IM 2 Quizzes

What is the average fluid deficit in Hyperosmolar Hyperglycemic State (HHS)?

8-10 L

Which of the following is a typical ECG findings in patients presenting with hypokalemia?

all of the above

What is the recommended insulin infusion rate in the initial treatment of diabetic ketoacidosis?

0.1 U/kg/hr

You are taking care of a 67-year old previously healthy non obese female in the ICU for community acquired pneumonia. She presented with worsening cough, fever and weakness over the last week. She was started on ceftriaxone and gentamicin as she has a severe fluoroquinolone allergy and multiple other medication allergies. Physical examination shows an elderly and feeble white female in mild respiratory distress. Her admitting vitals showed a temp of 101.4F, HR of 110 (NSR), BP 99/50, RR 22, O2 90% on room air. Her admitting creatinine was 0.5 mg/dl (GFR 81 ml/min) and WBC was 17,000 mm3. Portable chest x-ray showed bilateral infiltrates. If she were to go into renal failure from aminoglycoside toxicity when in the course of her therapy would she likely develop acute renal failure?

1 week after therapy initiation

In the treatment of diabetic ketoacidosis (DKA), the initial IV insulin infusion should be continued for how many hours after initiating subcutaneous insulin?

1-2 hrs after initiating subcutaneous insulin

You are treating a 33-year old male patient in the ICU who was admitted for diabetic ketoacidosis (DKA). His initial glucose was 679 mg/dl, Anion Gap was 29, bicarbonate is 9 mmol/L and pH is 7.10. His initial potassium came back at 4.1 mEq/L ( normal range is 3.7 to 5.2 mEq/L ). What is the best choice for potassium replacement in this patient?

10 mEq / hr for 4 hours

You are seeing a new 65-year old female patient in clinic who has a past medical history of stage III chronic kidney disease. Her recent lab work shows an anemia that is normocytic with a hemoglobin level of 8.8 g/dL. The best outcome is predicted if you raise the hemoglobin to what level?

10-12 g/dL

Roughly what percentage of patients diagnosed with COPD were never smokers?

15-25%

You are seeing a 29-year old male in the ED who presents with generalized abdominal pain, nausea, and vomiting the last 2 days. He has a prior history of type I diabetes mellitus and has been out of his insulin over the last 2 weeks. His initial ED glucose reads 560 mg/dl. His vitals show a heart rate of 140 bpm, blood pressure is 154/90, respiratory rate of 30/min, and oral temperature is 99.1 F. His ABG shows a pH of 7.15 and a bicarbonate of 8 mmol/L. His physical exam is non focal and his cardiopulmonary exam is normal except he is tachypnic with kussmaul respirations. Which of the following options is the best initial treatment for this patient?

2 Liter normal saline bolus

How much would the emergency clinician expect a patient's sodium to increase after receiving 100 cc of 3% hypertonic saline intravenously?

2.0 mEq/L

What percentage of cases of acute kidney injury are related drug induced nephrotoxicity?

20%

A 54-year old black male is referred to you after his GFR was found to be 45 ml/min over the last 3 months. What stage is his kidney disease?

3

A 25-year old female presents to the ER with worsening lightheadedness, weakness, excessive thirst and urination over the last three weeks. She denies any past medical history. She takes no medications and denies alcohol or drug use. Vital signs: oral temperature of 98.6 F, heart rate 130 beats/min, respirations 24/min, and blood pressure 101/64 Her labs show a sodium of 140 meq/L, chloride of 102 meq/L potassium of 6.8 meq/L, bicarbonate of 12, BUN mg/dl 21, Creatinine 0.8, glucose of 785, beta-hydroxybutarate >8.0. Her ABG shows a pH of 7.08. What is the most appropriate treatment?

30 ml/kg Fluid bolus of 0.9% Normal Saline along with insulin drip at 0.1 u/kg per hour

Renal dysfunction is extremely prevalent in patients with congestive heart failure. What is the reported percentage of patients with New York Heart Association (NYHA) class III/IV have a history of severely impaired renal function (creatinine clearance ​​​​​<30 ml/min)?

33%

A large, prospective CDC study of community-acquired pneumonia (CAP) in hospitalized adults in the US was recently completed and published in the New England Journal of Medicine. How often were pathogens detected in hospitalized CAP adult patients and what were the most commonly detected pathogens?

38%: Human Rhinovirus

What percentage of patients with psoriasis go on to develop psoriatic arthritis?

5%

A 78-year-old male presents to the ER for increasing weakness and confusion over the last week. He has lived in a nursing for 6-months secondary to his worsening dementia. He currently denies complaints. His family notes he has generalized weakness and has difficulty standing on his own. On exam he weighs 60 kg, blood pressure is 143/81, heart rate 98 beats/min, respirations 18/min, and oral temperature is 97.1F. He appears weak and dehydration. The rest of his exam is unremarkable. His labs show a serum sodium of 160 mEq/L, BUN 28 mg/dL, Cr 1.4m mg/dL. What is this patients calculated Total Body Water Deficit (TBW)?

5.35 L

A glomerular filtration rate (GFR) below ___ for ___ months accurately defines chronic kidney disease?

60 ml/min, 3 months

Approximately how many COPD exacerbations are triggered by viral or bacterial respiratory infections?

70-80%

What is the mortality rate for Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) respectively?

< 2% / 5% to 20%

Elevated serum phosphorus is a predictable accompaniment of end-stage renal disease (ESRD) in the absence of dietary phosphate restriction or supplemental phosphate binders. The consequences of hyperphosphatemia include the development and progression of secondary hyperparathyroidism and a predisposition to metastatic calcification when the product of serum calcium and phosphorus (Ca x PO4) is elevated. Both of these conditions may contribute to the substantial morbidity and mortality seen in patients with ESRD. What is the recommended calcium-phosphorus product in those with chronic kidney disease?

<55 mg2/dL2

The 2012 ACR guidelines for the management of gout and hyperuricemia included a call for treat-to-target serum uric acid what level?

Below 6 mg/dL at a minimum and below 5 mg/dL in select patients

A 24-year-old female presents to you with a 2-day history of right sided chest pain and shortness of breath. She describes the pain as sharp, located in the right upper chest, and worsened by deep breathing or coughing. She was previously healthy and has no recent history of travel. Her vital signs are normal. A pleural friction rub is noted on auscultation of the lungs. The remainder of her examination is normal. Her ECG shows a normal sinus rhythm and no ST changes. Her cardiac enzymes, oxygen saturation, and a D-dimer level are all normal. What is the next best step?

A chest radiograph

A 55-year-old white female presents with a complaint of weakness over the last three weeks. She has a history of hypertension that has been difficult to control despite the use of hydrochlorothiazide 25 mg daily; lisinopril 40 mg daily; amlodipine 10 mg daily and labetolol 100mg BID. Vitals signs show a blood pressure of 164/91 mm Hg and heart rate is 87 beats/min. Physical exam reveals normal pulses, a normal cardiac examination, and no abdominal bruits. Her only abnormal lab is a serum potassium level of 2.9 mmol/L (N 3.5-5.5). Which one of the following would be best for confirming the most likely diagnosis in this patient?

A plasma aldosterone/renin ratio

You are seeing a 38-year-old woman in your office who has been finding it more difficult to control her mild persistent asthma. Her disease had been under good control on therapy with moderate-dose inhaled corticosteroids plus as-needed albuterol until 6 weeks ago when she had an acute respiratory tract infection. Since then she has had significant worsening of her symptoms, with nightly cough and wheezing. She uses an albuterol rescue inhaler 6 to 8 times per day. Which of the following is the most appropriate therapy for this patient?

A short course of oral corticosteroid therapy

Which of the following statements about Type II Hepatorenal Syndrome (HRS) is true?

All of the above

You are seeing a 44-year old female who is presenting with worsening arthralgias and low grade fevers over the last few days. She has a history of Systemic Lupus Erythematosus and is currently on hydroxychloroquine. What laboratory results will indicate if this patient is having a lupus flare?

All of the above

You are seeing a 63-year old female in your clinic to review some recent labs and evaluate her response to new inhaled corticosteroid that you started her on for COPD last visit. Upon further questioning she is asking about potential risks/side effects of the new inhaler. Which of the following is a known complication/risk of using inhaled steroids for her COPD?

All of the above

You are seeing a male patient in your clinic for lower back pain. Which of the following characteristics would require you to further evaluate for ankylosing spondylitis?

All of the above

You are seeing a 65 year old white female in the ER. She is current smoker and has a history of severe COPD (FEV1 , 25% predicted) and is presenting with worsening shortness of breath and a productive cough for 2 days. You obtain an ABG before starting her on nebulizers and bipap. The results show: pH 7.23, PCO2 70, (last baseline PCO2 was 50) PO2 50, HCO3- 30 (last baseline HCO3- was 26) How do you define this patients blood gas?

