Comprehensive

A 25-year-old healthy male newly employed PA reports to the occupational health clinic for required testing. Based on his immunization history, it is recommended that he receive the full hepatitis B vaccine (Recombivax HB). Question What is the most appropriate dosing schedule for this hepatitis B vaccine?

0, 1 month, 6 months

A 45-year-old Caucasian woman presents because she is worried she may have skin cancer. While interviewing the patient, you note the patient has an extremely fair complexion. When you examine the lesions that the patient is concerned about, you note the following description in your documentation: "5 papules that vary in diameter from 0.3-0.6 centimeters dispersed on the skin around the sternal angle. Lesions vary in color from flesh-toned to slightly hyperpigmented, and when palpated have a sandpaper texture." Question Based on the most likely diagnosis, what would be the most appropriate pharmaceutical regimen at this time?

5-fluorouracil cream

A 22-year-old woman presents for evaluation of knee pain. The patient appears in moderate distress and is unable to fully bear weight as she moves to the exam table. Her physical exam reveals a swollen and tender left knee. She is tender at the lateral femoral condyle, lateral tibial plateau, and tibiofemoral joint line. Lachman and anterior drawer tests are positive. Posterior drawer, Apley grind, patellar grind, and McMurray tests are negative. There are no sag or apprehension signs. Valgus and varus stress tests are normal. An X-ray shows no fractures. Question What inciting event is most likely in this patient's history?

Sudden landing playing basketball

A 5-year-old boy presents with an erythematous skin rash associated with intense itching. The boy's mother has noticed that her son's rash has been recurrent, with 3-4 episodes per year. The itching and rash increases after consumption of certain foods. On examination, erythematous raised papules are seen on the cheek, trunks, and upper arms. Question What is most likely associated with the boy's condition?

Asthma

A 44-year-old man presents for follow-up of poorly controlled type 1 diabetes mellitus that was diagnosed 32 years ago. What change on his funduscopic examination would indicate a need for urgent referral to an ophthalmologist?

Neovascularization

A 32-year-old Gravida 4, Para 4, Ab 0 woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications. Vitals: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. The patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The next morning, the patient is found to be alert, oriented, and afebrile. Lab and imaging studies: WBC17.2 K/mcLESR25 mm/hrHgb12.4 gm/dLElectrolytesnormalHct37%BUN12 mg/dLPlatelets305 K/mcLCreatinine1.2 mg/dLNeutrophils68%Pregnancy testNegativeLymphocytes20%HIV immunoassayNegativeMonocytes2%Blood culturesNo growth (preliminary)Eosinophils10%EKGNSR, 1 PACBasophils1% Transthoracic echocardiogramNormal heart size and structure.Chest x-rayNormal heart size. No infiltrates or edema.CT Brain without contrastMultiple cystic lesions. Cyst with dot sign noted.MRI Brain with contrastMultiple cystic lesions. Cyst with dot sign present. Question What is the treatment of choice (the successful therapeutic trial) for this patient's disease?

Albendazole with IV prednisolone

A 4-year-old male patient accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The patient is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Pulse 94/min, BP 110/70 mm Hg, temperature 101°F. Direct fiberoptic laryngoscopy shows an edematous larynx. Cultures are taken, and an endotracheal tube is placed. Empiric antibiotics are started with ceftriaxone and vancomycin. The epiglottis cultures reveal Haemophilus influenzae, and acute Haemophilus influenzae epiglottitis is diagnosed. The mother is worried about her 1-year-old child living in the same house and is currently not vaccinated for H. influenzae. Question What prophylactic measure is recommended at this time?

All family members, excluding the patient, should receive prophylactic rifampin.

An 8-year-old girl presents with her mother to the pediatrician's office with persistent clear nasal drainage and nighttime cough for the past month. Her physical examination reveals clear rhinorrhea, dark circles under her eyes, and a transverse nasal crease. Question What is the most likely diagnosis?

Allergic rhinitis

A 19-year-old man presents with hair loss described as localized oval patches for the past month. Upon examination, the patches are sharply demarcated without tenderness, erythema, or scaling noted. Question What is the most likely diagnosis?

Alopecia areata

You have been asked to do a house call on an 88-year-old woman who is bed-bound and lives at home with her private home health aide. She has had no medical follow-up for the past year. Approximately 3 weeks ago, she appeared to be having "headaches." 2 weeks ago, she developed a rash on the left of her forehead that developed into "little blisters that popped and crusted over." She has a history of coronary artery disease and was diagnosed with "senile dementia" 6 years ago. The home health aide says she is occasionally combative and resistant to care. On exam, she is awake and mumbles several words but is not responsive to verbal commands. BP is 118/68 mm Hg, P 84/min R 20/min. Skin exam reveals clusters of vesicles with crusts on her left forehead. There are no other significant lesions noted on the body. Question What is the most appropriate treatment?

Aluminum acetate solution

A 35-year-old Hispanic man presents for an appointment but is too embarrassed to tell the nurse his chief complaint. You enter the room and coerce him to give you the reason he has come in to seek medical treatment. He admits to severe, intense itching around his anus that has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He would rank this pain as a 10/10 on a pain scale and it lasts hours afterward. This intense pain makes him not want to have any bowel movements. He admits to only 1 episode of a small amount of bright red blood on the toilet paper as well as on the stool itself. The patient denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease. Question What is this patient's most likely diagnosis?

Anal fissure

A 66-year-old man presents with a history of recurrent episodes of chest tightness and shortness of breath that originally occurred with exertion but are now happening at rest. Dizziness also occurs with exertion. The pain is retrosternal, 6/10 in intensity, lasts for 10 minutes, and radiates to the neck, jaw, and shoulders. On examination, pulse is 65/min and low in volume; BP is 100/80 mm Hg. On auscultation, a loud mid-systolic murmur is heard at the second right intercostal space and radiates to the carotid arteries bilaterally. There is a single second heart sound. What is the most likely diagnosis?

Aortic stenosis

A physician assistant arrives 45 minutes late to work due to traffic caused by a car collision. The PA forgot to notify the office of their tardiness. The PA arrives to find their first patient has been waiting 60 minutes in the examination room. The patient yells from the room, "This is how you treat your patients? Give me a different provider!" Question What should be done next?

Apologize to the patient and explain the delay.

A 37-year-old woman presents with a history of right-sided facial paralysis and periauricular discomfort since she awoke this morning. She is afebrile. She had a "cold sore" 1 week prior to her symptoms, but this resolved without complications. During her neurologic exam, she was discovered to have an inability to raise her right eyebrow and close her right eye completely. She also has drooping of the right corner of her mouth. The rest of her neurologic exam is normal. There are no masses or rashes evident. She denies history of prior CVA or neurologic illnesses. She does not take any medications. Question What is the most likely diagnosis?

