Call back day
A patient diagnosed with sarcoidosis presents with erythema nodosum, hilar adenopathy and migratory polyarthralgia. This presentation is characteristic of which of the following syndromes?
Löfgren syndrome acute presentation of sarcoidosis
What is the appropriate imaging modality for monitoring an ascending aortic aneurysm?
Magnetic resonance angiography
A four-year-old girl is brought to the clinic because of a rash. Five days prior, she developed fever, decreased appetite, eye redness, and coughing. Yesterday, the mother noted the appearance of a rash that started on the face and today has spread to the neck and trunk. The girl has not had any vaccines since the mother was opposed to it. On physical examination, temperature is 38.5ºC with erythematous, maculopapular, blanching rash on the neck, upper trunk, lower trunk, and extremities. Which of the following is the most likely diagnosis?
Measles
What is an acceptable alternative regimen to treat PID in those who are allergic to penicillin?
Clindamycin and gentamicin
Infection with what virus is necessary to develop kaposi sarcoma?
Human herpesvirus 8
A 71-year-old man presents to the Emergency Department after falling on ice outside his home. He complains of neck pain. He has an abrasion to his chin and decreased strength in his bilateral upper extremities. Strength is intact in his lower extremities. Which mechanism of trauma is most consistent with the suspected diagnosis?
Hyperextension injury
Which of following findings are most consistent with the diagnosis of minimal change disease?
Hyperlipidemia and hypoalbuminemia most common nephrotic renal disease in children
A 65-year-old farmer presents with a non-healing ulcer on the right side of his nose as seen above. The lesion bleeds when he scratches it. He denies any pain or systemic symptoms. What is the treatment for this lesion?
Mohs micrographic surgery squamous cell carcinoma,
A 62-year-old woman is admitted to the hospital for an eight-hour history of acute dyspnea and pleuritic chest pain. She has a history of uncontrolled diabetes mellitus and stage IV chronic kidney disease. On physical examination, she appears uncomfortable but stable. Temperature is 37.6°C (99.7°F), blood pressure is 148/90 mm Hg, pulse is 88/min, and respiration rate is 22/min. Oxygen saturation is 94% on 3 L/min of oxygen by nasal cannula. A ventilation-perfusion lung scan reveals multiple, bilateral, segmental filling defects consistent with a high probability of pulmonary embolism. Which of the following medications should be initiated first?
Unfractionated heparin
A 42-year-old woman presents to the emergency department complaining of right upper quadrant pain that radiates to her right shoulder and is associated with nausea, vomiting and anorexia. She appears ill, is febrile to 100.7F and tachycardic. Which of the following is most likely to be elevated on laboratory evaluation?
White blood cells acute cholecystitis.
Screening for gestational diabetes should be performed during which of the following weeks of gestation?
24-28 weeks
A 3-day-old, ex-30 week male infant presents with fever and abdominal distension. The patient has decreased bowel sounds and bloody stool in his diaper. What test should be obtained to make the diagnosis?
Abdominal Xray It may show intramural air (pneumatosis intestinalis), a loss of symmetrical gas pattern, dilation of loops of bowel or portal vein gas. concerned for necrotizing enterocolitis (NEC)
A 36-year-old woman is brought to the emergency department for intentional acetaminophen overdose that occurred approximately three hours prior to her arrival. Her four-hour acetaminophen level is 90 mcg/mL. Which of the following is the next best step in managing this patient?
Admit to the hospital for psychiatric evaluation If the 4-hour level of serum acetaminophen is less than 150 mcg/mL, then this patient is not at risk for liver damage
What is the first line treatment for a pregnant patient with known tick exposure and erythema migrans?
Amoxicillin
Which of the following is the serologic hallmark of primary biliary cirrhosis?
Anti-mitochondrial antibody Primary biliary cirrhosis is characterized by a T-lymphocyte-mediated attack on small intralobular bile ducts of the liver.
A 65-year-old man presents with increased shortness of breath. He began antibiotics three days prior to arrival for pneumonia. His chest X-ray is shown above. Which of the following findings most strongly suggests an empyema?
Bacteria on Gram stain of pleural fluid
A 3-year-old boy presents in severe respiratory distress. His mother informs you that he has been ill for the last 5 days, initially with a low-grade fever and "barky cough." He was seen at an urgent care facility 4 days ago and given a "breathing treatment" and discharged on steroids. He has become progressively worse despite compliance with the steroid regimen, which prompted his mother to call an ambulance this morning. He is otherwise healthy and up-to-date on his immunizations. On examination, the child is toxic in appearance and febrile. His oropharynx is clear. You hear both inspiratory and expiratory stridor. What is the most likely diagnosis?
Bacterial tracheitis croup has a less toxic appearance
A 24-year-old man presents with right shoulder pain after a fall onto his outstretched hand. A radiographic demonstrates an anterior inferior articular glenoid fracture. What is the name of this radiographic finding?
Bankart lesion secondary to an impaction injury of the posterosuperior aspect of the humeral head into the anteroinferior glenoid rim causing a fracture
A 30-year-old man presents with fever, neck stiffness, and headache. He is lying supine on the bed. When you lift the patients neck off of the stretcher, he flexes his hips and lifts his legs up off of the bed. Based on this information, which of the following signs is considered positive?
Brudzinski's sign The test is considered positive if passive flexion of the patients neck causes the patient to flex their hips and lift their legs off of the examination table or stretcher.
Which antibiotic is the most appropriate for treatment of acute otitis media in a child with a rash from amoxicillin?
