PANCE Prep

If you hear crackles in the lung fields list 3 pulmonary issues that should be in your differential.

pneumonia, fibrosis, CHF, bronchitis

Tall peaked T waves should make you think of what diagnosis?

right atrial enlargement

Nodular opacities in the upper lung fields should make you think of what diagnosis?

silicosis

List two ectopic tumors that may produce ACTH and give a patient Cushing's syndrome.

small cell lung cancer, pancreatic islet cells, thymoma

A pearl formation on CXR should make you think of what diagnosis?

squamous cell lung carcinoma

Name three medication "classes" which are indicated for reduction in LDL?

statins, ezetimibe, niacin, and nicotinic acid

What is the most common cause of postpartum hemorrhage?

uterine atony

What is the first line medical treatment for pericarditis?

Aspirin and NSAIDs (Indomethacin)

List four indications for the flu vaccine.

Child 6-59 months, pregnant female, healthcare worker, age greater than 50

List two risk factors for cervical cancer.

Multiple sexual partners, smoking

What is erythema nodosum?

Tender red nodules usually found on the shins.

A patient is bitten by a rabies infected raccoon. On what days do you give human diploid cells?

0, 3, 7, 14, 28

Which of the following statements made by a 25-year-old man with lower back pain would warrant a referral to a rheumatologist? "My pain gets worse with movement and improves with rest." "My pain gets worse with rest and improves with movement." "My pain improves as I lean forward on a shopping cart." "My pain is worse as the day goes along."

"My pain gets worse with rest and improves with movement" is a typical response from someone who has autoimmune inflammatory back pain. Ankylosing spondylitis and psoriatic arthritis, the two most common spondyloarthropathies, will typically get worse with rest and improve with movement. Pain and stiffness present when the patient wakes first thing in the morning, lasts for over 30 minutes, and then gradually improves throughout the day, is a hallmark of these diseases and should be treated by a rheumatologist. Also, prolonged sitting or inactivity during the day will typically trigger a return in the symptoms.

A 42-year-old woman presents to the clinic with a history of stage I differentiated papillary thyroid carcinoma that was treated five years ago with thyroidectomy and had an excellent clinical response. The patient requests monitoring for recurrent thyroid disease. A serum thyroid-stimulating hormone (TSH) level is ordered. Which of the following is the recommended range to maintain in this patient? < 0.1 mU/L 0.1-0.5 mU/L 0.1-2.0 mU/L 0.5-5.0 mU/L

0.1-2.0 mU/L. Thyroid malignancies can be divided broadly into five categories: primary thyroid lymphoma, medullary thyroid cancers, undifferentiated thyroid cancer, differentiated thyroid cancers, and metastases of other cancers to the thyroid. Differentiated thyroid cancers fall into two main groups: follicular and papillary, with papillary being the more common of the two. Diagnosis of thyroid cancer is made with ultrasound, fine-needle biopsy, and serum studies. Treatment of differentiated thyroid cancer can involve total or partial thyroidectomy and thyroid-stimulating hormone suppression with levothyroxine (T4) replacement, as well as radioiodine therapy in certain patients. Differentiated thyroid cancer is classified using the TNM classification system, which takes into account the patient's age, the tumor size and extension, regional lymph node involvement, and presence of metastasis. A patient under 55 years of age with stage I differentiated papillary thyroid carcinoma would have no distant metastasis and a favorable prognosis. Patients who have finished treatment for differentiated thyroid cancer should receive neck ultrasonography at six to twelve month intervals, as well as serum thyroid-stimulating hormone levels and serum thyroglobulin levels every three to six months during the first year post-treatment. Some higher-risk patients may also require full-body radioiodine scanning one year post-treatment. After the one year mark, patients who initially presented with low-risk disease and who had an excellent clinical response to treatment can be managed by maintaining a serum thyroid-stimulating hormone (TSH) level of 0.1-2.0 mU/L.

A 10-year-old child presents for a well child check. He is currently living in a shelter with his family. A tuberculin skin test is placed subcutaneously. Which of the following meets the minimum criteria for a positive test in 48 hours? 10 mm diameter of erythema 10 mm diameter of induration 15 mm diameter of induration 5 mm diameter of induration

10 mm diameter of induration The above child has recently been living in a shelter environment. Exposure to a homeless population is a risk factor for exposure to tuberculosis. Other risk factors for exposure include birth in high-prevalence regions of the world or travel to high-prevalence regions of the world. Increased risk of tuberculosis exposure also occurs through exposure to adults with HIV infection, users of illicit drugs, residents of nursing homes, incarcerated persons, or institutionalized persons. Children who are at increased exposure risk should undergo tuberculin skin testing with follow up injection-site inspection at 48-72 hours. A positive test in a child with known tuberculosis risk factors is 10 mm diameter of induration or greater. Notably, only the diameter of induration can be used for measurement of the skin reaction; erythema alone cannot be included in measurement.

Which of the following patients with Salmonella enteritis should receive antibiotics? 13-month-old with diarrhea and no signs of volume depletion 13-year-old boy with sickle cell disease 19-year-old man living in a college dorm 8-year-old boy with no medical problems

13-year-old boy with sickle cell anemia. Empirical antibiotic therapy for Salmonella enteritis is not recommended for otherwise healthy patients without severe disease. However, it is recommended in certain groups including patients with sickle cell disease. Salmonella is one of the most common documented bacterial enteritis in the US. The bacteria is acquired from ingestion of contaminated food, typically beef and poultry. The disease presents with fever, loose, watery stool that may have blood or mucous in them, and colicky abdominal pain. Empirical antibiotic therapy is typically not required in healthy patients. Antibiotics do not shorten the duration of the disease and may increase the length of time that a patient is a carrier of the bacteria. Antibiotics are recommended (although not proven to be effective) based on severity of disease, age, immune system competency, and other comorbidities. Additionally, health care workers or other people who may spread the disease should be treated to eradicate the carrier state. Treatment options include ciprofloxacin, norfloxacin, and azithromycin.

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

16-24 hours. Creatine kinase-MB (CK-MB) was the most commonly used serologic test for the diagnosis of myocardial infarction before troponin assays were widely available. CK-MB is predominantly found in the myocardium but also can be found in the skeletal muscle. It begins to rise 3 to 12 hours after the onset of ischemia and reaches a peak after an acute myocardial infarction in 16 to 24 hours. In patients with ischemic symptoms and without skeletal muscle damage, CK-MB elevations are relatively specific for myocardial infarction. CK-MB elevations return to baseline after 48 to 72 hours whereas troponin elevations can persist for as long as 10 to 14 days. This means CK-MB can be used to detect early reinfarction if levels rise again after falling.

What are the three major criteria for endocarditis?

2 positive blood cultures, a positive echocardiogram, a new murmur (valvular regurgitation)

Which of the following should be administered to a symptomatic 2-week-old infant with glucose of 25 mg/dL? 2-5 mL/kg of 10% dextrose 2-5 mL/kg of 25% dextrose 2-5 mL/kg of 50% dextrose Subcutaneous glucagon

2-5 mL/kg of 10% dextrose Hypoglycemia is the most common metabolic problem in neonates. A plasma glucose level < 50 mg/dL in the first 48 hours of life and < 60 mg/dL thereafter constitutes hypoglycemia in the newborn. Neonates at greatest risk for hypoglycemia include large for gestational age or small for gestational age newborns, those born to insulin-dependent mothers, those born prematurely, those born with sepsis or from a mother with chorioamnionitis, and those with inborn errors of metabolism. The clinical presentation of hypoglycemia reflects decreased availability of glucose for the CNS as well as an adrenergic response caused by a decreasing or low blood sugar level. Symptoms that suggest hypoglycemia include jitteriness, tachypnea, hypotonia, poor feeding, apnea, temperature instability, seizures, and lethargy. IV therapy should be the first treatment modality used in symptomatic infants, infants unable to tolerate enteral feedings, and those in whom the disturbance in glucose homeostasis is severe or is expected to last more than a few hours. This patient should be administered 2-5 mL/kg of 10% dextrose (D10).

Which of the following should be administered to a symptomatic 2-week-old infant with glucose of 25 mg/dL? 2-5 mL/kg of 10% dextrose 2-5 mL/kg of 25% dextrose 2-5 mL/kg of 50% dextrose Subcutaneous glucagon

2-5 mL/kg of 10% dextrose. Hypoglycemia is the most common metabolic problem in neonates. A plasma glucose level < 50 mg/dL in the first 48 hours of life and < 60 mg/dL thereafter constitutes hypoglycemia in the newborn. Neonates at greatest risk for hypoglycemia include large for gestational age or small for gestational age newborns, those born to insulin-dependent mothers, those born prematurely, those born with sepsis or from a mother with chorioamnionitis, and those with inborn errors of metabolism. The clinical presentation of hypoglycemia reflects decreased availability of glucose for the CNS as well as an adrenergic response caused by a decreasing or low blood sugar level. Symptoms that suggest hypoglycemia include jitteriness, tachypnea, hypotonia, poor feeding, apnea, temperature instability, seizures, and lethargy. IV therapy should be the first treatment modality used in symptomatic infants, infants unable to tolerate enteral feedings, and those in whom the disturbance in glucose homeostasis is severe or is expected to last more than a few hours. This patient should be administered 2-5 mL/kg of 10% dextrose (D10).

When does surfactant begin to be expressed in the fetal lung? 12 weeks gestation 20 weeks gestation 28 weeks gestation 35 weeks gestation

20 weeks gestation Surfactant begins to be expressed in the fetal lung at 20 weeks gestation and gradually increases until 33-36 weeks gestation. After 36 weeks gestation, there is a large increase in surfactant production. Pulmonary surfactant deficiency is the primary cause of respiratory distress syndrome, formerly known as hyaline membrane disease. Prematurity is the leading risk factor for surfactant deficiency and subsequent respiratory distress syndrome in the newborn. Pulmonary surfactant is a mixture of phospholipids and proteins that reduces alveolar surface tension resulting in increased alveolar expansion. Without surfactant, high surface tension leads to alveolar collapse and respiratory compromise. Signs of respiratory distress include the use of accessory muscles with respiration, tachypnea, nasal flaring or grunting, and cyanosis. The diagnostic criteria noted on chest radiograph are decreased lung volume and increased reticulogranular ground glass appearance with air bronchograms present. Surfactant can be administered as treatment, and continuous positive airway pressure (CPAP) has been shown to be an effective therapy even in those patients not receiving surfactant.

What is the test to begin with if you suspect a pheochromocytoma?

24 hour urine catecholamines

According to the American Diabetes Association (ADA) glycemic control goals, which of the following scenarios would prompt a change in insulin dosing in a patient with type 1 diabetes mellitus? A 10-year-old boy whose fasting serum glucose is 130 mg/dL A 14-year-old girl whose hemoglobin-A1c is 6.8% A 4-year-old girl whose hemoglobin-A1c is 7.8% An 8-year-old boy whose hemoglobin-A1c is 5.9%

4-year-old girl whose hemoglobin-A1c is 7.8%. Both forms of diabetes are properly treated with a multidisciplinary approach. Diet modification and education are necessary (dietitian). Disease education is helpful (primary or advance practice provider). Injection procedure and glucose monitoring education is also important (primary or advanced practice provider). Exercise modification may also be needed (physical therapist). There are several different classes of medications used in the treatment of diabetes. A special case is the child with type 1 diabetes mellitus. This child will likely be on insulin therapy for life. Therefore, monitoring and regimen modification becomes a large responsibility of primary care providers. The ADA recommends hemoglobin-A1c testing for monitoring and insulin adjustment. In 2014, the ADA released a position statement on the diagnosis and management of type 1 diabetes in all age groups. The statement includes a new pediatric glycemic control target of HbA1c of less than 7.5% (58 mmol/mol)across all pediatric age groups, replacing earlier guidelines that specified different glycemic control targets by age. The adult HbA1c target of less than 7% did not change. The 4-year-old girl whose hemoglobin-A1c is 7.8% needs a change (increase) in her insulin dosing as her hemoglobin-A1c is too high and the target A1c level is < 7.5%.

A three-year-old boy weighing 15 kg requires repair of a laceration to his forearm. What is the maximum amount of 1% lidocaine without epinephrine that can be used for analgesia during the repair? 10.5 ml 3.75 ml 7.5 ml 8 ml

7.5 mL. Wound anesthesia is an important consideration prior to beginning laceration repair on children. Lidocaine, an amide anesthetic, is an excellent agent capable of providing local anesthesia during laceration repair, foreign body removal, abscess management, and line insertion. There are multiple forms and concentrations of lidocaine. The maximum weight based dose of lidocaine without epinephrine is 5 mg/kg. The maximum dose of lidocaine with epinephrine is 7 mg/kg. This higher toxic dose is due to the vasoconstriction caused by epinephrine, which leads to less systemic absorption of lidocaine. Lidocaine toxicity affects the CNS, cardiovascular, and hematologic systems. For a patient that weighs 15 kg, the maximum dose of 1% lidocaine is 75 mg (5 mg x 15 kg = 75 mg). Because the question asked for the amount, not the dose, it is necessary to know how many mg/mL are present in a given solution. A 1% solution of lidocaine has 10 mg/mL. Therefore, 75 mg (maximum dose) / 10 mg/mL = 7.5 mL. So 7.5 mL of 1% lidocaine is the maximum amount that can be used for anesthesia in this patient. If a 1% lidocaine with epinephrine solution is used, the amount of volume that can safely be administered is 10.5 mL (7 mg x 15 kg / 10 mg/mL = 10.5 mL).

A 32-year-old woman has just delivered a term infant in the hospital parking lot. The infant is crying and moving her arms and legs. She coughs occasionally. Her face and trunk are pink, but her hands and feet are cyanotic. Her heart rate is 130 beats/minute. What is her APGAR score? 10 6 8 9

9. The APGAR score for newborns measures five aspects of newborn physiology, and is assessed at one and five minutes following birth. Appearance (A) assesses skin color and scores zero for a pale or cyanotic appearance, one point for normal appearance other than cyanosis of extremities, and two points for normal appearance throughout. Pulse (P) is scored with zero for absent pulse, one point for a pulse < 100 beats/min, and two points for pulse > 100 beats/min. Grimace (G) evaluates reflexes and scores zero for no response, one point for grimacing, and two points for active response (i.e., pushing away and coughing). Activity level (A) is scored with zero for absent muscle tone, one point for arms and legs flexed, and two points for active movement of the neonate. Respirations (R) measures respiratory effort and scores zero for absent respirations, one point for slow or irregular respirations, and two points for normal respirations or crying. Neonates with an APGAR score of seven or less require active resuscitation and should have sequential APGARs assessed every five minutes until the score is seven or above. This neonate has a score of nine. She receives one point for appearance (extremity cyanosis). She receives two points for pulse (pulse is > 100). She receives two points for grimace (coughs). She receives two points for activity (moving her arms and legs actively). She receives two points for respirations (crying).

Which of the following HIV-positive patients suspected of having Pneumocystis pneumonia should receive prednisone before treatment with trimethoprim/sulfamethoxazole? A 10-year-old with a normal chest X-ray and a PaO2 of 65 mm Hg A 15-year-old with diffuse interstitial infiltrates on chest X-ray, a pulse oximetry of 92%, and PaO2 of 80 mm Hg A 20-year-old with diffuse interstitial infiltrates on chest X-ray and an A-a gradient of 25 mm Hg An 18-year-old with diffuse interstitial infiltrates on chest X-ray, a pulse oximetry of 94% on room air, PaO2 of 75 mm Hg, and an A-a gradient of 10 mm Hg

A 10-year-old with a normal chest X-ray and a PaO2 of 65 mm Hg. Corticosteroids are used as adjunct therapy in HIV-positive patients with moderate to severe Pneumocystis jiroveci pneumonia, defined by a room air arterial oxygen partial pressure (PaO2) of less than 70 mm Hg (severe disease is less than 60 mm Hg) or an alveolar-arterial oxygen gradient that exceeds 35 mm Hg (exceeding 45 mm Hg for severe disease). When administered, steroids should be given before trimethoprim/sulfamethoxazole or pentamidine because microbial degradation and clearance caused by antibiotics may trigger a severe inflammatory response. Corticosteroid therapy can blunt this inflammatory response, improve oxygenation, and reduce the incidence of respiratory failure.

You diagnose a patient with shingles involving the trigeminal nerve. Since there is involvement of the tip of the nose, you examine her thoroughly to exclude concurrent involvement of the: tympanic membrane cornea nasal septum contralateral pinna ipsilateral epitrochlear node

Cornea This is Hutchinson's sign and suggests an involvement of the cornea with herpes. Ophthalmologic referral is indicated. (Fluorescein staining would show a dendritic lesion on the cornea).

30-year-old semi-professional tennis player returns to your clinic for persistent right elbow pain that is burning in nature and sometimes radiates down his forearm to his wrist. There is no swelling to the area and the pain is increased with wrist extension. When he was initially seen a few weeks ago you prescribed conservative therapy with rest, ice, a compression band, and over-the-counter nonsteroidal anti-inflammatories as needed, but he has seen no improvement and his grip strength seems to be decreased. What is your next most likely treatment option? Apply a long-arm cast Continue conservative therapy for another month Corticosteroid injection at the site of pain Refer to orthopedics for possible surgery

A corticosteroid injection at the site of pain is your next most logical step after conservative therapy has failed in the treatment of many cases of tendinitis or bursitis management. The classic exam finding of lateral epicondylitis is tenderness to palpation over the lateral epicondyle of the elbow. Inflammation there is typically caused by repetitive movements of the extensor muscles of the forearm which insert at the lateral epicondyle. In this case, depending upon the severity of symptoms, changing medications and more rest may be warranted next, but you would not want to wait a month to see improvement. Also, the fact that this person depends upon playing tennis for part of their livelihood may speed up your treatment options. Continuing conservative therapy for another month is too long, especially for a professional player. If some improvement had been seen, continuing conservative therapy for another couple of weeks would be appropriate.

Which of the following is a risk factor for developing small bowel carcinoma? Diet high in salt-cured foods History of irritable bowel syndrome Obesity Tobacco use

A diet high in salt-cured foods has been associated with an increased risk of small bowel carcinoma along with other diets including those that are high in refined sugar, red meat, and smoked foods. Alcohol intake has also been associated with an increased risk of small bowel cancer. Other risk factors include the following: Lynch syndrome, Peutz-Jeghers syndrome, familial adenomatous polyposis, and inflammatory bowel disease. Clinical presentation often involves abdominal pain, weight loss, nausea or vomiting, gastrointestinal bleeding, or intestinal obstruction. The most common types of small bowel malignancies are carcinoid tumors, adenocarcinoma, lymphoma, and sarcoma.

A 40-year-old woman presents to her primary care provider's office with complaints of droopy eyelids and difficulty chewing. She has difficulty keeping her eyes open as the day goes on. Throughout a meal, she has progressive difficulty chewing. She holds her jaw up at the end of the meal. Which of the following physical exam findings would this woman most likely exhibit? Decreased sensation to light touch in extremities Diminished or absent deep tendon reflexes Hyperreflexive deep tendon reflexes Normal deep tendon reflexes

A patient with myasthenia gravis will most likely exhibit normal deep tendon reflexes. Myasthenia gravis is an autoimmune disorder characterized by skeletal muscle weakness and fatigability. Myasthenia gravis is the most common neuromuscular transmission disorder. The majority of patients who develop myasthenia gravis have autoantibodies that attack acetylcholine receptors. Myasthenia gravis has a bimodal age distribution with the first peak in the second to third decades and a later peak in the sixth to eighth decade. The first peak has a female predominance and the second peak has a male predominance. Neonatal myasthenia gravis can occur as a result of transplacental passage of maternal autoantibodies to neuromuscular junctions. The hallmark symptom of myasthenia gravis is fluctuating skeletal muscle weakness and fatigue. The weakness and fatigue are made worse after contractile force or activity of the muscle. More than half of patients with myasthenia gravis present with ocular symptoms of ptosis, diplopia, or both. Bulbar muscles are commonly involved, resulting in difficulty chewing, dysphagia, and voice changes. Respiratory muscle involvement may lead to respiratory insufficiency and pending respiratory failure. Certain drugs can exacerbate myasthenia gravis, some of these drugs include aminoglycosides, fluoroquinolones, beta blockers, magnesium, and neuromuscular blocking agents used during anesthesia. The diagnosis of myasthenia gravis is based on clinical history and exam, serologic tests for acetylcholine receptor autoantibodies, and with nerve conduction studies. A chest radiograph and computed tomography scan should be obtained to assess for the presence of a thymoma. Acetylcholinesterase inhibitors, such as pyridostigmine, are typically the first line treatment for symptomatic myasthenia gravis. Chronic immunosuppressive agents or corticosteroids are used in patients who are still significantly symptomatic on pyridostigmine. Plasmapheresis or intravenous immunoglobulin (IVIG) are used in patients with severe myasthenia gravis. A thymectomy is recommended for patients younger than 60 years of age.

Which of the following patients requires human rabies immune globulin? A person who was not previously vaccinated awakens to find a bat in his room, and animal was not captured A person who was previously vaccinated was bitten by a dog, and animal was not captured A person who was previously vaccinated was bitten by a fox, and animal was not captured A person who was previously vaccinated was bitten by a rat, and animal was not captured A person who was previously vaccinated was bitten by a squirrel, and animal was not captured

A person who was not previously vaccinated awakens to find a bat in his room, and animal was not captured. The question as to which patient requires human rabies immune globulin and human rabies vaccine after exposure to a potentially rabid animal is common in emergency medicine. Even though there was no clear bite or abrasion, the Advisory Committee on Immunization Practices (ACIP) recommends postexposure prophylaxis with immune globulin and vaccine for unvaccinated patients who have been in close proximity to bats, even if there is no sign of injury or damage to the skin, including waking up and finding a bat in the room. In an unvaccinated individual, this means human rabies vaccine and immune globulin given at the time of presentation.

A 52-year-old man with COPD who is a current cigarette smoker presents for preoperative consultation. He reports worsening shortness of breath and productive cough over the past month. He reports no chest pain or dependent edema. Vital signs include a resting room air pulse oximetry of 97%. Physical exam reveals expiratory wheezing bilaterally. Which of the following diagnostic studies is indicated? Arterial blood gases Chest computed tomography Chest radiograph Pulmonary function tests

A preoperative chest radiograph should be obtained in patients with COPD and increasing respiratory symptoms, decreasing exercise tolerance, or new lung auscultation findings on exam to rule out an active infection and heart failure. A preoperative CXR may also be helpful in patients with known cardiopulmonary disease and patients over 50 years old prior to high-risk procedures, such as upper abdominal, aortic, esophageal, and thoracic surgery. Preoperative CXR provides little benefit in identifying healthy patients at risk for perioperative complications and is not indicated in the majority of patients undergoing elective procedures.

A 32-year-old woman presents to the office with a concerning skin lesion on her arm. The lesion is biopsied and she is diagnosed with melanoma that is less than 1 mm in thickness. Which of the following is the next best step in caring for this patient? Application of imiquimod for 90 days Mohs microsurgical approach Wide excision with a 1 cm margin of normal tissue Wide excision with a 2 cm margin of normal tissue

A wide excision with a 1 cm wide margin of normal tissue is standard for melanoma that is less than 1 mm in thickness. The 1 cm wide margin should be measured in the short axis of the elliptical incision. The excised tissue should extend down to the deep fascia. Clinical trials have shown the recurrence rates for tumors of this depth with a 1 cm wide excision margin at less than 2 percent with an 87 percent overall survival rate with wide excision alone. Application of imiquimod has been used to treat lentigo melanoma with some success but this treatment is still experimental. Mohs microsurgery is currently being studied as a treatment option in lentigo melanoma and tumors in difficult areas to excise, however, this is also an experimental treatment option. A wide excision with a 2 cm margin of normal tissue is used for tumors greater than 1 mm in thickness.

Which of the following medications used in the management of anxiety has a delayed onset of action? A. Buspirone (BuSpar) B. Diphenhydramine (Benadryl) C. Lorazepam (Ativan) D. Butalbital (Fiorinal)

A. buspirone (BuSpar) Buspirone takes several days to weeks for it to have clinical activity. B. Diphenhydramine works as a histamine blocker and will cause sedation immediately because of its anticholinergic effects.C. Lorazepam is an anxiolytic medication that has an immediate onset of activity.D. Butalbital is a short to intermediate-acting barbiturate that has immediate activity.

Which of the following is a classic sign of acute adrenal insufficiency? Abdominal pain Bluish-black discolorations of the mucous membranes Profound bradycardia Severe headache

Abdominal pain. Acute adrenal insufficiency can result from pituitary failure or from hypofunctioning of the adrenal cortex. The result of each is a deficiency of circulating mineralocorticoids and glucocorticoids. In the acute setting, these deficiencies lead to salt wasting, hypoglycemia, hypotension and circulatory collapse. The hallmarks of adrenal crisis are profound weakness, severe abdominal pain, peripheral vascular collapse, electrolyte abnormalities, and shock. In patients with chronic adrenal insufficiency, an acute adrenal crisis can be precipitated by stressors such as infection, trauma, or surgery. Laboratory studies in patients with acute adrenal insufficiency may show hyponatremia, hypoglycemia, hyperkalemia, low serum cortisol, eosinophilia, or sepsis. An abdominal CT scan may show adrenal hemorrhage, atrophy, or infiltrative disease, depending on the cause of the acute crisis. Treatment of acute adrenal insufficiency involves stabilizing the patient with fluid resuscitation, administration of glucocorticoids, regulation of serum sodium and potassium, and occasionally requires administration of fludrocortisone (a mineralocorticoid). Addressing underlying precipitating factors, such as sepsis, is also crucial.

A six-year-old boy is in the clinic for a well-child evaluation. He has good grades and has a lot of friends in school. He plays baseball. He eats a healthy and balanced diet with meat, fruits, and vegetables. His father frequently goes hunting with his friends and has several guns at home. Which of the following is the best statement that you would give to the boy's parents regarding firearm safety? Absence of guns from the home is the most effective means of prevention of firearm injuries in children Firearm mortality among children has increased since the early 1990s Gun safety programs alone appear to reduce the likelihood that children will handle firearms Storing ammunition locked with an unloaded gun reduces the risk of unintentional firearm injury

Absence of guns from the home is the most effective means of prevention of firearm injuries in children. Firearm-related injuries are an important cause of death among children and adolescents. Approximately 35 percent of households own guns in the USA. Pediatric health professionals can provide leadership for improved gun safety through education of patients and families, advocacy for legislation that protects children from firearm injuries, or becoming informed spokespersons for firearm safety. The most effective means of prevention of firearm injuries in children is the absence of guns. Locking and unloading guns as well as storing ammunition locked in a different location substantially reduces the risk of a suicide or unintentional firearm injury among youth by up to 73 percent. Because up to 50 percent of homes have at least one firearm stored unsafely, one potential approach to reducing these injuries could focus on improving household firearm storage practices where children and youth reside or visit.

Which of the following medical conditions excludes a child from participation in sports? Current fever History of HIV infection History of persistent asthma Known seizure disorder

According to the AAP, a child with a fever should be excluded from sports participation. A fever may indicate a pathologic medical condition that can cause increased resting metabolism, heart rate, heat storage and risk of heat illness, and decreased heat tolerance and exercise capacity. Also, fever can sometimes signify myocarditis or other dangerous conditions. The child can resume sports once the fever resolves and they feel well enough to play. For most chronic health conditions, children are encouraged to participate in athletics with medical clearance. Conditions that absolutely exclude children from sports participation include carditis, fever, and severe infectious diarrhea. Other conditions that require cardiology evaluation and most often exclude individuals from sports participation include hypertrophic cardiomyopathy, acute rheumatic fever with carditis, and Ehlers-Danlos syndrome.

Which of the following best represents an appropriate lipid screening protocol for an adult man with no other cardiovascular risk factors? Lipid profile beginning at age 20 Lipid profile beginning at age 30 Lipid profile beginning at age 35 Lipid profile beginning at age 40

According to the American Heart Association and the United States Preventive Screening Task Force, adult men with no other cardiovascular risk factors should begin screening for increased lipids at age 35 with a fasting lipid profile. The lipid profile may be repeated every five years (the American Heart Association recommends every four to six years) while cardiovascular risks remain stable. Factors which statistically increase a patient's risk for adverse cardiovascular events include: age over 40 years, male sex, African American race, current tobacco smoker, total cholesterol over 200 mg/dL, high-density lipoprotein cholesterol under 40 mg/dL, systolic blood pressure over 130 mm Hg, current treatment for hypertension, and diabetes mellitus. Patients with any of these risk factors should be evaluated using a cardiovascular risk calculator to determine their need for treatment with a statin. Any patient with preexisting cardiovascular disease or a low density lipoprotein cholesterol greater than 189 mg/dL should be considered at high risk for atherosclerotic cardiovascular disease and treated with a statin unless otherwise contraindicated. HMG-CoA reductase inhibitors (statin drugs) have proven to decrease the risk of adverse cardiovascular events and to decrease mortality in patients at high risk for atherosclerotic cardiovascular disease.

Screening for osteoporosis should be performed in which one of the following groups? 55-year old man with type 2 diabetes mellitus 55-year old woman with a BMI 30 kg/m2 65-year old previously healthy woman 75-year old previously healthy man

According to the United States Preventative ServicesTask Force (USPSTF), all women 65 years or older and at-risk women aged 50-64 should undergo universal screening for osteoporosis. There is no evidence for screening men. For women aged 50-64, the presence of factors associated with low bone density would merit screening. Risk factors include low body weight, previous fracture, a family history of osteoporosis with fracture, a history of falls, physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain medical conditions. Screening allows asymptomatic patients with osteoporosis to be identified and treated. The bone measurement tests most commonly used to screen for osteoporosis are DEXA of the hip and lumbar spine, and quantitative ultrasonography of the calcaneus. Quantitative ultrasonography is less expensive and more portable than DEXA, does not expose patients to ionizing radiation, and can feasibly be implemented in primary care settings. Quantitative ultrasonography of the calcaneus predicts fractures of the femoral neck, hip, and spine as effectively as DEXA. However, current diagnostic and treatment criteria for osteoporosis rely on DEXA measurements only, and quantitative ultrasonography measurements are not interchangeable with DEXA measurements. The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D3 and 1,000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized, postmenopausal women.

Posturing should make you think of what diagnosis?

Catatonic depression

Waxy flexibility should make you think of what diagnosis?

Catatonic schizophrenia

A 62-year-old, otherwise healthy, non-smoking woman presents to the clinic with a cough productive of green sputum for seven days. There is low-grade fever and scattered rhonchi on exam, with an oxygen saturation of 97% on room air. Which of the following is the most likely diagnosis? Acute bronchitis Acute exacerbation of COPD Pneumonia Upper respiratory infection

Acute bronchitis. Acute bronchitis is an inflammation of the tracheobronchial tree following an upper respiratory infection in otherwise healthy individuals. Viruses such as rhinovirus, coronavirus type 1 and 3, respiratory syncytial virus, influenza virus type A and B or parainfluenza virus are the usual causes of acute bronchitis. Rarely, Mycoplasma pneumoniae, Bordetella pertussis, or Chlamydia pneumoniae may be the cause. Symptoms of acute bronchitis include cough (productive or nonproductive), dyspnea, fatigue, and recent history of upper respiratory infection. Signs may include low-grade fever and scattered rhonchi or wheezing. Hypoxia and lung consolidation are not a part of the clinical picture of acute bronchitis. Diagnosis is made clinically, and should not involve a chest X-ray unless there are signs of serious illness or pneumonia. Treatment is symptomatic with acetaminophen, hydration, inhaled bronchodilators, and antitussives. Antibiotics are not generally indicated in the treatment of acute bronchitis.

Which of the following diseases is most commonly associated with a previous history of a hematologic disorder, such as myelodysplastic syndrome, aplastic anemia, or polycythemia vera? Acute lymphoblastic leukemia Acute myelogenous leukemia Chronic lymphocytic leukemia Chronic myelogenous leukemia

Acute myelogenous leukemia Acute myelogenous leukemia is a malignant bone marrow disease in which blood precursor cells are arrested at an early stage of development and begin to proliferate. More than twenty percent blasts will be seen on peripheral smear of patients with acute myelogenous leukemia. It is the most common form of acute leukemia in adults with a median age of onset at 65 years. Causative factors in the development of the disease include previous chemotherapy or radiation therapy, previous hematologic disorders (such as myelodysplastic syndrome, aplastic anemia, and polycythemia vera), environmental exposures, and familial syndromes. Most cases, however, are idiopathic. Patients with acute myelogenous leukemia can present with symptoms of bone marrow failure or with symptoms of organ infiltration by leukemic cells, or both. Bone marrow failure results in anemia, thrombocytopenia, and neutropenia leading to symptoms such as fatigue, ecchymoses, bleeding, and increased rates of infection. Organ infiltration by leukemic cells can cause splenomegaly, swollen gums, or skin lesions. Diagnosis is made with a peripheral blood smear and bone marrow biopsy. Treatment involves induction chemotherapy until remission is achieved, followed by postremission chemotherapy or stem cell transplantation to avoid relapse.

A 45-year-old man, currently employed as a janitor, presents to the clinic complaining of uncontrollable outbursts of anger. He reports having physical altercations with his wife and adult son on several occasions. He loudly complains that his last two psychiatric referrals were "no help." He raises his voice and demands efficacious treatment, stating that he is entitled to be seen before anyone else due to his position of prominence in the community. Which of the following is the next best step in treating this patient? Address appropriate communication and have the patient sign a contract regarding accepted communication in the office Begin pharmacologic treatment with a mood stabilizer such as topiramate Begin pharmacologic treatment with an antidepressant such as fluoxetine Refer the patient to a psychiatrist who will use transference-focused psychotherapy

Address appropriate communication and have the patient sign a contract regarding accepted communication in the office Narcissistic personality disorder is described as a persistent feeling of grandiosity which may manifest itself in obvious or subtle ways, lack of empathy, urgent need for attention and praise, and superficial interpersonal relationships. Patients who suffer narcissistic personality disorder are difficult to treat, because they often feel others are to blame for their psychosocial impairment. Anger is a common manifestation of narcissistic personality disorder, especially when a patient does not feel his needs for attention and praise are being met. In general, patients with narcissistic personality disorder should be treated with psychotherapy, and pharmacotherapy should be avoided. However, in instances where the patient is a threat to others or is experiencing gross affective instability, pharmacotherapy with mood stabilizers is warranted. When initiating treatment for any chief complaint in a patient with narcissistic personality disorder, it is helpful to begin with a signed contract between healthcare provider and patient regarding acceptable communication and behavior in the office. Patients who suffer narcissistic personality disorder can quite frequently be disruptive, demanding, and time-consuming. Having a written contract which is signed by the patient and healthcare provider will give the patient a sense of control and importance, while also giving the healthcare provider an agreement to refer back to if the patient should become disruptive or demanding.

A 57-year-old female with a history of pancreatitis presents for the third time in three weeks complaining of mid-epigastric pain. At this visit, you perform a CT scan, which reveals a mass in the pancreas. Which of the following is the most likely diagnosis? epithelial cell carcinoma gastrinoma adenocarcinoma teratoma insulinoma

Adenocarcinoma This patient has chronic pancreatitis which predisposes this patient to cancer. The head of the pancreas is sometimes palpable.

A 72-year-old man presents complaining of a cough, chest pain, and shortness of breath for the past couple of weeks. He was not concerned enough to seek care until he started noticing bright red blood in his sputum the past couple of days. His weight is down from the last visit. Electrocardiogram is normal. As you await the results of his chest X-ray, what is the most likely diagnosis? Adenocarcinoma Large cell carcinoma Small cell carcinoma Squamous cell carcinoma

Adenocarcinoma is the most common of the non-small cell lung cancers, which make up about 80-85% of all lung cancers. Adenocarcinomas themselves make up about 40% of all lung cancers. These tumors arise from mucus glands and usually appear in the periphery of the lung on chest X-ray. In addition to cough, chest pain, and shortness of breath, patients may exhibit lymphadenopathy, hepatomegaly, and clubbing of the digits. A carcinoembryonic antigen (CEA) is usually positive.

A 39-year-old woman presents with palpitations and lightheadedness. Her rhythm strip is shown above (SVT). Which of the following treatments is indicated? Adenosine Defibrillation Procainamide Sedation with etomidate following by electrical cardioversion

Adenosine. Vagal maneuvers, such as carotid sinus massage and valsalva, are often successful in terminating SVT, especially early in the dysrhythmia course. If vagal maneuvers are ineffective, adenosine is the treatment of choice. The initial dose of adenosine is 6 mg rapid intravenous push, followed by a dose of 12 mg if the first dose is ineffective. Beta-blockers and calcium channel-blockers are alternative agents. Electrical cardioversion is used for refractory SVT or patients who are clinically unstable. -The electrocardiogram reveals a supraventricular tachycardia (SVT). Most cases of SVT result from sustained reentry occurring within the atrioventricular (AV) node, with a minority of cases of SVT resulting from a reentry loop from an ectopic atrial focus. The electrocardiographic hallmarks of SVT are a fast, regular rhythm with a narrow QRS complex. Since the depolarization does not come from the sinoatrial node, P waves do not precede each QRS complex, though P waves may be buried within or seen immediately before or after each QRS complex, known as "retrograde" P waves. Paroxysmal SVT is more common in females than males, with a peak incidence in the late teenage and young adult years. Most patients with SVT do not have underlying heart disease. Common symptoms include palpitations, lightheadedness, and dyspnea.

A 4-year-old child properly restrained in a major motor vehicle crash is almost ready for discharge from your ED. A full trauma evaluation revealed no major injuries other than a 4 cm contaminated laceration over his upper left arm. His guardian was also injured in the crash and is unable to provide information regarding the child's immunizations. As you prepare for discharge, what should you do regarding his tetanus prophylaxis? Administer DTaP vaccine Administer Tdap vaccine and tetanus immune globulin No additional vaccines are needed for tetanus prophylaxis

Administer Tdap vaccine and tetanus immune globulin. Clostridium tetani is a ubiquitous organism that can release a neurotoxin in contaminated wounds leading to generalized muscle spasms and isotonic contractions. It is a clinical diagnosis and culture yield is poor. It most commonly affects infants in developing nations due to lack of maternal immunity. Children in the United States receive the DTaP vaccine at 2, 4, 6, and 18 months. An additional dose is given at four to six years of age followed by Tdap between 11-12 years of age. Recommendations for tetanus prophylaxis depend on the severity of the wound and the number of previous doses the patient has received. Also remember that Td or Tdap is not used until the patient is more than seven years old. Our patient is a 4-year-old who has a contaminated wound and his vaccine history is unknown so you should administer DTaP vaccine and tetanus immune globulin.

A 52-year-old man with a history of diabetes mellitus and hypertension presents to the ED with palpitations and dyspnea that have been present intermittently over the past week. His vital signs include HR 150 beats/minute, blood pressure 136/87 mm Hg, RR 15 breaths/minute, and oxygen saturation of 97% on room air. His electrocardiogram is shown above (shows a rapid irregular rhythm with narrow complexes and no P waves). Which of the following is the most appropriate initial management? Administer intravenous adenosine Administer intravenous diltiazem Sedate the patient and perform synchronized cardioversion with 100 joules Transport the patient to the cardiac catheterization suite

Administer intravenous diltiazem. The patient has atrial fibrillation with rapid ventricular response. Atrial fibrillation results when multiple areas of the atrial myocardium simultaneously depolarize and contract. As a result, the atrial walls do not contract in a coordinated fashion, but rather "quiver" or "fibrillate." The electrocardiographic hallmarks of atrial fibrillation are a narrow, complex, irregularly irregular rhythm, and no discernible P waves. The rate may be slow, normal, or fast. Atrial fibrillation is usually associated with ischemic or valvular heart disease, and can also be seen in cardiomyopathies, myocarditis, and thyrotoxicosis. Patients with atrial fibrillation may be asymptomatic or may complain of palpitations, dizziness, lightheadedness, chest pain, or dyspnea. Patients in whom atrial fibrillation results in a rapid ventricular rate may develop clinical heart failure due to inadequate ventricular filling and decreased cardiac output, manifested by pitting edema and pulmonary edema. The management of atrial fibrillation includes ventricular rate control, consideration of rhythm conversion, and anticoagulation for stroke prevention. Patients who are stable can be treated with rate control with beta blockers or calcium channel blockers (e.g., diltiazem), and consideration of rhythm control, either with pharmacologic agents or via synchronized cardioversion. Patients with atrial fibrillation are at increased risk of having a mural thrombus, which could dislodge and travel to the cerebral circulation and cause a stroke. Therefore, patients who have been in atrial fibrillation for more than 48 hours should undergo a period of anticoagulation prior to rhythm conversion. Finally, patients with unstable vital signs or other signs of hypoperfusion (e.g., ischemic chest pain, hypotension, or confusion) should undergo emergent synchronized cardioversion.

A 35-year-old woman presents to the psychiatric clinic complaining of increased stress. She denies marital difficulties, emotional difficulties and compulsive behaviors, but states that people around her seem to have no regard for the "rules". Co-workers do not follow procedures, her children do not perform their chores in proper order, and other drivers on the road do not strictly obey traffic laws as she does. This "lack of order" causes her great stress. Which of the following is the next best step in treatment of this patient's condition? Administer the Working Alliance Inventory Begin treatment with exposure therapy Prescribe buspirone 10 mg twice daily Prescribe fluoxetine 20 mg once daily

Administer the Working Alliance Inventory Obsessive-compulsive personality disorder is characterized by a controlling, rigid outlook which seeks to follow rules and maintain order in the surroundings, and is considered a cluster C personality disorder. Patients with obsessive-compulsive personality disorder are often high-functioning socially and occupationally and suffer less deleterious effects than those with cluster B or cluster A personality disorders. Patients with obsessive-compulsive personality disorder are also more likely to seek treatment than are their counterparts with other personality disorders, and are more likely to be accepting of treatment guidelines, although their rigidity may make it difficult to engage in self-evaluation. Pharmacotherapy is not recommended, unless comorbid psychological disorders are present. Psychotherapy is often beneficial, and assessing the therapist-patient relationship using a tool such as the Working Alliance Inventory is helpful while initiating and during treatment. The Working Alliance Inventory contains 36 (long form) or 12 (short form) self-reported items that both the healthcare provider and the patient use to determine goals for therapy and level of therapist-patient bond.

A 22-year-old woman presents with irregular vaginal bleeding and pelvic pain. Her last menstrual period was six weeks ago and she states that her menstrual cycle is typically 26 to 28 days in length. A urine pregnancy test is positive and a pelvic examination reveals mild right adnexal tenderness. Transvaginal ultrasound shows a right adnexal mass. Serum human chorionic gonadotropin (hCG) level is 3,520 IU/L. Which of the following is the next best step in managing this patient? Administer methotrexate Expectant management Prepare for emergent salpingostomy Repeat ultrasound in 48 hours

Administration of methotrexate is the appropriate treatment for an ectopic pregnancy unless there are contraindications to the use of the drug. These contraindications include current breastfeeding, active pulmonary disease, immunodeficiency, or hypersensitivity to methotrexate. The drug is a folic acid antagonist that inhibits DNA replication. The effectiveness of administration is similar to surgical treatment without the risk of surgical complications. Indications for methotrexate therapy include a hemodynamically stable patient, hCG levels below 5,000 IU/L, no fetal cardiac activity, and the ability to comply with post-treatment follow-up. Methotrexate can be administered intravenously, intramuscularly, or orally. It can also be injected into the ectopic pregnancy directly, although this route of administration is not commonly used. Intramuscular administration is the route of administration that is most commonly used for treatment of ectopic pregnancy.

What are the four steps of treating diphtheria?

Antitoxin, penicillin, remove membrane, report the case to the CDC

The presence of which one of the following best differentiates a diagnosis of premenstrual dysphoric disorder from premenstrual syndrome? Affective symptoms Confusion and other cognitive changes Mood stability Serotonin dysfunction

Affective symptoms. Premenstrual syndrome (PMS) is not clearly defined as its high prevalence, unclear etiology, and myriad of symptoms make it difficult to classify it as a disease or a cluster of physiologic changes. Age of presentation is mainly in the late 20s to early 30s, and it recurs in up to 75% of affected women. Etiological theories include psychological disturbance, alterations in estrogen and progesterone balance and serotonin function, hypoglycemia, and hyperprolactinemia. Symptoms include headache, insomnia, fatigue, low energy, bloating, breast tenderness, abdominopelvic pain, depression, anxiety, dysphoria, mood lability, appetite changes, crying episodes, poor coordination, and poor concentration. Symptoms typically interfere with the woman's daily life. According to the American Psychiatric Association DSM-5, mood swings, anger, irritability, a sense of hopelessness or tension, and anxiety or feeling on edge associated with severe PMS symptoms is defined as premenstrual dysphoric disorder. Affective symptoms may be common in PMS but at least one affective symptom is required for the diagnosis of PMDD.

A 23-year-old man with acute lymphoblastic leukemia presents with generalized weakness and muscle cramps. The patient states he started chemotherapy 3 days ago. A basic metabolic panel shows serum potassium 6.5 mEq/L, calcium 6.3 mg/dL, and creatinine 11.1 mg/dL. What management is indicated? Aggressive fluids and admit Aggressive fluids and emergent dialysis Sodium polystyrene sulfonate and admit Urine alkalinization

Aggressive fluids and emergent dialysis. This patient presents with symptoms and signs of tumor lysis syndrome and multiple electrolyte and metabolic abnormalities requiring dialysis. Tumor lysis syndrome occurs secondary to increased cell death in a rapidly growing tumor. It frequently occurs hours to a few days after the initiation of chemotherapy or radiation therapy. Tumor lysis syndrome is commonly seen in hematologic malignancies (acute lymphoblastic leukemia, non-Hodgkin lymphomas) and in some solid tumors like small cell lung carcinoma. Patients will present with symptoms and signs that reflect their electrolyte abnormalities and can be nonspecific, depending on severity. With hyperkalemia, ECG changes are common and can be exacerbated by concomitant hypocalcemia. Hyperphosphatemia and hyperuricemia are also common. Kidney function is a critical factor in the development and treatment of metabolic abnormalities, as it is responsible for the removal and resorption of the various electrolytes involved. Initial therapy should include stopping chemotherapy or radiation and starting fluids. Further care depends on the electrolyte abnormalities present. With severe metabolic derangements (hyperkalemia, hyperuricemia, hyperphosphatemia, Cr > 10, volume overload, symptomatic hypocalcemia), hemodialysis is required.

A septic patient is noted to have respiratory alkalosis. What electrolyte disturbance is commonly associated with this patient presentation? Hypercalcemia Hypermagnesemia Hypokalemia Hyponatremia

Alkalosis can result in hypokalemia and an intracellular acidosis from the shift of potassium from the serum into the intracellular space. In acidotic states, potassium is exchanged from the intracellular space for hydrogen ions causing an increase in serum potassium. In alkalotic states, the opposite occurs as potassium leaves the extracellular space in exchange for hydrogen ions. The same occurs with ionized calcium, causing decreased levels in the serum in alkalotic states. Hypokalemia and hypocalcemia can cause paresthesias, carpopedal spasm, and tetany. Hypocalcemia, not hypercalcemia, occurs with alkalosis. Hypomagnesemia, and not hypermagnesemia typically coincides with hypokalemia. When a patient is found to have low potassium levels, a magnesium level should also be assessed. Hyponatremia may occur in a respiratory alkalosis but it is a rare finding.

Which of the following groups of people should receive the pneumococcal polysaccharide vaccine? All healthy adolescents aged 10 to 18 years All healthy adults aged 50 years and older All healthy adults aged 65 years and older Everyone

All healthy adults aged 65 years and older. The incidence of pneumococcal infection rises significantly with older age. Because of this, the Advisory Committee on Immunization Practices recommends one dose of the pneumococcal polysaccharide vaccine for all healthy adults aged 65 years and older. The pneumococcal conjugate vaccine is no longer absolutely recommended for all healthy adults aged 65 years and older due to the success of the pediatric pneumococcal vaccination program in the United States. However, the pneumococcal conjugate vaccine may still be given based on shared clinical decision-making on a case-by-case basis in this population group. If both vaccines are given to a healthy older adult, the pneumococcal conjugate vaccine should be given first, followed by the pneumococcal polysaccharide vaccine at least one year later. Pneumococcal vaccination is also recommended for adult individuals who are immunocompetent but at high risk of death from pneumonia due to chronic illness, the immunocompromised, and those with asplenia who are at increased risk of sepsis from pneumonia.

Which of the following is the most common infection associated with erythema multiforme? Borrelia burgdorferi Haemophilus influenzae type b Hepatitis C virus Herpes simplex virus

Although numerous infections have been reported in association with erythema multiforme, herpes simplex virus (HSV) is the most common and best documented. Recurrent erythema multiforme is also associated with HSV infection. Demonstration of prior exposure to HSV by serology and documentation of a cutaneous recurrence was noted in a series of patients with recurrent erythema multiforme and was less common in patients with a single episode. The pathogenesis is not completely understood, but evidence increasingly implicates a host-specific, cell-mediated immune response to an antigenic stimulus that targets keratinocytes at the dermal-epidermal junction. Erythema multiforme has variable cutaneous manifestations. It is characterized by the acute onset of a symmetric, fixed cutaneous eruption of erythematous macules, papules, vesicles, or bullae most commonly distributed on the palms, dorsal surfaces of the hands and feet, and extensor surfaces of the arms and legs with relative sparing of the face, trunk, and mucous membranes. Lesions can expand and evolve over several days to assume the classic annular "target" appearance with a dusky, necrotic center surrounded by a ring of edema and pallor and an erythematous border. Borrelia burgdorferi is associated with Lyme disease and a skin condition called erythema migrans.

An 80-year-old man presents to your clinic with complaints of malaise, myalgias, fever, cough, and abdominal pain for the past three weeks. One month ago, he vacationed in Ohio on a bird watching trip. He is febrile with mild tachycardia and pulse oximetry of 90%. A chest X-ray shows mediastinal lymphadenopathy and a focal infiltrate. Which of the following is the most appropriate therapy? Amphotericin B Azithromycin Fluconazole Zidovudine

Amphotericin B. Histoplasmosis is an endemic mycosis that is generally asymptomatic, but may result in serious illness in patients with certain risk factors. In the United States, histoplasmosis is most commonly found in the midwestern states near the Ohio and Mississippi River valleys. Infected soil is found near areas where bats and birds live, such as chicken coops and caves. Birds cannot be infected with histoplasmosis and are not able to transmit the disease, but their excretions contaminate the soil, which provides the growth medium for the fungus. The majority of individuals with acute and subacute pulmonary histoplasmosis are asymptomatic. When symptoms occur, patients generally present with complaints of malaise, myalgias, fever, chills, cough and abdominal pain 3-14 days after exposure. Serious manifestations of histoplasmosis occur in immunocompromised individuals, such as those with human immunodeficiency virus (HIV) or the elderly. Treatment for more serious forms of the disease is with the antifungal medication, amphotericin B. Mild to moderate pulmonary disease can be treated with itraconazole.

What is the most common prophylactic antibiotic used preoperatively?

Cefazolin (Ancef), Cefalexin (Keflex)

A patient's blood pressure is 172/96 mm Hg. Which of the following is the LEAST likely the etiology? pericardial effusion aortic regurgitation arteriovenous fistula thyrotoxicosis patent ductus arteriosus

Aortic regurgitation Pericardial effusion would cause diastolic pressures. AV fistula would cause increased systolic pressures with decreased diastolic pressures as well. Thyrotoxicosis would cause high systolic, but low diastolic pressures (increased HR reduces filling time, so less EDV). PDA would cause increased systolic pressures with reduced diastolic pressures.

A 32-year-old woman presents to the emergency department with vaginal bleeding. She is 10 weeks pregnant and began spotting this morning. The bleeding has become heavier throughout the day and now she has pelvic discomfort and cramping. A pelvic exam is completed and the cervix is found to be dilated with products of conception in the cervical canal. What is the most likely diagnosis? Incomplete abortion Inevitable abortion Missed abortion Threatened abortion

An incomplete abortion refers to an abortion in which products of conception can be found in the cervical canal. This is often accompanied by bleeding and cramping. The cervix will be partially dilated. Treatment options include dilation and curettage (D&C), medical uterine evacuation, or expectant management. These options largely depend on the patient's presentation and wishes. Dilation and curettage can be performed for those women who do not want to wait and for those who do not wish to go through the process of passing the products of conception. For those who wish to avoid, or cannot tolerate, a surgical procedure, medical evacuation with misoprostol or expectant management are better options. All three of these plans carry similar rates of efficacy for complete passage of products of conception. Women should be counseled about the risks of bleeding, infection, and retained products of conception. During, and for two weeks after bleeding stops, women should maintain pelvic rest.

A patient is scheduled for a unilateral adrenal tumor resection for suspected adrenocortical carcinoma. Which of the following surgical approaches would be best for this adrenalectomy? Laparoscopic transabdominal Open transabdominal Posterior retroperitoneoscopic Retroperitoneal open

An open transabdominal approach is typically used for resection of any adrenal tumor when malignancy is suspected. The open approach allows for greater visualization of the surrounding structures and resection of the surrounding lymph nodes. The open approach also allows for resection of adjacent structures should this be necessary if abnormalities are discovered during the surgery. Minimally invasive techniques, such as laparoscopic techniques, have been associated with reduced blood loss and length of stay, fewer intraoperative complications, and quicker recovery than open approaches, however, when malignancy is known or suspected, the increased visualization and access to adjacent structures makes the open approach optimal. Minimally invasive techniques are the preferred method for benign adrenal tumors. Laparoscopic transabdominal and posterior retroperitoneoscopic approaches are both minimally invasive techniques and do not allow the visualization of or access to adjacent structures. The retroperitoneal approach is not preferred because of the increased risk of subcostal neuropathy and lumbar hernias, as well as the increased amount of incisional pain from cutting through the latissimus dorsi muscle.

What is the most common location for spontaneous bleeding in children with hemophilia A? Ankle Elbow Gastrointestinal tract Knee

Ankle. Hemophilia A is an X-linked recessive disease that includes a range of clinical manifestations characterized by the activity of factor VIII. Severe hemophilia is characterized by spontaneous hemarthrosis. It differs from platelet disorders, such as von Willebrand disease, that manifest as mucosal bleeding (epistaxis, gingival bleeding) and bullous hemorrhage of the buccal mucosa. In patients with mild (> 5% factor VIII activity) and moderate hemophilia (1%-4% factor VIII activity), usually an insult causes bleeding, whereas spontaneous bleeding is more common in severe disease (< 1% factor VIII activity). Spontaneous intracranial hemorrhage can occur in all ages but is more common in neonates. Patients with hemophilia seldom bleed from small cuts or venipuncture, but they do hemorrhage out of proportion to larger injuries. Delayed bleeding is also common. Although bleeding may occur in any area of the body, the most common sites include joints, muscles, and the GI tract. However, 80% of hemorrhage occurs in the joints. In children, the most common joint is the ankle. In adults, the most common joint is the knee, followed by the elbow and ankle.

Current guidelines recommend which of the following as long-term follow up of patients with Hodgkin lymphoma who have been treated to remission? Annual mammography starting at age 40 or five to eight years after radiation therapy CT scan of chest every two years for the first ten years Full body PET scan every two years for the first ten years Serum parathyroid hormone level every year for the first five years

Annual mammography starting at age 40 or five to eight years after radiation. Hodgkin lymphoma is a malignant proliferation of cells in the lymphoreticular system and can be localized or disseminated. It has a bimodal distribution peaking around age 20 years and age 65 years, although most patients are young. Clinical signs and symptoms include lymphadenopathy (often cervical and painless), pruritus, fever, night sweats, unintentional weight loss, and frequent infections. Diagnosis is made with lymph node biopsy, where pathognomonic Reed-Sternberg cells can be visualized. Treatment depends on disease stage at diagnosis and can involve chemotherapy, radiation, surgery, and stem cell transplantation. The cure rate for Hodgkin lymphoma is between seventy and eighty percent with treatment. Health maintenance in patients who are considered to be in complete remission consists of follow up office visits every three months in the first five years after post-treatment. These visits should include a history, physical, and laboratory studies (CBC, LDH, lipid panel, ESR, and glucose). Thyroid-stimulating hormone levels should be monitored yearly during the first five years. During the subsequent five to ten years post-treatment, an annual history and physical should be performed, as well as annual laboratory testing of CBC, complete metabolic panel, TSH and fasting glucose. Lipids should be measured twice yearly. Vaccinations should be kept up-to-date and annual mammography is recommended in women over 40 or in younger women five to eight years post radiation therapy. Cardiac stress testing, echocardiography, and carotid ultrasound should be performed in patients who are ten years post-treatment.

A 24-year-old man presents to the ED with a rash on his left flank. He is an avid hiker in the upper Midwest. He was bitten by a tick two weeks ago. What would you expect to find on physical examination? Annular erythematous patch with central clearing Diffuse erythroderma over the trunk and extremities Maculopapular rash over the trunk following Langer's lines Petechiae involving the palms and soles before spreading centrally

Annular erythematous patch with central clearing. This patient is exhibiting risk factors for and signs of Lyme disease. Lyme disease is the most common vector-borne disease in the United States. It is endemic to New England, the mid-Atlantic states, and the upper Midwest. It is caused by the spirochete Borrelia burgdorferi and transmitted by the Ixodes scapularis tick, more commonly known as the deer tick. The tick must be attached for more than 48 hours for transmission to occur. There are three stages of clinical Lyme disease. Early Lyme disease is characterized by erythema migrans, an annular erythematous patch with central clearing, which classically has a "bull's eye" appearance. Hematogenous spread leads to diffuse erythema migrans, which spares the palms and soles. Acute disseminated Lyme disease occurs approximately 4 weeks after initial infection and can include meningoencephalitis, Bell palsy (which may be bilateral), or carditis which often manifests with AV block. Late Lyme disease develops greater than 1 year after initial infection and includes chronic arthritis with or without chronic subtle encephalopathy. Only 50% of patients remember a tick bite; thus, diagnosis may be difficult. Erythema migrans is diagnostic; however, not all patients present with this finding. Initial screening involves ELISA testing with Western Blot and PCR to confirm the diagnosis. If the diagnosis is suspected, empiric treatment should be administered. Treatment for early Lyme disease and mild acute disseminated Lyme disease is doxycycline. Doxycycline can also be used in children < 8 years if given for < 21 days. In pregnant women, amoxicillin should be substituted. Patients with neurologic or cardiac manifestations should be admitted and treated with IV ceftriaxone.

A 55 year-old female presents with complaints of stiffness, aching, and pain in the muscles of her neck, shoulders, lower back, hips, and thighs. There is no associated weakness associated with the stiffness and achiness. Laboratory evaluation shows an elevated C reactive protein and erythrocyte sedimentation rate. Which of the following medications is used to treat this condition immediately and will also serve to prevent a known complication from this disorder? A. Glucocorticoids B. Cyclophosphamide (Cytoxan) C. Methotrexate (Rheumatrex) D. Azathioprine (Imuran)

Answer: A. Glucocorticoids This patient has polymyalgia rheumatica and treatment with glucocorticoids can relieve discomfort and prevent the associated ischemic temporal arteritis, which threatens vision. B. Cyclophosphamide is an immunosuppressant used in the treatment of acute leukemia. C. Methotrexate is a folate inhibitor used to treat rheumatoid arthritis, not polymyalgia rheumatica. D. Azathioprine is an immunosuppressant that is used to treat rheumatic disease and inflammatory bowel disease, not polymyalgia rheumatica.

A 40-year-old woman is found to have a rash as seen above. Which laboratory test has the highest sensitivity for this medical condition? Anti-double-stranded DNA Anti-nuclear antibody Cyclic citrullinated peptide antibody Erythrocyte sedimentation rate

Anti-nuclear antibody. Systemic lupus erythematosus (SLE) is a chronic inflammatory disease affecting multiple organ systems as a result of immune system dysregulation. It is characterized by the formation of autoantibodies which can damage tissues directly or combine with corresponding antigens to form tissue-damaging immune complexes. Autoantibodies that have been identified in systemic lupus erythematosus are anti-nuclear antibodies (ANA), including anti-deoxyribonucleic acid (anti-DNA) antibodies, anti-Smith (Sm) antibodies, and antiphospholipid antibodies. Anti-nuclear antibodies test has 95% sensitivity and is the best initial screening tool. The specificity of anti-nuclear antibodies for systemic lupus erythematosus is low since it is reported in disorders other than systemic lupus erythematosus (Rheumatoid arthritis, scleroderma, polymyositis, dermatomyositis, Sjogren's syndrome, mixed connective tissue disease). Anti-double-stranded DNA and anti-Smith antibodies have high specificity and are highly diagnostic for systemic lupus erythematosus. Anti-Smith is the most specific antibody for systemic lupus erythematosus. Anti-double-stranded DNA test is fairly specific as well and it can be used to monitor the severity of the disease in patients who have been diagnosed with systemic lupus erythematosus. In particular, this test may be used to monitor lupus nephritis.

A 32-year-old P0 woman at 33 weeks gestation has confirmed rupture of membranes. The patient is not in labor, and the fetal status is reassuring with a category 1 tracing. The fetus is vertex, and the cervix appears to be closed and long. What is the best next step in the management? Antibiotics Antibiotics, betamethasone Antibiotics, betamethasone, and induction of labor Antibiotics, betamethasone, and magnesium

Antibiotics, betamethasone. Preterm prelabor rupture of membranes (PPROM) is the rupture of membranes at less than 37 weeks without labor. Nearly half of PPROM patients deliver within one week of rupture of membranes. The latency between rupture of membranes and delivery is inversely related to the gestational age at time of rupture. The management of PPROM depends on the gestational age. A single course of betamethasone should be administered to patients with evidence of rupture between 24 and 37 weeks gestation. Steroids may be considered as early as 23 weeks if delivery is predicted within the next seven days and consultation with maternal-fetal medicine is recommended. Latency antibiotics should be given to all patients with evidence of rupture of membranes prior to 34 and 0/7 weeks. Latency antibiotics consist of a combination of IV ampicillin and erythromycin, followed by oral amoxicillin and erythromycin for a full seven-day course. Delivery is recommended at 34 and 0/7 weeks or sooner if there is evidence of infection or fetal distress. Fetal complications of PPROM include respiratory distress syndrome, sepsis, intraventricular hemorrhage, and necrotizing enterocolitis. Maternal complications include increased risk of chorioamnionitis, postpartum endometritis, and placental abruption. Recent evidence has shown that a single course of steroids should be administered in the late preterm period (34 and 0/7 to 36 and 6/7) who have not previously received them.

A 32-year-old woman presents complaining of "bumps" in her vaginal area that she noticed two weeks ago. She has never had these in the past. She denies any pain. Physical exam reveals several flesh colored lesions with prominent papillae that are non-tender to palpation on the labia as shown below (exophytic, papillomatous growths). Which of the following is the next best step in management? Application of trichloroacetic acid Perform colposcopy with acetic acid application Perform shave biopsy for confirmation Referral to general surgery for excision

Application of trichloroacetic acid. This patient is suffering from condyloma acuminatum, or genital warts, caused by an infection with the human papilloma virus (HPV), commonly types 6 and 11. HPV is a sexually transmitted infection that can be prevented with vaccination. All girls and boys who are 11 or 12 years old should get the recommended series of HPV vaccine regardless of sexual history. Symptoms include flesh colored to whitish, exophytic or papillomatous growths in the genital area. In women, this can affect the vagina, cervix, vulva, oropharynx, perineum, and perianal areas. HPV can be spread via sexual contact or rarely, from mother to newborn during passage through the birth canal. Treatment includes trichloroacetic acid solution, podophyllin, cryosurgery, surgical excision, or imiquimod cream application. Colposcopy with acetic acid application is indicated for evaluation of vulvar squamous intraepithelial lesions which are associated with oncogenic HPV subtypes and commonly present with vulvar pruritus.

A 26-year-old woman presents to your office for health care maintenance. She reports chronic pelvic pain. A review of her records reveals several emergency room visits for acute pelvic pain with a negative evaluation. You are suspicious for domestic violence. She does not report abuse. Her physical examination is normal. Which of the following is the best next step? Ask about specific types of abuse Call the police Discuss concerns with the patient's partner Schedule a follow-up visit

Ask about specific types of abuse. Domestic violence, or intimate partner violence (IPV), is a severe and major public health problem that is more common in women than men. It involves actual or threatened psychological, physical, or sexual harm by a current or former partner or spouse that could be both homo- or heterosexual. Although IPV can occur in any socioeconomic state or race, identified risk factors include being unmarried, low-income, and a history of childhood abuse. Physicians should be able to suspect, screen, and identify women with IPV in order to reassure patients that abuse is not normal, assess their safety, assist with referral to local resources, and be an active patient advocate. IPV results in diminished self-esteem, depression, mental trauma, physical injuries, and can lead to death. Clinical manifestations of IPV include depression, anxiety, substance abuse, pelvic pain, and noncompliance to medical appointments. There is no definitive screening algorithm for IPV, however, suggested dialogues consist of the physician directly asking about specific types of abuse such as actual or threatened, or physical or emotional.

A 3-year-old boy from South America presents to your office with his father for a well-child exam. While listening to his lungs you notice that his back is covered with circular lesions approximately 3-4 cm in diameter with central ecchymosis and petechiae. Which of the following is the next best step? Ask about traditional medicinal practices being used Begin workup for bleeding disorders Call child protective services Obtain a urinalysis

Ask about traditional medicinal practices being used. A number of cultural practices can mimic signs of child abuse. Cupping is a technique used in Latin America, Asia, the Middle East and Eastern Europe. An open-mouthed vessel is heated and applied to the skin. Practitioners believe this will pull out the ailments and the result is lesions that appear like circular burns. Familiarity with cultural practices and medical conditions that can mimic child abuse can help to determine the correct diagnosis, start appropriate treatment and avoid unnecessary reports to child protective services. Bleeding disorders such as von Willebrand disease, factor VIII and IX deficiency or immune thrombocytopenia can present similarly to bruising caused by child abuse. Workup for bleeding disorder (B) may be appropriate after a complete history including questions about cultural practices is completed. Child protective services (C) should be called once the diagnosis of child abuse has been made and differential diagnoses have been ruled out. When in doubt, involve an interdisciplinary team to help determine the best course of action. Urinalysis (D) should be obtained when the history and physical point to abdominal trauma, dehydration or renal failure as the cause of the lesions.

A 70-year-old male is beginning treatment for peripheral vascular disease. He has a 50 pack year smoking history and is currently smoking one pack per day. His ankle-brachial index is 0.76, and his dorsalis pedis pulses are diminished bilaterally. His main complaint is a reduction in his ability to continue morning walks with his brother due to pain in his calves that resolves with rest. Which of the following is the most appropriate therapy? Aspirin, cilostazol, rosuvastatin, smoking cessation, and structured exercise Aspirin, rosuvastatin, smoking cessation, and surgical referral Clopidogrel, endovascular reperfusion, rosuvastatin, and smoking cessation Clopidogrel, structured exercise, and smoking cessation

Aspirin, cilostazol, rosuvastatin, smoking cessation, and structured exercise represent the core medical treatment regimen for peripheral vascular disease, also called peripheral artery disease. In the majority of cases, progressive atherosclerosis of the peripheral arteries leads to a reduction in perfusion to the limbs via luminal reduction. Clinical manifestations may include muscular atrophy, decreased hair growth, thick toenails, and decreased skin temperature. Ischemic ulcerations (on the toes, lateral malleolus) may be present in more advanced cases. Diagnosis is usually established with a history of limb pain (intermittent claudication or rest pain), diminished or absent pulses, and an ankle-brachial index (ABI) of 0.9 or less, or a toe-brachial index of 0.7 or less, if significant vascular calcification is present. Additional diagnostic studies may include segmental pressure and pulse volume recordings, exercise testing, and vascular imaging. Angiography is the gold standard for diagnosing and locating peripheral vascular disease. Factors such as medications, activity, smoking status, glycemic control, blood pressure, and renal function affect progression and complications of the disease. Treatment consists of antiplatelet medication (clopidogrel or aspirin), structured exercise, smoking cessation, treatment of hypertension and hyperglycemia if present, a statin (reduces mortality and may reduce atheroma size), and cilostazol, a phosphodiesterase inhibitor, for claudication. Surgery or endovascular treatment may be indicated when symptoms remain severe despite optimal medical therapy, if ulceration or gangrene occurs, or when acute ischemia occurs. Acute ischemia is always an emergency, as the risk of amputation is high. There is also a high occurrence of coronary artery disease, therefore patients diagnosed with peripheral vascular disease should have a thorough assessment to identify concomitant disease requiring ongoing assessment and treatment.

