All things Internal

A CEA of > ________ is associated with a worse prognosis with colorectal CA

5

lung nodules > __________ size should be referred for bx when there is smoking hx

8mm

when can a lung nodule be followed w serial CT imaging?

<8mm

A 19yo M of Mediterranean descent comes to the ED for severe deep hip and leg pain x6h. Pain started in the middle of the night and has been increasing (11/10 scale). The patient says he may have pulled something bc he is training for police academy & ran in the mountains yesterday. He had a similar episode in the past, and the only tx that helped was a drug that starts with a "D." Med hx includes no chronic disease conditions, and he takes no medications. The pt appears mildly uncomfortable. Laboratory studies show WBC 9k Hgb of 12.9 g/dL, and Hct of 38%. Peripheral blood smear shows a few abnormally shaped cells as well as polychromatophilic red blood cells, target cells, and Howell-Jolly bodies. A 1L fluid bolus of 9% normal saline is administered. Which of the following is the bestt next step? A. Administer hydromorphone B. Administer nitric oxide C. Administer zosyn D. No treatment is necessary E. RICE

A. Administer hydromorphone Patient is suffering from a sickle cell crisis, specifically a vaso-occlusive crisis. Sickle cell anemia is a common genetic condition that affects African Americans at a rate of about 1 in 500. It also affects Hispanic-Americans from Central and South America as well as patients of Middle Eastern, Asian, Indian, and Mediterranean descent.It is caused by an autosomal recessive mutation that affects the hemoglobin beta chain. This causes the red blood cells to become deformed, which causes occlusion of capillaries and hypoxia. It also causes hemoglobin to bind nitric oxide. A crisis is usually caused by dehydration (in this case, training for the police academy). Appropriate treatment includes pain control and fluids.

A 68yo male comes to the clinic for routine examination. He feels well. Medical history includes chronic obstructive pulmonary disease, congestive heart failure, and diabetes mellitus, which are well-controlled. He is up-to-date on colon cancer screenings and immunizations. Vitals signs are within normal limits, and physical examination shows no abnormalities. Laboratory studies show the following: white blood cell count 7000/mm³; hemoglobin 10 g/dL; hematocrit 31%; mean corpuscular volume 94 µm³; mean corpuscular hemoglobin 33 pg/cell; mean corpuscular hemoglobin concentration 36 g/dL; reticulocyte count 0.3%; ferritin 144 ng/mL; vitamin B12 400 pg/mL; lactate dehydrogenase 160 U/L; and haptoglobin 113 mg/dL. Which of the following is the most likely cause of the findings in this patient? A. Anemia of Chronic Dz B. Anemia of Thalassemia C. Hemolytic anemia D. Iron deficiency anemia E. Vit B12 deficiency anemia

A. Anemia of Chronic Dz This patient has multiple comorbidities that can predispose him to anemia of chronic disease. The indices reveal a normocytic normochromic anemia with increased ferritin and vitamin B12 levels. He also has a decreased reticulocyte count. This indicates that the patient is not producing new red blood cells at a higher rate despite being anemic. Based on these findings, the most likely etiology is anemia of chronic disease or myelosuppression.

A 33-year-old transgender man with diabetes mellitus comes to the internal medicine clinic for follow-up to discuss recent laboratory results. Laboratory studies show a fasting plasma glucose level of >126 mg/dL on two occasions and hemoglobin A1c of 7.2%. He has tried diet and exercise changes with limited success. Medication needs to be initiated, and a first-line oral antihyperglycemic agent is chosen. This medication decreases hepatic glucose production as well as intestinal absorption while increasing the body's sensitivity to insulin, and most likely belongs to which of the following classes of antihyperglycemic agents? A. Biguanides B. Glucagon-like peptide 1 receptor agonists C. Meglitinides D. Sulfonylureas E. Thiazolidinediones

A. Biguanides Metformin is in the class of medications called biguanides and is the first-line oral medication for patients with diabetes mellitus, as long as they have no contraindications to the medication. The main mechanism of action of this class of drugs is to decrease hepatic glucose production as well as intestinal absorption while increasing the body's sensitivity to insulin.

A 22-year-old woman comes to the clinic for follow-up to review the results of recent laboratory studies. She initially presented to the clinic because she had been having fatigue and weight loss for six weeks. Peripheral blood smear indicates that she has Reed-Sternberg cells. Which of the following findings on physical examination is most likely? A. Cervical Lymphadenopathy B. Friable Cervix C. Hematochezia D. Hemoptysis E. Thyroid mass

A. Cervical Lymphadenopathy This patient has Reed-Sternberg cells that are the diagnostic B cell origin cells that indicate Hodgkin lymphoma. Most patients present with painless superficial lymphadenopathy. Other symptoms are weight loss, fatigue, and fevers/chills.

A 34-year-old woman comes to the emergency department because she has had dysuria for the past two days. She has not had abnormal vaginal discharge. Temperature is 39.4°C (103.0°F), pulse rate is 120/min, respirations are 22/min, and blood pressure is 105/65 mmHg. Physical examination shows marked costovertebral tenderness on the left side. Urinalysis shows cloudy urine and 20 white blood cells/hpf; results are positive for leukocyte esterase and white blood cell casts. Urine and blood cultures are pending. The patient is admitted to the hospital, and after administration of intravenous fluids, her heart rate and blood pressure improve. Which of the following is the most appropriate empiric antibiotic therapy? A. IV Ciprofloxacin B. IV Doxy C. IV metrondiazole D. Oral nitrofurantoin E. Oral trimethoprim-sulfathemaxazole

A. IV Ciprofloxacin This patient has acute pyelonephritis and sepsis. She should rapidly be started on intravenous fluids and intravenous antibiotics. An IV fluoroquinolone, such as ciprofloxacin or levofloxacin, is an appropriate medication choice for this patient. Other options for pyelonephritis requiring hospitalization include a broad-spectrum cephalosporin, a penicillin, or a carbapenem. The choice of agent is dependent on local resistance data; however, IV ciprofloxacin is the only appropriate choice of the options listed.

A 62yo man comes to the clinic for acute onset of severe pain in the right great toe that began overnight, about six hours ago. The patient says the pain is so extreme that he was unable to put his sock or shoe on his right foot. He has not had trauma to the toe, fever, chills, or previous similar episodes, but he says that he recently began taking HCTZ for treatment of high blood pressure. On physical examination, the first MCP joint of the right foot is erythematous and exquisitely tender to touch. Aspiration of the joint is performed. Analysis of the aspirate is most likely to show which of the following? A. Negatively birefringent, needle-shaped urate crystals B. Positively birefringent, rhomboid-shaped calcium pyrophosphate dehydrate crystals C. White blood cell count >50,000/mm³ with >75% polymorphonuclear leukocytes D. White blood cell count >2000/mm³ but less than 50,000/mm³ E. White blood cell count <200/

A. Negatively birefringent, needle-shaped urate crystals This patient has acute gouty arthritis, which is characterized by negatively birefringent, needle-shaped urate crystals. It is most common in adult men, and clinical risk factors include eating purine-rich foods such as steaks, drinking alcohol, and taking diuretics (thiazide, loop), pyrazinamide, ethambutol, and/or aspirin. Diagnosis includes both arthrocentesis with these findings as well as x-ray studies showing punched out erosions.

A 60-year-old man presents to the clinic with severe shortness of breath and orthopnea. An echocardiogram is significant for a pulmonary arterial pressure of 30 mm Hg, and his electrocardiography is significant for right ventricular and right atrial hypertrophy. Which of the following findings would you expect on this patient's physical exam? AAccentuation of the pulmonic component of the second heart sound BAn opening snap CDecreased jugular venous pressure DNo pitting edema

AAccentuation of the pulmonic component of the second heart sound his patient presents with pulmonary hypertension, which is defined by a mean pulmonary arterial pressure equal to or greater than 20 mm Hg. The increase in pulmonary vascular resistance will lead to right ventricular hypertrophy and will eventually progress to right-sided heart failure. Primary or idiopathic pulmonary hypertension is rare and found in those with no history of pulmonary or cardiac disorders. Secondary causes of pulmonary hypertension are most commonly due to pulmonary diseases, such as COPD,

A 45-year-old man presents to a primary care provider with fever, fatigue, worsening dyspnea, cough, and right-sided pleuritic chest pain for one week. PE is significant for diminished breath sounds over the right lower lobe and dullness to percussion over the same area. A cxr shows a R-sided 15 mm pleural effusion > 35% of the hemithorax. He is transferred to the ED where a thoracentesis is performed. Pleural fluid analysis reveals a pleural fluid protein to serum protein ratio of 0.7 and a pleural fluid LDH to serum LDH ratio of 0.8. The pleural fluid is free-flowing and has a pH of 7.4. Gram stain and culture of the pleural fluid are negative.Which of the following is also indicated in the treatment of this patient? AAntibiotics and supportive treatment BTube thoracostomy CTube thoracostomy and intrapleural fibrinolytic DTube thoracostomy with intrapleural fibrinolytic and deoxyribonuclease

