EM SMARTYPANCE EOR 1
Early clues to impending delirium tremens include A Agitation and decreased cognition B Visual hallucinations and diaphoresis C Autonomic hyperactivity and dehydration D Mental confusion and sensory hyperacuity
A Agitation and decreased cognition Anxiety, decreased cognition, tremulousness, increasing irritability, and hyperactivity are common early clues to impending delirium tremens.
A 19-year-old female presents with a sore throat for nearly two weeks. She complains of fatigue and a low-grade fever. On physical examination, there is cervical, axillary, and inguinal lymphadenopathy, and mild splenomegaly. On review of the blood smear, which of the following would be expected? A Atypical lymphocytes B Hypersegmented neutrophils C Hypochromic red blood cells D Schistocytes
A Atypical lymphocytes The hallmark of infectious mononucleosis is the presence of lymphocytosis with atypical large lymphocytes seen in the blood smear. These are larger than normal mature lymphocytes, stain more darkly, and frequently show vacuolated, foamy cytoplasm, and dark chromatin in the nucleus.
94 A 15-year-old girl is hit in the right eye by a golf ball. There is swelling and ecchymosis of the orbit. She complains of double vision. The right eye does not move with downward gaze or right lateral gaze. Which of the following diagnostic tests will provide the most accurate information regarding this injury? A CT-Scan of head B Schiotz tonometry C Fluorescein angiography D Slit lamp biomicroscopy
A CT scan may show a blow-out fracture of the orbital floor. Such fractures may lead to oculomotor nerve entrapment or may lead to swelling that impinges on the nerve, causing decreased eye movements.
Which of the following clinical manifestations is common in candidal vulvovaginitis? A Extreme vulvar irritation B Firm, painless ulcer C Tender lymphadenopathy D Purulent discharge
A Extreme vulvar irritation Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous.
Which of the following oral hypoglycemic agents when used as monotherapy is most likely to cause hypoglycemia? A Glipizide (Glucotrol) B Metformin (Glucophage) C Pioglitazone (Actos) D Acarbose (Precose)
A Glipizide (Glucotrol) Sulfonylureas increase insulin levels and predispose patients to hypoglycemia.
A 35-year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis? A Herpes Simplex Virus (HSV) B Molluscum Contagiosum Virus (MCV) C Human Papillomavirus (HPV) D Syphilis
A Herpes Simplex Virus (HSV) The presentation seen on the Tzanck preparation is characteristic of HSV.
A 23-year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis? A Hypertrophic cardiomyopathy B Aortic stenosis C Mitral regurgitation D Pulmonic stenosis
A Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining.
Which of the following is the first-line treatment for symptomatic bradyarrhythmias due to sick sinus syndrome (SSS)? A Permanent pacemaker B Radiofrequency ablation C Antiarrhythmics D Anticoagulation therapy
A Permanent pacemaker
A 72-year-old female presents with vulvar pruritus for the last nine months, which has progressively worsened over the last two months. She states that she went through menopause at age 54 and has been on estrogen and progesterone therapy since that time. Physical examination reveals red lesions with white plaques on the vulva. What should the next course of management include? A Refer to a gynecologist for biopsy B Refer to a dermatologist for antifungal therapy C Treat with a topical steroid D Treat with estrogen cream
A Refer to a gynecologist for biopsy Vulvar squamous cell hyperplasia causes thickening and hyperkeratosis of the vulva. The lesions are red and moist and cause intense pruritus over time the area becomes thickened and a white plaque may develop. Biopsy must be done to evaluate for intraepithelial neoplasm or invasive tumor.
85 Which of the following rotator cuff tendons is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament? A Supraspinatus B Infraspinatus C Teres minor D Subscapularis
A Supraspinatus A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is most commonly seen with the supraspinatus tendon, the long head of the biceps tendon and/or the subacromial bursa.
When performing a rectal examination, prostatic massage is contraindicated in A acute bacterial prostatitis B chronic bacterial prostatitis. C nonbacterial prostatitis D prostatodynia
A acute bacterial prostatitis Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.
