IM Rotation Question Bank

Diagnostic Criteria for AKI

Increase in serum creatinine of >= 0.3mg/dL or >= 50% in 48 hours OR Urine output of <0.5 mL/kg/hour for > 6 hours

Brugada Syndrome

-Autosomal dominant disorder most common in Asian males. -ECG pattern of pseudo-right bundle branch block and ST elevations in V1-V3. -⬆️risk of ventricular tachyarrhythmias and SCD. Prevent SCD with implantable cardioverter-defibrillator (ICD).

Diabetes Insipidus vs SIADH

-Diabetes Insipidus: too little ADH and then the kidneys fail to reabsorb water. It is central if there is decreased production of ADH and nephrogenic is kidney is just not absorbing it. Person will be excreting a lot of dilute urine, polydipsia, dehydrated, low specific gravity, fatigue, muscle pain, headache, postural hypotension -SIADH: excess ADH is released even though the body doesn't need it. Increased intravascular volume, water intoxication, and dilution hyponatremia. Will be fluid overloaded, changes in LOC, weight gain without edema, hypertension, tachycardia, anorexia, N/V, concentrated small amounts of urine

Sildenafil is prescribed for an otherwise healthy 54-year-old man who is diagnosed with erectile dysfunction. Which of the following is a potential adverse effect of this medication? A: Constipation B: Cyanopsia (blue vision) C: PSA elevation D: Urinary retention

B: Cyanopsia (blue vision)

A 2 yo boy is brought to the clinic with new edema in his feet, legs, hands, and face. He is an otherwise healthy and active and UTD on vaccinations. He had rhinitis & cough 2 weeks ago. A week after those sx abated, he developed facial swelling. Now, the swelling is primarily in his lower extremities. No meds and NKDA. BP 100/68, HR 126, RR 26, SpO2 98%, T 98.4. Bilateral periorbital edema and pitting edema of hands, feet, and legs, with nonerythematous, nontender skin, normal lung and cardiac sounds. GFR and complement levels wnl. UA: pH 6.0 SG 1.040 Protein: 200 mg/dL No glucose, bili, urobili, blood, ketones, nitrites, leuks. Clear & yellow CBC: WBC: 9.9 × 103/µL RBC: 5.27 × 106/µL HGB: 15.4 g/dL HCT: 44.1% MCV: 84 fL Platelets: 490 × 103/µL Which of the following is the most likely diagnosis? A: Acute tubulointerstitial nephritis B: Minimal change disease C: congenital nephrotic syndrome D: Post strep

B: Minimal change disease The patient in the vignette has nephrotic syndrome with the classic findings of generalized edema, hypoalbuminemia, and proteinuria > 50 mg/kg/day. The most common cause of nephrotic syndrome in children is minimal change disease (MCD), where there is a loss of anionic charge across the glomerulus and diffuse foot process effacement on electron microscopy without findings of structural damage or change. While the cause is often unknown, in some cases, minimal change disease may be provoked by a recent viral infection or allergic reaction. A child presenting with new-onset edema should have a urine dipstick performed. If more than 1+ proteinuria (30 mg/dL) is noted on urine dipstick, a first-morning urine protein to creatinine ratio should be obtained. If this is > 0.2, the patient has nephrotic syndrome. Clinically, a patient with nephrosis is likely to have minimal change disease if they are under 10 years old, do not have hypertension, do not have hematuria, and have normal complement levels with a normal glomerular filtration rate. Treatment of minimal change disease is with high-dose oral steroids for 2 to 3 months. Prednisone 60 mg/m2 per day (maximum 80 mg) is prescribed for the first 4 weeks, followed by 40 mg/m2 every other day for the duration of the treatment. Minimal change disease is generally responsive to steroid therapy, leading to a return of normal glomerular function in over 80% of patients.

Gold Criteria for CHF (4 cornerstones)

BB -- metoprolol xl, carvedilol, bisoprolol ACE/ARB -- losartan is good because it is an easy transition to Entresto Spironolactone SGLT-2 Inhibitors

Migraine Cocktail

Benadryl, Reglan, Steroids and Fluids

The serum creatine kinase-MB peaks after an acute myocardial infarction in which of the following time frames? A: 16-24 hours B: 48-72 hours C: 4-6 hours D: 8-12 hours

A: 16-24 hours

A 23-year-old woman presents with seizures. The patient received 2 mg of lorazepam by EMS but continues to seize. Serum lab tests show the following: Sodium: 118 mmol/L Potassium: 3.6 mmol/L Chloride: 90 mmol/L Bicarbonate: 21 mmol/L Blood urea nitrogen: 10 mg/dL Creatinine: 1.0 mg/dL Glucose: 89 mg/dL What treatment should be administered next? A: 3% hypertonic saline B: Dextrose C: Diazepam D: Pyridoxine

A: 3% hypertonic saline

Which one of the following is the most likely cause of acute kidney injury in a patient with eosinophiluria? A: Acute interstitial nephritis B: Ethylene glycol poisonings C: Poststreptococcal glomerulonephritis D: Rhabdomyolysis

A: Acute interstitial nephritis Acute interstitial nephritis is an important cause of acute renal failure resulting from immune-mediated tubulointerstitial injury. The presence of eosinophiluria in a patient with acute kidney injury suggests acute interstitial nephritis, which is typically an allergic reaction to medications such as penicillins, sulfa-containing antibiotics and diuretics, NSAIDs, and proton pump inhibitors. Patients with acute interstitial nephritis may also present with a rash, fever, eosinophilia, and other constitutional symptoms. The combination of elevated levels of creatine kinase or myoglobin, a dipstick positive for blood but negative for RBCs, and a history of muscle trauma would suggest rhabdomyolysis (D). Poisoning with ethylene glycol (B) or methanol should be suspected in a patient with acute kidney injury and altered mental status with an increased anion gap and osmolar gap. Ethylene glycol poisoning is associated with calcium oxalate crystals in the urine. An elevated antistreptolysin O titer when combined with the presentation of a full-blown nephritic syndrome with oliguric acute renal failure suggests poststreptococcal glomerulonephritis (C).

Which of the following valvular disorders is characterized by an early high-pitched, blowing diastolic murmur heard best over the left sternal border, and a wide pulse pressure? A: Aortic regurgitation B: Aortic stenosis C: Mitral stenosis D: Tricuspid stenosis

A: Aortic regurgitation

An 82-year-old man with a history significant for hypothyroidism presents to the emergency department with reports of unilateral weakness, facial droop, and speech difficulty. He has no history of vascular disease or diabetes. Vital signs are a heart rate of 114 bpm, respirations of 18/min, blood pressure of 122/68 mm Hg, a temperature of 98.4°F, and SpO2 of 97% on room air. A CT scan of the brain without contrast is negative for any hemorrhage. An MRI is positive for a cerebral infarct. Which of the following conditions is the most likely source of the embolus? A: Atrial Fibrillation B: Cardiac Myxoma C: Deep Vein Thrombosis D: Endocarditis E: Myocardial Infarction

A: Atrial Fibrillation

A 63-year-old man with a history of stage 3 chronic renal insufficiency presents feeling weak. Blood testing demonstrates a potassium of 6.7 mEq/L. A: Calcium gluconate, albuterol, regular insulin and glucose, furosemide B: Calcium gluconate, penicillin, warfarin C: Digoxin, metoprolol, furosemide D: Regular insulin and glucose, spironolactone

A: Calcium gluconate, albuterol, regular insulin and glucose, furosemide

A 23-year-old woman with no risk factors for heart disease presents to the clinic with sternal chest pain, fatigue, nonproductive cough, and shortness of breath. Vitals and physical exam are normal. Chest X-ray reveals bilateral hilar adenopathy and diffuse reticular opacities. Which of the following is the best next step to confirm the diagnosis? A: Endobronchial lung biopsy B: PET scan C: PFTs D: Surgical biopsy of mediastinum and lung

A: Endobronchial lung biopsy Sarcoidosis

A 64-year-old man presents to the clinic reporting a progressive tremor affecting his hands. He states the symptom onset was approximately seven years ago. He states his tremor is now affecting his writing but appears to improve in the evenings after a glass of wine. He has no significant medical history. He does report that his mother had a similar problem but never sought medical attention. On exam, he has no tremor at rest but develops an increasing amplitude tremor in both upper extremities when reaching for items. No bradykinesia or rigidity is present. The rest of his examination is unremarkable. Which of the following is the most likely diagnosis? A: Essential Tremor B: Parkinsons Disease C: Huntington Disease D: Wilson Disease

A: Essential Tremor

A 32-year-old woman with Marfan syndrome is brought to the emergency department by her husband after she experienced a syncopal episode. She reports the acute onset of sharp substernal chest pain with radiation to her back. On arrival, her vital signs are T 37.3C, HR 130, BP 90/40, RR 27. The blood pressure is similar in bilateral arms. Physical examination reveals no jugular venous distention and heart sounds are auscultated clearly without murmurs, rubs, or gallops. A CT scan is obtained and shown on flip side. Which of the following is the most appropriate next step in the management of this patients condition? A: Fluid resuscitation B: Labetalol C: Nitroprusside D: Norepinephrine