AAntibiotics and supportive treatment PATIENT HAS EXUDATIVE EFFUSION

A 78-year-old man presents with progressively worsening dyspnea on exertion over the last year. It is now beginning to interfere with his activities of daily living, which prompted his visit. His history includes hypertension and hyperlipidemia. He is a former smoker who quit approximately 10 years ago after he retired from working as an electrician. Physical exam is unremarkable except for some fine end-inspiratory crackles. A chest radiograph is obtained that shows bilateral parenchymal opacities. A computed tomography scan shows calcified pleural plaques. Which of the following is the most likely diagnosis? AAsbestosis BEmphysema CSarcoidosis DSilicosis

AAsbestosis Asbestosis is pneumoconiosis that is slowly progressive and caused by the inhalation of asbestos fiber particles. This causes diffuse pulmonary fibrosis. The use of asbestos was more widespread before the 1970s in the United States. However, many occupational and nonoccupational exposures occurred and are still occurring. Those who work with textiles, cement, or with the mining and milling of fibers are most at risk. Occupations that involve direct exposure to asbestos insulation also impose a greater risk.

A 32-year-old woman presents to a primary care practitioner, reporting back pain, hematuria, and headaches. She started keeping a blood pressure log 2 weeks ago after a high reading at a recent health fair and reports her systolic blood pressure has been 140-150 mm Hg. Physical examination reveals the presence of large, palpable kidneys bilaterally. The patient says her 53-year-old mother and 34-year-old sister have a history of autosomal dominant polycystic kidney disease. The patient's estimated glomerular filtration rate is 75 mL/min/1.73 m2. What diagnostic study is indicated at this time? ACT scan BExcretory infusion urography CRadiograph of the kidneys, ureters, and bladder DUltrasound

ACT scan pt has polycystic kidney dz. CT scan or MRI is the test of choice for patients with typical symptoms of autosomal dominant polycystic kidney disease and a positive family history. A CT scan with and without contrast is recommended for patients with an estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2 and allows for baseline imaging for future comparison, identification of complications of disease, and determination of prognosis and treatment plan.

A 62-year-old hospitalized man develops a fever and purulent sputum on day five of his admission. His oxygen desaturates to the point that he requires ventilatory support. On chest X-ray, a new infiltrate is seen. Which of the following is the best empiric antibiotic regimen? ACefepime, levofloxacin, and vancomycin BCeftriaxone and azithromycin CPiperacillin-tazobactam and linezolid DPiperacillin-tazobactam, amoxicillin, and vancomycin

ACefepime, levofloxacin, and vancomycin

A 45-year-old woman presents to a primary care provider with fatigue, generalized joint pain and stiffness, and multiple nodules over the extensor surface of her forearms. A complete laboratory workup is ordered and is significant for elevated levels of anti-cyclic citrullinated peptide and C-reactive protein. She is started on appropriate pharmacologic therapy. Which of the following diagnostic studies will most likely be indicated as her condition progresses, in addition to routine preoperative tests, for procedures requiring sedation? ACervical spine radiographs BDual-energy X-ray absorptiometry CPulmonary function testing DSchirmer test

ACervical spine radiographs Cervical changes may result in atlantoaxial instability or subluxation, necessitating cervical spine radiographs in patients with advanced rheumatoid arthritis who require intubation and sedation. Neck positioning required for intubation may be fatal in patients with undiagnosed atlantoaxial disease.

A 37yo woman presents to a primary care provider with anxiety, difficulty sleeping, and vision changes for the past three months. Her fmhx is significant with Hashimoto thyroiditis. She was diagnosed with a.fib x 2 y ago and has been taking amiodarone. PE reveals superior lid lag with a downward gaze and eyelid retraction. A nontender, diffusely enlarged thyroid is palpated on exam. Laboratory testing reveals elevated levels of antithyrotropin receptor antibodies, thyroid-stimulating immunoglobulin, antithyroglobulin antibodies, and antithyroid peroxidase antibodies. A radioactive iodine uptake study is ordered and shows a diffuse increased uptake in the thyroid tissue. What is the most likely diagnosis? AGraves disease BHashimoto thyroiditis CSubacute thyroiditis DToxic multinodular goiter

AGraves disease

An 18-year-old man presents to his primary care physician to follow up a recent visit to the emergency department. About 1 week ago, he fell off his bike and landed on his right side. Hours later, he developed pain and swelling over his right quadriceps muscle and presented to the ED where he was found to have bleeding into his quadriceps muscle with hematoma formation. A complete blood count was normal. His PTT was prolonged, with a normal PT. There was correction of the PTT with mixing of patient and control plasma. Because of his prolonged PTT, hematology was consulted, and factor VIII, IX, and XI levels and a von Willebrand factor antigen were drawn. Fresh frozen plasma was transfused. His bleeding subsequently stopped, and he was discharged. Past medical history is otherwise negative, and he takes no regular medications. He has no family history of bleeding diatheses. His factor VIII activity level is 30% of the

AHemophilia A Hemophilia A is the most common type of inherited hemophilia.X-linked recessive blood clotting disorder characterized by absent or decreased levels of factor VIII.The most common location for bleeding is the joints, but the soft tissues, such as muscles, are also common bleeding sites. classically present with a prolonged PTT that corrects upon the mixing of patient and control plasma as well as a reduced factor VIII level Tx: Factor VIII replacement (recombinant or purified concentrate)

A 25-year-old man presents to the clinic with concerns about pain in both eyes, right knee pain, and burning in his genitalia. He reports he is sexually active and recently was treated with antibiotics for a sexually transmitted infection. On physical exam, you note bilateral conjunctivitis, erythema of the right knee, and tenderness over the joint line of the knee. Genital examination reveals urethral irritation present at the meatus. Vitals are within normal limits. Which allele is implicated in the most likely diagnosis? AHuman leukocyte antigen B27 BHuman leukocyte antigen B47 CHuman leukocyte antigen DR2 DHuman leukocyte antigen DR3

AHuman leukocyte antigen B27 Reactive arthritis

A 45yo woman presents to her PCP for her annual checkup. Vital signs are T 98.8°F (37.1°C), BP 128/74 mm Hg, HR 84 bpm, RR 18 breaths per minute, and SPO2 100% on room air. Her BMI is 37. She was dx with type II DM five months ago. Her most recent Hgb A1C of 7.4% was done by her endocrinologist two months ago. Her past medical and surgical history is otherwise unremarkable. She is currently taking metformin, insulin glargine, and a multivitamin. Which of the following is the most appropriate next step in the management of this patient? AObtain a fasting lipid profile BPrescribe a third diabetes medication CPrescribe aspirin 81 mg PO once daily DRecheck hemoglobin A1C

AObtain a fasting lipid profile

A 53-year-old man comes to the internal medicine clinic because he has had pain in his lower legs for the past six months. He works for the postal service and says that he can walk about 20 blocks before he begins to feel pain in his legs. The pain resolves after he rests for five minutes. He does not have resting leg pain. Medical history includes hyperlipidemia and hypertension. He smokes approximately one half-pack of cigarettes per day. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows faint distal pulses and decreased capillary refill in the lower extremities. Both calves are shiny and hairless, and the skin is cool to the touch. Based on these findings, which of the following results is most likely on ankle-brachial index test? A. 0.35 B. 0.85 C. 1.0 D. 1.2 E. 1.4

B. 0.85 This patient has signs and symptoms of peripheral arterial disease with intermittent claudication. An ankle-brachial index (ABI) ≤0.9 is diagnostic for peripheral artery disease.

A 35-year-old woman comes to the internal medicine clinic for a routine physical examination. She says she has felt run down for the past six months and has had generalized fatigue, muscle weakness, myalgia, unintentional weight loss of 10 lb, and intermittent nausea. The patient also has been craving salt and has noticed that her skin has taken on a bronze tone even though she has not been tanning in the sun. Body mass index is 19 kg/m². Basic metabolic panel shows a sodium level of 128 mg/dL and a potassium level of 5.8 mg/dL. Which of the following is the most likely diagnosis? A. Acromegaly B. Addison Dz C. Cushing's dz D. Hyperaldosteroneism E. Pheochromocytoma

B. Addison Dz Addison disease is also known as primary adrenal insufficiency and causes deficiencies in adrenal androgens, glucocorticoids, and mineralocorticoids. This patient has signs and symptoms of Addison disease. Hyperpigmentation of the skin is found in >90% of these patients and is caused by increased adrenocorticotropic hormone stimulation. Hyponatremia and hyperkalemia are also common findings.