Acute Respiratory acidosis with compensatory metabolic alkalosis

You are seeing 29-year old male patient in your office who has a past medical history of mild intermittent asthma since he was about a teenager. He has been controlled well with short term rescue inhaler therapy and low dose inhaled corticosteroid that he started about four years ago until recently. Over the last few week he notes more recent nocturnal symptoms (2-3 times per week) and dyspnea about 4-5 times weekly requiring rescue therapy. His most recent in office pulmonary function shows a forced expiratory flow in 1 second (FEV1) is 65 percent of predicted. Out of the following options below, which of the following is the first-line step-up therapy option for this patient?

Add inhaled salmeterol

You are seeing a 31-year-old female in your pulmonology clinic because of worsening shortness of breath and wheezing. Currently she has been using an as-needed albuterol inhaler about three times per week and has been waking at night at least once a week with asthma symptoms that require the use of her inhaler. She is still able to perform most of her daily activities, including regular exercise, if she uses albuterol for prevention. On physical examination, vital signs are normal. Her lungs are clear. Spirometry shows forced expiratory volume in 1 second (FEV1) of 85% of predicted and an FEV1/forced vital capacity ratio of 80% of predicted. Which of the following is the most appropriate treatment?

Add low-dose inhaled glucocorticoid

You are seeing a 59-year-old black female in the ER who presents with increased shortness of breath since her last hemodialysis session 2 days ago. She has a past medical history of end-stage renal disease from uncontrolled hypertension. Her current vitals show a regular pulse of 88/min, respirations are 26/min and slightly labored, and blood pressure is 176/110 mm Hg. Physical examination shows jugular venous distention and pitting edema below the knees. Diffuse crackles are heard. Cardiac examination shows no murmurs, rubs, or gallops. Laboratory studies are shown below: Serum Na+ 138 mEq/L Cl− 100 mEq/L Arterial blood gas analysis on room air: pH 7.30 PCO2 28 mm Hg PO2 88 mm Hg HCO3− 14 mEq/L Which of the following is the most likely acid-base status of this patient?

Acute metabolic acidosis with respiratory compensation

You are seeing a 28-year old woman brought in by EMS after she was found unresponsive at home. She has an unknown past medical history. Vitals show an oral temperature of 99.1 F, pulse rate of 115/min, respirations are 20/min, and blood pressure is 96/61 mm Hg. Physical examination shows her to be obtunded, non verbal. Skin exam shows erythema, warmth, and induration of the upper back, buttocks, and posterior thighs. Urine toxicology screening is positive for opiates and cocaine. Urine dipstick is strongly positive for blood. Microscopic examination of the urine shows pigmented granular casts and rare erythrocytes. Which of the following conditions is this patient at risk for developing over the next 24 hours?

Acute tubular necrosis

You are seeing a 72-year-old black male for a follow-up exam following a COPD exacerbation. He has a history severe COPD from cigarette smoking currently without resting hypoxemia for the last 15-years. He presented to you 1 week ago with fever, productive cough, and mild dyspnea. You increased his albuterol inhaler to 5-6 times daily, added azithromycin and a 60 mg of prednisone daily. Today, he notes to be more fatigued, still coughing of brown mucous and feeling more short of breath. On physical examination, temperature is 100.1°F, blood pressure is 140/85 mm Hg, pulse rate is 101/min and regular, and respiration rate is 24/min. Pulmonary examination shows bilateral expiratory wheezing. Oxygen saturation is 90% on RA and 92% on 2 L oxygen via nasal cannula. Chest radiograph shows no infiltrate and no cardiomegaly. Which of the following is the most appropriate next step in management?

Admit to the hospital for further care

You are seeing A 76-year-old male who presents with worsening productive cough, shortness of breath, and fevers over the last three days. He has a past medical history of hypertension and prostate cancer. He has never smoked and does not drink alcohol. He lives at home with his wife and has not been admitted to the hospital in over 10 years. On physical examination, the patient is alert and oriented and appears is mild distress. His oral temperature is 103.1°F), blood pressure is 112/60 mm Hg, pulse rate is 120/min, respiration rate is 24/min, and oxygen saturation is 89% on ambient air. Pulmonary examination shows left-sided crackles and mild expiratory wheezes. His chest radiograph shows a left lower lobe infiltrate with no effusion. His white blood cell count is 19,000 mm3, BUN 41, creatinine 0.8 mg/dl, sodium 128 meq/L, serum lactic acid 1.5. You give him 1 gram of oral tylenol, 1 liter normal saline bolus, obtain blood cultures. Which of the following is the most appropriate disposition for this patient?

Admit to the medical ward to a telemetry bed with IV ceftriaxone and azithromycin

Which of the following are recommended therapies in the treatment of hyponatremia?

All of the above

Which of the following is considered a red flag symptom of low back pain?

All of the above

Which of the following risk factors can contribute to drug related nephrotoxicity?

All of the above

A 66-year-old black female is admitted to your hospital with fever, cough, and weakness. Her x-ray showed bilateral pneumonia. She was just recently discharged 1 week ago following an elective hip replacement surgery. Her initial stay was 3 days and she had no complications. She had no signs of infection until 2 days ago when she developed a temperature of 101.4°F, a cough with yellow sputum, and shortness of breath. She has a past medical history of hypertension that is well controlled with amlodipine. Vital signs show an oral temperature of 101.6 F, pulse rate is 120 beats/min, blood pressure 142/73, respirations 18/min, and O2 is 94% on 2 L nasal cannula. A chest radiograph confirms a right lower lobe and left upper lobe infiltrate. Of the following antibiotic regimens, which one would be the best initial treatment for this patient?

Ampicillin-sulbactam and clarithromycin

A 65-year old smoker with a history of hypertension presents to the ED with worsening shortness of breath, worsening cough with yellow sputum. The patient slept only about 6 hours in a chair last night. At home the patient used a nebulizer every 4 hours during the night. In the last 5 years, she has been admitted twice with COPD exacerbations. On arrival, the O2 sat is 90% on room air, the patient is tachypneic to 20/min and there is severe wheezing. A chest x-ray, EKG, CPK, and troponin are obtained with no acute changes. In the ED, albuterol nebs x 4, nebulized ipatropium, prednisone. After 4 hours in the ED the patient felt much better and tried to ambulate with pulse oximetry monitoring and did not desaturate. She is feeling better and wants to go home despite pushing her to stay overnight for observation. You plan on giving her an oral steroid, an antibiotic, and increase her nebulizer treatments at home. Which of the following statements is false regarding her treatment?

An oral steroid such as prednisone for 7 days always requires a steroid taper

The fractional excretion of sodium (FENa) measures the percent of filtered sodium that is excreted in the urine. This calculation is widely used to help differentiate prerenal disease (decreased renal perfusion) from acute tubular necrosis (ATN) as the cause of acute kidney injury (AKI, formerly called acute renal failure). Which of the following equations is correct? S= serum, U=urine

Answer A from above FENa, percent = (UNa x SCr)/(SNa x UCr) x 100

You are consulted to a 61-year-old female who presented to her PCP with body aches, hemoptysis, and shortness of breath and was directly admitted for further evaluation. She has a past medical history of migraines and fibromyalgia and takes topamax. Her vital signs show an oral temperature of 100.1 F, heart rate 101 bpm, blood pressure 115/71 mm Hg, and respiratory rate 22 breaths/minute with oxygen saturation 89% on room air. Physical examination is notable for bilateral rhonchi and crackles in both lower lung bases. Serum labs reveal a WBC of 12.9 mm3, Hgb 9.8 g/dL, BUN of 37 mg/dL, creatinine of 4.1 mg/dL. Cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA)is negative. A renal biopsy immunofluorescence staining is shown below. What is the most likely diagnosis?

Anti-glomerular basement membrane syndrome

Which one of the following drugs is most commonly implicated in the cause of interstitial nephritis?

Antibiotics

Continuous oxygen therapy should be prescribed for patients with COPD who have which of the following:

Arterial partial pressure of oxygen 55 mm Hg or less

A 83-year-old white male is admitted to the hospital because of worsening bilateral knee pains, swelling, and an inability to ambulate. He has a past history of gout and hypertension and takes lisinopril and norvasc. Vital signs show an oral temperature of 100.8°F, heart rate of 96 bpm, blood pressure 123/79, respiratory rate 16/min, O2 99% on room air. Physical exam shows large bilateral knee effusions that are warm to touch and there is limited range of motion due to pain and swelling. His serum labs show a WBC count of 18,000/mm3 with 86% segs and no bands, ESR 65 mm/hr and serum uric acid level is 8.5 mg/dL (N <6.5). Which one of the following would be most appropriate at this point?

Arthrocentesis

A previously healthy 32-year-old African-American female presents with a 3-day history of fever, cough, and shortness of breath. She denies previous illness over the last 6 months and has not been on any antibiotics. On exam her oral temperature is 100.7 F, blood pressure is 120/79, heart rate 97 beats/min, O2 97% on room air. Her upright chest x-ray reveals an infiltrate in the right lower lobe, consistent with pneumonia. Which one of the following options is the best choice for antibiotic treatment?

