Smarty PANCE: Internal Medicine

> 25 mm Hg Blood pressure in the lungs is usually very low < 15 mm HG. In pulmonary hypertension, the pressure increases > 25 mmHg at rest!

a 43-year-old woman with a history of COPD presents to the office with worsening dyspnea, especially at rest. She also complains of dull, retrosternal chest pain. On examination, she has persistent widened splitting of S2. Radiographic findings demonstrate peripheral "pruning" of the large pulmonary arteries. Which pulmonary arterial pressure is consistent with a diagnosis of pulmonary fibrosis? A ≥ 5 mm Hg B ≥ 10 mm Hg C ≥ 15 mm Hg D ≥ 25 mm Hg

ASO This patient has classic symptoms of hematuria, pretibial edema, and hypertension indicative of nephritic syndrome. The history of an untreated sore throat is key to the diagnosis of post-streptococcal glomerulonephritis. He would have a positive ASO titer.

A 15-year-old boy comes to your clinic after having a sore throat, he wasn't treated. He now has hematuria, pretibial edema, and hypertension. What antibody do you expect on lab findings? A ANCA B ASO C ANA D Anti GBM

Ceftriaxone (Rocephin) Ceftriaxone is an effective treatment for acute epididymitis caused by Neisseria gonorrhea and is given with doxycycline for patients under the age of 35 who are at risk for sexually transmitted infections.

A 19-year-old man comes to the office because he has had a fever, frequent urination, urgency, dysuria, and scrotal pain for the past 2 days. On physical examination, he has a temperature of 101 degrees F, scrotal swelling, and purulent urethral discharge is visible on penile examination. Gram stain of the discharge shows gram-negative intracellular diplococci. Which of the following is the most appropriate antibiotic therapy? A Ampicillin (Principen) B Ciprofloxacin (Cipro) C Ceftriaxone (Rocephin) D Nitrofurantoin (Macrobid)

Urinalysis, urine culture, KOH prep, and a urine pregnancy test This patient of reproductive age and ureteropelvic symptoms should be screened for pregnancy in addition to other diagnostic studies (e.g., urinalysis, urine culture, and KOH prep).

A 20-year-old female presents to the emergency department with dysuria. She denies any hematuria or dyspareunia. Her last menstrual period was 3 weeks ago, and she denies any recent sexual activity. Her temperature is 99.7°F (37.6°F), blood pressure is 124/68 mmHg, pulse is 88/min, and respirations are 18/min. An unusual odor is detected on inspection of the vagina and some gray discharge is noted. A speculum exam reveals a normal cervix and a bimanual exam is unremarkable for adnexal masses or tenderness. What is the next best step in management? A Complete blood count (CBC) B Urinalysis and Pap smear C Urinalysis, urine culture, and potassium hydroxide prep (KOH) D Urinalysis, urine culture, KOH prep, and a urine pregnancy test E Urinalysis, KOH prep, and nucleic acid amplification tests for N. gonorrhea and C. trachomatis

Insert a large-bore needle into the left 2nd ICS stat Simple aspiration by insertion of a needle into the involved side will decompress the tension pneumothorax until a chest tube can be inserted.

A 21-year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with an absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. Which of the following is the most appropriate next step? A Order a V/Q scan B Order a chest x-ray C Administer a sclerosing agent D Insert a large-bore needle into the left 2nd ICS stat

Discharge on oral doxycycline, with close follow-up Rocky Mountain spotted fever (RMSF) is a tick-borne febrile illness characterized by a maculopapular rash starting on the extremities, involving the soles and palms, and progressing to the trunk. Doxycycline is the agent of choice for the treatment of RMSF. Doxycycline is used in treating Rocky Mountain spotted fever. All others are not used in treating Rocky Mountain spotted fever.

A 21-year-old male who three days after returning from a camping trip has developed fever, chills, myalgias, and headache. He then developed a rash on the wrists, ankles, palms, soles, and forearms that rapidly extended to the neck, axillae, buttocks, and trunk. The remainder of the examination is unremarkable. Which of the following is the best step in the medical management of this patient's condition? A Admit for intravenous ceftriaxone B Give IM ceftriaxone and discharge C Discharge on oral amoxicillin, with close follow-up D Discharge on oral doxycycline, with close follow-up

Increased fluids and ibuprofen Acute bronchitis is defined by a cough that persists for more than five days. The most common cause of acute bronchitis is a viral infection (90% of cases). Therefore, supportive therapy such as increased fluids (cough results in increased fluid loss) and ibuprofen (antipyretic) is the most appropriate approach.

A 22-year-old man presents to his physician with a cough. He describes the cough as non-productive and lasting for a few days. He denies any subjective fever, acid reflux, and has not had his influenza vaccination. On physical exam, there are no wheezes but faint rhonchi on pulmonary auscultation. What is the best treatment at this time? A Amoxicillin/clavulanic acid 875 mg two times per day for 10 days B Doxycycline 100 mg PO two times per day for 14 days C Give the patient an albuterol inhaler D Increased fluids and ibuprofen

Sickle cell disease Sickle cell disease can lead to avascular necrosis, most frequently involving the acetabulum, head of the femur, and head of the humerus. Patients will report pain with different characteristics than the one associated with their sickle cell crises, which should raise concern.

