ROSH Practice

Which of the following is considered appropriate treatment for bacterial vaginosis?

2% clindamycin cream intravaginally for 7 days

25-year-old woman with a recent history of antibiotic use presents to your office with a complaint of vaginal discomfort. For the past week she has been experiencing intense vaginal pruritus and has noticed a white discharge. Which of the following is the most appropriate next step in her management?

A single dose of 150 mg fluconazole

67-year-old woman presents complaining of dark urine. Over several months she has had increased fatigue and weight loss. There has not been any fever or night sweats. On physical examination, her abdomen is soft, non-distended with a palpable mass in the right upper quadrant that is non-tender. Her laboratory values are notable for a total bilirubin of 6.4 mg/dl and a direct bilirubin of 5.0 mg/dl. Which of the following imaging studies is the next best step in the workup?

Abdominal CT scan

A 42-year-old man with a history of human immunodeficiency virus infection presents to his primary care provider with complaints of odynophagia and dysphagia. He also reports nausea and generalized chest pain. The man's last CD4 count was 90 cells/μL. Upper endoscopy reveals multiple, small ulcers in the distal esophagus. Which of the following is the most appropriate management?

Acyclovir

The presence of which one of the following best differentiates a diagnosis of premenstrual dysphoric disorder from premenstrual syndrome?

Affective symptoms

A 25-year-old G1P0 woman at 33 weeks gestation presents to her obstetrician with a complaint of wetness and leakage from her vaginal area. On physical exam, fluid can be seen coming from the cervical canal. The cervix is not dilated. Fern test is positive. Which of the following medications should be given at this time to delay delivery?

Ampicillin

28-year-old G3P0 woman presents to the office to discuss recurrent pregnancy loss and recent amenorrhea. She has not had a menstrual cycle for the last 2 months. She reports previously having a regular menstrual cycle of 28 days. Age of menarche was 14. Previous medical history is significant for anxiety, controlled well with sertraline. Surgical history is significant for three dilation and curettage procedures for retained products of conception, most recently 3 months ago. Vital signs include HR of 60 bpm, BP of 120/80 mm Hg, RR of 18/min, oxygen saturation of 99% on room air, and T of 98.7°F. Physical examination reveals a well-nourished woman, and findings on the exam are within normal limits. What is the most likely diagnosis?

Asherman syndrome

32-year-old G4P3 woman with a history significant for polyhydramnios is brought to the emergency department 15 minutes after a home birth. She complains of persistent vaginal bleeding with thick clots. She is anxious and diaphoretic. Her physical exam is notable for a large, boggy uterus. She receives oxytocin intramuscularly as intravenous access is started. Repeat examination reveals a persistently boggy uterus with significant active vaginal bleeding. Which of the following is an absolute contraindication to the use of carboprost in the management of this patient?

Asthma

Where is the uterine fundus palpable at 36 weeks gestation?

At the xiphoid process

64-year-old woman with a past medical history of asthma, hyperlipidemia, and hypertension presents to your clinic complaining of exertional chest pain. Her current medication list includes lisinopril, hydrochlorothiazide, simvastatin, and albuterol. After a cardiac workup is performed, she is diagnosed with angina pectoris. In addition to nitroglycerin for acute anginal symptoms, which of the following medications would be best suited to prevent anginal symptoms in this patient?

Atenplol

According to the United States Preventive Services Task Force (USPSTF), which of the following is considered to put a pregnant woman at high risk for developing preeclampsia?

Autoimmune disease

29-year-old pregnant patient presents with a three day history of diarrhea following a trip to Mexico. The patient describes having seven to eight loose, watery stools per day. She does not note any blood in the diarrhea and is otherwise asymptomatic. Vital signs are BP 116/72, HR 86, RR 15, T 38.7°C. Physical exam reveals mild dehydration, but is otherwise normal. After providing fluid replacement, what is the indicated treatment?

Azithromycin

Which of the following is the most effective initial treatment for a benign esophageal stricture?

Balloon dilation and proton pump inhibitor Need PPI to help prevent it from closing up again

A 43-year-old woman presents to the ED with abdominal pain. She was recently treated for a respiratory illness with azithromycin, and those symptoms improved. However, now she reports abdominal pain and is unsure whether it is related to her previous illness. She states the pain is epigastric and worse with food but reports no fevers, chills, vomiting, or diarrhea. She visited a gastroenterologist who told her she had a bacterial infection in her stomach. However, she did not return to that office for treatment or follow-up. On exam, her abdomen is soft and nontender to palpation. Which of the following is the most appropriate treatment regimen for this patient's condition?

Bismuth subsalicylate 300 mg qid, metronidazole 250 mg qid, tetracycline 500 mg qid, and lansoprazole 30 mg bid for 10-14 days

Which of the following correctly describes physiologic changes that occur in pregnancy?

