Emergency Medicine

A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and tremor in her hands. Past medical history is non-contributory. She takes a multivitamin and drinks 1-2 cups of coffee daily. She denies any recreational drug use. Blood pressure is 110/70 mm Hg. Heart rate 105 bpm, regular. Respirations 16/minute. She appears anxious, and you note the presence of bulging eyes. Thyroid is diffusely enlarged. Cardiovascular exam reveals normal S1 and S2 without murmurs, rubs, or gallops. Normal breath sounds bilaterally. Question Given the most likely diagnosis, what laboratory finding do you expect? Answer Choices 1 Decreased thyroid-stimulating hormone 2 Decreased total thyroid hormone 3 Decreased free T3 and free T4 4 Negative thyroglobulin antibody 5 Negative thyroid peroxidase antibody

1 Decreased thyroid-stimulating hormone

A 38-year-old woman presents with a new tremor. She also reports weight loss and heat intolerance along with increased anxiety and palpitations. She has noticed swelling of her neck. Question What finding on physical exam would help support your suspected diagnosis? Answer Choices 1 Exophthalmos 2 Conjunctivitis 3 Chemosis 4 Periorbital edema 5 Corneal abrasion

1 Exophthalmos

A 40-year-old man presents with severe pain in his left eye, decreased vision, nausea, and abdominal pain. He denies recent trauma. He wears glasses for myopia. On examination, the patient's left pupil is moderately dilated and nonreactive. The cornea is "steamy" in appearance and the eye is red in general. Question What is the most likely diagnosis? Answer Choices 1 Conjunctivitis 2 Uveitis 3 Acute angle-closure glaucoma 4 Presbyopia 5 Corneal infection

3 Acute angle-closure glaucoma

An 18-year-old woman presents to the emergency department with her mother due to pain in her right leg after a car accident. She points to her lower leg and describes the pain as severe. Upon physical exam, there is extreme pain with passive movement of right leg with diminished sensation. When asking the patient to stand on the leg, she reports weakness and extreme tenderness. Upon use of the Stryker IC pressure monitor system, the patient's pressure was 35 mm Hg. Question What is the most likely diagnosis? Answer Choices 1Acute compartment syndrome 2 Carpal tunnel syndrome 3 Exertional compartment syndrome 4 Rhabdomyolysis 5 Stress fracture

1Acute compartment syndrome

A 32-year-old woman presents for a follow-up visit. She was diagnosed with hyperthyroidism 2 weeks earlier, after presenting with tremors, heat intolerance, weight loss, and diarrhea. You prescribed propranolol for her, pending the results of her test during her last visit. She feels slightly better now. She denies any family history of thyroid disorder and has no drug allergies. She has a supportive husband. She does not smoke, drink alcohol, or use illicit drugs. Her physical examination is normal. She has been reading about management of hyperthyroidism; she prefers the 131I treatment. Question What is the most appropriate response to her request? Answer Choices 1 "It cannot be used for females of childbearing age." 2 "Take a pregnancy test prior to starting therapy." 3 "Surgery would be a better approach than 131I treatment." 4 "131I has been associated with a high recurrence rate." 5 "131I has been linked to cancer of the thyroid."

2 "Take a pregnancy test prior to starting therapy."

A 74-year-old man presents with a 90-minute history of severe pain and blurred vision in his left eye. He reports headache and some nausea along with halos surrounding lights. Upon examination, his left eye is erythematous with a steamy cornea and a poorly reactive mid-dilated pupil. An ophthalmologic consult is ordered and tonometry is completed, revealing an elevated intraocular pressure. Gonioscopy was used to confirm the diagnosis and examine the fellow eye, showing narrow anterior chambers in both eyes. Question What will be the definitive treatment for this patient after acute attack resolution? Answer Choices 1 Left laser peripheral iridotomy 2 Bilateral laser peripheral iridotomy 3 Intravenous acetazolamide 4 Oral hyperosmotic glycerin 5 Topical timolol 0.25%

2 Bilateral laser peripheral iridotomy

A 22-year-old woman presents with a 2-month history of weight loss despite the woman having a good appetite. She also reports of having frequent bouts of diarrhea. On detailed questioning, she reveals a feeling of heat intolerance and menstrual irregularity. The right lobe of the thyroid is palpably enlarged, and further investigations confirm the suspected diagnosis. Question What pair of symptoms is characteristic of this disease state? Answer Choices 1 Fatigue and lethargy 2 Palpitations and tremors 3 Slowed speech and movement 4 Thickening and dryness of skin 5 Impaired memory and sleepiness

2 Palpitations and tremors

A 22-year-old woman is started on methimazole for the treatment of her hyperthyroidism. She has been diagnosed with Graves' disease and has been symptomatic for the last 6 months. She is otherwise healthy and does not take any other medications. You receive a call 2 weeks later from the patient; she tells you that she has had a mild sore throat for the past 2 days and has been feeling like she is coming down with the flu. She states that the symptoms of her hyperthyroidism are a little bit better. Question What should you do? Answer Choices 1 Increase her daily dose of methimazole. 2 Initiate a prescription of a small dose of thyroxine. 3 Tell her to present ASAP for total and differential blood count. 4 Prescribe antiviral antibiotics. 5 Prescribe saltwater gargles and acetaminophen.

3 Tell her to present ASAP for total and differential blood count

An 18-year-old man presents with multiple painful vesicles on an erythematous base on the right side of his lower lip. He experienced similar symptoms a month ago with an associated sore throat. He has an oral temperature of 101°F and positive tender cervical lymphadenopathy. Question What is the most appropriate clinical intervention? Answer Choices 1 Oral amoxicillin/clavulanic acid for 10 days 2 Punch biopsy of 1 of the lesions 3 Oral valacyclovir 4 IV acyclovir 5 Tzanck preparation from the base of a lesion

3. Oral valacyclovir

A 35-year-old woman presents because of weight loss and palpitations. She lost 10 kg over 5 months despite having a good appetite. Her heart pounds and her hands tremble "all the time." She feels hot, is sweating profusely, and has difficulties going to sleep and maintaining sleep; the slightest stimulus wakes her. Her job is suffering because of her nervousness, and her supervisor became concerned because she uses the bathroom 3-4 times a day in a need to move her bowels. She thinks that poor sleep quality and frequent bowel movements make her weak; she cannot climb stairs anymore and has to take a rest every 10 steps or so. Physical examination reveals a slim anxious woman with pronounced stare, fine postural hand tremor at rest, and slight proximal weakness. Her thyroid is diffusely enlarged and non-tender; her pulse is 100/min; the rest of examination is within normal limits. Question What is the most likely diagnosis? Answer Choices 1 Hashimoto's thyroiditis 2 Toxic goiter 3 Grave's disease 4 Plummer's disease 5 Thyroid storm

3. Grave's disease

A 58-year-old man presents with a 1-day history of severe abdominal pain, nausea, and vomiting. He initially thought he had some indigestion with pain located in the epigastric region and tried some calcium carbonate (Tums) with no relief. The pain and vomiting progressed through the night and kept him from sleeping and going to work. He feels the pain boring through to his back. He denies hematemesis, fever, diarrhea, out-of-the-country travel, and contact with sick people. Prior to onset of pain, he reports good health. He has no known medical conditions and takes no medications. He has had no surgeries. He smokes cigarettes (40 pack-years), admits "moderate" alcohol use, and denies drug use. He is married and works as a welder. Vitals are: BP: 102/56 mm Hg; HR: 116 bpm; RR: 15; Temp: 98.9°F; O2 Sat: 95% on room air. On physical exam, the patient appears uncomfortable on the exam table and grimaces when changing position for exam. He is cooperative, alert, and oriented. Abnormal physical exam findings include distended abdomen, decreased bowel sounds, and epigastric region tenderness with guarding. He is tachycardic. No jaundice is noted. The remainder of the exam is normal. This patient's test results are shown in the table. TestResultNormal RangeUnitsComplete Blood Count (CBC)WBC15.13.6-9.0K/μLRBC4.634.18-5.22M/μLHemoglobin15.412.9-15.5g/dLHematocrit49.934.6-50.1%MCV87.280.0-100.0fLMCH29.427.0-34.0pgMCHC32.130.0-37.0g/dLRDW11.711.0-17.0%Platelets335140-440K/μLMPV7.36.5-12.0fLWBC differentialNormalComplete Metabolic Panel (CMP)Sodium144134-144mmol/LPotassium3.73.4-4.9mmol/LChloride102100-109mmol/LHCO32520-31mmol/LGlucose8270-99mg/dLBun217-18mg/dLCreatinine10.6-1.2mg/dLCalcium8.98.8-10.5mg/dLAlbumin3.53.5-5.0g/dLTotal Protein6.46.4-8.2g/dLAST (SGOT)7215-37U/LALT (SGPT)855-43U/LAlk Phosphatase15550-136U/LTotal Bilirubin0.90.1-1.2mg/dLeGFR>60>60mL/min/1.73m2Amylase35020-110U/LLipase4800-160U/LHepatitis panelNegativeAbdominal CTDiffuse pancreatic enlargement and inflammation, with single fluid collectionUrinalysisNormal Question What pharmacologic treatment is the most important intervention for this patient's most likely condition? Answer Choices 1 Ertapenem 2 Hyoscyamine 3 Lactated Ringer's 4 Pancrelipase 5 Promethazine

3. Lactated Ringer's

A 5-year-old girl presents with a rash. The girl's mother states that she took the child to an urgent care center over the previous weekend; the patient was diagnosed with a urinary tract infection. The child was started on a 7-day course of sulfamethoxazole/trimethoprim and currently only has one more dose to take. The mother states the child has never taken this type of medication before. The rash in question was first noticeable 2 days ago; it has spread, worsened, and intensified, prompting the mother to bring the child in today. She denies any recent fevers, irritability, itching, or other significant symptoms. On physical examination, you note scattered lesions on the child. Each lesion appears to have three concentric circles of color change. Question Making note of the characteristic target lesions this patient displays, what treatment would you recommend? Answer Choices 1 Continue sulfamethoxazole/trimethoprim; begin acyclovir. 2 Discontinue sulfamethoxazole/trimethoprim; begin topical Benadryl. 3 Continue sulfamethoxazole/trimethoprim; begin azithromycin. 4 Discontinue sulfamethoxazole/trimethoprim; monitor symptoms. 5 Discontinue sulfamethoxazole/trimethoprim; begin cetirizine.