Bell's palsy

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. Blood pressure is 180/110 mm Hg, heart rate 120 bpm, and respiratory rate 34/min. Physical examination findings include lungs clear to auscultation, heart regular rhythm, normal S1/S2 with an S4 present, and grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. Neck is negative for JVD and no carotid bruits present. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. A STAT chest X-ray shows a widening of the mediastinum. Question What medication class delivered intravenously is now needed to stabilize the patient?

Beta blocker

A 68-year-old man with a history of hypertension, hyperlipidemia, and myocardial infarction presents to the emergency room with a 3-day history of shortness of breath at rest. He has found it difficult to walk short distances due to shortness of breath. He reports orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is acutely dyspneic. He is afebrile but tachypneic and diaphoretic. There is a diminished first heart sound, S3 gallop, and laterally displaced PMI. The abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid-calf. A bedside chest X-ray revealed pulmonary vascular congestion and Kerley B lines. Question What additional finding is expected in this patient?

Bibasilar rales

An 8-month-old boy presents to the pediatrician in mid-January with 2 days of cough and nasal congestion. His mother reports decreased breastfeeding over the last day and difficulty breathing. The infant's temperature is 38.2°C (100.8°F), heart rate 120/minute, respiratory rate 34/minute, and oxygen saturation 95% on room air. Physical exam is remarkable for intercostal retractions. Question What exam finding would further suggest the suspected diagnosis?

Bilateral expiratory wheezing

A 21-year-old woman is markedly thin, and she describes being worried she is going to fail her college finals and not graduate. She presents because she cannot eat or sleep; she feels like she would be better off dead. She was doing well in classes until after a spring break trip to Europe. When queried about previous psychiatric treatment, she tells you that she went "a little nuts" when she was a freshman; it was her first semester and the first time she had lived so far from home. She stayed up for a week trying to write a novel, and during that time she bought two computers and a whole new wardrobe with her father's credit card. Question What is the most likely diagnosis?

Bipolar I disorder

A 15-year-old girl with a history of mild asthma has had worsening episodes of cough, wheezing, and increasing bloody sputum over the past 5 months. She denies weight loss, decreased appetite, lethargy, or travel. She has increased her bronchodilator use, but she had not sought further care. Her mother has noted facial flushing with sweating that sometimes appears when she feels stressed—brief at first but lasting longer now. On exam, her respiratory rate is 32 breaths/min, temperature is 98.6°F, heart rate 84 bpm, BP 114/76 mm Hg, oxygen saturation is 94%. Her throat is clear, RRR without murmur; on auscultation, breath sounds over the left hemithorax are diminished without retractions or wheezes; there are few fine crackles at the base. Right side is clear. Remainder of the exam is normal. Chest X-ray reveals a round area of increased opacification near the right hilar region. CBC shows normal white count and differential. Question What diagnosis would most easily explain the patient's symptoms?

Bronchial carcinoid tumor

A 2-year-old boy has a solid mass of tumor on the lower pole of his right kidney. Histopathological studies show whorls of mesenchymal cells and clusters of disorganized epithelial cells rather than renal corpuscles and renal tubules, which confirm your suspected diagnosis. Question What is true regarding treatment and/or prognosis of this diagnosis?

Combination chemotherapy is appropriate after surgery.

A 15-month-old toddler presents with sudden onset of generalized tonic and clonic convulsions for the last 30 minutes. Parents report that the patient was irritable in the minutes preceding the events, but there is no history of trauma, fever, or vomiting before the onset of convulsions. This is the first episode of seizure, and there is no history of convulsions in the family but the father has a history of cerebral aneurysm requiring surgical clipping. The patient's birth history, neonatal period, and developmental milestones are normal. Question After initial stabilization by securing the airway, oxygenation, and controlling the acute convulsion, what is the best investigation for this patient?

CT scan of the head

A family presents in the middle of winter. They live in a low-income housing development. Due to their gas furnace being broken, they have been using a kerosene heater at night for the past week. For the last 3 days, both parents and the two siblings have been experiencing varying degrees of headache, dizziness, nausea, vomiting, and fatigue; symptoms are particularly severe at night and have been increasing in intensity each night they occur. The 4-year-old daughter has been very lethargic; occasionally, she seems to black out or fall asleep very soundly. She and her 9-year-old brother have also had a cough, runny nose, and sore throat for the past week. On exam, other than seeming tired, findings are nonspecific. Both children have a runny nose but their lungs and ears are clear. Question What is the best test to confirm exposure to the most likely diagnosis in this case?

Carboxyhemoglobin level

A 24-year-old man presents with a painless, localized swelling of his left lower eyelid; it has developed over a period of weeks. He is seeking medical attention because it is now producing a foreign body sensation in his left eye; it is also hindering his path of vision. On physical examination, his visual acuity is normal; there is no evidence of injection or discharge. You palpate, and you observe a nontender, localized nodule on the lower eyelid. Question What is the most likely diagnosis?

Chalazion

A 29-year-old man presents with a chronic respiratory infection; he is seeking the advice of an ear, nose, and throat specialist. He reports a history of recurrent respiratory infections. A biopsy of his respiratory epithelium reveals an alteration in certain epithelial structures. Question What is most likely to be abnormal?

Cilia

A 35-year-old man presents with a 2-week history of constant burning and throbbing pain in his left hand. The pain also seems to affect his distant forearm. Contact with normal clothing and bed sheets worsen his hand pain. He also reports that his hand is swollen. He denies trauma to his hand, but he does report an uncomplicated left wrist fracture 3 months ago that resulted from a sports accident. By the time of cast removal at 7 weeks post-injury, he denied any pain or edema in the affected limb. He was instructed to return to normal activities, as tolerated. He was initially treated with ibuprofen and opioid pain pills. He discontinued all pain medicines within 2 weeks of the fracture. He now describes his hand pain as an 8/10. On physical exam, the left hand and forearm are noted to have some localized edema, warmer temperature, and increased hair growth compared to his right hand and forearm. No rash or skin lesions are noted. With even light palpation of the affected region, the patient cries out in pain. Range of motion is decreased, and reflexes are increased the left upper extremity (in comparison to the right). The rest of his exam is normal. X-ray of the left wrist and hand are normal, with good fracture resolution. Question What is the most likely diagnosis?

Complex regional pain syndrome

A 57-year-old Caucasian man is brought to the emergency department following an episode of palpitations and syncope. The patient is initially evaluated by the ED physician, then by a cardiology PA. While the PA is recording the patient's history and physical exam, the patient develops sustained monomorphic ventricular tachycardia at 120 beats per minute but with stable pulse and blood pressure. The PA contacts the on-call cardiologist, who arrives promptly. Intravenous anti-arrhythmic medication is initiated, but the patient remains in sustained monomorphic ventricular tachycardia. Two additional intravenous anti-arrhythmic medications are administered before the patient converts to normal sinus rhythm 45 minutes later. The patient is admitted to the hospital for further evaluation and treatment. The patient undergoes electrophysiology testing and an ablation procedure for ventricular tachycardia 2 days later; he is discharged from the hospital 4 days after admission. Question During this hospitalization, what services may be billed by the physician or by the PA but are excluded from shared physician-PA billing? (Assume that appropriate documentation requirements are met and that all services provided by either the PA or physician are within state licensure and state scope of practice regulations.)