Blood volume increases

35-year-old man with a history of ulcerative colitis presents to the emergency department with complaints of fever, mild abdominal pain, vomiting and diarrhea. His temperature is 102F, pulse is 125/min, and blood pressure is 88/52 mm Hg. Abdominal X-ray reveals colonic dilatation. In addition to fluid resuscitation, which of the following is the most appropriate initial step in management?

Bowel rest and nasogastric tube

3-month-old presents with three days of cough, congestion, and increasing work of breathing. On exam, respiratory rate is 60 breaths per minute with moderate subcostal retractions. Air movement is good, but there are scattered rhonchi, crackles, and expiratory wheezes. Heart rate is 145 beats per minute with a regular rate and rhythm and no murmurs. Oxygen saturation is 89% on room air. Which of the following is the next step in management?

Initiate supplemental oxygen by nasal cannula

A previously healthy 30-year-old woman presents to your office with complaints of abdominal pain and diarrhea for the past year. Her abdominal pain is located in the lower abdomen with relief after defecation. Her diarrhea symptoms include a small volume of loose stool, typically after meals. She has experienced some improvement in symptoms with dietary modifications, but overall is still having regular loose stools. Recently she has been feeling more fatigue than normal. Which of the following is the most appropriate initial laboratory test?

CBC -want to r/o any alarm symptoms like IDA so a CBC will show this

47-year-old man presents with decreased libido and low energy levels. In addition to low testosterone levels, laboratory results show a prolactin level of 102 ng/mL. All other hormone levels tested are normal. The patient is sent for MRI of the brain, which reveals an 8 mm x 4 mm sellar mass. Which of the following is the most appropriate therapy?

Cabergoline

Which of the following medical conditions excludes a child from participation in a sports event this weekend?

Current fever

72-year-old woman with a history of coronary artery disease, peripheral vascular disease, hypertension, and diabetes mellitus presents to the clinic with reports of episodic abdominal pain for 3 months. She describes the pain as dull and crampy and identifies the epigastric area as the site of her pain. The pain begins 30 minutes after each meal and has caused her to avoid eating, with subsequent significant weight loss. Her current medications include lisinopril, propranolol, metformin, simvastatin, and aspirin. Vital signs include HR 82 bpm, RR 17 breaths/min, BP 135/85 mm Hg, T 98.6°F, and SpO2 98% on room air. Physical examination reveals a soft abdomen without tenderness or guarding despite the current episode of pain. An epigastric bruit is noted with abdominal auscultation. Abdominal radiographs reveal no apparent abnormalities. Which of the following is the most likely diagnosis?

Chronic mesenteric ischemia

40-year-old G3P3A0 woman presents to the OB/GYN office for cervical cytology screening results. The results of her previous cervical cytology have been unremarkable. She has a history of diabetes mellitus type 2 and takes metformin 850 mg twice per day. Her vital signs are a BP of 131/81 mm Hg, HR of 81 bpm, RR of 16/min, SpO2 of 98% on room air, and a T of 98.7°F. Upon physical exam, normally developed genitalia are seen with no external lesions or eruptions. The vagina and cervix show no lesions, inflammation, or discharge. Her cervical cytology results show atypical glandular cells. What is the best next step in management?

Colposcopy with endometrial biopsy

A mother presents to clinic with her 15-year-old son. She is concerned because over the past 2 years he has been having significant behavioral problems. At home he is bullying his younger siblings, staying out past curfew, and she recently caught him setting fires in the backyard. At school he is consistently truant and failing all of his classes. Last weekend police picked him up for spray-painting graffiti on a local church. When asked to explain his behavior, the patient says, "I don't have to explain anything, I can do what I want." This patient meets criteria for which of the following disorders?

Conduct disorder

52-year-old man with a history of cirrhosis presents with worsening confusion. His wife reports he has been compliant with his lactulose at home. Which of the following is a common cause of worsening hepatic encephalopathy?

Constipation

10-month-old boy is being evaluated for bilious vomiting, diarrhea, and rectal bleeding. He appears to be in severe distress and is continuously crying. Which of the following is the most appropriate next step in management?

Contrast enema

Picture of erythema nodosum- A 34-year-old woman presents to the clinic with the skin lesions shown above. She also reports recent unintentional weight loss, low-grade fevers, and nonbloody diarrhea. Which of the following is the most likely diagnosis?

Crohn disease Can also have uveitis, sclerosing cholangitis, and arthralgias can have perianl tags and fissures, fistulas, abscesses occur as well in crohns

Over the last 7 months, a 13-year-old girl has had intermittent abdominal pain, which has made her quite irritable. The abdominal pain is associated with arthralgias and general malaise. Review of systems reveals that she has lost 5 kg (11 lb) and has painful bowel movements. Which one of the following is the most likely cause of these symptoms?

Crohn's disease

Of the following, which is the most common infectious etiology of diarrhea in patients with AIDS?