Azithromycin PO for 5 days

Which treatment plan for chronic back pain is NOT evidence-based as effective?

Bed rest for 2 days, then short walks twice

Which of the following options below have been shown to improve mortality in patients with COPD?

Both A and B

The manifestations of hyperphosphatemia are related to its effects on which of the following electrolytes?

Calcium

A 54-year-old obese black male presents to your office with a six month history of progressive pain of the fingers and knees, and morning stiffness lasting 45 minutes. He take ibuprofen only for pain. His vital signs are normal and physical examination reveals tenderness, erythema, some soft-tissue swelling, and bony hypertrophy of the second and third metacarpophalangeal joints bilaterally along with bony hypertrophy and fluctuance of both knees. Results of laboratory studies, show a normal erythrocyte sedimentation rate of 9mm/hr, rheumatoid factor and anti-cyclic citrullinated peptide antibody assay are negative. Radiographs of the hands reveal joint-space narrowing, particularly of the second and third metacarpophalangeal joints; osteophytes; subchondral sclerosis; and linear calcification of the cartilage. Radiographs of the knees show diffuse joint-space narrowing with osteophytes and cartilaginous calcification. Which of the following is the most likely diagnosis?

Calcium pyrophosphate dehydrate deposition disease

An 82-year-old female resident of a local nursing home is brought to the ER with fever, difficulty breathing, and a cough productive of purulent sputum. She was recently discharged from your hospital two weeks prior following UTI sepsis and two months ago for a COPD exacerbation. She has a past medical history of recurrent COPD, end stage renal disease and type II diabetes. Her vital signs show an oral temperature of 102.5 F, heart rate 123 beats/min, blood pressure 101/76, respiratory rate 28/min, and oxygen saturation of 86% on room air. A chest radiograph shows a new right lower lobe infiltrate. Her labs show a white blood cell count of 16.5 11.0 × 109/L (N= 4.5 to 11.0 × 109/L).Which one of the following antibiotic regimens would be most appropriate for this patient?

Ceftazidime, levofloxacin, and vancomycin

You are seeing a 59-year-old female for a follow up visit following a 3-day hospitalization one week ago. She mentions that she is feeling better but she is still having some mild shortness of breath and using her rescue inhaler four times per day. She is a former 40 pack year smoker with a past medical history of moderate COPD and this is only her second hospitalization in the last two years but was just started on medication about two months ago. She was treated with nebulizers, steroids, and sent home on a steroid taper and finished two days ago. Her current medications include tiotropium, a salmeterol dry powder inhaler, and an albuterol metered-dose inhaler as needed. On exam she is afebrile at 98.1F, heart rate 88 beats/min, blood pressure 125/61, O2 sat 96% on room air. She has a mild dry cough on exam that has decreased. There are faint expiratory wheezes bilaterally. The rest of her exam is unremarkable. What is the best next step?

Check the patient's inhaler technique

You are seeing a 51-year-old woman who is presenting with acute onset of lower back pain that radiates down her right leg to her right foot following a game of pickle ball two days ago. She has no leg weakness or numbness. She has been taking ibuprofen with some relief but the pain is still 5/10. Her medical history is notable for a hysterectomy. Her vitals show a temperature is 98.5˚F, heart rate is 84 beats/min, blood pressure is 145/81. On Physical exam her lumbar paraspinal muscles are tender to palpation. Straight leg raise test on both sides reproduces pain in the right leg. Her perineal sensation and rectal sphincter tone are intact. There are no motor or sensory deficits observed and no saddle anesthesia. Rectal tone is normal. She is able to walk with some discomfort. Which of the following is the most appropriate initial management of this patient?

Continue NSAIDS (with options of adding an opiate or muscle relaxer) and resuming normal activity

Patients with severe hyponatremia are at increased risk for which of the following?

Coma

Which of the following is the best initial treatment option in patients with sleep apnea who have daytime somnolence?

Continuous positive airway pressure

A 43-year old white female comes to your office with progressive weakness of her upper arms and thighs. She says that its hard to walk up stairs and get up out of chairs. You send some labs off and are suspecting polymyositis. What lab test will most likely be abnormal?

Creatinine Phosphokinase (CPK)

You are seeing a previously healthy 58-year-old Hispanic male who is presenting with worsening shortness of breath and a dry cough over the last three days. He was diagnosed with bronchitis at an urgent care and given azithromycin when his symptoms started 1-week prior. He has no past medical history is a never smoker. Vitals signs show an oral temperature is 100.9 F, blood pressure is 125/80 mm Hg, pulse rate is 125/min, and respiration rate is 30/min, oxygen saturation is 88% on room air. Physical exam shows no jugular venous distention. Pulmonary examination shows him to be tachypneic, with mild intercostal retractions, bilateral crackles in the midlung zones, and mild expiratory wheezing. Findings on cardiac examination are normal and there is no peripheral edema. His chest X-ray is shown below. What is the most likely diagnosis?

Cryptogenic organizing pneumonia

You are seeing a 46-year old male who is presenting with a cough, fever, dyspnea, and weakness for the last two days. He has a past medical history of hypertension, renal disease, and recently underwent a renal transplant four months ago. He takes norvasc and is currently on immunosuppressive therapy. His chest x-ray shows a left lower lobe pneumonia. What is the most common viral cause of concern in this patient?

Cytomegalovirus

You are treating a 56-year old male for hyponatremia. During treatment he develops flaccid paralysis, dysarthria, dysphagia, and hypotension, what is the initial therapy of choice?

D5W bolus

You are seeing a 67-year old black male in your clinic for a routine health visit. He has a past medical history of type II diabetes, hypertension and stage IV CKD (last GFR was 27 ml). He notes prior TIA and MI and has had 2 stents in the last 5 years. Which of the following is the most likely outcome of this patient?

Death from MI

Which of the following options are NOT typical laboratory findings seen in a patient with a moderate to severe lupus flare?

Decreased serum titer of anti-dsDNA antibodies

A 58-year-old female presents to you with a 3-day history of a rash over her face and hands that has not improved with the use of skin moisturizers, antibiotic ointments, or corticosteroid cream. She also has a 1-month history of progressive weakness. She notes a difficulty rising from her sofa chair as well as reaching over her head. On exam her vital signs are within normal limits. Physical exam shows muscle strength is 3/5 in the proximal upper and lower extremities. Which of the following is the most likely diagnosis?

Dermatomyositis

What is the most common cause of end stage renal disease in the United States?

Diabetes

A 23-year old male with Lupus presents with hemoptysis and shortness of breath the last 12 hours. His CT scan is shown below. What is the most likely diagnosis?

Diffuse alveolar hemorrhage

A 20-year-old male comes to your office because of a dull aching, and fullness of his scrotum over the last two weeks, he denies urethral discharge and is not sexually active. His vital signs are normal and examination shows a soft left-sided scrotal swelling; with negative transillumination testing. The scrotal swelling increases when the patient performs the Valsalva maneuver. The physical exam is otherwise unremarkable. Which of the following is the most likely cause of his condition?

Dilation of pampiniform plexus

You are rounding on a 61-year-old male in hospital after he presented for intermittent claudication. He has a past medical history of hypertension, type 2 diabetes mellitus, chronic kidney disease, and peripheral arterial disease. He currently takes aspirin 81 mg/d, metformin, 1000 mg twice daily; fosinopril, 80 mg/d; and hydrochlorothiazide 25 mg/d. His most recent labs show a creatinine level of 1.6 mg/dL (GFR 40 ml/min), sodium level is 136 mEq/L, potassium level is 4.2 mEq/L, chloride level is 108 mEq/L, and bicarbonate level is 22 mEq/L. You are planning to schedule him for an angiography of his legs later that evening. In addition to initiating therapy with 0.9% saline at 1 mL/kg 12 hours before the procedure, which of the following additional strategies is indicated?

Discontinue Metformin

You are seeing 62-year-old female in your office during a follow-up visit for persistent rheumatoid arthritis. She notes persistent pain and swelling in the hands and knees as well as increased morning stiffness for up to 3 hours daily for the past 2 months that interfere with her daily activities. She was diagnosed with this condition 1 year ago and began treatment with methotrexate, 20 mg/wk, and hydroxychloroquine, 400 mg/d; etanercept was added 6 months ago. Prednisone, 5 mg/d, was added 4 weeks ago and has provided only modest benefits. Medical history is significant for osteopenia. She also takes alendronate and calcium, vitamin D, and folic acid supplements. On physical examination, vital signs are normal. Range of motion of the shoulders is decreased. There are nodules on the elbows bilaterally and bilateral synovitis of the wrists. Grip strength is decreased. There are small effusions on the knees and squeeze tenderness of the metatarsophalangeal joints bilaterally. Her labs show a WBC of 8,400mm3 and erythrocyte sedimentation rate is 56 mm/h. Radiograph of the hands shows erosions of the right second metacarpophalangeal joint and the base of the left fifth metacarpal bone. Diffuse periarticular osteopenia is also visible. Which is the most appropriate next step in this patient's management?