89 A mother brings her teenage daughter to the emergency department. The teenager is anxious, tremulous, and in a dysphoric mood. She reports recent nightmares and insatiable hunger. Which of the following diagnostic tests would likely yield the most important information? A Serum TSH B Urine drug screen C Minnesota Multiphasic Personality Inventory (MMPI) D Electroencephalogram (EEG)
A drug screen would be helpful for many drugs of abuse that might cause these symptoms, but may not be definitive for amphetamines.
Which of the following physical examination findings would be consistent with a pleural effusion? A Hyperresonance to percussion B Increased tactile fremitus C Unilateral lag on chest expansion D Egophony
A lag on chest expansion may be seen in the presence of a pleural effusion.
A 52-year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study? A. Stool for occult blood B. Stool cultures C. Sigmoidoscopy D. Abdominal CT scan
A. Stool for occult blood Occult bleeding, as evidenced by the patient's history of black stools, is initially verified by a positive fecal occult blood test.
An HIV-positive patient presents with worsening dementia, fever, headache, and right hemiparesis. MRI of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. Which of the following is the treatment of choice? A. Sulfadiazine and pyrimethamine B. Trimethoprim-sulfamethoxazole C. Radiation therapy D. Ventricular shunt placement
A. Sulfadiazine and pyrimethamine Toxoplasmosis is commonly noted in HIV-positive patients and presents with multiple ring-enhancing lesions. Treatment of choice for possible toxoplasmosis is sulfadiazine and pyrimethamine. Trimethoprim-sulfamethoxazole is used for prophylaxis of toxoplasmosis, but not for treatment of acute infection.
Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus aureus? A Ingestion of mayonnaise-based salads 48 hours earlier B Bloody diarrhea with mucus for one week C Abdominal cramps and vomiting for 48 hours D High fever for 1 week
Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food poisoning.
A 70-year-old presents with headache and neck stiffness. On physical exam, the patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL, and glucose 35 mg/dL. Which of the following is the most appropriate treatment? A Acyclovir (Zovirax) B Fluconazole (Diflucan) C Ampicillin and ceftriaxone (Rocephin) D Penicillin and chloramphenicol (Chloromycetin)
Ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes , which is common in the elderly. Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia.
A 23-year-old female with a history of palpitations presents for evaluation. She admits to acute onset of rapid heart beating lasting seconds to minutes with associated shortness of breath and chest pain. The patient states she can relieve her symptoms with Valsalva. Which of the following is the most appropriate diagnostic study to establish a definitive diagnosis in this patient? A Cardiac catheterization B Cardiac MRI C Chest CT scan D Electrophysiology study
An electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardia.
83 A 22 year-old female presents to the emergency department with rapid heart rate. She appears quite thin and dehydrated. She denies that she is thin, stating "I am so fat that I can hardly stand myself! That is why I exercise every day." She runs twelve to fifteen miles a day, and on weekends also bicycles forty to fifty miles. Her LMP was six months ago. On exam, she is 5' 6" tall and weighs 98 pounds. Temp 98 degrees F, pulse 100, respirations 18, BP 98/60. EKG shows sinus tachycardia. Laboratory findings include Na 138 mEq/L, K 2.8 mEq/L, Cl 91 mEq/L, BUN 35 mg/dL, Creatinine 1.1 mg/dL. Which of the following is the next most appropriate treatment? A Propylthiouracil (PTU) and individual psychotherapy B Hormone replacement and cognitive therapy C Weight restoration and family therapy D IV hydration and antidepressant therapy
Anorexia nervosa requires a comprehensive, multidisciplinary approach to treatment that integrates medical management, individual psychotherapy, and family therapy. Currently, the best results have been shown with weight restoration accompanied by family therapy for patients with adolescent-onset anorexia nervosa and individual therapy for patients with onset after 18 years of age. Inpatient treatment is often required.
87 Which of the following is the most common cause of arterial embolization? A Rheumatic heart disease B Myxoma C Atrial fibrillation D Venous thrombosis
Atrial fibrillation is present in 60-70% of patients with arterial emboli and is associated with left atrial appendage thrombus.
An elderly patient with poorly controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient? A Administer nebulized corticosteroids B Admit to the hospital C Oral antimicrobial therapy D Endotracheal intubation
B Admit to the hospital Community-acquired pneumonia is the deadliest infectious disease in the U.S. Important risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, altered mental status, a respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30.