Critical care services (CPT codes 99291 or 99292)

A 13-year-old girl is drowsy and unable to answer questions. Her mother says that she has been extremely thirsty lately and urinates frequently. Her father notes that the patient has also been fatigued. There is a fruity odor to the patient's breath. Blood gases are drawn and reveal the following: pH7.3CO232HCO317 Question What is the most likely cause of the patient's condition?

Diabetes mellitus

A 34-year-old woman presents with worsening headaches. She says that the headaches are present throughout the day and that she has been feeling nauseous. She has also noticed difficulty in seeing vehicles on the freeway lately. She has had several close calls while driving due to this impairment. Her previously regular periods are now irregular, with heavy bleeding every 3-4 months. She has also noticed a milky discharge from both nipples. Her pregnancy test is negative. An MRI of the brain confirms the diagnosis. Question What is the best initial treatment for the most likely diagnosis?

Dopamine agonists

A 43-year-old woman was diagnosed with type 2 diabetes mellitus 6 months ago. She presents for follow-up. She states she is feeling well and has no current symptoms. She currently receives oral hypoglycemics. The patient has no other significant medical history. Her glucose, acetone, lactate, and glycated hemoglobin are performed, and they are reported as follows: Serum lactate0.5 mEq/LSerum acetone0.4 mg/dLFasting serum glucose130 mg/dLGlycated hemoglobin6% Question What is the best way to describe the patient's diabetic state?

Good glycemic control

An 82-year-old male patient with a past medical history of hypertension, dyslipidemia, type 2 diabetes, and chronic kidney disease is evaluated for progressive exercise-induced fatigue and shortness of breath over the last year. He admits to more recent chest pain and lightheadedness, both of which occur with ambulation. He denies cough, fever, chills, lower extremity edema, or abdominal problems. Physical exam reveals a narrow pulse pressure following blood pressure assessment. Cardiac exam notes a laterally displaced point of maximal impulse and a high-pitched rough mid-systolic ejection murmur loudest in the second right intercostal space. The murmur radiates to the bilateral carotid arteries. Peripheral vascular exam demonstrates a delayed peak of radial pulsations. Question What diagnostic procedure is best for this patient?

Echocardiography

A 22-year-old woman at 24 weeks gestation presents with a 3-day history of a nonproductive cough and fever. She states she has been battling an upper respiratory infection that does not seem to go away. Initially, she thought that she had a cold, but the symptoms persisted. She was told by her obstetrician that she has the flu and to drink plenty of fluids and get some rest. Vital signs reveal temperature 101.2°F, blood pressure 120/80 mm Hg, heart rate 110/bpm, and respiratory rate 22 breaths/min. On physical examination, she appears ill; lungs exhibit wheezing. Question What would be an appropriate treatment for this patient?

Erythromycin

A 16-year-old girl has had acne breakouts since age 10, and both she and her mother have noted the breakouts worsening significantly every year. She notes worsening of her breakouts around her menses each month, but she states she has multiple lesions consistently throughout the month. She has a history of using diet modification, topical retinoids, benzoyl peroxide, and two types of oral antibiotics without improvement. Physical examination of the patient reveals extensive open and closed comedones on the forehead, cheeks, and chin. Painful cystic lesions are present throughout. Isotretinoin is now considered. Question How often will this patient need to have a serum pregnancy test once the treatment regimen has begun?

Every 4 weeks

A 33-year-old man presents with a 2-day history of severe diarrhea and vomiting. He had been on a business trip to Asia 3 days ago, and he reports eating food bought from street vendors. He describes his stools as watery and not bloodstained. He is allergic to seafood, and he takes antacids for peptic ulcers. On examination, he is moderately dehydrated; temperature is 37°C, PR is 100, and BP is 120/60 mm Hg. Question What pathogenic organism is most likely causing his symptoms?

Vibrio cholera

A 57-year-old man presents with a 6-month history of a daily productive cough. The patient is a non-smoker, and he has worked in a local coal mine for the past 39 years. He very rarely comes in to see a healthcare provider. When asked if he is up to date with his vaccinations, he does not recall the last ones he received; he also does not recall when these may have been given. Question Given the most likely diagnosis, what pair of vaccinations would be recommended to help decrease any significant morbidity and mortality in this patient?

Influenzae and pneumococci

A 66-year-old man presents with a 2-month history of bone pain and weight loss. Lytic lesions were discovered on a routine X-ray. You order additional lab work. Question What electrolyte imbalance would you most likely find in this patient?

Hypercalcemia

A mother brought her 2-month-old infant son to a pediatric clinic because, during micturition, urine ran from the opening at the bottom of the midline groove of the scrotum instead of from the tip of the penis. Question What is the most likely diagnosis?

Hypospadias

A 55-year-old man became intoxicated at a bar after a serious argument with his wife about his diet and habits (he is overweight and a heavy smoker). On the way back home, he developed chest pain radiating to the left shoulder, shortness of breath, sweating, and anxiety. ECG shows pathological Q wave and ST elevation. Laboratory results are remarkable for an elevated troponin. Question What caused the rise in troponin levels in this patient?

Injury to myocardial cell membrane

A 34-year-old man was the driver in a single-car motor vehicle accident. Preliminary radiologic studies show a comminuted fracture of the right tibia. The patient is describing a substantially increasing amount of pain felt in the injured extremity. He describes the pain as being a 10/10; it seems as if it is becoming worse every minute. He describes it as a deep achy burning pain. You quickly examine the right leg; you note pallor, a tense wood-like feeling of the extremity, diminished sensation, and muscle weakness. Question What is the most appropriate clinical intervention based on the most likely diagnosis?

Fasciotomy

A 73-year-old man with no significant past medical history presents with a 1-month history of light-headedness, dizziness, and near syncope; it has been occurring in response to sitting up and standing from a supine position. He denies chest pain, palpitations, shortness of breath, cough, loss of consciousness, vision or speech changes, nausea or vomiting, numbness, tingling, paresthesias, and focal weakness. His physical exam is noteworthy for a drop in systolic blood pressure of 24 mm Hg from a supine to standing position. Question What clinical intervention should be recommended?

Fludrocortisone and compression stockings

A 15-year-old male patient presents for follow-up of previously diagnosed autism spectrum disorder. The patient is accompanied by his mother. Symptoms do not interfere too much with school or relationships. He attends public school, goes to daily cognitive/behavioral sessions, and attends weekly counseling sessions. The mother has noted a significant increase in anxiety symptoms that have become detrimentally disruptive to the patient's daily activities. Question What is the most appropriate initial choice of pharmacologic treatment to help decrease the effects of this patient's anxiety?

