IM Rosh Qbank

52-year-old man with diabetes presents to a primary care provider with complaints about lower extremity numbness. He reports that he has not been fully compliant with his medications. Physical examination of the lower extremities reveals bilateral, symmetric loss of sensation in a stocking-glove pattern. Which of the following exam findings is most consistent with the suspected diagnosis? Absent ankle jerk reflexes Ascending pain with 5.07 Semmes-Weinstein filament test Displacement of the submetatarsal fat pad posteriorly Increased vibratory sensation

Absent ankle jerk reflexes diabetic peripheral neuropathy

60-year-old man presents to the clinic complaining of severe shortness of breath and orthopnea. An echocardiogram is significant for a pulmonary arterial pressure of 30 mm Hg, and his electrocardiography is significant for right ventricular and right atrial hypertrophy. Which of the following findings would you expect on this patient's physical exam? Accentuation of the pulmonic component of the second heart sound An opening snap Decreased jugular venous pressure No pitting edema

Accentuation of the pulmonic component of the second heart sound pulmonary hypertension (mean pulmonary arterial pressure equal to or greater than 20 mm Hg)

32-year-old man with a history of type 1 diabetes presents with multiple complaints. He states that he has had a 15-pound unintentional weight loss over the last month and is feeling fatigued. He feels nauseous frequently and has had a loss of appetite. He has associated irritability and depression. His vital signs demonstrate a blood pressure of 89/52 mm Hg with orthostatic hypotension. You note hyperpigmentation of the elbows, knees, and knuckles. Which of the following is the most likely diagnosis? Addison disease Conn syndrome Gastric cancer Iron deficiency anemia

Addison disease primary adrenal insufficiency

63-year-old woman presents to a primary care provider as a new patient. She had cochlear implants placed 4 weeks ago and received the 13-valent pneumococcal conjugate vaccine. She has not received the 23-valent pneumococcal polysaccharide vaccine. Which of the following is best for the patient at this time? Administer a second dose of the 13-valent pneumococcal conjugate vaccine Administer the 23-valent pneumococcal polysaccharide vaccine Administer the 23-valent pneumococcal polysaccharide vaccine in 4 weeks Administer the 23-valent pneumococcal polysaccharide vaccine when the patient turns 65 years old

Administer the 23-valent pneumococcal polysaccharide vaccine in 4 weeks (patient in the vignette has cochlear implants and should receive the 23-valent pneumococcal polysaccharide vaccine (PPSV23) 8 weeks after the first.

61-year-old woman presents to a primary care provider for routine management of hypertension, hyperlipidemia, and diabetes mellitus. Her vital signs are significant for a BP of 148/96 mm Hg. Her most recent hemoglobin A1C was 7.6%. While at the office, the patient suddenly exhibits slurred speech, left-sided facial weakness, and right arm weakness. The patient is immediately taken to the emergency department. While en route, the patient's symptoms resolve. A stroke protocol is initiated upon arrival to the ED. A noncontrast CT of the head is shown above. The patient's complete blood count, comprehensive metabolic panel, coagulation profile, and urinalysis are normal. Serial cardiac enzymes and ECGs are normal. The physical exam is significant for a left-sided carotid bruit. No focal neurologic deficits are present. What is the best next step in the management of this patient? Administer recombinant tissue plasminogen activator Admit and order a diffusion-weighted MRI Discharge on aspirin with outpatient evaluation within 72 hours Emergent left carotid endarterectomy

Admit and order a diffusion-weighted MRI TIA ABCD2 scoring - >4 (needs admission and further evaluation) *read explanation*

56-year-old man presents to the office with complaints of anal pain with bowel movements for the past 2 weeks. He reports there is no pain at rest, but he often has residual pain after defecating. He has noted a small amount of bright red blood on the toilet paper after having a bowel movement. His past medical history is significant for a prior work-related back injury, for which he takes hydrocodone with acetaminophen on a daily basis. On physical examination, the finding demonstrated above is noted. A digital rectal exam is not performed due to the patient's significant pain. What is the most likely diagnosis based on the provided information? Anal fissure External hemorrhoid Internal hemorrhoid Perianal abscess

Anal fissure

50-year-old woman presents with muscle weakness of the shoulder and pelvic girdles that has progressively worsened over the last several months. Physical exam reveals a three out of five muscle strength in the hip flexors and the deltoids. Laboratory studies demonstrate elevated aldolase and creatine kinase. Which of the following positive laboratory results would be expected? Anti-double stranded DNA antibodies Anti-Jo-1 antibodies Anti-La antibodies Anti-SCL-70 antibodies

Anti-Jo-1 antibodies diagnostic marker for polymyositis - proximal skeletal muscle weakness

45-year-old woman presents with recurrent reflux and dysphagia. She reports that her fingers become cyanotic when she is exposed to cold temperatures and then hyperemic with rewarming. On exam, skin thickening and thickness over the extensor surfaces of the digits are noted. Which of the following positive laboratory results is most specific for the suspected diagnosis? Anti-Jo-1 antibody Anti-Smith antibody Anticentromere antibody Antinuclear antibody

Anticentromere antibody (ACA) scleroderma A- polymyositis (proximal muscle weakness B - SLE D - scleroderma (*but not specific*)

28-year-old PA student of Asian descent presents to a primary care provider with fatigue and gross hematuria. He started having cold-like symptoms last night along with a mild sore throat and noticed bloody urine in the toilet this morning. He has not taken any recent medication other than pseudoephedrine. He reports no tobacco, alcohol, or drug use. A serum complement level is normal. What is the most likely cause of his hematuria? Berger disease Buerger disease Postinfectious glomerulonephritis Pseudoephedrine

Berger disease IgA nephropathy (nephritic disease) seen in young Asian and Caucasian males *present with sudden onset of gross hematuria 1-2 days after URI*

73-year-old man with a 20 pack-year history of cigarette use presents to the clinic complaining of a change in his urine color. The patient states he has noticed his urine has a slight red tinge. He denies any symptoms of flank pain, dysuria, malodorous urine, urethral discharge, or urgency. His urinalysis is positive for occult blood. Which of the following is the most likely diagnosis? Benign prostatic hypertrophy Bladder cancer Nephrolithiasis Wilms tumor

Bladder cancer

75-year-old man presents to a primary care provider with worsening symptoms of urinary frequency, urgency, and nocturia. The patient reports a sensation of incomplete bladder emptying and a weak urine stream. A soft, smooth, boggy prostate with no nodules is palpated on digital rectal examination. The urinalysis is unremarkable. The prostate-specific antigen level is 8.7 ng/mL. The postvoid residual volume is increased on ultrasound. What is the mechanism of action of the first-line treatment used for rapid symptom relief for the patient's condition? Blocks the muscarinic receptors on the detrusor muscle Blocks the sympathetic alpha receptors Phosphodiesterase-5 inhibitor Stimulates the conversion of testosterone to dihydrotestosterone

Blocks the sympathetic alpha receptors benign prostatic hyperplasia (BPH) 1st line: *alpha-adrenergic receptor antagonist* (prazosin)

61-year-old woman presents to the emergency department with fever and abdominal pain for the past 2 days. She reports mild nausea but no episodes of emesis. She notes a previous history of an "abnormal colonoscopy". On physical examination, she is febrile to 100.8°F and is tender in the left lower quadrant. A mass is palpable in the left lower quadrant. Which of the following diagnostic studies would have the highest sensitivity and specificity for confirming the diagnosis, given her most likely diagnosis and associated complication? Abdominal radiograph Abdominal ultrasound CT scan of the abdomen MRI of the abdomen

CT scan of the abdomen diverticulitis (ct with IV contrast)

65-year-old man with a past medical history of chronic kidney disease stage IV presents to the clinic to discuss his lab results. The patient does not report any symptoms or concerns at this time. His BMP results include glucose 140 mg/dL, creatinine 3.86 mg/dL, eGFR 21 mL/min, sodium 142 mmol/L, potassium 7.2 mmol/L, chloride 108 mmol/L, carbon dioxide 21 mmol/L, and calcium 9.7 mmol/L. The patient's ECG is noted above. Which of the following should be administered as the most appropriate next step in this patient's management? Calcium gluconate Insulin Kayexalate Sodium bicarbonate

Calcium gluconate to stablize myocardium acute hyperkalemia (serum potassium >5) MC seen in patients with advanced kidney disease

35-year-old woman is diagnosed with iron deficiency anemia and is being treated with ferrous sulfate. Which of the following foods has the highest iron content and thus should be recommended in her diet? Beef Calf liver Ham Lamb

Calf liver

Which of the following laboratory studies has prognostic utility in patients diagnosed with colorectal cancer? Carbohydrate antigen Carcinoembryonic antigen Complete blood count Comprehensive metabolic panel

Carcinoembryonic antigen (CEA) best sensitivity at 46% but has a specificity of 89% > 5 ng/mL have a worse prognosis

50-year-old woman presents to the clinic with complaints of diarrhea, nausea, and lightheadedness. Her vital signs include blood pressure 100/50 mm Hg, heart rate 110 beats/minute, temperature 37°C, and oxygen saturation 95% on room air. On physical exam, her face is pink and flushed, and wheezing is noted on her lung exam. Which of the following is the most likely diagnosis? Carcinoid tumor Nonsmall cell carcinoma Pulmonary nodules Small cell carcinoma

Carcinoid tumor MC location in GI tract *Carcinoid syndrome*: cutaneous flushing, diarrhea, sweating, hypotension, and wheezing

28-year-old woman presents to the clinic with vaginal discharge and abdominal pain for one week. Pelvic exam is significant for cervical purulent drainage and no cervical motion tenderness. Gram stain of the vaginal discharge received the next day is shown above. Urine pregnancy test is negative. Which of the following is the most appropriate therapy? Ceftriaxone Ceftriaxone plus azithromycin Ceftriaxone plus doxycycline Doxycycline

Ceftriaxone plus doxycycline Gonorrhea with chlamydia coinfection if pregnant - ceftriaxone and azithromycin

45-year-old woman presents to a primary care provider with fatigue, generalized joint pain and stiffness, and multiple nodules over the extensor surface of her forearms. A complete laboratory workup is ordered and is significant for elevated levels of anti-cyclic citrullinated peptide and C-reactive protein. She is started on appropriate pharmacologic therapy. Which of the following diagnostic studies will most likely be indicated as her condition progresses, in addition to routine preoperative tests for procedures requiring sedation? Cervical spine radiographs Dual-energy X-ray absorptiometry Pulmonary function testing Schirmer test

Cervical spine radiographs Rheumatoid arthritis - Cervical changes may result in atlantoaxial instability or subluxation - Neck positioning required for intubation may be fatal

What surgical procedure is an alternative to ciprofloxacin to eradicate the carrier state for carriers of Salmonella? Billroth I Cholecystectomy Splenectomy Whipple procedure

Cholecystectomy typhoid fever - can colonize in *gallbladder* >> resulting in asymptomatic carrier state

30-year-old physician assistant student on her pediatrics rotation presents to her primary care provider with a sore throat, tonsillar exudates, anterior cervical lymphadenopathy, abdominal pain, and a subjective fever. Rapid strep testing is positive, and she is treated with amoxicillin. She presents with a fever of 102°F measured in the office 2 weeks later. She has no previous history of rheumatic fever. Which of the following additional findings would be sufficient to make an initial diagnosis of acute rheumatic fever? Carditis Chorea and reversible prolonged PR interval Erythema marginatum Polyarthralgia and elevated erythrocyte sedimentation rate

Chorea and reversible prolonged PR interval Acute rheumatic fever Jones Criteria - *two major criteria or one major and two minor criteria* Fever (minor) Chorea (major) prolonged PR (minor) (*other choices are not sufficient enough with fever to complete criteria*)

52-year-old man with a history of tobacco use presents to the clinic complaining of a productive cough. He reports being sick frequently with lung infections over the last three years. He states his current cough has been present for over three months and is associated with thick green sputum. His vitals today are as follows: weight 290 pounds, BMI 38 kg/m2, O2 at 93% on room air, and blood pressure at 132/86 mm Hg. A pulmonary function test is completed in the office and reveals FEV1 predicted at 60%, FEV1/FVC at 55%, and a total lung capacity within normal limits. He is given a nebulizer treatment with albuterol, and a pulmonary function test is repeated with no significant change or improvement. Which of the following is the most likely diagnosis? Chronic bronchitis Cystic fibrosis Emphysema Idiopathic pulmonary fibrosis

Chronic bronchitis COPD blue bloaters cough with sputum

46-year-old man presents to his primary care provider with a headache, shortness of breath, and palpitations. He reports that his symptoms started after a long weekend of binge drinking. He typically drinks seven beers per day. He has a 35 pack-year history and quit smoking five years ago when he was diagnosed with COPD. He has a history of hypertension and is currently taking lisinopril 40 mg PO daily. His family history is significant for a father who passed away from a myocardial infarction at 44 years of age and a brother who had a stroke at 32 years of age. His rhythm strip is shown above. Which of the following is the most likely underlying cause of the patient's dysrhythmia? Chronic obstructive pulmonary disease Excessive alcohol use Family history of coronary artery disease Hypertension

Chronic obstructive pulmonary disease EKG shows Multifocal Atrial Tachycardia (>3 P morphologies, rate >100, irregular) *commonly seen in COPD and other hypoxic states* B - a fib C - MI

30-year-old woman presents to the clinic complaining of a fever, cough, and shortness of breath. She reports associated symptoms of fatigue and chills. Her vital signs include blood pressure 126/84 mm Hg, heart rate 108 beats/minute, temperature 39°C, and oxygen saturation 96% on room air. Her physical exam is consistent with increased tactile fremitus and dullness to percussion over the left lower lung field. A sample of her sputum is obtained and observed with a Gram stain significant for gram-positive cocci in pairs. What is the appropriate treatment for this patient's suspected diagnosis? Azithromycin and ampicillin Clarithromycin Clindamycin Levofloxacin

Clarithromycin CAP from Strep. pneumoniae

40-year-old woman presents to her primary care provider with right leg pain that has been persistent for the past seven months. The patient has a history of a right tibial shaft stress fracture that was diagnosed two years ago. The patient reports sensations of burning, tingling, and severe muscle aches over the site of the previous fracture. She reports her right leg seems to be a different color and is painful to move at times. On physical examination, the right leg is pale and dusky in appearance. The patient has pain out of proportion to light touch over the anterior tibialis muscle. Ankle dorsiflexion is limited due to pain. AP and lateral radiographs of the right tibia are normal. What is the most likely diagnosis? Arterial ulcer Chronic osteomyelitis Complex regional pain syndrome Exertional compartment syndrome

Complex regional pain syndrome localized pain of more than six months' duration previous history of a fracture, sprain or strain, soft tissue injury, or surgery unilateral, severe, and out of proportion

65-year-old woman with a history of deep vein thrombosis who is taking warfarin reports to her primary care provider with a three-week history of lower leg swelling, pain, and an itchy rash on the leg that was previously affected by the deep vein thrombosis. Physical exam reveals 2+ pitting edema of the affected leg, brownish discoloration, and a diffuse, flaking, weeping rash over her affected calf. Venous ultrasound does not show new deep vein thrombosis. What initial intervention is recommended? Altering anticoagulation therapy Compression stockings Radioablation therapy Warm compresses

Compression stockings chronic venous insufficiency

50-year-old man presents to the clinic for an employment physical. His vitals are within normal limits. He reports no prior surgeries, current medical problems, or current daily medications and a 30 pack-year smoking history (currently still smoking). Physical exam is within normal limits. A chest X-ray is taken per the employer's request and reveals a 2.1 cm nodule in the left upper lobe. Which of the following is the best next step for evaluation of this patient? Bronchoscopic resection of the area of concern Computed tomographic scan of the chest Magnetic resonance imaging of the chest Repeat chest X-ray in one year

Computed tomographic scan of the chest

30-year-old man presents to a primary care provider with fatigue, decreased appetite, and a diffuse maculopapular rash involving his palms and soles. He reports that he is currently sexually active with both men and women and has had four different partners in the last year. He also reports that he had a painless sore on his penis about two months ago that healed spontaneously after a few weeks. A rapid plasma reagin test is positive. A follow-up fluorescent treponemal antibody absorption test is also positive. Which of the following physical exam findings is most consistent with the patient's diagnosis? Chancre Condyloma acuminata Condylomata lata Gummas

Condylomata lata secondary syphilis A - primary syphilis B - HPV D - tertiary syphilis

28-year-old man presents to the office complaining of daytime somnolence, decreased exercise tolerance, and shortness of breath. His body mass index is 40 kg/m2, his oxygen saturation is 90% on room air, and all other vitals are within normal limits. Arterial blood gas measurement reveals a partial pressure of arterial carbon dioxide of 48 mm Hg. Which of the following clinical interventions or therapeutics is most appropriate as first-line therapy for this patient? Acetazolamide 250 mg twice daily Bariatric surgery Continuous positive airway pressure during sleep Daytime oxygen via nasal cannula

Continuous positive airway pressure during sleep sleep apnea due to obesity hypoventilation syndrome

48-year-old man presents to a primary care provider with complaints of progressive weakness in his legs for the past three days. He reports his symptoms started in his feet and are now affecting his calves as well. His past medical history is significant for a gastrointestinal infection one week ago that was treated with erythromycin. Which of the following physical examination findings is most consistent with the suspected diagnosis? Decreased deep tendon reflexes Electrical sensation down the spine with neck flexion Muscle weakness that improves with use Relative afferent pupillary defect

Decreased deep tendon reflexes Guillain-barre syndrome (*bilateral ascending weakness, decreased DTR, preceding gastroenteritis infection*)

67-year-old man with a history of congestive heart failure presents with dyspnea and a dry cough for the past two days, and it has been worsening. He denies any fever or other upper respiratory symptoms. Exam of the lower extremities reveals +1 pitting edema at the level of the ankles. A chest radiograph shows obliteration and opacification of the bilateral costophrenic angles visualized in two views. Which of the following would you expect to find on physical exam? Decreased tactile fremitus Hyperresonant percussion Increased chest expansion Tracheal deviation

Decreased tactile fremitus pleural effusion from congestive heart failure

53-year-old man presents for a routine complete physical. Screening blood work is completed that demonstrates a fasting blood glucose of 189 mg/dL and hemoglobin A1C of 7.8%. The patient is prescribed metformin. Which of the following is the most common side effect of this medication? Diarrhea Hypoglycemia Lactic acidosis Vitamin B12 deficiency

Diarrhea (and other GI upset)

23-year-old man presents to your clinic with a two-day history of worsening parasternal chest pain. The patient reports the pain is sharp and made worse with breathing and lying down. Additional symptoms include a nonproductive cough, which the patient states started several days before the onset of his chest pain. Vital signs are within normal limits. Cardiopulmonary exam is unremarkable. You obtain an ECG and decide to treat this patient with high-dose aspirin. Which of the following ECG findings is most indicative of the suspected diagnosis? Diffuse ST segment elevations Normal sinus rhythm Sinus tachycardia T wave inversions

Diffuse ST segment elevations acute pericarditis (*pleuritic sharp chest pain that is made worse by lying down and improved with sitting up or leaning forward*) ECG: diffuse ST segment elevations and PR segment depressions

