumps, rubella (MMR) vaccine (B) and varicella vaccine (D) are also live vaccines and should not be administered to pregnant patients.

A 22-year-old man with a history of intravenous drug use presents to the Emergency Department with fever, chills, cough, and hemoptysis. His chest X-ray is shown above. Which of the following valves is the most likely involved? Aortic valve Mitral valve Pulmonic valve Tricuspid valve

Correct Answer ( D ) Explanation: This patient is presenting with signs and symptoms of infectious endocarditis. Risk factors for infectious endocarditis include rheumatic heart disease, congenital or acquired valvular disease, and intravenous drug use. Left-sided endocarditis involves either the aortic or mitral valve. It is more common than right-sided endocarditis. Right-sided endocarditis involves either the pulmonic or tricuspid valve (more common). It is classically seen in intravenous drug users. This patient's chest X-ray demonstrates septic emboli, a known complication of infectious endocarditis. Organisms implicated in right-sided endocarditis include Staphylococcus aureus, Streptococcus pneumoniae, and gram negative bacteria. Presenting symptoms often include fever, cough, hemoptysis, chest pain, and dyspnea. Right-sided endocarditis is frequently misdiagnosed initially as pneumonia. Management includes antibiotics for the suspected organism based on the clinical situation. In an IV drug user, coverage should include methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa in addition to the typically implicated organisms. The most appropriate antibiotics for this patient would include cefepime and vancomycin. The aortic valve (A) and mitral valve (B) are unlikely to be involved in patients with intravenous drug use and the chest X-ray above is highly suggestive of septic pulmonary emboli, which are seen in right-sided endocarditis. The pulmonic valve (C) while on the right side of the heart, is uncommonly affected by endocarditis in general and also very atypically involved in patients with intravenous drug use.

What electrolyte abnormalities are typically seen in primary adrenal insufficiency? Hypernatremia and hyperkalemia Hypernatremia and hypokalemia Hypokalemia and hypocalcemia Hyponatremia and hyperkalemia

Correct Answer ( D ) Explanation: Hyperkalemia and hyponatremia are typically seen in patients with primary adrenal insufficiency. Primary adrenal insufficiency (Addison's disease) is characterized by the adrenal gland's inability to produce aldosterone, cortisol or both. The hypothalamic-pituitary axis (HPA) is intact. Excess ACTH is produced due to the lack of negative feedback leading to increased melanocyte stimulation. Patients with adrenal insufficiency will present with vomiting, weakness, fatigue or anorexia. Hypocalcemia (C) is not seen in adrenal insufficiency. In primary adrenal insufficiency, the absence of aldosterone leads to hyponatremia and hyperkalemia not hypernatremia (A) or hypokalemia (B).

A 55-year-old man with no history of atherosclerotic cardiovascular disease presents to your office with questions about his cholesterol. He was previously taking atorvastatin, but stopped because his fasting low-density lipoprotein (LDL) level decreased below 100 and he was following the lifestyle modifications you previously recommended. Based on the 2013 American College of Cardiology/American Heart Association Cholesterol Guidelines, which of the following is the most appropriate next step in his management? Encourage the patient to continue with lifestyle modifications only Restart the atorvastatin at the previously prescribed dose Start the patient on a different statin and screen for diabetes Use a cardiovascular risk calculator to determine the patient's 10-year risk for atherosclerotic cardiovascular disease

Correct Answer ( D ) Explanation: The American College of Cardiology and the American Heart Association (ACC/AHA) released a new set of guidelines in November 2013 with information about treating blood cholesterol as a means of reducing the risk of atherosclerotic cardiovascular disease in adults. Four groups were identified as benefiting from initiation of statin therapy: patients with atherosclerotic cardiovascular disease, patients with LDL levels ≥190 mg/dL, patients aged 40-75 with diabetes and an LDL level of 70-189 mg/dL, and patients with LDL level of 70-189 mg/dL and a 10-year atherosclerotic cardiovascular disease risk ≥7.5%. The panel recommends calculating the 10-year risk for atherosclerotic cardiovascular disease as a way of initiating the conversation about prevention with patients. The new recommendations no longer promote the "treat to goal" strategy that the previous ATP III guidelines used. Lifestyle modifications (A) are the starting point of all efforts for medical providers in preventing atherosclerotic cardiovascular disease in patients, but are not the only tool. Atorvastatin (B) may be indicated, but only after determining the patient's 10-year risk for atherosclerotic cardiovascular disease, since he does not fall into the other three groups that benefit from statin therapy. Choice of a statin (C) is based on the need for high, medium or low-intensity therapy and the new guidelines provide recommendations for which statins to use at each level of treatment needed. Based on the patient's 10-year risk for atherosclerotic cardiovascular disease and fasting lipid levels, the medical provider may choose to continue with atorvastatin or use a different agent. Screening for diabetes is not specifically discussed in the new guidelines although a diagnosis of diabetes in patients 40-75 years old with an LDL level of 70-189 mg/dL is considered an indication for statin therapy.

