UVA Family Medicine Questions

Erythema infectiosum rash

"Slapped cheeks"

32. A 54 year old man presents with acute knee pain which began last night while he was sleeping. He is now in 9/10 pain and says that he is hardly able to walk secondary to his inability to flex his left knee. Past medical history includes hypertension, nephrolithiasis, and two similar episodes of pain that have occurred over the past 16 months, one in his toe and another in his left knee. On physical exam, the patient is visibly uncomfortable and is holding his leg perfectly still. There is marked erythema and soft tissue swelling surrounding the knee. Passive range of motion is severely diminished secondary to the patient's pain. Analysis of joint aspirate shows a WBC of 60,000 and abundant needle shaped crystals that show negative birefringence under a polarizing filter. Treatment is initiated with colchicine, prednisone, and indomethacin. What is the next most appropriate step in the management of this patient? A. 24 hour urine collection for uric acid B. Measurement of serum uric acid C. Plain film x-rays of knee D. Begin therapy with allopurinol E. Begin therapy with probenecid

A. 24 hour urine collection for uric acid

104. A 44 year old female presents with epigastric abdominal pain, nausea, and vomiting. Her symptoms began after eating fried chicken and ice cream at a carnival two nights ago, and have progressively worsened. Physical examination shows an obese, afebrile female, with pulse 110 and blood pressure 96/60. There is mild, diffuse tenderness to palpation throughout the abdomen and worst at the epigastrium. Bowel sounds are absent, and there is no rebound tenderness or guarding. Laboratory evaluation shows the following: WBC 12,000/mm3; Hct 49%; AST 18; ALT 25; Lipase 320; Total bilirubin 2.0. Right upper quadrant ultrasound reveals numerous gallstones, but no gallbladder wall thickening or pericholecystic fluid collection. Which of the following is the most likely diagnosis in this patient? A. Acute pancreatitis B. Biliary colic C. Cholecystitis D. Choledocholithiasis E. Ovarian torsion

A. Acute pancreatitis

Scleroderma marker

Anti-centromere antibodies

Celiac diagnostic tests

Anti-gliadin antibodies Anti-tissue transglutaminase antibodies (greatest S/S) Anti-endomysial antibodies

Which infections cause a more alkaline vaginal discharge?

Trichomoniasis Bacterial vaginosis

Isotretinoin indications

Severe acne vulgaris

pH=7.11,pCO2=73,PaO2=54,HCO3-=28

Severe respiratory acidosis, kidneys have not compensated yet (boo) Etiology: airway obstruction, intoxication with sedatives/narcotics, head trauma that decreases respiratory drive

Pathophysiology of WPW syndrome

presence of an "accessory pathway," an abnormal conduction pathway that allows electrical impulses from the SA node to reach the ventricle without having to conduct through the AV node. Normal conduction through the AV node is slower than conduction through this accessory or "pre-excitation" pathway, so the ventricle gets activated at different times by the two different pathways

Hepatitis A serologies

(+) IgM=acute (+) IgG=past infection and therefore immunity Hep A only causes ACUTE infection, not chronic

Hepatitis C serologies

(+) PCR=chronic hep C (only very rarely causes an acute hepatitis)

Annoying thing about clozapine

0.5-1% risk agranulocytosis --> weekly CBCs

Hepatitis B serology summed up

1) A patient who has never had hepatitis B, and has never been vaccinated. Their serologies will ALL be negative, since they've never been exposed to any part of the hepatitis B virus. 2) A patient who has been vaccinated for hepatitis B. This patient will have a positive hepatitis B surface antibody (HBsAb), since this is the antibody that provides protection against HBV, but all of their other serologies will be negative. 3) A patient with past hepatitis B infection who has since cleared it. This patient will have a positive surface antibody AND a positive core antibody, since the only way that the immune system learns what the inside of the hepatitis B virus looks like is by having seen it in the context of an infection. However, a patient with a past infection should NOT have detectable hepatitis B surface antigen, since they've cleared the virus. 4) A patient with chronic hepatitis B infection. This patient will have a positive viral surface antigen and a positive core antibody, but a negative surface antibody.

Most common causes of SIADH

1) Cancer - ectopic production of ADH by small cell lung cancers or pancreatic malignancies 2) CNS disturbances - traumatic injuries, strokes, infections, and hemorrhages can all cause increased ADH production 3) Drugs - most commonly caused by antipsychotic medications or chemotherapeutics, but the old (and seldom used) insulin secretagogue chlorpropamide is a commonly-tested causative agent

Intussusception key points

1) Intussusception is the most common cause of intestinal obstruction in ages 6 months to 36 months, but is very rare before 3 months and after 6 years of age. 2) Based on history and physical, if you have a high index of suscpicion for intussusception, it is appropriate to make the diagnosis using contrast enema, skipping other imaging modalities. 3) Water soluble contrast is used if perforation is likely, while barium contrast is appropriate only after perforation is ruled out. The new standard is an air contrast enema, which is just as efficacious as the others while also being cheaper and avoiding radiation exposure. 4) Surgery is needed if non-operative reduction is incomplete, a filling defect or mass persists, or perforation occurs (a risk of contrast enema)

Key features of ITP

1) There are two groups of patients who get ITP: children from 2-4, and adults (usually women) in their 20s-40s. Children in general do much better with the disease: over 80% of children will have a spontaneous remission of their disease, while only 20% of adults have a sustained remission. 2) It is extremely important to rule out other diseases before you make the diagnosis of ITP

Key features stevens-johnson syndrome

1) widespread blisters and 2) mucous membrane eruptions - if epidermal detachment is more than 30% --> TEN

PUBERTY POINTZ

1. Females: breast budding --> development of hair --> growth spurt --> menarche 2. Precocious in girls younger than 7-8 or boys younger than 8-9

Factors that place a patient into moderate or high risk for lung malignancy:

1. Only individuals less than 35 are considered low risk 2. >3 cm more likely to be malignant (only less than 2 can be considered low risk) 3. Benign are smooth and well-circumscribed, calcifications often seen

All diabetics should have a systolic less than?

130

When is hypercalcemia a medical emergency?

14 + --> heart conduction abnormalities EKG, fluids and furosemide (loops lose calcium)

When is maternal serum alpha feto-protein level typically checked?

15-20 weeks

Especially high risk strains of HPV

16 18 31

Onchomycosis treatment

3 months of po terbinafine and itraconazole *be sure to check LFTs prior to starting*

Definition of recurrent pregnancy loss (RPL)

3+ consecutive losses before the 20th week of gestation

Genetics of retinoblastoma

40% of parents have mutations to both RB tumor suppressor genes

Testicular feminization syndrome

46 XY Primary amenorrhea Dysfunction or absence of testosterone receptor --> phenotypic female with male chromosomes (well that is not pleasant)

Cefepime pearls

4th gen cephalosporin Good pseudomonas coverage Good for nosocomial infections

PSC association

80% of patients with PSC have coexisting IBD (usually UC)

LDL target in patients with known coronary heart disease

<100

When are PPDs positive in HIV/AIDS population

>5 mm induration

14. A 74 year old man presents with double vision. He first noticed this several months ago, and although his symptoms wax and wane, he now experiences daily episodes of "seeing double," most frequently in the evenings. He also reports increased generalized fatigue and notes that he sometimes gets so tired at dinner that he "can hardly chew" his food. Past medical history includes osteoarthritis, hypertension, and abdominal aortic aneurysm repair. Physical examination reveals a comfortable, age-appropriate elderly gentleman with mild dysarthria. Cardiac auscultation reveals both an S4 and a 2/6 holosystolic murmur heard best at the left upper sternal border with radiation to the carotids. On neurologic exam, the patient has 5/5 strength proximally and distally. Sensation is intact and reflexes are 2+ throughout. Ocular movements are sluggish but intact in all directions. The patient has mild bilateral ptosis, which is noted to increase with sustained upward gaze. Stroking the bottom of the foot results in downward deflection of the great toe bilaterally. Which of the following is the most appropriate next step in diagnosis? A. Administer IV edrophonium B. CT of the chest C. MRI/MRA of brain and cerebral vessels D. Temporal artery biopsy E. CSF examination for oligoclonal bands

A. Administer IV edrophonium

44. A 22 year old first year law student comes to the physician with amenorrhea for the past four months. The patient admits having been under a great deal of stress adjusting to the academic burden of law school, but did finish her first semester with a 3.7 GPA. Upon questioning, she acknowledges eating large amounts of food such as an entire large pizza when she is feeling stressed. She feels guilty after she eats, however, and forces herself to vomit it all up. The rest of the time, she eats a "normal diet" of salads and granola. Physical examination reveals an extremely thin female, with height is 69 in. (175 cm), weight is 103 lbs. (47 kg). There is diffuse fine hair growth on the extremities and mild erosion of the enamel of the anterior teeth. A callus is present on the dorsal surface of the index and middle fingers of the patient's right hand. TSH is within normal limits. A urine pregnancy screen is negative. Which of the following is the most appropriate diagnosis in this patient? A. Anorexia nervosa B. Obsessive-compulsive disorder C. Borderline personality disorder D. Bulimia nervosa E. Hyperprolactinemia

A. Anorexia nervosa

8. A 25 year old student presents with three days of vulvar pruritis. She has had a total of six lifetime partners, and is currently sexually active with one partner and states that they "occasionally" use condoms. One year ago, she was successfully treated for a Chlamydia infection. The patient denies vaginal odor or increased vaginal discharge. Physical exam reveals slight vulvar erythema, and speculum exam shows moderate clumpy white discharge. Vaginal discharge pH is 4.0. Whiff test is negative. Wet mount results: KOH prep shows occasional budding yeast and hyphae. Saline prep shows 3 WBCs, occasional squamous cells, and no bacteria. What is the next best step in the management of this patient? A. Clotrimazole vaginal cream B. Azithromycin and recommend that her partner see a physician for Chlamydia screening and treatment C. Metronidazole D. Ceftriaxone E. Reassurance and f/u in 2 weeks

A. Clotrimazole vaginal cream This is a classic case of vulvovaginal candidiasis, which is usually treated with a single dose of oral fluconazole or several days of miconazole or clotrimazole vaginal creams

How to remember pre-renal azotemia

If the kidneys can retain more BUN than creatinine, they must be intrinsically functioning okay

33. A 24 year old male comes to his physician after noticing multiple "bumps" on his hands and legs. There is a burning sensation in the lesions, but they do not itch. Eight days prior, the patient was found to have cold agglutinins and was started on erythromycin to treat Mycoplasma pneumoniae. The patient denies any recent travel or sick contacts, but does work with immigrants at his job as an immigration officer. Physical examination reveals numerous vesiculobullous lesions symmetrically on the palms of the hands and on the extensor surfaces of the arms and lower legs. A photograph of this patient's lesions is seen here. Which of the following is the most likely diagnosis in this patient? A. Erythema multiforme B. Smallpox C. Fixed drug eruption D. Stevens-Johnson syndrome E. Rocky Mountain spotted fever

A. Erythema multiforme

11. A 30 year old female comes to her physician's office for a routine health examination. She has been in good health recently and is up to date with her gynecological examinations. Her only medication is loratadine for seasonal allergies and ibuprofen for occasional headaches. Physical examination shows temperature 37.1 C (98.8 F), pulse 80, BP 170/92, RR 14, oxygen saturation of 99% on room air. A 3/6 mid-systolic ejection murmur is present. Abdomen is nontender with a soft systolic-diastolic bruit that lateralizes to the left side. The patient is grossly intact neurologically, and fundoscopic examination shows sharp optic disc margins. Laboratory evaluation shows Na+ 141, K+ 3.9, Cl- 106, HCO3- 27, BUN 18, Cr 1.0, glucose 98. Urinalysis shows trace proteinuria and no casts. What is the most likely pathological mechanism causing this patient's hypertension? A. Fibromuscular dysplasia B. Oversecretion of aldosterone C. Exogenous administration of corticosteroids D. Atherosclerotic disease E. Catecholamine-producing tumor

A. Fibromuscular dysplasia

A 30 year old female comes to her physician's office for a routine health examination. She has been in good health recently and is up to date with her gynecological examinations. Her only medication is loratadine for seasonal allergies and ibuprofen for occasional headaches. Physical examination shows temperature 37.1 C (98.8 F), pulse 80, BP 170/92, RR 14, oxygen saturation of 99% on room air. A 3/6 mid-systolic ejection murmur is present. Abdomen is nontender with a soft systolic-diastolic bruit that lateralizes to the left side. The patient is grossly intact neurologically, and fundoscopic examination shows sharp optic disc margins. Laboratory evaluation shows Na+ 141, K+ 3.9, Cl- 106, HCO3- 27, BUN 18, Cr 1.0, glucose 98. Urinalysis shows trace proteinuria and no casts. What is the most likely pathological mechanism causing this patient's hypertension? A. Fibromuscular dysplasia B. Oversecretion of aldosterone C. Exogenous administration of corticosteroids D. Atherosclerotic disease E. Catecholamine-producing tumor

A. Fibromuscular dysplasia

76. A 57 year old male presents with three weeks of fatigue. He denies depressed mood, palpitations, changes in bowel habits, syncope, or new medications. On physical examination, the patient's temperature is 36.7 C (98.6 F), pulse 100, and blood pressure 126/82. Peripheral pulses are 2+, but are noted to be irregularly irregular. Breath sounds are equal bilaterally, and there is no peripheral edema. Initial troponin I is not elevated. The patient is started on intravenous diltiazem, and an EKG is obtained. The patient's EKG is seen here. Which of the following is the most appropriate next step in the management of this patient? A. Heparin and warfarin B. Cardiac catheterization C. Cardiac defibrillator implantation D. Ibutilide E. Electrical conversion

A. Heparin and warfarin

89. A 46 year old homeless man is brought to the hospital after passersby witnessed him having convulsions on the street. On physical examination, the patient is disheveled, unshaven, and has a faint odor of alcohol on his breath. He is semicomatose, and arouses only to pain. Vital signs are temperature 38.3 C (101 F), pulse 115, blood pressure 166/96, respirations 15/min, and oxygen saturation 98% on room air. There is a 4cm simple laceration on his left temple. There are no other visible injuries, and the remainder of the physical examination is normal. Laboratory evaluation shows the following: Hematocrit 38%; mean corpuscular volume 109 fL; sodium 133 mEq/L; glucose 62 mg/dL; magnesium 1.0 mEq/L; albumin 3.0 g/dL; ALT 60 IU/L; AST 123 IU/L; PT 19 s. The patient is placed in mechanical restraints and i.v. fluid with glucose, thiamine, folate, and magnesium is begun. Which of the following is the most appropriate next step in the management of this patient? A. IV diazepam B. Oral phenobarbital C. MRI of head/neck D. LP E. IV somatostatin

A. IV diazepam

78. An 18 year old college student presents with the sudden onset of fever, headache, myalgias, and nausea and vomiting twelve hours ago. He also complains of neck stiffness and photophobia. Vital signs include temperature 39.7 C (103.5 F), pulse 120, blood pressure 95/60, and respirations 20/min. On physical examination, he is somnolent but arousable. There is pronounced nuchal rigidity. With the hips flexed, attempts to straighten the knee result in spasm of the hamstrings. Small, 1-2mm petechial lesions are present on the trunk, legs, and soft palate. Therapy with intravenous fluid and supplemental oxygen is begun, and lumbar puncture is performed. Which of the following is the most likely finding on CSF analysis in this patient? A. Increased WBC with neutrophilic predominance, increased protein, decreased glucose B. Increased protein with oligoclonal bands of IgG C. Xanthrochromia and increased RBCs D. Increased WBC with lymphocytic predominance, increased protein, normal glucose E. Increased WBC with lymphocytic predominance, numerous RBCs, elevated protein, normal glucose

A. Increased WBC with neutrophilic predominance, increased protein, decreased glucose

106. A 23 year old woman presents with a two week history of bloody discharge from her right breast. Family history is significant for a 58 year old aunt who was recently diagnosed with breast cancer. On physical examination, the right breast is slightly tender to palpation in the area of the nipple. There are no masses, and the skin shows no dimpling, retractions, or inflammatory changes. There is no axillary adenopathy. Urine beta-hCG is negative. Which of the following is the most likely diagnosis in this patient? A. Intraductal papilloma B. Infiltrating ductal carcinoma C. Acute mastitis D. Paget's disease of the breast E. Fibroadenoma

A. Intraductal papilloma (most common cause of isolated bloody nipple discharge in a healthy young female)

A 23 year old student has the acute onset of dizziness and nausea and vomiting. He feels like the room is rotating around him to the left. Six days ago, he had a low-grade fever, myalgias, and a sore throat, which resolved yesterday. He denies a history of similar episodes, and his past medical history is entirely benign. Physical examination reveals mild hearing loss on the left and horizontal nystagmus that resolves when the patient looks at a fixed object. Tympanic membranes are clear. Though the patient is able to ambulate, he shows marked gait instability. There is a positive head thrust test. There is no dysarthria, motor weakness, sensory loss, facial droop, or limb dysmetria observed. Which of the following is the most likely diagnosis in this patient? A. Labyrinthitis B. Cerebellar infarction C. Benign paroxysmal positional vertigo D. MS E. Suppurative otitis media

A. Labyrinthitis

Situations when you should absolutely treat onchomycosis

Hx of LE cellulitis with ipsilateral toenail infection Diabetics with CVI, edema or prior cellulitis Patients in pain

64. An 18 month old male presents for a well-child examination. While observing the child playing in his mother's lap, it appears that the child has a wandering right eye. The patient's mother denies any family history of visual disorders or cancer, and says that the child has appeared completely healthy lately. On physical examination, there is no tenderness to mild pressure on either eye. Sclera are non-injected. A white pupillary reflex is present on the right. With the child visually fixed on a toy, each of his eyes are separately covered and then uncovered. There is no eye movement when the patient's right eye is covered and rapidly uncovered, but the patient's right eye refixates on the toy when the left eye is covered and then uncovered. What is the most appropriate next step in the management of this patient? A. MRI of head B. Occlusion of left eye with patch C. Occlusion of right eye with patch D. Atropine eye drops E. Reassurance