Fluoxetine

A 4-year-old girl presents to the emergency department with her mother due to pain and itching in her right ear. The patient denies hearing loss and dizziness. She came back from her grandmother's house yesterday and told her mom that her ear "really itched inside." There is some drainage noted on exam from the affected ear. There is no pain when manipulating the tragus or erythema on the pinna. The mother mentions the patient and her sister were playing dress up with earrings yesterday. The mother reports the patient was inside most of the weekend and did not go swimming. Question What is the most likely diagnosis?

Foreign body

A 4-year-old male patient presents with poor weight gain, small size for his age, and dyspnea upon feeding. The mother notes that the patient has frequent upper respiratory tract infections. On physical exam, the patient is underweight for his age. There is a precordial bulge, a prominent right ventricular cardiac impulse, and palpable pulmonary artery pulsations. Second heart sound is widely split and fixed, and there is a mid-diastolic rumble at the left sternal border. Question What pharmacologic agent is most appropriate in the medical management of this patient at this time?

Furosemide

A 2-year-old girl is brought to an otolaryngologist by her mother for chronic ear infections. The patient is otherwise healthy, with the exception of recurrent episodes of otitis media (OM). Examination and history show that the child has had average growth and development; she has not had invasive infections, skin disorders, or hospitalization. The child's mother is concerned about the risk of hearing loss and its effects on development. Question What patient education information can you give the child's mother?

Hearing loss during OM may adversely affect cognition and language.

A 12-year-old Jewish girl is brought in by her father. The father reports that the child started to bleed profusely following tooth extraction 2 hours ago. Further questioning reveals that there is a history of bleeding disorder in the child's maternal uncle and aunt. Examination reveals tachycardia and bleeding from the site of tooth extraction. Coagulation profile reveals prolonged activated partial thromboplastin time (aPTT), normal prothrombin time (PT) and thrombin time (TT), and deficiency of factor XI. The child was treated with fresh frozen plasma (FFP) and fibrin glue. Question What is the likely diagnosis?

Hemophilia C

A 48-year-old Caucasian woman with a past medical history of hypertension and hypercholesterolemia was diagnosed recently with a cerebral aneurysm. The treatment plan for the aneurysm is endovascular coiling. Among other complications, this patient has an increased risk of thromboembolism postoperatively. Question What is the initial preventive medication that will be used to help minimize risk in this patient?

Heparin

A 20-month-old boy presents with a 1-week history of fever up to 101°F and irritability. His mother noted sores in his mouth 4 days ago; she states that she has noticed him drooling and that his appetite is quite diminished. His past medical history is unremarkable. He has no medical allergies and his only current medication is acetaminophen. He is current on his immunizations. His physical exam reveals normal vital signs except for a temperature of 100.5°F. On examination of his oral cavity, you note swollen erythematous gingiva with ulcerations present mostly on the left of his mouth. The ulcerations appear yellowish-white and friable. White-gray lesions approximately 3 mm in diameter are seen on the anterior tongue. The tonsils appear erythematous without exudates. His lips are slightly cracked, and his mucous membranes are slightly tacky. Neck examination reveals bilateral anterior cervical adenopathy. He has no skin lesions. The remainder of his exam is normal. His strep test is negative. Question What is the most likely cause of this patient's condition?

Herpetic gingivostomatitis

A 24-year-old woman presents with a 3-month history of excreting fluid from her left breast. When her symptoms first started, she had noted clear fluid staining her bra, which recurred infrequently. If she compressed the left breast tissue around her nipple area, she could easily express clear fluid. Occasionally, with difficulty, she was also able to express the same fluid from her right breast. Medical and surgical history is positive for depressive disorder; it has treated with tricyclic antidepressants for the past 4 months; she had an appendectomy 2 years ago. Her menstrual history is regular, with dysmenorrhea present. She drinks alcohol occasionally. Family history is positive for diabetes. Question What history has the most significance in regard to this patient's condition?

History of tricyclic antidepressant use

A 55-year-old man presents with severe central chest pain that started suddenly and radiates to the back and neck. He feels sick but has not vomited. He has no major illnesses and knows of none that run in his family. He does not use alcohol, tobacco, or recreational drugs. He is allergic to sulfa drugs. On exam, he appears in extreme pain and lying on his side. Temperature is 98.6°F, heart rate is 110 bpm, blood pressure of 180/105 mm Hg in left upper arm and 156/86 mm Hg in right upper arm, and respiratory rate is 20. Cardiac exam reveals normal S1 and S2 without rubs or gallop. The top of his internal jugular venous column is present at 2-3 cm above the sternal notch. Chest auscultation shows normal vesicular breathing. He has normal active bowel sounds tympanic to percussion. ECG shows left ventricular hypertrophy. Chest x-ray shows widened mediastinum. Question What treatment should be given immediately to this patient?

Intravenous labetalol

A 2-year-old boy presents to your office. He is from a poor rural family and has not had regular healthcare since birth. He is experiencing a childhood exanthematous disease that involves a maculopapular rash and a fever. It started 7 days ago. He now has corneal ulcers and pneumonia. Question What are the classic prodromal signs of his suspected diagnosis?

Koplik's spots, coryza, fever, cough, and conjunctivitis

A 76-year-old man with a past medical history of diabetes, hypertension, and hyperlipidemia is referred to a urologist for the evaluation of supranormal PSA readings associated with a reduction in urinary stream, back and hip pain, hematuria, and weight loss. He has not yet been managed for these symptoms. An in-office pelvic x-ray done reveals osteoblastic sclerotic areas of the pelvis and femurs bilaterally. Question What is the most appropriate pharmacotherapeutic agent for this patient?

Leuprolide

A 29-year-old female patient is taking D-penicillamine for Wilson's disease. Today, her laboratory findings (including liver function tests) are within reference ranges; there are no neurological signs. Her work requires frequent travel (3-5 days per week), including international overnight travel all over the world. She wants contraception that is both effective and easy to use. Question What is the best form of contraception for this patient?

Levonorgestrel-releasing intrauterine system

A 78-year-old man has a past medical history of HIV, hepatic cirrhosis secondary to chronic alcohol use and hemochromatosis, obesity, and thiamine deficiency; he presents with a 7-month history of progressive exertional shortness of breath, lower extremity edema, and lightheadedness. Symptoms are improved with rest. Physical examination reveals rales, elevated JVP, cardiomegaly, S3 gallop rhythm, high-pitched blowing holosystolic murmur at the apex, peripheral edema, and abdominal distension that suggests ascites. Bedside EKG notes sinus tachycardia, with non-specific ST-T wave changes and Q waves. An echocardiogram shows dilated ventricular chambers and systolic dysfunction. Question What health maintenance recommendation can be made for this patient?

Limited water consumption as disease progresses

A 32-year-old man is brought to the emergency department after falling off a roof at a construction site. He is unresponsive and intubated, requiring mechanical ventilation. Computed tomography (CT) scan of the head reveals an uncal herniation and mass effect due to intracranial hemorrhage. Further testing reveals no brain activity. His girlfriend reports he wanted to donate his organs; no other family is present. Question What is the best source of consent for this patient's donation of organs and tissues?