A 63-year-old right-handed man presents to the emergency department with a sudden onset of numbness on the right side of his face, arm, and leg, as well as right arm and leg weakness. His symptoms started fifteen minutes prior to presentation. On exam, the patient has mild aphasia, mild dysarthria, a pronator drift of his right arm, diminished strength of his right arm and leg, and diminished sensation on the right side. Computed tomography of the brain and computed tomography angiography of his brain and neck were performed and by the time the scans were finished the patient had complete resolution of his symptoms. The computed tomography angiography of the neck revealed a 90% stenotic atherosclerotic lesion of the left internal carotid artery. Carotid endarterectomy was scheduled. The most appropriate next step is administration of which of the following? Aspirin Clopidogrel Dual antiplatelet therapy Warfarin sodium

Aspirin. Transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. Large artery low-flow TIAs are commonly associated with a tightly stenotic atherosclerotic lesion at the internal carotid artery origin or in the intracranial portion of the internal carotid artery which causes impairment of collateral flow from the circle of Willis to the middle or anterior cerebral artery. Low-flow TIAs are usually short-lived (minutes) and are often recurrent. Symptoms often include hand, arm, and face numbness and weakness together. Additionally, when the dominant hemisphere is affected, aphasic syndromes can occur. When the nondominant hemisphere is affected, neglect can occur. Brain imaging with magnetic resonance imaging or CT is indicated in all patients with suspected TIA. Additional imaging should be obtained to evaluate for large vessel occlusive disease, which is often done alongside initial imaging. Options include computed tomography angiography (CTA), magnetic resonance angiography (MRA), carotid duplex ultrasonography, and transcranial Doppler ultrasonography. Treatment is primarily focused on resolving the symptomatic carotid atherosclerotic disease. In patients with recently (within the previous four to six months) symptomatic carotid stenosis of 70 to 99 percent who have a life expectancy of at least five years, a carotid endarterectomy (CEA) is recommended. For patients with recently symptomatic carotid stenosis of 70 to 99 percent, carotid artery stenting (CAS) is preferred if any of the following conditions are present: carotid lesion that is not suitable for surgical access, radiation-induced stenosis, or clinically significant cardiac, pulmonary, or other disease that increases the risk of anesthesia and surgery. For patients with symptomatic carotid stenosis that is less than 50 percent, medical management with antithrombotic medications is recommended. For patients undergoing CEA, low-dose aspirin treatment should be started prior to the procedure and is continued for at least three months after CEA is done. Carotid revascularization is not recommended for patients with chronic total occlusion of the carotid artery.

List three things that should be in your differential if you hear wheezes on a lung exam.

Asthma, COPD, bronchitis

A 40-year-old woman presents to the office with complaints of worsening headaches and double vision over the past three months. After reviewing her chart, you notice that she has gained over 40 pounds since her last visit to the office one year ago. Upon physical exam, you note her weight distribution is mainly in the waist, she has increased adipose tissue in the face, proximal muscle weakness and purple striae over the abdomen. She is not currently taking any prescription or over-the-counter medications. What is the most likely cause of her condition? Adrenocorticotropic hormone (ACTH) secreting small cell lung cancer Benign pituitary adenoma Cortisol secreting adrenal tumor Prolonged exposure to excess glucocorticoid therapy

Benign pituitary adenoma Cushing's syndrome is used to describe the condition resulting from hypercortisolism and has both endogenous and exogenous causes. The most common cause overall is exogenous and iatrogenic, resulting from long-term high dose corticosteroid therapy. The most common endogenous cause of Cushing's syndrome is Cushing's disease, which is caused specifically by excessive secretion of adrenocorticotropic hormone (ACTH) by a pituitary tumor, most commonly a benign pituitary tumor. Other endogenous sources include ectopic ACTH secreting tumors (e.g. small cell lung cancer or medullary thyroid cancer) and adrenal tumors (e.g. cortisol-secreting adrenal adenoma or carcinoma). Clinical features of Cushing's syndrome result from the presence of excess cortisol or ACTH, such as weight gain, central obesity, hypertension, facial plethora, proximal muscle weakness, glucose intolerance or diabetes mellitus, depression or psychosis, osteopenia or osteoporosis, easy bruising, violaceous striae, hirsutism, and hyperlipidemia. Complications include recurrent opportunistic or bacterial infections caused by immunosuppression. Diagnostic tests include dexamethasone suppression test, 24-hour urinary free cortisol levels, salivary cortisol levels, and CT or MRI imaging of the brain or suspected tumor location. Optimal treatment of Cushing syndrome involves direct surgical removal of the causal tumor; transsphenoidal removal being the treatment of choice for Cushing's disease. Second line treatments include medication to normalize cortisol levels or action, bilateral adrenalectomy, and radiation therapy. Antihypertensives, as well as glucose and cholesterol-lowering medications could be helpful adjunctive treatments. Gradual steroid taper is recommended for those whose symptoms are caused by iatrogenic corticosteroid therapy.

A 32-year-old G4P3 woman with a history significant for polyhydramnios is brought to the emergency department 15 minutes after a home birth. She complains of persistent vaginal bleeding with thick clots. She is anxious and diaphoretic. Her physical exam is notable for a large, boggy uterus. She receives oxytocin intramuscularly as intravenous access is started. Repeat examination reveals a persistently boggy uterus with significant active vaginal bleeding. Which of the following is an absolute contraindication to the use of carboprost in the management of this patient? Asthma Coronary artery disease Hypertension Seizures

Asthma. Postpartum hemorrhage is an obstetrical emergency and is the most common cause of maternal death globally. Postpartum hemorrhage is defined as a cumulative blood loss of greater than 1000 mL or bleeding that causes signs or symptoms of hypovolemia within 24 hours despite the delivery route. Management of postpartum hemorrhage should begin with identification of the cause of hemorrhage. The most common cause of postpartum hemorrhage is uterine atony. Other causes include retained products, genital tract lacerations, or, more rarely, maternal bleeding diathesis. First line treatment of uterine atony is manual uterine massage and uterotonic agents. Oxytocin is typically the first agent used, with carboprost and methylergonovine typically used in cases of continued bleeding after oxytocin use. Carboprost, a prostaglandin analog that stimulates uterine contractility, may cause significant bronchospasm and is contraindicated in patients with asthma.

Where is the uterine fundus palpable at 36 weeks gestation? At the umbilicus At the xiphoid process Between the pubic symphysis and umbilicus Between the umbilicus and xiphoid process

At the xiphoid process. At six to eight weeks, the gravid uterus is approximately the size of an orange. At 12 weeks, the top of the fundus should be at the level of the symphysis pubis; at 20 weeks, at the level of the umbilicus; and at 36 weeks, at the level of the xiphoid process. Subsequently, the fetus descends into the pelvis, and the fundal height may decrease.

A 52-year-old woman presents with recent recurrent bouts of shortness of breath with wheezing. Physical exam is normal and there are no other current symptoms. Vitals are normal, her body mass index is 36.5, and she only smoked socially when she was in college. She has a history of allergic rhinitis. What is her strongest predisposing factor for asthma? Atopy Being overweight Exposure to chemicals and pollutants Smoking

Atopy Atopy refers to the genetic tendency to develop allergic diseases, the most common of which are asthma, allergic rhinitis, and atopic dermatitis. Atopy is typically associated with heightened immune responses to common allergens, especially inhaled and food allergens. The term essentially combines a positive family history with having another allergic condition present. It is the strongest predisposing factor for asthma.

A 47-year-old Caucasian woman presents for evaluation of a 4-week history of dyspnea. Symptoms started when on vacation in Colorado. She initially attributed the symptoms to the altitude, but she continued to have shortness of breath with mild activity after returning home: walking more than 100 feet, walking up one flight of stairs. Symptoms resolve with rest. She also reports mild exertional chest tightness and easy fatigability. She denies paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, and syncope. Past medical history includes usual childhood illnesses, no previous surgeries, and no known allergies. She takes a daily multivitamin and occasional Tylenol for headache. She does not smoke, rarely drinks alcohol, and denies use of recreational drugs. Physical exam shows temp 96.9°F, pulse 80 and regular, respirations 16, and BP 136/82. O2 sat is 96% on room air. The patient is an alert Caucasian woman in no acute distress, with no obvious jugular venous distention; non-labored respirations; lung fields clear to auscultation and percussion; and no rhonchi, rales, or wheezes. Heart shows RV heave present; normal S1 with fixed, split S2 with prominent P2 component; and grade II/VI systolic murmur at the left upper sternal border at the second intercostal space. The remainder of exam is within normal limits. CBC and BMP are unremarkable. Free T4 and TSH are within normal limits. EKG shows normal sinus rhythm with right ventricular hypertrophy, right atrial enlargement, and right axis deviation. There is an RSR in leads v1 and v2. Question What congenital heart defect does this patient most likely have?1 1 Atrial septal defect 2 Coarctation of the aorta 3 Patent foramen ovale 4 Tetralogy of Fallot 5 Ventricular septal defect

Atrial septal defect (ASD) is an opening in the cardiac septum that divides the left and right atria. Left heart pressures are usually much higher than the right; ASD usually causes a left-to-right cardiac shunt, resulting in chronic volume overload of the right heart chambers and delayed closure of the pulmonary valve, in turn resulting in a widely split fixed S2. Chronic volume overload causes increased right ventricular stroke volume across the pulmonic outflow tract, resulting in a systolic ejection murmur of the left second intercostal space. Ventricular septal defect (VSD) is an opening in the septal wall between the left and right ventricles. Large VSDs often cause symptoms in infancy/childhood requiring surgical closure. Smaller VSDs may be asymptomatic or close spontaneously. In adulthood, the cardiac murmur associated with VSD is typically prominent, holosystolic, and located at the left lower sternal border.

A 7-year-old boy presents to the office with his mother for evaluation of his angry and defiant behavior that has been steadily worsening over the past year. The mother is teary and exasperated, explaining that it is a battle every day to get him to do normal tasks like getting ready for school or eating meals since he is often argumentative and does not do what he is told. He constantly blames her and her husband for making his life miserable. You suspect oppositional defiant disorder. Assessing for the presence of what common co-occurring disorder is key in effective treatment? Antisocial personality disorder Attention-deficit/hyperactivity disorder Autism spectrum disorder Disruptive mood dysregulation disorder

Attention-deficit/hyperactivity disorder Oppositional defiant disorder is described in patients who portray behaviors that show disobedience, defiance, and hostility toward authority figures. About half of children with attention-deficit/hyperactivity disorder oppositional defiant disorder and must be evaluated and treated with a combination of therapy and stimulants. Children are more likely to develop oppositional defiant disorder if they grow up in a home where the child's behavior is treated with harsh, punitive, and inconsistent parenting. Parent guidance and therapy for the child is essential for treatment, with early intervention being more effective than waiting for the child to outgrow these behaviors. Parent management therapy involves training parents to change their own behaviors which will help alter their children's problem behavior at home. Group therapy for adolescent is also effective. Children with untreated oppositional defiant disorder are prone to develop conduct disorder, which exhibits more severe symptoms such as stealing, physical violence, sexually inappropriate behaviors, destruction of property, and aggression toward people and animals.

A 70-year-old man with long-standing hypertension presents with fatigue and dyspnea. His dyspnea worsens on exertion and when lying supine. Which of the following physical exam findings would be consistent with a diagnosis of congestive heart failure? Audible fourth heart sound Diminished apical impulse Low-grade fever Pronounced, diffuse wheezing

Audible fourth heart sound Congestive heart failure involves ventricular dysfunction and can affect the right ventricle, left ventricle, or both. Heart failure may be due to filling defects, poor contractility, or a combination of the two. The percent of blood expelled from the ventricle during systole is measured as the ejection fraction, which is diminished in patients with systolic heart failure. In patients with diastolic heart failure, ventricular filling is impaired by a stiff ventricle, pericarditis, or valvular disease. Patients who suffer from congestive heart failure can present with dyspnea, fatigue, orthopnea, peripheral edema, distended neck veins, a sustained and laterally displaced apical impulse, audible extra heart sounds, bibasilar crackles or dullness to percussion at the lung bases. An audible fourth heart sound indicates a stiffened, noncompliant left ventricle. The patient in the above vignette may have a hypertrophied left ventricle from years of hypertension and increased arterial resistance during systole. Diagnosis of congestive heart failure can be made with chest X-ray, ECG, and echocardiography. Treatment of congestive heart failure includes addressing the causative factors. In this patient's case, adequate treatment of his hypertension is essential. Angiotensin-converting enzyme inhibitors, beta-blockers, and diuretics are often used to decrease symptoms, decrease cardiac remodeling, and increase diastolic function. Some patients with severe disease may require cardiac bypass surgery or an implantable defibrillator device. Patients with congestive heart failure should be advised to decrease sodium intake, monitor daily weights, and engage in light physical activity as tolerated.

A patient's mother has recommended that he see you. He lives on his own and is a computer programmer. He works from home. He has no friends and seldom leaves the house. She is concerned that clearly he would like to meet people, but he is terrified of doing so. What is the most likely diagnosis?

Avoidant Personality Disorder

A pregnant 26-year-old woman presents for an ultrasound at 16 weeks gestation. She has a past medical history significant for a pregnancy loss at 22 weeks gestation prior to her current pregnancy. Ultrasound confirms a shortened cervix. Following cervical cerclage, what additional lifestyle modifications should be recommended for this patient? Avoid coitus Bed rest Cessation of exercise No lifting over five pounds

Avoiding coitus should be recommended to pregnant women who have an ultrasound-confirmed shortened cervix and are at risk for preterm birth secondary to cervical insufficiency after cerclage placement. Cerclage placement is recommended in pregnant women who have a prior history of preterm birth or pregnancy loss (before 28 weeks gestation) and have a shortened cervical length (less than 25 mm) before 24 weeks gestation. Avoiding coitus is the only restriction recommended for pregnant women who undergo cerclage. Diagnosis of cervical insufficiency is made through physical exam, ultrasound, or obstetrical history.

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

Azelastine. Allergic rhinitis is an IgE mediated illness. It usually occurs after exposure to allergens such as pollen, mold, dust mites and animal dander. Symptoms include nasal congestion, rhinorrhea, sneezing and nasal and ocular pruritus. Treatment is multifold, and should be based on age and symptom severity. Avoidance of known allergens is crucial. First-line therapy is intranasal corticosteroids. Patients who are refractory, or have initial moderate to severe symptoms, should be treated with intranasal irrigation, decongestants, intranasal or oral antihistamines, such as azelastine, cromolyn or leukotriene receptor antagonists. Immunotherapy is considered in those who do not respond to pharmacologics. Air-filters (D) and mite-proof pillowcases (B) have not been shown to be effective in allergic rhinitis. Hydroxyzine (E), a first-generation oral antihistamine is not preferred over a second-generation agent since first-generation antihistamines have effects on the central nervous system.

A 15-year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice? A. Open reduction and internal fixation B. Continuous extension of the DIP with splinting C. Continuous flexion of the PIP with splinting D. Application of short arm cast

B. Continuous extension of the DIP with splinting The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via splinting for 6 to 8 weeks. D. Short arm casting is indicated in wrist and metacarpal injuries but not in DIP extensor injuries.

List four risk factors for breast cancer.

BRCA1 or BRCA2 positive, unopposed estrogen, nulliparity, early menarche, late menopause

A 67-year-old man presents to the clinic for evaluation of cough, wheezing, malaise, and shortness of breath. His social history is positive for daily cigar smoking for 30 years. He reports his symptoms have been present for four months. He had a similar presentation one year ago and was diagnosed with bronchitis. Which of the following is most likely on physical examination? Barrel chest Diastolic murmur Pectus carinatum Scaphoid abdomen

Barrel chest, or an increased anteroposterior diameter of the thorax, is a common finding in chronic obstructive pulmonary disease (COPD). The primary disease processes contributing to COPD are asthma, chronic bronchitis, and emphysema. The underlying pathology is not completely understood, but the main underlying effect is disordered airway inflammation and a high concentration of elastases and proteases. Inhaled toxins, particularly tobacco, are strongly correlated to the development of COPD, however, any chronic airway irritant may be contributory, as well as other medical conditions, such as alpha-1 antitrypsin deficiency. Chronic bronchitis is characterized histopathologically with mucous gland hyperplasia and a largely intact vascular bed, leading to high circulation but poor oxygenation. Emphysema is characterized by hyperexpansion of alveoli due to loss of elastic recoil, loss of alveolar wall structure (surface area), and subsequent loss of pulmonary vasculature, leading to poor circulation and poor oxygenation. Asthma is a condition with many possible pathophysiologic changes but is outlined by airway obstruction, inflammation, and bronchial hyperresponsiveness. Most cases of COPD involve varying degrees of emphysema, chronic bronchitis, and asthma, and culminate in air trapping and poor oxygenation. Formal diagnosis includes a thorough history and physical examination, as well as pulmonary function testing (PFT). Chronic bronchitis is suggested by two episodes of bronchitis within two years, each lasting three months or longer. Emphysema often presents as progressive shortness of breath and often with accompanying weight loss due to the increased effort of ventilation. Physical exam findings may include barrel chest, decreased breath sounds, hyperresonance to percussion, prolonged expiration, and often wheezing and rhonchi. Poor oxygenation is often reflected in clubbing of the digits, tachypnea, and in severe cases, altered mental status. Some patients may have features more consistent with either chronic bronchitis, such as cyanosis (blue bloater), or emphysema, such as a pink complexion (pink puffer), though these changes are noted late in the disease course. A diagnosis of COPD can be made using PFT if the ratio of forced expiratory volume in one second to forced vital capacity is less than 70%. Radiography suggests COPD, and often includes hyperinflation, flattened diaphragms, and increased bronchovascular markings. Treatment is multifaceted and includes inhaled corticosteroids, anticholinergics, bronchodilators, as well as smoking cessation, antibiotics during COPD exacerbations, phosphodiesterase inhibitors, vaccinations, and supplemental oxygen in select patients, which is proven to extend life. Care must be taken with the administration of oxygen, however, as this can lead to profound loss of the respiratory drive. Administration of alpha-1 antitrypsin may be indicated for COPD secondary to a deficiency. Surgical options for symptomatic relief and quality of life enhancement include bullectomy, lung volume reduction, and lung transplantation. Pulmonary rehabilitation is also proven to be beneficial. Complications from COPD include pulmonary hypertension, heart failure, frequent respiratory infections, and respiratory failure, which will occur as the disease progresses.

A 35-year old woman presents to your office with a 1-week history of high fevers, severe headaches and muscle pain. She also reports a rash. She denies any recent travel or changes in her diet. She is current on her immunizations. She currently lives in North Carolina and enjoys hiking outdoors. On physical exam her temperature is 102.3°F and she has a maculopapular rash on her extremities, including her hands and feet and sparing her face. She states the rash began a few days after her fever started and has progressively worsened. You decide to draw laboratory tests and titers in order to confirm the suspected disease. You also prescribe antibiotics immediately. Which of the following is most likely etiology of the disease? Babesiosis Ehrlichiosis Lyme disease Rocky Mountain spotted fever

Based on the history and presentation, this patient most likely has Rocky Mountain Spotted Fever (RMSF) which is a tick-borne disease caused by the organism Rickettsia rickettsia. The organism is endemic in parts of North, Central, and South America, especially in the southeastern and south-central United States, such as North Carolina. History of hiking in the outdoors increases the likelihood even though there is no specific history of a tick bite. RMSF should be considered in patients with unexplained febrile illness even if they have no history of a tick bite or travel to an endemic area. The classic clinical triad of fever, headache, and rash should raise a high suspicion for RMSF, especially high fevers over 102°F. The rash begins as a maculopapular eruption on the wrists and ankles and spreads centripetally to involve the trunk and extremities. The face is usually spared. After exposure to vector ticks, patients who develop fever, petechial rash, and vomiting require antibiotic therapy. Antibiotic therapy should be initiated before laboratory confirmation is available. Doxycycline is the antibiotic of choice for RMSF. Doxycycline therapy also treats Lyme disease, ehrlichiosis, and relapsing fever; diseases often clinically confused with RMSF. Doxycycline should be initiated immediately in this patient.

An 85-year-old woman with active vascular dementia is brought into the emergency department by her son after a fall. She is only able to groan. Her son says that she "tripped over a cat." She has mobility issues and depends on her family for her activities of daily living. Vitals are within normal limits. Her arms exhibit bruises of various stages of healing, and she is malnourished. Question What is the best next step? 1 Begin a physical exam. 2 Call another family member for history. 3 Inquire about anticoagulation medications. 4 Report the son for elder abuse. 5 Talk to the patient in private.

Begin a physical exam A physical exam should be conducted before abuse is suspected. When findings of abuse or neglect are confirmed, the appropriate authorities must be notified. Abuse and neglect are the actions or inaction of a caregiver who is capable of inflicting physical, sexual, or psychological harm on someone in their care, constituting criminal infringement. Abuse and neglect are often underreported, as perpetrators can cover up the act and make medical decisions on behalf of a victim. PAs should suspect abuse based on signs such as bruises, patients who cannot speak for themselves, malnutrition, poor hygiene, or difficulty with walking and sitting.

A 5-year-old boy with a recent history of constipation is seen by a pediatrician for a chief complaint of stool leaking onto his underwear. He was toilet-trained when he was three, but since then has had occasional periods of constipation which his mother has been treating with apple juice mixed with polyethylene glycol as needed. She believes the treatment works, but sometimes she doesn't know when to start giving it to the patient. Since he is more independent on the toilet now, she didn't realize he was having problems but noticed he had soiled his underwear and is concerned there is a new problem. Per the patient, he did not have a bowel movement today or yesterday and he cannot recall when the last bowel movement was. He does report the last time he had a stool it was painful. Rectal examination confirms the presence of hard, retained stool. Which of the following is the most appropriate next step in management? Abdominal X-ray and referral to gastrointestinal specialist Administer a sodium phosphate enema Begin polyethylene glycol and continue for at least six months Begin polyethylene glycol and continue until the problem resolves

Begin polyethylene glycol and continue for at least six months Fecal incontinence, also known as encopresis, is the passage of stool at inappropriate times when a child has completed toilet training or can be reasonably expected to maintain bowel control. It is most commonly associated with chronic, functional constipation, which indicates structural or biochemical causes for constipation have been ruled out. Ultimately, most cases of functional constipation begin with prior painful stool passage, and the fear that passing another stool will cause similar pain. Retained hard stools cause distension in the rectum, physiologically altering the response of nerves and muscles, and preventing fecal continence. Patients experience incontinence when soft stool moves around the hardened stool in the rectal vault and the child is physiologically unable to prevent voiding. Because this process involves emotional and physiologic responses, it is important to educate families on the problem and ensure children receive positive support rather than blame and shame. Bowel retraining and behavior modifications can break the cycle which leads to encopresis, but it is important for families to understand a long-term approach is needed. Initial treatment includes daily doses of polyethylene glycol to be given for at least six months rather than sporadically as seen in the vignette. Polyethylene glycol is an osmotic laxative which is usually well-accepted and well-tolerated; it is considered the first-line approach to treat chronic constipation. Concurrently, caregivers need to establish regular toileting patterns, having children sit on the toilet two to three times daily after meals for five to ten minutes each time. It is useful to keep a stool diary for follow-up with their providers, as the polyethylene glycol treatment may need dosing adjustments. The goal is for children to have one to two soft, painless stools a day, slowly decreasing stool retention and encopresis by eliminating the fear of painful stools and allowing neurologic and muscular recovery of the rectal vault. Providers and families may need to work together longer to aid children in full recovery and to establish healthy long-term preventive approaches.

A 9-year-old boy has been diagnosed with stage III non-Hodgkin lymphoma. It is anticipated that he will develop nausea and vomiting during chemotherapy. What class of medication is recommended prior to starting treatment to decrease these side effects? Benzodiazepines Glucocorticoids Neurokinin-1 receptor antagonists Three 5-hydroxytryptamine receptor antagonists

Benzodiazepines Non-Hodgkin lymphoma is divided into four stages depending on location. Stage I is a single nodule or single tumor outside of the abdomen or mediastinum. Stage II is either a single tumor with extension to the regional lymph nodes or two single nodules on the same side of the diaphragm. Stage III is defined by nodules on both sides of the diaphragm, paraspinal or epidural tumors, primary intrathoracic disease, or extensive primary intra-abdominal disease. Stage IV would be any of the above with bone marrow or central nervous system involvement. Combination chemotherapy without radiation is the most common treatment in the pediatric patient. Side effects from combination therapy can include myelosuppression, neutropenia, and nausea and vomiting. In the pediatric population, pretreatment with benzodiazepines can help ameliorate the nausea and vomiting side effects. During the acute treatment, three 5-hydroxytryptamine receptor antagonists are recommended for the pediatric population, they are most effective in the first 24 hours following treatment.

A 17-year-old boy experiences involuntary contractions of the facial and neck muscles after administration of haloperidol. The patient has arching of the back, deviation of the head to the left, and protrusion of the tongue. What management is indicated? Benztropine Cyproheptadine Dantrolene Diazepam

Benztropine. This patient presents with a dystonic reaction after administration of a neuroleptic agent and should be given benztropine. Acute dystonia is the most common adverse effect seen after the administration of neuroleptic agents and occurs in up to 5% of patients. This reaction is caused by disruption in the balance between dopaminergic and cholinergic pathways in the basal ganglia. They tend to occur within 48 hours of administration of a neuroleptic agent. Patients often experience tongue protrusion, acute torticollis, sustained eye deviation (usually upwards), and arching of the back. Laryngospasm is rare but potentially life threatening. Because dystonic reactions occur as a result of cholinergic dominance, they should be treated with anticholinergic agents including benztropine and diphenhydramine. These agents typically reverse symptoms immediately. Cyproheptadine (B) is the antidote for serotonin syndrome. Dantrolene (C) is the antidote for malignant hyperthermia. Patients present with muscle rigidity, hyperthermia, and myoglobinuria. Diazepam (D) is a benzodiazepine that can be used as a muscle relaxant but it will not help with most of the symptoms in dystonic reactions.

An 18-year-old woman presents with fever, confusion, weight loss, and palpitations. Her vital signs are T 100.7°F, HR 140 bpm, BP 143/93 mm Hg, RR 20/min, oxygen saturation 95%, and finger stick glucose of 118 mg/dL. Physical examination reveals a thin woman who is alert and oriented x 3 with a regular, fast heart rate and brisk reflexes. Her roommate tells you the patient has been taking a friend's levothyroxine in an attempt to lose weight. What management should be initiated? Beta-blocker Beta-blocker, dexamethasone Beta-blocker, dexamethasone, propylthiouracil, and potassium iodide Calcium channel blocker, dexamethasone

Beta-blocker, dexamethasone. This patient presents with thyroid storm secondary to exogenous thyroid hormone abuse (levothyroxine). Excess thyroid hormone leads to a hypermetabolic state and increased beta-adrenergic activity. In thyroid storm, patients present with fever, marked tachycardia, gastrointestinal symptoms, and central nervous system dysfunction. Cardiac complications include atrial tachydysrhythmias and high-output heart failure. An increase in catecholamine-binding sites leads to a heightened response to adrenergic stimuli. In endogenous thyroid storm, the thyroid gland produces excess T4 and T3. Peripherally, T4 is converted into the more active T3. Patients with a history of hyperthyroidism can decompensate to thyroid storm due to a number of precipitants, including sepsis, myocardial infarction, trauma, surgery, and pregnancy. Treatment of thyroid storm from endogenous thyroid hormone focuses on four targets: 1) blocking peripheral effects of hormone with beta-blockade, 2) blocking peripheral conversion of T4 to T3 with steroids (specifically dexamethasone), 3) blocking hormone synthesis with propylthiouracil (PTU) or methimazole, and 4) blocking hormone release from the thyroid gland with potassium iodide. Propranolol is the beta-blocker of choice, as it also acts to reduce peripheral conversion of T4 to T3. In addition to reducing peripheral conversion of T4 to T3, steroids also treat any relative adrenal insufficiency. PTU should be given 1 hour prior to administration of potassium iodide, as giving potassium iodide before blocking hormone release can lead to increased thyroid hormone production and synthesis. However, since this patient is hyperthyroid from taking too much levothyroxine (exogenous), treatment includes administration of beta-blockers and corticosteroids (dexamethasone).

Olanzapine is a commonly used medication in patients with schizophrenia. Which of the following can be expected with the rapid dispersing formulation (wafer) of olanzapine? Bioequivalence to the olanzapine tablet Bradycardia at overdose levels Increased risk of extrapyramidal side effects compared with haloperidol Rare association with orthostatic hypotension

Bioequivalent. Olanzapine is an atypical antipsychotic used in the treatment of schizophrenia, bipolar disorder, and acute agitation. It affects multiple receptors (serotonin, dopamine, muscarinic, adrenergic, histamine) but has the greatest affinity as a blocker of the serotonin (5HT2A) and dopamine (D2) receptors. It is available in oral, rapid dispersible (wafer), and intramuscular preparations. In the ED, the rapid dispersible preparation is particularly valuable when managing acutely agitated patients due to its rapid absorption through the oral mucosa resulting in somnolence. Oral and rapid dispersible (wafer) preparations are considered bioequivalent. Overdose leads to tachycardia, rather than bradycardia, mainly due to muscarinic blockade. Olanzapine is associated with a lower incidence of extrapyramidal effects than haloperidol. Olanzapine is associated with orthostatic hypotension due to the adrenergic (alpha) receptor blockade.

A 25-year-old G1P0 at 39 weeks' gestation presents to the hospital as she believes she is in labor. Which of the following would suggest that the woman should be admitted to the labor and delivery unit? Cervical dilation of 4 cm Intact membranes Mucus plug discharge Sporadic painful uterine contractions

Cervical dilation of 4 cm. A patient in active labor should be admitted to the labor unit. The determination of active labor compared to false labor is based on multiple criteria. Cervical dilation of > 4 cm typically marks the beginning of the active phase. However, the rate of cervical dilation is highly variable until 6 cm when dilation accelerates to approximately 1 cm/ hour in both nulliparous and multiparous women. Other criteria for admission include uterine bleeding, abnormal fetal heart rate pattern, and ruptured membranes. Women who are not in active labor at the time of admission are at increased risk of iatrogenic intervention such as epidural, oxytocin augmentation, and cesarean section.

A seven-year-old girl presents with a caregiver for concerns about having episodes of seizures and low blood sugar. The child has no documented medical problems and reportedly takes no medications. The child does not speak, appears frail, and is held closely by the caregiver throughout the visit. The caregiver presses you to admit the child to the hospital for an extensive workup. Which of the following is the most common caregiver population in which this disorder is diagnosed? Adoptive fathers Biological mothers Foster parents Older siblings

Biological mothers. This caregiver is exhibiting behavior consistent with factitious disorder imposed on another. Factitious disorder imposed on another is characterized by the production or feigning of physical or psychological symptoms in another person, usually a child but may also be an adult under the care of the person with the disorder. Common presentations of this disorder include bleeding, seizures, poisoning, apnea, altered mental status, diarrhea, vomiting, fever, rash, hypoglycemia, hematuria, or recurrent infections often with unusual organisms. Warning signs that raise the possibility of this disorder include unexplained, persistent, or recurrent illnesses, discrepancies among the history, clinical findings, and patient's general health, symptoms and signs that occur only in the caregiver's presence, a caregiver who is extremely attentive and always in the hospital, or a caregiver who appears less worried about the patient's illness than about the medical staff. Ninety-eight percent of perpetrators are biological mothers from all socioeconomic groups. Many may have an extensive medical education. Depression, anxiety, and somatization are common in the perpetrator population and many have a history of an abusive experience in the past. During clinical assessment of the victim in a case of factitious disorder imposed on another, clinicians should have a high index of suspicion. The provider should document inconsistencies of the caregiver's story with the patient's condition, lack of objective diagnostic evidence, lack of witnessing any symptoms, caregiver's response to negative testing, and whether treatment is provided for objective reasons or to meet the caregiver's demands. Treatment of factitious disorder imposed on another involves treating the victim, the perpetrator, and the family. These patients should universally be admitted to the hospital when the diagnosis of factitious disorder imposed on another is suspected in order to observe the caregiver-patient interaction, closely observe the suspected perpetrator, and determine the temporal relation between the symptoms and the perpetrator's presence.

A 55-year-old man presents to the emergency department with crushing chest pain that began approximately 30 minutes prior to his arrival while he was doing yard work. An electrocardiogram is performed immediately and shown above (ST elevation in leads II, III, aVF). The patient is stabilized and transported to the cardiac catheterization lab. Where is the coronary artery blockage most likely to be found in this patient? Circumflex artery Posterior descending coronary artery Proximal left anterior descending coronary artery Right coronary artery

Blockage of the right coronary artery (RCA) is responsible for the majority of myocardial infarctions (MI) involving the inferior portion of the heart. The RCA supplies blood to the sinoatrial (SA) node and the right atrial wall before traversing down to the inferior septum, atrioventricular (AV) node, and the inferior left ventricular wall. A small number of inferior MIs are the result of blockage of the left circumflex artery. The ECG findings that are seen in an inferior MI are noted in leads II, III, and aVF since these leads most closely demonstrate the electrical activity of the inferior portion of the heart. For a diagnosis of ST-elevation MI (STEMI) to be made, ST segment elevation of greater than 0.1 mV (or 1 small box) should be seen in two contiguous leads. Since different groups of ECG leads correspond to different areas of the heart, it is possible to localize the MI in many instances to a specific area based on the location of elevation. Leads I, aVL, V5, and V6 correspond to the lateral portion of the heart and the precordial leads correspond to the anterior part of the heart.

A 30-year-old man with no chronic conditions presents to the clinic as a new patient concerned about his mood and energy level. He has felt persistently sad, hopeless, and tired for the past two years. He cannot think of any life event that triggered these symptoms. Physical examination is unremarkable. Which of the following diagnostic studies is indicated? Blood analysis Brain magnetic resonance imaging Polysomnography Thyroid ultrasonography

Blood analysis Persistent depressive disorder, or dysthymia, is defined as a period of at least two consecutive years with a depressed mood most of the day and more days than not, and at least two of the following symptoms: decreased or increased appetite, insomnia or hypersomnia, fatigue, low self-esteem, impaired concentration, and hopelessness. Focused laboratory analysis should be performed for a suspected new-onset depressive disorder, especially if a clear precipitating factor is not present. Common screening tests for underlying general medical conditions include a complete blood count, a comprehensive metabolic panel, thyroid-stimulating hormone, urinalysis, and a urine toxicology screen. More extensive testing (vitamin B12, folate, ECG) may be indicated for patients with chronic medical conditions.

A 55-year-old postmenopausal woman presents to the clinic for her annual physical exam. She has a history of estrogen receptor-positive infiltrating ductal carcinoma and is status post lumpectomy and radiation therapy. Following local treatment, she was started on anastrozole. The patient remains asymptomatic and her most recent mammogram was normal. Which of the following screening evaluations is the most appropriate recommendation for this patient? Bone density scan Breast magnetic resonance imaging Breast ultrasound Positron emission tomography scan

Bone density scan. Breast Cancer is the second most common female cancer in the United States. The most common type of invasive breast cancer is infiltrating ductal carcinoma. Patients may present with a hard, nontender, immobile breast mass, although with the incorporation of screening mammography, patients often present due to an abnormal mammogram. The most common location is the upper outer quadrant of the breast. Additionally, breast skin changes such as erythema, thickening, or dimpling (peau d'orange) may be present on exam. Classic mammographic findings of breast cancer include the presence of a soft tissue mass or density and clustered microcalcifications. The most specific mammographic feature for breast cancer is a spiculated soft tissue mass. Women with abnormal imaging findings alone should undergo biopsy guided by mammogram (stereotactic biopsy), ultrasound, or breast magnetic resonance imaging (MRI). Women with a breast mass should undergo a fine needle aspiration or core needle biopsy. The diagnosis of breast cancer requires the presence of malignant epithelial cells (carcinoma) showing evidence of stromal invasion. Treatment is based on the extent and stage of breast cancer. In the early stage, treatment options often include lumpectomy or mastectomy, followed by radiation therapy. Chemotherapy may also be recommended. Patients with hormone receptor-positive (e.g., estrogen receptor-positive, progesterone receptor-positive) breast cancer should receive endocrine therapy with tamoxifen or aromatase inhibitors like letrozole or anastrozole. Post-treatment follow-up should include frequent history and physical examinations, patient education regarding the signs and symptoms of recurrence, and mammograms. It is recommended that a baseline bone density scan (i.e., dual energy X-ray absorptiometry) be performed on postmenopausal women who are taking an aromatase inhibitor, as they are at an increased risk for osteoporosis.

A 25-year-old woman presents to the emergency room two weeks postpartum complaining of fevers and breast tenderness. On exam, she is febrile to 102.1°F (39°C) with right-sided breast tenderness and a 4 cm x 4 cm fluctuant mass next to her nipple. What is the best next step in diagnosis? Breast milk culture Breast ultrasound Fine-needle aspiration Mammogram

Breast ultrasound. Patients with a breast abscess present with localized, painful inflammation of the breast associated with a fluctuant, tender mass and fever. The diagnosis is made via ultrasonography demonstrating a fluid collection. Management of an abscess requires drainage along with antibiotics, and the method of drainage depends on the state of the skin overlying the abscess and its depth.

Which of the following conditions has a negative Nikolsky sign? Bullous pemphigoid Pemphigus vulgaris Staphylococcal scalded skin syndrome Toxic epidermal necrolysis

Bullous pemphigoid. Nikolsky sign is a clinical finding defined as the slipping of the epidermis away from the underlying dermis when gentle lateral pressure is applied. It results in extension of an existing bullae or new bullae formation on previously intact skin. It is found in certain blistering skin conditions such as staphylococcal scalded skin syndrome, Stevens-Johnson syndrome, toxic epidermal necrolysis, and pemphigus vulgaris. Nikolsky sign is absent in bullous pemphigoid. Affecting patients between 60-80 years of age, bullous pemphigoid is a chronic, relapsing autoimmune disorder that involves autoantibody-mediated damage to the epithelial basement membrane zone. Patients present with a prodrome of a pruritic erythematous urticarial or papular rash followed weeks later by the development of tense bullae atop normal or erythematous skin. The bullae can rupture leaving moist, erythematous erosions and crusting. The lesions can be numerous and widespread, but do not typically affect the mucous membranes. Treatment includes topical steroid ointment for localized disease. Oral prednisone is indicated in widespread disease.

A 34-year-old woman presents to her primary care provider desiring information on smoking cessation. She has a 15-year-pack history and currently smokes 1 pack per day. She has a past medical history of asthma, anorexia nervosa, hypothyroidism, and migraine headaches. Which of the following smoking cessation medications is contraindicated in this patient? Bupropion Buspirone Varenicline Venlafaxine

Bupropion should be avoided in patients with a history of anorexia nervosa. Bupropion is an atypical antidepressant that enhances central nervous system noradrenergic and dopaminergic release. Bupropion also has the potential side effect of neuropsychiatric symptoms and patients should be monitored closely when treatment is initiated. Bupropion is contraindicated in patients with a seizure disorder or a history of anorexia nervosa. Bupropion is often used in patients who are concerned about gaining weight after quitting. Insomnia, agitation, and dry mouth are the most common side effects of bupropion. Cigarette use is the most common preventable cause of mortality in the United States. Almost 70% of patients who smoke say that they want to quit. There are two different types of pharmaceutical methods for helping patients quit smoking: nicotine replacement therapy (NRT) and the centrally-acting medications, varenicline and bupropion. First-line treatment for tobacco abuse is combination of NRT and either varenicline or bupropion. In the United States, NRT options include nicotine patches, lozenges, gums, nasal sprays, and inhalers. The most common side effects associated with NRT are local irritation, headache, and gastrointestinal symptoms (e.g. nausea, vomiting, diarrhea, and abdominal pain). NRT is safe to use in patients with stable cardiovascular disease. Varenicline is a partial nicotinic receptor agonist, thereby reducing nicotine withdrawal symptoms. Varenicline should be started one week prior to the anticipated start date. Varenicline is almost entirely excreted by the kidney and requires dose reduction in patients with moderate renal dysfunction. Neuropsychiatric side effects are a potential side effect of varenicline, although evidence regarding this side effect are mixed. Varenicline is not recommended in patients with a history of unstable psychiatric status or recent suicidal ideation. All patient started on varenicline should be monitored for anxiety, depression, agitation, irritability, or suicidal ideation.

Which of the following therapeutic options would be beneficial for a patient attempting to quit cigarette smoking before surgery?Bupropion Buspirone Sertraline Venlafaxine

Bupropion. Current cigarette smokers have a higher risk of postoperative complications, including pulmonary, neurological and wound complications, general infections, general morbidity, and ICU admission. Smoking cessation prior to surgery may reduce the risk of postoperative complications, and the longer the period of cessation the better. Current cigarette smokers should be encouraged to quit smoking immediately preoperatively. Pharmacotherapy attempts to reduce nicotine withdrawal symptoms making it easier to quit smoking. Pharmacotherapy with nicotine replacement therapy, bupropion, or varenicline increases smoking cessation rates and decreases postoperative complications. Bupropion blocks the reuptake of dopamine and norepinephrine to reduce the rewarding aspects of cigarette smoking. Varenicline does appear to be safe for patients with psychiatric or cardiovascular illness, although there were initial concerns about these populations. Varenicline can also aid in smoking cessation. If surgery is imminent, nicotine replacement therapy is preferred due to its rapid onset.

List three causes of decreased tactile fremitus.

COPD, Asthma, pleural effusion, pneumothorax

A 75-year-old man with a history of renal colic presents with right flank pain radiating to the right groin. During triage, the patient has a syncopal event. Urinalysis shows no red cells. His blood pressure is 110/60 mm Hg. What is the best management indicated for this patient? CT abdomen and pelvis with contrast CT abdomen and pelvis without contrast Discharge home with urology follow up Intravenous antibiotics

CT abdomen and pelvis with contrast. The patient presents with signs and symptoms concerning for an abdominal aortic aneurysm (AAA) and should have a CT scan of the abdomen and pelvis with contrast to confirm the diagnosis. AAA occurs when there is weakening of all three layers (intima, media, and adventitia) of the arterial wall creating a true aneurysm. It is rare before the age of 50 but is seen in 2-5% of men older than 50. The normal diameter of the infrarenal abdominal aorta is about 2 cm and any measurement over 3 cm defines an AAA. These aneurysms progressively enlarge over time and the risk of rupture markedly increases at diameters greater than 5 cm. Rupture of aneurysms under 4 cm is rare. In any older patient with abdominal pain, AAA should be considered. Patients often present with symptoms consistent with renal colic and this diagnosis often leads to missing early diagnosis of a leaking or large AAA. Syncope is common, particularly in leaking or ruptured AAA. The combination of back and abdominal pain should prompt the consideration of AAA in all patients. Physical examination may reveal a pulsatile abdominal mass as well. Management of a large, leaking, or ruptured AAA is directed at supportive care, blood product transfusion, and emergent operative intervention.

A 58-year-old man presents to the ED complaining of a moderate amount of hemoptysis that began earlier that day. He has no history of cigarette smoking or chronic lung disease. He has felt ill for the past week and has had an ongoing dry cough. After further clarification, he estimates he has expectorated < 30 mL of blood. Which of the following is the best next step in evaluating this patient? Chest radiograph High-resolution computed tomography Lung biopsy Magnetic resonance imaging

CXR. Hemoptysis is the expectoration of blood. Hemoptysis can be massive (≥ 500 mL) or simply blood-tinged sputum. The most common cause of massive hemoptysis is bleeding from a bronchial artery. Airway diseases like bronchitis, bronchiectasis, and bronchogenic carcinoma are the most common sources of hemoptysis in developed countries. A directed physical exam should include examination of sputum at bedside, evaluation for signs of respiratory distress (tachypnea, tachycardia, use of accessory muscles, or cyanosis), auscultation of heart and lungs, and examination of the extremities for edema. Initial laboratory analysis should include hemoglobin and hematocrit to evaluate the severity of bleeding and white blood cell count for possible infectious etiology. The most important initial diagnostic study for all patients with hemoptysis is a chest radiograph, which can identify a site and cause of bleeding in some cases or may reveal an abnormality that guides further testing. Risk for lung malignancy increases with increasing age, cigarette smoking, and longer duration of hemoptysis, and should be considered when ordering imaging beyond chest radiography. For patients who present with estimated blood loss < 30 mL, a likely benign infectious cause, no risk factors for malignancy, and a normal chest radiograph, it is reasonable to manage hemoptysis with observation for recurrence.

Scleroderma limited version has five main characteristics for which the CREST acronym is often used. What are those five things?

Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasia

A 65-year-old woman undergoes primary surgical cytoreduction for epithelial ovarian cancer. She has suboptimally cytoreduced disease with greater than 1 cm of residual disease still present. Which of the following is the best pharmaceutical treatment option for this patient? Carboplatin and paclitaxel intravenously Carboplatin intraperitoneally Cisplatin and docetaxel intravenously Cisplatin intraperitoneally and paclitaxel intravenously

Carboplatin and paclitaxel intravenously is the preferred first-line chemotherapy in women who have suboptimally cytoreduced disease after surgical cytoreduction for epithelial ovarian cancer. Platinum and taxane agents are used first-line. A dose-dense schedule is typically used with carboplatin administered every three weeks and paclitaxel administered once a week. This regimen is continued for a total of 15 weeks. Dose-dense therapy has shown either equivalent or, in some studies, improved outcomes when contrasted with conventional chemotherapy dosing. Usually, chemotherapy begins within two to four weeks after primary surgical cytoreduction. Delaying chemotherapy beyond four weeks after surgery has been shown in some studies to result in worse outcomes.

An otherwise healthy 36-year-old man reports 6 months of decreased libido and inability to maintain erections. He still experiences spontaneous nighttime erections. Vital signs include BP 130/84 mm Hg, HR 65 bpm, RR 15/min, and T 98.6° F. His physical exam is normal, and laboratory testing reveals a low total testosterone level on two separate mornings. Which of the following is the most appropriate next step? Checking luteinizing hormone and follicle-stimulating hormone Nocturnal penile tumescence testing Starting testosterone replacement therapy Treating with sildenafil

Checking luteinizing hormone and follicle-stimulating hormone. Testosterone deficiency or hypogonadism can be primary, secondary, or mixed. Primary hypogonadism is characterized by dysfunction of the testes while secondary hypogonadism is the result of disease of the hypothalamus or pituitary. In order to distinguish between the two, serum concentrations of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) must be measured. In primary hypogonadism, one or both of these levels is elevated, while in secondary hypogonadism, one or both is normal or low. Mixed hypogonadism presents with low testosterone and variable levels of LH and FSH. Hypogonadism can be congenital (e.g., Klinefelter syndrome) or acquired (e.g., tumors, chronic illness). Patients with primary hypogonadism should be considered for genetic testing, especially if they present at a younger age, and patients with secondary hypogonadism should be considered for work-up of pituitary disease.

Which of the following is most characteristic of Prinzmetal angina? Chest pain associated with nausea Chest pain in the early morning Exertional chest pain Sub-sternal chest pain

Chest pain in the early morning is most characteristic of Prinzmetal angina, or variant angina. Patients with variant angina typically present with a chronic pattern of recurrent episodes of chest pain. The quality of the chest pain is indistinguishable from classical angina pectoris associated with obstructive coronary artery disease; however, the context in which it occurs is different. In particular, patients with variant angina report that their episodes are predominantly at rest and that many occur from midnight to early morning. Each episode of chest pain generally lasts 5 to 15 minutes. Chest pain due to myocardial ischemia and variant angina tend to be similar. Some characteristic features include sub-sternal chest discomfort, radiation to the neck, lower jaw or upper extremity, gradual onset and offset, no change in the quality of pain with respiration, and associated symptoms of nausea, sweating, dizziness, dyspnea, or palpitations.

Which of the following conditions should prompt administration of the meningococcal vaccine prior to the standard 11 years of age? Cystic fibrosis Diabetes mellitus Hypoplastic left heart Sickle cell anemia

Children with sickle cell anemia (D) who no longer have a functional spleen should receive the meningococcal vaccine. Patients with sickle cell anemia are at high risk of developing functional or anatomical asplenia due to splenic infarction from vascular occlusion by defective red blood cells. Autosplenectomy dramatically increases the risk of serious infections from encapsulated organisms including Neisseria meningitides, Streptococcus pneumoniae and Haemophilus influenzae. For children under 19 months with functional asplenia, a 4-dose infant series of Meningococcal Groups C and Y and Haemophilus b or Quadrivalent meningococcal conjugate should be administered at 2, 4, 6 and 12 months of age. For children aged 19 through 23 months who have not yet been vaccinated against meningococcus, 2 doses of Meningococcal Groups C and Y and Haemophilus b at least 3 months apart should be administered. For children older than 2 years who have not gotten these vaccines should get 2 primary doses of either Quadrivalent meningococcal conjugate or Meningococcal Groups C and Y and Haemophilus b at least 2 months apart. Routine childhood vaccination entails Meningococcal Groups C and Y and Haemophilus b vaccine at 11 or 12 years with a booster at age 16. Meningitis is an infection of the fluid and lining around the brain and spinal cord and can lead to brain damage, hearing loss, learning disabilities, and even death. Cystic fibrosis (A), diabetes mellitus (B) and hypoplastic left heart (C) are not indications for early meningococcal vaccination, however early 23-valent pneumococcal vaccines are indicated in these patients. Complement deficiency is an indication for vaccination against meningococcus with similar guidelines as asplenic patients. Other indications to get an early meningococcal vaccine include HIV infection and travel to hyper-endemic or epidemic locations, such as in the African meningitis belt or the Hajj.

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

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

A 70-year-old man is brought into the office by his adult children because he has been leaving his house and wandering in the street. For the last six months, he became increasingly forgetful of names of family members and of places he often visited. He lost interest in his usual hobbies and is more restless. Which of the following is considered the first-line therapy for patients with mild-to-moderate Alzheimer's disease? Antidepressants Antiparkinsonian agents Cholinesterase inhibitors NMDA antagonists

Cholinesterase inhibitors. Alzheimer disease is the most common type of dementia. It is marked by cognitive and behavioral impairment that significantly disrupts social and occupational functioning. It is an incurable disease that is progressive. It may take decades before any signs or symptoms of the disease appear in an individual. It is characterized by loss of neurons and synapses in certain regions of the brain resulting in gross atrophy of the affected regions. This disease is characterized by amyloid plaques and neurofibrillary tangles which are clearly visible by microscopy in the brains of those with Alzheimer disease. Signs and symptoms of mild Alzheimer's disease include short-term memory loss, confusion about the location of familiar places, difficulty completing daily tasks that would normally take less time to do, poor judgment which can lead to bad decision-making, changes in mood or personality (e.g. increased anxiety). Those with moderate Alzheimer disease may present with increasing memory loss and confusion, difficulty recognizing faces of friends and family, short attention span, difficulty with reading and writing, illogical thinking, restlessness, agitation, anxiety, wandering, hallucinations, and lack of impulse control. Severe Alzheimer disease symptoms include weight loss, dysphagia, increased sleeping, lack of bladder and bowel control. Diagnosis is made through clinical examination using mental status exams. Lumbar puncture may show elevated levels of tau protein but is not routinely recommended for diagnosis. Imaging studies are useful for ruling out other causes in early disease but may show significant size reduction of certain regions of the brain with progression. First line treatment of patients with mild-to-moderate disease is monotherapy with cholinesterase inhibitors (e.g. donepezil). NMDA antagonists (e.g. memantine) can be used in addition to cholinesterase inhibitors for patients with moderate Alzheimer disease or as monotherapy in patients with severe Alzheimer's disease. However, they do not treat the underlying cause of the disease nor do they halt the progression of the disease.

Which of the following is a risk factor associated with the development of pancreatic cancer? Alcohol consumption Cigarette smoking Diet high in red meats Sedentary lifestyle

Cigarette smoking has been associated with 20 to 25 percent of all pancreatic cancers. It is the most common environmental and preventable risk factor associated with the disease. Other risk factors include genetic predisposition, chronic pancreatitis, and longstanding diabetes. Pancreatic cancer is the fourth leading cause of death from cancers in the United States and is often discovered at the time of metastatic disease. The five-year survival rate is just 6 percent for all stages. The majority of cases are caused by infiltrating ductal carcinomas affecting individuals between the ages of 65 and 84 most frequently. Physical exam findings may show jaundice, cachexia, or left supraclavicular lymphadenopathy (Virchow's node). Diagnosis may be confirmed with a EUS-guided fine needle aspiration. Treatment includes tumor resection when possible and adjuvant chemotherapy.

A previously healthy 30-year-old woman presents to your office with complaints of dysuria, flank pain, chills, and vomiting. Urine dipstick results are positive for nitrites and leukocyte esterase. Which of the following is the most appropriate therapy? Ciprofloxacin Fosfomycin Nitrofurantoin Penicillin

Ciprofloxacin. Previously healthy women with pyelonephritis may be managed as outpatients and oral empiric therapy with fluoroquinolones such as ciprofloxacin should be started immediately. Admission for pyelonephritis is indicated for patients with severe symptoms such as persistent vomiting, signs of dehydration, women who are pregnant, the elderly, the immunocompromised, or those with comorbid disorders such as chronic lung disease or diabetes mellitus. Urinary tract infections are classified as either cystitis, which is a bacterial infection affecting the bladder, or pyelonephritis, which is a bacterial infection affecting the kidneys. Bacteria generally reach the kidneys via the lower urinary tract; however, they may also reach the renal parenchyma through the bloodstream. Pyelonephritis is a potentially life-threatening infection in which timely diagnosis and treatment have a significant impact on outcomes. The majority of uncomplicated cases are caused by the bacteria Escherichia coli. Uncomplicated cases are defined as being in a patient who does not have an underlying condition that may cause therapy to fail, such as chronic kidney disease, pregnancy, poorly-controlled diabetes mellitus, indwelling catheter, or any immunocompromising condition. There is a high incidence of urinary tract infections in sexually active young women. The classic presentation of patients with pyelonephritis includes fever that may be above 103°F, costovertebral angle tenderness, and nausea or vomiting or both. Symptoms develop quickly, usually over the course of hours. Diagnosis is determined by history, physical exam and urinalysis results. Initial urine dipstick done in office will generally return positive for nitrites, leukocyte esterase, and hematuria. Urine specimens should then be sent to be cultured to determine the bacteria involved and antibiotic sensitivity.

A patient presents to the ER with progressive weakness, diplopia, and a very dry mouth. What organism may be causing this?

Clostridium botulinum

An 18-year-old man presents to the ED in police custody after using an unknown drug. Vital signs include a BP of 170/85 mm Hg, HR 120 bpm, T 37.8°C, RR 18 breaths/min, and pulse ox 99% on room air. On exam, he is agitated and diaphoretic. His pupils are 7 mm and reactive. Which one of the following substances did this patient most likely use? Cocaine Dextromethorphan Fluoxetine Phencyclidine

Cocaine. The sympathomimetic toxidrome is seen with the acute abuse of cocaine, amphetamines, or decongestants. Cocaine causes the release of dopamine, epinephrine, norepinephrine, and serotonin. The greatest impact comes from adrenergic stimulation by norepinephrine and epinephrine. Norepinephrine causes vasoconstriction by stimulating alpha-adrenergic receptors on vascular smooth muscle. Epinephrine increases myocardial contractility and heart rate through stimulation of beta-1-adrenergic receptors. In addition to causing catecholamine release, the reuptake of these neurotransmitters is inhibited. Clinically, patients are usually hypertensive, tachycardic, and exhibit mydriatic pupils. In massive overdoses, cardiovascular collapse can result in shock and wide-complex dysrhythmias. CNS effects include seizures. Sympathomimetic toxidrome is sometimes difficult to distinguish from anticholinergic toxidrome. The difference is that patients usually present with dry mucous membranes with an anticholinergic overdose, whereas patients are diaphoretic with sympathomimetics. Treatment is usually supportive. Benzodiazepines should be administered for agitation, hypertension, and hyperthermia.

Which of the following screening tools is a definitive test for the diagnosis of colorectal cancer? Colonoscopy Fecal immunochemical test Fecal occult blood test Flexible sigmoidoscopy

Colonoscopy A colonoscopy is the definitive test for the diagnosis of colorectal cancer. The study is designed to visualize the entire colon and biopsy suspicious lesions upon visualization. Abnormal pathology is sent for histology and the result of such testing dictates future screening or treatment if needed. Colorectal cancer is typically a very slow growing cancer that is curable when found early. Symptoms do not appear until later in the disease course, making routine screening pivotal to minimizing morbidity and mortality associated with this cancer. When symptomatic, right-sided lesions are more likely to cause chronic blood loss leading to an iron deficiency anemia. Left-sided lesions are more likely to cause changes in the quality, quantity, and frequency of stool. Routine screening for average-risk patients should begin at age 50. If a patient has a first degree relative with colon cancer, screening of the patient should begin 10 years prior to the time of cancer diagnosis in the family member. Treatment is based on surgical resection and may be followed by chemotherapy in patients with greater than Stage III cancer.

A 30-year-old G1P0 at 36 weeks gestation presents to the clinic for a routine check-up. Fetal position cannot be determined during the abdominal exam. Transabdominal ultrasound reveals fetal head in the fundus with both hips and knees flexed. Which of the following describes this fetal position? Complete breech Frank breech Incomplete breech Transverse fetal lie

Complete breech presentation describes a fetus whose head is in the fundus of the uterus and both hips and knees are flexed. This is in contrast to the ideal and most common fetal presentation which is known as cephalic position, or head down, where the fetus's head is toward the pelvic inlet. In the United States, patients are offered to undergo a maneuver known as external cephalic version, which is a procedure performed pre-labor in an attempt to convert the fetus from breech to cephalic position. If the version is successful, a trail of vaginal delivery can follow. If this maneuver fails, is contraindicated, or undesired by the patient, cesarean section delivery should be planned. Some women may choose to undergo planned cesarean delivery if the breech persists without an attempt at external cephalic version. Vaginal delivery of a complete breech fetus is possible if no other contraindications to vaginal delivery are identified and the clinician and facility are comfortable and equipped with this type of delivery.

A 60-year-old G2P2 woman presents to the clinic for a progressively worsening bulge sensation in her vagina for the past eight months and urinary incontinence when she laughs. Vaginal exam reveals a palpable break in the anterior vaginal fascia which becomes more prominent with Valsalva. Which of the following historical aspects put this woman most at risk for the most likely diagnosis? Connective tissue disorders Early age at menarche Radiation therapy Vaginal hysterectomy

Connective tissue disorders. Cystocele is the descent of the urinary bladder through an anterior vaginal wall herniation. Cystocele is a form of pelvic organ prolapse. Risk factors for prolapse are increased parity, vaginal delivery, advanced age, connective tissue disorders (eg: Ehlers-Danlos), and obesity. Women with cystocele may present with the sensation of a vaginal bulge or vaginal pressure, or with urinary dysfunction or incontinence. Women may actually experience improvement in urinary incontinence as the cystocele advances, but they will likely experience increased difficulty voiding, specifically obstructed voiding. This results from the prolapse causing a "kink" in the urethra. Cystocele is diagnosed clinically with pelvic examination, which reveals a palpable bulge in the anterior vaginal wall through a break in the anterior vaginal fascia. Treatment is only indicated for symptomatic women. Management options include expectant management, conservative therapy (pelvic floor muscle strengthening, pessary), or surgical therapy with anterior colporrhaphy.

A 79-year-old woman with Parkinson's disease is being treated with three-times-a-day carbidopa/levodopa for the past 5 years. She recently developed cervical dystonia and involuntary tongue movements, both of which have caused feeding impairments. She does not report problems with tremor or rigidity. Her medical history is significant for constipation and hypotensive episodes. Which of the following pharmacologic interventions is recommended at this time? Add benztropine, and switch to five-times-a-day dosing of carbidopa/levodopa Add nothing, but switch any immediate-release carbidopa/levodopa to a controlled-release formulation Add ropinirole, and switch to once-a-day dosing of carbidopa/levodopa Continue the current carbidopa/levodopa dosing, but add pramipexole

Continue the current carbidopa/levodopa dosing, but add pramipexole. Parkinson's disease is mainly characterized by its impairment on voluntary movement, leading to gait, balance and fine motor abnormalities which significantly affects functionality. Carbidopa/levodopa (immediate-release) is the most effective medication for this disease, and is the mainstay first-line medication used, especially early in the disease course (<5 years). Unfortunately, long-term use of carbidopa/levodopa can cause tardive dyskinesia and further motor control complications, which may cause further functional limitations, in up to 40% of patients treated with this drug for >5 years. As disease progresses, increasing the dose of carbidopa/levodopa is common practice. Dopamine agonists, such as bromocriptine, pramipexole and ropinirole, are also considered first-line treatment of motor abnormalities, albeit they have less benefit than carbidopa/levodopa, but fortunately have less motor side effects than levodopa. Overall, when carbidopa/levodopa has reached its end usefulness, there are several options to consider. Some clinicians will split up the total daily carbidopa/levodopa dose into 5 smaller doses a day. Others will decrease the carbidopa/levodopa dose, and some will convert any controlled-release preparations into immediate-release preparations. Another viable option is to add, or switch to adjuvant medications like dopamine-agonists (pramipexole). Other adjuvants include monoamine oxidase-B inhibitors like selegiline, catechol-O-methyltransferase inhibitors like tolcapone and entacapone, and anticholinergics like benztropine. The most sensible option above is to add an adjuvant medication.

A 64-year-old man with a history of diabetes mellitus presents with pain in his right calf while walking. The pain is relieved with rest. He has smoked one pack of cigarettes per day for the past 35 years. Exam reveals a cool extremity with diminished pulses. What is the gold-standard diagnostic study for your suspected diagnosis? Bedside ankle-brachial index Contrast arteriography Duplex ultrasound Plain radiograph

Contrast arteriography remains the gold standard for the evaluation of the threatened limb in peripheral artery disease. Peripheral artery disease may be silent or present with signs and symptoms indicative of extremity ischemia. The majority of patients with peripheral artery disease have atherosclerotic disease of the lower extremity. Risk factors for peripheral artery disease include advanced age, smoking, male gender, diabetes, and black ethnicity. Patients may present asymptomatically or with pain in affected extremity related to activity, known as intermittent claudication. They may also present with non-healing wounds, ulceration, or gangrene. Exam may reveal a cool extremity with absent or diminished pulses, though findings depend on the severity of the disease. Management is aimed at relieving symptoms and lowering the risk of cardiovascular disease progression. Exercise programs and possibly pharmacologic therapy with antithrombotics such as aspirin are recommended. Revascularization may be necessary.

A 20-year-old man presents to the emergency department with a bilateral loss of sensation in his hands. The patient states that he witnessed a motor vehicle collision that involved several fatalities. He reports he observed the incident but was not physically involved in the collision. The patient has no previous history of neurological problems or mental illness. On examination, the patient appears in mild emotional distress but is indifferent to the loss of sensation in his hands. He is concerned about missing work and asks to be discharged as soon as possible. The remainder of the physical exam is normal, including a full neurological workup. A psychological evaluation reveals that the patient is not intentionally feigning illness. Which of the following is the most likely diagnosis? Conversion disorder Factitious disorder Malingering Somatic symptom disorder

Conversion disorder Conversion disorder (also known as functional neurological symptom disorder) is an illness that most commonly shows symptoms of altered voluntary sensory or motor functions. Symptoms are not intentionally produced, they are caused by psychological factors, and they are often preceded by a significant stressor. Motor symptoms include involuntary movements, seizures, paralysis, or weakness. Sensory deficits include anesthesia, blindness, and deafness. A diagnosis of conversion disorder is made after clinical findings exclude neurological or medical conditions. Patients may show a cavalier attitude to serious symptoms, known as la belle indifférence, although this is not required to make a diagnosis. The onset of symptoms is usually acute and deficits are usually short in duration, with 95% resolving spontaneously within two weeks. Recurrence of symptoms can occur and in a small percentage of cases the symptoms do not resolve. Treatment is with insight-oriented or behavioral therapy.

Which of the following is the most common cause of cor pulmonale? Chronic obstructive pulmonary disease Connective tissue disorders Left-sided cardiac disease Right ventricular hypertrophy

Cor pulmonale is a condition of altered right heart function due to respiratory disease, and is estimated to account for 7% of all types of adult heart disease in the U.S. Acute forms are due to pulmonary emboli and acute respiratory distress syndrome. On the other hand, cor pulmonale more commonly has a chronic progressive course. Some pathophysiologic mechanisms include pulmonary vasoconstriction, pulmonary vascular bed compromise due to pulmonary interstitial or alveolar disease, connective tissue disease, and high blood viscosity. There are several underlying etiologies, the most common being COPD (>50%). Others include pulmonary hypertension, rheumatoid disease, pulmonary thromboemboli, polycythemia vera, and sickle cell disease. Although connective tissue disease can result in pulmonary vascular compromise and subsequent cor pulmonale, it is by far not the most common cause. A key fact in the diagnosis of cor pulmonale is that it is not likely due to left-sided heart disease. Right ventricular hypertrophy is the major result of, not cause of, cor pulmonale.

An India ink stain showing cysts should make you think of what diagnosis?

Cryptococcosis

A 26-year-old man presents with a severe retro-orbital headache, a sudden-onset fever of 103.3°F, nausea, and severe myalgias six days after returning from Panama. On exam, he has a morbilliform rash on his abdomen and back. Which of the following is most likely responsible for his symptoms? Dengue fever Japanese encephalitis Malaria Yellow fever

Dengue fever is the second most important tropical, febrile illness after malaria. Dengue has a short incubation period of four to seven days. It is transmitted by the Aedes aegypti mosquito. Travelers returning from Africa, the Americas, and the Indian subcontinent tend to have classic dengue. Those returning from Southeast Asia usually have the hemorrhagic variant. Classic dengue manifests as sudden onset of high fever with retro-orbital headache, nausea, vomiting, severe myalgias, and a rash. It is also known as "breakbone fever" due to the severe myalgias. Hemorrhagic dengue can result in death due to fever and shock. Diagnosis is clinical and confirmed with ELISA for IgM. Treatment is supportive with both variants.

A 38-year-old man presents with the worst headache of his life. A magnetic resonance angiogram is obtained which demonstrates a large unruptured cerebral aneurysm of the posterior communicating artery. Which of the following are you most likely to find on physical examination? Cranial nerve III palsy Cranial nerve V palsy Cranial nerve VI palsy Cranial nerve VII palsy

Cranial nerve III palsy is a likely physical examination finding in a patient presenting with a subarachnoid hemorrhage due to a cerebral aneurysm. A subarachnoid hemorrhage is bleeding within the subarachnoid space of the brain and is most commonly caused by a cerebral aneurysm or an arteriovenous malformation. A cerebral aneurysm is a ballooning of the blood vessels of the brain that when under continued pressure can rupture. This is a medical emergency which requires immediate intervention. An unruptured cerebral aneurysm is often incidentally found on brain imaging or when screening for a cerebral aneurysm if a patient has a strong family history. Patients are typically asymptomatic with an unruptured aneurysm but may become symptomatic if increased pressure on the aneurysm continues. Characteristic findings of both unruptured and ruptured cerebral aneurysms include headache, often the worst headache of life, cranial nerve III deficit, and visual loss. Cranial nerve III is the oculomotor nerve which can become compressed when a cerebral aneurysm is present at the junction of the internal carotid artery and posterior communicating artery, causing a unilateral strict downward gaze, ptosis, anisocoria, and blurred vision. When a cerebral aneurysm causes a cranial nerve III deficit with no other neurological symptoms, the aneurysm is likely to be unruptured, but is large enough to compress the nerve.

A 19-year-old man presents to the clinic after losing his job a month ago. During your interview, the patient reports he drinks daily. You suspect the patient has alcohol use disorder. Which of the following is a criterion for the diagnosis of alcohol use disorder? Craving or strong urge to use alcohol Drinking at least six alcoholic beverages per day Having legal problems related to alcohol use Symptoms lasting at least six months

Craving or strong urge to use alcohol Alcohol use disorder is classified based on severity, mild, moderate, or severe, which correlates to how many DSM-5 criteria are present. Mild severity includes two to three symptoms, moderate severity includes four to five symptoms, and severe includes six or more symptoms. DSM-5 criteria for alcohol use disorder include recurrent drinking resulting in failure to fulfill major role obligations, recurrent drinking in hazardous situations, continued drinking despite alcohol-related social or interpersonal problems, evidence of tolerance, evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal, drinking in larger amounts or over longer periods than intended, persistent desire or unsuccessful attempts to stop or reduce drinking, great deal of time spent obtaining, using, or recovering from alcohol, important activities given up or reduced because of drinking, continued drinking despite knowledge of physical or psychological problems caused by alcohol, and craving or having a persistent urge to drink alcohol. There are higher rates of alcohol abuse associated with young people, men, and Native Americans.

A 28-year-old man presents to clinic who was recently diagnosed with gout and started on allopurinol therapy. Which of the following lab values must be closely monitored when treating a patient with allopurinol over time? Aspartate aminotransferase and alanine aminotransferase Creatinine Hemoglobin and hematocrit Uric acid

Creatinine is a marker of kidney function and thus the most appropriate answer of those listed. Allopurinol is a uric acid lowering agent and standard first-line therapy for gout. The kidneys are the primary organ for the excretion of uric acid. For this reason, the recommended starting dose of allopurinol is 100 mg daily followed by creatinine monitoring every two to four weeks, titrating up to 300 mg as tolerated. Occasionally higher doses may be necessary to sufficiently lower a patient's uric acid level to prevent future gout attacks.