A. MRI of head

36. A 3 year old male is brought to the physician by his mother after she noted multiple bruises on his body. She denies any recent trauma. Two weeks ago, the patient had three days of cough and low-grade fever that resolved without antibiotic therapy, but since that time he has been well. Past medical history is otherwise unremarkable. The patient is up-to-date on all required immunizations. On physical exam, the patient is afebrile and playing happily at his mother's feet in the examination room. There are no peritonsillar exudates. Tympanic membranes are clear. There is no abdominal tenderness or organomegaly. Examination of the skin shows diffuse and numerous petechiae and purpura. Laboratory analysis reveals the following: WBC 7.5 k/mcL; hemoglobin 12 g/dL; hematocrit 36%; platelets 27 k/mcL; total bilirubin 0.7 mg/dL; AST 22 U/L; ALT 18 U/L; alkaline phosphatase 120 U/L; LDH 186 U/L; PT 11 s (normal 11-13s); PTT 22 s (normal 20-30s). Which of the following is the most appropriate initial treatment for this patient's disorder? 120 U/L; LDH 186 U/L; PT 11 s (normal 11-13s); PTT 22 s (normal 20-30s). Which of the following is the most appropriate initial treatment for this patient's disorder? A. Prednisone B. Ceftriaxone C. Vincristine D. Cyclophosphamide E. Immediate platelet transfusion

A. Prednisone (ITP)

12. A 23 year old male presents with syncope. He reports that while walking briskly to his car, he felt his heart "racing" in his chest, and shortly thereafter passed out. The patient denies any prior syncopal episodes, but does note occasional episodes of palpitations that occur after moderate activity or during periods of increased stress. There is no family history of neurological disease, cardiac disease, or sudden cardiac death. On physical examination, pulse is 85 and regular, BP is 124/74, respiratory rate is 16, and oxygen saturation is 98% on room air. Cardiac examination reveals pulsation at the fifth intercostal space at the left parasternal area in the midclavicular line. S1 is within normal limits, and S2 is heard to split on inspiration. The remainder of the physical exam is unremarkable. EKG taken in the office shows the following tracing in lead II. Which of the following would be the most appropriate treatment for this patient's disorder? A. Radiofrequency ablation of pre-excitation pathway B. Urgent DC cardioversion C. Heart transplant D. Biventricular pacemaker placement E. Coronary angioplasty

A. Radiofrequency ablation of pre-excitation pathway

A 29 year old female medical student comes to her physician with gallstones after serving as a model patient for a demonstration of abdominal ultrasound techniques. The stones were located within the gallbladder, and the patient was surprised at this finding, because she never had experienced any pain. Physical examination reveals a comfortable, afebrile, obese female. Murphy's sign is negative. Laboratory examination shows the following: WBC 7.0 K/mm3; albumin 4.2 g/dL; Alkaline phosphatase 72 U/L; ALT 16 IU/L; AST 19 IU/L; total bilirubin 0.3 mg/dL; conjugated bilirubin 0.1 mg/dL; lipase 18 U/L (normal: 10-140 U/L). Which of the following is the most appropriate next step in the management of this patient? A. Reassurance B. ERCP C. Abdominal CT D. Ursodeoxycholic acid E. Cholecystectomy

A. Reassurance

111. A 9 year old African-American female is brought to the physician by her mother, who is concerned about a "lump" in the patient's left breast. She noted this lump two weeks ago, and is concerned because the patient's grandmother was recently diagnosed with breast cancer. The child is otherwise well, and has not yet had onset of menses. On physical examination, the left breast and areola are enlarged and are Tanner stage 3. There is a small tender mass beneath the areola on the left. The right breast is flat and prepubertal. There is no axillary adenopathy. The external genitalia are grossly normal, and are covered with fine velus hair. Which of the following is the most appropriate next step in the management of this patient? A. Reassurance and anticipatory guidance B. Transdermal ethinyl estradiol C. Measurement of serum luteinizing hormone (LH) level D. Mammography E. Open biopsy of breast

A. Reassurance and anticipatory guidance (unilateral onset of breast development is common....and commonly tested)

99. A 25 year old graduate student returns to her physician with complaints of abdominal pain and diarrhea, which have been persistent nearly a year. She continues to experience nearly-daily episodes of postprandial abdominal pain and visible abdominal distension, which are relieved by the passage of stool. During these episodes, her stools are loose and gassy, and while she denies ever passing blood in her stool, she has periodically noticed large quantities of mucus. Workup to this point has been unrevealing, and has included thyroid function tests, colonoscopy, celiac sprue antibodies, and fecal occult blood testing. She denies fevers, weight loss, nausea and vomiting, and reflux symptoms. The patient's past medical history is significant only for depression, which is well controlled with sertraline. On physical examination, the patient appears healthy. She has normoactive bowel sounds and a nontender abdomen. Hemoccult is negative. Which of the following is the most appropriate next step in the management of this patient? A. Reassurance, education, and dietary modification B. Barium enema C. Culture of the stool for ova and parasites D. Mesalamine E. Exploratory laparotomy

A. Reassurance, education, and dietary modification (IBS)

27. In order to obtain a job at a prison, a 34 year old man undergoes a required chest x-ray to screen for tuberculosis. A 14mm rounded opacity is noted, surrounded by normal lung tissue. There are small calcifications within the opacity, but no adenopathy or atelectasis is seen radiographically. The patient has never smoked and has no known exposures to tuberculosis. There is no family history of lung cancer or other malignancy. On physical exam, the patient has temperature 37.0 C (98.6 F), pulse 76, blood pressure 130/83, respirations 14/min. Lungs are clear to auscultation and percussion. No nail clubbing is seen. Which of the following is the most appropriate next step in the management of this patient? A. Repeat CXR in 3 months B. Begin rifampin, isoniazid, pyrazinamide and ethambutol C. Bronchoscopy D. CT guided needle biopsy E. Thoracotomy

A. Repeat CXR in 3 months

59. A 51 year old supermarket cashier has had worsening pain and tenderness of her left leg. Her symptoms have been worsening for the past two days, ever since she had to work three consecutive days of "double shifts" due to a co-worker's absence. Medications include lisinopril for hypertension and hormone replacement therapy for hot flashes. Physical examination shows an obese female with temperature 38.1 C (100.5 F), pulse 88, BP 136/84, and respirations 14/min. There are numerous prominent varicose veins on the legs bilaterally. The left leg has a 6 inch (15 cm) linear area of erythema and edema on the medial aspect of the knee and calf, with a palpable, nodular, cordlike structure located just underneath the skin. Doppler ultrasonography is performed on both legs and shows a single thrombus extending from the middle to distal saphenous vein on the left. Which of the following is the most appropriate next step in management of this patient's condition? A. Rest, elevation, non-steroidal anti-inflammatory agents, and heat B. Enoxaparin C. Warfarin D. Spiral CT of the chest E. Placement of inferior vena cava filter

A. Rest, elevation, non-steroidal anti-inflammatory agents, and heat (superficial thrombophlebitis)

51. A 56 year old man returns to the office because his calcium was found to be elevated at a previous visit. Although the remainder of his labs, including complete blood count, liver panel, and chemistries were all within normal limits, the patient's calcium was 11.9 mg/dL (normal: 8.5-10.5 mg/dL). The patient feels well and has no complaints. Current medications include verapamil, cetirizine, and atorvastatin. EKG shows a right bundle branch block, stable from previous. Which of the following is the most appropriate initial step in the management of this patient? A. Serum parathyroid hormone level B. CT of chest/abdomen C. Genetic testing for multiple endocrine neoplasia, type 1 D. Discontinue verapamil E. Intravenous saline and furosemide

A. Serum parathyroid hormone level (over 80-90% of hypercalcemia is caused by malignancy or hyperparathyroidism)

Classic trial of congenital toxo

Hydrocephalus Chorioretinitis Intracranial calcifications

115. A 27 year old G2P2A0 at six weeks postpartum presents with depressed mood, dry skin, and problems breast feeding. Though she was initially able to breastfeed without difficulty, she has been unable to produce adequate lactation to feed her daughter, and lately her milk has completely "dried up." Her most recent pregnancy was uneventful, but delivery of her healthy female infant was complicated by severe uterine atony requiring multiple blood transfusions and treatment with prostaglandins. On physical examination, the patient has a blood pressure of 90/64. Skin tenting and fine wrinkles are noted around the eyes and mouth. There are diminished deep tendon reflexes with a prolonged relaxation phase. Laboratory evaluation is notable for a hemoglobin of 10.5 g/dL, thyroid stimulating hormone of 0.1 U/mL, and prolactin of 2 ng/mL (normal 0-20 ng/mL). Which of the following is the most likely diagnosis in this patient? A. Sheehan B. Graves C. Uterine rupture D. Hashimoto thyroiditis E. Pituitary prolactinoma

A. Sheehan

60. An otherwise healthy 26 year old female presents to her family physician with a rash on her neck. She just noticed it yesterday, but it is pruritic and painful. The patient has not been outdoors, and cannot think of anything in particular that could have caused the rash, other than perhaps using a new hairspray in preparation for her best friend's wedding several days ago. On physical exam, there is a papular and vesicular erythematous rash in a thin linear pattern that encircles her lower neck. The remainder of her physical exam is normal. What is the most appropriate initial step in the management of this patient? A. Topical steroid cream B. Oral prednisone C. Reassurance D. IgE testing E. Oral abx

A. Topical steroid cream (contact dermatitis)

97. A 10 year old boy returns to the physician for a non-healing rash on his arms, legs, and face. Two weeks ago, he initially developed a small, intensely pruritic area of erythema on his arm that progressed into small fluid-filled blisters. He was initially treated with prednisone for contact dermatitis, but after the rash continued to spread, he was given a prescription for cephalexin. Despite finishing the course of cephalexin, the rash has continued to spread to his legs, neck, and face. The patient's immunizations are up-to-date, and he has never been hospitalized and takes no chronic medications. On physical examination, the child is comfortable and pleasant, with vital signs including temperature 36.8 C (98.2 F), pulse of 90/min, blood pressure 100/68, and oxygen saturation of 99% on room air. There are numerous linear areas of erythema and excoriation are noted on the patient's arms, legs, neck, and face. The lesions appear to be in various stages of evolution: some are vesicular, while some are covered with a golden-yellow crust. Gram stain of one of the lesions shows numerous Gram-positive cocci in clumps. Which of the following is the most appropriate treatment for this patient at this time? A. Trimethoprim-sulfamethoxazole B. Acyclovir C. Dicloxacillin D. Vancomycin E. Varicella zoster immune globulin (ZVIG)

A. Trimethoprim-sulfamethoxazole (impetigo)

When is chest CT indicated for MG?

AFTER the primary diagnosis is made

Classic triad henoch-Schonlein purpura:

Abdominal pain Vasculitic, raised skin rash Renal involvement

Dihydroergotamine

Abortive therapy for migraines Has the potential for coronary and cerebral vasoconstriction, only used in those who do not respond to triptans

When do most patients start to show symptoms of hyperkalemia?

Above 7.0 Muscle weakness progressing to flaccid paralysis

PANDAS treatment

Abx can improve OCD symptoms

When is a ceftriaxone injection used for STDs?

Acute gonorrhea

Medical cause of acute abdomen

Addisonian criasis --> peritoneal signs

Most common cause primary glomerulonephritis?

IgA nephropathy

Atropine eye drops in amblyopia

Administration of atropine into the eye with better vision causes pupillary dilation and loss of accommodation, forcing the eye with worse vision to work harder. It's the same principle as occlusion therapy, but doesn't force a child to wear a patch (which can be difficult to do!)

When is a fib considered chronic?

After 7 days

Two most common causes of acute pancreatitis in the US

Alcohol abuse --> thickens pancreatic secretions and contracts the sphincter of Oddi Gallstones --> obstruction

Mechanism underlying type IV RTA

Aldosterone deficiency --> inability to absorb Na+ at the intercalated cells of collecting duct --> hyponatremia, hyperkalemia and non-anion gap acidosis

HIV prophylaxis

All patients: pneumococcal, influenza Below 200: bactrim (toxo and PCP) Below 50: azithromycin (MAC)

Gonorrhea screening:

All sexually active females <25 years old

Effect of calcium gluconate with hyperkalemia?

Although this does not affect the serum K+ concentration, calcium does decrease cardiac membrane excitability and provide short-term cardioprotection from the membrane depolarizing effects of hyperkalemia

Management of leukocoria

Immediate diagnosis with CT/MRI and surgery

Most common abx for COPD exacerbations

Amoxicillin Bactrim Doxycycline

Fun fact about lumbar spinal stenosis

An older patient with back pain that is worst while standing and walking but is relieved by sitting or spinal hyperflexion has lumbar spinal stenosis

Meropenem pearls

Anti-pseudomonal

How to treat bacteruria of pregnancy

Antibiotics to reduce risk of pyelo, even if ASYMPTOMATIC

Pathophysiology of Lambert-Eaton?

Antibodies are produced against the pre-synaptic Ca2+ channels

MG treatment

Anticholinesterase drugs (neostigmine, pyridostigmine) Prednisone, immunosuppressives

What should you try to do first in someone with a fib

Anticoagulant them

Common presenting symptom of infants with RSV

Apnea

Amyloidosis pearls

Apple green birefringence under polarized light with congo red stain Associated with MM, TB, RA, etc Progressive renal failure

Postinfectious glomerulonephritis latent period?

Around 10 days for pharyngitis *for glomerulonephritis following streptococcal impetigo, the latent period can be as long as 3-4 weeks

RhoGAM is typically given?

Around 28 weeks

Development of angina, syncopa or HF in AS is?

Associated with crappy prognosis Most die in 2-3 years, have high risk of SCD

Methacholine challenge test

Asthmatic --> breathes in methacholine --> significant decrease in FEV1

Ddx gout vs. pseudogout

Joint aspiration findings Gout --> monosodium urate --> needle-shaped and negatively birefringent Pseudogout --> rhomboidal

PE with meniscal injury

Joint line tenderness Pain or clicking on McMurray test

Big gun antibiotics do NOT treat?

Atypical causes of PNA (mycoplasma, chlamydia, legionella)

Pathophysiology of MG:

Autoantibodies that bind to postsynaptic ACh receptors

Genetics of tourette's

Autosomal dominant

Von Willebrand's genetics:

Autosomal dominant

Legg-Calve-Perthes Disease PE

Limited IR and abduction of the hip

52. An 83 year old female with dementia is brought to the physician by her granddaughter because of a change in her skin color, which has taken on a golden hue over the past few days. The patient's granddaughter also reports that she has been unable to get the patient to eat or drink for the past 24 hours, and that although the patient's urine output has decreased, her urine appeared dark brown when she changed her diaper this morning. Vital signs are temperature 39.1 C (102.4 F), pulse 105, blood pressure 77/45, respiratory rate 24, oxygen saturation 96% on room air. On physical examination, the patient is somnolent but arousable to pain. The skin is jaundiced and the sclerae are icteric. Lungs are clear to auscultation. Abdominal examination reveals decreased bowel sounds, with diffuse tenderness to palpation. There is voluntary guarding of the right upper quadrant. Which of the following is the most appropriate next step in management for this patient? A. Abdominal CT B. Administer 1 L bolus of 0.9% NaCl C. Begin i.v. nafcillin D. Urgent endoscopic retrograde pancreaticoduodenoscopy (ERCP) E. Percutaneous transhepatic drainage tube placement

B. Administer 1 L bolus of 0.9% NaCl

45. A 18 month old female is brought to the physician by her mother, who is concerned that her child is in pain. The child has had spells of intense sceaming and crying for the past few hours; during these episodes the child doubles over and curls up into a ball. The mother also reports two episodes of non-bilious, non-bloody vomit. The mother initially thought that the patient may have caught a virus at day care, but she became more concerned one hour ago when her daughter had a bowel movement and the stool seemed to be slimy with a purplish color. On physical exam, a sausage shaped abdominal mass is palpated in the right abdomen. There is no abdominal rigidity, guarding, or rebound tenderness. An abdominal ultrasound reveals a "bull's eye" or "coiled spring" appearing lesion. The patient is made n.p.o., i.v. fluids are started, and a nasogastric suction is begun. What is the next best step in the management of this patient? A. CT scan B. Air contrast enema C. Surgery D. Colonoscopy E. Administer a glycerin suppository

B. Air contrast enema (intussusception)

Toxic megacolon defined

The definition of toxic megacolon is total or segmental nonobstructive colonic dilation plus systemic toxicity. Although IBD is the most frequent cause, it can be caused by colon cancer, C. difficile infection, ischemic bowel disease, or volvulus

39. A 37 year old teacher has had three months of non-productive cough. The cough seems to be worst at night and upon awakening in the morning. She denies fevers, dyspnea, chest pain, wheezing, purulent nasal discharge, or heartburn. Past medical history includes IBS and hypertension. Medications include candesartan and an oral contraceptive pill. She has never smoked or traveled outside of the United States. Physical examination reveals an afebrile, well-nourished, healthy appearing female. The oropharynx is moist and without erythema or exudates. Nasal mucosa is pink and slightly edematous. Breath sounds are clear to auscultation bilaterally. First and second heart sounds are within normal limits, and no additional heart sounds or murmurs are noted. There is no peripheral edema. Chest x-ray shows normal lung fields. Which of the following is the most appropriate intervention at this time? A. Stop candesartan B. Begin antihistamine and decongestant C. Amoxicillin/clavulanate D. Place tuberculin purified protein derivative (PPD) E. Chest CT

B. Begin antihistamine and decongestant

37. A 36 year old construction worker is brought to the emergency room after a house frame collapsed on him. His upper thighs were trapped under a heavy wooden beam for almost two hours while his co-workers worked to free him. Vital signs are temperature 37.2 C (99.0 F), pulse 90, blood pressure 136/82, respirations 16/min. The patient is alert and oriented, but obviously in pain. There are occasional superficial abrasions on the face and arms, but no large lacerations are noted. Breath sounds are present and equal bilaterally. There is a normal S1 and S2. Abdomen is nontender, nondistended, and atraumatic. The patient's legs show bilateral ecchymoses and tenderness at the upper thigh. Dorsalis pedis and posterior tibial pulses are 2+, and distal leg sensation to light touch and pinprick is intact. Laboratory analysis shows the following Na+ 145; K+ 5.3; Cl- 101; bicarbonate 22; BUN 17; creatinine 1.1; glucose 106. Dipstick urinalysis is unremarkable except for 4+ blood. Microscopic urinalysis shows 2 WBCs/hpf, 0 RBCs/hpf, 3 epithelial cells/hpf, and no casts. What is the most appropriate next step in the management of this patient? A. Intubation and mechanical ventilation B. Bolus with 2 L i.v. 0.9% NaCl solution C. Cystoscopy D. Intravenous pyelogram E. Abdominal and pelvic CT

B. Bolus with 2 L i.v. 0.9% NaCl solution

28. A 7 year old girl is brought to her physician because her parents are concerned that she is shorter than all of her classmates. The patient's past medical history is benign, and she is otherwise healthy and thriving at home and at school. Her mother is 61 in. (155 cm) and her father is 67 in. (170 cm) tall. In reviewing her old records, it appears that her growth velocity is normal. Physical examination shows the child to be in the 3rd percentile for her age for both height and weight. The patient is Tanner stage 1 and is otherwise developmentally appropriate. The remainder of physical exam is normal. What is the most appropriate next step in the management of this patient? A. Reassurance B. Bone age C. HIV testing D. Serum IGF-1 E. Serum GH level

B. Bone age

57. A 34 year old female presents to her family physician in tears because she wants to have a baby. She has had three second trimester miscarriages over the past five years. She and her husband, who has two children from a previous marriage, desperately want to conceive, and their failure to do so has begun to cause stress in their marriage. The patient is otherwise healthy, and there is no history of sexually-transmitted infections or hematologic or rheumatologic diseases. Menarche began at age 11 and her menses are regular at intervals of 25 days. Her pelvic exam reveals a slightly retroverted uterus and normal size ovaries. What is the most likely etiology of this patient's recurrent pregnancy losses? A. Maternal balanced translocation B. Cervical incompetence C. Paternal balanced translocation D. Retroverted uterus E. Amniotic band syndrome

B. Cervical incompetence

How to confirm yeast infection

The diagnosis of candidiasis should be confirmed by finding budding yeast and hyphae on the 10% KOH wet mount.