A 23-year-old African American comes to the office with a chief complaint of limp. He says the pain is in his left groin and worsens with walking. He says that the pain has become worse over the past month and notes a history of painful attacks that occur once or twice a year and affect his hands and back. Examination shows marked tenderness to palpation over the head of the right femur and a slight limp of his left leg but otherwise normal ambulation. Which of the following is the most likely diagnosis? A Ewing sarcoma B Sickle cell disease C Slipped capital femoral epiphysis D Rheumatoid arthritis

Shigella species Shigella is a gram-negative bacteria that causes watery diarrhea or dysentery (the frequent and often painful passage of small amounts of stool that contains blood, pus, and mucus). The illness starts abruptly with diarrhea, lower abdominal cramps, and tenesmus accompanied by fever, chills, anorexia, headache, and malaise Stools are loose and mixed with blood and mucus. The abdomen is tender; dehydration is common. Transmission is via direct person-to-person contact and contaminated foods and water. The stool is positive for leukocytes and red blood cells; culture yields Shigella spp.

A 23-year-old prison inmate was brought in from the detention clinic with a 3-day history of crampy abdominal pain and diarrhea. Patient reports the stools were small volume and bloody. On examination his abdomen is tender, he has decreased skin turgor, and the temperature was found to be 101.5°F (38.6°C). Stool microscopy reveals numerous RBCs and WBCs and a stool culture was ordered. Which of the following is the most likely etiologic agent of his diarrheal infection? A Escherichia coli B Giardia lamblia C Shigella species D Vibrio cholerae

Perform a Cosyntropin stimulation test Primary adrenal insufficiency commonly presents with shock, and symptoms are consistent with decreased aldosterone levels. Pertinent laboratory values include hypoglycemia, hyperkalemia, and metabolic acidosis. Proper diagnosis includes confirmation of low levels of cortisol and aldosterone levels in the early morning (typically around 6 AM) when they should be at their highest. Additional testing could include a cosyntropin stimulation test, which involves administering a dose of cosyntropin, a synthetic form of ACTH. Cortisol levels are measured when the cosyntropin is given, 30 minutes after administration, and sometimes 60 minutes after administration. An increase of less than 9 μg/dL after cosyntropin administration indicates primary adrenal insufficiency, while higher levels would suggest secondary adrenal insufficiency. A dexamethasone suppression test is used with patients who have elevated cortisol. Dexamethasone suppresses ACTH production, which then suppresses cortisol production. As cortisol increases vascular tone, the patient's hypotension should indicate low cortisol levels. Further suppressing them would not yield additional diagnos

A 24-year-old man comes to your office with the following symptoms: an extreme feeling of weakness, a 20-pound weight loss, a change in the color of his skin (his skin has become hyperpigmented), and lightheadedness and dizziness. On examination, the patient has definite skin hyperpigmentation since you last saw him 9 months ago. His blood pressure is 90/ 70 mm Hg. He looks acutely ill. On laboratory examination, his serum sodium is low (115 mEq/ L), his serum potassium is high (6.2 mEq/ L), his serum urea is elevated at 9 mg/ dL, and his serum calcium is elevated (12 mg/ dL). After stabilizing his hemodynamics, which of the following is the most appropriate next diagnostic step in the management of this patient? A Check serum cortisol and aldosterone levels at midnight B Perform a dexamethasone suppression test C Perform a Cosyntropin stimulation test D Offer a dose of exogenous adrenocorticotropin hormone (ACTH)

Rome criteria The diagnosis of IBS can reasonably be made using the Rome criteria as long as patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology. Patients with one of these red flag findings require further imaging studies and/or colonoscopy.

A 25-year old female presents to the clinic with an 8-month history of intermittent crampy lower abdominal pain, with the passage of loose stools 4 times a day. Pain is usually worse during her menstrual period and is relieved by defecation. She also feels bloated. She says she has been undergoing work-related stress for months. There are no ALARM symptoms and there are no significant findings on physical examination. Which of the following is associated with this patient's condition? A Alvarado score B Ranson criteria C Rome criteria D Revised Jones criteria

Angiotensin-converting enzyme Sarcoidosis is most common in African Americans. Typical radiographic features include bilateral hilar lymphadenopathy. Also, ACE levels are elevated in as many as 50-60% of patients.

A 25-year-old African American man comes to the clinic because of a cough. He also notices that he's been becoming short of breath on his daily runs over the last few weeks. He denies any chest pain or wheezing. His temperature is 36.6 °C (97.9°F), pulse is 68/min, respirations are 16/min, and blood pressure is 128/84 mm Hg. Physical examination shows his lungs are clear to auscultation bilaterally. A chest x-ray is obtained and demonstrates bilateral hilar lymphadenopathy. Which of the following serum laboratory values is most likely to be abnormal? A 1,25-dihydroxyvitamin D B Adenosine deaminase C Angiotensin-converting enzyme D Calcium E Quantiferon gold

Fistula formation This patient has Crohn's disease which is characterized by a transmural inflammation of the GI tract. It may affect any part of the GI tract but is usually associated with the terminal ileum, the colon, or both. On colonoscopy, areas of ulceration and submucosal thickening give the bowel a cobblestone appearance, with some skipped areas of normal bowel. In addition to the transmural inflammation, there are granulomas, abscesses, fissures, and fistula formation. Symptoms include fever, weight loss, abdominal pain (usually the right-lower quadrant), diarrhea (rarely with associated blood), and growth retardation in children. Complications include intestinal obstruction; toxic megacolon, which is usually more common in ulcerative colitis; malabsorption, particularly associated with fat-soluble vitamins and especially vitamin B12; intestinal perforation; fistula formation; and development of gall and kidney stones.