A: Fluid resuscitation Aortic dissection is an uncommon but life-threatening phenomenon that occurs when damage of the intima allows the entry of blood between the intima and media, creating a false lumen. The most important risk factor for aortic dissection is hypertension. CT angiogram is the gold standard for diagnosis of dissection. Chest x-ray is neither sensitive nor specific for aortic dissection, but findings may include a widened mediastinum, hemothorax, or calcium sign. Aortic dissection typically presents with hypertension. Hypotension, when present, is a poor prognostic indicator as it likely indicates aortic rupture or cardiac tamponade. Severe aortic insufficiency may also cause hypotension due to cardiogenic shock. Pseudohypotension, which occurs when measuring blood pressure in an extremity whose vascular supply is compromised by the dissection, should be ruled out. The cause of the hypotension should be determined and first-line treatment of hypotension in the setting of aortic dissection with aortic rupture or tamponade is fluid resuscitation. This can be started with crystalloid, however the overall use of crystalloid should be limited and transitioned to blood products. A patient should be type and crossed for blood products and these should be available and utilized early.

What is the earliest change seen on electrocardiogram in an acute ST elevation myocardial infarction? A: Hyperacute T waves B: J point elevation C: PR depression D: ST elevation

A: Hyperacute T waves

A 75-year-old male is brought by his son for mental status changes. He was recently started on oxycodone and duloxetine (Cymbalta) for diabetic neuropathy. Past medical history (PMH) includes chronic kidney disease (CKD) with eGFR = 28 mL/min/1.73 m2, peripheral vascular disease, gout, congestive heart failure, and coronary artery disease. He has been unable to eat due to nausea but has been able to take fluids. What metabolic abnormality would you expect to see on his labs? A: Hyponatremia B: Hypokalemia C: Metabolic Acidosis D: Hyperca;cemia

A: Hyponatremia All SSRIs and SNRIs, as classes, can cause hyponatremia. The mechanism of action is believed to be syndrome of inappropriate antidiuretic hormone (SIADH). The hyponatremia can be profound with an incidence of 9% of all SSRIs prescribed with a higher incidence of hyponatremia in the elderly and those with compromised kidney function.

A 77-year-old man presents with syncope. He states he was walking to the bus when he felt chest pain, had shortness of breath, and passed out. The patient has a history of hypertension. Examination reveals dry mucous membranes and a systolic murmur that radiates to the carotids bilaterally. The patient continues to report chest pain. Vitals are unremarkable, and the ECG reveals left ventricular hypertrophy. What management is indicated? A: IV fluids and Cards consult B: Morphine and admit to telemetry C: Sublingual nitro and activation of cardiac cath lab D: Sublingual nitro and admit to telemetry

A: IV fluids and Cards consult The patient presents with syncope and a systolic murmur radiating to the neck, which suggests the presence of critical aortic stenosis. Management should focus on restoring preload and cardiology consultation.

A 17 yo girl is brought to the ED by with nausea, vomiting, and severe abdominal pain for 4 hrs. Vitals are BP 104/72, HR 116, RR 26, T of 98.6°F, SpO2 96% on RA. PE reveals the skin is dry without rashes, PERRLA, and she is A&Ox3. Lungs are clear to auscultation, and cardiac exam demonstrates tachycardia without murmurs or rubs. Abdominal exam reveals normoactive bowel sounds, and the abdomen is soft, mildly tender, and without masses or hernias. Laboratory results reveal the following: Sodium: 140 mEq/L Chloride: 100 mEq/L Bicarbonate: 12 mEq/L Glucose: 650 mg/dL pH: 7.29 PaCO2: 30 mm Hg Ketones: 3+ Urine pregnancy: Negative Urine drug test: Negative What primary acid-base disorder is most likely? A: Metabolic acidosis with elevated anion gap B: Metabolic acidosis with normal anion gap C: Metabolic alkalosis D: Respiratory acidosis with normal anion gap E: Respiratory acidosis with elevated anion gap

A: Metabolic acidosis with elevated anion gap anion gap is 140 - (100 + 12) = 28

A 29-year-old woman presents to the emergency department with a complaint of bloody diarrhea and abdominal cramping. Recently, she ate a rare hamburger at a birthday party for her 4-year-old son. He ate hot dogs instead, and has not been ill. A stool specimen is positive for Escherichia coli O:157. Which one of the following should you do next? A: Monitor BUN/Cr levels B: Provide levofloxacin ppx to her close contacts C: Renal biopsy D: Renal US

A: Monitor BUN/Cr levels Escherichia coli O:157 is an increasingly common cause of serious gastrointestinal illness. Hemolytic uremic syndrome is caused primarily by Shiga toxin-producing Escherichia coli O157:H7. The most common cause of acute renal failure in children, hemolytic uremic syndrome also can occur in adults. Therefore, this patient is at risk of renal failure and her renal function should be monitored. Renal function should be monitored by trending her BUN/creatinine levels. Characteristic features of the syndrome are microangiopathic anemia, thrombotic thrombocytopenia, and renal failure. Although the presentation of this syndrome is diverse, the classic prodromal illness is bloody diarrhea following ingestion of hamburger meat contaminated with E. coli O157:H7, the most common mode of infection in the United States. Children with hemolytic uremic syndrome generally present with gastro-enteritis complaints such as abdominal pain or tenderness, nausea or vomiting, fever and anemia. Typical hemolytic uremic syndrome is a self-limiting disease with spontaneous recovery, although close monitoring and treatment of symptoms are essential. Because hemolytic uremic syndrome has a wide spectrum of presentations, supportive therapy is crucial for a good outcome.

Which of the following laboratory values is most likely to be elevated in a patient with hypertonic hyponatremia? A: Serum Glucose B: Serum Potassium C: Serum Sodium D: Serum Triglycerides

A: Serum Glucose

What is an intrinsic kidney condition caused by damage to the renal tubules due to ischemia or nephrotoxic substances, typically does not present with fever, rash, or arthralgias and shows show muddy brown granular casts, epithelial cell casts, and free renal tubular epithelial cells on UA.

Acute Tubular Necrosis (ATN)

Which of the following clinical scenarios can be defined as a hypertensive emergency? A: A 25-year-old pregnant woman in her second trimester with a blood pressure of 155/100 mm Hg with a normal urinalysis B: A 55-year-old man with a blood pressure of 185/90 mm Hg whose creatinine has increased from 1.0 to 2.5 mg/dL within 36 hours C: A 59-year-old asymptomatic man requesting a medication refill and found to have a blood pressure of 210/110 mm Hg and an ECG consistent with left ventricular hypertrophy (LVH) D: A 63-year-old woman with a history of poorly controlled hypertension who presents with a finger laceration and is noted to have a blood pressure of 200/105 mm Hg

B: A 55-year-old man with a blood pressure of 185/90 mm Hg whose creatinine has increased from 1.0 to 2.5 mg/dL within 36 hours

A 45-year man with HIV presents with fever, headache, vomiting, and altered mental state. Physical examination shows neck stiffness, focal neurological deficit. Opening pressure during spinal tap is elevated. Cerebrospinal fluid (CSF) analysis shows reduced glucose, pleocytosis, and elevated protein. Indian ink preparation shows cryptococci. CSF cryptococcal antigen test is positive, and CSF culture shows cryptococci. Which of the following is the drug of choice in the initial treatment of this patient? A: Itraconazole B: Amphotericin B + Flucytosine C: Bactrim D: Fluconazole

B: Amphotericin B + Flucytosine

A 65-year-old man presents to your office with sudden severe chest pain, asymmetric blood pressures in his arms, and a new evolving aortic regurgitation murmur. The patient describes the chest pain as 10 out of 10 in severity. You decide to call 911 as you suspect what acute emergency? A: Acute Pericarditis B: Aortic Dissection C: Myocardial Infarction D: Pulmonary Embolism

B: Aortic Dissection

A 32-year-old man with a history of inherited hemolytic anemia along with a methicillin-resistant Staphylococcus aureus (MRSA) presents to the office due to an abscess. Physical exam reveals a 4 cm fluctuating abscess in the left axilla with extensive surrounding cellulitis. Foul smelling purulent material is expressed during incision and drainage. Patient reports a history of a hemolytic episode last year after being given an antibiotic by another provider for a similar abscess. What antibiotic was likely given for the patient's previous abscess? A: Cephalexin B: Doxycycline C: Nitrofurantoin B: Bactrim

B: Bactrim Trimethoprim-sulfamethoxazole and other medications in the sulfonamide drug class are known to be oxidative drugs. Oxidative drugs can lead to hemolytic episodes in patients with G6PD (glucose-6-phosphate dehydrogenase) deficiency due to the resultant decrease in glutathione allowing oxidative injury of the red blood cells. This injury to the red blood cells makes the cells susceptible to hemolysis due to their consequential rigid shape. G6PD deficiency is an X-linked recessive inheritance disorder. Because of this inheritance pattern the disease is less commonly seen in females. Most individuals are asymptomatic until they are exposed to a triggering substance, resulting in the development of jaundice, pallor, and dark colored urine. A small group of patients with severe G6PD deficiency can have chronic hemolysis. Hemolytic episodes are most commonly caused by medications (aspirin, dapsone, methylene blue, nitrofurantoin, phenazopyridine, primaquine, quinidine, sulfonamides, and uricase), infection, Henna dyes, fava beans, and bitter melon. Screening tests include the fluorescent spot test and the methemoglobin reduction test. Individuals with a positive screening test will go on to have a confirmatory test performed. Treatment includes avoiding offending agents. For hemolytic episodes, aggressive fluid hydration and potential transfusion for severe anemia are indicated.