Discontinue etanercept; switch to infliximab

You are seeing a 44-year old female in clinic to review some recent lab work. She has a past medical history of rheumatoid arthritis but takes no medications. Her last metabolic panel showed a (hyperchloremic) metabolic acidosis with a normal anion gap and a bicarbonate of 19 meq/l. What is the primary defect of a Type I Renal Tubular acidosis?

Distal acidification of urine

You are seeing a 64-year old female in your office to review some recent labs. She has a past medical history of hypertension and breast cancer that is currently in remission following lumpectomy and radiation therapy 9 years ago. She currently denies complaints. Her labs show an elevated calcium level of 12.1 mg/dl. What is the most likely cause of her hypercalcemia?

Recurrent breast cancer

What is the most characteristic laboratory abnormalities in patients with psoriatic arthritis?

Elevated erythrocyte sedimentation rate

A 57-year-old male with severe renal disease (CKD stage IV) presents with acute coronary syndrome. Which one of the following would most likely require a significant dosage adjustment from the standard protocol?

Enoxaparin

You are seeing a 31-year-old male in your clinic who is presenting with a 1-week history multiple painful nodules on his right shin. He has no history of trauma to either of these sites. . He denies past medical history and takes no medications. His review of systems is negative except for a remote episode of a sore throat 2-3 weeks ago. On physical examination, vital signs are normal. Physical exam shows few tender erythematous nodules that are warm and firm, over the right and left anterior lower extremity (See image below). The remainder of the physical examination is normal. What is the most likely diagnosis?

Erythema nodosum

You are seeing a 45-year old male who is presenting with cough, wheezing and shortness of breath over the last week. He notes similar episodes in the past but he has not seen a doctor. He denies any past medical history and he takes no medication, he denies alcohol use and he is 1 pack per day smoker for about 25 years. His current vitals show an oral temperature of 97.9 F, blood pressure is 122/80, heart rate is 91 beats/min, respirations 18/min, and O2 saturation of 98% on room air. Lung auscultation reveals wheezing bilaterally upon expiration only and the rest of his exam in unremarkable. His chest xray shows no abnormalities. In an attempt to understand more about his prior and underlying lung problems you want to ask him more about his history. Which of the following statements below is a more consistent finding in a patient with asthma vs that of chronic obstructive pulmonary disease?

Experiences symptoms intermittently and with more variability

A 29-year old black male presents to you with swelling of his hands and feet over the last week. He has a past medical history of IV drug use over the last two years and smokes tobacco. His labs show a BUN of 30 mg/dL, serum creatinine of 2.6 mg/dL, and his urinalysis shows 4+ protein, 2+ RBCs and waxy casts. What is the most likely diagnosis in this patient?

Focal-segmental glomerulosclerosis

What spirometry findings would you start a long acting bronchodilator and inhaled corticosteroid for a patient with COPD?

FEV1/FVC ratio <0.7; FEV1 <50% Predicted

You are evaluating a 64-year old male for a follow up visit. He has a past medical history of severe hypertension and CKD stage II. Last visit you noted his renal function declined from his baseline and you ordered an ultrasound of his kidneys. The report comes back showing a normal left kidney and a small right, smooth kidney. What is the most common cause of this ultrasound finding?

Renal artery stenosis

A 43-year old male presents to you with bilateral thigh and calf pains and generalized malaise over the last 2 days. He is a roofer and works outside most of the day. He has chronic lower back pain and takes alleve daily. His urine is yellow and urine dip stick shows no blood. True of False : A normal urinalysis rules out the possibility of underlying elevated serum creatine kinase from rhabdomyolysis? (extra credit 1pts extra credit) You didn't answer this question

False

Chest radiography is recommended as a routine test in the initial evaluation of asthma

False

Hyperkalemia is normally an early manifestation of Chronic Kidney Disease.

False

True or False: Diagnosing COPD in patients less than 50 years of age is common and does not warrant further investigation into the underlying cause.

False

True or False: Hyperkalemia is normally an early manifestation of chronic kidney disease.

False

True or False: In the setting of Diabetic Ketoacidosis, the use of an Arterial Blood Gas is recommend over the use of a Venous Blood Gas in the monitoring of pH disturbances.

False

True or False: Routine bicarbonate therapy is indicated in patient's with Diabetic Ketoacidosis (DKA) and serum pH <7.15.

False

True or False: There is clear and strong evidence that a combination of inhaled therapies (long-acting anticholinergics, long-acting beta agonists, or corticosteroids) has been proven superior and is recommended first line treatment to that of monotherapy for symptomatic patients with COPD and an FEV1 less than 60 percent predicted.

False

You are seeing a patient in your clinic with chronic kidney disease. His glomerular filtration rate (GFR) over the last year has remained around 30 ml/min. True or False: A patient should only be referred to a Nephrologist once their GFR falls below 20ml/min.

False

When approaching a patient with suspected gout, a joint aspiration sometimes fails to establish the diagnosis, such as when no crystals are seen or no fluid is obtained. Patients may decline the procedure or have contraindications. The preliminary American College of Rheumatology criteria for the definition of gout offers alternatives to establish the diagnosis in the absence of obtaining fluid analysis by fulfilling 6 of 12 criteria. Which of the following does not meet that criteria?

Fever

You are seeing a 46-year-old black male who presents with slurred speech, confusion, and ataxia. He works as an auto mechanic and has been known to consume alcohol heavily in the past, but denies recent alcohol intake. He appears intoxicated, but no odor of alcohol is noted on his breath. His labs show a glucose of 111 mg/dL, carbon dioxide content of 10 mmol/L, anion gap of 28., and a blood alcohol level is <10 mg/dL (0.01%). A urinalysis shows calcium oxalate crystals and an RBC count of 10-20/hpf. Woods lamp examination of the urine shows fluorescence. His arterial pH is 7.25. Which one of the following is the most appropriate treatment?

Fomepizole

You are seeing a 35-year old black female who presents with a weakness, productive cough with blood tinged sputum over the last few days. He has a history of recurrent ear and sinus infections over the last several months despite multiple doses of antibiotics. She has no past medical history and takes no medications. Serum c-ANCA is positive. What is her most likely diagnosis?

Granulomatosis with polyangiitis

You are seeing a 64-year old female who is complaining of weakness, intractable nausea and vomiting over the last week. She denies abdominal pain or shortness of breath. She has a past medical history of stage IV chronic renal disease, type II diabetes and hypertension. Her vital signs are normal and her physical exam in unremarkable. ECG shows a normal sinus rhythm at 80 bpm with normal QRS and QT intervals. Her labs show a serum Na 138 meq/L, K 5.4 meq/L, Cl 104 meq/L, HCO3 15 meq/L, BUN 96 mg/dL, Cr 7.7mg/dL, Hgb 10.2 g/dL , Plt 240 k/mcL. What is the next best step in management of this patient?

Hemodialysis

You are consulted to a 13-year-old girl in the pediatric ICU after she was initially hospitalized for dehydrated secondary to bloody diarrhea that started 3 days ago. She has no prior medical problems and takes no medications. Her most recent vital signs show an oral temperature of 101.5 F, heart rate 115 beats/min, blood pressure 96/65, O2 saturation 99% on room air. On physical examination her oral mucosa is dry and she has diffuse abdominal pain with some voluntary guarding. The remainder of the examination is normal. Her afternoon labs are shown below. Her peripheral blood smear shows many schistocytes. Which of the following is the most likely cause of this patient's acute kidney injury? Laboratory studies: Haptoglobin 8.2 mg/dL Hemoglobin 7.1 g/dL Platelet count 62,000/µL Reticulocyte count 8.6% of erythrocytes Serum creatinine 3.1 mg/dL Lactate dehydrogenase 2589 U/L Urinalysis > 182 RBCs and many erythrocyte casts

Hemolytic uremic syndrome

A 36-year old white female presents to your clinic complaining of a dry mouth, painful intercourse, and facial swelling over the last 6 months. She has no past medical history and takes no medications. Her vital signs are normal and physical exam reveals poor dentition and bilateral parotid swelling. What diagnosis is most likely in this patient?

Sjogren Syndrome

Which of the following medications can increase serum Uric Acid and increase the chance of acute gout?

Hydrochlorothiazide

Which electrolyte abnormality is most commonly associated with bradydysrhythmias?

Hyperkalemia

Which of the following metabolic complications occur in patients with Chronic Kidney Disease?

Hyperphosphatemia and Vitamin D deficiency

Patients with obstructive sleep apnea have an increased risk for which of the following?

Hypertension

You are seeing a 22-year old cross country runner who was brought in after collapsing during a race and was having seizure like activity when EMS arrived. She has no past medical history and takes no medications. She is confused and combative despite 10 mg of diazepam. What is the most appropriate treatment after she suffers another tonic-clonic seizure?