88. A 38 year old woman has sudden onset of nausea and vomiting and severe, colicky flank pain that radiates to the perineum. On physical examination, the patient shifts position frequently and seems unable to sit still. Urinalysis shows trace protein, 3+ blood, pH = 7.2. Microscopic analysis shows many red cells and a few white cells, but no casts or bacteria. Laboratory analysis shows: Na+ 141 K+ 3.0, Cl- 119, HCO3- 12, BUN 17, Creatinine 1.0, glucose 111, calcium 9.8, magnesium 1.6, phosphate 3.0. Which of the following is the most likely etiology of this patient's electrolyte abnormalities? A. Increased production of endogenous lactic acid B. Decreased net secretion of H+ at the distal renal tubule C. Deficiency of aldosterone D. Excessive release of parathyroid hormone E. Physiological stress response to pain

B. Decreased net secretion of H+ at the distal renal tubule

24. A 15 year old girl is referred from her dentist after she bled excessively following extraction of her wisdom teeth. She also reports prolonged menses lasting 8-10 days and recurrent epistaxis. Her mother experienced lengthy postpartum bleeding after the delivery of all three of her children. Physical examination reveals scattered petechiae. Laboratory analysis shows: WBC 7.6; Hemoglobin 9.8; Hematocrit 29.1; Platelets 229; PT 12 s (normal 11-15s); aPTT 35 s (normal 20-35s); Bleeding time 13 min (normal 2-7 min). Which of the following is the most appropriate treatment for this patient's disorder? A. Plasmapharesis B. Desmopressin C. Factor VIII concentrate D. Hydroxyurea E. Splenectomy

B. Desmopressin

61. A 10 year old girl presents with several months of diarrhea and flatulence. Her parents report that despite the fact that she has been eating well, she has had a small weight loss during this period. She denies blood in her stool, but does report that her stools have been quite foul smelling and greasy. Physical examination reveals a pale, thin girl with blonde hair and blue eyes. Bowel sounds are slightly hyperactive, and there is no tenderness to palpation. Lungs sounds are normal. There is an erythematous, papulo-vesicular rash with signs of excoriation bilaterally at the knees and elbows. Laboratory evaluation shows serum anti-tissue transglutaminase (anti-TTG) antibodies are elevated. Which of the following is the most appropriate next step in the management of this patient? A. Loperamide B. Dietary avoidance of wheat, barley and oats C. Chloride sweat test D. Rectal biopsy E. Amoxicillin

B. Dietary avoidance of wheat, barley and oats (celiac disease)

42. A 71 year old male with a history of coronary artery disease and congestive heart failure presents with worsening dyspnea on exertion, orthopnea, and peripheral edema over the past week. Two years ago, he had a coronary stent placed in his circumflex artery. Catheterization at that time showed an ejection fraction of 25%, and since that time the patient had been stable with medical therapy. Past medical history also includes diabetes, hypertension, and peripheral arterial disease. Current medications include clopidogrel, lisinopril, propranolol, bumetanide, spironolactone, glipizide, and metformin. Physical examination reveals diffuse crackles bilaterally extending from the lung bases to two-thirds of the way up the lung fields. An S3 is heard, and there is 3+ pitting edema of the lower extremities bilaterally. Chest x-ray shows cardiomegaly and pulmonary edema in a "bat wing" pattern. The patient is admitted to the hospital, placed on a fluid restriction, and treated with intravenous furosemide. Following a net diuresis of 3 L, the patient feels much better. Which of the following is the next most appropriate step in the management of this patient? A. Measurement of BNP B. EKG C. ABG D. Increase propranolol E. Endomyocardial biopsy

B. EKG

5. An otherwise healthy 8 year old girl presents with two weeks of perianal pruritis. She has two younger brothers, one of whom has had similar complaints for the past few days. Physical exam reveals perianal erythema with mild excoriations. The "scotch tape test" reveals several bean-shaped white eggs. What is the most likely diagnosis in this patient? A. Trichuriasis B. Enterobiasis C. Child abuse D. Fecal soliage E. Atopic dermatitis

B. Enterobiasis This is a classic case of enterobiasis (answer B) or "pinworm." The most common presenting symptom is intense anal itching or pruritus ani. Other symptoms (such as abdominal pain/fullness or nausea and vomiting) may occur if the worm burden is high. Girls may also present with a vulvovaginitis or urinary tract infection if the worms migrate. Eosinophilic enterocolitis and appendicitis are rarer complications.

86. A 53 year old female presents complaining of depression, insomnia, and increasing fatigue. She also describes occasional episodes where her face and neck become red and flushed. These frequently occur at night and wake her from sleep. Her last menstrual period was five months ago. Her menses had been irregular for one year, but before then, her menstrual history was normal. Physical exam is remarkable for an atrophic vaginal mucosa with decreased secretions. Which of the following diagnostic tests is most likely to menstrual history was normal. Which of the following diagnostic tests is most likely to confirm the cause of this patient's amenorrhea? A. Urine beta-hCG B. FSH C. TSH D. Karyotyping E. Prolactin

B. FSH (classic signs/symptoms/demographics of menopause) FSH will be elevated in menopause

73. A three year old male comes to the physician because of delayed speech development. The patient's mother is also concerned because her son makes poor eye contact and often repetitively bites or flaps his hands. Family history is significant for a maternal uncle with mild mental retardation. On physical exam, the patient has a long face with a large jaw and large everted ears. Further testing reveals normal hearing and vision, and an IQ of 55. Which of the following is the most likely diagnosis in this patient? A. Tay-Sachs B. Fragile X C. Down syndrome D. Prader-Willi E. Rett syndrome

B. Fragile X

112. A 4 year old Hispanic child is brought to his pediatrician after he developed swelling of his eyes and ankles over the past week. Temperature is 37.4 C (99.3 F), pulse is 120/min, blood pressure 104/61, and respirations 28/min. In addition to periorbital swelling and 2+ edema of the ankles, he has a protuberant abdomen with a positive fluid wave. Laboratory evaluation shows BUN 7 mg/dL, creatinine 0.4 mg/dL, albumin 1.4 g/dL, and cholesterol 498 mg/dL. Urinalysis shows no blood and 4+ protein. Which of the following is the most likely associated finding in this patient's disorder? A. "Apple green" birefringence under polarized light with Congo red stain B. Fusion of epithelial foot processes on electron microscopy C. Low complement C3 and increased anti-streptolysin O titer D. Presence of cytoplasmic anti-neutrophil antibody (ANCA) staining E. Granular deposits of IgG and C3 in the basement membrane

B. Fusion of epithelial foot processes on electron microscopy (minimal change disease, most common nephrotic syndrome in young children)

A 6 year old boy from Ghana presents with chest and abdominal pain for the past day. His pain began suddenly while at rest last night, is a 9/10 in intensity and unrelieved by ibuprofen, and is localized mainly to his epigastrium and left upper quadrant, back, and chest. Past medical history is unremarkable, and immunizations are up-to-date. On physical examination, the patient is afebrile and normotensive but tachycardic. Lungs are clear to auscultation, and there is moderate tenderness to palpation in the left upper quadrant. Laboratory evaluation shows a white blood count of 11,000 and a hematocrit of 31%. Chest x-ray shows no atelectasis or infiltrate, and abdominal x-ray shows no free air and moderate enlargement of the spenic silhouette. The patient is given i.v. fluids, ceftriaxone, and morphine. Which of the following is the most appropriate next step in the management of this patient? A. ELISA for HIV-1 antibodies B. Hemoglobin electrophoresis C. CT of chest D. Vancomycin E. Hydroxyurea

B. Hemoglobin electrophoresis (sickle cell disease)

119. A 33 year old female with a three year history of recurrent gastric and duodenal ulcers despite medical management is found on subsequent evaluation to have a fasting gastrin level of 989 pg/mL (normal: <100 pg/mL). Abdominal CT scan reveals a 2cm mass in the head of the pancreas, and surgical exploration is planned. Following successful resection of this mass, the patient's fasting gastrin level is found to be 1020 pg/mL. Pathological analysis of the resected specimen shows it to be a glucagonoma. Which of the following is the most likely additional associated finding in this patient? A. Squamous cell carcinoma of the lung B. Hyperplasia of the parathyroid glands C. Pheochromocytoma D. Pancreatic adenocarcinoma E. Breast carcinoma

B. Hyperplasia of the parathyroid glands (Zollinger-Ellison syndrome)

Dx of gestational diabetes

The diagnosis of gestational diabetes requires two abnormal tests: fasting serum glucose >126 mg/dL, a random glucose of >200 mg/dL, or an abnormal glucose tolerance test result (>130 or 135 for a one hour test, confirmed by abnormal results on the three hour test).

19. A 65 year old female with diabetes is found on routine screening to have a total serum cholesterol concentration of 198 mg/dL, with a serum HDL cholesterol of 58 mg/dL and serum LDL cholesterol of 128 mg/dL. Triglycerides are 78 mg/dL, and last hemoglobin A1c is 6.5%. The patient has no known history of coronary artery disease, does not smoke, and exercises daily. Current medications include rosuvastatin, fosinopril, glyburide, and metoprolol. Blood pressure is 129/78. Urinalysis shows no protein. Which of the following is the best management plan and treatment goal for this patient? A. Add niacin to increase HDL to >80 mg/dL B. Increase rosuvastatin to target LDL <100 mg/dL C. Add gemfibrozil to decrease triglycerides to <70 mg/dL D. Discontinue fosinopril and add hydrochlorothiazide to decrease blood pressure to <120/80 E. Begin insulin therapy to target Hgb A1c <6.0%

B. Increase rosuvastatin to target LDL <100 mg/dL

82. A 45 year old woman presents to her family physician complaining that the big toe on her right foot is yellow and somewhat painful at times. She noticed the discoloration of her nail last week when she removed her nail polish, and has been avoiding wearing her normal summer sandals because she feels embarrassed. She is otherwise healthy and has no history of diabetes or peripheral vascular disease. Physical exam reveals a thickened, yellow first toenail on the right foot; the other nails appear healthy. Peripheral pulses are strong and equal. There are no rashes or lesions on the surrounding skin. What is the most appropriate initial step in management of this patient? A. Griseofulvin B. KOH examination of nail scrapings C. Reassurance D. Nail removal E. Nail biopsy and culture

B. KOH examination of nail scrapings (dx of onchomycosis confirmed with dermatophytic hyphae and arthrospores)

2. A 55 year old female comes to the emergency department complaining of a headache for the past six hours. Her headache began abruptly after she finished eating breakfast, and quickly increased to 8/10 throbbing pain located mainly over her right temple. The pain has been associated with mild nausea but no vomiting. She denies chronic or recurrent headaches, but did have one headache similar to this one two weeks ago, which resolved after taking ibuprofen and lying in a quiet, dark room. She has smoked one pack of cigarettes daily for 38 years. On physical exam, the patient has temperature of 37.0 C (98.6 F), pulse of 99, and BP 147/95. Neurological examination is nonfocal, but mild photophobia and nuchal rigidity are noted. Fundoscopic examination reveals no papilledema. Skin exam shows no lesions. CT of the head, obtained without contrast, reveals no abnormalities. What is the most appropriate next step in the management of this patient? A. Obtain head CT with contrast B. Lumbar puncture C. Administer im sumatriptan D. Administer oral ibuprofen E. Administer IV ceftriaxone

B. Lumbar puncture

47. A 35 year old male with a history of bipolar disorder presents with several weeks of "depression." Though his mood is no worse than usual, he has been feeling extremely fatigued. He has also been sleeping more lately and reports a 9 lbs. weight gain over this period. He denies racing thoughts, hallucinations, or increases in goal-directed activity. Current medications include lithium and omeprazole. On physical examination, the patient has coarse facial features and slowed speech and movements. There are areas of diffuse hair loss on the scalp, as well as periorbital puffiness and non-pitting edema of the legs bilaterally. Serum lithium level is 1.45 mEq/L (normal therapeutic range: 0.50-1.50 mEq/L). Which of the following is the most appropriate next step in the management of this patient A. Decrease lithium dose by 50% B. Order thyroid stimulating hormone (TSH) and free T4 levels C. Begin escitalopram D. Begin risperidone E. Begin valproic acid

B. Order thyroid stimulating hormone (TSH) and free T4 levels (20-30% of patients on lithium will develop hypothyroidism)

120. A 17 year old female presents for follow-up of her anemia. Three months ago, routine lab work showed a hematocrit of 31%, and the patient was started on oral iron supplements. In the office today, the patient feels well and denies recent illnesses or medications, menorrhagia, hematemesis, hematochezia or melena, and trauma. Physical examination shows a comfortable female in no acute distress. There is moderate pallor of the conjunctivae bilaterally, and the spleen is palpable 1 cm below the left costal margin. There is no spooning of the nails, and position and vibratory sensation are intact on neurological exam. The stool is negative for occult blood. Further laboratory analysis shows the following: WBC 7.1 k/mL, Hgb 10 g/dL, Hct 30%, Platelets 220 k/mL; MCV 85 fL, MHC 31 pg, MCHC 39%; LDH 150 U/L, Total bilirubin 1.2 mg/dL, Reticulocytes 4%. A direct Coomb's test is negative. The patient's peripheral blood smear is seen here. Which of the following tests is most likely to confirm the diagnosis in this patient? A. Bone marrow biopsy B. Osmotic fragility test C. Hemoglobin electrophoresis D. Quantitative glucose-6-phosphage dehydrogenase enzyme activity E. Thick and thin blood smears

B. Osmotic fragility test (antibody-negative hemolytic anemia, smear shows spherocytes)

90. A 41 year old female presents with menstrual irregularities for the past several months. She also complains of increased hair growth on her face, and notes that at a recent health screening fair, she was told that she had "pre-diabetes." Her only medication is paroxetine. On physical examination, the patient's blood pressure is 160/94, and numerous purple striae are noted on the patient's abdomen. There is increased subcutaneous fat deposition in the skin of the cheeks and in the posterior cervical region. A 24-hour urine collection for cortisol is markedly elevated. Following the administration of high-dose dexamethasone, the patient's cortisol level decreases by 90%. Which of the following is the most likely cause of these findings in this patient? A. McCune-Albright syndrome B. Pituitary adenoma C. Adrenal adenoma or carcinoma D. Ectopic production of ACTH by a lung tumor E. Surreptitious use of exogenous glucocorticoids

B. Pituitary adenoma

16. A 62 year old woman with COPD presents to her physician complaining of two days of increasing dyspnea and cough. She uses supplemental oxygen at home and has had to increase her oxygen flow to relieve her shortness of breath. Recently, her cough has been productive of copious amounts of thick, dark yellow sputum. Although she never checked her temperature at home, she thinks she might have had a fever last night. Past medical history includes hypertension and peripheral arterial disease. She has smoked 1 1⁄2 -2 packs of cigarettes per day for the last 45 years and continues to smoke. Current medications include nebulized albuterol, tiotropium, inhaled fluticasone/salmeterol, lisinopril, and pentoxyfylline. Physical examination reveals an uncomfortable, thin female appearing older than her stated age. Vital signs are: temperature 37.2 C (99.0 F), pulse 80, blood pressure 136/70, respirations 20/min, oxygen saturation 88% on 2 L O2 by nasal cannula. The patient is using accessory muscles to breathe, and prolonged expirations and faint expiratory wheezes throughout the lung fields. Coarse crackles are heard at the lung bases. The patient's chest X-ray is shown. Which of the following is the most appropriate treatment for this patient? A. Methylprednisolone B. Prednisone and amoxicillin C. Guaifenasin D. Trimethoprim/sulfamethoxazole E. Aminophylline

B. Prednisone and amoxicillin

70. A 72 year old female with abdominal pain and unstable vital signs is found on angiography to have a ruptured abdominal aortic aneurysm. Past medical history includes hypertension, diabetes, and chronic renal insufficiency with baseline creatinine of 1.2 mg/dL. The patient is rushed to surgery and her aorta is successfully repaired in an eight hour operation where the patient receives five units of packed red blood cells and several liters of intravenous fluid. On the day following the operation, laboratory analysis reveals plasma creatinine of 2.1 mg/dL and BUN of 46 mg/dL. The fractional excretion of sodium (FeNa) is calculated to be 0.53%, and microscopic urinalysis shows occasional hyaline casts, but no RBCs, WBCs, or cellular or granular casts. Which of the following is the most likely explanation for this patient's abnormal laboratory values? A. Cytotoxic effects of iodinated contrast material B. Reduced blood flow to the kidneys C. Ischemic necrosis of renal tubule cells D. Obstruction of the distal urinary outflow system E. Interstitial inflammation caused by drug hypersensitivity

B. Reduced blood flow to the kidneys

87. A 10 year old male presents with a one week history of a limp that seems to be getting worse. The patient describes hip and upper leg pain that is worst when he stands with his full weight on his left foot. The pain started last week, but yesterday it suddenly worsened after he jumped off of a moving swing yesterday. On physical examination, the patient moderately obese and at Tanner stage 2 of sexual development. He walks with a pronounced limp, and refuses to bear weight on the left foot. There is marked limitation of both active and passive range of motion at the hip. Examination of other joints is within normal limits. Which of the following is the most likely diagnosis in this patient? A. Legg-Calve-Perthes disease B. Slipped capital femoral epiphysis C. Transient synovitis D. Osgood-Schlatter disease E. Growing pains

B. Slipped capital femoral epiphysis (usually an obese child in early adolescence)

65. An otherwise healthy 15 year old male comes to his physician with the complaint of facial acne. He has tried multiple over-the-counter acne washes without improvement, and he and his mother are hopeful that a medication will help. The patient's diet is acceptable but does include large amounts of fast food. He is under a moderate amount of stress juggling school and his competitive traveling soccer team, but both he and his mom feel that he is handling this well. On physical exam, the patient's face has scattered open and closed comedones and a few small papules. No scarring is noted, and his back and upper arms are not affected. What is the most appropriate initial step in the management of this patient? A. Isotretinoin B. Topical retinoid C. Oral erythromycin D. Reassurance E. Avoidance of greasy foods

B. Topical retinoid (mild comedonal acne)

6. A 66 year old male presents to the emergency department with chest pain. The pain began two hours ago as the patient was watching television. The pain is described as "squeezing" and is located primarily substernally with radiation to the jaw. Past medical history includes diabetes mellitus, hypertension, hyperlipidemia, and a 50 pack/year smoking habit. On physical exam, the patient appears anxious and diaphoretic. The patient is given supplemental oxygen by nasal cannula, and aspirin, morphine, and nitroglycerin are administered. EKG obtained on presentation to the ED is shown. Of the following, which is the most appropriate study to obtain next? A. Aortogram B. Troponin I C. Stress echo D. Exercise stress test E. CT angiogram of chest

B. Troponin I To evaluate ACS, EKG + serial troponins

108. A 14 year old boy with a history of insulin-dependent diabetes mellitus is brought to the clinic by his mother, who is concerned about worsening lethargy over the past few days. Current medications include glargine and lispro insulin, and the patient does his own injections and blood glucose monitoring. Review of symptoms is positive for polyuria, polydipsia, and generalized weakness. Vital signs include temperature 36.9 C (98.4 F), pulse 120, blood pressure 94/52, and respiratory rate 24/min. On physical examination, a fruity odor is noted on the patient's breath. The patient's skin and mucous membranes are dry, and there is decreased skin turgor. Which of the following sets of values would be most likely found on this patient's arterial blood gas (ABG)? A. pH=7.11,pCO2=73,PaO2=54,HCO3-=28 B. pH=7.20,pCO2=20,PaO2=98,HCO3-=13 C. pH=7.34,pCO2=60,PaO2=60,HCO3-=31 D. pH=7.48,pCO2=45,PaO2=98,HCO3-=30 E. pH=7.56,pCO2=20,PaO2=95,HCO3-=24

B. pH=7.20,pCO2=20,PaO2=98,HCO3-=13 (DKA)

When is the whiff test positive?