A 23-year-old man presents with multiple skin papules on his inner thighs, groin, and penis. The papules are about 3 mm in diameter, have a central indentation, and are nontender. A small amount of caseous material can be expressed from the papules. Which of the following is the most appropriate therapy? Cryotherapy Oral acyclovir Reassurance and watchful waiting Topical mupirocin

Cryotheraphy. For patients who desire treatment or who have suspected sexually transmitted molluscum contagiosum, treatment options include cryotherapy, keratolytics, and curettage. Molluscum contagiosum is a local infection caused by a poxvirus. Molluscum contagiosum is commonly seen in children. Molluscum contagiosum can also be seen in adolescents and adults as a sexually transmitted disease or due to contact sports. Molluscum contagiosum is spread by direct skin-to-skin contact, through autoinoculation, or through contact with contaminated fomites. Molluscum contagiosum typically presents with firm, dome-shaped papules that are 2-5 mm in diameter. The papules are shiny and have a central umbilication. The lesions may occasionally be visibly inflamed. Molluscum contagiosum can occur anywhere on the body except for the palms and soles. Eyelid lesions can induce conjunctivitis. Sexually transmitted molluscum contagiosum usually appears on the groin, genitals, inner thighs, and lower abdomen. Laboratory studies are unnecessary in children, but sexually active adolescents and adults with genital lesions should be tested for other sexually transmitted diseases. Extensive lesions should raise the suspicion for human immunodeficiency virus infection. Options for treatment include benign neglect, cryotherapy, curettage, or keratolytics. Benign neglect is often recommended because molluscum contagiosum is typically benign and lesions heal within 1-2 months. Treatment is recommended for teenagers and adults with suspected sexually transmitted infections due to risk of transmission.

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? Constipation Cyanopsia Prostate-specific antigen elevation Urinary retention

Cyanopsia, or blue discoloration of vision, is a potential side effect of sildenafil. The effect may be more likely with higher dosages of medication and is usually temporary. Sildenafil inhibits phosphodiesterase type 5 (PDE5), thereby increasing nitric oxide levels and cyclic guanosine monophosphate, which results in smooth muscle relaxation. Sildenafil is used most commonly for erectile dysfunction, however, it may also be used to treat pulmonary hypertension. Cyanopsia is hypothesized to be related to the vascular effects of the inhibition of PDE5, the effects of phosphodiesterase type 6 on the retina, and potentially to retinal exposure to elevated levels of cyclic guanosine monophosphate. Cyanopsia is uncommon but is a potential adverse effect from any PDE5 medication. Additional common side effects include hypotension, flushing, headache, dyspepsia, hearing loss, and nasal congestion. If phosphodiesterase medication is contraindicated or not tolerated, prostaglandin or papaverine cavernosa injections may be a treatment option, but they carry a risk of penile plaque formation. Additionally, vacuum devices may be useful but require significant planning and teaching on how to operate.

Owl eye inclusion bodies should make you think of what diagnosis?

Cytomegalovirus (CMV)

Pizza pie retinopathy should make you think of what diagnosis?

Cytomegalovirus CMV

A recently adopted 6-year-old from Eastern Europe presents to your office with his parents for a first time visit. His past medical history and physical exam is unremarkable. His parents do not know his immunization history, so you order the appropriate vaccine and immunoglobulin titers in addition to standard testing. His titers are all negative and laboratory work-up is otherwise unremarkable. What immunizations should he receive? DTaP, HepA, HepB, HiB, IPV, MMR, PCV13, Varicella DTaP, HepA, HepB, IPV, MMR, PCV13, Varicella DTaP, HepA, HepB, IPV, MMR, Varicella Tdap, HepA, HepB, IPV, MMR, PCV13, Varicella

DTaP, HepA, HepB, IPV, MMR, Varicella. According to the recommended immunization schedule from the Center for Disease Control, the following catch-up immunizations are recommended. DTaP should be administered to children under age 7. Hepatitis A (HepA) vaccine is recommended through age 18. Hepatitis B (HepB) vaccine should be administered in a 3-dose series to all unvaccinated persons. Inactivated poliovirus vaccine (IPV) is recommended in a 4-dose series for children under age 18. Measles, mumps, rubella (MMR) vaccine should be administered in a 2-dose series to all previously unvaccinated children through adolescence. Varicella (VAR) vaccine should be administered to all children through age 18 years without evidence of immunity in a 2-dose series. The following vaccines are not recommended in this patient based on his age and absence of risk factors. Haemophilus influenzae type B (HiB) vaccine (A) is not recommended for patients 5 years and older unless they have specific risk factors (e.g. anatomic or functional asplenia, HIV infection, hematopoietic stem cell transplant). Children 7 years of age and older should receive Tdap (D). Pneumococcal vaccine, for children 6 years or older, PCV13 (B) is only recommended if previously unimmunized against pneumococcus and specific risk factors (i.e. chronic heart disease, chronic lung disease, diabetes mellitus, alcoholism, or chronic liver disease). Incompletely vaccinated children ages 24-59 months should receive one dose of PCV13.

A 58-year-old man is undergoing a pre-operative evaluation before an elective surgery scheduled in two weeks. An ECG shows atrial fibrillation with rapid ventricular response. The patient has no symptoms and is completely unaware of his dysrhythmia. He has a past medical history significant for hypertension that is treated with lisinopril. His vital signs are BP 120/80, HR 150, RR 16 and oxygen saturation is 100% on room air. What is the appropriate management with regards to anticoagulation? Dabigatran Diltiazem No therapy Warfarin and aspirin

Dabigatran. New oral anticoagulants (direct thrombin inhibitor and oral factor Xa inhibitors) can be used to treat this patient with atrial fibrillation. Atrial fibrillation is caused by rapid and uncoordinated electrical activation within the atria. The most serious complication is arterial thromboembolism. Antithrombotic therapy with oral anticoagulation has been shown to lower the risk of thromboembolism in virtually all patients with atrial fibrillation. However, in the lowest-risk patients, the risk of anticoagulant-related major bleeding may equal or exceed the risk of thromboembolism without therapy. Thus, clinicians need guidance regarding when to recommend such therapy. Risk prediction models have been developed for this purpose. The CHA2DS2-VASc score is used for estimating the risk of stroke in patients with non-valvular atrial fibrillation. The score is used to determine whether or not treatment is required with anticoagulation therapy. The patient in the above scenario has a CHA2DS2-VASc score of 1 is considered low-moderate risk. This risk score is associated with the recommendation for new oral anticoagulant therapy. In regards to the upcoming surgery, the patient should initially be anticoagulated and then the anticoagulation be re-addressed at the time of surgery.

A 34-year-old man presents complaining of anterior neck pain for the past two days. He had a few days of nasal congestion, a mild sore throat, and a cough three weeks before the onset of neck pain. Physical exam reveals a diffusely enlarged and tender thyroid gland. Which of the following is the most likely diagnosis? De Quervain thyroiditis Graves' disease Hashimoto thyroiditis Plummer syndrome

De Quervain thyroiditis, also known as subacute thyroiditis, is caused by neutrophilic inflammation of the thyroid gland. It is typically viral in origin, and is preceded by an upper respiratory infection. Symptoms include an enlarged, painful thyroid gland. Early in the course of the disease, patients experience symptoms of hyperthyroidism due to destruction of thyroid follicles and subsequent release of thyroid hormone. Symptoms of hyperthyroidism include jitteriness, weight loss, tachycardia, hair loss, and heat intolerance. As the disease progresses and thyroid hormones are depleted, patients will become hypothyroid. Symptoms of hypothyroidism include weight gain, pretibial myxedema, and generalized weakness. De Quervain thyroiditis is a self-limited disease, and treatment consists of non-steroidal antiinflammatory drugs (NSAIDs) for pain.

A 58-year-old man with a 20 pack-year smoking history complains of a chronic, productive cough. Diffuse wheezing is noted on physical exam. Which of the following additional physical exam findings would be expected? Decreased anteroposterior chest diameter Decreased heart sounds Prolonged inspiratory phase of breathing Splitting of the first heart sound

Decreased heart sounds. Chronic obstructive pulmonary disease (COPD) is a disease of inflammation and airflow limitation caused by inhaled toxins. Cigarette smoking causes the vast majority of cases of COPD, although occupational exposure to inhaled toxins and hereditary diseases such as alpha-1 antitrypsin deficiency can also lead to COPD. Most patients with COPD have a twenty pack-year or more history of smoking. Common presenting symptoms are dyspnea, chronic productive cough and decreased exercise tolerance. Physical exam findings in patients with COPD may include increased anteroposterior chest diameter, prolonged expiratory phase of breathing, splitting of the second heart sound, wheezes, pursed-lip breathing, and decreased heart and lung sounds due to lung hyperinflation. Diagnosis is made using chest X-ray and pulmonary function testing. Chest X-ray may demonstrate lung hyperinflation, flattened diaphragms, increased bronchovascular markings, narrow cardiac shadow, or bullae. Pulmonary function testing shows decreased forced expiratory volume and forced vital capacity, as well as increased total lung capacity and increased residual volume. Treatment involves smoking cessation, inhaled bronchodilators, inhaled corticosteroids, and supportive care as necessary (oxygen, pulmonary rehabilitation).

Which of the following represents the classic order of the stages of grief? Anger, denial, bargaining, depression, acceptance Bargaining, anger, denial, depression, acceptance Denial, anger, bargaining, depression, acceptance Depression, denial, anger, bargaining, acceptance

Denial, anger, bargaining, depression, acceptance. The stages of mourning and grief represent a universal experience across cultures and backgrounds. The five stages of normal grief were first proposed by Elisabeth Kubler-Ross in 1969. People spend different amounts of time in each stage of grief. The first reaction to bad news is denial of the reality of the situation. Denial is a defense mechanism that buffers the immediate pain of shock. This is followed by anger that may be aimed at people or inanimate objects. It can often be directed at the doctor who delivered the news. Bargaining is the next stage and is a response to feelings of helplessness and vulnerability. Depression typically follows bargaining. There is often depression over the practical implications of the news as well as a deeper emotional depression. Finally, acceptance is reached. While this order is the classic teaching over time it has been found that people do not always progress through every stage nor necessarily in that order.

A 64-year-old man presents to the clinic for management of chronic symptomatic hypercalcemia of malignancy. Despite the continued use of bisphosphonates, his total calcium level remains elevated. Which of the following is the most appropriate medication this patient should receive next? Calcitonin Cinacalcet Denosumab Zoledronic acid

Denosumab. Hypercalcemia occurs when the entry of calcium into circulation exceeds the excretion of calcium into urine or the deposition of calcium into bone. Two of the most common causes of hypercalcemia are primary hyperparathyroidism (commonly caused by a parathyroid adenoma) and malignancy. Clinical manifestations vary. For patients with mild hypercalcemia (serum total calcium level of less than < 12 mg/dL), symptoms are often vague and can include constipation, fatigue, and depression. Moderate hypercalcemia, defined as total serum calcium levels of 12 to 14 mg/dL, may cause additional symptoms such as polyuria (most common renal manifestation), polydipsia, dehydration, muscle weakness, and altered sensorium. Severe hypercalcemia is diagnosed when serum total calcium levels rise above 14 mg/dL and can be associated with lethargy, stupor, and even coma. Treatment of mild hypercalcemia and asymptomatic moderate hypercalcemia focuses on avoidance of aggravating factors, such as thiazide diuretics and volume depletion. Treatment for acute hypercalcemia is reserved for patients who present with either altered sensorium or severe hypercalcemia and includes volume expansion with isotonic saline, administration of calcitonin, and concurrent administration of zoledronic acid or pamidronate (bisphosphonates). Ultimately, the underlying disease causing the hypercalcemia should be treated. In patients with chronic hypercalcemia due to malignancy, it is recommended to use intravenous zoledronic acid or pamidronate to prevent long term skeletal complications. In the case of a patient with chronic symptomatic hypercalcemia of malignancy that is refractory to bisphosphonate therapy, denosumab, a monoclonal antibody which inhibits bone resorption via inhibition of receptor activator of nuclear factor kappa-B ligand (RANKL) can be used. In addition, denosumab is an option for patients in whom bisphosphonates are contraindicated due to severe renal impairment, as it is not renally excreted.

Case A 43-year-old woman presents with reddish-pink eruptions on her neck, upper back, shoulders, and arms. The skin lesions appear annular and do not hurt or itch. The patient is concerned about having a contagious disease, but she does not feel sick. Her body temperature is 38.4°C, her pulse is 65, and her blood pressure is 150/70. She has a history of hypertension and gastritis, which she has been treating for several years. She exercises regularly, mostly outdoors, and uses sunscreen whenever she feels it is needed. Question: What is the most appropriate next step in the management of this patient? 1 Request anti-Ro/SSA and anti-La/SSB serological tests. 2 Prescribe a topical antibiotic cream. 3 Request her immunization records. 4 Determine the medication history of the patient. 5 Instruct patients about sun-avoidance techniques.

Determine the medication history of the patient. The lesions described are typical of subacute cutaneous lupus erythematosus (SCLE), a condition that can be induced by certain antihypertensive agents or some proton pump inhibitors used to treat gastritis. The patient has a history of hypertension and gastritis, so you should determine the medication history of the patient.

Which of the following is appropriate education for a man with newly diagnosed hypertension? Alcohol consumption should be limited to 2 ounces of ethanol or less per day Brisk walking 20 minutes per day, three days per week will decrease blood pressure Dietary intake of potassium (90 meq - 120 meq) may lower both systolic and diastolic blood pressure Recommended sodium intake is 2800 mg or less per day

Dietary intake of potassium (90 meq - 120 meq) may lower both systolic and diastolic blood pressure Patients who receive a new diagnosis of hypertension should be counseled on lifestyle modifications that may lower blood pressure. These include dietary changes, weight loss, and exercise. A diet low in sodium (under 2500 mg per day) and rich in potassium, calcium, and magnesium should be encouraged. Potassium supplementation has shown to lower both systolic and diastolic blood pressure. Dietary intake is the best solution with a goal of 120 meq however supplements can be used if the serum potassium is low. Patients should engage in a weight reduction plan with the goal of a body mass index under 25 kg/m2. Overweight patients can be encouraged that mean blood pressure may decrease by 5-20 mm Hg with every 10 kilograms of weight loss (to within ten percent of ideal body weight). Exercise is also important for blood pressure control. Hypertensive patients without contraindications should be encouraged to engage in moderate-intensity aerobic exercise (e.g. brisk walking) for 30 minutes per day, five days per week.

Name a common cause of a junctional rhythm.

Digitoxin toxicity

A bicuspid aortic valve is often associated with which of the following findings? Abdominal aortic aneurysm Dilation of the ascending aorta Left atrial dilation Patent foramen ovale

Dilation of the ascending aorta is frequently associated with a bicuspid aortic valve. Bicuspid aortic valve disease is one of the most common congenital heart lesions, occurring in approximately 1% of the population. Bicuspid aortic valve has an increased prevalence associated with congenital lesions such as coarctation of the aorta or Turner syndrome. More than 70% of patients with a bicuspid valve will require surgical intervention for a stenotic or regurgitant valve or aortic pathology over the course of a lifetime. Dilation of the ascending aorta in the setting of a bicuspid valve was previously considered a secondary event due to abnormal aortic valve function; however, it is now recognized to be caused by intrinsically abnormal connective tissue. As a result, serial evaluation of ascending aortic diameter should be performed by transthoracic echocardiography.

A 48-year-old man presents with bilateral swollen lower extremities. Which of the following may lead to a false-negative result for proteinuria on a urine dipstick? Alkaline urine Dilute urine Hematuria Prolonged dipstick immersion in urine

Dilute urine. Urine dipstick tests are often performed to evaluate for the presence of proteinuria as a sign of impaired renal function. This occurs through a color change of tetrabromophenol blue. There is an approximate relationship between the protein concentration and color intensity, however, reliably positive results occur only at concentrations above 30 mg/dL. Thus, dilute urine can generate false-negative results for proteinuria. In contrast, alkaline urine, hematuria, and prolonged dipstick immersion in urine can all generate false-positive results.

A 35-year-old man is administered IV metoclopramide for migraine abortive therapy. One hour later, the patient is noted to have the activity seen in the video above (involuntary spasms of the face, neck, back, and limb muscles). Which one of the following medications should be administered to the patient? Bromocriptine Dantrolene Diphenhydramine Haloperidol

Diphenhydramine. The patient is having an acute dystonic reaction secondary to metoclopramide. Acute dystonic reactions manifest as involuntary spasms that often involve the face, neck, back, or limb muscles. Although dystonic reactions are occasionally dose-related, they are more often idiosyncratic and unpredictable. Dystonic reactions are commonly associated with typical antipsychotics (haloperidol, droperidol, chlorpromazine) but can also occur, albeit less frequently, with atypical antipsychotics (clozapine, olanzapine) and other antidopaminergic drugs like metoclopramide. These reactions reportedly arise from a drug-induced alteration of dopaminergic-cholinergic balance in the nigrostriatum (i.e., basal ganglia). Most drugs produce dystonic reactions by nigrostriatal dopamine D2 receptor blockade, which leads to an excess of striatal cholinergic output. High-potency D2 receptor antagonists are most likely to produce an acute dystonic reaction. Acute treatment consists of the administration of anticholinergic agents such as diphenhydramine or benztropine. Patients should continue therapy for at least 48 hours to prevent recurrence and be referred back to their prescribing physician for medication adjustment.

An 85-year-old man with a past medical history of type 2 diabetes,peripheral neuropathy, and hypertension presents with hip pain following a recent fall. He takes metformin for diabetes, amitriptyline for neuropathy, and lisinopril for hypertension. Which of the following interventions would be the most beneficial to lower the risk of future falls? Check blood glucose levels prior to ambulating to rule out hypoglycemia Discontinue amitriptyline and choose a different agent to treat his neuropathy Reduce lisinopril dose to limit hypotension Suggest changing positions slowly to reduce risk of orthostatic hypotension

Discontinue amitriptyline and choose a different agent to treat his neuropathy. Amitriptyline is a tricyclic antidepressant. The American Geriatrics Society created a list of medications that may be inappropriate when used in the geriatric population, called the Beers Criteria. The criteria identify common drug classes to use with caution including antihistamines, antiparkinson medications, antispasmodics, antithrombotics, and antidepressants. Amitriptyline is a strong anticholinergic drug which may cause sedation and orthostatic hypotension. These side effects are associated with increased fall risk and should be avoided in the elderly. Therefore, discontinuing amitriptyline and choosing an alternative medication to treat his neuropathy is the best answer choice.

A 44-year-old man presents to the clinic with involuntary facial movements. He states that for the past several months, his lower lip and jaw move in writhing motions every half hour or so, and it is beyond his control. He is taking risperidone 2 mg daily. When questioned about the reason for taking risperidone, he states that his previous healthcare provider put him on the drug because he has no friends (and doesn't want any), has little facial expression, finds no pleasure in any activity, and prefers to be alone. He denies any past history of visual or auditory hallucinations. Which of the following therapeutic changes would be best to make for this patient? Decrease the dose of risperidone and add clonazepam Discontinue risperidone and refer for psychotherapy CDiscontinue risperidone and replace with clozapine DDiscontinue risperidone and replace with fluoxetine

Discontinue risperidone and refer for psychotherapy The patient in the above vignette has schizoid personality disorder. He has been wrongly diagnosed and put on an antipsychotic, and is now experiencing tardive dyskinesia. Schizoid personality disorder, according to the Diagnostic and Statistical Manual V, is a cluster A personality disorder. It is characterized by an enduring pattern of behavior with four of the following symptoms: no desire for close relationships, no desire for sexual intimacy, preference for solitary activities, anhedonia, flattened affect or emotional detachment, no close friends or confidantes apart from first-degree relatives, and no regard for praise or criticism. Patients who suffer personality disorders must have enduring behavioral traits that are not the result of substance use or another medical or mental condition, and must exhibit these traits to the extent that there is significant impairment in functioning. Schizoid personality disorder can be mistaken for negative symptoms of schizophrenia, but positive symptoms of schizophrenia, such as hallucinations, will not be present. Personality disorders are best treated with psychotherapy, and very rarely respond to pharmacologic treatment. Tardive dyskinesia is a serious side effect of antipsychotic medications which involves involuntary movement of the face or limbs and may become permanent, even after the offending drug has been removed. Prompt removal of the offending agent is the most appropriate treatment. The patient in the vignette above has no history of psychosis and should not have been prescribed an antipsychotic.

Which of the following guidelines for breast cancer screening is consistent with those of the United States Preventive Services Task Force (USPSTF)? Begin annual screening mammography at age 40 Begin annual screening mammography at age 55 Continue screening mammography as long as the patient is in good health Discontinue screening mammography at age 75

Discontinue screening mammography at age 75 Breast cancer is the leading cause of cancer deaths among women worldwide. Often the patient is asymptomatic but may present with a palpable lump, inverted nipple, or nipple discharge. Lumps that should raise concern on exam are those that are nodular, hard, fixed, unilateral or asymmetrical. Enlarged, firm axillary nodes may also be palpable in metastatic breast cancer. Imaging modalities differ in their specificity and sensitivity for detecting breast cancer and include mammography, ultrasonography, magnetic resonance imaging, scintigraphy, and positron emission tomography. Breast biopsy is performed for definitive diagnosis and to guide treatment. Treatment of breast cancer varies depending on type and stage but may involve lumpectomy, mastectomy, chemotherapy, radiation, or any combination of the same. Prevention of breast cancer is essential due to the significant morbidity and mortality of the disease. Several different medical associations have put forth their own guidelines for the prevention of breast cancer and they all differ slightly. All agree that mammography is an effective screening tool. Where they differ is at what age to begin and cease screening with mammography, and at what interval those screenings should take place. The United States Preventive Services Task Force (USPSTF) set forth the following recommendations: begin mammography at age 50, perform screening mammography every two years, and stop screening mammography at age 75. A decision to continue after age 75 years should be made on an individual basis and the USPSTF only recommends elective screening if life expectancy is greater than 10 years.The USPSTF also recommends that women who have a strong family history of breast cancer begin screening mammography at age 40.

A 14-year-old girl and her mother present to the clinic for a sports physical. The patient just started high school and wishes to try out for the basketball team. She is feeling well, and her past medical history is unremarkable. The structure of the office visit is outlined for the patient and her mother. In order to preserve confidentiality, which of the following steps of the office visit should be performed in the presence of both the patient and her mother? Determine method of notification of laboratory results Discuss and assure confidentiality Obtain medical history, including risk-taking behaviors Provide patient health guidance

Discuss and assure confidentiality. The concepts of patient confidentiality are complex but important, particularly for adolescent patients. The laws governing consent and confidentiality in adolescent health care vary by state in the United States. Studies show that adolescents are more likely to seek health care if they believe that their health information will be kept private by the clinician and health care staff. An office visit structured to support adolescent patient confidentiality may begin with the clinician outlining the structure of the visit, obtaining general medical and family history, and discussing confidentiality with both the patient and the parent present. This is done so that both parties understand what will and will not be divulged by the provider to whom, as well as what few exceptions must be divulged by the provider (conditional confidentiality). The next several steps of the office visit and discussions should be carried out in the patient's presence only, followed by a brief interaction with the parent only to address any parental concerns. Finally, appropriately discreet summaries and recommendations as well as billing issues may be addressed with both parties present.

Which of the following is an indicator of unresectability of gastric cancer? Disease encasement of the hepatic artery Distal splenic artery involvement Lesions in the distal two-thirds of the stomach Locoregional lymph node metastases

Disease encasement of the hepatic artery is considered an indicator of unresectability of gastric cancer. Gastric cancer is typically surgically resected along with regional lymph nodes with complete disease eradication representing the best chance for positive outcomes. During gastric and lymph node resection, complete abdominal exploration should occur. Indicators of unresectability include vascular involvement of the aorta, hepatic artery, or proximal splenic artery. Distant metastases are also an indicator of unresectability, although locoregional metastases are not always unresectable. Lymph nodes that are located in the aorto-caval region, in the porta hepatis, or behind the pancreas are also considered unresectable.

Which of the following is associated with an organic cause of psychosis? Auditory hallucinations Disorientation Normal vital signs Slow onset of symptoms

Disorientation. Psychosis can be caused by both organic (medical) and functional (psychiatric) etiologies. It is critical for the clinician to exclude organic causes of psychosis before transferring the patient to psychiatric services. The delay in diagnosis and therefore treatment is potentially harmful to the patient. Unfortunately, it can be difficult to differentiate the etiologies. Patients with organic causes of psychosis tend to have recent memory deficits, psychomotor retardation, visual hallucinations, emotional lability, disorientation, and occasional periods of lucidity. Additionally, those with organic psychosis are more likely to have a sudden onset of symptoms, abnormal vital signs or physical examination findings, and social immodesty. In patients over 40 years of age without a prior psychiatric history, an organic cause of psychosis should always be assumed.

A 42-year old man presents after jamming his index finger during a basketball game. When he tries to straighten his finger, the distal tip remains flexed as shown above (flexed DIP only). Which of the following describes the pathophysiology of this injury? Defect of the central slip causing volar migration of the lateral bands Disruption of the extensor tendon mechanism at the distal interphalangeal phalangeal (DIP) joint Disruption of the ulnar collateral ligament Inflammation of the abductor pollicis longus and extensor pollicis brevis tendons

Disruption of the extensor tendon mechanism at the distal interphalangeal phalangeal (DIP) joint. The patient has a mallet finger. A mallet finger is characterized by a closed disruption of the distal extensor apparatus, often occurring when there is sudden forceful flexion of an extended finger, such as when struck by a ball. Because the disrupted extensor tendon no longer connects with the distal phalanx, the DIP joint is held in flexion due to unopposed action of the flexor digitorum profundus. A mallet finger injury is the most common hand injury seen in athletes. On examination, the distal tip of the finger is flexed at the DIP joint. Pain, swelling, and tenderness may be present over the DIP joint. Passive extension is usually intact, but patients are unable to actively extend the distal phalanx. Radiographs may show an associated dorsal avulsion fracture. The treatment involves immobilizing the DIP joint in slight hyperextension for 6-8 weeks to allow tendon healing. The proximal interphalangeal (PIP) joint and metacarpophalangeal (MCP) joints should be allowed to move freely.

A 7-year-old girl presents with the rash seen above (erythematous bull's eye lesion with central clearing). Her mother states it appeared seven days after hiking through the woods near their home in New Jersey. The patient has no known drug allergies. Which of the following is the most appropriate treatment for this patient? Ampicillin Azithromycin Cephalexin Doxycycline

Doxycycline. Lyme disease is the most common vector-borne disease in the United States. It is a tick-borne illness caused by the spirochete Borrelia burgdorferi. The early phase of the disease results in the characteristic rash seen above, erythema migrans. Prompt treatment of early disease can shorten the duration of symptoms and prevent progression to later stages of disease. Previously it was recommended that pregnant or lactating women and children younger than 8 years should receive amoxicillin. This is still a viable alternative in patients who cannot tolerate doxycycline. Doxycycline, a tetracycline, may be used for all patient populations and can be recommended if the treatment length is less than 21 days in pregnant patients and children. Advanced or severe disease should be treated with intravenous ceftriaxone or penicillin.

A 28-year-old male presents to the clinic with a four-year history of abdominal bloating, flatulence, diarrhea, and a pruritic rash on his buttocks and knees. He states his symptoms are worse with the consumption of pasta. Which of the following is most likely to confirm the diagnosis? 25-hydroxyvitamin D Duodenal biopsy HLA-DQ genotyping Tissue transglutaminase IgA antibody

Duodenal biopsy is the confirmatory test for celiac disease (gluten-sensitive enteropathy). Celiac disease is an autoimmune disease that is triggered by consumption of gluten and its metabolic byproducts (gliadin peptides). Associated diseases include diabetes, thyroid disease, and Turner syndrome. The exact etiology remains unclear, but environmental and genetic factors, particularly presence of human leukocyte antigen haplotypes DQ2 and DQ8, are believed to have a complex interaction predisposing to changes in IgA and IgG antibodies. When the small intestine mucosa is exposed to gluten and gliadin, inflammation of the microvilli and hypertrophy of the crypts occur. Chronic inflammation of the microvilli leads to atrophy and the characteristic smooth appearance of the small intestine on endoscopy. Malabsorption subsequently occurs with progressive loss of structure and function. Celiac disease classically presents with gastrointestinal symptoms, such as diarrhea, cramping, bloating, malabsorption, and steatorrhea, but may coincide with neurologic, dermatologic, psychiatric, hematologic, or skeletal diseases. The physical exam is non-specific, though the presence of dermatitis herpetiformis, often found on knees, buttocks, and elbows, may suggest the diagnosis. Some symptoms may be related to malabsorption, particularly of iron, calcium, fat, and fat-soluble vitamins (A, D, E, and K), which may lead to anemia, vitamin or mineral deficiencies, weakness, paresthesias, osteopenia, growth retardation, sterility, bleeding, and dermatitis. Diagnosis includes serology, as well as endoscopy and biopsy. Elevated levels of tissue transglutaminase IgA antibodies (IgA tTG), as well as anti-deamidated gliadin peptide IgG antibodies (IgG DPG) strongly suggest the diagnosis and are recommended screening tests. Guidelines recommend first testing tissue transglutaminase antibodies as a screening exam in those not deficient of IgA; anti-deamidated gliadin peptide antibodies are tested in children under two years old, or if IgA deficiency is present. Additional testing may include HLA DQ2 and DQ8, which essentially excludes celiac disease if negative. Endoscopic biopsy generally confirms the diagnosis. Scalloping of the small bowel folds, reduced number of folds, and a smooth or mosaic pattern of the mucosa are observed grossly. Histology may reveal an increased crypt to villi ratio, various stages of villi atrophy, and increased intraepithelial lymphocytes. A gluten-free diet is the primary treatment, however, glucocorticoids may rarely be required. Gluten is found in wheat, barley, and rye. Rice, and corn do not cause celiac disease. Complications include reduced quality of life related to symptoms, depression, lymphoma, osteopenia, and the myriad complications from vitamin and mineral deficiencies.

When educating a patient about risks of undergoing surgical repair of a rectocele, which of the following potential complications should be mentioned? Dyspareunia Rectal fissure Rectus diastasis Small bowel obstruction

Dyspareunia. A rectocele is a posterior vaginal wall defect associated with anterior prolapse of the rectum. It is a defect in the rectovaginal septum rather than the rectum. Patients typically complain that they feel increased pelvic pressure or the sensation that something is "falling out" of the vagina. In addition, patients often utilize splinting of the vagina, perineum or rectum in order to achieve a bowel movement. Splinting is the firm application of pressure on a particular anatomical location. Other symptoms include constipation, fecal incontinence or sexual dysfunction. Diagnosis can usually be made during vaginal and rectal examination by observing a bulge in the posterior vaginal area upon bearing down. Imaging is rarely needed. Nonsurgical management involves medications for constipation to minimize straining that may make the rectocele worse and pessary placement. Surgical repair with a posterior colporrhaphy has an anatomic cure rate of up to 96%. Dyspareunia is a potential complication that patients should be educated about when undergoing surgical repair of a rectocele.

Define pulsus alternans.

EKG waveform changes, SBP changes, LV stroke volume changes from beat to beat

A 12-year-old girl with no significant medical history presents to her pediatrician complaining of two weeks of joint pain. Initially, the pain started at the same time as a fever, first in her knees, then her ankles, and now she feels like her elbows are bothering her as well. Ibuprofen helps a great deal, but the pain is still present after the medication wears off. Her only recent illness was strep throat which was treated with amoxicillin. On physical exam, mild erythema and swelling around her elbows is appreciated and her lower extremities appear normal but are painful to move. The rest of her physical exam is also normal, including ear, nose and throat, cardiac, and skin exams. Which of the following is the most appropriate diagnostic test? Antistreptolysin O titer Complete blood count with differential Echocardiogram X-ray of affected joints

Echocardiogram This patient presents with a migratory polyarthritis, primarily affecting her large joints. Her recent history of streptococcal pharyngitis should raise concern for acute rheumatic fever. The most severe subsequent complication is rheumatic heart disease, the most common acquired valvular heart disease globally. The Jones criteria describe manifestations of acute rheumatic fever and are used by the American Heart Association to guide diagnosis. The manifestations are divided into "major" and "minor" categories. In patients with a history of a preceding group A Streptococcus infection (GAS), a diagnosis of acute rheumatic fever can be made when two major manifestations are present, or one major and two minor manifestations are present. The five major manifestations are arthritis, carditis, Sydenham chorea, erythema marginatum, and subcutaneous nodules. Of these, arthritis and carditis are by far the most commonly seen. Typically, arthritis is the first symptom to appear, about 21 days after the associated GAS infection, and is characterized by joint pain which responds to nonsteroidal anti-inflammatory medications. Carditis may be more difficult to diagnose because it is often asymptomatic. Acute rheumatic fever causes a pancarditis, but the primary manifestation is a valvulitis, usually involving the mitral and aortic valves. In some patients, a mid-systolic murmur, heard loudest at the apex, can indicate the regurgitation associated with this valvulitis; however, it may not be appreciated in all patients. Thus, echocardiography is recommended in all cases of suspected and confirmed acute rheumatic fever. In addition to making the diagnosis of carditis, echocardiography also provides robust data essential to the long-term management of the most important sequelae of acute rheumatic fever.

A newborn examination is conducted on a 1-day-old, 36-week gestation infant born via spontaneous vaginal delivery with no complications. His physical exam is unremarkable except for an empty left scrotum. On closer examination of his genitalia, one hand is used to gently express any palpable tissue from the anterior superior iliac spine along the inguinal canal towards the scrotum, which is held by the examiner's other hand. During this maneuver, the hand on the scrotum receives testicular tissue which is gently held in the scrotum for at least one minute. Upon letting go, the testis disappears out of the scrotum. Which of the following is the most likely explanation for these findings? Absent testis Ectopic testis Retractile testis True undescended testis

Ectopic testis Cryptorchidism is an undescended or "hidden" testis. It is usually an isolated finding and is associated with low birth weight and prematurity. Bilateral cryptorchidism in particular is more commonly seen with some endocrine, genetic, and morphologic problems, including Prader-Willi and Noonan syndromes. The first clinical finding will usually be an empty or hypoplastic scrotal sac, with or without inguinal fullness. An important part of evaluating a child with cryptorchidism is differentiating between a palpable and impalpable testis, and in the case of a palpable testis, attempting to manipulate testicular tissue into the scrotal sac to differentiate between an ectopic, retractile, or true undescended testis. In the physical exam, a testis that can be palpated should be gently milked into the scrotal sac, if possible. Once the testis is in the scrotal sac, holding it in place for at least one minute should fatigue the cremasteric muscle, after which a retractile testis will remain in the scrotal sac. An ectopic testis, examined with the same maneuver, will immediately spring back out of the scrotum. Ectopic testes have previously descended normally, but have ultimately adopted an aberrant location, most commonly the superficial inguinal pouch. All testicular structures (testis, testicular vessels, vas deferens) in an ectopic testis will be normal, albeit in an incorrect location. Most testis that have not completely descended will do so by three to four months of age. After six months of age, further descent is rare. For infants who continue to have undescended testis after four months of age, a surgical orchiopexy is recommended to free the testis, manipulate it into the scrotum, and suture it in place, decreasing the likelihood of complications associated with cryptorchidism including testicular torsion, infertility, and malignancy.

A 25-year-old woman presents to her obstetrician for evaluation of recurrent second trimester pregnancy loss. During each of her previous two pregnancies, she presented during week 15 with painless cervical dilation and effacement with subsequent rapid delivery of a preterm infant. Which of the following is a risk factor for this woman's cervical insufficiency? Ehlers-Danlos syndrome History of pelvic inflammatory disease Human papillomavirus infection Obesity

Ehlers-Danlos syndrome is a congenital risk factor for cervical insufficiency. Cervical insufficiency is defined by the American College of Obstetricians and Gynecologists (ACOG) as the inability of the uterine cervix to retain a pregnancy throughout the second trimester, in the absence of uterine contractions. Cervical insufficiency can be congenital or, more commonly, acquired. Congenital risk factors include genetic collagen disorders, such as Ehlers-Danlos syndrome, uterine anomalies, and in utero diethylstilbestrol exposure. Acquired risk factors include cervical trauma during labor or delivery, rapid mechanical cervical dilation, and treatment of cervical intraepithelial neoplasia. Patients with cervical insufficiency may present with mild symptoms, such as pelvic pressure or vaginal discharge, or be asymptomatic. Uterine contractions are mild to absent. During late presentation, pelvic exam may reveal a soft, effaced and dilated cervix with grossly prolapsed or ruptured membranes. The diagnosis of cervical insufficiency is usually based on history of recurrent midtrimester loss, risk factors, and a transvaginal ultrasound measurement of cervical length. Cerclage placement is recommended at 12-14 weeks for with a history suggestive of cervical insufficiency.

At what age should the quadrivalent meningococcal vaccine be offered to immunocompetent children? Birth Eleven years of age One year of age Two months of age

Eleven years of age The meningococcal vaccine can be offered to children beginning at eleven years of age. The quadrivalent vaccination is considered to be the vaccination of choice. Efficacy data is favorable in that the vaccination has successfully decreased the number of cases related to Neisseria meningitidis in the United States. Common side effects of the vaccination include headache, dizziness or erythema at the injection site. The vaccine is administered as an intramuscular injection. Bacterial meningitis is one of the top ten deadliest infectious diseases. Typical presenting features include fever, nuchal rigidity, change in mental status described commonly as lethargy or confusion, and a severe, generalized headache. Diagnosis is made by lumbar puncture. Empiric treatment with broad-spectrum antibiotics is recommended prior to confirmation of diagnosis due to the high mortality rate associated with delayed treatment of bacterial meningitis. Meningococcal disease prevented by vaccination also includes meningococcemia without meningitis. Meningococcemia typically presents as a more severe presentation of common flu-like symptoms such as myalgia, fever, and fatigue. Meningococcemia can also cause the characteristic petechial rash and altered state of consciousness seen with meningitis. Other manifestations of meningococcal infection include pericarditis, arthritis, pneumonia, pharyngitis, and urethritis.

A 55-year-old woman presents to the oncology clinic to discuss therapy options for her newly diagnosed, non-metastatic, unilateral, invasive breast cancer. Routine analysis reveals estrogen receptor-positive and progesterone receptor-positive tumor expression. Which of the following therapies will likely be most effective for this patient? Cytotoxic chemotherapy Endocrine therapy Mastectomy Radiation therapy

Endocrine therapy. Breast cancer management guidelines recommend that both estrogen receptor (ER) and progesterone receptor (PR) analysis should be routinely performed in all invasive breast cancers because tumor expression can best predict which patients will benefit from endocrine therapy. Tumors that are ER-negative and PR-negative are unlikely to respond to endocrine therapy. Progesterone receptor status is heavily dependent on estrogen receptor status and does not seem to have independently predictive value when the estrogen receptor status is unknown. Endocrine therapy, chemotherapy, or biologic therapy are all systemic adjuvant therapy options which can be used to treat breast cancer in addition to surgical therapy and radiation. Tamoxifen, an estrogen receptor modulator, significantly reduces the risk of recurrence and death in patients with ER-positive disease.

A 46-year-old woman presents to your office for a second opinion. She has been experiencing abnormal uterine bleeding for more than two years. Her periods are heavy, prolonged, and associated with clotting. Imaging of her uterus was unremarkable. A recent endometrial biopsy was negative for infection or malignancy. She has three children, all born by uncomplicated vaginal deliveries, and is not interested in future conception. She declines hormonal therapy and would like to proceed with surgical therapy. Which of the following is recommended? Abdominal hysterectomy Dilation and curettage Endometrial ablation Wedge resection of the uterine wall

Endometrial ablation. Abnormal uterine bleeding (AUB) is a gynecologic complaint that has a variety of causes, some of which can be premalignant or malignant. A comprehensive workup should be performed to classify the type of AUB according to the PALM-COEIN classification. Special attention is needed in women who are 45 years of age or older and those who have risk factors for unopposed estrogen exposure, such as those who are obese or have polycystic ovary syndrome, as these populations are at an increased risk of malignant disease. An endometrial biopsy, in this setting, is warranted as part of the workup. If premalignancy and malignancy are ruled out, surgical interventions affecting the endometrial lining can be considered. Endometrial ablation is performed via various techniques such as using radiofrequency, cautery, or thermal energy. It is a minimally invasive procedure that is performed during or after a hysteroscopy.

A 55-year-old postmenopausal woman presents to your office with a complaint of vaginal bleeding. Which of the following is the most appropriate next step in management? Abdominal ultrasound Endometrial biopsy Hysterectomy Watchful waiting

Endometrial biopsy. Vaginal bleeding after menopause is an abnormal finding. The most common cause of vaginal bleeding after menopause is atrophy of the vaginal mucosa or endometrium, however 5-10% of postmenopausal women with vaginal bleeding have endometrial cancer. Endometrial cancer is potentially lethal, therefore any postmenopausal woman who presents with vaginal bleeding needs to be evaluated to rule out this etiology. After a careful history and physical exam, initial diagnostic testing to rule out endometrial cancer involves either endometrial biopsy or transvaginal ultrasound. Advantages of an endometrial biopsy include its high sensitivity, low cost and low incidence of complications. Women who need evaluation of the adnexa or myometrium, or who can't tolerate endometrial biopsy should be referred for transvaginal ultrasound. If either test is inconclusive, further testing is warranted. Cervical cancer screening should also be a part of the workup for postmenopausal vaginal bleeding.

A 32-year-old G0P0 woman presents with dull, crampy pelvic pain that has been intermittent over the last six months. She is currently menstruating and notes the pain seems to worsen with menses. She also reports pain with intercourse but denies any vaginal discharge. On examination, she is in no acute distress and is afebrile. She has scant blood in the vaginal vault and no significant focal tenderness. No masses are felt. Her pregnancy test is negative. What is the most likely diagnosis? Endometriosis Mittelschmerz Pelvic inflammatory disease Ruptured ovarian cyst

Endometriosis is a benign, estrogen-dependent condition that results in endometrial tissue developing in extrauterine sites. The most common site for endometrial implantation is the pelvis, with the ovaries, posterior cul-de-sac, and anterior cul-de-sac affected most frequently. Endometriosis is a disease of women of reproductive age and is rare in postmenopausal women unless they are on estrogen replacement therapy. Dysmenorrhea, pelvic pain, and dyspareunia are the most frequent presenting complaints, but patients may have bowel or bladder symptoms as well. Infertility is found in a quarter of patients. Physical examination is often normal, but depending on the location and size of the implants patients may have localized tenderness on pelvic examination. Pelvic ultrasound is routinely ordered as a first-line test in women with pelvic pain. Although it is unlikely to provide a diagnosis of endometriosis, it can rule out other causes of the patient's symptoms. Definitive diagnosis is made via laparoscopy. Treatment of endometriosis consists of pain management with nonsteroidal anti-inflammatory medications, interruption or cessation of the menstrual cycle via oral contraceptives, and gynecology referral. Surgical management with laparoscopic removal of the implants is another option, especially for those patients wishing to get pregnant.

A 24-year-old woman presents to the clinic complaining of cyclical pelvic pain and painful intercourse for the past year. She states that the pelvic pain occurs a few days prior to the start of menstruation. She denies any menorrhagia, abdominal pressure or vaginal discharge. She denies any history of sexually transmitted infections. Vital signs are within normal limits. Pelvic examination reveals lateral displacement of the cervix but is otherwise normal. Which of the following is the most likely diagnosis? Adenomyosis Endometriosis Leiomyoma Pelvic inflammatory disease

Endometriosis is defined as endometrial glands and stroma which occur outside of the uterine cavity. Lesions are most commonly located within the pelvis, but can also occur in the bowel, diaphragm, and pleural cavity. The most common site of endometriosis are the ovaries, where they are called endometriomas. Risk factors for the development of endometriosis are nulliparity, prolonged exposure to endogenous estrogen, exposure to diethylstilbestrol in utero, and lower body mass index. Women classically present during their reproductive years complaining of pelvic pain (including dysmenorrhea and dyspareunia), infertility, and ovarian mass. The location of the endometriosis can also affect the symptoms a patient will present with. For women with bladder endometriosis, symptoms are predominantly urinary frequency and urinary urgency, whereas women with bowel endometriosis may present with complaints of diarrhea, constipation, and dyschezia. Physical examination may reveal tenderness on vaginal examination, nodules in the posterior fornix, adnexal masses, and immobility or lateral displacement of the cervix or uterus. Transvaginal ultrasound and magnetic resonance imaging may reveal endometriomas, nodules on the rectovaginal septum, and bladder nodules. Definitive diagnosis requires a histologic analysis of a lesion biopsied during surgery, typically laparoscopy. For women with mild to moderate pain, treatment generally includes continuous hormonal contraceptives and nonsteroidal anti-inflammatory drugs (NSAIDs). In patients who continue to suffer from severe symptoms despite treatment with contraceptives and nonsteroidal anti-inflammatory drugs, a trial of a gonadotropin-releasing hormone agonist with add-back hormonal therapy may be warranted. Additionally, symptomatic and expanding endometriomas may require laparoscopic excision.

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

Enlarged renal pelvis and proximal ureter. Hydronephrosis is the distension of the renal calyces and pelvis due to obstruction of distal urinary flow which commonly accompanies hydroureter. It can occur in both acute and chronic forms, and can affect one or both kidneys. Major childhood causes include congenital ureteropelvic junction abnormalities, urethral valves and urethral stricture. Major adult causes include urolithiasis, benign prostatic hyperplasia and other bladder outlet obstruction, prostate carcinoma, bladder prolapse and retroperitoneal or pelvic neoplasms. Acute hydronephrosis leads to changes in renal function and acute renal failure, while chronic forms cause infection and sepsis, renal scarring, permanent nephron loss and calculous formation. Acute cases typically present with pain (renal or ureteral colic), which alludes to the level of obstruction. Renal pelvic or superior ureteral obstruction causes flank pain, while inferior ureteral obstruction refers pain to the ipsilateral testicle or labia. Severe pain usually is the result of acute complete or partial bilateral stone obstruction, or acute fluid overload in previously asymptomatic and undiagnosed ureteropelvic junction abnormality. Leukocytosis and pyuria suggests an infectious etiology. Hematuria suggests urolithiasis as the cause. Renal ultrasonography is the initial test of choice to diagnose the level of urinary tract obstruction. If unremarkable, intravenous pyelography or CT scanning may be necessary. Treatment is geared at treating the underlying etiology.

A 68-year-old woman presents to the clinic with progressive lower abdominal bloating for the past six months. Ascites is present on exam, and a right-sided adnexal mass is palpable. Pelvic ultrasonography reveals a solid complex mass on the right ovary and confirms presence of associated ascites. Which of the following is the most likely diagnosis? Endometrioma Epithelial carcinoma Mature cystic teratoma Sex cord-stromal tumor

Epithelial carcinoma. The incidence of ovarian cancer grows with increasing age, and at least 30 percent of all ovarian neoplasms in women over age 50 are malignant. Average age at diagnosis is 60 years. Ovarian cancer is the most common cause of gynecologic death in the United States. Epithelial carcinoma is the most common histologic type of cancer of the ovary, fallopian tube and peritoneum. Affected women usually complain of vague gastrointestinal symptoms including early satiety, bloating, and dyspepsia. Many women with ovarian cancer are asymptomatic, and symptoms are associated with advanced disease. Physical exam findings may include a pelvic or adnexal mass, abdominal distention with ascites, or a pleural effusion. Pelvic ultrasound usually shows a complex ovarian mass and ascites. Definitive diagnosis is histologic after surgical removal of the affected ovary. Surgical staging and cytoreduction followed by adjuvant chemotherapy is typical management for affected patients. The majority of women with early-stage disease will be recurrence-free at five years. Prognosis is poor for women with advanced stage disease; most of these women will relapse and mortality is high.

A patient complains of new onset hematuria, left flank pain and unintentional weight loss. Her past medical history is significant for chronic hypertension and tobacco use. Abdominopelvic imaging reveals a mass within the confines of the left renal capsule. A surgical biopsy is taken. When considering the most common kidney cancer in adults, the histology report of this patient's biopsy would most likely describe abnormalities of which of the following cells? Connective tissue cells of the renal stroma Epithelial cells of the proximal convoluted tubule Stromal cells of the metanephrogenic blastema Transitional cells of the renal pelvis

Epithelial cells of the proximal convoluted tubule. Renal cell carcinoma is the most common type of kidney cancer in adults. It originates from the epithelial cells of the proximal convoluted tubule. There are 5 different histological subtypes of renal cell carcinoma. The most common risk factors are tobacco use, obesity, prolonged anti-inflammatory use and hypertension. Most tumors remain clinically silent until advanced progression. Most renal cell carcinomas are found incidentally on unrelated imaging reports. Only 10% of cases present with the classic triad of flank pain, flank mass and hematuria. Other symptoms include weight loss, fever, hypertension, hypercalcemia, night sweats and malaise. The characteristic radiographic appearance of renal cell carcinoma is a solid, irregular or lobulated border, mass which distorts the renal contour. Initial treatment involves a radical or partial nephrectomy, as this cancer is relatively resistant to radiotherapy and chemotherapy. Some cases respond to immunotherapeutics.

A 5-year-old boy with a history of sickle cell anemia presents with dyspnea and fatigue. His mother notes that 1 week prior, he had a fever, headache, and bright red rash on his cheeks, which has since resolved. Laboratory studies show a decrease in his baseline hemoglobin by 30%. Infection with which virus likely precipitated his current symptoms? Coxsackievirus Human herpesvirus 6 Measles virus Parvovirus B19

Erythema infectiosum is a generally benign, self-limiting disease that affects young children ages 4 to 10 years. It is caused by parvovirus B19. After a brief, mild prodrome of malaise and low-grade (if any) fever, patients develop a characteristic facial rash with a slapped cheek appearance. One to four days later, the rash spreads to the trunk and extremities and takes on a lacy appearance. While most children recover in a week, certain children with a history of hematologic abnormalities, such as sickle cell anemia, may develop transient aplastic crisis due to a marked reduction of erythroid cell precursors. These patients may present with onset of pallor, fatigue, lethargy, and shortness of breath due to anemia. Laboratory studies will show an undetectable reticulocyte count and a drop in hemoglobin concentration of > 30%. Anemia is often severe enough to require transfusion. Fortunately, as the name suggests, transient aplastic crisis is self-limited as red cell production returns to normal once the infection has cleared (typically in one to two weeks).

A 65-year-old man with a past medical history of hypertension presents to the emergency department with "tearing" chest and abdominal pain radiating towards his back. His blood pressure is 185/98 mm Hg. Which of the following medications should be administered first? Aspirin Esmolol Heparin Nitroprusside

Esmolol is the first line treatment for a hypertensive patient with an aortic dissection. Rate-controlling medication (e.g. esmolol) should be given before vasodilators to prevent reflex tachycardia and subsequent increase in aortic shearing forces. An aortic dissection occurs when the intima tears allowing blood to cause a false channel and intramural hematoma. If this extends to the heart it can precipitate myocardial infarction, severe aortic regurgitation, or pericardial tamponade leading to death. Risk factors include a history of hypertension, collagen vascular disease or aortic aneurysm, as well as current pregnancy and cocaine use. Based on the Stanford classification, a dissection is classified as type A if it involves the ascending aorta while a type B dissection is limited to the descending aorta. Treatment of a type A dissection requires surgical management while type B dissections are typically managed medically.

A 25-year-old woman with a history of hypertension presents to the emergency department after a syncopal event. She is complaining of lower abdominal pain. Her heart rate is 132 beats/minute and her blood pressure is 85/41 mm Hg. Her urine pregnancy test is positive. Which of the following is the most appropriate next step in management? Administer rho(D) immune globulin Establish intravenous access Obtain a 12-lead electrocardiogram Order an abdominal ultrasound

Establishing intravenous access is the most appropriate next step in this hemodynamically unstable patient. This patient likely has significant hemorrhage from a ruptured ectopic pregnancy and requires fluid resuscitation and possible blood transfusion. An ectopic pregnancy occurs when the developing blastocyst implants somewhere outside of the endometrium of the uterus. Risk factors include smoking tobacco, multiple sexual partners, fertility medications (e.g. clomiphene citrate), and a history of pelvic inflammatory disease. Symptoms include abdominal pain, vaginal bleeding, and in severe cases signs of hypovolemic shock (e.g. hypotension, tachycardia, syncope). Medical therapy with methotrexate can be considered to treat a select group of stable patient with no signs of rupture. However, unstable patients require emergency surgery.

A 62-year-old man is admitted to the hospital for sepsis secondary to a urinary tract infection. His medical history is significant only for hypertension. On examination he has a temperature of 36.5°C, a TSH level of 0.2 mcIU/mL, and a T3 level of 60 ng/dL. Which one of the following is the most likely explanation for these findings? Euthyroid sick syndrome Graves' disease Subacute thyroiditis Subclinical hyperthyroidism

Euthyroid sick syndrome can be described as abnormal findings on thyroid function tests that occur in the setting of a nonthyroidal illness, without preexisting hypothalamic-pituitary and thyroid gland dysfunction. This is most commonly diagnosed in a hospitalized patient and after recovery from the underlying illness. The thyroid function test abnormalities subsequently resolve. The most prominent alterations are low serum triiodothyronine (T3). Thyroid-stimulating hormone (TSH), thyroxine (T4), and free T4 (FT4) are also affected in variable degrees based on the severity and duration of the nonthyroidal illness. As the severity of the underlying illness increases, both serum T3 and T4 levels drop and gradually normalize as the patient recovers.

An 11-month-old girl is brought to the ED by her mother. Mom reports that when she picked her up from daycare in the afternoon the infant seemed fine, but she didn't eat much for dinner and subsequently vomited. There were what looked like clumps of blood in her vomit. She has had no recent illnesses and no known injuries. Her vital signs are normal on presentation. On exam, she is a well-appearing, playful child. Her physical exam, including abdominal exam, is generally unremarkable. However, there appears to be dried blood in her left nare. No foreign bodies or masses are visualized. What further history is most important to obtain? Dietary inventory Events while at daycare Family history of bleeding disorders Gastrointestinal history

Events while at daycare In a child with active bleeding, a rapid assessment should be taken to evaluate respiratory and hemodynamic stability, as airway intervention or fluid resuscitation may be urgently needed. In this scenario, we have a clinically stable child who presents with signs of a recent but not active bleed. The first goals of evaluation should be to determine the location and cause of the bleeding. The primary physical findings to note are hematemesis and dried blood in one of her nares, which point towards epistaxis, or nose bleed, as the source. There is a wide range of possible causes for epistaxis, from minor, localized, or self-limited causes, to systemic, incidental, or chronic causes. The major red flag in this case requiring further investigation is the patient's age. Children less than two years of age rarely develop epistaxis. Thus, their presentation with active or recent history of epistaxis should trigger concern for serious systemic illness or trauma (both intentional and unintentional). Hematemesis suggests this patient likely swallowed blood, which can be more common with posterior nasal bleeds; blood present in the oropharynx is also consistent with a posterior bleed. Examination of the nasopharynx can be challenging in children and may be aided by application of a topical vasoconstrictor with or without anesthetic. Examination for posterior bleeding usually requires endoscopy by an otolaryngologist. The absence of explanation around the timing and occurrence of epistaxis for this child is concerning. It will be essential to ascertain what events occurred unobserved by the parent, in this case while at daycare, which may explain the mechanism of injury, location of bleeding, measures taken to stop the bleeding, and duration and quantity of the bleeding. At the very least, these data would add to clinical decision-making around whether additional studies for serious illness are needed. More importantly, the fact there was no incident reported to the mother is concerning for intentional injury or negligence. Studies to evaluate for other findings of physical child abuse may be warranted.

A 32-year-old man presents with persistent ringing in his ears that occurs daily and lasts throughout the day. This has been going on for several months, but recently has been getting gradually worse. He is a construction worker by trade. Health history is unremarkable except for lower back pain for which he pops some ibuprofen throughout the day. He denies any other medications. He does not smoke but usually has five to six beers on the weekend. His examination is unremarkable. What is the most likely cause of his tinnitus? Excessive alcohol consumption Excessive caffeine use Excessive ibuprofen use Exposure to excessive noise at work

Excessive ibuprofen use Excessive ibuprofen use, or use of any nonsteroidal anti-inflammatory drugs (NSAID), including aspirin, has been commonly known to cause tinnitus. This used to be a very common complaint among patients with inflammatory arthritis when NSAIDs were the main form of treatment. Younger men, in particular, are notorious for underestimating how many over-the-counter medications they are taking and the possible consequences they could have. Providers should try to elicit a clear history of medication use and patients should also be educated on the risk of taking excessive medications.

An 8-year-old girl with a history of sickle cell anemia presents with diffuse pain consistent with an acute sickle cell pain crisis. While in the emergency department, she develops acute onset headache, right-sided facial droop, and right arm weakness. A CT scan confirms the diagnosis. Which of the following is the next best step in management? Alteplase Exchange transfusion MRI brain Tranexamic acid

Exchange transfusion. Cerebrovascular events are a potential complication of sickle cell disease. This patient developed symptoms concerning for acute ischemic stroke. For pediatric patients with acute ischemic stroke in the setting of sickle cell disease, exchange transfusion is the treatment of choice. Transfusion goals include decreasing hemoglobin S levels to less than 30% and obtaining a total hemoglobin level of 10 g/dL. For adults with acute ischemic stroke in the setting of sickle cell disease, use of tissue plasminogen activator (tPA) is an area of controversy. However, tPA is not indicated or approved for use in pediatric patients.

Which of the following clinical findings can best differentiate Graves disease from other causes of hyperthyroidism? Diplopia Exophthalmos Lid lag Lid retraction

Exophthalmos. Graves disease, also known as diffuse toxic goiter, is the most common cause of hyperthyroidism in the United States. It is an autoimmune disorder that results from the production of autoantibodies to the TSH receptor causing increased stimulation of the gland. The classic triad of Graves disease includes the presence of a diffuse goiter, exophthalmos and pretibial myxedema. Exophthalmos is not the result of excess thyroid hormone (which causes other eye findings such as lid lag and lid retraction) but rather is due to cellular inflammation and the accumulation of hydrophilic glycosaminoglycans in the extraocular muscles and retroorbital tissues. This increased volume results in proptosis and periorbital edema. Smoking has been found to be a risk factor for the development of Graves ophthalmopathy. Decreasing thyroid hormone secretion does not improve the pathology of Graves ophthalmopathy but will reduce other eye symptoms that are associated with excess thyroid hormone. Medical therapies that may improve symptoms include selenium, glucocorticoid therapy and rituximab. Orbital decompression surgery is indicated in severe cases. Diplopia is the result of weakness of the extraocular muscles. Lid lag describes when the upper lid remains retracted when the patient follows an object downward. Lid retraction describes how the upper lid is retracted more than usual when at rest. This results in the patient appearing as if he is staring and can also be confused with true proptosis. These findings can all be seen in patients with hyperthyroidism and are not specific to Graves disease. Unlike exophthalmos, these findings will also improve with return to normal thyroid hormone levels.

Which of the following diagnostic studies would be most helpful to obtain in a patient complaining of syncopal episodes? Alkaline phosphatase Fasting glucose Sedimentation rate Thyroid stimulating hormone

Fasting glucose Syncope is defined as a transient loss of consciousness with loss of postural control, followed by a spontaneous recovery. The causes of syncope are multifactorial and can involve different systems, such as the cardiovascular system, the nervous system or the endocrine system. It is important to obtain a detailed history of the events prior to the syncopal episode, as well as all medications the patient was taking prior to the syncopal episode. History and physical exam alone may help to differentiate the etiology of the syncope, but often further studies are required. Laboratory studies that may be obtained in patients with a history of syncope include a CBC, serum electrolytes, fasting glucose, total creatine kinase, cardiac enzymes, and urinalysis. An ECG should also be performed. Further diagnostic studies can be tailored to the individual, based on results of laboratory testing and history. A chest X-ray may help to rule out pneumonia, mediastinal widening due to aortic dissection, congestive heart failure, or pleural effusion. A CT scan of the head is indicated if the patient presents with any focal neurologic signs. A computed tomography pulmonary angiogram, or ventilation/perfusion scan if that is contraindicated, can be performed if a pulmonary embolus is suspected. An EEG is useful for ruling out seizure disorder, and echocardiography is useful for evaluation of cardiac etiologies. Tilt table testing can be performed when autonomic dysfunction is suspected. Treatment is tailored to the specific disease process.

A 25-year-old sexually active woman presents to the Emergency Department with a complaint of painful vulvar ulcers and a swollen inguinal lymph node. She denies dysuria and vaginal discharge. Which of the following is most consistent with the description of the offending infectious organism? Gram negative coccobacillus Gram negative diplococcus Obligate intracellular gram negative organism Spirochete

Gram negative coccobacillus. Chancroid is a common sexually transmitted disease in developing nations, but is relatively rare in the United States. Chancroid is caused by Haemophilus ducreyi, a gram negative coccobacillus, which has an incubation period of 4 to 10 days. Initially, a small pustule will form at the site of inoculation and progresses to multiple, painful ulcerations with sharply demarcated purulent bases. The number of ulcers and the pain associated with the ulcers are the distinguishing features of chancroid and differentiate it from syphilis. Chancroid is also associated with painful inguinal lymphadenopathy, termed a bubo, which is unilateral, large, painful, fluctuant and may become suppurative. Patients will frequently complain of dysuria, but this is typically due to urine passing over the exposed ulcers and not due to urethral inflammation. Diagnosis is made with culture and both herpes and syphilis should be ruled out. Treatment is with Azithromycin 1 gm orally once, ceftriaxone 250 mg intramuscularly once, ciprofloxacin 500 mg orally twice a day for three days, or erythromycin 500 mg orally four times a day for 7 days. Syphilis, caused by the spirochete (D) Treponema pallidum, first presents as a painless chancre or genital lesion after a 3 week incubation period, and is easily confused with the painful lesion of chancroid. The chancre spontaneously heals in 3-6 weeks before the infection progresses on to secondary (characterized by a rash and lymphadenopathy) and tertiary syphilis which affects the nervous and cardiovascular system through neuropathy and widespread granulomatous lesions.

You examine a three-year-old girl for possible drowning. She was unsupervised for a few minutes and later her mother found her by the pool. The mother called 911, and CPR was performed for five minutes. Upon arrival in the emergency room, she is unresponsive and is immediately intubated. Her blood pressure is 70/50 mm Hg, heart rate is 125 beats per minutes, and pulse oximetry reading is 95 percent. Which of the following is the correct statement regarding water safety? Adolescents who had swimming lessons are allowed to swim alone Fencing that surrounds a pool with a self-locking gate reduces the risk of drowning Less supervision is fine for toddlers who had swimming lessons Water wings and floaters can be relied upon as drowning prevention measures

Fencing. The pediatrician has the opportunity to inform families at risk regarding water safety through anticipatory guidance. Prevention is the most effective way to decrease the injury burden of drowning. A family-centered approach to anticipatory guidance for water safety is to explore and identify the water hazards that each family is exposed to in their environment. The practitioner can then discuss the best tools and strategies for prevention that are relevant for the particular family. A common preventive strategy for exposure to all water types and all ages is ensuring appropriate supervision. Pediatricians should define for parents what constitutes appropriate supervision at the various developmental levels of childhood. Supervision of infants and young children means that a responsible adult should be with the child every moment. Another strategy to reduce the risk of drowning is with isolation fencing that completely surrounds a pool, with a secure, self-locking gate. In families who have a pool on their property, caregivers often erroneously believe that if a child falls into the water there will be a loud noise or splash to alert them. On the contrary, drowning events are usually silent, increasing the time until the child is discovered. This finding highlights the importance of the guideline that the fence actually separates the pool from the house, not just surround the entire property.

Which of the following clinical scenarios in a patient with chronic ethanol use should prompt admission to the hospital? Fever, tachycardia, hypertension Intoxication with vomiting Mild tachycardia, tongue fasciculations Normal vital signs, one seizure six hours ago

Fever, tachycardia, hypertension When alcohol use is abruptly stopped or markedly decreased, patients may develop alcohol withdrawal with mild symptoms, alcohol related seizures, or in the most serious and life-threatening form of withdrawal, delirium tremens. The patient described here has several abnormal vital signs (fever, tachycardia, hypertension). These abnormalities are concerning for major alcohol withdrawal which is a constellation of symptoms which may include anxiety, irritability, tremors, tachycardia, fever, hypertension, decreased seizure threshold, and both auditory and visual hallucinations. In its most severe form, patients develop delirium tremens, which is a severe, hyper-adrenergic state with confusion, hallucinations, and hemodynamic instability. This condition is life-threatening and requires aggressive treatment with benzodiazepines and possibly antipsychotics.

Which of the following best describes a barrier to treatment for a patient with paranoid personality disorder? Aggression Agoraphobia Delusions of persecution Fragile self-concept

Fragile self-concept In paranoid personality disorder, the patient is obsessed with threats or perceived threats to their safety. They see threats where others do not. There is a persistent, pervasive distrust of others' actions and motivations, and a cynical worldview. This creates barriers to psychotherapy, because the patient often misinterprets phrases used by the therapist as personal threats. To overcome this barrier, the therapist must remember that the paranoia manifested in paranoid personality disorder is often a by-product of a fragile self-concept. When miscommunication occurs, as it often will in conversations with a patient with paranoid personality disorder, it is important to address the miscommunication immediately and in a non-threatening way. Continued affirmation, gentleness and patience may help maintain the therapist-patient relationship.

A 22-year-old woman presents with a mass in her right breast that she noticed while showering. She has noticed pain in the area just prior to her menstrual cycles each month. An ultrasound is ordered and shows multiple cystic lesions in the right breast. Which of the following historical factors may be contributing to this condition? Family history of breast cancer Frequent alcohol consumption Obesity Tobacco use

Frequent alcohol consumption, particularly in younger women, has been shown to increase the risk of fibrocystic conditions of the breast. A fibrocystic condition is the most frequently occurring condition of the breast and commonly occurs in premenopausal women. The condition refers to histologic changes in the breast epithelium that are benign. These could cause some discomfort in response to hormonal changes associated with the menstrual cycle. Patients may complain of lumps or masses in the breasts that are transient and tender. Ultrasound may be able to distinguish cancerous masses from fibrocystic lesions. Any suspicious lesion should be biopsied. Treatment includes supportive measures to relieve pain and avoiding trauma to the breasts. The role of caffeine in exacerbating symptoms is controversial. Patients should be counseled on the condition and those with a higher risk of developing breast cancer should be educated on the importance of regular self-examinations of the breasts.

While assessing a patient's functional capacity as part of the preoperative cardiac risk, the patient states that she can walk independently, but slowly, and can complete light chores around her home, but she cannot do her own yard work or go up and down stairs without assistance. Which of the following options is the correct way to document her functional capacity? 4-7 METs 7-10 METs Greater than 10 METs Less than 4 METs

Functional capacity, or cardiac functional status, is an important indicator of postoperative cardiac complication risk, and it should be assessed at the initial preoperative evaluation. Poor functional capacity is associated with increased cardiac complications in noncardiac surgery. A patient's functional capacity is expressed in metabolic equivalents (1 MET equals 3.5 mL O2 uptake/kg per minute, which is the resting oxygen uptake in the seated position). Self-care, the ability to complete activities of daily living (ADLs), vacuuming, walking 2 mph, and writing are examples of poor functional capacity (less than 4 METs). The ability to walk up a flight of stairs, walk 4 mph, walking a golf course, doing yard work, and cycling are examples of moderate functional capacity (4-10 METs). Jogging, playing singles tennis, swimming, and skiing are examples of excellent functional capacity (greater than 10 METs). One specific indicator of increased risk of postoperative cardiopulmonary complications is the inability to climb two flights of stairs or walk four blocks.

A 62-year-old woman with a history of breast cancer and rheumatoid arthritis presents with stiff neck and severe headache that started a couple of days ago; symptoms are worsening. Upon awakening the morning of presentation, she felt nauseated and vomited twice. Your neurological examination shows right-sided hemiparesis and dilated and non-reactive left pupil. Question: What will be your next step? 1 Fundoscopic examination 2 Lumbar puncture 3 Perform doll's eye maneuver 4 Magnetic resonance imaging 5 Chest X-ray

Fundoscopic examination Having a history of breast cancer and signs of possible intracranial hypertension, your patient may have a metastatic tumor in the brain. Right-sided hemiparesis and dilated non-reactive pupil on the left point to the compression from the left side. While in the office, she should be examined for the presence of papilledema. Papilledema will confirm your suspicion that she has a transtentorial herniation, in which brain tissue bulges out of the cranium through the tentorial notch because of the increased intracranial pressure. You should schedule magnetic resonance imaging (MRI) of the endocranium. While waiting for the MRI, undertaking a simple fundoscopic examination in the office will contribute to your diagnosis.