86-year-old woman presents to the office to discuss her worsening dizziness. She reports an increasing sense of fear of falling recently, which is significantly limiting her daily life. She does not often experience dizziness while sitting or walking, but upon standing, she feels very weak and often needs to sit for 10 minutes before she attempts to stand again. Her past medical history includes type 2 diabetes mellitus, depression, hypertension, and atrial fibrillation. She is compliant with her medications, which include metformin, paroxetine, hydrochlorothiazide, and apixaban. What is the best first step in management? Begin using compression stockings Discontinue hydrochlorothiazide Initiate therapy with fludrocortisone Initiate therapy with midodrine

Discontinue hydrochlorothiazide orthostatic hypotension due to chronic volume depletion (due to diuretics) 1st line tx - discontinue/change offending pharmacologic agent

62-year-old obese woman with diabetes presents to the office complaining of worsening dyspnea and dizziness. She has a longstanding history of alcohol use and currently reports decreasing her alcohol consumption to 12 beers per week. On physical exam, she appears to be in no acute distress. Cardiovascular exam reveals jugular venous distention and rales bilaterally on auscultation of the lungs. Which initial diagnostic study is most helpful for eliminating a valvulopathy as the possible cause of her symptoms? Cardiac magnetic resonance imaging Chest radiography Echocardiography Electrocardiography

Echocardiography worried about dilated cardiomyopathy with heavy alcohol use

60-year-old man presents with severe substernal chest pain, dyspnea, and diaphoresis that started one hour prior to the presentation. Pain radiates to his left neck and arm. His past medical history is significant for hypertension and hypercholesterolemia. On exam, he is noted to be tachycardic, diaphoretic, and hypertensive. Which of the following is the most appropriate next step in diagnosis? Chest radiography Echocardiography Electrocardiography Nuclear scintigraphy

Electrocardiography STEMI

A previously healthy 58-year-old woman presents to an urgent care clinic, brought by her coworker, after she fainted at work. The coworker states he was talking with the patient while she was sitting at her cubicle when she suddenly became unresponsive and slumped over in her chair. The coworker did not notice any diaphoresis or pallor and was able to catch the patient to prevent her from hitting her head. The patient regained consciousness within a few seconds. The patient states this is the first time this has happened. What is the best initial diagnostic study for this patient? Echocardiography Electrocardiography Electrophysiology studies Orthostatic blood pressure test

Electrocardiography all patients undergoing evaluation syncope

72-year-old woman presents to the office complaining of worsening aching, throbbing, and heaviness in both legs. She also reports frequent night cramps in her legs and feeling like she cannot get comfortable while falling asleep. On physical exam, both lower extremities appear edematous with scattered patches of reddish-brown hyperpigmentation. On her distal lower legs bilaterally, there is a fibrosing panniculitis with hyperpigmentation and induration involving most of the leg circumferentially. Her left medial ankle is edematous and has a 7 mm shallow ulcer with a red base and irregular borders. Doppler ultrasound reveals a reflux of 1005 milliseconds in the left great saphenous vein and 1007 milliseconds in the right. Considering this information, what would be the most effective clinical intervention for this patient? Endovenous laser ablation Sclerotherapy Surgical vein stripping Venous reconstruction

Endovenous laser ablation chronic venous insufficiency

63-year-old man with a history of Barrett esophagus presents to the office with concerns of progressively worsening dysphagia over the past few months. He reports the dysphagia initially seemed to affect only solid foods, but now it is starting to impact thicker liquids. Sometimes he feels that food gets stuck in his throat and upper chest when swallowing. When comparing his anthropometrics from his previous visit 6 months ago, it is apparent he has lost 17 pounds. On physical examination, he is also noted to have a hoarse voice, which he reports has been present for the past 2 months. Which of the following diagnoses is of greatest concern given his presentation? Calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia syndrome Esophageal cancer Myasthenia gravis Zenker diverticulum

Esophageal cancer suspect in pts with Barrett esophagus with progressive dysphagia and weight loss Barrett = adenocarcinoma MC = squamous cell carcinoma

58-year-old man presents to the office with frequent heartburn, difficulty swallowing, and a sensation of pressure and mild pain in his chest after every meal. More recently, he has been having difficulty swallowing liquids as well. He has been taking ranitidine daily for years but continues to have worsening symptoms. Which of the following is the best initial test to diagnose the suspected condition? Chest radiograph Computed tomography of the chest Esophageal manometry Esophagogastroduodenoscopy

Esophagogastroduodenoscopy esophageal stricture barium esophagography is the first-line test EGD is typically ordered in those who present with esophageal dysphagia to diagnose esophageal strictures and rule out malignancy.

65-year-old woman with a history of Hashimoto thyroiditis presents to your office with complaints of an enlarged mass on her neck and unexplained weight loss over the past 3 months. She is now retired but previously worked as a hairdresser and is an avid gardener. Physical exam reveals cervical lymphadenopathy and splenomegaly. Which of the following is the most appropriate diagnostic test? Endoscopy Excisional lymph node biopsy Magnetic resonance imaging Neck ultrasound

Excisional lymph node biopsy lymphoma

68-year-old man presents with a substernal chest tightness that occurred while he was walking his dog this morning. The pain lasted approximately five minutes and was relieved by rest. Physical examination and laboratory studies are unremarkable. Resting ECG is normal. Which of the following is the most likely next step in diagnosis? Exercise ECG Myocardial perfusion scintigraphy Radionuclide angiography Stress echocardiography

Exercise ECG stable angina - 1 mm horizontal or downsloping ST segment depression

2-week-old boy presents to the emergency department with his mother. The child was born at 37 weeks gestation, and his mother had sporadic prenatal care. The child presents with fever, lethargy, and vomiting. Vital signs are 101.5°F, pulse 155 beats per minute, respirations 30/min, blood pressure 95/60 mm Hg, and oxygen saturation of 98% on room air. Physical exam reveals a lethargic baby with dry mucous membranes. What cerebrospinal fluid analysis confirms the most likely diagnosis? 20 cm opening pressure, clear appearance, 30 mg/L protein, 75 g/dL glucose, and 15 cells/HPF white blood cells 25 cm opening pressure, fibrin webs visible, 100 mg/L protein, 45 mg/dL glucose, and 100 cells/HPF white blood cells 35 cm opening pressure, turbid appearance, 200 mg/L protein, 35 mg/dL glucose, and 80,000 cells/HPF white blood cells 40 cm opening pressure, clear appearance, 150 mg/L protein, 80 g/dL glucose, and 2,000 cells/HPF white blood cells

35 cm opening pressure, turbid appearance, 200 mg/L protein, 35 mg/dL glucose, and 80,000 cells/HPF white blood cells bacterial meningitis

45-year-old man is screened for tuberculosis with a tuberculin skin test. He had recent close contact with an individual with active and contagious tuberculosis. Which of the following induration measurements is the minimum induration for a positive tuberculin skin test in this patient? 10 mm 15 mm 2 mm 5 mm

5 mm for those at high risk (HIV infection, *close contact with an active tuberculosis case*, abnormal chest X-ray with fibrotic changes consistent with old tuberculosis, and immunosuppressed patients such as those with a history of organ transplantation or who are chronically on steroids) (15mm - for healthy individuals with no RF)

35-year-old woman with central obesity, a large hump in her supraclavicular area, striae of her skin, and easy bruising presents to the health clinic for worsening proximal muscle weakness. She is noted to be hypertensive, has gained weight, and has darkening of the skin on the back of her neck with a velvety texture. She is also noted to have hirsutism and acne on her face. Laboratory studies show a normal glucose level and hypokalemia. High-dose dexamethasone suppression test shows ACTH suppression, and an MRI shows a pituitary adenoma. What is the best clinical intervention for this patient, based on the most likely diagnosis? Adrenalectomy Ketoconazole Steroid taper Transsphenoidal surgery

Transsphenoidal surgery Cushing disease is caused by excess ACTH produced most commonly by a benign pituitary adenoma.

35-year-old man presents with epigastric pain, which radiates to the back, accompanied by nausea and vomiting. On exam, he is noted to have cream-colored retinal vessels. Laboratory studies demonstrate elevated amylase and lipase. Which of the following findings is most likely to also be elevated? High-density lipoprotein Lipoprotein(a) Low-density lipoprotein Triglyceride

Triglyceride *Severe elevation in triglycerides can cause pancreatitis*

68-year-old woman presents with progressively worsening diarrhea over the past 3 weeks. She describes the bowel movements as frequent and small in volume with bright red blood often present. She averages five episodes per day. She experiences a frequent, and sometimes sudden, urge to evacuate her bowels. She reports she sometimes does not make it to the bathroom in time. She reports fatigue. She is afebrile. Abdominal exam reveals mild abdominal tenderness without palpable mass. A gastroenterology referral is prepared. What is the most likely diagnosis given the patient's history and physical exam? Celiac sprue Crohn disease Diverticulitis Ulcerative colitis

Ulcerative Colitis *absence of peri oral involvment (prevalent in crohns) read explanation

77-year-old man presents to a primary care provider with fever, malaise, and a pruritic rash for three days. The patient reports that he cared for his grandchildren two weeks ago and that they had similar symptoms that did not seem as severe. The patient states that the rash began on his head and body and then spread to his arms and legs. Physical examination reveals the presence of a scattered, erythematous maculopapular rash with a centripetal pattern. Sporadic vesicles, as seen in the image above, are present. A few of the vesicular lesions are crusted over. The patient states that he and his children are against vaccinations. What is the causative agent of the most likely diagnosis? Human herpesvirus-6 Rubella virus Rubeola virus Varicella zoster virus

Varicella zoster virus chicken pox

23-year-old woman presents to the emergency department four days after surgical repair of her anterior cruciate ligament. She has no significant past medical history, and her only medication is a combined oral contraceptive pill. She reports increased pain and swelling in her left leg. On exam, her left calf is erythematous, and its circumference is 4 cm greater than her right calf. What is the initial diagnostic study of choice for the suspected condition? Computed tomography angiography Plain radiography Venous duplex ultrasound Ventilation-perfusion scan

Venous duplex ultrasound DVT

50-year-old man presents to his primary care provider with complaints of fatigue, night sweats, weight loss, and bone pain. Laboratory testing is significant for a normochromic, normocytic anemia. The peripheral blood smear is shown in the image above. A comprehensive metabolic panel is significant for a blood urea nitrogen of 50 mg/dL, a creatinine of 3.5 mg/dL, and a total protein of 14.7 g/dL. Bence Jones proteins are present in the urine. Which of the following pathologic fractures is most commonly associated with the patient's diagnosis? Acetabular fracture Humeral neck fracture Humeral shaft fracture Vertebral fracture

Vertebral fracture multiple myeloma bence jones proteins rouleaux formation (stacked plates) renal insufficiency anemia MC: vertebral, pelvic, femoral neck, and rib fractures

74-year-old man with a past medical history of hypertension presents to the emergency department for sudden-onset confusion and a coarse tremor. The patient presents with altered mental status, and on physical exam, you notice significant myoclonus of the upper extremities as well as muscle rigidity, postural instability, and bradykinesia. Vitals are heart rate 92 bpm, blood pressure 142/79 mm Hg, respiratory rate of 16 breaths per minute, O2 saturation of 97% on room air, and temperature of 98.7°F. His daughter reports the pair recently returned from a camping trip, where the patient complained of being bitten by multiple mosquitos. What is the most likely diagnosis? Bacterial meningitis Lyme disease Rocky Mountain spotted fever Viral encephalitis

Viral encephalitis West Nile encephalitis - transmitted through mosquitos

40-year-old Black man presents to a primary care provider for a follow-up visit to discuss his laboratory results. On the previous visit, a nontender, nodular prostate was palpated on digital rectal examination. His prostate-specific antigen level is 12.4 ng/mL. A transrectal ultrasound-guided biopsy is ordered. Which of the following is most likely present in the patient's history? Bone pain Painless hematuria Weak urinary stream Weight loss

Weak urinary stream concerned for prostate cancer - compression of urethra (will have BPH-like symptoms - urinary frequency, urgency, nocturia, incomplete bladder emptying, weak urinary stream, straining) A, D - metastatic disease B - bladder cancer

34-year-old man presents to his primary care provider with complaints of fatigue, subjective fever, and muscle aches for 4 days. He reports that the symptoms began 2 days after he returned from a 3-day hiking trip in Connecticut. Physical examination is significant for the rash shown in the image above (target lesion). Which of the following correctly describes the transmission cycle for the patient's condition? Rats to Xenopsylla cheopis to human White-footed mouse to Ixodes scapularis to human White-tailed deer to Amblyomma americanum to human Wild rodent to Dermacentor variabilis to human

White-footed mouse to Ixodes scapularis to human DUMB question

23-year-old woman presents to her primary care provider with complaints of vaginal itching, dysuria, and odorless, white, curd-like discharge. Which of the following diagnostic study results is most consistent with the suspected diagnosis? pH of 4.0 and hyphae on potassium hydroxide prep pH of 4.7 and a positive whiff test pH of 5.2 and clue cells on wet mount pH of 5.5 and motile trichomonads on wet mount

pH of 4.0 and hyphae on potassium hydroxide prep candidiasis

58-year-old man is in the cardiac intensive care unit after undergoing percutaneous coronary intervention for an acute anterior myocardial infarct. The patient reports worsening chest pain 24 hours after arriving in the ICU. When you arrive in the room, the patient is clutching his chest and appears to be in respiratory distress. Vital signs are BP 92/70 mm Hg, HR 102 bpm, RR 28 breaths per minute, and T 98°F. Physical exam reveals elevated jugular venous pressure. What is the most likely etiology of cardiogenic shock in this patient? Dressler pericarditis Free wall rupture Mitral valve regurgitation Recurrent infarction

Free wall rupture Hemopericardium causing CARDIAC TAMPONADE (*hypotension, elevated jugular venous pressure, muffled heart sounds [Beck triad], tachycardia, narrowed pulse pressures*) seen 24-48 hrs post MI

A previously healthy 31-year-old woman presents to the emergency department with shortness of breath. She states it has been going on for a day, and she also notes a cough and pleuritic chest pain. She reports she just got over a cold last week. Vitals are pulse 120 bpm, respirations 22 per minute, BP 104/58 mm Hg, and oxygen saturation 97% on room air. Physical exam reveals an S3 gallop, ECG reveals sinus tachycardia, and chest X-ray reveals cardiomegaly. What medication should be initiated in this patient? Aspirin Ceftriaxone Dopamine Furosemide

Furosemide for fluid overload due to viral myocarditis

52-year-old man presents to a primary care provider for severe joint pain in his great toe. He reports an acute onset of pain yesterday and denies any injury or trauma. He has had several similar presentations intermittently throughout the past two decades. Vital signs are T 38.1°C, BP 122/72 mm Hg, HR 86 bpm, RR 18 breaths per minute, and pulse oximetry 99% on room air. Physical examination reveals a great toe that is swollen and erythematous and exquisitely tender and warm to the touch. His WBC count is 14,600/mcL, and his uric acid level is 5.9 mg/dL. A radiograph of his toes is shown above. Which of the following is the most likely diagnosis? Gouty arthritis Pseudorheumatoid arthritis Rheumatoid arthritis Septic arthritis

Gouty arthritis

65-year-old man with HIV presents to a primary care provider with fever, chills, cough, and pleuritic chest pain for one week. His initial chest radiograph is shown above. He is admitted to the hospital and started on empiric antibiotics for bacterial pneumonia. His WBC count is 16,000/mcL, and his LDH is 140 U/L. While in the hospital, the patient develops an irregularly shaped, verrucous cutaneous lesion on his back. A biopsy is sent to the laboratory, and thick-walled cells with a single broad-based bud are seen on microscopy. The same findings are present on sputum culture. Which of the following United States geographic regions would a history of recent travel be most consistent with the suspected diagnosis? Great Lakes Pacific Coast Pacific Northwest Southwest

Great Lakes blastomycosis - in moist soil and decomposing wood and leaves

50-year-old man presents to a primary care provider for his annual examination and review of bloodwork. His vital signs are T 37.1°C, BP 150/96 mm Hg, waist circumference 41 inches, body mass index 39 kg/m2, HR 70 bpm, RR 18 breaths per minute, and pulse oximetry 99% on room air. Which of the following additional findings would give this patient a diagnosis of metabolic syndrome? Fasting blood sugar level of 90 mg/dL HDL level of 35 mg/dL LDL level of 150 mg/dL Triglyceride level of 120 mg/dL

HDL level of 35 mg/dL at least three of the following criteria: Abdominal obesity Serum triglycerides ≥ 150 mg/dL or drug treatment for elevated triglycerides Serum high-density lipoprotein (HDL) cholesterol < 40 mg/dL in men and < 50 mg/dL in women or drug treatment for low HDL cholesterol Blood pressure ≥ 130/85 mm Hg or drug treatment for HTN Fasting glucose ≥ 100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose

36-year-old man returns to the office for follow-up evaluation. He recently completed an antibiotic course of clarithromycin, amoxicillin, and omeprazole for acute gastritis. What would you expect to learn from his history based on this information? A recent colonoscopy revealed transmural involvement with skip lesions He had a biopsy revealing eosinophilic inclusions He had a positive urea breath test He was overusing NSAIDs for chronic back pain

He had a positive urea breath test H. pylori infection tx: CAP

50-year-old man presents with a gradual onset of weight loss, malaise, and abdominal pain. On exam, he is noted to have painful violaceous plaques surrounded by livedo reticularis on the extremities. Laboratory studies demonstrate elevated C-reactive protein and erythrocyte sedimentation rate. Which of the following diseases should be screened for based on the suspected diagnosis? Acute cholecystitis Hepatitis A Hepatitis B Hepatitis E

Hepatitis B polyarteritis nodosa associated with Hep B and Hep C

Which of the following is the first serologic marker to be positive in acute hepatitis B? Hepatitis B core antibody Hepatitis B core antigen Hepatitis B surface antibody Hepatitis B surface antigen

Hepatitis B surface antigen appears 1 to 10 weeks after an acute exposure

68-year-old man with rheumatoid arthritis and Crohn disease presents with fatigue and exertional dyspnea. On exam, he is noted to be tachycardic and hypotensive. Laboratory studies show a serum hemoglobin level of 10 g/dL with an MCV of 90 fL, elevated CRP, and elevated ESR. Which additional finding is most likely to be present in this patient? High ferritin High iron High TIBC High transferrin

High ferritin anemia of chronic disease Labs: normochromic normocytic anemia, low serum iron and TIBC, *high or normal ferritin*

65-year-old woman presents to a primary care provider with complaints of jaw claudication, throat pain, and scalp tenderness. She also reports soreness in her neck, shoulders, and pelvic girdle. She denies vision loss. Physical examination reveals a pulsatile temporal artery. Her C-reactive protein is elevated. A temporal artery biopsy is obtained. What is the best next step in the management of this patient? High-dose prednisone and low-dose aspirin IV methylprednisolone IV methylprednisolone and high-dose aspirin Treatment with corticosteroids if temporal artery biopsy is abnormal

High-dose prednisone and low-dose aspirin Temporal (Giant Cell) Arteritis *initiate high dose corticosteroids before biopsy results* *low dose aspirin - to decrease risk for CVA and vision loss* *IV methylprednisolone - for vision loss*

40-year-old woman presents to her primary care provider with complaints of hand pain. She states her wrists and hands hurt and feel very stiff every morning. She does not notice the pain as much later in the day after she has been moving around for a while. Physical exam reveals ulnar deviation at the metacarpophalangeal joint bilaterally, as well as swollen, tender interphalangeal joints. What physical exam finding is most likely, given the suspected diagnosis? Hard, fixed nodules at the distal interphalangeal joint Hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint Inability to extend the distal interphalangeal joint Unstable first metacarpophalangeal joint in the neutral position

Hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint (Boutonniere deformity) (RA can also see swan neck deformity: PIP hyperextension, DIP flexion) A - seen in OA C - mallet finger D - skiers thumb

46-year-old woman presents to a primary care provider as a new patient. Her vital signs are T 98.8°F (37.1°C), BP 200/164 mm Hg, HR 98 bpm, RR 18 breaths per minute, and pulse oximetry 100% on room air. Her body mass index is 38. She is a heavy smoker and has a 35 pack-year history. On physical exam, she has a low hairline, low-set ears, webbed neck, and a broad chest. The patient reports that horseshoe kidneys were present on a previous renal ultrasound. While in the office, the patient suddenly experiences severe tearing chest pain that radiates to her back. Which of the following is the most common risk factor for the suspected diagnosis? Hypertension Marfan syndrome Smoking Turner syndrome

Hypertension MCC of aortic dissection

32-year-old man presents to the office for a routine physical exam. He has a history of seasonal allergies but is otherwise healthy. He takes no medications, does not smoke, and drinks beer occasionally in social situations. He has an athletic build, however, he reports not exercising much due to shortness of breath while exercising. His vital signs show a blood pressure of 112/72 mm Hg, pulse of 87 bpm, temperature of 98.2°F, and respirations of 10 breaths per minute. On cardiac exam, you hear a crescendo-decrescendo systolic murmur beginning slightly after S1 that is best heard at the apex and left lower sternal border. The murmur increases with the Valsalva maneuver. His electrocardiogram is shown above. What is the most likely diagnosis? Aortic regurgitation Aortic stenosis Hypertrophic cardiomyopathy Patent ductus arteriosus

Hypertrophic cardiomyopathy crescendo-decrescendo systolic murmur beginning slightly after S1 that is best heard at the apex and left lower sternal border, increases with the Valsalva maneuver.