Cryptosporidium

55-year-old man with a past medical history of hypertension presents to the emergency department with two days of left lower quadrant pain and a fever of 38.2°C at home. He denies nausea or vomiting and has been able to tolerate oral intake at home. He endorses some intermittent painless hematochezia over the last year but states that he has never had a colonoscopy. His vitals are HR 89 beats per minute, RR 16, and BP 142/90. His abdominal exam is significant for moderate tenderness to palpation of the left lower quadrant without rebound or rigidity. His CBC shows a white blood cell count of 12,000. A CT scan confirms diverticulitis without perforation or abscess formation. Which of the following is the most appropriate next step in the management of this patient's diverticulitis?

Discharge home with oral antibiotics

21-year-old man presents to the emergency department with a 1 cm laceration to the left forearm. The patient is in good health and has no other chief concerns. At triage, the patient's blood pressure is noted to be 155/94 mm Hg. The remainder of his vital signs are within normal limits. Following the laceration repair, the patient's blood pressure is rechecked and found to be unchanged. What is the best approach to this patient's elevated blood pressure?

Instruct the patient to follow-up with his private physician for recheck

A 45-year-old man presents to the clinic reporting retrosternal chest pain and a bitter, metallic taste in his mouth for the past several months. The symptoms occur about 2 to 3 times per week, about 30 minutes after meals, and sometimes cause him to wake up from sleep at night. His symptoms are relieved by taking antacids and standing up from a supine position. He has a body mass index of 34 kg/m2, a temperature of 98.4°F, blood pressure of 128/72 mm Hg, and a heart rate of 82 bpm. Which of the following is the primary mechanism of his underlying condition?

Decreased lower esophageal sphincter tone

80-year-old man who presents to the emergency department with a complaint of sudden onset left-sided abdominal pain and bloody diarrhea. Abdominal CT demonstrates thickening of the bowel wall and free peritoneal fluid. What is the most likely diagnosis?

Ischemic colitis

A new first-time mother calls for advice on nipple pain with breastfeeding. She is 6 days post partum after an uncomplicated delivery. Which one of the following is most effective for reducing the pain?

Education on positioning

25-year-old truck driver presents with a 1-day history of throbbing rectal pain. Your examination shows a large thrombosed external hemorrhoid. Which one of the following is the preferred initial treatment for this patient?

Elliptical excision of the thrombosed hemorrhoid

A 30-year-old Gravida 2, Para 1 woman at 12 weeks of pregnancy presents for routine prenatal care. She has a history of gestational diabetes mellitus managed with diet alone during her previous pregnancy. She reports no episodes of hypoglycemia. Today, her fasting blood glucose is 145 mg/dL and her hemoglobin A1C is 7.5%. Which of the following represents an ideal intrapartum glycemic target for this patient?

Fasting glucose level < 95 mg/dL

A woman presents to the clinic reporting a positive home pregnancy test result. She is unsure of the date of her last menstrual period but reports it was < 3 months prior. Exam reveals a BMI of 24.4 kg/m2, HR of 94 bpm, RR of 18 breaths per minute, T of 98.5°F, BP of 121/78 mm Hg, and SpO2 of 98% on room air. The patient's abdomen is rounded without tenderness to palpation. Bimanual exam reveals nontender, unremarkable adnexa bilaterally with a retroverted, closed cervical os. Chadwick sign is noted during the speculum exam. Which of the following is the best method to estimate the delivery date in this patient?

Fetal crown-rump length

2-year-old girl presents to the emergency department with her parents for a rash. She has lesions on her palms and on the soles of her feet, as well as in her oral cavity as shown above. Which of the following indicates that the child can safely return to daycare? Picture of small white ulcers with red surrounding halo

Fever resolution

14-year-old girl sprained her ankle. She rates her pain 5/10. On examination, she has moderate tenderness and swelling with decreased range of motion secondary to pain. Although quite painful, she is able to ambulate. What is the grade of this ankle sprain?

Grade 2

14-year-old girl with onset of menarche 6 months prior reports irregular menstrual cycles, with variations between cycle lengths of as much as 12 days. Most of her periods consist of painless, heavy bleeding. She is currently experiencing such a period, with blood loss that requires frequent changing of menstrual pads with use of 10 or more pads per day. She has no history of epistaxis or easy bruising and takes no medications. Bimanual and speculum exam reveals copious blood in the vaginal vault with no identifiable nonuterine source. The uterus is of normal size and contour without tenderness. Adnexa are nontender to palpation without identifiable masses or abnormalities. She has been sexually active with one partner and her urine pregnancy test result is negative. What is the most likely cause for this patient's menstrual irregularities?

Hypothalamic-pituitary-ovarian axis immaturity

A 45-year-old man presents with severe rectal pain and bleeding for three hours. He is known to have chronic stage IV internal hemorrhoids that bleed severely from time to time. Vital signs are temperature 98.6°F, respiratory rate 22 breaths/minute, blood pressure 100/55 mm Hg, heart rate 105 bpm, and oxygen saturation 98% on room air. Physical exam shows purple, necrotic nodules covered by mucosa that is protruding through the anal canal. Complete blood count shows white blood cell count 5.8/L, hemoglobin 10 mg/dL, hematocrit 30%, and platelet count 265,000/microL. Which of the following is the most effective management?

