#11 Rosh Review

Question: True or false: women who have been vaccinated against human papillomavirus do not need cervical cancer screening?

Answer: False.

Question: What four populations is ANUG most commonly seen in?

Answer: HIV patients, malnourished children, young adults who experience a great deal of stress, polysubstance abusers. Rapid Review Acute Necrotizing Ulcerative Gingivitis Poor oral hygiene, tobacco use, immunodeficiency Halitosis, metallic taste, fever Oral ulcers with pseudomembrane Warm saline, ABX

Question: To assess functionality post stroke, a provider should evaluate which measures?

Answer: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Rapid Review Ischemic Stroke Anterior cerebral artery: frontal lobe dysfunction, apraxia, contralateral paralysis (lower > upper) Middle cerebral artery: contralateral paralysis (upper > lower), contralateral hemianopsia, aphasia Posterior cerebral artery and VBI: LOC, nausea/vomiting, CN dysfunction, ataxia, visual agnosia Rule out hypoglycemia CT reveals loss of grey-white interface, acute hypodensity Thrombolytics

Question: What dangerous complication of parvovirus B19 infection is seen in patients with sickle cell disease?

Answer: Aplastic anemia. Rapid Review Erythema Infectiosum (Fifth Disease) Patient will be a child With a history of URI symptoms 3 - 4 days prior to rash PE will show "slapped cheek" rash Most commonly caused by parvovirus B19 Comments: Aplastic crisis in sickle cell patients

Question: Why is it required to administer 3 grams of calcium gluconate and only 1 gram of calcium chloride?

Answer: 1 gram of calcium gluconate contains 1/3 of the amount calcium as 1 gram of calcium chloride due to the difference in the size of the two molecules. Rapid Review Hypocalcemia Serum Ca2+ <8.5 mg/dL Blood transfusions Seizures, paresthesias Chvostek's sign (facial muscle contraction) Trousseau's sign (carpopedal spasm) Hyperreflexia ↑ QT interval

Question: When should serum potassium be measured after beginning treatment for hyperkalemia?

Answer: 1-2 hours after initiating therapy. Rapid Review Hyperkalemia Patient with a history of renal failure, DKA, rhabdomyolysis, tumor lysis Complaining of lethargy, weakness, paralysis PE will show bradycardia, hypotension, cardiac dysrhythmia ECG will show peaked T waves, prolonged PR, wide QRS Treatment is calcium gluconate, insulin, albuterol, kayexalate, bicarbonate

Question: What is a normal intraocular pressure?

Answer: 12-22 mm Hg. Rapid Review Central Retinal Artery Occlusion Patient will be complaining of sudden, painless monocular vision loss Fundoscopy will show "boxcar" look or "cherry red spot" Treatment is globe massage, ↓ IOP, ophthalmology consultation

Question: What is the peak age for Achilles tendon rupture?

Answer: 30 to 40 years. Rapid Review Achilles Tendon Rupture Patient will be a deconditioned athlete With a history of fluoroquinolone use Complaining of "pop" or "snap" and sudden pain in the calf area PE will show absent plantarflexion upon calf squeeze (Thompson test) Treatment is posterior splint in plantarflexion, orthopedic consult

Question: What is the upper age limit for tPA administration up to 4.5 hours?

Answer: 80-years-old. Rapid Review Anterior Cerebral Artery Stroke Contralateral weakness of leg > arm and face with minimal sensory findings Frontal lobe dysfunction

A 3-week-old infant presents with projectile vomiting. Mom reports he has vomited after each feed for the last 24 hours. What electrolyte abnormality do you expect to see? Hyperchloremic, hyperkalemic metabolic alkalosis Hyperchloremic, hypokalemic metabolic alkalosis Hypochloremic, hyperkalemic metabolic alkalosis Hypochloremic, hypokalemic metabolic alkalosis

Explanation: Hypertrophic pyloric stenosis is the most common cause of intestinal obstruction in infants beyond one month of age. Classically, infants present between 2 and 6 weeks of age with progressive emesis that ultimately becomes projectile. Since the stenosis is at the level of the pylorus, emesis is non-bilious. Infants finish a feeding and then regurgitate the entire volume of feeding and continue to be hungry. On examination of the abdomen, the hypertrophic pylorus may be palpable in the upper abdomen and is often described as an olive. With continued vomiting, infants lose both hydrogen ions and chloride present in the gastric juices. As the condition continues, renal compensation occurs with an exchange of hydrogen ions for potassium leading to the metabolic alkalosis. The resulting metabolic condition is a hypochloremic, hypokalemic, metabolic alkalosis. Ultrasound is the diagnostic modality of choice demonstrating a thickened pylorus. If an upper GI series is performed with contrast, the "string sign" may be present as a small amount of contrast passes through the hypertrophied pylorus. Hyperchloremic, hyperkalemic metabolic alkalosis (A), hyperchloremic, hypokalemic metabolic alkalosis (B) and hypochloremic, hyperkalemic metabolic alkalosis (C) are generally not associated with pyloric stenosis.

Question: What test is diagnostic for pyloric stenosis?

Answer: Ultrasound. Rapid Review Pyloric Stenosis 2-6 weeks old First born males Nonbilious projectile vomiting Early satiety and refeeds RUQ olive-like mass (hypertrophied pylorus) Hypochloremic hypokalemic metabolic alkalosis Ultrasound or UGI series (string sign)

Question: What role does epidermal melanin play in the protection against actinic keratosis?

Answer: Absorbs ultraviolet radiation and shields keratinocytes. Rapid Review Actinic Keratosis (AK) Patient will be a man With a history of an outdoor occupation and sun exposure Complaining of rough bumps on his head PE will show rough, scaly, erythematous papules on sun-exposed areas Comments: Potential to progress to squamous cell carcinoma

Question: What is a typical radiographic finding that supports a diagnosis of a Lisfranc dislocation-fracture?

Answer: An AP view which reveals lateral shift of the second metatarsal off the middle cuneiform. Rapid Review Lisfranc Injury Definition: any fracture or dislocation of the tarsal-metatarsal joint Plantar ecchymosis Fleck sign (pathognomonic): avulsion fracture of the medial aspect of the base of the second metatarsal Weight-bearing films may be necessary Treatment: Nondisplaced: non-weight bearing casting Displaced: surgery

Question: What vascular structure is at risk of injury with a proximal fibular fracture?

Answer: Anterior tibial artery. Rapid Review Lower Extremity Nerve Deficits Superior gluteal: Trendelenburg sign/gait (lesion is contralateral to the dropped side) Inferior gluteal: ↓ hip extension Obturator: ↓ thigh sensation (medial), adduction Femoral: ↓ thigh flexion, leg extension Common peroneal: ↓ foot eversion/dorsiflexion Tibial: ↓ foot inversion/plantarflexion

Question: What should be measured in all patients with newly diagnosed celiac disease?

Answer: Bone mineral density. Rapid Review Celiac Disease Patient will be complaining of diarrhea, steatorrhea, flatulence, weight loss, weakness and abdominal distension Labs will show IgA anti-endomysial (AGA) and anti-tissue transglutaminase (anti-tTG) antibodies Diagnosis is made by small bowel biopsy Treatment is gluten free diet Comments: associated with dermatitis herpetiformis (chronic, very itchy skin rash made up of bumps and blisters)

Question: What syndrome is most commonly seen in Asian men and associated with sudden cardiac death secondary to ventricular fibrillation?

Answer: Brugada syndrome.

Question: Premature ventricular complexes are often caused by or made worse by what common agents?

Answer: Caffeine, alcohol and nicotine.

Question: What is at risk for developing by correcting hyponatremia too rapidly?

Answer: Central pontine myelinosis. Rapid Review Diabetes Insipidus (DI) ADH deficiency → polyuria + inability to concentrate urine ↑ Plasma osmolality + dec urine osmolality Central DI: ↓ ADH production Water deprivation test: >50% ↑ in urine osmolality Rx: intranasal DDAVP Nephrogenic DI: Renal unresponsiveness to ADH Water deprivation test: no change in urine osmolality Rx: HCTZ, amiloride, indomethacin

Question: What is the pathognomonic finding on microscopic exam to diagnose bacterial vaginosis?

Answer: Clue cells. Rapid Review Bacterial Vaginosis Patient will be complaining of malodorous vaginal discharge PE will show thin, gray/white discharge Labs will show pH > 4.5, clue cells Diagnosis is made by KOH to smear → fishy odor, "whiff test", Amsel Criteria Most commonly caused by Gardnerella vaginalis Treatment is metronidazole

Question: What is the treatment for digoxin toxicity?

Answer: Digoxin immune Fab.

Question: What is the most common pathogen found in acute bacterial prostatitis?

Answer: Escherichia coli. Rapid Review Prostatitis Patient will be complaining of fever, chills, perineal/back pain and dysuria PE will show a warm, exquisitely tender prostate Most commonly caused by: < 35 y/o: N. gonorrhoeae, C. trachomatis > 35 y/o: E. Coli Treatment is: < 35 y/o: Ceftriaxone or ofloxacin and doxycycline > 35 y/o: Ciprofloxacin or TMP/SMX Comments: Avoid vigorous prostatic massage can lead to septicemia

Question: An elevated thyroid peroxidase antibody (TPO) level is diagnostic for which thyroid disorder?

Answer: Hashimoto's thyroiditis.

Question: What is the principal cause of peptic ulcer disease?

Answer: Helicobacter Pylori. Rapid Review Ischemic Colitis Large bowel ischemia Low-flow state → ischemia Hypotension Severe abdominal pain Bloody stools Address underlying cause, surgery consultation

Question: G. Bonnano's research has contradicted the five stages grief reaction in which manner?

Answer: His summary of peer-reviewed studies show that those who experience a significant loss do not grieve, but show resilience instead. Rapid Review Grief Reaction Stages: denial, anger, bargaining, depression, acceptance Nonpathologic symptoms: guilt, weight loss, simple hallucinations Pathologic symptoms: >12 months, severe functional impairment, suicidal ideation, psychotic symptoms

Question: What medication can lead to vitamin A toxicity?

Answer: Isotretinoin. Rapid Review Hypervitaminosis A Patient with a history of intake of cod liver oil or multivitamins Complaining of headaches, facial acne, nausea, joint pain, itchy and peeling skin, dizziness PE will show enlargement of liver and spleen

Question: What is the expected pulse oximetry finding in methemoglobinemia?

Answer: Low, typically around 85 percent. However, the Pa oxygen will be normal.

Question: Why is androgen replacement indicated in women but not men with Addison's disease?

Answer: Male testes produce adequate testosterone, however the adrenals are the main source of androgen production in women Rapid Review Primary Adrenal Insufficiency (Addison's Disease) Patient will be complaining of abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE will show hyperpigmentation of skin and mucus membranes and hypotension Labs will show hyponatremia and hyperkalemia Most commonly caused by autoimmune Treatment is hydrocortisone

One Step Further Question: What is the most common X-ray finding in acute aortic dissection?

Answer: Mediastinal widening is seen in the majority of aortic dissection cases. Rapid Review Aortic Dissection Patient will be older With a history of HTN, smoking, Marfan syndrome Complaining of sudden "ripping" or "tearing" CP radiating to back PE will show asymmetric pulses/BP CXR will show widened mediastinum Diagnosis is made by CT or transesophageal echocardiogram (TEE) Treatment is reduce BP, surgery

Question: What should be considered first when patients are not at therapeutic blood pressure goals?

Answer: Medication compliance and lifestyle intervention adherence. Rapid Review Hypertension: Eighth Joint National Committee (JNC 8) Recommendations PreHTN: systolic blood pressure (SBP) 120-139 mmHg or diastolic blood pressure (DBP) 80-89 mmHg Stage I HTN: SBP 140-159 mmHg or DBP 90-99 mmHg Stage II HTN: SBP >160 mmHg or DBP >100 mmHg Treatment goals: >60 years: SBP <150, DBP <90 All others: SBP <140, DBP <90 1st line rx for general population: thiazide, CCB, ACEI, or ARB 1st line rx for African Americans: CCB or thiazide Chronic kidney disease: rx should include ACEI or ARB

Question: What eye finding is seen in clonidine toxicity?

Answer: Miosis. Rapid Review Salicylate Toxicity: Aspirin, wintergreen, Pepto-Bismol Respiratory alkalosis + anion gap metabolic acidosis Hypoglycemia Tinnitus Rx: AC (if < 1 hour from ingestion), urine alkalinization, K+ Hemodialysis indications: Level > 100 Coma Rising levels despite alkalinization Renal failure Pulmonary edema Altered mental status Clinical deterioration

Question: What birefringence is acute gout associated with?