Hypertonic saline

Which of the following can falsely lower the anion gap?

Hypoalbuminemia

You are seeing a 64-year old male in the office to follow up on routine lab work. He has a past medical history of hypertension and type II DM. She takes lisinopril 5 mg and takes metformin 1000 mg BID. Her metabolic panel shows that she has new mild hyperkalemia of 5.8 meq/L without evidence of hemolysis. His renal function is normal with a BUN of 18 mg/dL and Cr of 0.8 mg/dL. What is likely contributing to this lab finding?

Hypoaldosteronism

You are seeing a 64-year old male who is presenting with nausea, vomiting blood and severe abdominal pains over the last 24 hours. He has a past medical history of cirrhosis secondary hepatitis-c, and he takes lasix, spironolactone, and rifampin. His vital signs show an oral temp of 101.4 F, heart rate 122 beats/min, RR 16, O2 95% on room air. Physical exam shows him to be pale, he looks edematous with moderate abdominal ascites, severe 3+ lower extremity edema. His abdomen is tender in all 4 quadrants. His labs show a serum WBC of 18,000 mm3, Hgb of 8.1 g/dl and new elevated Cr of 2.3 g/dl. His ascitic fluid is very cloudy and has 800 wbc/hpf. His working diagnosis is Spontaneous Bacterial Peritonitis, Upper GI Bleed likely from varices and Type I hepatorenal syndrome. Which of the following options would be detrimental in his treatment?

IV Furosemide (Lasix)

You are seeing a 59-year-old Hispanic female for follow-up after her last metabolic panel showed an estimated glomerular filtration rate of 50 mL/min. She has a past medical history of type II diabetes mellitus and stage 3 chronic kidney disease. Which one of the following medications should she avoid to prevent further deterioration in renal function?

Ibuprofen

What is the most frequently diagnosed primary glomerular disease in adults from biopsy series, and the leading primary glomerular disease causing end-stage renal disease (ESRD) in young Caucasian adults?

IgA nephropathy

What is the mechanism behind type 3 renal tubular acidosis?

Impaired proximal HCO3- reabsorption

A 70-year old white male with a history of COPD requiring home 3L O2 presents to you with increasing shortness of breath despite his oxygen at home. He says that he is normally fine during mild strenuous activity but now he has been getting more short of breath the last few days. His vitals show a heart rate of 70 bpm, blood pressure is 145/76, respirations of 16, temperature of 99.2 F, O2 sat of 91% on 3 L nasal cannula. His lungs sounds are decreased bilaterally with scattered rhonchi. You leave the room to order some tests and the nurse sees his O2 sat and puts him on a non rebreather mask. When you return a 20 minutes later to ask him more questions you find him unresponsive and not breathing. What is the likely cause of his acute decompensation?

Increased arterial oxygen partial pressure

You are seeing a 54-year old female in the office to review and discuss treatment recommendations for newly diagnosed rheumatoid arthritis. Which of the following medications require her to be screened for tuberculosis before starting?

Infliximab (Remicade)

Which of the following mechanisms correctly describes the lactic acidosis seen in patients who are on metformin?

Interference with oxidative phosphorylation, suppression of hepatic gluconeogenesis

Early in the course of acute gout arthritis, radiography may occasionally help rule out other causes of joint pain and swelling, such as fractures or calcium pyrophosphate deposition disease (pseudogout). Later in the course of disease, radiography can show more long-term changes due to gout. However, gout is less likely to cause which of the following radiographic findings?

Joint space narrowing

You are seeing a 75-year-old male in your clinic for a follow up evaluation because he has had worsening renal function over the last 3 months. He has a past medical history of hypertension and benign prostatic hyperplasia and his only medications are tamsulosin and norvasc. On physical examination, he is afebrile. Blood pressure is 125/81 mm Hg, and pulse rate is 72/min. Cardiopulmonary examination is normal. His abdomen is nontender, with normal bowel sounds and some suprapubic fullness. His latest serum creatinine level was 2.3 mg/dL (GFR 28 ml/min) compared to a serum creatinine level of 1.8 mg/dL (GFR 40 ml/min) last month. Urinalysis shows a specific gravity of 1.011; pH 6.1; trace leukocyte esterase; 0-3 erythrocytes/high-power field; and 0-5 leukocytes/high-power field. Which of the following is the most appropriate diagnostic test to perform next?

Kidney ultrasonography

Dabigatran is predominantly cleared/excreted by what organ?

Kidneys

Most disc pathology in the spine occurs at levels?

L4-S1

What is the most common cause of pulmonary hypertension?

Left heart disease

It is mid June and you are seeing another 83-year old male from the same nursing home who has already sent you at least 4 patients in the last few days. His complaints per his family are a cough, fever, diarrhea, abdominal pain and worsening altered mental status. He has a past medical history of Type II DM, dementia, and hypertension. His vitals show an oral temp of 39.6 C, BP 114/71, heart rate 123 beats/min, respiratory rate 20 and O2 of 93% on RA. His labs are notable for a serum sodium of 127 meq/L, BUN 45 mg/dL, creatinine 17 mg/dL and a WBC of 16,000mm3. His chest x-ray shows a patchy left lower lobe infiltrate. What is the most likely cause of this patient's illness?

Legionella

Because of safety concerns, which one of the following asthma medications should be used only as additive therapy and not as monotherapy?

Long-acting β2-agonists

You are seeing a 24-year old female patient in the ER who is presenting with an acute asthma exacerbation that started 1 hour prior to arrival. Her vitals show a heart rate of 120 bpm, blood pressure 123/75, respirations 24/min, O2 saturation 96% on a non rebreather. Physical examination shows her to be in mild distress and is slightly tachypneic with some mild intercostal retractions and there is wheezing noted bilaterally. If you were to order an ABG, what findings would you expect to see in the setting of an early acute asthma exacerbation?

Low PaCO2

You are seeing 29-year old male patient in your office who has a past medical history of mild intermittent asthma. He has been controlled well with short term rescue inhaler therapy until recently as he notes more recent nocturnal symptoms (2-3 times per month) and dyspnea about twice weekly requiring rescue therapy but not affecting his daily activity. His most recent in office pulmonary function shows abnormality with a peak expiratory flow rate (PEFR) variability of 20-30% (2 years ago his peak expiratory flow rate, PEFR, was 15%). Of the options below, what is the next best treatment option for this patient?

Low-dose inhaled corticosteroid

You are seeing a 65-year-old female for 3 months of back pain after she slipped and fell on a wet floor 1 month ago. She denies fever, weight loss, numbness or tingling in her legs, radicular pain, and bowel or bladder incontinence. She has been taking tylenol daily for with some improvement in her pain. She has a history COPD and takes prednisone daily. Her current dose of prednisone is 10 mg daily. She also takes calcium and vitamin D. On examination, her vital signs are normal. Physical exam shows point tenderness to palpation of the lumbar spine at the L3/L4 level. Her neurologic examination findings are normal, and she has a negative straight leg raise test result. Which of the following is the most appropriate initial imaging test?

Lumbar spine radiography

What is the reason that it is necessary to replace magnesium as well as potassium in hypokalemic patients?

Magnesium is required in the activation of the sodium/potassium pump

Which of the following conditions has been associated with the development of COPD?

Marfan syndrome

You are seeing a 61-year-old male with hypertension and chronic kidney disease presumed secondary to diabetic nephropathy in the office before a planned débridement of his right foot for a chronic nonhealing diabetic foot ulcer. His current medications are lisinopril, atenolol, furosemide, metformin, and augmentin that was added by his podiatrist. His most recent labs show his creatinine level to be 2.8 mg/dL. On physical examination, pulse rate is 68/min and blood pressure is 135/68 mm Hg. Cardiac examination reveals a normal S1 and S2 and a grade 2/6 systolic murmur radiating to his axilla. Pulmonary examination is normal. There is a 12-mm ulcer extending across the right lateral heel with purulent drainage. Which of the following is recommended to determine the stage of this patient's chronic kidney disease?

Mathematical formula for estimation of the glomerular filtration rate

You are consulted to see a 34-year-old black male after he was found to have an abnormal chest x-ray that was done for a chronic intermittent nonproductive cough of 6 months' duration. The radiograph showed bilateral hilar lymphadenopathy and normal lung parenchyma. The patient has fatigue and intermittent mild central chest discomfort when he coughs. He denies weight loss, fever, night sweats, or recent respiratory illness. Vital signs and cardiopulmonary examination are normal. There is no cervical or axillary lymphadenopathy and no skin findings. Laboratory studies show normal electrolytes and normal complete blood count with differential; serum calcium is 10.8 mg/dL (N 8.5-10.5 mg/dL). You order a Chest CT scan with contrast that shows bilateral hilar and mediastinal and subcarinal lymphadenopathy along with bilateral small lung nodules with a perihilar distribution. Which of the following is the most appropriate next test in the evaluation of this patient?