A 74-year-old female is being treated for mild hypertension. She is found at home with right hemiparesis and brought to the emergency department. Her daughter states that the patient fell in her kitchen 2 days ago, but had no complaints at that time. She did state that her mother sounded a little confused this morning. The patient's left pupil is dilated. Which of the following diagnostic studies should be ordered first? A MRI of the brain B CT scan of the brain C Skull x-ray D Lumbar puncture
B CT scan of the brain
A 3-year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin O (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is A Renal B Cardiac C Pulmonary D Hepatic
B Cardiac The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.
A 12-month-old child with tetralogy of Fallot is most likely to have which of the following clinical features? A Chest pain B Cyanosis C Convulsions D Palpitations
B Cyanosis Cyanosis is very common in tetralogy of Fallot.
A 63-year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis? A Aortic dissection B Inferior wall myocardial infarction C Acute pericarditis D Pulmonary embolus
B Inferior wall myocardial infarction Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction.
A 36-year-old woman admits that her husband has abused her for over ten years. You should inform the woman that she is at most risk for injury or death A Just before a holiday B Just after leaving an abusive spouse C When an abusive spouse arrives home after work D When an abusive spouse has been drinking heavily
B Just after leaving an abusive spouse Women are more likely to be assaulted or murdered when attempting to report the abuse or leave the abusive relationship; up to 75% of domestic assaults occur after separation.
A 25-year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the proper name for this condition? A Galeazzi fracture B Monteggia fracture C Colles' fracture D Smith fracture
B Monteggia fracture A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head.
Treatment of Bell's palsy includes which of the following? A Acyclovir B Reassurance of the patient's recovery C Referral to a neurosurgeon D Electromyography
B Reassurance of the patient's recovery Bell's palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell's palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell's palsy.
A 28-year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear leukocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis? A Rheumatoid arthritis B Septic arthritis C Gouty arthritis D Osteoarthritis
B Septic arthritis Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels.
A 43-year-old asymptomatic diabetic female is found to have an elevated total calcium level of 12.4 mg/dL. Which of the following tests must be assessed in order to evaluate this laboratory abnormality? A Intact parathyroid hormone B Serum albumin C 24 hour urine calcium level D Complete blood count
B Serum albumin Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels.
99 A 26-year-old woman requests screening after her boyfriend was treated for a sexually transmitted infection recently. On examination you find a painless vulvar ulcer. Which of the following is the most likely diagnosis? A Herpes B Syphilis C Chancroid D Granuloma inguinale
B Syphilis
84 Which of the following is the most common cause for acute myocardial infarction? A Occlusion caused by coronary microemboli B Thrombus development at a site of vascular injury C Congenital abnormalities D Severe coronary artery spasm
B Thrombus development at a site of vascular injury Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion.
A 20-year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that extends into the scrotum. The patient denies any trauma. The most likely diagnosis is A an indirect inguinal hernia B a direct inguinal hernia C an obturator hernia D a femoral hernia
B a direct inguinal hernia An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum.
A 30-year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The most likely diagnosis is A placenta abruptio B ectopic pregnancy C pelvic inflammatory disease. D ruptured ovarian cyst
B ectopic pregnancy Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis.
A 15-year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is A tuberculosis B mycoplasma pneumonia C pneumococcal pneumonia D staphylococcal pneumonia
B mycoplasma pneumonia The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely.
A 38-year-old female with a history of coarctation of the aorta repair at the age of two presents with fevers for four weeks. The patient states that she has felt fatigued and achy during this time. Maximum temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms. Physical examination reveals a pale tired appearing female in no acute distress. Cardiac auscultation reveals a new grade III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border. What is the most likely diagnosis? A Acute myocardial infarction B Bacterial endocarditis C Acute pericarditis D Restrictive cardiomyopathy
Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific symptoms, echocardiogram often reveals vegetations on affected valves.
In infants, the eyes should move in parallel without deviation by the age of A 2 weeks B 3 months C 6 months D 1 year
C 6 months Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months.