4 Discontinue sulfamethoxazole/trimethoprim; monitor symptoms.

A 39-year-old woman presents with a rash. The rash started 5 days ago; it is pruritic and located primarily on her arms and legs, with a few sores in her mouth. Her husband described the rash as like a "bullseye." She has felt mildly "flu-like," but she denies fevers. She denies any changes in soaps, detergents, or diet. She has not been around anyone with a similar condition, and she denies travel. Otherwise, she reports feeling better than usual, with more improved control of her migraines since her neurologist started her on topiramate about 3 weeks ago. She has not needed to use her sumatriptan for over 1 month. Her review of systems is negative. She suffers from migraines, but she has no other chronic health conditions. Her current medications are topiramate daily, with sumatriptan as needed. She is allergic to amoxicillin. She has regular menses; she had a tubal ligation as contraceptive. On physical exam, a few small oral lesions are noted. The lesions on the extremities are primarily on the dorsal surfaces, with a ringed appearance, similar to a target. The remainder of her exam is normal, including vital signs. Question What is the most important and appropriate intervention in this case? Answer Choices 1 Admission to burn unit for skin management 2 High-dose oral antihistamines 3 High-dose oral steroids 4 Immediate discontinuation of the new medication 5 Topical steroid cream

4 Immediate discontinuation of the new medication

A 14-year-old boy presents for a sports physical. History is significant for a high degree of myopia bilaterally first diagnosed at age 4 and a dislocated shoulder at age 10 that was easily reduced. Family history is significant for several unidentified ancestors having died in their 40s of an unidentified cardiovascular disorder. Physical examination reveals normal vital signs, height of 6'1", and weight 145 lb. The upper to lower segment ratio is 0.65 (decreased). Arm span is 76". The palate is highly arched. Mild pectus excavatum was present. A 2/6 early diastolic murmur is present best heard at the second intercostal space at the right sternal border. Arachnodactyly of the fingers and toes and generalized loose jointedness and pes planus are also present. Echocardiography reveals a tricuspid aortic valve with grade 1 (out of 4) aortic regurgitation with a normal aortic root diameter. Question In addition to echocardiography, what evaluation would be most productive? Answer Choices 1 Brain MRI 2 Growth hormone level 3 Muscle biopsy 4 Ophthalmology evaluation 5 Rheumatoid factor

4 Ophthalmology evaluation

A 45-year-old man presents with progressive dyspnea and chest discomfort. He is 2 days status post total hip arthroplasty, which was uncomplicated. He denies any trauma to the chest. On exam, his pulse is 110 bpm; respirations are 40/min. The chest radiograph reveals a wedge-shaped opacity. Lab studies reveal a higher D-dimer level. Question What is the most likely cause of his chest pain? Answer Choices 1Esophageal reflux 2Pneumothorax 3Aortic dissection 4Pulmonary embolism 5Unstable angina

4. Pulmonary embolism

A 35-year-old woman who recently finished a round of oral antibiotics for pneumonia presents due to her tongue having "a thick white coating"; she adds that it is "also red and irritated." She is able to "scrape the white stuff off" some areas of her tongue, which she reports have become raw and more erythematous. Question What is the most likely diagnosis? Answer Choices 1 Hairy leukoplakia 2 Atrophic glossitis 3 Hairy tongue 4 Geographic tongue 5 Candidiasis

5 Candidiasis

A 28-year-old man presents with a rash. The lesions, which are mildly pruritic, are located on his arms and legs. They have been present for about 3 days without change or resolution. He has tried over-the-counter anti-itch creams, but they have been ineffective. The patient reports that he was seen approximately 1 week ago for some blister-like lesions on his penis. He was given an antiviral medicine, and those lesions resolved. He is wondering if he was misdiagnosed and if the two rashes are related. He admits to feeling some malaise over the last 2 weeks, but he is otherwise healthy. He denies fevers, unusual travel, medication use (except for as listed above), and known allergies. He has no known chronic conditions. On physical exam, vitals are normal; the patient is in no apparent distress. A pink-to-red papular rash is observed on the backs of the hands and feet and extensor surfaces of the arms and legs. The individual lesions are quite distinct; they have a red center, and they are surrounded by a pale ring and then another outer ring of red, inflamed tissue. The remainder of his physical exam is normal. Question What test will confirm the suspected diagnosis? Answer Choices 1 Complete blood count (CBC) with differential 2 Fungal culture 3 Herpes culture 4 Heterophile antibody 5 Skin biopsy

5. Skin biopsy

A 40-year-old woman undergoing chemotherapy develops fevers and respiratory symptoms. A chest radiograph is ordered; it reveals bilateral fluffy pulmonary infiltrates. A bronchoscopy with biopsy is performed; the specimen is found to contain septate hyphae with acute-single branching. Question What treatment should the patient receive? Answer Choices 1 Erythromycin 2 Tetracycline 3 Penicillin 4 Vancomycin 5 Voriconazole

5. Voriconazole

A 7-year-old boy presents with his mother with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the patient. Total lung capacity (TLC) is 111% on spirometry. Pre-bronchodilatorsPost-bronchodilatorsFVC%4963FEV1%4146FEV1/FVC4955 Question What is the most likely diagnosis? Answer Choices 1 Asthma 2 Pneumonia 3 Pleural effusion 4 Kyphoscoliosis 5 Tuberculosis

1. Asthma

A 4-year-old boy accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The child is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Pulse is 94/min, BP is 110/70 mm Hg, temperature is 101°F. Question What is the next step to confirm the diagnosis? Answer Choices 1 Direct fiberoptic laryngoscopy in operating room 2 Indirect laryngoscopy 3 Examination with tongue depressor 4 Lateral neck radiograph 5 Complete blood count and blood culture

1. Direct fiberoptic laryngoscopy in operating room

A 19-year-old woman presents with a 2-week history of rash. Other than a sore throat that she had last week, she reports being in good health; her sore throat was treated with penicillin. She does not believe that she has come in contact with any type of irritants or any individuals who are sick. On physical examination, you note several target-like lesions on the palms of her hands that are bilateral and symmetric. She indicates that she is on birth control medication. Question What is the most likely diagnosis? Answer Choices 1 Erythema multiforme 2 Erysipelas 3 Atopic dermatitis 4 Erythema nodosum 5 Steven-Johnson syndrome

1. Erythema multiforme

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? Answer Choices 1 Streptococcus pneumoniae 2 Haemophilus influenzae 3 Staphylococcus aureus 4 Pseudomonas aeruginosa 5 Moraxella catarrhalis

1. Streptococcus pneumoniae

A 28-year-old woman presents to the emergency department due to a 3-hour history of nausea, abdominal cramping, vomiting, and watery diarrhea. She recounts her lunch approximately 8 hours ago, which consisted of a shrimp salad and a diet soda. She denies any neurological or other symptoms. She also denies any similar problems prior to this episode and was feeling well just before this incident. She denies fever or recent travel. Question What is the most likely organism responsible for her symptoms? Answer Choices 1 Vibrio parahaemolyticus 2 Staphylococcus aureus 3 Clostridium difficile 4 Clostridium perfringens 5 Campylobacter jejuni

1. Vibrio paraemolyticus

A 65-year-old woman presents with general weakness for the past few days; it gets worse as the day progresses. She says she has been having double vision, and you notice she has poor posture. A blood test reveals the presence of antibodies to acetylcholine receptor. A repetitive nerve stimulation test showed a decremental response. Question What is the most likely diagnosis? Answer Choices 1 Marfan syndrome 2 Myasthenia gravis 3 Duchenne muscular dystrophy 4 Rheumatoid arthritis 5 Systemic lupus erythematosus

2. Myasthenia gravis

A 14-year-old boy presents with a 1-week history of acute watery diarrhea with vague abdominal discomfort and vomiting. He has developed fever, malaise, facial and periorbital edema, and myalgias. He is experiencing pain and swelling of the calf muscles. The patient ate some food prepared from pork and game meat in a restaurant 3-4 weeks ago. Blood examination shows moderate eosinophilia. Question What is the most likely etiological agent responsible for the patient's illness? Answer Choices 1 Ascaris lumbricoides 2 Trichinella spiralis 3 Taenia solium 4 Necator americanus 5 Giardia lamblia

2. Trichinella spiralis

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? Answer Choices 1 Observation only 2 Intravenous heparin therapy 3 Fasciotomy 4 Placement of a long leg cast 5 Intravenous antibiotic therapy

3. Fasciotomy

A 3-year-old boy is evaluated for a 24-hour history of diarrhea. His mother reports that he had five episodes of foul-smelling watery diarrhea associated with decreased appetite. A few other children at the same daycare center have presented with the same problem. On physical examination, the child is well hydrated and his abdomen is tender. Stool microscopy shows the presence of motile trophozoites representing the etiological agent. Question What is most likely causing this patient's symptoms? Answer Choices 1 Cryptosporidiosis 2 Cyclosporiasis 3 Giardiasis 4 Isosporiasis 5 Microsporidiosis

3. Giardiasis

A 45-year-old woman presents with diarrhea and vomiting that started last evening. She says she warmed up leftover rice for supper last night and symptoms began shortly thereafter. She has no fever, and her blood pressure and pulse are within normal limits. Question What would be the best next step? Answer Choices 1 Admit for observation 2 Start oral fluids and metronidazole 3 Reassure and send home with oral rehydration 4 Send stool specimen to the lab and follow up tomorrow 5 Admit for parenteral fluids and antibiotics

3. Reassure and send home with oral rehydration

A 22-year-old man presents with sudden onset of shortness of breath and right-sided chest pain. Symptoms began abruptly yesterday. He felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He smokes one pack per day; he has an otherwise non-contributory past medical history. On physical exam, the patient is in mild respiratory distress. He has 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. Question What test finding is most diagnostic for your suspected diagnosis of this patient? Answer Choices 1 Blunting of costophrenic angles on chest X-ray (CXR) 2 Increased pH on arterial blood gas (ABG) 3 Oxygen saturation less than 90% on pulse oximetry 4 Pleural line on chest X-ray (CXR) 5 Sputum smear positive for acid-fast bacilli (AFB)

4. Pleural line on chest X-ray

A 63-year-old man who is 2 days status post left total hip replacement begins to report chest pain. The pain is worse with deep inspiration, and it is associated with dyspnea. His heart rate and respiratory rate are both elevated. EKG is significant for sinus tachycardia. Question What method is the gold standard for diagnosing the patient's suspected condition? Answer Choices 1 Echocardiogram 2 Chest X-ray 3 Chest CT 4 Bronchoscopy 5 Pulmonary angiography

5. Pulmonary angiography

A 35-year-old woman presents with 5-hour history of progressive shortness of breath, cough, and wheezing. This morning she felt that she was "catching a cold" because of sore throat and thin purulent rhinorrhea, for which she took aspirin. Her past medical history is significant for persistent rhinitis resistant to therapy. Question What should your patient do to prevent future asthma attacks? Answer Choices 1 Avoid aspirin. 2 Take antihistamine. 3 Inhale cromolyn. 4 Take albuterol. 5 Get influenza vaccine.