Answer: Negative birefringence. Rapid Review Gout Patient will be a middle-aged man Complaining of acute onset of pain in the first MTP (Podagra) Labs will show needle-shaped crystal with negative birefringence Most commonly caused by uric acid crystals Treatment is: Acute: NSAID's Chronic: allopurinol or colchicine Comments: can be triggered by loop and thiazide diuretics

Question: What are borborygmi?

Answer: Noises made by fluid and gas moving through the intestines. Rapid Review Small Bowel Obstruction Causes: adhesions (pelvic surgery) > tumor > hernia (inguinal) Proximal = bilious vomiting, distal = feculent vomiting High pitched bowel sounds X-ray: dilated bowel, air fluid levels, "stack of coins" or "string of pearls" sign NGT, surgery

Question: What do you call the impaired mineralization of bone that usually occurs together with rickets?

Answer: Osteomalacia.

Question: What testing may be used to diagnose allergic contact dermatitis, which involves placement of suspected and standard allergens on the skin surface for 48 hours?

Answer: Patch testing. Rapid Review Contact Dermatitis Patient will complain of a rash PE will show erythematous, scaly plaques, vesicles, and bullae Diagnosis is made by patch test Most commonly caused by nickel, poison ivy, soaps, and clothing Comments: Cell-mediated reaction type IV

Question: What is the most common otologic sequela of lightning injuries?

Answer: Perforated tympanic membrane. Rapid Review Tympanic Membrane Perforation Foreign body, infection, blast, ↑ barometric pressure Pars tensa most commonly perforated Pain, ↓ hearing, bleeding ​Keep ear dry, analgesics 90% heal in few months

Question: Where in the esophagus do most iatrogenic injuries occur?

Answer: Pharyngoesophageal junction because the wall is the thinnest in this area. Rapid Review Boerhaave Syndrome Full-thickness esophageal rupture Most commonly occurs at the left posterolateral distal esophagus Severe chest pain Hamman's crunch Mediastinitis Water soluble oral contrast for esophagram

Question: Which medication is indicated for either pregnant or breast feeding patients who have hyperthyroidism?

Answer: Propylthiouracil (PTU), because methimazole is teratogenic. Rapid Review Hyperthyroidism Patient will be complaining of heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE will show hyperreflexia Labs will show low TSH and high free T4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Treatment is methimazole or PTU Comments: Propylthiouracil (PTU) P for pregnant

Question: What criteria on ultrasound are consistent with pyloric stenosis?

Answer: Pyloric wall greater than 4 mm wide or 14 mm long. Rapid Review Pyloric Stenosis 2-6 weeks old First born males Nonbilious projectile vomiting Early satiety and refeeds RUQ olive-like mass (hypertrophied pylorus) Hypochloremic hypokalemic metabolic alkalosis Ultrasound or UGI series (string sign)

Question: What is the most common source of posterior epistaxis?

Answer: Sphenopalatine artery. Rapid Review Epistaxis Most common source: Anterior bleeds: Kiesselbach's plexus Posterior bleeds: Sphenopalatine artery Treatment is: Anterior bleeding: direct pressure, packing, cautery, Posterior bleeding: packing (foley, gauze pack, intranasal balloon device) Admit patients with posterior packing to a monitored bed

Question: What is the most common cause of septic arthritis?

Answer: Staphylococcus aureus is the most common cause of septic arthritis in adults. Rapid Review Septic Arthritis Age < 35: N. gonorrhea S. aureus most common overall Hematogenous spread Fever, pain, ↓ ROM Knee (most common) Arthrocentesis (WBC > 50,000 with > 75% PMNs) IV ABX, surgical washout

Question: Which interventional pain management procedures are commonly used for medication-refractory complex regional pain syndrome?

Answer: Sympathetic ganglion/nerve anesthetic blocks: lumbar sympathetic chain blocks for lower extremity symptoms, celiac plexus blocks for abdominopelvic symptoms and stellate ganglion blocks for upper extremity symptoms. Rapid Review Complex Regional Pain Syndrome Patient will have a history of previous extremity injury or fracture Complaining of light touch causing extreme pain and allodynia (pain felt from a nonpainful stimulus, such as clothes or bed sheets on the skin) Treatment is NSAIDs, gabapentin, sympathectomy

Question: Which lobe of the brain controls hearing?

Answer: Temporal lobe.

Question: While AV block is first examined by determining the length of the PR interval, bundle branch blocks are first examined by determining the length of which electrocardiographic entity?

Answer: The QRS complex. Rapid Review Right Bundle Branch Block (RBBB) QRS > 120 ms RSR' pattern in V1-V3 Wide, slurred S wave in lateral leads

Question: Which arteries supply the nose?

Answer: The ethmoid branch of the internal carotid artery, and the facial and internal maxillary branches of the external carotid artery. Rapid Review Epistaxis Most common source: Anterior bleeds: Kiesselbach's plexus Posterior bleeds: Sphenopalatine artery Treatment is: Anterior bleeding: direct pressure, packing, cautery, Posterior bleeding: packing (foley, gauze pack, intranasal balloon device) Admit patients with posterior packing to a monitored bed

Question: What is the approximate duration of action of calcium on cardiac membrane stabilization?

Answer: The time is 30 to 60 minutes. Rapid Review Hyperkalemia Patient with a history of renal failure, DKA, rhabdomyolysis, tumor lysis Complaining of lethargy, weakness, paralysis PE will show bradycardia, hypotension, cardiac dysrhythmia ECG will show peaked T waves, prolonged PR, wide QRS Treatment is calcium gluconate, insulin, albuterol, kayexalate, bicarbonate

Question: Aspirin is the first-line antiplatelet used in managing stable angina in all cases except for which patients?

Answer: Those with a recent MI or coronary stent, in which case, clopidogrel is the recommended first-line antiplatelet agent. Rapid Review Ischemic Heart Disease #1 cause of death in USA RFs: family hx, smoking, HTN, DM, cholesterol, male, age >55 Stable angina: activity → chest pain (CP), relieved by rest, NTG Unstable angina: CP at rest CP, dyspnea, diaphoresis, nausea, hiccups, radiation to shoulder/jaw/back Elderly, diabetics, females, hx of stroke or HF: ↑ risk for atypical presentation Earliest ECG sign of MI: hyperacute T waves Up to 50% of ECGs are negative or nonspecific Highest S/S: troponin I

Question: Which type of diabetes mellitus is more common?

Answer: Type 2.

Question: What is the most common cause of immune thrombocytopenia?

Answer: Unknown in most cases, can be due to viral illness. Rapid Review Idiopathic Thrombocytopenic Purpura (ITP) Patient will be a child 2 - 6 yrs old With a history of recent viral infection Complaining of red spots on skin or easy bleeding PE will show petechiae, purpura, and gingival bleeding Labs will show platelets < 50,000 µL Most commonly caused by antiplatelet antibodies Treatment is observation, steroids, IVIG

Question: What is the most common congenital heart disorder?

Answer: Ventricular septal defect. Rapid Review Tetralogy of Fallot MC cyanotic CHD Pulmonic stenosis + RVH + VSD + overriding aorta Pulmonic stenosis determines degree of cyanosis Tet spells (crying/feeding → ↑ RV outflow obstruction) CXR: "boot-shaped" heart Acute cyanosis rx: place child in squatting or knee to chest position (↑ SVR → ↓ shunting), morphine, O2 Definitive rx: surgery

Question: The triad of opthalmoplegia, ataxia and confusion is classically referred to as which thiamine deficiency?

Answer: Wernicke's encephalopathy (or disease). Rapid Review Vitamin B1 Deficiency Alcoholism Malnutrition Wernicke-Korsakoff syndrome

Question: Is azithromycin recommended in the treatment of pregnant women with chlamydia infection?

Answer: Yes.

A 35-year-old woman is seen in the clinic with a chief complaint of frequent palpitations associated with symptoms of pre-syncope. She experiences these episodes two to three times per day. Her resting ECG in the office is normal sinus rhythm with heart rate 65/min. Her physical exam is unremarkable. Which of the following is the most appropriate next step in management? 24-48 hour continuous ambulatory ECG monitor Electrophysiologic testing Implantable loop recorder Post-symptom event recorder

Correct Answer ( A ) Explanation: 24-48 hour continuous ambulatory ECG monitor, also known as a Holter-monitor, is the most appropriate next step in management. It is one of the most frequently used and cost-effective noninvasive tests used to evaluate cardiac rhythm abnormalities. The clinical utility of the ambulatory ECG recording lies in its ability to continuously examine the patient's cardiac rhythm over an extended period of time during normal routine activity, including any physical and psychological changes. Various rhythm recorders can be used to capture a dysrhythmia. Selection depends on the frequency and duration of symptoms. A Holter monitor is worn for 24-48 hours and is used for evaluation of more frequent symptoms. This patients symptoms occur daily, so a 24-48 hour monitor is likely to capture a possible dysrhythmia during an episode of palpitations or pre-syncope. Several other options to monitor cardiac rhythm abnormalities exist and include event recorders and implantable loop recorders. These monitors are most useful when symptoms are infrequent. A post-symptom event recorder (D) is held to the chest when symptoms occur. The advantage of a post-symptom recorder is the lack of electrode leads, making it more comfortable to carry. Implantable loop recorders (C) allow for continuous ECG monitoring to detect cardiac arrhythmias over months to years. This device is placed subcutaneously, similar to a pacemaker, and can be interrogated non-invasively. A looping event recorder records several seconds of the rhythm prior to the device being triggered and is useful in patients with syncope who many not be able to trigger the recording device. This patient's symptoms are frequent making these devices unnecessary. Electrophysiologic testing (B) is invasive and reserved for those at risk of sudden cardiac death. It is indicated in select, high risk patients with unexplained syncope, particularly those with structural heart disease. Electrophysiologic testing should be considered when noninvasive tests have failed to make a diagnosis. This patient is not likely to have structural heart disease or be at risk for sudden cardiac death based upon her history, physical exam findings and initial testing.

You are managing the blood pressure of a 49-year-old Caucasian woman with enalapril 20 mg twice a day. She does not have diabetes or chronic kidney disease. She has been taking the enalapril for over 1 month. Repeated blood pressure readings in both arms average out to 138/96. Which of the following is the most appropriate treatment at this time? Continue enalapril and add amlodipine Continue enalapril and add losartan Continue enalapril and add nothing, as she is at goal with just one medication Double the dose of enalapril

Correct Answer ( A ) Explanation: According to JNC-8, first-line antihypertensives in the African-American population include thiazide-type diuretics (TTD) or calcium channel blockers (CCB), while first-line medications in the non-African-American population include thiazide-type diuretics (TTD) or calcium channel blockers (CCB), in addition to angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). If the blood pressure goal is not achieved during one month of treatment, clinicians should increase the dose of the first drug, or continue the first drug and add a second drug. The patient above is already taking max dose enalapril. Therefore, a second agent (e.g. amlodipine) should be added to her regimen. If two drugs fail, a third drug should be added. If three drugs fail, or contraindications limit the use of any combination of the above four drugs, other antihypertensives can be used. These include alpha1-blockers, alpha2-agonists, beta-blockers, loop diuretics, aldosterone-receptor-blockers, adrenergic neuronal depleting agents and vasodilators. Furthermore, the clinician should consider referral to a hypertension specialist if 4 drugs are necessary to achieve a goal pressure. ACEIs and ARBs, like losartan (B), should never be used together. She is < 60 years old, and does not have DM or chronic kidney disease. Proper blood pressure goal is < 90 mm Hg diastolic. There is insufficient evidence to recommend a systolic goal in this age group, however, the consensus is to use < 140/90 mm Hg as a final goal (C) in those < 60 years of age. She is already at the maximum target dose of enalapril (40 mg per day). Doubling this dose (D) is not recommended, but adding a second class is.

A 25-year-old woman presents to your clinic with concerns about sexually transmitted infections. She admits to unprotected sex with multiple partners. She is asymptomatic, but her last partner told her that he recently tested positive for chlamydia. The most appropriate next step is administration of which of the following? Azithromycin Ciprofloxacin Metronidazole Penicillin

Correct Answer ( A ) Explanation: Chlamydia trachomatis is susceptible to macrolides and tetracyclines antibiotics, which is the most common bacterial cause of sexually transmitted infections (STIs) in the United States. Azithromycin may be given in a one-time oral dose of 1 gram. Doxycycline may also be prescribed as 100 mg twice per day for seven days and should be avoided in pregnant individuals. Azithromycin is generally the preferred treatment since the patient can be observed taking the dose, allowing for greater patient compliance and eradication of the infection. A single injection of 250 mg of ceftriaxone is also given for uncomplicated gonococcal infections. Co-infection with chlamydia and gonorrhea is common and empiric therapy for both should be given for symptomatic patients and those with recent known or uncertain sexual exposure to gonorrhea. Ciprofloxacin (B) is a quinolone which has not been shown to be effective against Chlamydia trachomatis. Penicillin (D) is used in the treatment of syphilis and is not used to treat chlamydia. Metronidazole (C) is used for the treatment of vaginal trichomoniasis and bacterial vaginosis, but is ineffective against Chlamydia.