12-year-old boy presents to the emergency department with sudden-onset scrotal pain, nausea, and vomiting. His physical exam is significant for an erythematous, swollen, tender, and retracted testicle. There is a negative Prehn sign and an absent cremasteric reflex. A testicular Doppler ultrasound is completed at his bedside and demonstrates an avascular testicle. Which of the following is the most appropriate next step in management? Administer pain medications and reevaluate in one hour Bed rest, scrotal elevation, and cold compresses to affected testicle Discharge home with a prescription for azithromycin and ceftriaxone Immediate surgical consult

Immediate surgical consult testicular torsion = medical emergency

A previously healthy 50-year-old man presents to your office for his annual physical exam. He wants to make sure he is up to date on all of his preventive screenings. He asks about the need for hepatic cancer screening because one of his friends was recently diagnosed. Which of the following groups should be screened for hepatic cancer? Individuals aged 50 years and older Individuals with a 30 pack-year history of smoking Individuals with alcohol use disorder Individuals with liver cirrhosis

Individuals with liver cirrhosis

62-year-old man with chronic obstructive pulmonary disease uses an albuterol inhaler as needed for symptoms. Despite using the albuterol inhaler, the patient has frequent daily symptoms. He denies any exacerbations in the past year. Which of the following additions to his therapeutic regimen would be most appropriate? Inhaled ipratropium Inhaled tiotropium Oral prednisone Oral theophylline

Inhaled tiotropium (long acting muscarinic antagonist bronchodilator)

45-year-old woman presents to her primary care provider with painful discoloration of her fingers and nose when cold. She states her fingers become pale when cold and then become red and painful when they begin to warm up. She also complains of difficulty swallowing and early satiety. On physical exam, she has tight, shiny skin and multiple telangiectasias. She currently smokes one pack per day and has no significant past medical history. What clinical intervention should be recommended first? Initiate methotrexate Initiate nifedipine Initiate sildenafil Initiate varenicline

Initiate varenicline for smoking cessation assistance scleroderma

72-year-old man with a past medical history significant for hypertension presents for a routine yearly physical exam. He has been feeling well and has no complaints. His physical exam is benign, and a basic metabolic panel is ordered as part of a routine series of blood tests. The results show a calcium level that is 0.8 mg/dL above normal limits. When compared to last year's results, this is a new lab finding. Which of the following studies should be ordered next to confirm the most likely diagnosis? 1,25-dihydroxyvitamin D Intact parathyroid hormone Phosphate Thyroid ultrasound

Intact parathyroid hormone primary hyperparathyroidism = hypercalcemia

35-year-old man with a past medical history of hypertension presents to the urgent care clinic with intermittent left-sided lower back pain with radiation to his flank, hematuria, nausea, and increased urinary frequency. He denies any recent trauma or falls. He is not sexually active. Vital signs are heart rate of 68 bpm, blood pressure of 132/81 mm Hg, O2 saturation of 98% on room air, respiratory rate of 16 breaths per minute, and temperature of 98.1°F. Physical exam shows mild tenderness to palpation of the left lower back and left flank without bruising. There is no hernia present, and a genital exam is unremarkable. What is the initial management of choice for this patient, based on the most likely diagnosis? Cystoscopy Foley catheter placement Intravenous fluids and anti-inflammatory medications Reassurance and follow-up

Intravenous fluids and anti-inflammatory medications nephrolithiasis

55-year-old man presents to a primary care provider with complaints of depression, resting tremor, slowed movements, and problems with balance. Physical examination is significant for rigidity, a shuffling gait, and masked facies. Which of the following pathologic findings is associated with the patient's condition? Atrophy of the caudate nucleus and putamen Increase in dopaminergic neurons in the substantia nigra Lewy bodies in the substantia nigra Tau tangles in the intercellular spaces of neurons

Lewy bodies in the substantia nigra parkinsons disease B - Parkinson's associated with decreased dopaminergic neurons in substantia nigra A - Huntingtons D - alzheimers

63-year-old man presents to the emergency department with rapid onset of severe epigastric pain that radiates to the back and has been ongoing for the past 3 hours. Pain is progressively worsening. He has accompanying nausea and vomiting. Vital signs reveal hypotension and tachycardia. Physical examination reveals significant tenderness to palpation in the epigastrum and diffusely throughout the abdomen. The skin finding above is observed. Which of the following laboratory studies is most sensitive for the suspected diagnosis? Amylase C-reactive protein Lipase Trypsin

Lipase most sensitive marker in acute pancreatitis

45-year-old African American woman presents to the ED, brought by her daughter, who reports the patient had a sudden-onset severe headache while playing the clarinet, followed by nausea, vomiting, and brief loss of consciousness. A noncontrast head CT scan is ordered results: negative), as seen above. Which of the following diagnostic studies is indicated next? Digital subtraction angiography Head CT scan with contrast Lumbar puncture Magnetic resonance angiography

Lumbar puncture If CT negative (as in this patient) and suspicion high = lumbar puncture

33-year-old woman from Texas presents to a primary care provider with pain and decreased vision in her right eye, difficulty walking, and tremors in both hands. She reports that she has had multiple similar episodes in the past two years that seem to occur whenever the weather gets really hot. During her previous episode last summer, she felt very tired, experienced urinary urgency, and had a feeling of an electrical shock radiating down her neck and back into her extremities whenever she bent her head forward. Her symptoms typically resolve spontaneously after a few days, but they seem to be lasting longer now. Her mother had similar symptoms that were treated with injections of glatiramer acetate. Which of the following is the best test for confirming the suspected diagnosis? Brain biopsy Computed tomography Lumbar puncture Magnetic resonance imaging

Magnetic resonance imaging most useful test in dx Multiple Sclerosis - White matter plaques are most commonly seen in the ventricles as perpendicular projections (Dawson fingers) or ovoid lesions

78-year-old woman presents to the emergency department with sudden-onset dyspnea, weakness, and altered mental status. Her vital signs show a blood pressure of 78/45 mm Hg, pulse of 117 bpm, temperature of 100.4°F, and respirations of 19 breaths per minute. She is alert and oriented to person and place but appears confused about time and situation. Physical exam reveals a thin woman in acute distress complaining of chest pain. Arterial pulses are rapid and thready with low amplitude. Auscultation along the left sternal border and apex of the heart reveals a systolic, soft, low-pitched decrescendo murmur without thrill radiating to the axilla. Which acute issue is the most likely diagnosis? Aortic dissection Aortic stenosis Mitral regurgitation Mitral valve prolapse

Mitral regurgitation systolic, soft, low-pitched decrescendo with or without thrill radiating to the axilla and best heard at the apex of the heart.

20-year-old college student presents to the clinic complaining of a low-grade fever and right-sided ear pain that started three days ago. She also notes a persistent nonproductive cough and fatigue that she has had for about a month. The patient attributes the lingering cough and fatigue to a previous cold-like illness. On exam, her right tympanic membrane is slightly erythematous but not bulging, and slight crackles are noted diffusely to bilateral lung fields. A Gram stain is obtained with no organisms noted. Chest X-ray is significant for bilateral diffuse patchy infiltrates. Which of the following is the most likely diagnosis? Aspiration pneumonia Legionella pneumophila pneumonia Mycoplasma pneumoniae pneumonia Streptococcus pneumoniae pneumonia

Mycoplasma pneumoniae pneumonia MCC of atypical pneumonia (slow onset, young and healthy patients)

A 38-year-old woman with an allergy to sulfa drugs presents to the clinic complaining of a burning pain when she urinates for the last two days. She also reports symptoms of lower abdominal pain and an increase in urinary frequency. She denies any similar symptoms in the past. A urine sample is obtained in the office. The urine dipstick is positive for leukocytes and nitrites. A urine pregnancy test is negative. Which of the following is the best treatment for this patient's diagnosis? Amoxicillin oral Ampicillin intravenous Nitrofurantoin oral Trimethoprim-sulfamethoxazole oral

Nitrofurantoin oral UTI oral amoxicillin if pregnant

61-year-old woman presents to the urgent care clinic complaining of nonbloody diarrhea and vomiting for the past four days. Vital signs are radial pulse 110 beats per minute and weak, blood pressure 90/50 mm Hg, respirations 20 per minute, and temperature 100.7°F. Physical exam reveals decreased skin turgor, dry lips, and dry oral mucosa. Which of the following represents the appropriate initial treatment for this patient? Ciprofloxacin 500 mg bid for 5 days and oral rehydration salts Loperamide 2 mg after each loose stool and clear liquid diet Normal saline 30 mL/kg intravenous in the first 30 minutes and hospitalization Ondansetron 4 mg intramuscular and oral rehydration salts

Normal saline 30 mL/kg intravenous in the first 30 minutes and hospitalization severe dehydration

74-year-old man with a 35 pack-year smoking history presents to a primary care provider with shortness of breath, nonpleuritic right-sided chest pain, fatigue, generalized weakness, and a 12-pound weight loss over the past three months. He denies any sick contacts, travel, or changes in daily activities. He typically spends most of his time volunteering at Habitat for Humanity since he is a retired construction worker but has been unable to volunteer in the past month because of his worsening symptoms. His father and two older brothers passed away from complications due to lung cancer. His chest radiograph is shown above. Pleural fluid to serum protein ratio is 0.7, and pleural fluid to serum lactate dehydrogenase ratio is 0.66. A red blood cell count of the pleural fluid reveals 230,000 cells/µL. Cytology of the pleural fluid is unremarkable. A video-assisted thoracoscopic surgery is performed to obtain a biopsy of the pleural lining. Histology of the specimen confirms the diagnosis. Which of the following is an independent risk factor for the patient's condition? Elderly age Family history Occupation Smoking history

Occupation mesothelioma caused by asbestos (smoking does not cause mesothelioma in the absence of asbestos exposure)

44-year-old obese woman presents to the clinic to discuss the results of her recent upper endoscopy. Several confluent, erosive, and exudative lesions were noted in the distal esophagus. Biopsies of the inflamed tissue were negative for dysplasia and Helicobacter pylori. Which of the following initial treatment options is best for this patient? Amoxicillin 1 g bid, omeprazole 40 mg bid, and clarithromycin 500 mg bid for 14 days Famotidine 20 mg bid for 6 months Omeprazole 40 mg daily for 8 weeks Sucralfate 1 g qid and calcium carbonate 8 g daily for 4 weeks

Omeprazole 40 mg daily for 8 weeks esophagitis due to reflux treated with PPI

63-year-old woman presents to the emergency department for an initial presentation of a moderately severe temporal headache, scalp tenderness, and pain with chewing for six days. She has no change to her vision. She has a history of polymyalgia rheumatica with specific symptoms of neck and shoulder stiffness. Lab results indicate an elevated erythrocyte sedimentation rate and C-reactive protein. Imaging studies are pending. Which of the following is the first priority in caring for this patient, even before the diagnosis is confirmed? Arterial biopsy Hospital admission Immediate ophthalmology referral Oral corticosteroid treatment

Oral corticosteroid treatment temporal arteritis - often occurs with polymyalgia rheumatica

45-year-old man presents with increasing glove and shoe sizes. A physical exam reveals macrognathia, doughy hands, and macroglossia. Laboratory studies demonstrate an equivocal serum level of insulin-like growth factor 1. Which of the following is the next step in diagnosis? MRI of the brain Oral glucose suppression test Random serum growth hormone measurement Serum insulin-like growth factor 1 binding protein 3 measurement

Oral glucose suppression test acromegaly acromegaly have values that are greater than 2 ng/mL post-glucose ingestion, which indicates inadequate suppression of the growth hormone

45-year-old man presents to his primary care provider with a sudden onset of left-sided facial weakness and severe left ear pain. He reports that he woke up this morning and was unable to close his left eye. In addition to his ear pain, he reports increased sensitivity to sound on the left side. On physical examination, the patient is unable to close his left eye, raise his left eyebrow, or smile on the left side. He has a history of diabetes mellitus and recurrent fever blisters. His left external ear canal is normal. Which of the following interventions is most likely to increase the patient's chance of a full recovery? Lubricant eye drops Oral prednisone Physical therapy Valacyclovir

Oral prednisone bell palsy - caused by HSV (recurrent fever blisters) (Ramsay hunt syndrome = vesicles on external ear)

32-year-old pregnant woman presents to the clinic complaining of acute onset myalgias, cough, and fever. She states she woke up this morning feeling okay and then all of a sudden felt as if she were "hit by a truck." She notes her coworker was just diagnosed with the flu a couple of days ago. Her vitals today are as follows: weight 158 pounds, body mass index 27 kg/m2, temperature 102°F, O2 98% on room air, and blood pressure 120/86 mm Hg. What is the most appropriate treatment for this patient? Azithromycin Baloxavir Oseltamivir Penicillin

Oseltamivir tx for flu A and B in pregnancy

53-year-old woman presents to a primary care provider for right knee pain. She reports a gradual onset over the last four months and describes the pain as dull and achy. She reports joint stiffness in her right knee that typically occurs every morning, but it does not last more than 15 minutes. It is aggravated by activity and alleviated with rest and acetaminophen. She denies any acute or previous injury to her right knee. She also reports joint stiffness in her fingers. She has otherwise been healthy. Physical examination of the right knee reveals decreased flexion and extension, crepitus, and mild swelling. No erythema, warmth, or ecchymosis is present. Bony enlargements over the carpometacarpal joint of the thumb and the distal interphalangeal joints of the remaining digits are present bilaterally. Her right knee radiograph is shown above. What is the most likely diagnosis? Osteoarthritis Pseudogout Reactive arthritis Rheumatoid arthritis

Osteoarthritis lasting <15 minutes, relieved with rest

58-year-old man presents to a primary care provider with increasing right leg pain for the past four months. He reports that the pain is deep and achy and worse at night. The pain initially seemed to be localized to his upper thigh but is now also affecting his leg just above the knee. He also reports that his teeth have become more misaligned over the past few months and is wondering if that may be associated with the intermittent headaches he started having four months ago. He denies any falls, trauma, or changes in his daily activity. On physical examination, dilated scalp veins are present. Range of motion, strength, and stability of the lower extremities are within normal limits. A radiograph of the right femur is shown above. What is the most likely diagnosis? Osteoarthritis Osteochondritis dissecans Osteoid osteoma Paget disease

Paget disease deep and aching pain that is worse at night proximal portion of long bones initially and advances distally Dilated scalp veins "candle flame" or "blade of grass" sign in the long bones

66-year-old woman presents with a sensation of pulsation in her neck and abdomen. The patient reports that she has also had progressively worsening dyspnea on exertion and peripheral edema that began two months ago. She had a pacemaker placement nine months ago for a chronic bifascicular block. Physical exam is significant for distended, pulsatile neck veins, hepatomegaly, and 1+ generalized pitting edema. Palpation of the liver results in increased distension of the neck veins. Which of the following findings on physical exam would most likely correlate with the patient's condition? Harsh midsystolic crescendo-decrescendo murmur radiating to the left shoulder Loud midsystolic murmur best heard with the patient sitting and leaning forward Pansystolic murmur that becomes louder with inspiration Pansystolic murmur with prolonged apical impulse

Pansystolic murmur that becomes louder with inspiration tricuspid regurg eventually leading to right sided heart failure (Pacemaker lead placement is an increasingly common iatrogenic cause)

65-year-old man with a past medical history of non-small cell lung cancer who was treated with radiation therapy and chemotherapy presents to the emergency department with a three-day history of shortness of breath, fatigue, and swelling in his legs. Physical exam reveals hypotension, elevated jugular venous distension, and 2+ pitting edema bilaterally. Echocardiogram reveals a thickened pericardium. Which of the following physical exam findings would you expect to find, given the suspected diagnosis? Displaced point of maximal impulse Muffled heart sounds Pericardial knock S3 gallop

Pericardial knock constrictive pericarditis *thickened pericardium* on echo elevated regular venous distention, hepatojugular reflux, and a pericardial knock dyspnea, fatigue, and signs of right-sided heart failure B - seen in cardiac tamponade (EKG will show presence of an *effusion and evidence of diastolic collapse of heart chambers*)

44-year-old woman presents with complaints of gradually worsening dyspnea on exertion, fatigue, and dry cough over the course of several months. Her vital signs are within normal limits. A chest radiograph is obtained that shows symmetric, bilateral hilar adenopathy. Which of the following would be the most likely finding on physical exam? Digital clubbing Erythema nodosum Peripheral lymphadenopathy Rales

Peripheral lymphadenopathy sarcoidosis

48-year-old woman presents to the clinic with insidious onset of fever, fatigue, decreased appetite, and generalized weakness and pain in the extremities developing over weeks to months. Skin findings include ulcerations and subcutaneous nodules on both lower legs. An arterial medium-vessel biopsy shows necrotizing arteritis. Which of the following is the most likely diagnosis? Cryoglobulinemic vasculitis Eosinophilic granulomatosis Microscopic polyangiitis Polyarteritis nodosa