Bloody stool with cysts and trophozoites should make you think of what diagnosis?

amebiasis

A morbidly obese 32-year-old woman has a 4-month history of hypertension that has been nonresponsive to multiple antihypertensive medications. Blood pressure readings over the past month have an average diastolic pressure of 115 mm Hg. Her serum creatinine is 1.2 mg/dL. Which of the following diagnostic tests is most appropriate at ruling-in the most common cause of this refractory hypertension? Captopril renography Duplex Doppler ultrasonography Gadolinium-enhanced magnetic resonance angiography KUB radiograph

Gadolinium-enhanced magnetic resonance. Systemic hypertension is a common disease in America. Most cases are essential, however, secondary hypertension exists and is commonly caused by renal vascular hypertension, with renal artery stenosis (RAS) being a common pathology. Atherosclerosis and fibromuscular dysplasia are the most common underlying sources of renal artery stenosis. RAS accounts for 5% of all systemic hypertension. RAS is especially prevalent in cases of refractory, malignant or accelerated hypertension, as well as in significant diastolic hypertension in those less than 35-years-old. Clinical manifestations include abdominal or renal bruit, deteriorating renal function and other signs of generalized atherosclerosis. Magnetic resonance angiography (MRA) has the highest sensitivity for detecting renal artery stenosis. Due to the risk of gadolinium-induced nephrogenic systemic fibrosis, MRA should be avoided in patients with a creatinine clearance less than 30 mlL/min. Diagnosis can also be made with computed tomography angiography which has a comparable sensitivity for detecting renal artery stenosis. Limitations include use of contrast (contraindicated in patients with limited renal function) and radiation exposure. Diagnosis can also be made with duplex Doppler ultrasonography (B), which is particularly useful in patients with reduced renal function, however, this modality may miss pathology of small arteries. It is also time consuming, operator dependent, and technically difficult, especially in obese patients.

A 63-year-old man with a 40-pack-year smoking history presents for evaluation of a 25-pound weight loss over the past six months. He complains of intermittent epigastric pain as well as progressive difficulty swallowing. Physical exam reveals a nodule around the umbilicus and left supraclavicular lymphadenopathy. Which of the following is the most likely diagnosis? Duodenal ulcer Esophageal cancer Gastric cancer Gastric ulcer

Gastric cancer is the third leading cause of global cancer mortality and the leading cause of infection-associated cancer death. Histologically, it is most often adenocarcinoma. Risk factors include smoking, chronic Helicobacter pylori infection, a diet high in salt, and obesity. Most patients with gastric cancer already have advanced incurable disease at the time of presentation. Weight loss and persistent epigastric abdominal pain are the most common symptoms at initial diagnosis. Dysphagia may be present in patients with cancers arising in the proximal stomach. Physical exam may reveal a palpable abdominal mass. Tumor extension or spread may cause left supraclavicular adenopathy, called a Virchow's node, a periumbilical nodule, called Sister Mary Joseph's node, or a left axillary node, called an Irish node. Upper gastrointestinal endoscopy with biopsy is the diagnostic study of choice. Treatment depends on staging.

A 29-year-old woman is in active labor. Her history is significant for shoulder dystocia during the birth of her previous child. Which of the following would best diagnose shoulder dystocia in her current labor? Gentle downward traction on the fetal head fails to deliver the anterior shoulder Head-to-body expulsion time is greater than 30 seconds The fetal anterior shoulder presents before the posterior shoulder The fetal head retracts into the uterus after expulsion

Gentle downward traction on the fetal head fails to deliver the anterior shoulder. Shoulder dystocia is defined as failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head, requiring extra maneuvers to enable delivery of the fetal shoulders. In a normal labor and delivery, the head is expulsed first, followed by the shoulders. In normal circumstances, gentle downward traction on the head of the fetus is all that is needed for delivery of the shoulders. As the infant proceeds down the pelvis, the shoulders enter at an oblique angle, with the posterior shoulder in front of the anterior one. At the pelvic outlet, when the fetal head externally rotates, the shoulders switch position, becoming anterior-posterior, and the anterior shoulder slides out after the head is expulsed. In shoulder dystocia, the shoulders descend simultaneously into the pelvis or descend anterior-posterior before rotation of the fetal head, and the shoulders become impacted, either anteriorly (on the symphysis pubis) or posteriorly (on the sacral promontory). Subjectively, the provider notices gentle traction on the fetal head does not produce delivery of the shoulders, and extra manipulation is needed for full delivery of the fetus. Initial approach should involve McRoberts' maneuver first without followed by with suprapubic pressure to release the impacted shoulder. If this is unsuccessful, delivery of the posterior fetal arm should be tried next. McRoberts' maneuver is performed by two assistants who each flex one of the mother's legs until her thighs touch her abdomen, thus flattening the sacrum and rotating the symphysis pubis cephalically. Several other noninvasive, invasive, and surgical maneuvers exist for shoulder dystocia, but the aforementioned are the most commonly used. The goal of management is to prevent fetal asphyxia, permanent brachial plexus palsy, death, and fetal or maternal physical injury.

A 65-year-old woman presents to the ED with sudden onset of right eye pain and blurred vision. Physical examination reveals circumcorneal injection, a 7 mm right pupil that is unresponsive to light and an intraocular pressure of 35 mm Hg. Which of the following is the gold standard test to confirm the diagnosis? Dark room provocation Dilated fundus examination Gonioscopy Slit lamp grading

Gonioscopy is considered the gold standard in the diagnosis of acute angle closure glaucoma, an ocular emergency that this patient is experiencing. This method allows the examiner to examine the angle that is formed between the cornea's posterior surface and the iris' anterior surface. An experienced provider, such as an ophthalmologist, should perform this test. Care must be taken to not shine light directly onto the pupil as the angle could widen and create an error in measurement.

A gram-negative coccobacilli found in sputum of a patient with pneumonia should make you think of what diagnosis?

H. flu

What are the 5 criteria for metabolic syndrome?

HDL <40 men <50 females, BP >135/85, Triglycerides >150, Fasting glucose >100, Waist >40 inches in men >35 inches in women

Community acquired carditis is most often caused by one of the HACEK organisms. List the HACEK organisms.

Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella

List three positive symptoms of schizophrenia.

Hallucinations, delusions, movement disorders

A 14-year-old boy is treated in the emergency department for a sprained ankle. Just prior to discharge, his mother states that he has a severe egg allergy and asks if he should get a flu vaccination. His regular medications include aspirin. Of the following, which should you tell the mother? He is not at increased risk of anaphylaxis from the influenza vaccine He is unable to receive the influenza vaccine due to his allergy He should get the live attenuated nasal vaccination He should get the vaccine from his pediatric allergy specialist

He is not at increased risk of anaphylaxis from the influenza vaccine. Both the intramuscular and the live-attenuated influenza vaccines are cultured using a fluid from chicken embryos and contain a small amount of egg protein. As such, many parents with children that have egg allergies are concerned that receiving the vaccine could cause anaphylaxis in their child. A 2012 review of data showed that children with egg allergy are not at increased risk of anaphylaxis from the influenza vaccine. Anaphylaxis still may occur, at a rate of 1-10 in a million, similar to those without egg allergies, and is thought to be due to the immunizing agent itself or other residual proteins used in the creation of the vaccine. In regard to influenza immunization, the American Academy of Pediatrics recommends that patients with an allergy to eggs can receive the influenza vaccine. A recommendation that persons with a history of severe allergic reaction to egg (i.e., any symptom other than hives) should be vaccinated in an inpatient or outpatient medical setting (including but not necessarily limited to hospitals, clinics, health departments, and physician offices), under the supervision of a health care provider who is able to recognize and manage severe allergic conditions.

A 31-year-old man presents to the emergency department after an episode of syncope following sexual intercourse. Upon regaining consciousness at home, patient began complaining of a severe headache and started to vomit. Physical examination reveals an uncomfortable man with positive meningeal signs. Blood pressure is 162/94 mm Hg. CT scan of the head without contrast reveals no acute pathology. Based on the most likely diagnosis, what would you expect on the patient's lumbar puncture? Decreased opening pressure Decreased protein Elevated glucose Hemoglobin degradation products

Hemoglobin degradation products (xanthochromia) are found in the cerebrospinal fluid of a patient with a subarachnoid hemorrhage. A subarachnoid hemorrhage is most commonly caused by a ruptured saccular aneurysm. Patients often present complaining of a sudden onset of "worst headache of my life", typically in the setting of physical exertion. Patients can also experience loss of consciousness, nausea, vomiting, and meningeal signs. Noncontrast head CT scan should be the initial diagnostic study. Lumbar puncture is performed in the setting of a negative CT scan, but strong suspicion of subarachnoid hemorrhage. Severity of subarachnoid hemorrhage is based on the Hunt and Hess grading system. Complications include vasospasm, rebleeding, seizures, hydrocephalus, and death. Treatment includes antihypertensives, antiepileptics, and aneurysm management. Decreased opening pressure is incorrect, as the opening pressure in a patient with a subarachnoid hemorrhage would have an increased opening pressure. Decreased protein is incorrect. A patient with a subarachnoid hemorrhage would likely have increased protein due to the presence of blood products in the cerebrospinal fluid. Elevated glucos is incorrect, as glucose fluctuations in cerebrospinal fluid are typically attributed to infection. A patient with a severe subarachnoid hemorrhage may be found to have decreased glucose in the cerebrospinal fluid sample.

Case A 31-year-old multigravida known to have blood group A and Rh-negative red blood cells is pregnant with her third child. Her husband is also type A, but he is Rh-positive. She has an indirect Coombs titer at 1:16 dilution of her serum at 28 weeks gestation. Her past medical history includes two pregnancies; her first child (a boy) was healthy, while the second child (a girl) was born at 36 weeks gestation after the mother was noted to have an indirect Coombs titer at 1:16. Amniotic fluid obtained at 26, 28, 30, 32, and 34 weeks of gestation was analyzed by determining the optical density (OD) for bilirubin and indicated a progressive increase in the bilirubin level. Question: What is the most likely explanation for the increase in bilirubin? 1 Hemolysis of red blood cells in the fetus 2 High red blood cell count 3 Increased maternal IgG 4 Rh factor is present in the fetal blood 5 Swelling of the fetus

Hemolysis of red blood cells in the fetus An increased level of bilirubin is most likely the result of the breakdown of heme, indicating that the fetus's red blood cells were hemolyzed. The fetus most likely has from HDN (hemolytic disease of the newborn).

A 46-year-old man presents complaining of discomfort and pruritus around the anus for the past several weeks. The area then became quite painful two days ago. Pain does not seem to get worse during bowel movements but he does notice a small amount of bright red blood on the toilet paper afterward. Physical exam reveals a small soft tissue mass that is just outside the anus with extreme tenderness to palpation. What is the best treatment option at this time? Acetaminophen as needed Hemorrhoid excision Ibuprofen as needed Regular warm baths

Hemorrhoid excision would be the best choice for this patient at this time. The recent worsening pain and extreme tenderness on exam likely indicate that the hemorrhoid has thrombosed. Excising the hemorrhoid typically provides immediate relief for the patient and is most effective if done within 72 hours of the clot formation. Keeping the area clean afterwards would be recommended. Acetaminophen and Ibuprofen as needed may be recommended as temporary symptomatic treatments of discomfort for hemorrhoids that have not thrombosed. Regular warm baths of plain water lasting 10 to 15 minutes two to three times a day can help relieve symptoms and keep the area clean. Also, applying cold compresses or topical hemorrhoidal cream can help reduce swelling of the area.

What is the most common symptom of hemorrhoids? Bleeding with defecation Mucoid discharge Painful defecation Pruritus

Hemorrhoids occur with engorgement of the anal vascular cushions and deterioration of the supportive tissue around these cushions. Bleeding with defecation is the most common symptom associated with hemorrhoids. Most hemorrhoids are painless unless they become thrombosed. Symptoms get exacerbated by frequent bowel movements, constipation, prolonged sitting, lifting, and straining. Patients often complain of pruritus, swelling, and a moist perianal area. None of these is the most common presenting symptom.

You are treating a 62-year-old man who is seven days status-post coronary angiogram and stent placement, following an acute myocardial infarction. He has been on a heparin drip for five days. Lab calls to notify you that his previously normal platelet count is now 48,000/mcL. Which of the following is the most likely diagnosis? Disseminated intravascular coagulation Heparin-induced thrombocytopenia Immune thrombocytopenia Thrombotic thrombocytopenic purpura

Heparin-induced thrombocytopenia is a relatively common, life-threatening complication following exposure to heparin. It is caused by autoantibodies to platelet factor 4 (PF4) complex. Antibodies cause thrombocytopenia and thrombosis by peripheral platelet consumption and platelet activation. It is more common with unfractionated heparin over low molecular weight heparin. The first clinical finding is generally a decrease of at least 50% in the platelet count, followed by bleeding, venous thrombosis (deep vein thrombosis or pulmonary embolism), or both. When heparin-induced thrombocytopenia is suspected, heparin must be immediately discontinued and a non-heparin anticoagulant should be started. Heparin should be avoided in any patient with a history of heparin-induced thrombocytopenia.

You are evaluating a patient with polyneuropathy. His nerve conduction study reveals a predominantly demyelinating injury process. Which of the following serum laboratory tests would best delineate this patient's diagnosis? Creatinine Hemoglobin A1C Hepatitis B panel Thyroid function studies

Hepatitis B panel Electrodiagnostic testing is initially used in the evaluation of polyneuropathy with the goal of defining a predominant injury process as either axonal or demyelinating nerve damage. Specific lab tests should be reserved until after this determination as certain diseases tend to cause specific nerve injury patterns. Hepatitis B may reveal peripheral nerve demyelination. Uremia/chronic renal impairment, diabetes mellitus, and hyperthyroidism are associated predominantly with axonal neuropathy.

A 5-year-old boy presents to the clinic with concerns for fatigue and pallor. His family history is positive for his father having a "blood disorder." Physical exam reveals a palpable spleen. Laboratory studies reveal a normocytic anemia. Reticulocyte count and mean corpuscular hemoglobin concentration are increased. Which of the following is the most likely diagnosis? Hereditary spherocytosis Iron deficiency anemia Sickle cell anemia Vitamin B12 deficiency

Hereditary spherocytosis is an autosomal dominant disease that causes an abnormal shape to the red blood cell (RBC). Typically, the RBC has a biconcave shape that allows it to both be durable and pass through the small capillaries in various tissues. Patients with hereditary spherocytosis have a defect in one of the RBC membrane proteins causing a spherical shape to the cell. This shape causes the cell to be more fragile than a biconcave cell and allows it to hemolyze more readily. The shape of the cell also makes it unable to pass easily through the splenic red pulp fenestrations which leads to hemolysis. Lab studies will show a microcytic or normocytic anemia with a normal hematocrit. Reticulocytosis will typically be demonstrated and a peripheral smear will show spherocytes. Spherocytosis is the only disorder that will cause an increase in mean corpuscular hemoglobin concentration (MCHC) a value ≥ 36 g/dL is diagnostic of spherocytosis. Coombs test indicating autoimmune hemolysis will be negative. Treatment should include daily folic acid. Surgical splenectomy is recommended to eliminate hemolysis at this site.

A woman presents to the clinic complaining of pedal edema. Which of the following would be most suggestive of congestive heart failure as the likely etiology? History of bulimia nervosa History of chronic renal insufficiency History of diabetes mellitus History of inflammatory bowel disease

History of diabetes mellitus. Congestive heart failure involves ventricular dysfunction and can affect the right ventricle, left ventricle, or both. Heart failure may be due to filling defects, poor contractility, or a combination of the two. The percent of blood expelled from the ventricle during systole is measured as the ejection fraction, which is diminished in patients with systolic heart failure. In patients with diastolic heart failure, ventricular filling is impaired by a stiff ventricle, pericarditis, or valvular disease. Patients at increased risk of heart failure are those with a history of myopathy, familial heart disease, rheumatic heart disease, hyperthyroidism, pheochromocytoma, dyslipidemia, diabetes mellitus, hypertension, sleep apnea, peripheral arterial disease, substance abuse, or chemotherapy or radiation to the chest. Patients who suffer congestive heart failure can present with dyspnea, fatigue, orthopnea, pedal edema, distended neck veins, a sustained and laterally displaced apical impulse, audible extra heart sounds, bibasilar crackles or dullness to percussion at the lung bases. Diagnosis of congestive heart failure can be made with chest X-ray, electrocardiogram, and echocardiography. Treatment of congestive heart failure includes addressing the causative factors. Patients with congestive heart failure should be advised to decrease sodium intake, monitor daily weights, and engage in light physical activity as tolerated.

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? Etanercept Hydroxychloroquine Leflunomide Methotrexate

Hydroxychloroquine is generally considered to be safe until the patient knows they are pregnant. It is then advised that they stop all medications for their rheumatoid arthritis, not only for precautionary measures, but most patients typically have low or no disease activity while they are pregnant. In the event that a patient continues to experience disease activity while pregnant, hydroxychloroquine is considered generally safe to use throughout pregnancy based on analysis of over 400 pregnancies that showed no increased risk for birth defects. Hydroxychloroquine belongs to a class of drugs called DMARDs (Disease Modifying Anti-Rheumatic Drugs) and is used in a number of diseases, including rheumatoid arthritis, systemic lupus erythematosus, mixed-connective tissue disease and other autoimmune diseases. Originally used as an antimalarial drug, its mechanism of action in rheumatic disease is still largely unknown.

A 56-year-old woman with a history of lung cancer presents to the emergency department with confusion, nausea, and vomiting. She is unable to provide much history due to her confusion. She is dehydrated and is oriented only to self. She is afebrile. Her renal function is normal. Her serum calcium level is 14 mg/dL. What is the most likely mechanism for her hypercalcemia? Abnormal calcium clearance in the kidneys Bony erosion due to metastases Production of vitamin D analogues by the tumor Secretion of parathyroid hormone related protein from the tumor

Hypercalcemia is a common complication of malignancy. Breast cancer, lung cancer, and multiple myeloma are the most common malignancies associated with hypercalcemia. Solid tumors are most likely to result in hypercalcemia due to secretion of parathyroid hormone related proteins (PTHrp) from the tumor. PTHrp stimulate osteoclast activity leading to increased bone resorption. The resultant hypercalcemia leads to an osmotic diuresis and dehydration. Initial treatment is to replenish hypovolemia with crystalloid fluids. Diuresis is occurring due to the osmotic action of hypercalcemia and is not due to abnormal calcium clearance of the kidneys. Bony erosion due to metastases can contribute to hypercalcemia but is not the most common cause in solid tumors. Production of vitamin D analogues is associated with lymphoma and less common in solid tumors.

A 42-year-old woman presents to the office complaining of fatigue and generalized malaise over the past month. She feels like her neck "looks thick," and she is concerned about her thyroid. On exam, you palpate a nodular lesion in the left isthmus. A thyroid-stimulating hormone test is done and shows decreased levels. She is sent for a thyroid ultrasound that confirms a nodule that is solid, regular in shape, and 0.9 cm in diameter. Which of the following would you expect on thyroid scintigraphy? Autonomous nodule Hyperfunctioning nodule Indeterminate nodule Nonfunctioning nodule

Hyperfunctioning nodule. Thyroid nodules can be found on clinical exam as an incidental finding or as a more focused exam secondary to symptoms of thyroid dysfunction. Characterizing a thyroid nodule arises from the need to determine whether the nodule is malignant or benign. The chances of the nodule being cancerous are higher in children, young adults, patients with a history of neck radiation, and patients with a family history of thyroid cancer. The initial evaluation of a thyroid nodule should begin with a TSH and an ultrasound of the thyroid. On physical exam, cancerous nodules may be harder and fixed compared to a benign nodule. Patients with cancerous nodules also may complain of rapid growth over time. Thyroid ultrasound is useful in determining the size, shape, and characteristics of the nodule. If the TSH is low, then thyroid scintigraphy can determine how the nodule is functioning. Hyperfunctioning nodules are typically not malignant but can cause issues with hyperthyroidism. Nodules that have suspicious ultrasound findings, such as being greater than 1 cm in diameter, irregular, or having calcifications, should be evaluated further with a fine needle aspiration to determine if the nodule is cancerous. Nodules that do not appear concerning on ultrasound and are hyperfunctioning on thyroid scintigraphy can be monitored over time.

A 44-year-old man with a history of hypertension presents with purple, polygonal, papular lesions on the wrists. The lesions are pruritic and have been present for the last several weeks. A skin biopsy is ordered. Which of the following histology results would be most consistent with the suspected diagnosis? Homogenized superficial dermis with a flattened dermoepidermal junction Hyperkeratosis, degeneration of the basal cell layer and colloid bodies Hyperkeratosis, parakeratosis, and acanthotic epidermis Leukocytoclasia, nuclear dust, and endothelial cell swelling

Hyperkeratosis, degeneration of the basal cell layer, and colloid bodies (non-nucleated eosinophilic deposits) are typical histologic findings associated with lichen planus. Lichen planus is an idiopathic skin disorder that causes skin lesions sometimes with associated mucous membrane involvement. The cause is unknown; however, evidence suggests a possible immune-mediated cause. Lichen planus skin lesions are often described using the "five Ps": purple, polygonal, pruritic, planar, and papular. The papules are often located on the wrists and ankles; however, they can be found on other areas of the body. Close inspection of the skin lesions will reveal a reticulate, fine pattern of white lines (Wickham's striae). There may be only a few lesions or many in a scattered distribution. Mucous membrane involvement often manifests as painful ulcerations. Some drugs can cause lichen planus-like eruptions, including thiazide diuretics, phenothiazines, quinidine, and chloroquine. The course of the disorder may be chronic and last from several months to years.

A patient is found to be hyponatremic. Laboratory evaluation reveals low serum osmolality, urine sodium concentration > 20 mmol/L, and a fractional excretion of sodium (FENa) > 1%. He appears to be "fluid overloaded." Which of the following is the most likely cause of this hyponatremia? Cirrhosis Heart failure Hypertensive nephropathy Syndrome of inappropriate ADH release (SIADH)

Hypertensive nephropathy. Hyponatremia is defined as sodium less than 135 mEq/L. Hyponatremia can occur in a hypovolemic, euvolemic, or hypervolemic state. Hypervolemic hypo-osmolar hyponatremia is associated with fluid overload. The etiology is usually from a perceived low intravascular volume by the kidneys and active water reabsorption in excess to sodium retention. If urine sodium is low (<20) causes include liver failure, cirrhosis, hepatorenal syndrome, nephrotic syndrome, and heart failure. If urine sodium is high (>20) causes include acute or chronic renal failure, such as that caused by hypertensive nephropathy. Treatment of hypervolemic hypo-osmolar hyponatremia is dialysis. Cirrhosis and heart failure is often the cause of hypervolemic hypo-osmolar hyponatremia when the urine sodium is low (<20). SIADH results in euvolemic hyponatremia with urine osmolality greater than serum osmolality. The excess ADH causes total body water to increase thereby diluting total body sodium. Despite the increased total body water, these patients typically do not show evidence of edema or heart failure as the increased water is intracellular not intravascular.

List four symptoms of serotonin syndrome.

Hyperthermia!, seizure, mental status change, tremor

Which Thyroid Cancer is the most aggressive?

anaplastic

A 55-year-old man presents to the clinic, reporting progressive pain in his lower back, pelvis, and right hip that started eight months ago. He reports pain while walking and it feels worse at night. Ibuprofen provides some relief. On physical exam, he has tenderness and warmth at the lumbar spine, right iliac wing, and right greater trochanter. A mild varus deformity of the right thigh is noted. Lab analysis reveals high serum alkaline phosphatase and radiographs show lytic lesions. Which of the following is the most likely cause of these findings? Chronic soft tissue degeneration Hypervascular bone Osteolytic infectious process Soft tissue mass effect

Hypervascular bone, due to the presence of Paget disease of the bone, initially causes osteolysis with subsequent overactive osteoblastic activity leading to bone deposition and resulting in high bone turnover. The exact etiology of Paget disease is unknown, but there appears to be a genetic and geographical predisposition. With the exception of Scandinavia, people of northern European lineage have the highest disease prevalence. The initial effects of Paget disease are reflected as changes in osteoclasts, leading to focal osteolysis. As osteoclastic activity begins to subside, osteoblasts are activated, rapidly proliferate, and cause new bone and collagen synthesis. The collagen and bone deposits are significantly disorganized and have a mosaic appearance, sometimes described as "woven bone." The new bone is structurally weaker, more porous, hypervascular, and prone to fracture. Warmth, tenderness, and pain at affected sites may be noted. Continuous pain that is worse at night is common. Neurologic symptoms from nerve impingement resulting in spinal or cranial nerve deficits may be present as well. Asymmetry of the bones may also be noted. Most patients, however, are asymptomatic. The most common locations for Paget disease are the skull, spine, femur, pelvis (most commonly affected) and sacrum, but it can occur anywhere in the body and there may be multiple lesions undergoing different stages of remodeling. Diagnosis is made by plain radiographs. Lytic lesions, bony enlargement, cortical thickening, increased trabecular pattern, and deformity or bowing may be seen. Skull involvement typically begins with radiolucent areas followed by osteoblastic activity resulting in a classic 'cotton wool' appearance. Bone scintigraphy can identify active lesions and subsequent X-rays of highly active areas should be obtained for a definitive diagnosis. Magnetic resonance imaging may be helpful to evaluate for malignancy or to assess neurological complications if the axial skeleton is involved. Computed tomography may be used to identify fractures, particularly if there is articular involvement. Laboratory analysis may reveal elevated alkaline phosphatase. Biopsy is usually only required to assess lesions with a suspicious appearance or when medical therapy fails to provide relief of pain. Generally, treatment should be initiated if there are complications such as uncontrolled pain, fractures, hypercalcemia, high output heart failure, weight-bearing joints are affected, cranial or spinal lesions are present, alkaline phosphatase is significantly elevated, or if surgery is planned on an affected bone. Nitrogen-containing bisphosphonates are the primary agents used for treatment. Calcitonin may be used if contraindications exist for bisphosphonate use. Calcium and 25-hydroxyvitamin D levels should be obtained prior to treatment. Supplemental calcium and vitamin D3 are routinely administered throughout treatment. Acetaminophen or nonsteroidal anti-inflammatories, in addition to bisphosphonates, are usually given to treat pain. Surgery may be warranted in cases of significant deformity or axial skeleton involvement. Physical therapy and orthotics may be helpful if movement is impaired. Additional complications may include deafness, neuromuscular syndromes, arthritis, bleeding at lesion sites, and neoplastic conversion, particularly sarcoma. Routine serial alkaline phosphatase testing is recommended to monitor disease activity.

Perforation is a complication that occurs in 10% of patients with acute cholecystitis and is characterized by which of the following? Coarse cough Hypoactive bowel sounds Jaundice Nausea and vomiting

Hypoactive bowel sounds are an indicator that a perforation has occurred. Other symptoms include high fever, systemic signs of toxicity (tachycardia and increased respiratory rate), and increased abdominal pain with rebound tenderness. Jaundice is a yellowing of the skin. It is unusual early in the course of acute cholecystitis but may occur when edema and inflammatory changes affect the bile ducts.

A 47-year-old man presents with hiccups for three days. He is unable to stop them with any home remedies. His physical examination is benign. Which of the following is a potential cause of hiccups? Hypercalcemia Hyperkalemia Hypoglycemia Hyponatremia

Hyponatremia. Hiccups commonly begin secondary to gastric distention resulting from a number of causes including excess eating, carbonation, and aerophagia. Additionally, excess alcohol ingestion as well as an acute emotional stress or excitement may lead to hiccups. When hiccups become intractable, evaluation for a more significant cause is indicated. Within the central nervous system, pathologies that lead to inhibition of the normal hiccup reflex include vascular malformations, meningitis, encephalitis, and structural lesions. Any lesions that cause irritation to the vagus or phrenic nerves may lead to hiccups (e.g. tumors, infection, foreign bodies). Within the gastrointestinal system, there are multiple possibilities involving the stomach, esophagus, and pancreas. Additionally, any lesions that potentially irritate the diaphragm (pneumonia, effusions) can cause hiccups. Myocardial ischemia or infarction is a rare cause of hiccups. In the metabolic category, hyponatremia and hypocalcemia are two possible causes of hiccups.

A 9-year-old girl presents to the clinic for evaluation. Her mother is concerned she may have had a seizure yesterday and has since been too weak to play outside the house. On physical examination, the girl is found to be below the 5th percentile in height for age with normal vital signs. She has multiple dental caries, widening of costochondral junctions, bowing of the legs, and enlarged wrists and ankles. Which of the following laboratory screening studies suggest nutritional vitamin D deficiency? Hyperphosphatemia, hypocalcemia, and elevated parathyroid hormone Hyperphosphatemia, normal serum calcium, and elevated parathyroid hormone Hypophosphatemia, hypocalcemia, and elevated parathyroid hormone Hypophosphatemia, normal serum calcium, and low parathyroid hormone

Hypophosphatemia, hypocalcemia, and elevated parathyroid hormone Rickets is a disease in the mineralization of growing bone usually manifesting at the epiphyses of growing children and in ossification centers in adults. It is caused primarily by a deficiency in vitamin D, a fat-soluble vitamin, either from nutritional deficiencies, malabsorption, calcium deficiency, phosphorus deficiency, or distal renal tubular acidosis. Inadequate mineralization as the growth plate continues to expand results in widening of the epiphyseal regions and softening of the bones causing them to bend easily when subjected to forces. This results in most of the manifestations of rickets such as craniotabes or softening of the cranial bones, widening of the costochondral junctions or rachitic rosary, and growth plate widening in the wrists and ankles. Other manifestations, such as failure to thrive, weakness, and seizures, result from the imbalances in minerals such as calcium and phosphorus, and parathyroid hormone (PTH). Nutritional vitamin D deficiency and malabsorption of vitamin D usually presents with hypophosphatemia, hypocalcemia, and elevated parathyroid hormone as a result of low calcium levels. In malabsorption, however, there is usually accompanying gastrointestinal symptoms and other manifestations from malabsorption of other fat soluble vitamins. The treatment for nutritional vitamin D deficiency is supplementation with vitamin D and adequate nutritional intake of calcium and phosphorus to which affected individuals usually respond well.

A 12-month-old boy presents to your clinic with his concerned mother for abnormal movements. The mother reports that the child has sudden flexion and stiffening of the neck, limbs, and trunk followed by gradual extension and relaxation. These jerking spells have become more frequent and occur in clusters throughout the day. The baby will cry briefly after the spells and then become sleepy. The mother also reports that about a month ago, he started walking consistently; however, he is no longer doing that at present. Which electroencephalographic finding is most consistent with the diagnosis? Abnormally slow background with diffuse slow spike and slow wave (< 2.5 Hz) activity Frequent spike and wave discharges in the centrotemporal region Hypsarrhythmia Normal background for age with 3-Hz generalized spike and wave discharges

Hypsarrhythmia The boy in the clinical vignette has symptoms concerning for infantile spasms. This is a severe type of epilepsy syndrome with a peak incidence between approximately 4 and 12 months of age. Children experience brief jerking spells of flexion, extension or a combination of both, involving the head, neck, arms, trunk and legs that usually last a few seconds or less. Spasms often occur in clusters during sleep-wake transitions. The presence of hypsarrhythmia in the electroencephalogram (i.e., diffuse giant waves with a chaotic background of irregular, multifocal spikes and sharp waves) confirms the diagnosis of infantile spasms. West syndrome is a triad of infantile spasms, developmental regression, and hypsarrhythmia on EEG.

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? Ceftriaxone Diphenhydramine Dobutamine Ibuprofen

Ibuprofen is a treatment option for the Jarisch-Herxheimer reaction, a phenomenon that classically occurs within the first 24 hours after beginning treatment for any spirochetal infection, including syphilis. The exact mechanism of the reaction remains unknown at this time. Diagnosis is made clinically. Symptoms in an immunocompetent patient usually begin within eight hours of initiation of antibiotic therapy, however, disease type and host immune factors may alter both the onset and duration of the reaction. Presentation includes fever, chills, malaise, headache, tender lymphadenopathy, hyperventilation, decreased blood pressure, and worsening of lesions caused by the infection. Treatment is usually symptomatic, with acetaminophen or ibuprofen being the most commonly used medications. If a severe reaction occurs, appropriate care is oriented to the nature of the complication, such as intubation and mechanical ventilation if respiratory compromise occurs. Complications are most often related to constitutional symptoms and brief exacerbation of cutaneous lesions. Serious complications are related to exacerbation of localized infection, such as degradation of gummas, or heart failure from cardiovascular syphilis. Pregnancy presents a unique risk for the development of complications from syphilis treatment, as a Jarisch-Herxheimer reaction may precipitate early labor, however, this risk does not preclude treatment of syphilis.

A 10-year-old boy presents after noticing red streaks in his stool that began yesterday. He also complains of crampy periumbilical pain and his stools have been looser than normal since yesterday. A stool guaiac is positive. Exam is notable for non-blanching pinpoint macules on his ankles that appear slightly urticarial. What is the most likely etiology of the child's hematochezia? Bacterial enteritis Hemolytic uremic syndrome IgA vasculitis Meckel's diverticulum

IgA-mediated vasculitis was formerly known as Henoch-Schönlein purpura. The classic rash of IgA vasculitis is purpuric. It typically begins on the bilateral lower extremities and may initially look petechial or urticarial prior to becoming classic palpable, non-blanching reddish-purple macules and patches. In addition, the vasculitis may involve the abdominal vasculature as well, resulting in purpura along the intestinal mucosa. The intestinal purpura may cause both abdominal cramping and bloody stools and they may serve as a lead point for intussusception. Arthralgias and arthritis are also typical of early IgA vasculitis and renal abnormalities may develop during several months following diagnosis. Notably, the skin findings of IgA vasculitis may be delayed until days after the abdominal pain, hematochezia, or arthritis have developed. As such, clinicians must maintain a high suspicion for a diagnosis of IgA vasculitis in a child with abdominal pain and rectal bleeding even if purpura or arthritis are not yet apparent on examination.

Which of the following is a confirmatory test for cholecystitis? Abdominal X-ray Cholescintigraphy scan Complete blood count Liver function test

In a cholescintigraphy scan, an injected radioisotope is excreted by the liver into the biliary system. Normally, the gallbladder concentrates the isotope and is visualized; however, nonvisualization suggests cystic duct obstruction, which is highly specific for acute cholecystitis. A cholescintigraphy scan is useful when the pretest probability is high and the ultrasound is nondiagnostic.

A 62-year-old woman with a long-standing history of hypertension presents with a severe headache; it started this morning and is rapidly worsening. During the interview, she suddenly collapses. Your brief examination shows that she responds with extensor posturing on external stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by a brief insufficient release and the end-inspiration pause. How do you best describe her respiratory pattern? Cheyne-Stokes Apneusis Ataxic Cluster Kussmaul

In the hypertensive patient with sudden loss of consciousness and decerebrate response (extensor posturing), you should consider brain stem hemorrhage. Abnormal breathing patterns can be observed in both pontine and medullary lesions; they sometimes can be prognostic. Her breathing pattern is apneustic. Apneustic breathing pattern characterizes deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release and the end-inspiration pause before expiration. Lesion in the pons or upper medulla causes the removal of input from the vagus nerve and the pneumotaxic center. Normally, apneustic center of the lower pons promotes inspiration by stimulation of the dorsal respiratory center in the medulla to delay the 'switch off' signal of the inspiratory ramp provided by the pneumotaxic center of pons. Therefore, the apneustic center controls the intensity of breathing. Apneusis is an ominous sign, with a generally poor prognosis.

An otherwise healthy 38-year-old man reports six days of a painful boil on his upper back. Vital signs are BP 128/82, HR 70, RR 16, T 98.6 F. He has been applying warm compresses to the area, but it is increasing in size, and the pain is worsening. On exam, you palpate a 1 x 1 cm erythematous, tender, fluctuant abscess without induration or surrounding cellulitis. What is the most appropriate treatment for your patients abscess? Continue warm compresses and discharge home Perform incision and drainage and prescribe antibiotics Perform incision and drainage only Prescribe antibiotics only

Incision and drainage only are the recommended treatments for simple abscesses in otherwise healthy patients. Antibiotics are indicated when there is surrounding cellulitis, in immuno-compromised individuals, or when there are signs of systemic infection. Abscesses are formed by collections of pus in the dermis and deeper layers of the skin most often as a result of infection, usually Staphylococcus aureus. They present as painful, erythematous, fluctuant, tender nodules with or without surrounding erythema that may spontaneously drain purulent matter. Systemic symptoms are uncommon. Furuncles and carbuncles are two forms of abscesses caused by infected hair follicles that occur most commonly in areas of friction and perspiration such as the axillae, buttocks, back of the neck and face. A furuncle is a single small abscess in the subcutaneous tissue that develops as a result of an infected hair follicle, while a carbuncle consists of a collection of several infected hair follicles that produce a single abscess. Larger furuncles, carbuncles, and abscesses require incision and drainage. Untreated abscesses may lead to cellulitis and systemic infections. Recurrent infections in the same location are usually the result of a local defect such as a cyst, hidradenitis suppurativa or a retained foreign body, but immunodeficiency should be considered in a patient with recurrent infections arising in multiple sites.

A 39-year-old man presents to the emergency department with left hand pain. He denies recent trauma, genital or oral lesions, or fever. His medical history is significant for diabetes mellitus and tobacco abuse. His examination is shown above. Which of the following is the most appropriate initial therapy for this patient? Acyclovir PO Clindamycin IV Incision and drainage Trephination

Incision and drainage. The patient has a felon, which is a pyogenic infection of the digital subcutaneous tissue and pulp. Staphylococcus aureus is the most common causative organism. The finger pads contain septae that confine the infection leading to increased pressure at the distal finger. The infection can cause intense pain, swelling, and redness. Minor trauma of the overlying skin is often the primary cause. Incision and drainage is the recommended initial treatment if the finger is swollen and tense with palpable fluctuance. If left untreated, the infection may spread to the flexor tendon sheath leading to flexor tenosynovitis, or to the bone leading to osteomyelitis. A unilateral longitudinal incision is made to spare the sensate portion of the finger pad. This approach usually achieves adequate drainage of infection. Dissection with a hemostat to break up septations may be required to sufficiently access the wound contents. Wounds should be thoroughly irrigated then dressed with a sterile, dry dressing. The wound should be evaluated 48 hours later. Oral antibiotics covering Staphylococcus aureus, Streptococcus pyogenes, and anaerobes (e.g., trimethoprim-sulfamethoxazole) are recommended as most felons are accompanied by cellulitis.

A 73-year-old man with a history of atrial fibrillation and hypertension presented to the emergency department with a severe headache and change in mental status beginning suddenly two hours prior to arrival. Given patients acute presentation and history of known dysrhythmia, stroke protocol was initiated and an ischemic stroke was confirmed on a non-contrast CT scan of the head. If the patient had an embolic event in his left anterior cerebral artery, which of the following findings would be expected on physical examination? Broca aphasia Incontinence Left-sided upper extremity weakness Macular-sparing homonymous hemianopsia

Incontinence is a potential presenting symptom of a cerebrovascular accident occurring in one of the anterior cerebral arteries. The anterior cerebral arteries are responsible for the anterior and medial vascularization of the cerebrum. Based on the cortical homunculus, this would have a greater effect on the lower extremity and genitals. A cerebrovascular accident is most commonly caused by ischemia of the brain, commonly from a thrombus or embolus. A smaller percentage of strokes are a result of hemorrhage within the brain. Cerebrovascular accidents are more common in patients with hypertension, history of cigarette use, and heart disease. Presenting symptoms of strokes are dependent on the area of the brain affected by the ischemia or hemorrhage. Symptoms often associated with cerebrovascular accidents are facial droop, slurred speech, and unilateral weakness. A non contrast CT scan of the head should be performed emergently to determine if the stroke is hemorrhagic or ischemic in nature. Patients with an ischemic stroke presenting within 4.5 hours of symptom onset who do not have any thrombolytic exclusion criteria should receive recombinant tissue plasminogen activator (r-tPA).

A 27-year-old woman is on an estrogen-progestin oral contraceptive. Which of the following mechanisms of action is the most important for providing contraception? Alteration in cervical mucus Impairment of normal tubal motility and peristalsis Inhibition of the midcycle luteinizing hormone surge Rendering the endometrium less suitable for implantation

Inhibition of the midcycle luteinizing hormone surge The most important mechanism of oral contraceptives for providing contraception is inhibition of the midcycle luteinizing hormone surge so that ovulation does not occur. Combination estrogen-progestin oral contraceptives are potent in this regard, but progestin-only pills are not. There are many other indications for the use of oral contraception including hyperandrogenism, dysmenorrhea, menorrhagia, and other menstrual cycle disorders such as premenstrual syndrome as well as hormone replacement in women with primary hypogonadism.

Activation of the hypothalamic-pituitary-adrenal axis through excess fetal or maternal stress has been implicated as one causative factor of preterm labor. Which of the following best describes the physiologic cascade triggered by stress in a pregnant patient? Increased adrenocorticotropic hormone inhibits estrogen receptors, allowing stimulation of oxytocin receptors in the myometrium, thus producing uterine contractions Increased adrenocorticotropic hormone stimulates cortisol, which in turn inhibits cyclooxygenase-2 receptors in the amnion, leading to rupture of membranes Increased circulating cortisol inhibits corticotropin-releasing hormone through a negative feedback loop, which leads to decreased prostaglandin synthesis and cervical ripening Increased cortisol leads to increased corticotropin-releasing hormone, which activates prostaglandins that cause cervical change and rupture of membranes

Increased cortisol leads to increased corticotropin-releasing hormone, which activates prostaglandins that cause cervical change and rupture of membranes. Preterm labor refers to sustained, progressive uterine contractions which lead to cervical dilatation and effacement from 20 to 37 weeks of gestation. Before 20 weeks, such contractions would be termed inevitable spontaneous abortion. After 37 weeks, such contractions are considered full-term labor. Many causative factors have been studied in regard to preterm labor, and they can be generally classified into four main groups: pathologic uterine distention, decidual hemorrhage and abruption, exaggerated response to infection or inflammation, and premature activation of the hypothalamic-pituitary-adrenal (HPA) axis secondary to maternal or fetal stress. Uterine distention can be pathologic in the presence of multiple gestation or polyhydramnios. Damaged decidual blood vessels (which can occur in maternal hypertension) can lead to placental abruption and preterm labor. Inflammation and infection can lead to a cascade which activates tissue necrosis factor, leading to increased apoptosis of the amniotic epithelial cells and premature rupture of membranes (PROM). Maternal or fetal stress can activate the HPAaxis, which will increase adrenocorticotropic hormone. This hormone will increase levels of circulating cortisol. Cortisol increases the release of corticotropin-releasing hormone, which activates prostaglandins and can lead to cervical ripening and rupture of membranes.

Which of the following is associated with a decreased risk for endometriosis? Avoiding oral contraceptives Increasing consumption of long-chain omega-3 fatty acids Increasing consumption of trans unsaturated fat Maintaining a low body mass index

Increasing consumption of long-chain omega-3 fatty acids. When endometrial glands and stroma implant outside of the uterine cavity, it is known as endometriosis. The patient presentation of endometriosis depends on where the glands form. The patient is many times asymptomatic, but symptoms may include pelvic pain, dysmenorrhea, abnormal uterine bleeding, dyspareunia and hemoptysis. Increasing consumption of long-chain omega-3 fatty acids can decrease a woman's risk of endometriosis. Having multiple childbirths, extended periods of lactation, and use of oral contraception may also decrease risk. Some protective factors include race, late menarche, and early menopause.

Which of the following is true regarding botulism? Foodborne botulism develops 10-14 days following toxin ingestion Foodborne botulism is caused by ingestion of a heat-stable toxin (type A) Infantile botulism is the most common form Intestinal colonization is common in foodborne botulism

Infantile botulism is the most common form of botulism in the United States. Children typically present with poor feeding, decreased suckling, loss of facial expression, constipation, and noticeable neck and peripheral weakness—a constellation of symptoms known as "floppy baby syndrome." It occurs in children younger than 12 months of age, with a peak incidence at 3 months. It has been associated with ingestion of honey, corn syrup, and vacuum or environmental dust. It is caused by the ingestion and subsequent intestinal colonization of Clostridium botulinum spores in the intestinal tract.

A 65-year-old woman presents to the ED with a cough and rapid heart rate. She reports a history of hyperthyroidism. On physical exam, you note tachycardia and bilateral ocular proptosis. Which of the following is the most common trigger for this patients disease process? Infection Medication noncompliance Myocardial infarction Recent surgery

Infection. This patient is exhibiting signs and symptoms consistent with thyroid storm. Thyroid storm is a rare, life-threatening hypermetabolic state caused by severe thyrotoxicosis. The most common precipitating factor is infection; however, it can also be triggered by trauma, surgery, burns, pregnancy, diabetic ketoacidosis, myocardial infarction, stroke, withdrawal of thyroid medication, or iodine administration. Signs and symptoms of thyroid storm include anxiety, tremulousness, psychosis, obtundation, seizures, coma, fever, tachycardia (out of proportion to fever), high-output heart failure, circulatory collapse, diarrhea, and vomiting. Thyroid storm is a clinical diagnosis; however, the thyroid panel will reflect that of a patient with hyperthyroidism with a low TSH and elevated T4 and T3. Management of thyroid storm includes supportive therapy with airway protection, intravenous fluids, cardiac monitoring, and supplemental oxygen. Fever may be treated with acetaminophen as salicylates have the potential to increase T4 and T3 levels. Adrenergic blockade is the most important initial component of therapy. Propranolol, a nonspecific b-blocker, is used to decrease sympathetic hyperactivity and partially block peripheral conversion of T4 to T3. Antithyroid drugs should then be initiated. Propylthiouracil and methimazole are both options as both block the synthesis of thyroid hormone; however, propylthiouracil has the added benefit of decreasing conversion of T4 to T3 and works faster than methimazole. One hour after antithyroid drug administration, iodine should be given to inhibit the release of stored thyroid hormone. Steroids also serve as an adjunct to decrease peripheral conversion of T4 to T3.

Which of the following is appropriate initial treatment for uncomplicated symptomatic Crohn's disease? Antibiotic treatment Chemotherapy Immunosuppressant therapy Watchful waiting

Initial treatment for uncomplicated Crohn's disease is immunosuppressant therapy. If this is not effective, surgery may be required, especially for complications of perforation, hemorrhage, and toxic colitis. The distinction between Crohn's disease and ulcerative colitis is important as chronic treatment approaches vary. Resection is strongly recommended for ulcerative colitis patients who are young, have frequent recurrence, or are steroid-dependent. Avoidance of surgery is desired in patients with Crohn's disease due to the natural history of recurrence. Indications for surgery in both Crohn's disease and ulcerative colitis include intractable or fulminant disease, massive hemorrhage, colonic obstruction, cancer prophylaxis, colon dysplasia, or cancer. Indications for surgery specific to ulcerative colitis include toxic megacolon, colonic perforation, or extracolonic disease. Indications for surgery specific to Crohn's disease include stricture and obstruction, refractory fistula, abscess, or perianal disease unresponsive to medical therapy.

A 30-year-old man presents with progressive memory impairment and mental fatigue after sustaining head trauma during a motorcycle accident. He also reports significant weight gain even though his diet is unchanged. Physical exam reveals generalized muscle weakness and a loss of muscle bulk but no dry mucous membranes or peripheral edema. A basic metabolic panel is normal. Electrodiagnostic testing shows no evidence of myopathy or neuropathy. A DEXA scan uncovers the presence of low bone mineral density. Which of the following serum laboratory tests would help you in securing a diagnosis? Antidiuretic hormone Fasting glucose Growth hormone Insulin-like growth factor-1

Insulin-like growth factor-1. A childhood deficiency of growth hormone (GH) causes dwarfism. However, adults may also be diagnosed with growth hormone deficiency. Growth hormone is normally produced and secreted by the pituitary gland, a process which is stimulated by hypothalamic growth hormone releasing-hormone and inhibited by somatostatin. Symptoms of growth hormone deficiency in the adult include decreased muscle mass, weakness, poor exercise tolerance, decreased bone density, increased subcutaneous fat and weight gain, poor cognition, mental fatigue and memory impairment. Some patients will display manifestations of other pituitary hormone deficiencies. Causes are congenital, acquired (head trauma or radiation) and idiopathic, with the most common cause being a pituitary tumor. It is diagnosed by a low level of serum insulin-like growth factor-1, an insulin tolerance test or a GHRH-arginine test.

A patient complains of pain in his legs when he walks. It goes away after sitting. What term comes to mind for this symptom? What diagnosis is it associated with?

Intermittent claudication caused by peripheral arterial disease.

A 28-year-old woman with no known drug allergies presents to the clinic after discharge from the hospital for acute rheumatic fever with carditis. Echocardiographic records reveal subsequent mitral valve disease. Which of the following is the most appropriate choice for secondary prophylaxis of rheumatic fever in this patient? Intramuscular injection of penicillin G benzathine every 21-28 days for 10 years Intramuscular injection of penicillin G benzathine every 21-28 days until age 40 Oral azithromycin 250 mg once daily for 10 years Oral penicillin V 250 mg twice daily for 10 years

Intramuscular injection of penicillin G benzathine every 21-28 days until age 40. Acute rheumatic fever is a complication of group A Streptococcus pharyngitis. Signs and symptoms of the disease are divided into major and minor categories. Minor criteria for diagnosis include fever, arthralgia, elevated erythrocyte sedimentation rate or elevated C-reactive protein, and prolonged P-R interval on ECG. Major criteria for diagnosis include Sydenham's chorea, carditis, erythema marginatum, polyarthritis, and subcutaneous nodules. According to the modified Jones criteria, a patient who demonstrates previous infection with group A Streptococcus (via rising antibody titer or positive throat culture) must manifest two major or one major and two minor criteria for a diagnosis of acute rheumatic fever. Patients with acute rheumatic fever are at risk for rheumatic heart disease, which can appear years after infection and usually presents as valvular stenosis. The valve most commonly affected is the mitral valve. The risk of rheumatic heart disease increases with each subsequent group A Streptococcus infection. For this reason, patients who have suffered acute rheumatic fever should receive secondary prophylaxis against group A Streptococcus. For patients who are not allergic to penicillin, the prophylactic treatment of choice is with penicillin G benzathine, administered intramuscularly every 21-28 days. The duration of prophylactic therapy depends upon the age and health status of the patient at presentation. For a patient who has rheumatic fever with carditis and echocardiographic evidence of persistent valvular disease, current recommendations call for prophylaxis to continue for ten years or until age 40, whichever is longer.

A 35-year-old man presents to the Emergency Department four hours after being bitten on his left hand by a spider while cleaning out his shed. He currently complains of whole arm pain as well as headache, severe back spasms, and abdominal pain. What is the treatment of choice to control his symptoms? Intravenous calcium gluconate Intravenous diazepam Intravenous ketorolac Intravenous normal saline

Intravenous diazepam. Latrodectus, or "widow", spiders are most often found in woodpiles, basements, garages, and sheds. Latrodectus spiders aggressively defend their web, particularly when guarding eggs. Black widow bites occur most often between April and October and usually occur on the hands and forearms. Envenomation of a neurotoxic venom occurs when bitten, the most active component of which is α-latrotoxin. The neurotoxin causes receptor stimulation, pore formation, and release of neurotransmitters; predominantly acetylcholine and norepinephrine. Most Latrodectus bites are felt immediately as a pinprick sensation at the bite site followed by increasing local pain that may spread to include the involved extremity. A target lesion with a blanched center and surrounding erythema may develop at the site of the bite and frequently localized diaphoresis near the site of where envenomation occurs. The clinical syndrome with envenomation is referred to as latrodectism. Patients frequently complain of muscle cramps and spasms in large muscle groups including trunk, back, and abdomen, however, physical examination rarely reveals rigidity. If untreated, the pain with envenomation frequently resolves after one day but can persist for several days. Pain and muscle spasms can be effectively controlled with liberal doses of opioids and benzodiazepines. For severe envenomations, admission may be required for continued analgesia. The most effective therapies for severe envenomation are parenteral opioids and Latrodectus antivenin. Administration of Latrodectus antivenin often causes rapid resolution of symptoms and can significantly shorten the course of illness. However, this is reserved for the most severe cases.

Which of the following is considered a minor diagnostic criterion for diagnosis of infective endocarditis, according to the Duke criteria? Deep vein thrombosis Heberden's nodes Intravenous drug abuse Temperature of 99.0°F

Intravenous drug abuse Intravenous drug abuse predisposes a patient to bacteremia which can lead to infective endocarditis and is one of the modified Duke minor diagnostic criteria. In infective endocarditis, microorganisms colonize the endocardial surface. The most common microorganisms found in infective endocarditis are Staphylococcus aureus, Streptococcus viridans, group A, C and G streptococci, and enterococci, with Staphylococcus aureus being the most likely microorganism in intravenous drug abusers with infective endocarditis. Diagnosis of infective endocarditis can be made using the Duke criteria. Two major criteria for diagnosis exist. The first involves positive blood cultures of typical microorganisms from two separate blood cultures drawn twelve hours apart and the second is echocardiographic evidence of an oscillating intracardiac mass or a new valvular regurgitation. Two major criteria, one major and three minor criteria, or five minor criteria are necessary for diagnosis of infective endocarditis.

A 22-year-old man presents to the emergency department after being bitten by a shiny, black spider. He complains of severe abdominal pain and cramping. On exam, there is intermittent muscle rigidity involving his right arm, abdomen, and back. There is a pale circular patch around a central punctum and surrounding erythema on the posterior surface of his right hand. Which of the following is the most appropriate treatment? Black widow antivenin Intravenous morphine and diazepam Intravenous sodium bicarbonate Oral cephalexin and wound debridement

Intravenous morphine and diazepam is the most appropriate treatment for this man with moderate widow spider envenomation. In the United States, widow spiders (genus Latrodectus) are one of the most commonly implicated species in envenomations. Black widow spiders are commonly encountered outdoors in cluttered areas, such as garages, wood piles, or sheds. People are commonly bitten while putting on shoes or gloves, gathering or chopping wood, or moving garbage. The majority of bites are on the extremities. The black widow venom is an excitatory neurotoxin that triggers large exocytosis from presynaptic nerve terminals. Patients typically present acutely with pain around the bite and severe abdominal pain. Vital signs are usually within normal limits. Intermittent muscle rigidity adjacent to the bite or involving the abdomen, chest, or back is present in more than half of patients. The bite appears as a circular area of pallor with a surrounding erythematous perimeter and a central puncture. Laboratory studies are unnecessary and are non-specific. Additional diagnostic imaging may be required to rule out abdominal surgical emergencies that can also cause severe abdominal pain and rigidity. Patients with mild envenomation can be managed with local wound care, oral analgesics, and tetanus prophylaxis. Moderate to severe envenomation treatment involves wound care, tetanus prophylaxis, parenteral opioids, and parenteral benzodiazepines. Intravenous calcium is not generally recommended. Widow antivenom is recommended for patients with severe envenomation that are unresponsive to parenteral analgesic and benzodiazepine therapy. Most patients with widow spider bites can be managed on an outpatient basis. Pain typically resolves within 24-72 hours if untreated.

A 31-year-old woman presents to the clinic complaining of groin pain. The patient states that she returned from a trip to the Caribbean three weeks ago, and had unprotected sex with a male partner during her trip. She noticed a painless genital ulcer that appeared prior to returning home, but states that it was gone three days later. A few days ago, she noticed some pain and swelling in her groin, which has become progressively worse. On physical examination, there are inflamed superficial and deep inguinal lymph nodes forming a "groove" sign bilaterally. Which of the following is the most likely diagnosis? Chancroid Granuloma inguinale Lymphogranuloma venereum Syphilis

Lymphogranuloma venereum is a sexually transmitted infection caused by Chlamydia trachomatis serotypes L1, L2, and L3. It causes lymphangitis which subsequently leads to areas of necrosis within the lymph nodes and ultimately causes abscess formation. It is most commonly found in tropical and subtropical areas of the world (e.g., Caribbean, East and West Africa). Risk factors include HIV infection, previously diagnosed sexually transmitted infections, recent travel abroad, and unprotected anal sex. There are three stages of infection, each with a specific characteristic to identify it. Primary infection occurs 3 to 12 days following exposure, and is characterized by a genital ulcer or an inflammatory reaction of the mucosa at the site of inoculation, which heals within a few days. Secondary infection occurs two to six weeks later and is characterized by local direct extension of the infection to regional lymph nodes, most commonly the inguinal and femoral nodes. At this stage, there can be severe inflammation and invasive infection, indicated by the associated systemic symptoms a patient experiences. The "groove" sign is characteristic and is caused by inflammation of the superficial and deep inguinal lymph nodes. An anorectal syndrome can also occur, which results in an inflammatory mass present in the rectum and retroperitoneum. Late infection results in fibrosis and strictures in the anogenital tract, which are a result of untreated infection. Diagnosis can be difficult due to the lack of standardized laboratory tests, but involves either culture, direct immunofluorescence, or nucleic acid detection of Chlamydia trachomatis using genital, rectal, or lymph node specimens (e.g., lesion swabs or bubo aspirate). First line treatment is doxycycline 100 mg orally twice daily for 21 days. Second line treatment is erythromycin 500 mg orally four times daily for 21 days. Buboes may require needle aspiration or incision and drainage.

Which of the following medications blocks the release of stored thyroid hormone? Iodine Methimazole Propranolol Propylthiouracil

Iodine. Management of thyroid storm, characterized by pyrexia, tachycardia, gastrointestinal symptoms, mental status changes, and cardiovascular collapse, requires a multistep approach to control symptoms, reduce thyroid hormone production, prevent thyroid hormone release and block peripheral conversion of T4 to T3. Inorganic iodine (given as potassium iodide or sodium iodide) blocks the release of thyroid hormone from the thyroid gland. It should only be given one hour after either propylthiouracil or methimazole, both of which block synthesis of thyroid hormone, because an iodine load can increase synthesis of the hormone. Lithium is an alternative medication that can block release of thyroid hormone in iodine-allergic patients.

Which of the following laboratory results are most consistent with a diagnosis of immune thrombocytopenia? Isolated thrombocytopenia with platelets of predominantly normal morphology Isolated thrombocytopenia with platelets that lack granules Isolated thrombocytopenia with predominantly large platelets Thrombocytopenia with anemia and leukopenia

Isolated thrombocytopenia with platelets of predominantly normal morphology Isolated thrombocytopenia with platelets that lack granules Immune thrombocytopenia is a clinical syndrome of decreased platelets which cannot be explained by a hereditary or systemic illness. For unknown reasons, patients develop autoantibodies to platelet surface proteins, and the platelets are destroyed in the spleen. Patients present with petechiae, easy bruisability, and bleeding tendencies. Diagnosis is made by peripheral smear, and by excluding other causes of low platelets. The peripheral smear will show isolated thrombocytopenia with platelets of predominantly normal morphology, although a few large platelets might be seen. If the majority of the platelets are large, lack granules, or have an abnormal color, then a hereditary platelet disorder should be considered. If there is anemia or neutropenia as well as thrombocytopenia, then a myelodysplastic disease should be suspected. Immune thrombocytopenia can manifest as acute or chronic. The acute form is more prevalent in children, while the chronic form is more common in adults. Patients with acute immune thrombocytopenia often have a history of a recent viral illness. High dose corticosteroids given over twenty-one days and then tapered are recommended as first-line therapy for adults with severe immune thrombocytopenia. Most children suffering immune thrombocytopenia will recover spontaneously and only require observation. In cases of serious pediatric disease, one dose of IVIG or a short course of corticosteroids is recommended.

A patient receiving quadruple drug therapy for active tuberculosis develops pain and paresthesias in his fingers and toes. What is the most likely agent responsible for these symptoms? Ethambutol Isoniazid Pyrazinamide Rifampin

Isoniazid Active tuberculosis is caused by Mycobacterium tuberculosis and is transmitted via aerosolized droplets. The disease may affect any area of the body but most commonly affects the lungs, leading to cavitary lung lesions which have a proclivity for the upper lung lobes. Empiric treatment of active tuberculosis involves a four-drug regimen: isoniazid, ethambutol (or streptomycin), rifampin, and pyrazinamide. Isoniazid can cause peripheral neuropathy in more than 10 percent of patients taking the drug. Signs of peripheral neuropathy include numbness or tingling in the hands or feet, as well as sensations of freezing or burning in the extremities or lack of coordination. The peripheral neuropathy associated with isoniazid treatment is dose-dependent and can be modified by co-administering pyridoxine (vitamin B6). Isoniazid and rifampin are continued for the entire six months of treatment.

Which of the following is true regarding hyperosmolar hyperglycemic state? Cerebral edema is a common complication due to rapid hydration Hypokalemia is commonly seen It is associated with a significantly higher mortality than diabetic ketoacidosis It is caused by increased insulin sensitivity

It is associated with a significantly higher mortality than diabetic ketoacidosis. Hyperosmolar hyperglycemic state is defined by progressive hyperglycemia and hyperosmolarity that generally occurs in debilitated patients who have poor access to water, poorly controlled or undiagnosed type 2 diabetes, and commonly a precipitating medical event. The condition is characterized by severe hyperglycemia, with serum glucose usually > 600 mg/dL, elevated calculated plasma osmolality of > 315 mOsm/kg, serum bicarbonate > 15 mEq/L, arterial pH > 7.3, and serum ketones that are negative to mildly positive. Because it is associated with concurrent illness, the hyperosmolar hyperglycemic state has a much higher mortality rate than diabetic ketoacidosis (DKA).

How do you calculate mean arterial pressure? MAP = [DBP + (2 x SBP)]/3 MAP = DBP + 1/3(SBP−DBP) MAP = DBP + 2/3(SBP−DBP) MAP = SBP + 1/3(SBP−DBP)

MAP = DBP + 1/3(SBP−DBP) Calculation of the mean arterial pressure (MAP) provides a weighted average of the systolic blood pressure (SBP) and the diastolic blood pressure (DBP). It is a determination of tissue perfusion and is normally 70-100 mm Hg in adults. A MAP of approximately 60 mm Hg is necessary to perfuse the coronary arteries, brain, and kidneys. The MAP is calculated by either formula:

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? Etomidate Ketamine Midazolam Propofol

Ketamine. In a majority of the population, acute severe asthma can be successfully treated with aggressive use of β-agonists, anticholinergics, and glucocorticoids. However, prompt intubation may be necessary if these interventions are inadequate and the patient is in obvious respiratory distress. Signs of respiratory distress in asthmatics may include extreme fatigue, depressed mental status, cyanosis, accessory muscle use, chest wall retractions, brief, fragmented speech, inability to lie supine, profound diaphoresis, agitations, and rapid, shallow breathing. Ketamine should be used as in induction agent for intubation in patients with severe asthma. It is a dissociative anesthetic that improves pulmonary function and is of benefit in severe asthmatics. It acts as a direct smooth muscle dilator, increases circulating catecholamines, which indirectly dilate smooth muscle, inhibits vagal outflow, decreases the production of vasodilatory nitric oxide, and does not cause histamine release. In addition, ketamine is less likely to cause hypotension upon administration, making it a favorable choice for induction in the setting of acute severe asthma.

A mother brings her 16-year-old son to your medical office for a comprehensive history and physical examination. She tells you she is concerned about his immature physical development and insecure behavior. She thinks these characteristics are markedly different from her other children. His IQ is 70, and he is in special education for a language-based learning disability. On physical examination, he is tall and thin; he has sparse body hair and a high-pitched voice. Heart, lungs, abdomen, and neurologic exam are unremarkable. Pertinent positive findings include disproportionately long arms and legs, gynecomastia, as well as small testes and phallus. Question What is the most likely diagnosis? 1 Fragile X syndrome 2 Klinefelter syndrome (XXY) 3 Turner syndrome (XO) 4 Triple X syndrome (XXX) 5 XYY syndrome (XYY)

Klinefelter's Syndrome The combination of hypogonadism, long extremities, decreased intelligence, and behavioral problems makes Klinefelter syndrome (also referred to as XXY syndrome, 47,XXY, and Klinefelter's syndrome) the most likely diagnosis. The original syndrome, as described by Dr. Klinefelter, consisted of gynecomastia, testicular atrophy, and infertility. Intelligence profiles can range from specific learning disabilities (language learning or reading impairment most common) to intellectual disability. The only constant feature of the syndrome is testicular atrophy with resulting azoospermia and infertility. The atrophy of the testis is the result of fibrosis, which begins to appear in childhood and progresses until all the seminiferous tubules are replaced by fibrous tissue. In males presenting with gynecomastia, intellectual disability, and eunuchoidism (loss of male secondary sexual characteristics, small penis, loss of body hair, and a high-pitched voice), Klinefelter syndrome should be at the top of the list in the differential diagnosis. Most patients with Klinefelter's syndrome have 47 chromosomes instead of the normal 46 chromosome karyotype. The extra chromosome is an X chromosome, making the sex chromosome constitution XXY instead of XY. Klinefelter's syndrome is one of the most common chromosome abnormalities seen in males and occurs in 1 in 300 of the male population. Patients with this syndrome show that the Y chromosome is strongly sex-determining; a patient who has an XXY chromosome constitution may therefore have the appearance of a normal male—with infertility being the only incapacity—while the loss of a Y chromosome leads to the development of a bodily form that is essentially feminine.

A thumbprint sign on x-ray should make you think of what two diagnoses?

Lateral cervical spine: epiglottitis Abdominal: intestinal ischemia

A biphasic p-wave should make you think of what diagnosis?

Left atrial enlargement

An older patient presents with pneumonia and diarrhea. What is the most likely diagnosis?

Legionella pneumoniae

Name one oral medication that can be used for MRSA.

Linezolid (Zyvox) and Bactrim

A 69-year-old man presents to the emergency department complaining of 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? Atorvastatin Glipizide Levothyroxine 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. Glipizide and levothyroxine do not have to be discontinued in the setting of acute kidney injury. However, glipizide should be used with caution as it can cause hypoglycemia. There is conflicting evidence surrounding the association of Atorvastatin and other statins with renal failure, as some studies actually suggest a slowed rate of decline of kidney function in patients with chronic kidney disease.

A 25-year-old man presents with increased urination and thirst. Over the past 3 days, he has been unable to satisfy his thirst and has to urinate up to 20 times per day. He noticed that his urine is very clear and colorless. In general, he feels very weak. He has never had any problems with urination before. His medical history is remarkable for a recently diagnosed psychiatric condition for which he began medical treatment. On physical exam, he appears to be lethargic, dehydrated, and pale. His vital signs are as follows: blood pressure 96/52 mm of Hg, temperature 101.2 degrees Fahrenheit, pulse 108 beats per minute, and a respiratory rate of 26 per minute. Which of the following is a common cause of diabetes insipidus? Lithium Carbamazepine Amitriptyline Valproic acid Vasopressin

Lithium, used in the treatment of bipolar disorder, is a common cause of diabetes insipidus. It is freely filtered through the glomerulus and reabsorbed in the proximal tubule along with sodium and water. Even small doses of lithium may cause diabetes insipidus. Lithium can also make the distal renal tubules resistant to the action of vasopressin. This patient had recently started this medication, which resulted in his new symptoms.

A 68-year-old man presents to the clinic with a past medical history of hepatitis B infection and hepatic cirrhosis. Which of the following is the best choice for surveillance of development of hepatocellular carcinoma in this patient? Abdominal CT scan every 12 months Abdominal CT scan every two years Liver ultrasound every 12 months Liver ultrasound every six months

Liver ultrasound every six months. The major risk factor for hepatocellular carcinoma is cirrhosis of any etiology. Chronic hepatic diseases such as hepatitis B (dominant cause worldwide), hepatitis C (dominant cause in the United States and Europe), steatotic liver disease, hemochromatosis, Wilson's disease, and alcoholic hepatitis can increase the risk for development of cirrhosis and hepatocellular carcinoma. Screening patients with cirrhosis for the development of hepatocellular carcinoma has shown to improve early detection rates and survival. Patients with cirrhosis of any type should receive a liver ultrasound every six months to monitor for the development of hepatocellular cancer. Patients who have coinfection with hepatitis and human immunodeficiency virus and patients who have neurovisceral porphyrias should undergo regular surveillance as well. Treatment choices for hepatocellular carcinoma depend on the stage of the disease at diagnosis and can include surgical resection, liver transplantation, radiofrequency ablation, percutaneous ethanol injection, radiation therapy, and chemotherapy.