A 25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having a "nervous stomach," irritable bowel syndrome, and "depression." Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed painful oral ulcers and a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area. Which of the following would be associated with this patient's condition? A Inflammation limited to the superficial layer of the bowel wall B An affinity to involve the rectosigmoid junction C Decreased risk of colon cancer D Continuous mucosal areas of ulceration that affect the anus E Fistula formation

Hydrochlorothiazide This patient has nephrogenic diabetes insipidus. This has resulted from the lack of renal response to antidiuretic hormone (ADH); in this case, the diabetes insipidus is of the nephrogenic subtype and caused by the drug lithium carbonate. Typically the first step is to discontinue the offending drug, however at this point discontinuing lithium is not acceptable to the patient based on her difficulty with managing her mood disorder. As a result, thiazide diuretics are the most appropriate next step because they are the first-line pharmacological therapy for nephrogenic diabetes insipidus. By causing volume depletion through sodium and chloride loss in the distal renal tubule, thiazides can significantly decrease urine loss. This is caused by inducing greater reabsorption of sodium and water in the proximal convoluted tubule in physiologic response to a transient thiazide -induced hypovolemia.

A 25-year-old woman presents with the sudden onset of increased thirst and increased urination. This began abruptly 1 week ago and has not abated since. She states that since then, she has been thirsty all the time. The only significant illness in her life has been a diagnosis of bipolar affective disorder that was made 5 years ago treated with lithium carbonate 1200 mg/ day. Her serum lithium levels have been normal since starting treatment. On examination, her blood pressure is 110/ 70 mm Hg. She has lost 5 pounds during the past week and looks somewhat dehydrated. When informed that her symptoms may be caused by medication taken for her mood disorder, she becomes distraught and refuses to discontinue or switch medications due to past difficulties with medication trials. What is the first step in pharmacological management? A Discontinue her lithium B Desmopressin C Hydrochlorothiazide D Amiloride

Lymph Node Biopsy This patient presents with possible lymphoma. Diagnosis is made by lymph node biopsy. Bone marrow biopsy and CT scan of the chest are used for staging of the disease.

A 26-year-old male presents with a four-week history of fatigue, night sweats, and a painless mass in his neck. Physical examination confirms the presence of an enlarged right posterior cervical lymph node. What is the next best step in the evaluation of this patient? A Bone marrow biopsy and aspiration B Lymph node biopsy C CT scan of the chest D Reexamine in 2-4 weeks

Beta thalassemia minor An asymptomatic patient of Mediterranean origin presenting with isolated, microcytic anemia is most likely due to beta thalassemia minor. This patient would present with increased levels of hemoglobin A on gel electrophoresis.

A 27-year-old man comes into your office for a yearly physical exam and check-up. He has no current complaints and states that his family is healthy. He was originally born in Italy and is up to date with all of his vaccinations. His physical exam is within normal limits and his vitals are HR 80, BP 125/70, T 97.9 F, RR 11. His CBC is significant for Hgb 12.0, Hct 35, WBC 6.5, and Plts 210. Upon obtaining the differential for his low hemoglobin, you see an MCV of 65 along with a reticulocyte count of 4%. His iron studies are within normal limits. You order a peripheral blood smear which demonstrates microcytic red blood cells along with target cells and teardrop cells. What is the most likely diagnosis? A Alpha thalassemia trait B Alpha thalassemia major C Beta thalassemia minor D Beta thalassemia major E Iron deficiency anemia

7 This patient's GCS score is 7 (2 + 1 + 4 = 7)

A 27-year-old man is brought by the paramedics to the ED after an MVA involving a head-on collision with a similar-sized car. The cervical spine appears to be adequately immobilized, and the patient is in acute respiratory distress, with a respiratory rate of 32 breaths/ minute. Breath sounds are absent in the right lung field. There is blood and pink-tinged fluid leaking from his nose, and a large scalp laceration is present. The patient's neurologic status changes are as follows: (1) eyes: closed, no response to verbal commands but eyes open in response to pain. (2) best verbal response: none. (3) best motor response: flexion withdrawal to pressure on the brachial plexus. What is the patient's Glasgow Coma Scale score? A 12 B 8 C 7 D 4

Relapsing-remitting The most common pattern or clinical category of MS is the relapsing-remitting category. In relapsing-remitting MS, episodes of acute worsening are followed by recovery and a stable course between relapses. In the secondary progressive category, gradual neurologic deterioration occurs with or without superimposed acute relapses in patients who previously had relapsing-remitting MS. In primary progressive MS, gradual continuous deterioration occurs from the onset of symptoms. In progressive relapsing MS, gradual neurologic deterioration occurs from the onset of symptoms but with subsequent superimposed relapses. A small fraction of patients has a relatively benign form that never becomes debilitating. The patient described most likely has relapsing-remitting MS.