1. Avoid aspirin

A 34-year-old man presents for evaluation of left calf pain after being struck by a car. He reports burning pain in his calf and numbness and tingling in his right foot. Physical exam is remarkable for calf swelling, increased pain with passive muscle stretching, and muscle weakness and decreased sensation in his right ankle and foot. Question What other findings are expected in this patient? Answer Choices 1 Pain out of proportion to exam 2 Calf compartment pressure 5 mm Hg 3 Erythematous streaks 4 Palpable calf cord 5 Groin lymphadenopathy

1 Pain out of proportion to exam

A newborn presents for a 2-week physical exam. On exam, white plaques on the buccal mucosa and palate are noted. Upon trying to remove the plaques, there is an underlying erythematous base and small punctate areas of bleeding. The area appears to be quite tender to touch. Question What is the most likely diagnosis? Answer Choices 1 Thrush 2 Epstein pearls 3 Bohn's nodules 4 Milk residue 5 Aphthous ulcers

1 Thrush

A 35-year-old woman presents with a 2-month history of palpitation and nervousness. She mentions that she always feels hot, even if the weather is cold. Her menses have been irregular lately, and she has had no fevers recently. She was also told that her eyes are "weird looking." On examination, her blood pressure is 150/70 mm Hg, and her pulse is 89 beats per minute. Her eyes show exophthalmos, and she has lid lag when looking down. What follows is the thyroid scan result: Refer to the image. Question What is the nature of this patient's illness? Answer Choices 1 Autoimmune 2 Hypersensitivity 3 Neoplastic 4 Inflammatory 5 Malingering

1. Autoimmune

A 4-year-old boy accompanied by his mother presents with fever, sore throat, muffled voice, and breathing and swallowing difficulty. The child is leaning forward with his head and nose tilted upward and forward. He is irritable, with moderate respiratory distress and inspiratory stridor. Vitals are as follows: pulse is 94/min; BP is 110/70 mm Hg; temperature is 101°F. Direct fiberoptic laryngoscopy is performed and shows an edematous larynx. Cultures are taken, and an endotracheal tube is placed. The epiglottis cultures reveal Haemophilus influenzae, and the diagnosis of acute Haemophilus influenzae epiglottitis is made. 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 would you recommend at this time? Answer Choices 1 All family members, including the patient, should receive prophylactic rifampin. 2 All family members, excluding the patient, should receive prophylactic rifampin. 3 Only the 1-year-old child should receive prophylactic rifampin. 4 The 1-year-old-child should receive the Hib polysaccharide vaccine. 5 Only the infected child needs to be treated.

1. All family members, including the patient, should receive prophylactic rifampin

A 47-year-old man presents to an urgent care center with 18 hours of abdominal pain, nausea, vomiting, and chills. He is a single construction worker, denies smoking, and has at least a 10-year history of drinking 2-4 alcoholic beverages daily. A series of lab work is performed on the patient to evaluate his abdominal pain prior to abdominal imaging. Question What laboratory results would be most indicative of the patient suffering from acute pancreatitis? Answer Choices 1 Amylase 310 U/L and lipase 760 U/L 2 Amylase 50 U/L and lipase 10 U/L 3 Aspartate aminotransferase 32 U/L and alanine aminotransferase 29 U/L 4 Aspartate aminotransferase 120 U/L and alanine aminotransferase 40 U/L 5 White blood cell count 14,000/mm3 and total bilirubin 1.8 mg/dL

1. Amylase 310 U/L and lipase 760 U/L

A 58-year-old man presents to the emergency department for a 4-hour history of chest pain and shortness of breath. He is a long-haul truck driver and noted the symptoms started while he was driving. He admits a mild cough with some blood in his sputum. The chest pain seems to be associated with breathing and gets worse with deeper inspiration. He denies fever or chills. He is a smoker. He reports no known medical conditions, no medication use, and no prior surgeries. On physical exam, the patient is mildly obese, tachypneic (respiratory rate of 22), and tachycardic (pulse of 112). He appears to be in mild distress. Lungs are normal to auscultation and percussion. Heart exam is normal. His left lower leg has some dependent edema and tenderness. The patient thinks he strained a muscle or bumped it, but he had been too worried about his shortness of breath and failed to mention this in his history. The remainder of his exam is normal. He was immediately placed on oxygen at arrival. Several tests results are available. TestResultOxygen saturation92% on oxygenComplete blood countNormalComprehensive metabolic panelNormalElectrocardiogram (ECG)NormalTroponin and CK-MBNormalChest X-rayNormalD-dimerElevated Question Assuming all modalities are available to this patient, what intervention is most appropriate for his current condition? Answer Choices 1 Anticoagulation 2 Chest tube decompression 3 Hyperbaric oxygen therapy 4 Inferior vena cava filter 5 Percutaneous coronary intervention (PCI)

1. Anticoagulation

A 50-year-old man presents with multisystem failure secondary to bilateral pneumonia. He recently traveled from a work conference last week and presented to his primary care physician with fever, cough, and malaise 4 days ago. He was given a broad-spectrum antibiotic and he progressively became worse over the course of the antibiotic treatment. On exam, his body temperature is 40°C, respiration is 35/min, and pulse is 100/min. Laboratory examination is significant for impaired liver and renal function. Chest X-ray shows patchy infiltrates without evidence of consolidation. A sputum culture is performed and is significant for the presence of WBC in the Gram stain, but there are no organisms present. The culture result is negative. Question Based on your suspected diagnosis, what is the drug of choice in treating this patient? Answer Choices 1 Azithromycin 2 Metronidazole 3 Penicillin 4 Vancomycin 5 Cefazolin

1. Azithromycin

A 5-week-old male infant presents with a 2-week history of prominent cough, nasal congestion, and wheezing. His symptoms have been getting progressively worse. Yesterday, the patient's mother took her son to her primary care doctor. The doctor started albuterol nebulizers every 4 hours and told her that the child had a viral infection and would get better. His mother is now particularly concerned that her child has had dry diapers for over 15 hours. The child has been irritable during this time. He has not had any fevers, vomiting, or diarrhea. The child is not tolerating breastfeeding or bottle-feeding well. The physical exam shows that the child is acyanotic and alert. The temperature is 97.8°F (36.5°C), respirations are 40/minute, and the pulse is 119/minute. There are no lymph nodes observed, and his tympanic membranes appear normal. There are rales noted diffusely on auscultation. The mucous membranes are moist and the skin has good turgor. You also detect conjunctivitis. Blood work is obtained; including a set of blood cultures, and a urine culture. The following lab values return: Hemoglobin12.6 mg/dLHematocrit37.1%Platelet count204 x 109Eosinophilia count6% The chest film demonstrates interstitial infiltrates and hyperinflation. Question What organism is causing the infant's symptoms? Answer Choices 1 Chlamydia trachomatis 2 Human parvovirus 3 Parainfluenza virus 4 Respiratory syncytial virus 5 Staphylococcal species

1. Chlamydia trachomatis

A 52-year-old man presents with vomiting and epigastric distress for the past few hours. He has been drinking alcohol for over 20 years, and he has been a moderate-to-heavy drinker. 5 years ago, he was diagnosed with a "gastric/duodenal ulcer," for which he has been taking cimetidine and antacids. The pain now radiates towards the left along the costal margin. He has noticed his appetite has been reduced lately, and his stools are bulky and foul smelling. His friends have commented on his sickly look and weight loss. Question What is the most likely diagnosis? Answer Choices 1 Chronic pancreatitis 2 Acute recurrent pancreatitis 3 Myocardial infarction 4 Acute cholecystitis 5 Left-sided ureteric colic

1. Chronic pancreatitis

A 62-year-old man presents with a 2-month history of worsening fatigue and shortness of breath. He has a past medical history of emphysema attributable to his 85 pack-year smoking history. The patient complains of nearly passing out while climbing the stairs in his house. He tells you that he feels like his heart races. He reports chronic shortness of breath and cough, but he now he feels like his dyspnea is dramatically worse; he can no longer sleep in his bed. He has been trying to sleep propped up in a chair at night. He is also experiencing fatigue. He has gained about 15 pounds, and he notes that he can no longer lace up his shoes. He denies fever, chills, and chest pain. His cough produces some mucus, but no hemoptysis. His vitals are shown in the table. Weight212 lbHeight69"Body mass index31.3Pulse108Blood pressure140/88Temperature98.2°FPulse oximetry88% On physical exam, you see a man in mild respiratory distress; he is sitting upright and leaning forward, and he uses accessory respiratory muscles for breathing. The exam is significant for reduced air movement and mild rales bilaterally in the lungs; distended neck veins; mild tachycardia with prominent P2; lower extremity edema; and right upper quadrant abdominal tenderness with hepatomegaly. Question Based upon this patient's history and physical, what is the most likely diagnosis? Answer Choices 1 Cor pulmonale 2 Hepatitis 3 Lung abscess 4 Pneumonia 5 Pulmonary embolism

1. Cor pulmonale

A 67-year-old Caucasian woman presents with shortness of breath and chest pain. She admits to getting home yesterday from a 2-day car ride after visiting her grandchildren. Her heart rate is 110 beats/minute and respirations are 22 breaths/minute. Blood pressure is 125/85 mm Hg. Her oxygen saturation is 99% on room air and temperature is 98.9°F. With additional information provided, her Wells' Criteria Score is calculated to be 4.5. Question What is the most appropriate initial diagnostic test? Answer Choices 1 D-dimer 2 Echocardiogram 3 CT chest without contrast 4 ECG 5 CT chest pulmonary angiography

1. D-dimer

A 34-year-old man is brought to the emergency department after a single-car motor vehicle collision. Preliminary radiologic studies show a comminuted fracture of the left tibia. The patient is describing a markedly increasing amount of pain felt in the injured extremity. He describes the pain as being a 10/10 that is becoming worse with each passing minute. With anguish on his face, he describes it as a deep achy burning pain. You quickly examine the left leg and note pallor, a tense "wood-like" feeling of the extremity, diminished sensation, and muscle weakness. Question Based on the most likely diagnosis, what is the best pharmaceutical intervention for this patient's pain? Answer Choices 1 IV opioids 2 Oral acetaminophen 3 Oral NSAIDs 4 PCA opioids 5 Topical NSAIDs