Aortic stenosis can lead to which of the following general patterns of left ventricular remodeling? A: Asymmetric LVH B: Concentric LVH C: Eccentric LVH D: Mixed concentric/eccentric LVH

B: Concentric LVH

Which laboratory study is required to confirm the diagnosis of thalassemia? A: Bone Marrow Biopsy B: Hemoglobin Electrophoresis C: Iron studies D: Peripheral Smear

B: Hemoglobin Electrophoresis Hemoglobin electrophoresis is the confirmatory test used in the diagnosis of thalassemia. Thalassemia is a hereditary disease that results in a microcytic anemia based on a defect in the alpha or beta-globin chains. The defect can either be a gene deletion or a point mutation. Clinical presentation can vary from mild symptoms to severe disease depending on the abnormality. Alpha thalassemia can manifest as mild disease in carriers to moderate disease in individuals with one alpha-globin chain. Beta thalassemia (Cooley anemia) manifests between the ages of four to six months as fetal hemoglobin drops and adult hemoglobin increases. These patients can have severe hemolytic anemia. Laboratory studies include complete blood count, iron studies, peripheral smear, and hemoglobin electrophoresis. Serum iron levels can be normal or increased in patients with thalassemia. The mean corpuscular volume is usually lower in individuals with thalassemia in comparison to individuals with iron deficiency anemia. Hemoglobin electrophoresis is used to evaluate for normal hemoglobin, hemoglobin H, hemoglobin A2, and hemoglobin F. Iron chelation and stem cell transplants are the treatment of choice. Patients with beta thalassemia need transfusions to maintain a normal hemoglobin level. It is important to avoid iron in individuals with thalassemia as it can lead to iron overload. Genetic counseling should be discussed in individuals who are planning to have children.

Which of the following best describes the etiology of the jaundice seen in patients with thyroid storm? A: Direct constricting effects of thyroid hormone on the biliary duct B: Hepatic tissue hypoxia due to increased peripheral consumption of oxygen C: Hypotension leading to decreased gut motility D: Impaired reabsorption of thyroid hormone in the enterohepatic circulation

B: Hepatic tissue hypoxia due to increased peripheral consumption of oxygen

A 31-year-old woman, newly diagnosed with rheumatoid arthritis, presents to the clinic to start treatment for her disease. Other than her joint pain and fatigue, she is otherwise healthy and denies any other complaints. She has two children and, although not currently trying to conceive, she is considering having one more child in the near future. What is the most likely medication you would start her on? A: Etanercept B: Hydroxychloroquine C: Leflunomide D: Methotrexate

B: Hydroxychloroquine A and C are DMARDS Methotrexate is teratogenic

A 59-year-old woman presents to the clinic reporting numbness in her hands and around her mouth, as well as muscle cramps, fatigue, and intermittent hoarseness. Her medical history includes hypertension, hyperlipidemia, diabetes, and a thyroid malignancy which was recently treated by surgical excision. On physical examination, she is noted to have an ataxic gait, hyperresponsive deep tendon reflexes, and appears to be anxious. Additionally, carpal spasms are noted when her blood pressure is taken. Her vital signs are within normal limits for her age. Results of a complete blood count and complete metabolic profile are notable for a low total calcium. Which of the following is the most likely diagnosis? A: Hyperparathyroidism B: Hypoparathyroidism C: Hypophosphatemia D: Hypothyroidism

B: Hypoparathyroidism

An 80-year-old woman with a history of end-stage kidney disease, type 2 diabetes mellitus, and hypertension presents to the emergency department for evaluation of altered mental status. Her medications include insulin lispro, insulin glargine, and lisinopril. Her vital signs are HR 60 bpm, RR 16/min, BP 117/70 mm Hg, T 98.3°F, SpO2 98%, and BMI 22 kg/m2. Her laboratory results show an estimated glomerular filtration rate of 16 mg/mmol, blood urea nitrogen of 24 mg/dL, creatinine of 1.6 mg/dL, serum calcium of 8.4 mg/dL, magnesium of 4.5 mg/dL, and serum phosphorus of 5.0 mEq/L. Her complete blood count shows a normal white blood cell count. Which of the following clinical findings do you expect to see on her physical exam? A: Hyperreflexia B: Hyporeflexia C: Nystagmus D: Tachycardia E: Tremor

B: Hyporeflexia Hyporeflexia is a clinical manifestation of hypermagnesemia. The most common cause of hypermagnesemia is chronic kidney disease due to the poor excretion of magnesium. Hyperreflexia (A), nystagmus (C), tachycardia (D), and tremor (E) are physical exam findings present in a patient with hypomagnesemia.

A 26-year-old man presents with an acute severe asthma exacerbation. You decide to perform rapid sequence endotracheal intubation due to impending respiratory failure. The patient has no known medication allergies. Which of the following agents is most appropriate for induction in this case? A: Etomidate B: Ketamine C: Midazolam D: Propofol

B: Ketamine Etomidate (A) is a hemodynamically neutral, sedative hypnotic frequently used for induction. It is not shown to provide bronchodilatory effects and does not provide analgesia, thus requiring an agent such as fentanyl for premedication. Propofol (D) is a non-barbiturate, sedative hypnotic that has similar, but less profound bronchodilatory effects to ketamine. Due to its tendency to cause hypotension during induction, it should be avoided in patients who are hypotensive. In a hemodynamically stable patient, propofol would be an appropriate second choice if ketamine was contraindicated or unavailable. Midazolam (C) is a benzodiazepine that is generally used as an adjunctive agent during or before induction. Due to its mild systemic vasodilatory properties, it is not ideal in the setting of acute severe asthma.

In the treatment of Alzheimer disease, which of the following pharmacologic treatment options is found to be neuroprotective? A: Donepezil B: Memantine C: Selegiline D: Vitamin E

B: Memantine Memantine is classified as an N-methyl-D-aspartate (NMDA) receptor antagonist. Studies have found excessive NMDA stimulation can cause ischemia in the cortex and hippocampus. By inhibiting NMDA, memantine works to prevent this ischemia and is found to be neuroprotective in dementia treatment. Memantine is found to be most beneficial when used in conjunction with cholinesterase inhibitors to treat moderate-to-severe Alzheimer disease. The most common side effects of memantine include dizziness, confusion, and hallucinations. Donepezil (A) is a cholinesterase inhibitor commonly used in the treatment of Alzheimer disease. Cholinesterase inhibitors, including rivastigmine and galantamine, work to improve cholinergic function by inhibiting the cholinesterase enzyme. Cholinesterase inhibitors are not neuroprotective. Selegiline (C) is a monoamine oxidase inhibitor that has been studied in the treatment of Alzheimer disease but has limited benefit in the setting of many side effects. Vitamin E (D) has been found to be beneficial in delaying the progression of functional impairments in Alzheimer disease but has no effect on cognitive performance nor neuroprotection.

A 26-year-old pregnant woman presents to the office to discuss her concerns regarding genetic conditions that may affect her child. She states that her father was diagnosed with Huntington disease twelve years ago. Patient reports the only other individual in her family known to have Huntington disease was her paternal grandmother. The patient has not personally been tested. Which of the following values indicates the likelihood that the patient received the abnormal gene from her father if it was passed down in an autosomal dominant disorder? A: 100% B: 25% C: 50% D: The patient cannot receive the abnormal gene from her father

C: 50% autosomal dominent is not related to the sex chromosome... 50% of children from the parent will inherit the gene

A 28-year-old male presents to a urologist upon referral from a fertility medicine specialist who evaluated the patient and his wife. The patient was told that he had a low sperm count with 'poor quality' sperm. Examination reveals a scrotum that, on the right side only, is enlarged and feels like a 'bag of worms' on palpation. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. Which of the following is the best next step in the management or evaluation of this patient's presentation? A: Observation with no further testing or management B: MRI Pelvis C: CT Abdomen D: Embolization E: Surgical Repair

C: CT Abdomen This patient's presentation is consistent with a varicocele. Right-sided varicocele, bilateral varicocele, and failure of a varicocele to disappear upon lying supine are signs suggestive of inferior vena cava (IVC) obstruction and warrant further investigation with a CT scan of the abdomen.