A 27-year-old woman comes to your office for assessment of symptoms including weakness, visual loss, bladder incontinence, sharp shooting pain in the lower back, clumsiness when walking, and sensory loss. These symptoms have occurred during three episodes (different combinations of symptoms each time) approximately 3 months apart, and each episode lasted approximately 3 days. The first episode consisted of weakness, bladder incontinence, and sharp shooting pains in the lower back (in both hip girdles). The second episode consisted of visual loss, clumsiness when walking, and sensory loss. The third episode (last week) consisted of sharp shooting pains in the lower back and sensory loss (bilateral) in the upper extremities. There are four clinical categories of this disease. Which of the following subtypes does the patient fit into? A Relapsing-remitting B Secondary progressive C Primary progressive D Progressive relapsing

CT abdomen This patient's presentation is consistent with a varicocele. Right-sided varicocele, bilateral varicocele, and failure of a varicocele to disappear upon lying supine are signs suggestive of inferior vena cava (IVC) obstruction and warrant further investigation with a CT scan of the abdomen.

A 28-year-old male presents to a urologist upon referral from a fertility medicine specialist who evaluated the patient and his wife. The patient was told that he had a low sperm count with 'poor quality' sperm. Examination reveals a scrotum that, on the right side only, is enlarged and feels like a 'bag of worms' on palpation. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. An ultrasound and color Doppler study of the patient's right testicle is shown here. Which of the following is the best next step in the management or evaluation of this patient's presentation? A Observation with no further testing or management B MRI pelvis C CT abdomen D Embolization E Surgical repair

Electrophysiology study Electrophysiology studies are used to evaluate the excitability of the myocardium and to reproduce the ventricular tachycardia (VT). Catheter ablation can cure VT in 90% of cases in those without structural heart disease. Repeating the ECG when she has no symptoms and documented Holter monitor demonstrates the likely etiology of the syncope. Exercise treadmill test is not indicated as she has had multiple sustained ventricular tachycardia episodes. Transesophageal echocardiography is used most commonly to evaluate the aorta for evidence of dissection, to elucidate evidence of atrial clots, and to assess for evidence of valvular vegetation.

A 28-year-old woman is admitted to the hospital for further evaluation of her syncopal episodes after a Holter monitor reveals three runs of sustained ventricular tachycardia that lasted between 20 and 30 seconds. While in the hospital, her monitor tracings reveal multifocal premature ventricular contractions. She has no symptoms, and a 12-lead ECG is without evidence of ST-segment elevation or depression. What study would you recommend to evaluate her ventricular excitability? A Loop recorder B Electrophysiology study C Exercise treadmill stress test D Transesophageal echocardiogram

Factor V Leiden The patient presents with a deep venous thrombosis (DVT) given her swollen and tender lower extremity. The most common inherited form of hypercoagulability is factor V Leiden. It is caused by a mutation in factor V which prevents it from being inactivated by protein C. This leads to unregulated prothrombin activation and an increase in thrombotic events. Epidemiologically, factor V Leiden is the most common heritable cause of a hypercoagulable state. Patients who have presented with multiple DVTs or pulmonary embolisms may require lifelong anticoagulation.

A 29-year-old Caucasian woman presents to the emergency room with a painful and swollen leg. She noticed that over the past day, her right leg and thigh have been tender and swollen. She has no past medical history and has never had symptoms like this before. Her vital signs are unremarkable. Physical exam is notable for pain to palpation of the leg and pain with dorsiflexion of the foot. Physical exam is notable for a swollen and red right lower extremity. Which of the following is the most likely etiology of this patient's symptoms? A Antiphospholipid syndrome B Antithrombin III deficiency C Factor V Leiden D Protein C deficiency E Protein S deficiency

Initiate ibuprofen This patient's presentation is consistent with Reiter's syndrome, also known as reactive arthritis. Nonsteroidal anti-inflammatory medications, such as ibuprofen, are the recommended first-line treatment to reduce the pain and inflammation associated with this disease. Reiter's syndrome or reactive arthritis is an autoimmune response to infection that classically involves a triad of noninfectious urethritis, arthritis, and conjunctivitis. This classic triad is actually only seen in approximately one-third of patients with reactive arthritis. The disease is associated with preceding gastrointestinal infection with organisms such as Salmonella, Shigella, Yersinia, or Campylobacter as well as preceding genitourinary infection, with the most common causative organism being Chlamydia. Diagnosis is primarily based on history and clinical presentation.

A 29-year-old male presents to his primary care physician with complaints of pain with urination, eye dryness, and left ankle and knee pain that has developed over the last several weeks. He reports an illness 3 weeks ago that involved frequent diarrhea as well as nausea and vomiting. This episode resolved without treatment within 2 days. Physical exam shows moderate conjunctivitis; the knee and ankle joints show mild crepitus but no overlying redness or warmth. Which of the following is the best next step in the management of this patient? A Prescribe azithromycin and doxycycline B Initiate ibuprofen C Aspiration of the left knee and ankle joints D Initiate PO prednisone E Obtain MRI of the left knee and ankle

Diphtheria Diphtheria spreads by direct or droplet infection. Clinical manifestations include sore throat, low-grade fever, and a grayish-white pseudomembrane on the posterior pharynx.