Polyarteritis nodosa

55-year-old woman presents to the internal medicine clinic for a follow-up visit. She reports diffuse soreness and sharp pain of both upper and lower extremities and inability to sleep. In the morning, she is significantly fatigued and experiences stiffness in her legs, arms, and shoulders. She denies any trauma. She has tried ibuprofen, but it did not help. She denies any chronic medications. Previously evaluated bloodwork is within normal limits. Physical examination reveals mild to moderate tenderness of multiple muscles and joints. Her vitals on today's visit are within normal limits. Which of the following is the most appropriate initial clinical intervention for this patient, given the most likely diagnosis? Begin NSAID therapy Initiate a tricyclic antidepressant regimen Prescribe low-impact aerobic exercise Refer to pain management

Prescribe low-impact aerobic exercise fibromyalgia tx

42-year-old woman presents with neck pain and tenderness, palpitations, and anxiety. She states that the symptoms have been present for the past two weeks. A review of systems is insignificant except for a viral upper respiratory infection a few weeks ago that resolved. Physical exam reveals a mildly diffusely tender, symmetrically enlarged thyroid gland. Which of the following would be the best next step in managing this patient's care? Begin levothyroxine Order a radioiodine imaging study Prescribe naproxen Refer for fine-needle aspiration biopsy

Prescribe naproxen subacute thyroiditis - following viral infection tx = supportive measures (NSAIDS/oral steroids) - to dec neck pain, propranolol for hyper sx

44-year-old woman presents to the emergency department with chest pain, nausea, and diaphoresis. She reports multiple episodes of early morning chest pain for the past three weeks. She has a 20 pack-year smoking history and reports cocaine use in the last month. The initial ECG obtained shows ST elevations in the inferior leads. Serial troponins and CK-MB are negative. No stenotic lesions are seen on coronary angiography. Which of the following medications would be *inappropriate* in the management of the suspected diagnosis? Amlodipine Isosorbide dinitrate Lisinopril Propranolol

Propranolol prinzmetal angina - worsen coronary vasospasm

32-year-old man presents to the hospital with a recent history of new-onset dizziness. While interviewing the patient, he suddenly falls to the floor and starts to convulse with his eyes tightly shut. His convulsions last for about two minutes. Which of the following most likely occurred? Clonic seizure Complex partial seizure Psychogenic seizure Tonic-clonic seizure

Psychogenic seizure no apparent tonic phase and his eyes remained tightly shut *read explanation*

7-year-old boy is brought into the clinic for a cough. His mother states that she has noticed the cough has gotten more frequent over the past few months and is worse at night. The cough is dry. She has also noticed occasional wheezing and coughing when he has participated in baseball practice. He denies fever, rhinorrhea, headache, chest pain, or shortness of breath but does state that occasionally after practicing sports, his chest feels "tight." Which of the following is the most appropriate diagnostic test to order? Chest radiograph Complete blood count IgE antibody tests Pulmonary function studies

Pulmonary function studies Asthma

45-year-old woman with a past medical history of diabetes mellitus presents to the emergency department with one week of cough and dyspnea. She is from Mississippi and works on a farm. She denies any history of smoking cigarettes. Chest X-ray shows a unilateral infiltrate with mediastinal adenopathy. An angiotensin-converting enzyme level is checked and is normal. Which of the following is the most likely diagnosis? Lung cancer Pulmonary coccidioidomycosis Pulmonary histoplasmosis Sarcoidosis

Pulmonary histoplasmosis from soil contaminated with bird and bat droppings endemic in Mississippi and Ohio river valleys

32-year-old woman presents to her primary care provider with a chronic, productive cough. Her medical history includes rheumatoid arthritis, for which she is treated with prednisone. She is a physician assistant in the emergency department in a nearby large city. The cough has been present for 4 weeks, and she also notes some shortness of breath and a 10 lb weight loss. She was initially treated with a course of azithromycin, but she states it did not resolve any of her symptoms. Chest X-ray reveals middle lobe consolidation and pleural effusion. Which medication is included in the treatment regimen for the suspected condition? Pantothenic acid Phenazopyridine Polymyxin Pyrazinamide

Pyrazinamide Active Tuberculosis tx: *rifampin, isoniazid, pyrazinamide, and ethambutol*

36-year-old diabetic health care worker is being treated for latent tuberculosis after a positive tuberculin skin test and a negative chest radiograph. The health care provider prescribes isoniazid daily for nine months. Which of the following medications should be prescribed in addition to this medication? Pyrazinamide Pyridoxine Rifampin Rifapentine

Pyridoxine (vit B6 supplementation) Isoniazid can cause peripheral neuropathy due to the interference with pyridoxine metabolism

14-year-old girl presents to her primary care provider for an annual sports physical. Her past medical history is unremarkable. On physical exam, a left-sided rib hump is present on the Adam forward bend test. Examination of the chest wall reveals pectus excavatum. A midsystolic click is heard on cardiac auscultation. A Cobb angle of 15° is calculated from spine radiography. Her ECG rhythm strip is shown above. A transthoracic echocardiogram reveals a left ventricular ejection fraction of 70%, bowing of the mitral leaflets into the left atrium during systole, and trace to mild tricuspid regurgitation. Which of the following is the most appropriate next step in management? Reassurance and clearance for sports participation Referral to a cardiologist for further evaluation Repeat echocardiography annually for three years Surgical consult for valve repair

Reassurance and clearance for sports participation (I guess because she's asymptomatic and no audible murmur?? don't need further evaluation??) *dumb question*

25-year-old man develops acute hemolytic anemia and hemoglobinuria after being treated with primaquine as a prophylaxis for malaria. On exam, he is noted to have generalized jaundice, dark urine, and pallor. Heinz bodies are seen on a peripheral blood smear. He is of African descent. Which of the following is the most likely cause of his symptoms? Absence of decay-accelerating factor Antibody-mediated destruction of red cells Defective red cell membrane-tethering proteins Reduction in glutathione levels in red cells

Reduction in glutathione levels in red cells G6PD deficiency Heinz bodies and bite cells *read explanation*

69-year-old woman with a 30 pack-year history and recent travel overseas presents to the emergency department with chest pain, shortness of breath, and cough. There is concern for pulmonary embolism, and she has a computed tomography scan of the chest completed that shows a 9 mm nodule in the left lower lobe. The rest of the scan is unremarkable, and she is diagnosed with bronchitis. Which of the following is the best management of this lesion? Order a follow-up CT scan in three months Order positron emission tomography scan Refer the patient for biopsy Send sputum for cytology

Refer the patient for biopsy for nodules found *>8mm*, with risk factors that increase chance of malignancy (*smoking*)

65-year-old woman with a history of hypertension is four days post-total knee replacement. She reports a red, swollen leg that started last night. Today, she is experiencing shortness of breath and pleuritic chest pain. Her electrocardiogram is shown above. What dysrhythmia is consistent with the patient's underlying condition? Left anterior fascicular block Left bundle branch block Left posterior fascicular block Right bundle branch block

Right bundle branch block may be caused by PE ECG: wide QRS complex (> 120 ms), QRS complex with sR′ or rsR′ in V1 and V2, and S waves that are slurred in V6 and I.

66-year-old man presents to your clinic for a preventive exam. Screening fasting blood work shows a blood sugar of 116 mg/dL and LDL-C of 191 mg/dL. What is the most appropriate medical treatment for primary prevention of atherosclerotic cardiovascular disease for this patient, using the 2018 ACC/AHA guidelines on blood cholesterol management? Atorvastatin 20 mg Lovastatin 20 mg Pravastatin 80 mg Rosuvastatin 20 mg

Rosuvastatin 20 mg LDL-C >190 need maximum high intensity statin (*atorvastatin 40-80 mg or rosuvastatin 20-40 mg*)

38-year-old woman who is eight weeks postpartum presents to the office for a follow-up of an internal hemorrhoid that she has had for the past two months. She was seen about six weeks ago for the same problem and was told to increase her fiber and fluid intake. However, she continues to see bright red blood after passing stools and feels pressure to the anus that lasts for about one hour after every bowel movement. A physical exam reveals a pink, nontender lump extruding from the anus that is easily reducible with gentle pressure. She would like to explore other treatment options since she finds these symptoms very bothersome. Which of the following is the best next step in treatment for this patient? Hemorrhoidectomy Infrared photocoagulation Rubber band ligation Sclerotherapy

Rubber band ligation

60-year-old man with a history of coronary artery disease presents to his primary care provider for increasing fatigue and shortness of breath. He also reports a productive cough and trouble sleeping in his bed to the point he has switched to a recliner chair. Physical exam reveals 2+ pitting edema bilaterally, elevated jugular venous distention, bibasilar rales, and laterally displaced point of maximal impulse. What other physical exam finding is most commonly associated with the suspected diagnosis? Fixed split S2 Pericardial friction rub S3 gallop S4 gallop

S3 gallop systolic heart failure A - atrial septal defect B - pericarditis D - diastolic heart failure

65-year-old woman with a history of COPD presents to your clinic with multiple presyncopal events over the past three months. You obtain ECG and initiate treatment with metoprolol. The pathophysiology of the disease that is causing the symptoms in your patient is a single excitable electrical focus in the left or right atrium. Which of the following most accurately describes the ECG findings in this dysrhythmia? Delta waves Irregularly irregular R-R intervals Multiple P wave morphologies Sawtooth pattern waves

Sawtooth pattern waves atrial flutter = single excitable electrical focus in the left or right atrium A - prolonged upsloping of the QRS complex, result of an accessory pathway (Wolff-Parkinson-White syndrome) B - multiple electrical foci that depolarize in a random pattern (atrial fibrillation) C - multiple electrical foci in the atrium that depolarize randomly (multifocal atrial tachycardia)

35-year-old woman presents to a primary care provider with fatigue, arthralgias, and myalgias. Physical examination is significant for a malar rash. Laboratory testing reveals an antinuclear antibody titer of 1:640 and the presence of anti-Smith and anti-double-stranded DNA antibodies. The provider discusses the diagnosis and treatment plan with the patient and educates her on belimumab and hydroxychloroquine. Which of the following statements should be communicated to the patient? Avoid live vaccines three months prior to beginning treatment Discontinue hydroxychloroquine if pregnant Schedule an ophthalmologic examination within one year Short-term high-dose IV corticosteroids should be avoided

Schedule an ophthalmologic examination within one year Systemic lupus erythematosus (SLE) Hydroxychloroquine can cause *retinal toxicity* > need ophthalmologic exam

85-year-old man presents to the emergency department with new-onset fever and cough for one day. He lives in an assisted living facility and has a history of hypertension and COPD. His vitals are 88/42 mm Hg, pulse 122 bpm, temperature 101.5°F, respiration 22/min, and oxygen saturation 97% on room air. Lab work reveals a white blood cell count of 16,000 cells/HPF, creatinine of 1.9 mg/dL, and serum lactate of 6.5 mmol/L. While in the ER, he was given 2 L of 0.9% normal saline. A repeat blood pressure is 85/40 mm Hg. What is the most likely diagnosis? Sepsis Septic shock Severe sepsis Systemic inflammatory response

Septic shock *sepsis criteria*: suspected infection and acute organ dysfunction based on the Sequential Organ Failure Assessment (SOFA) scoring system *Septic shock*: + sepsis criteria AND lactate level > 2.0 despite adequate fluid restriction and vasopressor support to keep the MAP ≥ 65 mm Hg. (*Sepsis + refractory hypotension*)

26-year-old woman presents to the emergency department with a chief complaint of hematemesis. Emesis is described as bright red blood. She had two episodes prior to presenting to the hospital. She reports no known history of stomach ulcer. She denies abdominal pain. Vital signs indicate a blood pressure of 102/76 mm Hg and heart rate of 52 bpm. Her body mass index is 16.6 kg/m2. Physical examination reveals lanugo, calluses on the dorsum of the right hand, and a small left subconjunctival hemorrhage. An endoscopy is performed that demonstrates a longitudinal tear in her esophagus with minimal active bleeding. Which of the following would you expect to learn from her history, given her history and likely underlying medical condition? She has a history of alcohol use disorder She has a history of chronic NSAID use She has a history of rumination syndrome She has a history of self-induced vomiting

She has a history of self-induced vomiting Mallory-weiss syndrome

24-year-old man with Crohn disease presents to the clinic with abdominal pain and is found to have three strictures within a short segment of the proximal small bowel on endoscopic evaluation. The patient has not undergone any previous surgical interventions. Which of the following is the appropriate clinical intervention for this patient? Balloon dilatation Small bowel resection with anastomosis Small bowel resection with stoma Strictureplasty

Small bowel resection with anastomosis definitive treatment D - diffuse or recurrent strictures or for patients who have lost much small bowel length due to previous resections

nonsymptomatic, overweight, 68-year-old smoker with a history of diabetes, hypertension, and hyperlipidemia undergoes a screening ultrasound for an abdominal aortic aneurysm. Screening reveals an abdominal aortic aneurysm with a diameter of 3 cm. Which recommendation would result in the greatest immediate reduction of risk for this patient? Adding an angiotensin-converting enzyme inhibitor Initiating a diet and exercise routine Initiating statin therapy Smoking cessation

Smoking cessation tobacco use poses the greatest risk

19-year-old football player presents to his primary care provider with fatigue, sore throat, and myalgia for five days. He reports that he missed several morning practices this past week because he overslept, even though he has been going to bed around 6:00 PM. He states that he has been under a lot of stress lately because his father passed away from lymphoma last month. His vital signs are T 101°F, BP 122/70 mm Hg, HR 64 bpm, RR 16 breaths per minute, and pulse oximetry 100% on room air. Physical examination is significant for posterior cervical lymphadenopathy. There is no hepatosplenomegaly. Rapid strep and mononuclear spot tests are negative. His WBC count is 14,600/mcL. Lymphocytosis with 22% atypical lymphocytes is seen on manual differential. Further testing reveals a positive Epstein-Barr virus viral capsid antigen antibody. What is the most appropriate intervention at this time? Bone marrow biopsy for lymphoma No intervention is needed Sports restriction for four weeks Trial of acyclovir

Sports restriction for four weeks infectious mononucleosis risk of spleenic rupture

38-year-old woman has been diagnosed with papillary thyroid cancer. The tumor is 2.3 cm in diameter with metastasis to regional lymph nodes and no distant metastasis. Which of the following best describes the stage of this cancer? Stage I Stage II Stage III Stage IV

Stage I (<45yo, tumor of any size, without distant metastasis) *read explanation*

45-year-old man who is a strict vegan presents with fatigue and exertional dyspnea. Physical exam reveals pallor and glossitis. Laboratory studies demonstrate a mean corpuscular volume of 110fL/red cell, elevated homocysteine, and elevated methylmalonic acid. Which of the following additional physical findings is most likely to be present in this patient? Jaundice Koilonychia Pica Stocking-glove paresthesia

Stocking-glove paresthesia Vitamin B12 deficiency

65-year-old retired man presents with fatigue, dyspnea on exertion, and a chronic cough for the past two months. He reports a subjective fever for the past three days. He has no history of smoking or tobacco use. Which of the following occupations is most consistent with the patient's radiograph shown above? Coal mining Glass manufacturing Shipbuilding Stonecutting

Stonecutting pneumoconiosis - silicosis XRAY: calcifications of the peripheral hilar lymph nodes (eggshell calcifications) (shipbuilding = asbestosis > honeycombing, linear treating at bases)

61-year-old man who does not have housing presents to an urgent care with reports of facial and lower extremity swelling. He states his face and eyes appear puffy in the morning and his feet and ankles seem swollen in the evening. He also reports he has been urinating less frequently and his urine is darker than normal. He had a sore throat and abdominal pain 2 weeks ago that resolved on its own. He was diagnosed with hepatitis 6 months ago. He cannot recall his childhood medical history. His blood pressure is 148/98 mm Hg. A urinalysis is obtained and reveals a cola-colored specimen with 11 RBCs/high-powered field and 3+ protein. Serum complement C3 is significantly low. Anti-DNase B antibodies are positive. Which of the following conditions in the patient's past medical history would be most consistent with the suspected diagnosis? Focal segmental glomerulosclerosis Hepatitis A infection Minimal change disease Streptococcal infection

Streptococcal infection Poststreptococcal glomerulonephritis - hematuria, htn, periorbital edema

61-year-old woman presents to the office with worsening flu-like symptoms for five weeks. She reports low-grade fever most days, general malaise, and night sweats. On physical exam, you notice painless erythematous macules on the palms and soles, as well as tender nodules on the pads of the fingers. Laboratory results reveal leukocytosis and anemia, blood cultures show gram-positive cocci, and the blood agar shows a green discoloration. What is the most common pathogen responsible for this patient's symptoms? Enterococcus Staphylococcus aureus Streptococcus pyogenes Streptococcus viridans

Streptococcus viridans bacterial endocarditis

Which of the following statements is true regarding emphysema? Associated with mucopurulent sputum and chronic cough Characterized by submucosal and peribronchiolar fibrosis Structural changes occur distal to the terminal bronchioles There is airflow obstruction that is reversible with treatment

Structural changes occur distal to the terminal bronchioles

23-year-old man with no significant past medical history presents to the clinic with an acute cough for 10 days. He states that he initially had rhinorrhea and a sore throat, but these symptoms have improved. Vital signs are normal and lungs are clear to auscultation. Which of the following is the best treatment? Amoxicillin Azithromycin Prednisone Supportive Care

Supportive care acute bronchitis due to respiratory virus

45-year-old Caucasian man presents to the office for a routine checkup and is found to have elevated serum iron levels. He complains of some fatigue but has no other symptoms. A physical exam is negative. A transferrin saturation level is ordered, which is elevated at 17 ng/mL, and a genetic test shows the presence of a mutation in the HFE gene. Which of the following is the best initial treatment of choice for this patient? Dietary changes to avoid organ meats and alcoholic beverages Iron chelation Therapeutic erythrocytapheresis Therapeutic phlebotomy

Therapeutic phlebotomy hereditary hemochromatosis - mutation in HFE protein = iron overload state 1st line - phlebotomy 2nd - Iron chelation (when phlebotomy is CI (anemia or heart failure))

53-year-old man with a past medical history of hypertension and insulin-dependent type 2 diabetes presents to his primary care clinic with 12 hours of increasing weakness, fatigue, and shortness of breath. Vitals show a heart rate of 34 bpm, blood pressure of 89/43 mm Hg, respiratory rate of 20 breaths per minute, O2 saturation of 95% on room air, and temperature of 97.5°F. Physical exam shows a pale, diaphoretic, and lethargic man with cool skin. An ECG is obtained and shows the above rhythm. What is the most likely diagnosis? First-degree atrioventricular block Second-degree type 1 atrioventricular block Second-degree type 2 atrioventricular block Third-degree atrioventricular block

Third-degree atrioventricular block *read explanation*

50-year-old man presents with fatigue and weakness. On exam, he is noted to be febrile and to have paresis of the upper limbs. CBC is remarkable for a hematocrit of 18%, a hemoglobin level of 6 g/dL, and a platelet count of 100,000/microL. CMP reveals a creatinine level of 2.7 mg/dL, elevated indirect bilirubin, elevated LDH, and decreased serum haptoglobin. Reduced activity of ADAMTS13 is seen on an enzyme assay. Which of the following is the most likely diagnosis? Evans syndrome Heparin-induced thrombocytopenia Megaloblastic anemia Thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura decreased ADAMTS13 Classic pentad: fever, anemia, thrombocytopenia, kidney insufficiency, and neurological disturbances