Upon stroking of the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan. This is a positive A Kernig's sign B Brudzinski's sign C Babinski's sign D Gower's sign
C Babinski's sign A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan in a positive test.
23 Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism? A Epstein-Barr virus B Group C Streptococcus C Coxsackievirus D Gonorrhea
C Coxsackievirus Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx.
Which of the following diagnostic tests should be ordered initially to evaluate for suspected deep venous thrombosis of the leg? A Venogram B Arteriogram C Duplex ultrasound D Impedance plethysmography
C Duplex ultrasound
Use of systemic corticosteroids can cause which of the following adverse effects in the eye? A Cortical blindness B Optic atrophy C Glaucoma D Papilledema
C Glaucoma Glaucoma can be caused by the long-term use of steroids.
During a baseball game, a 22-year-old college student is hit in the right eye by a baseball. He complains of blurry vision in that eye. On physical exam, the physician assistant notes proptosis of the right eye, and limitation of movement in all directions. On CT scan, which of the following is most likely to be seen? A Fracture of the medial orbital wall B Prolapse of orbital soft tissue C Hematoma of the orbit D Orbital emphysema
C Hematoma of the orbit Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma.
Which of the following views on plain films is preferred to identify spondylolysis? A Anterior B Posterior C Oblique D Lateral
C Oblique The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films.
A 53-year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals sinus tachycardia. Which of the following is the most likely diagnosis? A Atelectasis B Pneumothorax C Pulmonary embolism D Myocardial infarction
C PE This patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bed rest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal.
A 23-year-old female with a history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30-minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A Chest x-ray B Sputum gram stain C Peak flow D Ventilation-perfusion scan
C Peak flow A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.
A 52-year-old male with a history of hypertension and hyperlipidemia presents with acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient? A Coronary artery bypass grafting (CABG) B Streptokinase C Percutaneous coronary intervention (PCI) D Warfarin (Coumadin)
C Percutaneous coronary intervention (PCI)
What type of chest pain is most commonly associated with a dissecting aortic aneurysm? A Squeezing B Dull, aching C Ripping, tearing D Burning
C Ripping, tearing
In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis? A Femur B Humerus C Vertebral spine D Tibia
C Vertebral spine The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection.
Acute rebound hypertensive episodes have been reported to occur with the sudden withdrawal of A verapamil (Calan) B lisinopril (Prinivil) C clonidine (Catapres) D hydrochlorothiazide (HCTZ)
C clonidine (Catapres) Clonidine (Catapres) is a central alpha agonist and abrupt withdrawal may produce a rebound hypertensive crisis.
Which of the following is a cause of prerenal azotemia? A. Infection B. Renal toxins C. Poor renal perfusion D. Urinary tract obstruction
C. Poor renal perfusion Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored.
A 19-year-old patient was involved in a motor vehicle crash and brought to the emergency department fully immobilized. The patient sustained multiple blunt injuries to the chest and abdomen. During the trauma assessment, there was no blood at the urethral meatus and a Foley catheter was placed. The urine was positive for blood on the dipstick. Which of the following is the most appropriate diagnostic test? A Retrograde urethrography B CT scan of abdomen and pelvis C Serum haptoglobin D Urine myoglobin
CT scan of the abdomen and pelvis is indicated in blunt trauma including those resulting in hematuria or when a renal injury is suspected.
An 80-year-old female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with an osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use? A Calcitonin (Miacalcin) nasal spray B Alendronate (Fosamax) C Raloxifene (Evista) D Combined estrogen and progesterone (Prempro) therapy
Calcitonin has the ability to cause analgesia when used for acute compression fracture of the vertebral body.
Which of the following can be used to treat chronic bacterial prostatitis? A Penicillin B Cephalexin (Keflex) C Nitrofurantoin (Macrobid) D Levofloxacin (Levaquin)
Chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.
92 A 33-year-old male presents to your office with a complaint of right knee injury associated with pain and swelling. He states he was running after his loose dog and suddenly stopped, hyperextended his knee, heard a pop and noticed immediate swelling. On physical examination, the Lachman test and anterior drawer test demonstrates joint laxity. Which of the following ligaments is most likely injured? A Medial collateral B Lateral collateral C Posterior cruciate D Anterior cruciate
D Anterior cruciate
Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)? A Drooling B High fever C "Hot potato" voice D Barking cough
D Barking cough Viral croup is characterized by a history of upper respiratory tract symptoms followed by the onset of a barking cough and stridor.