A 30-year-old woman comes to the clinic because of a sore throat, cough, and tiredness. She immigrated from Indonesia two years ago and has not had to seek medical care until now. Her temperature is 38.5°C (101.3°F), pulse is 85/min, respirations are 22/min, and blood pressure is 130/80 mm Hg. Her symptoms started with a mild sore throat nine days ago and have progressed to pain when swallowing solid foods. Examination of her oropharynx shows a grayish-white lesion that bleeds slightly with scraping. She has prominent cervical lymphadenopathy, swelling of the anterior neck, and stridor. Which of the following is the most likely diagnosis? A Diphtheria B Epiglottitis C Oropharyngeal candidiasis D Infectious mononucleosis

Primary stage Primary syphilis is characterized by Chancre (painless superficial ulcer with a clean base and firm, indurated margins) and regional lymphadenopathy.

A 32- year old man presents to you with a painless superficial ulcer with a clean base and firm, indurated margins on his penis with associated bilateral nontender inguinal lymphadenopathy. Darkfield microscopic examination of fresh exudate from lesion shows Treponema pallidum. At what stage of the disease is this patient in? A Primary stage B Secondary stage C Latent stage D Tertiary stage

Replacement therapy of factor VIII Hemophilia A is the genetic deficiency of factor VIII. The best primary treatment for this condition is replacement with recombinant factor VIII, which reduces exposure to blood products.

A 32-year-old man with a history of easy bruising and joint swelling is being prepped for an appendectomy. During the physical examination, the patient states that he had surgery to correct a heart defect when he was 4, and during the procedure, he was bleeding uncontrollably. Since then he has been diagnosed with a bleeding disorder and must be treated prophylactically prior to any surgical procedure. He adds that his maternal grandfather and 2 of his grandfather's brothers also had the same disorder. Which of the following is the best primary perioperative treatment to prevent uncontrollable bleeding? A Intravenous infusion of antifibrinolytics B Corticosteroids C Replacement therapy of factor X D Replacement therapy of factor VIII E Platelet transfusion

Polycystic kidney disease Polycystic kidney disease (PKD) is an autosomal dominant disorder that affects approximately 500,000 patients in the United States, occurring in about 1 in 800 live births. Fifty percent of patients will reach ESRD by age 60, and PKD accounts for approximately 10% of hemodialysis patients. It is the most common hereditary disorder to result in ESRD. Family history is positive in 75% of cases, but genetic mutations can occur spontaneously, and patients can present without a family history. Signs and symptoms of PKD include abdominal fullness due to enlarged kidneys, abdominal pain due to bleeding into cysts, microscopic or gross hematuria, depending on the extent of the disease, and hypertension. Patients are often asymptomatic, and the first signs of the disease may be hypertension, microscopic hematuria, and mild proteinuria. Abdominal fullness and pain occur later in the disease, as the number and size of cysts increase. Ultrasound is the diagnostic test of choice to detect PKD.

A 32-year-old woman presents for a routine physical examination. She feels well with no specific complaints. On physical examination, her blood pressure is noted to be 154/92 mm Hg. You note slight fullness to the abdomen on palpation without tenderness or obvious mass. Routine labs are ordered, including a UA, with the following results: UA and sediment analysis: 2+ blood, trace protein, negative leukocyte esterase, negative nitrite; 10 to 20 red blood cells (RBCs) per high power field (HPF), no leukocytes, bacteria, or other cells; rare granular casts. BUN 12, Creatinine 0.8. What is the most likely cause of the hematuria? A Urinary tract infection B Glomerulonephritis C Renal calculi D Urinary sample contamination E Polycystic kidney disease

Abdominal Ultrasonography The diagnostic procedure of choice in this patient is abdominal ultrasonography. Gallstones will be demonstrated in approximately 95% of cases, and the specificity of the procedure is high. Ultrasound examination should be done after 8 hours of fasting because gallstones are visualized better in a distended, bile-filled gallbladder. Ultrasound findings that suggest acute cholecystitis are pericholecystic fluid, gallbladder thickening, and sonographic Murphy sign. CT scan and MRI is more sensitive in diagnosis of choledocholithiasis; however, they are expensive and offer no more sensitivity in the diagnosis of gallstones or acute cholecystitis. The HIDA scan is expensive and reserved for cases in which the ultrasound study or CT scan is nondiagnostic but there is a high suspicion of cholecystitis.