A patient presents two weeks following a myocardial infarction. He reports fever, malaise, and chest pain that improves with leaning forward. Vital signs are BP 125/70, HR 105, RR 14, and pulse oxygenation 98% on room air. Lab results reveal a leukocytosis and negative troponin. ECG shows sinus tachycardia. Which of the following is the most likely diagnosis? A: Acute MI B: Bacterial Pneumonia C: Dressler Syndrome D: Spontaneous Pneumothorax

C: Dressler Syndrome Dressler syndrome or post myocardial infarction pericarditis is due to an inflammatory reaction to transmural myocardial necrosis. It usually presents as a recurrence of pain with pleural-pericardial features. On physical exam, a friction rub may be heard. The troponin may be residually elevated from the initial myocardial infarction. It can occur from 2-10 weeks post-myocardial infarction. Treatment is with NSAIDs and aspirin. Colchicine and steroids are second-line therapies.

Which of the following is a mainstay for the treatment of Kawasaki disease during the acute febrile phase? A: Aspirin 3-5 mg/kg/day B: Dexamethasone 0.6 mg/kg C: IV Immunoglobulin 2 g/kg D: Warfarin 0.2 mg/kg/day

C: IV Immunoglobulin 2 g/kg Kawasaki disease is an acute illness with fever, rash, conjunctivitis, swollen lymph nodes, and widespread inflammation of muscular arteries. Intravenous immunoglobulin (IVIG) and high-dose aspirin form the two components of the treatment of Kawasaki disease during the acute febrile phase of the disease. IVIG involves an infusion of 2 g/kg over 10-12 hours. High-dose aspirin (80-100 mg/kg/day divided into 6-hour dosing regimens) is continued until the child is afebrile for 48-72 hours or longer. Aspirin (A) (3-5 mg/kg/day) is initiated after the patient becomes afebrile and continued until the patient shows no coronary changes by 6-8 weeks.

An 80-year-old woman with a 36-pack-year history of smoking tobacco presents with a chief complaint of increasing dyspnea on exertion over the past six months. Physical exam reveals clubbed digits and bilateral lower lung crackles. Computed tomography shows honeycombing of the lung parenchyma. What is the most likely diagnosis? A: Bronchiectasis B: COPD C: Idiopathic Pulmonary Fibrosis D: Sarcoidosis

C: Idiopathic Pulmonary Fibrosis Bronchiectasis (A) is a widening of the airways and destruction of the bronchial walls that results from recurrent infection. It often presents with unusually large volumes of foul-smelling or blood-streaked sputum with "tram tracks" present on chest X-ray. Chronic obstructive pulmonary disease (COPD) (B) often presents with increasing dyspnea on exertion in the setting of prolonged tobacco use, but it does not have the classic honeycomb appearance on CT. Sarcoidosis (D) is a disease that causes non-caseating granulomas throughout the body, resulting in a variety of symptoms. Lung imaging often shows bilateral hilar adenopathy, unlike the honeycombing seen in idiopathic pulmonary fibrosis.

A 19-year-old man presents with vomiting, rapid breathing, and confusion after a week of not using his prescribed medications. He takes topiramate for epilepsy and loratadine for seasonal allergies. His vital signs include BP of 132/90 mm Hg, HR of 102 bpm, RR of 21/min, and T of 98.5F. He is disoriented and lethargic, and his skin is pale, cool, and moist. You order serum electrolytes, serum creatinine and urea nitrogen, arterial blood gases, lactate levels, and a toxicology screen. You calculate an anion gap to be > 18 mEq/L. Which of the following tests is most likely to be useful in evaluating the etiology of the most likely disorder? A: Amylase B: Aldosterone C: Ketones D: Leukocytes E: Urinary pH

C: Ketones The initial workup of metabolic acidosis is determining if there is an increased serum anion gap. Anion gap (AG) is the difference between the sodium, chloride, and bicarbonate concentrations (Na − [Cl + HCO3]). A normal AG is 3-11 mEq/L, whereas an increased anion gap is > 11-20 mEq/L. If an increased anion gap is found, check for ketones, lactate, blood urea nitrogen, creatinine levels, and a toxicology screen. A common mnemonic for anion gap metabolic acidosis etiologies is MUDPILES

A 69-year-old man presents to the emergency department reporting nausea and vomiting for three days. His past medical history is significant for hypertension, diabetes, hypothyroidism and hyperlipidemia. His medications include lisinopril, levothyroxine, glipizide and atorvastatin. Lab work reveals a creatinine of 3.2. He previously had normal kidney function. Which of the following medications should be discontinued? A: Atorvastatin B: Glipizide C: Lisinopril D: Levothyroxine

C: Lisinopril Lisinopril should be discontinued in the setting of acute kidney injury. This patient likely has pre-renal acute kidney injury secondary to dehydration from nausea and vomiting. A common cause of prerenal disease is true volume depletion, which can be caused by dehydration, hemorrhage, diuretics, vomiting, diarrhea or other types of fluid loss. In all cases the glomerular filtration rate is diminished because of decreased renal blood flow. The appropriate treatment is to increase renal perfusion with volume repletion. Intrarenal perfusion pressure is already reduced and maintenance of glomerular filtration rate is maintained in part by an angiotensin induced increase in resistance at the efferent arteriole. Blocking this response with an angiotensin converting enzyme inhibitor will sequentially relax the efferent arteriole, lower intraglomerular pressure, and reduce the glomerular filtration rate. Patients with acute volume loss due to vomiting or diarrhea may be particularly susceptible and may be associated with deterioration of renal function and increases in serum creatinine

A 17-year-old girl with a history of severe menorrhagia was admitted for a blood transfusion after fainting at school. Her history is positive for fatigue, exertional dyspnea, and increased cravings for ice over the past several weeks. Laboratory findings show hemoglobin 6 g/dL, hematocrit 22%, mean corpuscular volume 72 fL, total serum iron 23 mcg/dL, and total iron binding capacity 92 micromol/L. The patient was found to have conjunctival pallor and koilonychia on physical examination. What additional physical exam finding would you expect? A: Facial Plethora B: Jaundice C: Loss of tongue papillae D: Petechiae

C: Loss of tongue papillae IDA -- chelitis, atrophic glottitis, koilonychia (spoon nails)

A 21-year-old woman presents to the clinic with several large, anterior and posterior cervical lymph nodes. She reports weight loss and night sweats for the past 4 months. Which of the following is the most effective next step in the diagnosis of Hodgkin lymphoma? A: CT scan of neck, chest, abdomen B: Fluorescence immunophenotyping C: Lymph node excisional biopsy D: Lymph node fine needle aspiration

C: Lymph node excisional biopsy

A patient with a history of diabetes mellitus, hypertension, coronary artery disease and hypothyroidism is being discharged after a cardiac catheterization with placement of a drug eluting stent. Which of the following medications must be temporarily held post catheterization? A: Clopidogrel B: Levothyroxine C: Metformin D: Ramipril

C: Metformin Metformin must be withheld for 48 hours after the administration of a contrast agent. Intravascular administration of iodinated contrast media to patients who are receiving metformin can result in lactic acidosis. Metformin is excreted primarily by the kidneys. Continued intake of metformin after the onset of contrast induced nephropathy can result in a toxic accumulation of the drug and subsequent lactic acidosis. To avoid this complication, metformin must be withheld after the administration of the contrast agent for 48 hours, during which the contrast induced renal failure becomes clinically apparent. If renal function is normal at 48 hours, the metformin can be restarted.

44-yo man presents to clinic after hospitalization for an acute MI 1 week ago. He is sore in his right groin from the cardiac cath and has increasing fatigue and DOE, but denies CP. His history includes HTN and HLD. He is now taking lisinopril 10 mg qd, carvedilol 6.25 mg BID, aspirin 81 mg qd, clopidogrel 75 qd, and atorvastatin 40 mg qd. Vital signs are a BP of 100/60 mm Hg, HR of 62 bpm, RR 24/minute, SpO2 of 95% RA, and a temp of 98.7°F. PE reveals small bruise in right groin, trace pedal edema, diminished breath sounds in his bilateral lung bases, and new systolic, blowing, high-pitched apical murmur that radiates to the left axilla. Which of the following is the most likely pathophysiologic cause of this patient's physical exam findings? A: Free wall rupture B: Left septal fascicular block C: Papillary muscle rupture D: Peri-infarction pericarditis E: Sinoatrial node dysfunction

C: Papillary muscle rupture Mitral regurgitation is defined as reentry of blood from the left ventricle into the left atrium during systole due to dysfunction of the mitral valve leaflets. Mitral regurgitation can be chronic, subacute, or acute. As in this vignette, mitral regurgitation can occur acutely after a myocardial infarction due to rupture of the papillary muscles. Patients may present with acute heart failure or have a more subtle presentation.