An 18yo F comes to clinic for a sore throat, fevers, and chills x4 days. She says the sx started 4 days after coming home from a trip to Indonesia. Her family did not believe in vaccinations, and she says she rarely saw a medical provider as a child. The patient had sexual intercourse with two new partners during the past four weeks. T is 38.1°C (100.6°F). PE shows a thick, gray, adherent pseudomembrane on the tonsils and throat. Diffuse cervical lymphadenopathy is also noted. Gram stain of a throat culture shows nonencapsulated, nonmotile, club-shaped gram-positive bacilli. Which of the following is the most likely diagnosis? A. Chlamydia B. Diphtheria C. Influenza D. Mumps E. Strep pharyngitis

B. Diptheria This patient has signs and symptoms consistent with diphtheria infection. This includes a nonspecific flulike illness and grey, pseudomembranous tonsillitis. The throat smear/gram stain confirms this diagnosis with nonencapsulated, nonmotile, club-shaped gram-positive bacilli. This condition is endemic to the South Pacific countries such as Indonesia, Bangladesh, Myanmar, and Vietnam. It is more likely to occur if patients have not been vaccinated. It is important to start diphtheria antitoxin as well as antibiotics as soon as possible in order to avoid the complication of airway compromise.

A 34-year-old woman with type 1 diabetes mellitus comes to the internal medicine clinic for routine follow-up. The patient has no concerns. Medical history includes worsening kidney disease over the past three years. Her most recent estimated glomerular filtration rate is 35 mg/mL, and she is not yet on dialysis. Physical examination shows no abnormalities. Recent laboratory studies show hemoglobin level of 8.5 g/dL, hematocrit of 27%, and mean corpuscular volume of 92 μm³. Peripheral blood smear shows normocytic, normochromic red blood cells. Which of the following is the most likely explanation for the anemia in this patient? A. Acute blood loss B. Erythropoietin deficiency C. Iron deficiency anemia D. Polycythemia vera E. Sideroblastic anemia

B. Erythropoietin deficiency This patient has anemia of chronic kidney disease. This is a form of normocytic, normochromic hypoproliferative anemia, as evidenced by the findings on this patient's laboratory values. It is due to decreased production of erythropoietin by the kidneys.

A 61-year-old woman comes to the emergency department because she has had shortness of breath for the past three days. Medical history includes end-stage kidney disease, and she says she missed her two most recent hemodialysis treatments. She is afebrile; pulse rate is 94/min, respirations are 24/min, and blood pressure is 148/96 mmHg. Oxygen saturation is 95% on 2 L oxygen. Physical examination shows crackles in the lung bases bilaterally. A basic metabolic panel shows a potassium level of 6.9 mEq/L. Electrocardiography shows peaked T waves. The patient is admitted to the hospital. The medical team is informed that it will be one hour before hemodialysis can be initiated in this patient. Which of the following is the most appropriate next step in management? A. IV 0.9% Saline B. IV calcium gluconate C. Intravenous insulin D. Oral sodium polystyrene sulfonate E. Supportive care

B. IV calcium gluconate This patient has severe hyperkalemia and has ECG changes present which constitutes a hyperkalemic emergency. Her hyperkalemia was caused by reduced potassium excretion due to her kidney failure and missed dialysis treatments. She should be promptly treated with intravenous calcium gluconate to decrease the likelihood of a cardiac arrhythmia. Calcium gluconate does not lower serum potassium, but it does stabilize the myocardium and counteracts the toxic effect of hyperkalemia by lowering the threshold potential. The hyperkalemia is evidenced by the elevated serum potassium as well as the peaked T waves on EKG. The next step would be to give insulin and glucose (do not give glucose if the serum glucose is ≥250 mg/dL).

A 61-year-old man comes to the emergency department because he has had crushing substernal chest pain radiating to his left arm for the past two hours. Medical history includes hypertension and hyperlipidemia. The patient has a history of smoking cigarettes. Temperature is 37.0°C (98.6°F), pulse rate is 94/min, respirations are 20/min, and blood pressure is 150/90 mmHg. Oxygen saturation is 95% on room air. The patient is diaphoretic and is clutching his upper left chest with his right arm. Cardiac troponin levels are significantly elevated. Electrocardiography shows ST-elevation in leads V1 through V4. The patient undergoes percutaneous coronary intervention and is admitted to the ICU. The most likely cause is occlusion of which of the following arteries? A. Circumflex Artery B. Left Anterior Descending Artery C. Left main coronary artery D. Posterior Descending Artery E. R Coronary Artery

B. Left Anterior Descending Artery This patient has ST elevation in leads V1 through V4, which is consistent with occlusion in the left anterior descending artery. The left anterior descending artery is the most commonly occluded coronary artery involved in myocardial infarction.

47-year-old woman presents to the emergency department with intense right upper abdominal pain beginning several hours ago. She reports she has experienced similar pain in the past but not as severe. Pain radiates to her shoulder. She notes associated nausea with one episode of nonbloody, nonbilious emesis. On physical examination, she has a fever of 101.1°F, tenderness to palpation in the right upper quadrant, and a positive Murphy sign. Complete blood count reveals leukocytosis with normal transaminases and normal alkaline phosphatase. Abdominal imaging is pending. What is the most likely diagnosis? AAcute cholangitis BAcute cholecystitis CAcute pancreatitis DAcute viral hepatitis

BAcute cholecystitis

A 65-year-old man with a history of diabetes mellitus type 2 and heart failure presents with substernal chest pain, nausea, and diaphoresis. On exam, he is mildly tachycardic and hypertensive. His rhythm strip shows ST depression in leads II, III, and aVF. Laboratory studies demonstrate an elevation in the level of serum troponin. Which of the following medications should he be started on today? AAlteplase BAtorvastatin CMetoprolol DVerapamil

BAtorvastatin

A 26-year-old man with a past medical history of cystic fibrosis presents to the clinic with a chronic cough and purulent, foul-smelling sputum. The patient has crackles noted to bilateral bases of lungs. A CT scan is significant for abnormal dilation of bronchial walls. Which of the following is the most likely diagnosis? AAsthma BBronchiectasis CChronic bronchitis DEmphysema

BBronchiectasis

Which of the following laboratory studies has prognostic utility in patients diagnosed with colorectal cancer? ACancer antigen BCarcinoembryonic antigen CComplete blood count DComprehensive metabolic panel

BCarcinoembryonic antigen

A 50-year-old man presents to the clinic for an employment physical. His vitals are within normal limits. He reports no prior surgeries, current medical problems, or current daily medications and a 30 pack-year smoking history (currently still smoking). Physical exam is within normal limits. A chest X-ray is taken per the employer's request and reveals a 2.1 cm nodule in the left upper lobe. Which of the following is the best next step for evaluation of this patient? ABronchoscopic resection of the area of concern BComputed tomographic scan of the chest CMagnetic resonance imaging of the chest DRepeat chest X-ray in one year

BComputed tomographic scan of the chest

An 86-year-old woman presents to the office to discuss her worsening dizziness. She reports an increasing sense of fear of falling recently, which is significantly limiting her daily life. She does not often experience dizziness while sitting or walking, but upon standing, she feels very weak and often needs to sit for 10 minutes before she attempts to stand again. Her past medical history includes type 2 diabetes mellitus, depression, hypertension, and atrial fibrillation. She adheres to her medications, which include metformin, paroxetine, hydrochlorothiazide, and apixaban. What is the best first step in management? ABegin using compression stockings BDiscontinue hydrochlorothiazide CInitiate therapy with fludrocortisone DInitiate therapy with midodrine

BDiscontinue hydrochlorothiazide Orthostatic Hypotension Decrease in systolic blood pressure of 20 mm Hg Decrease in diastolic blood pressure of 10 mm Hg Inadequate physiologic response to postural changes First step in management is identifying and discontinuing any causative medications. Pharmacotherapeutics that can cause or exacerbate orthostatic hypotension include terazosin, antidepressant drugs, antihypertensive drugs, beta-blockers (specifically propranolol), diuretics (specifically hydrochlorothiazide and furosemide), vasodilators (specifically hydralazine and calcium channel blockers), narcotics, and alcohol.