A 32-year-old woman presents with 4-day history of sudden right upper quadrant abdominal pain that is referred to the right shoulder tip. Pain was initially colicky, and then became constant. Positive history of fever, nausea, and vomiting. On examination, she's acutely ill looking, anicteric, febrile, positive murphy's sign, right upper quadrant abdominal tenderness with muscle guarding and rebound tenderness present. CBC done showed WBC: 13 x 109/L; Serum amylase: 170U/L. Which of the following investigative procedures would be the best initial test to aid in the diagnosis? A Computed tomography (CT) scan of the abdomen B Hydroxy iminodiacetic acid (HIDA) scan C Abdominal ultrasonography D Magnetic resonance imaging (MRI) of the abdomen

Intravenous rehydration The patient is severely dehydrated; therefore he requires immediate intravenous rehydration to prevent hypovolemic shock and to maintain circulation. (Cholera)

A 33-year-old female with watery, nonbloody diarrhea, vomiting, lethargy, and abdominal cramps for the past 2 days. She also reports a low-grade fever. She returned from a medical mission trip to South America yesterday. While on the trip she spent time in a remote area and is uncertain of the quality of the water she drank. She also ate shrimp one night for dinner. On examination, the stools are liquid with flecks of mucus. Physical exam reveals sunken eyes, dry mucous membranes, and decreased skin turgor. The patient is afebrile. Blood pressure is 90/60 mmHg. Which of the following is the most important in the immediate management of this patient? A Intravenous rehydration B Antibiotic C Oral rehydration D Report to the appropriate public health authority

T4 elevated, free T4 elevated, T3 elevated, TSH decreased This patient most likely has Graves' disease. The thyroid studies would demonstrate elevated levels of T4, free T4, and T3 with a decrease in TSH.

A 34-year-old female complaining of irritability and nervousness, heat intolerance with increased sweating, and weight loss despite an increase in appetite. On physical exam, you note exophthalmos and pretibial myxedema. She has a pulse of 110, a fine tremor, and 4+ deep tendon reflexes. Her hair is fine in texture and you note a palpably enlarged thyroid gland. The patient does not take birth control and her urine pregnancy test is negative today. You order thyroid function tests for workup. What thyroid function values are most expected? A T4 elevated, free T4 normal, T3 elevated, thyroid-stimulating hormone (TSH) normal B T4 elevated, free T4 elevated, T3 elevated, TSH elevated C T4 elevated, free T4 elevated, T3 elevated, TSH decreased D T4 decreased, free T4 decreased, T3 decreased, TSH decreased E T4 normal, free T4 normal, T3 normal, TSH elevated

Cisapride Cisapride is a prokinetic agent. It's not used in the treatment of anal fissure.

A 35-year man presents with 1 week history of anal pain that occurs during defecation and subsides after a few hours. He also says he noticed bright-red blood on the toilet paper. He has been constipated for the past 6 months. Gentle perianal examination with inspection of the anal mucosa reveals a posterior midline ulcer. Which of the following is not a treatment option for this condition? A Topical diltiazem B Topical bethanechol C Botulinum toxin D Cisapride E Fiber

Chronic daily headache, tension-type This patient has chronic tension-type headache. Chronic tension-type headaches are often described as a steady, aching, vise-like sensation that encircles the entire head. Chronic tension-type headaches are often accompanied by tight and tender muscles at the site of maximal pain, often in the posterior cervical, frontal, or temporal musculature. Chronic tension-type headache is defined as tension-type headache occurring more than 15 days a month. Chronic daily tension-type headaches are usually related to causal factors that include stress and worry, depression, overwork, lack of sleep, incorrect posture, and marital and family dysfunction.

A 35-year-old man comes to your office with a 6-month history of recurrent headaches at least three or four times a week, usually in the late afternoon. The headaches are described by the patient as "a vise around my head." The headaches are not associated with nausea, vomiting, or malaise. The patient does not have photophobia or phonophobia. He smokes one pack of cigarettes per day and says he does not drink alcohol. On examination, the patient's blood pressure is 140/70 mm Hg. His optic fundi are normal. There are no neurologic abnormalities. What is the likely type of headache in this patient? A Chronic daily headache, tension-type B Cluster headache C Migraine headaches D Subarachnoid hemorrhage

Single-fiber electromyography (SFEMG) Myasthenia gravis is often diagnosed using the Tensilon test. However, it is most definitively diagnosed with single fiber electromyography which shows a decremental response to motor nerve stimulation.

A 35-year-old woman presents with a history of a self-limited upper respiratory illness 3 weeks prior to this clinic visit. She now complains of persistent weakness and malaise, which worsens near the end of the day. She complains that she has a difficult time keeping her right eye open during the later part of the day. Taking a nap often helps. You notice that her right eyelid covers the top portion of her pupil. Pupillary reactions are normal. A complete neurological evaluation is otherwise negative. Which evaluation is most likely to confirm your preliminary diagnosis? A CT scan of the thorax B Edrophonium (Tensilon) test C Muscle biopsy D Single-fiber electromyography (SFEMG)

Arthrocentesis A monoarticular arthritis should raise the question of a septic versus a crystalline arthritis. Septic arthritis and crystalline arthritis can be notoriously similar in their clinical presentations, so clearly establishing the diagnosis, particularly in a patient with no known history of crystalline disease, is of great advantage before initiating definitive therapy. Crystal-induced and septic-induced joint can coexist in the same joint. An arthrocentesis is the most appropriate choice and allows examination of fluid for WBCs, crystals, and bacteria. Colchicine (choice A), NSAIDs (choice B), and antibiotics (choice C) are all inappropriate before the arthrocentesis. If diagnosis of a septic joint is missed, the joint can be destroyed from the bacteria.