Cefidinir
A five-year-old boy with sickle cell anemia presents with fever and pain over the right tibia. There is tenderness along the anterior tibia but no pain with motion of the knee or ankle. Which of the following is the most appropriate initial treatment for this patient?
Cefotaxime Osteomyelitis
A 55-year-old-man with known alcoholic cirrhosis presents with a fever and abdominal pain. He is mildly confused and has asterixis on exam. His abdomen is distended and tender to palpation. Paracentesis is completed. The ascitic fluid has a neutrophil count of 280/mm3. Which of the following is the most appropriate intravenous antibiotic for treatment of this condition?
Cefotaxime Spontaneous bacterial peritonitis
A 24-year-old woman presents for follow-up after an abnormal Pap smear. Colposcopy is performed and reveals a white, sharply demarcated area on the cervix after application of acetic acid. What is the most likely diagnosis?
Cervical dysplasia
Which of the following is most characteristic of Prinzmetal angina?
Chest pain in the early morning
A 53-year-old man with a 30-pack-year smoking history presents complaining of progressive shortness of breath for the past four months. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50%. These findings are most consistent with which condition?
Chronic bronchitis In obstructive lung disease, the FEV1 is reduced due to an obstruction of air escaping from the lungs. Since COPD is an obstructive lung disease, the diagnosis is made when the FEV1/FVC ratio is less than 0.7 and the FEV1 is less than 80% of predicted.
Which of the following is a risk factor associated with the development of pancreatic cancer?
Cigarette smoking
A mother brings in her 8-year-old son in for evaluation after stepping on a nail with his bare right foot in their unfinished basement this morning.He was able to pull the nail out of his foot and the nail measured one inch. Examination of his foot reveals a nontender 2 mm puncture wound with no surrounding erythema. He completed his DTaP (Pediatric-Diphtheria-Tetanus-acellular Pertussis) vaccination series three years ago. What is the most appropriate next step?
Clean the wound and discharge home
A 35-year-old man with a history of gastroesophageal reflux disease presents to the Emergency Department with chest pain and fever. An outpatient esophagogastroduodenoscopy was performed three days ago and revealed no gastric ulcers. On exam, he is ill-appearing and tachycardic. Which of the following is the next best step in management of this patient?
Consult thoracic surgery esophageal perforation
A 38-year-old man presents to the emergency room for persistent anal pain and throbbing. Though the rectum appears normal, a digital rectal exam shows moderate warmth, tenderness, and fluctuant swelling of the ischiorectal fossa. The patient is in no acute distress and is afebrile. Which of the following interventions is the best management of his condition?
Consult to surgery for operative drainage an ischiorectal abscess
Which of the following causes secondary osteoporosis in women?
Corticosteroid use
In human immunodeficiency virus positive patients, what is the most common etiology for toxic megacolon?
Cytomegalovirus
A 60-year-old woman presents to your office with complaints of bilateral lower extremity pain that worsens throughout the day with prolonged standing. Physical exam reveals distended veins in both legs distal to the knees. Which of the following is the most appropriate diagnostic test to confirm the suspected diagnosis?
Duplex ultrasound
A 60-year-old postmenopausal woman presents with painless vaginal bleeding. Her last papanicolaou smear, performed two years ago, was normal. Her pelvic exam in the office reveals a small amount of blood at the cervical os. Which of the following is the most appropriate diagnostic test?
Endometrial biopsy important to rule out endometrial cancer.
What individual test is most accurate for diagnosing iron deficiency?
Ferritin
Which of the following conditions requires droplet precautions?
Influenza
Which of the following fetal heart tracings patterns is indicative of uteroplacental insufficiency?
Late decelerations
Can you use low molecular weight heparin in advanced kidney disease?
NO
What is the most common presentation of a child with Meckel's diverticulum?
Painless rectal bleeding
Which of the following antibiotics is first line in the treatment of acute Group A streptococcal pharyngitis?
Penicillin VK
A 26-year-old woman presents with tooth pain. Physical examination of her mouth reveals the above findings. Which of the following is the most likely diagnosis?
Periapical abscess
A previously healthy 55-year-old woman presents to your office with a complaint of vertigo that occurs with positional changes of her head. Which of the following structures is most likely to be involved?
Posterior semicircular canal Benign paroxysmal positional vertigo (BPPV)
Which of the following signs is indicative of a retrocecal location of the appendix?
Psoas sign
A 19-year-old man presents to your clinic with a complaint of hair loss. Which of the following physical exam findings would suggest a diagnosis of alopecia areata rather than androgenetic alopecia?
Smooth, circular areas of complete hair loss
Which of the following bacteria most commonly causes acute mastoiditis?
Streptococcus pneumoniae
Which oral antifungal agent has the highest cure rate for toenail onychomycosis?
Terbinafine for 12 weeks monitor liver enzymes
Which of the following laboratory studies are routinely monitored in a patient with bipolar disorder on lithium therapy?
Thyroid function studies lithium can cause goiter, hypothyroidism, chronic autoimmune thyroiditis, and possibly hyperthyroidism
What is the most common cause of acute compartment syndrome?
Tibia fracture
A six-month-old girl is brought to the clinic for routine health supervision visit. She interacts well with her parents. She can babble and roll over. She has also started eating solid food. The family is going on a vacation to Philippines for two weeks. The parents express concern that there is currently a measles outbreak in Manila. Which of the following is the best statement regarding measles transmission?