A 64-year-old man is diagnosed with pneumonia and admitted into the hospital. Which of the following findings supports Legionella as the pathogen causing pneumonia? AHypoglycemia BHyponatremia CInfiltrate in the upper lobes DPleuritic chest pain

BHyponatremia

A 72-year-old man with a past medical history significant for hypertension presents for a routine yearly physical exam. He has been feeling well and has no complaints. His physical exam is benign, and a basic metabolic panel is ordered as part of a routine series of blood tests. The results show a calcium level that is 0.8 mg/dL above normal limits. When compared to last year's results, this is a new lab finding. Which of the following studies should be ordered next to confirm the most likely diagnosis? A1,25-dihydroxyvitamin D BIntact parathyroid hormone CPhosphate DThyroid ultrasound

BIntact parathyroid hormone pt has primary PTH which causes increased serum calcium

A 55yo F presents with gradual onset joint stiffness and swelling that has progressively worsened over the last two years. The stiffness usually affects the metacarpophalangeal joints and proximal interphalangeal joints of her fingers and is worse in the am, lasting >30 minutes. On exam, a bowstring sign is noted. Anti-cyclic citrullinated peptide antibodies are present in serum. She has never been on any medication for her condition. Which of the following medications slows the progression of the suspected disease and should be initiated at the time of diagnosis? ALow-dose corticosteroids BMethotrexate CNonsteroidal anti-inflammatory drugs DSulfasalazine

BMethotrexate Your patient has RA The first-line therapy for rheumatoid arthritis is disease-modifying antirheumatic drugs (DMARDs). DMARDs prevent bone and joint destruction and slow the progression of the disease. Two forms of DMARDs exist: synthetic and biologic. Methotrexate is the first synthetic DMARD to be initiated. It is generally well tolerated and produces a beneficial effect within two to six weeks. The most common side effects include gastric irritation and stomatitis, although cytopenia (most commonly leukopenia or thrombocytopenia, or rarely pancytopenia), hepatotoxicity with fibrosis, and cirrhosis can also occur

A 70-year-old woman with a known history of congestive heart failure presents to the clinic with pleuritic chest pain. On physical exam, the patient has decreased tactile fremitus, decreased breath sounds, and dullness to percussion to bilateral lower lung bases. A chest X-ray is significant for blunting of costophrenic angles. A thoracentesis is performed and the pleural fluid is sent for further evaluation and chemistry. Which of the following findings would you expect to see in the patient's fluid analysis? APleural fluid lactate dehydrogenase > two-thirds the upper limit of normal lactate dehydrogenase BPleural fluid lactate dehydrogenase: serum lactate dehydrogenase = 0.5 CPleural fluid lactate dehydrogenase: serum lactate dehydrogenase = 0.7 DPleural fluid protein: serum protein = 0.6

BPleural fluid lactate dehydrogenase: serum lactate dehydrogenase = 0.5 pt has CHF so its a TRANSUDATIVE EFFUSION Review your lights criteria

A 36-year-old diabetic health care worker is being treated for latent tuberculosis after a positive tuberculin skin test and a negative chest radiograph. The health care provider prescribes isoniazid daily for nine months. Which of the following medications should be prescribed in addition to this medication? APyrazinamide BPyridoxine CRifampin DRifapentine

BPyridoxine Isoniazid can cause peripheral neuropathy due to the interference with pyridoxine metabolism, and therefore, administration of pyridoxine while taking isoniazid is recommended in those who have a predisposition to developing neuropathy.

An 85yo man presents to the ED w/ new-onset fever and cough x1 day, He lives in an assisted living facility and has a hx of HTN and COPD. His vitals are 88/42 mm Hg, pulse 122 bpm, temperature 101.5°F, respiration 22/min, and oxygen saturation 97% on room air. Lab work reveals a WBC of 16,000 cells/HPF, Cr of 1.9 mg/dL, and lactate of 6.5 mmol/L. While in the ER, he was given 2 L of 0.9% normal saline. A repeat blood pressure is 85/40 mm Hg. What is the most likely diagnosis? ASepsis BSeptic shock CSevere sepsis DSystemic inflammatory response

BSeptic shock Septic shock is due to a systemic inflammatory response in the body that leads to abrupt peripheral vasodilation, causing a decrease in systemic vascular resistance Septic shock, the final step, is when the patient has sepsis and refractory hypotension despite aggressive fluid administration.

A 62yo M with BPH comes to the clinic for one episode of painless hematuria two days ago. He says he had a red tinge in his urine during that episode but has not noted this in his urine since that time. The patient has not had dysuria, fever, increased urinary frequency. He has smoked 2 packs daily for 30 years. T is 36.1°C (97.0°F), HR 75/min, Resp are 16/min, and BP is 133/83 mmHg. On physical examination, the prostate is moderately enlarged, but no nodules. Lab studies show a prostate-specific antigen level of 2.8 ng/mL. UA shows the following: protein 1+, white blood cells 2/hpf, blood 3+, red blood cells too numerous to count, no casts, nitrites negative, and leukocyte esterase negative. CT scan of the abdomen is ordered. Which of the following is the most appropriate next step? A.Biopsy of the prostate B. Ciprofloxacin therapy C.Cystoscopy with biopsy D.Finasteride therapy E. Transrectal ultrasonography

C. Cystoscopy w Bx Hematuria in a patient with a smoking history is concerning for bladder cancer until proven otherwise. A cystoscopy is the most appropriate next step and can be diagnostic or curative. Other risk factors for bladder cancer include occupational exposure to dyes, rubber, or leather and age over 40 years. Bladder cancer is two times more likely in white males and four times more likely in men than in women.

A 43-year-old man comes to the clinic because he has had fatigue and DOE x 6 weeks. His partner is concerned because he occasionally stops breathing at night when he is snoring. These sx came on gradually and have been making it hard for him to function. Med hx includes prediabetes and HTN for which he takes amlodipine. BMI is 42 kg/m². Temperature is 37.3°C (99.2°F), HR 102/min, RR 22/min, and BP 128/78 mmHg. SPO2 is 94%. Physical examination shows a thick neck with a crowded oropharynx. Cardiac examination shows a regular rate and a prominent S2. The lungs are clear to auscultation. Bilateral +2 pitting edema is noted in the lower extremities. Which of the following abnormal laboratory results is most likely? A. Decreased blood urea nitrogen level B. Decreased sodium level C. Elevated bicarbonate level D. Elevated creatinine level E. Elevated potassium level

C. Elevated bicarbonate level This patient is likely suffering from obesity hypoventilation syndrome, which can cause chronic respiratory acidosis. This causes compensation from the metabolic system and kidneys leading to retention of bicarbonate in order to maintain homeostasis. Rates are highest in males with a BMI >30 kg/m² being the primary risk factor. This patient should undergo workup for obstructive sleep apnea. Aggressive weight loss is recommended.

A 53-year-old woman is recovering in the hospital after undergoing thyroidectomy two days ago for treatment of Graves disease. Currently, she says she has anxiety, muscle cramps, and tingling in her hands, feet, and around her mouth. On physical examination, light tapping of the region anterior to the ears causes twitching of the perioral muscles. Which of the following is the most likely explanation for this physical examination finding? A. Hyperkalemia B. Hypermagnesemia C. Hypocalcemia D. Hyponatremia E. Hypophosphatemia

C. Hypocalcemia The physical exam finding described is Chvostek sign, which is a sign of hypocalcemia. This patient just underwent thyroidectomy, which places her at risk for developing hypocalcemia due to inadverant damage/destruction/removal of the parathyroid glands. Postsurigcal hypoparathyroidism is the most common cause of hypoparathyroidism. These postsurgical changes may be permanent or transient. The tingling and muscle cramps are also associated with hypocalcemia.

A 40-year-old man comes to the clinic for routine physical examination. During the interview, he asks if he needs to get a colonoscopy. It is most appropriate to tell this patient that he will only need a colonoscopy at this age if he has which of the following findings on history and physical examination? A. A 20—pack-year history of cigarette smoking B. African American ethnicity C. Inflammatory bowel disease D. Irritable bowel syndrome E. Significant diverticulosis

C. Inflammatory bowel disease Inflammatory bowel diseases such as ulcerative colitis or Crohn disease are reasons to start colon cancer screening early. Other reasons are: having a first-degree relative with colon cancer, having certain genetic diseases, or having previous abnormal polyps removed. Otherwise, the US preventative task force recommends colon cancer screening beginning at 45 years of age and typically continuing until 75 years of age.

A 78-year-old man is admitted to the ICU after a bystander saw him fall in the grocery store. At the scene, the patient appeared to be unconscious but had sporadic twitching. In the emergency department, the seizure subsided with administration of lorazepam. Which of the following components of this patient's history is most likely to support a diagnosis of status epilepticus? A. Duration of the seizure B. History of previous seizures C. Interval of time it took to regain normal mental status D. Presence of an aura E. Tonic-clonic features

C. Interval of time it took to regain normal mental status Status epilepticus is defined as a seizure that lasts longer than five minutes or as incomplete recovery of consciousness between two or more discrete seizures. The duration of time is the key to diagnosis.