A woman presents for her annual examination. She is treated for stable angina with aspirin and a statin. She continues to have angina 3-4 times a week, but its character, intensity, frequency and duration is unchanged. She has no history of myocardial infarction, diabetes or pulmonary disease. Which of the following interventions is most appropriate at this time? Begin atenolol Begin lisinopril Begin nitroglycerin Continue current medications and follow-up in 1 month

Correct Answer ( A ) Explanation: Chronic stable angina is properly managed with lifestyle modifications and statin, antihypertensive and antiplatelet therapies. Concerning antihypertensive therapy in patients with documented coronary artery disease and chronic stable angina, first-line therapy is accomplished with beta-blockers. Even if patients do not have hypertension, beta-blockade is recommended. Their β1 and β2 antagonism decreases myocardial demand by decreasing heart rate and myocardial contractility, as well as increasing diastolic filling time. Other antihypertensive agents include ACE-inhibitors, ARBS and calcium-channel blockers. ACE-inhibitors (B) are considered first-line if the patient has had an MI or currently has diabetes. They are considered second-line therapy in all other hypertensive patients once beta-blockade therapy has been established. Nitrates (C) may be considered in patients with continued stable angina if they have failed beta or calcium-channel antagonists. This patient has not been trialed on either. Proper management of stable angina includes three classes of medications. This patient is missing an antihypertensive agent, and should be started on one at today's visit (D).

A 16-year-old boy is in clinic because of a rash. He noticed an itchy rash on his abdomen that is close to his umbilicus. He is a previously healthy boy and is not on any medications. On physical examination vital signs are normal. On skin examination there is a well-demarcated and pruritic area at the subumbilical region with weeping and vesiculation. Which of the following is the most likely diagnosis? Allergic contact dermatitis Cellulitis Herpes zoster Impetigo

Correct Answer ( A ) Explanation: The boy has findings that are suspicious for allergic contact dermatitis from the nickel of the metal fasteners of his pants. Allergic contact dermatitis is an acquired, inflammatory reaction of the skin that requires absorption of antigen from the skin surface and recruitment of previously sensitized, antigen-specific T lymphocytes into the skin. An intact immune system is required for the development of allergic contact dermatitis, which occurs in two phases: the sensitization phase and the elicitation phase. Contact allergens are found in both the natural and man-made environment. The most common contact allergen is urushiol, a pentadecylcatechol found in plants of the Toxicodendron species, such as poison ivy, poison oak, and poison sumac. Other common childhood contact allergens in the United States and Europe include metals such as nickel, cobalt, and potassium dichromate. Acute allergic contact dermatitis lesions consist of erythematous, indurated, scaly plaques. Vesiculation and bullae may be seen in severe cases. Edema may be prominent in areas in which the skin is thin. Repeated or continued exposure to allergens results in chronic disease. The skin becomes dry, scaly, and thicker as a result of acanthosis, hyperkeratosis, edema, and cellular infiltration in the dermis. Lichenification and fissuring may develop later. Secondary changes include excoriation or impetiginization. A history of allergen exposure and the pattern of the eruption are important factors in making the correct diagnosis. Patterns of dermatitis that are suggestive of allergic contact dermatitis include persistent, localized dermatitis that has not responded as expected to therapy, and dermatitis in an unusual pattern or distribution. Cellulitis (B) manifests as areas of skin erythema, edema, and warmth that involves the deeper dermis and subcutaneous fat. The rash of herpes zoster (C) starts as erythematous papules, which quickly evolve into grouped vesicles or bullae. Within three to four days, these vesicular lesions can become more pustular or occasionally hemorrhagic. Impetigo (D) is a contagious superficial bacterial infection observed most frequently in children. Lesions begin as papules that progress to vesicles surrounded by erythema. Subsequently, they become pustules that enlarge and rapidly break down to form thick, adherent crusts with a characteristic golden appearance.

A 24-year-old athlete undergoes anterior cruciate ligament repair surgery. Two weeks later, he presents with excruciating pain distal to the knee. Fracture, soft tissue injury and intraarticular infection are ruled-out. Examination reveals a swollen, warm, red foot and ankle that is painfully sensitive to light touch. The other leg appears normal. The patient guards this area and active range-of-motion is restricted. Complete pinprick sensory testing is deferred as initial testing is too painful to continue. Vibration testing results in continued pain even after removal of the tuning fork. Which of the following medications will you most likely prescribe? Gabapentin Intranasal desmopressin Intravenous immunoglobulin Pyridostigmine

Correct Answer ( A ) Explanation: Complex regional pain syndrome (CRPS) is not commonly encountered in primary care. However, CRPS presents with profound signs and symptoms. CRPS-1 occurs after a noxious neurological event, such as soft tissue crush injury, immobilization, orthopedic surgery and podiatric surgery. Any insult to the integrity of peripheral nerves is a possible etiology. This condition is felt to be due to activation of peripheral nociceptors, causing an increase in neuroexcitatory agents in the spinal cord, leading to upregulation and sensitization of peripheral and central pain pathways. Lowered neuronal thresholds result in over activity and dysregulation of the sympathetic nervous system. The most common presenting symptoms include: neuropathic pain (spontaneous, burning, dysesthetic, diffuse), allodynia (pain felt from a nonpainful stimulus, such as clothes or bed sheets on the skin), hyperesthesia (exaggerated pain response to a painful stimulus), hypoesthesia (decreased sensation/numbness in a painful area), hyperpathia (continued sensation after a stimulus is removed, such as continuing to feel vibration after a tuning fork is removed), decreased range-of-motion and joint guarding, skin changes (edema, erythema, temperature alterations, changes in hair growth and nail composition) and motor impairment. A classic presentation is post-surgical patients with days-to-weeks onset of distal extremity diffuse neuropathic pain, edema and erythema, as in the above patient. Most patients are treated with a mix of medication options: corticosteroid burst, intranasal calcitonin, NSAIDs, short course of opioids, gabapentin, tricyclic antidepressants and transdermal clonidine or lidocaine. Intranasal desmopressin (B) is an antidiuretic hormone analogue used in treating central diabetes insipidus, not CRPS. Intranasal calcitonin has been shown to be beneficial in treating CRPS. IVIG (C) is used in treating immune deficiencies, autoimmune disease and some infections. It has no role in the treatment of CRPS. Pyridostigmine (D) is an anticholinesterase agent used in treating the motor disorder myasthenia gravis. It plays no role in treating neuropathic pain such as CRPS.

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 μU/mL (N 0.4-5.0), and a free T4 level of 0.4 ng/dL (N 0.6-1.5). Which one of the following is the most likely explanation for these findings? Euthyroid sick syndrome Graves' disease Subacute thyroiditis Subclinical hyperthyroidism

Correct Answer ( A ) Explanation: 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. Subclinical hyperthyroidism (D) is defined as an abnormally low serum thyroid-stimulating hormone level (TSH) and normal levels of free thyroxine (T4) and triiodothyronine (T3). Subclinical hyperthyroidism has the potential to convert to overt hyperthyroidism. Graves' disease (B) is the most common cause of hyperthyroidism. It is an autoimmune disease caused by an antibody, active against the thyroid-stimulating hormone (TSH) receptor, which stimulates the gland to synthesize and secrete excess thyroid hormone. An undetectable TSH level is diagnostic of hyperthyroidism. Antithyroid antibodies and thyroxine are elevated in Graves' disease. Subacute thyroiditis (C) produces an abrupt onset of thyrotoxic symptoms as hormone leaks from an inflamed, painful gland. It often follows a viral illness. Symptoms usually resolve within eight months. This condition can be recurrent in some patients. A transient hypothyroidism often occurs before resolution.

A 27-year-old man presents after a fall. He struck his leg on a table and sustained a fracture of the fibular neck. Which of the following nerves is commonly injured in this type of injury? Common peroneal Femoral Posterior tibial Saphenous

Correct Answer ( A ) Explanation: Fractures of the fibula usually occur as a result of direct blunt trauma or varus stress to the knee. Isolated fractures of the fibula are frequently inconsequential because the fibula is almost completely a non-weightbearing bone. The exception to this is the significant injury of a Maisonneuve fracture when the proximal fibular fracture is associated with disruption of the medial portion of the ankle joint. The common peroneal nerve passes around the neck of the fibula and its function must be evaluated in the setting of a proximal fibula fracture. The common peroneal nerve is a branch of the sciatic nerve and divides into the deep and superficial branches. These nerves provide sensation to the anterior and lateral portion of the leg and to the top of the feet. The motor innervation is for dorsiflexion of the foot. As a result, a patient with a peroneal nerve injury will develop a foot drop. The femoral nerve (B) is the largest branch of the lumbar plexus arising from L2-L4. It emerges from the psoas muscle in the upper thigh and does not anatomically cross near the proximal fibula. The posterior tibial nerve (C) is the larger branch of the sciatic nerve (along with the peroneal nerve). In the popliteal fossa, the posterior tibial nerve travels with the popliteal vein and artery and gives off branches innervating the gastrocnemius, popliteus and soleus muscles. The saphenous nerve (D) is a cutaneous branch of the femoral nerve. It travels along the medial aspect of the leg along the tibia and is not at risk of injury from a fibular fracture.

A 52-year-old woman presents complaining of increased anxiety, palpitations, weight loss, and heat intolerance over the past 4 weeks. A physical exam is significant for a diffusely enlarged thyroid with a bruit. Radiographic and laboratory results reveal elevated radioactive iodine uptake, elevated free T4 levels, and suppressed TSH levels. Which of the following is the most likely diagnosis? Graves' disease Hashimoto's thyroiditis Pituitary failure Subacute thyroiditis

Correct Answer ( A ) Explanation: Graves' disease is an autoimmune disorder affecting the thyroid gland, characterized by an increase in the synthesis and release of thyroid hormones. It is the most common cause of thyrotoxicosis. In Graves' disease, the formation of autoantibodies (thyroid-stimulating immunoglobins [TSI]) bind to the TSH receptor in the thyroid cell membranes and stimulate the gland to hyperfunction. Clinical features of thyrotoxicosis include nervousness, palpitations, restlessness, heat intolerance, increased sweating, fatigue, weakness, frequent bowel movements, and weight loss. Graves' disease may be accompanied by infiltrative ophthalmopathy (Graves exophthalmos) and, less commonly, by infiltrative dermopathy (pretibial myxedema). Graves' disease is associated with an elevated uptake on the radioactive thyroid scan due to an increase in the activity in the thyroid gland. Because the gland is actually making thyroid hormone, the free T4 level will be increased and the TSH will be suppressed as a result of negative feedback to the hypothalamus and pituitary gland. Patients with Hashimoto's thyroiditis (B) will have an underactive thyroid gland with a decrease in the radioactive iodine uptake. The thyroid gland is not producing enough thyroid hormones so the free T4 level will be low and the TSH level will be increased as the body tries to stimulate the thyroid gland to produce more thyroid hormone. Pituitary failure (C) will not be able to produce thyroid stimulating hormone so these patients will have a decreased radioactive thyroid uptake, a low free T4 level and a low TSH. Patients with subacute thyroiditis (D) have an increase in the release of thyroid hormone rather than an increase in the actual activity of the gland. These patients will have a normal or decreased iodine uptake on the radioactive thyroid scan which is the main differentiating feature between this condition and Graves' disease. The free T4 level can be variable and depends upon when in the course of this condition the thyroid hormones are measured.