A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time? A Oral prednisone B Oral theophylline (Theo-Dur) C Salmeterol (Serevent) inhaler D Beclomethasone (Qvar)inhaler
D Beclomethasone (Qvar)inhaler This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control.
Which of the following conditions would cause a positive Kussmaul's sign on physical examination? A Left ventricular failure B Pulmonary edema C Coarctation of the aorta D Constrictive pericarditis
D Constrictive pericarditis Kussmaul's sign is an increase rather than the normal decrease in the JVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.
A 65-year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever but has had photophobia and a stiff neck. Which of the following is the most likely diagnosis? A Transient ischemic attack B Bacterial meningitis C Migraine headache D Cryptococcosis
D Cryptococcosis Cryptococcus is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients.
A patient with which of the following is at highest risk for coronary artery disease? A Congenital heart disease B Polycystic ovary syndrome C Acute renal failure D Diabetes mellitus
D Diabetes mellitus Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with established atherosclerotic disease.
90 A 75-year-old woman presents to the office with complaint of vision loss. Examination reveals a palpable cord in the temporal region. Which of the following is the most helpful initial test to order on this patient? A Carotid ultrasound B Chest x-ray C Complete blood count D Erythrocyte sedimentation rate
D Erythrocyte sedimentation rate The patient is suspected of having temporal arteritis. This disease is most commonly noted in patients over age 50 and should be suspected in patients with sudden vision loss and a palpable cord in the temporal region. Erythrocyte sedimentation rate is almost always increased in this disease.
Which of the following drugs is first-line therapy for schizophrenia? A Chlorpromazine (Thorazine) B Clozapine (Clozaril) C Haloperidol (Haldol) D Olanzapine (Zyprexa)
D Olanzapine (Zyprexa) Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychotic drugs, such as olanzapine, risperidone, quetiapine, and ziprasidone because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms.
An 18-year-old sexually active female was seen in the student health clinic 1 week ago for a sore throat. A streptococcal antigen test was positive, and she was given a prescription for oral penicillin. After 3 days, she stopped her medication because she felt better. She now presents with a severe sore throat. On physical examination, she has a temperature of 102.6° F (39.2° C), marked pharyngeal erythema, medial deviation of the soft palate on the left, tender left anterior cervical adenopathy, and a "hot potato" voice. The rest of her history and physical examination are unremarkable. Which of the following is the most likely diagnosis? A Recurrent streptococcal pharyngitis B Infectious mononucleosis C Gonococcal pharyngitis D Peritonsillar abscess
D Peritonsillar abscess The soft palate deviation and a muffled voice are classic signs of peritonsillar abscess.
A 17-year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using "some drugs" but does not know what they were. On physical examination, temperature is 103 degrees F, BP 140/90, pulse 120, respirations 20. Remainder of the examination is unremarkable. Which of the following diagnostic studies will be of most help in managing this patient? A Drug screen B Urine dipstick C Complete blood count D Serum creatinine kinase
D Serum creatinine kinase Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse.
A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated with? A Bladder B Stomach C Pancreas D Small bowel
D Small bowel Pain from the small intestine, appendix, or proximal colon causes periumbilical pain.
The finding of egophony is most consistent with A emphysema B atelectasis C pneumothorax D lobar pneumonia
D lobar pneumonia Egophony occurs with consolidation caused by lobar pneumonia.
A patient presents with an acutely painful and cold left leg. Distal pulses are absent. Leg is cyanotic. There are no signs of gangrene or other open lesions. Symptoms occurred one hour ago. Which of the following treatments is most appropriate? A Vena cava filter B Embolectomy C Amputation D Aspirin
Embolectomy within 4 to 6 hours is the treatment of choice.