28-year-old woman presents to the emergency department with complaints of palpitations and high fever. She had pneumonia one week ago, for which she was treated with antibiotics, and she socially drinks alcohol. Vitals are temperature 101.5°F, pulse 130 beats per minute, blood pressure 130/85 mm Hg, and respirations 20/min. Physical exam reveals an agitated patient, resting tremor, and peripheral edema. ECG reveals atrial fibrillation. What is the most likely diagnosis? Delirium tremens Myxedema coma Sepsis Thyroid storm

Thyroid storm (hyperthyroidism)

71-year-old man presents to the office for a routine exam. He has a history of a minor myocardial infarction without sequelae two years ago and hypertension, and he is obese, with a body mass index of 31 kg/m2. A prior chest X-ray revealed slight cardiomegaly, and an echocardiogram revealed left ventricular hypertrophy. He has had 2 admissions for heart failure exacerbations. At this time he reports feeling well and denies dyspnea, orthopnea, or fatigue. Physical exam reveals an obese man who appears otherwise healthy. Auscultation of the heart and lungs reveals no bibasilar crackles, pleural effusions, or tachycardia. There is no jugular venous distension or pitting edema. Palpation of the abdomen is grossly normal. What is the recommended maximum sodium intake per day for this patient? 2.0 g per day 2.5 g per day 3 g per day 4.5 g per day

2.0 g per day

Which of the following patients meets the diagnostic criteria of diabetes mellitus, according to the American Diabetes Association? A patient with a fasting glucose level of 100 mg/dL and an A1C value of 5.5% A patient with polyuria, excessive thirst, and a random glucose level of 240 mg/dL An asymptomatic patient with a fasting glucose level of 136 mg/dL (day 1) and 110 mg/dL (day 2) An asymptomatic patient with a random glucose level of 220 mg/dL

A patient with polyuria, excessive thirst, and a random glucose level of 240 mg/dL *sx + random >200* fasting >126 >200 2 hrs post 75g glucose load A1C >6.5%

47-year-old woman presents to the emergency department with intense right upper abdominal pain beginning several hours ago. She reports she has experienced similar pain in the past but not as severe. Pain radiates to her shoulder. She notes associated nausea with one episode of nonbloody, nonbilious emesis. On physical examination, she has a fever of 101.1°F, tenderness to palpation in the right upper quadrant, and a positive Murphy sign. Complete blood count reveals leukocytosis with normal transaminases and normal alkaline phosphatase. Abdominal imaging is pending. What is the most likely diagnosis? Acute cholangitis Acute cholecystitis Acute pancreatitis Acute viral hepatitis

Acute cholecystitis due to gallstones (cholangitis presents with Charcot triad: *fever, abdominal pain and jaundice*)

35-year-old man of Southeast Asian descent presents with severe fatigue and shortness of breath. On exam, he is tachycardic and tachypneic. Laboratory studies reveal a hematocrit level of 22% and increased red blood cell count. Target cells and poikilocytes are seen on a peripheral blood smear. Electrophoresis demonstrates the presence of hemoglobin H. Which of the following is the most likely diagnosis? Alpha-thalassemia H Alpha-thalassemia minor Beta-thalassemia major Beta-thalassemia minor

Alpha-thalassemia H *read explanation*

32-year-old woman is being evaluated for infertility. She also complains of headaches and vision disturbance. On exam, she is noted to have bitemporal hemianopsia. Laboratory studies reveal a serum prolactin level of 210 ng/mL. Which of the following history findings would most likely be present? Amenorrhea Dysmenorrhea Increased libido Regular menses

Amenorrhea pituitary adenoma

68-year-old man presents to the clinic complaining of worsening chest pain and difficulty breathing. He reports first noticing occasional, brief chest pain and infrequent shortness of breath eight months ago. Physical exam reveals a harsh, crescendo-decrescendo systolic ejection murmur heard over the aorta that radiates into the carotid arteries. He also has a delayed carotid upstroke. Which of the following is the most likely diagnosis based on this patient's history and physical exam findings? Aortic regurgitation Aortic stenosis Mitral stenosis Mitral valve prolapse

Aortic stenosis *harsh, crescendo-decrescendo systolic ejection murmur heard over the aorta that radiates into the carotid arteries*

65-year-old man with a history of diabetes mellitus type 2 and heart failure presents with substernal chest pain, nausea, and diaphoresis. On exam, he is mildly tachycardic and hypertensive. His rhythm strip shows ST depression in leads II, III, and aVF. Laboratory studies demonstrate an elevation in the level of serum troponin. Which of the following medications should he be started on today? Alteplase Atorvastatin Metoprolol Verapamil

Atorvastatin high dose statins improve outcomes and delay death or major cardio events in patients with NSTEMI *read explanation*

patient presents to the emergency department for dizziness and shortness of breath. The above electrocardiogram is obtained. His vitals are 88/40 mm Hg, pulse 45 bpm, respirations 16 per minute, and oxygen saturation 98%. Which of the following clinical interventions is indicated first? Atropine Defibrillation Observation Permanent pacemaker

Atropine 2nd degree Mobitz type II AV block

42-year-old woman presents with vague complaints of fatigue and unexplained weight gain for the last several months. A thyroid-stimulating hormone assay is elevated, and free T4 is low. Which of the following physical exam findings would be most consistent with the diagnosis? Brittle fingernails Ophthalmopathy Pitting edema Skin hyperpigmentation

Brittle fingernails hypothyroidism

26-year-old man with a past medical history of cystic fibrosis presents to the clinic complaining of a chronic cough with purulent, foul-smelling sputum. The patient has crackles noted to bilateral bases of lungs. A CT scan is significant for abnormal dilation of bronchial walls. Which of the following is the most likely diagnosis? Asthma Bronchiectasis Chronic bronchitis Emphysema

Bronchiectasis

32-year-old woman presents to a primary care provider with complaints of back pain, hematuria, and headaches. She started keeping a blood pressure log 2 weeks ago after a high reading at a recent health fair and reports that her systolic blood pressure has been between 140-150 mm Hg. Physical examination reveals the presence of large, palpable kidneys bilaterally. The patient recalls that her 53-year-old mother and 34-year-old sister have a history of autosomal dominant polycystic kidney disease. Her estimated glomerular filtration rate is 75 ml/min/1.73 m2. What is the diagnostic study indicated at this time? CT scan Excretory infusion urography KUB radiograph Ultrasound

CT scan *better choice for patients with typical sxs and positive family history of PCKD* (US is initial test in asx with normal kidney function with positive family history to rule out disease)

62-year-old hospitalized man develops a fever and purulent sputum on day five of his admission. His oxygen desaturates to the point that he requires ventilatory support. On chest X-ray, a new infiltrate is seen. Which of the following is the best empiric antibiotic regimen? Cefepime, levofloxacin, and vancomycin Ceftriaxone and azithromycin Piperacillin-tazobactam and linezolid Piperacillin-tazobactam, amoxicillin, and vancomycin

Cefepime, levofloxacin, and vancomycin Hospital-acquired pneumonia gram-negative coverage, including Pseudomonas aeruginosa (cefepime), and gram-positive coverage, including methicillin-resistant Staphylococcus aureus (Vanco) *1) piperacillin-tazobactam, cefepime, ceftazidime, meropenem, or imipenem, plus 2) ciprofloxacin, levofloxacin, or aztreonam, plus 3) vancomycin or linezolid.*

37-year-old man presents to his primary care provider for recurrent episodes of chest pain. He reports that the pain is midsternal and feels like an elephant is sitting on his chest. He started powerlifting four years ago and would periodically experience chest pain for a few minutes during his workouts. However, his chest pain now occurs more frequently, occasionally comes on at rest, and seems to last longer. He has a history of hypertension and hyperlipidemia. His current medication list includes sublingual nitroglycerin, aspirin, atorvastatin, and amlodipine. Which of the following in the patient's history would be most indicative of unstable angina? Angina relieved after two doses of sublingual nitroglycerin Angina responsive to amlodipine Chest pain lasting for more than 10 minutes Painful midsternal spasms at rest with preservation of exercise capacity

Chest pain lasting for more than 10 minutes D - characteristic of prinzmetal angina

45-year-old man with progressive dyspnea is given a survival prediction of less than 10 years. His computed tomography scan is significant for diffuse reticular opacities. Considering the advanced stage of his current disease, what other findings would you expect on his physical exam? Bilateral lungs clear to auscultation Clubbing of his fingertips Decreased FEV1/FVC Pursed lip breathing

Clubbing of his fingertips idiopathic pulmonary fibrosis - *diffuse reticular opacities, also known as "honeycombing," and ground-glass opacities*

55-year-old man presents with abdominal discomfort and pain for the last year. He had previously been taking naproxen 500 mg twice daily for arthritic pain in his knees but stopped after the epigastric pain started becoming intolerable. His esophagogastroduodenoscopy report details a shallow ulcer in the antrum of the stomach. He is prescribed 40 mg of omeprazole once daily. Helicobacter pylori testing is negative at this time. Which of the following represents the most appropriate therapy at this time? Add bismuth subsalicylate, metronidazole, and tetracycline and continue omeprazole Add clarithromycin and amoxicillin and continue omeprazole Continue omeprazole 40 mg once daily as monotherapy Replace omeprazole with sucralfate

Continue omeprazole 40 mg once daily as monotherapy peptic ulcer disease that is H. Pylori neg

55-year-old woman presents with worsening dry eyes over the past 6 months. She has tried using artificial tears but her ocular symptoms persist. Physical exam reveals a positive Schirmer test. Anti-La antibodies are found to be present on laboratory studies. Which of the following medications is indicated at this time? Cevimeline taken orally Corticosteroids taken orally Cyclosporine eye drops Pilocarpine taken orally

Cyclosporine eye drops improve ocular symptoms from sjogren syndrome (oral cholinergic agonists for nonocular symptoms - pilocarpine and cevimeline)

You respond to a code blue of a 45-year-old woman in the cardiac intensive care unit. Upon arrival in the room, a defibrillator has already been attached to the patient and a nurse is performing cardiopulmonary resuscitation. The ECG of the patient (EKG shows VFIB) is shown above. Which of the following is the best next step in management? Cardiopulmonary resuscitation Defibrillation Epinephrine intravenous Intubation

Defibrillation *because Vfib is shockable* when shockable rhythm is discovered, shock then return to cpr

55-year-old woman presents to the clinic with acute onset of cough, shortness of breath, and fever. Based on the clinical manifestations and above image, which of the following exam findings would further support the most likely diagnosis? Decreased tactile fremitus Diffuse end-expiratory wheezing Dullness to percussion of the right lower lobe Hyperresonance to percussion of the right lower lobe

Dullness to percussion of the right lower lobe pneumonia

55-year-old man presents to a primary care provider for concerns about erectile dysfunction. He reports that he has had difficulty maintaining an erection for several months. He is currently on medication for depression, anxiety, benign prostatic hyperplasia, and angina. Which of the following medications is the most likely cause of his erectile dysfunction? Duloxetine Nitroglycerin Prazosin Selegiline

Duloxetine antidepressants SE: ED

65-year-old man with a history of rheumatic fever presents with decreased exercise tolerance that has progressively worsened over the years. On exam, a low-pitched diastolic murmur is auscultated. The murmur is best heard at the apex with the patient in the left lateral decubitus position. An opening snap is also present. Which of the following is the most common presenting symptom based on the most likely diagnosis? Chest pain Exertional dyspnea Hemoptysis Hoarseness

Exertional dyspnea MC sx of mitral stenosis

58-year-old cachectic man with a 40 pack-year history of tobacco use presents to the clinic with severe shortness of breath and a cough. He is tachypneic and is using accessory muscles to breathe. A chest X-ray shows flattened diaphragm and an increase in anteroposterior diameter. Which of the following would you expect to find on this patient's pulmonary function test? Decreased expiratory reserve volume Decreased total lung capacity FEV1/FVC less than 70% Increased diffusing capacity of the lungs for carbon monoxide

FEV1/FVC less than 70% emphysema - *obstructive disease* (will also see increase in total lung capacity,an increase in expiratory reserve volume, and a decrease in the diffusing capacity of the lungs for carbon monoxide)

20-year-old man presents to his primary care provider in July with complaints of fever, chills, headache, and muscle aches for four days. The patient recalls removing a tick on his arm several days before his symptoms began and is unsure how long the tick had been there. The patient reports that he has been dog sitting for the past week in North Carolina and noticed that one of the dogs had multiple ticks attached. He brought one of the ticks with him to the office today. Which of the following physical exam findings is most consistent with the suspected diagnosis? Erythematous circular rash with central clearing Facial flushing and abdominal pain Maculopapular rash on the trunk that spreads to the extremities Tic douloureux

Facial flushing and abdominal pain Rocky Mountain spotted fever (rickettsia rickettsii carried by American dog tick) blanching and maculopapular rash that becomes petechial and begins on the wrists and ankles

5-year-old boy presents to the internal medicine clinic with recurrent bruising on his lower extremities. The patient's guardian reports that the child often gets swollen and painful ankles that persist for days to weeks after minor falls. Laboratory evaluation reveals an aPTT of 80 seconds, a PT of 12 seconds, and a platelet count of 180,000/mcL. Deficiency in which of the following accounts for the suspected diagnosis? Factor VIII Factor X Protein C Vitamin K

Factor VIII hemophilia A male normal PT normal Platelets prolonged aPTT

Which of the following is the first step in the pathogenesis of primary pulmonary tuberculosis infection? Creation of the Ranke complex Development of regional lymphadenopathy Formation of a tubercle Formation of the Gohn focus

Formation of a tubercle *read explanation*

25-year-old man presents to the clinic with concerns about pain in both eyes, right knee pain, and burning in his genitalia. He reports he is sexually active and recently was treated with antibiotics for a sexually transmitted infection. On physical exam, you note bilateral conjunctivitis, erythema of the right knee, and tenderness over the joint line of the knee. Genital examination reveals urethral irritation present at the meatus. Vitals are within normal limits. Which allele is implicated in the most likely diagnosis? Human leukocyte antigen B27 Human leukocyte antigen B47 Human leukocyte antigen DR2 Human leukocyte antigen DR3

Human leukocyte antigen B27 reactive arthritis- recent chlamydia trachomas or GI infection, HLA-B27 "cant see, cant pee, cant climb a tree"

64-year-old man is diagnosed with pneumonia and admitted into the hospital. Which of the following findings supports Legionella as the pathogen causing pneumonia? Hypoglycemia Hyponatremia Infiltrate in the upper lobes Pleuritic chest pain

Hyponatremia gi symptoms

62-year-old man presents with a gradual onset of worsening dyspnea on exertion and dry cough over the last few months. A chest radiograph demonstrates increased reticular markings. A high-resolution computed tomography scan is completed and shows scattered ground-glass opacities superimposed on a fine reticular pattern. Pulmonary function studies are ordered and demonstrate a restrictive pattern. Which of the following diagnostic results would be most consistent with the diagnosis? Increased FEV1/FVC ratio Increased forced expiratory volume in one second Increased forced vital capacity Increased residual volume

Increased FEV1/FVC ratio idiopathic pulmonary fibrosis (*Pulmonary function studies will typically show a restrictive pattern with a decreased forced vital capacity (FVC) and a decreased forced expiratory volume in one second (FEV1). These changes are in proportion to the decreased lung volumes secondary to the restrictive disease and, typically, this causes the FEV1/FVC ratio to be within normal limits or slightly increased*) B, C, D - decreased due to fibrotic changes and restrictive pattern

65-year-old man with a history of poorly controlled type 2 diabetes mellitus and hypertension presents to your office for his diabetes visit. Routine laboratory testing reveals elevated serum creatinine and blood urea nitrogen levels, increased from the previous year. Which of the following is the most appropriate diagnostic study to evaluate this patient? Intravenous urogram Kidney computed tomography Kidney ultrasound Kidney, ureter, bladder radiography

Kidney ultrasound best initial dx tool for AKI

Which of the following joints are most commonly affected in patients with pseudogout? First metatarsophalangeal joint Hip Knee Pubic symphysis

Knee

55-year-old woman presents with gradual onset of joint stiffness and swelling that has progressively worsened over the last two years. Joint stiffness often affects the metacarpophalangeal joints and proximal interphalangeal joints of the fingers and is worse in the morning, lasting more than 30 minutes. On exam, a bowstring sign is noted. Anti-cyclic citrullinated peptide antibodies are present in serum. She has never been on any medication for her condition. Which of the following medications slows the progression of the suspected disease and should be initiated at the time of diagnosis? Low-dose corticosteroids Methotrexate Nonsteroidal anti-inflammatory drugs Sulfasalazine

Methotrexate Rheumatoid Arthritis 1st line tx: DMARDS - methotrexate (also supplement with *daily folate*)

35-year-old woman with a history of seizure disorder presents with an acute onset of seizure activity. She recently decreased the dosage of her seizure medications. Her seizures usually last less than 1 minute, but her family brought her in today because the seizure has lasted more than 5 minutes and still persists. On exam, bilateral tonic stiffening followed by rhythmic jerking of the limbs is noted. Which of the following is the most appropriate therapy indicated for this patient? Fosphenytoin Levetiracetam Midazolam Phenobarbital

Midazolam benzos for status epileptics

40-year-old woman presents with widespread pain for four months. She also reports sleep disturbance, headaches, and fatigue. Laboratory studies are within normal limits. Which of the following physical exam findings is most likely to be seen in this patient? Gottron papules Musculoskeletal tenderness Sclerodactyly Tophi

Musculoskeletal tenderness fibromyalgia syndrome

62-year-old woman with a history of hypertension presents to the emergency department for new-onset headache and blurry vision that started one hour ago. Vital signs are BP 220/120 mm Hg, HR 100 bpm, and RR 16 breaths per minute. Physical exam is significant for flame hemorrhages on funduscopy. Lab work reveals anemia, thrombocytopenia, and an acutely elevated serum creatinine. The patient is admitted to the ICU for blood pressure stabilization. Which of the following is the most appropriate pharmacologic therapy? Captopril Clonidine Nicardipine Nifedipine

Nicardipine hypertensive emergency do not lower bp TOO quickly Dihydropyridine calcium channel blockers (e.g., *nicardipine*) and labetalol have been shown to be the most effective at lowering blood pressure in most clinical scenarios

55-year-old woman presents to her primary care clinic with complaints of chronic dry eyes. She has also noticed a dry mouth, bad breath, and swelling on the side of her cheeks. Physical exam is notable for dry mucosal membranes and parotid gland enlargement. Lab work reveals positive rheumatoid factor and positive anti-Ro antibodies. What complication is this woman at risk of developing? Deep vein thrombosis Gastric carcinoma Non-Hodgkin lymphoma Pulmonary hypertension

Non-Hodgkin lymphoma sjogren syndrome

68-year-old man with a past medical history of diabetes mellitus and hypertension presents to the emergency department with acute onset of chest pain. The ECG is shown above. The initial troponin is elevated. Which of the following is the best treatment? Coronary artery bypass graft surgery Fibrinolysis Percutaneous coronary intervention Pharmacologic treatment without further intervention

Percutaneous coronary intervention STEMI

22-year-old man with no past medical history presents to the clinic complaining of sudden-onset shortness of breath and right-sided pleuritic chest pain. He reports his symptoms "came out of nowhere." His vitals are as follows: weight 155 pounds, body mass index 21 kg/m2, O2 90% on room air, and blood pressure 120/86 mm Hg. His lung exam is consistent with decreased breath sounds, decreased tactile fremitus, and hyperresonance to percussion over the right upper lung field. The remainder of the lung exam is normal. Which of the following is the most likely diagnosis for this patient? Asthma Pleural effusion Pneumonia Pneumothorax

Pneumothorax

45-year-old man presents to a primary care provider for intermittent attacks of palpitations, headaches, and episodic diaphoresis for the past three months. His past medical history is significant for multiple endocrine neoplasia type 2A. Previous thyroid studies have been within normal limits. A noncontrast abdominal CT scan reveals the presence of an adrenal mass. A follow-up nonionic contrast CT with a washout protocol is immediately performed. The adrenal mass is found to retain 60% of the contrast after 15 minutes. Which of the following tests is most sensitive for the suspected diagnosis? 24-hour urinary fractionated catacholamines Plasma fractionated catecholamines Plasma fractionated free metanephrines Serum chromogranin A

Plasma fractionated free metanephrines (most sensitive test) pheochromocytoma (associated with MEN2)

70-year-old woman with a known history of congestive heart failure presents to the clinic with pleuritic chest pain. On physical exam, the patient has decreased tactile fremitus, decreased breath sounds, and dullness to percussion to bilateral lower lung bases. A chest X-ray is significant for blunting of costophrenic angles. A thoracentesis is performed and the pleural fluid is sent for further evaluation and chemistry. Which of the following findings would you expect to see in the patient's fluid analysis? Pleural fluid lactate dehydrogenase > two-thirds the upper limit of normal lactate dehydrogenase Pleural fluid lactate dehydrogenase: serum lactate dehydrogenase = 0.5 Pleural fluid lactate dehydrogenase: serum lactate dehydrogenase = 0.7 Pleural fluid protein: serum protein = 0.6

Pleural fluid lactate dehydrogenase: serum lactate dehydrogenase = 0.5 transudate pleural effusion due to CHF *light criteria* *exudative*: pleural fluid protein: serum protein > 0.5, pleural fluid LDH: serum LDH > 0.6, or pleural fluid LDH > two-thirds the upper limit of normal LDH

68-year-old woman presents to urgent care with a rapid onset of symmetrical pain and stiffness of the shoulders, neck, and hip girdle that is worse in the morning and after prolonged inactivity. Because of the stiffness and pain, she is having difficulty with daily activities, such as combing her hair, taking a shower, putting on a coat, and driving. Which of the following is the most likely explanation for these findings? Giant cell arteritis Polymyalgia rheumatica Polymyositis Takayasu arteritis

Polymyalgia rheumatica pain and stiffness around the shoulder, neck, and hip area.