A 42-year-old man comes to the internal medicine clinic because he has had intermittent headaches and heart palpitations accompanied by excessive sweating during the past three months. He is otherwise healthy and takes no medications. He is not currently experiencing these symptoms. Blood pressure is 150/100 mmHg. Result of a 24-hour urine catecholamine test is elevated. Which of the following imaging studies is most likely to determine the diagnosis? A.CT scan of the head B. CT scan of the thyroid gland C. MRI of the adrenal gland D. PET scan of the brain E. Ultrasonography of the thyroid gland

C. MRI of the adrenal gland This patient is exhibiting signs and symptoms of pheochromocytoma, which is caused by a catecholamine-secreting adrenal tumor. It is a rare cause of secondary hypertension. This tumor secretes norepinephrine and/pr epinephrine autonomously and intermittently, which causes hypertension, as well as palpitations, headaches, and excessive sweating. Diagnosis is made if 24-hour urinary catecholamine test result is elevated. Both a CT scan and MRI can be used, but MRI may be the preferred choice because of its excellent anatomic detail and potential to better visualize the tissue characterization. Treatment includes resection along with catecholamine blockade before surgery with common antihypertensives such as calcium channel blockers, alpha-adrenoceptor antagonists, or angiotension-receptor blockers.

A 22-year-old man comes to the urgent care because he has had dry cough, fever, and worsening dyspnea over the past three weeks. He says these symptoms came on gradually and are getting worse. He has been taking over-the-counter medications with minimal relief of symptoms. He has never had anything like this in the past and does not have a history of asthma. Medical history includes a recent diagnosis of thrush. Body mass index is 22 kg/m². Temperature is 37.8°C (100.0°F), pulse rate is 98/min, and respirations are 22/min. Oxygen saturation is 89% on room air. On physical examination, auscultation of the lungs shows rhonchi and crackles throughout the lung fields. Chest x-ray study shows diffuse perihilar interstitial infiltrates. It is most important to ask this patient about which of the following aspects of his history? A. Family history B. Medication history C. Sexual history D. Smoking history E. Travel histo

C. Sexual history This patient has signs of Pneumocystis jirovecii pneumonia and recently had thrush. Both of these are opportunistic infections that indicate he is immunocompromised. It is very important to discuss sexual history in order to identify risk factors for HIV infection. This type of pneumonia can be severe, and treatment should be initiated promptly without waiting for results of diagnostic studies (HIV, cultures etc). Trimethoprim-sulfamethoxazole for 21 days is the first-line treatment.

A 2-week-old boy presents to the ED with his father. The child was born at 37 weeks gestation, and his mother had sporadic prenatal care. The child presents with fever, lethargy, and vomiting. Vital signs are 101.5°F, pulse 155 beats per minute, respirations 30/min, blood pressure 95/60 mm Hg, and oxygen saturation of 98% on room air. Physical exam reveals a lethargic baby with dry mucous membranes. What cerebrospinal fluid analysis confirms the most likely diagnosis? A20 cm opening pressure, clear appearance, 30 mg/L protein, 75 g/dL glucose, and 15 cells/HPF white blood cells B25 cm opening pressure, fibrin webs visible, 100 mg/L protein, 45 mg/dL glucose, and 100 cells/HPF white blood cells C35 cm opening pressure, turbid appearance, 200 mg/L protein, 35 mg/dL glucose, and 80,000 cells/HPF white blood cells D40 cm opening pressure, clear appearance, 150 mg/L protein, 80 g/dL glucose, and 2,000 c

C35 cm opening pressure, turbid appearance, 200 mg/L protein, 35 mg/dL glucose, and 80,000 cells/HPF white blood cells

A 23-year-old man with type 1 diabetes presents with acute onset of severe nausea, vomiting, and abdominal pain. He reports excessive thirst and frequent urination but reports no dysuria, hematuria, or urgency. On exam, he is hypotensive and tachycardic. Kussmaul respirations are also noted. Laboratory studies demonstrate serum glucose of 550 mg/dL, serum potassium of 3.1 mmol/L, a venous pH of 7.1, and a serum bicarbonate level of 13 mmol/L. A total of 2 L of 0.9% normal saline has been administered. Which of the following is the next step in management? AAdministration of dextrose BAdministration of insulin CAdministration of potassium chloride DOxygen therapy

CAdministration of potassium chloride

A 40-year-old woman presents to her primary care provider with right leg pain that has been persistent for the past seven months. The patient has a history of a right tibial shaft stress fracture that was diagnosed two years ago. The patient reports sensations of burning, tingling, and severe muscle aches over the site of the previous fracture. She reports her right leg seems to be a different color and is painful to move at times. On physical examination, the right leg is pale and dusky in appearance. The patient has pain out of proportion to light touch over the anterior tibialis muscle. Ankle dorsiflexion is limited due to pain. AP and lateral radiographs of the right tibia are normal. What is the most likely diagnosis? AArterial ulcer BChronic osteomyelitis CComplex regional pain syndrome DExertional compartment syndrome

CComplex regional pain syndrome The patient in the vignette above has complex regional pain syndrome. Complex regional pain syndrome is a diagnosis of exclusion characterized by localized pain of more than six months' duration. The pain is typically unilateral, severe, and out of proportion to any physical examination or diagnostic findings.

A 32-year-old woman presents to the clinic for a three-month follow-up. She is currently taking loperamide 2 mg and hyoscyamine 0.25 mg 45 minutes before each meal for irritable bowel syndrome with predominant diarrhea. She states the diarrhea is well controlled, but her abdominal pain and bloating continue unabated. Which of the following is the best therapeutic choice for this patient? AAdd alprazolam 0.25 mg tid to current regimen BAdd dicyclomine 20 mg qid to current regimen CDiscontinue hyoscyamine and add amitriptyline 12.5 mg qhs DDiscontinue loperamide and add rifaximin 550 mg tid

CDiscontinue hyoscyamine and add amitriptyline 12.5 mg qhs pt has Diarrhea prodiminant IBS - since hyoscyamine didnt work add TCA

Which of the following is the first step in the pathogenesis of primary pulmonary tuberculosis infection? ACreation of the Ranke complex BDevelopment of regional lymphadenopathy CFormation of a tubercle DFormation of the Ghon focus

CFormation of a tubercle If the defense system fails to eradicate the infection, then the infection can begin to grow within the alveolar space. Eventually, the infection may spread to extrapulmonary tissues. Macrophages create cytokines and chemokines that, in turn, attract alveolar macrophages and neutrophils. These cells combine to form a granulomatous nodule called a tubercle. As the tubercle grows, the infection spreads to local lymph nodes, creating lymphadenopathy. This lesion (Ghon focus), which is the combination of tubercle expansion into the lung parenchyma or lymph node enlargement or calcification, leads to the Ranke complex.**

A 55-year-old man presents to a primary care provider with complaints of depression, resting tremor, slowed movements, and problems with balance. Physical examination is significant for rigidity, a shuffling gait, and masked facies. Which of the following pathologic findings is associated with the patient's condition? AAtrophy of the caudate nucleus and putamen BIncrease in dopaminergic neurons in the substantia nigra CLewy bodies in the substantia nigra DTau tangles in the intercellular spaces of neurons

CLewy bodies in the substantia nigra Lewy bodies in the substantia nigra and a decrease in dopaminergic neurons in the substantia nigra are postmortem findings in patients with Parkinson disease.

A 52-year-old woman presents to a primary care provider with photosensitivity, foreign body sensation, and eye fatigue bilaterally. She also reports a sore tongue and dry, peeling lips. A Schirmer test and rose bengal stain are positive in both eyes. What is the most likely finding on salivary gland biopsy? ADecreased salivary output BIncreased salivary output CMononuclear cell infiltration DPolynuclear cell infiltration

CMononuclear cell infiltration pt has Sjogren syndrome hallmark of sjogren= monocular cell infiltrate on salivary gland bx

A 62-year-old woman with a history of hypertension presents to the emergency department for new-onset headache and blurry vision that started one hour ago. Vital signs are BP 220/120 mm Hg, HR 100 bpm, and RR 16 breaths per minute. Physical exam is significant for flame hemorrhages on funduscopy. Lab work reveals anemia, thrombocytopenia, and an acutely elevated serum creatinine. The patient is admitted to the ICU for blood pressure stabilization. Which of the following is the most appropriate pharmacologic therapy? ACaptopril BClonidine CNicardipine DNifedipine

CNicardipine

A 66-year-old woman presents with a sensation of pulsation in her neck and abdomen. The patient reports that she has also had progressively worsening dyspnea on exertion and peripheral edema that began two months ago. She had a pacemaker placement nine months ago for a chronic bifascicular block. Physical exam is significant for distended, pulsatile neck veins, hepatomegaly, and 1 generalized pitting edema. Palpation of the liver results in increased distension of the neck veins. Which of the following findings on physical exam would most likely correlate with the patient's condition? AHarsh midsystolic crescendo-decrescendo murmur radiating to the left shoulder BLoud midsystolic murmur best heard with the patient sitting and leaning forward CPansystolic murmur that becomes louder with inspiration DPansystolic murmur with prolonged apical impulse