A 61-year-old man with a history of diabetes mellitus presents to the emergency department with complaints of weakness, fatigue, chest pain and shortness of breath. His pulse is 58/min, respirations are 14/min and blood pressure is 110/78 mm Hg. Physical exam findings include absent deep tendon reflexes. An ECG shows peaked T-waves, shortened QT interval and ST-segment depression. Which of the following is the most appropriate initial therapy? Calcium Epinephrine Potassium Sodium bicarbonate

Correct Answer ( A ) Explanation: Hyperkalemia is a common clinical finding that occurs when the serum potassium concentration is above 3.5-5.5 mEq/L in adults. The most common cause of hyperkalemia is decreased potassium excretion. This can occur in patients with renal impairment, diabetes mellitus and those taking certain medications such as potassium-sparing diuretics, nonsteroidal anti-inflammatory agents and ACE inhibitors. It can also be the result of increased potassium intake or a shift of potassium from the intracellular to the extracellular space. Many patients with hyperkalemia are asymptomatic. When clinical manifestations occur, patients generally present with symptoms related to cardiac and muscular function. The most common patient complaints are fatigue and weakness. Other symptoms may include chest pain, shortness of breath, nausea, vomiting, and paresthesias. Diagnosis is made when elevated serum potassium is determined through blood testing. The blood test should be repeated before any action is taken to reduce the potassium level in a patient without a previous history of hyperkalemia. Rapid acting therapy should be initiated in patients with hyperkalemia and ECG changes, serum potassium greater than 6.5-7 mEq/L, or in which the serum potassium level is rapidly increasing. Initial therapy is with calcium. Calcium helps to stabilize cardiac membranes but does not actually lower serum potassium levels. Therefore, after calcium is administered, other agents such as insulin with dextrose, should be administered to shift potassium intracellular. Beta-2-adrenergic agents drive potassium into the cells, and albuterol is sometimes used in the management of hyperkalemia. The use of epinephrine (B), another beta-2-adrenergic agent, should be avoided in patients with hyperkalemia because of potential adverse effects such as tachycardia and angina. All potential sources of exogenous potassium should be discontinued in patients with elevated serum potassium and additional potassium (C) should not be given. Sodium bicarbonate (D) raises the systemic pH, resulting in potassium movement into the cells in order to maintain electroneutrality. It may be used as part of the management of hyperkalemia, but is not recommended as initial or monotherapy.

Which of the following is the most common cause of small-bowel obstruction in a 70-year-old man with a history of an appendectomy 50 years ago? Adhesion Incarcerated hernia Intussusception Neoplasm

Correct Answer ( A ) Explanation: In developed countries, postoperative adhesions are responsible for approximately 60% of all cases of small-bowel obstruction (SBO). A particularly high incidence of SBO is found after gynecologic and intestinal surgery, as well as in patients who have previously undergone surgery in the presence of peritonitis or significant abdominal trauma. Overall, adhesions, hernias, and cancer account for more than 90% of cases of small-bowel obstruction. A hernia (B) is the cause of an SBO in approximately 10% of cases. However, this is steadily decreasing due to the elective treatment of external hernias (ironically, by surgery). The most common locations of obstruction from a hernia are inguinal followed by femoral. Intussusception (C) occurs in all age groups but is primarily a disease of infancy and early childhood (3 months to 3 years), constituting the most common cause of SBO in children. Only 5% of intussusceptions occur in adults. Neoplasm (D) is the cause of an SBO in approximately 20% of cases. The most common neoplasm is colon cancer, followed by pancreatic, gastric, and gynecologic malignancies.

A 77-year-old man presents with left sided weakness. The patient woke this morning with difficulty moving his left side. On examination, his leg is weaker than his arm. Which vascular structure is likely responsible for this stroke? Anterior cerebral artery Basilar artery Middle cerebral artery Posterior cerebral artery

Correct Answer ( A ) Explanation: The patient has a stroke syndrome characteristic of the anterior cerebral artery. Patients with ischemic insults to the anterior cerebral artery will often affect frontal lobe function causing patients to lack insight and have impaired judgment. Motor function and sensation is decreased on the opposite site of the body with the lower extremities affected more than the upper extremities. A basilar artery (B) stroke syndrome causes a wide variety of symptoms as this artery feeds the entire vertebrobasilar system or posterior circulation. This structure feeds the reticular activating system leading to impaired levels of consciousness or even loss of consciousness. The basilar artery gives rise to the posterior cerebral artery (D), which supplies the occipital lobe and cerebellum. Patients may experience visual changes related to the occipital lobe involvement. Cerebellar function is impaired demonstrated by nystagmus, difficulty with coordination and ataxia. Patients may also have nausea and vomiting with this vascular involvement. Strokes involving the middle cerebral artery (C) have significant motor and sensory loss on the opposite side of the lesion. The upper extremities are affected more than the lower extremities. If the patient's dominant hemisphere with the language center is involved (most commonly left side of the brain), aphasia is present.

A 67-year-old man with hypertension and end-stage renal disease presents after an incomplete dialysis session secondary to shortness of breath. His vital signs are BP 110/95, HR 65, RR 22, T 37.3°C, and oxygen saturaiton 99% on 2L NC. You obtain the ECG above. Which of the following is the most appropriate next step in this patient's management? Calcium gluconate Cardiology consultation Defibrillation Transcutaneous pacing

Correct Answer ( A ) Explanation: This ECG is indicative of hyperkalemia, one of the most lethal complications of chronic kidney disease encountered in the ED. A potassium level of 6 mEq/L should be considered potentially dangerous, even though many patients with ESRD chronically tolerate serum levels above this and do not manifest ECG changes. The most rapid treatment for hyperkalemia is intravenous calcium (gluconate with peripheral access, chloride with central access), which transiently reverses cardiac effects of hyperkalemia by antagonism of potassium at the cardiac membrane. Calcium is indicated in all patients with suspected hyperkalemia who have widening of the QRS, an unstable dysrhythmia, bradycardia, or hypotension. Cardiology consultation (B) is not needed; the patient's ECG findings are due to an underlying electrolyte abnormality, not a primary cardiac condition. Defibrillation (C) may be necessary if the rhythm deteriorates to ventricular fibrillation. However, should that occur, the definitive management remains removal of potassium from the serum. Transcutaneous pacing (D) can be used as a temporizing measure in patients with symptomatic bradycardia. Hyperkalemic bradycardia responds poorly to pacing. The primary treatment is cardiac membrane stabilization with calcium and subsequent lowering of the serum potassium.

An 18-year-old man presents to the ED with mouth pain for two days. He complains of associated fever, malaise, and a foul metallic taste in his mouth. On examination, you note poor dentition and fetid breath. He has pseudomembrane formation with gingival ulcerations and cervical adenopathy. Which of the following is the most likely diagnosis? Acute necrotizing ulcerative gingivitis Bulimia Diphtheria Ludwig's angina Oral candidiasis

Correct Answer ( A ) Explanation: This patient has acute necrotizing ulcerative gingivitis (ANUG), also referred to as trench mouth. Poor oral hygiene, tobacco use, and immunocompromised states all predispose to ANUG. Anaerobic fusobacterium and spirochetes (Borellia sp.) are the predominant bacterial organisms involved. Painful and severely edematous interdental papillae characterize ANUG. Oral ulcers with an overlying grayish pseudomembrane and a "punched out" appearance are also characteristic. The inflamed gingival tissue is friable and necrotic, and represents an acute destructive disease process of the periodontium. Patients often exhibit fever, malaise, and regional lymphadenopathy and describe a foul-smelling breath and metallic taste in their mouth. The condition is treated by warm saline irrigation of the mouth and antibiotics with oropharyngeal coverage (penicillin, clindamycin, or metronidazole). Hydrogen peroxide or chlorhexadine oral rinses are also useful. Advanced disease requires consultation with an oral surgeon for dental extraction. Bulimia (B) is characterized by binge eating with self-induced vomiting. Patients are at risk for damage to the dental enamel and dentin as a result of repeated episodes of vomiting with chronic exposure to regurgitated gastric acid contents. The lingual dental surfaces are most commonly affected. The toxin-producing bacteria Corynebacterium diphtheria (C) causes diphtheria. It may involve any mucous membrane but most commonly affects the mucosa of the upper respiratory tract. It typically produces an ulcerated pharyngeal mucosa with a white to gray pseudomembrane, classically associated with a "wet mouse" odor. Unlike ANUG, the gingiva is not involved. Ludwig's angina (D) is an extensive cellulitis of the submandibular and sublingual spaces with associated tongue elevation. It is polymicrobial. Patients generally present with fever, trismus, dysphonia, odynophagia, and drooling. Oral candidiasis (E) is associated with white, flaky, curd-like plaques covering the tongue and buccal mucosa with an erythematous base. The white plaques can be removed with a tongue depressor, unlike the plaques of hairy leukoplakia, an opportunistic infection caused by Epstein-Barr virus.

5-year-old boy presents with fever and rash for 2 days. Examination reveals a well appearing child with marked erythema to both cheeks as seen above. What management is indicated? Acetaminophen for fever Cephalexin Mupirocin Topical hydrocortisone

Correct Answer ( A ) Explanation: This patient presents with symptoms consistent with erythema infectiosum and requires supportive care. Erythema infectiousum, or fifth disease is caused by infection with parvovirus B19. The disease is characterized by rash and mild systemic symptoms. The classic rash is deeply red on the face giving a "slapped-cheek" appearance with circumoral pallor. Additionally, a maculopapular, lacelike rash may be seen on the arms and progresses caudally. Rarely, parvovirus B19 has been associated with hepatitis. There is no specific treatment for erythema infectiosum and so management should focus on supportive care and parental reassurance. Acetaminophen or ibuprofen can be used to treat the fever. Cephalexin (B) is a first generation cephalosporin with activity against many streptococcus and staphylococcus species, which are not implicated in erythema infectiousum. Mupirocin (C) is used in the treatment of impetigo. Topical hydrocortisone (D) is useful in the treatment of allergic reactions but not in parvovirus B19 infections.

A 12-year-old boy is brought to the clinic for progressively worsening blurry vision and generalized headaches that are worse in the morning. On further questioning, he is also revealed to have nausea, joint pain, itchy and peeling skin, dizziness, and irritability. Historically, he has been a healthy child and his family follows an organic diet with additional supplements that include 2 tablespoons of cod liver oil and a multivitamin tablet a day. On exam, his weight dropped from the 50th percentile a year before to the 10th percentile currently. He has oily skin and hair and cracking at the corners of his mouth. Chronic overdose of which of the following most likely caused his symptoms? Vitamin A Vitamin C Vitamin D Vitamin E

Correct Answer ( A ) Explanation: Vitamin A toxicity can lead to increased intracranial pressure (associated with headaches, nausea, vomiting, dizziness, blurred vision), oily and peeling skin, cheilosis, alopecia, drowsiness, fatigue, decreased appetite, poor weight gain, joint pain, and liver damage (which leads to jaundice). Cod liver oil supplements contain high levels of vitamin A, which is a fat-soluble vitamin. The maximum level of vitamin A that should be consumed per day is 10,000 international units (IU) and toxicity can occur in daily doses greater than 1,500 IU per day. One tablespoon of cod liver oil can contain more than 14,000 international units of vitamin A. Dietary sources rich in vitamin A include the livers of seals, walruses, moose, and polar bears. Lower amounts are found in milk, eggs, and fresh fruits and vegetables, particularly those with orange, yellow or red color. Although most excess vitamin C (B) is flushed from the body in the urine because it is water soluble, extremely high amounts can lead to toxicity leading to abdominal discomfort, diarrhea, vomiting and headache. Vitamin D (C) and vitamin E (D) are fat-soluble vitamins so are more likely to build-up in the body and cause toxicity. Vitamin D toxicity can lead to vomiting, decreased appetite, constipation, muscle weakness and calcification of soft tissues. Vitamin E toxicity can lead to increased triglycerides, blotchy skin and decreased activity of vitamin K which can lead to increase bleeding.

A homeless man presents with difficulty walking and painful calves. He has a history of alcohol abuse and ulcerative colitis, both untreated. He denies a history of chronic diarrhea. A blood tox screen is negative for alcohol and illicit drugs. His examination is significant for several neurologic findings: altered proprioception, distal numbness, hyporeflexia, mental confusion and nystagmus. Perioral and tongue examination is normal. These symptoms are most likely related to a deficiency of which of the following vitamins? Vitamin B1 Vitamin B2 Vitamin B3 Vitamin C

Correct Answer ( A ) Explanation: Vitamin B1, thiamine, is necessary for energy, carbohydrate, lipid and amino acid metabolism. It acts as a component of the coenzyme responsible for conversion of pyruvate to acetyl-CoA. Thiamine is also essential for proper nerve and muscle function. Risk factors include a diet high in refined sugars, alcoholism, malnourishment, pancreatitis, liver disease, inflammatory bowel disease, bariatric surgery, renal failure and kidney dialysis, chemotherapy, cancer, AIDS, hyperthyroidism and chronic diarrhea. Although uncommon in most developed countries, thiamine deficiency still exists in present-day prisons. Chronic thiamine deficiency can lead to beriberi, a condition marked by cardiac ("wet" beriberi) and nervous system ("dry" beriberi) abnormalities. Concerning dry beriberi, symptoms include numbness, paresthesias, decreased proprioception, ataxia, hyporeflexia, painful calves, confusion, abnormal eye movements, nystagmus, vomiting and partial paralysis. Deficiency of vitamin B2 (B), riboflavin, causes rash, cracked red skin in the corner of the mouth, a painful smooth purplish tongue and light sensitivity. Deficiency of vitamin B3 (C), niacin, is called pellagra, and is characterized by diarrhea, dermatitis and dementia. Deficiency of vitamin C (D), ascorbic acid, is called scurvy, and results in anemia, abdominal complaints, frequent infections, bleeding gums, loose teeth, bruising, poor wound healing, myalgia, headache, fatigue and bone disorders.