Transmission occurs via person-to-person contact as well as airborne spread
A 26-year-old woman presents to the emergency room with severe right sided lower quadrant pain and vomiting. The pain started two days ago and has progressively worsened. Her current medications include clomiphene citrate. On physical exam the patient is constantly changing positions in an attempt to relieve the pain. There is a small mass felt on deep palpation in the right lower quadrant. Which of the following is considered first-line in diagnosing the suspected condition?
Transvaginal ultrasound
A 62-year-old woman presents with a 4-week history of light vaginal bleeding. She achieved menopause 10-years ago. Pelvic examination is unremarkable. Which of the following is the most appropriate next step?
Transvaginal ultrasound first-line imaging study for women with suspected uterine cancer.
Pathologic activation of which of the following enzymes contributes to the pathogenesis of pancreatitis?
Trypsinogen
A preterm newborn is delivered at 28-weeks gestation. She has tachypnea, nasal flaring, expiratory grunting, and cyanosis shortly after birth. Physical examination shows subcostal retractions. Auscultation of the lungs shows decreased breath sounds. A substance produced by which of the following cells is most likely deficient in this newborn?
Type 2 pneumocytes the cells primarily responsible for the production and secretion of surfactant.
A 40-year old man presents to the emergency department with a severe headache. His skin is flushed and diaphoretic. His blood pressure is 220/90 mm Hg. He went to a party at a friend's house this evening where he sampled several red wines and aged cheeses. He tells you that he recently had a MRSA skin infection and is currently taking "a strong antibiotic" for the infection. What is the most likely diagnosis?
Tyramine reaction
A previously healthy 55-year-old woman presents to your office with questions about preventive health. She would like to know when she should start being screened for osteoporosis. Which of the following is the most appropriate advice for this patient?
age 65
Patellar tendonitis
caused by repetitive activities such as jumping, running (especially uphill), squatting or standing from sitting. It results in anterior knee pain at the proximal portion of the tendon.
What is the most likely site of a malignant brain tumor in children?
cerebellum Medulloblastomas are the most common malignant brain tumor found in children
Roseola rash starts where and spreads where?
characterized by a blanching macular or maculopapular rash, starting on the neck and trunk and spreading to the face and extremities
What is the most common presenting complaint in patients with lung cancer?
cough
A 16-year-old female competitive runner complains of pain and tenderness over her shins when she runs. On physical exam you notice point tenderness over her left tibia. X-rays are normal but MRI reveals a hairline fracture in the tibia. She has suffered multiple stress fractures of this bone before. A prompt workup should be initiated for which of the following disorders?
osteoporosis female athlete triad
A patient presents with hearing loss involving the right ear. The Weber test lateralizes to the right ear. The patient notes hearing better when the tuning fork is on the mastoid during the Rinne test. Which of the following is the likely cause of his hearing loss?
otitis media This patient has evidence of a conductive hearing loss. Common causes include otitis media, serous otitis, and cerumen impaction.
A 35-year-old man presents with acute onset epigastric abdominal pain. He has marked tenderness on exam and is tachycardic. You suspect a perforated viscus. Which of the following is the first line imaging modality?
upright chest x-ray
What is the most common side effect of olanzapine?
weight gain
Which of the following fetal heart rate acceleration patterns is considered a reassuring fetal nonstress test after 32 weeks of gestation?
Accelerations that last ≥ 15 seconds and peak ≥ 15 bpm above baseline
A 37-year-old man presents to your office with complaints of headache, fever, and malaise for the past week. He is positive for the human immunodeficiency virus and his most recent CD4 cell count was 80 cells/µL. His heart rate is 85 beats per minute, blood pressure is 135/85 mm Hg, respiratory rate is 20 breaths per minute and temperature is 102.1°F. Physical exam findings include mild confusion and multiple umbilicated, erythematous papules on the patient's face. Which of the following is the most appropriate therapy?
Amphotericin B Cryptococcosis
A nine-year-old boy presents to your office for evaluation of bilateral heel pain that has occurred for the past three months. He plays sports several times a week and the pain begins several minutes into the start of his activities. The pain subsides at rest and with walking. The patient has not noticed any numbness, tingling, or weakness. There is some swelling and tenderness of the heel upon physical examination. Reflexes, strength, and range of motion at the ankle are intact, but he does have bilateral posterior heel pain upon dorsiflexion of the ankles. Which one of the following is the most likely diagnosis?
Calcaneal apophysitis
A 75-year-old man presents to his primary physician with excessive fatigue over the past three months and swollen lymph nodes in his neck. Upon further questioning, he also admits to night sweats and early satiety. On physical exam, there are two palpable lymph nodes, one along the cervical neck and the other in the inguinal region. Laboratory data shows a white blood count of 25,000 with a B cell proliferation. The peripheral blood smear reveals smudge cells. Which of the following is the most likely diagnosis?
Chronic lymphocytic leukemia
A 72-year-old man presents with episodic exertional syncope and dyspnea that has been occurring over the last two months. Physical exam demonstrates a mid-systolic murmur heard best at the second intercostal space near the right sternal border. Echocardiogram demonstrates aortic valve stenosis. Which of the following would you expect to find on physical exam?
Decrease in the intensity of the murmur with isometric handgrip also standing, and Valsalva maneuvers associated with aortic stenosis
A 72-year-old man presents to your office complaining of increased awakenings due to the urge to urinate during the night. He notes that his urine stream is weak and notices that he is dribbling when he urinates. He denies burning or pain with urination, blood in his urine or any recent changes in his weight. He denies all constitutional symptoms. A digital rectal exam, urinalysis, and PSA were performed which confirmed the suspected diagnosis. Which of the following can be used for first-line treatment of the suspected disorder as well as for alopecia?