A 7-year-old boy presents to the ED with his mother with abdominal pain and vomiting. His mother notes he has been very thirsty over the past several weeks and urinating often. On physical exam, you note diffuse tenderness without rebound or guarding. Vital signs are BP 86/48 mm Hg, HR 140 beats per minute, RR 40 breaths per minute, and T 100.6°F. Which of the following laboratory abnormalities would you expect to find? Hypernatremia Hypocalcemia Low bicarbonate Low serum lactate

Low bicarbonate. This patient is exhibiting signs and symptoms consistent with diabetic ketoacidosis (DKA). DKA is more common in insulin-dependent diabetics. The diagnosis of DKA involves several laboratory abnormalities including glucose levels usually > 300 mg/dL, an anion gap metabolic acidosis with low bicarbonate, glucosuria and ketonuria on urinalysis, and elevated serum β-hydroxybutyrate. The serum potassium level may be falsely elevated as patients are total body potassium depleted; however, it may also be normal or low. Ketoacidosis occurs because insulin deficiency results in hyperglycemia, leading to osmotic diuresis and severe dehydration. As the body is then unable to metabolize the glucose, ketosis will occur when the body alternatively breaks down fatty acids for calories and produces acidosis as a result. DKA is most commonly the result of noncompliance with insulin therapy. Signs and symptoms of DKA include tachycardia, altered mental status, tachypnea with deep respirations (Kussmaul breathing) in response to acidosis, dry mucous membranes, abdominal pain, blurry vision, and a fruity odor to the breath. Management of DKA includes cardiac monitoring, aggressive intravenous fluid hydration, and insulin administration, most often in the form of an insulin drip. Therapy should be continued until the anion gap is closed. Electrolytes and blood gases should be checked every two hours to monitor progress during treatment. The most serious complication of DKA and its treatment is cerebral edema. This is most commonly seen in children under the age of 5 years. Intravenous rehydration should be undertaken in a less aggressive manner and monitored closely in this pediatric patient population.

How do you treat polymyalgia rheumatica?

Low dose prednisone

A 44-year-old man with systemic lupus erythematosus presents to the ED with chest pain and dyspnea. Vital signs are notable for tachycardia and hypotension with a narrow pulse pressure. Bedside ultrasound confirms a large pericardial effusion with collapse of the right ventricle during diastole. Which classic electrocardiogram findings are associated with this disease process? Delta wave and shortened PR interval Diffuse ST elevation Low voltage and electrical alternans S wave in lead I and a Q wave and inverted T wave in lead III

Low voltage and electrical alternans. The patient has cardiac tamponade. In cardiac tamponade, fluid distends the pericardial sac and compresses the heart, impairing ventricular filling and cardiac output. Many disorders can result in a pericardial effusion, including inflammatory disorders like SLE, infections (tuberculosis, viruses), and malignancies. The pericardium can stretch to accommodate excess fluid, but when fluid accumulates to the point where intrapericardial pressure exceeds the normal filling pressures of the right heart, ventricular filling is impaired, and cardiac tamponade results. Cardiac tamponade is diagnosed by a combination of clinical signs and ultrasound findings. Tachycardia and hypotension with a narrow pulse pressure are characteristic, and echocardiogram will reveal a large pericardial effusion causing right atrial compression and right ventricular diastolic collapse. Classic ECG findings of cardiac tamponade include low voltage QRS complexes and electrical alternans, where there is beat-to-beat variation in the amplitude of the R waves. The treatment for cardiac tamponade causing hemodynamic instability is emergent pericardiocentesis.

A 35-year-old Caucasian man presents to the emergency department with slurred speech and right facial drooping. He had a similar episode a few months ago and did not suffer any residual effects. He also has a history of deep venous thrombosis in the left leg but has no history of surgeries, hypertension, or diabetes. Which of the following should be included in the evaluation to determine the cause of this condition? Bone marrow biopsy D-dimer Hemoglobin electrophoresis Lupus anticoagulant

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, miscarriage (especially if in the late trimester or recurrent), history of heart murmurs or cardiac valvular vegetations, history of hematologic abnormalities, and 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). Genetic disposition and familial association have also been linked. 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, tobacco cessation, 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.

An 82-year-old man presents with slurred speech and unilateral arm weakness that have resolved. His non-contrast head CT is negative and he is given aspirin. Which of the following is the most appropriate management plan? Discharge home with PCP follow-up Low molecular weight heparin MRI and MRA of the head and neck Transcranial dopplers

MRI and MRA of the head and neck. This patients symptoms are concerning for a transient ischemic attack (TIA), neurologic deficits that occur and then resolve within 24 hours. Most patients with a TIA will resolve within one hour (the previous definition). Patients who have a TIA are at high risk for stroke in the period immediately following a TIA and therefore further testing is warranted in a timely fashion. In most cases, patients should be admitted to an observation unit or hospital in order to rule out any reversible causes of the TIA. Testing includes vascular imaging to identify any critical stenosis. The MRI will also identify the subset of patients with TIA symptoms who ultimately have an infarct on MRI. If MRA is not available, carotid dopplers are an acceptable alternative. Once the vasculature has been evaluated, patients may be discharged with outpatient follow-up. Routine testing that often occurs during the observation period includes cardiac telemetry for dysrhythmia (particularly atrial fibrillation) and echocardiography to evaluate for valvular lesions or intracardiac thrombus.

Which of the following statements is most accurate regarding health maintenance for a patient with chronic pancreatitis? Abstinence from alcohol will improve symptoms but will not decrease mortality Enteric coated pancreatic enzymes require coadministration with an H2 antagonist Long chain triglycerides can provide extra calories in patients with weight loss Malabsorption of fat soluble vitamins may occur but is rarely clinically symptomatic

Malabsorption of fat soluble vitamins may occur but is rarely clinically symptomatic. Treatment of chronic pancreatitis involves lifestyles changes, pain management, and administration of pancreatic enzymes. Cessation of alcohol intake and smoking is imperative. Small, low-fat meals should be advised. Pain can be managed with tricyclic antidepressants, narcotics, or occasional hospitalizations to keep the patient nothing by mouth (NPO) for a short duration and allow pancreatic rest. Pancreatic enzymes are prescribed for patients with chronic pancreatitis to break the feedback loop of cholecystokinin release and pancreatic exocrine stimulation. Medium chain triglycerides are easily absorbed and can provide extra calories for patients suffering weight loss. Malabsorption of vitamins due to pancreatic exocrine malfunction may occur but is usually not clinically symptomatic. Replacement of the fat soluble vitamins and cyanocobalamin may be necessary for patients with substantial steatorrhea. Patients who fail medical therapy may be candidates for surgical procedures, such as denervation, decompression, and resection. Inflammation of the pancreas which is persistent and causes structural damage and eventual decline in pancreatic function is known as chronic pancreatitis. The cause of chronic pancreatitis may be obstructive or necrotic in nature. In obstructive pancreatitis, ductal stone formation leads to chronic inflammation which causes progressive pancreatic fibrosis and eventual atrophy. In necrotic pancreatitis, recurrent attacks of acute pancreatitis lead to necrotic tissue, which is eventually replaced by fibrotic tissue. Smoking and alcohol consumption are two main risk factors for pancreatitis. Other etiologies of pancreatitis include autoimmune disease, genetic disorders, and tumors. Symptoms of chronic pancreatitis are abdominal pain, nausea, vomiting and weight loss. Steatorrhea develops later in the disease course after the pancreas has lost much of its exocrine function. Diagnosis can be made via visualizations of calcifications on plain film or CT scan, magnetic resonance cholangiopancreatography, endoscopic ultrasound, or pancreatic function tests (such as stimulation of the pancreas and subsequent collection of duodenal fluid for analysis).

A 27-year-old man with a history of asthma presents to your office for his annual exam. He reports that in the past month he has experienced wheezing and shortness of breath about once per week which resulted in using his rescue inhaler. He woke up once because of coughing. He has a peak flow meter and home readings have been 85-90% of his personal best. Which of the following best describes the classification of his asthma? Mild intermittent Mild persistent Moderate persistent Severe persistent

Mild intermittent. Asthma severity is determined by monitoring patient symptoms over the past 2-4 weeks, determination of the patient's current lung function and number of asthma exacerbations that require oral glucocorticoids each year. A step-wise approach is used to classify asthma severity and determine approach to treatment. Mild intermittent asthma is defined as having two or fewer daytime symptoms per week, two or fewer nighttime awakenings due to symptoms in the past month, use of short-term beta agonist rescue inhaler less than two times per week, no impairment in activities of daily living (ADLs) between exacerbations, home readings of lung function within the normal range (greater than or equal to 80% of normal), and zero or one exacerbation requiring oral glucocorticoids in the past year.

Which of the following is one of the eight criteria needed for the diagnosis of post-traumatic stress disorder? Duration of the disturbance associated with the traumatic event is more than two months Marked alterations in mood and cognition associated with and beginning after the traumatic event Persistent pursuance of stimuli related to the traumatic event, beginning after the event has occurred Presence of two or more intrusion symptoms associated with the traumatic event and beginning after the event has occurred

Marked alterations in mood and cognition associated with and beginning after the traumatic event Post-traumatic stress disorder is a complex reaction to psychological trauma which causes significant social, interpersonal, and occupational dysfunction. Diagnosis of post-traumatic stress disorder can be made when patients meet all of eight diagnostic criteria. The first is exposure to an actual or threatened death, serious injury, or sexual violence. The second is the presence of one or more intrusion symptoms associated with the event. Thirdly, there must be persistent avoidance of stimuli that are associated with the traumatic event. Fourth, the patient suffers negative alterations in cognition and mood related to the event. Fifth, marked alterations in arousal and reactivity are associated with the event. Sixth, the duration of the aforementioned disturbances is more than one month. Seventh, the disturbance must cause clinically significant distress or impairment in important functioning. Eighth, the disturbance cannot be attributed to substance use or another medical condition. The disturbances must begin after the traumatic event has occurred. Risk factors for developing post-traumatic stress disorder include female gender, low socioeconomic status, young age, low educational status, poor social support, previous exposure to trauma, personal or family psychiatric history, exposure to childhood adversity, and intensity of initial reaction to the traumatic event. Treatment of post-traumatic stress disorder involves cognitive behavioral therapy and pharmacotherapy with one or more of the following: serotonergic antidepressants, second-generation antipsychotics, and alpha-adrenergic receptor blockers.

A 53-year-old man presents with a complaint of numbness of his right hand for 3 to 4 months. He states that he notices the numbness upon waking up in the morning, but that it gets better when he shakes his hands around. The patient indicates the numb areas are on the first, second, and third digits of his right hand. Which of the following tests is most sensitive for this diagnosis? Finkelstein test Hand elevation test Median nerve compression test Tinel sign

Median nerve compression test. The patient presents with signs and symptoms consistent with carpal tunnel syndrome, which is the most common entrapment neuropathy of the wrist. It is caused by compression of the median nerve and is associated with numbness and weakness in its distribution. Patients typically present with numbness, pain, and paresthesias of the first three digits that are worse at night and with activity but improve with shaking their hands out. Median nerve compression testing (Durkan test) consists of direct pressure application to the median nerve at the carpal tunnel. It is positive if this maneuver reproduces the symptoms, and the test is 87% sensitive and 90% specific for the diagnosis. Conservative treatment with wrist splinting and cortisone injections often relieves symptoms. Referral for orthopedic management is indicated in patients with recurrent or refractory symptoms.

Which of the following medications is first-line therapy for males with pedophilic disorder? Bupropion PO Fluoxetine PO Medroxyprogesterone IM Methylprednisolone IM

Medroxyprogesterone IM Pedophilic disorder is a paraphilic disorder characterized by a patient ≥ 16 years old who has recurrent sexual fantasies, urges, or behaviors directed toward a prepubescent child or young adolescent. Most pedophiles are male. In most cases, the adult is known to the child. Family dysfunction, divorce, and a personal history of abuse are common. Child pornography use is a reliable indicator of attraction to children and may be the only sign of pedophilic disorder. Diagnosis is made by clinical presentation including evidence that the patient has either acted on their urges or is greatly distressed by them. Therapy consists of counseling and pharmacotherapy. First-line pharmacotherapy is libido reduction with medroxyprogesterone IM, which blocks testosterone synthesis by blocking pituitary follicle-stimulating hormone and luteinizing hormone production. The gonadotropin-releasing hormone agonist leuprolide also reduces testosterone synthesis but is more expensive than medroxyprogesterone. Therapy is usually long-term. Serum testosterone should be maintained in the normal female range (< 62 ng/dL). Selective serotonin reuptake inhibitors like fluoxetine (B) may be useful for pedophilic disorder in addition to anti-androgen therapy, but are not as effective for monotherapy as anti-androgens.

A 41-year-old woman presents to the clinic with symmetrically distributed, coalescent, hyperpigmented macules in sun-exposed areas of the face. Which of the following is the most likely diagnosis? Melanoma Melasma Seborrheic keratoses Solar lentigines

Melasma Melasma is an acquired condition of sun-exposed areas of the body which presents as hyperpigmented macules that are symmetrically distributed and often coalescent. The most common locations for melasma are the cheeks, chin, upper lip, and forehead, although they may be found in other sun-exposed areas of the body. Patients present with slowly growing hyperpigmentation of the face that is not painful or pruritic. In females, the onset of the condition may be associated with pregnancy or oral contraceptive use. Diagnosis of melasma is made clinically. Treatment involves avoidance of sun exposure, avoidance of exogenous estrogen, and application of hydroquinone (2-4%) with broad-spectrum sunscreen. Applications of the monobenzyl ether of hydroquinone or of higher concentrations of hydroquinone must be avoided, as they can lead to irreversible leukoderma. For recalcitrant or severe cases, laser treatment may be of benefit.

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

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.

A 29-year-old man presents to the office with episodic, spontaneous attacks of severe dizziness that last for several hours and are associated with nausea, vomiting, diaphoresis, tinnitus, and hearing loss. After the episodes, he is fatigued for up to a day. Which of the following is the most likely diagnosis? Acute labrynthitis Meniere disease Otosclerosis Presbycusis

Meniere disease is a common disorder consisting of fluctuating sensorineural hearing loss, tinnitus, episodic vertigo, and aural fullness. The hearing loss typically begins as a fluctuating low-frequency loss but progresses to a permanent loss. The tinnitus is most commonly described as "buzzing" or "roaring" and can fluctuate in loudness and character. The aural fullness perhaps is the most consistent and stable complaint, but it also usually fluctuates. The vertigo of Meniere disease is the most disabling aspect of the disorder. The characteristic presentation consists of episodic, spontaneous attacks of severe, spinning vertigo that last for several hours. The attacks frequently are associated with nausea, vomiting, and diaphoresis. After the attacks, patients usually are fatigued for 24 hours or more. The vertigo may be associated with a concomitant or preceding change in the other symptoms of hearing loss, tinnitus, or aural fullness. Many patients also have various combinations of disequilibrium or motion-provoked vertigo between the classic attacks. Although acute labyrinthitis can cause vertigo and unilateral hearing loss, it is generally a single episode that can last for days rather than recurrent episodes.

A 48-year-old woman presents to the office for her annual physical exam. She has not had a period for over 12 months. Which of the following hormonal changes are likely to occur during the menopausal transition? A decrease in estrone, decrease in estradiol, and an increase in testosterone A decrease in estrone, increase in estradiol, and no change in testosterone An increase in estrone, decrease in estradiol, and decrease in testosterone An increase in estrone, decrease in estradiol, and no change in testosterone

Menopause results from the loss of ovarian sensitivity to gonadotropin stimulation due to loss of follicular number. The oocytes in the ovary decline in both quantity and quality of follicles in a woman's lifetime. During the transition between premenopause into perimenopause and menopause, anovulatory cycles and loss of regularity of menstrual cycles become common. Menopause is diagnosed after 12 months of amenorrhea. Over time, aging follicles become more resistant to gonadotropin stimulation, causing circulating follicular stimulating hormone (FSH) and luteinizing hormone (LH) to increase. Elevated FSH and LH levels lead to stromal stimulation of the ovary, resulting in an increase in estrone (E1) levels and decrease in estradiol (E2) levels. Estradiol is produced in the ovaries and is the predominant form of estrogen found in premenopausal women. Estrone is formed from estradiol and is predominant after menopause. These changes in estrogen lead to higher total cholesterol levels, low-density lipoprotein (LDL), and apolipoprotein B levels with the loss of the protective effect of high-density lipoprotein (HDL). With cessation of ovulation, estrogen production continues from the aromatization of androgens and estrogen production in extragonadal sites (adipose tissue, muscle, liver, bone, bone marrow, fibroblasts, and hair roots). Since progesterone production by the corpus luteum is ceased with the cessation of ovulation, perimenopausal and postmenopausal women are therefore exposed to unopposed estrogen which is a risk factor for endometrial cancer. Menopause can be diagnosed clinically, but a rise in FSH is an indication that it has occurred. Repeated measurement of FSH and LH at two to three-month intervals is also helpful. Total testosterone levels do not change during transition to menopause.

A 17-year-old woman with a history of type 1 diabetes presents to the emergency room. She states that she was in her usual state of health yesterday, but today developed nausea, vomiting, and severe abdominal pain. She states that she ran out of her insulin yesterday. On exam, you notice her to be tachypneic. Laboratory results reveal the following: sodium 140, chloride 100, bicarbonate 12 glucose 650, pH 7.29, PaCO2 30, ketones 3+. What primary acid/base disorder does this patient exhibit? Metabolic acidosis with elevated anion gap Metabolic acidosis with normal anion gap Respiratory acidosis with elevated anion gap Respiratory acidosis with normal anion gap

Metabolic acidosis with elevated anion gap is seen in diabetic ketoacidosis (DKA). The pH in this example is below 7.35, which is consistent with acidemia. Once the acid/base is classified, look at the bicarbonate and note that it is also low. This scenario, low pH and low bicarbonate, is consistent with a metabolic acidosis. The anion gap is calculated by subtracting the serum anions from the serum cations. The common calculation for the anion gap is [sodium - (chloride + bicarbonate)]. In this scenario, the anion gap is 140 - (100 + 12) = 28. Therefore, this patient has an anion gap metabolic acidosis. A normal anion gap is between 3 to 10 mEq/L. Anything above 10 is considered an elevated anion gap. Patients with diabetic ketoacidosis have an elevated anion gap acidosis, hyperglycemia, and ketonemia. The most common precipitant of DKA is infection and missed insulin doses. Symptoms at presentation include nausea, vomiting, and abdominal pain. Compensatory deep and labored breathing (Kussmaul respirations) occurs, as the patient works to remove excess carbon dioxide through increased respirations. Some other conditions that cause an elevated anion gap are lactic acidosis, ketoacidosis, and ingestion of methanol, ethylene glycol, salicylates, and propylene glycol.

A 78-year-old man undergoes laparoscopic surgery for a small bowel obstruction. Which metabolic disturbance is he most at risk for postoperatively? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic alkalosis would be the most likely acid-base disturbance to develop postoperatively in this patient presentation. Volume contraction combined with gastric fluid loss is the most common cause. During this type of surgery, aggressive third-spacing of fluid into the peritoneal cavity, as well as the intestinal lumen, is the cause of volume contraction. Postoperatively, nasogastric decompression of the stomach causes acid loss. As the stomach works to replenish hydrochloric acid, bicarbonate (HCO3-) is released into the serum. The patient also loses potassium from the gastric fluid during nasogastric suctioning. The combination of the volume contraction and the postoperative measures causes a hypochloremic, hypokalemic metabolic alkalosis.

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? Clopidogrel Levothyroxine Metformin Ramipril

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.

A patient who is undergoing a transesophageal echocardiogram suddenly develops profound hypoxemia and cyanosis. His respiratory rate is 18 breaths/minute, but his saturation remains at 80% despite adequate application of supplemental oxygen by non-rebreather mask. A quick review of the medication record reveals that he received benzocaine, fentanyl, midazolam, and propofol during the procedure. What substance should you administer to treat his underlying condition? Flumazenil Methylene blue Naloxone Phenylephrine

Methylene blue. This patient has methemoglobinemia. Methemoglobin is a substance that is present in the conversion pathway of iron to deoxyhemoglobin. It is always present in red blood cells, but it is constantly enzymatically metabolized under normal circumstances. Certain medications, including benzocaine, can disrupt this pathway, leading to an accumulation of methemoglobin and reducing the oxygen-carrying capacity of the blood. It may also alter the appearance of the arterial blood and make it appear chocolate colored. To confirm methemoglobinemia, an arterial blood gas with co-oximetry is needed to show the levels of methemoglobin and oxyhemoglobin. The classic finding in methemoglobinemia is a pulse oximetry reading around 80-85% despite administration of supplemental oxygen. In these patients, the PaO2 may be normal but their pulse ox is low because the pulse oximeter cannot detect methemoglobin Besides providing respiratory support, the treatment is methylene blue, which converts the methemoglobin to oxyhemoglobin.

A 12-year-old boy presents to clinic with a history of conduct disorder. His parents report he is having increased high-risk behavior despite behavioral and psychological therapy. They are concerned about his safety. Which of the following medications is the best choice for treating patients with a diagnosed conduct disorder? Citalopram Lithium Methylphenidate Valproic acid

Methylphenidate is a central nervous system stimulant and is the best medication to use in patients with conduct disorder who are experiencing worsening symptoms despite behavioral and psychologic intervention. Conduct disorder is characterized by a pattern of behavior that includes the violation of basic rights of others or social norms with at least three aggressive acts toward people or animals, destruction of property, deceitfulness or serious violation of rules. It is more common in boys than in girls. Common comorbidities include attention deficit disorder and attention deficit hyperactivity disorder as well as learning disabilities, mood disorders and eventual substance misuse.

A 73-year-old woman with a history of hypertension presents with a unilateral headache for 3 weeks. She states she has a throbbing pain at her right temple and has pain in her jaw with opening and closing. The vision in her right eye has worsened over the previous day. Her blood pressure is 173/100 mm Hg. What treatment is indicated? Carbamazepine Labetalol Methylprednisolone Noncontrast head CT scan

Methylprednisolone. This patient presents with a unilateral, subacute headache with associated jaw claudication and vision change, symptoms consistent with temporal arteritis. Temporal arteritis or giant cell arteritis is a systemic inflammatory process of large and medium-sized arteries. The most commonly involved vessels are the ophthalmic vessels and the extracranial branches of the aortic arch. The disease typically affects patients over 70 years of age and is more common in women than in men. Patients present with a subacute headache that is throbbing in nature and may be present for weeks to months. Often, patients will have symptoms for more than 2 months. Patients may also report jaw claudication secondary to vascular insufficiency of the masseter and temporalis muscles. Physical examination may reveal tenderness over the temporal artery. Systemic symptoms may also be present, including fever, joint pains, and weight loss. Diagnostic testing in the emergency department generally begins with an erythrocyte sedimentation rate (ESR), with a cutoff of 50 mm/hour, although the level may be > 100 mm/hour. However, the ESR will be normal in 10-25% of patients. The gold standard diagnostic test is a temporal artery biopsy. In patients with a high clinical likelihood of temporal arteritis, treatment should be initiated regardless of initial diagnostic testing, as delay can lead to permanent visual loss. Prednisone should be started at 60-120 mg/day. If vision loss is present, methylprednisolone is the recommended medication.

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? Furosemide Insulin lispro Lisinopril Metoclopramide

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. 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.

What is the most effective antimicrobial pharmacological treatment for tetanus?

Metronidazole

Which of the following is the most appropriate first-line treatment for symptomatic giardiasis? Ciprofloxacin Fluconazole Ketoconazole Metronidazole

Metronidazole Giardia lamblia is a flagellated parasite that colonizes and reproduces in the small intestine. It is an important cause of waterborne and foodborne diarrhea. Giardiasis is common in areas with poor sanitary conditions and unsanitized water sources, such as mountain streams. Symptoms generally develop seven to fourteen days after exposure and include diarrhea, malaise, foul-smelling stools and flatulence, and abdominal bloating. Treatment with antimicrobial therapy is indicated in symptomatic patients with confirmed giardiasis. Due to its low cost and well-established efficacy, metronidazole is generally the accepted first-line agent in the treatment of giardiasis. A five-day course is efficacious in the majority of patients. Tinidazole is also a reasonable first-line agent and may be administered as a one-time dose due to its longer half-life; however, it is not as cost-effective as metronidazole. Along with antimicrobials, patients should also be counseled to hydrate aggressively.

A 38-year-old woman presents with fatigue, anorexia, muscle aches and hyperpigmentation. Laboratory tests are significant for a sodium level of 128 and a potassium level of 5.6. Which of the following is the most appropriate to obtain next in the work up of this patient's condition? ACTH (Cosyntropin) stimulation test Adrenocorticotropic hormone (ACTH) level CT scan Morning serum cortisol level

Morning serum cortisol level. Primary adrenal insufficiency, or Addison's disease, has many causes, the most common of which is autoimmune adrenalitis. Autoimmune adrenalitis results from destruction of the adrenal cortex, which leads to deficiencies in glucocorticoids, mineralocorticoids, and adrenal androgens. The clinical manifestations before an adrenal crisis are subtle and can include hyperpigmentation, fatigue, anorexia, orthostasis, nausea, muscle and joint pain, and salt craving. Cortisol levels decrease and adrenocorticotropic hormone levels increase. When clinically suspected, serum morning cortisol levels should be measured. Treatment of primary adrenal insufficiency requires replacement of mineralocorticoids and glucocorticoids. During times of stress (e.g., illness, invasive surgical procedures), stress-dose glucocorticoids are required because destruction of the adrenal glands prevents an adequate physiologic response. Management of primary adrenal insufficiency or autoimmune adrenalitis requires vigilance for concomitant autoimmune diseases; up to 50% of patients develop another autoimmune disorder during their lifetime. If low serum cortisol levels are present then the patient should undergo an ACTH (Cosyntropin) stimulation test to confirm the diagnosis. ACTH levels are measured in order to differentiate between primary and secondary adrenal insufficiency. ACTH levels are increased in primary adrenal insufficiency and decreased in secondary adrenal insufficiency.

Which of the following is characteristic of pemphigus vulgaris? Mucous membrane involvement Negative Nikolsky sign Primarily affects patients over 60 years of age Tense bullae

Mucous membrane involvement. Pemphigus vulgaris is a dermatologic disease characterized by bullous lesions. It is most commonly seen in patients ages 40-60 years and affects men and women equally. It is thought to be autoimmune in origin. Most patients develop mucous membrane lesions initially, sometimes months prior to the onset of skin lesions. Like the skin lesions, the oral lesions present on the gums and vermilion border of the lips, are bullous and break, leaving painful and superficial ulcerations. The skin lesions can involve any site on the body and are small, flaccid bullae that break easily. Nikolsky sign, extension or new bullae formation when lateral pressure is placed on intact skin in the next 24 hours, is positive. Diagnosis is made clinically and confirmed by serum immunofluorescence. A Tzanck test will also be positive, but is not specific to pemphigus vulgaris. Treatment consists of pain control, wound care, and oral glucocorticoids. Prior to the use of steroids, the mortality rate was over 90%. With steroid management and appropriate wound care, the mortality rate is now less than 15%.

Which of the following is the most common cause of hypertrophic cardiomyopathy in the newborn? Inborn errors of metabolism Multiple congenital anomaly syndromes Mutations of sarcomeric proteins Neuromuscular disorders

Mutations of sarcomeric proteins True hypertrophic cardiomyopathy of the neonate is predominantly caused by mutations in sarcomeric proteins. This is also called "idiopathic" or "familial" hypertrophic cardiomyopathy. Other types of hypertrophic cardiomyopathy can mimic the sarcomeric form, including inborn errors of metabolism, multiple congenital anomaly syndromes (such as Noonan syndrome), neuromuscular disorders, and mitochondrial disorders. There are also disease states which cause an acquired hypertrophic cardiomyopathy, including pulmonary disease, vascular disease, endocrine disease, rheumatic disease, and exposure to cardiotoxins. Sarcomeric hypertrophic cardiomyopathy is often asymptomatic, but symptoms depend on the severity of the hypertrophy and outflow tract obstruction. Severe cases may cause syncope, dyspnea, heart failure, chest pain, or sudden cardiac death. Only about half of the patients with hypertrophic cardiomyopathy have an audible murmur. The murmur is usually best heard at the left sternal border or apex and is a harsh crescendo-decrescendo systolic murmur which increases in intensity with Valsalva maneuver and decreases with squatting. Diagnosis is made with echocardiography, and treatment is aimed at reducing symptoms and preserving left ventricular function. The pharmacologic agent used most often in the pediatric population to obtain these treatment goals is a beta-blocker.

A 27-year-old woman presents to your clinic with a complaint of her eyelids drooping for the past three months. She says that now she is also experiencing choking while eating and has difficulty holding her head up. Physical exam reveals ptosis, asymmetric, weak extraocular muscle movements and a mask-like appearance to the face. Which of the following is the most likely diagnosis? Botulism Guillain-Barré syndrome Multiple sclerosis Myasthenia gravis

Myasthenia gravis is an autoimmune disorder that causes abnormalities in neuromuscular transmission. Antibodies form that block receptors at the neuromuscular junction of skeletal muscles, causing the classic weakness presentation. There are two forms of the disease, ocular and generalized. The cause of the disorder is unknown. Myasthenia gravis occurs more commonly in females and can occur at any age. Patients present with fluctuating and variable combinations of weakness in the ocular, bulbar, extremity and respiratory muscles. The initial symptoms are extraocular eye muscle weakness and ptosis. The disease progresses from mild to more severe forms over weeks or months. Weakness spreads from the eyes to the face, then the extremities, with respiratory muscles being the last affected. Diagnosis is based on history, physical exam, serologic tests including an anti-acetylcholine receptor antibody test, and electrophysiological studies. Medical treatment includes anticholinesterase medications such as pyridostigmine bromide and immunosuppressive agents such as corticosteroids. The most severe manifestation of myasthenia gravis is when the disease progresses to the respiratory system, therefore patients with myasthenia gravis require close care and monitoring. Intubation and intensive care unit admission is indicated for patients with the disease who progress to respiratory crisis.

A 70-year-old man with a history of HIV infection presents to the office for routine testing of his CD4 count. His last CD4 count was 90 cells/mcL and the results from this visit show a CD4 count of 45 cells/mcL. Which of the following opportunistic infections are patients prone to developing when their CD4 count drops below 50 cells/mcL? Histoplasmosis Kaposi sarcoma Mycobacterium avium complex Toxoplasmosis

Mycobacterium avium complex. Human immunodeficiency virus (HIV) infection is a blood-borne infection that is characterized by cellular immune deficiency caused by the depletion of helper T lymphocytes. The loss of these cells results in the development of opportunistic infections and neoplastic processes. Those with CD4 counts below 200 cells/mcL are considered to have developed acquired immunodeficiency syndrome (AIDS) and require prophylactic treatment for a variety of opportunistic infections. Many infections can be prevented by taking antibiotics or antifungal medications. Patients with CD4 counts less than 50 cells/mcL are at risk for infection with mycobacterium avian complex and cytomegalovirus retinitis. Histoplasmosis (A), a lung infection caused by Histoplasma capsulatum fungal spores found in the soil and in droppings of bats and birds, and toxoplasmosis (D), a parasitic infection caused by eating undercooked meat and exposure to infected cat species, are opportunistic infections that may appear with CD4 counts lower than 150 cells/mcL and 100 cells/mcL, respectively. Kaposi's sarcoma (B) is a type of cancer with skin manifestations that is commonly seen in HIV positive patients and is not associated with specific CD4 counts.

A 37-year-old woman presents with a history of episodic vertigo, right-sided aural fullness, and right-sided tinnitus for the past several months. The episodes typically last 12 hours. Physical exam reveals her ears to be normal. Audiometric evaluation shows a low-frequency sensorineural hearing loss in the right ear. Dix-Hallpike testing is negative. MRI of the brain and internal auditory canals was normal. Which of the following is the most appropriate treatment for the suspected diagnosis? Epley maneuver Intratympanic gentamicin Restricting sodium intake to 2 to 3 g daily Triamterene/hydrochlorothiazide

Ménière disease is a triad of symptoms including episodic vertigo, sensorineural hearing loss, and tinnitus. Vertigo will persist from 20 minutes to 24 hours. Hearing loss will fluctuate with the vertigo and initially affects the lower frequencies. Patients may complain of unilateral aural fullness or pressure and describe tinnitus as machinery or roaring. There is no specific diagnostic test to confirm the diagnosis, though diagnostic evaluation should include an audiogram and an MRI to rule out vestibular schwannoma. Initial management includes recommending a salt-restricted diet as well as limiting caffeine, nicotine, and alcohol. Patients who do not respond to conservative management may be candidates for diuretics (triamterene/ hydrochlorothiazide) or betahistine which reduce the degree of endolymphatic hydrops. Intractable cases may benefit from invasive treatments including intratympanic gentamicin or labyrinthectomy/vestibular nerve section.

A 14-year-old girl has been diagnosed with primary amenorrhea. Pelvic ultrasound reveals an absent uterus. Genetic testing confirms a 46,XX karyotype. Which of the following is the most likely diagnosis? Asherman syndrome Imperforate hymen Müllerian dysgenesis Turner syndrome

Müllerian dysgenesis (normal complement of sex chromosomes: 46,XX) is a uterine abnormality in which there is a congenital absence of the uterus and vaginal upper two-thirds. Primary amenorrhea can be a result of several gynecologic anatomic abnormalities, as discussed below.

A previously healthy 21-year-old woman presents to your clinic with a complaint of pelvic cramping. The cramping generally begins just before her menses, lasts for approximately three days and ends one to two days after her menses begins. Which of the following is the most appropriate therapy? Acetaminophen Aspirin Indomethacin Naproxen

Naproxen Dysmenorrhea is defined as painful menstruation and is generally described as crampy, recurrent, lower abdominal pain during the beginning of menses. There are two categories of dysmenorrhea. Primary dysmenorrhea involves symptoms when there is no other pelvic pathology. Secondary dysmenorrhea is due to an organic disease. Primary dysmenorrhea begins within six months of menarche, lasts 48-72 hours, often starts just before the menstrual flow begins, is located in the lower abdomen, is described as a cramping sensation and generally yields unremarkable findings if a pelvic exam is done. The cause and pathophysiology of primary dysmenorrhea have not been completely determined; however, the current evidence points to the presence of prostaglandin F2α, a vasoconstrictor and myometrial stimulant, as the pathogenesis. In patients with primary dysmenorrhea, there is also a complex relationship between basal body temperature, hormones and mediators, patterns of sleep and the central nervous system which is not fully understood. The goal of treatment is to provide pain relief. Treatment is empiric and no laboratory tests or imaging are needed when the history and physical exam suggest the diagnosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and oral contraception are first-line medications in the treatment of primary dysmenorrhea. NSAIDs work by decreasing intrauterine pressure and lowering prostaglandin F2α levels in menstrual blood.

A seven-year-old boy has redeveloped nocturnal enuresis over the past month. His family denies new stressors, but they have noted increased frequency of urination during the daytime. He has lost three pounds since his last visit six months ago. He appears thin but well hydrated. Which of the following is the most appropriate next step? Obtain a blood glucose measurement Obtain a urinalysis Obtain spinal ultrasonography Provide reassurance

Obtain a urinalysis. This patient's history of nocturnal enuresis, polyuria, and weight loss is suggestive of diabetes mellitus. Blood glucose measurement is the first step in diagnosis for any patient with suspected new-onset diabetes. Further workup should include venous pH, urinalysis, blood ketones, hemoglobin A1C, insulin and C-peptide levels, and pancreatic autoantibodies. Secondary nocturnal enuresis is a recurrence of enuresis after a dry period of at least six months. It may be provoked by stressors such as the birth of a new sibling, parental divorce, trauma, hospitalization, or sexual abuse. All patient's with enuresis should be evaluated with urinalysis even if urinary tract infection is not highly suspected. Less common organic etiologies of enuresis include spinal cord abnormalities, diabetes insipidus, seizures, obstructive sleep apnea, chronic kidney disease, and psychogenic polydipsia.

A 4-week-old girl is brought to urgent care with eye discharge. Her father reports four days of yellow discharge from both eyes. Her eyes have not appeared red. Her physical exam is notable for tearing of both eyes, scant yellow discharge, and non-injected conjunctiva. Which of the following is the best next step? Artificial tears four times per day Nasolacrimal duct massage three times per day Surgical probing Systemic antibiotics

Nasolacrimal duct massage three times per day. Congenital nasolacrimal duct obstruction, or dacryostenosis is a common condition in newborns. The condition may be present at birth or may present at several weeks of life. It is caused by failure of canalization of the epithelial cells that form the nasolacrimal duct. Clinical findings include a large tear lake, overflow of tears onto the cheek, and presence of mucoid material in the canthi that has refluxed from the lacrimal sac. The presence of tears triggers rubbing and irritation of the eyes, which may lead to erythema or maceration of the skin. Infection and inflammation of the nasolacrimal sac may occur in infants with dacryostenosis, including dacryocystitis, pericystitis, and rarely periorbital cellulitis. These patients will have swelling, redness, and tenderness of the lacrimal sac, and may also exhibit fever and irritability. Treatment of uncomplicated dacryostenosis consists of nasolacrimal massage 2-3 times daily and cleansing with warm water. Topical antibiotics may be added if there is mucopurulent drainage. Most cases resolve spontaneously.

List three side effects of digoxin.

Nausea/vomiting, anorexia, confusion, arrhythmias (sinus brady, AV block), fatigue, vision disturbances etc.

A 23-year-old woman presents with several erythematous, painful ulcers on the vaginal introitus which have been present for seven days and began as small red papules, which then evolved to pustules and then ulcerations. There is marked lymphadenopathy of bilateral inguinal nodes. Polymerase chain reaction for herpes simplex virus is negative. Which of the following additional diagnostic tests is necessary before diagnosing chancroid in this patient? Gram stain of the ulcer exudate showing gram-negative rods Negative Tzanck smear Negative venereal disease research laboratory test Positive polymerase chain reaction for Haemophilus ducreyi

Negative venereal disease research laboratory test. Chancroid is a sexually transmitted disease which results in painful genital ulcers. The causative pathogen is Haemophilus ducreyi, a gram-negative rod which is very contagious but rarely found in the developed world. Cases of chancroid in the developing world may be underreported due to the difficulty of definitive diagnosis. Chancroid begins as one or several erythematous papules on areas of the genitals most susceptible to friction, such as the glans penis or the vaginal introitus. The papules become pustules which ulcerate and form painful open sores, usually of one to two centimeters in diameter. The ulcers have an erythematous base covered by a gray or yellow purulent exudate. In about half of patients with chancroid, there will also be marked lymphadenopathy in the inguinal chain. The definitive diagnosis of chancroid is elusive because it requires a specific culture medium which is not readily available. Therefore, the vast majority of chancroid cases are diagnosed based on the presence of all four of the following criteria: one or more painful genital ulcers, a negative polymerase chain reaction (or culture) for herpes simplex virus, no evidence of Treponema pallidum on darkfield microscopy of the ulcer exudate or a negative venereal disease research laboratory test (or other serologic test for syphilis), and clinical signs and symptoms consistent with chancroid. Treatment of chancroid is with ceftriaxone 250 mg injected intramuscularly or with one gram of oral azithromycin.

What is the most common form of child abuse in the United States? Emotional Neglect Physical Sexual

Neglect is the most common type of child maltreatment in the United States (78.5%) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is likely the most common form of neglect that is recognized, typically in the form of failure to thrive (FTT). Risk factors for neglect include poverty, poor support systems, parental mental health issues or mental disability, parental substance abuse, poor parenting skills, or complex child needs. The history and physical exam are extremely important when child abuse is suspected. A thorough history from everyone involved using open-ended questions, is the recommended approach. A full physical exam, including a genital exam is warranted. Signs such as bruising in non-mobile children, ligature marks, or burn marks are red flags for child abuse. Imaging should include a full skeletal survey in any child younger than 2 years with suspected physical abuse as well as a non-contrast computed tomography scan of the head in all children aged 6 months or younger with suspicion of abuse or children younger than 24 months with any suspected intracranial trauma. In cases of neglect, particularly when failure to thrive (FTT) is in question, a workup for organic problems may be undertaken. A provider who can follow up the laboratory results, monitor weight gain closely, and work with the family should be involved. Failure to thrive may require admission or close follow up with a specialist.

Which of the following is the most common solid renal tumor of childhood? Adenocarcinoma Leiomyoma Nephroblastoma Renal lipoma

Nephroblastoma, or Wilms tumor, is the most common solid renal tumor of childhood. It accounts for approximately 5% of all childhood cancers and in 5% of those cases the cancer occurs bilaterally. There is a sporadic form that arises from two postzygotic mutations and a familial form that arises after one pre-zygotic mutation and one postzygotic mutation. Signs and symptoms range from the discovery of an asymptomatic abdominal mass to abdominal pain, anorexia, abdominal distention, vomiting, and hematuria. Urinalysis will demonstrate hematuria and a complete blood count (CBC) may show anemia. Diagnosis can be made by obtaining abdominal ultrasound or CT scans of the abdomen, although chest X-ray is used to evaluate for metastatic lung disease. Treatment includes surgical resection of the kidney and is usually accomplished through a radical nephrectomy through a transabdominal incision. Chemotherapy and radiation therapy are also used as adjuncts to surgical resection. If the histology of the tumor is favorable, the prognosis is good with a 4-year-survival rate around 90%.

A 26-year-old woman presents to the outpatient family practice office with a past medical history significant for schizoaffective disorder. She reports that she is dead already. She also believes that a 7.0 magnitude earthquake is going to occur in seven days. She describes that she was reading a gardening magazine three weeks ago when she was struck with the knowledge that she no longer exists and that a natural disaster is around the corner. She has been unable to focus on anything else. She denies any visual or auditory hallucinations. When presented with the information that she was present in the office and there has never been a recorded earthquake where she lives, she remains undeterred from this thought. How should this information be documented in the history of present illness? Erotomanic delusions Grandiose delusions Nihilistic delusions Persecutory delusions

Nihilistic delusions Delusions are beliefs that a patient believes to be true, even when presented with information that is in conflict with the belief. Delusions can be conceptualized by themes. Nihilistic delusions, as described in this scenario, may be focused on the belief that the world, body, or a body part have ceased to exist or that there is an impending catastrophic event. In addition to identifying the theme, delusions should be further classified as bizarre or nonbizarre. Bizarre delusions are thought concepts that are implausible or impossible (e.g., being abducted by aliens and replaced on earth with an altered version of themselves). Nonbizarre delusions are improbable but not impossible (e.g., police are watching their home). Patients with schizoaffective disorder may experience a range of bizarre and nonbizarre delusions with a variety of themes. According to the DSM-V, patients with schizoaffective disorder must experience a major depressive episode or a manic episode while also meeting the first criteria for schizophrenia. The first criteria (criterion A) for schizophrenia states that two or more of the following must be each present for a significant portion of time during a one month period (or less if successfully treated): delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. The DSM-V states the patient must experience delusions, hallucinations, or disorganized speech as at least one of the two symptoms. In addition to meeting this particular criteria, the DSM-V requires that patients with schizoaffective disorder experience delusions or hallucinations for two or more weeks in the absence of a major mood episode. In addition, symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. Schizoaffective disorder affects women more than men and has a typical onset of early adulthood. It is about one third as common as schizophrenia. The course is chronic and carries a significant risk of suicide, especially in those who experience depressive symptoms. Treatment is with antipsychotics, as with schizophrenia. Adjunctive medication may be needed to address acute depressive or manic symptoms.

A 50-year-old man presents to the emergency department with sudden onset of shortness of breath. He has a history of heart failure with an ejection fraction of 25%. Vital signs include temperature 100°F, blood pressure 220/110 mm Hg, heart rate 125 beats/minute, and respiratory rate 30 breaths/minute. On examination, he appears anxious and tachypneic. Chest X-ray demonstrates diffuse bilateral interstitial opacification. Which of the following is the most appropriate initial treatment? Albuterol Dobutamine Furosemide Nitroglycerin

Nitroglycerin. Acute hypertensive heart failure can result in pulmonary edema that must be managed with aggressive preload and afterload reduction. Nitroglycerin can be administered sublingually and intravenously to achieve rapid and titratable improvement in hypertension via vasodilation with a reduction in preload and afterload. Initial management involves sublingual administration until IV access is established and a titratable infusion can be initiated. In addition to addressing hypertension, acute heart failure exacerbations are managed with supplemental oxygen, non-invasive positive pressure ventilation, loop diuretics (e.g., furosemide) in cases of severe volume overload, and assessment of an underlying cause (e.g., acute myocardial infarction, pericardial tamponade). Patients may require intubation when hypoxic or hypercarbic respiratory failure ensues. Patients who present with hypotension in the setting of acute heart failure (i.e. cardiogenic shock) should not receive nitroglycerin and may require vasopressors to maintain hemodynamic stability.

A 48-year-old man with a history of hypertension presents to the emergency department with a headache and blurring of vision. He reports poor compliance with his blood pressure medications due to lack of access to a primary care provider. On presentation, his vital signs are 36.9°C, HR 87, BP 190/120, RR 16. He denies chest pain or shortness of breath. Physical examination is unremarkable. His laboratory studies are notable for a creatinine of 2.5 U/L. Which of the following is contraindicated in the control of this patient's blood pressure? Esmolol Labetalol Nicardipine Nitroprusside

Nitroprusside. Hypertensive emergency is an acute elevation of blood pressure associated with end-organ damage, typically of the kidneys, brain, heart, aorta, or eyes. This is in contrast to hypertensive urgency, which is an elevation in blood pressure without signs of end-organ damage. Hypertensive emergency is most common in patients with chronic hypertension who are noncompliant with medications. It results from the eventual overwhelming or failure of compensatory mechanisms for end-organ perfusion in the setting of increased mean arterial pressure. This leads to fibrinoid necrosis and end-organ hypoperfusion and ischemia. Blood pressure control is the cornerstone of management for all hypertensive emergencies, but the method of blood pressure control differs based both on the etiology of the hypertensive emergency and the evidence of end-organ damage. In acute renal failure, as seen in the patient above, the goal for blood pressure control is to decrease the mean arterial pressure by no more than 20% acutely to avoid further organ hypoperfusion. Preferred agents include calcium channel blockers such as nicardipine or clevidipine. Nitroprusside should be avoided in the setting of renal failure due to the risk of cyanate and thiocyanate toxicity.

A splinter went deep into the arm of a man while he was working in the yard. After thorough wound cleansing, you inquire about his tetanus status. He is certain that he received all of his childhood vaccines and a tetanus booster 4 years ago, but does not know which vaccine he received. Which one of the following is the best choice for this patient regarding tetanus immunization at this time? No immunization Tetanus immune globulin Tetanus toxoid Tetanus toxoid with reduced diphtheria

No additional vaccine is needed at this time since received his initial childhood vaccinations as well as a tetanus booster within the past 5 years. Tetanus immune globulin is recommended in addition to tetanus vaccine for wounds that are tetanus-prone due to contamination and tissue damage in persons with an uncertain primary vaccine history. Tetanus toxoid (TT) is usually indicated only when the diphtheria component is contraindicated, which is uncommon. The tetanus toxoid with reduced diptheria (Tdap) should be administered to any person with an uncertain or incomplete history of completing a three-dose primary series of tetanus toxoid-containing vaccine, or if the most recent dose was given ≥ 10 years ago (for minor and clean wounds) or ≥ five years ago (for puncture wounds or wounds contaminated with dirt).

A 51-year-old man presents with a 3-day history of severe pain associated with bowel movements. The pain lasts up to 1 hour following each bowel movement. His stools are described as "hard", but they retain their normal brown color, with the occasional presence of a few drops of bright red blood. His dietary history is remarkable for a low-fiber diet lacking in raw fruits and vegetables. He denies any sexual contact, drug use, or other gastrointestinal symptoms. He takes ferrous sulfate for anemia and oxycodone for chronic joint pain. His rectal exam reveals a small tear in the lining of the anus. What is the most appropriate diagnostic test to order at this time? CT scan of the abdomen and pelvis No diagnostic tests are necessary HIV ELISA test Anoscopy Rectal biopsy

No diagnostic tests are necessary. This patient's diagnosis is a posterior anal fissure. Along with a history, the diagnosis can usually be made based on findings from a gentle perianal examination with inspection of the anal mucosa. In this case, no diagnostic procedures are required. A digital rectal examination is painful and often can be deferred. Anoscopy may be required for lesions that are not well-visualized; however, this is not well tolerated by a patient with an acute anal fissure. In this case, anoscopy can often be deferred; the patient can be treated based only on the symptoms. If an ordinary anal fissure is suspected, and if it is located in the posterior or anterior midline, then no laboratory or imaging tests are necessary. If the fissure is off the midline or irregular, or if an underlying illness (e.g., Crohn disease, squamous cell cancer, AIDS) may be present, then the appropriate tests should be ordered. These tests include erythrocyte sedimentation rate, stool and viral cultures, human immunodeficiency virus (HIV)testing,and biopsy of the lesion/fissure.

A 35-year-old woman presents to her primary care physician for follow up of an incidental finding on chest CT found during a workup for possible pulmonary embolism. She is a non-smoker and has a negative family history for lung cancer. A solid, solitary pulmonary nodule of 4 mm was seen on chest CT. The scan was otherwise unremarkable. Which of the following is the next best step? CT scan at 12 months Needle biopsy No further follow-up Serial CT surveillance

No further follow-up is necessary in a low-risk patient with a solitary pulmonary nodule of < 6 mm. Pulmonary nodules can be either benign or malignant. Most nodules are benign even among smokers. Benign nodules can be caused by infectious granulomas, hamartomas, arteriovenous malformations or inflammatory lesions. When deciding how to best evaluate a nodule, things to consider are the probability of malignancy, the age of the patient, risk factors for either lung cancer or non-lung cancer nodules, and the size and features of the nodule. A solid nodule less than 6 mm does not require follow-up as they are generally benign. Nodules between 6-8 mm can be followed with a CT scan. If the patient is at high risk, a second CT scan 18 months later can be considered. Serial CT surveillance would be considered with a low to intermediate risk nodule over 8 mm. If there is a high probability of malignancy, biopsy and excision should be considered.

Define missed abortion.

No vaginal bleeding, cervix is closed, products of conception are still inside.

Which of the following is the leading cause of non-solid organ cancer-related death? Acute myeloid leukemia Hodgkin lymphoma Multiple myeloma Non-Hodgkin lymphoma

Non-Hodgkin lymphoma (NHL) is the leading cause of non-solid organ cancer-related death. It has a significantly worse prognosis than that of Hodgkin lymphoma. Signs and symptoms of NHL include persistent, painless, peripheral lymphadenopathy. It is found in the epitrochlear nodes, mesenteric nodes, mediastinal nodes, retroperitoneal nodes, and pelvic nodes. Enlargement of oral and nasal lymphoid tissue is also consistent with NHL. Any lymph node that is > 1 cm in size and persistent for > four weeks without association with a documented infection should be considered for biopsy. NHL may mimic infectious mononucleosis. Patients may also present with chest discomfort or superior vena cava (SVC) syndrome. Diagnosis is typically made by lymph node biopsy or bone marrow aspiration. Management is with supportive care, chemotherapy, and radiation. Other potential treatments include interferon-α, monoclonal antibodies, and bone marrow transplantation. Acute myeloid leukemia (A), Hodgkin lymphoma (B), and multiple myeloma (C) are all much less common causes of cancer-related death than Non-Hodgkin lymphoma.

A 64-year-old woman is brought to the emergency department due to sudden-onset headache with nausea, vomiting, and a sensation that the "room is spinning." The patient developed the symptoms yesterday when she awoke, and they have not improved. She has had no ear pain or hearing loss. The patient was recently prescribed hydrochlorothiazide for hypertension. Medical history also includes type 2 diabetes mellitus and hyperlipidemia. Blood pressure is 124/76 mm Hg and pulse is 86/min. Neurologic examination with the patient lying still shows nonfatigable nystagmus. Walking worsens symptoms, and the patient falls toward the left side. Which of the following is the best next step in management of this patient? Ambulatory ECG monitoring Discontinuation of hydrochlorothiazide Noncontrast CT scan of the head Otolith repositioning maneuver Reassurance and oral meclizine therapy

Noncontrast CT scan of the head. This patient with vascular risk factors, acute-onset headache, a sensation that the room is spinning, and nystagmus likely has had a stroke or hemorrhage affecting the cerebellum. Vertigo is often described as a sensation of spinning (as in this patient), whirling, or tilting and can be due to an underlying disease in either the central or the peripheral nervous system. Patients with central vertigo have nystagmus that is not fatigable and not inhibited by fixation of gaze. They may be unable to walk because, in addition to a false sensation of movement, vertigo from a central underlying cause (eg. stroke) may also affect postural stability and coordination. Patients with central vertigo, such as this woman, should be evaluated for cerebellar stroke or hemorrhage, particularly if the have the following: prominent stroke risk factors (eg. HLD, HTN, DM), new-onset headache, neurologic signs/symptoms (eg. weakness/numbness of the face or limbs, dysarthria). Head imaging should be obtained urgently. CT scan is often obtained first because it can be completed faster than an MRI. However, if the CT scan is negative, an MRI is usually required to exclude brainstem or cerebellum pathology, which may not be visualized well on CT scan.

A 60-year-old man with a history of chronic obstructive pulmonary disease presents by EMS in respiratory distress. He is diaphoretic and is sitting up in bed leaning forward. His vital signs are T 100.1°F, HR 95 beats/minutes, RR 30 breaths/minute, BP 150/90 mm Hg, and oxygen saturation 79% on room air. There is poor air movement with prolonged expiratory wheezes. A nonrebreather face mask is placed, but his work of breathing and oxygen saturation are not improving. In addition to intravenous glucocorticoid and nebulized beta-agonist medications, which of the following is most appropriate next step in management? Ceftriaxone and azithromycin Endotracheal intubation Intravenous magnesium sulfate Noninvasive positive pressure ventilation

Noninvasive positive pressure ventilation. This patient is having an acute exacerbation of his chronic obstructive pulmonary disease (COPD). Acute exacerbations are characterized by worsening pulmonary symptoms that are brought on by pulmonary irritants or infection. The most common bacterial causes of infection are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Other triggers include cold weather, narcotics, beta-blockers, and hypoxia. Inflammatory mediators are released, leading to bronchoconstriction, pulmonary vasoconstriction, and mucus secretion. This creates increased airway resistance and lung hyperinflation, both of which lead to increased work of breathing. Hypoxemia is the most life-threatening feature of COPD exacerbations. Patients are often tachypneic, tachycardic, and may be altered due to carbon dioxide retention. An arterial blood gas should be obtained to assess for acid-base status and management is guided accordingly. Emergency department management is aimed at improving oxygenation and ventilation, alleviating bronchospasm and treating the underlying cause. Therapeutic options include administration of supplemental oxygen, aerosolized beta-adrenergic agonists, and anticholinergics (e.g., albuterol, ipratropium bromide), glucocorticoids (e.g., methylprednisolone 125 mg IV), and antibiotics as needed. Noninvasive positive pressure ventilation (NIPPV) is beneficial for patients with severe acute exacerbations who are acidemic (pH < 7.36), hypercapnic (PaCO2 > 50 mm Hg), hypoxemic (PaO2 < 60 mm Hg or SaO2 < 90 mm Hg), or who have severe dyspnea, respiratory fatigue or increased work of breathing.

A four-year-old patient presents to the clinic with his mother, who complains that he is "wall-eyed". The child is demonstrating well-coordinated, well-aligned gaze during the exam. A cover test shows no abnormalities, but a cover-uncover test is positive for slight medial repositioning of the covered eye immediately upon uncoverage. Visual acuity is 20/20, red reflex is present bilaterally, and fundoscopic examination is normal. Which of the following is the best choice for ongoing care of this patient? Observation with regular follow-up with ophthalmologist every six months Observation with regular follow-up with primary care provider every six months Occlusion therapy and visual training exercises Surgical extraocular muscle resection

Observation with regular follow-up with ophthalmologist every six months Strabismus refers to misalignment of the eyes and is commonly encountered in the pediatric population. Causes of strabismus may be benign or pathological, and treatments vary depending on etiology and severity of discordant gaze. During the first six months of life, ocular instability of infancy causes transient strabismus and is a normal finding. After infancy, strabismus can be categorized as esotropia, exotropia, esophoria, or exophoria. Hyper- and hypo- types also exist and refer to upward or downward turns of the eye. Eso refers to an inward turn, and exo refers to an outward turn. Tropia describes manifest strabismus, which can be seen with both eyes uncovered. Phoria refers to latent strabismus that becomes evident when one eye is covered. The patient in the above vignette suffers exophoria, as the affected eye repositions itself medially after being covered. Small, intermittent deviations in gaze in which fusion can be demonstrated do not require treatment, but regular follow-up with an ophthalmologist is recommended, to evaluate for disease progression or the development of amblyopia.

A 24-year-old woman presents to Urgent Care after tripping over her backpack and hitting her head at home. A friend noted brief period of unconsciousness lasting less than 3 seconds. Prior to arrival to urgent care, she vomits once. On your physical exam, she is noted to have a normal physical exam with normal vital signs. According to the Canadian CT Head Rule, which of the following is the most appropriate next step in management? Observation Transfer to emergency department for a CT scan of the head with contrast Transfer to emergency department for a CT scan of the head without contrast Transfer to emergency department for an MRI scan of the head

Observation. Head injuries can be life threatening therefore it is critical to identify those patients at risk for significant pathology. Serious head trauma can result in an epidural hematoma, subdural hematoma, subarachnoid hemorrhage, intracerebral hemorrhage, and skull fracture. For minor head trauma, guidelines help clinicians decide on whether a head CT scan is needed to diagnose or rule out an intracranial injury. One set of rules called the Canadian CT Head Rule devised a set of criteria seen below on which patients with minor head trauma require a head CT scan. The patient in the clinical scenario does not meet any of these criteria and therefore can undergo a period of observation. The patient should be watched closely for signs of increased intracranial pressure (due to expanding hematoma) such as vomiting, confusion, motor or sensory deficits, visual changes, altered consciousness. It should be noted that the Canadian CT Head Rule is a guideline and any time a clinician feels a patient may have an intracranial injury despite not meeting the Canadian CT Head Rule, the clinician should go ahead and get the head CT scan.

An asymptomatic G2P2 58-year-old woman presents to the clinic for routine gynecologic examination. Pelvic exam reveals a posterior vaginal bulge and a palpable break in the rectovaginal fascia. Which of the following interventions is the best next step? Fit the patient for a pessary Observe with yearly examination Order abdominal and pelvic computed tomography Refer the patient for pelvic floor muscle strengthening

Observe with yearly examination. Rectocele is the anterior protrusion of the rectum into the posterior vaginal wall. Observation with yearly examinations is appropriate management for asymptomatic women or for women with mild symptoms and a mild prolapse because the majority of these women may never experience prolapse progression. The Women's Health Initiative estrogen and progestin trial found that the majority of women with Baden Walker grade I pelvic organ prolapse (distal descent of prolapse halfway to the hymen with Valsalva maneuver) would experience prolapse regression, while the majority of women with more advanced prolapse would experience prolapse progression. When indicated, treatment for symptomatic women may consist of directly treating bowel symptoms (constipation or defecatory dysfunction), supportive or space-occupying pessary, pelvic floor muscle training, or surgery with traditional posterior colporrhaphy or site-specific defect repair. Space-occupying or supportive pessaries provide significant symptomatic relief without the cost and time needed for pelvic floor muscle strengthening or the risk involved with surgery. Pelvic floor muscle strengthening can improve urinary and fecal incontinence, but its role in the treatment of pelvic organ prolapse is unclear. Since treatment is only indicated for women with symptomatic prolapse, neither a pessary nor pelvic floor muscle strengthening would be the best next step for this patient. Since rectocele is clinically diagnosed, abdominal and pelvic CT scan is not typically performed, nor is any other form of imaging indicated.

A 25-year-old man presents to the clinic complaining of anxiety. He states that he greatly fears that he will get lost while driving. For this reason, he repeatedly checks his GPS device, even while driving routes with which he is very familiar. He has been in four motor vehicle collisions this past year as a result of checking his GPS device instead of watching the road. Which of the following is the most likely diagnosis? Generalized anxiety disorder Obsessive-compulsive disorder Paranoid personality disorder Specific phobia

Obsessive-compulsive disorder typically begins in childhood or adolescence and persists throughout life. The disorder consists of obsessions, which are intrusive, unwanted thoughts that cause the patient considerable anxiety and distress, and compulsions, which are repetitive behaviors performed in response to the obsessive thoughts and for the purpose of relieving the anxiety those thoughts cause. Obsessions and compulsions generally center around one of four themes: cleaning, symmetry, harm, or forbidden thoughts. Diagnosis of obsessive-compulsive disorder is made when a patient displays obsessions or compulsions (or both) that are time-consuming, disruptive or impairing, not attributable to a medical condition or substance use, and not better explained by another mental disorder. Obsessive-compulsive disorder is often found to be comorbid with other psychological disorders, such as major depressive disorder. The rate of suicidal ideation and suicidal attempts is higher among patients with obsessive-compulsive disorder than the general population. Serotonergic antidepressants have shown great efficacy in treating the disorder, although treatment must often be continued for life. Psychotherapy combined with pharmacotherapy has shown the most benefit.

A 35-year-old man presents to the clinic for his annual physical. He was a project manager for a construction company until a few weeks ago. He was fired for failing to complete multiple projects on time, which he states is because every detail needs to be perfect prior to submission. He disliked delegating tasks to his co-workers as he feels they were unable to complete things his way. At home he has been having some marital difficulties due to his preoccupation with saving as much as he can. Which of the following is the most likely diagnosis? Borderline personality disorder Narcissistic personality disorder Obsessive-compulsive disorder Obsessive-compulsive personality disorder

Obsessive-compulsive personality disorder Obsessive-compulsive personality disorder is characterized as a pervasive pattern of preoccupation with orderliness. It is part of the cluster C personality disorders. It is more common in males. Individuals with obsessive-compulsive personality disorder tend to have professional success, but struggle with their interpersonal skills. Clinical manifestations include perfectionism, mental and interpersonal control at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts. The perfectionism may hinder task completion, cause reluctance in delegating tasks or to work with others unless they submit to exactly his or her way of doing things, adopt a miserly spending style, and form a preoccupation with details to the extent that the major point of the activity is lost. This pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning, which is required for the diagnosis as specified in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). First-line treatment involves psychotherapy, including cognitive-behavioral therapy. Pharmacotherapy is only used to treat associated comorbid disorders, such as anxiety or depression.

An 18-year-old G1P0 woman at 16 weeks gestation presents with vaginal bleeding. She has had no prenatal care. Vital signs are unremarkable and physical examination only reveals a small amount of blood in the vaginal vault. A transvaginal ultrasound is performed as seen above (large uterus with multiple vessels within the uterus cause a "snowstorm" appearance). What is the next best step in management of this patient? Administer methotrexate CT scan of the abdomen and pelvis Intravenous antibiotics Obstetrics consultation

Obstetrics consultation. This patient presents with vaginal bleeding and an ultrasound consistent with a hydatidiform mole or molar pregnancy requiring obstetrics consultation. Molar pregnancy is a spectrum of diseases characterized by abnormal chorionic villi proliferation. A complete hydatidiform mole refers to the situation in which there is no fetal tissue. In an incomplete mole, there is some fetal tissue along with trophoblastic hyperplasia. Patients with molar pregnancy may present with nausea, vomiting, abdominal pain, and vaginal bleeding. Without ultrasound, it is difficult to differentiate these patients from a threatened miscarriage or ectopic pregnancy. Often, the uterine size is larger than the expected for dates in molar pregnancy and the beta-hCG is higher than expected for dates. Diagnosis is based on characteristic findings on ultrasound. Hydropic vessels within the uterus cause a "snowstorm" appearance. Because of the potential for complications and the non-viability of the pregnancy, dilation and curettage is recommended. Once a hydatidiform mole is diagnosed, a chest X-ray should be obtained as trophoblastic tumors metastasize to lung, liver, and brain.

A 65-year-old man presents to his physician because he is concerned about skin lesions on his back as seen above (thickened "stuck on" lesions that can have a greasy characteristic). Which of the following is the next step in diagnosis? Obtain a shave biopsy of the lesion Obtain an excisional biopsy of the lesion Prescribe a low dose topical steroid Take a photograph of the lesions and ask the patient to follow up in 1 month

Obtain a shave biopsy of the lesion. This patient has seborrheic keratoses which is the most common benign tumor in older individuals. They are characterized as sharply defined hyperpigmented macules that appear most commonly on the trunk and upper extremities. Their size is usually less than 1 cm however they do grow over time. Over time they begin to appear as thickened "stuck on" lesions that can have a greasy characteristic. Keratotic plugging of the surface is a defining factor for this condition. No laboratory testing or imaging is needed. A shave biopsy is necessary in order to provide a histologic material for accurate diagnosis and remove the lesion in a cosmetically acceptable manner. This lesion does not lead to cancer however a biopsy is needed in order to rule out carcinoma. The lesion is primarily removed due to cosmetic purposes.

Which of the following statements best explains the use for penicillin in patients with a history of acute rheumatic fever? Penicillin is only recommended for patients with carditis during their acute rheumatic fever Penicillin is recommended to prevent Group A Strep colonization, which is more common in patients with acute rheumatic fever Penicillin is used for its anti-inflammatory effect on the affected heart valves Penicillin is used to prevent future episodes of acute rheumatic fever, which can lead to worsening heart disease

Penicillin is recommended as prophylaxis for patients with rheumatic heart disease to prevent future Group A Strep infections, which can lead to recurrence of acute rheumatic fever and worsening heart disease. Prior to the availability of penicillin prophylaxis, up to 75% of patients with rheumatic heart disease had a recurrence of acute rheumatic fever. Such recurrences can cause worsening of heart disease in patients who had carditis during their initial episode of acute rheumatic fever. The risk of recurrent acute rheumatic fever decreases with time from the initial episode of acute rheumatic fever.

A 22-year-old woman presents to the clinic complaining of loss of appetite, increased anxiety and dental caries. She displays increased energy and irritability, increased talkativeness, excoriations of the extremities, tachycardia, pupillary dilatation and diaphoresis. Which of the following is the most likely next step in diagnosis of this patient? Administer the Mood Disorder Questionnaire Obtain a thyroid-stimulating hormone level Obtain a urine toxicology screen Question the patient about past episodes of mania or depression

Obtain a urine toxicology screen The patient in the vignette demonstrates many of the signs and symptoms of methamphetamine abuse, and should receive a urine toxicology screen. Methamphetamines are stimulant drugs of abuse which are prevalent worldwide. Signs and symptoms of methamphetamine use include: pupillary dilatation, dry mouth leading to dental caries, decreased need for sleep, increased talkativeness, increased energy, irritability or other mood changes, tachycardia, diaphoresis, tooth grinding, jaw muscle tightening, euphoria, increased libido, nausea, vomiting, diarrhea, pruritus, and loss of appetite. Methamphetamines may be smoked, inhaled, injected or ingested orally. Methamphetamine users are more likely to engage in risky sexual behavior and are thus at increased risk for development of HIV and hepatitis C. Methamphetamines cause cardiovascular stimulation and most deaths due to methamphetamine use are cardiac in nature. Psychological comorbidities, such as anxiety, major depression, bipolar disorder, and schizophrenia are also more common among methamphetamine users than the general public. Methamphetamine use disorder is diagnosed when a patient meets two or more of the following criteria in a twelve-month period: craving the drug, tolerance to methamphetamine, withdrawal symptoms or using the drug to avoid withdrawal symptoms, recurrent use resulting in failure to meet obligations, continued use despite persistent interpersonal problems related to the substance, continued use despite physical or psychological problems associated with the substance, persistent use in physically hazardous situations, repeated unsuccessful attempts to cease use of the drug, spending a great deal of time in pursuit of methamphetamine use, ignoring obligations in favor of methamphetamine use, and using more of the substance or for longer periods than desired.

A 38-year-old man with a history of heavy alcohol use presents with hematemesis. After obtaining a history and performing a physical exam, a Mallory-Weiss tear is suspected. The patient's vital signs are stable with a normal heart rate and blood pressure. Which of the following is the next best step in caring for this patient? Administer an antiemetic Obtain intravenous access Place a nasogastric tube Prepare the patient for emergent upper endoscopy

Obtaining intravenous (IV) access is the most important first step in caring for a patient with gastrointestinal (GI) bleeding. Intravenous access allows blood to be drawn for a type and screen, coagulation studies, and determination of hematocrit and hemoglobin levels. It also allows for fluid resuscitation to maintain intravascular volume. Two large bore IV catheters should be used. A Mallory-Weiss tear is a tear in the esophageal mucosa often following forceful vomiting. Patients with a history of chronic alcohol use are at greater risk for developing a Mallory-Weiss tear. Once the patient is stabilized, an esophagoduodenoscopy (EGD) can confirm the diagnosis and allows for treatment options if the bleeding has not resolved spontaneously. Epinephrine injection, embolization, or coagulation therapy can be used to stop the bleeding although most cases resolve spontaneously as the mucosa heals over 48 to 72 hours. Administering an antiemetic is important to prevent further vomiting and subsequent worsening of the bleeding; however, this is not the most important first step in a patient that is actively bleeding and has the potential to become hemodynamically unstable.