CPansystolic murmur that becomes louder with inspiration Tricuspid regugitation

A 45-year-old man presents to a primary care provider for intermittent attacks of palpitations, headaches, and episodic diaphoresis for the past three months. His past medical history is significant for multiple endocrine neoplasia type 2A. Previous thyroid studies have been within normal limits. A noncontrast abdominal CT scan reveals the presence of an adrenal mass. A follow-up nonionic contrast CT with a washout protocol is immediately performed. The adrenal mass is found to retain 60% of the contrast after 15 minutes. Which of the following tests is most sensitive for the suspected diagnosis? A24-hour urinary fractionated catacholamines BPlasma fractionated catecholamines CPlasma fractionated free metanephrines DSerum chromogranin A

CPlasma fractionated free metanephrines Pheochromocytomas are tumors of the sympathetic nervous system arising from the adrenal medulla and have a poor prognosis if untreated. These tumors secrete excess catecholamines (e.g., norepinephrine, epinephrine, dopamine). Norepinephrine is metabolized to normetanephrine and vanillylmandelic acid, epinephrine is metabolized to metanephrine and vanillylmandelic acid, and dopamine is metabolized to homovanillic acid. These excess catecholamines and their metabolites have a variety of effects on the body. The most common signs and symptoms associated with pheochromocytomas include hypertension, palpitations, headache, and episodic diaphoresis. A 24-hour urine specimen may be tested for fractionated metanephrines and creatinine in patients with a low index of suspicion blood test for plasma fractionated free metanephrines is the most sensitive test for secretory pheochromocytomas. A noncontrast abdominal CT scan may detect adrenal tumors indicative of a pheochromocytoma. If an adrenal mass is present, a follow-up nonionic contrast CT with a washout protocol is performed.

A 55-year-old woman presents to the internal medicine clinic for a follow-up visit. She reports diffuse soreness and sharp pain of both upper and lower extremities and inability to sleep. In the morning, she is significantly fatigued and experiences stiffness in her legs, arms, and shoulders. She reports no trauma. She has tried ibuprofen, but it did not help. She has no chronic medications. Previously evaluated bloodwork is within normal limits. Physical examination reveals mild to moderate tenderness of multiple muscles and joints. Her vitals on today's visit are within normal limits. Which of the following is the most appropriate initial clinical intervention for this patient, given the most likely diagnosis? ABegin NSAID therapy BInitiate a tricyclic antidepressant regimen CPrescribe low-impact aerobic exercise DRefer to pain management

CPrescribe low-impact aerobic exercise Fibromyalgia Risk factors: age 20-55, female sex Widespread or multisite musculoskeletal pain for ≥ 3 months, nonrestorative sleep, and generalized fatigue PE: areas of soft tissue tenderness (newer guidelines move away from palpating specific tender points), no joint swelling Labs: normal CBC, chemistry, acute phase reactants Diagnosis is made clinically Treatment is education, exercise, antidepressants, avoid opioids

A 42-year-old woman presents with neck pain and tenderness, palpitations, and anxiety. She states that the symptoms have been present for the past two weeks. A review of systems is insignificant except for a viral upper respiratory infection a few weeks ago that resolved. Physical exam reveals a mildly diffusely tender, symmetrically enlarged thyroid gland. Which of the following would be the best next step in managing this patient's care? ABegin levothyroxine BOrder a radioiodine imaging study CPrescribe naproxen DRefer for fine-needle aspiration biopsy

CPrescribe naproxen Subacute thyroiditis is typically associated with neck pain with a tender goiter and abnormal thyroid function tests. It affects women more often than it affects men. etiology is thought to be a preceding viral infection, typically two to eight weeks prior to the thyroid inflammation.Treatment includes supportive measures. Nonsteroidal anti-inflammatory medications, such as naproxen, or oral steroids can help decrease neck pain. Propranolol is used to help with transient symptoms of hyperthyroidism that some patients experience, such as palpitations and anxiety.

A 69-year-old woman with a 30 pack-year history and recent travel overseas presents to the emergency department with chest pain, shortness of breath, and cough. There is concern for pulmonary embolism, and she has a computed tomography scan of the chest completed that shows a 9 mm nodule in the left lower lobe. The rest of the scan is unremarkable, and she is diagnosed with bronchitis. Which of the following is the best management of this lesion? AOrder a follow-up CT scan in three months BOrder positron emission tomography scan CRefer the patient for biopsy DSend sputum for cytology

CRefer the patient for biopsy

A 38-year-old woman who is eight weeks postpartum presents to the office for a follow-up of an internal hemorrhoid that she has had for the past two months. She was seen about six weeks ago for the same problem and was told to increase her fiber and fluid intake. However, she continues to see bright red blood after passing stools and feels pressure to the anus that lasts for about one hour after every bowel movement. A physical exam reveals a pink, nontender lump extruding from the anus that is easily reducible with gentle pressure. She would like to explore other treatment options since she finds these symptoms very bothersome. Which of the following is the best next step in treatment for this patient? AHemorrhoidectomy BInfrared photocoagulation CRubber band ligation DSclerotherapy

CRubber band ligation

A 58-year-old man comes to the internal medicine clinic for routine follow-up. He has been keeping a log of his blood pressures, and review shows blood pressures mostly in the 140s systolic and 90s diastolic over the past two months. The patient does not currently take any medications. Body mass index is 32 kg/m². Current blood pressure is 142/90 mmHg. Laboratory studies show a hemoglobin A1c of 6.8%. Microalbuminuria is noted on urinalysis. Physical examination shows no abnormalities. Which of the following is the most appropriate initial drug therapy to manage hypertension in this patient? A. Amlodipine B Diltiazem C. HCTZ D. Lisinopril E. Metoprolol

D. Lisinopril Lisinopril is an angiotensin-converting enzyme inhibitor (ACE-i) and would be the preferred initial treatment in a patient with both hypertension and type 2 diabetes mellitus with evidence of albuminuria. ACE inhibitors and angiotensin receptor blockers (ARBs) have antialbuminuric effects and are recommended as first-line therapy in those with both hypertension and diabetes mellitus showing signs of diabetic kidney disease. The National Kidney Foundation (NKF) recommends ACE-i and ARBs as the preferred agent, and a systematic review of ACE-i in those with diabetic kidney disease demonstrated a significant reduction in all-cause mortality.

A 41yo patient who identifies as gender nonconforming comes to the clinic for intermittent RUQ pain that has been worsening over the past 2 weeks. Today, the patient feels "pretty awful." The pain radiates to the shoulder blade on the right side and is worse in the evenings, particularly if they eat fatty foods. Body mass index is 32 kg/m², but they have been on a weight loss program and has lost 15 lb over the past three months. Temperature is 38.3°C (101.0°F). Physical examination shows tenderness with palpation to the right upper quadrant. White blood cell count is elevated at 12,000/mm³. Which of the following abdominal imaging studies is the most appropriate next step in diagnosis? A. CT scanm B. MR cholangiopancreatography C. MRI D. Ultrasonography E. Radiograph

D. Ultrasonography This presentation is most consistent with acute cholecystitis. They have worsening right upper quadrant abdominal pain after meals that has been worsening. They in a high risk group for this condition given their age, obesity, and recent weight loss. The initial imaging test of choice is abdominal ultrasonography. The patient will most likely need to be evaluated by general surgery.

A previously healthy 50-year-old man presents to your office for his annual physical exam. He wants to make sure he is up to date on all of his preventive screenings. He asks about the need for hepatic cancer screening because one of his friends was recently diagnosed. Which of the following groups should be screened for hepatic cancer? AIndividuals aged 50 years and older BIndividuals with a 30 pack-year history of smoking CIndividuals with alcohol use disorder DIndividuals with liver cirrhosis

DIndividuals with liver cirrhosis High-risk patients, such as those with known cirrhosis and those with chronic hepatitis B infection, should be screened at regular intervals for hepatocellular carcinoma.

A 45-year-old woman presents to her primary care practitioner with painful discoloration of her fingers and nose when cold. She states her fingers become pale when cold and then become red and painful when they begin to warm up. She also reports difficulty swallowing and early satiety. On physical exam, she has tight, shiny skin and multiple telangiectasias. She currently smokes one pack of cigarettes per day and has no significant medical history. Which clinical intervention should be recommended first? AInitiating methotrexate BInitiating nifedipine CInitiating sildenafil DInitiating varenicline

DInitiating varenicline Scleroderma is a disease that affects the connective tissue in the body, leading to cutaneous and visceral fibrosis. Endothelial and vascular injury, T-lymphocyte infiltration in the skin, and collagen overproduction are the three main contributing factors to the pathophysiology of scleroderma and lead to extensive fibrosis. Scleroderma is most common in women and typically presents during a patient's 40s to 50s. Risk factors include history of cytomegalovirus infection, exposure to certain toxins, and exposure to drugs such as bleomycin, cocaine, and paclitaxel. Patients will typically present with Raynaud phenomenon and tight, thick skin. They may also present with dysphagia and telangiectasias.