Finasteride 5-alpha reductase inhibitors are the only class of medications that treat both BPH and alopecia
Which of the following best describes the fetal presentation pictured above?
Frank breech
A five-year-old boy was brought to the emergency room because of possible bat exposure. The boy reports that he found a bat in his room when he woke up in the morning. The boy was asleep and was not aware if he had contact with the bat. Physical examination is normal. Which of the following is the next best step?
Give rabies vaccine and rabies immunoglobulin In those previously unvaccinated, post-exposure rabies prophylaxis should always include both rabies immunoglobulin (passive immunization) and rabies vaccine (active immunization).
A 26-year-old African-American man presents with diffuse abdominal and back pain a few days after being diagnosed with streptococcal pharyngitis. He appears mildly ill, with slight scleral icterus. Laboratory findings are as follows: unconjugated bilirubin: 3.2 mg/dL (N < 0.2), hemoglobin: 9.6 g/dL (N 13.0-18.0), hematocrit: 29.4% (N 37.0-49.0), peripheral blood smear: keratocytes, blister cells, and polychromatic macrocytes. Which one of the following is the most likely diagnosis?
Glucose-6-phosphate dehydrogenase deficiency
The tendons of what three muscles comprise the pes anserinus?
Gracilis, sartorius and semitendinosus.
A 62-year-old female with a history of congenital long QT syndrome presents to the emergency room complaining of fatigue and a racing heart. She is just getting over an acute gastrointestinal infection with vomiting and diarrhea. She is placed on the cardiac monitor as seen above. Which of the following is the most appropriate next step in management?
Intravenous magnesium sulfate
A seven-year-old boy with a history of bone marrow transplant at age five presents for a low-grade fever, shortness of breath, and wheezing. Viral antigen testing of his nasal washings confirms diagnosis with respiratory syncytial virus. In addition to hydration and humidification of his inspired air, which of the following interventions is most appropriate for this patient?
Nebulized ribavirin respiratory syncytial virus (RSV)
A 29-year-old woman presents with hand pain and paresthesias. On physical exam, you note sharply demarcated pallor distal to the metacarpophalangeal joints of the third and fourth digits. Which of the following is a potential treatment for this disease process if it is recurrent and severe?
Nifedipine Raynaud's disease
A 39-year-old woman presents to the Emergency Department with left knee pain. She is a housekeeper and has complained of "knee problems" on and off for several years. She denies any recent falls or procedures. She has no leg swelling on examination. Her distal pulses are symmetric. She has tenderness with anteroposterior compression and percussion of the patella. Which of the following is the most likely diagnosis?
Prepatellar bursitis
A 22-year-old man presents with low back pain that began four days ago. He denies recent trauma, urinary or bowel dysfunction, or lower extremity tingling. Bilateral straight leg raise tests are negative. There is reproducible tenderness just medial to the right gluteal muscle. What is the most likely diagnosis?
Sacroiliitis
A four-year-old girl is in the clinic for a follow-up. She experienced two severe allergic reactions in the past following the isolated ingestion of scrambled egg. These episodes required treatment with epinephrine in the emergency department. The parents are anxious about her allergic reaction and want further testing. Physical examination is normal. Which of the following is the next best step in management?
Skin prick testing
A 43-year-old man with a past medical history of poorly controlled diabetes mellitus and obesity presents for an itching rash on his penis for the last week. Physical exam reveals an uncircumcised penis with a slightly erythematous and mildly swollen glans and white discharge inside the foreskin. A potassium hydroxide preparation reveals pseudohyphae. Which of the following is the best pharmacologic treatment?
Topical miconazole cream Candida balanitis
A 45-year-old woman presents to your office with a complaint of hair loss. Examination reveals thinning of the hair over the central superior portion of the scalp. Her frontal hairline is preserved. There are no oval patches of baldness and no scarring. She has a history of hirsutism, infertility, irregular menses, and cystic acne. Her testosterone, dehydroepiandrosterone sulfate, and prolactin levels are normal, as are thyroid and iron levels. Of the following, which one would be most appropriate for treatment of this patient's hair loss?
Topical minoxidil female pattern hair loss
A 36-year-old man presents to the emergency room with mouth sores, eye pain, and fever. Upon questioning, he admits to recently starting allopurinol. Physical exam reveals an ill-appearing man with hemorrhagic erosions on his vermilion border and severe conjunctivitis. Approximately 35% of his skin is sloughing, although his palms and soles are spared. Which of the following is the most likely diagnosis?
Toxic epidermal necrolysis TEN involves > 30% of the body surface area
A 7-year-old boy presents to the office with his mother. His mother reports he has been struggling with school this year. He has not been able to sit still in class, does not follow directions, gets easily frustrated with projects, and struggles to stay focused on details. There is a strong family history of attention deficit hyperactivity disorder in his brothers and his father. His mother wants him evaluated early so he does not get behind in school. Which of the following is the most appropriate test to complete?
Vanderbilt assessment scales
A 42-year-old woman presents to the clinic stating that she has constant feelings of "being worried." She notes that she has felt this way for over a year and notes that she has always been a worrier, but the constant thoughts are making it difficult to sleep and concentrate on her work. She feels restless and irritable most days. Which of the following medications is the most appropriate for long-term management of her diagnosis?