Which of the following best describes the finding seen in the ECG above? Left bundle branch block Right bundle branch block Third-degree AV block Type I second-second degree AV block

Correct Answer ( B ) Explanation: Bundle branch blocks are abnormal conduction abnormalities (not rhythm disturbances) in which the ventricles depolarize in sequence, rather than simultaneously, thus producing a wide QRS complex (> 120 msec) and a ST segment with a slope opposite that of the terminal half of the QRS complex. A right bundle branch block (RBBB) is a unifascicular block in which ventricular activation is by way of the left bundle branch. The impulse travels down the left bundle, thus activating the septum from the left side (as it normally does in the absence of RBBB). This is followed by activation of the free wall of the left ventricle and finally the free wall of the right ventricle. Because of the two changes in direction, there is a tendency toward triphasic complexes in a RBBB (RSR'). The ECG in a RBBB will show a wide S wave in lead I and a RSR' pattern in lead V1. In left bundle branch block (A), lead I has a large R wave and in lead V1 there is a negative QS or rS complex. Third-degree AV block (C) presents with unmatched ratios of P waves to QRS complexes. Type I second-second degree AV block (D) has prolonged PR intervals.

A 72-year-old man with a history of hypertension and coronary artery disease presents with acute onset, painless loss of vision in his right eye. His visual acuity is 20/200 OD and 20/25 OS. His fundoscopic examination is shown above. What is his likely diagnosis? Acute angle closure glaucoma Central retinal artery occlusion Central retinal vein occlusion Retinal detachment

Correct Answer ( B ) Explanation: Central retinal artery occlusion is an ischemic stroke of the retina. It occurs most commonly in patients 50-70 years of age and those with risk factors including hypertension, cardiac and carotid artery disease, vasculitis, and collagen vascular disease. Patients present with an acute onset of unilateral, painless loss of vision that occurs over seconds to minutes. Visual acuity is markedly reduced and there will be an afferent pupillary defect. Fundoscopic examination will reveal an edematous, pale retina with a cherry-red spot. Emergent ophthalmologic consultation is indicated. Potential therapies include digital globe massage, anterior globe paracentesis, intraocular pressure lowering agents such as acetazolamide, and intraarterial thrombolytic therapy. Unfortunately, none of these therapies have been conclusively shown to be beneficial and the prognosis for recovery of vision is poor. Acute angle closure glaucoma (A) presents with acute onset of severe eye pain, headache, nausea and decreased visual acuity. Central retinal vein occlusion (C) also causes a painless loss of vision, but fundoscopic examination will show retinal hemorrhages ("blood and thunder" appearance). Symptoms of retinal detachment (D) include flashes of light and floaters followed by painless vision loss described as curtain-like. Large detachments may be visualized by direct fundoscopy, but indirect ophthalmoscopy is often necessary. Retinal detachment can also be seen on bedside ultrasound.

What is the most commonly seen symptom or sign in patients with acute aortic dissection? Aortic insufficiency murmur Chest pain Pulse deficit Syncope

Correct Answer ( B ) Explanation: Chest pain is the most common symptom seen in patients with acute aortic dissection. Aortic dissection is an uncommon presentation but it represents a difficult and life-threatening diagnosis. Difficulty in diagnosing the disease stems from the myriad of presentations and manifestations the disease can assume. Approximately 73% of patients with acute aortic dissection will present complaining of chest pain. This symptom is more common in those patients with ascending dissections whereas back pain is more common in those with descending thoracic dissections. Some complaint of pain is seen in up to 96% of patients. The pain is classically described as ripping or tearing but only about 50% of patients will describe it in this way. Aortic insufficiency murmur (A) results from an ascending dissection that compromises the aortic valve but is only seen in about 32% of patients. Pulse deficit (C) is even less common (15%). Syncope (D) is seen in approximately 9% of aortic dissections.

Which of the following is the most appropriate treatment for bacterial vaginosis? Azithromycin Ceftriaxone Fluconazole Metronidazole

Correct Answer ( D ) Explanation: Metronidazole is highly effective therapy for bacterial vaginosis. The patient with bacterial vaginosis is most likely to complain of malodorous discharge. The discharge tends to be thin and yellowish-gray. The odor is best described as "fishy" and is caused by amines such as methylamine. These amines volatilize at increased pH, which explains the propensity of the patient to notice the odor when her secretions are more alkaline (e.g., during menses, after intercourse). Vulvovaginal irritation is not usually a prominent symptom, hence the use of the term vaginosis rather than vaginitis. Vaginal pH is typically elevated to greater than 4.6. A fishy amine odor is produced when vaginal secretions are mixed with 10% KOH. Microscopic examination of vaginal secretions suspended in 0.9% NaCl reveals few leukocytes and many small bacilli - described as clue cells. Azithromcycin (A) is used as treatment for chlamydia. Ceftriaxone (B) is used to treat gonorrhea, whereas fluconazole (C) is used in the treatment of candidiasis.

A 82-year-old woman with a history of diabetes mellitus, coronary artery disease, and congestive heart failure is hospitalized for sepsis secondary to a urinary tract infection. She complains of disequilibrium and tinnitus which has developed over the past few days. In addition, she cannot hear high frequency sounds well. Which of the following of her medications is the most likely culprit? Aspirin Gentamicin Hydrochlorothiazide Metformin

Correct Answer ( B ) Explanation: Numerous medications can cause injury to the inner ear, known as ototoxicity. By affecting the cochlea, semicircular canals, and otoliths, ototoxic medications result in clinical symptoms of high frequency hearing loss, tinnitus, disequilibrium, and vertigo. Over 100 classes of medications have been implicated as ototoxic. Aminoglycoside antibiotics are the most commonly implicated class of medications. Kanamycin, amikacin, and neomycin preferentially injure the cochlea and affect hearing, while streptomycin and tobramycin affect the vestibular system, causing disequilibrium and vertigo. Gentamicin can affect both the cochlea and vestibular systems. The exact mechanism of aminoglycoside-induced ototoxicity is unknown, and may be multifactorial. Proposed mechanisms include free radical-induced damage to the inner ear, direct toxic effects on cellular membrane potentials, and loss of sensory hair cells in the cochlea and vestibule. Risk factors for aminoglycoside-induced ototoxicity include higher doses, elevated blood levels, and longer durations of therapy. Ototoxicity is more likely in elderly patients and those with underlying renal insufficiency. Other medications associated with ototoxicity include macrolide antibiotics, vancomycin, loop diuretics, antineoplastic agents, salicylates, and quinine. If ototoxicity is suspected, the offending agent should be stopped. Prognosis for recovery of function depends on the ototoxic agent. Aspirin (A) and other salicylate overdoses can cause tinnitus and ototoxicity, but there is no indication from the question stem that she has overdosed on aspirin. Hydrochlorothiazide (C) is not associated with hearing loss. However, furosemide, a loop diuretic is. Metformin (D) does not commonly cause ototoxicity.

A 12-year-old boy presents to the ED after his brother bumped into his elbow while he was using a cotton-tipped swab to clean out his ear. He denies dizziness, vertigo, nausea, or hearing loss. On exam, you note a tear of the tympanic membrane and a small amount of blood in the external canal. Which of the following is the most appropriate next step in management? Begin antibiotics Discharge with instructions to keep the ear canal dry Emergency department consultation to ENT Pack the ear with gauze

Correct Answer ( B ) Explanation: Perforation of the tympanic membrane (TM) can result from a penetrating object, loud noise, infection, lightning strike, or rapid change in pressure. Otoscopic exam usually reveals a tear with immobility of the membrane. Acute perforations have irregular borders with blood on the edges or in the canal. Patients may complain of hearing loss, nausea, vomiting, vertigo, or facial palsy. Most perforations heal spontaneously, and since this patient is asymptomatic, he can be discharged home with instructions to keep the ear dry. If the patient was symptomatic, it would suggest the presence of concurrent injury to the inner ear structures and require emergent ENT referral (C). Furthermore, antibiotics (A) are not recommended in patients with ruptured tympanic membranes unless caused by an infection. Packing the ear with gauze (D) is not recommended, though some people find it helps keep the ear canal dry during a shower.

Which of the following is true regarding posterior nasal packing for epistaxis? Packing should be left in place for 7 days Patients should be admitted to a monitored bed Topical antibiotics are sufficient for infection prophylaxis Toxic shock syndrome is a common complication «

Correct Answer ( B ) Explanation: Posterior nasal packing causes vagal stimulation and therefore can cause bradycardia and bronchoconstriction. In addition to the bleeding risks, these patients are at increased risk for dysrhythmia and airway compromise. Therefore, they should be admitted to at least a telemetry monitored bed. Systemic and topical antibiotics (C) have not be shown to be of clear benefit in preventing toxic shock syndrome or sinusitis related to nasal packing. Although toxic shock syndrome (D) is a known complication of posterior nasal packing, it is rare. Packing should be removed in 3-5 days (A), as the risk of tissue necrosis increases with the length of time packing is in place.

A 36-year-old woman presents with numbness to her arms and legs for 2 hours. She had a total thyroidectomy 3 days prior to presentation and is on thyroid hormone replacement therapy. Vital signs are normal and the patient's exam is significant for a clean, well-healing surgical incision on her neck and twitching of the corners of the mouth with tapping at the angle of the jaw. What treatment is indicated? Obtain a non-contrast CT scan of the head Replete calcium Replete potassium Stop thyroid hormone replacement

Correct Answer ( B ) Explanation: The patient presents with hypocalcemia requiring emergent calcium repletion. Hypocalcemia can present with varied symptoms including parasthesias, muscle weakness, muscle spasm, bradycardia, hypotension, QT prolongation, bronchospasm, anxiety, confusion, seizures and hyperreflexia. A common finding is neuromuscular hyperexcitability, which can be demonstrated by eliciting twitching of facial muscles by tapping over the facial nerve at the angle of the mandible (Chvostek's sign). Carpal spasm in response to inflation of a blood pressure cuff to 20 mm Hg above systolic blood pressure for 3 minutes (Trousseau's sign) is another common finding of neuromuscular hyperexcitability. Treatment of hypocalcemia should start with verification of the serum calcium level (ionized calcium is preferred) although treatment can be started in clinical scenarios that are highly suggestive of hypocalcemia or if the patient is experiencing tetany, seizures, hypotension or dysrhythmias. Hypocalcemia is a common complication of thyroid surgery secondary either to inadvertent parathyroidectomy or interruption of the parathyroid vascular supply. Either calcium chloride or calcium gluconate can be used for calcium repletion. Hyperthyroidism caused by excess levothyroxine (D) can cause a vast number of symptoms including parasthesias but patients will usually have other manifestations of hyperthyroidism (hyperreflexia, tachycardia, weight loss etc.). Additionally, hypocalcemia is not a common finding in hyperthyroidism. Hypokalemia (C) can also cause a multitude of symptoms but neuromuscular hyperexcitability is not among them. A non-contrast head CT (A) is indicated in the workup of a patient with central neurologic pathology (i.e. stroke) but the facial muscle twitching in this patient is peripheral hyperexcitability not central.

A 19-year-old sexually active woman presents to your office with questions about cervical cancer screening. She wants to know when she should start getting screened since she's been sexually active for two years. Which of the following is the most appropriate next step in management? Initiate screening at age 21 with cytology and human papillomavirus testing Initiate screening at age 21 with cytology only Initiate screening now with cytology and human papillomavirus testing Initiate screening now with cytology only

Correct Answer ( B ) Explanation: The two main types of cervical cancer are squamous cell carcinoma and adenocarcinoma, with squamous cell carcinoma being more common. Risk factors for cervical cancer include activities that lead to infection with the human papillomavirus (HPV), oral contraceptive use and cigarette smoking. Cervical cancer rates in the United States have decreased significantly since the Papanicolaou (Pap) screening test to evaluate cytology was introduced. Testing for the presence of HPV is also a part of cervical cancer screening. Cervical cancer screening can detect pre-cancerous cells and early stage cancer, allowing for more rapid intervention and treatment. Women aged 21-65 should undergo screening with cytology using the Pap smear every three years. Women aged 30-65 years who want to increase the interval of testing may add HPV testing to the Pap smear and undergo co-testing every five years. Abnormal results require individualized adjustments to the screening schedule. HPV testing is not recommended in women under age 30 (A). Younger women are more likely to have transient HPV infections and testing at a young age leads to unnecessary colposcopies. Cervical cancer screening with cytology only (D) or co-testing with HPV (C) is not recommended in women under age 21 regardless of sexual activity.