1. IV opioids

A 43-year-old man without any significant PMHx presents with acute onset of a productive cough, shortness of breath, pleuritic chest pain, and fever. His sputum is described as "thick, brown-colored, and mucoid" but without blood. He also notes associated fatigue and night sweats. He denies chills, changes in weight, a history of travel, sick or confined contacts, exposure to animals, cigarette smoking, otalgia, sore throat, swollen glands, abdominal pain, diarrhea, rashes, myalgias, and arthralgias. His physical exam is remarkable for fever, tachycardia, and tachypnea. The lung exam is noteworthy for right lower lung field increased tactile fremitus, dullness to percussion, inspiratory crackles, and bronchial breath sounds. Question What is the most likely etiologic agent responsible for this patient's presentation? Answer Choices 1 Streptococcus pneumoniae 2 Histoplasma capsulatum 3 Chlamydia psittaci 4 Pseudomonas aeruginosa 5 Mycobacterium tuberculosis

1. Streptococcus pneumoniae

A 10-year-old boy presents due to a lesion on his gums. For the past 2 days, he has reported soreness around his teeth and inside his cheeks. When his mother looked closely in his mouth with a flashlight, she noted bright red areas and patches of white curd-like lesions. There are no ill contacts in the last few weeks. There has been no fever or shortness of breath. The patient's past medical history is positive for severe seasonal allergies and mild persistent asthma. Daily medications include: pediatric multivitamin, cetirizine hydrochloride 10 mg 1 tablet at bedtime, montelukast sodium 5 mg 1 chewable tablet in the morning, beclomethasone disproportionate HFA 40 mcg 2 puffs twice daily in the am and pm, and albuterol sulfate inhalation powder 2 inhalations every 4-6 hours as needed for wheezing and 15 minutes before physical activity. Examination reveals adherent thick white plaques with underlying erythematous tender mucosa on the gingival and buccal surfaces. Question What medication has increased this patient's risk for developing this condition? Answer Choices 1 Albuterol sulfate 2 Beclomethasone dipropionate 3 Cetirizine hydrochloride 4 Montelukast sodium 5 Multivitamin

2 Beclomethasone dipropionate

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? Answer Choices 1 Oral candidiasis 2 Herpetic gingivostomatitis 3 Herpangina 4 Nursing bottle caries 5 Foreign body impaction

2 Herpetic gingivostomatitis

Early one afternoon, a 15-year-old boy presents with abdominal pain, nausea, and vomiting. The pain has been worsening since the onset of symptoms in the morning. There is no known gastrointestinal disease in the history; no one in the immediate environment has one, either. Physical examination finds no abdominal tenderness, but Psoas sign and tenderness on rectal examination are detected. Temperature and pulse are slightly elevated. Skin turgor is reduced, and there is a 10 mm Hg drop in postural blood pressure. Laboratory studies find 18,000 white blood cells per microliter. Question What is the most likely diagnosis? Answer Choices 1 Acute mesenteric lymphadenitis 2 Acute appendicitis 3 Salmonella gastroenteritis 4 Meckel's diverticulitis 5 Regional enteritis

2. Acute appendicitis

A 65-year-old man presents with watery diarrhea and mild abdominal pain. He has had 8-9 non-bloody bowel movements per day for the last 10 days; he currently feels a general abdominal discomfort. On examination, his pulse rate, blood pressure, and oral temperature are normal. There is no abdominal tenderness. The stool guaiac test is negative. He does not travel. He eats home-cooked meals most of the time, and he reports using water from his private well for all of his needs. Question In addition to consulting the EPA for decontamination advice, what recommendation would you provide this patient? Answer Choices 1 Close the well and never use it again. 2 Boil water before using. 3 Filter water before using. 4 Chlorinate water before using. 5 Send samples of water for lab analysis.

2. Boil water before using

A 3-year-old girl presents with a 1-day history of irritability and weakness in her legs. Neurologic exam reveals an ascending symmetrical paralysis with cranial neuropathy. A lumbar puncture is performed and cerebrospinal fluid is found to have a normal glucose level, <10 leukocytes/mm3, and elevated protein. Medical history shows the child recently recovered from a mild diarrheal illness. Question What organism is triggering this syndrome? Answer Choices 1 Shigella dysenteriae 2 Campylobacter jejuni 3 Clostridium botulinum 4 Escherichia coli 5 Salmonella enteritidis

2. Camylobacter jejuni

A 25-year-old man with no significant medical history presents due to sudden onset of shortness of breath associated with right-sided chest pain. The pain is worse with inspiration but is unaffected by position. He states he was grocery shopping when it started. He denies chest trauma. Patient admits to an upper respiratory infection earlier in the month that had resolved without incident. He smokes 1 pack of cigarettes per day. On examination, he is afebrile, BP is 138/80 mm Hg, pulse is 124, respiratory rate is 24, and pulse oximetry is 94% on room air with mild respiratory distress. Trachea is midline. He has increased resonance to percussion with no breath sounds on the right anterior apex; the other lung fields are clear to auscultation. Heart is tachycardic with normal S1 and S2; no murmur, rubs, or gallops are present. Question What is the imaging of choice to make the diagnosis? Answer Choices 1 Chest computed tomography (CT) 2 Chest radiograph 3 Chest ultrasound 4 Electrocardiogram (ECG) 5 Spiral chest computed tomography (CT)

2. Chest radiograph

A 56-year-old man presents with moderately severe substernal and left anterolateral chest pain. There is some exacerbation of pain on inspiration that has been increasing in severity over the last 36 hours. He works as a truck driver and has a history of heavy cigarette smoking, hypertension, and obesity. Over the past week, he has experienced swelling and discomfort in his right calf. Examination shows BP of 90/55 mm Hg, P of 122/min, RR of 40/min, and temp of 37.6°C. The patient is mildly agitated and confused. Systemic examination reveals tachycardia, soft systolic murmur, and questionable ventricular gallop. Lungs show dullness to percussion at left base, with scattered crackles and wheezes throughout. Abdominal and neurological exams are negative. The right calf is 0.5 cm larger than left, with some deep tenderness and a trace of ankle edema. Laboratory analysis reveals hemoglobin 16.4 g/dL, Hct 51%, WBC 12,300 cells/µL, PaO2 52 mm Hg, PaCO2 38 mm Hg, and pH 7.35. Chest radiograph shows borderline cardiomegaly and a prominent aorta, scattered patchy infiltrates bilaterally, and a small left pleural effusion. Question What is the most accurate diagnostic modality for diagnosing this patient's condition? Answer Choices 1 Cardiac ultrasound 2 Computerized tomographic angiography 3 Impedance plethysmography 4 Myocardial scan 5 Spirometry

2. Computerized tomographic angiography

A 69-year-old man presents with dyspnea on exertion (climbing stairs and walking short distances) that has slowly progressed over the last year. He has fatigue, palpitations, intermittent retrosternal chest pain, lower extremity swelling, dizziness, and "feeling faint." Associated symptoms occur upon exertion. He denies fever, chills, weight changes, cough, abdominal pain, early satiety, nausea, vomiting, diarrhea, changes in urine color/odor, flank pain, hematuria, or dysuria. No cigarette, alcohol, or drug use. Cardiac exam shows increased pulmonic component of the second heart sound (P2), wide inspiratory splitting of S2 over the cardiac apex, right-sided S3 and S4 gallops, left parasternal lift, loud diastolic murmur increasing with inspiration and diminishing with Valsalva maneuver, prominent "A" waves in jugular venous pulsations, and increased JVD. Enlarged liver with hepatojugular reflux, peripheral edema, and ascites. EKG reveals peaked P waves, rightward axis deviation, and prominent R waves in the early V leads. Question What is the most likely diagnosis? Answer Choices 1 Myocardial infarction 2 Cor pulmonale 3 Primary biliary cirrhosis 4 Left ventricular heart failure 5 Pulmonary embolism

2. Cor pulmonale

You are performing a physical examination on a patient with longstanding COPD. Significant findings include wheezing respirations, cyanosis, and distended neck veins; a left parasternal lift and a tender liver are both noted on palpation. Question What is most likely causing the patient's symptoms? Answer Choices 1 Constrictive pericarditis 2 Cor pulmonale 3 Rheumatic fever 4 Dilated cardiomyopathy 5 Congestive heart failure

2. Cor pulmonale

An 80-year-old man has a past medical history of chronic obstructive pulmonary disease, persistent asthma, and hypertension. He presents due to acute chest pain, dyspnea, and pleurisy that began suddenly 30 minutes ago. He denies fever, chills, hemoptysis, wheezing, diaphoresis, cough, or abdominal pain. His vital signs are notable for tachycardia and tachypnea. His thorax demonstrates unilateral decreased tactile fremitus, hyperresonance to percussion, and decreased to absent breath sounds. There is no jugular venous distension, cyanosis or accessory muscle usage. He is identified as a poor surgical candidate, and he has had previous episodes of similar manifestations in the past. Question What medication would be recommended to treat the underlying condition given the recommendation not to pursue surgery? Answer Choices 1 Warfarin 2 Doxycycline 3 Furosemide 4 Levofloxacin 5 Prednisone

2. Doxycycline

A 24-year-old African American G2P1 presents to her obstetrician at 34 weeks gestation with weight gain, fatigue, diffuse "swelling," and headache. On physical examination, you note periorbital edema and 3+ pitting edema in the lower extremities peripherally. Physical examination also demonstrates tenderness to palpation in the right upper quadrant. The patient has increased reflexes bilaterally. Vital signs are as follows: Temperature is 99.2°F. Pulse is 89 beats/minute. Respirations are 18. Blood pressure is 174/99 mm Hg. Urinalysis reveals no erythrocytes per high power field and no casts, but there is a large amount of protein in the urine. Laboratory values are as follows: Hemoglobin 9.2 g/dL; 13.0-16.0 g/dL Hematocrit 27%; 37-47% Platelets 38 K/mm; 3130-400 K/mm3 White blood cells 12.7 K/μL; 3.8-10.8 K/μL AST 595 IU/L; 7-40 IU/L ALT 585 IU/L; 0-40 IU/L Alkaline phosphatase 295 U/L; 70-230 U/L Question What is the most likely diagnosis? Answer Choices 1 Disseminated intravascular coagulation (DIC) 2 Hemolysis, elevated liver tests, and low platelets syndrome (HELLP) 3 Idiopathic thrombocytopenic purpura (ITP) 4 Thrombotic thrombocytopenic purpura (TTP) 5 Normal laboratory values of pregnancy