A 33-year-old woman from Texas presents to a primary care provider with pain and decreased vision in her right eye, difficulty walking, and tremors in both hands. She reports that she has had multiple similar episodes in the past two years that seem to occur whenever the weather gets really hot. During her previous episode last summer, she felt very tired, experienced urinary urgency, and had a feeling of an electrical shock radiating down her neck and back into her extremities whenever she bent her head forward. Her symptoms typically resolve spontaneously after a few days, but they seem to be lasting longer now. Her mother had similar symptoms that were treated with injections of glatiramer acetate. Which of the following is the best test for confirming the suspected diagnosis? ABrain biopsy BComputed tomography CLumbar puncture DMagnetic resonance imaging

DMagnetic resonance imaging pt has Multiple Sclerosis

A 63-year-old woman presents to the emergency department for an initial presentation of a moderately severe temporal headache, scalp tenderness, and pain with chewing for six days. She has no change to her vision. She has a history of polymyalgia rheumatica with specific symptoms of neck and shoulder stiffness. Lab results indicate an elevated erythrocyte sedimentation rate and C-reactive protein. Imaging studies are pending. Which of the following is the first priority in caring for this patient, even before the diagnosis is confirmed? AArterial biopsy BHospital admission CImmediate ophthalmology referral DOral corticosteroid treatment

DOral corticosteroid treatment if you suspect--> give prednisone asap to avoid vision loss--> then do bx

A 63-year-old man presents to the clinic reporting his "hands shaking." He notices whenever he is trying to do a specific task, such as reaching out to grab a drink or writing in his journal, his hands shake. The patient notes the tremor improves after drinking whiskey. On physical exam, there is no resting tremor noted, however, when performing the finger-to-nose exam, the patient's tremor increases as he approaches the target. The remainder of the neurologic exam is normal. Which of the following is the most appropriate first-line treatment for this patient's condition? AAlprazolam BCarbidopa CGabapentin DPropranolol

DPropranolol

A 44yo female presents to the ED with chest pain, nausea, and diaphoresis. She reports multiple episodes of early morning chest pain for the past three weeks. She has a 20 pack-year smoking history and reports cocaine use in the last month. The initial ECG obtained shows ST elevations in the inferior leads. Serial troponins and CK-MB are negative. No stenotic lesions are seen on coronary angiography. Which of the following medications would be inappropriate in the management of the suspected diagnosis? AAmlodipine BIsosorbide dinitrate CLisinopril DPropranolol

DPropranolol AVOID β-blockers (e.g., propranolol, nadolol, sotalol, timolol) exacerbate coronary vasospasm and should be avoided in patients with Prinzmetal angina in the absence of coronary stenosis. pt has prinzmetal angina tx= nitrates of CCB

A 24-year-old man with type 1 diabetes presents to the clinic, brought by a friend, and is feeling clammy, sweaty, and dizzy. He looks confused but is speaking full sentences. A rapid random blood glucose is completed and is 48 mg/dL. Which of the following is the best intervention at this time? AAdminister intranasal glucagon BBegin normal saline intravenously CInject subcutaneous insulin DProvide an oral fast-acting carbohydrate load

DProvide an oral fast-acting carbohydrate load

A 25-year-old man develops acute hemolytic anemia and hemoglobinuria after being treated with primaquine as a prophylaxis for malaria. On exam, he is noted to have generalized jaundice, dark urine, and pallor. Heinz bodies are seen on a peripheral blood smear. He is of African descent. Which of the following is the most likely cause of his symptoms? AAbsence of decay-accelerating factor BAntibody-mediated destruction of red cells CDefective red cell membrane-tethering proteins DReduction in glutathione levels in red cells

DReduction in glutathione levels in red cells

A 67-year-old man with a history of alcohol use disorder is admitted to the hospital and subsequently diagnosed with cirrhosis. His chemistry panel and blood gas show the following results: Sodium: 142 mmol/L Potassium: 4.0 mmol/L Chloride: 110 mmol/L Albumin: 4.0 g/L pH: 7.55 PaCO2: 32 mm Hg PaO2: 90 mm Hg Bicarbonate: 23 mmol/L What is the most likely diagnosis? AAnion gap metabolic acidosis BMetabolic alkalosis CNon-anion gap metabolic acidosis DRespiratory alkalosis

DRespiratory alkalosis An increased pH, a decreased PaCO2, and a decreased or normal bicarbonate are indicative of respiratory alkalosis. The most common cause of respiratory alkalosis is hyperventilation. Other pulmonary conditions (e.g., pneumonia, asthma, restrictive lung disease), sepsis, liver disease (e.g., cirrhosis), heart failure, and salicylate intoxication may also cause respiratory alkalosis.

A 65-year-old woman with a past medical history of chronic obstructive pulmonary disease presents to her primary care clinic with worsening dyspnea, orthopnea, and lower extremity edema. On physical exam, you hear an accentuated S2 and observe elevated jugular venous pressure, peripheral edema, and ascites. An ECG shows R axis deviation. Which of the following is the pathophysiology behind this patient's symptoms? AAcute pulmonary embolism from a deep vein thrombosis BLeft ventricular failure in the setting of acute myocardial infarction CRight ventricular dilation in the setting of untreated coarctation of the aorta DRight ventricular hypertrophy in the setting of increased pulmonary hypertension

DRight ventricular hypertrophy in the setting of increased pulmonary hypertension

A 66-year-old man presents to your clinic for a preventive exam. Screening fasting blood work shows a blood sugar of 116 mg/dL and LDL-C of 191 mg/dL. What is the most appropriate medical treatment for primary prevention of atherosclerotic cardiovascular disease for this patient, using the 2018 ACC/AHA guidelines on blood cholesterol management? AAtorvastatin 20 mg BLovastatin 20 mg CPravastatin 80 mg DRosuvastatin 20 mg

DRosuvastatin 20 mg

A patient with chronic alcohol use disorder is admitted to the hospital after presenting to the ED with severe abdominal pain that radiates to her back. She reports consuming about six to eight cans of beer per day. She reports that she has not been adherent to her enzyme replacement therapy. She had a cholecystectomy two years ago. Which additional history and physical exam findings would most support the suspected diagnosis? AAbsent bowel sounds, abdominal distention, nausea, and vomiting BDiarrhea, fever, gastric reflux, and soft and nontender abdomen CRight upper quadrant pain, jaundice, and positive Murphy sign DSteatorrhea, insulin use, calcifications on computed tomography, and epigastric pain

DSteatorrhea, insulin use, calcifications on computed tomography, and epigastric pain pt has chronic pancreatitis.

A 61yo man who does not have housing presents to an urgent care with reports of facial and lower extremity swelling. He states his face and eyes appear puffy in the morning and his feet and ankles seem swollen in the evening. He also reports he has been urinating less frequently and his urine is darker than normal. He had a sore throat and abdominal pain 2 weeks ago that resolved on its own. He was diagnosed with hepatitis 6 months ago. His BP is 148/98 mm Hg. A urinalysis is obtained and reveals a cola-colored specimen with 11 RBCs/high-powered field and 3 protein. Serum complement C3 is significantly low. Anti-DNase B antibodies are positive. Which of the following conditions in the patient's past medical history would be most consistent with the suspected diagnosis? AFocal segmental glomerulosclerosis BHepatitis A infection CMinimal change disease DStreptococcal infection

DStreptococcal infection

A 29-year-old woman presents to the clinic due to fatigue, arthralgias, and chest discomfort over the past 4 months. She has lost 6 lbs during this same period. Her medical history is insignificant, and she takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has rheumatoid arthritis, and her father has type 2 diabetes mellitus. Her temperature is 98.9°F, heart rate is 76 bpm, and blood pressure is 128/78 mm Hg. Physical examination is significant for a faint facial exanthem but is otherwise unremarkable. Which of the following is the most likely diagnosis? APrimary biliary cholangitis BScleroderma CSjögren syndrome DSystemic lupus erythematosus