A 38-year-old woman presents with a swollen and tender right wrist. The symptoms began a day earlier and have become more severe. She had a fever and shaking chills last night. She has no past medical history and takes no medications, except for ibuprofen for occasional tension headaches. On physical examination, the wrist has decreased ROM and is tender to palpation. The joint space has an obvious effusion and is tender, erythematous, and warm. Which of the following is the most appropriate next step in management? A Colchicine B Indomethacin C IV antibiotics D Arthrocentesis

Positive antimicrosomal antibodies Hashimoto thyroiditis is the result of an autoimmune-mediated lymphocytic inflammation and destruction of the thyroid tissue. Diagnosis is based on thyroid function tests, as well as the presence of certain antibodies, such as anti-thyroid peroxidase (anti- microsomal) and anti-thyroglobulin.

A 39-year-old female complains of constant fatigue, weight gain, cold intolerance, depression, and irregular menses with menorrhagia. Her temperature is 36.5°C (97.7°F), pulse is 48/min, blood pressure is 124/88 mm Hg, and BMI is 22 kg/m2. Physical examination shows cold, dry skin and thinning hair on the scalp. There is 1+ non-pitting edema on both lower extremities. Laboratory result shows elevated TSH, low free T4, and positive TPO antibodies. Which of the following additional findings is likely present in this patient? A Positive antimicrosomal antibodies B Decreased thyroid stimulating hormone levels C Positive TSH-receptor antibodies D Diffuse uptake of radioactive iodine on thyroid scintigraphy

Anemia of chronic disease Anemia of chronic disease is characterized by anemia in the setting of a chronic illness such as systemic lupus erythematosus and rheumatoid arthritis. Lab values will show decreased serum iron levels, decreased total iron-binding capacity, and increased ferritin.

A 39-year-old woman comes to her primary care provider's office because of increasing fatigue over the past several weeks. Her past medical history is significant for rheumatoid arthritis. Laboratory testing shows a low serum iron level and a low total iron-binding capacity level. A blood smear is done and shows normochromic and normocytic erythrocytes. Which of the following is the most likely diagnosis? A Iron deficiency B Folate deficiency C Vitamin B12 deficiency D Anemia of chronic disease

Amlodipine This patient has Raynaud phenomenon secondary to limited scleroderma. Treatment involves stress management and cold avoidance. Calcium channel blockers (CCB), such as oral nifedipine or amlodipine, are the first-line option. Topical nitrates and phosphodiesterase type 5 inhibitors (e.g. sildenafil) can be used in patients with contraindications to CCBs or who have failed prior CCB treatment.

A 39-year-old woman is being evaluated for episodes of "hand discoloration." The patient reports that these episodes are triggered by cold temperatures and resolve after 15-20 minutes. Past medical history is significant for hypertension, for which she has been prescribed lisinopril. Her temperature is 36.8°C (98.2°F) and her blood pressure is 142/83. Physical examination is notable for skin tightening over the face and hands. Calcium deposits are present at the elbows. Which of the following medications would be most effective in managing this patient's symptoms? A Sildenafil B Topical corticosteroids C Methotrexate D Amlodipine

acute interstitial nephritis Acute interstitial nephritis (AIN) is a renal lesion that causes a decline in kidney function and is characterized by an inflammatory infiltrate in the kidney interstitium. Drugs (remembered as the 5 Ps) are the most common cause of AIN. The 5 Ps are Pee (diuretics, especially sulfa ones), Pain-free (NSAIDs), Penicillins and cephalosporins, Proton pump inhibitors, and rifamPin. Patients will present with elevated creatinine, eosinophils, WBC casts, and hematuria.

A 62-year-old man presents to your office with a sudden onset of fever and rash. His review of systems is negative. He was recently started on omeprazole for acid reflux 14 days ago. Routine laboratory tests reveal a serum creatinine of 3.5 mg/dL and eosinophilia. Urine studies showed white blood cell casts. What is the most likely diagnosis? A Acute interstitial nephritis (AIN B Acute tubular necrosis C IGA Nephropathy D Postreptococcal Glomerulonephritis

Neuroendocrine tumor metastasis to the liver The patient has carcinoid syndrome, a disease which features a neuroendocrine cell tumor which secretes a large amount of serotonin in an episodic manner. Many neuroendocrine tumors originate in the GI tract and release their active products into the portal venous system. Serotonin is metabolized by the liver before they reach the systemic circulation. Thus, patients usually remain asymptomatic until the tumors metastasize to the liver, allowing their vasoactive products to bypass hepatic metabolism. Serotonin causes the patient's symptoms of flushing, wheezing, diarrhea, and hypotension. In addition, carcinoid syndrome patients often have right-sided heart valve defects, most commonly tricuspid regurgitation. Symptoms of carcinoid syndrome can be memorized using the mnemonic FDR (flushing, diarrhea, and right-sided heart valves).