A 91-year-old man was diagnosed with a middle cerebral artery thrombotic stroke last week. He currently has 3/5 motor strength in his left upper extremity and his left leg. According to the World Health Organization, this patient's hemiplegia would be considered a(an)? Disability Handicap Impairment Limitation

Correct Answer ( C ) Explanation: "Disability" is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure. The United States government funds 3 major disability programs: Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), and worker's compensation. An activity limitation, or disability (A), is a difficulty encountered by an individual in executing a task or action. A participation restriction, or handicap (B), is a problem experienced by an individual in involvement in life situations. There is no specific definition of a limitation (D).

You are called to examine a three-year-old boy in the emergency department for possible ingestion. He was found by his father drooling and playing with an opened drain cleaner. After suspecting a caustic ingestion, he immediately called poison control and was advised to bring the boy to the Emergency Department. The boy is irritable and drooling. His physical examination is normal. Which of the following is the most appropriate next step in management? Give activated charcoal Give prophylactic antibiotics Order an upper endoscopy Perform gastric lavage

Correct Answer ( C ) Explanation: Caustic materials cause tissue injury. Caustic alkaline materials are found in drain cleaners, various cleaning agents, hair relaxers, dishwasher agents, and disk batteries. Alkalis produce liquefaction necrosis that allows further tissue penetration of the toxin and setting the stage for possible perforation. On the other hand, acids in household products include toilet bowl cleaners, swimming pool cleaners, and rust removers. Acids produce a coagulative necrosis that limits further tissue penetration, though perforation can still occur. Ingestion of caustic materials can produce injury to the oral mucosa, esophagus, and stomach. The symptoms include pain, drooling, vomiting, abdominal pain, and difficulty swallowing. Initial treatment of caustic exposures includes thorough removal of the product from the skin or eye by flushing with water. Endoscopy should then be performed within 12 to 24 hours of ingestion in symptomatic patients or those in whom injury is suspected. Giving activated charcoal (A) is not appropriate because it does not bind the caustic agents and can predispose the patient to vomiting and subsequent aspiration. Giving prophylactic antibiotics (B) does not improve the outcome of caustic ingestion. Performing gastric lavage (D) is contraindicated because it can lead to emesis and subsequent aspiration.

A patient is diagnosed with central diabetes insipidus. Which of the following medications should you prescribe? Carvedilol Demeclocycline Desmopressin Metformin

Correct Answer ( C ) Explanation: Diabetes insipidus is a disorder of antidiuretic hormone (ADH) function that leads to excessive urination and thirst. Treatment is geared at monitoring, replacing lost fluid and ADH analogues. Most patients are able to take in enough oral fluids to replace that lost in the urine. If dehydration is prominent, intravenous fluids may be necessary, and are usually given at 500-750 ml/h. If diabetes insipidus is found to be of the central type, the drug of choice is desmopressin (DDAVP), an ADH analogue. It can be given orally, intranasally, intravenously or subcutaneously. Electrolyte and fluid status monitoring is still important in those taking desmopressin. Alternatives to desmopressin include chlorpropamide, the thiazides and carbamazepine. A low protein, low sodium diet may also help in decreasing urinary output. Carvedilol (A) is a beta-blocker used in the treatment of congestive heart failure. Demeclocycline's (B) action as a vasopressin (ADH) antagonist makes it an ideal medication to treat excess ADH (SIADH), not insufficient ADH, as in diabetes insipidus. Metformin (D) is used in treating diabetes mellitus, not diabetes insipidus.

A 21-year-old track-and-field athlete trips during her last race, costing her the win, and resulting in severe foot pain. She presents with erythema and edema. During examination, stabilization of the calcaneus and rotation of the forefoot results in a clicking sensation and severe dorsal foot discomfort. Toe flexion and extension is maintained in a normal, nonpainful range. You most likely suspect a dislocation of which of the following joints? Fibulotalar Metatarsophalangeal Tarsometatarsal Tibiotalar

Correct Answer ( C ) Explanation: Fracture-dislocation of the tarsometatarsal joints is commonly called a Lisfranc injury. These joints exist between the three cuneiforms and the cuboid proximally and the five metatarsals distally, with the key joint being the "locking" interaction between the middle cuneiform and the second metatarsal base. Common mechanisms of injury include trauma and tripping. Pain is located on the dorsum of the midfoot, as compared to perimalleolar ligamentous pain. As such, Lisfranc injuries are easily misdiagnosed as ankle sprains. A key exam finding is pain with forefoot rotation against a stabilized hindfoot (calcaneus). This maneuver is not painful in ankle sprains or ankle mortise injury, but severely painful with Lisfranc injuries. Diagnosis can be upheld when an AP radiograph reveals lateral shift of the second metatarsal off the middle cuneiform. Nondisplaced injuries are treated with non-weight bearing casting, however, any displacement necessitates surgical intervention. Metatarsophalangeal (B) injury would typically result in painful and limited toe flexion-extension. Fibulotalar (A) and tibiotalar (D) instability/malalignment injuries occur with ankle sprain, dislocation or fracture. With these injuries, forefoot rotation around the hindfoot does not commonly result in pain.

A three-year-old boy is brought to the Emergency Department by his father because of possible poisoning. He was found in the garage with furniture polish on his cheeks, mouth, and clothes. The father saw him coughing but denies choking or vomiting. On examination, the boy is active with normal vital signs. Which of the following is the next best step? Consult pulmonology Give activated charcoal Obtain chest X-ray Perform gastric lavage

Correct Answer ( C ) Explanation: Hydrocarbon toxicity can result from ingestion of furniture polish. A transient and mild CNS depression is commonly noted after hydrocarbon ingestion or inhalation. Aspiration is characterized by coughing, which usually is the first clinical finding. It is important to obtain a chest radiograph. It may initially be normal, but they often show abnormalities within six hours of exposure in patients who have aspirated. Respiratory symptoms can remain mild or progress rapidly to the acute respiratory distress syndrome (ARDS) and respiratory failure. If hydrocarbon-induced pneumonitis develops, respiratory treatment is supportive. Corticosteroids or prophylactic antibiotics have not shown any clear benefit. Standard mechanical ventilation, high-frequency ventilation, and ECMO have all been used to manage the respiratory failure and ARDS associated with severe hydrocarbon-induced pneumonitis. The patient should be stabilized and worked up in the ED before consulting pulmonology (A). Giving activated charcoal (B) is not useful because it does not bind the common hydrocarbons and can also induce vomiting. Performing gastric lavage (D) is contraindicated given the risk of aspiration.

An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient's bleeding? Angiodysplasia Diverticular bleeding Ischemic colitis Peptic ulcer disease

Correct Answer ( C ) Explanation: Ischemic colitis is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and possible gangrene of the bowel wall. Patients typically present with fairly acute onset crampy abdominal pain with tenderness over the affected bowel. Patients may have bloody diarrhea or passage of frank blood although it is not usually enough to warrant transfusion. The presentation with ischemic colitis differs from acute mesenteric ischemia which presents as pain that is disproportionate to physical examination findings. Risk factors include a history of atherosclerotic disease at other sites, such as coronary artery disease or cerebrovascular disease, advanced age, sepsis and extreme exercise. Bowel wall edema is the most common finding on CT imaging. All cases of ischemic colitis with signs of peritonitis or possible bowel infarction, generally warrant immediate surgical intervention for the resection of the ischemic or necrotic bowel, although this only occurs in about 20% of cases. Most cases resolve with supportive care (eg. IV fluids and bowel rest). Angiodysplasia (A) is a degenerative lesion of previously healthy blood vessels found most commonly in the cecum and results in hematochezia. Bleeding is usually chronic or recurrent and, in most cases, low grade and painless because of the venous source. Diverticular bleeding (B) is the most common cause of lower gastrointestinal hemorrhage. Patients with diverticular bleeding usually present with an abrupt onset of painless rectal hemorrhage. Occasionally, patients may present with mild abdominal cramping or the urge to defecate, secondary to blood within the colon. Peptic ulcer disease (D) can result in an upper gastrointestinal bleed, which often presents with coffee ground emesis, dysphagia, black stools, and chest pain. A negative gastric lavage indicates a very low likelihood of an upper gastrointestinal bleed.

Perforation of what gastrointestinal structure is associated with the highest mortality? Cecum Duodenum Esophagus Stomach

Correct Answer ( C ) Explanation: Perforation of any viscus is associated with significant morbidity and mortality. Perforation of the esophagus most often is diagnosed late resulting in a fulminant course ending in death. Anatomically the esophagus lacks a serosal layer causing immediate contamination of the mediastinum with most esophageal perforations. Perforations can occur from various causes including forceful vomiting, childbirth, cough, heavy lifting, endoscopy, and nasogastric tube placement. More than 90% of spontaneous esophageal ruptures occur in the distal esophagus. In contrast, rupture resulting from blunt trauma to the neck or thorax usually occurs in the proximal and middle third of the esophagus. Treatment includes early initiation of broad-spectrum antibiotics. The combination of a second-generation cephalosporin and an aminoglycoside usually provides adequate coverage. Patients should be kept NPO and early consultation is warranted. As stated above, perforation of any viscus is associated with high morbidity and mortality. Rupture of the esophagus is associated with a higher mortality than then rupture of the cecum (A), duodenum (B), and stomach (D). Stomach and duodenal perforations most commonly occur from ulcers. Intestinal perforations typically lead to peritonitis which presents rapidly with fever and abdominal pain. Many small perforations get walled off such as in Crohn's disease.

A four-year-old boy is new to your practice and comes into the clinic with his mother for a health supervision visit. The family recently migrated from the Middle East. The mother does not have any concerns. On exam, you note height at 5th percentile, enlargement of the costochondral junction, widening of the wrist and varus deformities of the legs. X-ray shows osteopenic epiphyseal centers. Laboratory tests reveal elevated alkaline phosphatase and low serum phosphorus and calcium. Which of the following is the most likely diagnosis? Blount disease Hypophosphatasia Rickets Skeletal dysplasia

Correct Answer ( C ) Explanation: Rickets refers to deficient mineralization at the growth plate. The boy in the vignette has calcipenic rickets that is caused by calcium deficiency. This is due to insufficient intake or metabolism of vitamin D. The typical findings are enlargement of the costochondral junction or "rachitic rosary," widening of the wrists, bowing of the distal radius and ulna, and progressive lateral bowing of the femur and tibia. The epiphyseal bone centers may be delayed, or they may be small, osteopenic, and ill-defined in radiographs. In severe rickets, there are pathological fractures and Looser zones (or Milkman pseudofractures). Typical laboratory findings include elevated serum alkaline phosphatase and low serum phosphorus concentrations. The serum calcium concentration may be either decreased or normal in calcipenic rickets. Blount disease (A) is pathologic varus deformity that results from disruption of normal cartilage growth at the medial aspect of the proximal tibial physis. Typical radiographic finding is that of a varus deformity of the proximal tibia with medial beaking and downward slope of the proximal tibial metaphysis. Hypophosphatasia (B) is a rare genetic disorder characterized by bone demineralization that is similar to rickets. But in contrast to rickets, serum alkaline phosphatase activity is very low. In skeletal dysplasia (D) there is the presence of bilateral and symmetric bowed legs. The radiographic features can be similar to those of rickets. However, serum phosphorus is usually normal.

A 72-year-old man presents to the Emergency Department with chest pain. During triage, he collapses and nursing staff cannot feel his pulse. The patient is taken to a treatment room where cardiopulmonary resuscitation is initiated and the above cardiac rhythm is noted. What is the next best step? Administration of amiodarone Cardioversion Defibrillation Two minutes of chest compressions

Correct Answer ( C ) Explanation: Sudden cardiac death is a leading cause of mortality. It occurs in a bimodal age distribution: infancy and individuals > 45 years or age. There is a slight predominance in men. In a sudden episode of cardiac death, the initial rhythm is most likely ventricular fibrillation, or ventricular tachycardia that degenerates into ventricular fibrillation. In a witnessed cardiac arrest, if the initial rhythm is amenable to defibrillation, a shock should be administered as soon as possible. Defibrillation is the best chance of recovering a perfusing rhythm from a nonperfusing rhythm. The longer a heart is in a nonperfusing rhythm, the less likely it is to respond to defibrillation and cardiac life support. Two minutes of chest compressions (D) is the standard cycle length for chest compressions. In the unwitnessed cardiac arrest, two minutes of chest compression should be initiated to "prime" the heart to receive defibrillation. However, in a witnessed arrest an immediate shock should take precedence. Administration of amiodarone (A) is a pharmacologic attempt to achieve a stable cardiac rhythm. It is indicated for persistent pulseless ventricular tachycardia or ventricular fibrillation after defibrillation and epinephrine have not resulted in a perfusing cardiac rhythm. Cardioversion (B) is indicated in an unstable (but not pulseless) cardiac rhythm (e.g. atrial fibrillation with rapid ventricular response) in an attempt to recover a normal sinus rhythm for the patient. Cardioversion does not play a role in the pulseless patient.