Living will

A 56-year-old woman presents with sudden onset of palpitations, trembling, sweating, anxiety, headache, and confusion that started 1 hour ago after a 5-mile early morning run. She has had similar episodes in the past, but never any symptoms this severe. Sometimes she wakes up in the morning with headaches and trembling, but they usually go away after she has gotten ready and has breakfast. On physical exam, she is found to have heart rate 114, blood pressure 125/86, respiration rate 18, weight 160 lb, and temperature 98.7°F. Patient is alert and appears somewhat anxious and diaphoretic but otherwise well. HEENT exam is unremarkable. Cranial nerves, cerebellar function, strength, sensation, deep tendon reflexes, and balance testing/Romberg are all normal. Patient is tachycardic, but S1 and S2 are normal with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. EKG shows sinus tachycardia. Lab work is significant for a glucose level of 36. Question What would be most likely if the patient's low blood glucose was due to accidental, surreptitious, or malicious administration of exogenous insulin such as glargine (Lantus)?

Low C-peptide levels

A 9-year-old boy presents with episodes of severe impulsivity, lack of attention, poor listening skills, and obsessive and compulsive characteristics; symptoms have been evident to his mother and multiple teachers at school. There have been numerous episodes. The patient has had mild evidence of these signs since he was in kindergarten, but they have become substantially worse in the last 4 months. Question Considering the differential diagnosis, what is an associated feature that would support the most likely diagnosis?

Low frustration tolerance

A 75-year-old man presents to his pain management office for follow-up after a lumbar laminectomy 2 weeks ago. He states that he has had a fever for the past 6 days. He denies any headache, chest pain, shortness of breath, cough, abdominal pain, nausea, diarrhea, vomiting, or extremity pain. He has a past medical history of hypertension, hyperlipidemia, chronic lumbar stenosis (now status post laminectomy), and type 2 diabetes mellitus. He also has a history of intravenous drug use. He was referred for an MRI of the spine, which revealed destruction of the vertebral body of L4 with significant collapse. Question What is the most likely additional clinical manifestation in this patient?

Lower back pain

A 21-year-old woman presents with urinary frequency. Her BMI is 41. A urinalysis is positive for glucose. Her random blood sugar is 257 mg/dL, hemoglobin A1c is 8.5%, and C-peptide is 1.5 ng/mL. She is diagnosed with type 2 diabetes; diet and exercise are recommended. Question What is the drug of choice for managing her diabetes?

Metformin (Glucophage)

A 12-year-old female patient presents with hypertension. There is a cardiac gallop and a medium-pitched systolic murmur best heard posteriorly in the interscapular area, with radiation to the left axilla, apex, and anterior precordium. A prominent anterior chest heave is observed. The lower extremities demonstrate a 16 mm Hg pressure difference from the upper extremities. There are delayed femoral pulsations. Upper extremity pulsations and the remainder of the physical exam are unremarkable. A recent chest x-ray shows cardiomegaly and rib notching. Question What pharmacotherapeutic agent will be most beneficial to this patient?

Metoprolol

A 22-year-old woman presents due to palpitations. She denies chest pain and shortness of breath; she has not had any recent infections. Aside from a tonsillectomy as a child, she has no significant past medical history. Examination reveals a thin woman in no acute distress. Lungs are clear to auscultation bilaterally. Cardiac exam reveals a mid-systolic click. Question What is the most likely diagnosis?

Mitral valve prolapse

An 83-year-old woman is currently in a nursing home following a short hospitalization for a CVA. She experienced a thromboembolic stroke 2 weeks ago, which resulted in right hemiparesis and dysphagia. Other medical problems include congestive heart failure, atrial fibrillation, osteoarthritis, and depression. The nursing staff contacts you to reports a sacral pressure ulcer measuring 3 x 2 cm. On physical examination, there appears to be interruption of the epidermis with an abrasion. The lesion is clean; there is no cellulitis. Question After wound cleansing, what is the most appropriate management step?

Moist dressing

A 24-year-old man presents with a 2-day history of skin rash on his back. He notes pain in his joints and tiredness. He has just returned from a camping trip. Vital signs are normal. Examination reveals an expanding lesion with a concentric circle of erythema. Question If left untreated, what is a complication of early dissemination of this condition?

Myocarditis

A 50-year-old man presents for the evaluation of a 1-year history of progressive cognitive, motor, and behavioral problems. He complains of inattention, reduced concentration, slowing of processing, and difficulty changing mental sets. What started as slow movements now is clumsiness and problems with coordination. His friend states that the patient is "not himself anymore" and has become apathetic, non-communicative, and "down." He is HIV-positive and was diagnosed with AIDS 2 years ago because of the presence of Pneumocystis carinii with CD4 of 100. He had an excellent response to antiretroviral therapy, however, and his last CD4+ lymphocyte counts were normal and viral load undetectable. On examination, you find an apathetic male in mild distress. Neurological exam shows loss of coordination, unsteadiness, generalized weakness (more pronounced in legs), ataxia, and tremor. Question What should be the next diagnostic step in this patient?

Neuroimaging methods

A 26-year-old woman presents with 20 weeks of amenorrhea. This is the first time she has been to the doctor in 5 years, and she believes she is pregnant. You perform a complete physical examination and cannot auscultate the fetal heart rate. The ultrasound reports a "snowstorm" pattern with placental and fetal remnants missing. The patient tells you she has history of miscarriage "that had something to do with high blood pressure." The doctor explains that she is not pregnant and has a disease related to the proliferation of trophoblasts. Question What is a risk factor in the development of this disease?

Nutritional deficiency

A 14-year old girl presents due to right leg pain. She is a competitive gymnast and works out in the gym 6 days a week. Upon physical exam, there is knee pain, swelling, and tenderness at the tibial tubercle. The patient's muscles are very tight in front and behind her thigh. All laboratory findings are within normal limits. Question What is the most likely diagnosis?

Osgood-Schlatter disease

A 39-year-old woman presents with a history of repeated short episodes of intensely anxious and fearful moments with physiologic manifestations, such as trembling, tachycardia, dizziness, sweating, and a smothering sensation. She has these episodes almost daily and feels they greatly impact her life when they occur. She denies symptoms of agitation, insomnia, and depression, and she states she does not have a history of recreational drug use. After an extensive workup, a diagnosis is made. Question What is the best drug for treatment of her most likely condition?

Paroxetine

A 24-year-old woman presents with a 12-hour history of lower abdominal pain, nausea, and vomiting. She rates the pain at a 4 last night when it initially began, but she currently puts it at a 9; she states that the pain seems to be worsening with each passing hour. She states she had her menses 1 week prior, noting an irregular flow and excessive vaginal discharge since it ceased. She is single and admits to not being monogamous; she only occasionally uses barrier contraception during sexual encounters. She takes a daily oral contraceptive pill. Question What is the most likely diagnosis?