Hemorrhoidectomy

A man with a strangulated, indirect inguinal hernia undergoes hernia repair surgery. Three weeks later, he presents with a complaint of numbness about his "beltline." Examination reveals no recurrent hernia. During light touch testing, he reports partial numbness and paresthesias in the anterior L1 dermatome. Irritation of which of the following nerves is most likely causing these symptoms?

Iliohypogastric

23-year-old man presents with testicular pain for 3 hours. He denies any trauma. The pain is constant, sharp, and severe and is accompanied by nausea and vomiting. His vital signs are normal, except for a heart rate of 110 beats/min. On examination, there is no swelling, but the left testicle is extremely tender to palpation. The cremasteric reflex is absent. What management is indicated?

Immediate urology consultation followed by scrotal ultrasound

27-year-old woman presents in the fall for her first prenatal visit. Her last menstrual period started 8 weeks ago. The patient reports she is in a monogamous relationship with one male partner. She has a family history of diabetes mellitus but has never been diagnosed with diabetes herself. Her body mass index is 21 kg/m2. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination findings include a soft and nontender abdomen, no blood in vaginal vault, and a closed cervical os. Transvaginal ultrasound shows an intrauterine fetal pole with a fetal heart rate. Which of the following is indicated at this prenatal visit?

Inactivated influenza vaccine

A 35-year-old man presents to the primary care clinic with heartburn after eating. Pain occurs mostly in the evening, approximately 30 minutes after consuming his evening meal. He also reports mild regurgitation and belching at night. He reports no dysphagia, bloody stools, or weight loss. For the past 2 months, he has taken omeprazole 20 mg every morning but is on no other medication, and he has no other significant medical history. He does not smoke. His vitals are BP 122/78 mm Hg, pulse 78 bpm, RR 15 breaths/minute, temperature 98.6°F, and O2 saturation 99% on room air. He is nontender on abdominal physical exam with no guarding or rigidity. What is the best next step in the treatment of this patient?

Increase omeprazole to twice a day

26-year-old woman who is nine weeks pregnant presents to the clinic with vaginal bleeding. She reports crampy pelvic pain. Vaginal exam reveals a dilated cervix. Products of conception can be visualized through the cervical os. Which of the following best describes this patient's condition?

Inevitable abortion

45-year-old woman with a history of osteoarthritis, hypertension, hypercholesterolemia, and tobacco use presents to clinic. The patient states that she has been experiencing a burning epigastric pain that occurs several hours after eating a meal and is relieved by antacids or food. Several times, the pain has awakened her from sleep. She reports no nausea, vomiting, diarrhea, or bloody stools. Her current medications include lisinopril, rosuvastatin, and naproxen. Vitals are temperature 37°C, BP 120/80 mm Hg, pulse 76 bpm, SpO2 99% on room air. Her physical examination reveals mild epigastric tenderness to palpation. The remainder of the physical exam is unremarkable. Laboratory tests reveal hemoglobin 13 g/dL, WBC 5,000/µL, and platelets 200,000/µL. A urea breath test is negative. Upper endoscopy shows evidence of ulceration in the duodenum. Which of the following is the correct pathogenesis of the disease described above?

Inhibition of cyclooxygenase-1 leading to prostaglandin deficiency

What is the most common cause of intestinal obstruction in children under two years of age?

Intussusception

A four-year-old boy presents to the office with seven days of fever. On HEENT exam you note bilateral conjunctivitis, note some fissuring of his lips and palpate a cervical lymph node. The cardiovascular and pulmonary exams are normal. Skin exam reveals a macular rash on his chest and skin desquamation on his feet. Which of the following is the most likely diagnosis?

Kawasaki disease

Which of the following findings seen on rectal examination is most consistent with a concomitant systemic process?

Lateral anal fissure

Which of the following statements is most correct regarding appendicitis?

Leukocytosis is seen in the majority of cases

A 66-year-old woman has been on estrogen-replacement therapy for nine years. Her social history is significant for 20 years of heavy alcohol use and 30 years of tobacco use. Her family history is positive for familial adenomatous polyposis. Which of the following organs is most likely to undergo malignant transformation due to this patient's alcohol use?

Liver

A patient of yours with a history of diverticulosis develops acute diverticulitis. He is admitted to the hospital for inpatient care. He is successfully treated and discharged home. He follows up with you a few days later. Which of the following should you most likely recommend to him at this time?

Low fiber diet until 6 weeks of no symptoms

Which of the following can help reduce the risk of developing lactational mastitis?

Lubricating ointment for excoriations and cracking

21-year-old previously healthy man presents to clinic after several nights of partying. He complains of headache, nausea, and emesis that now contains blood. He also endorses a constant burning sensation in the left upper quadrant of his abdomen that started after the retching began. What is the most likely diagnosis?