A previously healthy 29-year-old G2P1A0 at 37 weeks and 4 days gestation presents to obstetric triage complaining of right upper quadrant pain that has been consistent since this morning. She also endorses a mild headache. Her blood pressure is 161/90 mm Hg and then 165/93 mm Hg on repeat 10 minutes later. Her pulse is 80 beats per minute. The fetal heart tracing is reassuring. Her physical exam is notable for hyperreflexia and her laboratory testing is remarkable for platelets at 80,000 platelets/microL. Which of the following is the best next step? CT of the head Delivery Expectant inpatient management Outpatient management

Of the available answer choices, delivery is the best next step. This patient likely has preeclampsia with severe features, given that she was previously healthy and now has severely elevated blood pressure (greater than 160 mm Hg systolic or 110 mm Hg diastolic), persistent right upper quadrant pain, and thrombocytopenia. This patient should be admitted to labor and delivery, her blood pressure should be treated with antihypertensives, and she should be started on intravenous magnesium sulfate for seizure prophylaxis. Delivery is the definitive treatment for preeclampsia with severe features, and the decision to proceed with induction of labor or cesarean delivery is based on usual obstetric indications.

What is the treatment for a tetanus infection?

Penicillin, immune globulin and supportive care (especially respiratory support)

Which of the following causes acute painful loss of vision? Central retinal artery occlusion Central retinal vein occlusion Optic neuritis Retinal detachment

Optic neuritis, an inflammatory, demyelinating disease of the optic nerve, presents as an acute monocular loss of vision. It is more frequently seen in young women. Although often idiopathic, approximately 30% of patients will develop multiple sclerosis (MS) within five years. Vision loss, most commonly a loss of central vision, and loss of color perception, develop over a period of hours and peaks in about one week. Eye pain, typically worse with eye movements, occurs in about 90% of patients. On examination, an afferent pupillary defect is usually present as is a swollen disk. Diagnosis is made based on history and physical exam findings. Magnetic resonance imaging of the brain and orbits with gadolinium will confirm the diagnosis and is helpful in determining those patients at risk for developing multiple sclerosis. After peak vision loss at one to two weeks, symptoms will gradually improve. Intravenous corticosteroids have been shown to increase the rate of recovery, as well as delay the onset of multiple sclerosis, although long-term visual outcome and rate of developing MS at five years are not affected by this treatment.

An 18-year-old pregnant woman presents to her primary care physician for treatment of her acne vulgaris. Which of the following would be the recommended treatment? Isotretinoin Oral erythromycin Oral tetracycline Topical tazarotene

Oral erythromycin Acne vulgaris, the most common cutaneous disorder in adolescents and young adults, is caused by a combination of factors that affect the pilosebaceous unit. The four main pathogenic factors are Cutibacterium acnes, previously known as Propionibacterium acnes, within the follicle, follicular hyperkeratinization, increased sebum production, and inflammation. Treatment can be either topical or systemic. During pregnancy, many medications are contraindicated due to teratogenicity. The best medication for this patient would be oral erythromycin as it is a pregnancy class B drug. Topical clindamycin or topical azelaic acid are also pregnancy class B drugs. Topical benzoyl peroxide is class C. In the case of patients who are not pregnant, initial treatment is a topical antimicrobial, such as benzoyl peroxide, with a topical retinoid. If this treatment fails, oral or topical antibiotics would be the next step in management. Hormonal therapy or the use of isotretinoin would be the next options in the case of treatment failure.

A 27-year-old pregnant woman at 16 weeks gestation presents with vaginal discomfort and discharge. Nucleic acid amplification is consistent with trichomonas. Gonorrhea and chlamydia testing is negative. What is the best treatment regimen? Administer intramuscular ceftriaxone and oral azithromycin in single doses Administer oral metronidazole in a single dose Prescribe intravaginal metronidazole for 5 days Recommend watchful waiting and follow up with obstetrics

Oral metronidazole x1 dose. Trichomoniasis is associated with adverse pregnancy outcomes, particularly premature rupture of membranes, preterm delivery, and delivery of a low birthweight infant. Despite the lack of evidence demonstrating decreased risk of these outcomes, treatment is recommended in symptomatic pregnant women because it improves symptoms, reduces risk of other sexually transmitted infection transmission and might decrease infection of the newborn after delivery. The preferred treatment regimen per the CDC for symptomatic trichomoniasis is metronidazole 2 g orally in a single dose. Alternative regimens include 2 g oral tinidazole in a single dose and 500 mg oral metronidazole twice a day for 7 days. Watchful waiting is not recommended. One trial with significant methodologic flaws showed increased risk of preterm delivery but subsequent trials have shown no association between adverse pregnancy outcomes and metronidazole use. Treatment is controversial in asymptomatic women, but many experts recommend treatment after a discussion of risks and benefits with the patient. Trichomoniasis increases vertical transmission of HIV so screening is recommended in pregnant patients with HIV.

Which of the following is a valid statement regarding a well-documented adverse effect causally related to a vaccine administration? Inactivated influenza vaccine can cause clinical influenza Measles vaccine is associated with autism The oral polio vaccine causes paralytic disease in immune-deficient individuals Thimerosal, a preservative contained in most vaccines, is associated with mental retardation in infants receiving thimerosal-based vaccines

Oral polio vaccine is a live attenuated viral vaccine that can lead to paralytic polio in patients with humoral immune deficiency. This complication has an incidence of approximately 1 in 500,000 recipients and is largely the rationale for switching from the live (oral) polio vaccine to the killed (injected) polio vaccine. Inactivated influenza vaccine cannot cause influenza disease in a recipient; only the live wild influenza virus can do so. The misimpression results from the fact that the vaccine is less than optimally effective and the unprotected vaccine recipients get temporally related wild influenza viral infections. Many scientifically rigorous studies performed around the world have proven conclusively that there is no causal relationship between measles vaccination and autism. Thimerosal, ethyl mercury, has been used as a preservative in vaccines made for human infants and children for decades. The concerns regarding toxicity to infants have been disproven, but it is no longer used in vaccines made for routine use in infants.

A 13-year-old male presents to the urgent care clinic with left eyelid swelling, erythema and eye pain which is worse with movement of the eye. He also complains of fever and double vision in his left eye. Which of the following is the most likely diagnosis? Bacterial conjunctivitis Hordeolum Orbital cellulitis Preseptal cellulitis

Orbital cellulitis is an infection involving the contents of the orbit. The most common symptoms of orbital cellulitis are ocular pain and eyelid swelling. Other symptoms include pain with movement of the eye, restricted extraocular movements, fever, proptosis, and diplopia. The most typical pathogens implicated are Staphylococcus aureus and Streptococci. The diagnosis of orbital cellulitis is confirmed using a CT scan. It is initially treated with broad-spectrum parenteral antibiotics and an ophthalmology consult. The most common complication with orbital cellulitis is abscess formation, which is treated surgically.

A 27-year-old man presents with a diagnosis of stage I seminoma. What is the initial treatment of choice? Orchiectomy Orchiectomy plus chemotherapy Orchiectomy plus combination chemotherapy and radiation therapy Orchiectomy plus radiation therapy

Orchiectomy is usually curative for patients with stage I seminoma. Orchiectomy is followed by active surveillance rather than chemotherapy or adjuvant radiation therapy. Classification as stage I seminoma requires histologic diagnosis of pure seminoma, no pretreatment elevation of a-fetoprotein, no evidence of distant metastases, and normal tumor markers following orchiectomy. Testicular cancer is the most common solid malignancy affecting men between the ages of 15 and 35. Germ cell tumors account for 95 percent of testicular cancers. Testis tumors are divided into two broad categories: pure seminoma and nonseminomatous germ cell tumors. Patients usually present with complaints of a nodule or painless swelling of one testicle. Exam typically reveals a hard, fixed area within the substance of the tunica albuginea. Diagnostic evaluation includes scrotal ultrasound, followed by radiographic testing to evaluate for metastases, measurement of serum beta-human chorionic gonadotropin and serum alpha-fetoprotein, radical inguinal orchiectomy, and sometimes retroperitoneal lymph node dissection. Treatment is based on histologic type as well as staging. Orchiectomy plus chemotherapy is recommended for patients with stage IIB or IIC seminomatous and nonseminomatous germ cell tumors. Treatment is with cisplatin-based chemotherapy.

A 32-year-old woman who is 35 weeks pregnant presents for a routine prenatal examination. Upon palpation of the uterus, the firm resistance of the fetal head is not able to be felt above the symphysis pubis. Upon further palpation, the fetal head seems to be located in the left upper quadrant. Which of the following is the next best step? Order an abdominal ultrasound Perform external version procedure Perform fetal non-stress test Plan an immediate cesarean delivery

Ordering an abdominal ultrasound to confirm a transverse fetal lie is the next best step in caring for this patient. Ultrasound allows the practitioner to determine the precise position of the fetus. Imaging also allows for determination of potential underlying causes including maternal pelvic abnormalities, uterine abnormalities, and placenta previa. A vaginal examination should not be performed until underlying abnormalities are excluded, particularly, placenta previa. External version can be attempted in cases of a singleton gestation without any underlying abnormality. External version is typically attempted at 37 weeks gestation which allows for ample amniotic fluid while restricting the time period for recurrence.

A 6-year-old boy has gradually increasing sharp pain in his left anterior hip that seems worse at night. He is moderately overweight, but he remains active and plays baseball. There is no history of trauma. There is no redness, swelling, or fever; there is no involvement of the other hip. Ibuprofen seems to help. There is no family history of any bone or joint disease. His weight is at the 95th percentile and height is at the 50th percentile. On exam, there is mild tenderness to palpation over his left anterior hip, but the rest of the exam is normal. Laboratory studies show a normal complete blood count, hemoglobin, sedimentation rate, platelets, and C reactive protein. Plain X-rays show a small round lytic lesion surrounded by mild reactive bone formation. Question What is the most likely diagnosis? 1 Legg-Calve-Perthes disease 2 Osteomyelitis 3 Primary lymphoma of bone 4 Osteoid osteoma 5 Ewing sarcoma

Osteoid Osteoma Osteoid osteoma is a common benign bone tumor consisting of an ovoid or spherical nidus of osteoid-rich tissue with interconnected bone trabeculae on highly vascularized connective tissue. It does not progress or have malignant potential. There may be bone sclerosis around the central nidus. The proximal femur and tibia are commonly involved. Pain is usually the presenting symptom. X-rays reveal the central nidus as a small spherical or oval lytic lesion surrounded by soft tissue edema and possible reactive bone formation. The primary goal of treatment is pain control with NSAIDs. If pain is not controlled or if complications such as neuropathy develop, the lesion should be removed. Ewing sarcoma is a highly malignant primary bone tumor derived from bone marrow. The earliest symptom is intermittent pain that becomes intense and may radiate. X-rays will show a long permeative lytic lesion in the metadiaphysis and diaphysis with a prominent soft tissue mass extending from the bone or a lesion with poorly defined margins. Occult metastatic disease is usually present.

There is a sunburst appearance on x-ray. What is the most likely diagnosis?

Osteosarcoma

A 24-year-old woman presents with sudden onset of lower right sided abdominal pain, nausea, and vomiting. She is not currently sexually active and pregnancy test is negative. She is found to have a right adnexal mass on exam. A pelvic ultrasound reveals an heterogenous enlarged ovary with decreased doppler flow. Which of the following is the most common risk factor for the suspected diagnosis? Intra-abdominal malignancy Ovarian mass Pregnancy Premenopausal age

Ovarian mass. Ovarian torsion is one of the most common gynecologic emergencies. It occurs when the ovary rotates on its ligamentous supports, which often blocks its blood supply. The primary risk factor for ovarian torsion is an ovarian mass (neoplasm or cyst), and the risk of torsion increases with the size of the mass. Other risk factors include reproductive age, pregnancy, and ovulation induction for infertility treatment. The classic presentation is a woman of childbearing age with acute-onset of severe pelvic pain with nausea and vomiting and an adnexal mass on exam. Since torsion can occur without an ovarian mass, and because torsion can lead to loss of ovarian function and necrosis of torsed tissue, a high index of suspicion is often needed for diagnosis. Pregnancy testing is essential since pregnancy is a risk factor for ovarian torsion, and ectopic pregnancy must be ruled out in a pregnant patient with acute-onset pelvic pain. Abdominal and pelvic ultrasound is the first imaging study of choice for suspected ovarian torsion because it is less expensive than and has similar diagnostic performance as computed tomography (CT) and magnetic resonance imaging (MRI). Definitive diagnosis is direct visualization of a torsed ovary during surgery, and prompt operative evaluation is the mainstay of treatment to preserve ovarian function.

Which of the following treatments for chronic obstructive pulmonary disease-related chronic bronchitis is associated with decreased mortality? inhaled glucocorticoids oxygen therapy pneumococcal vaccine short-acting bronchodilators

Oxygen therapy Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. COPD includes both emphysema and chronic bronchitis. Chronic bronchitis is defined as a chronic productive cough occurring most days for three months of the year for at least two or more consecutive years. Emphysema results in enlarged air spaces due to alveolar septae destruction. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) allows for stratification of disease severity and associated treatment guidelines. The airway in patients with COPD is typically inflamed with an increased number of goblet cells, mucous gland hyperplasia and narrowing due to fibrosis. Emphysema specifically affects the lung parenchyma more so than chronic bronchitis. Diagnosis is made with pulmonary function testing. Forced expiratory volume over one second (FEV1) is expected to be decreased in people with obstructive lung conditions. Forced vital capacity (FVC) is a measurement of how much air can be expelled from the lungs with maximal effort. Diagnosis of chronic obstructive lung disease is based on the FEV1 being less than 80% of predicted or the forced expiratory volume over one second divided by the forced vital capacity (FEV1/FVC) being less than 0.7. Chronic bronchitis is managed with a short-acting beta agonist or anticholinergic bronchodilators as individual or combination therapy. Long-acting bronchodilators and inhaled corticosteroids are also used to improve lung function and limit exacerbations. However, oxygen therapy and smoking cessation are the only two interventions associated with decreased mortality in patients with chronic obstructive pulmonary disease-related chronic bronchitis.

What is the first symptom of a rabies infection?

Pain and anesthesia at the site of the bite

List the six P's of an ischemic limb.

Pain, paresthesias, pallor, pulselessness, poikilothermia, paralysis

A 77-year-old man presents to his primary care provider with progressive jaundice for the past 2 weeks. He also reports a 15 lb unintentional weight loss. The man has a 50 pack-year smoking history. On physical exam, jaundice and hepatomegaly are noted. Additionally, his gallbladder is able to be palpated but is nontender. Which of the following is the most likely diagnosis? Cholecystitis Cirrhosis Hepatocellular carcinoma Pancreatic cancer

Pancreatic Cancer. The man in this case with progressive jaundice and Courvoisier sign, most likely has pancreatic cancer. More than 95% of pancreatic neoplasms arise from the exocrine portions of the pancreas. Cancer of the exocrine pancreas is the fourth leading cause of cancer-related deaths in the United States. The majority of exocrine pancreatic cancers are adenocarcinomas arising from the ductal epithelium. The head of the pancreas is the most commonly involved area. Men are more commonly affected than women. Risk factors for exocrine pancreatic cancer include family history of exocrine pancreatic cancer, hereditary pancreatitis, BRCA1 or BRCA2 mutation, Peutz-Jeghers syndrome, Lynch syndrome, chronic pancreatitis, diabetes mellitus, cigarette smoking, pancreatic cysts, and obesity. The most common presenting symptoms are pain, progressive jaundice, and weight loss. Jaundice is commonly due to obstruction of the common bile duct by a mass in the head of the pancreas. Courvoisier sign (palpable, nontender gallbladder) is an infrequent finding. Trousseau syndrome (migratory thrombophlebitis) may also be present. Pancreatic cancer most commonly metastasizes to the liver, peritoneum, and lungs. Initial laboratory studies should include serum aminotransferases, bilirubin, and lipase. Triple-phase contrast-enhanced thin-slice helical computed tomography is the preferred method for diagnosing and staging pancreatic cancer and for identifying metastatic disease. The only potential known curative modality of treatment for pancreatic cancer is complete surgical resection usually through a pancreaticoduodenectomy. However, because pancreatic cancer typically has a late presentation, only 10-15% of patients are candidates for resection. Vascular invasion is one of the most frequent causes of unresectability.

What is the most common thyroid cancer?

Papillary carcinoma, which makes up about 80% of thyroid cancers. This is also the least aggressive form.

Name the four thyroid cancers.

Papillary, Follicular, Medullary, Anaplastic

An 18-month-old uncircumcised boy with no significant past medical history presents to the ED. His parents report increasing fussiness throughout the day and he seemed to be itching or playing with his diaper region more than usual. While changing his diaper this evening they noticed significant swelling of his foreskin and he vigorously fought having his diaper area cleaned. He is still producing wet diapers and has been eating fine. He has otherwise been healthy with no fevers or recent illnesses. On physical exam, the patient has notable swelling of the distal foreskin and a band of tissue proximal to the head of the penis appears constricting. Both the glans penis and the distal foreskin are swollen and exquisitely tender to manipulation. The penile shaft appears flaccid and normal. Which of the following is the most likely diagnosis? Balanoposthitis Paraphimosis Phimosis Tourniquet syndrome

Paraphimosis Paraphimosis is the inability to return a retracted foreskin to a normal position. In young children, foreskin retraction may occur on a regular basis because of cleaning or self-manipulation. Failure to return the foreskin to the normal position can result in an entrapment of the foreskin behind the coronal sulcus. Boys with a partial phimosis are at the greatest risk of developing a paraphimosis. The constricting ring of foreskin can subsequently lead to venous engorgement, swelling, and ultimately, if it is not corrected, necrosis. Patients present with swelling and pain. Dysuria, decreased urinary stream, and complete urinary obstruction can also result. Paraphimosis is a clinical diagnosis based on the presentation of penile pain and swelling accompanied by a constricting band of distal foreskin at the coronal sulcus once a physical tourniquet like a hair or clothing fiber has been excluded. Other causes of swelling like angioedema or an insect bite should also be excluded. No additional tests or imaging are indicated. Manual reduction aided by appropriate pain control is the first approach to treatment. If this approach fails, minor surgical approaches and referral to urology should be considered.

Which of the following best describes the mechanism of action of delta-9-tetrahydrocannabinol (THC), the psychoactive substance in marijuana? Partial agonist at the cannabinoid 1 and cannabinoid 2 receptors Partial agonist at the cannabinoid 2 receptor Pure agonist with high affinity at cannabinoid 1 receptor and moderate affinity at cannabinoid 2 receptor Pure agonist with very high affinity at the cannabinoid 1 receptor

Partial agonist at the cannabinoid 1 and cannabinoid 2 receptors Marijuana is the most widely used illegal psychoactive substance in the world. Its psychoactive properties come from delta-9-tetrahydrocannabinol which is chiefly found in the flowering heads of the female plant. Delta-9-tetrahydrocannabinol is a partial agonist at both the cannabinoid 1 and cannabinoid 2 receptors. Cannabinoid 2 receptors are found on immune cells and some neurons, and stimulation of these receptors does not lead to positive reinforcing or rewarding effects. In contrast, cannabinoid 1 receptors are located throughout the body, including the dopaminergic mesolimbic brain circuit, otherwise known as the body's brain reward system. It is the stimulation of these receptors which leads to the potential for abuse of marijuana. Cannabis can be smoked, inhaled as a vapor, or ingested orally. Smoked and inhaled cannabis has a rapid onset of action, while ingested cannabis has a slower absorption and leads to less intense effects. The potency of cannabis is determined by the ratio of delta-9-tetrahydrocannabinol to cannabidiol contained in the substance. Cannabidiol is not psychoactive and tends to inhibit or lessen the effects of delta-9-tetrahydrocannabinol, so the lower the ratio of delta-9-tetrahydrocannabinol to cannabidiol, the lower the potency of the drug. Negative health consequences of cannabis use include decreased memory, attention, and concentration. Some users may also experience transient psychosis. A cannabis use disorder, similar to that seen in other drugs of abuse, can develop. Not all users of marijuana develop cannabis use disorder. Genetic predilection and environmental factors play important roles in determining those who will progress from recreational use to cannabis use disorder.

A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his fingers after returning home from 4-week summer camp one week ago. He reports several other campers had similar symptoms. On exam, you note excoriations in the inguinal region and axillae, surrounding scattered erythematous papules. Which of the following is the most appropriate treatment? Ketoconazole Lindane Permethrin Prednisone

Permethrin. This patient has scabies, a pruritic dermatitis caused by cutaneous infection with the mite Sarcoptes scabiei var. hominis. Scabies is spread by skin-to-skin contact and should be considered in patients with generalized pruritus, especially when exposure to others with similar symptoms is reported. The rash of scabies involves papules, which are often excoriated. Burrows are pathognomonic but not uniformly present. Unless previously infected, pruritus generally takes three to six weeks to develop because symptoms are due to delayed (type IV) sensitivity reaction. The pruritus is classically worse at night and affects the web spaces of the fingers, flexor aspect of the wrists, axillae, groin, nipples, and the periumbilical region. Except in cases involving an immunocompromised host, the scalp and face are generally spared. Diagnosis is clinical but can be confirmed by placing scrapings collected with a #15 blade scalpel in mineral oil for microscopic examination. The treatment of choice for primary scabies infection is the application of topical scabicidal agents, with repeat application in seven days. The treatment of choice is permethrin 5% lotion. Individuals affected by scabies should avoid skin-to-skin contact with others. Patients with typical scabies may return to school or work 24 hours after the first treatment.

A 23-year-old woman presents to the clinic complaining of feeling sad and hopeless for the past three years. She reports that she wants to sleep almost all of the time and that she has been overeating. She has never sought medical attention for these symptoms before. Which of the following options is the most likely diagnosis? Major depressive disorder Persistent depressive disorder Premenstrual dysphoric disorder Seasonal affective disorder

Persistent depressive disorder, or dysthymia, is defined as a period of at least two years of feeling sad, down, or depressed most of the time and on most days, with at least two of the following additional symptoms: decreased or increased appetite, insomnia or hypersomnia, fatigue, low self-esteem, impaired concentration, and hopelessness. Depressive disorders are twice as prevalent in women as they are in men. Social factors such as isolation, poor social support, criticism from family members, and depression in one's friends or family may lead to dysthymia or to major depressive disorder. Physical examination and laboratory examination should focus on identifying general medical conditions which could cause depressive symptoms, including any chronic medical conditions. A combination of psychotherapy and pharmacotherapy with selective serotonin reuptake inhibitors is first-line therapy.

A 14-year-old boy presents with one week of an itchy rash over his back. On examination, there are multiple oval-shaped papules in linear distributions over his upper back. There is also a prominent oval-shaped plaque on his upper back. This larger plaque has a small area of central clearing and fine scale. What is the most likely diagnosis? Pityriasis rosea Secondary syphilis Tinea corporis Tinea versicolor

Pityriasis rosea is an inflammatory exanthem of unknown etiology. It most commonly affects adolescents and older children rather than young children. It begins with the appearance of a herald patch, a larger salmon-colored, annular plaque that is most commonly located on the back, chest, or neck. The pigmentation of the center of the herald patch gradually regresses. As it does, the center of the lesion clears, and the margin develops a scale. Additional ovoid-shaped papules then begin to affect the trunk and proximal extremities. New lesions may progress caudally or centrifugally in crops. The oval lesions align with the cleavage lines of the skin, leading to a "Christmas tree" distribution over the back. The lesions may be quite pruritic and the mainstay of supportive care is to control the itching with antihistamines as needed. The etiology of pityriasis rosea is unknown, but the lesions do fade in time. However, dark-skinned individuals may develop post-inflammatory hypopigmentation at the site of prior lesions.

Which of the following factors is more indicative of premenstrual dysphoric disorder than premenstrual syndrome? Missing work and school Presence of symptoms for most of the preceding year Symptom onset during the week before menses Symptom onset in early 20s

Presence of symptoms for most of the preceding year. Premenstrual syndrome (PMS) is characterized by physical, behavioral, and affective symptoms that occur during the luteal phase of the menstrual cycle and interfere with a woman's usual activities. Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent. Symptom onset is usually in the early 20s. Premenstrual irritability is the most common symptom. DSM-5 diagnostic criteria for premenstrual dysphoric disorder requires prospective documentation of physical and behavioral symptoms (using diaries) being present for most of the preceding year. Evaluation should consist of a detailed menstrual history and exclusion of endocrine disorders that can cause similar symptoms, like thyroid disease or cortisol excess. First-line therapy for premenstrual dysphoric disorder is relaxation techniques and a selective serotonin reuptake inhibitor. Second-line therapies are combination oral contraceptives and gonadotropin-releasing hormone agonists.

A 28-year-old woman, G1P0, presents at 38 weeks gestation complaining of painful contractions and mild vaginal bleeding. Her prenatal care course is complicated by cocaine and tobacco use. On physical exam, her uterus is firm. Fetal heart rate tracing reveals a baseline of 135 bpm with moderate variability in the absence of accelerations. Tocometer reveals regular contractions. A vaginal exam performed reveals a cervix that is 7 cm dilated and a fetus in cephalic presentation. A transabdominal ultrasound is suspicious for placental abruption as the etiology of her vaginal bleeding. Which of the following is the most appropriate management? Cesarean delivery Expectant management Misoprostol Terbutaline

Placental abruption is a complication of pregnancy that can result in significant maternal and fetal morbidity and mortality. The degree of morbidity associated with placental abruption is affected by extent and dynamics of the detachment, with partially stable detachments being less likely to affect the mother and the fetus compared to active and complete abruptions. The classic clinical presentation of abruption is abdominal pain with vaginal bleeding that occurs during or prior to the onset of labor. On physical exam, suspicious findings include a firm and tender uterus. Although ultrasound has low sensitivity for detecting placental abruptions, its ease of performance and low cost explain its use in this setting. A retroplacental collection of fluid of different echogenicity between the placenta and the uterine wall is typically seen. Management of placental abruption in a woman at term and in active labor is dependent on fetal and maternal status. In the absence of fetal heart rate abnormalities or maternal hemodynamic instability, labor is allowed to progress, and expectant management is preferred. Placental abruption is not an indication for cesarean delivery in this setting.

A 45-year-old man presents to the office complaining of a "racing heart", palpitations, increased sweating, and headaches for the past three months. He denies any new life stressors and history of anxiety or panic attacks. He is not currently on any medications. The patient reports his father experienced similar symptoms when he was around the same age and was ultimately diagnosed with a tumor on his adrenal gland. Patient's blood pressure in the office is 164/98 mm Hg and his pulse rate is 88 beats per minute with a regular rhythm. Physical examination reveals a diaphoretic, well developed man without focal neurological deficits. TSH and T3/T4 levels were all reported within normal limits. Which of the following diagnostic tests would be the most appropriate next step for this patient? 24-hour urine fractionated metanephrines and catecholamines CT scan Genetic testing Plasma fractionated metanephrines

Plasma fractionated metanephrines would be the initial biochemical test performed for a patient who is considered high risk for a pheochromocytoma (family history, familial tumor syndrome, history of previously resected pheochromocytoma, or presence of adrenal mass found incidentally). Pheochromocytoma is a neuroendocrine catecholamine-secreting tumor typically found on the adrenal gland. These types of tumors are often associated with familial tumor disorders, such as multiple endocrine neoplasia type 2 (MEN2) and von Hippel-Lindau (VHL) syndrome. The triad associated with pheochromocytoma include palpitations or tachycardia, episodic headaches, and diaphoresis. Patients have a history of hypertension. The majority of tumors are located on the adrenal gland. Patients in whom a pheochromocytoma is suspected, who have a positive family history, or who have an adrenal mass found incidentally, should be tested for the disease. Prior to diagnostic studies, any possible offending drug should be discontinued. In patients who are low risk for a pheochromocytoma, 24-hour urine fractionated metanephrines and catecholamines should be the first biochemical test. After a positive biochemical test, patients should be evaluated via imaging (either CT scan or MRI) to locate the catecholamine-secreting tumor. Genetic testing may also be indicated if a familial disorder is suspected. Treatment includes surgical resection of the pheochromocytoma preceded by a preoperative α-adrenergic blockade using phenoxybenzamine and β-adrenergic blockade using a β-blocker such as propranolol to maintain cardiovascular and hemodynamic stability during surgery.

A patient is diagnosed with Campylobacter jejuni enteritis, receives treatment, and recovers. Two weeks later, he presents with weakness in his legs followed by weakness in his arms. He denies dyspnea, but reports diplopia and dysphagia. Examination reveals a mild fever, extraocular muscle palsies, hyporeflexia, distal paresthesias, and intact proprioception. Laboratory testing is significant for a normal CBC and a PaO2 of 88 mmHg. Which of the following is the most appropriate intervention at this time? Continuous positive airway pressure (CPAP) Corticosteroids Plasmapheresis Vitamin B12

Plasmapheresis Guillain-Barre syndrome (GBS) is a symmetric, progressive ascending muscle weakness that usually starts in the legs and may be acute or subacute. The condition is life-threatening if respiratory or swallowing muscles are involved. GBS can follow minor respiratory or GI illness, inoculation, or surgical procedures. It carries a poorer prognosis when it follows Campylobacter jejuni infection. The clinical hallmark of GBS is lack of deep tendon reflexes. Patients experience weakness of >2 limbs that typically begins with the proximal lower extremities. As weakness progresses, patients may experience shortness of breath, constipation, facial weakness, dysphagia, ophthalmoplegia, dysarthria, and sensory disturbances. Lumbar puncture results will demonstrate increased CSF protein but a normal cell count. Treatment is supportive. Plasmapheresis or IVIG may improve recovery time and decrease residual neurologic effects.

Which of the following hematological disorders is characterized by intermittent venous and arterial thrombosis, splenomegaly, and abnormal proliferation of all three myeloid cell lines? Aplastic anemia Chronic myelogenous leukemia Disseminated intravascular coagulopathy Polycythemia vera

Polycythemia vera is a chronic myeloproliferative disorder in which vascular thromboses and splenomegaly occur secondary to an increased red blood cell mass, although abnormal proliferation is seen in all three cell lines. It should be suspected in a patient with any combination of the following: abnormally elevated hemoglobin levels (> 16.5 g/dL in men or 16 g/dL in women), normal oxygen saturation, bleeding complications, portal vein thrombosis, splenomegaly, plethora, or pruritus after bathing. Treatment is accomplished through use of myelosuppressive agents.

A 3-week-old girl is referred to the ED by her pediatrician who has been following her closely due to herpes simplex exposure via primary maternal infection. The patient's mother insists she had no active lesions during pregnancy. In the last 12 hours, the infant developed a fever of 103°F and parents also report two brief seizure-like episodes, lethargy, and poor feeding. On physical exam, the infant is sleepy but arousable. A full septic workup is initiated, including a lumbar puncture. Which of the following tests of the patient's cerebrospinal fluid is most likely to confirm the diagnosis? Gram stain Polymerase chain reaction Serology Viral culture

Polymerase chain reaction Because of high risk for morbidity and mortality, herpes simplex infection should always be considered on the differential diagnosis of a neonate presenting with fever, especially when there is a known exposure to the herpes virus, or clinical signs and symptoms consistent with herpes simplex. Seizures, lethargy, and poor feeding are neurological signs associated with, though not specific to, herpes simplex meningitis. Vesicular lesions may also be noted in many patients with neonatal herpes simplex meningitis. Herpes simplex is a virus acquired through inoculation of skin, or oral, genital, or conjunctival mucosa, ultimately infecting sensory nerves and residing in dorsal root ganglia. There are two types of herpes simplex: type 1 and type 2. Herpes simplex type 1 is typically associated with oral lesions, while most genital lesions are caused by type 2. Polymerase chain reaction (PCR) of cerebrospinal fluid for the herpes simplex virus is the test of choice to confirm infection of the central nervous system. This test detects viral DNA and is the most sensitive and specific test available for herpes simplex on cerebrospinal fluid. The turnaround time for polymerase chain reaction testing is approximately 36-48 hours for in-house laboratories and longer if cerebrospinal fluid needs to be transported to an outside laboratory. While the test is pending, it is appropriate to start a neonate with suspected viral meningitis on an empirical antiviral like acyclovir. In the early stages of illness, false negatives are still possible with polymerase chain reaction testing, and repeat testing is warranted if a high suspicion for herpes infection remains despite a first negative result.

A male child born at 40 weeks of gestation has an Apgar score of 4 at birth. He is gasping for air and has a pulse of 68 despite positioning and airway clearance. Which of the following would be the best choice for initial clinical intervention in this patient? Intubation Positive pressure ventilation Supplemental oxygen by facemask Warming, drying, and close observation

Positive pressure ventilation. Apgar refers to a scoring method used to assess neonatal status at one minute and five minutes after birth. The five elements assessed are pulse, reflex crying to unpleasant stimuli, color, muscle tone, and respirations. Two, one, or zero points are awarded for each category. A total Apgar score of seven or more at one minute indicates that the infant is not in distress and can be returned to his mother for skin-to-skin contact. Apgar scores of six or less at one minute indicate neonatal distress and call for clinical intervention. If a neonate has a pulse, but it is less than 100 beats per minute, this is most often indicative of respiratory distress, not cardiac pathology. A neonate who demonstrates a weak cry with gasping and a pulse less than 100 beats per minute should receive positive airway pressure within one minute of birth. After 30 seconds of positive airway pressure, the heart rate is reassessed. If the heart rate is over 100 beats per minute and spontaneous breathing has begun, positive airway pressure can be discontinued. If the pulse continues to be under 100 beats per minute, the neonate should be reassessed for adequacy of ventilation. Repositioning, suction, mask adjustment, or pressure increases may need to be made. While Apgar scores at one minute and five minutes after birth are not accurate predictors of neonatal morbidity and mortality, they are useful in assessment of the neonate's need for further clinical intervention.

A 5-year-old boy has acute onset of hematuria, periorbital edema, and hypertension. He has no other complaints and review of systems is unremarkable. Recent medical history is significant for a "cold" last week. What is the most likely etiology of his hematuria? Coagulopathy IgA nephropathy Post-streptococcal glomerulonephritis Urinary tract infection

Post-streptococcal glomerulonephritis classically presents as hematuria that begins 1-2 weeks after an episode of streptococcal pharyngitis or 3-6 weeks after a streptococcal skin infection. Often the initial infection is mild and thus does not lead to medical evaluation or recognition. Affected children are typically 5 - 12 years old with a mean age of 7 years old. Treatment is supportive. Although > 60% of patients briefly develop hypertension, > 95% make a full recovery.

In infectious mononucleosis, where is lymphadenopathy most commonly noted? Anterior cervical chain Axillary chain Inguinal chain Posterior cervical chain

Posterior cervical chain Infectious mononucleosis is characterized by a triad of fever, tonsillar pharyngitis, and lymphadenopathy, most commonly in the posterior cervical chain. It is caused by Epstein-Barr virus. It is typically passed person-to-person via saliva. The incubation period prior to the development of symptoms averages four to eight weeks. Exam findings are notable for posterior cervical chain lymphadenopathy, white, gray-green, or necrotic tonsillar exudates, and palatal petechiae with streaky hemorrhages and blotchy red macules. Splenomegaly may also be present as well as a generalized maculopapular, urticarial, or petechial rash. The most common laboratory finding is lymphocytosis with a peripheral smear notable for atypical lymphocytes. A positive heterophile antibody test helps confirm diagnosis, though, occasionally, testing for Epstein-Barr virus-specific antibodies is warranted. Primary infections rarely require more than supportive therapy. Most initial symptoms resolve within one month but fatigue can persist up to six months.

Which one of the following is highly suspicious for non-accidental trauma in a pediatric patient? Clavicle fracture Distal radius fracture Posterior rib fracture Spiral fracture of the tibia

Posterior rib fractures, metaphyseal fractures, multiple and bilateral fractures, fractures in different stages of healing, vertebral body fractures, fractures of the digits, scapular fractures, sternal fractures, and complex skull fractures are usually seen in child maltreatment or abuse. A skeletal survey should be obtained if suspicion for any of the above fractures is present as well as a consult to child protective services. Due to the greater pliability of children's ribs, greater force is required to produce a fracture and is usually caused by a direct blow to the ribs. Spiral fractures of the tibia are commonly known as "toddler fractures" and occur after a rotational fall.

A 28-year-old man presents to the emergency department with lethargy and vomiting. He has a history of type I diabetes mellitus. Vital signs include heart rate 112 bpm and blood pressure 110/80 mm Hg. Laboratory analysis reveals sodium 135 mEq/L, potassium 4.0 mEq/L, chloride 100 mEq/L, bicarbonate 10 mEq/L, creatinine 1.4 mg/dL, glucose 558 mg/dL, pH 7.2. Normal saline and insulin have been ordered. Which of the following should be administered next? 5% dextrose with 0.45% saline Magnesium Potassium chloride Sodium bicarbonate

Potassium chloride. The diagnosis of diabetic ketoacidosis can be established with the presence of hyperglycemia, ketosis and acidemia. The goals of treatment are aimed at insulin therapy, fluid resuscitation and electrolyte replacement. The exact amount of insulin administered varies, however many start with a bolus of 0.1 U/kg or 10 U of regular insulin IV followed by a maintenance of 0.1 U/kg/hr regular insulin IV. Fluid resuscitation should start with a one to two liter bolus of normal saline in adults or a 20 mL/kg bolus in a child. Potassium levels are often initially high or normal due to severe acidemia. The potassium levels often decrease significantly as the acidemia is corrected along with the administration of insulin. Potassium should be administered with intravenous fluids when the potassium is less than or equal to 5.0 mEq/mL. In patients where the initial potassium is low (< 3.3 mEq/L), levels could become life-threatening following the administration of insulin, therefore potassium should be vigorously repleted in concentrations of 20 to 40 mEq/L prior to initiating insulin therapy. Five percent dextrose with 0.45% saline should be used once glucose decreases to below 200 mg/dL to avoid hypoglycemia.Sodium bicarbonate may be indicated in patients with a pH less than 7.0.

A 60-year-old man with a history of diabetes presents to your office with a complaint of thickened and discolored toenails. He tells you that his toenails have had this appearance for over a year, and now he is experiencing discomfort when wearing tight-fitting shoes. Physical exam reveals hyperkeratosis and onycholysis of bilateral great and second toes. Which of the following is the most appropriate next step in management? Begin treatment with oral terbinafine Check serum aminotransferases Potassium hydroxide examination of toenail scrapings Watchful waiting

Potassium hydroxide examination of toenail scrapings. Onychomycosis is a fungal infection of the toenails or fingernails that can involve any part of the nail including the plate, bed or matrix. There are several subtypes of onychomycosis, with the most common being distal subungual onychomycosis. This type presents with the great toe being the first affected. A white, yellow or brown discoloration can be seen that eventually spreads to the entire nail. Onycholysis, the separation of the nail from the plate, may also be seen. Onychomycosis is initially a cosmetic concern, however with time it can cause pain, disfigurement, and decreased quality of life. Other nail dystrophies can present similarly to onychomycosis, therefore establishing the presence of a fungal etiology is recommended prior to initiation of treatment. Diagnosis is with potassium hydroxide (KOH) examination of nail scrapings. Patients who are immunocompromised or who have diabetes mellitus are at an increased risk of bacterial infections due to onychomycosis. Treatment should be considered in these patients to avoid sequelae.

A 35-year-old man presents to the ED with a severe rash. A localized portion is seen in the image above. He states that he was cleaning away some brush from the woods behind his house a couple of days ago while wearing only shorts. On exam, you note similar lesions on his face, back, legs, arms, and chest. Which of the following is the most appropriate treatment? Cephalexin for 7 days Diphenhydramine as needed Prednisone taper over 21 days Prednisone taper over 7 days

Prednisone taper over 21 days. The patient was exposed to poison ivy and developed allergic contact dermatitis. Contact dermatitis is an inflammatory reaction of the skin to a chemical, physical, or biologic agent. The inducing agent acts as an irritant or allergic sensitizer. Clothing, jewelry, soaps, cosmetics, plants, and medications contain allergens that commonly cause allergic contact dermatitis. The most common allergens include rubber compounds, plants of the Toxicodendron genus (poison ivy, poison oak, sumac), nickel (often found in jewelry), paraphenylenediamine (an ingredient in hair dyes and industrial chemicals), and ethylenediamine (a stabilizer in topical medications). Clinical presentation is variable with primary lesions being papules, vesicles, or bullae on an erythematous base. The distribution of the eruption depends on the specific allergen and may be localized, asymmetric linear, or unilateral. The classic lesion of poison ivy is a linear eruption that occurs from the person brushing against the poison ivy leaf. The rash usually appears 2-21 days after exposure and is associated with intense pruritus. Treatment for mild cases of contact dermatitis from poison ivy includes calamine lotion or a topical steroid and oral antihistamine. However, in moderate to severe cases, systemic steroids are indicated and should be gradually tapered over 2-3 weeks to prevent rebound of the disease. A seven-day course may resolve the lesions temporarily, but often the rash returns. Systemic antihistamines can be taken concomitantly to help control the pruritus.

A 38-year-old man with a past medical history of hypertension and stage III chronic kidney disease presents with severe left foot pain that began in the middle of the night. He appears comfortable but has exquisite tenderness to palpation of the left, first metatarsophalangeal joint. The joint is erythematous and warm. His vital signs include a temperature of 99.1°F, BP 132/85 mm Hg, RR 16 breaths/minute, and oxygen saturation 99% on room air. Arthrocentesis of the involved joint is performed and synovial fluid analysis reveals negatively birefringent crystals. Which of the following is the most appropriate therapy at this time? Allopurinol Naproxen Prednisone Probenecid

Prednisone. The patient has acute gouty arthritis. Gout is caused by precipitation of sodium urate crystals in the synovial fluid. Pain is most commonly in the knee and foot, classically the first metatarsophalangeal joint (podagra). The diagnosis is made by joint aspiration and analysis of synovial fluid for the presence of polarizing crystals. Negatively birefringent crystals are diagnostic of gout. Negative birefringence describes the blue color and perpendicular orientation of the uric acid crystals relative to the microscopic light source. First-line treatment for acute gout is with colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin or naproxen unless contraindications exist. Advanced kidney disease is a contraindication to NSAID use and should be avoided in this patient. Patients intolerant to NSAIDs may be treated with steroids such as prednisone.

A 23-year-old G1P0 woman with no significant past medical history presents to the outpatient obstetrics office for a follow-up on an isolated elevated blood pressure reading last week. She is at 31 weeks gestation and has had no complications during this pregnancy except that last week her blood pressure was 150/88 mm Hg. Her urine dip at that time that showed 3+ protein. She has no complaints today. Vital signs today are blood pressure 148/92 mm Hg, pulse 78 bpm, respirations 16 bpm, temperature 98.8℉. Outpatient 24-hour urine for protein showed 400 mg in 24 hours. The physical exam is within normal limits. What is the most likely diagnosis? Chronic hypertension Eclampsia Gestational hypertension Preeclampsia

Preeclampsia is the most likely diagnosis for this patient given her elevated blood pressure on two separate occasions and proteinuria after 20 weeks gestation. Preeclampsia can present with either systolic pressure ≥ 140 mmHg or diastolic pressure ≥ 90 mmHg on two occasions more than 4 hours apart and proteinuria, as with this patient, or hypertension and end-organ dysfunction with or without proteinuria. In preeclampsia, findings must present after 20 weeks of gestation in a previously normotensive woman in order to differentiate this from other conditions. A single SBP ≥ 160 mm Hg or a DBP ≥ 110 mm Hg in the presence of proteinuria also qualifies a patient as having preeclampsia. Proteinuria is defined as either greater than 1+ protein on urine dipstick, greater than or equal to 300 mg in a 24-hour urine specimen or a protein/creatinine ratio of 0.3 or higher. In general, urine dipstick findings must be confirmed with a more quantitative test prior to making the diagnosis. Preeclampsia is caused by endothelial dysfunction resulting in poor placental formation. Risk factors include nulliparity, autoimmune disorder, obesity, multifetal gestation, family history of preeclampsia, chronic hypertension, renal disease and type 1 or type 2 diabetes. Preeclampsia is often asymptomatic making routine prenatal care essential for early diagnosis and monitoring. When patients experience symptoms, they typically complain of vision changes, headache, dyspnea, change in mentation or, epigastric or chest pain. Management depends on gestational age and maternal clinical picture. Delivery is the only definitive treatment for preeclampsia.

Which of the following factors causes a urinary tract infection to be considered a complicated infection rather than an uncomplicated infection? History of pyelonephritis Hypertension Pregnancy Previous urinary tract infection within the last month

Pregnancy Pregnancy automatically classifies a urinary tract infection as complicated. Other factors include poorly-controlled diabetes mellitus, hospital-acquired infection, acute kidney injury, urinary obstruction, indwelling Foley catheter, history of renal transplant, immunocompromise, functional abnormality of the urinary tract, or known infection with a resistant pathogen. Complicated infections are treated first-line with a fluoroquinolone because of the increased rates of resistance in pathogens to other antibiotics. In pregnancy, fluoroquinolones are not used and patients are instead given nitrofurantoin for seven days. Patients should be followed more closely to ensure that symptoms are resolving within 48 hours in complicated urinary tract infections.

A 23-year-old woman presents to the clinic complaining of abdominal bloating, fatigue, insomnia, mood swings, and persistent irritability for the past nine months. Symptoms have been occurring during the week leading up to her period and remit completely within a few days after onset of menses. She requests a note excusing her from work because she has missed several days due to these symptoms. She has no pre-existing endocrine or psychiatric disorders, and she has sought care at the clinic for several years only for routine screening and infrequent acute illnesses. Which of the following is the most likely diagnosis? Factitious disorder Major depressive disorder Premenstrual dysphoric disorder Premenstrual syndrome

Premenstrual dysphoric disorder is characterized by both physical and behavioral symptoms that interfere with usual activities (work, school, social life) and occur cyclically during the luteal phase (second half) of the menstrual cycle. Affective and behavioral symptoms include mood swings, anger, internal tension, irritability, anxiety, and depressed mood, and typical somatic symptoms include abdominal bloating, breast pain, nausea, fatigue, and headache. Symptoms classically resolve shortly after onset of menses (follicular phase). Disease onset is often in the early 20s. Evaluation should consist of a detailed menstrual history and exclusion of endocrine disorders that can cause similar symptoms, like thyroid disease or cortisol excess. Premenstrual dysphoric disorder diagnosis requires five or more affective, behavioral or somatic symptoms experienced in most of the menstrual cycles for the past year. Effective therapy is important to improve the affected woman's quality of life. Untreated premenstrual dysphoric disorder can lead to decreased work productivity and increased work or school absenteeism. Mainstays of treatment include exercise and relaxation techniques in addition to selective serotonin reuptake inhibitors, although some women who also desire contraception may choose to try a hormonal contraceptive before a selective serotonin reuptake inhibitor, which works by inducing anovulation. Women who fail SSRIs and hormonal contraceptives may be successfully treated with a gonadotropin-releasing hormone agonist.

A 74-year-old man with family history of macular degeneration presents with worsening day and night vision and difficulty reading even with his bifocal glasses on. Which of the following fundoscopic findings is more suggestive of exudative advanced macular degeneration? A cup-to-disc ratio of 0.3 with arteries narrower than veins Accumulation of small yellow deposits on the macula Presence of choroidal neovascularization with subretinal fluid and vessel hemorrhages Presence of cotton wool spots and flame hemorrhages

Presence of choroidal neovascularization with subretinal fluid and vessel hemorrhages Age-related macular degeneration is the most common cause of irreversible vision loss in the U.S. Although the exact cause is unknown, most patients with the diagnosis are over the age of 50 and have a positive family history. Signs and symptoms of dry age-related macular degeneration include poor night vision, visual fluctuation (i.e., daily changes in visual acuity), difficulty reading, and distortion of visual images. Symptoms of advanced disease result from central retinal degeneration with central vision loss as the disease progresses. Fundoscopic examination in patients can help with distinguishing between nonexudative (dry) age-related macular degeneration and exudative (wet) age-related macular degeneration. Nonexudative age-related macular degeneration is the most common type, characterized by the presence of drusen (yellow deposits) upon fundoscopic examination in early disease. Advanced states of nonexudative age-related macular degeneration show large zones of retinal atrophy. Exudative (wet) age-related macular degeneration is characterized by formation of new, damaged blood vessels (choroidal neovascularization) with exudates, subretinal fluid or hemorrhaging. Generally, nonexudative age-related macular degeneration has much slower progressive visual loss (over decades) compared to exudative (wet) age-related macular degeneration (over months). About 10-20% of patients with nonexudative age-related macular degeneration progress to exudative age-related macular degeneration. In addition to fundoscopic examination, Amsler grid test is an important clinical screening test. Fluorescein angiography and fundus photography are procedures that can give more information once diagnosis is made. Prevention and routine screening for conversion to exudative age-related macular degeneration is important because there is no proven treatment to reverse this condition. Management of exudative age-related macular degeneration may include intravitreal injections with blood vessel growth inhibitors, laser surgery and photodynamic therapy. Non-pharmacotherapy for both wet and dry age-related macular degeneration include antioxidant vitamin and mineral supplements, eye protection, and tobacco cessation.

A 65-year-old woman with no known illness presents with dyspnea and a grade 3/6 systolic murmur. Which of the following would suggest the diagnosis of aortic stenosis rather than mitral valve regurgitation? Hyperdynamic left ventricle Murmur best heard at apex Prominent fourth heart sound Wide splitting of S2

Prominent fourth heart sound In aortic stenosis, the aortic valve becomes hardened and its leaflets do not fully open during systole, causing a harsh holosystolic murmur. Aortic stenosis also leads to a fixed stroke volume despite vasodilation and often a subsequent decline in systemic blood pressure. Such a decline can lead to exertional syncope. The classic triad of symptoms seen in patients with aortic stenosis is chest pain, dyspnea, and syncope. On physical exam, a patient with aortic stenosis will have a harsh holosystolic murmur best auscultated at the right sternal border and will have an absent or delayed aortic component of the second heart sound due to calcified and immobile aortic valve leaflets. As the aortic valve becomes more calcified and less mobile, the left ventricle must work harder during systole to eject its blood volume and therefore becomes hypertrophied. This leads to an audible and prominent fourth heart sound (S4).

A 16-year-old boy is in clinic for a routine health check. He is doing well in school and has plans to join the military when he reaches 18 years of age. He practices and plays basketball about 60 minutes per day. He denies smoking and drug use. Physical examination is normal. At this visit, you recommend meningococcal vaccine booster. Which of the following is the best statement regarding meningococcal infection? Chemoprophylaxis can be administered two weeks after exposure to the index case Droplet precaution is not necessary for patients infected with meningococcal meningitis Nasopharyngeal cultures are needed in determining the need for chemoprophylaxis Prophylaxis is indicated in close contacts of patients with meningococcal infection

Prophylaxis is indicated in close contacts of patients with meningococcal infection. The methods for the prevention of meningococcal infection include antimicrobial chemoprophylaxis following identification of an index case, use of droplet precautions, vaccination prior to exposure, and avoidance of risk factors. Antimicrobial chemoprophylaxis was first used successfully to abort the spread of meningococcal infection in the 1930s. Prophylaxis is indicated in close contacts of patients with meningococcal infection and should be given as early as possible following the exposure. Close contacts may include individuals exposed in the following way: household members, roommates, intimate contacts, contacts at a childcare center, young adults exposed in dormitories, military recruits exposed in training centers. Also included are individuals who have been exposed to oral secretions. Because the rate of secondary disease for close contacts is highest immediately following onset of disease in the index patient, antimicrobial chemoprophylaxis should be administered as early as possible (ideally less than 24 hours after identification of the index patient).

A 62-year-old man presents to the clinic with bilateral eye irritation for the past several months. Physical exam reveals soft, flat, pink, triangular growths extending toward and involving a small portion of the cornea bilaterally. What is the most likely diagnosis? Conjunctival neoplasm Episcleritis Pinguecula Pterygium

Pterygium A pterygium is fibrovascular tissue overlying the conjunctival tissue. It is typically described as triangular, pink or red in color, and arises from the limbal conjunctiva on the medial aspect of the eye. They can also be described as flat and white appearing. As pterygia grow, they can encroach upon the corneal surface causing changes in vision. Other symptoms may include eye irritation and redness. Risk factors for developing pterygia are older age, male gender, and outdoor job location. Artificial tears can reduce eye irritation. Topical decongestants, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical glucocorticoids can also help.

What is the drug of choice to treat toxoplasmosis? for HIV prophylaxis?

Pyrimethamine and sulfadiazine for treatment. Bactrim for prophylaxis.

A 4-year-old girl with no significant medical history presents to her pediatrician for a routine well-check. During the visit, her mother asks about a skin lesion she noticed recently. The area in question is a pale, firm, hyperkeratotic papule about 4 millimeters in diameter on the lateral aspect of the patient's right knee. When scraped gently with a tongue depressor, some of the overlying debris can be removed, revealing scattered, pinpoint, deep-red dots. The area is not painful. Which of the following is the most appropriate therapy? Cryotherapy with liquid nitrogen Reassurance and watchful waiting Shave biopsy with pathology consultation Topical salicylic acid

Reassurance and watchful waiting This child presents with a verrucous or warty lesion, a diagnosis usually made by clinical appearance. Such cutaneous warts are common clinical manifestations of the human papilloma virus. Reassurance and watchful waiting is the most appropriate course of action for this young child, because the majority of children will experience a spontaneous remission of the lesion within two years. While there are treatments available for cutaneous warts, many of them are painful, require prolonged adherence, and introduce the potential for adverse side effects. In young children, these approaches should be reserved for cases in which the lesion is associated with pain or discomfort, is cosmetically unacceptable, when the lesion is persistent, or when there is an underlying immunosuppressive condition enabling the virus to thrive. Because cutaneous warts are infectious, families should be educated about how to prevent transmission of the virus, including avoiding touching and manipulating the lesions, refraining from cutting or filing the lesion, and not using shared implements like nail files or cutters on the lesion. In cases where the wart is on the foot, using slippers and shoes in shared areas, especially showers, can also reduce transmission.

A 25-year-old man presents to the clinic for follow-up after being diagnosed with alcohol use disorder of moderate severity. He was recently discharged from the hospital after being involved in a motor vehicle collision. During his stay, he expressed a desire to stop drinking and completed a medical detox. His last alcoholic drink was 10 days ago. Prior to discharge from the hospital, he was started on naltrexone 50 mg per day by mouth, which he is tolerating well and continues to take daily without issue. Which of the following is the most appropriate next step in management?AChange naltrexone to acamprosate Change oral naltrexone to depot naltrexone Recommend psychosocial treatment Recommend residential treatment

Recommend psychosocial treatment Alcohol use disorder is characterized by a problematic pattern of alcohol use, leading to clinically significant impairment or distress. Populations at an increased risk of developing alcohol use disorder include young adults between the ages of 18 to 29, males, and Native Americans. Excessive alcohol consumption is the third leading preventable cause of death in the United States. Alcohol use disorder can be defined as mild indicating the presence of two to three symptoms, moderate which indicates the presence of four to five symptoms, or severe in which there are six or more symptoms present. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for alcohol use disorder includes recurrent drinking which results in failure to fulfill obligations, recurrent drinking in hazardous situations, continued drinking despite alcohol-related social or interpersonal problems, evidence of tolerance, evidence of alcohol withdrawal, and alcohol craving. Physical examination may be normal but may also display features of alcohol withdrawal (e.g., tremor, agitation, altered sensorium) or features of advanced liver disease (e.g., spider angiomata, palmar erythema). Laboratory evaluation may reveal elevated liver enzymes with an aspartate aminotransferase to alanine aminotransferase ratio of two-to-one, anemia and macrocytosis, and an elevated gamma-glutamyltransferase level. All patients with alcohol use disorder should receive some form of psychosocial treatment (e.g., motivational interviewing, cognitive behavioral therapy, alcoholics anonymous). In patients with moderate to severe alcohol use disorder, medication can also be used. First-line pharmacotherapy is oral naltrexone.

The drug isotretinoin was pulled from the market in 2009 but is still available in limited form. This is a treatment for recalcitrant acne that works by which of the following mechanism of action? Killing bacteria Reducing the amount of skin oil Reducing the effects of hormones Unplugging skin pores and preventing them from getting replugged

Reducing the amount of skin oil. Reducing the amount of skin oil is accomplished by reducing the size of the sebaceous glands and thus decreasing sebum production. Close monitoring is required with isotretinoin due to the potential for significant side effects including: harmful birth defects, depression, increased risk of suicide, and inflammatory bowel disease. Also, dry skin, dry mouth, pruritus, and myalgias are among other side effects that have been reported.

A 42-year-old man presents to your office with complaints of uncontrollable fidgeting, irritability and difficulty with short-term memory. He tells you that his father had similar symptoms and died at a young age. Which of the following is the most appropriate next step in management? Discussion of end-of-life issues Magnetic resonance imaging Positron emission tomography scan Referral for genetic testing

Referral for genetic testing. Huntington disease (HD) is an autosomal dominant inherited, neurologic disorder characterized by choreiform movements, dementia and psychiatric disturbances. Patients with early symptoms of HD present with mild chorea which may be mistaken for fidgeting. Cognitive decline occurs and the behavioral aspect of the disorder often presents with symptoms of depression, mania, psychosis or changes in personality. Diagnosis is with genetic testing and patients who are suspected to have HD should be referred as soon as possible. Asymptomatic patients with a known family history of HD may also request genetic testing prior to the onset of symptoms. Currently there is no cure and no treatment that will modify the disease process. Treatment focuses on supportive care for the patient and family along with management of symptoms. Prognosis is poor, as HD is a progressive disorder that leads to disability and death.

A 32-year-old woman presents to your office for a physical exam including a Papanicolaou test (Pap smear). Lab results reveal negative cytology and positive human papillomavirus (HPV). Which of the following is the most appropriate next step in management? Counsel patient on safe sex practices Order colposcopy Repeat Pap smear and human papillomavirus testing in five years Repeat Pap smear and human papillomavirus testing in one year

Repeat Pap smear and human papillomavirus testing in one year. Cervical cancer screening is done through the use of the Papanicolaou (Pap) test for cytology and testing for high-risk strains of the human papillomavirus (HPV). The USPSTF recommends screening begin at age 21, regardless of sexual activity. Type and frequency of testing then depend on the patient's age. Women under 30 years should be screened with the Pap smear alone every three years. Women 30 and older should be screened with Pap smear and HPV co-testing. Management of abnormal results is based on the immediate risk of severe dysplasia. If the Pap smear test is negative and HPV test is positive, providers may either repeat Pap smear and HPV co-testing in one year or order HPV DNA typing to detect HPV subtypes 16 or 18. These subtypes are associated with the highest risk of cervical cancer and are important to identify early, allowing for prompt intervention. Patients positive for HPV 16 or 18 should receive colposcopy. Patients with other high-risk HPV types may have repeat HPV-based testing in one year. If the HPV test is again positive, colposcopy should be performed. Studies have shown that the longer an HPV infection has been present, the higher the risk of pre-cancer and cancer.

A 21-year-old non-pregnant woman presents for her first Papanicolaou screening test. Cervical cytology shows low-grade squamous intraepithelial lesions. Which of the following is the best next step in management? Colposcopy Cone biopsy Endocervical curettage Repeat cervical cytology in one year

Repeat cervical cytology in one year. Cervical dysplasia usually results from human papillomavirus (HPV) infection. Risk factors for contracting HPV and developing cervical dysplasia are multiple sex partners and unprotected sex. Pap smear results showing cervical dysplasia are not diagnostic (except for HSIL); rather, they identify women who require further diagnostic intervention, such as accelerated serial pap smears, a colposcopy or an excision (cone biopsy, loop electrosurgical excision procedure, endocervical curettage). Most low-grade squamous intraepithelial lesions are highly associated with HPV infection, but women age 21-24 years have much lower risk for progression to cancer than older women. The risk in this age group closely mimics that of ASC-US with positive HPV testing. Management decisions should hinge on identifying any HPV-related disease and avoiding unnecessary destructive treatments for disease unlikely to progress to cancer. Clinicians should give special consideration to destructive intervention for women of childbearing age, since an incompetent cervix could lead to pregnancy complications. Low-grade squamous intraepithelial lesion necessitates colposcopy in a patient older than 24 years of age, but repeating cervical cytology in 12 months is an appropriate management plan if the patient is between 21 and 24 years of age.

A 35-year-old woman with no past medical history, taking oral contraceptives presents for evaluation of thigh pain and swelling of her entire leg. She was seen six days ago for the same complaint and had a negative ultrasound. Which of the following is the most appropriate plan? CT venogram D-dimer Reassurance Repeat duplex ultrasound

Repeat duplex ultrasound. Venous doppler ultrasound performed by a qualified sonographer has a sensitivity and specificity of approximately 95% in the detection of deep vein thrombosis (DVT) of the proximal leg. The evaluation typically includes three different points: common femoral vein, superficial femoral vein, and the popliteal vein. In patients with a high pre-test probability (as in this case of a woman with her entire leg swollen), a repeat duplex ultrasound is indicated in patients with persistent symptoms. An alternative approach on the initial visit is to also perform a D-dimer which, if negative in combination with the three-point ultrasound, excludes the diagnosis of DVT.

An 8-year-old boy presents for a well-child check. He wants to join his school's basketball team that involves weightlifting. His mother has concerns regarding whether this is appropriate for a child his age. Which of the following is the most accurate statement regarding resistance training? Most injuries related to resistance training are the result of weightlifting movements such as modified cleans, pulls, and presses Resistance training can begin as early as age 6 with appropriate supervision Resistance training is appropriate for children who are at least 10 years of age or are at least 4 feet 5 inches in stature The mechanical stress from heavy resistance training can negatively impact linear growth during childhood and early adolescence

Resistance training can begin as early as age 6 with appropriate supervision. Strength or resistance training refers to a type of physical conditioning which involves the progressive use of resistive loads and a variety of modalities including weights, weight machines, elastic bands, and medicine balls. This is distinguished from power lifting programs which focuses on lifting maximal amounts of weight and from bodybuilding which focuses on increasing muscle size and definition. Substantial concern exists within the general public that any type of strength training is an unsafe practice for the developing child, and specifically that it may stunt growth. There is no evidence to suggest that appropriate strength-training programs negatively impact linear growth. Rather, the mechanical stress of resistance training may actually support childhood bone formation as well as have a beneficial effect on overall cardiovascular fitness, lipid profiles, bone mineral density, and mental health. Proper weight training involves many reps with low resistance. It is essential that proper techniques and safety precautions are followed and that strict supervision by a qualified instructor is provided in order for strength training to be safe and effective. Also, prior to beginning such programs, a clinician should perform a thorough medical evaluation. Therefore, resistance training can begin as early as age 6 with appropriate supervision. Referral to a sports medicine specialist may be indicated for patients with a history of chemotherapy and childhood cancer or with uncontrolled hypertension. Likewise, children with a history of congenital heart disease should be referred to a pediatric cardiologist prior to starting resistance training. Finally, the pediatrician should remind the patient that a complete fitness program also includes aerobic exercise and that the use of anabolic steroids and other performance enhancing substances is strongly discouraged.

Which one of the following is the most common manifestation of abusive head trauma in infants? Epidural hematoma Retinal hemorrhage Subarachnoid hemorrhage Subdural hematoma

Retinal hemorrhage. Abusive head trauma (previously referred to as shaken baby syndrome) is a form of inflicted head trauma and the leading cause of child abuse fatalities. It is a well-recognized clinical syndrome caused by the violent shaking of infants, direct blows to the head, dropping or throwing a child, and asphyxia. It typically occurs in infants younger than 1 year of age, but may be seen in children up to 3 years old. The classic constellation of abusive head trauma includes subdural hematoma, traumatic brain injury, and retinal hemorrhages. Retinal hemorrhages are present in up to 75% of cases and have a high specificity. The absence of retinal hemorrhages does not rule out child abuse. The pathophysiology of retinal hemorrhages is uncertain. It is unclear whether the bleeding is a result of increased intracranial pressure transmitted to the eye or occurs directly within the eye itself, perhaps through increased pressure along the retinal vein and subsequent disruption of the vessel. Retinal hemorrhages may involve the area in front of the retina (preretinal hemorrhages), the vitreous, and the subretinal space, in addition to the retina. Hemorrhages may be described as "dot and blot," flame, or splinter hemorrhages.

An elderly appearing adult male patient is transported to the emergency room with unconsciousness for an underdetermined amount of time. There is no family and the only history is provided by the paramedics. The patient arouses to verbal and painful stimuli. VS: T-97.0 degrees F rectally, P-52 bpm, R-10, BP-95/60 mmHg. Physical examination is unremarkable except for ecchymosis across his extremities. A Foley catheter is inserted draining a small amount of dark brown urine. Urine dipstick reveals 4+ positive hemoglobin and protein. Microscopic urinalysis reveals no RBCs but many renal tubular epithelial cells and renal tubular casts. Drug screen is negative, blood alcohol is 2.5 mg/dL, and creatinine is 4.9 mg/dL. What is the most likely diagnosis? Rhabdomyolysis causing acute renal failure Obstructive uropathy causing acute renal failure Ethanol ingestion causing acute renal failure Methanol ingestion causing acute renal failure

Rhabdomyolysis causing acute renal failure. Since the patient was found unconscious for an undetermined amount of time and the blood alcohol is elevated the patient has been in a state of prolonged immobilization resulting in muscle ischemia resulting in myoglobinuria. This is responsible for turning the dipstick positive without the RBCs seen on the urinary microscopy. The myoglobin causes an acute tubular necrosis resulting in the sloughing of the renal tubular epithelium. Obstructive uropathy does not cause acute tubular necrosis and occurs over time. Methanol ingestion causes visual symptoms, ethylene glycol causes renal failure.

A 67-year-old man with a history of hypertension and diabetes mellitus presents to the emergency department with sudden onset of left leg weakness. His examination is notable for 3/5 strength in his left lower extremity as well as diminished sensation over his left toes, foot, and leg. He has a flat affect and appears slow in his speech. Which of the following vascular territories is most likely affected in this patient? Left lenticulostriate arteries Left posterior cerebral artery Right anterior cerebral artery Right middle cerebral artery

Right middle cerebral artery. Ischemic strokes are the most common type of cerebrovascular accident and can be caused by thrombosis, embolism, and hypoperfusion. Thrombosis is the most common cause of ischemic stroke. Risk factors for ischemic stroke include smoking, increasing age, male sex, diabetes, hypertension, and hyperlipidemia. The middle cerebral artery is the artery most commonly affected by ischemic strokes. Anterior cerebral artery (ACA) infarcts are more rare due to collateral blood flow supplied by the anterior communicating artery. The ACA supplies the frontal, prefrontal, and supplementary motor cortex. Symptoms of an ACA infarction include contralateral lower extremity weakness and sensory loss with sparing of the upper extremity and face. Management of an ACA stroke depends on the timing of presentation, with administration of tPA improving outcomes in eligible candidates. Management of all stroke syndromes should include reduction of risk factors, including optimization of blood sugar, smoking cessation, and control of blood pressure and cholesterol.

A 12-month-old girl, accompanied by her mother, presents to the clinic with a rash. The patient has a three-day history of fever ranging from 102-103°F with associated nasal congestion and diarrhea. The rash developed 24 hours after fevers had resolved, beginning around her neck and torso and gradually spreading to her arms and legs. Physical exam reveals a blanching maculopapular rash on the trunk and extremities. Which of the following is the most likely diagnosis? Erythema infectiosum Roseola infantum Rubeola Scarlet fever

Roseola infantum, also known as sixth disease or exanthema subitum, is a viral illness that is most commonly caused by human herpesvirus 6 (HHV-6). Roseola infantum is characterized by high fever which may exceed 104°F and last three to five days, followed by abrupt resolution of fever and development of a rash. Infants may also show signs of irritability, malaise, upper respiratory symptoms, inflamed tympanic membranes, conjunctivitis, and red papules on the soft palate known as Nagayama spots. The rash pattern associated with roseola infantum is a blanching macular or maculopapular rash with a distribution that begins at the neck and trunk region and spreads to the face and extremities. The rash will rarely include vesicles and is typically not pruritic. Duration of the rash is usually one to two days, however, it can be as short as two to four hours. Roseola infantum most commonly affects children less than two years of age with the highest prevalence between ages 7-13 months. Diagnosis is made clinically, based on a history of a rash that begins after abrupt cessation of high fever. Roseola is a self-limited disease and the rash does not require treatment. Supportive care is recommended and may include antipyretics if fever is causing discomfort.

A 31-year-old man presents to the emergency department in police custody after he was found unclothed, confused, and running down a snowy street. His urine drug test is positive for phencyclidine (PCP). Which of the following ocular findings is most likely present on physical examination? Pinpoint pupils Proptosis Ptosis Rotary nystagmus

Rotary nystagmus. Phencyclidine (PCP) is a dissociative anesthetic that presents with agitation, violence, and confusion. It often causes a diminished pain response and perceptions of superhuman strength. Tachycardia and hypertension are commonly seen vital sign abnormalities. Rotary nystagmus is classically associated with phencyclidine, but horizontal and vertical nystagmus may be present. Phencyclidine is associated with several complications including rhabdomyolysis, seizures, and hypoglycemia. Benzodiazepines are the first-line treatments for the severe agitation. Antipsychotics may be used as an adjunct therapy.