2. Hemolysis, elevated liver tests, and low platelets syndrome (HELLP)

A 36-year-old woman presents with fatigue and diplopia; symptoms started in the morning and worsened during her time at work. On examination, the patient has ptosis bilaterally and decreased ocular muscle power. A CT scan of the chest shows a thymoma. Question What is the pathophysiology of this patient's neuromuscular disorder? Answer Choices 1 Defective plasma cholinesterase 2 Immune-mediated destruction of the acetylcholine receptor 3 Deficient quantity of plasma cholinesterase 4 Impaired repolarization at the motor endplate 5 Deficiency in dystrophin

2. Immune-mediated destruction of the acetylcholine receptor

A 5-month-old infant presents in the winter months with wheezing, rapid respirations (>45 breaths/min), and chest retractions. The patient has a 2-day history of rhinorrhea and low-grade fever. Breath sounds are normal, and there is no cyanosis. Question What test can confirm the most likely diagnosis? Answer Choices 1 Chest X-ray 2 Immunofluorescence of nasal secretion 3 Gram stain of the sputum 4 Blood gas analysis 5 Complete blood count with differential

2. Immunofluorescence of nasal secretion

A 32-year-old man presents with occasional shortness of breath and associated cough, especially when he is working outside. He has associated chest tightness that resolves within minutes when he sits down and rests. These symptoms occur 1-2 days a month. He is otherwise healthy and does not smoke. Blood pressure 128/74 mm Hg, pulse 76, respiration 14, and pulse oximetry 100% on room air. His FEV1 is 96%. Question What is the treatment of choice? Answer Choices 1 Leukotriene modifiers 2 Inhaled corticosteroid plus inhaled short-acting beta-agonist 3 Oral steroids 4 Inhaled anticholinergic plus inhaled short-acting beta-agonist 5 Oral beta-agonist

2. Inhaled corticosteroid plus inhaled short-acting beta-agonist

A 27-year-old male accident victim with a head injury is admitted to the ICU and kept on mechanical ventilatory support. On the seventh day after admission, he is clinically diagnosed with pneumonia. Blood samples and lower respiratory secretions are submitted to the laboratory for culture; empiric antimicrobial therapy is started. Question What is the most likely etiologic agent of pneumonia in this patient? Answer Choices 1 Streptococcus pneumoniae 2 Klebsiella pneumoniae 3 Mycoplasma pneumoniae 4 Moraxella catarrhalis 5 Haemophilus influenzae

2. Klebsiella pneumoniae

A 23-year-old woman presents with increasing fatigability and muscle weakness. On further questioning, she reveals that she has experienced difficulty swallowing over the past month, and there have been episodes of double vision as the day progresses. Several of her professors have expressed concern because she looks sleepy during the day. A CT of the chest reveals an anterior mediastinal mass. Question What is the most likely diagnosis? Answer Choices 1 Myasthenic syndrome 2 Myasthenia gravis 3 Amyotrophic lateral sclerosis 4 Botulism 5 Hyperthyroidism

2. Myasthenia gravis

A 55-year-old man presents with a COPD exacerbation managed with a ventilator. The patient's blood pressure drops and the ventilator alarm goes off. The only medication being administered is amlodipine via nasogastric tube. This patient is afebrile, even though the hospital has been having problems with pseudomonas infection in ventilated patients. On examination, there is a middle-aged orally-intubated man with temperature 99.4°F, pulse 145/min, and BP 62/34 mm Hg; he breathes above the ventilator at a rate of 36 cycles/min. His breathing is shallow, and there are diminished breath sounds in the right hemithorax. Question What is the most appropriate next step? Answer Choices 1 Add positive end-expiratory pressure. 2 Perform needle thoracotomy, chest tube placement. 3 Start antibiotics. 4 Give IV fluid boluses. 5 Start pressor agents.

2. Perform needle thoracotomy, chest tube placement

You are examining a 6-month-old male infant who has not received any immunizations since birth. He was born at home and has a history of multiple respiratory tract infections and chronic diarrhea since birth. His parents are not related. Family history is significant for two of his older brothers dying of pneumonia at ages 8 and 1. His 4-year-old sister is healthy. His parents moved to the US from an underdeveloped country 3 months ago. They are worried because one of their neighbors' children (age 6) developed a pruritic skin rash and fever 2 days ago; another child (age 6 months) is in the hospital because of severe vomiting and diarrhea. On examination, your patient's vitals are normal. His weight is <5th percentile, his height is at the 5th percentile, and his head circumference is at the 50th percentile. Physical exam shows an eczematous skin rash, and mucocutaneous changes suggestive to a fungal infection are noted. His thyroid, heart, lungs, abdomen, genitalia, and nervous system are within normal limits. There are no palpable lymph nodes and no hepatosplenomegaly. Question What vaccine should you recommend? Answer Choices 1 Rotavirus vaccine (RV) 2 Pneumococcal vaccine (PCV13) 3 Measles, mumps, and rubella vaccine (MMR) 4 Bacille Calmette-Guerin vaccine (BCG) 5 Varicella vaccine (Var)

2. Pneumococcal vaccine

A 6-year-old boy with Down syndrome is brought to the emergency department after a drowning accident in a lake. Submersion time is unknown, but he was missing for some time. He was resuscitated and intubated by emergency medical technicians during transport. On arrival, his heart rate is 76 beats/min, BP 104/72 mm Hg, and rectal temperature is 81°F (27°C). He remains comatose, exhibiting non-purposeful flexion withdrawal to pain. His pupils are equal and reactive. Question What is the best way to treat this patient's drowning-related hypothermia? Answer Choices 1 Passive rewarming 2 Active external warming 3 Active internal warming 4 Maintain this degree of hypothermia 5 No warming measure necessary

3. Active internal warming

A 41-year-old woman presents due to worsening symptoms. She was diagnosed with idiopathic pulmonary hypertension about 2 years prior to presentation; she is on home oxygen therapy. She has longstanding fatigue and dyspnea, but she is now experiencing profound dyspnea with exertion, swelling in her ankles, some discomfort in her right upper abdomen, and the inability to breathe well when lying down. She has always been thin, but her weight has increased by 10 pounds in the last month. She denies fever and chills. She recently had an electrocardiogram (ECG), but she has not seen a healthcare provider to discuss the results. The ECG report indicates peaked p waves, right axis deviation, and tall r wave in V1. Question What is the most appropriate intervention for her current condition? Answer Choices 1 Prescribe a calcium channel blocker, such as verapamil. 2 Prescribe a diuretic, such as furosemide. 3 Prescribe a fluoroquinolone, such as levofloxacin. 4 Prescribe a lipase inhibitor, such as orlistat. 5 Prescribe a thiazolidinedione, such as pioglitazone.

2. Prescribe a diuretic, such as furosemide

A 39-year-old previously well Caucasian man presents to the emergency department with a 10-day history of fever >101°F and acute dyspnea with pleuritic chest pain. His past medical history is notable only for childhood asthma (no recurrences since age 12) and appendectomy. He has no known drug allergies. He denies taking prescribed medications on a regular basis. Social history is notable for use of IV drugs. Vital signs show temperature 100.8°F, pulse 108, respirations 24, blood pressure 98/60. O2 saturation is 90% on room air. Physical examination reveals mild crackles of the mid-lung fields bilaterally and a grade II/VI soft systolic murmur, loudest at the left lower sternal border. A spiral CT reveals evidence of multiple pulmonary emboli. He is admitted to the general medical floor of an acute care hospital. Additional diagnostic tests are ordered; preliminary results of blood cultures showed 4+ growth of gram-positive cocci. Infectious Diseases is consulted and he is started on an IV antibiotic regimen. Question What is the most likely source of the multiple pulmonary emboli in this patient? Answer Choices 1 Deep venous thrombosis 2 Tricuspid valve vegetation 3 Left atrial thrombosis from atrial fibrillation 4 Disseminated intravascular coagulation 5 Metastatic cancer

2. Tricuspid valve vegetation

A 4-year-old boy presents with a 3-day history of fever with chills, cough, and fast breathing. His parents report decreased oral intake and increased difficulty breathing with retractions over the last 24 hours. His initial vital signs are heart rate 144 bpm; respiratory rate 32/min; temperature 101.3°F (38.5°C); oxyhemoglobin saturation 89% on room air. He is immediately started on supplemental oxygen, and his oxyhemoglobin saturation improves to 95%. Subsequent evaluation, including a chest X-ray, is suggestive of right middle and lower lobe pneumonia. Question What is the mechanism for the low oxyhemoglobin saturation in this patient? Answer Choices 1 Hypoventilation 2 Ventilation-perfusion mismatch 3 Diffusion block 4 Shunt 5 Increased dead space in lungs

2. Ventilation-perfusion mismatch

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? Answer Choices 1 Enterotoxigenic E. coli 2 Vibrio cholerae 3 Norwalk virus 4 Shigella dysenteriae 5 Clostridium difficile

2. Vibrio cholerae

A 35-year-old man presents with a 2-week history of recurrent swollen painful lips and a rash primarily affecting the arms and hands. His first episode occurred while in jail 6 months ago. He has had two additional episodes since then. He was treated with oral steroids each time, which improved his symptoms, but symptoms always returned. On examination, you notice several targetoid lesions on the dorsal hands and forearms, with darkening, swelling, and peeling of the lips. Question What additional information should you ask for to properly manage this patient? Answer Choices 1 Any recent changes in personal hygiene products? 2 Are there any pets at home? 3 Have you ever had fever blisters, cold sores, or genital herpes? 4 Were you working outside before onset of the rash? 5 Any changes to diet before the onset of rash?

3 Have you ever had fever blisters, cold sores, or genital herpes?

A 27-year-old man is admitted to the hospital following a motor vehicle accident. He sustained lacerations to his arms bilaterally and has fractures of the right tibia and fibula. A cast is placed and the patient is scheduled for surgery the following day. A few hours after the cast is placed, he develops severe pain; the pain is unresponsive to several doses of intravenous morphine. His pain increases when he extends his right leg. Peripheral pulses are weak but present. Question Based on the history and physical, what should be done next? Answer Choices 1 Take X-ray of the tibia and fibula. 2 Perform MRI of the right leg. 3 Remove cast and check compartment pressure. 4 Perform ultrasound of the lower extremity. 5 Monitor and continue giving narcotics.