25-year-old man presents to urgent care with general fatigue, slight fever, and pain, warmth, and swelling to his left knee for the past two weeks. He reports an occurrence of gastroenteritis nearly one month before these symptoms presented. On exam of the left knee, there is erythema, swelling, warmth, and extreme tenderness at locations of tendon insertion. Which of the following is the most likely diagnosis? Pseudogout Reactive arthritis Rheumatoid arthritis Septic arthritis

Reactive arthritis asymmetric, following GI or GU symptoms

50-year-old man presents to the clinic for results of his first screening colonoscopy. He takes no medications, has no symptoms, and has a negative family history of colorectal cancer. On colonoscopy, two villous adenomatous polyps of 1 cm each were removed and no other lesions noted. Which of the following is the correct interval between future surveillance colonoscopies for this patient, according to the United States Preventive Task Force? 1 year 10 years 3 years 5 years

3 years A - over 10 to 20 adenomas on initial colonoscopy or familial adenomatous polyposis or Lynch syndrome B - negative initial screening colonoscopy C - *three or more adenomas, with tubular adenomas that are 10 mm or larger, with villous adenomas, or with high-grade dysplasia* D - one or two tubular adenomas under 10 mm discovered on initial screening colonoscopy

78-year-old man presents with progressively worsening dyspnea on exertion over the last year. It is now beginning to interfere with his activities of daily living, which prompted his visit. His history includes hypertension and hyperlipidemia. He is a former smoker who quit approximately 10 years ago after he retired from working as an electrician. Physical exam is unremarkable except for some fine end-inspiratory crackles. A chest radiograph is obtained that shows bilateral parenchymal opacities. A computed tomography scan shows calcified pleural plaques. Which of the following is the most likely diagnosis? Asbestosis Emphysema Sarcoidosis Silicosis

Asbestosis restrictive disease - subpleural linear densities, parenchymal fibrosis, and pleural plaques

42-year-old man presents to a primary care provider with sudden-onset high fever, chills, dysuria, and perineal pain. Digital rectal examination reveals the presence of a warm, exquisitely tender prostate. The patient is prescribed ciprofloxacin. His fever is resolved the next day. Which of the following best describes the most common route of infection of the patient's condition? Ascending urethral spread Direct extension from the bladder Hematogenous spread Lymphatic spread from the rectum

Ascending urethral spread acute bacterial prostate

35-year-old man presents to the clinic complaining of a retrosternal burning sensation after eating, with an occasional acidic taste in his mouth. Which of the following lifestyle modifications should be recommended for this patient? Avoid caffeine, chocolate, and carbonated beverages Avoid eating a meal six hours before bedtime Avoid foods containing tomatoes, onions, and garlic Sleep in a prone position

Avoid caffeine, chocolate, and carbonated beverages

58-year-old woman with a history of choledocholithiasis presents to the emergency department with acute abdominal pain and altered mental status. Upon physical assessment, the patient is found to have a temperature of 102.8°F, blood pressure of 89/52 mm Hg, heart rate of 122 beats per minute, and oxygen saturation of 97% on room air. She has significant tenderness in the right upper quadrant. Initial laboratory assessment reveals an elevated white blood cell count, elevated serum alkaline phosphatase, elevated gamma-glutamyl transpeptidase, and elevated bilirubin. What other information would likely be gathered from her history and physical examination based on the suspected diagnosis? Concurrent jaundice History of inflammatory bowel disease Preceding pruritus Recent travel to Bolivia

Concurrent jaundice with acute cholangitis *reynolds pentad*: fever, abdominal pain, jaundice, confusion, hypotension

32-year-old woman presents to the clinic for a three-month follow-up. She is currently taking loperamide 2 mg and hyoscyamine 0.25 mg 45 minutes before each meal for irritable bowel syndrome with predominant diarrhea. She states the diarrhea is well controlled, but her abdominal pain and bloating continue unabated. Which of the following is the best therapeutic choice for this patient? Add alprazolam 0.25 mg tid to current regimen Add dicyclomine 20 mg qid to current regimen Discontinue hyoscyamine and add amitriptyline 12.5 mg qhs Discontinue loperamide and add rifaximin 550 mg tid

Discontinue hyoscyamine and add amitriptyline 12.5 mg qhs IBS tx: diarrhea-predominant: loperamide 2 mg 45 minutes before each meal constipation-predominant: polyethylene glycol abdominal pain and bloating: 1. diet modifications 2. antispasmodic agents (hyoscyamine and dicyclomine) *3. tricyclic antidepressant (amitriptyline)*

Which of the following conditions is the most common cause of secondary hypertension in adults? Graves disease Pheochromocytoma Primary aldosteronism Renal artery stenosis

Renal artery stenosis

67-year-old man is admitted to the hospital for cough, hemoptysis, and dyspnea and is subsequently diagnosed with Legionnaires' disease. He is started on azithromycin. On the third day of admission, the patient begins to have nausea, vomiting, and mild confusion. A comprehensive metabolic panel is ordered, and the sodium level is 122 mEq/L. Serum osmolality is 210 mOsm/kg, urine osmolality is 450 mOsm/kg, and urine sodium is 40 mEq/L, indicating a hypotonic, euvolemic hyponatremia. After further testing, there is no indication of cardiac, thyroid, hepatic, renal, or adrenal disease. What is the most appropriate next step in the management of this patient? 3% hypertonic saline 100 mL over 10 minutes Demeclocycline 300 mg PO tid Fluid restriction and 2 g of sodium chloride tablets Furosemide 80 mg PO tid

3% hypertonic saline 100 mL over 10 minutes acute symptomatic SIADH = *hypotonic hyponatremia* (Fluid restriction and 2 g of sodium chloride tablets (C) bid to tid is an appropriate treatment for SIADH in asymptomatic patients if the sodium level is > 130 mEq/L.)

45-year-old woman with type 2 diabetes mellitus presents to your clinic for her diabetes exam. She was diagnosed 5 years ago and has been stable on oral medications. She wants to make sure she is up to date with her ongoing diabetes care. Which of the following is recommended for ongoing health maintenance in patients with diabetes mellitus? Annual dilated eye exam Annual lipid panel Exercise stress testing Hepatitis A vaccine

Annual dilated eye exam

Which of the following patients is at risk for having an atypical presentation of an acute myocardial infarction? 21-year-old man with a history of asthma 37-year-old man with a history of obesity 72-year-old woman with a history of diabetes and hypertension 75-year-old man with a family history of coronary artery disease

72-year-old woman with a history of diabetes and hypertension Atypical presentation can be seen in elderly patients, women, or those with diabetes.

24-year-old woman presents to the office for intermittent dull abdominal pain that occurs about 20 minutes after eating certain meals. She occasionally has nausea but no fever, vomiting, or sweating. Her symptoms last for about two hours after onset and do not occur after every meal. Her diet is high in carbohydrates and fat. Which of the following is the best initial diagnostic study of choice for her condition? Abdominal Ultrasound Computed tomography of the abdomen Magnetic resonance imaging of the abdomen Plain abdominal radiograph

Abdominal Ultrasound cholelithiasis

12-year-old boy presents to your office for a routine sports physical exam. Family history reveals the patient had an uncle who died of a sudden unexplained cardiac event. You obtain a screening ECG, which is shown above. Which of the following best describes the pathophysiology of the suspected diagnosis? Accessory conduction pathway Atrioventricular nodal reentrant pathway Decreased atrioventricular node transmission Multiple atrial electrical foci

Accessory conduction pathway wolff-parkinson-white syndrome ECG = narrow complex tachycardia, a short PR interval, and a *delta wave*. *read explanation*

57-year-old CrossFit athlete presents to a primary care provider with a fever, maculopapular rash, and arthralgias. She reports she has been working out for 3 hours a day but has not had an increase in the duration or frequency of her workouts in the last year. The only change she can recall is the use of ibuprofen 800 mg three times daily over the last 2 weeks for a mild quadriceps strain. Urinalysis is significant for proteinuria, eosinophiluria, increased white blood cells, and white cell casts. No red blood cells are seen on urine microscopy. What is the most likely diagnosis? Acute interstitial nephritis Pyelonephritis Rhabdomyolysis Systemic lupus erythematosus

Acute interstitial nephritis abrupt decline in kidney function due to damage or inflammation of the renal tubules and interstitium caused by NSAID use

65-year-old woman who is a former smoker with a past medical history of hypertension, hyperlipidemia, and arthritis presents to her primary care clinic for three months of cough with hemoptysis, generalized chest discomfort, and weight loss. Vitals show a heart rate of 68 bpm, blood pressure of 132/81 mm Hg, O2 saturation of 96% on room air, respiratory rate of 16 breaths per minute, and temperature of 98.1°F. Vaccines are up to date, and there has been no travel or sick contacts. Chest X-ray and CT scan of the chest show multiple irregularly shaped nodules in the periphery of the lungs bilaterally. Which of the following is the most likely diagnosis? Adenocarcinoma Large cell carcinoma Small cell lung cancer Squamous cell carcinoma

Adenocarcinoma MC form of bronchogenic carcinoma seen in *periphery* of lungs

35-year-old woman presents with palpitations, dyspnea, and mild chest pain that started at rest. On physical exam, she is noted to be diaphoretic and tachycardic. Her blood pressure is 130/80 mm Hg, heart rate is 170 beats per minute, and respiratory rate is 22 breaths per minute. Her rhythm strip is shown above. The rhythm persists despite the initiation of the Valsalva maneuver. Which of the following is the most appropriate pharmacologic treatment to give next for this patient's condition? Adenosine Diltiazem Esmolol Procainamide

Adenosine paroxysmal supra ventricular tachycardia in stable pts

78-year-old woman with metastatic breast cancer presents with nausea, anorexia, and generalized weakness for the past several days. A basic metabolic panel reveals a serum creatinine of 0.9 mg/dL and a serum calcium of 14.2 mg/dL. Which of the following interventions should be done immediately? Administer intravenous saline Begin administering oral bisphosphonate Prepare patient for hemodialysis Prescribe oral glucocorticoids

Administer intravenous saline tx for hypercalcemia

23-year-old man with type 1 diabetes presents with acute onset of severe nausea, vomiting, and abdominal pain. He reports excessive thirst and frequent urination but reports no dysuria, hematuria, or urgency. On exam, he is hypotensive and tachycardic. Kussmaul respirations are also noted. Laboratory studies demonstrate serum glucose of 550 mg/dL, serum potassium of 3.1 mmol/L, a venous pH of 7.1, and a serum bicarbonate level of 13 mmol/L. A total of 2 L of 0.9% normal saline has been administered. Which of the following is the next step in management? Administration of dextrose Administration of insulin Administration of potassium chloride Oxygen therapy

Administration of potassium chloride diabetic ketoacidosis (hyperglycemia) serum K levels <3.3 - administer potassium chloride before insulin (to further prevent hypokalemia) -- *treat metabolic acidosis before hyperglycemia*

10-year-old boy presents to the pediatrics clinic for evaluation of his asthma. He is currently only taking a rescue inhaler as needed. He has daytime symptoms four days per week, nighttime symptoms once per month, and uses a rescue inhaler four days per week. Which of the following medication regimens is most appropriate for this patient? Albuterol Albuterol and fluticasone Albuterol, fluticasone, and salmeterol Albuterol, fluticasone, salmeterol, and a short course of oral prednisone

Albuterol and fluticasone mild persistent asthma tx: SABA and LDCS

66-year-old man with a history of severe COPD, nonalcoholic steatohepatitis, and single-vessel coronary artery disease presents to your clinic with worsening angina. He reports that, over the last month, he has been getting two to three anginal episodes a week that are improved with sublingual nitroglycerin and rest. Vital signs show HR of 74 beats per minute and BP of 136/84 mm Hg. Physical exam is unremarkable. A recent echocardiogram showed an ejection fraction of 55%. What is the most appropriate treatment for this patient? Amlodipine Lisinopril Propranolol Ranolazine

Amlodipine stable angina 1st line: BB (CI in COPD) 2nd line: CCB

52-year-old man with a history of diabetes mellitus type 2 and cigarette smoking presents to your clinic with a six-month history of worsening leg pain. The patient reports his pain is worse when walking and improved with rest. Physical exam reveals decreased hair growth over the distal extremities and bilateral diminished dorsalis pedis pulses. What is the most appropriate diagnostic test to establish the suspected diagnosis? Ankle-brachial index CTA of the lower extremities Duplex ultrasonography MRA of the lower extremities

Ankle-brachial index PAD initial test of choice other choices used for surgical planning for tx

45-year-old man presents to a primary care provider with fever, fatigue, worsening dyspnea, cough, and right-sided pleuritic chest pain for one week. Physical examination is significant for diminished breath sounds over the right lower lobe and dullness to percussion over the same area. A chest radiograph is ordered and shows a right-sided 15 mm pleural effusion over 35% of the hemithorax. He is transferred to the ED where a thoracentesis is performed. Pleural fluid analysis reveals a pleural fluid protein to serum protein ratio of 0.7 and a pleural fluid LDH to serum LDH ratio of 0.8. The pleural fluid is free-flowing and has a pH of 7.4. Gram stain and culture of the pleural fluid are negative.Which of the following is also indicated in the treatment of this patient? Antibiotics and supportive treatment Tube thoracostomy Tube thoracostomy and intrapleural fibrinolytic Tube thoracostomy with intrapleural fibrinolytic and deoxyribonuclease

Antibiotics and supportive treatment uncomplicated parapneumonic effusion secondary to bacterial pneumonia Exudate = serum protein >0.5

A 75-year-old man presents with a gradual onset of exertional dyspnea, syncope, and angina that has progressively worsened over the last three months. Physical examination reveals a crescendo-decrescendo systolic murmur that is heard best in the right second intercostal area. The murmur decreases with the Valsalva maneuver. A palpable left ventricular heave is also felt on exam. Which of the following is the most appropriate therapy? Aortic root replacement Aortic valve replacement with bioprosthetic valves Aortic valve replacement with mechanical valves Medical therapy

Aortic valve replacement with bioprosthetic valves (preferred in >70yo, or when anticoagulant tx is contraindicated) aortic stenosis **mechanical valves in pt <50 who can take warfarin, (anticoags required with mechanical valves)

76-year-old woman with congestive heart failure presents with palpitations and dyspnea. On exam, her pulse is irregular, with a rate of 78 beats/minute. Crackles at the lung bases are also present on lung auscultation. Her rhythm strip is shown above. Which of the following medications should be initiated? Apixaban Aspirin Enalapril Verapamil

Apixaban (eliquis) Atrial Fibrillation anticoagulation superior to aspirin (anti platelet) in preventing strokes

37-year-old woman complains of a sudden onset of polyuria and polydipsia. A first-morning urine shows an inappropriately low osmolality after a water deprivation test. After the patient is given desmopressin, the urine osmolality increases to levels within normal limits. What is the most likely diagnosis? Central diabetes insipidus Nephrogenic diabetes insipidus Primary polydipsia Type 2 diabetes mellitus

Central diabetes insipidus Decreased ADH > excess secretion of free water *Central responds to desmopressin test* (nephrogenic will not respond do desmopressin)

46-year-old man presents to the office for a routine wellness exam. His blood pressure is 138/84 mm Hg. You see he is sitting with his legs crossed, leaning forward, and he appears nervous. After appropriately repositioning the patient and allowing him to relax, you retake his blood pressure. The second reading is 131/83 mm Hg on the left arm and 130/84 mm Hg on the right arm. Careful chart review reveals his last two blood pressure measurements, 2 months apart, were 132/81 mm Hg and 139/87 mm Hg. His past medical history reveals a myocardial infarction 2 years ago. At his last visit, you discussed initiating a healthy low-sodium diet, exercise, and avoidance of alcohol. The patient reports he adhered to these recommendations. Which is an appropriate first-line therapy for this patient according to ACC/AHA guidelines? Angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker in combination Beta-blocker and angiotensin-converting enzyme inhibitor Calcium channel blocker and thiazide diuretic Nondihydropyridine calcium channel blocker

Beta-blocker and angiotensin-converting enzyme inhibitor

36-year-old man presents to a primary care provider with fever, chills, urinary frequency, and dysuria. His vital signs are T 39.1°C, BP 138/82 mm Hg, HR 112 bpm, RR 19 breaths per minute, and pulse oximetry 99% on room air. Physical examination reveals pronounced right-sided costovertebral angle tenderness. A CBC is significant for a WBC count of 14,600/mcL and 22% bands. A urinalysis is significant for bacteriuria and white cell casts. A urine culture is ordered, and the patient is started on empiric antibiotic therapy. Which of the following diagnostic studies is warranted if the patient fails to respond to antibiotic therapy within 48 hours? CT scan Kidney biopsy Repeat urine culture Urethral swab for nucleic acid amplification testing

CT scan (to identify complicating factors (obstruction, anatomy) pyelonephritis

76-year-old woman presents to the emergency department after having a seizure. She has been vomiting for the past three days and has been lethargic since yesterday. A basic metabolic panel reveals a sodium level of 155 mEq/L. Which of the following complications should be considered when initiating volume repletion and serum sodium reduction? Cerebral edema Hypoglycemia Osmotic demyelination syndrome Prolonged QT interval

Cerebral edema with rapid correction of sodium levels

47-year-old man presents to the clinic for evaluation of insomnia, fatigue, abdominal pain, and progressive lower extremity edema over the past nine months. He has a history of hypertension and major depressive disorder. His medications include lisinopril and duloxetine. He does not use tobacco and drinks one to two alcoholic beverages per month. He has a history of intravenous heroin use 18 years ago but does not currently use any illicit drugs. His vital signs are within normal limits. No abnormalities are heard on cardiopulmonary auscultation. His abdomen is soft and nontender with moderate distention. Physical examination is also significant for palmar erythema and pedal edema bilaterally. Abdominal ultrasound shows mild ascites, hypoechoic nodules within the liver, and splenomegaly. Which of the following is the most likely underlying cause for this patient's condition? Alcoholic liver disease Chronic hepatitis C Nonalcoholic fatty liver disease Nonalcoholic steatohepatitis

Chronic hepatitis C secondary to IV heroin use

55-year-old man presents with a gradual onset of unintentional weight loss, fatigue, and low-grade fever. On exam, splenomegaly is noted. Laboratory studies reveal a white blood cell count of 150,000/microL. The polymerase chain reaction of bone marrow aspirate demonstrates the presence of the BCR-ABL1 gene. Which of the following is the most likely diagnosis? Acute lymphocytic leukemia Acute myelocytic leukemia Chronic lymphocytic leukemia Chronic myelocytic leukemia

Chronic myelocytic leukemia BCR-ABL1 = philadelphia chromosome = CML

57-year-old man with a past medical history of recent right-sided hip replacement presents to the emergency department with sudden-onset chest pain, shortness of breath, cough, diaphoresis, and hemoptysis. Vitals show heart rate of 110 beats per min, blood pressure of 147/81 mm Hg, respiratory rate of 22 breaths per min, and O2 saturation of 97% on room air. Physical exam shows clear lung sounds in all fields and a new systolic murmur heard over the second intercostal space on the left side of the sternum. Which of the following is the diagnostic test of choice to confirm the diagnosis? Chest X-ray Computed tomography angiogram of the chest D-dimer Ventilation-perfusion scan

Computed tomography angiogram of the chest PE (ventilation-perfusion scan reserved for who cannot tolerate or have contraindications to a CT angiogram).