Mediastinoscopy

You are seeing a 60-year old white male presents to the Emeregency room with shortness of breath, nausea and vomiting. He has a past medical history of diabetes mellitus type 1 and moderate COPD. His current medications are Advair, albuterol, metformin and lantus. His current temp is 37.4 C, RR 20, HR 110, BP 141/87 Physical exam shows him to be in mild distress, slightly tachypneic with mild wheezing bilaterally. His heart rate is regular without murmurs on cardiac auscultation. Abdomen exam is soft with mild tenderness in his epigastrum. His chest xray shows no acute infiltrate and findings consistent with underlying COPD. His blood gas and serum electrolytes are shown below. PH: 7.20 PaCO2: 30 PaO2: 90 Na: 130 Cl: 77 K: 3.6 Bicarb: 10 Glucose: 445 WBC: 11.4 Hgb: 12.6 Plt: 190 What acid base disorder/disorders does this patient have?

Metabolic Acidosis without appropriate respiratory compensation and additional Metabolic Alkalosis

You are seeing an 80-year old white female who is accompanied by her husband in the ER with a chief complaint of altered mental status after being found by unresponsive. She has a past medical history of type II diabetes currently on insulin. Her current vitals show a blood pressure of 90/60, pulse rate of 101 beats/min, and oral temp of 98.6 F. You administer a liter if Normal saline and draw some labs which are shown below: BUN 24 mg/dl, Cr 0.8 mg/dl, Na 141 mmol/L, K 2.7 mmol/L, Chloride of 116 mmol/L, HCO3 13 mmol/L, ABG shows a pH 7.26, PCO2 28, PO2 88, HCO3 13. What is this patient's primary abnormality?

Metabolic acidosis

What it is the proposed mechanism causing hypertension in patients with obstructive sleep apnea?

Nocturnal hypoxemia can lead to changes in the reninangiotensin- aldosterone system

You are seeing a 24-year old male for a follow up visit. You are suspicious that he has asthma despite normal spirometry studies on his last visit. He notes having recurrent episodes of shortness of breath and a nocturnal cough for the last 6 months. Which of the following studies is the next best step in the diagnosis of asthma?

Methacholine hyperresponsiveness (bronchoprovocation test)

A 34-year-old white female presents to you with increasing fatigue and worsening arthralgias in her shoulders, knees, wrist, hands and fingers. She notes the symptoms are worse in the morning and slightly improve as the day progresses. Her erythrocyte sedimentation rate (ESR) is 60 mm/hr and rheumatoid factor is strongly positive. What is the best treatment for this patient?

Methotrexate

You are rounding on a 90-year old nursing home patient who was admitted to your service after being diagnosed with community acquired right lower lobe pneumonia and started on IV levaquin. Her admission labs showed a WBC was 17,000, Hgb of 10.2 g/dL, Plt 210,000, BUN 30 and Cr was 1.2mg/dL. Her initial blood pressure in the ED was 91/60 and her heart rate was in the 80s. Since her blood pressure has dropped into the 70s/40s and her heart rate is in the 120s and she appears very dry despite receiving 1 liter of normal saline. Her AM labs show a new Cr of 3.1mg/dL (up from 1.2 mg/dL upon admission) and a urine sodium of 65. What other findings on her urinalysis are you likely to find?

Muddy brown granular casts

Which of the following nail changes is not commonly associated with psoriatic arthritis?

Muehrcke lines (white lines that extend all the way across the nail and lie parallel to the lunula)

What is the most common extrapulmonary site of sarcoidosis?

Skin

A previously healthy 35-year-old white female presents to you with a 6-month history of difficulty swallowing and regurgitation of undigested food. She also has had color changes and pain in her fingertips when they are exposed to cold temperatures. Examination of the face shows thick, tightly bound skin. Her fingertips are tapered and covered with ischemic ulcerations. There are also telangiectasias diffusely distributed over the trunk and upper extremities. Which of the following is the most appropriate pharmacotherapy for this patient's pain and ulcerations?

Nifedipine

You are seeing a 72-year-old who is presenting with a one year history of gradually progressive shortness of breath and was referred to you by his PCP. His symptoms started initially with a mild dry nonproductive cough along with some shortness of breath on exertion but now are he is short of breath even at rest. He has a 25-pack-year history of smoking and quit 20 years ago. He notes working in a textile factory for over 40 years and was exposed to asbestos. On physical examination, his temperature is 98.1 F, blood pressure is 140/71 mm Hg, pulse rate is 91/min, respiration rate is 26/min, and oxygen saturation on ambient air is 92% and drops to 88% with exercise. Pulmonary examination shows fine inspiratory crackles bilaterally in the posterior lung zones. His outpatient chest x-ray demonstrates linear opacities in the lung bases bilaterally and linear calcifications along the diaphragm. His outpatient CT scan of the chest without contrast shows basilar interstitial fibrosis, fine and course honeycombing, traction bronchiectasis, increased interlobular septal thickening in the subpleural regions, and diaphragmatic plaques with calcification. His in office pulmonary function testing shows a predominantly restrictive disease pattern. What is the next best step?

No further testing

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, regular inhaled corticosteroid treatment in the maintenance of stable COPD has been found to modify which of the following outcomes?

None of the above

Which of the following studies is warranted in the initial evaluation of a patient with suspected asthma?

None of the above

You are seeing a 72-year-old female who is presenting with a 2-week history of fatigue, lethargy, constipation, and urinary frequency. She has a past medical history of breast cancer, which has metastasized to her spine. Conventional therapy is no longer helpful, and she is scheduled to see her oncologist to discuss the next steps in management. On physical examination, she is pale and lethargic. Blood pressure is 85/65 mm Hg and pulse rate is 112/min. Her mucous membranes are dry. Cardiopulmonary examination is normal. Blood urea nitrogen 48 mg/dL Calcium 15.7 mg/dL Serum creatinine 1.9 mg/dL Sodium 154 mEq/L What is the next best step?

Normal saline bolus

You are seeing a gentleman in clinic to review some routine blood work. You notice his calcium is elevated. What calcium level requires immediate treatment despite lack of symptoms?

Only when >14 mg/dl

A 45-year old smoker presents to the ED with a non productive cough, wheezing, and mild dyspnea. He had no chest pain. For the past 5 days he used albuterol at home and has now run out. He has never been intubated or admitted. He has had only one prior exacerbation in the last year. On arrival the room air oxygen saturation is 94% and the respiratory rate is 20/min. There is moderate wheezing on exam. The chest x-ray is negative. In the ED he was given albuterol nebulizer x2 and ipatropium nebulizer are given with good effect. He is stable for discharge home and to follow-up with his primary care physician. Which of the following treatments upon discharge is not indicated at this time.

Oral antibiotic

A 37-year-old black female presents to your clinic because of worsening shortness of breath upon exertion over the last 3 months. She more recently developed painful red spots on her lower legs that were present for 2 weeks but resolved spontaneously. She denies past medical history and takes no medications. On exam her temperature is 99.3°F, pulse is 82/min, respirations are 18/min, and blood pressure is 140/90 mm Hg. Physical exam shows a well appearing non obese black female in no acute distress. Her lungs are clear to auscultation, and cardiac examination shows no abnormalities. An x-ray of the chest shows bilateral hilar adenopathy. Which of the following is the most likely diagnosis?

Sarcoidosis

What are the classic ECG changes that appear sequentially as the serum potassium level increases?

Peaked T-wave, prolonged PR interval, wide QRS, sine-wave pattern

You are seeing a 54-year old male who presents with a two day history of fever, productive cough, dyspnea, and myalgias. He has a past history of epilepsy and takes Keppra. His vitals show a oral temperature of 102.4 F, heart rate 124 beats/min, respiratory rate of 22/min, blood pressure 134/87, O2 saturation of 94% on room air. On physical examination his you note rhonchi on the right. His chest x-ray is shown below. What is the most likely cause of this patient's illness?

Pneumonia secondary to anaerobes

Which of the following is not a true statement regarding small vessel vasculitis?

Polyarteritis nodosa and Kawasaki disease are notable examples

You are consulted to see a 49-year-old male who was admitted to the ICU after he presented with shortness of breath and was found to be in acute renal failure. He noted the prior week that he had a dry cough which developed into hemoptysis and worsening dyspnea. He has a past medical history of hypertension and take losartan 50 mg. His vital signs show an oral temperature of 99.1 F, heart rate 111 bpm, blood pressure 91/63 mm Hg, and respiratory rate 18 breaths/minute with oxygen saturation 91% on room air. Physical examination is notable for bilateral rhonchi and crackles in both lower lung bases. Serum labs reveal a WBC of 10.9 mm3, Hgb 11.8 g/dL, BUN of 56 mg/dL, creatinine of 5.2 mg/dL. Cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA)is negative. A high-power light micrograph is shown below. What is the best treatment option for this patient?

Plasmapheresis + Prednisone + Cyclophosphamide

You are seeing a 58-year old white male in clinic. He has a past medical history of hypertension that is controlled with lisinopril 20mg and has a 40 pack per year smoking history. He is complaining of a chronic cough for the last year as well as mild dyspnea with exertion. What spirometry findings would support the diagnosis of COPD?