A previously healthy six-year-old girl is brought to the emergency room by her parents because of sudden bruising. She noted bruising when she woke up this morning. She denies trauma, fever, joint pain, weight loss, headache, nose bleeding, or blood in the stool. She did not have any prior illness. On physical examination, vital signs are normal, with petechiae and purpura on the extremities, chest, and buttocks. Laboratory testing shows platelet count of 30,000/microL. Which of the following is the next best step in management? Infuse intravenous immunoglobulin (IVIG) Platelet transfusion Restrict physical activities with risk of trauma Start glucocorticoids

Correct Answer ( C ) Explanation: The girl's signs, symptoms, and laboratory findings are most suspicious for immune thrombocytopenia (ITP). ITP typically presents with the sudden appearance of a petechial rash, bruising, or bleeding in an otherwise healthy child. According to a large registry study of children with newly diagnosed ITP, the following bleeding manifestations were reported: cutaneous (petechiae, purpura, or bruising) in 86 percent, oral in 19 percent, nasal in 20 percent and no bleeding in 9 percent. Serious bleeding occurs in approximately 3 percent of children with ITP and intracranial hemorrhage may develop in approximately 0.5 percent. The diagnosis of ITP is based upon the following criteria: platelet count < 100,000/microL, otherwise normal complete blood count, and no abnormalities on the peripheral blood smear. ITP in children often resolves spontaneously within three months. Depending on individual patient characteristics, appropriate initial management of newly diagnosed ITP may be either watchful waiting or pharmacologic intervention. As recommended by the American Society of Hematology, no pharmacologic intervention or "watchful waiting" is done for most children with no bleeding or mild bleeding (only bruising and petechiae), regardless of platelet count. Restricting physical activities with risk of trauma is recommended for children with moderate or severe thrombocytopenia. Infusing IVIG (A) and starting glucocorticoids (D) are pharmacologic interventions for ITP that are not indicated at this time for the girl in the vignette. Pharmacologic intervention is generally reserved for children with severe or life-threatening bleeding. When it is decided to use pharmacologic therapy to acutely increase the platelet count, treatment options include IVIG, intravenous anti-D immune globulin (anti-D), or glucocorticoids. Platelet transfusion (B) is generally contraindicated in ITP with the exception of patients with active life-threatening hemorrhage like intracranial hemorrhage.

A 45-year-old man presents with left leg pain. He describes a sudden onset pain in his calf area while playing basketball with his son. On exam, you squeeze his right calf and elicit plantar flexion of the right foot. When you do the same with his left calf there is no plantar flexion of his left foot. You administer ibuprofen and place the left leg in a posterior splint. Which of the following is the most appropriate next step in management? Obtain X-rays of the ankle and foot Prescribe physical therapy Refer to orthopedic surgery Screen for autoimmune diseases

Correct Answer ( C ) Explanation: This patient has an abnormal Thompson test, a common clinical test used to diagnosed Achilles tendon rupture. Achilles tendon rupture typically occurs in the setting of sudden and forced dorsiflexion during athletic activity. Patients often report an audible "pop" and sudden pain in the calf area that improves or subsides quickly, followed by decreased ability to plantar flex the foot. The diagnosis is typically clinical. On physical examination, patients may exhibit a palpable tendon defect in the lower calf area. Some plantar flexion is usually maintained, even in cases of complete tendon rupture, due to the actions of the surrounding muscles. The Thompson test is a classic maneuver to assess the Achilles tendon. The patient lies prone, with the legs flexed at the knee at 90 degrees. The examiner then squeezes the calf muscles and observes for passive plantar flexion of the foot. The injured extremity will have a weakened or no response compared to the uninjured side. Risk factors for Achilles tendon rupture include rheumatological diseases, chronic renal failure, steroid use and recent treatment with fluoroquinolone antibiotics. Controversy remains regarding the best treatment. While early operative repair is associated with lower risk of rerupture and possibly improved functional outcome, it also has a higher rate of complications. Nonoperative management consists of a series of casts. Ultimately, the decision depends on the patient's age, activity level and preference, and is best made on a non-emergent basis in consultation with an orthopedic surgeon or sports medicine physician. Thus, initial management includes non-steroidal anti-inflammatory analgesics, crutches and non-weightbearing status, immobilization of the ankle in plantar flexion with a splint, and outpatient referral. Achilles tendon rupture is a primarily clinical diagnosis, and imaging studies such as ankle and foot X-rays (A) are not routinely indicated. While early mobilization with physical therapy (B) leads to improved functional outcomes, definitive management (operative or nonoperative) should be initiated first. Even though Achilles tendon rupture is more common in patients with autoimmune diseases (D) such as rheumatoid arthritis or systemic lupus erythematosus, screening is not initially indicated and not performed in the setting of traumatic rupture.

A 73-year-old man presents to his primary care provider complaining of rough bumps on his head. The man is a retired farmer. On physical exam, there are three rough, erythematous papules on his forehead. The lesions are nontender to palpation. Which of the following is the most appropriate management? Bacitracin Topical 0.1% triamcinolone Topical 5% 5-fluorouracil Topical clotrimazole

Correct Answer ( C ) Explanation: Topical 5% 5-fluorouracil is the most appropriate management for actinic keratosis. Actinic keratosis (AK) are ultraviolet light-induced skin lesions that arise from proliferation of atypical epidermal keratinocytes. AKs have the potential to progress to squamous cell carcinoma. It is estimated that AKs have a transformation rate of 0.03 to 20% per year. Risk factors for the development of AK include fair skin, outdoor occupations, history of sunburn, male sex, increased age, and immunosuppression. AKs most commonly present as solitary or multiple, rough, scaly, erythematous papules on sun-exposed areas. The scalp and forehead are the most common site in men. AKs are commonly seen on the lower extremities in women. The diagnosis of AK is made through physical exam. A punch or shave biopsy is indicated if squamous cell carcinoma is suspected. There are multiple treatment options for AK include surgery, cryotherapy, topical medications (e.g. 5-fluorouracil, imiquimod, diclofenac), chemical peels, and photodynamic therapy. Topical medications are commonly used to treat multiple AKs. Bacitracin (A) is a topical antibiotic that is commonly used to treat and prevent minor skin infections. Bacitracin is one of the first-line treatments for limited impetigo. Bacitracin works by inhibiting bacterial cell wall synthesis. Topical 0.1% triamcinolone (B) is a high-potency corticosteroid. High-potency topical corticosteroids are often used to treat conditions such as lichen planus, psoriasis, lichen simplex chronicus, atopic dermatitis, and allergic contact dermatitis. High-potency topical corticosteroids should not be used on the face or around the genitals. Topical clotrimazole (D) is used to manage cutaneous dermatophytosis and cutaneous candidiasis. Topical clotrimazole works by increasing cell membrane permeability and thereby allowing leakage of intracellular elements. Neither bacitracin, topical 0.1% triamcinolone, or topical clotrimazole are used in the management of actinic keratosis.

A 35-year-old man with a history of human immunodeficiency virus presents to your office with complaints of urinary symptoms, chills and muscle aches. Physical exam findings include a temperature of 102.1°F, pain to palpation of the suprapubic area, and a warm, firm, exquisitely tender prostate on rectal exam. Which of the following is the most appropriate therapy? Abacavir Nitrofurantoin Tamsulosin Trimethoprim-sulfamethoxazole

Correct Answer ( D ) Explanation: Acute bacterial prostatitis occurs when microorganisms enter the prostate gland through the urethra. Prostatitis often presents in the primary care setting among young and middle-aged men, however bacterial prostatitis is relatively uncommon. Risk factors include conditions that predispose men to urogenital infections such as anatomical anomalies and urogenital instrumentation. Lower urinary tract symptoms including prostatitis occur more frequently in men with human immunodeficiency virus (HIV). It is unclear why this occurs. Men with acute bacterial prostatitis present as acutely ill with spiking fever, malaise, chills, urinary symptoms and myalgias. Diagnosis is made clinically with digital rectal exam. Urine gram stain and culture establishes the microbial etiology. Pathogens causing infection are generally gram-negative organisms, therefore empiric treatment with antibiotics that treat gram-negative infections should be administered immediately. First-line treatment is with trimethoprim-sulfamethoxazole or a fluoroquinolone such as ciprofloxacin or levofloxacin. Patients who cannot tolerate oral medication, are exhibiting signs of sepsis or have bacteremia should be hospitalized. Abacavir (A) is a nucleoside/nucleotide reverse transcriptase inhibitor used in the treatment of human immunodeficiency virus (HIV). Nitrofurantoin (B) is commonly used to treat urinary tract infections in women, but has poor tissue penetration and is not recommended for treatment of prostatitis. Tamsulosin (C) is an alpha-one blocker used to treat benign prostatic hypertrophy, symptoms of bladder outlet obstruction and ureteral calculi expulsion.

A 73-year-old man with a history of arthritis presents with complaints of a low-grade fever and severe right knee pain for the past three days, with an inability to bear weight since this morning. On exam, you note exquisite right knee tenderness and a large effusion. There is limited range of motion both actively and passively, and he refuses to ambulate. You perform an arthrocentesis and drain 20 mL of turbid fluid. Laboratory analysis of the joint fluid reveals the following: WBC of 55,000/µL with 95% neutrophils and a glucose level of 60 mg/dl (serum glucose is 140 mg/dl). Gram stain and crystal analysis are not immediately available. Which of the following is the most likely diagnosis? Acute gout Osteoarthritis Rheumatoid arthritis Septic arthritis

Correct Answer ( D ) Explanation: Any patient with an acute monoarticular arthritis should be considered to have septic arthritis until proven otherwise. Patients at increased risk for septic arthritis include the elderly, those with prosthetic joints, IV drug abusers, and the immunocompromised. Septic arthritis often occurs in patients with a history of chronic arthritis, complicating the diagnosis. In healthy adults, the knee is the most commonly affected joint, but in IV drug abusers, common sites include the sacroiliac, sternoclavicular, and intervertebral joints. In children, the knee and hip are most commonly affected. Synovial fluid results in this case are consistent with a bacterial rather than inflammatory etiology (see table below). Fluid culture will help confirm the diagnosis of septic arthritis, but such results take time to complete. Empiric treatment should be initiated. Gout (A) is a disease of middle-aged men and elderly adults and is typically monoarticular. It is caused by deposition of uric acid crystals and usually affects the lower extremities, particularly the great toe (podagra). Evaluation of synovial fluid reveals needle-shaped crystals within PMNs that are negative birefringence under polarized light. Osteoarthritis (B) is a degenerative joint disease that results in joint-space narrowing seen on radiograph. Rheumatoid arthritis (C) typically affects older women and most commonly occurs in the hand (metacarpal phalangeal and proximal interphalangeal joints), wrist, and elbow.

Which of the following is a risk factor for type 2 diabetes mellitus? Age greater than 25 years Hypertension in a first degree relative Hypothyroidism Polycystic ovary syndrome

Correct Answer ( D ) Explanation: Approximately 8% of individuals in the United States have type 2 diabetes mellitus. It is important to identify risk factors for diabetes mellitus in order to determine who should be screened. Risk factors include polycystic ovary syndrome, being overweight, sedentary lifestyle, dyslipidemia, and a history of gestational diabetes mellitus. Screening tests include hemoglobin A1C, measurement of fasting plasma glucose, and two-hour plasma glucose during an oral glucose tolerance test. Individuals exhibiting signs and symptoms of diabetes mellitus should be screened regardless of risk factors. Patients complaining of polyuria, polydipsia, unexplained weight loss or blurry vision are among those individuals who should be screened. Risk of diabetes increases with age and 45 years old or greater is considered a risk factor, not 25 years old (A). Hypothyroidism (C) has no connection with risk factors for type 2 diabetes mellitus. Hypertension in the individual is a risk factor and family history of diabetes mellitus is a risk factor. A first degree relative with hypertension (B) is not considered a risk factor for type 2 diabetes mellitus.