BV Trich

Clinical course of acute measles:

Begins with a fever, which is soon followed by an erythematous maculopapular rash that begins on the face and spreads to the trunk and extremities. Patients with measles also have the "three c's" of cough, coryza, and conjunctivitis.

Acute dystonic reaction treatment

Benztropine/diphenhydramine, anticholinergics that penetrate the BBB

Tricky cause of depression

Beta-blockers

Migraine prophylaxis

Beta-blockers = propranolol, timolol Anticonvulsants = topiramate, valproic acid TCAs

Elevated alkaline phosphatase localizes disease to?

Bile epithelium Bone

Who gets MG?

Bimodal 1. Young women in 20s or 30s with another autoimmune disorder 2. Men in their 70s or 80s

Risk factors in elevated LDL

Blasting cigs FH of premature CV death Low HDL <40 HTN

Myoglobinuria

Blood on a dipstick UA but no RBCs microscopically

Acute mastitis pearls

Breastfeeding mothers Fever + hard, red and tender area of breast S. aureus is common bug Treat with dicloxacillin, cephalexin or augmentin

DDx for solitary pulmonary nodule (SPN)

Broad, and includes granulomatous diseases like old or active TB or fungal infections, benign hamartomas, scarring, and of course, cancer

Kawasaki complications

The most serious and feared complication of Kawasaki disease is the formation of coronary artery aneurysms, and all patients need serial echocardiograms to monitor for the formation of aneurysms.

Medullary carcinoma of the thyroid

C-cells that produce calcitonin Associated with MENII

105. A 58 year old male with a history of diabetes mellitus and coronary artery disease presents with failure to achieve or sustain an erection. This problem has been persistent for the past year, and has been causing a great deal of stress in his marriage. When questioned regarding nocturnal erections, he states that he cannot recall the last time that he awakened with an erection. Previously, this had been a typical occurrence. Current medications include atorvastatin, glyburide, metformin, isosorbide dinitrate, and metoprolol. Physical examination reveals normal external genitalia. There is diminished sensation to pinprick in the distal lower extremities bilaterally. Which of the following is the most appropriate initial step in the management of this patient? A. Sertraline B. Yohimbine C. Alprostadil D. Tadalafil E. Reassurance

C. Alprostadil (the patient is on nitrates and should not take PDE5 inhibitors with it)

35. A 36 year old G1P0A0 at 18 weeks gestation presents for routine prenatal care. She has no complaints and has felt the baby moving normally. Her only medication is a prenatal vitamin. Family history is significant for mental retardation in a nephew. Physical examination shows a fundal height of 17 cm and a fetal heart rate in the 160s by Doppler ultrasonography. Laboratory analysis shows alpha fetoprotein to be elevated to 3.5 multiples of the median (MoM). Unconjugated estriol and beta-hCG are within normal limits. This woman's fetus is most likely to have which of the following conditions? A. Fragile X syndrome B. Cystic fibrosis C. Anencephaly D. Trisomy 18 E. Trisomy 21

C. Anencephaly

53. A 20 year old previously healthy college female presents with two weeks of occasional dysuria and increased vaginal discharge. She has recently become sexually active, and she and her asymptomatic partner occasionally use condoms as their only method of birth control. Speculum exam reveals a friable cervix with a moderate amount of purulent cervical discharge. The patient tests positive for Chlamydia and negative for gonorrhea. UA shows pyuria but no organism is identified on gram stain. Urine culture is negative. What is the next best step in management for this patient? A. Cipro B. Ceftriaxone and doxycycline C. Azithromycin D. Benzathine penicillin G E. Reassurance

C. Azithromycin

83. A 13 month old female presents to her doctor two weeks after being successfully treated for an uncomplicated febrile UTI. Since that time, a voiding cystourethrogram (VCUG) showed grade I reflux bilaterally, and a renal ultrasound showed normal kidneys. The patient's past medical history is otherwise unremarkable. On physical exam, the patient is afebrile. Urinalysis is negative for leukocyte esterase and nitrite and microscopic examination shows only occasional hyaline casts and squamous epithelial cells. What is the most appropriate next step in the management of this patient? A. Culture urine monthly B. Repeat renal ultrasound in one month C. Begin antibiotic prophylaxis D. Repeat VCUG in three months E. Reassurance

C. Begin antibiotic prophylaxis (low dose TMP/SMZ or nitrofurantoin)

13. A 20 year old healthy female presents to her family physician for routine annual gynecological exam. She is sexually active with her monogamous male partner and currently uses the withdrawal method for contraception. Although this is her first sexual partner, she thinks her boyfriend has probably had intercourse with other women prior to their relationship. Her LMP was 2 days ago. She agrees to routine gonorrhea and Chlamydia testing. On speculum exam after swabbing for the test, some bleeding from the cervical mucosa is noted. Bimanual exam is normal. The test returns positive for N. gonorrheae. What is the best initial step in the management of this patient? A. Reassurance and encourage condom use B. Start an oral OCP C. Ceftriaxone and azithromycin D. Doxycycline E. Ciprofloxacin

C. Ceftriaxone and azithromycin

113. A 57 year old female with hypertension presents for scheduled follow-up. On physical examination, the patient's blood pressure is 128/80, but a new mass is palpated on the patient's left thyroid lobe. The mass is firm, smooth, and nontender, and measures 2cm by 1cm. There is no cervical lymphadenopathy or lid lag, and the patient has no history of head or neck radiation or thyroid disease. Laboratory evaluation shows TSH of 1.9 mU/L and calcium of 9.9 mg/dL. Which of the following is the most appropriate next step in the management of this patient? A. Reassurance B. Radionuclide thyroid scan C. FNA D. Begin PTU E. Total thyroidectomy

C. FNA

38. A seven-year old male is brought by his mother to the physician because of a bald patch on his head which has been getting larger for the past three weeks. The child has been afebrile and feeling well throughout this time. The patient's mother has seen her son scratch the patch only occasionally, and the boy says that it only itches "a little bit." Past medical history includes asthma treated with albuterol. Physical examination reveals multiple non-erythematous, scaling, well-demarcated patches on the scalp. A microscopic examination of scrapings from one of the lesions prepared with KOH shows spores, but there is no fluorescence under ultraviolet light. A photograph of the lesion is shown. Which of the following is the most appropriate treatment for this patient's condition? A. Clobetasol ointment B. Mupirocin C. Griseofulvin D. Permethrin cream E. Lindane shampoo

C. Griseofulvin (tinea capitis)

81. A 25 year old graduate student complains of a "lump" under his clavicle for the past two weeks. He first noticed the lump after being hit in the shoulder during a rugby match. He has otherwise been well, and denies any other symptoms including fever, night sweats, weight loss, or recent infections or illnesses. On physical examination, the patient is comfortable and afebrile. There is a 4 cm, rubbery, nontender supraclavicular lymph node on the left, as well as numerous 1-2 cm enlarged cervical and axillary nodes. The clavicle is nontender, and there is full range of motion at both shoulders. There is no evidence of a draining abscess or resolving cellulitis. Laboratory evaluation shows the following. WBC 8.0 k/mcL (Normal: 4.5-11.0 k/mcL) Differential: 66% neutrophils, 30% lymphocytes, 3% monocytes, 1% eosinophils Hemoglobin 14.3 g/dL (Normal: 13.5-17.5 g/dL) Hematocrit 43% (Normal: 39-49%) Platelets 212 k/mcL (Normal: 150-450 k/mcL) Which of the following is the most likely diagnosis in this patient? A. Acute myelogenous leukemia B. Infectious mononucleosis C. Hodgkin's lymphoma D. Trauma E. Felty's syndrome

C. Hodgkin's lymphoma

96. At the insistence of his wife, a 71 year old farmer presents to have a "bump" on his shoulder evaluated. The bump has been there for several years, and though it is not painful, it does itch from time to time. The patient does report many years of sun exposure while working on his farm. Physical examination reveals a comfortable, fair-skinned gentleman. On the patient's left shoulder, there is a smooth, 3cm by 4cm papular lesion with numerous dilated blood vessels throughout. A photo of this lesion is seen here. Which of the following is the most appropriate therapy for this patient? A. Podophillin resin B. Shave biopsy C. Local excision D. Topical tacrolimus E. Excision, lymph node biopsy, and radiation

C. Local excision

30. A 72 year old man comes to his physician because he has been feeling sad and "thinks he needs help." For the past several weeks, he has noted decreased appetite and an 8 lb weight loss, and he has seldom left his house, even to participate in his weekly bowling league. While he is able to fall asleep normally, he awakens after 3-4 hours and is unable to fall asleep again. He has also had increasing difficulty balancing his checkbook and writing his Christmas cards, and believes that he just can't stay focused enough to complete these tasks. Six months ago, his wife of fifty years died, and he often feels guilty that he did not treat her as kindly as he should have. When he thinks about his wife, he thinks that he would rather be dead than without her, although he denies having a plan to harm himself. Past medical history includes coronary artery disease and gout. Medications include lisinopril, allopurinol, metoprolol, furosemide, and aspirin. Which of the following is the most likely diagnosis in this patient? A. Adjustment disorder B. Bereavement C. Major depressive disorder D. Dysthymic disorder E. Alzheimer's dementia

C. Major depressive disorder

101. An otherwise healthy 2 year old male returns for follow-up of bilateral ear effusions. Several months ago, the patient completed a course of amoxicillin for bilateral acute otitis media, but later follow up revealed persistent effusions. At his last visit, audiometry revealed only slight hearing loss bilaterally (<20 db). Today, his mother states that she does feel that he doesn't seem to hear as well as his siblings, though he has been afebrile and has no other symptoms. Physical exam reveals nonerythematous, immobile tympanic membranes with persistent effusions bilaterally. Repeat audiometry reveals a bilateral hearing deficit of 42 decibels. What is the most appropriate next step in the management of this patient? A. Chlorpheniramine and pseudophedrine B. Prednisolone C. Referral for tympanostomy tube placement D. Cefdinir E. Follow up in three months

C. Referral for tympanostomy tube placement (OME)

34. A mother brings her 5 year old son to the doctor because he has been scratching an area on his chest for the past week. The itching is much worse at night. The patient has not had a known contact with poison ivy, has no history of a tick bite and his mother says that no one else has a rash like this. The child has been afebrile and has not been acting sick. There is a family history of eczema and so the patient's mother used some of her own steroid cream on her son's rash for the past three days, but this was not helpful. Physical exam reveals an area of small erythematous papules that are excoriated and tipped with blood crusts on his right upper chest extending under his right arm. There are several faint thin, brownish lines just under the surface of the skin. Several of the web spaces between his fingers also seem to have a similar appearing rash, as do the bottom of his feet. What is the most likely diagnosis in this patient? A. Contact dermatitis B. Atopic dermatitis C. Scabies D. Molluscum contagiosum E. Skin atrophy and telangiectasias from the topical steroids

C. Scabies

58. A mother brings her 8 year old son to the family physician because of strange behavior for the past year that appears to be getting worse. For the past twelve months, the patient's mother has noted episodes of repetitive blinking or grimacing. These episodes appear to be beyond her son's control, and often occur at inopportune times. The patient is now being teased at school by his classmates for these behaviors. During the patient interview, the child appears to be listening intently to the conversation with his mother; there is a minute or so of rapid, repetitive blinking followed by several grunting noises from the patient. When asked, the child is aware of the blinking and grunting, but cannot explain why he was doing it. The patient denies hallucinations or bizarre thoughts and states that his mood is fine. He does well in school and has a close group of friends in his neighborhood who he enjoys playing with. His growth and development are within normal limits. What is the most likely diagnosis in this patient? A. Autism B. Rett syndrome C. Tourette syndrome D. Syndenham chorea E. ADHD

C. Tourette syndrome

48. A 38 year old HIV positive male presents for regularly-scheduled follow-up. He received pneumococcal and influenza vaccinations last year, and has had no opportunistic infections for several months. Current medications include efavirenz and nevirapine. Physical exam is unchanged from previous. Laboratory evaluation shows CD4+ lymphocyte count of 179/mm3. Tuberculin purified protein derivate (PPD) is placed intradermally, and is read 72 hours later as causing 4 mm of induration. Which of the following is the most appropriate next step in the management of this patient? A. Chest x-ray B. Clarithromycin C. Trimethoprim-sulfamethoxazole D. Fluconazole E. Isoniazid, rifampin, and pyrizinamide

C. Trimethoprim-sulfamethoxazole (PCP prophylaxis due to CD4+ count below 200)

A 24 year old student seeks treatment for nasal congestion, sneezing, and a runny nose. His symptoms occur daily for four to six weeks every year in the spring and fall, and are worse when he is outdoors or doing yardwork. Recently, he has been taking over-the-counter pseudophedrine and chlorpheniramine, but these have not significantly improved his symptoms. The patient's family history includes a mother with asthma and a brother with eczema. On physical exam, the conjunctivae are injected, and the patient's palpebrae are swollen. The nasal turbinates are boggy and edematous, and are bluish-gray in color. There is no lymphadenopathy or thyromegaly. Which of the following is the most appropriate step in the management of this patient? A. diphenhydramine B. fexofenadine C. nasal beclomethasone D. guaifenasin E. IgE levels

C. nasal beclomethasone

Newborns with ambiguous genitalia and hypotensia

CAD, low 21-hydroxylase

t(9,22) is pathognomonic for?

CML (Philadelphia chromosome) --> BCR-ABL fusion product

Diagnostic findings desmoid (benign cystic teratomas) tumor

Calcifications

CHIMPANZEES mnemonic for hypercalcemia

Calcium oversupplementation Hyperparathyroidism Immobility, iatrogenic (thiazides) Milk alkali syndrome Paget's Acromegaly, addison's Neoplasms Zollinger-Ellison syndrome Excess vitamin D, E Excess A Sarcoidosis

When crypto can f*** you over...bad

Can form focal cryptococcomas that behave as mass lesions and increase ICP Before doing LP, look for focal neuro deficits or get CT to prevent herniation

Why do you need to give thiamine with IV fluids containing glucose

Can precipitate Wernicke's or Korsakoff's

Pseudohyponatremia

Caused by dramatically elevated glucose levels or high levels of triglycerides/ketones

Characteristic for pasteurella

Cellulitis develops quickly after bite

Commonly used abx to treat UTIs in pregnant women

Cephalosporins (cephalexin) Amoxicillin Amoxicillin/clavulanate Nitrofurantoin

Anatomical causes of late pregnancy loss

Cervical incompetence Uterine anomalies Leiomyoma Intrauterine synechiae

Gonorrhea most commonly presents as:

Cervicitis, urethritis or proctitis

Acute chest syndrome

Chest pain Tachypnea Leukocytosis Pulmonary infiltrates

VUR screening

Children <5 with febrile UTI Any male child with a first UTI Girls <3 with a first UTI Kiddos with recurrent UTI or other prenatal renal anomalies Kids with 3 UTIs caused by weirdo bugs *screen with voiding cystourethrogram*

pH=7.34,pCO2=60,PaO2=60,HCO3-=31

Chronic respiratory acidosis Etiology: COPD that retains CO2

Diagnostic criteria dysthymic disorder

Chronicity: symptoms must be present for at least 2 years, while this patient's symptoms have been present for a much shorter period of time. While dysthymia shares symptoms with major depression, the symptoms of dysthymia tend to be fewer and less pronounced

Notorious thugs causing c diff

Clindamycin Second and third generation cephalosporins Amoxicillin

How do OCPs reduce pain with periods?

Combination OCPs make the endometrial lining thin, meaning that there are less inflammatory products produced at the time or menses, which in turn reduces menstrual flow and uterine contractions

pH=7.48,pCO2=45,PaO2=98,HCO3-=30

Compensated metabolic alkalosis, lungs retain CO2 in an effort to decrease pH Etiology: Vomiting (loss of H+) or contraction alkalosis

Pathophys scarlet fever

Complication group A strep --> exotoxin-mediated

Two most common causes of short stature

Familial Constitutional delay of growth (both have normal growth velocity) Dx: bone age

Polymyalgia rheumatica treatment

Corticosteroids

Treatment of autoimmune hemolytic anemias

Corticosteroids

Labyrinthitis management

Corticosteroids (shortens duration) Antiemetics, benzos, antihistamines

Why are macrolides (clarithromycin, azithromycin) used for CAP?

Cover h. flu well Cover s. pneumo, morazella

Dx Cryptococcal meningitis

CrAg or india ink prep to look for encapsulated yeasts

Severe von Willebrand's may require?