A 26-year-old man is stung by a bee, and shortly thereafter, a wheel develops at the site of the sting. He soon feels flushed and develops hives, rhinorrhea, and tightness in the chest. He is seen in the urgent care center. Immediate therapy should be to A transfer him to a local hospital emergency department B apply a cold compress to site of the sting C administer intramuscular epinephrine D administer oral albuterol
Epinephrine Hydrochloride 1:1000, 0.2 to 0.5 mL IM is indicated for the initial treatment of this systemic reaction. Additional injections may be given 5 to 15 minutes after the first injection or every 20 to 30 minutes if needed.
An 18-year-old male presents with pain in his wrist after he fell off of a moving motorcycle. Physical examination reveals tenderness in the anatomic snuffbox. No fracture is noted on plain radiography of the wrist. Which of the following is the recommended treatment for this patient? A Ace wrap of the wrist B Closed reduction of the fracture site C Thumb spica cast application D Open reduction of the fracture site
Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical snuffbox are treated as a stable fracture with immobilization in a thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.
95 A 68-year-old male with a history of atrial fibrillation treated with warfarin (Coumadin) presents to the emergency department after vomiting large amounts of bright red blood. INR is 3. Which of the following is most appropriate to rapidly lower the patient's INR? A Discontinue warfarin B Administer fresh frozen plasma C Administer protamine sulfate D Administer heparin sulphate
Fresh frozen plasma is the most rapid way to lower the patient's INR.
A 36-year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size, but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis? A Congestive heart failure B Subacute bacterial endocarditis C Pulmonary embolus D Pneumonia
Given the presence of cardiomyopathy, the patient's heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure.
93 A 22-year-old woman comes to the office because her urine is cola-colored and she has not urinated since yesterday morning. Her past medical history is significant for pharyngitis two weeks ago. Her mother and grandmother have type II diabetes. Her blood pressure is 146/92 mmHG. On physical examination, she has edema of her face and hands. Which of the following is the most likely diagnosis? A Glomerulonephritis B Acute tubular necrosis C Nephrolithiasis D Diabetic nephropathy
Glomerulonephritis presents with hematuria, cola-colored urine, oliguria, and edema of the face and eyes in the morning. Urinalysis reveals red blood cells, mild proteinuria and red blood cell casts. Glomerulonephritis can occur 1-3 weeks after a strep infection.
A 25-year-old female graduate student presents to the student health center for the eighth time in three weeks to be sure she does not have meningitis. She read that there was a student on campus who had meningitis last month, and now she has headaches and is requesting to be tested to make sure she does not have meningitis. She has been evaluated at each visit, and physical examination has been completely normal each time. Which of the following is the most likely diagnosis? A Conversion disorder B Illness anxiety disorder C Malingering D Somatization disorder
Hypochondriasis is the chronic preoccupation with the idea of having a serious disease, which is usually not amenable to reassurance.
To further assess ascites in a patient, the physician assistant instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver? A Testing for shifting of dullness on percussion B Shifting of internal organs making percussion easier C Trying to elicit any pain while moving D Trying to produce a caput medusa
In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid.
100 A 57-year-old male recently on a high protein diet presents with an exquisitely tender, erythematous, warm right great toe. Which of the following is the treatment of choice for this patient? A Corticosteroids B Colchicine C Allopurinol D Non-steroidal anti inflammatory agents
Nonsteroidal antiinflammatory drugs (NSAIDs) are the drugs of first choice in most settings. There is no evidence that one NSAID is superior to another in the treatment of gout. Systemic corticosteroid therapy can be used for patients with acute polyarticular gout who have not responded to other therapies as well as for patients in whom other therapies are contraindicated. Intra articular injections of corticosteroid medication are usually effective in patients with acute monoarticular gout.
91 A 53-year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient? A Cardiac catheterization B CT Angiogram of the chest C Echocardiogram D Nuclear stress test
Nuclear stress testing is the most appropriate initial diagnostic study in the evaluation of a patient with signs and symptoms consistent with stable angina.
Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct or A cystic duct B pancreatic duct C duodenal ampulla D common hepatic duct
Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed the gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis.
96 An 85-year-old nursing home resident presents with abrupt onset of cough, sore throat, headache, myalgias, and malaise. On examination the patient's temperature is 102 degrees F; the rest of the exam is unremarkable. Nasal smear is positive for Influenza B. Which of the following is the treatment of choice in this patient? A Amantadine (Symmetrel) B Oseltamivir (Tamiflu) C Acyclovir (Zovirax) D Nevirapine (Viramune)
Oseltamivir is used to treat both influenza A and B.