Venlafaxine
The clinical manifestations of anaphylaxis most often involve which organ system?
skin
A 21-year-old woman presents with pelvic pain that has been worsening over the last two days. She reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin, copious vaginal discharge, cervical motion tenderness, and a mass in the left adnexa. Pregnancy test is negative. A pelvic ultrasound reveals a complex multiloculated left adnexal mass. Which of the following intravenous antibiotic regimens represents the most appropriate pharmacotherapy?
Cefoxitin and doxycycline tubo-ovarian abscess (TOA)
A patient presents with right-sided homonymous hemianopia. Which of the following is the location of the suspected lesion?
Left optic tract
A nine-year-old girl is brought to the clinic because of fever. During the past three days, she developed low-grade fever, sore throat, and fatigue. On physical examination, her temperature is 39°Celsius, with palatal petechiae, hyperemic posterior pharyngeal wall, tonsillar exudates, multiple enlarged cervical lymph nodes and enlarged spleen. Complete blood count shows lymphocytosis composed of atypical lymphocytes on peripheral smear. Which of the following is the most appropriate therapy?
Acetaminophen
A 16-year-old boy presents with a marked hemarthrosis of his knee after tripping and striking it against the edge of a step. This has happened in the past. His activated partial thromboplastin time is prolonged and his prothrombin time and thrombin time are normal. What is the most likely diagnosis?
Hemophilia B
A six-year-old boy presents with left hip pain that started four weeks ago. He denies any history of trauma. He describes the pain as a dull, aching pain that is worse with activity. The pain has gradually worsened, and the mother notes that he now walks with a limp. On examination, his temperature is 37.6oC. He denies pain with palpation of the left leg, but has pain and limited range of motion with internal rotation at the hip. What is the most likely diagnosis?
Legg-Calvé-Perthes disease
Koebner's phenomenon is most likely to be observed in which disease process?
Lichen planus when lesions appear at the site of mechanical or thermal trauma
Which of the following findings would be consistent with a diagnosis of Tetralogy of Fallot?
Loud, single second heart sound with a harsh systolic murmur
Which of the following is characteristic of pemphigus vulgaris?
Mucous membrane involvement positive Nikolsky sign
A 17-year-old woman presents to your clinic with a chief complaint of sadness, loss of appetite, and the inability to sleep. She is having a hard time focusing at work and she is tired all of the time. She tells you that for the past month she has been hearing voices telling her to harm herself. She is interested in treatment. What is the most appropriate first-line therapy for this condition?
Sertraline and olanzapine major depressive disorder
A 74-year-old woman presents with complaints of fever, productive cough with bloody sputum, shortness of breath, and headache. These symptoms developed and worsened drastically over the past 3 days. She recently recovered from an influenza infection 1 week ago. Her medical history otherwise includes only well-controlled hypertension. Vital signs on presentation are as follows: T 39°C, HR 106, BP 110/75, RR 30, oxygen sat 95% RA. A chest radiograph is obtained and a subsequent CT scan of the chest demonstrates multiple cavitary lung lesions. Which of the following organisms is most likely responsible for this patient's presentation?
Staphylococcus aureus post-viral secondary necrotizing pneumonia.
A 55-year-old woman complains of itchy patches on her wrists for the past week. She denies new exposures, medication changes, or other areas of involvement. Physical exam reveals purple, polygonal, papular lesions on the volar aspect of the wrists. Close inspection reveals tiny, white lines on the surface of the lesions. What is the best initial treatment for this skin disorder?
Topical fluocinonide
A 14-year-old has open and closed comedones without evidence of surrounding inflammation on his face and upper back. Which one of the following is the most appropriate initial treatment?
Topical retinoids
A 9-year-old child is being evaluated for frequent epistaxis and easy bruising tendencies. Bleeding time is prolonged. PT, PTT, and INR are within normal limits. What is the most likely diagnosis?
Von Willebrand disease
A 34-year old woman is diagnosed with rheumatoid arthritis and started on hydroxychloroquine. Which of the following should be monitored while she is taking this medication?
eye exam With long-term use, hydroxychloroquine can cause irreversible damage to the retina
An 18-year-old woman is brought in by her parents for a suspected overdose. Her parents found an empty bottle of acetaminophen in her room after the patient threatened suicide. The patient admits to taking approximately 12,000 milligrams of acetaminophen approximately two hours prior to arrival. She weighs 58.2 kilograms. Which of the following is the most appropriate next step in managing this patient?
Administer activated charcoal the first step in treatment of a patient who presents to the emergency department within four hours of acetaminophen overdose
A 22-year-old man with a recent diagnosis of schizophrenia is brought by his parents for evaluation of abnormal behavior. His mother notes that he has been very restless and has been pacing around the house constantly. On examination, his vital signs are unremarkable. He is noted to be mildly agitated and rocking back and forth on the examining table. What is the likely diagnosis?
Akathisia subjective sensation of motor restlessness. It occurs most frequently with high-potency dopamine-2 receptor antagonists (e.g. haloperidol, fluphenazine, and thiothixene), but can also be seen with any antipsychotic medication
A nine-year-old boy who recently immigrated from Ethiopia presents to the ED with a painless facial mass involving the jaw, as well as ipsilateral lower facial numbness. Physical exam is shown above. Which of the following is the most likely diagnosis?