Cryoprecipitate

Gold standard for basal cell carcinoma treatment

Cryosurgery Local radiation Topical 5-FU Surgical excision

Intussusception buzzword

Currant jelly stool Sausage shaped mass Ultrasound --> bull's eye or coiled spring lesions

102. A 24 year old woman with a history of recurrent headaches returns for follow up. For the past year and a half, she has experienced severe headaches accompanied by nausea and vomiting several times per week. Her pain is pulsating and throbbing, and typically affects the left temporal region of her head. The headaches last at least several hours, but have lasted as long as three days and have required her to miss several days of work. Past medical history is significant for major depression and dysmenorrhea. Her mother has a history of similar headaches. Several weeks ago, she was seen and given a prescription for oral sumatriptan. Today, she states that she continues to have several headaches each week, just as she did previously, but taking sumatriptan and lying in a dark room helps relieve them within a few hours. Her neurological examination is normal. There is no papilledema. Which of the following is the most appropriate step in the management of this patient? A. Inhalation of 100% oxygen B. Head CT with and without contrast C. Lumbar puncture D. Amitriptyline E. Intranasal dihydroergotamine

D. Amitriptyline

A 13 year old, 121 lb (55 kg) male presents with nausea and periumbilical abdominal pain and is diagnosed with appendicitis. Following an uncomplicated laparoscopic appendectomy, the patient is comfortable and stable, with vital signs in the normal range. The patient is not yet eating. Laboratory analysis shows electrolytes within normal limits and creatinine at pre-operative baseline. Which of the following is the most appropriate maintenance fluid and infusion rate for this patient? A. Normal saline (0.9% NaCl) + 20 mEq KCl at 70 mL/h B. Ringer's lactate at 70 mL/h C. Normal saline (0.9% NaCl) at 95 mL/h D. 5% dextrose and 1⁄4 normal saline (0.225% NaCl) + 20 mEq KCl at 95 mL/h E. 5% dextrose and 1⁄4 normal saline (0.225% NaCl) + 20 mEq KCl at 120 ml/h

D. 5% dextrose and 1⁄4 normal saline (0.225% NaCl) + 20 mEq KCl at 95 mL/h

15. On routine examination, a five year old child is noted to have a loud S1 with a fixed and widely split S2 that does not vary with respiration. A soft, mid-systolic ejection murmur is heard best on the left in the second intercostal space. Remainder of physical exam is otherwise unremarkable. There is no nail clubbing, hepatomegaly, or jugular venous distension. The child is healthy and active and her mother has no health concerns. Which of the following is the most likely diagnosis in this patient? A. Mitral valve prolapse B. Pulmonic regurg C. Tetralogy of fallot D. ASD E. VSD

D. ASD

10. A 71 year old male comes to his physicians office complaining of muscle weakness. The weakness began insidiously several weeks ago, and has now progressed to the point where he has difficulty with normal activities such as brushing his hair or sitting unsupported. Past medical history is significant for hyperlipidemia, chronic renal insufficiency, coronary artery disease, and coronary artery bypass and grafting. Current medications include atorvastatin, fosinopril, metoprolol, aspirin, and spironolactone. Physical examination reveals diminished deep tendon reflexes and decreased motor strength. Laboratory evaluation shows Na+ 143, K+ 7.4, Cl- 101, HCO3- 28, BUN 30, and creatinine 1.8. EKG is obtained on presentation and is seen here. What is the most appropriate initial step in the management of this patient? A. Administer IV insulin and glucose B. Administer po sodium polystyrene sulfate C. Administer IV sodium bicarb D. Administer IV calcium gluconate E. Urgent hemodialysis

D. Administer IV calcium gluconate

41. A 56 year old male with hypertension and history of drug abuse and medication noncompliance presents to the clinic for follow up. He has been feeling well since his last appointment several months ago, but does admit to cocaine use last night when he ran into some old friends. He denies any other drug use. Medications include hydrochlorothiazide, atenolol, and paroxetine. Vital signs are temperature 36.9 C (98.4 F), pulse 85, blood pressure 202/122, and respirations 14/min. Physical examination reveals a comfortable, pleasant male in no distress. There is no papilledema or retinal hemorrhage on fundoscopic exam. The patient is alert, oriented, and neurologically intact. Laboratory evaluation, including CBC, electrolytes, BUN and creatinine, and urinalysis are all unremarkable. Which of the following is the most appropriate next step in the management of this patient? A. Obtain urine drug screen B. Head CT without contrast C. Administer naloxone D. Administer oral labetalol E. Administer intravenous nitroprusside

D. Administer oral labetalol

23. A 55 year old woman has had four days of a cough productive of dark yellow sputum. She has also experienced occasional shaking chills and has sharp chest pain that is worst on inspiration. She denies recent travel history, known sick contacts, or recent hospitalization. Past medical history is significant for osteoarthritis and hypertension. Temperature is 38.0 C (100.4 F), pulse 85, blood pressure 132/80, respirations 22/min, oxygen saturation 97% on room air. The patient is alert, oriented, and interactive. Heartbeat is regular with normal S1 and S2. There is no JVD. There are decreased breath sounds as well as egophony and positive tactile fremitus at the right lung base. Abdomen is obese, nondistended, and nontender. There are no petechiae or rashes noted on skin exam. Chest x-ray is shown. Which of the following is the most appropriate therapy for this patient? A. Enoxaparin B. Vanc and meropenem C. Cefepime and gentamicin D. Azithromycin E. Immediate needle thoracostomy

D. Azithromycin

72. A four year old male presents with a painful right hand. One week ago, he was bitten by his pet kitten on the hand. His mother also reports an occasional low-grade fever. On physical exam, there are several erythematous, painful cutaneous papules and pustules present near the nearly healed bite site, as well as tender unilateral axillary lymphadenopathy on the right. Which of the following is the organism most likely to be the cause of this patient's infection? A. Methicillin-sensitive Staphylococcus aureus B. Yersinia pestis C. Francisella tularensis D. Bartonella henselae E. Pasteurella multocida

D. Bartonella henselae (cat scratch fever)

29. A 26 year old G2P1 is at 28 weeks gestation of an uncomplicated pregnancy. The patient denies decreased fetal movement, dysuria, urinary frequency or urgency, vaginal bleeding or discharge, and nausea and vomiting. Medications include a prenatal vitamin and folate and iron supplements. Physical exam shows uterine fundal height 29 cm with fetal heart rate in the 150s. Laboratory testing shows: Fasting serum glucose 115mg/dL; Maternal blood type B+. The patient's urinalysis shows the following. Color: yellow; Specific gravity: 1.020 (normal: 1.002 - 1.030); pH: 5.2; Glucose: negative; Ketones: negative; Protein: 1+; RBC: negative; Leukocyte esterase: trace; Nitrite: 2+; Urobilinogen: 0.3 EhrU/dL (normal: 0.2-1.0 EhrU/dL). Urine culture grows 25,000 cfu/mL Gram negative rods. Cervical cultures for N.gonnorheae and Chlamydia are negative. Which of the following is the most appropriate next step in the management of this patient? A. Administer RhoGAM B. Measure maternal serum alpha feto-protein (MSAFP) C. Begin insulin therapy D. Begin cephalexin E. Reassurance and routine follow-up

D. Begin cephalexin

20. A 5 year old female presents for a pre-kindergarten physical and is found to have a blood pressure of 146/85 in both arms. Past medical history is unremarkable, and the child has been healthy and asymptomatic. Physical examination reveals a short, stocky female with a broad, shield shaped chest and widely-spaced nipples. There are diminished femoral pulses bilaterally. On cardiac auscultation, a short 2/6 midsystolic murmur is heard at the left paravertebral interscapular area. Which of the following is the most likely associated finding in this patient? A. Increased urine homovanillic acid (HVA) and vanillylmandelic acid (VMA) B. Tonsillar hypertrophy C. Decreased levels of thyroid stimulating hormone (TSH) D. Chest x-ray showing notching of the ribs bilaterally E. Sensorineural hearing loss and hematuria

D. Chest x-ray showing notching of the ribs bilaterally

100. A 24 year old female returns to her physician after a routine Pap smear showed atypical squamous cells of undetermined significance. She has no past history of abnormal Pap smears or sexually-transmitted infections, and other testing from her last visit (including beta-hCG and testing for gonorrhea and chlamydia) was negative. She has a lifetime total of four sexual partners, and is currently sexually active with one partner, using only an oral contraceptive pill for birth control. Menarche was at age 11, and menses have been unremarkable. PCR reveals the presence of human papillomavirus DNA, type 18. Which of the following is the most appropriate next step in the management of this patient? A. Rapid plasma reagin (RPR) testing B. Begin imiquimod C. Endometrial biopsy D. Colposcopy E. Reassurance and routine follow-up

D. Colposcopy

Key features of Addison's

Fatigue Weight loss Hypotension Hyponatremia Hypoglycemia Hyperpigmentation (dx between primary/secondary)

50. A three-week old infant is brought to the clinic after the patient's adoptive parents noted a red rash on her hands and feet. The child was born at term via vaginal delivery to a 28 year old woman who received no prenatal care and gave her child up for adoption shortly after birth. On physical examination, the infant appears lethargic and has generalized lymphadenopathy. There is profuse, blood-tinged purulent nasal discharge, and there is an erythematous maculopapular rash on the dorsal and ventral surfaces of the hands and feet. Abdominal examination reveals hypoactive bowel sounds and hepatosplenomegaly. Which of the following is the most likely explanation of these findings? A. Congenital toxo B. Congenital rubella C. Congenital CMV D. Congenital syphilis E. Herpes neonatorum

D. Congenital syphilis

68. A 31 year old female presents with several weeks of progressive fatigue, weakness, and weight loss. She has also had occasional nausea and diarrhea. Past medical history includes juvenile diabetes and hypothyroidism. On physical examination, the patient has areas of bronzed hyperpigmentation on her face, neck, and the dorsum of her hands. The remainder of physical exam is within normal limits. Laboratory examination is significant for a sodium of 130 mEq/L and a glucose of 65 mg/dL. Which of the following is the most appropriate next step in the diagnosis of this patient? A. Thyroid ultrasound B. Measurement of IGF-1 C. Measurement of 21-hydroxylase activity D. Cosyntropin stimulation test E. Dexamethasone suppression test

D. Cosyntropin stimulation test (primary adrenal insufficiency, cosyntropin=ACTH)

A 23 year old G2P2 presents on postpartum day 10 with fever and a tender left breast. Her symptoms began two days ago, and have been accompanied by myalgias, chills, and malaise. She has been breastfeeding her new daughter, and reports that this has been going well, and that her child has appeared healthy since birth. Vital signs include temperature 38.4 C (101.1 F), pulse 90, and blood pressure 112/68. On physical examination, the patient's left breast is erythematous and engorged, and very tender to palpation. No masses or areas of fluctuance are appreciated. The right breast is unremarkable. Which of the following is the most appropriate initial step in the management of this patient? A. Incision and drainage B. Mammography C. Tetracycline D. Dicloxacillin E. Cephalexin and temporary cessation of breastfeeding

D. Dicloxacillin (acute mastitis) *don't tell mom to quit breastfeeding because the bug comes from that baby's nasty azz mouth*

18. A 36 year old African-American male comes to the clinic complaining of fatigue and dark, cola-colored urine for the past five days. He denies fever, nausea or vomiting, recent travel, and i.v. drug use. Past medical history includes ulcerative colitis. Medications include sulfasalazine as well as trimethoprim/sulfamethoxazole which the patient began taking one week ago for a presumed Staphylococcal skin infection. Vital signs are temperature 36.8 C (98.2 F), pulse 78, blood pressure 118/72, respirations 14/min. Physical examination shows scleral icterus and a nontender abdomen without organomegaly. Laboratory evaluation shows: WBC 8.6; Hgb 9.1; Hct 27.3; Platelets 212; MCV 88 fL; Na+ 144; K+ 4.8; Cl- 101; HCO3- 26; BUN 14; Creatinine 1.0; Glucose 101; LDH 410 U/L; Haptoglobin 8 mg/dL. Which of the following is the most appropriate next step in management of this patient? A. Quantitative IgM for hepatitis A virus B. Begin darbopoietin injections C. Begin methylprednisolone D. Discontinue trimethoprim/sulfamethoxazole E. Immediate transfusion of packed red blood cells

D. Discontinue trimethoprim/sulfamethoxazole

7. A 73 year old male presents to his physician complaining of cough and fatigue. His cough began 6 months ago and has steadily worsened, and is now associated with occasional expectoration of mucus streaked with bright red blood. Patient has also noted worsening dyspnea on exertion and a weight loss of 15 lbs. The patient has smoked a pack and a half of cigarettes every day for the past 60 years. Past medical history is significant for bipolar disorder treated with lithium. Physical exam shows unilateral localized wheezing on the left chest and clubbing of the distal extremities. Capillary refill is brisk. No skin tenting is observed. Chest X-ray is obtained, which shows a large mass at the left hilum. Labs show: Glucose 130, Na+ 125, K+ 4.0, Cl- 91, HCO3- 25, BUN 15, Creatinine 1.0; Plasma osmolality 270 (Normal: 282-295 mOsm/kg); Urine osmolality 650 mOsm/kg (Normal: 50 - 1400 mOsm/kg). Which of the following is the most likely mechanism for this patient's hyponatremia? A. Increased oral intake of hypotonic fluids B. Decreased oral intake of solutes C. Impaired secretion of ADH in the posterior pituitary D. Ectopic overproduction of vasopressin E. Resistance to ADH action on the cortical and medullary collecting tubules

D. Ectopic overproduction of vasopressin When you see euvolemic hyponatremia (especially on the USMLE), think SIADH! The constellation of findings in this patient, including euvolemic hyponatremia, hypotonicity (plasma osmolality <280 mOsms), inappropriately concentrated urine, and normal renal function are diagnostic for the syndrome of inappropriate ADH secretion (SIADH). SIADH has a number of causes.

17. A 64 year old male presents for routine health evaluation. He has been feeling well and has no complaints. Past medical history includes hypertension, osteoarthritis, and generalized anxiety disorder. Medications include hydrochlorothiazide, ibuprofen, atenolol, and paroxetine. Physical exam shows temperature 37.9 C (99.3 F), pulse 61, blood pressure 131/70, and respirations 15/min. Laboratory evaluation shows: Na+ 141; K+ 3.9; Cl- 103; HCO3- 25; BUN 18; Creatinine 1.2; WBC 9.7; Hemoglobin 10.1; Platelets 179; MCV 73 fL. Which of the following is the most appropriate next step in the management of this patient? A. Add lisinopril B. Measure reticulocyte count C. Test B12/folate D. Endoscopy E. Indirect and direct coombs test

D. Endoscopy

21. An 84 year old woman has experienced three weeks of diffuse myalgias. In addition to worsening fatigue, she has stiffness upon awakening in her shoulders, hip girdles, neck, and torso. The stiffness usually resolves after several hours. She has also had occasional low-grade fevers and a 6 pound weight loss since her symptoms began. Physical examination shows decreased active range of motion of the shoulders and neck, but no muscle tenderness. Neurological exam shows normal sensation and reflexes. No abnormal findings are noted on skin examination. Which of the following is the most likely associated finding in this patient's disease? A. Anti-centromere antibodies positive at 1:640 B. Absolute neutrophil count of 950/mm3 (Normal: >1800 mm3) C. Karyotyping showing t(9,22) chromosomal rearrangement D. Erythrocyte sedimentation rate (ESR) of 96 mm/h (Normal: <20 mm/h) E. X-rays demonstrating expansion of the bony cortex in a mosaic pattern

D. Erythrocyte sedimentation rate (ESR) of 96 mm/h (Normal: <20 mm/h)

Presentation CML

Fatigue, weight loss, low-grade fevers Splenomegaly

A 10 year old male with asthma returns to his physician for follow up. Two months ago, his teacher noted him wheezing after playing on the playground, and pulmonary function testing confirmed a diagnosis of asthma. Since that time, he has been using a rescue inhaler approximately one time a week at school to relieve wheezing and chest tightness that seem to occur following strenuous activity. He has also been using his rescue inhaler approximately one time a week at home at night when he awakens with chest tightness or difficulty breathing. Current medications include albuterol and atomoxetine. On physical exam, the patient is comfortable and afebrile. The patient's lungs are clear to auscultation, and no wheezing or prolonged expiration is noted. Which of the following is the most appropriate next step in the management of this patient? A. Repeat spirometry B. Cetirizine C. Inhaled salmeterol D. Inhaled fluticasone E. Oral prednisone

D. Inhaled fluticasone

31. A 2 year old male child returns to the physician with continued fever and a rash. Eight days ago, he had the abrupt onset of fever, which was later accompanied by irritability and anorexia. Fevers to 104 F (40 C) have continued and have not decreased despite his mother's repeated administration of acetaminophen and ibuprofen. Physical exam reveals inflammation of the conjunctiva bilaterally without purulent drainage. There is diffuse cervical lymphadenopathy and peeling of the skin around the fingernails. Scattered target-like, erythematous, macular lesions are present on the trunk and extremities. There are no tonsillar exudates, but a photo of the child's tongue is seen here. Which of the following is the most likely diagnosis in this patient? A. Drug hypersensitivity B. Scarlet fever C. Erythema infectiosum D. Kawasaki disease E. Rocky mountain spotted fever

D. Kawasaki disease

117. A 45 year old male presents with intermittent chest pain for the past month. He describes burning, retrosternal pain that usually occurs after eating or while lying down or bending over. He also notes that he has been hoarse lately, especially upon awakening in the morning. Past medical history includes a father and grandfather who died of coronary artery disease in their 60s. In the office, the patient is comfortable, and physical examination is entirely unremarkable. Which of the following is the most appropriate initial step in the management of this patient? A. Metoclopramide B. Ranitidine C. Lansoprazole D. Lifestyle modification and smoking cessation E. Upper endoscopy

D. Lifestyle modification and smoking cessation

116. A 12 month old male is brought to the physician for a well-child checkup. He has been healthy, and his mother's only particular concern is that he has grown increasingly uneasy around any adults other than her. The child eats three meals a day, and is able to feed himself small finger foods. He can pull to stand and can temporarily stand unsupported, but he has to hold onto furniture or adults in order to walk. His mother reports that he responds by turning his head when his name is called, and that he is able to shake his head "no." He babbles frequently, but has not yet said "Mama" or other simple words. Which of the following most accurately represents this child's development? A. Motor - normal; social - normal; language - normal B. Motor - delayed; social - normal; language - normal C. Motor - normal; social - delayed; language - normal D. Motor - normal; social - normal; language - delayed E. Motor - delayed; social - delayed; language - delayed