Mallory-Weiss tear Can have occasional burning pain

A 36-year-old G2P1002 woman who is 38 weeks pregnant presents in active labor. Her vital signs are a HR of 92 bpm, RR of 19/min, BP of 124/86 mm Hg, T of 97.8°F, SpO2 of 99% on room air, and BMI of 29.6 kg/m2. During delivery, the fetal head retracts into the perineum after expulsion, and the anterior shoulder does not deliver. Which of the following is the greatest risk factor for this presentation?

Maternal type 2 diabetes mellitus

70-year-old woman presents to your office with a complaint of difficulty having bowel movements. She tells you that she has a bowel movement every 2-3 days, the stool is hard and she has to strain. Which of the following is the most appropriate initial therapy?

Methylcellulose

You are evaluating a 73-year-old woman with a history of weakness, fatigue, and difficulty walking. She lives alone and unassisted. She has no past medical history and takes no medications. Physical examination shows an enlarged, smooth, and tender tongue. Pallor of the conjunctivae is also seen. Which of the following laboratory studies would be most likely to confirm the diagnosis?

Methylmalonic acid and homocysteine levels

A 26-year-old G1P1 woman with a history of peptic ulcer disease was recently placed on a daily nonsteroidal anti-inflammatory medication therapy to treat joint pain. A medication to reduce nonsteroidal anti-inflammatory medication induced ulcers was recommended. Which of the following medications carries a black box warning and should be avoided or used in extreme caution in this patient?

Misoprostol

How does the presentation of abdominal pain differ in patients of advanced age?

More likely to need an emergent surgical procedure

An 83-year-old man from a nursing home is sent for evaluation of abdominal distention and vomiting. Nursing home records report no bowel movement for two days and no fevers. His X-ray is shown above. On CT scan, no obstructing lesion is identified. What of the following may be beneficial in relieving this condition?

Neostigmine -Ogilvie syndrome (pseudo-obstruction)

A 55-year-old woman presents to the gynecology clinic with a 3-month history of gradual progressive dyspnea, rapid weight gain, and abdominal fullness. She also reports urinary frequency and urgency. Her last menstrual period was 5 years ago. Her T is 99.1°F, BP is 123/79 mm Hg, HR is 69 bpm, RR is 18/min, and oxygen saturation level is 98% on room air. Her urinary analysis is normal. Her physical examination reveals a distended abdomen with shifting dullness, and pelvic exam reveals a left adnexal mass. Which of the following would have been an appropriate recommended screening test for her condition before her symptoms started?

No screening recommended

A 36-month-old boy is being evaluated at your office. Parents are concerned because he is short and has evidence of developmental delay with hypotonia. He was born at term with a birth weight of 3250 grams. He has a history of poor suck that required physical therapy. Recent fluorescence in situ hybridization was positive for a deletion on chromosome 15. This patient is at a higher risk of suffering from which of the following conditions

Obesity: Prader Willi Syndrome

A 38-year-old man with a history of heavy alcohol use presents with hematemesis. After obtaining a history and performing a physical exam, a Mallory-Weiss tear is suspected. The patient's vital signs are stable with a normal heart rate and blood pressure. Which of the following is the next best step in caring for this patient?

Obtain intravenous access

A 66-year-old white woman presents to your office for a routine physical examination. Her medical problems include hypertension, diabetes mellitus, hypercholesterolemia, and gastroesophageal reflux, all controlled with medications. A bone density study is consistent with osteopenia. She is taking a multivitamin and calcium carbonate 1200 mg daily. Which of the following medications act to reduce calcium absorption?

Omeprazole

32-year-old woman with no significant medical history presents to her OB/GYN for evaluation of dyspareunia. She reports she has not had sexual activity for the past few months due to the significant amount of pain. She has tried condoms and lubricants without any improvement in her pain. Her last menstrual period was 2 weeks ago. Her vital signs are a HR of 78 bpm, RR of 16/min, SpO2 of 99% on room air, BP of 128/82 mm Hg, T of 97.8°F, and BMI of 27.1 kg/m2. On physical exam, the patient has significant pain when the speculum is opened, and an immobile uterus is noted on bimanual exam. Which of the following is the most appropriate management for this patient's condition?

Oral contraceptives and ibuprofen

A 52-year-old man with a history of heavy alcohol use presents with hematemesis. He has had several episodes of bright red vomitus over the last 2 hours. His blood pressure is 136/84 mm Hg, and his heart rate is 86 bpm. A complete blood count reveals a hematocrit and hemoglobin that is within normal limits. What is the next best step in management?

Order a type and screen and begin fluid resuscitation

You are called to examine a 3-year-old boy in the emergency department for possible ingestion. He was found by his father drooling and playing with an opened drain cleaner. After suspecting a caustic ingestion, he immediately called poison control and was advised to bring the boy to the emergency department. The boy is irritable and drooling. His physical examination is otherwise normal. Which of the following is the most appropriate next step in management?