Pelvic inflammatory disease

A 22-year-old man presents with a sudden onset of shortness of breath and right-sided chest pain. Symptoms began yesterday, and he felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He is a 1 pack-per-day smoker; otherwise, he has a noncontributory past medical history. On physical exam, the patient is in mild respiratory distress, with a slightly elevated heart rate and respiratory rate. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to the left. Other than tachycardia, his cardiovascular exam is normal. A chest X-ray is obtained, and a pleural line is visible. Question What is the most likely diagnosis?

Pneumothorax

A 22-year-old postpartum woman presents with a loss of interest in eating, increased sleepiness, and fatigue at her first-week checkup. It was her first pregnancy. She has been happily married for 2 years; she has a stable job and good family support. Out of her hearing range, her husband reports that she seems more irritable, snapping at him for trivial things. She broke down sobbing when asked about her parents, who passed away in a car accident 1 year earlier. Question What is the most likely diagnosis?

Postpartum blues

A 16-year-old girl presents with a history of severe nodulocystic acne. She has used topical benzoyl peroxide and topical tretinoin and has undergone numerous courses of oral tetracycline. The acne has not responded to any treatment. You decide to change her treatment plan and prescribe the appropriate next step in management to treat her condition. Question What must be obtained before beginning treatment?

Pregnancy test

A 30-year-old woman presents with a 2-week history of vaginal discharge. She denies vaginal burning or itching, urinary frequency, hesitancy, and dysuria. The discharge is reported as light yellow in color. She is hesitant to provide much detail, so a physical exam is performed. On physical exam, the patient is in no distress, is afebrile, has normal vitals, and the exam is normal except for the pelvis. On speculum examination, the cervix is inflamed, bright red, and slightly friable with yellow discharge at the os. Vaginal mucosa is pink, moist, and without inflammation. Uterus and ovaries palpate to normal size and are non-tender on bimanual exam. Samples are collected for analysis and the results that are available are listed. TestResultUrine hCGNegativeUrinalysis (dipstick)Normal, except for 1+ WBCWet mount/KOH slideNegative for trichomonads, hyphae, and clue cells, >10 WBC per high-powered fieldComplete blood countNormal Question What is the most appropriate intervention for this patient given the most likely diagnosis?

Prescribe empiric antibiotics

A 55-year-old male patient presents with a pale appearance and bilateral ankle edema that started 1 week ago and has progressively worsened. He has a 5-year history of type 2 diabetes, but the last physical exam was 2 years ago. He does not take any medications because he prefers to "control the health with a healthy lifestyle." Temperature 37°C, blood pressure 155/100 mm Hg, heart rate 80, respirations 15/min. He is otherwise well-developed and well-nourished; BMI 25 kg/m2. TestResultsReference Range for Male PatientsSerum creatinine 2 mg/dL0.5-1.5 mg/dLGlomerular filtration rate (GFR)42Greater than 90Urine dipstickProtein +NegativeBlood urea nitrogen (BUN)607-20 mg/dLHematocrit (Hct)3538-54%Hemoglobin (Hgb)1114-18 g/dLHemoglobin A1c (HbA1c)8.5Goal 6.5% or lessNon-fasting glucose250 79-140 mg/dLSerum albumin23.5-5.5 g/dLPotassium5.9 3.5-5.5 mEq/LSodium148 135-147 mEq/LCholesterol250Less than 225 mg/dLTriglycerides200 Less than 150 mg/dL Question In addition to starting glycemic and blood pressure control, what dietary advice can help slow the progression of the new diagnosis?

Protein restriction

A 19-year-old man without significant past medical history presents to the ED with a 2 cm laceration on his right calf with several small flecks of organic material within the wound. The patient is a hospital volunteer who reports that he obtained this injury while accompanying a hospitalized patient on a walk through the hospital gardens. He is unsure of his specific vaccination record, but he has received all required childhood vaccinations and recently received Tdap (booster tetanus toxoid-reduced diphtheria toxoid-acellular pertussis) vaccination required for college admission. Question What is the best course of action?

Provide wound care alone.

A 23-year-old woman presents with fatigue and the recent onset of a yellowing of her skin. Her physical examination is remarkable for the presence of splenomegaly. Laboratory results are as follows: TESTRESULTSREFERENCE RANGEHematocrit3840-50 (male)36-44 (female)Hemoglobin12.6 g/dL13.8-17.2 g/dL (male)12.1-15.1 g/dL (female)RBC3.3 x 106/µl4.5-5.7 x 106/µl (male)3.9-5.0 x 106/µl (female)MCHC3731-36Platelets258,000/mm3130,000-400,000/mm3WBC5.4 x 103/mm34.0-11 x 103/mm3Neutrophils5740-75%Lymphocytes3715-45%Monocytes41-10%Eosinophils21-6%Basophils00-2%Comments: Red blood cells are spherocytes. Red blood cells demonstrate increased osmotic fragility. Question Where is the primary pathology in this patient's condition?

RBC membrane

You are a physician assistant assisting an orthopedic surgeon with a total knee arthroplasty (TKA). You reviewed the knee X-ray prior to the case and confirmed on the consent the correct side. A surgical time out was performed, and all agreed that the patient is having a left TKA. There is no mark on either leg by the surgeon to identify the correct leg. The surgery is completed, and the patient is transferred to the recovery room. Upon waking, the patient reports that they were supposed to have a right TKA. The consent is reviewed and does read as left. Question Which of the following CME activities based on this case presentation is performance improvement and not self assessment?

Re-evaluate the consent procedure

A 40-year-old woman undergoing a gynecologic workup for metromenorrhagia presents with a several-week history of fatigue and lightheadedness. Laboratory evaluation reveals a hemoglobin of 11 g/dL (12-16 g/dL), hematocrit of 34%, MCV of 70 fL (80-100 fL), and MCH of 24 pg (27-33 pg). Further studies reveal a ferritin level of 25 ng/mL (12-300 ng/mL), TIBC of 500 mcg/dL (250-450 mcg/dL), and an iron level of 45 mcg/dL (60-170 mcg/dL). The patient is diagnosed with iron deficiency anemia. She is prescribed ferrous sulfate 325 mg po tid. Several days later, she presents to the ER. She reports resting dyspnea and chest discomfort. Oxygen and nitroglycerin are given. Cardiac enzymes are pending. The patient's hematocrit is 23% with hemoglobin of 7.5. Question What treatment is most appropriate for this patient?

Red blood cell transfusion

A 15-year-old girl has been dieting for 6 months and has lost over 30 pounds. She tells you that she still feels fat. She is afraid to eat for fear of becoming obese. Her last menstrual period was 3 months ago. On physical exam, the patient is cachectic and slightly pale. Her heart rate is 50 beats/minute, her blood pressure is 90/60 mm Hg, and her temperature is 95.5°F. Her weight is 92 lb and her height is 5'6". Question What laboratory value is most likely present?

Reduced luteinizing hormone (LH)

A 33-year-old man with no past medical history presents with groin mass. He denies pain and trauma to the region. When the patient stands, there is a round swelling in the inguinal area. If the patient is supine, the mass disappears. Question What is the appropriate intervention in this patient?