D. Motor - normal; social - normal; language - delayed

98. A 43 year old teacher returns to her physician after routine lab evaluation revealed elevated liver transaminases with an ALT of 158 U/L and an AST of 108 U/L. The patient has been in her normal state of health, and has no complaints. Past medical history is significant for diabetes mellitus and hypertension, and current medications include metformin and enalapril. The patient denies foreign travel, blood transfusions, or use of over-the-counter or herbal medications. She is a Jehovah's Witness and does not smoke or use alcohol. Physical examination shows a comfortable, obese female. There is no organomegaly, right upper quadrant or abdominal tenderness, jaundice, scleral icterus, asterixis, or spider angiomata. Laboratory evaluation shows the following: Hepatitis A IgM: negative; Hepatitis A IgG: positive; Hepatitis B surface antigen (HBsAg): negative; Hepatitis B surface antibody (HBsAb): positive; Hepatitis B core antibody (HBcAb): negative; Hepatitis C PCR: negative. Which of the following is the most likely explanation for this patient's elevated liver enzymes? A. Hep A B. Hep B C. Adverse effect metformin D. NASH E. Alcohol abuse

D. NASH

79. A 53 year old female with type II diabetes presents is brought to the physician by her husband because of lethargy, fatigue, and decreased responsiveness. She had been feeling well until two days ago, when she developed myalgias and upper respiratory congestion. Medications include glipizide, metformin, lisinopril, and atorvastatin. On physical examination, the patient is somnolent but arousable. Vital signs include temperature 36.7 C (98.6 F), pulse 130, blood pressure 102/64, respirations 15/min. There is no nuchal rigidity. There is poor skin turgor and the patient's mucous membranes are dry. Laboratory evaluation shows the following: Na+ 124, K+ 4.0, Cl- 92, HCO3- 24, BUN 70, creatinine 2.1, glucose 965, total protein 6.1 g/dL, albumin 4.5 g/dL, AST 12 U/L, ALT 17 U/L, Alk. Phosphatase 110 U/L, total bilirubin 0.7 mg/dL. Which of the following is the most likely diagnosis in this patient? A. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) B. Diabetic ketoacidosis C. Bacterial meningitis D. Nonketotic hyperosmolar coma E. Acute sinusitis

D. Nonketotic hyperosmolar coma

62. A 53 year old female consults her physician due to progressive itching, yellowing of her skin, and fatigue. She denies any past history of jaundice and denies ever receiving a blood transfusion or abusing alcohol. Her past medical history includes hypertension and Sjogren's syndrome. Physical examination shows prominent hepatomegaly and scattered excoriations throughout the skin. Laboratory evaluation shows an elevated bilirubin, moderately elevated transaminases, and markedly elevated alkaline phosphatase with a normal albumin. Anti-mitochondrial antibodies are positive at >1:256. Which of the following is the most likely diagnosis for this patient? A. Hepatitis C B. Autoimmune hepatitis C. PSC D. PBC E. Pancreatic carcinoma

D. PBC (primary biliary cirrhosis, anti-mitochondrial antibodies)

A 15 year old otherwise healthy female presents to her family physician with right lower quadrant abdominal pain. Although the pain waxes and wanes, it reaches a 7/10 on the pain scale, and ibuprofen has been ineffective. Menarche occurred at age 10 and her menses have always been regular at 26 day cycles. The patient is not sexually active. LMP was 2 weeks ago. Bimanual exam appreciates normal size ovaries, but the patient experiences pain on palpation of the right adnexae. An abdominal ultrasound reveals a 5 cm smooth, thin walled, unilocular cystic structure on the right ovary. Urine pregnancy test is negative and WBC is normal. What is the most likely diagnosis? A. PCOS B. Desmoid tumor C. Endometriosis D. Physiological ovarian cyst E. Tubo-ovarian abscess

D. Physiological ovarian cyst

What not to do with cocaine-induced HTN....

Don't treat with pure beta blocker --> unopposed alpha adrenergic activation --> vasoconstriction, gangrene, ischemia Drug of choice=labetalol

Treatment options for tourette's

Dopamine agonists/antagonists Botox (vocal, motor) Alpha agonists SSRIs

9. A seven year old female is brought to the physician by her mother because of facial swelling and dark, cola-colored urine. These symptoms began abruptly two days ago and have been associated with anorexia and malaise. There have been no known sick contacts. Her mother states that the child is up to date with her immunizations and has been in good health except for a runny nose and sore throat around two weeks ago, which resolved after a few days without treatment. Vital signs are temperature 37.2 C (98.9 F), heart rate 95, and blood pressure of 148/86. There is diffuse edema of the lower extremities, face, and eyelids. Lungs and heart are clear to auscultation. Urinalysis shows moderate hematuria and proteinuria, and dysmorphic RBCs and occasional RBC casts are noted on microscopic examination. Based on these findings, what is the most likely diagnosis? A. IgA nephropathy B. Alport syndrome C. Thin basement membrane nephropathy D. Postinfectious glomerulonephritis E. Henoch-Schonlein purpura

D. Postinfectious glomerulonephritis 1. Age <7 years old 2. Dark brown urine (hematuria) 3. Periorbital and peripheral edema

22. An 18 year old female presents to her family physician to discuss options for birth control. Menarche was at age 12. Her menses occur at regular 28 day intervals, but she does have moderate abdominal cramping, bloating, and occasional nausea that sometimes prevent her from going to school. She is interested in becoming sexually active but her boyfriend, who has had other sexual partners in the past, doesn't like to use condoms. Her family history is significant for her mother having had ovarian cancer at age 40. The patient does not smoke and is otherwise healthy. What would be the most appropriate initial step in the management of this patient? A. Recommend condom use because of the patient's family history of ovarian cancer B. Prescribe an OCP after a work-up of her cyclical abdominal cramping C. Start a progestin-only pill to limit the patient's intake of estrogen D. Prescribe a combined oral contraceptive E. Recommend an intrauterine device (IUD)

D. Prescribe a combined oral contraceptive

69. A six-month old female is brought to the clinic in December with wheezing and respiratory difficulty for the past several hours. She did have a low-grade fever two days ago accompanied by rhinorrhea, but has otherwise been well since birth. Vital signs are temperature 38.6 C (101.5 F), pulse 160, blood pressure 87/59, respirations 60/min. Nasal flaring and intercostal retractions are noted. Auscultation of the lungs reveals faint inspiratory crackles at the lung bases and diffuse expiratory wheezing. A chest x-ray shows a normal cardiac silhouette, hyperexpanded lungs, and peribronchial thickening. Which of the following tests would be most likely to confirm the diagnosis in this patient? A. Rigid bronchoscopy B. EKG C. Methacholine challenge test D. Rapid antigen test for RSV E. Sweat chloride test

D. Rapid antigen test for RSV (bronchiolitis)

Oculobular MG:

Double vision Ptosis Dysarthria Difficulty chewing

49. An 18 year old G1 at 39 weeks gestation presents in labor. Her pregnancy has been complicated by excessive weight gain and gestational diabetes mellitus. Soon after presentation, the patient rapidly dilates and the infant's head descends. The infant's head is delivered without difficulty, but before delivering the body, the head appears to retract toward the pelvis. Initial attempts to deliver the body are unsuccessful. A fetal scalp electrode is attached, which shows a wavy tracing with heart rates between 140 and 150 bpm with marked beat-to-beat variability. Which of the following is the most appropriate next step in the management of this patient? A. Caesarean section B. Fundal pressure C. Oxytocin D. Suprapubic pressure E. Fracturing the baby's clavicles

D. Suprapubic pressure

A 19 year old college female presents to student health because she is no longer menstruating. She has missed her last 5 menses and states that the 3 prior menses were very light and unpredictable. Menarche occurred at age 10 and her menses had been occurring at regular at 24 day intervals until this recent change. She is sexually active using only condoms for birth control. She takes no medications. The patient denies breast tenderness, abdominal fullness, and nausea, though she has noticed a 10 pound weight gain over the past few months. She feels that she might have a little less energy than usual. Physical exam is within normal limits. BMI is 21. A qualitative serum beta-hCG is negative for pregnancy. What is the most appropriate next step in the management of this patient? A. Urine pregnancy test B. Serum hCG C. FSH D. TSH and prolactin E. Serum androgen levels

D. TSH and prolactin (management for secondary amenorrhea)

77. A 25 year old male with a history of intravenous drug abuse presents with fever, chills, and shortness of breath for two days. He last used heroin five days ago. Vital signs include temperature 38.8 C (102 F), pulse 90, blood pressure 116/78, respirations 18/min. There is a grade II/VI systolic murmur heard best at the lower right sternal border. Faint crackles are heard throughout the lung fields. There are no splinter hemorrhages, peripheral petechiae, or erythematous patches on the palms or soles. No abnormalities are seen on fundoscopic exam. Neurological exam is normal. A chest x-ray shows no evidence of pneumonia. Three sets of blood cultures are drawn, and the patient is started on empiric antibiotic therapy with vancomycin and cefepime. Which of the following is the most appropriate next step in the management of this patient? A. Naloxone B. Buprenorphine C. Ciprofloxacin D. Trans-thoracic echocardiogram E. D-dimer

D. Trans-thoracic echocardiogram

Transient synovitis

DDx in kiddos with a limp 50% have recent URT

Presentation congenital rubella

Deafness Cataracts Numerous purpuric skin lesions --> blueberry muffin baby

EMG findings in MG

Decremental response to repetitive nerve stimulation

Pathognomonic EKG finding at rest with WPW:

Delta wave

Treatment for mild von Willebrands?

Desmopressin --> increases production and release from endothelium

How does rib notching on CXR form?

Development of arterial collaterals (through the intercostal arteries in an attempt to bypass the blockage in the aorta)

What is D-xylose test used for

Diagnoses carb malabsorption

S1 compression -->

Diminished ankle jerk

L4 compression -->

Diminished knee jerk

FeNa is limited by

Diuretic use - use FeUrea instead

Acute epiglottitis triad

Drooling Respiratory distress Dysphagia

Pulsus paradoxus in asthma

Drop of BP >10 on inspiration, directly correlates with severity attack and is a predictor of CO2 levels greater than 35

What kind of RBC finding is highly suggestive of glomerular disease

Dysmorphic RBCs (especially acanthocytes)

1. A 50 year old female with a ten year history of type II diabetes presents for regularly-scheduled follow up. She has no complaints, and just visited her ophthalmologist last week. Current medications include glyburide, metformin, and simvastatin. On physical exam, vital signs are virtually unchanged from previous visits, with temperature 37.1 C (99 F), HR 80, BP 140/83, RR 15, and O2 Sat 98% on room air. Neurological examination reveals diminished sensation to light touch and pinprick in a stocking distribution on the lower extremities bilaterally. Remainder of physical exam is benign. Laboratory evaluation reveals: Na+ 136, K+ 3.9 Cl- 104, HCO3- 25, BUN 15, Cr 1.0, Glucose 150; hemoglobin A1c: 7.1%; Urinalysis: negative for ketones, glucose, bilirubin, leukocyte esterase, or blood; moderate protein; Lipid profile: Total cholesterol 146, HDL 46, LDL 100. At this time, which of the following would be the most appropriate intervention? A. Increase simvastatin B. Increase glyburide C. Increase metformin D. Add HCTZ E. Add lisinopril

E. Add lisinopril All diabetics should be on ACE inhibitor or ARB for CV and renal protection

55. A 37 year old HIV+ male presents with one week of headache and low grade fever. For the past two days, he has had nausea and vomiting. On physical exam, temperature is 38.1 C (100.6 F), pulse 80, blood pressure 108/68, respirations 15/min. The patient is somnolent but arousable. Nuchal rigidity is present. With the patient supine, passive knee extension elicits neck pain. Lungs are clear to auscultation. There are no petechiae or cutaneous hemorrhages seen. CT scan shows no focal lesion, and lumbar puncture is performed. CSF analysis shows clear, light yellow CSF with an opening pressure of 290 mm Hg (normal: 70-180 mm Hg), 25 WBC (normal 0-5) with 96% lymphocytes, 15 RBCs, a glucose of 38 mg/dL (normal: 40-70 mg/dL)and protein 50 mg/dL (normal: 15-45 mg/dL). Which of the following would be the most appropriate therapy for this patient? A. Ceftriaxone B. Acyclovir C. Vanc + cefotaxime D. Trimethoprim-sulfamethoxazole E. Amphotericin B + flucytosine

E. Amphotericin B + flucytosine

80. A 52 year old female comes in for a yearly physical. She has been feeling completely well, and denies chest pain, shortness of breath, weight loss, decreased exercise tolerance, or change in stool frequency or caliber. Past medical history is significant for hypertension controlled with hydrochlorothiazide. Although she has a history of several abnormal Pap smears thirty years ago, her tests have been normal since then, with her last normal Pap occurring two years ago. She had a normal mammogram earlier this year. She has smoked one half a pack of cigarettes daily for thirty-five years, and drinks 1-2 glasses of wine nightly. Her mother died at age 63 from ovarian cancer, and her father died at age 70 from lung cancer. Her siblings are alive and well. EKG shows sinus rhythm with a normal axis and intervals. Of the following, which is the most appropriate screening test to offer this patient? A. Pap smear B. CA-125 C. CXR D. Exercise stress test E. Colonoscopy

E. Colonoscopy

Catch with LDL goals:

Patient's with known CAD --> less than 100 Equivalents=cerebrovascular disease, AAA, PAD, diabetics (Goal of less than 70 in VERY high risk patients)

71. A 38 year old woman has had four weeks of watery, non-bloody diarrhea and cramping abdominal pain. She denies a history of similar symptoms, sick contacts, drinking unpurified water, and recent travel. There have been no changes to her diet, and she does not drink milk or eat dairy products. Current medications include esomeprazole and ibuprofen. She completed a course of amoxicillin/clavulanate for a sinus infection two months ago. On physical examination, she is afebrile. Bowel sounds are slightly hyperactive, and there is mild lower abdominal tenderness to palpation. Which of the following tests will most likely lead to the diagnosis in this patient? A. Sudan stain for fecal fat B. Microscopic examination of the stool for ova and parasites C. D-xylose test D. Barium upper gastrointestinal series E. ELISA for C.difficile-associated toxins A and B

E. ELISA for C.difficile-associated toxins A and B

25. A 27 year old male has had a sore throat for two weeks. The pain has now become so great that he has great difficulty swallowing and has only been able to eat and drink small amounts over the past few days. He has had occasional fevers, but denies cough or coryza. Prior to this, the patient had been very healthy and had not been to a physician for fifteen years. Vital signs on presentation include temperature 38.0 C (100.4 F), pulse 90, blood pressure 118/75, and respirations 14/min. On physical exam, no tonsillar exudates are seen, but there are numerous soft, fluffy white plaques in the patient's tongue and oropharynx. The lesions bleed slightly when they are scraped. Which of the following is the most appropriate next step in the management of this patient? A. Peripheral blood smear for atypical lymphocytes B. Rapid antigen detection test for Group A beta-hemolytic C. Streptococcus Antibody assay for measles virus IgM (MVIgM) D. Lateral neck radiographs E. ELISA for HIV-1 antibodies

E. ELISA for HIV-1 antibodies

118. A 27 year old G0 presents with heavy menstrual periods and pain during menses. Her symptoms began two and a half years ago when she discontinued her oral contraceptive medication so that she could attempt to become pregnant. Her symptoms seem to be getting worse, and her pain is now only minimally controlled with over-the-counter medications. Current medications include escitalopram and as-needed ibuprofen and naproxen. Pelvic examination reveals a nontender, fixed, retroverted uterus. Speculum examination shows small bluish spots in the posterior fornix, but no cervical drainage or discharge. There is moderate uterosacral nodularity on rectovaginal examination. The patient's hematocrit is 30%, and her urine beta-hCG is negative. Which of the following is the most likely diagnosis in this patient? A. Endometrial carcinoma B. PID C. Endometritis D. Premenstrual dysphoric disorder E. Endometriosis

E. Endometriosis

93. A 38 year old female presents with weakness and tingling in her hands and lower extremities. She was feeling well until yesterday when she noted a "pins-and-needles" sensation in her fingers and toes. She noted weakness in her hands and legs today, and had difficulty holding a pen or walking without dragging her toes on the ground while at work today. Her past medical history includes gastroesophageal reflux and an overnight hospitalization three weeks ago for dehydration following an episode of gastroenteritis. Physical examination shows poor inspiratory effort and diminished breath sounds bilaterally. Deep tendon reflexes cannot be elicited at the ankle, knee, wrist, or elbow, and the patient has 3+ muscle strength distally and 4+ muscle strength proximally. There is a flexor plantar response. Cerebellar testing and cranial nerve testing show no gross deficit. Which of the following is the most likely diagnosis in this patient? A. Cauda equina syndrome B. MS C. ALS D. MG E. Guillain-Barre

E. Guillain-Barre (LP and EMG)

81. A 19 year old male presents to the emergency room at midnight with wheezing and shortness of breath. Although history is difficult to obtain secondary to the patient's tachypnea, he is able to state that his symptoms started one hour ago and have been progressively worsening. Past medical history is significant for seasonal allergies and asthma. Current medications include inhaled albuterol and budesonide. On physical exam, the patient appears anxious and is sitting upright. Vital signs on presentation are pulse 120, respirations 42/minute, BP 118/68, and O2 Sat 93% on room air. Nasal flaring is noted. The skin appears pale. No murmurs, rubs, or gallops are appreciated on cardiac auscultation. Bilateral, symmetrical wheezing is present. ABG obtained on presentation shows pH 7.51, pO2 70 mm Hg, and pCO2 29 mm Hg. Supplemental O2 by nasal cannula is started, and the patient is treated with nebulized albuterol and i.v. methylprednisolone. Thirty minutes after treatment, the patient is reassessed. No wheezing is noted, and breath sounds are equal bilaterally. Vitals are pulse 121, respiratory rate 35/minute, BP is 120/71, which drops to 108/65 on inspiration. Repeat ABG is obtained, showing pH 7.40, pCO2 41 mm Hg, pO2 72 mm Hg. What is the most appropriate next step in management? A. Obtain chest x-ray B. Begin i.v. albuterol C. Begin i.v. theophylline D. Administer inhaled salmeterol E. Intubation and mechanical ventilation

E. Intubation and mechanical ventilation (rise in CO2, impending respiratory failure)

67. A 17 year old basketball player comes to the physican after "twisting" his knee in a game one week ago. After jumping to catch a pass, he twisted on his flexed right knee and felt a sharp pain. He denies any joint dislocation or popping sounds or sensations, but was scarcely able to bear weight after the injury and had to be helped off the court. The following morning, his knee was swollen, and although his pain has improved, he has had several episodes where his knee "locks" into an extended position. On physical examination, there is a moderate effusion of the right knee and tenderness to palpation along the medial joint line. Extending the fully-flexed knee while applying a moderate varus stress causes an audible click and reproduces the patient's pain. With the knee flexed to ninety degrees, there is no movement of the tibia on the femur when the lower leg is pulled anteriorly. Which of the following is the most likely diagnosis in this patient? A. Osgood-Schlatter disease B. Torn ACL C. IT band syndrome D. Slipped capital femoral epiphysis E. Meniscal injury

E. Meniscal injury

56. A 68 year old woman has had worsening back pain for the past three months. Her pain radiates to her legs bilaterally. The pain is worst while walking or standing upright and is associated with weakness and numbness of her legs while walking. Sitting or lying down relieves the pain, but the patient also found that leaning forward over her grocery cart improved her symptoms while shopping earlier this morning. She has not had fever or bowel or bladder incontinence. Past medical history is significant for hypertension controlled with lisinopril. The patient does not smoke. Physical examination shows no tenderness along the lumbar spine and a negative straight-leg raising test. The feet are warm, and dorsalis pedis pulses are 2+ bilaterally. No saddle anesthesia is present, but the patient has weakness of the extensor hallucis longus bilaterally. Which of the following is the most likely pathological mechanism for this patient's symptoms? A. Herniation of the nucleus pulposus against the L4 nerve roots B. Pyogenic abscess of the epidural space in the lumbar spine C. Atherosclerotic occlusion of the popliteal arteries D. Malignant tumor invasion of the lumbar spine E. Narrowing of the lumbar spinal canal

E. Narrowing of the lumbar spinal canal

When are IVC filters used?