List six extrapulmonary complications of lung cancer.

SPHERE: SVC syndrome, Pancoast tumor, Horner's syndrome, Endocrine problems, Recurrent laryngeal symptoms, Effusions (exudative)

A 24-year-old woman presents to the clinic with complaints of nausea, headache, fatigue, and mood swings that have been occurring during the week leading up to her period. She has routinely had to miss work due to her symptoms. Her symptoms go away shortly after menses begin. She denies suicidal ideation. She has no pre-existing endocrine or mood disorders. Which of the following is the best initial treatment for this patient? Daily exercise and relaxation techniques Gonadotropin-releasing hormone agonist Hormonal contraception Selective serotonin reuptake inhibitor

SSRI. The premenstrual syndrome is defined as affective, behavioral, and somatic symptoms during the week before the onset of the menstrual cycle. Symptoms classically resolve shortly after the beginning of menses. For women with mild premenstrual symptoms that do not cause distress or socioeconomic dysfunction, regular exercise and stress reduction techniques may be effective. However, selective serotonin reuptake inhibitors are recommended as first-line therapy for women with premenstrual symptoms that include socioeconomic dysfunction that have been documented prospectively. Fluoxetine and sertraline have been most extensively studied for premenstrual syndrome and premenstrual dysphoric disorder, and they are specifically indicated for premenstrual disorders. Some women who also desire contraception may choose to try a hormonal contraceptive before a selective serotonin reuptake inhibitor, which works by inducing anovulation. For women who have not responded to or cannot tolerate selective serotonin reuptake inhibitors or oral contraceptives and continue to experience severe symptoms, gonadotropin-releasing hormone (GnRH) agonist therapy with estrogen-progestin add-back can be suggested.

A patient is found to have the following basic metabolic panel results: sodium 143 mmol/L, potassium 3.6 mmol/L, chloride 107 mmol/L, bicarbonate 14 mmol/L, BUN 16 mg/dL, creatinine 1.2 mg/dL, and glucose 92 mg/dL. Which of the following is a possible cause of these laboratory results? Addison disease Diarrhea Renal tubular acidosis Salicylate toxicity

Salicylate toxicity. This patient has a metabolic acidosis as defined by a decrease in serum bicarbonate concentration. This can occur when there is the addition of excess acids, when acid secretion is impaired, or when there is an inappropriate loss of alkali. The causes of metabolic acidosis can be divided into elevated anion gap and normal anion gap. The anion gap is calculated using the formula Na - (Cl + HCO3) and a normal anion gap is 10 +/- 2. In this example, the patient's anion gap is 22 (143 - (107 + 14)) and therefore considered elevated. Causes of an elevated anion gap acidosis, defined as an anion gap > 12, can be remembered by using the mnemonic MUDPILES (Methanol, Uremia, Diabetic ketoacidosis, Paraldehyde, Isoniazid, Lactic acidosis, Ethylene glycol, and Salicylate toxicity). Addison disease, diarrhea, and renal tubular acidosis are all causes of a normal anion gap metabolic acidosis.

A 32-year-old disheveled man, wearing a construction hat, presents to the clinic for a rash. He believes the rash was "sent" to him by a neighbor who hates him and put a curse on him. He knows the neighbor hates him because he feels a dark aura follow the neighbor around. He lives alone because he fears any roommate will rob him while he sleeps. He wears a construction hat at all times, to protect his head from falling objects. While speaking, he often searches for words and seems to daydream. He is employed from home, takes no medications, does not use drugs or alcohol, has no previous psychiatric diagnoses, denies depression, and answers questions appropriately. Family members state he has always been "like this". Which of the following is the most likely diagnosis? Paranoid personality disorder Schizoid personality disorder Schizophrenia Schizotypal personality disorder

Schizotypal personality disorder is an enduring condition affecting cognition, perception, and social interaction. Patients with schizotypal personality disorder display extreme discomfort and avoidance of close personal relationships and social situations, as well as distortions in thought and perception, and oddities of behavior. Five of the following distortions or oddities are needed for diagnosis of the condition: ideas of reference, magical thinking, unusual perceptual experiences, odd thinking and speech, odd behavior, paranoia or suspicion, constricted or inappropriate affect, lack of close friends, and extreme social anxiety. The social anxiety of schizotypal personality disorder is not secondary to self-doubt but rather to paranoid fear of others. The unusual perceptual experiences of schizotypal personality disorder are not usually auditory or visual hallucinations, but rather feelings or odd sensations. Their ideas or delusions of reference are generally related to their social paranoia. Symptoms of schizotypal personality disorder often begin in childhood or adolescence and remain stable or gradually intensify with age. Comorbid psychological disorders are common in patients with schizotypal personality disorder, with high rates of co-existing personality disorders, substance use disorders, mood disorders, and panic disorder. Treatment is with psychotherapy, and pharmacotherapy for any comorbid conditions that merit it.

Which one of the following screening practices is recommended for the adolescent/young adult population by the U.S. Preventive Services Task Force? Chlamydia screening in sexually active females younger than 25Correct Answer Diabeties screening Scoliosis screeningYour Answer Testicular examination

Screening for Chlamydia in all sexually active, non-pregnant women <25 years of age is recommended. Chlamydia trachomatis is usually asymptomatic in women, however, it may present with purulent discharge on exam as well as a friable cervix. In order to diagnose Chlamydia, a test sample from urine or a cervical swab must be collected for culture.

A 45-year-old Caucasian man presents to your office with questions about prostate cancer screening. He does not have a family history of prostate cancer and wants to know at what age he should begin screening. According to the U.S. Preventive Services Task Force, which of the following is the most appropriate next step in management? Begin screening at age 50 Order serum prostate specific antigen now, then begin screening at age 50 Perform an initial digital rectal exam now, then begin screening at age 50 Screening is not recommended

Screening is not recommended. In the United States, prostate cancer is the most frequently diagnosed type of cancer in men after skin cancer. Prostate cancer is seen more commonly in African-American men and the likelihood of developing this type of cancer increases with age. Risk factors include a family history of prostate cancer, cigarette smoking and a diet high in animal fat. Routine screening for prostate cancer has been a controversial subject. Current United States Preventive Services Task Force guidelines recommend against prostate specific antigen (PSA) screening for prostate cancer. Some men will request screening and a discussion about the risks and benefits of screening should occur prior to initiating PSA testing or digital rectal exam (DRE). Most patients diagnosed with prostate cancer are asymptomatic and the cancer is found on DRE or because of an elevated serum PSA. Diagnosis is made with biopsy. Treatment decisions are determined after discussion with the patient about the severity of disease and quality of life related to treatment side effects. Options include active surveillance, prostatectomy, radiation therapy and hormonal therapy.

A 24-year-old woman presents for an initial evaluation of cyclical symptoms of irritability, painful bloating, and depression. These symptoms occur regularly 4-5 days prior to the beginning of menstruation. During these few days, the patient typically has to miss work due to the "awful pain and mental clouding." Which one of the following treatment options do you recommend as first-line therapy? Anticholinergics Hysterectomy Oral contraceptive pills Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors. Treatment of mild premenstrual syndrome (PMS) symptoms, those considered not to alter daily socioeconomic function, includes stress reduction techniques and regular exercise. This patient reports historical points that reveal moderate to severe symptomatology. In women whose daily function is altered due to the cyclical, luteal phase symptoms of PMS, selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line therapy. Options include sertraline or fluoxetine, administered on a daily basis or only during the second half (luteal phase) of the patient's menstrual cycle. Oral contraceptive pills (C) are recommended as second-line therapy in those women who cannot tolerate the side effects of or do not respond to SSRIs.

A 42-year-old man presents to the emergency department with fever, chills, cough, and hemoptysis. He has a history of intravenous opioid use. Vital signs include BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4F. Chest X-ray is shown above (shows diffuse round patches throughout pulmonary circulation). Which of the following is the most likely diagnosis? Diffuse alveolar hemorrhage Granulomatosis with polyangiitis Miliary tuberculosis Septic emboli

Septic emboli. This patient is presenting with signs and symptoms of infectious endocarditis. Risk factors for infectious endocarditis include rheumatic heart disease, congenital or acquired valvular disease, and intravenous drug use. Infectious endocarditis is classified as acute or subacute depending upon the time course and presentation. Acute endocarditis more often affects normal valves in younger patients. Septic emboli (as shown in the above chest X-ray) and significant illness are common on presentation. Subacute endocarditis has a predilection for abnormal valves and more frequently occurs in older patients. These patients are typically less ill on presentation with intermittent fevers and constitutional symptoms. Left-sided endocarditis involves either the aortic or mitral valve. It is more common than right-sided endocarditis. Organisms often implicated in left-sided endocarditis include Streptococcus viridans, Staphylococcus aureus, and those in the Enterococcus family. Complications include systemic infarcts from septic emboli. Right-sided endocarditis involves either the pulmonic or tricuspid valve. It is classically seen in intravenous drug users. Organisms implicated in right-sided endocarditis include Staphylococcus aureus, Streptococcus pneumoniae, and gram negative bacteria. Presenting symptoms often include fever, cough, hemoptysis, chest pain, and dyspnea. Right-sided endocarditis is frequently misdiagnosed initially as pneumonia.

A 25-year-old woman presents to your office with a complaint of anxiety. She says that for the past year she has had worsening insomnia, restlessness, irritability, and difficulty concentrating. The symptoms are starting to impact her performance at work so she is interested in treatment. Which of the following is the most appropriate medication? Lorazepam Nortriptyline Quetiapine Sertraline

Sertraline Anxiety disorders are the most common psychiatric disorders although they are often not recognized and therefore often go untreated. There are a number of different anxiety disorders including generalized anxiety, social anxiety, panic disorder, separation anxiety, specific phobias, and agoraphobia. Generalized anxiety disorder is characterized by excessive worry and anxiety about everyday activities and events. Diagnosis is made using Diagnostic and Statistical Manual of the American Psychiatric Association, Fifth Edition (DSM-5) criteria and individuals need to experience at least three out of six symptoms for six months or longer. These symptoms include restlessness, difficulty concentrating, fatigue, irritability, insomnia and muscle tension. Women are more commonly affected than men and many disorders begin in childhood or adolescence. Recommended treatment is with medication, cognitive behavioral therapy or a combination of the two. When medication is indicated, first-line therapy is with either a selective serotonin reuptake inhibitor such as sertraline or a selective norepinephrine reuptake inhibitor.

A 17-year-old woman presents to your clinic with a chief complaint of sadness, loss of appetite, and the inability to sleep. She is having a hard time focusing at work and she is tired all of the time. She tells you that for the past month she has been hearing voices telling her to harm herself. She is interested in treatment. What is the most appropriate first-line therapy for this condition? Lithium Psychotherapy Sertraline Sertraline and olanzapine

Sertraline and olanzapine Major depressive disorder is defined as an episode of major depression lasting at least two weeks with the following symptoms: (SIG E CAPS) sleep changes, interest (lack thereof), guilt, energy (lack thereof), cognition/concentration (lack thereof), appetite (increased or decreased), psychomotor (agitation or retardation), and suicide (thoughts of or attempts). Major depressive disorder with psychotic features is defined by the above mentioned symptoms plus psychotic features of delusions or hallucinations, either auditory or visual. The first-line treatment for major depressive disorder with psychotic features is an antidepressant plus an antipsychotic medication. Studies show that sertraline, an antidepressant, in combination with olanzapine, an antipsychotic, works more effectively than just sertraline or just olanzapine alone.

A 35-year-old woman presents to the clinic complaining of increased irritability and decreased concentration for the past ten days. She also notes that she feels rested after four hours of sleep for the past ten nights, and has received two speeding tickets in the past week. On exam, the patient is unable to sit still and exhibits pressured speech and easy distractibility. Which of the following additional elements of her history would help lead to a diagnosis of bipolar I disorder? She has been married for 12 years and has been employed with the same company for 15 years She has not been hospitalized for any reason She is experiencing increased energy and has completed 350 pages of her "memoirs" in the past ten days Two months ago she felt "down" and stayed in bed for seven days

She is experiencing increased energy and has completed 350 pages of her "memoirs" in the past ten days Bipolar I disorder is characterized by at least one manic episode, as evidenced by expansive, elevated, or irritable mood and increased energy and goal-directed behavior. Manic symptoms must last for at least one week, nearly every day for most of the day. If elevated mood predominates, three of the following symptoms must also be present for a diagnosis of mania: grandiosity, decreased need for sleep, increased talkativeness or pressured speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities despite potential negative consequences. However, if irritable mood predominates, then four of the aforementioned symptoms must also be present. Patients with bipolar I disorder often also suffer episodes of major depression. For diagnosis as a major depressive episode, depressive symptoms must be present for at least two weeks duration. Bipolar I disorder must be distinguished from bipolar II disorder, cyclothymic disorder, substance abuse related bipolar disorder, and bipolar disorder secondary to another medical condition. Patients with bipolar I disorder experience manic episodes which often lead to hospitalization due to their severity. The manic episodes lead to severe interruptions in social and professional functioning. In contrast, bipolar II disorder involves hypomanic episodes. These episodes have many of the elements of mania, but to a lesser degree and for a shorter duration (four days or less). Likewise, patients with cyclothymic disorder have symptoms of mania which fall short of the diagnostic criteria for either mania or hypomania. If the patient in the above vignette admitted to increased energy and writing many pages of a memoir, she would be exhibiting an increase in goal-directed behavior and energy, which is a crucial element in the diagnosis of bipolar I disorder. First-line treatment for bipolar I disorder presenting with acute mania is with lithium, anticonvulsants such as valproic acid, or antipsychotics.

A mother brings her 12-month-old daughter for routine vaccinations. She is up to date with her vaccinations. The girl has a history of a simple febrile seizure at 10 months of age and has a history of respiratory distress after eating eggs. She lives with her parents and her paternal grandmother who is currently undergoing chemotherapy for breast cancer. Because of anxiety of her daughter getting a fever and a febrile seizure, the patient's mother would like to spread out her vaccines. Today she would like her daughter to get the varicella vaccine. She would like to bring the patient back to the office in 2 weeks to get her measles-mumps-rubella (MMR) vaccine but you explain this is contraindicated. Why can the patient not get the MMR vaccine then? Her risk of vaccine-induced seizure She has an anaphylactic egg allergy She is living with an immunosuppressed family member She must wait 4 weeks between live vaccines

She must wait at least 4 weeks between getting live vaccines if they are not initially given concurrently. Live vaccines include the varicella vaccine, the MMR vaccine, the intranasal influenza vaccine, the rotavirus vaccine, the yellow fever vaccine, the BCG vaccine, the typhoid vaccine, the rabies vaccine, and the oral polio vaccine. Live vaccines must replicate to cause an immune response. Antibodies developed after the first live vaccine can interfere with viral replication of the subsequent vaccine if live vaccines are given apart but too close together.

What is the most common cause of hyperparathyroidism?

Single parathyroid adenoma in 80% of cases

A 23-year-old woman, with no risk factors for heart disease, presents to the clinic with complaints of sternal chest pain, fatigue, and shortness of breath. She was recently diagnosed with sarcoidosis. In your review of systems check, other than pulmonary, what area do you want to focus on the most? Gastrointestinal Musculoskeletal Renal Skin

Skin and lymph nodes are the two most commonly affected areas, after the lungs, by sarcoidosis. History and physical exam should include a thorough review of skin changes. Sarcoidosis is an inflammatory condition characterized by the presence of noncaseating granulomas in organs and tissues, such as the lungs, skin, lymph nodes, eyes, kidneys, joints, and various others. In the skin, various rashes - papular, nodular, or plaque-like can occur; scarring, changes in skin color, and erythema nodosum may develop. Lungs are most commonly involved and characterized by bilateral hilar adenopathy and diffuse reticular or ground glass opacities on chest X-ray. Symptoms include pain around the sternum, shortness of breath, fatigue, dry cough, and wheezing.

A 35-year-old woman with melasma presents to the clinic because over-the-counter treatments have not improved the hyperpigmentation on her face. Physical exam reveals dark-brown hyperpigmentation of her forehead, cheeks, upper lip, and nose. She is given a prescription for tretinoin 0.1% cream. Which of the following is a common side effect of this medication? Skin atrophy Skin exfoliation Skin irritation Skin photosensitivity

Skin irritation occurs in approximately 4 to 6% of patients using topical tretinoin cream and can be severe in some cases. It is applied once daily at bedtime for melasma and has been shown to modestly reduce hyperpigmentation in some studies. Tretinoin is also used in combination medications that use hydroquinone and/or fluocinolone as well. Combination therapies are showing more promise than monotherapy in reducing discoloration. Melasma often presents during pregnancy and is characterized by light- to dark-brown patches of skin on the face. It is sometimes called "the mask of pregnancy". This is often secondary to hormonal changes and can occur in women taking oral contraceptives as well. The macular, hyperpigmented areas are either found on the forehead, cheeks, and upper lip area, the mandibular area, or in a malar distribution.

A 14-year-old boy presents with one month of increasing knee pain. Initially, he noted the pain in his right knee, but now his left knee is also bothering him. His parents note he has been walking with a limp, which at first improved when treated with ibuprofen but now he seems to be getting worse. He denies recent injury or illness, fever, swelling or point tenderness in either lower extremity. He is not having night symptoms, and he is not experiencing numbness or tingling. The pain is most noticeable with weight-bearing activities. On initial inspection you note an obese adolescent boy, with limping gait, and no apparent lower extremity irregularities. During your exam, no tenderness to palpation over the lower extremity is found, including the knee joints bilaterally, but manipulation is significant for decreased range of motion of the hips bilaterally, particularly internal rotation and abduction. Which of the following is the most likely diagnosis? Juvenile idiopathic arthritis Legg-Calvé-Perthes disease Osgood-Schlatter disease Slipped capital femoral epiphysis

Slipped capital femoral epiphysis The combination of progressively painful limp in an obese adolescent with restricted range of motion at the hip is a typical presentation for slipped capital femoral epiphysis (SCFE). In this process, the femoral epiphysis is displaced from the femoral neck at the position of the growth plate, putting the patient at risk for avascular necrosis and premature hip osteoarthritis. The patient's denial of injury or illness, fever, swelling, point tenderness, and night symptoms make inflammatory processes such as infection or neoplasm a less likely cause of his symptoms, and a lack of neurologic symptoms decreases the likelihood that a space-occupying lesion is a culprit. Patients with slipped capital femoral epiphysis may report a dull achy pain originating at the hip or may experience pain referred to the knee. Bilateral involvement is seen in approximately half of presenting patients. On exam, patients may be noted to passively maintain an external rotation of their hips, and a decreased range of motion with internal rotation and abduction can be observed. Diagnosis of slipped capital femoral epiphysis is usually confirmed with bilateral hip radiographs which demonstrate a posterior and inferior displacement of the femoral head with the appearance of "ice cream slipping off a cone". Definitive treatment requires surgical fixation.

A 53-year old previously healthy woman visits her primary care physician to review the results from the biopsy obtained from the solitary 8 mm polyp discovered in her colon by a routine colonoscopy. The report confirms that this is a hyperplastic polyp. Her family history is negative for colon cancer. Which one of the following is the most appropriate interval for follow-up colonoscopy in this patient? 1 year 10 years 3 years 5 years

Small hyperplastic polyps, which are defined as less than 10 mm in size, are not neoplastic and are considered low risk. For patients at low risk, the recommended interval between screening colonoscopies is 10 years. Adenoma polyps are the most common sub-classification of neoplastic polyps and always need more frequent monitoring. Patients with only 1 to 2 small (<1cm) tubular adenomas should undergo repeat colonoscopy in 5-10 years. Patients with 3-10 adenomas or any adenoma greater than 1 cm, displaying high-grade dysplasia or with villous features, should undergo a repeat colonoscopy at 3 years. The interval for more extensive disease is best individualized but can be as often as annually in unusual cases such as sessile adenomas or a familial syndrome.

Which of the following statements best describes a contributing factor in the pathogenesis of panic disorder? Patients who demonstrate hypoactivity in the amygdala and hypothalamus are at increased risk for development of panic disorder Patients who suffer narcissistic personality disorder are at increased risk for development of panic disorder Patients with low anxiety sensitivity are at increased risk for the development of panic disorder Smoking in childhood increases the risk of development of panic disorder as an adult

Smoking in childhood increases the risk of development of panic disorder as an adult Panic disorder is characterized by repeated, often unexpected panic attacks and appears to be multifactorial in origin. Research suggests that panic disorder has a genetic component, and is also influenced by temperament, neurobiology, childhood trauma, and stressful life experiences. Patients who have first-degree relatives who suffer panic disorder are more likely than the general population to have the disorder themselves. Patients who have anxious personality traits or neurotic personality trait are at increased risk of developing panic disorder. Childhood exposure to sexual or physical abuse and childhood smoking increases the risk of developing panic disorder in adulthood. Life stressors, especially involving loss, threat to life, or illness, are often triggers for the development of panic disorder. Neurobiologic factors are also implicated in panic disorder. Neurotransmitters such as GABA and serotonin are targeted in therapy of panic disorder and appear to have an influence on the development of the disease, as well as neural structural changes in the amygdala, hypothalamus, prefrontal cortex, temporal area, anterior cingulate and insula.

Which of the following counseling statements should be given regarding tobacco use and smoking cessation? A Currently, there are more active smokers in the U.S. than former smokers B Heart disease risk is reduced within six months of smoking cessation C Smoking increases the risk for infertility D There is no benefit to smoking cessation over the age of 80

Smoking increases the risk for infertility Tobacco use has been linked to the development of COPD, coronary artery disease, stroke, and multiple types of cancer. Smoking has been linked to acute myeloid leukemia, bladder cancer, lung cancer, kidney cancer, and cancers of the gastrointestinal system. Tobacco use in a pregnant woman has many detrimental effects on a growing fetus, and smoking tobacco has been proven to increase a woman's risk of infertility. Addressing tobacco use with a patient at each health encounter has been shown to increase the likelihood of smoking cessation. Counseling on tobacco use should include warnings of the health risks posed by tobacco smoking, as well as the benefits to health that quitting entails. Counseling should also include information on free community resources available for smoking cessation. If the patient desires pharmacotherapy for help with smoking cessation, several options exist. Bupropion is a norepinephrine dopamine reuptake inhibitor used to treat major depression and is also indicated for smoking cessation. Other pharmacotherapeutic options are varenicline (a nicotinic receptor agonist), and nicotine replacement therapy (such as the nicotine patch or nicotine gum).

A 59-year-old, heavy smoker, presents for the evaluation of facial swelling. Upon examination, you note swelling, not only of the face but also of the neck and upper extremities. You appreciate diminished breath sounds and tactile fremitus in the right upper lobe. Which of the following diagnosis is most likely? Pancoast tumor Tuberculosis pneumothorax superior vena cava syndrome pneumonia

Superior vena cava syndrome This is superior vena cava syndrome suggestive of bronchogenic carcinoma causing lymphadenopathy in the mediastinum which can impinge on the SVC.

A 93-year-old man on aspirin presents to the ED with epistaxis. On physical exam, you note bleeding from bilateral nares and down the posterior pharynx. You are unable to visualize the source of bleeding. Which of the following vessels is most likely the source of bleeding in this patient? Facial artery Kiesselbach plexus Labial artery Sphenopalatine artery

Sphenopalatine artery. This patient is exhibiting signs and symptoms of posterior epistaxis. Posterior epistaxis is less common than anterior epistaxis and is most commonly due to bleeding from the sphenopalatine artery, located at the posterior aspect of the middle nasal turbinate. Patients with posterior epistaxis typically complain of bleeding from both nostrils. Inspection of the posterior pharynx may reveal profuse bleeding. In treating epistaxis, start by having the patient gently blow his nose or suction out the blood. If the bleeding is profuse, apply cotton balls soaked in a topical anesthetic and vasoconstrictor for at least five minutes. A good option is 1% tetracaine plus 0.05% oxymetazoline solution. In posterior epistaxis, this may not achieve hemostasis or allow visualization of the location of bleeding. Management of posterior epistaxis should be with either a Foley catheter or dual balloon pack. A 10 to 14 French Foley catheter with a 30 cc inflatable balloon may be inserted past the site of the bleeding and inflated with 5 to 7 cc of air or saline. It should then be pulled back onto the site of the posterior bleed and inflated until it is snug. An anterior nasal pack should then be placed in both nares. A dual balloon pack is placed by anesthetizing the nare and advancing the pack past the site of the bleeding. The posterior balloon is inflated with 5 to 7 cc of saline or air and pulled back onto the site of bleeding. It is then further inflated until it is snug. The anterior balloon is then inflated. The opposite nare should be packed as well. Complications of posterior epistaxis packing include aspiration, hypoxia, hypercarbia, and symptomatic bradycardia. Prophylactic antibiotic use is controversial as there is no evidence to support a reduction in toxic shock syndrome with use. All patients with posterior packing should be admitted to a telemetry bed for further monitoring while the packing is in place.

Describe the characteristics of a lytic lesion on x-ray.

Spiculated, elevated periosteum, bone destruction

A mother brings in her 5-year-old son due to papular and pustular lesions on his face. A serous honey-colored fluid exudes from the lesions. You suspect impetigo. A Gram stain reveals spherical gram-positive arrangements in irregular grape-like clusters. Question What organism is most likely causing this patient's condition? 1 Staphylococcus epidermidis 2 Staphylococcus aureus 3 Peptostreptococcus 4 Streptococcus pneumoniae 5 Haemophilus influenzae

Staphylococcus aureus The history and lab findings suggest the diagnosis of impetigo, in which Staphylococcus aureus is likely the causative organism. The most common causes of impetigo are usually more than likely Staphylococcus aureus, but also may be beta-hemolytic streptococcus group A. S. aureus causes inflammatory and toxin-mediated diseases. When a Gram stain has been completed, S. aureus will appear as spherical gram-positive cocci arranged in irregular grape-like clusters, as is described in this patient. Inflammatory diseases that can be caused by an active S. aureus infection include the following: skin infections, including impetigo, furuncles, carbuncles, and cellulitis, surgical wound infections, eyelid infections, and postpartum breast infections septicemia (sepsis), which can originate from any localized lesion, especially wound infection, or as a result of intravenous drug abuse endocarditis on normal or prosthetic heart valves osteomyelitis and arthritis, either hematogenous or traumatic pneumonia in postoperative patients or following viral respiratory infection, especially influenza abscesses (metastatic) in any organ

A 34-year-old man presents to the clinic with rash and fever. He states he felt like he was developing the "flu" and initially had body aches, malaise and fever of 100.1℉. Soon after, he developed a rash on his body that was painful to the touch. He states he was recently switched from levetiracetam to lamotrigine for his seizure disorder. Physical exam reveals diffuse erythematous macules with scattered bullae and vesicles covering less than 10% of the body. You also note painful oral and genital lesions. Nikolsky's sign is present. Based on these findings, what is the most likely diagnosis? Erythema multiforme Herpes zoster Stevens-Johnson syndrome Toxic epidermal necrolysis

Stevens-Johnson syndrome is a severe reaction characterized by extensive skin necrosis, erythema, and skin detachment. Stevens-Johnson syndrome is predominantly triggered by medications, but cases have also been reported secondary to infections, vaccinations, contrast mediums, and foods. Patients generally present with a prodrome of fever and influenza-like symptoms one to three days before mucocutaneous lesions develop. Cutaneous lesions generally start on the face and thorax as coalescing areas of exquisitely tender erythema with purpuric centers. The palms and soles are usually spared. Later in the disease, bullae and vesicles will form. Nikolsky sign is the ability to extend the area of sloughing by applying gentle lateral pressure to the skin. Mucosal involvement is seen in a majority of cases, including oral, ocular and urogenital lesions. Stevens-Johnson syndrome is differentiated from toxic epidermal necrolysis by severity and is classified by body surface area involvement of less than 10%.

A 35-year-old woman with a history of migraines and polycystic kidney disease presents to the Emergency Department with a severe, diffuse headache. The onset was abrupt approximately one hour prior to arrival. Her vital signs are within normal limits. She has photophobia and phonophobia, as well as pain with extraocular movements. Which of the following is the most likely diagnosis? Classic migraine Idiopathic intracranial hypertension Meningitis Subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) accounts for approximately one-third of all hemorrhagic strokes. Atraumatic SAH is due to ruptured aneurysms. A history of polycystic kidney disease is a risk factor for the development of berry aneurysms which may spontaneously rupture and cause a subarachnoid hemorrhage. Other medical conditions associated with SAH include Marfan syndrome, coarctation of the aorta and fibromuscular dysplasia. Classic symptoms include an abrupt "thunderclap" headache that is maximal in severity at onset. Patients often have signs of meningeal irritation secondary to blood in the subarachnoid space. These include nuchal rigidity, painful extraocular movements, photophobia, and a positive Brudzinski or Kernig sign. Subarachnoid blood appears white on noncontrast head CT and most often appears in the cerebral cisterns within which lies the vessels that compose the circle of Willis. Management includes supportive care, including airway management as needed, nimodipine, and neurosurgical consultation.

You examine a five-year-old girl for a routine child check. She likes to sing and dance. She knows her name and address. She can also draw a person with six body parts. She also eats fruits, vegetables, fish, and meat. The physical examination is normal. Her mother has no concerns. The girl is excited for the coming break because the family is going to the beach. Which of the following is the correct statement regarding sun exposure? Sunburn is primarily due to UV-A exposure Sunscreen should be applied generously five minutes before going outdoors Sunscreen should be avoided on infants < 6 months of age when adequate clothing and shade is available Use a broad-spectrum, water-resistant sunscreen product with a minimum SPF of 20

Sunscreen should be avoided on infants < 6 months of age when adequate clothing and shade is available. Discussion of sun exposure should be part of the routine well-child visit. Ultraviolet radiation (UVR) emitted from the sun is divided into three wavelength ranges namely, UV-A (320 to 400 nm), UV-B (290 to 320 nm), and UV-C (200 to 290 nm). Exposure to ultraviolet light, whether from the sun or via indoor tanning, is the most significant environmental risk factor for all types of skin cancer. Sunscreens work by absorbing radiation in the range of 290 to 400 nm by either physical or chemical mechanisms. Sun protection factor (SPF) is primarily a measure of UV-B protection and is defined as the least amount of UV radiation required to produce minimal erythema on sunscreen-protected skin to that required to produce the same erythema on unprotected skin. To reduce ultraviolet exposure, the American Academy of Dermatology recommends using sunscreens as a third line of defense, after clothing and shade. Patients should be encouraged to use a broad-spectrum, water-resistant sunscreen product with a minimum SPF of 30. Sunscreen should be applied generously (1 ounce) 15 minutes before going outdoors (every day, all year round) and reapplied every two hours, especially after swimming or sweating. Sunscreen should be avoided, on infants < 6 months of age if adequate clothing and shade is available. When adequate shade and clothing are not available, a small amount for sunscreen (minimum of SPF 15) can be used on small areas.

A 28-year-old man presents to the emergency department by ambulance. His family called for help after finding him unresponsive at home with a syringe on the floor beside him. His blood pressure is 120/78 mm Hg, pulse 95/min, and respirations are 6/min and shallow. On physical exam he is non-responsive to questions, his skin is cool with cyanosis, and his pupils are minimally reactive to light and constricted. Which of the following is the most appropriate next step in management? Administer naloxone Administer sodium bicarbonate Place a nasogastric tube and administer activated charcoal Support airway and breathing

Support airway and breathing. Opioid abuse and overdose is a problem in the United States and worldwide. Deaths due to overdose are common and increasing in number. Clinical features of opioid intoxication include altered mental status, hypoventilation, decreased bowel sounds, low to normal blood pressure and heart rate, and miotic pupils. Medical providers should attempt to obtain as much historical information as possible, however an accurate history is not essential in initial management of these patients. Hypoventilation is the most common vital sign abnormality. The first step in management of an overdose is supporting the patient's airway by providing assisted ventilation with supplemental oxygen through the use of a bag-valve-mask. Naloxone is an opioid antagonist and should be administered to all patients with opioid overdose, preferably by intravenous route. Naloxone may be given by subcutaneous or intramuscular route if obtaining intravenous access will cause a delay in administration. However, the treatment for opioid overdose is oxygen. Meaning, these patients first require management of airway and breathing.

A 30-year-old man presents to the emergency department with an ankle injury after he twisted his ankle when stepping off of the curb. The patient mainly complains of pain near the right lateral malleolus. Which of the following examination findings would be more indicative of an ankle sprain that would not require further diagnostic imaging? Bony tenderness in the malleolar zone Bony tenderness in the midfoot zone Inability to bear weight on the ankle Swelling over the bilateral malleoli

Swelling over the bilateral malleoli. The most common type of ankle injury is an ankle sprain to the lateral ankle. Typically, these are minor and are due to an inversion injury. Sprains are categorized into three grades. Grade I involves no tearing of the ligaments with minimal functional loss, pain, swelling, and ecchymosis. Weight-bearing is tolerable. Grade II sprains occur with a partial tear and some loss of functional ability. They tend to be more painful, with swelling, ecchymosis, and difficulty bearing weight. Grade III sprains result from a complete tear, with significant functional loss, pain, swelling, and bruising, and an inability to bear weight. The Ottawa Ankle Rules are frequently used by physicians and nurses to determine the likelihood of a fracture versus a sprain and the need for imaging. Swelling over the bilateral malleoli is a common finding in ankle sprains. This finding, particularly without other bony tenderness in a patient who is able to bear weight, is more indicative of an ankle sprain and would not make a physician more suspicious for an ankle fracture. In patients with a lateral sprain and the ability to bear weight, treatment consists of analgesics, an elastic bandage or ankle brace, and no sport involvement with follow up in a week if no improvement.

A 15-year-old girl presents with a 1-hour history of rapid heartbeat, faintness, sweating, and nervousness. She is also experiencing shortness of breath and chest pain. The patient has no significant past medical history. There is no history of similar episodes. The patient is on no medications, and she denies illicit drug use. On exam, her vital signs are BP70/60 mmHg; pulse 200 bpm; RR 22/min, temperature afebrile. She looks pale, and her palms are slightly sweaty. She is not comfortable sitting up, so she prefers lying down. She looks slightly apprehensive. Her heart and lung exam are negative except for the tachycardia; except for cool sweaty hands, a brief abdominal and extremity exam are non-revealing. The physician quickly places the paddles on the patient's chest to record the rhythm; this shows a narrow-complex regular tachycardia at 210 bpm. He requests oxygen, IV line, and continuous monitoring. An EKG is in the process of being completed. At this point, what should be done? Carotid sinus massage Synchronized cardioversion Adenosine 6 mg IV push Diltiazem 10 mg IV push Verapamil 5 mg IV push

Synchronized cardioversion. Tachycardia can be classified based on the appearance of the QRS complex on the ECG as narrow and wide complex tachycardia. Narrow complex tachycardia consists of sinus tachycardia, atrial fibrillation, atrial flutter, AV nodal reentry, and atrial tachycardia (ectopic and reentrant). Wide complex tachycardia consists of ventricular tachycardia and supraventricular tachycardia with aberrancy. The patient presents with a tachycardia and associated serious symptoms of faintness, shortness of breath, chest pain and apprehension, mild hypotension, and peripheral vasoconstriction. Thus, while young patients can tolerate a rapid heartbeat for some time, this patient would be classified as hemodynamically unstable. The treatment of choice for unstable patients with a narrow complex tachycardia would be immediate synchronized cardioversion. However, whenever possible, it is advisable to provide analgesia and sedation for conscious patients before cardioversion.

Posttussive rales should make you think of what diagnosis?

TB

An exudative pleural effusion should make you think of what diagnosis?

TB, lung cancer

A 28-year-old primigravida presents in her 34th week of gestation with dichorionic twins. Her prepregnancy body mass index was 20 kg/m². Her blood pressure is 120/80 mm Hg and her hemoglobin is 11 g/dL. Which of the following represents the best counseling to offer this patient? Aim for a total pregnancy weight gain of 55-65 pounds Observe bedrest from 37 weeks of gestation until delivery Prepare for a cesarean section, no matter how the fetuses present at delivery Take two prenatal vitamins with iron daily instead of one

Take two prenatal vitamins with iron daily instead of one. Multiple gestation pregnancies put patients at increased risk of nearly all pregnancy complications, such as premature labor, preeclampsia, congenital birth defects, and anemia. Twin pregnancies can be classified as either monochorionic or dichorionic, depending on whether the fetuses share a placenta. Monochorionic twin pregnancies can be further classified as either monoamniotic or diamniotic, which refers to whether the twins share an amniotic sac or inhabit separate ones. Monochorionic, monoamniotic twins are at highest risk for complications. Fetal complications in twin pregnancies include increased risk of congenital anomalies, low birth weight, and twin-twin transfusion syndrome. Recommendations to give a patient who is pregnant with twins include (but are not limited to): aim for total weight gain of 37-54 pounds during pregnancy, take one prenatal vitamin with iron during the first trimester and two prenatal vitamins with iron during the second and third trimesters, exercise as tolerated, supplement the diet with 1 mg of folate and 1000 mg of vitamin D, expect and keep appointments for more frequent ultrasounds than a singleton pregnancy, and sleep on the left side during the second and third trimesters.

A 14-year-old boy developed an erythematous, papular rash over his palms and fingers. A complete physical examination reveals scaling and cracking in the interdigital webs of his feet. No other areas are affected. What is the most appropriate treatment? Intramuscular benzathine penicillin G Permethrin cream applied from the neck down Supportive care for hand-foot-and-mouth disease Terbinafine cream applied twice daily to feet

Terbinafine cream applied twice daily to feet. The above patient presents with auto-eczematization, also known as an id reaction, which is thought to be due to a delayed-type hypersensitivity reaction to a fungal infection. In this case, it is secondary to his tinea pedis. Tinea pedis, also known as athlete's foot, is the most common dermatophytic fungal infection. Affected individuals develop vesicles or papules over the soles and interdigital webs of the feet, followed by scaling and cracking. It most commonly results in sterile vesicles over the palms and soles. The id reaction resolves with treatment of the primary infection. The treatment of choice for tinea pedis is a topical antifungal, such as terbinafine or clotrimazole, applied to the affected area for four weeks. The correct answer is terbinafine applied twice daily to feet.

Which person is statistically most likely to be phenotypically Rh(D)-negative? A 31-year-old man from Nigeria A 40-year-old woman from the Basque Country A 49-year-old man from Canada A 51-year-old woman from Japan

The Basque Country is located in northern Spain and southern parts of France near the western end of the Pyrenees. The area is culturally unique to the surrounding areas. Populations in this area have a prevalence of between 30 to 35 percent of Rh(D)-negative phenotypes. Knowing the prevalence of Rh-negative phenotypes is important to ensuring adequate screening and prophylaxis against Rh alloimmunization in pregnant woman. Rh antigens are located on transmembrane proteins within the red blood cell membrane. There are many different types of Rh antigens, however, individuals who do not express the Rh(D) antigen are considered Rh-negative. This is an important distinction during pregnancy. If a woman who is Rh-negative is exposed to fetal red blood cells that are Rh(D) positive, that woman may develop anti-D antibodies. Once maternal Rh(D) alloimmunization occurs, the fetus is at risk for hemolytic disease. These women should have indirect Coombs titers monitored closely while the pregnancy progresses as Rh(D) immunoglobulin is not helpful once maternal alloimmunization has occurred. To prevent maternal alloimmunization, Rh(D) immunoglobulin is administered to pregnant women who are Rh-negative before and after delivery.

How do you define 1st degree AV block?

The PR interval is longer than 0.2 seconds or one block on EKG.

Why must the preoperative preparation for surgical resection of a patient with a diagnosed pheochromocytoma involve propranolol initiation after a 10-14 day course of phenoxybenzamine? To allow for an initial decrease in the contracted blood volume To avoid unopposed alpha-adrenergic receptor stimulation To avoid unopposed beta-adrenergic receptor stimulation To normalize the blood pressure elevation exacerbated by phenoxybenzamine

The beta-adrenergic blockade is initiated after the alpha-adrenergic blockade during medical preparation for a pheochromocytoma resection to avoid unopposed alpha-adrenergic receptor stimulation. Patients need adequate preparation due to the high risk of cardiovascular (hypertension, tachycardia) and hemodynamic instability, which can occur due to the release of catecholamines from the manipulation of the adrenal gland during surgery. Phenoxybenzamine is used to initiate alpha-adrenergic blockade. During the alpha-adrenergic blockade, blood pressure is normalized while allowing for blood volume expansion. Following effective alpha-adrenergic blockade, beta-adrenergic blockade is initiated with a medication such as propranolol, to allow for blocking of the vasodilatory peripheral beta-adrenergic receptors. If the beta-adrenergic blockade is initiated first, the unopposed alpha-adrenergic receptor stimulation can cause worsening hypertension.

A routine EKG 5 weeks ago determined that a 59-year-old Caucasian man had developed new-onset atrial fibrillation. The atrial fibrillation was asymptomatic and was not associated with dizziness, palpitations, chest pain, or shortness of breath. He was started on warfarin 5 mg daily for anticoagulation and his Toprol dose was adjusted. Cardioversion was scheduled as a subsequent elective outpatient procedure. The patient's past medical history is notable for hypertension and coronary artery disease with prior RCA stent. He has no history of stroke or TIA. Allergies: bee stings. Usual home medications: aspirin 81 mg daily, hydrochlorothiazide 25 mg daily, metoprolol tartrate 50 mg b.i.d., warfarin 5 mg daily. He quit smoking 20 years ago. He now presents to the outpatient cath lab for a planned elective cardioversion procedure. Patient reports no new medical problems or symptoms since his diagnosis of new-onset atrial fibrillation. He claims compliance to his medical regimen. He denies chest pain or shortness of breath. His vital signs are stable. Physical exam reveals clear lung fields and an irregular cardiac rhythm. EKG shows atrial fibrillation with a ventricular rate of 87 beats per minute. Review of his lab work from 3 days prior shows the following: WBC6.2 K/mcLSodium140 mEq/LHgb11.2 g/dLPotassium4.8 mEq/LHct42%Chloride102 mEq/LPlatelets342 K/mcLCO224 mEq/LProtime16.2 secondsBUN19 mmol/LINR1.7Creatinine1.1 mg/dL Today's lab work shows protime 19.2 seconds and INR 2.1. Question What is the most appropriate course of action? 1 Perform pharmacologic (rather than electrical) cardioversion. 2 Perform transesophageal echocardiogram, reschedule cardioversion in 2 weeks. 3 Postpone cardioversion procedure. 4 Proceed with cardioversion. 5 Proceed with cardioversion after a dose of enoxaparin (Lovenox).

The cardioversion procedure should be postponed due to failure to achieve a therapeutic anticoagulation level for a full 4 weeks prior to cardioversion. The INR of 1.7 on lab work 3 days prior to the scheduled procedure was subtherapeutic, as target INR should be 2.0-3.0 during the 3-week window before cardioversion. Despite the fact that INR was therapeutic at 2.1 on the day of presentation, the cardioversion should be postponed, especially since he is stable and does not complain of any shortness of breath, dizziness, or chest pain. Atrial fibrillation is a completely disorganized atrial rhythm with ineffective atrial contractions. Blood tends to stagnate or pool in the fibrillating left atrium, resulting in an increased risk of thrombus development. Should that thrombus become dislodged, it will travel through the systemic circulation, resulting in possible stroke or acute arterial thrombosis. Patients with atrial fibrillation or atrial flutter for 48 hours or longer should be anticoagulated for at least 3 weeks before and 4 weeks after cardioversion to decrease risk of thromboembolism related to cardioversion. This is regardless of the patient's CHADS2 or CHA2DS2-VASC score.

Which of the following is one of the most helpful signs to rule out testicular torsion? Presence of a bell-clapper deformity Presence of Prehn sign (relief of scrotal pain upon elevation of scrotum) Presence of the cremasteric reflex Vertical lie of testicle

The cremasteric reflex is a superficial reflex elicited by lightly stroking the superior and medial (inner) thigh of a man. The normal response is an immediate contraction of the cremaster muscle that pulls up the testis (> 0.5 cm) on the side stroked. The presence of a cremasteric reflex appears to be one of the most helpful signs in ruling out testicular torsion. The cremasteric reflex may be absent in conditions such as testicular torsion, upper and lower motor neuron disorders, spinal injury of L1-L2, and iatrogenic transection of the ilioinguinal nerve during surgery for hernia repair. Despite being one of the most helpful signs, it is important to note the presence of a cremasteric reflex cannot rule out testicular torsion with 100% certainty.

A 45-year-old man presents with a 2-year history of worsening dyspnea and a 1-month history of a dry cough. The patient gives no history of fever, chills, chest pain, or wheeze. History is significant for smoking (25 cigarettes/day for more than 22 years). A chest X-ray shows hyperinflated lungs with bullae, tubular heart, flattened diaphragm, and no areas of consolidation. Pulmonary function tests (PFT) reveal a decrease in forced expiratory volume in 1 second (FEV1) along with reduction of FEV1/FVC (forced vital capacity) ratio. These findings are characteristic of what condition? Congestive cardiac failure Chronic bronchitis Emphysema Bronchiectasis Diffuse alveolar damage

The findings described in the above patient suggest that the patient is suffering from emphysema. Emphysema is a chronic obstructive airway disease; it is characterized by abnormal, permanent enlargement of the airways distal to the terminal bronchioles and destruction of their walls. Cigarette smoking is a major contributor in the development of emphysema. Other causes include air pollution, alpha1-antitrypsin deficiency, and occupational exposure. The classical symptomatology includes prolonged progressive dyspnea with late-onset non-productive cough, occasional mucopurulent relapses, and eventual cachexia and respiratory failure. The patients are usually thin and have a barrel-shaped chest. There is tachypnea with pursed lip breathing and use of accessory muscles; they may also adopt a tripod sitting position. A chest X-ray shows hyperinflated lungs with bullae, tubular heart, and flattened diaphragm. Forced expiratory spirometry quantifies airway obstruction. Pulmonary function tests (PFT) reveal a decrease in forced expiratory volume in 1 second (FEV1) along with reduction of FEV1/FVC (forced vital capacity) ratio. Treatment includes general measures such as cessation of smoking, breathing exercises, symptomatic treatment like antibiotics to control secondary infection, bronchodilators, corticosteroids, and oxygen therapy. Lung volume reduction surgery and lung transplantation may be required depending on the severity.

A 14-year old girl is accompanied by her parents for amenorrhea. She never had menses. She denies sexual activity and does not take any medications. She is a straight A student in school and plays basketball. On physical examination, her height is at the 90th percentile, weight at the 50th percentile, breasts at Tanner II, no axillary hair and no pubic hair. The rest of her examination is normal. Which of the following is the most likely diagnosis? Complete androgen insensitivity syndrome Klinefelter syndrome Polycystic ovarian syndrome Turner syndrome

The girl in the vignette most likely has complete androgen insensitivity syndrome (AIS) (formerly known as testicular femininization). Complete AIS is an extreme form of failure of virilization wherein genetic males appear female at birth and are invariably reared accordingly. The external genitalia are female. The vagina ends blindly in a pouch, and the uterus is absent. This is due to the normal production and effect of antimullerian hormone by the testes. The testes are usually intra-abdominal although some may descend into the inguinal canal. At puberty, the diagnosis is suspected by the normal development of breasts, but menstruation does not occur and sexual hair is absent. Adult heights are commensurate with those of normal males. Klinefelter syndrome (B) has XXY chromosomes and presents with gynecomastia, small testicles, infertility, mild delays, and a low upper-to-lower segment ratio. Polycystic ovarian syndrome (C) presents with irregular menses, acne, excess body hair, and signs of insulin resistance. Turner syndrome (D) has XO chromosomes and presents with breast buds, short stature, pedal edema, wide-spaced nipples. They may have primary amenorrhea from streak ovaries and ovarian failure.

Which of the following is the mode of genetic transmission for hemophilia B? Autosomal dominant Autosomal recessive X-linked dominant X-linked recessive

The mode of inheritance for hemophilia B is X-linked recessive. Hemophilia B is a bleeding disorder characterized by a deficiency of factor IX. Most cases of hemophilia B are hereditary, but the disorder can also be acquired through spontaneous mutation or autoimmunity. Hemophilia B is less common than hemophilia A. Hemophilia can be categorized as mild, moderate, and severe, based on the percentage of factor activity. Transmission occurs from female carrier to half of her male children; father-to-son transmission does not occur. Most patients with severe hemophilia present during the first 18 months of life with easy bruising, hemarthrosis, or excessive bleeding after an invasive procedure. Patients with severe hemophilia can present with spontaneous bleeding or bleeding that is out of proportion to the degree of injury. Mild hemophilia may only become apparent when the patient encounters significant hemostatic challenges, such as surgery or trauma. Common sites of bleeding include joints, muscles, oropharynx, gastrointestinal tract, and genitourinary tract. Intracranial hemorrhage is rare compared to other sites of bleeding but can be life-threatening. Initial laboratory studies should include prothrombin time (PT), partial thromboplastin time (PTT), and platelet count. Hemophilia will result in prolonged PTT and normal PT and platelet count. Factor replacement is the mainstay of treatment. The dosage of factor replacement is dependent upon the severity of the bleed and the severity of the factor deficiency. Hemophilic arthropathy is one of the most common complications of hemophilia.

A 25-year-old woman presents for her initial prenatal visit. What is the most accurate method for determining her estimated date of delivery? Crown-rump length Gestational sac size Naegele's rule Uterine size

The most accurate method of determining estimated delivery date is crown-rump length. Transvaginal ultrasound is more accurate than abdominal ultrasound. The results are most accurate early in the pregnancy, ideally before the 22+0 week, and less accurate as the pregnancy progresses, due to biological differences in development and variations in fetal position. When assessing fetal development and gestational age using sonogram, there are milestones that should be noted during the first trimester. Fetal cardiac activity can be detected by week six. The fetal yolk sac should be visible at around five weeks, but degrades between weeks 10 and 12. The second and third trimester assessment relies on biometric markers such as biparietal diameter and head circumference, the more reliable of the markers to estimate gestational age.

Which of the following is correct regarding the condition seen in the image above? (well-demarcated erythematous plaques and papules with silvery white scales) Involvement of the scalp and nails is uncommon It is associated with the Auspitz sign Lesions most commonly occur on flexor surfaces Systemic steroids are the preferred treatment

The well-demarcated erythematous plaques and papules with silvery white scales are characteristic of psoriasis. Removal of the scale typically reveals pinpoint-bleeding areas referred to as the Auspitz sign. There is a hereditary predilection for the condition, which often begins in the second or third decade of life. Lesions tend to be symmetric and most commonly found on the trunk, scalp, nails (A), and extensor surfaces (C). Systemic steroids (D) should be avoided due to the risk of developing rebound or induction of pustular psoriasis.

Which of the following is the most likely etiologic agent of the rash pictured above (bright red facial rash with circumoral pallor)? Coxsackievirus Group A Human herpes virus 6 Parvovirus B19 Rubella virus

The most commonly recognized manifestation of parvovirus B19 infection is erythema infectiosum, also known as fifth disease. This is a benign, self-limited childhood exanthem. After a two-week incubation period, patients often develop very mild URI-type symptoms followed in three to four days by the classic "slapped-cheek" rash that appears suddenly. It is believed that the development of the rash corresponds to the onset of immune response and sudden production of anti-B19 antibodies. Parvovirus B19 has also been associated with the development of severe disease, including a symmetric polyarthropathy, myocarditis, and pericarditis. Prior theories also connected Parvovirus B19 to kidney disease, specifically focal segmental glomerulonephritis, however, this has recently been found to be coincidence rather than correlation or cause. Primary infection in patients with sickle cell disease may lead to an aplastic crisis due to disruption of hematopoiesis. Nonimmune women who become infected during pregnancy are at risk of congenital infection that may lead to hydrops fetalis and fetal loss.

A 27-year-old woman has pleuritic chest pain and mild shortness of breath. A D-dimer was performed and is negative. What value best estimates the likelihood that this patient does not have a pulmonary embolism given the negative test result? Negative predictive value Positive predictive value Sensitivity Specificity

The negative predictive value is the likelihood that a person with a negative test does not have the disease in question. A positive predictive value (B) allows one to understand the likelihood of having a disease with a positive test. This is calculated by A/(A+B), or the number of patients with disease and a positive test result divided by the cohort of all patients with positive test results. Sensitivity (C) refers to the test's ability to correctly detect patients who do have the condition. The sensitivity of the test is the proportion of people who test positive for the disease among those who have the disease, A/(A+C). These tests are frequently used as helpful rule out tests because with a high sensitivity a negative test result effectively rules out disease because most people with the disease have a positive test. Specificity (D) relates to the test's ability to correctly detect patients without a condition. Specificity of a test is the proportion of healthy patients known not to have the disease, who will test negative for it, D/(B+D). These tests are more helpful if they are positive reflecting a higher chance of an individual having a disease.

A 28-year old woman presents with several painful ulcers she has developed in the vaginal area. Examination reveals multiple 0.5 cm to 1.5 cm oval ulcers with sharply defined borders and a yellowish-white membrane. She denies recent sexual activity. Except for recurring aphthous ulcers of her mouth, her past history is unremarkable. Which of the following is the most likely diagnosis? Behçet syndrome Herpes simplex Reactive arthritis Syphilis

The original description of Behçet syndrome included recurring genital and oral ulcerations and relapsing uveitis. The genital and oral ulcers are classically painful with a necrotic center and surrounding red rim. Behçet syndrome is more common in Japan, Korea, and the Eastern Mediterranean area, and affects primarily young adults. The cause is unknown. Two-thirds of patients will develop ocular involvement that may progress to blindness. Patients may develop arthritis, vasculitis, intestinal manifestations, or neurologic manifestations. This disease is diagnosed based on physical exam and clinical symptoms. Treatment of Behçet syndrome must be tailored to each patient's clinical manifestations. Corticosteroids are considered palliative as they are useful in controlling acute manifestations primarily. Cytotoxic medications are usually indicated in patients with ocular, CNS, and vascular disease. Decreasing morbidity and mortality is the goal of treatment for children with Behçet syndrome.

A 32-year-old man presents with severe, acute left knee pain that occurred while wrestling with his brother. He is unable to bear weight. His knee is held in flexion and he is unable to actively extend it. His leg is shown above. Which of the following is the best next step in management? AngiogramYour Answer Closed reduction Computed tomography scan Orthopedic consultation

The patient has a lateral patellar dislocation. Closed reduction is the management of a patellar dislocation. The hip is flexed and the knee is passively extended while simultaneous medial stress is applied to reduce the laterally displaced patella to its anatomic location. Pain relief is usually immediate, but the patient may continue to be sore. Patellar dislocations must not be confused with knee dislocations, which are more severe. Patellar dislocations are usually caused by tibial rotation against a flexed knee during quadriceps contraction. The patella is most commonly displaced laterally. The hip and knee are classically flexed at 90 degrees. Once closed reduction is successful, an X-ray should be performed to rule out fractures or other abnormalities and a knee immobilizer placed. Management is with rest and orthopedic follow-up. An angiogram should be obtained in patients with suspected knee dislocations (not patellar dislocations). The most feared complication from a knee dislocation is a popliteal artery injury. These injuries often present after relocation and may appear clinically normal. However, if vascular repair does not occur within six to eight hours of injury, permanent ischemia and limb loss may ensue.

A 32-year-old man presents with an acute onset of right-sided facial weakness that he first noticed upon waking this morning. You ask him to smile, as seen in the image above (unilateral & ipsilateral forehead crease and facial drop). Which of the following clinical features, if present, suggests a more severe diagnosis? A vesicle found on the right tympanic membrane Dysgeusia Hyperacusis Unilateral symptoms

The patient has idiopathic facial nerve paralysis (Bell palsy). Bell palsy is characterized by a rapid onset of unilateral facial paralysis. More than half of patients have a prodromal viral illness (rhinorrhea, myalgias, low grade fever). Bell palsy is associated with ear pain, decreased tearing, an overflow of tears onto the cheek (epiphora), hyperacute hearing (hyperacusis), and dysgeusia (an impairment of taste). Idiopathic facial nerve paralysis involves the lower motor neuron. Features that suggest an upper motor neuron etiology include a slow progression of symptoms, recurrent symptoms, and intact forehead movement. A herpetiform vesicular eruption on the tympanic membrane, pinna, external auditory canal, soft palate, oral cavity, face, or neck suggests a diagnosis of Ramsay Hunt syndrome (herpes zoster oticus). In Ramsay Hunt syndrome, the pain is more severe than in Bell palsy, and the prognosis is worse, with a lower incidence of complete facial recovery and the possibility of associated sensorineural hearing loss. Bilateral facial nerve paralysis suggests a diagnosis of Lyme disease, which is treated differently than Bell palsy or Ramsay Hunt syndrome. Bell palsy and Ramsay Hunt syndrome are treated with steroids and antivirals for 7-10 days.

A 32-year-old woman, who is at 20 weeks gestational age, presents to the ED after a seizure. Her vital signs are BP 115/70 mm Hg, HR 105 bpm, RR 16/min, T 38.5°C, and pulse oximetry 98% on room air. On exam, you note some confusion, but otherwise there are no focal deficits. Lab results reveal a hemoglobin of 7 g/dL and platelets of 12,000/µL. A peripheral blood smear reveals schistocytes. Which of the following is the most appropriate treatment for her condition? Delivery of fetus Magnesium sulfate Plasmapheresis Platelet transfusion

The patient has thrombotic thrombocytopenic purpura (TTP). The classic pentad of TTP includes CNS abnormalities, renal pathology, fever, microangiopathic hemolytic anemia, and thrombocytopenia. However, diagnostic criteria have recently been simplified to include all adults with microangiopathic or microvascular hemolytic anemia and thrombocytopenia with no other explanation for these findings. TTP shares many clinical and laboratory features of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. HELLP syndrome is less common before 24 weeks gestation. The derangements in hemoglobin and platelet levels are more severe in TTP. The mainstay of treatment for TTP is plasmapheresis (plasma exchange), which can achieve remission of disease in 80% of patients. If plasmapheresis cannot be immediately performed, fresh frozen plasma (FFP) should be administered until plasmapheresis can be performed. Medical therapy and plasmapheresis are the first lines of treatment. Magnesium sulfate is used in the treatment of eclampsia. Although this patient had a seizure, her blood pressure is normal and her lab results are more consistent with TTP than eclampsia. Although platelet levels are low in TTP, platelet transfusion is reserved only for patients with life-threatening bleeding. Any administration of platelets will result in destruction from platelet aggregation in the microvascular circulation.

A 75-year-old man with a long-standing history of constipation presents complaining of abdominal pain for the last two days. He is now experiencing abdominal distention, constipation, and inability to pass gas for the last 12 hours. On examination, his abdomen is distended and tympanitic to percussion. You obtain an upright abdominal X-ray as seen above (air filled U-shaped bowel overlies fecal impacted large bowel with no gas in the rectum). What is the most likely diagnosis? Cecal volvulus Intussusception Irritable bowel syndrome Sigmoid volvulus

The patient is suffering from a sigmoid volvulus, an intestinal obstruction that resulted when a non-fixed, redundant loop of the sigmoid colon twisted and obstructed the lumen. Sigmoid volvulus is more common in elderly, debilitated patients with a history of chronic constipation. The hallmark symptoms include abdominal pain, distention, and constipation. If the twist involves the vascular supply, the patient can develop gangrenous bowel. If this occurs, the patient may have associated fever, chills, peritonitis and cardiovascular instability. Plain films of the abdomen are often sufficient to make the diagnosis. Findings include a grossly distended loop of colon lacking haustral markings and classically have a "bent inner tube" appearance in which the loop points to the RUQ. Contrast enema will show the characteristic "bird's beak" appearance. If there is no concern for underlying gangrene, endoscopic detorsion should be attempted. Surgical consultation should be placed and the patient should be admitted for definitive repair.

A 3-year-old boy is referred to the pediatric hematologist with a chief complaint of easy bruising, nosebleeds and decreased activity for one week. He has no history of fever or appetite changes. His past medical history is remarkable for multiple congenital anomalies but no workup has been done. There is no travel history, history of recent illnesses, or known exposure to toxins. The physical examination reveals an active boy with short stature, notable hyperpigmentation of the trunk, neck, and intertriginous areas, as well as café-au-lait spots and vitiligo. The boy also has microcephaly, broad nasal base, epicanthal folds, micrognathia, anicteric sclera, pale palpebral conjunctivae, no cervical lymphadenopathy, clear breath sounds, adynamic precordium, no heart murmur, soft non-tender abdomen, full equal pulses, and capillary return time of less than two seconds. Laboratory tests reveal hemoglobin 7.9 g/dL, hematocrit 24%, platelet count 12,000/mcL, WBC 3,000/mcL with 90% lymphocytes, absolute neutrophil count 210 cells/L, and reticulocyte count 0.5%. Which of the following is the most likely diagnosis? Beta thalassemia Diamond-Blackfan anemia Fanconi anemia Paroxysmal nocturnal hemoglobinuria

The patient presents with the common manifestations of Fanconi anemia. Fanconi anemia is inherited in an autosomal recessive pattern and classically presents with pancytopenia and characteristic congenital anomalies. These include hyper- or hypopigmentation or cafe-au-lait spots on the trunk, neck and intertriginous areas, short stature, upper limb abnormalities, hypogonadism, skeletal anomalies, eye or eyelid changes, renal malformations, and more rarely, deafness, gastrointestinal and cardiopulmonary malformations. Thrombocytopenia typically occurs first, followed by neutropenia and then anemia. Severe aplastic anemia develops months to years after initial complete blood count changes. Bone marrow shows patchy hypoplasia. The diagnostic test for Fanconi anemia is a chromosome breakage analysis using clastogenic agents such as diepoxybutane or mitomycin C. Therapy consists of supportive care with transfusions and antibiotics for infection. Some patients respond to corticosteroid and androgen therapy. Stem cell transplantation from a matched sibling donor, or from an unrelated donor if a sibling donor is not available, is recommended in patients who are not responsive to corticosteroid and androgen therapy.

A 4-year-old girl presents to your office with a fever for the last 7 days. Her mother reports that her temperature was as high as 104.4°F and decreases with ibuprofen but does not resolve. She reports that her daughter has been irritable and, even when her fever goes down, still acts uncomfortable. She complained of abdominal pain and had several episodes of vomiting but no diarrhea. On physical examination, her temperature is 103.0°F, pulse 118, respiratory rate 26 breaths per minute, and blood pressure 110/80. She has bilateral injected conjunctiva but no discharge is noted. Her lips are red and cracked and her posterior pharynx is erythematous, as well. Her tongue is dark red and has enlarged fungiform papillae. She has anterior and posterior cervical lymphadenopathy, with a right anterior node measuring 18 mm. Her fingers and hands are swollen and she pulls away and cries when you try to move her wrist and says "ouch." Regarding the patient's suspected condition, which of the following is true? Coronary artery aneurysms typically present within 10 days High-dose aspirin should be initiated and continued in this patient for 6 weeks duration Live vaccines should be delayed for 3 months The risk for developing coronary artery aneurysms is greatest for children under 1 year of age

The risk for developing coronary artery aneurysms is greatest for children under 1 year of age. Classic Kawasaki disease is diagnosed based on the presence of a fever lasting five or more days, accompanied by four out of five findings: bilateral conjunctival injection, oral changes such as cracked and erythematous lips and strawberry tongue, cervical lymphadenopathy, extremity changes such as erythema or palm and sole desquamation, and polymorphous rash. The risk of developing coronary artery aneurysms in Kawasaki disease is greatest for children under 1 year of age. Other risk factors include prolonged fever, prolonged elevation of inflammatory parameters such as elevated ESR and CRP, and male gender. It is important to remember that IVIG, which is the mainstay of therapy for Kawasaki disease and should be initiated in a single dose at diagnosis, will artificially increase the ESR thus CRP should be followed following IVIG therapy when monitoring inflammatory parameters.

A 17-year-old woman presents for routine evaluation of her asthma. She notes daily symptoms requiring the use of her rescue inhaler as well as nocturnal awakenings two times per week. What is the most appropriate treatment regimen for controlling the patient's asthma symptoms? Continue short-acting inhaled beta-2-agonist as needed Short-acting inhaled beta-2-agonist as needed plus high-dose inhaled corticosteroid and long-acting inhaled beta-2-agonist Short-acting inhaled beta-2-agonist as needed plus low-dose inhaled corticosteroid Short-acting inhaled beta-2-agonist as needed plus low-dose inhaled corticosteroid and long-acting inhaled beta-2-agonist

The severity of asthma is considered moderate persistent when patients have daily symptoms requiring rescue medication, nocturnal awakenings more than once per week, some limitation in normal activity, or FEV1 between 60 and 80 percent of predicted and FEV1/FVC below normal. The goals of chronic asthma management include a reduction in impairment and reduction of risk. Moderate persistent asthma is treated with a short-acting inhaled beta-2-agonist as needed plus a low-dose inhaled corticosteroid and long-acting inhaled beta-2-agonist. Symptoms over the past two to four weeks should be assessed at each visit. Questionnaires such as the Asthma Control Test along with peak expiratory flow rate and spirometry should be used for severity monitoring.

A 65-year-old woman with Crohn's disease that is well controlled on infliximab presents to her primary care physician. As you are updating her immunization status, which one of the following should be noted? Hepatitis A vaccine is contraindicated Pneumococcal vaccine is contraindicated Tetanus toxoid is contraindicated Zoster vaccine is contraindicated

The varicella zoster vaccine is recommended for immunocompetent patients over the age of 50. There is not sufficient research at this time in immunocompromised hosts and therefore it is contraindicated in this patient due to her immunocompromised state. This patient is considered immunocompromised since she is taking infliximab. Hepatitis A vaccine is recommended for any person with chronic liver disease or traveling and working in endemic areas. This vaccine is not a live attenuated vaccine and therefore can be given to patients that are immunocompromised. The pneumoccocal vaccine is recommended for all patients greater than 65 years of age or patients who are immunocompromised or who have a chronic disease. This patient should therefore receive the pneumococcal vaccine. The tetanus toxoid is not routinely given unless the patient has a contraindication to receiving the diptheria component.

Which one of the following has been shown to render some improvement in individuals with borderline personality disorder? Dialectic behavioral therapy Omega-3 fatty acids Second-generation antipsychotics Selective serotonin reuptake inhibitors

There are no proven therapies to reduce the severity of borderline personality disorder (BPD). The most promising psychological therapy is dialectic behavioral therapy (DBT). DBT is a multi-faceted program specifically designed to treat BPD. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings and behaviors that lead to the undesired behavior. The few, small studies of DBT found improvement in many symptoms of BPD, but long-term data is lacking. Another promising therapy is psychoanalytic-oriented day hospital therapy.

A previously healthy, 22-year-old sexually active woman presents to your office with a complaint of a recurrent, painful genital rash. Physical exam reveals grouped, erythematous vesicles on the patient's labia majora; some intact and some ruptured with ulcerations. Which of the following diagnostic mechanisms is most appropriate? Clinical diagnosis based on appearance Serum antibody test Skin biopsy Tzanck smear Viral culture

There are two types of herpes simplex virus, herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2), which are both commonly seen worldwide. HSV is widespread and has a variety of complications including morbidity and mortality of the fetus through perinatal transmission, making it a major global public health concern. The clinical course of the virus depends on the type of virus, immune status and age of the host, and the affected site. Clinical manifestations of HSV-2 infection include a prodrome of constitutional symptoms including fever, malaise, headache, and myalgias as well as localized symptoms at the affected site including pain, burning, and tingling. Shortly after the prodrome, herpetic vesicles appear and then rupture, leaving painful ulcerations. Clinical diagnosis should be verified with laboratory testing including viral culture, polymerase chain reaction (PCR), and direct fluorescence antibody. Treatment is with antiviral medication to slow the duration and severity of infection.

You provide care to a middle-aged man with hypertension and diabetes. He recently lost his job, and you are concerned he may be exhibiting mild symptoms of depression. According to the US Preventive Services Task Force, screening for depression is recommended if which of the following exists? A local suicide prevention hotline routinely handles calls from your surrounding area The patient has strong social support of friends, family, and coworkers There is an adequate system in place for diagnosis and follow-up You have developed a detailed depression screening form

There is an adequate system in place for diagnosis and follow-up The US Preventive Services Task Force recommends that all adults who have never been screened for depression should be screened. There should be adequate systems in place that can make an accurate diagnosis, offer effective treatment and provide follow-up care. There is evidence this model improves clinical outcomes over time. Staff-assisted care support refers to ancillary staff that can assist the primary care physician in many areas, such as behavior treatment, medication adherence, and follow-up care. This can include trained nursing staff, cognitive behavior therapists, psychiatrists, and psychologists. There is limited evidence to guide the optimal frequency of screening for depression. To facilitate ease of implementation, screening at the time of a routine health visit is suggested, and if positive, a more detailed screening should be done.