3 Remove cast and check compartment pressure.

A 40-year-old woman presents with anxiety, difficulty sleeping, rapid heartbeat, and a tremor in her hands for the past 3 months. She has also noted weight loss. You note the presence of bulging eyes. Question What gland is responsible for secreting the hormone involved in making this patient's diagnosis? Answer Choices 1 Adrenal gland 2 Pancreas 3 Thyroid gland 4 Ovary 5 Pineal gland

3 Thyroid gland

A 35-year-old man presents after several episodes of vomiting in the last 24 hours; there is loose stool and strong pain localized in the upper middle region of the abdomen. Physical examination indicates a temperature of 101°F and a tender epigastrium. Lab tests reveal an initial WBC count of 18x109/L. C-reactive protein level is 325 mg/L, and amylase is 130 U/L. There is a lactate dehydrogenase level of 816 U/L. The patient has no history of pancreatic disease and denies alcohol use. He is overweight. He has a history of type 2 diabetes and hypertension. He takes medicine to control his high blood pressure and obesity. Question What is the most appropriate next step in establishing the diagnosis? Answer Choices 1 Abdominal radiography 2 Abdominal ultrasonography 3 Abdominal computed tomography scanning 4 Endoscopic retrograde cholangiopancreatography 5 Endoscopic ultrasonography

3. Abdominal computed tomography scanning

A 3-year-old boy presents with a 4-hour history of respiratory distress, dysphagia, and fever. On examination, temperature is 104.3°F, pulse 150, and respirations 32 and shallow. Marked inspiratory stridor with an open-mouth appearance and sialorrhea is present. Question What is the initial step in management? Answer Choices 1 Arterial blood gas analysis 2 Intravenous cephalosporins 3 Securing the airway 4 Soft tissue lateral neck radiograph 5 Visualizing epiglottis with tongue blade

3. Securing the airway

A 28-year-old man with a history of crack cocaine abuse is rushed in to the emergency room. His mother found him in his apartment; he was cyanotic and severely short of breath. No other history is available. Examination reveals a young man in severe respiratory distress with temperature 99.2°F, pulse 102/min, respiration 40/min, BP 165/95 mm Hg, and pulse oximetry of 66%. He was intubated at his apartment by EMS personnel because of lack of improvement of his pulse oximetry on 100% non-rebreathing mask. His chest X-ray shows bilateral alveolar and interstitial infiltrates. The arterial blood gas on the mechanical ventilation (set at a rate of 12 cycles/min, tidal volume 500 mL) shows the following: PAO2/Fi02 ratio = 100 mm Hg, pH 7.52, PCO2 30, PO2 55, and O2 saturation 88%. Question What can be done to improve his oxygenation? Answer Choices 1 Increase tidal volume. 2 Increase respiratory rate. 3 Add positive end-expiratory pressure. 4 Add positive end-inspiratory pressure. 5 Perform emergent thoracentesis.

3. Add PEEP

A 44-year-old male salesperson presents after driving cross-country in a rural part of southern Ohio. His car had broken down and he found a local farmer who let the salesman spend the night in his farmhouse. His car was repaired the next day, and he promptly returned home. Several weeks later, he experienced an abrupt onset of a fever, non-productive cough, shortness of breath, and mild chest pain. Believing he has just caught a cold, the salesman thinks nothing of it. A few days after the onset of symptoms, he is much better, but he presents to your office for an opinion. You order a CXR that reveals airspace consolidations. Question What is the most likely cause of his symptoms? Answer Choices 1 Spontaneous pneumothorax 2 Goodpasture syndrome 3 Blastomycosis 4 Community-acquired pneumonia 5 Mycobacterium infection

3. Blastomycosis

A 14-year-old boy presents with worsening shortness of breath; it most often occurs when he plays soccer. He often awakens in the middle of the night due to "attacks": he starts to feel anxious because he feels like he cannot breathe, and he experiences chest tightness. He suffers from a dry cough, especially after playing sports. His mother has put a humidifier in his room and has him use his sister's inhaler, which seems to help temporarily; the boy has been using it 5-6 times daily. The family history is significant for asthma in his sister, father, and three other paternal relatives. The patient and his mother are not aware of any allergies. He denies fever, chills, and chest pain. In between "attacks," he feels well and normal. The patient's past medical history is noncontributory. There are no known medical conditions; he has no drug allergies, and he has not had any surgeries. Other than the aforementioned inhaler, he does not take any medications. Question In addition to his own albuterol inhaler, what medication should be prescribed for this patient? Answer Choices 1 Burst of oral prednisone 2 Daily inhaled salmeterol 3 Daily low-dose inhaled budesonide 4 Daily oral zileuton 5 Subcutaneous injections of omalizumab

3. Daily low-dose inhaled budesonide

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? Answer Choices 1 Doxycycline 2 Ciprofloxacin 3 Erythromycin 4 Amoxicillin 5 Penicillin

3. Erythromycin

A 14-year-old girl presents with a 4-day history of flatulence, foul-smelling stools, and abdominal distention. Her appetite has also been decreased. She has not seen any blood in her stools. She returned from a 2-week camping trip in the mountains of the western United States 1 week ago. Others in her expedition group are asymptomatic. Her physical examination reveals a well developed and well nourished adolescent with slight abdominal distention and tenderness; otherwise, everything is within normal limits. Question What is the most likely cause of her symptoms? Answer Choices 1 Shigella flexneri 2 Staphylococcus aureus 3 Giardia lamblia 4 Salmonella typhimurium 5 Rotavirus

3. Giardia lamblia

A 16-year-old girl presents with shortness of breath, wheezing in her chest, and swelling of the lips that started several minutes after she had a snack. She had similar symptoms several months ago at a Chinese buffet. She appears restless. Her face is erythematous and her lips and tongue are swollen. She is able to repeat her name when asked. Her blood pressure is 89/60 mm Hg, and heart rate is 110/min rhythm regular, with respirations 26/min and shallow. On auscultation, diffuse wheezing is heard. Question What is the next step in management of this patient? Answer Choices 1 Take arterial blood gases. 2 Intubate the patient. 3 Give epinephrine. 4 Give corticosteroid. 5 Give a beta blocker

3. Give epinephrine

A 24-year-old man undergoes a routine medical check-up to become a volunteer in the ER. PPD skin test shows an induration diameter of 9 mm. Sputum and chest X-ray are done; they are negative for tuberculosis. He is otherwise healthy and has no fever, cough, or other symptoms of Mycobacterium tuberculosis infection. Question What is the most appropriate explanation for the doubtful tuberculin test in this patient? Answer Choices 1 Sputum and chest X-ray report could be wrong. 2 Adequate sputum samples were not supplied. 3 He was given BCG vaccination earlier in life. 4 He may suffer from chronic cavitary lesion in the lung. 5 He has an active tubercular infection.

3. He was given BCG vaccination earlier in life

A 58-year-old woman with a past medical history of hypertension, hyperlipidemia, breast cancer, hip fractures, and coronary artery disease is being evaluated for acute-onset severe left-sided pleuritic chest pain over the course of the last 2 hours. The pain is associated with feelings of anxiety, hemoptysis, shortness of breath, and nausea. She "feels warm" but denies chills, palpitations, wheezing, edema, vomiting, abdominal pain, abnormal bowel habits, or dietary intolerances. She admits to a 30 pack-year smoking history but denies drug or alcohol use. Upon physical exam, she is found to be febrile, hypotensive, tachycardic, tachypneic, diaphoretic, and in acute painful distress. There are perioral cyanosis and a pleural friction rub to the left lung fields; the remainder of the exam is normal. Question What is the most appropriate therapeutic intervention for this patient at this time? Answer Choices 1 Indomethacin 2 Doxycycline 3 Heparin 4 Prednisolone 5 Albuterol

3. Heparin

A 50-year-old man presents to the emergency department with epigastric pain. Pain is sharp with radiation into the back and accompanied by nausea and vomiting. On exam, the patient exhibits tenderness to palpation of the upper right quadrant and upper left quadrant without rigidity or guarding. Laboratory findings reveal the following: WBC9.4 k/uLCO228 mg/dLTotal bilirubin1.2 mg/dLHgb13.5 g/dLBUN8 mg/dLAlkaline phosphatase140 U/LHCT41%Cr0.7 mg/dLAST200 U/LPLT152 k/uLGlucose115 mg/dLALT155 U/LNa135 mEq/LCalcium8.1 mg/dLAmylase477 U/LK3.2 mEq/LTotal protein6 g/dLLipase625 U/LCl100 mmol/LAlbumin3 g/dLLDH300 Question What is the most important component of this patient's treatment? Answer Choices 1 Oral creon 2 Oral omeprazole 3 Intravenous normal saline 4 Intravenous meropenem 5 Surgical debridement

3. Intravenous normal saline

A 19-year-old Caucasian man has come to see you as the last patient of the day. He presents with sudden onset of severe shortness of breath. He states that he has been an avid basketball player all his life and was practicing about 4 hours prior to his visit when he experienced sudden chest pain and immediate shortness of breath that is still bothering him currently. He describes the chest pain in the middle of the chest, more so on the right anterior side. The patient admits to smoking half a pack of cigarettes daily. Physical examination reveals a tall, thin, well-developed man in mild distress. The only other abnormalities discovered are mild tachycardia (120 beats per minute) and diminished breath sounds in the posterior right lower lobe. Question Based upon the examination so far, what is the most likely diagnosis? Answer Choices 1 Pneumonia 2 Pulmonary embolism 3 Pneumothorax 4 Myocardial infarction 5 Asthma

3. Peumonthorax

A 23-year-old primigravida is referred to her obstetrician by a community nurse. The nurse noted two blood pressure readings of 150/90 and 154/90 taken 15 minutes apart. Physical examination reveals a uterus at roughly 24 weeks gestation and grade 2 pitting edema. Urine analysis is 1+ positive for albumin. A sonogram at 8 weeks gestation showed a single live intra-uterine gestation. She has had regular antenatal checkups and has no past history of hypertension or diabetes. Her parents and grandparents are hypertensive. She is unaware of whether her mother or grandmother faced similar problems during their pregnancies. Question What is the most likely initiating event for her condition? Answer Choices 1 Overactivation of renin-angiotensin system 2 Overproduction of B-HCG 3 Placental ischemia 4 Renal artery stenosis 5 Essential hypertension

3. Placental ischemia

A 3-year-old child presents with sudden onset of high-grade fever, sore throat, pain during swallowing, and drooling of saliva. There is no history of a cough. The child appears toxic and is dyspneic with inspiratory stridor. The child is sitting upright and leaning forward with chin up and mouth open. Suprasternal and intercostal retractions are present. Chest is clinically clear. Blood count shows polymorphonuclear leukocytosis. Lateral radiograph of upper airway shows "thumb sign." Question What is the most likely diagnosis? Answer Choices 1 Acute laryngotracheobronchitis 2 Bacterial tracheitis 3 Retropharyngeal abscess 4 Epiglottitis 5 Laryngomalacia