Burkitt lymphoma
Tx for Akathisia
Diphenhydramine or benztropine (anticholinergics)
A 76-year-old woman suffers from chronic constipation. Secondary causes such as hypothyroidism and diabetes have been ruled out. The only medications she takes are a daily multivitamin and ibuprofen occasionally for her osteoarthritis. Which of the following medications should be added to her daily regimen in order to help her with her constipation?
Psyllium form of supplemental fiber and also has the benefit of reducing lipids and improving glucose control in diabetics.
A 60-year-old homeless man with a history of diabetes presents with a four-week history of low-grade fever, night sweats, and productive cough. Treatment with isoniazid, rifampin, pyrazinamide and ethambutol is initiated. Which of the following medications should also be prescribed to prevent adverse events?
Pyridoxine to help reduce the risk of neuropathy.
A 35-year-old man presents to the emergency department with pain and swelling under the tongue for the last 3 days. The pain worsens when eating. Physical exam reveals normal range of motion of the jaw and tongue. The oropharynx is normal. At the base of the tongue, there is a tender, firm, mobile mass without purulent discharge. There is no erythema or swelling of the external, submandibular region. Which of the following is the most appropriate next step in management?
Recommend hard candies, ibuprofen and massage of the affected area salivary gland stone
A 47-year-old man presents as a trauma activation after a head-on motor vehicle crash at 20 mph. He was a restrained driver and the airbags did deploy. There were no drugs or alcohol involved. He is uncertain if he lost consciousness. EMS extricated him, put him in spinal immobilization, and splinted an obviously fractured femur. On primary survey, his airway is protected, he is breathing easily, and is normotensive. Vital signs are within normal limits. Secondary survey is notable for a GCS score of 15, a mildly tender right trapezius muscle, and an ecchymotic and deformed left femur with normal distal neurovascular function. The presence of which historical or physical finding necessitates cervical spinal imaging?
Distracting injury
A 49-year old woman presents to a rural emergency department with acute onset monocular vision loss in her right eye. She denies pain or any other deficits but states she has been feeling nervous and has lost weight over the past three weeks. On physical exam, she has complete visual field loss in the right eye. Fundoscopic exam reveals a pale retina and a single bright red spot just off of center. After she is treated appropriately for her emergent problem, what additional testing is most appropriate?
EKG An ECG will aid in the diagnosis of atrial fibrillation and thyroid function studies (TSH and T4) will confirm the etiology of her atrial fibrillation. Central retinal artery occlusion
What valve abnormality is associated with coarctation of the aorta?
Fifty percent of patients with coarctation also have a bicuspid aortic valve.
A 39-year-old man presents with a worsening sore throat and difficulty swallowing for the past day. He is dyspneic. Palpation of the neck reveals bilateral cervical adenopathy and pain with gentle palpation of the anterior neck. A soft tissue lateral neck radiograph demonstrates a "thumbprint" sign. Which of the following is the most appropriate pharmacotherapy?
Intravenous ceftriaxone epiglottitis
A 44-year-old previously healthy woman presents with unilateral facial pain that began several hours ago. She now has swelling in the left side of her face and tenderness in this area. Physical exam reveals left-sided parotid gland swelling, trismus, and purulent ductal discharge. Which of the following is the best pharmacologic treatment?
Intravenous nafcillin acute suppurative sialadenitis
An 83-year-old man presents for evaluation. His family notes that he has had decreased attention, confusion, and difficulty with memory over the past six weeks. He has had difficulty walking and three episodes of urinary incontinence in the past week. On examination, he has a broad-based, slow gait with short steps. What finding would likely be found on noncontrast CT of the brain?
Ventriculomegaly Normal pressure hydrocephalus
Which of the following is the most common cause of hyperviscosity syndrome?
Waldenstrom's macroglobulinemia associated most commonly with the plasma cell dyscrasias during which there is abnormal synthesis of IgM paraproteins
A 64-year-old man presents to the emergency department with crushing chest pain, dyspnea, and diaphoresis that began approximately 30 minutes prior to arrival. An ECG is performed and shows ST elevation in leads I and AVL with reciprocal ST changes in leads III and AVF. He is prepped for immediate cardiac catheterization after stabilization. Which coronary vessel is most likely occluded?
Circumflex artery supplies blood to the lateral wall of the left ventricle.
A 55-year-old man presents to the ED with left knee pain after a fall from standing 2 days prior. He has a history of diabetes mellitus. He states he has been progressively less able to walk because of the pain. On physical examination, the left knee is warm, erythematous, diffusely tender, and swollen with a large effusion. There are no rashes or deformities. He has significant pain on passive range of motion. His vital signs are BP 150/85 mm Hg, HR 105 beats per minute, RR 16 breaths per minute, and T 102.7°F. Which of the following synovial fluid analysis results is most indicative of a diagnosis of septic arthritis?
80,000 WBC per high power field with 90% neutrophils and glucose 40 mg/dL
A 23-year-old man with a history of type 1 diabetes presents to the Emergency Department with abdominal pain, vomiting, and fatigue. He has not been taking his insulin. He is found to have diabetic ketoacidosis. His vital signs and mental status are normal except for RR of 26 bpm and HR of 112 bpm. He has a normal electrocardiogram. Treatment is initiated with intravenous normal saline and insulin. After one hour of insulin therapy, his pH is 7.21, glucose is 190 mg/dL, anion gap is 22, bicarbonate is 13 mmol/L, and potassium is 5.5 mEq/L. Which of the following is the most appropriate next step?