Order an upper endoscopy

12-year-old boy presents to the office with his mother with concerns about daily underwear soiling with loose stools as well as small, hard stools about once a week. The patient has a history of autism spectrum disorder, chronic constipation, and eating difficulties. He is able to take food and liquid by mouth but is supplemented through a gastrostomy tube to support his nutrition. His vital signs include a heart rate of 80 bpm, blood pressure of 112/77 mm Hg, respirations of 17/minute, and oxygen saturation of 99% on room air. On exam, the patient is able to respond to questions and follow commands. Abdominal exam reveals a gastrostomy tube in place that is clean, dry, and intact, and his abdomen is nondistended and soft. The patient does not show signs of pain on abdominal palpation. Rectal exam shows good sphincter tone, with hard stool palpable in the rectum and a small external hemorrhoid. An X-ray obtained today is shown above. What is the most likely underlying cause of this patient's fecal incontinence?

Overflow of loose stool

35-year-old obese woman who just delivered a 10 lb baby after 48 hours of labor starts hemorrhaging from the vaginal area and has a sudden drop in blood pressure. She was in her 41st week of gestation when she was admitted to have labor induced. Which of the following is the best initial step in diagnosing the underlying cause of bleeding?

Palpate to determine the size and firmness of the uterus

43-year-old woman presents to the emergency department via emergency medical services after ingesting an unknown amount of buprenorphine-naloxone. The patient is noted to be extremely agitated and physically aggressive with emergency department staff, necessitating physical restraints. The patient is sedated with 2 mg of intramuscular lorazepam and states that she took her roommate's buprenorphine-naloxone because she ran out of her own methadone. Which of the following best describes the activity of buprenorphine at the mu opioid receptor?

Partial agonist

38-year-old man presents to the primary care clinic for a 6-week follow-up. He was recently diagnosed with Helicobacter pylori-associated peptic ulcer disease (PUD) after an upper endoscopy. At his last visit, he was placed on omeprazole 40 mg BID and bismuth subcitrate potassium 140 mg/metronidazole 145 mg/tetracycline 125 mg four times daily for 14 days. Today, he states his dyspepsia has significantly improved, and he is no longer having any other gastrointestinal symptoms. Vital signs are BP 118/78 mm Hg, pulse 77 bpm, RR 13 breaths/minute, and temperature 99°F. Physical exam reveals a nontender abdomen with no rigidity or guarding. What is the best next step in the treatment of this patient?

Perform urea breath test for Helicobacter pylori

A woman with chronic constipation and poorly controlled diabetes mellitus presents with acute anal pain that is exacerbated by defecation. Inspection of the anal border reveals no abnormalities. Which of the following is the most likely diagnosis?

Perirectal abscess

Xray of distal esophageal closure A 52-year-old man presents to the clinic with concerns over his worsening dysphagia. He describes difficulty with both solids and liquids and occasionally regurgitates bland, undigested food. He has been diagnosed previously with gastroesophageal reflux disorder, which was unresponsive to a 4-week trial of omeprazole. His vitals include a HR of 83 bpm, RR of 16/min, BP of 128/88 mm Hg, T of 98.7°F, and SpO2 100% on room air. Physical exam reveals a well-appearing man in no acute distress without palpable lumps or defects on his throat. A barium swallow study is obtained with the results shown above. Which of the following is the best treatment?

Pneumatic balloon dilation

A male child born at 40 weeks of gestation has an Apgar score of 4 at birth. He is gasping for air and has a pulse of 68 despite positioning and airway clearance. Which of the following would be the best choice for initial clinical intervention in this patient?

Positive pressure ventilation

A 61-year-old man presents to the clinic for evaluation. His medical history includes chronic obstructive pulmonary disease with an ongoing 25 pack-year history of tobacco use. The patient takes albuterol as needed in addition to his daily medications, which include salmeterol and budesonide. Following a thorough history and physical exam, the patient undergoes diagnostic colonoscopy, which identifies a polypoid, endoluminal mass in the ascending colon. Subsequent biopsy indicates colorectal adenocarcinoma. Which of the following does this patient most likely report during the initial evaluation?

Progressive fatigue and weight loss

70-year-old man with a history of cigarette smoking and BMI of 31.2 kg/m² presents to the clinic with gross hematuria for the past week. He reports unintentional weight loss of 15 pounds during the past 6 weeks. He has had no difficulty urinating, painful urination, or changes in urinary frequency. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a regular rate and rhythm with lungs clear to auscultation. His abdomen is soft and nontender without palpable masses. His prostate is enlarged but symmetric, and firm on a digital rectal exam. His urinalysis is negative for leukocyte esterase, nitrites, pyuria, and bacteriuria but shows 100 RBC/hpf. His CT is shown above. Which of the following is the most likely diagnosis? CT showing kidney mass

Renal cell carcinoma

A 47-year-old man with a history of alcohol use disorder presents with severe abdominal pain, nausea, and vomiting for 1 day. Examination reveals marked epigastric tenderness to palpation. Labs show the following: Lipase: 4,300 U/L AST: 451 U/L ALT: 532 U/L Alkaline phosphatase: 313 U/L Total bilirubin: 5.3 mg/dL Which of the following is the best next step?