81 A 62-year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis? A Viral hepatitis B Pancreatic cancer C Acute cholecystitis D Gilbert's syndrome
Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer.
A 57-year-old male was working on his farm when some manure was slung hitting his left eye. He presents several days after with a red, tearing, painful eye. Fluorescein stain reveals uptake over the cornea looking like a shallow crater. Which of the following interventions would be harmful? A Ophthalmic antibiotics B Pressure patch C Examination for visual acuity D Copious irrigation
Patching of the eye after abrasion associated with organic material contamination is contraindicated due to increased risk of fungal infection.
A 29-year-old patient with idiopathic thrombocytopenia purpura (ITP) is treated with prednisone therapy. Despite therapy, platelet counts remain consistently below 20,000/microliter over the course of 6 weeks. Which of the following is the most appropriate intervention for this patient? A Aspirin B Intravenous immunoglobulin C Danazol (Danocrine) D Splenectomy
Persistently low platelet counts (less than 20,000) require effective long-term treatment, and splenectomy is the treatment of choice.
86 A 13-year-old boy with leukemia presents with epistaxis for two hours. The bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is A Electrocautery of the bleeding site B Silver nitrate application C Posterior nasal packing D Intranasal petrolatum gauze
Petrolatum gauze will provide pressure to the bleeding point while the cause of bleeding is corrected.
A 16-year-old male involved in a fight sustained a laceration to his right upper eyelid. He is unable to open his eye, and a possible laceration of the globe is suspected. Which of the following is the next step? A Use a slit lamp to determine the extent of the injury B Use fluorescein strips to determine the extent of injury C Apply a metal eye shield and refer to an ophthalmologist. D Apply antibiotic ointment to the lid and recheck in 24 hours
Protect the eye from any pressure with a rigid metal eye shield and refer for immediate ophthalmologic consultation. Avoid unnecessary actions that would delay treatment or cause further injury.
A patient presents with edema, which is most noticeable in the hands and face. Laboratory findings include proteinuria, hypoalbuminemia, and hyperlipidemia. The most likely diagnosis is A congestive heart failure B end-stage liver disease C nephrotic syndrome D malnutrition
Proteinuria, hyperlipidemia, and hypoalbuminemia are consistent with nephrotic syndrome.
98 A 20-year-old male presents with complaint of brief episodes of rapid heart beat with a sudden onset and offset that have increased in frequency. He admits to associated shortness of breath and lightheadedness. He denies syncope. Electrocardiogram reveals a delta wave prominent in lead II. Which of the following is the most appropriate long-term management in this patient? A Implantable cardiac defibrillator B Radiofrequency ablation C Verapamil (Calan) D Metoprolol (Lopressor)
Radiofrequency ablation is the procedure of choice for long-term management in patients with accessory pathways (WPW) and recurrent symptoms.
A 25-year-old male with a history of syncope presents for evaluation. The patient admits to intermittent episodes of rapid heart beating that resolve spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which of the following is the treatment of choice in this patient? A Radiofrequency catheter ablation B Verapamil (Calan) C Percutaneous coronary intervention D Digoxin (Lanoxin)
Radiofrequency catheter ablation is the treatment of choice on patients with accessory pathways, such as Wolff-Parkinson-White Syndrome.
79 Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes? A Cerebrovascular disease B Encephalitis C Tumor D Idiopathic epilepsy
Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.
A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, diminished breath sounds without wheezes, rhonchi, or other signs of respiratory distress. Which of the following would be an appropriate treatment for this patient? A Broad-spectrum antibiotic B Admission to the hospital C Oxygen at 6 L/min by nasal cannula D Brief course of oral theophylline
Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly.