4 Epiglottitis

A 33-year-old man presents with shortness of breath, wheezing, mild fever, and fatigue. He has had several similar episodes in the past, and each previous episode began after a cold that moved into his chest. Over the past several weeks, he has had a productive cough most mornings. He has no other symptoms or exam findings. He smokes on a social basis. His CXR is normal and most recent pulmonary function tests reveal a reversible airflow limitation. Question What is the most likely diagnosis? Answer Choices 1 Chronic emphysema 2 Chronic bronchitis 3 Cor pulmonale 4 Asthmatic bronchitis 5 Bronchiectasis

4. Asthmatic bronchitis

A 3-year-old boy presents due to severe bouts of coughing for the last 10 days that started as a common cold. During coughing, his face becomes red. The episode of cough often ends with a loud sound during breathing or vomiting. He also has low-grade fever off and on for the last 10 days. Immunization records of the child are not available. Blood count shows leukocytosis with lymphocytosis. Question What is the antibiotic of choice to treat and prevent spread of the infection? Answer Choices 1 Cotrimoxazole 2 Erythromycin 3 Rifampicin 4 Azithromycin 5 Ampicillin

4. Azithromycin

You are evaluating a 78-year-old man who lives in a nursing home due to moderate Parkinsonism. The patient does not have any specific complaints, but nursing home staff have noticed that he does not seem as alert as usual and is spending more time in his room sleeping. He is also eating less and has dropped 2 lb in the last 2 weeks. The patient's temp is 100.8°F; pulse 100 bpm; respiration 25/min; and bp 120/70 mm Hg. On exam, he is aware of the place, but not the exact time or date. His HEENT exam is unremarkable. His cardiac exam reveals tachycardia, but no murmurs or rubs. His lung sounds are decreased at the bases. Question Based on this presentation, what should be included as part of the initial workup? Answer Choices 1 Psychiatric evaluation 2 CT of the head 3 Nutritional evaluation 4 Complete blood count 5 Erythrocyte sedimentation rate (ESR)

4. Complete blood count

A 50-year-old obese woman undergoes a cholecystectomy and T-tube drainage of the common bile duct. On postoperative day 7, she develops sudden epigastric and left-sided chest pain. She is short of breath and is sweating profusely. Her temperature has been between 99-100°F for the past 2 days. The patient's vitals are: pulse 90/min, BP 110/60 mm Hg, and RR 24/min. The ECG reading shows tachycardia, and the ventilation-perfusion lung scan shows a VQ mismatch. Question Based on the most likely diagnosis, what should be the initial management of this patient? Answer Choices 1 Pulmonary embolectomy 2 Urokinase therapy 3 Exploratory laparotomy 4 Heparinization 5 Inferior vena cava filter

4. Heparinization

A 41-year-old woman presents due to worsening symptoms. She was diagnosed with idiopathic pulmonary hypertension about 2 years ago; she is on home oxygen therapy. She has longstanding fatigue and dyspnea, but she is now experiencing profound dyspnea with exertion, swelling in her ankles, some discomfort in her right upper abdomen, and the inability to breathe well when lying down. She has always been thin, but her weight has increased by 10 pounds in the last month. She denies fever and chills. She recently had an electrocardiogram (ECG), but she has not seen a healthcare provider to discuss the results. The ECG report indicates peaked P waves, right axis deviation, and tall R wave in V1. Question Based on this patient's history and test results, what physical exam findings would be expected? Answer Choices 1 Abdominal bruit 2 Absent breath sounds in right lung 3 Dry mucous membranes and reduced skin turgor 4 Hepatojugular reflux 5 Virchow's node enlargement

4. Hepatojugular reflux

A 69-year-old woman suffered a massive stroke 6 weeks ago. She is now recovering from the stroke, but she has residual paralysis and sensory impairment of her right arm. She is also unable to speak and unable to turn her eyes to the right. Question The most likely site of her lesion is in the area that is supplied by what artery? Answer Choices 1 Right anterior cerebral artery 2 Left anterior cerebral artery 3 Right middle cerebral artery 4 Left middle cerebral artery 5 Right posterior cerebral artery

4. Left middle cerebral artery

A 74-year-old woman presents for management of an ischemic stroke. She reports difficulty seeing objects on her right side. You perform confrontational visual field testing as part of your neurological examination and you discover she has a right inferior homonymous quadrantanopsia. Question This lesion localizes to what part of the body? Answer Choices 1 Left optic tract 2 Optic chiasm 3 Left optic nerve 4 Left parietal lobe 5 Right optic tract

4. Left parietal lobe

A 75-year-old man is recovering from a pneumonia caused by Streptococcus pneumoniae; his condition suddenly deteriorates. He presents after developing a persistent fever, chills, cough, and diaphoresis. A CBC reveals leukocytosis with a left-shift. A chest X-ray demonstrates an air-fluid level in the pleural space, which is suggestive of an abscess. Question What organism caused the patient's deterioration? Answer Choices 1 Pseudomonas aeruginosa 2 Chlamydia trachomatis 3 Coccidioides immitis 4 Staphylococcus aureus 5 Legionella pneumophila

4. Staphylococcus aureus

An 88-year-old man with abdominal pain presents to the emergency room with his wife. A mini-mental status exam reveals pronounced forgetfulness and confusion. The patient is discovered to have acute appendicitis requiring immediate surgery. He is unable to understand the situation and cannot provide informed consent. Question What further action should the physician take? Answer Choices 1 Do not perform surgery. 2 Have another doctor confirm the necessity of surgery. 3 Obtain a court order to perform surgery. 4 Obtain consent from his wife to perform surgery. 5 Try to persuade the patient to consent to surgery.

4. Obtain consent from his wife to perform surgery

A 1-month-old premature male infant with bronchopulmonary dysplasia (BPD) remains intubated and monitored in the NICU. He has been doing relatively well and is being gradually weaned from the respirator. Suddenly, his O2 saturations and heart rate plummet, and he becomes very dusky. On quick exam, there are decreased breath sounds on the right with an asymmetric chest rise. Question What is the most likely explanation for his sudden respiratory and clinical change? Answer Choices 1 Inadequate tidal volume 2 Large leak around the tracheal tube 3 Displacement of the tracheal tube 4 Tension pneumothorax 5 Disconnected oxygen supply

4. Tension pneumothorax

A 33-year-old African American woman with no significant past medical history, who is in her 38th week of a normal pregnancy, presents with a 1-hour history of shortness of breath. She does not recall any precipitating activities or events that may have provoked these symptoms and recalls that she was laying in her bed for several hours since waking when the symptoms developed. She admits to an associated sharp, non-radiating pleuritic chest pain, as well as lower extremity swelling, which she states has been "persistent throughout the course of her pregnancy." She denies palpitations, chest pressure, cough, sputum, fever, chills, changes in weight, rashes, diaphoresis, abdominal pain, nausea, or a history of allergies.Her physical exam is noteworthy for tachypnea and tachycardia, but the rest of the vital signs are normal. Her lungs are clear to auscultation bilaterally, without wheezing, rhonchi, or crackles. Her lower extremities are remarkable for 2+ pitting edema up to the level of her knees; there is no calf tenderness, venous cords, or Homan's sign appreciated. Her skin and mucous membranes were without diaphoresis or cyanosis. A bedside EKG reveals sinus tachycardia at 120 bpm with prominent S waves in lead I and Q waves in lead III. Question What is the most likely diagnosis? Answer Choices 1 Acute myocardial infarction 2 Bacterial pneumonia 3 Pulmonary edema 4 Pulmonary embolism 5 Bronchial asthma

4. Pulmonary embolism

A patient recovering from hip surgery begins to ambulate for the first time about 2 hours postoperatively. Suddenly, they experience shortness of breath. The patient becomes tachypneic and tachycardic and experiences pain on inspiration. Prior to getting out of bed, their postoperative course was unremarkable. There is no swelling; there is no palpable thrill at the incision site. Question What is your initial diagnosis? Answer Choices 1 Postoperative pneumonia 2 Atelectasis 3 Arteriovenous fistula at surgical site 4 Pulmonary embolism 5 Abdominal aortic aneurysm rupture

4. Pulmonary embolism

In the winter, an 11-month-old male infant presents with a 2-day history of vomiting, diarrhea, and fever. He has not had routine medical care since birth. Mother reports no significant past medical history. His temperature is 102°F. Clinically, he appears dehydrated; his white blood cell count is 5400 cells/mm3 with a normal differential. His stool and urine are negative for white blood cells. Question What is the most likely cause of gastroenteritis in this child? Answer Choices 1 Escherichia coli 2 Clostridium difficile 3 Norovirus 4 Rotavirus 5 Shigella

4. Rotavirus

A 5-year-old boy presents with a 4-day history of bloody diarrhea. He has had fever up to 104°F, abdominal pain, and painful defecation. His past medical history is unremarkable, and he has had no surgeries. He is on no medications and has no drug allergies. He attends a local daycare with nine other children. On physical examination, his abdomen is tender with hyperactive bowel sounds. While in the emergency department, he has a 5-minute generalized seizure. Question What pathogen is the most likely cause of the patient's diarrhea and seizure? Answer Choices 1 Campylobacter jejuni 2 Giardia lamblia 3 Rotavirus 4 Shigella sonnei 5 Salmonella typhimurium

4. Shigella sonnei

A 4-year-old child presents in cardiopulmonary arrest after being found at the bottom of a swimming pool. CPR is administered by paramedics, and an intraosseous needle and endotracheal tube are inserted. What confirms that an intraosseous needle is correctly inserted into the marrow cavity? Answer Choices 1 An X-ray showing the needle is in the bone 2 A sudden increase in resistance as the needle passes through the bony cortex and reaches the other side 3 Pulsations of blood can be seen in the hub 4 The needle remains upright without support 5 Insertion of the needle up to the hub

4. The needle remains upright without support

A 48-year-old Caucasian man presents with acute onset of blurring of vision and severe pain in the left eye that began 30 minutes ago. He notes seeing halos with his left eye. He is also experiencing nausea and vomiting. These symptoms started at the same time as the pain. The patient reports that he was relaxing on his porch when the pain started. His temperature is 36.9°C, pulse 90/min, BP 130/90 mm Hg, and respirations 20/min. Physical examination reveals a shallow anterior chamber, a hazy cornea, a fixed, moderately dilated pupil, and ciliary injection. Question What would be the next step in the management of this patient? Answer Choices 1 Lumbar puncture 2 X-ray to rule out a foreign body 3 Topical atropine to the eye to facilitate ophthalmoscopy 4 Tonometry 5 Discharge with topical antibiotic drops for the eye

4. Tonometry

A 52-year-old man presents with a 3-day history of persistent diarrhea, having up to 7 watery bowel movements without bleeding a day. He has associated lower-abdominal cramping and notes mild nausea. He denies travel outside of the country. He does not recall eating anything unusual, and none of his family members are sick. Past medical history is significant for GERD, for which he takes pantoprazole daily. He recently had an upper respiratory infection and completed a course of oral levofloxacin approximately 3 weeks ago. A stool sample is obtained. Stool is negative for ova and parasites, but PCR testing is positive for Clostridium difficile. Question What is the appropriate first-line treatment in this patient? Answer Choices 1 Loperamide 2 Diphenoxylate/atropine 3 Prednisone 4 Vancomycin 5 Clindamycin

4. Vancomycin

A 17-year-old boy develops progressively abnormal muscle fatigability. He is diagnosed with myasthenia gravis and is admitted to a hospital. In the course of his treatment with pyridostigmine, he develops increased weakness, nausea, vomiting, sweating, and bradycardia. Question What is the best management for this patient? Answer Choices 1 Perform thymectomy. 2 Add corticosteroids. 3 Perform plasmapheresis. 4 Withdraw pyridostigmine. 5 Add neostigmine.