Post bronchodilator FEV1-FVC ratio < 0.70

You are seeing a 31-year-old male with HIV (CD4 of 80) who is presenting to the emergency department with progressive cough and dyspnea on exertion over the last 2 weeks. His x-ray shows bilateral diffuse interstitial infiltrates. Arterial blood gas levels show an increased alveolar-arterial gradient and a pO2 of 48 mm Hg on Room air. In addition to trimethoprim/sulfamethoxazole (Bactrim, Septra), which one of the following medications should be prescribed?

Prednisone

You are seeing a 71-year-old female who presents with fatigue, weakness, and lightheadedness. Her symptoms started after going fishing with her husband, where she was exposed to the sun most of the day. She has a past medical history of hypertension, which is treated with hydrochlorothiazide. She also takes ibuprofen daily for joint pains and last took it about 3 hours ago. Her vital signs show an oral temperature is 99.1F, supine blood pressure is 102/52 mm Hg, supine pulse rate is 91/min, and respiration rate is 12/min. When standing, blood pressure is 90/45 mm Hg, and the pulse rate is 115/min. The remainder of the examination is normal. Her labs are shown below, Which of the following is the most likely diagnosis? Serum creatinine 1.2 mg/dL (baseline: 0.6 mg/dL) Sodium, Bicarbonate, Potassium and Chloride Normal Fractional excretion of sodium 1.3% Fractional excretion of urea 25.1% Urinalysis Specific gravity 1.038; pH 6.5; trace protein; no cells; 2-3 hyaline casts

Prerenal azotemia

NSAIDs are among the most common causes of drug-induced renal injury, what is the mechanism of this injury?

Prostaglandin inhibition

You are seeing a 56-year-old obese white male in clinic who has been having pain and swelling of the right knee for 2 weeks. On exam you note a non erythematous joint effusion on exam and you perform a diagnostic arthrocentesis which and the synovial fluid reveals a leukocyte count of 15,000/mm3, and crystals that appear as short, blunt rods, rhomboids, and cuboids when viewed under polarized light. What is the most likely diagnosis?

Pseudogout

You are seeing a 76-year old male in clinic who is presenting with a six month history of shortness of breath that is worse with exertion and better with rest. He has a past medical history of hypertension and smoked 1/2 pack of cigarettes per day for 15 years but quit 15-years ago. He denies cough or chest pain or leg swelling. On exam his vitals show a blood pressure is 141/87, heart rate 94 bpm, respiratory rate 16/min, and oxygen saturation is 93% room air. On auscultation you note bilateral crackles. Cardiac examination shows persistent splitting of S2. Chest X-ray shows diffuse reticular infiltrates that are most prominent in the upper lung zones. His spirometry testing shows a forced expiratory volume in 1 second (FEV1) that is 60% of predicted and an FEV1/forced vital capacity ratio of 80%. Total lung capacity is 70% of expected. Diffusing capacity of carbon monoxide is 45% of expected. What is the most likely cause of his symptoms?

Pulmonary fibrosis

You are seeing a 39-year old black male in the ER who presented with shortness of breath and a cough for 5 days. His chest X-ray showed a spontaneous pneumothorax on the right. You perform a needle thoracostomy and use a pigtail catheter to re-inflate his lung and connect it to low continuous suction. He immediately coughs and you here breath sounds on the right side now. His O2 saturation improves and his heart decreases. About 10 minutes later he becomes more short of breath and is now hypoxic in the high 80s on nasal cannula 4L. His repeat X-ray is shown below. What is the diagnosis?

Re-expansion pulmonary edema

A 41-year-old white male comes to you because of non radiating lower back pain for 3 days after working in his yard the day prior to his symptoms starting. He has not had any change in bowel movements or urination. He had one similar episode 5 years ago that resolved spontaneously following and minor MVC. On exam his Vital signs are within normal limits. Physical examination of the back shows bilateral paravertebral muscle spasm. Range of motion is limited by pain. Straight-leg raising is negative. In addition to analgesia, which of the following is the most appropriate next step in management?

Regular activity

You are seeing a 74-year-old male who presents with increasing weakness, body aches and decreased urine output over the last week. He has had no fever, bloody stool, or vomiting. His appetite has been poor. He has a history of hypertension treated with hydrochlorothiazide 25 mg daily and arthritis for which he takes motrin 800 mg tid on a daily basis. Laboratory testing reveals a serum creatinine level of 3.0 mg/dL (N 0.6-1.5), a potassium level of 6.5 mmol/L (N 3.4-4.8), and a BUN of 50 mg/dL (N 8-25). His prior baseline values were normal 2 months ago. Which one of the following is most likely to lower the serum potassium within 1 hour?

Regular insulin plus dextrose intravenously

Which of the studies is best used to screen for the evaluation of renal artery stenosis?

Renal ultrasound and with renal doppler

Which of the following will not cause a transcellular potassium shift into cells?

Respiratory acidosis

You are seeing a 58-year-old white male in your clinic who is presenting with a 3-month history of fatigue and pain in both of his hands and knees. He notes recently the pain has progressively worsened and is accompanied by 1-2 hours of morning stiffness. He takes alleve as needed, which provides minimal pain relief. His vital signs are normal. and physical exam is unremarkable except synovitis to his proximal interphalangeal joints, elbows, left knee, and ankles. Radiographs of the hands and knees are normal. Aspiration his right knee demonstrates a moderately large effusion and fluid analysis reveals a synovial fluid leukocyte count of 12,400/µL. Serum ESR is mildly elevated at 30 mm/hr. Rheumatoid Factor and CCP tests are pending. What is the most likely diagnosis?

Rheumatoid arthritis

You are seeing a 31-year-old male in your clinic who is presenting with a 1-week history of left leg and ankle pain/swelling and multiple painful nodules on his right shin. He has no history of trauma to either of these sites. Upon review of systems he endorses a 2-month history of a dry cough. He denies past medical history and takes no medications. . On physical examination, vital signs are normal. Physical exam shows his left ankle to be warm and swollen, and with decreased range of motion due to pain along with a few tender erythematous nodules that are warm and firm, over the right anterior lower extremity (See image below). The remainder of the physical examination is normal. A plain x-ray of the right ankle is normal. Arthrocentesis of the right ankle is performed, and synovial fluid analysis reveals a leukocyte count of 4200/µL (80% lymphocytes, 12% macrophages), without the identification of crystals. Chest x-ray shows bilateral hilar adenopathy. What is this patients most likely underlying diagnosis?

Sarcoidosis

Regarding asthma, which of the following is TRUE?

Scalene muscle contractions are more suggestive obstruction than intercostal and subcostal retractions

Routine phosphate replacement in patients with Diabetic Ketoacidosis has been shown to improve outcomes if treated below which values?

Routine replacement is not recommended

You are seeing a 43-year old white female in clinic and as she think she has vasculitis as her mother was recently diagnosed with it and read that it is hereditary. She currently has no other complaints. Screening for primary vasculitic syndrome should be done with serum testing?

Screening testing should not be used for "vasculitis"

A 60-year old male presents with progressive weakness and muscle aches over the past few days. He has a past medical history of type II diabetes and arthritis. He takes metformin 500 mg BID and ibuprofen 400 mg for arthritis daily. His vitals signs are normal and physical exam shows diffuse generalized muscle tenderness to his bilateral thighs. His Labs show a BUN 30 mg/dL, Cr 6.1 mg/dL, Na 142 meq/L, K 6.2 meq/L, Ca 6.1 meq/L, Phosphorus 7.6 meq/L. What is the next best test for this patient?

Urinalysis

You are seeing 35-year-old white female who is continuing to have fatigue, widespread pain, and difficulty sleeping. She currently takes an over-the-counter nonsteroidal anti-inflammatory drug intermittently without relief of pain. She has a past medical history of fibromyalgia and migraines. Her last lab values from 6 months ago showed erythrocyte sedimentation rate of 7mm/hr, CRP of 2.1 mg/dL, TSH 2.1 U/mL. Last visit you started her on Pregabalin and an aerobic exercise program but the pregabalin was discontinued because she developed hives. On physical examination, you note multiple tender points but no synovitis or muscle weakness. The remainder of the examination is normal. Which of the following is the most appropriate class of pharmacologic treatment for this patient?

Serotonin-norepinephrine reuptake inhibitors

You are seeing a 68-year old male with a past medical history of hypertension and tobacco abuse (2 ppd for 40 years) who presents with muscle weakness and unintentional weight loss of 10 lbs the last month. He also notes a chronic cough over the last 6 months along with some new blood streaked sputum. His metabolic panel shows a BUN of mg/dl, creatinine 1.5 mg/dl, sodium 145 mg/dl, calcium level 13.2 mg/dl. All of the following are treatments acceptable treatment options EXCEPT

Sodium bicarbonate

A 68-year-old white male comes to your office for follow-up after a recent bout of acute bronchitis that was diagnosed at local urgent care. He reports having a productive cough for several months and he gets breathless with exertion and notes that every time he gets a cold it "goes into my chest and lingers for months." He has been smoking 1 PPD for 30 years. A physical examination is negative except for scattered rhonchi. A chest radiograph done 4 months ago at his urgent care visit was negative except for hyperinflation and flattened diaphragms. Which one of the following would be best for making the diagnosis?