DSystemic lupus erythematosus

A 20-year-old unvaccinated college student is brought in by his roommate to the college infirmary for altered mental status. The roommate reports the patient began having a fever, headache, and stiff neck yesterday. This morning, he was found in bed and was difficult to wake up. On evaluation, the patient only moans to painful stimuli, has a fever of 101.7°F, and is unable to put his chin to his chest. He has a diffuse purple rash that is nonblanching. You perform a lumbar puncture. What are the most likely cerebrospinal fluid results? ABloody color, elevated opening pressure, normal lymphocytes, normal protein, and normal glucose BClear color, high opening pressure, normal lymphocytes, normal protein, and normal glucose CClear color, normal opening pressure, normal lymphocytes, normal protein, and normal glucose DTurbid color, elevated opening pressure, elevated lymphocytes, elevated protein, and low glucose

DTurbid color, elevated opening pressure, elevated lymphocytes, elevated protein, and low glucose

A 59yo M presents with vague epigastric pain that has progressed over the past three months. Associated sx : dysphagia, nausea, and early satiety. The pt has decreased appetite and has lost approximately 15 lbs over 6 mo. He has no diarrhea, constipation, hematemesis, or melena. PM hx : type 2 diabetes mellitus and HTN. His mes include metformin and lisinopril. He does not use alcohol, tobacco, or illicit drugs. Fam medical hx is significant for type 2 diabetes mellitus in his father and thyroid cancer in his mother. On physical examination, vital signs are within normal limits. Cardiopulmonary examination is unremarkable. Abdominal examination is significant for mild abdominal distention with a palpable epigastric abdominal mass, and the liver edge is palpable 2.75 cm below the costal margin. Which of the following is the most appropriate diagnostic test at this time? AHelicobacter pylori urea breath test BSerum gas

DUpper endoscopy Cancers of the stomach should be suspected in patients who present with historical findings of epigastric pain, dysphagia, early satiety, and weight loss. Persistent abdominal pain and weight loss are the most common symptoms at the initial diagnosis of gastric cancer but are typically associated with advanced disease. Pain is typically epigastric and becomes constant with disease progression. Dysphagia is a common symptom in patients with cancers originating in the esophagogastric junction or proximal stomach. The most common physical exam finding is a palpable abdominal mass, which is indicative of advanced disease. Physical exam also reveals abdominal distention and a palpable liver edge

A 50yo male presents to his PCP with multiple episodes of severe headache every day for the past six days. He states that the pain is localized to his right eye and is accompanied by right-sided tearing, redness, and a runny nose. His symptoms last for 15-30 minutes, during which he is unable to sit or lie still. He has no fever, jaw claudication, nuchal rigidity, or a "thunderclap" headache sensation. Imaging is ordered to rule out other causes and is unremarkable. Which of the following is the most appropriate prophylactic therapy? A100% oxygen via nasal cannula BAmitriptyline CDihydroergotamine mesylate DVerapamil

DVerapamil The abortive treatment of choice for a cluster headache is 100% oxygen via nasal cannula. If 100% oxygen is not readily available, triptan medications (e.g., sumatriptan) or dihydroergotamine mesylate may be administered subcutaneously or intramuscularly as abortive treatment. For prophylactic treatment of cluster headaches, a short-term corticosteroid along with a calcium channel blocker (e.g., verapamil) may be given. The corticosteroid is then tapered as the calcium channel blocker takes full effect.

A 74-year-old man with a past medical history of hypertension presents to the emergency department for sudden-onset confusion and a coarse tremor. The patient presents with altered mental status, and on physical exam, you notice significant myoclonus of the upper extremities as well as muscle rigidity, postural instability, and bradykinesia. Vitals are heart rate 92 bpm, blood pressure 142/79 mm Hg, respiratory rate of 16 breaths per minute, O2 saturation of 97% on room air, and temperature of 98.7°F. His daughter reports the pair recently returned from a camping trip, where the patient reported being bitten by multiple mosquitos. What is the most likely diagnosis? ABacterial meningitis BLyme disease CRocky Mountain spotted fever DViral encephalitis

DViral encephalitis West Nile encephalitis is characterized by the viral infiltration of the central nervous system, resulting in acute neurologic symptoms.Focal neurologic deficits such as flaccid paralysis, coarse tremor, rigidity, postural instability, and bradykinesia can also be observed.Diagnosis is made via cerebrospinal fluid (CSF) examination using enzyme-linked immunosorbent assay (ELISA). Treatment of West Nile encephalitis is mainly supportive, with many patients regaining their baseline motor function in six to eight weeks

According to the US Preventive Services Task Force, what is the appropriate lung cancer screening method for patients who are aged 50-80, currently smoke tobacco or those with a former heavy history of smoking? ALow-dose helical computed tomography every three years BMagnetic resonance imaging of chest every two years CYearly chest X-ray DYearly low-dose helical computed tomography

DYearly low-dose helical computed tomography

A 65-year-old woman comes to the internal medicine clinic because she has had widespread muscular pain for the past four months which started primarily in her neck and shoulders. She says she also has had fatigue, headaches, and poor sleep during this time. The patient is also concerned that her memory is worsening. Physical examination shows diffuse bilateral tenderness to palpation in the neck, shoulder girdle, and upper back. On laboratory studies, C-reactive protein level and erythrocyte sedimentation rate are within normal limits. Which of the following conditions is most likely associated with this patient's disorder? A. Celiac disease B. Diverticulosis C. Gallstones D. Inflammatory bowel disease E. Irritable bowel syndrome

E. Irritable bowel syndrome This patient has symptoms of fibromyalgia as evidenced by the diffuse pain and the associated symptoms of fatigue, headaches, poor sleep, and concentration issues. It is associated with irritable bowel syndrome as well as anxiety and depression. Studies have shown patients to have an increased incidence of GERD when compared with the general population.

A 36-year-old woman comes to the office because she has had intermittent acne-like breakouts on her cheeks and chin during the past eight months. She says that she has had flushing of the skin as well as burning and stinging in these same areas for years. Temperature is 37.1°C (98.8°F), pulse rate is 80/min, respirations are 16/min, and blood pressure is 128/87 mmHg. Oxygen saturation is 98% on room air. Physical examination shows erythema, telangiectasias, papules, and tiny pustules on both cheeks and chin. Which of the following is the most appropriate initial treatment? A Laser therapy B Oral erythromycin C Oral isotretinoin D Topical fluorinated corticosteroids E. Topical metronidazole

E. Topical metronidazole This patient has papulopustular rosacea and also exhibits features of erythematotelangiectatic rosacea. Most patients with mild to moderate disease can be managed with topical therapy using agents such as metronidazole, azelaic acid, ivermectin, or sulfacetamide-sulfur.

What will labs look like in a pt with acute cholecystitis?

Leukocytosis NORMAL alk phos NORMAL bilirubin

What are the 2 most common sites affected by paget's dz?

Pelvis Lumbar spine

what type of distal lesions may you see on a colonoscopy of a patient with aggressive colon ca?

Signet-ring

what is the distinguishing factor between mitral regurgitation & tricuspid regurgitation?

TR has pansystolic murmur that's LOUDER w inspiration

A CT scan of his chest showed a dense, well-circumscribed lesion with a surrounding halo of ground glass attenuation with air-crescent sign with a cavity... what does this sound like?

This patient is likely suffering from pulmonary aspergillosis. The CT scan is consistent with a fungal ball.

immunocompromised patinet with aspergillosis.... whats the treatment?

Voriconazole

what labs may be elevated in pts w paget's dz

alk phos

Treatment of choice for paget dz

bisphosphonates

what lab value do you expect to see on a pt with metabolic syndrome & obstructive sleep apnea?

elevated HCO3 these pts typically have an elevated HCO3 to maintain homeostasis

______________________-are recommended in all patients with NSTEMI as they improve outcomes and delay death or major cardiovascular events by up to three months.

high dose statins (atorvastatin)

weakness pattern of polymyositis

hips, shoulders, neck

what labs will be elevated in a patient w polymyositis

leukocytosis elevated ESR & CRP elevated CK & Lactate elevated LFTs anti-Jo-1 antibodies (anti-histidyl-transfer RNA synthetase) anti-SRP antibodies

r/f for colorectal CA (10)

lynch syndrome FAP MUTYH- mutation polyposis BRCA gene FmHx UC CD radiation CF

disease is characterized by abnormal bone remodeling

paget dz

starburst livedo (painful violaceous plaques that are surrounded by livedo reticularis) is pathognomonic for _________________________-

polyarteritis nodosa

anti-jo antibodies.....

polymyositis REMEBER anti-Jo-1 antibodies ARE AKA anti-histidyl-transfer RNA synthetase

most specific tesst for paget's dz

radiography (lytic & sclerotic lesions)

seizure that lasts longer than five minutes or as incomplete recovery of consciousness between two or more discrete seizures.

status epilepticus

PANSYSTOLIC MURMUR LOUDER W INSPIRATION best heard at LSB

tricuspid regurgitation