Add dextrose to the intravenous fluids This prevents hypoglycemia while still allowing administration of the insulin for the treatment of the acidosis and ketonemia.
A 22-year-old woman presents to the Emergency Department with right ankle pain after twisting her ankle while playing soccer. What is the most likely ligament involved in her injury?
Anterior talofibular ligament
A 30-year old woman presents complaining of pelvic pain and fever. She had a Cesarean section 3 days prior to presentation at 36 weeks gestation for failure to progress and premature rupture of membranes. Her incision is clean and dry. She is tender in the lower abdomen and foul-smelling lochia is noted during pelvic examination. Which of the following is the most important risk factor in the development of this condition?
Cesarean section post-partum endometritis
A 57-year-old type 2 diabetic man presents to his primary care provider for his annual physical. He was diagnosed with diabetes seven years ago and has a history of alcohol abuse. His most recent hemoglobin A1C was 7.9 percent and fasting glucose of 156. He is not on any diabetic medications. He states that two years ago he had an episode of intense mid-abdominal pain that radiated to his back. He has had two more similar episodes. Ever since then, he has constant epigastric pain and has noticed loose, foul smelling stools that float in the toilet. Considering his glycemic control and past medical history, what class of anti-hyperglycemic agents is contraindicated for this patient?
Glucagon-like peptide-1 agonists contraindicated in patients with a history of pancreatitis and should be used with caution in patients with pancreatitis risk factors (alcoholism, biliary disease)
The finding seen in the image above is most commonly associated with which of the following viral infections?
Herpes simplex virus Herpes simplex virus (HSV) is the most common viral infection associated with erythema multiforme (EM)
A 28-year-old man was exposed to poison ivy. Between 48 and 72 hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms and neck. He was given oral methylprednisolone starting with 24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day 6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and vesiculation, involving extensive areas of his arms, neck, and face. The most appropriate management at this time would be which one of the following?
High-dose oral prednisone and taper over 2 weeks Toxicodendron dermatitis is an allergic contact dermatitis that occurs from exposure to poison ivy and poison oak
A 42-year-old man presents with low back pain and a normal neurologic examination. Which of the following would prompt emergent imaging of the lumbosacral spine?
History of intravenous drug use
A 63-year-old woman was recently diagnosed with herpes zoster. Which of the following signs could indicate the impending development of herpes zoster ophthalmicus?
Hutchinson's sign blistering associated with herpes zoster infection at the tip of the nose
Which of the following features is most consistent with essential tremor?
occurs with action
Which of the following causes acute painful loss of vision?
optic neuritis
A 34-year-old woman presents with lower abdominal pain and fever. She had a full-term delivery via cesarean section 4 days ago. On examination, she has a temperature 38.6°C and a heart rate of 112 beats/minute. Her lower abdominal incision is intact with no fluctuance, surrounding erythema, or drainage. She has midline lower abdominal tenderness to palpation. On pelvic examination, she has uterine tenderness with foul smelling lochia. What is the most appropriate management of this patient?
Intravenous clindamycin and gentamicin Postpartum endometritis
A 19-year-old woman presents with pelvic pain that has been worsening over the last four days. She reports associated nausea and several episodes of emesis today. Vital signs include blood pressure of 113/68 mm Hg, pulse of 112 beats per minute, and oral temperature of 38.2°C. Physical exam reveals cervical motion tenderness and fullness in the left adnexa. Urine pregnancy test is negative. Which of the following would be the most appropriate next step in managing this patient?
order pelvic ultrasound This patient has symptoms consistent with a tubo-ovarian abscess (TOA)
A 45-year-old woman presents with a painful, red, and swollen right leg that has gotten worse over the past couple of days. She denies any trauma, travel or insect bites or any systemic symptoms such as fevers or chills. She has a history of insulin-controlled diabetes mellitus She also has a history of hyperhomocysteinemia and Factor V Leiden. She had an episode of cellulitis six months ago. On palpation there is a swelling and tenderness of her entire right leg compared to her left. Measurement of her right calf is 3 cm in diameter greater than her left leg. Imaging and lab work confirm your suspected diagnosis. Which of the following treatment regimens should be initiated in this patient?
Low molecular weight heparin initially and continue anticoagulation therapy for at least twelve months DVT tx
A 26-year-old woman with a history of dysmenorrhea and depression presents to the ED after having a seizure witnessed by her husband. He reports finding her on the bedroom floor with an empty pill bottle. Which of the following non-steroidal anti-inflammatory (NSAIDs) medications did she most likely ingest?
Mefenamic acid associated with seizure activity
A 14-year-old girl present with a pruritic rash since yesterday. She began amoxicillin for acute pharyngitis three days ago. She still complains of sore throat, pain with swallowing, fatigue, and cervical lymphadenopathy. Physical exam reveals a diffuse, morbilliform rash. Which of the following is the most appropriate test to order?
Monospot should be considered in this patient because of the history of pharyngitis and the development of a rash with amoxicillin treatment
A 66-year-old man presents with nausea, intermittent abdominal cramping, and frequent diarrhea for the past three days. He was recently hospitalized for pneumonia and was discharged one week ago. He was feeling better until yesterday. Physical examination reveals mild lower abdominal tenderness but is otherwise unremarkable. Of the following choices, which is the most appropriate initial treatment?
Oral metronidazole for mild to moderate Clostridium difficile infection
A five-year-old boy presents with severe vigorous coughing fits followed by deep, high-pitched inspiration. What phase of the underlying disease is this patient most likely experiencing?