A 12-year-old girl is brought to the clinic for evaluation of hip pain. She describes the pain as dull, non-radiating and aching pain on the right hip that is increased with physical activity and slightly relieved with rest. The pain has been intermittent for the past four weeks. She denies any trauma. On physical exam, weight is at the 95th percentile, the right anterior hip is tender to palpation, and there is decreased internal rotation, abduction, and flexion of the right hip. The rest of the examination is normal. Radiographs show a blurring of the junction between the metaphysis and the growth plate on AP view and step-off of the epiphysis on the femoral neck on frog-leg view. Which of the following is the next best step in management? Advise rest and close follow-up Obtain magnetic resonance imaging Prescribe an anti-inflammatory medication Refer to an orthopedic surgeon

Correct Answer ( D ) Explanation: The clinical presentation of the girl is consistent with slipped capital femoral epiphysis (SCFE). It is one of the most common hip disorders of adolescents. It occurs at the time of peak linear growth. The most common presentations are pain and altered gait. The classic feature is that of an obese adolescent complaining of pain in the hip, groin, thigh, or knee and no history of preceding trauma. The pain may be chronic or intermittent, and it is increased by physical activity and relieved with rest. The gait may be antalgic if the SCFE is unilateral. The anterior hip may be tender to palpation. The range of motion of the hip shows decreased internal rotation, abduction, and flexion but may be painful in all directions. The degree of restriction of range of motion depends upon the severity of the slip. The diagnosis is made based upon plain radiographs that reveal an apparent posterior displacement of the femoral epiphysis, like ice cream slipping off a cone. Early plain radiographic changes show widening and irregularity of the physis, with thinning of the proximal epiphysis that are best seen on lateral views. The treatment of SCFE is operative stabilization, and children with SCFE should be referred promptly to an orthopedic surgeon. Advising rest and close follow-up (A) and prescribing an anti-inflammatory medication (C) are insufficient management of SCFE because it requires an evaluation by an orthopedic surgeon. Obtaining an MRI (B) is a useful adjunct in the evaluation; however, plain radiographs are usually sufficient for the diagnosis of SCFE.

A 22-year-old woman presents with lower abdominal pain and vaginal discharge. She is sexually active with men with inconsistent barrier protection. Her temperature is 101°F. On examination, there is yellow cervical discharge, no cervical motion tenderness, but uterine and left adnexal tenderness. An ultrasound does not show any evidence of tubo-ovarian abscess. Which of the following is the most appropriate treatment for this patient's condition? Cefoxitin 2 gm and metronidazole 500 mg PO BID for 14 days Cefoxitin 2 gm IM and clindamycin 600 mg IV Ceftriaxone 250 mg IM and azithromycin 1 gm PO Ceftriaxone 250 mg IM and doxycycline 100 mg BID for 14 days