33-year-old woman with a long history of recurrent abdominal pain and diarrhea presents to the office with increasing pain and pressure to the rectal area for about three weeks. She was diagnosed with an abscess to the buttocks about two weeks ago and given a course of antibiotics. However, she continues to have throbbing pain in the area that is worse with sitting and defecating. She complains of a new symptom of foul-smelling perianal leakage for about three days. Upon physical exam, there is induration to the perianal area with a small opening that exudes purulent fecal material when expressed. Which of the following diseases are her symptoms classically associated with? Crohn disease Hidradenitis suppurativa Irritable bowel syndrome Ulcerative colitis

Crohn disease anal fistula crohns affects *full thickness* of gastrointestinal wall (UC only affects *mucosa level*)

A 35-year-old woman presents to her primary care provider for a one-week history of dark urine. She has a past medical history of systemic lupus erythematosus but is not currently on medication due to a lapse in insurance. Her blood pressure is 165/105 mm Hg. Urine dipstick reveals 2+ protein and hematuria. Lab tests reveal low complement protein and azotemia. The patient is started on prednisone. What other medication is indicated for the treatment of this complication of systemic lupus erythematosus? Cyclophosphamide Furosemide Hydroxychloroquine Ibuprofen

Cyclophosphamide Lupus nephritis tx = corticosteroids (prednisone) + immunosuppressant (cyclophosphamide) *hydroxychloroquine for indicated in all SLE for skin lesions and joint pain >> used after kidney function stabilizes*

A 53-year-old man presents to his primary care provider for his annual physical. His blood pressure reading is 131/83 mm Hg at this visit. He returns to the clinic 2 weeks later for a second blood pressure measurement, and his BP at this time is 135/80 mm Hg. Which of the following is the most appropriate diagnosis according to ACC/AHA guidelines? Elevated blood pressure Normal blood pressure Stage 1 hypertension Stage 2 hypertension

Stage 1 hypertension elevated BP: 120-129/< 80 mm Hg stage 1: 130-139/80-89 mm Hg stage 2: ≥ 140/≥ 90 mm Hg.

A 32-year-old man presents to the clinic for treatment of newly diagnosed, asymptomatic HIV infection. His viral load is 200,000 copies/mL, and his CD4 cell count is 110 cells/microL. He is currently taking no medications and is allergic to sulfa drugs (generalized urticaria). A chest X-ray reveals no active pulmonary disease, and tuberculosis skin and sputum tests are negative. Which of the following antimicrobials should be prescribed prophylactically for this patient in addition to antiretroviral medication? Azithromycin 1,200 mg once weekly Dapsone 100 mg daily Rifabutin 300 mg daily Trimethoprim-sulfamethoxazole DS daily

Dapsone 100 mg daily CD4 <200 - ppx for PCP > first line: Trimethoprim-sulfamethoxazole DS (but pt has sulfa allergy, so use dapsone instead)

40-year-old woman presents to the clinic reporting three weeks of worsening chest discomfort and dyspnea. The patient notes her dyspnea worsens when lying down at night or when she lies on her recliner to watch television. An echocardiogram is done at the bedside and is significant for fluid within the pericardial sac. Cardiac function remains intact, and there is no change in ventricular filling. Which of the following is most likely going to be found on this patient's physical exam? A blood pressure reading of 88/48 mm Hg A pericardial knock Distant heart sounds Jugular venous distension

Distant heart sounds pericardial effusion (pericardial tamponade = loss of diastolic function DUE to pressure from effusion)

72-year-old man with a history of tobacco use disorder presents with fatigue and unintentional weight loss over the last month. He is also complaining of a feeling of fullness in his head that is made worse with bending forward. A chest radiograph is obtained and shows a large hilar mass with bulky mediastinal adenopathy. Which of the following physical exam findings would be most consistent with his diagnosis? Alteration in gait Distention of the chest wall veins Dry mouth with reduced salivation Ptosis

Distention of the chest wall veins Superior Vena Cava Syndrome due to malignancy compressing SVC

26-year-old man who uses intravenous drugs presents with an acute onset of fever, chills, malaise, and anorexia. On physical exam, his temperature is 101.4°F, BP 98/50 mm Hg, HR 120 beats per minute, and RR 22 breaths per minute. Splinter hemorrhage and Osler nodes are present. Which of the following diagnostic tests would confirm the suspected diagnosis? Chest radiography Computed tomography Echocardiography Electrocardiogram

Echocardiography Acute bacterial endocarditis osler nodes (painful, violaceous raised lesions of the fingers, toes, and feet),

57-year-old man presents to a primary care provider with fatigue and stocking-glove paresthesias. Physical examination reveals a smooth tongue, cheilosis, and abnormal vibration and joint position sense. A CBC shows leukopenia, anemia, and thrombocytopenia. The MCV is 120 fL. Hypersegmented neutrophils and macro-ovalocytes are present on the manual differential. Serum homocysteine and methylmalonic acid levels are increased. What is the most likely diagnosis? Aplastic anemia Folate deficiency G6PD deficiency Pernicious anemia

Pernicious anemia (B12/cobalamin) (folate is similar but has *normal* methylmalonic acid)

40-year-old man presents to his primary care provider with unilateral scrotal discomfort. He describes the discomfort as dull, heavy, and achy. He is up-to-date on all of his immunizations. He has been in a monogamous relationship for the past 15 years and is not currently using condoms. His family history is significant for a father who was diagnosed with leukemia at 65 years of age. Physical examination is significant for swelling and tenderness along the posterosuperior portion of the right testicle. Elevation of the right testicle relieves the pain. Urinalysis is significant for pyuria and bacteriuria. Urine culture is positive for an organism that grows readily on eosin methylene blue agar and has a metallic green sheen. Nucleic acid amplification testing is pending. What is the most likely diagnosis? Epididymitis due to Chlamydia trachomatis Epididymitis due to Escherichia coli Leukemia-induced epididymitis Viral epididymitis

Epididymitis due to Escherichia coli characteristically grows on eosin methylene blue agar and has a metallic green sheen MCC in ppt >35

56-year-old woman is being treated on the medical floor for hospital-acquired pneumonia. A nurse reports that the patient had a bowel movement with copious amounts of bright red blood and some clots. The patient is awake and alert and denies any pain or lightheadedness. Vital signs are BP 111/70 mm Hg, HR 78 bpm, and RR 16 breaths per minute. You order a CBC, prothrombin time and international normalized ratio, PTT, CMP, and a type and cross. What is the most appropriate next step in the workup for this patient? Colonoscopy Computed tomography angiography Esophagogastroduodenoscopy Gastric lavage

Esophagogastroduodenoscopy to rule out upper GI bleed before (then do colonoscopy if suspected lower GI bleed) *Hematochezia can also occur in a sizable portion of upper GI bleeds if bleeding is occurring rapidly*

64-year-old man presents to the ED for worsening dyspnea on exertion and is admitted for a COPD exacerbation. His medical history is significant for coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus, and obstructive sleep apnea. He has a 40 pack-year smoking history and a history of cocaine use. He was discharged from the hospital nine days ago after being admitted for a myocardial infarction. During the first night of his current admission, the patient begins experiencing chest pain. Vital signs are T 102°F (38.9°C), BP 132/78 mm Hg, HR 105 bpm, RR 22 breaths per minute, and pulse oximetry 96% on 2 L via nasal cannula. His WBC count is 14.7 × 109/L. His rhythm strip is shown above. Which of the following characteristics most likely indicates a diagnosis of postmyocardial infarction syndrome rather than an acute myocardial infarction? Dyspnea Fever and leukocytosis ST elevation in the anterior leads Tachycardia

Fever and leukocytosis Dressler syndrome (postmyocardial infarction syndrome) - autoimmune inflammatory response

46-year-old man from New Mexico with a past medical history of a renal transplant presents to the emergency department with one week of cough and fever. Vital signs are T 100.6°F, HR 108 bpm, BP 116/76 mm Hg, RR 20.min, and oxygen saturation 97% on room air. Chest X-ray shows an upper lobe infiltrate with hilar adenopathy. A fungal pathogen is suspected. Which of the following is the recommended treatment? Amphotericin B Ceftriaxone and azithromycin Fluconazole Supportive care

Fluconazole healthy with mild/moderate dz: no tx healthy, non pregnant, severe illness, or *immunocompromised*: fluconazole or itraconazole Respiratory compromise (mechanical ventilation):Amphotericin B

58-year-old man with poor preventative care presents to the emergency department by ambulance due to worsening weakness in the context of vomiting blood for the past 5 hours. An accompanying family member reports they called 911 after the patient became confused at home. The family member cannot quantify the amount of blood or vomit. The patient does not smoke cigarettes. He drinks 1 pint of bourbon nightly and has done so for the past 20 years. The patient is tachycardic to 118 bpm, and his blood pressure is 88/60 mm Hg. Physical examination reveals ascites, temporal wasting, palmar erythema, and scleral icterus. Two large-bore intravenous catheters are placed. What intervention would be most appropriate at this time? Administration of octreotide Fluid resuscitation Packed red blood cell transfusion Transjugular intrahepatic portosystemic shunt

Fluid resuscitation hemodynamically unstable due to esophageal varices

55-year-old woman is brought to her primary care provider by her daughter, who reports the patient has been exhibiting some strange behavior and personality changes over the past year. The daughter says the patient has been more withdrawn and has lashed out at family members and pets. The daughter also notes the patient has been caught multiple times with inedible objects in her mouth. The patient has no history of psychiatric illness or previous behavioral problems. The physical examination is significant for the presence of palmar grasp and rooting reflexes. A Mini-Mental State Examination is normal. MRI is ordered, and a neurology consult is made. Which of the following is the most likely diagnosis? Alzheimer disease Frontotemporal dementia Pseudodementia Vascular dementia

Frontotemporal dementia *read explanation*

68-year-old man presents to the clinic complaining of abdominal distention and shortness of breath. He takes no daily medications, has not seen a healthcare provider in decades, and has consumed 12 beers per day for the past 20 years. On physical exam, vital signs are within normal limits. Skin is nonicteric, and body habitus demonstrates central adiposity. Physical exam reveals a firm, irregular liver border just below the right costal margin, abdominal fluid wave, and dullness to percussion with decreased breath sounds on the right chest. Which of the following represents appropriate initial management of this patient's complaints? Furosemide 20 mg daily and salt restriction Insertion of a thoracostomy tube in the right chest and abdominal paracentesis Liver transplantation Metoprolol tartrate 50 mg bid and potassium restriction

Furosemide 20 mg daily and salt restriction cirrhosis - to tx ascites

29-year-old man who has a history of chronic homelessness and IV drug use presents to you for hospital admission after arriving at the emergency room with fevers, chills, and rapid weight loss over the past five days. Vital signs show HR of 82 bpm, BP of 110/65 mm Hg, and temperature of 102.1°F. Physical exam reveals a rash on the patient's palms that is shown above. Which of the following is most likely to confirm the suspected diagnosis? Gram-positive cocci seen in the patient's blood culture Hemorrhagic exudates seen on the patient's retina Hyperpigmented linear lesions under the patient's nails Subcutaneous nodules seen over the patient's distal phalanx

Gram-positive cocci seen in the patient's blood culture infective endocarditis caused by staph aureus *read explanation*

37-year-old woman presents to a primary care provider with anxiety, difficulty sleeping, and vision changes for the past three months. Her family history is significant for a mother and grandmother with Hashimoto thyroiditis. She was diagnosed with atrial fibrillation two years ago and has been taking amiodarone. Her vital signs are T 37.1°C, BP 122/72 mm Hg, HR 56 bpm, RR 18 breaths per minute, and pulse oximetry 99% on room air. Physical examination reveals superior lid lag with a downward gaze and eyelid retraction. The patient is unable to look upwards when testing extraocular movements. A nontender, diffusely enlarged thyroid is palpated on exam. Laboratory testing reveals elevated levels of antithyrotropin receptor antibodies, thyroid-stimulating immunoglobulin, antithyroglobulin antibodies, and antithyroid peroxidase antibodies. A radioactive iodine uptake study is ordered and shows a diffuse increased uptake in the thyroid tissue. What is the most likely diagnosis? Graves disease Hashimoto thyroiditis Subacute thyroiditis Toxic multinodular goiter

Graves disease MCC of hyperthyroidism

68-year-old man with sickle cell anemia has painful episodes that are becoming more frequent. He is currently pain-free but wants to be started on a therapy that can improve his painful crisis. Which of the following therapies should be initiated to improve his painful episodes? Bone marrow transplant Gene therapy Hydroxyurea L-glutamine oral powder

Hydroxyurea increases hemoglobin F and reduces the production of hemoglobin S, thereby reducing the number of red cells that are susceptible to sickling

55-year-old woman presents to your clinic with a two-week history of right leg pain. She reports a burning aching pain located on her right anterior thigh. Vital signs are BP of 122/68 mm Hg, HR of 84 bpm, and temperature of 97.3°F. Physical exam reveals bilateral lower extremity nonpitting edema, bilateral moderate varicose veins, and a tender linear erythematous induration measuring approximately 3 cm in length on the right anterior medial thigh. What is the most appropriate treatment for the suspected diagnosis? Cephalexin Dabigatran Doxycycline Ibuprofen

Ibuprofen superficial thrombophlebitis (inflammation of superficial vein, sometimes results in thrombosis) (RF: varicose veins)

According to the US Preventive Services Task Force, what is the appropriate lung cancer screening method for patients who are aged 50-80, currently smoke tobacco or those with a former heavy history of smoking? Low-dose helical computed tomography every three years Magnetic resonance imaging of chest every two years Yearly chest X-ray Yearly low-dose helical computed tomography

Yearly low-dose helical computed tomography

45-year-old Asian American man presents to the urgent care for one day of severe toe pain. He has a past medical history of obesity and hypertension. His current medications are chlorthalidone and a multivitamin. He reports his toe is painful, swollen, and sensitive to touch. On exam, the first metatarsophalangeal joint on his left foot is erythematous, swollen, and tender. Manipulation of the joint causes the patient distress. What is the first-line therapy for the suspected diagnosis? Allopurinol Indomethacin Observation Probenecid

Indomethacin 1st line tx for gout - NSAID

54-year-old woman is being discharged on warfarin after being admitted for new-onset atrial fibrillation. Which of the following foods should she be advised to avoid while on warfarin? Bananas Kale Oats Pasta

Kale high in vitamin K

2-year-old girl presents for intermittent diarrhea, poor weight gain, and low appetite that has gotten worse over the past month, according to her mother. The patient's anti-tissue transglutaminase immunoglobulin A is elevated. Which of the following is the mainstay of treatment of this condition? Life-long avoidance of foods containing gluten Life-long avoidance of foods containing lactose Oral mesalamine Oral prednisone therapy

Life-long avoidance of foods containing gluten celiac disease

67-year-old man with a history of alcohol use disorder is admitted to the hospital and subsequently diagnosed with cirrhosis. His chemistry panel and blood gas show the following results: Sodium: 142 mmol/L Potassium: 4.0 mmol/L Chloride: 110 mmol/L Albumin: 4.0 g/L pH: 7.55 PaCO2: 32 mm Hg PaO2: 90 mm Hg Bicarbonate: 23 mmol/L What is the most likely diagnosis? Anion gap metabolic acidosis Metabolic alkalosis Non-anion gap metabolic acidosis Respiratory alkalosis

Respiratory alkalosis increased pH, a decreased PaCO2, and a decreased or normal bicarbonate

52-year-old woman presents to a primary care provider with photosensitivity, foreign body sensation, and eye fatigue bilaterally. She also reports a sore tongue and dry, peeling lips. A Schirmer test and rose bengal stain are positive in both eyes. What is the most likely finding on salivary gland biopsy? Decreased salivary output Increased salivary output Mononuclear cell infiltration Polynuclear cell infiltration

Mononuclear cell infiltration on *salivary gland biopsy* Sjogren syndrome decreased salivary output on *sialometry*

60-year-old man presents to the ER for acute abdominal pain. The patient has a significant past medical history of hepatitis B. The patient reports a history of recent malaise, 10 lb weight loss, and fevers leading up to this episode of abdominal pain. Physical exam reveals elevated blood pressure, diffusely tender abdomen, and a rash on the patient's legs. Computed tomography with IV contrast of the abdomen reveals microaneurysms with sudden cutoffs and evidence of mesenteric ischemia. What description of the rash would be consistent with the suspected diagnosis? Diffuse maculopapular Mottled, lace-like purple discoloration Palpable purpura Violaceous, raised discoloration

Mottled, lace-like purple discoloration (livedo reticularis) Polyarteritis nodosa: microaneurysms, Hep B/C, mesenteric ischemia