A 40-year-old female presents to her primary care physician with complaints of worsening muscle aches and diffuse weakness over the past several months. She states that she now has difficulty climbing stairs and extending her neck. Ultimately, she became more concerned when she began having trouble swallowing and experienced shortness of breath. Physical examination confirms symmetric proximal muscle weakness and is also significant for bilateral atrophy of the shoulder and hip girdle musculature. An EMG is conducted and shows fibrillations. A muscle biopsy is ordered; however, results are pending. Which of the following is the first-line treatment for this patient's condition? A: Naproxen B: IV IG C: Prednisone D: Cyclophosphamide

C: Prednisone This patient's presentation is consistent with polymyositis. The first-line treatment of inflammatory myositis is high-dose glucocorticoids. Polymyositis is a systemic, autoinflammatory connective tissue disease that is characterized by proximal muscle pain and weakness. More advanced disease is associated with shortness of breath and difficulty swallowing with involvement of the pharyngeal and/or esophageal musculature. EMG is abnormal in almost all patients with polymyositis. Muscle biopsy provides more definitive diagnosis and shows inflammation as well as muscle cell necrosis and regeneration. Management is first with corticosteroids followed by immunosuppressants and other agents (IVIG, monoclonal antibodies) as second-line agents as appropriate.

A 34-year-old man presents to the emergency department with complaints of worsening chest pain, fever, and malaise. The pain is pleuritic, worsens when he lies down and improves when he leans forward. On exam, he appears unwell, but is not in acute distress. Auscultation over the precordium reveals a scratchy, grating sound with a normal S1 and S2. Which of the following is the most likely electrocardiogram finding in this patient? A: Shortened PR interval and slurring of the QRS complex B: ST segment depression in leads V2-V4 C: ST segment diffuse elevation with reciprocal ST depression in leads aVR and V1 D: U waves and flat T waves

C: ST segment diffuse elevation with reciprocal ST depression in leads aVR and V1 This patient with pericarditis will most likely have diffuse ST segment elevation (except for aVR and V1 which will show reciprocal ST depression and PR elevation). Pericarditis is an inflammation of the pericardial sac. The pericardium is composed of a visceral layer, which forms the epicardium, and the parietal layer. These layers are separated by a space that normally contains 15-50 mL of serous fluid. During acute pericarditis, changes in the ECG reflect inflammation of the epicardium, since the parietal layer of the pericardium is electrically inert. The ECG evolves through as many as four stages during acute pericarditis.

A 47-year-old woman presents to the clinic reporting bilateral swelling of her cheeks, as well as dry mouth and eyes. She reports insidious progression of the symptoms, with no distinct date of onset. Physical exam reveals dry mucous membranes and bilateral parotid gland swelling. Lab results indicate elevated rheumatoid factor, elevated antinuclear antibody with a speckled staining pattern, and a positive anti-Ro antibody test. Which of the following is the most likely diagnosis? A: Lymphoma B: Rheumatoid Arthritis C: Sjogren Syndrome D: Systemic Lupus Erythematosus

C: Sjogren Syndrome

If you have a patient with an acute hemorrhagic GI Bleed in the setting of cirrhosis and esophageal varices what medication does the patient need to be on to prevent SBP?

Ceftriaxone

A patient with the following ABG has what type of acid-base disorder? ph 7.52, PCO2 40, Bicarb 38 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal). A: Respiratory acidosis B: Respiratory alkalosis C: Metabolic acidosis D: Metabolic alkalosis

D: Metabolic alkalosis The PH is high which means this is an alkalosis, the PCO2 is normal so it's not respiratory and the bicarb (HCO3) is high so you know it is metabolic.

What is the antibiotic of choice for pyelonephritis?

Ciprofloxacin

a 43-year-old woman with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. Radiographic findings demonstrate peripheral "pruning" of the large pulmonary arteries. Which pulmonary arterial pressure is consistent with a diagnosis of pulmonary fibrosis? A: >= 5 mmHg B: >= 10 mmHg C: >= 15 mmHg D: >= 25 mmHg

D: >= 25 mmHg Blood pressure in the lungs is usually very low < 15 mm HG. In pulmonary hypertension, the pressure increases > 25 mmHg at rest!

An 8-month-old boy fails to obtain age-appropriate milestones. His mother feels that he is too fatigued to properly feed. An echocardiogram reveals a large atrial septal defect. Which of the following physical examination abnormalities would you most expect to find in this infant? A: Bradycardia B: Cyanosis C: Prominent LV Impulse D: Widely split and fixed S2

D: Widely split and fixed S2 In the vast majority of cases, an atrial septal defect results in an intracardiac left-to-right shunt, which typically manifests as right ventricular overload and increased stroke volume. ASDs are associated with some physical examination abnormalities, depending on the degree of shunting and the compliance of the ventricles, systemic vasculature and peripheral vasculature. A hyperdynamic right ventricular impulse may be appreciated. Pulmonary artery dilation may produce an ejection click. Splitting of S1 and S2 is also common. In fact, a widely split and fixed S2 is very common in large left-to-right shunts. Large shunts can also produce a left sternal murmur, heard higher as a systolic crescendo-decrescendo murmur, and lower as a middiastolic rumble.

A 55-year-old woman with a history of HIV presents to the clinic reporting a productive cough and dyspnea for 2 weeks. Her oxygen saturation is 92%, temperature is 101.5°F, pulse is 95/minute, respirations are 17/minute, and blood pressure is 130/85 mm Hg. She has a 10-year history of rheumatoid arthritis and is currently being treated with infliximab. Chest X-ray shows diffuse, bilateral, interstitial infiltrates. The diagnosis is confirmed by examination of respiratory secretions. Which of the following is the most appropriate therapy? A: Azithromycin B: Levofloxacin C: Prednisone D: Bactrim

D: Bactrim Pneumocystis pneumonia (PCP) is a form of pneumonia caused by the yeast-like fungus Pneumocystis jirovecii. HIV-infected patients with a CD4 count < 200 are at the highest risk of PCP. Clinical manifestations include dyspnea on exertion, dry cough, and fever. Laboratory findings may reveal elevated lactate dehydrogenase (LDH). Chest X-ray features of PCP are bilateral, diffuse, interstitial infiltrates. Trimethoprim-sulfamethoxazole is the recommended first-line treatment for PCP in an HIV-infected patient of any severity. For patients with allergy to trimethoprim-sulfamethoxazole, desensitization should ideally be performed since TMP-SMX is the most effective regimen. If the patient has a history of severe reaction, alternatives should be considered. Clindamycin with primaquine is an alternative in mild, moderate, and severe disease. IV pentamidine can also be used in severe disease.

A 63-year-old man with a history of alcohol use disorder presents with a chief complaint of stabbing chest pain on inspiration for the last 48 hours. The patient also complains of cough, fever, fatigue, and joint pain for the last week. He received a liver transplant 5 weeks ago with no surgical complications. On physical examination, the patient is found to have a fever of 100.8°F and is otherwise unremarkable. Chest radiographs show interstitial infiltrates predominantly in the lower lobes. Given the time frame, which of the following best explains this patient's symptoms? A: Acute graft versus host disease B: Chronic graft versus host disease C: Parvovirus B19 infection D: Cytomegalovirus infection

D: Cytomegalovirus infection Cytomegalovirus (CMV) is the most common viral infection in solid organ transplant recipients. CMV infection usually develops during the first few months post-transplantation and is associated with clinical infectious diseases and acute and/or chronic graft injury and dysfunction. It often presents with fever, fatigue, arthralgias, pneumonia, GI ulcers, and hepatitis.