Referral to general surgeon

A 42-year-old man presents with a 3-day history of "not being able to hear in my right ear." He is otherwise healthy and is not taking any medications. There is no history of trauma. On physical exam, the whisper test is decreased on his right, the Weber test lateralizes to the right ear, and the Rinne test is as follows: right ear bone conduction is greater (lasts longer) than air conduction; left ear air conduction lasts longer than bone conduction. Question What is the most likely diagnosis?

Right ear conductive hearing loss, possibly due to cerumen impaction

A 40-year-old Caucasian man presents to your office to ask for advice regarding the inability of his wife to conceive. She is younger than him by 8 years and he believes she is in good health. Additionally, she has two children from a previous marriage, both pregnancies without complication. He was also married once before, but his first wife did not conceive children. He has not yet undergone any fertility tests. Question What is the most common cause for infertility in this case?

Spermatogenesis and motility

A 66-year-old man with moderately well-controlled type 2 diabetes mellitus presents to his primary care provider for the management of pneumonia. His influenza test was negative. He is currently being treated with levofloxacin. He is afebrile; pulse is 93, blood pressure is 130/90 mm Hg, respirations are 18/min, and oxygen saturation is 92% on room air. Question What is the most common bacterial cause of this patient's pneumonia?

Streptococcus pneumoniae

A 36-year-old woman presents with a 24-hour history of sudden severe diarrhea described as profuse, gray, cloudy, watery stools without blood or fecal odor. She was recently in Bangladesh for work and returned yesterday, which was when the diarrhea began. She is also experiencing a mildly elevated temperature with a very dry mouth, headache, and severe fatigue. Question What is most likely offending organism?

Vibrio cholerae

A 67-year-old woman is hospitalized because of lung cancer. During her stay in the hospital, she becomes obtunded. During a physical exam, she has a seizure. Soon thereafter, she goes into a coma. Lab results show that her urine is hypertonic. Additional laboratory results are as follows: TESTRESULTSREFERENCE RANGEBUN12 mg/dL10-20 mg/dLCalcium9.9 mg/dL8.5-10.5 mg/dLPotassium4.2 mEq/L3.5-5.0 mEq/LSodium120 mEq/L135-145 mEq/LGlucose (fasting)91 mg/dL65-110 mg/dL The results of her urinalysis are as follows: TESTRESULTSREFERENCE RANGEUrine dipstick bloodNegativeNegativeUrine dipstick glucoseNegativeNegativeUrine dipstick ketonesNegativeNegativeUrine dipstick proteinNegativeNegative24 hour urine protein124 mg/24 hour<150 mg/24 hourUrine specific gravity1.0351.001-1.035Urine pH6.24.5-8.5 Question What is the most likely diagnosis?

Syndrome of inappropriate ADH secretion

A 29-year-old woman presents with a previous history of mitral valve prolapse with murmur of regurgitation confirmed on echocardiogram with prosthetic valve replacement 1 year ago. Question Based on the recommendations by the American Heart Association, what procedure is antibiotic prophylaxis recommended for in this patient?

Tooth extraction

A 25-year-old female patient presents with a 2-day history of acute pain in the mouth; there is no significant past medical history. The patient states that the pain is in a localized part of the inner cheek; it is aggravated by eating food, speaking, and smiling. She denies any history of smoking, risky sexual behavior, drug use, transfusions, trauma, fever, chills, otalgia, otorrhea, rhinitis, eye pain/discharge, halitosis, regurgitation, skin changes, swollen glands, sore throat, or headache. Physical exam is noteworthy for painful ulcerations of buccal and labial mucosa with a yellowish base and red halos. Question What is the most appropriate intervention?

Topical corticosteroids

A 28-year-old man presents with a 1-week history of an itchy scaly rash on his elbows. When he scratches it hard, scales come off and the rash bleeds. Examination reveals the elbows are affected bilaterally. The lesions appear as 3-4 cm annular whitish scales on an erythematous base that is irregular and well-demarcated. The antecubital fossae are unaffected. Question What is an appropriate treatment?

Topical fluorinated glucocorticoids

A 35-year-old man presents for medical care, but he is too embarrassed to tell the nurse his chief symptom. Eventually, he admits to severe, intense itching around his anus; it has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He ranks this pain as a 10/10 on a pain scale. This intense pain makes him try to avoid having bowel movements regularly. He admits to one episode of a small amount of bright red blood on the toilet paper and on the stool itself. Reviewing documentation on this patient reveals that this is the fourth similar episode in the last 14 months. The patient denies fever and diarrhea; according to him, he has never been diagnosed with inflammatory bowel disease. Question Considering the most likely diagnosis, what pharmaceutical intervention should be initiated?

Topical nitroglycerin 0.2-0.4%

A 16-year-old female patient presents with a 6-month history of blackheads and whiteheads on the face. On examination, there are a few papules and pustules on the cheeks; there are no nodules. The mother reports having similar spots on her face at this age. Question What is an appropriate first-line medication for this patient?

Topical tretinoin

A 23-year-old male patient presents with an unspecified personality disorder. His group and individual therapy sessions are going well, but he wants to gain even more improvement with his diagnosis. He feels that his mood, self-image, and personal relationships have improved overall, but he specifically states he wants to have better anger management. When he becomes angry, for whatever reason, he still becomes extremely irritated, hostile, and even aggressive. Question What pharmaceutical therapy is most beneficial for this patient?

Topiramate

A 38-year-old woman with a past medical history of rheumatic fever and endocarditis presents with progressive dyspnea on exertion associated with palpitations and intermittent episodes of left-sided chest pain. Both symptoms resolve at rest. Her physical exam reveals resting tachycardia and a widened pulse pressure. The cardiac exam is notable for a decrescendo diastolic high-pitched murmur, loudest at the left sternal border and accentuated with the patient leaning forward in full expiration. Abrupt distention and quick collapse are observed upon palpation of the peripheral arterial pulses. Booming systolic and diastolic sounds are auscultated over the femoral arteries. Question What is the diagnostic test of choice to confirm this patient's most likely diagnosis?

Transthoracic echocardiography

A 68-year-old non-smoking man presents to your pulmonology practice for long-standing dyspnea and non-productive cough. The patient has had the cough and progressively worsening dyspnea for about 1.5 years with no current exacerbation. He denies fevers, chills, night sweats, and any other symptoms. He denies unusual travel, hobbies, or occupational exposures. He does, however, endorse relatively frequent reflux symptoms. The rest of his review of systems is negative. He has had a workup through his family practice and was then sent to the cardiologist, who ruled out cardiovascular causes of his dyspnea. He has been given trials of various antibiotics, inhalers, and steroids, all without improvement in symptoms, despite good compliance. He currently takes no medications. Several tests have been performed, and results are shown in the table. Blood count, metabolic panel, HIV, and autoimmune markersNormalHigh-resolution computed tomography (HSCT) scanFew reticular opacitiesPulmonary function test (PFT)Restrictive impairment and reduced perfusion of carbon monoxide Physical exam is significant for fine inspiratory bibasilar crackles and clubbing in the fingers. An occasional dry cough is noted. Question What intervention is most likely to prevent complications in this patient?