Right upper quadrant ultrasound

Twenty-four hours after eating a salad containing bean sprouts, a 25-year-old man became ill with fever, abdominal pain and diarrhea. Which of the following organisms is the most likely cause of his symptoms?

Salmonella enterica

Xray of broken tibia in TWO SPOTS An 18-year-old man is found to have a tibia fracture after he was struck by a motor vehicle while crossing the road. An X-ray of his leg is seen above. What is the orientation of this fracture?

Segmental

33-year-old woman presents to her primary care office for an annual physical. The patient notes no significant medical history or history of radiation. Family history consists of diabetes and hypertension. She has no concerns or symptoms during today's visit and reports a healthy diet and exercise routine. Her vital signs are a HR of 88 bpm, RR of 17/min, BP of 118/78 mm Hg, T of 98.3°F, weight of 145 lbs, and BMI of 23.6 kg/m2. On physical exam, she is noted to have a small thyroid nodule, but otherwise, her exam is normal. What is the best next step in the management of this patient's condition?

Serum thyroid-stimulating hormone

68-year-old man with a 31 pack-year smoking history and a medical history including hypertension, diabetes mellitus, hyperlipidemia, and peripheral vascular disease is 3 days status post transcatheter aortic valve replacement surgery. He now reports acute, crampy abdominal pain with associated tenesmus and hematochezia. His current medication list includes simvastatin, aspirin, enalapril, metformin, sitagliptin, and cilostazol. Pertinent laboratory findings include lactic acidosis, leukocytosis, and thrombocytopenia. Vital signs reveal a HR of 103 bpm, RR of 17/min, BP of 143/83 mm Hg, T of 102.1°F, and SpO2 of 97% on 2 L of oxygen. Results from computed tomography of the abdomen and pelvis are pending. What area of the intestine is most likely to demonstrate abnormal findings with the suspected condition?

Splenic flexure

30-year-old woman with a history of Crohn disease presents to the emergency department with a report of rectal pain for about 2 weeks. She states she has pain with sitting and bowel movements and has noticed some discharge from her rectal area. She reports no fevers. Her vital signs show a heart rate of 80 bpm, blood pressure 119/75 mm Hg, respiratory rate 17 breaths/min, and SpO2 of 98% on room air. On physical exam, her abdomen is soft with mild tenderness to palpation in the suprapubic region. On rectal exam, there is scant purulent drainage with a small pustule noted in the perianal region. There is a palpable cord felt from the external surface to the anal canal. Imaging and labs are pending. What is the most appropriate management for the suspected diagnosis?

Surgical referral for evaluation Anorectal fistula

A 30-year-old woman presents to the emergency department with left lower quadrant pain. The pain started suddenly while she was sleeping and is rated a 10/10 in severity. Which of the following will yield a definitive diagnosis of an ovarian torsion?

Surgical visualization

45-year-old woman presents to the ED with three hours of constant right upper quadrant abdominal pain that radiates to her right scapula. The pain was sudden in onset and awoke her from sleep. Vital signs are BP 130/70 mm Hg, HR 90, RR 16, T 98.8℉, and oxygen saturation 99% on room air. On exam, the patient is well appearing, with no pallor, jaundice or abdominal tenderness. Her AST, ALT, total bilirubin, alkaline phosphatase, and lipase are normal. Which of the following is the most likely diagnosis?

Symptomatic cholelithiasis AKA biliary colic

You are caring for a patient who is diagnosed with pancreatic adenocarcinoma. The oncologist makes a note of a positive Trousseau syndrome in the documentation. Which of the following is she referring to?

Tender migratory thrombophlebitis

30-year-old man, currently being treated with paroxetine daily for generalized anxiety disorder, presents to the clinic complaining of episodes of tachycardia, sensations of impending doom, chest pain, and shortness of breath over the past six months. The episodes are triggered by anticipation of certain stressful events and resolve themselves within 15 minutes. Which of the following would be the most appropriate evaluation to perform when considering the diagnosis of panic disorder in this patient?

Thyroid-stimulating hormone, complete metabolic panel, and complete blood count laboratory tests

A 72-year-old man presents with progressive dysphagia. He initially had difficulty swallowing solid foods, but is now having difficulty swallowing liquids. An esophagogastroduodenoscopy reveals a fungating mass on the middle third of the esophagus. Biopsy of the lesion is positive for squamous cell carcinoma. Which of the following historical features does this man most likely have?

Tobacco use

6-year-old girl presents with a limp. The parents noted that the girl was having difficulty walking for the past two days. They deny trauma or fever but did note a cold one week prior. On physical exam, the girl appears well and is afebrile, with the left hip held flexed and abducted. Laboratory tests reveal normal erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and WBC. Ultrasound shows the presence of joint effusion of the left hip. Which of the following is the most likely diagnosis?