Paroxysmal phase
A thin 19-year old woman presents with abnormal vaginal bleeding stating that her menstrual cycle interval has shortened to 18 days. She reports normal flow and that her cycle lasts for 3-4 days. She has been under a lot of stress. What is this pattern of bleeding called?
Polymenorrhea cycles are occurring at intervals less than 21 days
A 43-year old woman presents to the Emergency Department after being bitten on the lip by her dog. The laceration is approximately four centimeters long and approximate 1.5 cm deep, extending vertically from the lower vermilion border to the inner oral mucosa. After thorough irrigation and debridement, what is best method for wound closure?
Primary closure with sutures can be performed on the scalp, face, torso, and extremities other than the hands and feet
A 42-year-old woman presents to the emergency department after a suicide attempt. The patient was depressed two days ago and took an entire bottle of acetaminophen. She initially felt slightly nauseous and generally unwell but was otherwise asymptomatic. A family member convinced her to come to the emergency department for further evaluation. Which of the following history or physical exam findings is most consistent with toxic acetaminophen ingestion?
Right upper quadrant abdominal tenderness
A seven-year-old boy presents with right ankle pain after jumping off his bunk bed. On examination, he has tenderness and swelling over the medial malleolus. His ankle X-ray is shown above. What is the diagnosis?
Salter-Harris type III fracture a fracture that extends through the epiphysis intra-articularly through the physis
A 32-year-old woman with history of migraine headaches presents for evaluation of increased frequency of headaches. She takes abortive medication for migraines 2-4 times weekly and misses several days of work a month. You decide to start topiramate daily for migraine prophylaxis. Of the following, which one is the most common side effect of this medication?
paresthesias
Bounding pulses and a continuous machine-like murmur
patent ductus arteriosus
A 31-year-old woman presents with thinning of her hair over the past month. She says she thinks she's pulling out more hair than normal when she grooms. Her history is significant for an uncomplicated labor and delivery three months ago. During an exam, a pull-test extracts 25-30 hairs with white bulbs at the ends. Which of the following tests would most likely reveal an underlying cause?
serum ferritin underlying iron deficiency in patients with symptoms suggestive of telogen effluvium
Which type of lung cancer results in the majority of malignancy-related syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
small cell lung cancer
A 27-year-old tall, thin male presents to the emergency room with moderate right-sided chest pain and dyspnea. He says it started quickly while he was watching television 30 minutes ago. He is tachypneic and tachycardic, however his heart rate and blood pressure are stable at this point. Lung exam reveals decreased breath sounds at his right lung field. Which of the following other physical exam findings would be expected in this patient?
Decreased right-sided tactile fremitus
A 26-year-old man presents complaining of right shoulder pain after a fall from an all-terrain vehicle onto his shoulder. Radiographs are completed and show a Hill-Sachs lesion. Which of the following best describes this finding?
Defect of the posterosuperior humeral head
An 18-year-old woman comes to the emergency department with sudden onset of right lower abdominal pain. She describes the pain as crampy and intermittent. Her last menstrual period was 7 weeks ago. She has noticed vaginal spotting during the past few days. Physical examination shows a tender lower abdomen with guarding. Pelvic examination shows a slightly enlarged uterus, cervical motion tenderness, and a palpable adnexal mass. Which of the following is the most likely diagnosis?
Ectopic pregnancy
A 27-year-old G2P1 woman is diagnosed with an HIV infection after undergoing routine prenatal blood work testing. Her estimated gestational age by first-trimester ultrasound is 12 weeks. Her CD4 count is 550 and her viral load is 26,000 copies/mL. She denies any symptoms of HIV infection. Which of the following highly active antiretroviral therapy (HAART) medications should be avoided in this patient?
Efavirenz
A 58-year-old woman with a history of previous cerebrovascular accident presents to the emergency department by ambulance due to concern for possible overdose. According to her husband, at home she was vomiting and complaining of nausea and ringing in her ears. The patient is confused and unable to answer questions upon arrival. Her blood pressure is 90/57 mm Hg, heart rate is 112 beats/minute, respiratory rate is 28 breaths/minute, and temperature is 103.1°F. Which of the following interventions should be avoided if possible?
Endotracheal intubation
A six-year-old girl is brought to the clinic because of a rash. She was in school when she developed a rash about 30 minutes after eating peanuts. The lesions are pruritic. She denies difficulty of breathing, throat tightness, vomiting, or abdominal pain. On physical examination, there are multiple raised, erythematous plaques, with central pallor that are less than one centimeter to several centimeters in diameter. The lesions are scattered over her chest, abdomen, and arms. Which of the following is the most appropriate therapy?
Fexofenadine acute urticaria.
A three-year-old girl is brought to the clinic by her mother due to complaints of a sore throat and decreased oral intake. She has had elevated temperatures with a Tmax of 99.9°F. She has also had nasal congestion, occasional cough, and general malaise. On examination, the child appears tired but non-toxic and well-hydrated. Her conjunctiva are mildly injected bilaterally. Clear-to-white nasal discharge is present in the bilateral nares. Her oropharynx is erythematous with 2+ tonsils and cobblestoning of the posterior pharynx. She has shotty, non-tender bilateral cervical adenopathy. Her lungs are clear to auscultation. Her heart rate is regular with no murmurs, rubs, or gallops. Her abdomen is soft, non-tender, and non-distended. Her extremities are warm and well-perfused. What intervention is indicated?
supportive care viral pharyngitis