Spirometry

A 54-year-old male presents to your clinic with worsening fatigue, 15 lb weight loss over the last three months, and abdominal swelling. He has a past medical history of uncontrolled hypertension and hepatitis C. On physical exam, you note a purpuric rash bilaterally on his lower extremities and upper extremities and multiple raised lesions (see image below) along with bilateral 1+ lower extremity swelling in his feet and pretibial regions. Urinalysis shows 2+ proteinuria and hematuria. Serum labs show low serum complement levels, creatinine is 2.5 mg/dL (baseline was 0.6 mg/dL). What is the best treatment for this patient?

Start on interferon and ribavirin for the untreated hepatitis C

You are seeing a 31-year-old male in your clinic who is presenting with a 1-week history multiple painful nodules on his right shin. He has no history of trauma to either of these sites. He denies past medical history and takes no medications. On physical examination, vital signs are normal. Physical exam shows few tender erythematous nodules that are warm and firm, over the right and left anterior lower extremity (See image below). The remainder of the physical examination is normal. What is the most common cause of this patients symptoms?

Streptococcal pharyngitis

You are seeing a 34-year-old black female in the hospital because of worsening fatigue, myalgias and intermittent pain and swelling of both ankles over the past month. When the pain occurs, it is so severe that she is unable to walk. She denies associated fever or chills. She is sexually active and has had one sexual partner for 12 months. Her vitals show a temperature is 98.6°F, pulse is 89/min, and blood pressure is 140/87 mm Hg. Physical examination shows no abnormalities or tenderness of the ankle joints. Oral exam shows a non painful ulcer on the oral buccal mucosa. The lungs are clear to auscultation and cardiac examination shows no abnormalities. Her labs are as follows: Leukocyte count 5400/mm3, Platelet count 68,000/mm3, Erythrocyte sedimentation rate 91 mm/h, Serum Antinuclear antibodies 1:320, Anti-DNA antibodies positive, RPR 1:16, Rheumatoid factor: negative, Urinalysis shows 3+ Protein, no RBC casts, and 10-20 wbc/hpf. X-rays of the ankles show no abnormalities other than tissue swelling. What is the most likely diagnosis?

Systemic lupus erythematosus

You are seeing a 66-year-old female who is presenting with a fever and headache for 3 days. In addition she notes a weight loss of 7-lbs in the last 2 weeks and a 1 month history of pain and stiffness of the shoulders and hips. She notes her symptoms are worse in the morning, and better as the day improves. She has no past medical history and takes no medications. Her vitals show her temperature is 101.5°F, blood pressure is 130/70 mm Hg, pulse rate is 125/min, and respirations 18/min. On physical exam you note mild tenderness to her right temporal scalp to palpation. Musculoskeletal examination reveals mild pain and limitation to range of motion of her shoulder and hips without evidence of joint effusion. Cardiac exam reveals a regular tachycardic rhythm and neurological examination is unremarkable. Laboratory studies show an Hemoglobin of 12g/dl, WBC 12,400mm3, Erythrocyte sedimentation rate of 108 mm/h, BUN 14 mg/dL, Creatinine 0.9 mg/dL and urinalysis showing no blood or wbc's. What is the most appropriate next step in management?

Temporal artery biopsy

Which of the following statements regarding hyperlactemia/lactic acidosis is incorrect?

The kidneys account for up to 70% of wholebody lactate clearance

Which class of diuretics is most likely to lead to hyponatremia?

Thiazide diuretics

Which of the following is NOT an essential laboratory test used in the evaluation of patients with hyponatremia?

Thyroid-stimulating hormone (TSH) levels

Estimated GFR and Creatinine clearance provide a more accurate measure of renal function than serum creatinine alone.

True

True or False: Hyperosmolar Hyperglycemic State (HHS) is more likely to occur in a patient with underlying type II diabetes than a patient with underlying type I diabetes.

True

A 31-year old female presents to you with a 1 month history of shortness of breath and a cough that is blood tinged at times. This morning she noticed some blood in her urine which prompted her visit today. She has a past medical history of mild intermittent asthma and takes albuterol as needed. Her vitals are within normal limits and physical exam shows trace bilateral pitting edema to her lower extremities and crackles at bilateral bases to auscultation. Her CBC and CMP are within normal limits and UA shows 3+ blood, 3+ protein. ANCAs are negative. What is the recommended treatment duration for this patients underlying pathology?

Until remission

You are consulted to see a 49-year-old male who was admitted to the ICU after he presented with shortness of breath and was found to be in acute renal failure. He noted the prior week that he had a dry cough which developed into hemoptysis and worsening dyspnea. He has a past medical history of hypertension and take losartan 50 mg. His vital signs show an oral temperature of 99.1 F, heart rate 111 bpm, blood pressure 91/63 mm Hg, and respiratory rate 18 breaths/minute with oxygen saturation 91% on room air. Physical examination is notable for bilateral rhonchi and crackles in both lower lung bases. Serum labs reveal a WBC of 10.9 mm3, Hgb 11.8 g/dL, BUN of 56 mg/dL, creatinine of 5.2 mg/dL. Cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA)is negative. A high-power light micrograph is shown below. What is the recommended treatment duration for this patients underlying pathology?

Until remission

Which of the following is an absolute indication for renal replacement therapy in patients with CKD?

Uremic encephalopathy

Proteinuria refers to increased excretion of any urinary protein, including albumin and other serum proteins (tubular proteins). Which of the following statements is false?

Urine dipstick testing is sensitive for the measurement of small amounts of albumin and is recommended for CKD screening

You are seeing a 64-year old male dialysis patient in the ER who presents with palpitations and shortness of breath over the last week. He notes missing his last two dialysis sessions because he was unable to get a ride. His labs show a K of 7.4. and his ECG shows a wide QRS complex and peaked T waves along with absent P waves. When initiating your treatment one the nurses asks why you are give calcium. What is the best response?

Used to stabilize the myocardium

Below are list of drugs that are associated with nephrotoxicity. Which of the following causes acute interstitial nephritis as its mechanism?

Vancomycin

A 68-year-old male presents to your clinic because of a 3-month history of progressive weakness, fatigue, joint pains, a 2-month history of sinus congestion, a 3-week history of cough, and a 1-week history of blood-tinged sputum. He denies fever, nausea, vomiting, or diarrhea. He has high cholesterol, stable angina pectoris, and hypertension. His medications include atorvastatin, labetalol, isosorbide, and aspirin. Over the past 3 weeks, he has been taking over the counter ibuprofen as needed for the joint pain. Vital signs show his pulse rate of 84/min, respirations are 12/min, and blood pressure is132/76 mm Hg. ENT exam shows clear nasal discharge with no nasal or oral lesions. All his joints are diffusely tender with no warmth or erythema; range of motion is full. His labs are shown below: Which of the following is the most likely underlying mechanism of this patient's renal failure? Laboratory studies show: Hemoglobin 12g/dL Leukocyte count 13,800/mm3 Segmented neutrophils 74% Platelet count 325,000/mm3 Urea nitrogen 30 mg/dL Creatinine 2.8 mg/dL Antinuclear antibodies 1:256 Rheumatoid factor (RA): negative Antineutrophil Cytoplasmic antibodies (ANCA): positive Urine Blood 3+ Protein 3+ RBC 15-17/hpf WBC 1-2/hpf RBC casts rare

Vasculitis

Most clinical manifestations of Behçet's disease are believed to be due to which of the following?

Vasculitis

Which of the following is not a part of the diagnostic criteria for Hyperosmolar Hyperglycemic State (HHS)?

bicarbonate <15

You are seeing a 67-year old white female in the ER who is presenting with generalized abdominal pain and vomiting. She has not tolerated any oral intake in two days. She has a history of hypertension and osteoarthritis and takes lisinopril 10 mg daily and alleve for pain PRN. Vitals show a heart rate 115 beats/min, blood pressure 130/74, respirations 16/min, O2 99% on room air, oral temperature 99.1F. On physical exam she appears dehydrated and mildly uncomfortable. Labs show a serum creatinine of 2.8 mg/dl (GFR of 25 ml/min, basline is 65 ml/min). You suspect acute kidney injury in the setting of dehydration and concurrent NSAID use and you admit her for IV hydration and cessation of her ACE inhibitor for the time being. What is the likely mechanism for the renal failure?

decreased circulating prostaglandins to vasodilate the afferent arterioles

What is the difference between the total osmolality in plasma and effective osmolality in plasma?

the urea concentration