Transient synovitis

An 85-year-old woman with a medical history of dementia and diabetes mellitus presents to the emergency department from a nursing home with abdominal pain and distention for the past 4 days. Her associated symptoms include decreased appetite and vomiting once today. The patient's daughter reports that she has never had any abdominal surgeries. Vital signs today include a HR of 95 bpm, BP of 110/70 mm Hg, RR of 20/min, oxygen saturation of 95% on room air, and T of 98.2°F. Physical examination reveals diffuse abdominal distention with mild tenderness. There is no guarding or rebound tenderness. Laboratory findings include a white blood cell count of 12,000/μL, lipase of 100 U/L, aspartate aminotransferase of 24 U/L, alanine aminotransferase of 35 U/L, alkaline phosphatase of 110 U/L, and total bilirubin of 0.7 mg/dL. Abdominal plain film shows distended bowel loops without haustra extending from the pelvis to the right upper quadrant in an upside-down U-shape loop. There is no air in the rectum. Which of the following is the most likely cause of the patient's symptoms?

Twisting of the sigmoid colon

23-year-old G1P0 woman at 30 weeks gestation presents to the emergency department for vaginal bleeding. She has had no prior prenatal care. She reports that she is soaking through one pad every 8 hours, denies abdominal cramping or a gush of water and endorses good fetal movement. Her vital signs are T 37.2°C, HR 100, BP 105/70, RR 18. Her abdomen is soft, non-tender, and consistent with a 30 week pregnancy. A transabdominal ultrasound shows a viable intrauterine pregnancy and a placenta that completely overlies the cervical os. Which of the following investigations is indicated in this patient?

Type and screen

18-month-old boy is brought to the emergency department by his mother for two days of intermittent episodes of inconsolable crying. During these episode, the child is noted to stop playing, lay down, and draw his legs up to his chest. His mother denies any emesis or bloody bowel movements. Physical examination and vital signs in the emergency department are normal. Which of the following is the most appropriate imaging modality for the confirmation of a diagnosis of intussusception in this patient?

Ultrasonography

What is the most common presenting symptom in a woman with vaginal cancer?

Vaginal bleeding

28-year-old woman at 31 weeks gestation comes to the emergency department after noticing a gush of clear fluid from her vagina. Which of the following features is most suggestive of prelabor rupture of membranes?

Vaginal fluid pH > 6.5

Which of the following suture material is absorbable?

Vicryl (Polyglactin)

2-year-old boy is brought to the clinic for progressively worsening blurry vision and generalized headaches that are worse in the morning. On further questioning, he is also revealed to have nausea, joint pain, itchy and peeling skin, dizziness, and irritability. Historically, he has been a healthy child and his family follows an organic diet with additional supplements that include 2 tablespoons of cod liver oil and a multivitamin tablet a day. On exam, his weight dropped from the 50th percentile a year before to the 10th percentile currently. He has oily skin and hair and cracking at the corners of his mouth. Chronic overdose of which of the following most likely caused his symptoms?

Vitamin A, causes increased intracranial pressure... can be seen in overuse of cod liver oil

A 55-year-old man with a history of alcohol use disorder presents with an unsteady gait. He is slightly confused, with ophthalmoplegia noted on neurologic examination. Which of the following is the primary treatment of this syndrome?

Vitamin B 1 (Thiamine) Pt has wernike's

A 53-year-old man presents to the clinic for evaluation of a painless "bulge" in his groin. He noticed the protrusion while attempting to sit up from a supine position. His medical history includes hypertension and atherosclerosis, for which he takes enalapril, simvastatin, and aspirin. Vital signs include HR 76 bpm, RR 16 breaths/min, BP 121/77 mm Hg, T 98.7°F, and SpO2 99% on room air. Physical examination reveals a patient who is endomorphic and in no apparent distress. There are no surgical scars on the abdomen. Abdominal palpation identifies a symmetric, malleable, easily reducible mass in the right lower quadrant. Ultrasound imaging suggests the protrusion lies medial to the inferior epigastric vessels. Which of the following is the correct pathogenesis of this condition?

Weakness of the transversalis fascia indirect: incomplete obliteration of process vaginalis direct: weakness in transverse fascia

Surgical treatment of peptic ulcer disease is reserved for those patients with complications associated with ulcer lesions, those refractory to medical intervention, or patients with giant (greater than 3 cm) gastric ulcers. Which of the following is considered the most common postsurgical complication experienced by patients undergoing surgical treatment for peptic ulcer disease?

Weight loss

You are seeing a 4-week-old boy with vomiting. Which of the following findings is most concerning for pyloric stenosis as an underlying cause?

Weight loss

A 22-year-old woman with no prior medical history presents with pain and swelling to the vulva. On examination, you notice an area of swelling with induration and central fluctuance at the 8 o'clock position. What is the best next step in management?

Word catheter placement for 4-6 weeks