62-year-old man presents to a primary care provider with exertional weakness in his shoulders and thighs that improves with rest. He also complains of ptosis, double vision, and difficulty chewing his food. Physical exam reveals 2+ reflexes in the upper and lower extremities. Two-point discrimination and pinprick sensation are intact. Laboratory testing is positive for acetylcholine receptor antibodies and negative for muscle-specific tyrosine kinase antibodies. His CT scan is shown above. What is the most likely diagnosis? Amyotrophic lateral sclerosis Lambert-Eaton syndrome Multiple sclerosis Myasthenia gravis

Myasthenia gravis *proximal muscle weakness and fatigue improves with rest* caused by thymoma (MC anterior mediastinal neoplasm)

65-year-old man with a history of hyperlipidemia who is a current everyday smoker presents to the emergency department with chest pain that started two hours ago. The pain began when he was shoveling snow. Physical exam is unremarkable. His initial ECG is shown above. His initial troponin level is 0.5 ng/mL, and his serum troponin two hours later is 1.2 ng/mL. Which of the following is the most likely diagnosis? Non-ST elevation myocardial infarction Prinzmetal angina ST elevation myocardial infarction Unstable angina

Non-ST elevation myocardial infarction 2 elevated troponin levels 2 hrs apart, ST depressions or T wave inversions

68-year-old man presents to a primary care provider with complaints of fatigue, anorexia, insomnia, and muscle cramps. A complete laboratory workup is ordered and is significant for a hemoglobin of 9.1 g/dL, potassium of 5.4 mmol/L, phosphate of 1.8 mmol/L, and glomerular filtration rate of 29 mL/min/1.73 m2. Which of the following dietary modifications is most appropriate for this patient? Increased phosphate intake to > 1,000 mg/day Increased water intake to > 2 L/day Restricted calcium intake to < 1,000 mg/day Restricted protein intake to < 0.8 g/kg/day

Restricted protein intake to < 0.8 g/kg/day to slow progression of stage 4 CKD

45-year-old woman presents to her primary care provider for her annual checkup. Vital signs are T 98.8°F (37.1°C), BP 128/74 mm Hg, HR 84 bpm, RR 18 breaths per minute, and pulse oximetry 100% on room air. Her body mass index is 37. She was diagnosed with type 2 diabetes mellitus five months ago. Her most recent hemoglobin A1C of 7.4% was done by her endocrinologist two months ago. Her past medical and surgical history is otherwise unremarkable. She is currently taking metformin, insulin glargine, and a multivitamin. Which of the following is the most appropriate next step in the management of this patient? Obtain a fasting lipid profile Prescribe a third diabetes medication Prescribe aspirin 81 mg PO once daily Recheck hemoglobin A1C

Obtain a fasting lipid profile for hyperlipidemia (tx statin) ( A - should be by endocrinologist after 3 months of duel therapy)

75-year-old woman presents to the emergency department after collapsing at work. She reports this is her third syncopal episode in the past month. The electrocardiogram above is obtained during the initial workup. What definitive clinical intervention is indicated for this patient? Amiodarone Flecainide Observation Permanent pacemaker

Permanent pacemaker Sick sinus syndrome EKG = bradycardia alternating with tachycardia as well as extended periods of sinus inactivity

50-year-old woman is brought to the ED by her husband for sudden-onset nausea, abdominal pain, and blurred vision that began 30 minutes ago while she was sitting in the car at a drive-in movie theater. She reports that she saw halos around all the street lights on the way over to the ED. Physical examination reveals a right eye with ciliary injection, a hazy cornea, and a mid-dilated, fixed pupil that is nonreactive to light. An intraocular pressure of 65 mm Hg is obtained (normal 12-22 mm Hg). A bolus of acetazolamide 500 mg IV brings the intraocular pressure down to 22 mm Hg. The patient is discharged with acetazolamide 250 mg PO four times daily and instructed to follow up with an ophthalmologist the following morning. Which of the following medications is most appropriate in the management of the patient's condition? Brimonidine 0.2% ophthalmic solution Glycerin PO 2 g/kg Pilocarpine 4% ophthalmic solution Prednisolone acetate 1% eye drops

Pilocarpine 4% ophthalmic solution acute angle-closure glaucoma (emergency) Pilocarpine works by causing constriction of the pupillary sphincter muscle which pulls the iris away from the angle and allows the trapped aqueous fluid to flow out through the trabecular meshwork.

40-year-old woman presents to the office complaining of weakness in her muscles that for the past six months began in her legs, arms, and neck. She does not complain of any pain or changes in the skin. Her physical exam reveals bilateral weakness to proximal muscles in the hips, shoulders, and neck bilaterally without tenderness to palpation. Serologic testing is positive for anti-Jo-1 antibodies, and a muscle biopsy is ordered to confirm diagnosis. Which of the following is the most likely diagnosis? Dermatomyositis Polymyalgia rheumatica Polymyositis Systemic lupus erythematosus

Polymyositis progressive bilateral proximal muscle weakness anti-Jo-1 antibodies, anti-SRP antibodies, and anti-Mi-2 antibodies. Anti-Jo-1 antibodies myopathic inflammatory changes on muscle biopsy A - similar but has additional dermatologic signs B - pain and stiffness in proximal muscles (not weakness) D - similar sx but no anti-Jo-1-ab

72-year-old man presents with acute pain, stiffness, and swelling of his left knee. His medical history is significant for hypothyroidism and osteoarthritis. On physical exam, the knee is erythematous, warm, and tender to touch. Cartilage calcification is seen on plain film radiography. Which of the following findings of synovial fluid analysis is best to diagnose the suspected condition? Negatively birefringent monosodium urate crystals Nonpathogenetic crystals of cholesterol artifact Positive Gram stain with positive culture Positively birefringent calcium pyrophosphate crystals

Positively birefringent calcium pyrophosphate crystals pseudo gout - MC in knee

55-year-old man presents to his primary care provider for palpitations and mild dyspnea. His past medical history is significant for dilated cardiomyopathy. An ECG done in the office is shown above. Vital signs in the office are T 98.8°F (37.1°C), BP 116/70 mm Hg, HR 165 bpm, and RR 22 breaths per minute. He is taken to the emergency department for a full cardiac workup. His ECG is unchanged from earlier. CBC, CMP, magnesium, and serial troponins are within normal limits. The patient is alert and oriented. Vitals are T 98.8°F (37.1°C), BP 122/72 mm Hg, HR 170 bpm, RR 24 breaths per minute, and pulse oximetry 97% on room air. Which of the following is the most appropriate next step in management? Amiodarone 300 mg IV over two minutes Catheter ablation Procainamide 100 mg IV over two minutes Synchronized cardioversion

Procainamide 100 mg IV over two minutes to treat *stable monomorphic V Tach* Recommended administration for Amiodarone for stable VT: *150 mg IV of 10 minutes*

63-year-old man presents to the clinic complaining of his "hands shaking." He notices whenever he is trying to do a specific task, such as reaching out to grab a drink or writing in his journal, his hands shake. The patient notes the tremor improves after drinking whiskey. On physical exam, there is no resting tremor noted, however, when performing the finger-to-nose exam, the patient's tremor increases as he approaches the target. The remainder of the neurologic exam is normal. Which of the following is the most appropriate first-line treatment for this patient's condition? Alprazolam Carbidopa Gabapentin Propranolol

Propranolol (or primidone) first line tx for essential tremor

24-year-old man with type 1 diabetes presents to the clinic, brought by a friend, and is feeling clammy, sweaty, and dizzy. He looks confused but is speaking full sentences. A rapid random blood glucose is completed and is 48 mg/dL. Which of the following is the best intervention at this time? Administer intranasal glucagon Begin normal saline intravenously Inject subcutaneous insulin Provide an oral fast-acting carbohydrate load

Provide an oral fast-acting carbohydrate load hypoglycemia A - for those who is unable to take oral load

65-year-old woman with a history of emphysema arrives in the cardiovascular intensive care unit after percutaneous coronary intervention with stent placement for an ST elevation myocardial infarction. The patient reports chest pain and shortness of breath. Vital signs show a heart rate of 120 beats per minute and a blood pressure of 90/60 mm Hg. Physical exam is remarkable for jugular venous distention. You obtain an ECG, which is shown above. What additional physical exam finding is most consistent with the diagnosis? Diastolic decrescendo murmur Kussmaul sign Pericardial knock Pulsus paradoxus

Pulsus paradoxus (> 10 mm Hg decrease in systolic blood pressure during inhalation) cardiac tamponade

56-year-old man presents to the emergency department for an acute flare-up of gout to his right great toe. He is currently taking allopurinol and has not had a flare-up of gout in over two years. He recently went on a cruise that had an all-you-can-eat buffet for all three meals each day. Patients with gout should avoid consuming foods containing which of the following elements? Phosphorus Purine Pyrimidine Pyruvate

Purine when broken down >create uric acid

65-year-old woman with a past medical history of chronic obstructive pulmonary disease presents to her primary care clinic with worsening dyspnea, orthopnea, and lower extremity edema. On physical exam, you hear an accentuated S2 and observe elevated jugular venous pressure, peripheral edema, and ascites. An ECG is shown above. Which of the following is the pathophysiology behind this patient's symptoms? Acute pulmonary embolism from a deep vein thrombosis Left ventricular failure in the setting of acute myocardial infarction Right ventricular dilation in the setting of untreated coarctation of the aorta Right ventricular hypertrophy in the setting of increased pulmonary hypertension

Right ventricular hypertrophy in the setting of increased pulmonary hypertension cor pulmonale

45-year-old woman presents to the clinic. She appears quite somnolent and states she is in pain. She reports pain in her hands, forearms, and knees, along with abdominal discomfort. She also describes sensitivity to cold in her hands, which she says makes her hands turn white and become painful. She reports her symptoms have been present on and off for the last few years but have begun to significantly worsen. Her medical history is significant for hypertension and interstitial lung disease with home oxygen use. The patient reports no tobacco or illicit drug use. She takes lisinopril, metoprolol, hydrochlorothiazide, and mycophenolate. Physical exam reveals puffy, thickened skin over the fingers on both hands, tenderness over multiple joints, rales, labored respirations, general body atrophy, abdominal rigidity, and a systolic regurgitation murmur of grade 3 over the tricuspid area. Her vitals are a temperature of 99.5°F, HR of 95 bpm, RR of 20/minute, BP of 140/100 mm Hg, oxygen saturation of 93%, and body mass index of 14 kg/m2. Which of the following is the most likely diagnosis? Acromegaly Polymyalgia rheumatica Polymyositis Scleroderma

Scleroderma CREST syndrome

24-year-old man presents to the office complaining of worsening epigastric pain (especially at night) pain after eating spicy foods, and a metallic taste in his mouth that occurs on a daily basis. He only takes calcium carbonate tablets as needed and does not take any other medications. A chest radiograph is performed, which shows evidence of a hiatal hernia. Which of the following is the best initial approach to treating this condition? Encourage lifestyle changes, such as weight loss and avoidance of spicy foods Perform Nissen fundoplication Start treatment with an H2 receptor blocker Start treatment with an oral proton pump inhibitor

Start treatment with an oral proton pump inhibitor (poor worded question - A is right too, but bc severity of symptoms need PPI)

A patient with chronic alcohol use disorder is admitted to the hospital after presenting to the ED with severe abdominal pain that radiates to her back. She endorses consuming about six to eight cans of beer per day. She reports that she has not been compliant with her enzyme replacement therapy. She had a cholecystectomy two years ago. Which additional history and physical exam findings would most support the suspected diagnosis? Absent bowel sounds, abdominal distention, nausea, and vomiting Diarrhea, fever, gastric reflux, and soft and nontender abdomen Right upper quadrant pain, jaundice, and positive Murphy sign Steatorrhea, insulin use, calcifications on computed tomography, and epigastric pain

Steatorrhea, insulin use, calcifications on computed tomography, and epigastric pain chronic pancreatitis

17-year-old boy presents to your office after experiencing a head injury while playing football 3 weeks ago. He lost consciousness for less than 5 seconds after hitting his head during a tackle. Upon regaining consciousness, he was taken to the hospital for evaluation due to experiencing symptoms of headache, nausea, and mild confusion. Computed tomography of the head was negative for any acute findings. The patient and his parents now have questions about return to activity and ongoing health maintenance after a concussion. Which of the following is the most appropriate guidance? Annual brain imaging Cognitive rehabilitation Immediate return to activity Stepwise return to activity

Stepwise return to activity concussion

55-year-old man with a history of hypertension presents to the emergency department for a headache that has lasted three days. The patient reports that the headache started suddenly, is unilateral, and is associated with photophobia. The patient also reports a stiff neck. Vital signs are within normal limits. A noncontrast CT scan is performed and the radiologist reports "no acute intracranial abnormalities." A lumbar puncture reveals an opening pressure of 28 cm H2O and a clear dark yellow appearance of the cerebrospinal fluid. Which of the following is the most likely diagnosis? Infectious meningitis Migraine Pseudotumor cerebri Subarachnoid hemorrhage

Subarachnoid hemorrhage sudden onset HA, nuchal rigidity, xanthocromia, *sometimes CT is negative*

29-year-old woman presents to the clinic due to fatigue, arthralgias, and chest discomfort over the past four months. She has lost 6 lb during this same period of time. Her past medical history is insignificant, and she takes no medications. She does not use tobacco, alcohol, or illicit drugs. Her mother has rheumatoid arthritis, and her father has type 2 diabetes mellitus. Her temperature is 98.9°F, HR is 76 bpm, and blood pressure is 128/78 mm Hg. Physical examination is significant for a faint facial exanthem but is otherwise unremarkable. Which of the following is the most likely diagnosis? Primary biliary cholangitis Scleroderma Sjögren syndrome Systemic lupus erythematosus

Systemic lupus erythematosus fatigue, fever unresponsive to antipyretics, myalgias, arthritis, skin or mucosal lesions, chest pain, cough, and weight loss

28-year-old woman with no past medical history presents to the clinic with complaints of chronic headaches. She states her current headache started this morning and feels like there is a "sweat band" tightly wrapped around her head. She notes she is in finals week for her master's program, and she has been very stressed lately. The patient denies any other symptoms at this time, including nausea, vomiting, or photophobia. Which of the following is the most likely diagnosis? Cluster headache Migraine headache Rebound headache Tension headache

Tension headache headband

65-year-old man presents with acute onset of severe muscle cramps and extremity spasms. QT prolongation is seen on ECG. Laboratory studies are remarkable for a serum calcium level of 7.3 mg/dL. Carpopedal spasm is witnessed with inflation of the sphygmomanometer. Which of the following best describes this physical exam finding associated with the underlying diagnosis? Band keratopathy Chvostek sign Decreased deep tendon reflex Trousseau sign

Trousseau sign (carpal spasm after blood pressure cuff is applied for 3 minutes) *is a more specific sign of hypOcalcemia* than Chvostek sign (spasm of facial muscle after tapping facial nerve)

30-year-old woman with a recent diagnosis of HIV and history of smoking presents to your office for her annual exam. She wants to make sure she is up to date with the screenings recommended with her new diagnosis. Which of the following preventive screening tests should be done? Fecal occult blood test Low-dose computed tomography of the chest Mammogram Tuberculin skin test

Tuberculin skin test done after ALL patients with HIV diagnosis

20-year-old unvaccinated college student is brought in by his roommate to the college infirmary for altered mental status. The roommate reports the patient began complaining of fever, headache, and stiff neck yesterday. This morning, he was found in bed and was difficult to wake up. On evaluation, the patient only moans to painful stimuli, has a fever of 101.7°F, and is unable to put his chin to his chest. He has a diffuse purple rash that is nonblanching. You perform a lumbar puncture. What are the most likely cerebrospinal fluid results? Bloody color, elevated opening pressure, normal lymphocytes, normal protein, and normal glucose Clear color, high opening pressure, normal lymphocytes, normal protein, and normal glucose Clear color, normal opening pressure, normal lymphocytes, normal protein, and normal glucose Turbid color, elevated opening pressure, elevated lymphocytes, elevated protein, and low glucose

Turbid color, elevated opening pressure, elevated lymphocytes, elevated protein, and low glucose *bacterial meningitis* : elevated OP, inc protein, low glucose, A - subarachnoid bleed B - intracranial htn C - viral/aseptic meningitis

55-year-old patient with a history of chronic kidney disease, hypertension, and coronary artery disease presents to your clinic with a five-day history of right lower extremity edema. Physical exam reveals 2+ pitting edema in the right lower extremity and tenderness along the deep venous system. Lab work reveals the patient has a creatinine clearance of 20 mL/min. A duplex ultrasound shows a thrombus in the right proximal popliteal vein. Which of the following is the most appropriate therapy? Enoxaparin Fondaparinux Rivaroxaban Unfractionated heparin

Unfractionated heparin DVT tx bridged with warfarin used in pt with creatinine <30 (other options appropriate for tx of DVT but are largely really cleared)

35-year-old patient presents to the hospital following a motor vehicle collision. When you arrive in the exam room, the patient is unresponsive. Which of the following exam findings most likely indicates early uncal herniation? Absent oculovestibular reflex Bilateral pinpoint pupils Gaze preference away from the lesion Unilateral dilated and fixed pupil

Unilateral dilated and fixed pupil ipsilateral eye affected

59-year-old man presents to the clinic with vague epigastric pain that has progressed over the past three months. Associated symptoms include dysphagia, nausea, and early satiety. The patient has decreased appetite and has lost approximately 15 lbs over the course of six months. He denies diarrhea, constipation, hematemesis, and melena. Past medical history includes type 2 diabetes mellitus and hypertension. His medications include metformin and lisinopril. He does not use alcohol, tobacco, or illicit drugs. Family medical history is significant for type 2 diabetes mellitus in his father and thyroid cancer in his mother. On physical examination, vital signs are within normal limits. Cardiopulmonary examination is unremarkable. Abdominal examination is significant for mild abdominal distention with a palpable epigastric abdominal mass, and the liver edge is palpable 2.75 cm below the costal margin. Which of the following is the most appropriate diagnostic test at this time? Helicobacter pylori urea breath test Serum gastrin concentration Somatostatin receptor scintigraphy Upper endoscopy

Upper endoscopy gastric cancer

A 32-year-old man presents to the clinic complaining of heaviness and a "dull ache" in his left scrotum. The patient reports his scrotum appears larger when he is standing up. On physical exam, the patient has a palpable mass to the superior aspect of his scrotum that is nontender to palpation, transillumination test is negative, and cremasteric reflexes are intact. Which of the following is the most likely diagnosis? Epididymitis Hydrocele Testicular Torsion Varicocele

Varicocele palpable mass ("bag of worms") disappears when recumbent

50-year-old man presents to a primary care provider with multiple episodes of severe headache every day for the past six days. He states that the pain is localized to his right eye and is accompanied by right-sided tearing, redness, and a runny nose. His symptoms last for 15-30 minutes, during which he is unable to sit or lie still. He denies fever, jaw claudication, nuchal rigidity, or a "thunderclap" headache sensation. Imaging is ordered to rule out other causes and is unremarkable. Which of the following is the most appropriate prophylactic therapy? 100% oxygen via nasal cannula Amitriptyline Dihydroergotamine mesylate Verapamil

Verapamil CCB for *prophylactic* tx of cluster HA