Which of the following antiarrhythmic medications is contraindicated in the setting of coronary artery or structural heart disease? A: Amiodarone B: Dofetilide C: Dronedarone D: Flecainide

D: Flecainide

A 46-year old resident of Ohio River Valley presents with a 2-week history of cough, chest pain, dyspnea, and fever. Chest radiograph shows hilar lymphadenopathy and patchy infiltrates. Which of the following would you have a high index of suspicion for? A: Coccidioidomycosis B: Tuberculosis C: Mucormycosis D: Histoplasmosis

D: Histoplasmosis

A 26-year-old man presents to the clinic four hours after receiving benzathine penicillin G for primary syphilis. He states he has sweating after resolution of a brief fever two hours after his injection. Physical examination reveals diaphoresis, a significantly more pronounced chancre, tender lymphadenopathy, and mild tachycardia. His vital signs are as follows: temperature of 100.2°F, heart rate of 108 beats per minute, blood pressure 104/60 mm Hg, and respiratory rate of 24 breaths per minute. Which of the following is the best treatment option? A: Ceftriaxone B: Diphenhydramine C: Dobutamine D: Ibuprofen

D: Ibuprofen Syphillis

A 22-year-old man presents to the emergency department reporting chest pain and a rapid heartbeat. He states he drank several energy drinks last night in preparation for his organic chemistry final today. He has no other significant medical history or medication use. He is afebrile, blood pressure is 118/78 mm Hg, and oxygen saturation is 98%. A telemetry strip is above. What is the mechanism of action of the first-line medication used to treat this patient's dysrhythmia? (ECG on flip side) A: Blocks beta receptors B: Blocks calcium channels C: Blocks sodium channels D: Inhibits atrioventricular nodal conduction E: Prolongs action potential

D: Inhibits atrioventricular nodal conduction SVT -- use adenosine

A 29-year-old woman presents to the office with fever, rash, and arthralgias that began after starting penicillin for a dental infection. Her vital signs are BP of 118/76 mm Hg, HR of 83 bpm, RR of 11/min, and T of 98.4°F. The physical exam is unremarkable. A complete blood count reveals the presence of peripheral eosinophilia. The urine contains red cells (no red cell casts) and white cell casts but no bacteria. Serum blood urea nitrogen is 20 mg/dL, and creatinine is elevated at 2 mg/dL (baseline 1 mg/dL). Which of the following is the most likely diagnosis? A: Acute Tubular Necrosis B: Prerenal Azotemia C: Glomerulonephritis D: Interstitial Nephritis E: Urinary Tract Infection

D: Interstitial Nephritis The patient has developed renal insufficiency (her serum creatinine has doubled). The active urinary sediment suggests that her acute kidney injury is the result of intrinsic renal disease (e.g., acute tubular necrosis (ATN), acute glomerulonephritis, or acute interstitial nephritis). Of these, acute interstitial nephritis is most likely given the presence of fever (seen in > 80% of patients), rash (seen in 25-50% of patients), and peripheral eosinophilia (80%). Acute interstitial nephritis results from interstitial inflammation, most commonly in response to medication (penicillin in this case), but it is also associated with infections and autoimmune disease. The most commonly implicated medications include penicillins, diuretics, anticoagulants, and NSAIDs. Treatment is mainly supportive, but it is critical to discontinue the offending agent. Steroids may be necessary if there is significant renal impairment. Renal function generally returns to baseline over weeks.

A 35-year-old woman presents to the emergency department with slurred speech and right facial drooping. She had a similar episode a few months ago and did not experience any residual effects. She also has a history of deep vein thrombosis in the left leg and a second-trimester spontaneous abortion. She has no history of hypertension or diabetes. Vital signs demonstrate a BP of 148/88 mm Hg, HR of 104 bpm, RR of 15/min, SpO2 of 98%, and T of 99.0°F. Physical examination reveals impaired facial muscle strength on the right, decreased right upper extremity strength, and hyperreflexia of the right upper and lower extremity. An ECG reveals sinus tachycardia. Which of the following should be included in the evaluation to determine the cause of this condition? A: Bone Marrow Biopsy B: D-Dimer C: Hemoglobin Electrophoresis D: Lupus Anticoagulant E: Osmotic Fragility Test

D: Lupus Anticoagulant Antiphospholipid syndrome is an acquired autoimmune disorder that causes a hypercoagulable state. Individuals with this disorder are known to have recurrent venous or arterial thrombosis at an early age, although not all patients are symptomatic. Any patients with the following presentations should be tested for antiphospholipid syndrome: history of thrombosis in the absence of known risk factors, stillbirth, recurrent pregnancy loss, history of heart murmurs or cardiac valvular vegetations, history of hematologic abnormalities, or pulmonary hypertension. The cause of this disorder is unknown, but it is associated with a variety of autoimmune and rheumatic diseases, certain infections (e.g., syphilis, hepatitis C, malaria), and drugs (e.g., procainamide, phenytoin, amoxicillin). Important lab markers include the presence of lupus anticoagulant (associated with the strongest risk for thrombosis), anticardiolipin, and anti-beta-2 glycoprotein I antibodies. Treatment is individualized based on the patient's current clinical status and history of thrombotic events. Known risk factors for hypercoagulability must be addressed, including discontinuing oral contraceptives, ceasing tobacco use, and treating hypertension and hyperlipidemia, if present. Any associated autoimmune diseases must be managed as well. Low-dose aspirin is a common therapy for primary prevention of thrombotic events. Thrombotic events are initially treated with intravenous heparin or subcutaneous enoxaparin. Life-long treatment with warfarin is standard for patients who experience recurrent thrombotic events.

A 60-year-old man with insulin-dependent diabetes mellitus, gastroparesis, hypertension, and congestive heart failure has just received a new diagnosis of pheochromocytoma. Which of the following medications should be discontinued? A: Furosemide B: Insulin Lispro C: Lisinopril D: Metoclopramide

D: Metoclopramide Pheochromocytoma is a rare neuroendocrine neoplasm which secretes catecholamines and can cause hypertension, headache, sweating, tachycardia and can lead to hypertensive crises. Most cases of pheochromocytoma are discovered incidentally on abdominal CT scan or MRI. The discovery of an adrenal mass should lead to further testing, including plasma and urinary measurements of catecholamines and fractionated metanephrines. Once pheochromocytoma is diagnosed, surgical excision is the next step in treatment. To prepare for surgical excision, medications which cause stimulation of pheochromocytoma activity must be discontinued. These medications include beta-blockers (in the absence of alpha-blocking agents), glucagon, metoclopramide, and histamine. Metoclopramide blocks the inhibitory effects of dopamine receptor activation on sympathetic nerves, which can potentially lead to catecholamine release in the setting of a pheochromocytoma. Beta-blockers are routinely administered to patients with pheochromocytoma, but only after they have been established on treatment with alpha-adrenergic blocking agents such as phenoxybenzamine. If beta-blockers are administered prior to alpha-adrenergic blockade, the result can be further elevation in blood pressure due to unopposed alpha-adrenergic action in the peripheral blood vessels. Surgical excision of a pheochromocytoma is a high-risk procedure and must be performed by a skilled surgical team. Proper preoperative medical preparation to ensure volume expansion and blood pressure control is essential.

A 40-year-old man comes to the emergency department because of fever and diarrhea for the past 2 days. He has also had severe fatigue for the past 10 days. Past medical history is significant for human immunodeficiency virus diagnosed 3 years ago. Physical examination shows cervical lymphadenopathy and a palpable liver 3cm below the right costal margin. The CD4 count is <50/mm3. Which of the following is the most likely diagnosis? A: Cytomegalovirus B: Kaposi Sarcoma C: Lymphoma D: Mycobacterium avium complex

D: Mycobacterium avium complex Mycobacterium avium complex (MAC) should be considered in HIV positive patients with CD4 counts <50 presenting with cough, fever, right upper quadrant abdominal pain, fatigue, and weight loss.

A 70 yo man presents to the ED after his spouse called EMS because he was less responsive than usual. His spouse reports that for the past 6 weeks he has had a cough, hemoptysis, and unexplained weight loss. He became very drowsy the past couple of days. Vitals include HR 90, BP 122/80, RR 24, oxygen saturation 94% on room air, and T 98.6°F. Physical examination reveals a drowsy man who is arousable to painful stimuli. He has a regular rate and rhythm and rhonchi with auscultation of the mid-lung fields. The patient's laboratory findings are below: Glucose: 135 mg/dL Sodium: 116 mEq/L Blood urea nitrogen: 30 mg/dL Creatinine: 1.0 mg/dL Serum osmolality: 254 mOsm/kg Urine osmolality: 140 mOsm/kg Which of the following conditions is this patient at risk for with rapid correction of hyponatremia? A: Cerebral edema B: CHF C: Diplopia D: Osmotic demyelination syndrome E: Ventricular arrhythmias

D: Osmotic demyelination syndrome Patients with hyponatremia who either have severe hyponatremia (serum sodium < 120 mEq/L) or symptomatic hyponatremia are usually treated in the hospital for close monitoring while the hyponatremia is corrected. The treatment of severe hyponatremia must balance correcting the hyponatremia to avoid worsening symptoms but not correcting too quickly and causing osmotic demyelination syndrome. Osmotic demyelination syndrome occurs when individuals with chronic hyponatremia (hyponatremia present for at least 48 hours) have irreversible damage to the brain from overly rapid correction of sodium. The clinical manifestations typically occur 2-6 days after the overly rapid correction and include dysarthria, dysphagia, paraparesis or quadriparesis, behavioral disturbances, movement disorders, seizures, lethargy, confusion, disorientation, obtundation, and coma. Can be prevented by not correcting sodium more than 6-8 mEq/L in any 24-hour period. Furthermore, desmopressin can sometimes be used to prevent osmotic demyelination syndrome. The recommended goal for correcting severe or symptomatic hyponatremia is to correct by 4-6 mEq/L in the first 24-hour period. This 4-6 mEq/L correction should be accomplished in the first 6 hours in patients with severe symptoms of hyponatremia, such as a coma or seizure. Hypertonic (3%) saline is often used in the treatment of hyponatremia. Fluid restriction is also recommended in patients with severe hyponatremia and one or more of the following: hypervolemic status (such as heart failure and cirrhosis), syndrome of inappropriate antidiuretic hormone secretion, advanced kidney disease, and primary polydipsia. Vasopressin antagonists may also be used in the treatment of refractory hyponatremia.