Treatment of gastroesophageal reflux disease

A 47-year-old Latina female patient presents with a 2-month history of persistent abdominal pains. She becomes uncomfortable after eating, especially after consuming fats, eggs, chocolate, fried foods, fatty foods, and rich desserts. Her pains are primarily located in her right upper abdominal quadrant and often radiate to her right shoulder blade. Physical examination is essentially unremarkable. Blood pressure is 122/82 mm Hg, she has a pulse of 72 per minute, and a temperature of 98.6°F with respirations 16 per minute. Her abdominal examination reveals no tenderness, no guard, no rebound, and normally active bowel sounds. Her liver and spleen are not palpable. She has no readily palpable abdominal masses. She is not jaundiced. She has no scleral icterus. Question What test should be given to confirm the probable diagnosis?

Ultrasound abdomen

A 68-year-old woman presents with shortness of breath, fatigue, dry cough, and swelling in her ankles. Symptoms started around the time of her son's wedding 6 weeks ago. She dismissed them as stress-related, but symptoms have worsened in intensity and frequency. Now she becomes very short of breath with any exertion, such as climbing stairs in her home. She feels like she may pass out and has to sit when she gets lightheaded. Breathing is more difficult when lying down. She denies productive cough, fever, or chest pain. She has had no medical care for several years. Past medical history is unremarkable, with no known medical conditions and no surgeries. She is menopausal, takes no medications, and has no allergies. She denies use of tobacco, alcohol, and recreational drugs. Physical exam was performed by the provider on an earlier shift, and the patient's care was turned over. Weight171 lbHeight65"BMI28.5Pulse101Blood pressure158/98Temperature97.9°F/36.6°C Complete blood count (CBC)NormalThyroid-stimulating hormone (TSH)NormalUrinalysisNormalComplete Metabolic Panel (CMP)NormalBeta natriuretic peptide (BNP)ElevatedChest x-rayPerivascular edema,slightly enlarged cardiac shadow12-lead electrocardiogramMild left ventricular hypertrophyCardiac echocardiogramPendingCardiac enzymesNormal Question Once this patient is stabilized and educated about her diagnosis and treatment, she asks what she could have done to prevent her condition. What is the greatest modifiable contributing factor to this condition at the population level?

Untreated hypertension

A 75-year-old woman presents with heartburn and dyspepsia. She was diagnosed with osteoarthritis 4 years ago. For the past 18 months, she has been managing pain with naproxen. The gastroenterologist suggests that the patient be tested for Helicobacter pylori infection. Question What is the most sensitive and specific non-invasive method to diagnose this infection?

Urea breath test

A 64-year-old woman presents with urine leakage that has been progressively worsening for the past 6-12 months. She also admits to having vaginal dryness, poor lubrication with intercourse, and subsequent dyspareunia. Urinary leakage primarily seems to occur with coughing, sneezing, or high-impact exercise. She denies dysuria, hematuria, urgency, and vasomotor symptoms. She tries to empty her bladder every 2-3 hours and has cut out all alcoholic and caffeinated beverages, but symptoms persist. The patient is a G6P6. She has no chronic medical conditions and no past surgeries. She wants to do everything she can to avoid surgery. She is in a monogamous relationship. She was last seen 1 year ago with a normal well-woman exam and normal Pap smear. On physical exam, vitals are normal. The pelvic exam reveals dry pale vaginal mucosa with a bulge on the anterior vaginal wall that increases in size with a Valsalva maneuver. Urinalysis is normal. Question Given this patient's strong preference to avoid surgery, what else could be done to improve her urinary symptoms?

Vaginal pessary

A 72-year-old man is admitted with an acutely severe myocardial infarction. His status quickly deteriorates. His symptoms include hypotension, altered mental status, cold clammy skin, and metabolic acidosis seen on laboratory tests. Question What is the most appropriate initial pharmaceutical choice for a patient in this type of shock?

Vasopressors

A 70-year-old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have become "dull." Over the past month, she has started having urinary urgency and involuntary leaking of urine. Besides multivitamins and local application of Timolol for glaucoma, she takes no other medications; there are no other symptoms. Question What is most likely the best method of treating the patient's urinary problems?

Ventriculoperitoneal shunt

A 62-year-old woman presents due to urine leakage for 2 years that has worsened. She leaks urine when she coughs or sneezes; she wears a pad daily as a result. The amount of leakage varies. The patient denies hematuria, dysuria, and pelvic pain. She sometimes feels vaginal pressure and fullness. She is considering quitting her job from embarrassment. Past medical history includes 4 vaginal deliveries. No other known medical conditions, medications, or allergies. She is married and works part-time at a call center; she denies tobacco, alcohol, and recreational drugs. On physical exam, she is obese, with an atrophic vulva/vagina. Pelvic examination reveals downward and forward rotation of the vaginal wall, with an anterior bulging when the patient is asked to strain. A dipstick urinalysis is normal. Question After completing treatment of her condition, what is the most appropriate way of preventing recurrence?

Weight loss

A 3-year-old girl presents with progressive abdominal enlargement associated with abdominal pain. The mother denies any past medical history. Physical examination shows a palpable mass over the right upper quadrant extending to the right flank. Patient looks pale and the BP is slightly elevated. Urinalysis shows microscopic hematuria. Question What is the most likely diagnosis?

Wilms tumor

A 52-year-old man presents with concerns over hearing changes. He has noticed a decreased ability to hear sounds for the past few months; he tested it at home by covering each ear, and he now thinks there is a hearing loss in only the left side. He also hears a ringing sound all the time. He denies occupational exposure to loud noises. He denies head trauma, headaches, and prior ear problems. His wife thinks this is just normal age-related hearing loss. His review of systems is negative for other neurological symptoms. Past medical history is unremarkable; he has no known medical conditions. He takes no medications. He has no allergies, and he has not had any surgeries. He denies alcohol, tobacco, and recreational drug use. On physical exam, his vitals are normal. His HEENT exam is significant only for decreased auditory acuity and Weber test lateralizing to the right. Audiometry confirms a sensorineural hearing loss on the left. An MRI shows a well-delineated intracranial mass. Further investigation reveals the origin of cells is from Schwann cells. Question After completing treatment for his current condition, what is the best approach for health maintenance?

Yearly head imaging

A 36-year-old G1P1001 woman presents with a 4- to 5-week history of pain along her right lateral wrist; the pain worsens when she tries to grasp something. There was no trauma. She gave birth 6 weeks ago and carrying her baby is difficult secondary to pain. She is right-handed and has never had any issues like this before. On exam, there is tenderness and edema over the radial styloid. You then have the patient fully flex her thumb, adduct, and grasp it with that hand. You then place her hand in ulnar deviation, which reproduces the pain described above. Question What is the most likely diagnosis?

de Quervain tenosynovitis