4. Withdraw pyridostigmine

A 27-year-old Caucasian man returns to the emergency department with unbearable left lower leg pain approximately 6 hours after initial discharge. While playing lacrosse, the patient sustained a closed mid-shaft tibial fracture. After casting and an anti-inflammatory, his pain was noted to be mild (2/10) at time of discharge. He reports his pain is increasing dramatically (it is now rated 9/10) and is unresponsive to his prescribed narcotic, acetaminophen, icing, and elevating his leg. He also describes a feeling of tingling and numbness throughout the lower left extremity. The patient arrived on crutches and appears in obvious pain. He is afebrile; he has a pulse of 105. The cast is intact and the remainder of the left leg and foot is examined. The patient is tender to palpation of the left foot and ankle, with swollen firm tissue. The skin appears shiny. Pulses are normal, but capillary refill and sensation are decreased on the left foot compared to the right. With passive movement of the patient's left toes, he cries out in pain. There is no ecchymosis or visible skin lesions on the left foot or ankle. Question What explains the physiologic basis for this patient's severe pain? Answer Choices 1 Chronic peripheral vascular disease, leading to poor arterial blood flow 2 Demyelination of the neuron sheath, leading to pain and paresthesias 3 Immobility of the affected limb, leading to venous stasis and thrombosis 4 Increased dopamine release, leading to activation of the reward centers 5 Increased pressure within the tissue space, leading to venous obstruction

5 Increased pressure within the tissue space, leading to venous obstruction

A 10-year-old boy presents due to a lesion on his gums. For the past 2 days, he has reported soreness around his teeth and inside his cheeks. When his mother looked closely in his mouth with a flashlight, she noted bright red areas and patches of white curd-like lesions. There are no ill contacts in the last few weeks. There has been no fever or shortness of breath. The patient's past medical history is positive for severe seasonal allergies and mild persistent asthma. Daily medications include: pediatric multivitamin, cetirizine hydrochloride 10 mg 1 tablet at bedtime, montelukast sodium 5 mg 1 chewable tablet in the morning, beclomethasone disproportionate HFA 40 mcg 2 puffs twice daily in the am and pm, and albuterol sulfate inhalation powder 2 inhalations every 4-6 hours as needed for wheezing and 15 minutes before physical activity. Examination reveals adherent thick white plaques with underlying erythematous tender mucosa on the gingival and buccal surfaces. Question What medication would be most appropriate to prescribe? Answer Choices 1 Amoxicillin suspension 2 Azithromycin suspension 3 Chlorhexidine gluconate 4 Fluticasone propionate 5 Nystatin suspension

5 Nystatin suspension

A 44-year-old man starts to notice that his eyelids are drooping. Some time afterward, his jaw becomes weak. He has difficulty swallowing and experiences weakness in his limbs. He is quite embarrassed when he eats because he must use his hand to help support his jaw. His weakness gets progressively worse. Finally, he seeks medical attention. His physical examination demonstrates the weakness in his limbs, but no sensory defects are present. A Tensilon test is done and is positive. Question What is the most likely underlying pathology of these symptoms? Answer Choices 1 Inhibition of acetylcholine release 2 Blockage of the sodium channels 3 Demyelination 4 Subacute combined degeneration of the spinal cord 5 Antibodies to the acetylcholine receptor

5. Antibodies to the acetylcholine receptor

A 20-year-old primigravida presents at 30 weeks gestation with a 2-day history of a headache, decreased urine output, and facial puffiness. On examination, vitals are as follows: pulse 90/min, blood pressure 164/116 mm Hg and 166/114 mm Hg (taken 6 hours apart), RR 20/min. There is generalized edema and exaggerated deep tendon reflexes with presence of clonus. Abdominal examination reveals a fundal height corresponding to 30 weeks gestation and the presence of good fetal heart sounds (FHS). Urine dipstick for protein reveals 3+proteinuria (300 mg/dL) on 2 occasions. Question What is the next step in the management of this patient? Answer Choices 1 Strict bed rest at home 2 Intravenous phenytoin 3 Immediate induction of labor 4 Immediate cesarean section 5 Injection of betamethasone

5. Injection of betamethasone

A 67-year-old man presents with dyspnea and chest pain 3 days after flying home from Europe. His past medical history is unremarkable. Workup reveals a pulmonary embolism. The patient has required 6 L of O2 to maintain a saturation above 90% and remains tachycardic. Question What therapy should you initiate now? Answer Choices 1 Aspirin plus rivaroxaban 2 Warfarin plus clopidogrel 3 Clopidogrel plus apixaban 4 Low molecular weight heparin plus aspirin 5 Low molecular weight heparin plus coumadin

5. Low molecular weight heparin plus coumadin

A 48-year-old Caucasian man presents with severe epigastric pain radiating to the back after a bout of drinking. He seeks medical attention and receives treatment. Symptoms improve within 5 days. 4 weeks later, his symptoms return with epigastric pain, weight loss, and decreased appetite. A repeat ultrasound shows a round thin-walled hypoechoic lesion near the pancreas tail measuring 4 cm in its largest diameter and with some calcifications in its walls. MRCP visualized a communication between this cavity and the pancreatic duct, which confirms the suspected diagnosis. Question What is the most appropriate next step in management? Answer Choices 1 Sphincteroplasty 2 Angiography with coil embolization 3 ERCP and transpancreatic drainage 4 Endoscopic ultrasound (EUS)-guided transgastric drainage 5 Nasogastric feeding

5. Nasogastric feeding

A 17-year-old boy presents with intermittent bouts of shortness of breath, coughing, and chest tightness. The symptoms most often occur during football practice, sometimes when he is just standing outdoors in cold weather. He denies palpitations, fever, and chills. Past medical history is non-contributory. He is a non-smoker. Physical exam is unremarkable. Vital signs are as follows: BMI 19 kg/m2, BP 116/70 mm Hg, HR 80 bpm, SpO2 99% on room air. His physician orders pulmonary function testing (PFT) and a chest X-ray (CXR). Question Based on the most likely diagnosis, what chest X-ray finding is most likely? Answer Choices 1 Hyperinflation 2 Ground glass shadowing 3 Bronchial wall thickening 4 Perihilar fluffy infiltrates 5 Normal chest X-ray

5. Normal chest X-ray

A 5-year-old girl has paroxysms of cough that increase in severity and duration. Some coughing episodes are followed by a high-pitched inspiratory noise, and vomiting has also occurred after paroxysms. Question What laboratory test could lead to the earliest confirmation of the likely diagnosis? Answer Choices 1 Chest X-ray 2 Blood cell analysis 3 Culture 4 Immunofluorescent antibody staining 5 PCR assay and antigen detection

5. PCR assay and antigen detection

A 30-year-old immunocompromised patient presents with a 2-week history of breathlessness and a nonproductive dry cough. The patient is afebrile, pulse is 100, and BP is 110/70 mm Hg. On auscultation, scattered rales all over the chest are heard. A chest X-ray shows diffuse air-space and interstitial shadowing in both lungs. The shadowing is more prevalent in the apical region. Question What is the most likely diagnosis? Answer Choices 1 Tuberculosis 2 Mycoplasma pneumoniae 3 Viral pneumonia 4 Streptococcus pneumoniae 5 Pneumocystis pneumoniae

5. Pneumocystis pneumoniae

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? Answer Choices 1 Bronchiectasis 2 Bronchitis 3 Foreign body in the bronchus 4 Pneumonia 5 Pneumothorax

5. Pneumothorax

A 47-year-old previously healthy Caucasian woman presents due to a 4-week history of dyspnea that started approximately when on vacation in Colorado. She initially attributed these symptoms to the altitude, but she continued to have shortness of breath with mild activity: walking >100 feet, walking up a flight of stairs, housekeeping. Her symptoms resolve with rest. She also reports mild exertional chest tightness and easy fatigability. She denies paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, and syncope. Past medical history includes usual childhood illnesses. She has no previous surgeries and no known allergies. Medications include a daily multivitamin and occasional Tylenol for headaches. She is a non-smoker, rarely drinks, and denies recreational drugs. Physical exam reveals an alert white woman in no acute distress: temp 98.2°F, pulse 80 and regular, respirations 16, BP 136/82, O2 sat 96% on room air. There is no obvious jugular venous distention. Respirations are non-labored. Lung fields are clear to auscultation and percussion. No rhonchi, rales, or wheezes are present. Heart shows RV heave present, normal S1 with fixed, split S2 with prominent P2 component. Grade II/VI systolic murmur is present at the left upper sternal border at the second intercostal space. The remainder of a complete physical examination is within normal limits. CBC and BMP are unremarkable. Free T4 and TSH are within normal limits. EKG shows normal sinus rhythm with right ventricular hypertrophy, right atrial enlargement, and right axis deviation. There is an RSR in leads v1 and v2. Question What initial diagnostic test should you order to confirm the suspected diagnosis? Answer Choices 1 Exercise stress test 2 Holter monitor 3 Nuclear stress test 4 Right and left heart catheterization 5 Transthoracic echocardiogram

5. Transthoracic echocardiogram