A 55-year-old man presents to the emergency department after a bicycle accident. The patient is complaining only of left hip pain for the past 9 months. His temperature is 98.9°F, blood pressure is 132/88 mm Hg, pulse is 92/min, respirations are 17/min, and oxygen saturation is 98% on room air. Examination of the left hip reveals mild crepitus, normal range of motion, adequate distal sensation, and palpable posterior tibial and dorsalis pedis pulses. X-ray demonstrates lytic lesions and thickened bone cortices. Labs demonstrate an alkaline phosphatase of 876 U/L with a normal vitamin D and parathyroid hormone level (PTH). Which of the following is the most likely underlying etiology of this patient's symptoms? A: Multiple Myeloma B: Osteoarthritis C: Rheumatoid Arthritis D: Paget's Disease of Bone

D: Paget's Disease of Bone Paget disease of the bone presents with bone pain, an elevated alkaline phosphatase, and sclerotic/lytic lesions on radiography.

A 55-year-old man presents to the emergency department 45 minutes after falling from a 10-foot ladder. He has dyspnea and chest pain. He has a medical history of controlled hypertension on lisinopril as well as coronary artery disease with a history of coronary bypass grafting on aspirin, atorvastatin, and metoprolol. On exam, he is pale, diaphoretic, and appears anxious. Breath sounds are without rales, rhonchi, or wheezing. He is afebrile. HR is 128 bpm, BP is 88/60 mm Hg, RR is 20/min, and SpO2 is 99% on room air. Heart sounds are muted, and he is noted to have dilated neck veins. Chest X-ray is shown on flip side. What additional signs or symptoms are most likely to be seen, given the most likely diagnosis? A: Kussmaul Sign B: Pericardial Knock C: Pulsus alternans D: Pulsus paradoxus E: Third heart sounds

D: Pulsus paradoxus Cardiac Tamponade

A 56-year-old woman presents to the office with complaints of double vision, drooping eyelids, and speech that becomes slurred late in the day. Patient reports symptoms have been ongoing for weeks. Physical exam reveals ptosis and speech that is "nasal" in quality. The patient underwent a positive tensilon test. Blood work was positive for acetylcholine receptor binding antibodies. Which of the following is first line in the treatment of this patient's neuromuscular disease? A: Carbidopa/levodopa B: Edrophonium C: Plasmaphoresis D: Pyridostigmine

D: Pyridostigmine Myasthenia Gravis

A patient presents to your primary care clinic for a new patient evaluation. Which of the following physical examination findings would prompt you to order a lipid panel? A: Cholesteatoma B: Corneal Ulcer C: Pitting edema D: Xanthoma

D: Xanthoma

A term 20-day-old infant presents to the ED from urgent care for an abnormal ECG obtained for fussiness. His mother had routine prenatal care and states he has not had fever, is gaining weight, eating well without sweating or cyanosis, and making normal wet and dirty diapers. At this time, his symptoms have resolved. Your exam is unremarkable and his vitals are within normal limits for age. The ECG is only remarkable for a rightward axis of +140°. Which of the following is the best next step in the management of this patient? A: CXR for heart size B: Emergent echocardiogram C: OP Holter Monitor D: Reassurance and discharge home

D: Reassurance and discharge home This infant has no signs of congenital heart defects but has a rightward axis. Infants less than 1 month normally have a degree of right ventricular hypertrophy because in utero the newborn heart pumps systemic blood from both the left and the right ventricle (through the ductus arteriosus). The right ventricle is more dominant in utero, handling just over half of the combined cardiac output. As the pulmonary vascular resistance drops and less work is required of the right ventricle the left becomes more dominant over the first weeks to months of life. A normal QRS axis in patients less than 1 month of age can be as right as +160 to 180°, and as right as +115 to 125° at 3 months of age. A superior axis of 0 to - 180° is rarely seen in a child with a normal heart and should be investigated further. An infant with no signs of congenital heart disease and a normal ECG should be given reassurance and discharged home.

A 52-year-old man states he took his blood pressure and it was elevated to 180/100 mm Hg. He states that he missed his regular dose of antihypertensive medication because he was traveling for business and returned home today. His blood pressure now is 176/102 mm Hg. The patient is otherwise asymptomatic and has a normal physical exam. What is the most appropriate action? A: Admission for BP monitoring B: Obtain an ECG C: Reduce mean arterial pressure by 25% with an intravenous antihypertensive D: Resume outpatient medication

D: Resume outpatient medication Patients do not require admission for blood pressure monitoring (A) when they are asymptomatic. Patients with hypertensive emergency will need admission to the hospital and may require an intensive care unit setting. An ECG (B) is required only if the patient has chest pain or has some other reason suggestive of a dysrhythmia or coronary ischemia. In cases of hypertensive emergency and end-organ damage, the goal is to reduce mean arterial pressure by 25% (C) in the first hour. Normalization of blood pressure should occur over the next 8 to 24 hours. Intravenous medications are preferable for this situation since they have a rapid onset and are titratable.

A 65-year-old man with a medical history of atherosclerosis, hypertension, and stable angina presents to the clinic for routine follow-up. Current medications include lisinopril, atorvastatin, aspirin, and propranolol. Vital signs are HR 76 bpm, RR 17 breaths per minute, BP 142/88 mm Hg, T 97.6°F, and SpO2 97% on room air. During cardiac auscultation, a harsh crescendo-decrescendo systolic ejection murmur is heard over the right upper sternal border with radiation to the carotids bilaterally. Which of the following maneuvers is most likely to accentuate this murmur? A: Abrupt standing B: Forceful expiration C: Hand grip D: Squatting E: Valsalva maneuver

D: Squatting Aortic Stenosis Squatting can cause increased murmur intensity due to increased left ventricular volume or decreased murmur intensity secondary to increased systemic vascular resistance. Aortic stenosis has also been associated with a fourth heart sound (S4) secondary to significant left ventricular outflow obstruction.

A 55-year-old man presents to the emergency department with palpitations, nausea, and dizziness for 30 minutes. He is afebrile, his heart rate is 140 bpm, and his blood pressure is 78/50 mm Hg. As the nurse attaches him to the cardiac monitor, you see the rhythm strip shows a wide complex tachycardia (image on flip). What is the most appropriate treatment? A: Adenosine 6 mg IV push B: Defibrillation at 360 joules C: Procainamide 18 mg/kg infused over 30 minutes D: Synchronized Cardioversion at 200 joules

D: Synchronized Cardioversion at 200 joules The monitor shows a wide complex tachycardia. Clinically, he is hypotensive and hemodynamically unstable, which necessitates the use of electrical rather than pharmacologic treatment. Synchronized cardioversion is indicated for the treatment of unstable tachydysrhythmias, including certain supraventricular dysrhythmias as well as monomorphic ventricular tachycardia. For treatment of ventricular fibrillation or pulseless ventricular tachycardia, defibrillation (not synchronized cardioversion) is indicated.