Correct Answer ( D ) Explanation: This patient has a clinical presentation consistent with pelvic inflammatory disease (PID). PID is an ascending infection that begins in the vagina or cervix. In the sexually active female, the most common responsible organisms are Chlamydia trachomatis and Neisseria gonorrhoeae. Frequently, the infection is polymicrobial. The most common presenting symptom is lower abdominal pain. Patients may also develop fever, vaginal discharge, dyspareunia, or abnormal bleeding. On physical examination, the patient typically has a fever and is tender on pelvic examination either in the lower abdomen over the uterus, on cervical motion, or in the adnexa. The absence of cervical motion tenderness does not rule out PID and the CDC recommends empiric treatment for sexually active women presenting with lower abdominal pain and one of the following if no other cause is identified: cervical motion tenderness, adnexal tenderness, or uterine tenderness. For outpatient management, patients are treated with ceftriaxone 250 mg IM followed by a 2-week course of doxycycline. Metronidazole is sometimes added to the regimen at the judgment of the clinician. Ceftriaxone 250 mg IM and azithromycin 1 gm PO (C) is the recommended treatment choice for cervicitis without suspicion for PID. The CDC changed the guidelines to recommend 250 mg of ceftriaxone for the treatment of all gonococcal infections because of increasing resistance. Cefoxitin 2 gm IM and clindamycin 600 mg IV (B) and cefoxitin 2 gm IM and metronidazole 500 mg PO BID for 14 days (A) are not standard regimens for pelvic inflammatory disease. Cefoxitin and doxycycline are used together intravenously for the inpatient treatment of PID. If the patient cannot tolerate those medications an alternative regimen is clindamycin and gentamicin intravenously.

What is the treatment of choice for the bradycardic component of sick sinus syndrome? Ablation of accessory pathways Chronotropic medications No treatment is necessary Pacemaker

Correct Answer ( D ) Explanation: Treatment generally requires a permanent pacemaker to prevent sinus arrest. The term sick sinus syndrome was coined to describe patients with SA node dysfunction that causes marked sinus bradycardia or sinus arrest. Often, junctional escape rhythms occur, which may lead to symptoms of lightheadedness and syncope. In some patients with sick sinus syndrome, bradycardic episodes are interspersed with paroxysms of supraventricular tachycardia (atrial fibrillation, atrial flutter, PSVT). Sometimes the bradycardia occurs immediately after spontaneous termination of the tachycardia. An important subset of patients are those with paroxysmal atrial fibrillation that have marked sinus bradycardia and even sinus arrest after spontaneous conversion of atrial fibrillation. The term brady-tachy syndrome has been used to describe patients with sick sinus syndrome who have both tachydysrhythmias and bradydysrhythmias. The diagnosis of sick sinus syndrome and, in particular, the brady-tachy variant often requires monitoring the patient's heart rhythm over several hours, days, or even weeks. A single ECG strip may be normal or may reveal only the bradycardic or tachycardic episode. Ablation of accessory pathways (A) and medications (B) are often used after pacemaker placement to control the tachcycardias. Without pacemaker placement (C), these patients can have sinus arrest.

What is the most common cause of tricuspid valve stenosis? Bacterial endocarditis Dilation and dissection of aortic root Marfan's syndrome Rheumatic heart disease

Correct Answer ( D ) Explanation: Tricuspid valve stenosis (TS) is mostly caused by rheumatic heart disease and is typically associated with other valvular involvement. TS can also be caused by the carcinoid syndrome and certain connective tissue diseases. Secondary causes of TS (e.g., tumors, thrombi) can also precipitate TS. Clinically, patients may be dyspneic with activity. There is jugular vein distention with a large a wave, indicating atrial contraction against a stiff tricuspid valve. TS is usually treated with percutaneous valvular commissurotomy. Open commissurotomy is performed, or valve replacement if the leaflets and subvalvular structures are not reparable. Bioprosthetic valves or mechanical valves can both be used. If a mechanical valve is chosen, patients start warfarin therapy after tricuspid valve replacement. Patients with mitral regurgitation may have a history of rheumatic fever, endocarditis (A), CAD, or CHF. Aortic valve insufficiency is generally acquired through valve infection, dilation and dissection of the aortic root (B), trauma, or long-term degenerative change of the valve, particularly in the setting of hypertension. Primary mitral valve prolapse might be familial and is inherited as an autosomal dominant trait with different rates of penetrance. It is typically found in patients with connective tissue disease, cardiomyopathies, and Marfan's syndrome (C).

Question: Isolated tricuspid regurgitation is most often seen in which group of patients?

Reveal Answer: Rapid Review Tricuspid Stenosis Most common cause: rheumatic heart disease almost always occurs with mitral stenosis (MS) Murmur: Diastolic murmur along left sternal border Louder than MS during inspiration JVP: giant "a" waves