A 42-year-old man presents with foot complaints. Last night, he was awakened with severe pain in his right great toe. He denies a history of recent injury. Examination reveals significant edema and erythema of the first metatarsophalangeal joint. The overlying skin is intact but warm. Range of motion, both passive and active, are limited. Which of the following is the most likely diagnosis? Pediculosis Pellagra Pes planus Podagra

Correct Answer ( D ) Explanation: Arthritis has several causes other than degeneration (OA) and autoimmune dysfunction (RA). Deposition of crystals into the synovium is one of those causes. Gout involves deposition of monosodium urate crystals. Acute, nighttime onset of intense monoarticular edema and pain is typical of gouty arthritis. 50% of cases occur in the great toe's metatarsophalangeal joint, which is termed podagra, while other cases commonly occur in the knee and tarsal joints. Joint aspiration and fluid analysis is recommended. Radiographs may be normal, or may only show soft tissue edema. Serum uric acid levels may be normal during an acute attack of gout, however, interval asymptomatic hyperuricemia commonly exists between, and prior to, the onset of acute attacks. Acute cases are treated with colchicine, indomethacin, intraarticular corticosteroids and decompressive-aspiration. Pediculosis (A) is lice infestation characterized by superficial pruritus and secondary skin infection. It is common in the head and pubis, but not typically localized to the great toe. Pellagra (B) is vitamin B3 (niacin) deficiency, characterized by diarrhea, dermatitis and dementia. Desquamation, keratosis and erythema of sun-exposed skin are the common cutaneous findings. Pes planus (C), or flat-feet or fallen-arches, is a foot arch deficiency that results in a majority of the sole of the foot coming in contact with the ground. Ankle eversion predominates. It can result from biomechanical defects, trauma, normal aging, obesity and pregnancy. It is usually involved with ankle pain and/or instability, but not digital joint edema and erythema.

A 30-year-old man with chronic rhinitis presents with 3 hours of epistaxis. He denies hemoptysis or a history of coagulopathy. Inspection reveals an anterior single vessel bleed. You place gauze in the affected nostril and hold compression for 10 minutes. You remove the gauze and he begins to bleed again. Use of which of the following is the most appropriate next step in managing this patient? Double-balloon device Electrocautery Ribbon gauze packing Topical 4% cocaine solution

Correct Answer ( D ) Explanation: Epistaxis occurs most commonly in those 10 years and younger and 50 years and older. Rare cases, usually posterior in origin, may lead to hemorrhagic death. Local causes include foreign bodies, nose picking, chronic sinusitis, rhinitis, septal deviation and perforation and trauma. Systemic causes include vascular malformations, thrombocytopenia, hemophilia, hypertension, leukemia and liver failure. Common medications which increase the risk for epistaxis include aspirin, anticoagulants and nonsteroidal anti-inflammatory drugs. Most bleeds occur in the anterior part (Kiesselbach) and are easily identified during inspection. Posterior bleeds, although less common, are usually more serious. Posterior bleeds may be asymptomatic, or present as nausea, hematemesis, anemia, hemoptysis or melena. Initial treatment is with direct compression, nasal plugging with gauze and tilting the head forward to stop blood collection in the pharynx. If bleeding does not stop, careful inspection is necessary to determine the location (anterior or posterior) and the extent (single or multiple vessels) of the bleeding. If a single anterior bleeding site is identified, the next step is to use gauze soaked in oxymetazoline or phenylephrine. If this fails, adding a 4% cocaine or lidocaine solution is recommended. A common practice is to use cotton pledgets, soaked in the above solutions, for at least 5 minutes then removed. If bleeding continues, chemical cautery with silver nitrate is tried. Other packing techniques use absorbable gelatin foam or oxidized cellulose. Balloon devices (A) are usually reserved for posterior epistaxis. These patients require ICU monitoring. Larger or multiple bleeding sites may require electrocautery (B), however, this practice is rarely recommended due to the risk of destroying normal tissue and septal perforation. If the above local treatments fail, then posterior-to-anterior packing with ribbon gauze (C) impregnated with petroleum jelly, bacitracin, neomycin, and polymyxin B or 3% bismuth tribromophenate, or the use of a nasal tampon, is recommended. Packing involves the use of a nasal speculum and Bayonet forceps to secure the gauze in a tightly packed, accordion-like arrangement.

A 2-month-old child presents with projectile vomiting. The child initially remains hungry following the episodes of vomiting but, in time, loses interest in feeding and presents to the emergency department appearing wasted and severely dehydrated. On physical exam the patient appears dehydrated and a small olive like structure can be palpated in the right upper quadrant. What is the most likely diagnosis? Formula intolerance Gastroesophageal reflux disease Hirschprung disease Pyloric stenosis

Correct Answer ( D ) Explanation: Infants with infantile hypertrophic pyloric stenosis (IHPS) are typically asymptomatic until three to four weeks of age, although a small number may present as early as the first week of life. Initially infants present with mild spitting, which progresses to nonbilious projectile vomiting following feedings. Vomiting may be so forceful that it exits through the nostrils, as well as the mouth. Emesis may contain "coffee ground" material or small amounts of frank blood, but is not bilious. Early in the course the infant remains hungry following vomiting episodes but, with time, loses interest in feeding and may present wasted and severely dehydrated. Infantile hypertrophic pyloric stenosis is a form of gastric outlet obstruction caused by hypertrophy of circular muscle surrounding the pyloric channel. Correction of IHPS is the most common abdominal operative procedure during the first six months of life. Infantile hypertrophic pyloric stenosis is arguably not a true congenital defect because the muscular hypertrophy and obstruction tend to be an evolving process during the postnatal period. On physical examination the infant with IHPS may appear wasted and dehydrated, but the extent is variable and related to severity and duration of symptoms. The classic physical signs are a palpable pyloric mass and visible peristaltic waves. The palpable "olive" is most easily felt in a wasted patient, immediately following emesis or aspiration of the stomach. Boys outnumber girls by a ratio of 4-5:1. The initial therapy for IHPS is fluid and electrolyte replacement to correct dehydration and hypochloremic metabolic alkalosis. Depending on severity, fluid and electrolyte repletion can usually be accomplished within 24 hours. Definitive therapy is the Ramstedt pyloromyotomy, which entails a longitudinal incision through the hypertrophied pyloric muscle down to the submucosa on the anterior surface of the pylorus. Formula intolerance (A) and gastroesophageal reflux (B) usually manifests as spitting up and not projectile vomiting with no positive physical exam signs as demonstrated by the palpable "olive" like structure in pyloric stenosis. Hirschprung disease (C) would present as early failure to pass meconium, vomiting and abdominal distention.

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

Correct Answer ( D ) Explanation: 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 (A) to confirm the diagnosis. ACTH levels (B) 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. Radiographic imaging is also helpful in determining the cause of Addison disease, but it is relatively nonspecific in patients with autoimmune destruction. It is important to make a biochemical diagnosis of adrenal insufficiency before radiographic imaging. CT scan (C) demonstrates small adrenal glands in patients with autoimmune adrenal destruction. In other causes of Addison disease, CT scan may show hemorrhage, calcification associated with tuberculosis infection, or masses in the adrenal gland. However, CT scan is not necessary to diagnose adrenal insufficiency.

Which of the following is a cyanotic congenital heart disease? Atrial septal defect Coarctation of the aorta Patent ductus arteriosus Tetralogy of Fallot

Correct Answer ( D ) Explanation: Tetralogy of Fallot is a cyanotic congenital heart defect. Cyanotic congenital heart disease (CHD) results either from decreased pulmonary blood flow to the lungs or right-to-left shunting of desaturated blood into the systemic circulation. The classic cyanotic CHDs include the 5 "t's" - truncous arteriosus, transposition of the great vessels, tetralogy of Fallot, total anomalous pulmonary venous return and tricuspid atresia. Tetralogy of Fallot accounts for 10% of all CHDs. It consists of 4 abnormalities: right ventricular outflow obstruction, over-riding aorta, large VSD and right ventricular hypertrophy. Together, these defects result in right-to-left shunting of deoxygenated blood and decreased pulmonary blood flow leading to cyanosis. Atrial septal defect (A), coarctation of the aorta (B) and patent ductus arteriosus (C) are all acyanotic CHDs.

A five-year-old girl is rushed to the ED because of possible ingestion. She was unattended for a few minutes and later found playing with her grandmother's bag. The grandmother's bag contains over-the-counter medications and herbal products. The girl complained to her grandmother that her ears were buzzing. Upon arrival at the ED, the girl had one episode of vomiting. Her examination was normal except for diaphoretic skin. Which of the following is the medication that most likely caused her symptoms? Acetaminophen Chlorpheniramine Ibuprofen Oil of wintergreen

Correct Answer ( D ) Explanation: The girl manifests signs and symptoms of salicylism. Oil of wintergreen contains 5 g of salicylate in one teaspoon and ingestion of very small volumes of this product has the potential to cause severe toxicity. Early signs of acute salicylism include nausea, vomiting, diaphoresis, and tinnitus. Moderate salicylate toxicity can manifest as tachypnea, tachycardia, and altered mental status. Signs of severe salicylate toxicity include hyperthermia, coma, and seizures. For the patient who presents soon after an acute ingestion, initial treatment should include gastric decontamination with activated charcoal. Initial therapy focuses on aggressive volume resuscitation and prompt initiation of sodium bicarbonate therapy in the symptomatic patient, even before obtaining serum salicylate levels. The primary mode of therapy is serum and urinary alkalinization wherein it enhances the elimination of salicylates by converting salicylate to its ionized form, "trapping" it in the renal tubules, and thus enhancing elimination. The initial signs of acetaminophen (A) are nonspecific, including nausea and vomiting. This is the followed by an asymptomatic period. If toxic ingestion is suspected, serum acetaminophen should be obtained. Chlorpheniramine (B) is an antihistamine found in over-the-counter cough and cold formulations that cause sedation and mild lethargy at lower doses. At higher doses, it can cause flushed and dry skin, hyperthermia, dilated pupils, agitation, tremor, and urinary retention. Ibuprofen (C) is well tolerated even in overdose. In children, acute doses of < 200 mg/kg rarely cause toxicity, but ingestions of > 400 mg/kg can produce more serious effects, including altered mental status and metabolic acidosis.

A wife is upset about how her husband has behaved after receiving a new diagnosis of terminal lung cancer. He has spent the last few days on the internet feverishly looking up his old girlfriends in an attempt to find phone numbers and call them. He has only slept a few hours in this time period, and has eaten only pretzels and soda. When the wife is finally able to get his attention, she asked him what he was doing, to which he responded "I feel great, so I thought I'd catch up with some old friends." He does not meet diagnostic criteria for a manic episode, and has no history of bipolar disorder. You suspect he may be in which stage of the Kubler-Ross grief reaction? Anger Bargaining Catastrophizing Denial

Correct Answer ( D ) Explanation: The grief reaction has been described to occur in five stages by Elisabeth Kubler-Ross. This popular theory has not been tested though. It describes the emotions people experience when they are dealing with the death of a loved-one, catastrophic loss, tragedy or a new diagnosis of terminal illness. This staging system helps practitioners identify people who are grieving. Passage through the stages may not be linear, and some patients do not experience each stage. Denial is the first stage and acceptance is the fifth and final stage. Denial is a temporary attempt at personal defense, experienced consciously or subconsciously, in which a person downplays their symptoms ("I feel fine") or minimizes the situation ("This can't happen to me"). Usually people in the denial stage become ever more aware of their possessions and those who will survive their death. This can lead to a "reaching-out" to long lost relationships. Anger (A) is the second stage, in which a person realizes that denial cannot continue. They frequently ask "Why me?" or "Who is to blame?" for their current condition. Rage and envy are common. Bargaining (B) is the third stage. It is characterized by a hope of escaping the inevitable. Feelings are commonly expressed as "I'll do or give anything to buy more time" or "I'll give all the money I have to beat this". Depression is the fourth stage, in which a person begins to understand the certainty of death, becomes isolated and silent, refuses visitors, becomes emotionally detached and cries frequently. "Who cares anymore" and "What's the point" are common expressions. Catastrophizing (C) is not a stage of the grief reaction. Acceptance is the fifth stage. It is characterized by a coming to terms with the situation and frequently, an optimistic outlook. "I can fight this" or "Let's start treating this thing" are common expressions in this stage.

Which of the following disorders is associated with celiac disease? Medullary thyroid cancer Parathyroid hyperplasia Pheochromocytoma Type 1 diabetes mellitus

Correct Answer ( D ) Explanation: Type 1 diabetes mellitus is a disorder associated with celiac disease. Conditions which have autoimmune features such as type 1 diabetes mellitus, thyroid disease, juvenile rheumatoid arthritis, dermatitis herpetiformis and autoimmune liver disease are commonly associated with celiac disease. Additionally, celiac disease is also associated with Down syndrome, small bowel lymphoma, and selective IgA deficiency. Celiac disease occurs secondary to ingestion of wheat gluten or related rye and barley proteins in genetically predisposed persons. Characteristic findings include chronic diarrhea or steatorrhea, bloating, weight loss and abdominal pain, pruritic papulovesicular rash on the extensor surfaces called dermatitis herpetiformis, iron and fat soluble vitamin deficiencies and osteoporosis. Medullary thyroid cancer (A), parathyroid hyperplasia (B), and pheochromocytoma (C) are associated with multiple endocrine neoplasia (MEN) type IIa, which is a syndrome of autosomal dominant disorders involving dysfunction of multiple endocrine glands.