A patient presents with a grade II/VI late systolic murmur heard best in the fifth intercostal space in the midclavicular line. Which of the following cardiac processes best correlates with this finding? A: Left-to-right blood flow across a small, muscular ventricular septal defect B: Regurgitant blood flow from the left ventricle to the left atrium C: Regurgitant blood flow from the right ventricle to the right atrium D: Turbulent blood flow across redundant mitral valve tissue

D: Turbulent blood flow across redundant mitral valve tissue MVP -- is mid systolic with a click MR -- early systolic

A 68-year-old man presents to the clinic with a medical history of hepatitis B infection and hepatic cirrhosis. Which of the following is the best choice of surveillance for the development of hepatocellular carcinoma in this patient? A: CT Abdomen every 12 months B: CT Abdomen every 2 years C: US Liver every 12 months D: US Liver every 6 months

D: US Liver every 6 months

A 57-year-old woman presents to the clinic due to difficulty getting out of bed in the morning and climbing the stairs into the house. She also reports a weight loss of 20 pounds over the past 6 months. You suspect a diagnosis of polymyositis. Which of the following physical exam findings is most consistent with the diagnosis of polymyositis? A: Painful proximal muscles without weakness B: Positive Homan's sign C: Several positive tender points D: Weakness of the proximal muscles without pain

D: Weakness of the proximal muscles without pain

A 55-year-old man with a medical history of hypertension presents to the emergency department with worsening diffuse muscle cramps and weakness for the past 2 days. The weakness started bilaterally in his legs but now involves his arms. He reports that exercising is more difficult because of the weakness. The patient takes hydrochlorothiazide, which he started 2 weeks earlier for hypertension. Vital signs include HR of 103 bpm, BP of 142/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a distressed man with 3 out of 5 strength in each extremity. The patient has no ptosis, intact cranial nerves, or intact sensation with light touch. Which of the following is the most likely cause of the patient's symptoms? A: Hypermagnesemia B: Hyperuricemia C: Hypocalcemia D: Hyponatremia E: Hypokalemia

E: Hypokalemia

A 45-year-old woman with a history of polycystic kidney disease receives chronic dialysis but missed her last two scheduled sessions. Examination reveals a drowsy patient with a blood pressure of 102/64 mm Hg, a heart rate of 110 bpm, generalized muscle weakness, and hyporeflexia. Which of the following compensatory mechanisms would be expected in this patient? A: Decreased respiratory rate to decrease carbon dioxide and increase serum pH B: Decreased respiratory rate to increase carbon dioxide and decrease serum pH C: Decreased respiratory rate to increase carbon dioxide and increase serum pH D: Increased respiratory rate to decrease carbon dioxide and decrease serum pH E: Increased respiratory rate to decrease carbon dioxide and increase serum pH

E: Increased respiratory rate to decrease carbon dioxide and increase serum pH The kidneys are extremely important in the body's regulation of its narrow pH range (7.35-7.45). They are involved with the excretion and reabsorption of acids and bases. The kidneys and respiratory system work together to maintain the body's pH and have compensatory effects when an imbalance in serum pH occurs. This imbalance may be iatrogenic in nature or may occur due to a variety of causes such as infection, worsening of chronic disease, changes in breathing patterns, trauma, or ingestion of medications, poisons, or toxins. A patient who misses scheduled dialysis sessions begins to have a buildup of acid in the serum, which results in a decrease in serum pH and causes a metabolic acidosis. The physiologic response is to increase the respiratory rate to exhale more carbon dioxide (decrease carbon dioxide) in an attempt to raise and bring the serum pH closer to the normal range.

A 71-year-old woman comes to the emergency department because of severe central chest pain for 30 minutes this morning. She says the pain was cramping in nature and radiated down her left arm. She has a history of atrial fibrillation and type 2 diabetes mellitus. Her temperature is 36.8°C (98°F), pulse is 97/min, respirations are 18/min, and blood pressure is 163/91 mm Hg. An ECG is obtained and shows ST elevations in II, III, and aVF. Which of the following biochemical measures would most likely be elevated and remain elevated for a week after this acute event? A: Alanine aminotransferase B: Aspartate transaminase C: Creatinine kinase-MB D: Lactate Dehydrogenase (LDH) E: Troponin I

E: Troponin I Troponin I is an enzyme that's useful in evaluating a myocardial infarction (MI). Troponin I levels begin to rise within 2-3 hours post-MI, peak at about 2 days, and continue to stay elevated for about 7 days.

A 22 yo man is brought into the ED for evaluation of seizure. He has a hx of primary generalized epilepsy & takes valproic acid. He has been w/o his med for the past week. His vitals are BP 148/86, HR 118, RR 24, SpO2 93%, T 98.9°F. His PE reveals an impaired level of consciousness and intermittent tonic-clonic motor activity. Labs w/ POC glucose of 108 mg/dL, and ABG show a pH of 7.31, PaCO2 of 30 mm Hg, and bicarbonate of 15 mEq/L. Which of the following represents the best treatment plan for correction of his arterial blood gas findings? A: Fomepizole 15 mg/kg IV infusion over 30 minutes B: Glucagon 1 mg subcutaneous injection with repeat injection in 15 minutes if needed C: Intravenous insulin infusion at 0.1 units/kg/hour D: Sodium bicarbonate 2-5 mEq/kg IV infusion over four to eight hours E: Watchful waiting for auto-correction of the acidosis once seizure activity is controlled

E: Watchful waiting for auto-correction of the acidosis once seizure activity is controlled Fomepizole 15 mg/kg IV infusion over 30 minutes (A) is the treatment of choice for use in metabolic acidosis secondary to methanol and ethylene glycol overdose. After the initial infusion, 10 mg/kg of IV fomepizole is given every 12 hours for four doses, then 15 mg/kg is given every 12 hours until the serum concentration of fomepizole is between 8.6 and 24.6. Treatment is maintained until ethylene glycol or methanol serum levels are < 20 mg/dL. Glucagon 1 mg subcutaneous injection with repeat injection in 15 minutes if needed (B) would be appropriate for a patient with hypoglycemia. While a seizure can occur secondary to hypoglycemia, they most commonly occur in patients with diabetes or pancreatic tumors, such as an insulinoma. Intravenous insulin infusion at 0.1 units/kg/hour (C) is the treatment of choice for ketoacidosis. Diabetes-related ketoacidosis is treated with fluid resuscitation and insulin therapy until the ketoacidosis abates. Aggressive correction of the blood glucose < 200 mg/dL should not be attempted in the first 4 to 5 hours of treatment, as profound hypoglycemia can result. Sodium bicarbonate 2-5 mEq/kg IV infusion over 4 to 8 hours (D) is the treatment of choice in certain cases of severe acute metabolic acidosis. Adjustments in the rate of infusion are made based on the serum pH. Patients with metabolic acidosis due to status epilepticus often do not require normalization of their acidosis, as the blood pH tends to self-regulate quickly once the seizure activity has ceased. If sodium bicarbonate infusion is administered to patients with status epilepticus, the result is often rebound alkalosis.

What is something you have to be careful of when using SGLT-2i in T1DM?

Euglycemic DKA

Iron Deficiency Anemia (labs)

Ferritin < 30 High TIBC Low Iron

What is associated with dependent edema and hypertension and is characterized by the presence of red cell casts.

Glomerulonephritis

Which is correlated positively birefringent crystals and which with negatively birefringent crystals? Gout or Pseudogout

Gout -- Negative Pseudogout -- Positive

Hypocalcemia

Hypercalcemia results when the entry of calcium into the circulation exceeds the excretion of calcium into the urine or deposition in bone. This occurs when there is accelerated bone resorption, excessive gastrointestinal absorption, or decreased renal excretion of calcium. Immobilization can cause hypercalcemia due to increased bone resorption such as seen in this patient recovering from spine surgery. Patients with mild hypercalcemia (calcium < 12 mg/dL) may be asymptomatic, or they may have nonspecific symptoms such as constipation, fatigue, and depression. Serum calcium of 12 to 14 mg/dL may be well-tolerated chronically. On the other hand, an acute rise may cause marked symptoms such as polyuria, polydipsia, dehydration, anorexia, nausea, muscle weakness, and changes in sensorium. Acute hypercalcemia also shortens the myocardial action potential, which is seen in a shortened QT interval. Treatment for severe or symptomatic hypercalcemia is aimed both at lowering the serum calcium concentration and in treating the underlying cause when possible.

Nephrotic vs Nephritic

Nephrotic: protein Nephritic: blood

Common Bone Deformities Seen in Psoriatic Arthritis

Pencil-in-cup deformity, ankylosis, periostitis, and dactylitis (sausage- finger deformity due to enthesitis) more likely to affect the DIP joints

What results from decreased renal perfusion due to a decrease in intravascular volume, a fall in cardiac output, or a change in vascular resistance and is associated with a blood urea nitrogen to creatinine ratio of > 20:1.

Prerenal Azotemia

Common Bone Deformities Seen in Rheumatoid Arthritis

Rheumatoid arthritis's early signs include soft tissue swelling, osteopenia, erosions, and joint space narrowing. Later changes include subluxation causing ulnar deviation, z- thumb, boutonniere, and swan neck deformities, and ankylosis. more likely to affect the PIP and MCP joints

Common Bone Deformities Seen in Osteoarthritis

Subchondral sclerosis subchondral cysts osteophyte formation joint space narrowing are the classic quartet

What is a common side effect of administering Reglan through an IV too quickly?

Tardive Dyskinesia (TD) -- does not happen if given slowly in fluids or orally

What is it called when you have an elevated troponin after an episode of stress on the heart from something not coronary related like rapid heart rate or sepsis?

Type II NSTEMI

Ranson Criteria

Used to assess severity of pancreatitis Factors: -Age > 55 -WBCs > 16,000 -Blood glucose > 200 -LDH > 350 -AST > 250

4 Signs of Needing to Initiate Dialysis

hyperkalemia, hypovolemia, hyperuremia, acidosis

Refeeding Syndrome

metabolic alterations that may occur during nutritional repletion of starved patients