80 A 32-year-old presents with a 3-day history of diarrhea. The patient denies blood, mucus, or night awakening with diarrhea. He recently returned from a business trip to Canada. On physical examination, the patient is afebrile and vital signs reveal BP 115/80, pulse is 76, and respirations are 14. The abdominal examination reveals hyperactive bowel sounds, but is otherwise unremarkable. Which of the following is the most appropriate initial intervention? A Stool for culture, ova, and parasites B Proctosigmoidoscopy C Metronidazole (Flagyl) D Supportive treatment
Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration
97 A 25-year-old male presents to the emergency department for evaluation of a wound on his hand. He cut his hand while tearing down a chicken coop. On examination of his right hand you note a dirty 3 cm jagged laceration. The patient is unaware of his tetanus immunization status. Besides cleaning and debriding the wound, what is the recommended clinical intervention in this patient? A Administer tetanus-diptheria toxoid (Td) and tetanus immune globulin (TIG) B Administer diphtheria, tetanus, and pertussis vaccine (DTP) C Administer tetanus toxoid vaccine (TT) and tetanus immune globulin (TIG) D No tetanus immunization or tetanus immune globulin is necessary in this patient
Td or Tdap with TIG is recommended as tetanus prophylaxis in a patient with a contaminated wound and unknown tetanus vaccination status.
A 65-year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected? A L3-L4 B L4-L5 C L5-S1 D S1-S2
The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus muscles.
A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected? A T6 B T8 C T10 D T12
The dermatome T10 is at the level of the umbilicus
Which of the following conditions will produce a transudative pleural effusion? A Kaposi's sarcoma B Bacterial pneumonia C Cirrhosis D Mesothelioma
The most common causes of transudative pleural effusions in the United States are heart failure and cirrhosis. Conditions associated with transudative pleural effusions include: Congestive heart failure Liver cirrhosis Severe hypoalbuminemia Nephrotic syndrome Acute atelectasis Myxedema Peritoneal dialysis Obstructive uropathy End-stage kidney disease
88 A 25-year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is A acyclovir (Zovirax) B omeprazole (Prilosec) C fluconazole (Diflucan) D penicillin G
The patient has Candida esophagitis and the treatment of choice is fluconazole.
A 53-year-old male is seen in the emergency department following a motor vehicle collision in which his knee impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced in the emergency department. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory? A Anterior plain film of knee B Sunrise view of the knee C Measurement of compartment pressures D Angiography
The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses.
A 75-year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be encountered? A Inability to extend the wrist against resistance B Numbness over the deltoid muscle in the shoulder C Winging of the scapula D Weakness of the rotator cuff
The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.
A 15-year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice? A Open reduction and internal fixation B Continuous extension of the DIP with splinting C Continuous flexion of the PIP with splinting D Application of short arm cast
The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via splinting for 6 to 8 weeks.
A 72-year-old patient with a history of hypertension and atrial fibrillation presents with episodes of weakness, numbness, and paresthesias in the right arm. At the same time, she notes speech difficulty and loss of vision in her left eye. These symptoms come on abruptly and clear within minutes. Physical examination is normal except for the previously known arrhythmia. Which of the following is the most likely diagnosis? A Focal seizure B Migraine headache C Hypoglycemic episodes D Transient ischemic attack
This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.
A patient with severe COPD presents to the Emergency Department with a 3-day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment? A Decrease the oxygen flow rate B Administer oral corticosteroids C Intubate the patient D Administer salmeterol (Serevent)
This person has increasing respiratory failure as indicated by the raising PaCO2 levels. Intubation is required at this time.
A 45-year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago. On physical examination, vital signs are stable and he is in no acute distress. Hemoglobin and hematocrit are unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is positive. Which of the following is the most appropriate treatment at this time? A Schedule for a selective vagotomy and antrectomy B Start an antacid along with omeprazole (Prilosec) C Schedule elective ulcer excision and start sucralfate (Carafate) D Start omeprazole (Prilosec) and antibiotic therapy against H. pylori
Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.
A 26-year-old female arrives in the emergency department with friends who say she was standing in front of her church, dressed in a white bathrobe, claiming to be the Virgin Mary and handing out $100 bills to all passers-by. Her friends noted that she had been depressed lately, but now seems completely euphoric. She had a similar episode two years ago. Which of the following is the most appropriate treatment? A Inpatient olanzapine (Zyprexa) therapy B Inpatient electroconvulsive therapy C Outpatient paroxetine (Paxil) therapy D Outpatient psychotherapy
Treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants.