Which of the following statements is true concerning patients with cholestatic jaundice? They have decreased hepatic concentration of bile salts They have decreased serum concentration of bile salts They have decreased total bile salt pool size They have increased bile salts in enterohepatic recirculation

They have decreased total bile salt pool size. Cholestasis is the accumulation of bile in the liver as a result of decreased secretion of bile by hepatocytes or obstruction of the bile ducts. Cholestatic jaundice is much more common and multifactorial in the neonatal period because the liver of a neonate is much more susceptible to injury. In older children and adults, cholestatic jaundice can result from hepatocellular causes such as drug-induced cholestasis, viral hepatitis, and progressive familial syndromes. Obstructive cholestasis in older children and adults can result from cholelithiasis, various types of cholangitis, and tumors. As bile salts are retained in the parenchyma of the liver during cholestasis, down-regulation occurs and less bile salts are produced, resulting in a decrease in the total bile salt pool size as well as a decrease in the enterohepatic recirculation of the bile salts. As bile salts and bilirubin build up in the liver, they are regurgitated into the serum, leading to jaundice. Patients who present with jaundice should have laboratory serum tests for total bilirubin, conjugated bilirubin, unconjugated bilirubin, lipids, lipoprotein-X, alkaline phosphatase and gamma-glutamyl transferase. Elevations in these serum levels will vary depending on the etiology of the patient's cholestasis. Liver and gallbladder ultrasound, CT scan of the abdomen, endoscopic retrograde cholangiography, and percutaneous transhepatic cholangiography may be employed to identify anatomic causes of obstruction. Biliary nuclear medicine studies can be employed to differentiate between obstructive and hepatocellular causes of cholestasis.

A 22-year-old woman presents with a new lump in her right breast that she noticed while she was doing a self-exam in the shower about one week ago. The lump has not changed in size. Upon physical exam, you note a 2 cm discrete lump that is round, mobile and nontender to palpation to the upper outer quadrant of the right breast. The lump is solitary and you do not notice any other abnormalities. Which of the following statements is most likely given the suspected diagnosis? They are usually rapid growing and develop in one breast They usually have a cobblestoning texture They usually have ill defined bordersThey usually regress after menopause

They usually regress after menopause. Fibroadenomas are common benign breast tumors frequently found in young women in their 20s and 30s although they can be diagnosed at any age. Typically, fibroadenomas range from 1-5 cm in size, are round or ovoid, rubbery in texture, discrete, mobile and nontender. Although solitary tumors are usually found, some women can also develop multiple. They usually increase in size in pregnancy and in patients being treated with estrogen therapy but they usually regress after menopause. Tumors are usually discovered incidentally. Definitive diagnosis is made by needle biopsy or cytologic examination. Excision can be performed if diagnosis is uncertain or for fibroadenomas that continue to grow or change shape. However, removing tumors can disrupt normal breast tissue causing scarring that can change the shape of the breast. Often these tumors stop growing and even shrink on their own without treatment. Risk of breast cancer in patients depends on histologic classification and family history of breast cancer. The relative risk with simple fibroadenomas is low, about 1.5 times more than normal, and slightly higher in patients with complex fibroadenomas. It is important for women with history of fibroadenomas to have regular breast exams to monitor the stability of the tumors.

Which of the following best represents a positive prognostic variable for successful external cephalic version of a breech fetus? Amniotic fluid index less than ten Anterior placental location Non-longitudinal fetal position Thinner myometrial thickness

Thinner myometrial thickness. External cephalic version is an elective procedure used to reorient a fetus who is in breech position, with the goal of successful vaginal delivery and avoidance of cesarean section. In women who opt to undergo external cephalic version, the rate of cesarean sections is decreased, although it remains higher than the rate of cesarean sections performed in patients with cephalic presentations who did not require external cephalic version. The procedure involves pharmacologic uterine relaxation and external bimanual manipulation of the fetus to cause the fetus to perform a forward or backward somersault and reorient cephalically. The procedure should not be attempted in cases of placenta previa and previous cesarean section. Likelihood of successful external cephalic version is increased in patients who are Black, who present with nonlongitudinal fetal lie, and whose fetus has an unengaged presenting part. Nonlongitudinal lie aids in external cephalic version because the fetus need not be rotated 180 degrees, and because transverse lie is an inherently unstable lie. Risks of external cephalic version include stillbirth, placental abruption, emergency cesarean section, cord prolapse, vaginal bleeding, rupture of membranes, maternofetal transfusion, and transient abnormal changes in fetal heart rate. The rate of serious complications in large studies was found to be very low.

A 31-year-old G1P1 woman at 39 weeks gestation has a normal spontaneous vaginal delivery. The patient is evaluated immediately after delivering for possible obstetric perineal laceration. On physical examination, the patient is found to have a laceration through the perineal fascia and musculature extending into the external anal sphincter. Based on the description of the laceration, which of the following would be the patient's correct diagnosis? First-degree laceration Fourth-degree laceration Second-degree laceration Third-degree laceration

Third-degree lacerations are perineal lacerations that involve the perineal fascia, musculature, and involve the external and internal anal sphincter. Obstetric perineal lacerations are graded depending on the severity and involvement of the perineal structures. First and second-degree lacerations are easily repaired in the delivery room with suture material, but depending on the extent of a third or fourth-degree laceration, more extensive repair in an operating room may be necessary for adequate anesthesia and management of aseptic conditions. Patients with third and fourth-degree lacerations are started on broad-spectrum antibiotics to help prevent postoperative infection. In the past an episiotomy was used to allow for easier delivery of the fetus, however, it is used less frequently now and reserved for patients who are at greater risk of more severe perineal lacerations during delivery, such as nulliparous woman requiring vacuum-assisted or forcep delivery. Complications of third- and fourth-degree lacerations include wound breakdown, infection, incontinence, and prolapse.

A 3-day-old female developed a rash 1 day ago that has continued to progress and spread. The infant was born at term after an uncomplicated pregnancy and delivery to a healthy mother following excellent prenatal care. The infant was discharged 2 days ago in good health. She does not appear to be irritable or in distress, and she is afebrile and feeding well. On examination, abnormal findings are confined to the skin, including her face, trunk, and proximal extremities, which have macules, papules, and pustules that are all 2-3 mm in diameter. Her palms and soles are spared. A stain of a pustular smear shows numerous eosinophils. Which one of the following is the most likely diagnosis? Acne neonatorum Erythema toxicum neonatorum Herpes simplex virus keratitis Staphylococcal pyoderma

This infant has a typical presentation of erythema toxicum neonatorum. Erythema toxicum neonatorum (ETN) is a benign self-limited eruption occurring primarily in healthy newborns in the early neonatal period. Erythema toxicum neonatorum is characterized by macular erythema, papules, vesicles, and pustules, and it resolves without permanent sequelae.

A 34-year-old man presents to the emergency department with facial flushing, nausea, vomiting, and palpitations after eating tuna just one hour prior to presentation. His vital signs are T 36.7°C, HR 120 bpm, BP 130/70 mm Hg, and RR 18/min. On physical exam, he appears diaphoretic and anxious. He has normal bowel sounds and no abdominal tenderness on exam. The rest of his exam is unremarkable. What is the most likely etiology of this patient's symptoms? Ciguatera Histamine fish poisoning Staphylococcus Tetrodotoxin Vibrio parahaemolyticus

This patient's presentation is most consistent with histamine fish poisoning. Histamine fish poisoning is a food-related illness that occurs from the consumption of improperly stored fish. Bacteria on the surface of the fish decarboxylate histidine, a ubiquitous amino acid, forming a histamine. Commonly implicated fish include the following: tuna, mackerel, and mahi-mahi. When ingested, the histamine is absorbed and causes symptoms of flushing, headache, vomiting, abdominal pain, palpitations, and anxiety. Focal neurological findings are uncommon. The onset of symptoms is rapid, generally within the hour.

A 23-year-old man presents with leg pain for three months and requests hydromorphone for pain. The nurse approaches you because she believes the patient is "drug seeking" as he became extremely upset when she told him that he would have to wait for the doctor to evaluate him before pain medications could be given. Upon entering the room, the patient speaks pleasantly with you and compliments you on your kindness. He tells you that he only comes to this hospital because "it's the best in the world," and "none of the other doctors understand me." Upon informing the patient that you will not be prescribing hydromorphone, he becomes extremely upset and starts yelling. This patient is exhibiting traits that are consistent with which of the following personality disorders? Antisocial Borderline Histrionic Narcissistic

This patient exhibits a number of features typically seen in borderline personality disorder. Borderline personality disorder is characterized by unstable relationships, self image, and affect. This instability is often marked with impulsiveness. In the emergency department, these patients will often "split" providers: they will act with affection and respect to some providers and anger and disregard to others. Substance abuse and drug seeking behavior are often seen in borderline patients as well. Antisocial personality disorder (A) is typified by a disregard and violation of the rights of others. Histrionic personality disorder (C) involves excessive emotionality and attention seeking. Narcissistic personality disorder (D) involves patterns of grandiosity and lack of empathy to others.

This above rash has been present for 36 hours (lesions in crops, with central lesion surrounded by pale edematous skin further surrounded by a sharp red ring). What is the most likely cause of the lesions? Acute rheumatic fever Drug reaction Herpes simplex virus Lyme disease Syphilis

This patient has erythema multiforme, an acute immune-mediated self-limited rash characterized by target-shaped skin lesions. The most common known causes include reactivated herpes simplex, Mycoplasma pneumonia, and upper respiratory tract infections. Rarely, it can be associated with allergens, drugs, connective tissue diseases, and internal malignancies. While it can present with multiple forms, such as red macules and papules, urticarial-like lesions, vesicles and bullae, most of these will evolve over 24-48 hours to form 1-3 cm target lesions. Diagnosis is based on this classic clinical appearance, with a central lesion surrounded by a pale area of edematous skin and a surrounding sharp discrete ring of erythema. Lesions appear in crops, resolve in two to four weeks, and often involve the palms and soles. Involvement of oral mucosa differentiates erythema multiforme major from erythema multiforme minor. Treatment involves symptomatic treatment and topical steroids, systemic steroids with taper for severe disease or mucosal involvement, and antiviral suppressive therapy for recurrent lesions associated with herpes.

A 21-year-old woman presents to the emergency department after an intentional ingestion. On physical examination, she is lethargic, flushed, hot to the touch, and her pupils are dilated. Vital signs include BP 130/90 mm Hg, HR 130 beats/minute, and RR 22 breaths/minute. After several minutes, she has a generalized tonic clonic seizure. What is the mechanism by which this class of medications causes cardiac toxicity? AV nodal blockade Fast inward sodium channel blockade Inhibition of the sodium/potassium-ATPase pump Rapid outward potassium channel blockade

This patient is exhibiting signs and symptoms of a tricyclic antidepressant (TCA) overdose. TCAs act by fast inward sodium channel blockade, causing QRS complex widening (> 100 ms) on ECG. TCAs also have anticholinergic effects, which lead to a presentation of pupillary dilation, dry, hot, flushed skin, tachycardia, decreased or absent bowel sounds, and urinary retention. In addition to severe cardiac effects, TCAs can also cause rapid deterioration of mental status and seizures. The most important first step in diagnosis is to perform an electrocardiogram to evaluate for widening of the QRS complex. Another hallmark finding of TCA toxicity on ECG is a dominant terminal R wave in lead aVR. Management of TCA toxicity includes administration of sodium bicarbonate to combat the sodium channel blockade if there is widening of the QRS complex on ECG or telemetry. Sodium bicarbonate boluses should be administered, 50 mEq IV at a time, until the QRS complex narrows. A continuous infusion of 150 mEq of sodium bicarbonate in 1 L D5W at a rate of two to three times maintenance should be initiated at that time. Potassium levels will need to be monitored closely while sodium bicarbonate is infusing. Lorazepam or diazepam should be administered for seizures. Intubation may be required for airway protection given the potential for neurologic deterioration. Any patient with a symptomatic TCA overdose should be admitted for telemetry monitoring and frequent neurologic checks.

A 77-year-old woman presents to the ED with acute painless vision loss. On funduscopic exam, you note the above (pale retina with a cherry red spot on the fovea). Which of the following is the most likely diagnosis? Central retinal artery occlusion Central retinal vein occlusion Idiopathic intracranial hypertension Optic neuritis

This patient is exhibiting signs and symptoms of central retinal artery occlusion. Central retinal artery occlusion is defined by the occlusion of blood flow to the retina, typically by emboli from the carotid artery or from the heart in patients with atrial fibrillation. Risk factors for central retinal artery occlusion include hyperlipidemia, coronary artery disease, atherosclerosis, hypertension, diabetes, and glaucoma. Signs and symptoms include sudden, painless, complete loss of monocular vision. Physical exam will reveal an afferent pupillary defect or Marcus Gunn pupil, which is a pupil that will have a normal consensual light response followed by a paradoxical dilatation with direct light exposure. Diagnosis is on funduscopic examination as you will see a boxcar appearance of the retinal vessels due to interruption of the blood flow and a pale retina with a cherry red spot on the fovea. Management of central retinal artery occlusion involves a multi-pronged approach. Ophthalmology should be consulted immediately upon suspicion of the diagnosis. Orbital massage may be used to attempt to dislodge the clot. Anterior chamber paracentesis may also be attempted. Pharmacologic agents may be used such as acetazolamide, mannitol, or timolol in an attempt to decrease intraocular pressure.

During a newborn's first feeding attempt, choking, coughing and cyanosis occur. Historically, the mother had polyhydramnios during the pregnancy. Which diagnosis is most likely the explanation for the newborn's distress? choanal atresia respiratory distress syndrome polycystic kidney disease congenital heart disease tracheoesophageal fistula

Tracheoesophageal fistula This is the classic presentation of tracheoesophageal fistula - when the patient drinks he aspirates because there is a connection between the trachea and the esophagus.

A 7-year-old boy presents to the primary care physician with his parents. The parents state that he would not eat this morning and was complaining that it hurt to swallow and to urinate. He has been running a fever for the past week and is up to date on his vaccinations. He has a past medical history of epilepsy and started a new medication, carbamazepine, two weeks ago for seizures. On physical exam there are intraoral hemorrhagic erosions covered with a greyish white membrane on the oral mucosa. There are also lesions surrounding his vermillion border. He has a severe case of conjunctivitis. Which of the following is the most likely diagnosis? Diphtheria Herpetic gingivostomatitis Staphylococcal scalded skin syndrome Stevens-Johnson syndrome

This patient is likely suffering from Stevens-Johnson syndrome. The most common etiology of this condition is medication. Carbamazepine is one of a number of medications known to cause this type of drug eruption, especially in children. Several HLA types have been associated with an increased risk of Stevens-Johnson syndrome, particularly in certain ethnic groups. The FDA has recommended that anyone of Asian or South Asian descent be genetically tested for HLA-B*15:02 prior to starting on carbamazepine. Drug-induced Stevens-Johnson syndrome will normally begin within the first eight weeks of starting the medication. A prodrome of fever and malaise may precede the eruption. Hemorrhagic erosions with a greyish white membrane on mucous membranes, severe conjunctivitis, and Nikolsky positive bullae are common features of the condition.

A 3-year-old girl is brought to the urgent care clinic for a 4-hour history of dysphagia, fever, drooling, and difficulty breathing. She is in acute distress, restless, and irritable. Her immunizations are up to date. Her temperature is 40.0°C (104°F). Auscultation of the lungs reveals inspiratory stridor. Which of the following is the most likely diagnosis? Acute epiglottitis Anaphylaxis Croup Diphtheria

This patient most likely has acute epiglottitis. Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures and results from bacteremia or direct invasion of the epithelial layer by the pathogenic organism. Haemophilus influenzae type b (Hib) is the most common infectious cause of epiglottitis in children. Although the incidence of Hib epiglottitis declined after Hib was added to the routine infant immunization schedule in the United States and other developed countries, Hib epiglottitis still occurs, even in immunized children. Additional causes of epiglottitis in children include other H. influenzae (types A, F, and nontypeable), streptococci, and Staphylococcus aureus, including methicillin-resistant strains. Without treatment, epiglottitis can progress to life-threatening airway obstruction. Anaphylaxis typically develops as a result of an allergic reaction. These patients typically present with swelling of the lips and tongue, urticarial rash, dysphagia, and sometimes inspiratory stridor.

A 54-year-old man presents with abdominal pain, vomiting, and fever. Physical examination reveals an ill-appearing man with a mass in the right groin as seen above (shows an indurated scrotum with mass high in the sac and penis pushed away from the mass). Which of the following is the most immediate next step required? Abdominal X-ray CT scan of the abdomen and pelvis Scrotal ultrasound Surgical consultation

This patient presents with signs and symptoms concerning for an strangulated hernia and should have an emergent surgical consultation for possible operative management. A hernia occurs when part of the viscus protrudes from its surrounding tissue walls. There are three presentations seen with hernias. The first is a reducible hernia where the hernia is soft and non-tender (or minimally tender) and can easily be reduced through the neck of the defect. An incarcerated hernia is firm and painful and cannot be reduced through its defect. Lastly, a strangulated hernia occurs after incarceration and involves impairment of blood flow (arterial, venous or both) to the viscus. Patients with strangulated hernias typically present with bowel obstruction and are toxic appearing. The hernia site itself is firm and extremely painful to palpation. There are often changes to the overlying skin. A strangulated hernia is a true surgical emergency. Emergent surgical consultation should be obtained prior to imaging as patients will require operative management. A delay in definitive treatment can lead to bowel ischemia or infarction.

A 45-year-old woman with a no significant past medical history presents with a 4-month history of dull, aching heaviness sensation in her proximal right leg. She notes that this sensation is provoked by extended periods of standing and walking, and is relieved when she lies in a recumbent position. Her past medical history is remarkable for pregnancy 4 times, the most recent being approximately 2 years ago. She denies a history of smoking, trauma, injuries, fever, chills, chest pain, shortness of breath, hemoptysis, cough, skin changes and coolness, and peripheral edema. Her physical exam reveals several dilated, tortuous, elongated veins along the medial right thigh, which are especially pronounced upon standing. The remainder of the physical exam is normal. What will be the most appropriate therapeutic approach for this patient at this time? Warfarin (Coumadin) Clopidogrel (Plavix) Sclerotherapy Furosemide (Lasix) Cilostazol (Pletal)

This patient's diagnosis is varicose veins. Sclerotherapy can be used to treat varicose veins. It involves the injection of an irritating solution into the varicose vein to promote an inflammatory response, scarring, and obliteration of the lumen

A 26-year-old man presents to the ED after briefly losing consciousness when hit in the head by a foul baseball. The patient was initially alert and talking to you. He is now becoming progressively more somnolent. Which of the following would you expect to see on a non-contrast computed tomography scan of the head? A collection of blood layering in the basilar cisterns A crescent-shaped frontal hematoma crossing suture lines A lenticular-shaped hematoma in the temporal region An intraparenchymal hemorrhage within the frontal lobe

This patient's presentation and physical examination are consistent with a traumatic acute epidural hematoma, a collection of blood between the skull and the dura. The diagnosis is made with a non-contrast CT of the head. This characteristically shows a hyperdense lenticular-shaped hematoma in the temporal region that is sharply defined and does not cross suture lines. Epidural hematomas are usually associated with skull fractures in the temporal bone region resulting in laceration of the middle meningeal artery. Arterial bleeding is the etiology of two-thirds of epidural hematomas and is typically rapid. Signs and symptoms include a severe headache, drowsiness, nausea, and vomiting. The classic finding is the lucid interval just prior to rapid deterioration; however, this is present in less than 30% of epidural bleeds. Neurosurgery should be consulted immediately for surgical evacuation of the hematoma. A collection of blood layering in the basilar cisterns is the classic imaging presentation of subarachnoid hemorrhage. A crescent-shaped frontal hematoma crossing suture lines is the classic appearance of a subdural hematoma. An intraparenchymal hemorrhage within the frontal lobe is the appearance of a traumatic contusion or hypertensive hemorrhage.

A 22-year-old woman with regular menstrual cycles presents with symptoms concordant with premenstrual syndrome. In evaluating the large differential of these symptoms, which one of the following serum laboratory tests is recommended? Estrogen Follicle-stimulating hormone Human chorionic gonadotropin Thyroid-stimulating hormone

Thyroid-stimulating hormone. Premenstrual syndrome (PMS) includes more than 150 behavioral, physical, cognitive, and emotional symptoms. The most common behavioral symptom is mood swings, although anxiety, depression, increased appetite, anhedonia, and emotional sensitivity are common. A key historical point in making the diagnosis of premenstrual syndrome is the absence of symptoms during the follicular phase of the menstrual cycle. It is important to remember that other common conditions, such as thyroid disorders and hypercortisolism, can mimic the behavioral and affective changes of PMS. Thyroid abnormalities, both hyperthyroidism and hypothyroidism, can result in such mood symptoms. Although the initial laboratory evaluation of suspected PMS is limited, a serum thyroid-stimulating hormone level is recommended.

A 62-year-old woman presents for an elective laparoscopic hysterectomy. Her past medical history is remarkable for uterine leiomyomas and hypertension. Her regular medications include hydrochlorothiazide as well as a daily multivitamin. She has no known allergies and has never had adverse effects due to anesthesia. Before entering the operating room, the patient is approached by a surgical resident and an anesthesiologist who will both be present at the surgery. Together, they confirm with the patient her identity using two identifiers, the procedure, site, side, and level of procedure. All information is verified in the patient's chart, and the operative site is marked with a permanent marker on the patient. These steps are part of which of the following techniques for risk reduction in surgery? Patient handoff Preoperative briefing Structured communication Timeout

Timeout. Hazards specific to the operating room can be minimized by implementing routine techniques and institutional approaches designed to reduce risk, minimize errors, and improve patient safety. For example, surgical timeouts were established by the Joint Commission on Accreditation of Healthcare Organizations in order to confirm the accuracy of the patient's identity, type of surgery, and surgical location before the procedure begins. The initial timeout process begins in the preoperative holding room, with participation of the patient and at least two medical professionals. The patient's identity is confirmed using two identifiers (e.g., name, identification number, date of birth, phone number). The type of surgery, site of the surgery, and side or level of the body requiring the surgery are confirmed and marked with permanent marker. All documents in the patient's chart should be reviewed for the correct information, and any discrepancies should be addressed before starting surgery. The operating team takes a final timeout before starting surgery to verify the correct patient, procedure, and site.

Which one of the following Tinea infections in children always requires systemic antifungal therapy? Tinea capitis Tinea corporis Tinea cruris Tinea pedis

Tinea capitis. Tinea infections are caused by dermatophytes and are classified by the involved site. The most common infections in prepubertal children are tinea corporis and tinea capitis, whereas adolescents and adults are more likely to develop tinea cruris, tinea pedis, and tinea unguium (onychomycosis). In the United States, tinea capitis (scalp) most commonly affects children of African heritage between three and nine years of age. Early disease can be limited to itching and scaling, but the more classic presentation involves scaly patches of alopecia with hairs broken at the skin line and crusting. Tinea capitis may progress to kerion, which is characterized by boggy tender plaques and pustules. Tinea capitis must be treated with systemic antifungal agents because topical agents do not penetrate the hair shaft. However, adjunct treatment with selenium sulfide shampoo or 2% ketoconazole shampoo should be used for the first two weeks because it may reduce transmission. For many years, the first-line treatment for Tinea capitis was griseofulvin because it has a long track record of safety and effectiveness. However, randomized clinical trials have confirmed that newer agents, such as terbinafine and fluconazole, have equal effectiveness and safety and shorter treatment course.

A 4-month-old infant presents with erythematous plaques to the bilateral cheeks that have been worsening over the past three weeks. Similar plaques are noted over both elbow extensors. He has been growing and developing normally. What is the treatment of choice? Reassurance Topical emollients Topical mupirocin Topical triamcinolone

Topical emollients. The infant has atopic dermatitis, also known as eczema. In infants, eczema is most common on the cheeks and extensor surfaces of the extremities. This distribution is in marked contrast to in children and adolescents who classically have involvement of the flexor surfaces, such as the antecubital and patellar fossas. The first-line treatment for eczema is a topical emollient on the face of an infant. Thick, unscented creams and ointments are preferred to lotions. Emollients should be applied at least twice per day and re-applied after bathing, swimming, or hand-washing. If the eczema is persistent, a topical steroid may be applied in addition to topical emollients. The lowest effective potency of corticosteroid should be prescribed, and steroids should be applied only to affected skin to avoid the side effects of skin thinning, atrophy, and telangectasias. Desonide or hydrocortisone are good initial low-potency topical corticosteroids. Topical triamcinolone is a mid-potency corticosteroid that may be used to treat eczema that does not respond to topical emollients and low-potency corticosteroids. It should not be used on the face or genital region and should only be applied to affected skin.

According to the American Heart Association, which of the following is used as a risk factor for the medical management of atherosclerotic cardiovascular disease? Age greater than 35 years Blood pressure 120/92 mm Hg Sedentary lifestyle Total cholesterol 218 mg/dL

Total cholesterol 218 mg/dL According to the American Heart Association risk algorithm for atherosclerotic cardiovascular disease, there are certain factors which statistically increase a patient's risk for adverse cardiovascular events. These include age over 40 years, male sex, African American race, current tobacco smoker, total cholesterol over 200 mg/dL, high-density lipoprotein cholesterol under 40 mg/dL, systolic blood pressure over 130 mm Hg, current treatment for hypertension, and diabetes mellitus. Patients with any of these risk factors should be evaluated using a cardiovascular risk calculator to determine their need for treatment with a statin. Any patient with preexisting cardiovascular disease or with a low-density lipoprotein cholesterol greater than 189 mg/dL should be considered at high risk for atherosclerotic cardiovascular disease and treated with a statin unless otherwise contraindicated. HMG-CoA reductase inhibitors (statin drugs) have proven to decrease the risk of adverse cardiovascular events and to decrease mortality in patients at high risk for atherosclerotic cardiovascular disease.

Which of the following statements is most correct regarding total parenteral nutrition in a patient with Crohn disease? Patients tolerate enteral feedings well after total parenteral nutrition is discontinued Total parenteral nutrition carries the risk of deep vein thrombosis and cardiomyopathy Total parenteral nutrition is an alternative to chronic low dose steroids Total parenteral nutrition is not recommended in those with short bowel syndrome

Total parenteral nutrition is an alternative to chronic low dose steroids. Fulminant Crohn's disease is marked by such symptoms as high fevers, persistent vomiting, signs of abscess formation, peritoneal signs, intestinal obstruction, or patients whose symptoms persist despite glucocorticoid therapy or despite therapy with a biologic agent. Some of these patients will require surgical management. Many of these patients will require chronic, low-dose steroid therapy. Total parenteral nutrition can be considered as an alternative to chronic low-dose glucocorticoids. Many patients who receive total parenteral nutrition achieve remission, although often their symptoms will return once enteral feedings are resumed. Crohn's disease is a chronic, inflammatory disease of the bowel involving any part of the gastrointestinal tract (mouth to anus), but with a predilection for the distal ileum and colon. The mucosal inflammation of Crohn's disease is transmural, leading to the formation of fistulas, abscesses, and stricture formation. Affected segments of bowel are often separated by segments of non-diseased bowel and are sometimes referred to as "skip lesions". Symptoms of Crohn's disease can include chronic diarrhea, fever, weight loss, and abdominal pain. Diagnosis is with colonoscopy, upper endoscopy, CT enterography or magnetic resonance enterography. Crohn's disease can be divided into four disease states, with each state necessitating differing treatment strategies. The most mild state is asymptomatic remission, where patients have no symptoms either after successful medical or surgical management, or spontaneous remission. These patients can be maintained with daily dosing of a drug from the 5-ASA class, such as mesalamine. The drug choice will be dependent on the disease site. Patients with mild-to-moderate Crohn's disease will manifest varying degrees of symptoms but will be able to tolerate oral nutrition without dehydration, significant (>10 percent) weight loss, abdominal tenderness, mass, obstruction, or toxicity. Many treatment options exist for these patients, including 5-ASA drugs, corticosteroids, antibiotics, probiotics, antidiarrheal medications and dietary changes. Patients who have failed treatment for mild-to-moderate disease or who manifest severe abdominal pain, significant weight loss, fever, nausea and vomiting, or fever are considered to have moderate-to-severe Crohn's disease. These patients often require hospitalization for intravenous glucocorticoids and often require treatment with biologic agents to obtain remission.

A 68-year-old woman presents with worsening right knee pain. She has had pain there for years, but it has gradually increased in the past couple of months. Acetaminophen is no longer effective. Plain films show joint space narrowing bilaterally with osteophytes on the right. Medical history is unremarkable, except for the presence of pyrosis, peptic ulcer disease ten years ago, and lifelong obesity. What treatment would you likely prescribe next? Celecoxib 200 mg twice a day Hydrocodone 5/325 mg twice a day Ibuprofen 800 mg up to four times a day as needed Tramadol 50-100 mg up to four times a day as needed

Tramadol 50-100 mg up to four times a day as needed Tramadol in this scenario would be your next most logical choice. It is a mild narcotic with low abuse potential, especially compared to hydrocodone or other narcotic therapy. It would not worsen her pyrosis symptoms or be contraindicated with her ulcer history. The dosing range of one to two 50 mg tablets at a time and flexibility of taking up to four times a day as needed, makes it an attractive option. Osteoarthritis is the process by which the cartilage covering the surfaces of the ends of bone begins to break down and wears away. Resulting pain is thought to be from bony surfaces rubbing on one another during movement. To date, there is no proven treatment to regrow the cartilage.

In what part of the prostate does benign prostatic hyperplasia most commonly develop? Central zone Fibromuscular stroma Peripheral zone Transitional zone

Transitional zone Benign prostatic hyperplasia develops primarily in the transitional zone or periurethral zone of the prostate causing compression of the prostatic urethra. Older age and the presence of functioning Leydig cells of the testes are essential for the development of benign prostatic hyperplasia. Patients typically present with lower urinary tract symptoms including urinary frequency, urgency, nocturia, slow urinary stream, and terminal dribbling. Exam reveals a diffusely enlarged firm, nontender prostate. Initial medical therapy is typically with alpha-1-adrenergic antagonists. Surgical treatment may be required.

A 32-year-old woman presents complaining of "bumps" in her vaginal area that she noticed two weeks ago. She has never had these in the past. She denies any pain. Physical exam reveals several flesh colored lesions with prominent papillae that are non-tender to palpation on the labia as shown below. Which of the following is the next best step in management? Application of trichloroacetic acid Perform colposcopy with acetic acid application Perform shave biopsy for confirmation Referral to general surgery for excision

Trichloroacetic acid. This patient is suffering from condyloma acuminatum, or genital warts, caused by an infection with the human papilloma virus (HPV), commonly types 6 and 11. HPV is a sexually transmitted infection that can be prevented with vaccination. All girls and boys who are 11 or 12 years old should get the recommended series of HPV vaccine regardless of sexual history. Symptoms include flesh colored to whitish, exophytic or papillomatous growths in the genital area. In women, this can affect the vagina, cervix, vulva, oropharynx, perineum, and perianal areas. HPV can be spread via sexual contact or rarely, from mother to newborn during passage through the birth canal. Treatment includes trichloroacetic acid solution, podophyllin, cryosurgery, surgical excision, or imiquimod cream application.

During a routine physical exam on a 66-year-old man, he asks why his toenails have progressively become discolored. You note that multiple nails on his feet are thickened and are yellow-brown in color. Which of the following is the most likely etiology of this man's condition? Candida albicans Malassezia furfur Staphylococcus aureus Trichophyton rubrum

Trichophyton rubrum is the most common cause of distal lateral subungual onychomycosis. Distal lateral subungual onychomycosis is the most common subtype of onychomycosis. Onychomycosis is an infection of the nail that can be caused by fungi, yeasts, and non-dermatophytes. Onychomycosis is the most common cause of abnormal nails. Risk factors for onychomycosis include advanced age, male sex, swimming, tinea pedis, psoriasis, immunodeficiency, and contact with people who have onychomycosis. While T. rubrum is the most common etiology of distal lateral subungual onychomycosis, other subtypes have different etiologies. Trichophyton mentagrophytes is the most common cause of white superficial onychomycosis. Patients with onychomycosis often present with discolored nail as the sole complaint, although severe infections can be associated with pain or burning. Distal lateral subungual onychomycosis typically presents with yellow or brown discoloration and thickening of the nail. White superficial onychomycosis presents with dull white spots on the surface of the nail. Tinea pedis frequently accompanies onychomycosis. KOH preparation is a quick in-office test that has high specificity for onychomycosis. Other laboratory studies that can be used to diagnose onychomycosis include culture, polymerase chain reaction, and calcofluor white staining. Treatment is not required unless the patient has underlying immunodeficiency, is at risk for cellulitis, or desires treatment for cosmetic reasons. Topical antifungal medications are typically used for mild disease or in patients who cannot tolerate systemic antifungal drugs. Systemic antifungal drugs result in faster infection clearing.

A 32-year-old man presents to the emergency department with complaints of fever and shortness of breath. On physical exam, he is noted to have coarse breath sounds bilaterally and a systolic murmur. A chest radiograph is obtained and shown above (bilateral multifocal pneumonia). Which of the following abnormalities is likely to be noted on echocardiogram? Diffuse myocardial hypokinesis Mitral valve vegetations Pericardial effusion Tricuspid valve vegetations

Tricuspid valve vegetations are the most likely abnormalities seen on echocardiogram. This patient has endocarditis affecting his tricuspid valve. Risk factors include injection drug use, male sex, age over 65 years old, and underlying structural heart disease. Diagnostic workup includes blood cultures and a transesophageal echocardiogram. A transesophageal echocardiogram has a higher sensitivity to detect vegetations than a transthoracic echocardiogram. Complications include sepsis and embolic events. In this case, the vegetations are on the right side of the heart and have embolized to the lungs causing a multifocal pneumonia (as shown above). Right-sided endocarditis is more common in intravenous drug users. Treatment includes intravenous antibiotic therapy (directed specifically against Staph. aureus) and supportive care. Mitral valve vegetations are characteristic of endocarditis, however, embolic events would present in the systemic circulation; not in the lungs.

A 66-year-old man with type II diabetes mellitus presents to the clinic one week after undergoing a lower leg mole biopsy to discuss pathology results. He complains of redness, tenderness, and pus at the biopsy site. Physical exam reveals erythema and edema surrounding the biopsy site and purulent drainage, but no fluctuance is appreciated. Which of the following therapies would be best for the most likely diagnosis?Cephalexin Ciprofloxacin Piperacillin/tazobactam Trimethoprim/sulfamethoxazole

Trimethoprim/sulfamethoxazole. Cellulitis is a skin infection caused by bacterial entry into a break in the skin. Cellulitis is more common in middle-aged and elderly patients. Risk factors for cellulitis are skin barrier disruption due to trauma, skin inflammation, edema due to impaired lymphatic drainage or venous insufficiency, obesity, and immunosuppression (HIV or diabetes). Patients usually present with skin erythema, edema, and warmth, and may present with fever. Cellulitis is almost always unilateral. Diagnosis is based on clinical presentation. Culture and susceptibility testing should be obtained of the purulent material. The most common cause of purulent cellulitis is Staphylococcus aureus. Empiric therapy (pending culture results) should be an agent that covers infection due to methicillin-resistant S. aureus (MRSA). Appropriate therapeutic options include clindamycin, trimethoprim/sulfamethoxazole, or tetracyclines (doxycycline or minocycline). Cephalexin (A) is a first-generation cephalosporin effective against Gram-positive and some Gram-negative bacteria including MSSA, but not MRSA. Cephalexin is indicated in non-purulent cellulitis infection. Ciprofloxacin (B) is a broad-spectrum fluoroquinolone effective against Gram-positive and Gram-negative bacteria including methicillin-susceptible S. aureus (MSSA), but not MRSA. Piperacillin-tazobactam (C) is a broad-spectrum beta-lactam effective against Gram-positive bacteria including MSSA and Gram-negative bacteria including Pseudomonas aeruginosa, but not MRSA.

Any question about rabbits and pneumonia should make you think of what diagnosis?

Tularemia

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? Left-to-right blood flow across a small, muscular ventricular septal defect Regurgitant blood flow from the left ventricle to the left atrium Regurgitant blood flow from the right ventricle to the right atrium Turbulent blood flow across redundant mitral valve tissue

Turbulent blood flow across redundant mitral valve tissue describes mitral valve prolapse, which is the most common cause of a late systolic murmur and is typically preceded by a click. Mitral valve prolapse occurs when the leaflets of the mitral valve billow into the left atrium during systole. Mitral valve prolapse can be the result of a disruption or elongation of the leaflets, chordae, or papillary muscles. Patients may be born with elongated leaflets or may acquire mitral valve prolapse secondary to myocardial ischemia and subsequent papillary muscle dysfunction. Some genetic syndromes such as Marfan syndrome and certain connective tissue disorders can also cause mitral valve prolapse. The murmur of mitral valve prolapse occurs later in systole because the disparity of valvular redundant tissue to valvular ring increases with a decrease in left ventricular volume. Maneuvers which decrease left ventricular volume, such as Valsalva and standing, can cause the murmur of mitral valve prolapse to occur earlier in systole and last longer. Patients with mitral valve prolapse may develop mitral valve regurgitation if the prolapse is great enough to cause lack of apposition of the mitral leaflets. Mitral valve regurgitation is diagnosed by transesophageal echocardiogram. Definitive treatment is through surgical or percutaneous repair of the mitral valve, although this is reserved for only the severest cases.

A 32-year-old man presents to clinic with worsening colicky stomach pains, and bloody, mucous streaked diarrhea. He reports he has no fever, nausea, or vomiting. His symptoms began vaguely a week ago and have progressed in severity since then. He reports he is otherwise healthy, is not on any medications, and has not traveled recently. He has no family history of colon cancer and reports the symptoms are so bad he is no longer able to go out in public for fear of having to use the toilet. Stool studies are negative. Colonoscopy reveals edema, friability, mucus, and erosions of the mucosal surface of the rectosigmoid region. Which of the following is the most likely diagnosis? Colon cancer Crohn disease Irritable bowel syndrome Ulcerative colitis

Ulcerative colitis (UC) is one of two inflammatory bowel diseases, the other being Crohn disease. UC is a chronic idiopathic inflammatory bowel disease with recurrent symptoms and significant morbidity. The clinical presentation is highly variable and can mimic other types of disease such as pseudomembranous colitis and other infectious diseases which should be ruled out by stool studies as in the above scenario. The hallmark of UC is bloody diarrhea. Other symptoms include abdominal pain which is oftentimes cramping in nature, tenesmus, and fecal urgency. Patients can also present with anemia secondary to bleeding. UC is limited to the mucosal lining of the colon and always involves the rectum and spares the proximal gastrointestinal tract. In UC, it is characteristic to have periods of symptomatic flare-ups and remissions. The goal of treatment in UC is to get flares into remission as well as provide relief of symptoms. First-line treatment for mild to moderate UC is 5-aminosalicylic agents. These agents achieve clinical improvement in 50-70% of patients and remission in up to 30% of patients. Unlike UC, the depth of inflammation in Crohn disease (B) is transmural as opposed to mucosal. Also in Crohn the entire gastrointestional tract can be affected as opposed to the limited area affected in UC, which is often, times referred to as left sided colitis.

Which of the following is the most sensitive finding in cauda equina syndrome? Back pain Saddle anesthesia Urinary incontinence Urinary retention

Urinary retention. Cauda equina syndrome refers to a characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris. Midline rupture of the L4-L5 disk is the most common cause. Other causes include tumors, trauma, or spinal epidural abscesses. The presence of urinary retention is the most sensitive finding (90% sensitivity). A postvoid residual of greater than 100-200 ml should alert the emergency physician to the likelihood of this syndrome in the right clinical setting. Lower motor neuron findings may be present, in contrast to upper motor neuron findings, which suggest conus medullaris syndrome (a true cord syndrome). MRI is the diagnostic modality of choice. Cauda equina syndrome is a neurosurgical emergency that requires operative decompression.

A two-day-old, full-term female with a history of breech presentation and delivery by cesarean section has an unremarkable newborn examination, including a normal bilateral hip exam. There is no family history of developmental dysplasia of the hip reported. Given this patient's presenting risk factors, which of the following is the most appropriate plan for follow-up of her hip exam? Hip examination with ultrasound for any abnormalities at every health visit Hip X-ray at four to six months of age No special follow-up unless patient has delayed achievement of developmental milestones Ultrasound of the hips at four to six weeks of age

Ultrasound of the hips at four to six weeks of age Developmental dysplasia of the hip, also known as congenital hip dysplasia, is an abnormal spectrum of development of the acetabulum and proximal femur leading to hip instability. This condition is typically found in otherwise-healthy infants. Known risk factors for developmental dysplasia of the hip include female sex, breech positioning at ≥ 34 weeks gestation, family history of developmental dysplasia of the hip (including dysplasia-related hip replacement before age 40 in a close relative), and tight lower extremity swaddling. Newborns should be screened for hip instability using the Barlow and Ortolani maneuvers which test for subluxation indicating hip laxity or mild instability, and dislocation which would indicate hip instability. Additional signs of hip abnormality include those which demonstrate asymmetry such as the Galeazzi (also known as the Allis or Perkins) sign in which a child lying supine with knees and hips flexed will have knees of unequal height and asymmetrical skin folds. Even with a normal initial exam, infants with risk factors for developmental dysplasia of the hip, other than female sex alone, should have routine screening by manipulation at each health visit and an ultrasound of their hips at four to six weeks of age. In young infants, ultrasound measurements enable hip classification by the Graf method. A child with a normal ultrasound may still warrant repeat imaging at six months by radiograph if limited mobility of the hip, especially abduction, is concerning.

A previously healthy 10-year-old boy presents to the clinic with his mother because she is worried he has an infection. He has had a fever and malaise for five days for which he was given antipyretics. On physical examination his vital signs are within normal limits for age except for a low-grade fever. Which of the following is most consistent with mumps virus infection? Gradual bilateral swelling of the parotid glands Sudden onset of firm, erythematous swelling of the parotid gland Unilateral painless parotid swelling Unilateral parotid swelling and tenderness that becomes bilateral

Unilateral parotid swelling and tenderness that becomes bilateral Mumps is a self-limited infection characterized by fever and bilateral or unilateral parotid swelling and tenderness. It is caused by the mumps virus in the family Paramyxoviridae similar to measles. Mumps virus targets the salivary glands, the central nervous system, pancreas, testes, and sometimes the thyroid, ovaries, and joint synovia accounting for the various symptoms of the disease. The incubation period for mumps is usually 16-18 days. The prodrome of fever, headache, vomiting, and malaise lasts one to two days and is then followed by parotitis. Parotitis occurs most commonly among children between two and nine years of age. Tenderness, occasionally associated with earache, typically precedes parotid swelling. Parotitis may be unilateral or bilateral; however, initial unilateral involvement is followed by contralateral involvement a few days later in 90% of cases. Parotid swelling can last up to ten days. On physical examination, parotid swelling may obscure the angle of the mandible, and the orifice of Stensen's duct is erythematous and enlarged. Laboratory findings include leukopenia with a relative lymphocytosis and an elevated serum amylase concentration. Diagnosis of mumps is mainly clinical, especially in areas with epidemics and outbreaks. Treatment is aimed at reducing the pain associated with inflammation and ensuring adequate hydration. The complications of mumps include meningitis and meningoencephalitis, orchitis and oophoritis with sterility being very rare even in bilateral involvement, and, rarely, pancreatitis, arthritis, and thyroiditis.

A 25-year-old woman presents with intermittent flank pain, hypertension, and blood in her urine. Renal ultrasound shows polycystic kidneys bilaterally. Which of the following complications will this patient most likely develop? End stage renal disease Intracranial aneurysms Portal hypertension Renal carcinoma

Up to half of patients with polycystic kidney disease develop end stage renal disease by age 60 and require renal replacement therapy which may include hemodialysis, peritoneal dialysis, or renal transplantation. Polycystic kidney disease is a progressive autosomal dominant disease. It is characterized by cyst formation and kidney enlargement and can affect other organs (e.g. liver, pancreas, spleen) as well. Abdominal, flank or back pain is the most common initial complaint and is seen in almost all patients. The pain can be caused by enlargement of one or more cysts, bleeding within or related to the cyst which can lead to hematuria, and acute urinary tract infection. One of the earliest signs of polycystic kidney disease is hypertension (usually with elevated diastolic blood pressure), which may worsen as renal insufficiency progresses. Other physical exam signs include palpable, bilateral flank masses, nodular hepatomegaly, and symptoms related to renal failure in end stage renal disease. Genetic testing is sometimes used, but imaging is a much more widely used diagnostic test. Ultrasonography is the technique of choice and can be used for screening other family members. Management of disease includes blood pressure control (with angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers), maintaining electrolyte levels due to renal insufficiency and failure, treating urinary tract infections, treating cyst infections, and pain management. More invasive treatments include surgical drainage of infected cysts that do not respond to antibiotics, nephrectomy as a last resort for those who have uncontrolled pain, partial hepatectomy, and liver transplantation.

A 24-year-old woman presents to the emergency department with a headache and receives a lumbar puncture. She is eventually discharged home in improved condition, but returns 24 hours later with a worsened headache, now throbbing in nature, which is worse in the standing position and relieved in the supine position. Which of the following reduces the risk of post-lumbar puncture headache? Inserting the needle bevel perpendicular to the spine Lying supine for one hour after the lumbar puncture is completed Using a higher gauge needle Using a Quincke needle

Using a higher gauge needle. Post-lumbar puncture headache is the most common complication of a lumbar puncture (LP). The headache usually presents within the first 48 hours after LP and tends to be worsened by standing up and improved by lying down. The exact etiology is unclear, but may be related to the persistent leak of cerebrospinal fluid from the dural puncture site. Post-LP headache is generally benign and self-limiting within 24 to 48 hours, but can in some cases be debilitating. Bed rest and intravenous caffeine have been shown to improve symptoms, as has epidural blood patching, though the invasiveness of this procedure leads most providers to reserve it only for the most intractable and debilitating cases. Prevention of post-LP headache has been the subject of much research, with mixed and sometimes inconsistent results. Modern evidence-based strategies for prevention include the use of a higher gauge spinal needle (which corresponds to a smaller caliber needle), orientation of the needle's bevel parallel to the spine, use of a noncutting needle like the pencil-point Whitacre or Sprotte models, and reinsertion of the stylet prior to needle removal.

Which EKG leads are used to diagnose an anterolateral MI?

V5 & V6

Which of the following antiepileptic drugs has a black box warning concerning teratogenicity? Lamotrigine Levetiracetam Valproic acid Zonisamide

Valproic Acid The goal of epileptic seizure treatment is to maximize seizure-free intervals while at the same time minimizing side effects of therapy. There are many antiepileptic drugs to choose from and some of them come with black box warnings that require the provider's awareness and vigilance. Valproic acid is a broad spectrum anticonvulsant used to treat many different forms of epilepsy and is the drug of choice in idiopathic, generalized epilepsy. The exact mechanism of action of valproic acid is unknown, although it is thought to increase the synthesis of gamma-aminobutyric acid (GABA) and modulate voltage-gated sodium currents. Valproic acid comes with a black box warning concerning teratogenic effects which include neural tube defects and lower cognitive functioning. As a result, this drug should not be used in pregnant women and should be avoided in women of childbearing potential unless absolutely necessary. Effective birth control must be stressed for any non-pregnant women of childbearing potential taking valproic acid.

A 2-year-old boy presents to the ED with a three-day history of increasing fussiness, decreased appetite, and intermittent non-bloody, non-bilious vomiting. He has not had any sick contacts, but he recently visited relatives who live in an old home currently undergoing renovations. His mother is concerned he may have been exposed to lead paint. Which of the following is the best test to confirm the diagnosis? Bone lead level Capillary blood lead level Dentine lead level Venous blood lead level

Venous blood lead level Lead poisoning is a serious toxicity which can lead to encephalopathy and irreversible cognitive and neurologic impairment. Exposure to lead usually occurs through lead-containing paint or gasoline. Lead is also present in some industrial processes, especially in developing countries. Lead poisoning should be considered in children presenting with vomiting, colicky abdominal pain, fatigue, and renal and neurologic changes with a history concerning for lead exposure. Children at higher risk are younger than six years old, living in urban settings, living in older housing and from lower-income families. The gold standard for diagnosis of lead poisoning in children is venous blood lead level. This test both confirms diagnosis and guides management. Any detectable blood lead level (< 5 mcg/dL) should be followed by education, lead removal, close follow-up, and a management plan which includes repeat testing. Chelation therapy is recommended for blood lead levels ≥ 45 mcg/dL or greater.

Rice water stools are indicative of what organism?

Vibrio cholerae

Which of the following suture material is absorbable? Nylon (Polyamide) Prolene (Polypropylene) Silk (Silk) Vicryl (Polyglactin)

Vicryl. Absorbable sutures are degraded and lose strength in less than 60 days. Absorbable sutures are generally used for subcutaneous and mucosal closures. Their highly reactive nature allows them to be broken down and absorbed over weeks. Vicryl is an absorbable braided polymer of lactide and glycolide with low reactivity and good strength, making it suitable for subcutaneous and mucous membrane use.

A 16-year-old girl presents to the ED complaining she cannot walk up steps. She has been well recently except for an episode of gastroenteritis two weeks ago. On exam, she has decreased strength in her bilateral lower extremities with absent patellar and ankle jerk reflexes. What is the most important next test to perform? Electromyography Lumbar puncture MRI lumbar spine Vital capacity

Vital capacity. This patient has Guillain-Barré syndrome (GBS), an immune-mediated peripheral neuropathy caused by myelin sheath destruction. It is often preceded by a viral illness, infection with Campylobacter jejuni, or vaccination. In the classic presentation of GBS, a viral illness is followed by an ascending symmetric weakness or paralysis with decreased or absent deep tendon reflexes. The most serious complication of GBS is respiratory failure from diaphragmatic weakness. Measuring the vital capacity or negative inspiratory force (NIF) is critical to assessing respiratory effort. These easily repeated tests predict developing diaphragmatic weakness and the need for prophylactic intubation. GBS is treated with supportive care, IV immune globulin, and possibly plasmapheresis. All patients with suspected GBS should be admitted to an intensive care unit.

A 35-year-old woman is having a preoperative evaluation in clinic. Preoperative blood analysis reveals a hemoglobin 6.2 g/dL, hematocrit 18%, platelets 210 x 109/L. The patient mentions that she has been anemic on and off for several years which was always attributed to her heavy menstrual periods. She has no previous surgical history. She does not take any medications. A few of her male and female family members have required blood transfusions after routine surgery. Which of the following tests is most likely to reveal the correct diagnosis? Factor IX level Factor VIII level Prothrombin time Von Willebrand factor antigen

Von Willebrand disease (VWD) is the most common heritable bleeding disorder. An autosomal dominant mutation causes the deficiency in von Willebrand factor (VWF), which assists in hemostasis by bridging platelets with subendothelial factors at sites of injury as well as transporting factor VIII. Patients typically present with easy bruising, skin bleeding, and prolonged bleeding from mucosal surfaces. They may have a history of epistaxis longer than 10 minutes, heavy menstrual bleeding, and prolonged bleeding after dental surgeries or other procedures, including childbirth. Patients with a presentation suggesting VWD should have an initial laboratory analysis that consists of a complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), plasma VWF antigen, plasma VWF activity, and factor VIII activity. Patients with VWD usually have a low VWF antigen, low VWF activity or both and may have low factor VIII due to inability to bind to VWF, but the rest of the analysis is often normal. Patients who are actively bleeding may present with a normocytic anemia. Further testing to determine the specific type of VWD is indicated to direct therapy. Desmopressin (DDAVP) or replacement with VWF concentrate can be effective therapies for the most common types of VWD in the postsurgical setting. A hematologist should be consulted on recommended therapy prior to surgery in patients with known VWD.

A 30-year-old woman presents to the clinic to obtain preoperative clearance for her elective cholecystectomy. She has a history of a bleeding disorder, diagnosed when she was a teenager. Her symptoms include easy bruising, prolonged bleeding after prior dental extractions, and heavy menstrual bleeding. Other family members have the same bleeding disorder. Laboratory evaluation reveals a normal platelet count, decreased platelet function, normal prothrombin time, a normal activated partial thromboplastin time, and a prolonged bleeding time. Which of the following is the most likely diagnosis? Hemophilia A Hemophilia B Thrombocytopenia Von Willebrand disease

Von Willebrand disease is the most common inherited bleeding disorder, which results in a decreased level or an impairment in the action of von Willebrand factor. The most common type is type one, which is a partial, quantitative deficiency of von Willebrand factor with an autosomal dominant inheritance pattern. Many patients are asymptomatic and those who do have symptoms often experience easy bruising, skin bleeding, and prolonged bleeding from mucosal surfaces (e.g., oropharyngeal, gastrointestinal, uterine). Women may have a history of heavy menstrual bleeding and bleeding during the peripartum period. Laboratory testing often reveals a normal platelet count, a normal prothrombin time, and a normal activated partial thromboplastin time, although this can be prolonged depending on the degree of reduction of the factor VIII level. Initial screening tests include plasma von Willebrand factor (VWF) antigen, plasma VWF activity, and factor VIII activity. A VWF activity or antigen level of 30 international units/dL or less establishes a diagnosis of von Willebrand disease. If one of the initial screening tests is abnormal, then two specialized assays should be performed, the VWF multimer distribution using gel electrophoresis and the ristocetin-induced platelet aggregation test. These tests will determine the type of von Willebrand disease. A trial of desmopressin (DDAVP) should be performed to assess the clinical response prior to its actual need. Treatment using DDAVP depends on the type of von Willebrand disease but is generally limited to situations when bleeding occurs, like during minor surgery. For major bleeding and major surgery or those who fail to respond to DDAVP the use of a plasma-derived VWF concentrate or recombinant VWF is recommended.

A 68-year-old postmenopausal woman presents to the outpatient gynecology office complaining of a single, pruritic plaque located on the left labia majora for two months. She denies vaginal or vulvar discharge, hematuria, abdominal pain, weight loss, nights sweats or fatigue. She denies any changes to her laundry detergent or body soaps. Her gynecologic history is significant for prior abnormal PAP smears secondary to human papillomavirus infection that was successfully treated with colposcopy. What is the most likely diagnosis? Candidiasis Condyloma accuminata Vulvar cancer Vulvar contact dermatitis

Vulvar cancer is the most likely diagnosis based on the patient's age, clinical presentation and history of previous HPV infection. Vulvar cancer typically occurs in postmenopausal women with the average age of diagnosis being 65 years. Women typically present with a singular pruritic lesion to the labia majora. Rarely, vulvar cancer will present with multiple lesions or lesions located on the labia minora, clitoris or mons. Women may also present with vulvar discharge, vulvar bleeding or local lymph node enlargement, however these symptoms typically indicate more advanced disease. Risk factors include prior HPV infection, cigarette smoking, northern European ancestry, vulvar dystrophy, immunocompromised state, prior cervical cancer, and vulvar or cervical intraepithelial neoplasia. Diagnosis is confirmed with biopsy which typically shows squamous cell carcinoma.

A 57-year-old man presents to the ED with headache, blurred vision, and fatigue. His wife notes he has a "blood problem" that his doctor is monitoring. Which of the following underlying conditions is most frequently complicated by hyperviscosity syndrome? Acute myeloid leukemia Multiple myeloma Polycythemia vera Waldenstrom macroglobulinemia

Waldenstrom macroglobulinemia. This patient is exhibiting signs and symptoms associated with hyperviscosity syndrome. Hyperviscosity syndrome is defined as elevated serum viscosity that causes sludging, decreased microvascular perfusion, and vascular stasis. The most common cause of hyperviscosity syndrome is elevated serum protein, most often secondary to Waldenstrom macroglobulinemia or less often due to multiple myeloma. It can also be caused by marked leukocytosis with > 100,000 cells/mm3 or erythrocytosis from diseases such as leukemias, polycythemia vera, or hemoglobinopathies like sickle cell disease, respectively. Signs and symptoms of hyperviscosity syndrome are primarily secondary to end-organ ischemia creating mimics of disease processes such as myocardial ischemia, stroke, pulmonary infarction, congestive heart failure, renal failure, mucosal hemorrhages, or visual disturbances secondary to retinal ischemia. Laboratory studies will yield significant leukocytosis or hyperproteinemia depending upon the etiology. Management of hyperviscosity syndrome also depends upon the etiology. Supportive care for any etiology includes intravenous fluid hydration and diuresis in tandem. Temporizing measures for leukemias include leukapheresis, patients with elevated proteins require plasmapheresis, and patients with polycythemia vera require phlebotomy.

Which of the following represents the best treatment plan for correction of systemic acidosis in status epilepticus? Fomepizole 15 mg/kg IV infusion over 30 minutes Intravenous insulin infusion at 0.1 units/kg/hour Sodium bicarbonate 2-5 mEq/kg IV infusion over four to eight hours Watchful waiting for auto-correction of the acidosis once seizure activity is controlled

Watchful waiting for auto-correction of the acidosis once seizure activity is controlled. Treatment of status epilepticus involves stabilizing the patient and rapid administration of a benzodiazepine such as midazolam. This is followed by administration of an intravenous anticonvulsant such as phenytoin. If the seizure activity does not cease after these two measures, then a barbiturate or a general anesthetic such a propofol are used. Correction of the systemic acidosis found in status epilepticus is not necessary since the acidosis is thought to have anticonvulsant effects. Also, the acidosis corrects itself quickly once seizure activity has ceased, and treatment with alkalinizing agents often leads to a rebound systemic alkalosis. Treatment of status epilepticus with benzodiazepines and anticonvulsants should not be delayed, due to the serious nature of the disorder. However, after the patient is stabilized and no longer actively seizing, measures must be taken to investigate the cause of the seizure activity. These measures are symptom-specific but can include complete blood count, complete metabolic panel, toxicology screening, electroencephalography, computed tomography or magnetic resonance imaging of the brain, chest radiograph, or lumbar puncture. Status epilepticus refers to a prolonged epileptic crisis (> or equal to 5 minutes of continuous seizure activity) or more than one seizure without recovery from the postictal state in between episodes. Patients may present with a long history of seizure disorder or may be experiencing their first seizure event. In patients with a history of seizure disorder, a change to their medication regimen is the most common precipitating factor in status epilepticus. Other causes of the disorder are stroke, hemorrhage, tumor, infection, electrolyte abnormalities and toxins. Patients in status epilepticus may present with a sustained tonic-clonic seizure or may suffer sustained simple partial or complex partial seizures. Complications resulting from status epilepticus can be life-threatening and include respiratory failure, hypotension, acidosis, hyperthermia, rhabdomyolysis, and aspiration.

A 25-year-old G1P0 at 39 weeks' gestation has been admitted to the labor and delivery department. On admission, a digital cervical examination was performed. Which of the following best describes the appropriate time for repeat cervical examinations during labor? After administration of anesthesia Every 15 minutes during stage two Every hour during stage one When the woman feels the urge to push

When the woman feels the urge to push. Repeat digital cervical examinations should be done at varying intervals during labor to confirm that dilation of cervix is progressing at an appropriate rate and to determine cervical effacement and fetal station. The first cervical examination should be performed at the time of admission. During the first stage of labor, the examinations should be performed every two to four hours. During stage two, every one to two hours is sufficient. When the woman feels the urge to push, a cervical examination is done to determine whether the cervix is completely dilated. If the woman has chosen to have anesthesia, a cervical examination should be done prior to its administration. Additionally, if the fetal heart rate becomes irregular, a cervical exam is indicated to evaluate for complications such as cord prolapse or uterine rupture. The results of the examination can be documented on a partogram, a graphical representation of the progression of dilation, in addition to the medical record.

What heparin complication is relevant to endocrinology?

bilateral adrenal hemorrhage leading to addison's disease

Honeycombing and tram tracks on the CXR should make you think of what diagnosis?

bronchiectasis and idiopathic pulmonary fibrosis

A 4-year old boy presents to the office for his well-child examination. Upon listening to his heart, you hear a soft murmur. Which of the following features would be concerning for a pathologic murmur? A crescendo/decrescendo quality Split S2 sound that changes with inspiration Systolic murmur that decreases in intensity with standing Widely split and fixed S2

Widely split and fixed S2 Atrial septal defect is a commonly recognized congenital cardiac condition that presents in adulthood. It is a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium. Depending on the size of the defect, the shunt, and the presence of any associated cardiac anomalies, atrial septal defect can have a wide variation of disease from no significant cardiac sequelae to right heart overload and failure, pulmonary hypertension or even atrial arrhythmias. Atrial septal defects are congenital but since they are associated with subtle physical exam findings and lack of symptoms, they are commonly undiagnosed until adulthood. Children usually do not present with symptoms, but some may have symptoms of easy fatigability, recurrent respiratory infections or shortness of breath with exertion. In adults, the most common symptoms include dyspnea, easy fatigability, palpitations, sustained atrial arrhythmia, syncope, stroke, and heart failure. Upon physical examination, atrial septal defects are characterized by increased precordial activity upon palpation, fixed and widely split S2 heart sound, systolic murmur heard best at the upper left sternal border, and intensity of murmur does not vary with position changes. Some patients may have a diastolic murmur characterized by a low-frequency diastolic rumble best heard with the bell of the stethoscope at the lower left sternal border Other findings may depend on the degree of left-to-right shunt, size of defect, ability of ventricles to fill and contract, and pulmonary and systemic resistance. Atrial septal defects are often confused with innocent murmurs upon auscultation and do have some differences based on specific physical exam findings.

Which of the following is a risk factor for occiput posterior position at birth? Gestational age less than 38 weeks Maternal age < 35 years Nulliparity Posterior placenta

Women who are previously nulliparous are at greater risk of an occiput posterior fetal malposition at birth. This is the most common fetal malposition and puts the fetus and mother at increased risk. Occiput posterior delivery is associated with greater risk of lower Apgar scores, umbilical artery acidemia, and neonatal intensive care admission. Maternal risk includes anal sphincter injury or failed vacuum or forceps delivery. The normal fetal position at delivery is occiput anterior. Diagnosis of fetal malposition is typically made during the second stage of labor and can be confirmed with ultrasound. Manual rotation may be attempted before delivery although operative vaginal delivery or cesarean delivery are also options. Maternal age > 35 years is a risk factor. Gestational age greater than 41 weeks is associated with increased risk of fetal malposition. A posterior placental position is not a contributing factor; however, data suggests that an anterior placenta may be a factor in occiput posterior fetal presentation.

A 22-year-old woman presents with pain and swelling to the vulva. On examination, you notice an area of swelling with induration and central fluctuance at the 8 o'clock position. Which of the following statements is true regarding this? All patients require antibiotics Gonorrhea and chlamydia are the most common causes Incision should be performed in the operating room Word catheter is placed for four to six weeks

Word catheter is placed for four to six weeks. A Bartholin's abscess occurs with infection of an obstructed Bartholin gland, a pea-sized mucous secreting gland located on each side of the labia minora in the 4 and 8 o'clock positions. When the duct that drains fluid from the gland becomes blocked, a mucous-filled cyst forms and eventually, if not drained, bacterial overgrowth occurs leading to an abscess. It is also possible to have a primary infection of the Bartholin gland itself. Most commonly, the causative organism is normal vaginal flora of which E. coli is most prevalent in cultures. Treatment of the abscess is with incision and drainage. After the loculations are broken up and all contents of the abscess have been expressed, either gauze packing or a Word catheter is placed. Gauze packing is removed after 24 to 48 hours and patients may require marsupialization at a later date. The Word catheter is a plastic catheter with a balloon on the end that is filled with 2 to 4mL of water and expanded within the abscess cavity. It is important that the incision is made only slightly larger than the opening required for catheter placement. The catheter remains in place for four to six weeks and patients are instructed to abstain from vaginal intercourse. This duration is required for epithelialization of the tract and the formation of a small fistula tract that will allow appropriate drainage without obstruction.

Which of the following is an example of a positive symptom of schizophrenia? Anxiety Apathy Impaired memory Word salad

Word salad Schizophrenia is a complex psychiatric syndrome in which there is impairment in several different domains. Positive symptoms of schizophrenia include hallucinations, delusions, and disorganization. Hallucinations may be auditory, visual, or both. Delusions are fixed false beliefs which may either be bizarre or non-bizarre. Disorganization may be evidenced by tangential speech, circumstantial speech, derailment, word salad (words thrown together without sensible meaning), or neologisms. Along with positive symptoms, patients with schizophrenia can also exhibit negative symptoms. While positive symptoms may be thought of as something being "added to" normal experience (e.g., hallucinations, delusions), negative symptoms are thought of as a deficit of normal experience (e.g., decreased emotional expressiveness, apathy, flat affect, and lack of energy, etc.). Yet another domain affected by the illness is cognition. Patients with schizophrenia suffer varying degrees of cognitive impairment, including decreased attention, decreased processing speed, decreased memory, decreased reasoning, difficulty interpreting social cues, and difficulty comprehending verbal communication. Mood and anxiety symptoms are also common in patients with schizophrenia. Finally, several physical manifestations of schizophrenia have been noted, including catatonia, metabolic disturbances (such as diabetes, dyslipidemia and hypertension), and neurologic disturbances (such as poor motor coordination and sensory integration). Schizophrenia often appears in the late teen to early adult years, may have an abrupt or an insidious onset and is considered a lifelong illness, although patients may experience periods of symptom remission. Treatment is with antipsychotic medication.

A question about Prinzmetal's angina will often contain what key thing in the patient's history?

cocaine use

define pulsus paradoxus

decrease in systolic blood pressure by at least 10mmHg upon inspiration; can occur minimally w/ cardiac tamponade, constrictive pericarditis, morbid obesity, asthma, obstructive sleep apnea, croup

In Cushing's disease is ACTH elevated or decreased?

elevated

A patient without a functioning spleen is more susceptible to what type of organisms?

encapsulated organisms most commonly Strep pneumoniae and H. flu

Where is disease of the tricuspid valve best heard?

along the left sternal border

A 68-year-old man is being evaluated in your radiation oncology clinic for treatment of a solid tumor. Your hospital has just purchased a new proton beam purported to deliver targeted radiation with fewer side effects than traditional radiation therapy. The patient expresses strong interest in receiving proton beam therapy, and you feel that he may have a better outcome with this new treatment modality. Later that day, an executive from the patient's insurance company calls to tell you that proton beam therapy will cost the insurance company, but not the patient, a much larger amount of money than traditional therapy. They are willing to pay for proton beam therapy, but request that you convince the patient to undergo traditional therapy instead. You have a longstanding relationship with this insurance company as well as this particular executive. How should you proceed? Call your hospital's ethics committee for a formal consultation Discuss the issue of cost to the insurer with your patient and let him know keeping his insurance company happy will likely result in better coverage in the future Inform the patient that proton beam therapy will not be covered by insurance, so he will need to proceed with traditional radiation therapy Proceed with proton beam therapy as discussed at your patient's appointment

You should proceed with proton beam therapy. When making a decision between different treatments, patient medical need and preference should take precedence over cost of a procedure to an insurer. The ethical principles of autonomy and beneficence govern the tension between patient's medical need and insurer's desire to minimize costs. As a clinician, you are obligated to respect your patient's autonomy by respecting his preferences in medical care, and to respect the core principle of beneficence by acting in his best interest. In this case, there is no conflict between autonomy and beneficence - you feel that proton beam therapy is best for his condition, and he desires it. Cost to the insurer should not enter the equation, and you as a clinician should not ration care to patients based on the cost of treatment. As clinicians, our responsibility is to do whatever is in the best interest of our patient's welfare.

What drug do you use to treat pinworm?

You treat everyone in the house with albendazole. Two weeks later you treat them again.

List the 4 minor criteria for diagnosing endocarditis.

fever >38 C, embolic event (Janeway lesions, petechiae, splinter hemorrhages), immunologic event (Osler nodes, Roth spots, glomerulonephritis), 1 positive blood culture, IVDA or prosthetic heart valve + regurgitation

What medication class is used to lower triglycerides?

fibric acid derivatives (Fenofibrate & Gemfibrozil)

Define the second stage of labor.

fully dilated to delivery; from the completion of effacement & dilatation until the delivery of the fetus; time from complete effacement & dilitation or 10cm & 100 % to Birth

Is Klebsiella gram (+) or gram (-)?

gram negative

What is the most common organism causing pneumonia in COPD patients?

haemophilus influenzae

What lab result will increase the risk of digoxin toxicity?

hypokalemia or hypercalcemia

Tympany to percussion should make you think of what diagonsis?

large pneumothorax

A blockage of which artery causes a lateral wall MI?

left circumflex artery

What will the likely findings be on a CXR of a patient with asbestosis?

linear opacities at the bases with pleural plaques

A surge in what hormone leads to ovulation?

luteinizing hormone (LH)

What is Samter's triad?

nasal polyps, asthma, aspirin sensitivity

What location within the pelvis is endometriosis most commonly found?

on an ovary