Patients with DVT who have absolute contraindications to anticoag (recent surgery, head trauma, active bleeding) Patients who have PE even though they are adequately anticoagulated

54. A 35 year old man presents to his physician with neck pain that began suddenly while at rest four hours ago. His past medical history is significant for a ten-year history of disorganized schizophrenia, which has been treated unsuccessfully with a number of medications including olanzapine, risperidone, and haloperidol, and he has been recently switched to thiothixene. Examination shows a disheveled male with a flat affect, holding his head twisted to the right. There is limited cervical range of motion and pronounced muscle contraction of the sternocleidomastoid and paracervical muscles. Which of the following is the most appropriate pharmacologic intervention for this patient's condition? A. IV dantrolene B. Increase po thiothixene C. Add clozapine D. Oral ibuprofen E. Oral diphenhydramine

E. Oral diphenhydramine

84. A 65 year old male comes to the physician because of fatigue and increasing abdominal girth. Over the past six months, he has also experienced an unintentional weight loss of 15 lbs., which he believes is due to the fact that he feels full after only a few bites of his meals. The patient has no past medical history, as this his first visit to a physician since being discharged from the army 40 years ago. The patient denies smoking but does drink 1-3 beers every evening. On physical examination, the patient appears emaciated with a visibly distended and protuberant abdomen. No icterus is noted. Neck veins are non-distended and lungs are clear to auscultation. There is an S4 present on cardiac auscultation. Abdominal examination shows shifting dullness to percussion and a positive fluid wave. There is a firm, red, nontender nodule at the umbilicus. Examination of the skin shows no spider angiomata or palmar erythema. There is 1+ edema at the ankles bilaterally. Labaratory results include albumin of 3.6 g/dL, AST 39 U/L, and ALT 29 U/L. Paracentesis is performed, yielding clear, straw colored fluid, with an albumin concentration of 2.7 g/dL, 650 leukocytes (85% lymphocytes, 15% PMNs). No organisms are seen on Gram stain. Which of the following is the most likely cause of this patient's ascites? A. Spontaneous bacterial peritonitis B. Alcoholic cirrhosis C. Budd-Chiari syndrome D. Congestive heart failure E. Peritoneal metastatic disease

E. Peritoneal metastatic disease

40. Following a 10 hour car trip, a 73 year old female develops left ankle swelling and acute shortness of breath. Ultrasound with Doppler of her left leg confirms the presence of deep venous thrombosis, and the patient is hospitalized and started on a heparin drip and oral warfarin. Two days later she is discharged from the hospital with subcutaneous heparin and warfarin. Shortly upon arrival home, she develops pleuritic chest pain and shortness of breath and presents to her physician. Physical examination reveals tachypnea and an oxygen saturation of 89% on room air. Laboratory analysis shows her activated partial thromboplastin time to be therapeutically increased, while her prothrombin time remains below the optimal therapeutic level. A ventilation/perfusion scan is obtained, which shows a large perfusion defect in the left lower lobe. Which of the following is the most appropriate intervention at this time? A. Hospital admission for observation B. Begin aspirin C. Increase heparin D. Increase warfarin E. Placement of an IVC filter

E. Placement of an IVC filter

92. A 31 year old female presents to her physician in January with several days of fever, malaise, and a cough productive of yellow-green sputum. She had been feeling well until four days ago when she developed a sore throat and rhinorrhea; this was soon followed by fever, malaise, and myalgias. Two days ago she began experiencing a hacking cough that has been occasionally productive of purulent sputum. Vital signs include temperature 37.2 C (99.0 F), pulse 80, blood pressure 118/78, respirations 14/min, oxygen saturation 98% on room air. No crackles or rhonchi are appreciated on auscultation of the lungs. Which of the following is the most appropriate initial step in the management of this patient? A. Azithromycin B. Ceftriaxone and levofloxacin C. Salmeterol D. Amantadine E. Pseudophedrine and acetaminophen

E. Pseudophedrine and acetaminophen

What is PANDAS?

Pediatric autoimmune neuropsychiatric disorder, associated with group A streptococci

Physiological cysts symptoms when large

Pelvic fullness Constipation Urinary frequency Dx with US

66. A 19 year old female comes to her physician because of visual blurring for the past week. For the past few months, she has also has experienced daily headaches, which are worst in the morning upon awakening and improve throughout the day or after taking ibuprofen. Her past medical history is unremarkable, and her only medication is a combination oral contraceptive pill. Physical examination shows height 62 inches (157 cm), weight 206 lbs. (93 kg), temperature 37.2 C (99.0 F), pulse 72, blood pressure 118/76. Fundoscopic examination shows bilateral papilledema. Neurological examination shows no focal deficits. CT shows normal ventricles and no evidence for mass lesion, but increased volume and distension of the perioptic subarachnoid space. Lumbar puncture shows an elevated opening pressure and clear CSF with normal cell counts, protein, and glucose. Which of the following is the most likely diagnosis in this patient? A. Aseptic meningitis B. Craniopharyngioma C. Dandy-Walker malformation D. Subdural hemorrhage E. Pseudotumor cerebri

E. Pseudotumor cerebri

74. A 72 year old female presents after "passing out" while walking back to her house from the mailbox. Other than an abrasion on her elbow, she denies any trauma from the fall and recovered quickly following the incident. There was no bowel or bladder incontinence or prodrome before the attack. On review of systems, the patient admits to occasional exertional chest pains that are relieved by taking her husband's nitroglycerin. Physical examination shows vital signs of heart rate 75 and regular, blood pressure 138/78, and respirations 13/min. There is a small abrasion and associated ecchymosis on the patient's left elbow, but no other signs of trauma. On cardiac auscultation, there is a harsh, III/VI systolic crescendo-decrescendo murmur heard best at the base of the heart and bilaterally at the clavicles. Lung fields are clear, and there is no peripheral edema. Neurological examination shows no focal abnormality. EKG shows normal sinus rhythm with left ventricular hypertrophy and normal PR and QT intervals. Which of the following is the most appropriate step in the management of this patient's syncope? A. UDS B. Head CT C. Title table testing D. Referral to a cardiologist for pacemaker placement E. Referral to a cardiac surgeon for valve replacement

E. Referral to a cardiac surgeon for valve replacement

75. A 31 year old male with a 9 year history of ulcerative colitis presents with severe abdominal pain for the past few hours. He had been stable with sulfasalazine treatment, but one week ago was started on high-dose prednisone and loperamide for a flare. Vital signs are temperature 38.6 C (101.6 F), pulse 120, blood pressure 118/75, and respirations 20/min. The abdomen is distended, with markedly decreased bowel sounds. Though the lower abdomen is tender, there is no rebound tenderness or rigidity. Laboratory analysis is notable for a white blood count of 12,000 (normal: 4,500-11,000) and a hematocrit of 34.5% (normal: 39-49%). The remainder of the patient's labs, including LFTs, lipase, and lactic acid, are normal. Which of the following is the most likely diagnosis in this patient? A. C diff B. Sigmoid volvulus C. Acute pancreatitis D. Ischemic colitis E. Toxic megacolon

E. Toxic megacolon

4. A 30 year old female presents to her physician with a breast mass. She first noted a small "lump" in her left breast while showering about six weeks ago. She has noted no change in the size of the mass since that time, and she denies pain or nipple discharge. Family history is significant for a paternal grandmother who had breast cancer at age 79. Physical examination reveals a soft, round, mobile 1cm mass in the lower outer quadrant of the left breast. No skin changes are noted. What is the most appropriate next step in the management of this patient? A. Mammography B. Refer patient for radical mastectomy C. Begin levonrgestrel/etinyl estradiol D. Genetic testing for BRCA1 and BRCA2 E. Ultrasound of breast mass

E. Ultrasound of breast mass Mammogram is the preferred imaging study for women over 35, while women younger than 35 should get ultrasound to evaluate a breast mass. In women younger than 35, the breast tissue is often too dense to evaluate mammographically, and the incidence of breast cancer younger women is still very low.

43. A 5 year old boy presents with bedwetting. His mother states that for the past two months, he has been wetting the bed several times a week. The child is embarrassed about this new incontinence, and has had no problems in the daytime. The patient's mother insists that the child has otherwise been healthy; she denies fevers and increased appetite or fluid intake. The patient's past medical history is remarkable only for a hospitalization at age 1 for bronchiolitis. The boy lives with his mother, father, and a younger sister who was adopted from Russia several months ago. Everyone at home has been well. On physical exam, the patient is a talkative, interactive male. Speech, motor, and physical development are all normal. What is the most appropriate initial step in the management of this patient? A. Urine culture B. Voiding cystourethrogram C. Recommend an enuresis alarm D. Desmopressin E. Urinalysis

E. Urinalysis (New onset enuresis should prompt the physician to perform a thorough history and physical and to initially obtain a urinalysis)

103. A 16 year old female presents with abdominal pain and fever. The pain began 12 hours ago, and was initially focused in the umbilical area, but has since shifted to the right lower quadrant. She has also experienced nausea and had one episode of vomiting. She is sexually active with one partner, and her last menstrual period was three weeks ago. She has not eaten anything since yesterday and does not feel hungry. Vital signs include temperature 38.1 C (100.5 F), pulse 96/min, blood pressure 112/70. The patient is lying very still on the examination table with her hips flexed. Her abdominal examination shows voluntary guarding and tenderness to palpation greatest in the right lower quadrant, approximately midway between the umbilicus and the anterior iliac spine. Laboratory analysis shows a white blood count of 14,000. Which of the following is the most appropriate next step in the management of this patient? A. Diagnostic peritoneal lavage B. Doxycycline C. Bolus with 3 L i.v. normal saline (0.9% NaCl) D. CT of abdomen E. Urine beta-hCG

E. Urine beta-hCG (even though she has classic appendicitis, have to rule out pregnancy, especially ectopic)

107. A 73 year old male is brought to the physician by his wife, who is concerned about a rapid functional decline over the past several months. Her husband used to manage the family's finances, but he has become increasingly forgetful, and now is unable to perform this task or even to remember the last few words of a conversation. Over this time, he has also developed difficulty walking, and recently has become incontinent of urine. Mini-mental state examination shows impaired short term memory. Thyroid function tests and serum B12 levels are normal. Which of the following is the most likely finding on CT imaging of the head? A. Gross atrophy of the caudate nucleus B. Biconvex, extra-axial area of hemorrhage that does not cross suture lines C. Multiple ring-enhancing lesions throughout the brain D. Cortical atrophy and ventricular enlargement E. Ventricular enlargement without cerebral atrophy

E. Ventricular enlargement without cerebral atrophy (NPH)

Good way to remember pregnancy loss

Early=genetic Later=anatomical Anytime=immunologic

Speculum exam with cervicitis

Friable cervix

Fixed drug eruptions are usually?

Edematous plaque with a bullous center Common drug culprits include tetracycline antibiotics, barbiturates, sulfonamides, NSAIDs, and phenolphthalein

How to confirm diagnosis of myasthenia gravis?

Edrophonium improves patient's symptoms AKA the Tensilon Test

Which patients should be hospitalized for CAP?

Elderly Unstable vitals AMS Medical comorbidities

Features that point to pre-renal azotemia

Elevated BUN/creatinine Low FENA Bland urine sediment

Jaundice due to hemolysis?

Elevated LDH Low haptoglobin

CML abnormalities CBC

Elevated WBCs + platelets Anemia

Down syndrome associations

Endocardial cushion defects VSDs Tracheoesophageal fistula Hirschsprung's ALL Atlantoaxial instability Alzheimer's

McCune-Albright syndrome

Endocrine hyperfunction --> precocious puberty ACTH-independent cushing syndrome

Classic triad of pheochromocytoma:

Episodic headache Sweating Tachycardia

RMSF rash

Eruption of vasculitic rash on all extremities

What does von Willebrand factor do?

Functions as a carrier protein for Factor VIII Aids in platelet adhesion

Indications for any male or postmenopausal woman with iron deficiency anemia:

Evaluated for occult GI source, preferably with upper and lower endoscopy

Characteristic Paget's disease finding:

Expansion of the bony cortex in a mosaic pattern

Which sex is gonorrhea more likely to be asymptomatic in?

Females

Key features of PBC

Females 6:1 (late 40s-early 60s) Associated with other autoimmune diseases (most frequently RA and sjogrens) Most common presentation is pruritus (cholestyramine helps) Attacks the small intrahepatic ducts

Classic features of fibromuscular dysplasia:

Females under 50

Shoulder dystocia risk factors

Fetal macrosomia Gestational diabetes Maternal obesity Postdate pregnancy Prolonged 2nd stage of labor

Key features of NMS

Fever Muscle rigidity Autonomic instability Increased CPK

Diagnosis of Kawasaki disease

Fever of at least 5 days At least 4 of the following: peripheral edema, desquamation (especially of the fingertips, palms, and soles), bilateral conjunctivitis; polymorphous, nonvesicular rash; cervical lymphoadenopathy (often unilateral); dry or fissured lips; or "strawberry tongue."

Clues to a spinal epidural abscess

Fever, localized spinal pain, history of IV drug use, rapidly progressive course

PE findings with WPW:

Few or no findings is not uncommon

When can you not use fluoroquinolones?

Pregnant women --> fetal toxicity Peds --> arthrotoxicity

ASD buzzword

Fixed splitting of S2

Endometriosis pearls

Fixed, retroverted uterus Blue spots in posterior fornix Infertility Dyspareunia Rectal pain during menstruation Pain with pooping

Fluids in rhabdo

Fluid replacement is usually accomplished with normal saline at 1-2 L/hour, titrated to maintain a urine output of 200-300 mL/hour

Genetics of Alport Syndrome:

Genetic mutation in collagen type IV

When there are casts in the urine sediment, you know it is ______

Glomerular disease

When there are casts in the urine sediment, you know it is ______

Glomerular disease (it's only when cells get squeezed through the glomerulus that they will form casts)

Key features of Alport Syndrome

Glomerular hematuria Sensorineural deafness Ocular abnormalities

Patient's with 2+ LDL risk factors=

Goal of less than 130

Ceftriaxone and bacterial meningitis

Good empiric therapy when there isn't a concern for drug-resistant s. pneumo (DRSP) *use vanc + cefotaxime when there is concern for DRSP*

vesicoureteral reflux

Graded from I-V For grades I and II medically manage because they have a high likelihood of resolving spontaneously

What used to be most common source of acute epiglottitis

H. flu (type B) "Thumb sign"

Hepatitis B serologies

HBsAg (+) = active hepatitis B infection HBsAb (+) = immune to the virus, you will see this after vaccination HBcAb (+) = previous infection with hep B

Leukocoria

Hallmark of retinoblastoma, white pupillary reflex

TOA presentation

History of PID, lower abdominal pain often with fever and leukocytosis

When is a radionuclide scan warranted?

Hyperthyroid to determine adenoma vs. background hyperthyroidism

Common precipitant of a fib:

Hyperthyroidism

Lab findings in alcoholics

Hypoglycemia Macrocytic anemia Elevated AST/ALT Low mag Elevated PT Low albumin

Presentation in Conn's syndrome:

Hypokalemia HTN

RTA type I lab findings

Hypokalemia Urine pH>5.5

Hodgkin's ANn Arbor staging

I: single LN region II: 2+ LN regions on the same side of diaphragm III: Bilateral LN regions IV: Disseminated disease

Why are IUDs not the best choice in young sexually active patients?

IUDs are like foreign bodies that can increase the risk of an upper genital tract infection if a patient acquires an STI, so they're not the best choice in a young sexually active patient who is not using condoms

Treatment of refractory MG

IV IG Plasmapharesis

How to treat NMS

IV dantrolene or bromocriptine + IV hydration

Kawasaki treatment

IVIG Corticosteroids Aspirin

Which drugs can be used to cardiovert a fib back to NSR

Ibutilide Amiodarone Propafenone Flecainide

Legg-Calve-Perthes Disease

Idiopathic avascular necrosis, kiddos 3-12 (usually 5-7) Most are male, 10% familial Limp and trendelenburg gait Pain=mild, referred to anteromedial thigh or knee

Imiquimod

Immunomodulator that treats genital warts

RTA type 1

Impaired H+ secretion in distal tubule and collecting ducts which leads to metabolic acidosis and alkalinization of the urine --> nephrolithiasis

ALL microcytic anemias are caused by:

Impaired incorporation of hemoglobin into RBCs

Dx Addison's vs. iatrogenic

In Addison's, there are deficiencies in mineralocorticoids AND glucocorticoids

Lab findings with neuroblastoma?

Increased HVA and VMA *But NOT urine metanephrines and normetanephrines as are seen in pheochromocytomas

CSF findings consistent with herpes encephalitis

Increased WBC, lymph predominance Numerous RBCs

What supports the dx of acute ischemic colitis

Increased lactic acid

CSF findings herpes encephalitis

Increased lymphs Markedly elevated RBCs

Saline wet mount for BV shows?

Increased numbers of coccobacilli Clue cells (vaginal epithelial cells studded by adherent coccobacilli around the cell's edges)

Albuminocytologic dissociation

Increased protein but normal WBC Seen in Guillain-Barre

Hirschsprung disease presentation

Infancy --> failure to pass meconium, symptoms of distal intestinal obstruction

How does Dandy-Walker malformation present

Infancy/childhood with slow motor development, progressive enlargement skull or signs of cerebellar dysfunction/increased ICP

Most common causes of increased oxidative stress and hemolysis?

Infection (viral, bacterial) Fava beans Nitrofurantoin Quinine Dapsone Sulfonamides

Uncomplicated yeast infection?

Infections are uncomplicated when the patient experiences mild to moderate symptoms, the infections are sporadic, the suspected organism is Candida albicans, and the host is otherwise healthy.

What meds cause a shift of K+ from the serum into cells?

Insulin + glucose Sodium bicarb

LP finding characteristic of cryptococcal meningitis

Isolated elevated opening pressure

Chickenpox basics

Itchy rash, multiple lesions in various stages Treat only in IC patients

Classic presentation temporal arteritis

Jaw claudication Vision loss Elevated ESR

Patient's with zero or one LDL risk factor

LDL goal of less than 160

Management of fluid-filled cyst

Lap cystectomy if it increases in size, is greater than 6 cm or causes symptoms --> wall sent for path

Infectious mono peripheral blood smear

Large numbers of atypical lymphocytes

Chronic diarrhea=

Lasting >4 weeks

Stable patient with suspected epiglottitis -->

Lateral neck radiographs

Hemophilias and clotting factor deficiencies -->

Less minor mucosal bleeding Can't form stable mature clots, so get deep tissue bleeds (hemarthrosis) "Petechiae suggest Platelet deficiency; Cavity or joint bleeding suggests Clotting factor deficiency."

Fragile X key findings

Long face with large jaw and ears Big balls Autistic-like behavior

CXR active pulmonary TB

Looks like lobar pneumonia (ipsilateral hilar adenopathy and atelectasis)

Classic murmur of VSD:

Low-pitched, harsh holosystolic Heard best at LLSB

Malignant melanoma treatment

Lymph node biopsy, chemo, radiation

Malabsorption diarrhea

Malodorous Bulky Greasy

BV discharge:

Malodorous, thin, grey-white

Key clues for renal artery stenosis?

Markedly elevated BP in otherwise healthy young person Abdominal bruit

A1C of 7.0 correlates to

Mean glucose level of less than 150

Koplik spots

Measles White or bluish-gray dots or "grains of sand" on a red base

First line treatment for enterobiasis?

Mebendazole Albendazole

Waterhouse-Friderichsen syndrome

Meningococcal sepsis --> bilateral hemorrhagic destruction of adrenal glands

When is RSV immunization (palivizumab) given?

Premature infants Infants with chronic lung or heart disease

Classic pentad TTP

Microangiopathic hemolytic anemia Thrombocytopenia AMS/neuro abnormalities Fever Renal dysfunction (treat with plasmapharesis)

Murmur associated with increased flow across pulmonary valve

Mid-systolic ejection murmur Left 2nd intercostal space

Classic auscultory finding with MVP:

Midsystolic click followed by a late systolic murmur Heart best @ apex

When to use POPs?

Migraine headache Smokers over 25 Postpartum period Clotting diseases Uncontrolled HTN SLE Hypertriglyceridemia

What is characteristic with autoimmune hepatitis?

More striking elevations in AST/ALT vs. alk phos because the disease is going after the hepatocytes (vs. bile ducts)

IgA nephropathy course?

Most benign ACE/ARBs can minimize glomerular injury if disease progresses

Membranous nephropathy

Most common cause nephrotic syndrome adults

Saline wet mount for trichomoniasis will show?

Motile trichomonads

Where is pasteurella found

Mouths of animals - cats and dogs

Sydenham chorea key features

Movement disorder characterized by chorea, emotional lability and hypotonia - complication of acute rheumatic fever Usually resolves within 3 months

Platelet disorders -->

Mucosal bleeding

Casts that are pathognomonic for ischemic ATN

Muddy brown (granular)

Key features of MG

Muscle weakness that gets worse throughout day

VZIG

Must be given within 96 hours of exposure

Does ASD cause a murmur?

NO! The resultant increased volume of blood going over pulmonary valve does --> flow or ejection murmur

Treatment for acute gout flare

NSAIDs Colchicine Steroids

Etiology for increased AFP

NT defects Gastroschisis Omphalocele

Key features of cat scratch fever

Painful regional lymphadenopathy Exposure to kittens, even with no history of bite or scratch

Buzzword for Henoch-Schonlein purpura

Palpable purpura

Sickle cell pearls

Newborn testing almost universal Usually present between 6 months-1 year (all has to do with how long HgF hangs around)

Which medication has profound effects on HDL?

Niacin (statins and fibrates modestly raise)

Low risk SPN=

Nonsmokers Under 35 Less than 2 cm Followed with CXR or CT every 3-6 months

Gynecomastia in puberty bois

Normal - almost half Usually resolves within 6-18 months

Von Willebrand's labs

Normal PT Normal or increased aPTT Increased bleeding time

What helps ddx with SVT and DVT?

Palpating a "cord" superficially --> SVT Superficial=saphenous Deep=femoral, popliteal

Presentation bereavement

Normal bereavement can cause depressive symptoms and even some symptoms that appear psychotic, such as hearing the loved one's voice. However, the diagnosis of bereavement is superseded by the diagnosis of major depression if there is severe impairment of functioning or suicidal ideation. Even if these factors are lacking, you should diagnose a major depressive episode if the patient meets criteria for two months.

Lab findings with antibody-mediated hemolysis?

Normocytic anemia Elevated retic count Increased LDH and bilirubin Decreased haptoglobin

Common cause of secondary HTN in children

OSA due to tonsillar hypertrophy

Classic patient with idiopathic intracranial HTN

Obese, young females takes OCPs

AML presentation

Pancytopenia Blood smear shows numerous circulating blasts

MEN-1

Parathyroid hyperplasia Pancreatic islet tumors Pituitary tumors + gastrinomas and ZES

Presentation of pancreatic carcinomas begininning in head

Obstructive jaundice

Clinical clues to Paget's:

Older patient Slowly going deaf Hat size increasing Frontal bossing Tibial bowing Elevated alkaline phosphatase Deep bony pain

Doxycycline dose when treating chlamydia?

One week

Management of gestational diabetes

Oral hypoglycemics contraindicated (cross placenta) Diet and exercise, insulin as last resort

IUDs are best in?

Parous, monogamous relationships

Aplastic crisis in sickle cell

Parvovirus B19

Erythema infectiosum is caused by

Parvovirus B19 (fifth disease)

CSF basics

PMNs --> usually bacterial Lots of lymphs --> usually viral Protein --> indicator of meningeal irritation (MS or guillain-barre can also do it)

DDx peripheral vs central nystagmus

Peripheral is inhibited by visual fixation, aka if you ask patient to focus on fixed point

Markedly elevated ESR is the hallmark of?

Polymyalgia rheumatica *usually above 70-80, sometimes over 100

Things that can be common to all TORCH infections

Poor feeding Fever Deafness Mental retardation Hepatosplenomegaly Thrombocytopenia

Anti-streptolysin O titer

Positive in postinfectious glomerulonephritis, indicates recent exposure to Group A strep

Radiographs in SCFE

Posterior displacement of left femoral epiphysis, "ice-cream slipping off a cone"

Disease in which there is an oversecretion of aldosterone?

Primary hyperaldosteronism (Conn's syndrome)

4 hallmarks of nephrotic syndrome

Proteinuria Edema Hypoalbuminemia Hyperlipidemia

Scabies buzzword

Pruritus out of proportion to appearance of rash Small erythematous papules with excoriations is classic, as is the description of lesions occurring in the web spaces of the fingers

Test of choice for Hirschsprung's (aganglionic megacolon)

Rectal biopsy

Most common presentation IgA nephropathy?

Recurrent episodes of gross hematuria that occur around 5 days after an upper respiratory infection.

Trichomoniasis discharge:

Purulent, green-grey, frothy

Best way to diagnose acute hep A?

Quantitative IgM

Syphilis diagnostics

RPR and VDRL for screening Darkfield microscopy or FT-ABS for confirmation

Non-anion gap metabolic acidosis

RTAs GI bicarb loss

Acute cholangitis (Charcot's triad)

RUQ pain Jaundice Fever/chills

How to obtain bone age

Radiographs of hand and wrist

How to diagnose strep throat in office

Rapid antigen detection test for GABHS (group A strep)

Congenital syphilis presentation

Rash involving palms and soles Blood-tinged purulen nasal discharge (snuffles) Lymphadenopathy Organomegaly

Dermatitis herpetiformis

Rash on knees and elbows Associated with celiac

Peritoneal signs

Rebound tenderness Guarding Rigidity (indicate perforation)

Benign paroxysmal positional vertigo presentation/dx

Recurrent episodes of vertigo lasting a few seconds Caused by otoliths Dix-Hallpike

When do you do urgent hemodialysis for hyperkalemia?

Refractory cases Ongoing release of K+ from injured cells (ex: severe myonecrosis)

How to confirm diagnosis of IgA nephropathy

Renal biopsy

IV drug users are prone to?

Right-sided endocarditis Don't get Janeway lesions or Osler nodes, which form by throwing septic emboli into the systemic circulation

How is thin basement membrane nephropathy most common detected?

Routine UA (patients usually completely asymptomatic)

Osteo in sickle cell

Salmonella

Paget's disease of the breast pearls

Scaly, eczematous lesion on nipple or breast Underlying carcinoma

When is strawberry tongue seen?

Scarlet fever Kawasaki

Pain with herniated discs

Shooting, radicular pain Key dx is straight leg raise Numbness in affected dermatome Motor weakness and reflex loss

Turner's presentation

Short stature Primary amenorrhea

Definition of short stature

Short stature is defined as 2 standard deviations below normal the mean height for children of the same sex and age

Turner's buzzwords

Short, squat female Webbed neck Shield shapped chest Widely spaced nipz

Description of a true peaked T wave

Should be sharp enough to really hurt if you sat down on it (lol)

MDD: SIG: E CAPS 25 mnemonic

Sleep disturbance Loss of interest Feelings of guilt Decreased energy Decreased concentration Appetite disturbance Psychomotor retardation SI 2 symptoms present for at least 2 weeks, 5 required to make dx

Doubling time of lung cancers

Slowest growing ~400 days, if lesion is stable 2 years, likely benign

Lambert-Eaton is usually associated with?

Small cell lung cancer

Interventions that prolong life in COPD

Smoking cessation Supplemental O2

Relationship between sodium and glucose levels

Sodium will drop 2.5 for every 100 rise in glucose levels

Criteria for anorexia nervosa

The criteria for anorexia nervosa include amenorrhea, body weight less than 85% of expected ideal weight, and intense fear of gaining weight or becoming fat.

Starting xanthine oxidase inhibitors with gout

Starting either allopurinol or probenecid in an acute flare of gout is contraindicated, however, since sudden changes in the serum uric acid concentration often cause another attack.

Qualitative assessment for steatorrhea

Sudan stain for fecal fat

When venous thrombosis gets TRICKY

Superficial femoral vein IS A DEEP VEIN Start that anticoagulation baby

When is biventricular pacemaker placement indicated?

Symptomatic bradyarrhythmias SA or AV node dysfunction

Neurogenic claudication

Symptoms occur during ambulation Flexing the spine relieves (leaning over grocery cart)

Presentation adjustment disorder

Symptoms should emerge within three months of an identifiable stressor and should resolve within six months. Additionally, this patient's symptoms are more pathological than would be explained by adjustment disorder

Syncope definition

Syncope is defined as the abrupt and transient loss of consciousness associated with an absence of postural tone. It may sometimes be difficult to distinguish true syncope from things like seizures and cardiac arrest. Patients who describe bowel or bladder incontinence are more likely to have had a seizure, while patients who require CPR for resuscitation have more likely had a true cardiac arrest than simple syncope

What are CA-MRSA usually susceptible to

TMP-SMX Clinda

Polymyalgia rheumatica association?

Temporal arteritis (tenderness, headache, jaw pain, evidence of ischemia)

Adverse effects isotretinoin

Teratogenic Can elevate triglycerides Can be hepatotoxic May be linked to depression and suicide

Mnemonic for microcytic anemias: TAILS

Thalassemias Anemia of chronic disease Iron deficiency Lead poisoning Sideroblastic

Gold standard for gonorrhea diagnosis?

Thayer-Martin medium

Pathognomonic for scabies =

The burrow (thin gray-red lines under the skin

Contact dermatitis rash

The rash is usually intensely pruritic and if allergic in nature, can occur up to two weeks after exposure. The rash itself is usually papular and erythematous with indistinct margins, distributed along areas of exposure. Fluid collects in the epidermis causing vesicles and oozing

Rash of scarlet fever

The rash of scarlet fever is - as its name implies - scarlet, and may resemble a "boiled lobster" or sunburn. Later, punctate lesions the size of pinheads give the skin a rough, sandpaper-like texture. There can be skin peeling as well, but this is a late occurrence

Rhabdomyolysis complications

The two most serious complications of rhabdomyolysis are renal failure induced by myoglobinuria and electrolyte abnormalities (like hyperkalemia, hypocalcemia, and metabolic acidosis) caused by the release of massive amounts of intracellular ions

How does uricosuric medication work

These medications block the reabsorption of uric acid in the renal tubule and cause increased clearance of uric acid in the urine.

Scleroderma clinical presentation

Thickening of the skin, Raynaud phenomenon, esophageal dysmotility, and interstitial lung disease

When should sulfonamides be avoided in preggerz patients

Third trimester, risk of hyperbilirubinemia of newborn

What is Felty's syndrome?

Triad of seropositive RA + splenomegaly + granulocytopenia (decreased absolute neutrophil count)

Campyobacter jejuni

Throwin back some contaminated chicken

MG's association with another part of body?

Thymus 75% have thymic hyperplasia 15% have overt thymoma (Removal can be curative in those failing medical treatment)

Scabies treatment

Topical permethrin cream or oral ivermectin

Celiac patients are at increased risk for

Type I diabetes Thyroid disease Autoimmune hepatitis

Ulceroglandular form tularemia

Ulcers at site of inoculation Tender lymphadenopathy Arkansas, oklahoma, missouri, texas "Hunting or skinning rabbits"

Less than 600 mg of uric acid secreted in 24 hours

Undersecretors --> uricosuric therapy (probenecid or sulfinpyrazone)

ITP clues

Up to 85% of pediatric patients have antecedent infection

Treatment for tension pneumothorax

Urgent needle thoracostomy

Congenital rubella transmission

Usually before 20 weeks - MMR vaccine avoided in pregnant women

Thin basement membrane nephropathy features:

Ususally hereditary and benign Glomerular hematuria Minimal-moderate proteinuria can be seen occasionally

Rhythm disturbances in which urgent DC cardioversion is indicated:

V tach V fib *may be indicated with new-onset a fib

Renal findings in Henoch-Schonlein purpura

Variable, but include: Hematuria Proteinuria Rising creatinine

Presentation herpes neonatorum

Vesicular lesions Complication --> dissemination, encephalitis

Most common cause of aseptic meningitis

Viral, caused by enteroviruses

Condyloma acuminate

Visible genital warts 6 and 11 are the common offenders

Complicated yeast infections?

infection occurring in a host with pre-existing conditions (uncontrolled diabetes, immunosuppression, pregnancy), severe symptoms, infection with non-albicans species, or recurrent infections (>4 per year)

G6PD deficiency genetics/epidemiology

X-linked recessive disease that tends to affect men of Mediterranean or African descent

CSF findings subarachnoid hemorrhage

Xanthrochromnia Increased RBCs

Low pH of vaginal discharge (<4.5) points to

Yeast

When they say antimitochondrial antibodies

You say primary biliary cirrhosis

Bronchiolitis epidemiology

Younger, under 2 usually Vast majority during winter 3/4 RSV, majority of the rest are parainfluenza and adenoviruses

How do topical retinoids (tretinoin, adapalene) work?

affect terminal differentiation of the follicular epithelium, thus helping to normalize follicular keratinization and prevent the formation of new comedones

Wegener's granulomatosis

c-ANCA Upper/lower respiratory symptoms Nephritic syndrome Hematuria, red cell casts

Speculum exam with gonorrhea:

cervix is often friable and cervical discharge may be seen

HTN urgency

defined as a systolic blood pressure >200 or a diastolic >120 in the absence of symptoms

PMH in von Willebrand's

easy bruising, mucosal bleeding, bleeding after dental procedures or tonsillectomy, or heavy menstrual bleeding.

Pathophysiology simple cysts

failure of the maturing follicle to ovulate and involute

Molluscum contagiosum (pox virus) rash

flesh colored, dome-shaped umbilicated papules on any part of the body

Adolescent PCOS presentation

hyperandrogenism including hirsutism, treatment resistant acne, hyperhydrosis, and alopecia or signs of anovulation such as menstrual irregularity and infertility

Classic COPD CXR

hyperexpanded lungs, flattened diaphragms, and a narrow cardiac silhouette

Etiology erythema multiforme

idiopathic viral infections (like HSV and hepatitis viruses), bacterial infections (including Mycoplasma and Yersinia enterocolitica), and drugs (most notably antibiotics and NSAIDs)

Use of oral abx in acne

inflammatory acne to prevent the growth of P. acnes in the pilosebaceous unit

When should you consider a diagnosis of secondary HTN?

known onset of hypertension before age 30, patients whose blood pressure remains elevated despite multiple medications, patients who have severe (>160/100 mm Hg) hypertension above age 55, or patients with a sudden increase in their blood pressure from a stable baseline

Key features of Cushing's:

obesity, bone loss, glucose intolerance, moon facies, a "buffalo hump," purple striae, and hypertension

DDx of simple cyst in adolescent patient:

obstructive genital lesions, ovarian tumors such as benign cystic teratoma, tubal conditions (ectopic pregnancy) and tuboovarian abcess

PSC marker

p-ANCA

End-organ damage seen in HTN emergency

papilledema, stroke, hematuria, headache, altered mental status, acute coronary syndrome, etc

PANDAS diagnostic criteria

pediatric onset, presence of obsessive compulsive disorder and/or a tic disorder, abrupt onset with episodic symptom course, associated with group A strep infections, association with neurological abnormalities like motoric hyperactivity, choreiform movements and tics

Acute labyrinthitis findings

peripheral nystagmus, hearing loss, and an abnormal head thrust test AKA vestibular neuritis

Mono clinical presentation

tonsillopharyngeal exudates, tonsillar or palatal petechiae, cervical adenopathy, and hepatosplenomegaly

Smallpox presentation

viral prodrome followed by the eruption of the characteristic rash that begins as macules and progresses rapidly to small papules

Signs/symptoms yeast infection

vulvar pruiritis, which is often the dominant feature of a yeast infection (and may be the only complaint from the patient). Other symptoms could include dysuria, vulvovaginal irritation, or dyspareunia. Classically, the discharge of a yeast infection is described as white with a curd-like consistency (often described as "cottage cheese" like), but many real-life patients will not complain of increased discharge.