A 40-year-old man comes to the emergency department because of a 3-week history of episodic cutaneous flushing, diarrhea, and wheezing. He has a past medical history of hypertension and type 2 diabetes mellitus. His temperature is 36.6°C (97.9°F), pulse is 125/min, respirations are 30/min, and blood pressure is 90/60 mm Hg. Pulmonary examination shows diffuse wheezes in both lung fields. Cardiac examination shows a prominent "v" wave of the jugular vein and a 1/6 holosystolic murmur best heard at the lower sternal border. Abdominal examination shows hyperactive bowel sounds. Which of the following is the most likely diagnosis? A Catecholamine secreting adrenal tumor B Chronic obstructive pulmonary disease C Community-acquired pneumonia D Neuroendocrine tumor metastasis to the liver E Serotonin-secreting tumor isolated to the gastrointestinal tract

Mycobacterium avian complex Mycobacterium avium complex (MAC) should be considered in HIV positive patients with CD4 counts <50 presenting with cough, fever, right upper quadrant abdominal pain, fatigue, and weight loss.

A 40-year-old man comes to the emergency department because of fever and diarrhea for the past 2 days. He has also had severe fatigue for the past 10 days. Past medical history is significant for human immunodeficiency virus diagnosed 3 years ago. Physical examination shows cervical lymphadenopathy and a palpable liver 3cm below the right costal margin. The CD4 count is <50/mm3. Which of the following is the most likely diagnosis? A Cytomegalovirus B Kaposi sarcoma C Lymphoma D Mycobacterium avium complex

decreased acetylcholine release This patient presents with blurry vision and vertical diplopia after prodromal gastrointestinal symptoms following ingestion of home-canned foods, most consistent with foodborne botulism. The underlying mechanism is decreased acetylcholine release in the presynaptic terminal of the motor neuron.

A 41-year-old man presents to the emergency room with sudden onset of blurry vision one hour ago. He states that he was resting at home when he noticed he had difficulty reading. Currently, he is also starting to see double, and is seeing two images on top of each other. Earlier today, he felt ill with nausea, vomiting, and watery diarrhea, which he attributed to food he had eaten at a picnic the day before. When asked which foods he ate, he lists potato salad, a hamburger, deviled eggs, and pickles made by his neighbor. He also heard that his friend who went to the picnic with him has developed similar symptoms and was seen in another hospital earlier. While in the emergency room, the patient's temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 122/84 mmHg, and respirations are 13/min. Cranial nerve exam is notable for fixed pupillary dilation, and difficulty depressing both eyes. The remainder of his exam is normal. Which of the following is the pathogenesis of this patient's presentation? A Decreased acetylcholine release B Overactivation of adenylate cyclase C Release of interferon-gamma D Degradation of phospholipids E Inhibition of GABA release

Tetanus immune globulin, tetanus toxoid, and metronidazole Clostridium tetani infection is a vaccine-preventable disease that results in approximately 50 cases per year in the United States. Even with modern medical resources, 20% to 25% of patients with generalized tetanus die. Treatment includes airway protection, benzodiazepines for muscle spasm, tetanus immune globulin immediately, and three doses of tetanus toxoid given by the standard schedule. Metronidazole or penicillin is also administered to destroy the organism and prevent toxin production.

A 42-year-old homeless man presents to the emergency department with fever, painful muscle spasms in his arms and legs, and difficulty eating because of painful spasms in his jaw muscles. Until a week ago, he was wandering around the city looking for food and work and taking shelter in a commercial construction site. He reports not having seen a medical professional in more than 15 years. Examination of his feet reveals shoes with holes in the soles and a small, puncture-type wound on the bottom of the right foot. It is surrounded by erythema and somewhat tender to touch. The patient is uncertain what he may have stepped on. X-ray is negative for any radiopaque foreign body. In addition to hospital admission, which of the following is the first-line therapy for this patient? A Tetanus immune globulin and tetanus toxoid B Tetanus immune globulin and metronidazole C Tetanus toxoid and penicillin D Tetanus immune globulin, tetanus toxoid, and metronidazole

Standing The 'click' of mitral valve prolapse, caused by the tightening of the chordae tendinae, moves closer to S2 with increased preload. Increased preload causes the left ventricle to stretch, as a result, the chordae tendinae are stretched as well. This makes it harder for the mitral valve to prolapse until the ventricles shrink enough to allow the chordae tendinae to let the mitral valve prolapse. Since there is more blood in the ventricles, it takes them longer to pump it out and shrink to a point at which MVP can occur, hence it occurs later in systole. Thus, the click will get closer to S2 with increased preload. Hand grip, rapid squatting, and inspiration all increase preload. Standing decreases preload and will cause an earlier onset of the click.

A 43-year-old man with a history of rheumatic fever comes to the primary care clinic for a check-up. Cardiac examination reveals a late systolic crescendo murmur with midsystolic click best heard over the apex and loudest just before S2. Which of the following maneuvers will cause an earlier onset of the click/murmur? A Inspiration B Rapid squatting C Standing D Hand grip E Left lateral cubital position

Anti-Sm antibodies Selected antinuclear antibodies (ANAs), including anti-double-stranded deoxyribonucleic acid (dsDNA) and anti-Sm, are highly specific for the diagnosis of systemic lupus erythematosus (SLE). The ANA test is positive in virtually all patients with SLE at some time in the course of their disease. If the ANA is positive, one should test for other specific antibodies, such as anti-dsDNA, anti-Smith (anti-Sm), Ro/SSA, La/SSB, and U1 ribonucleoprotein (RNP).

A 44-year-old female presents to your office complaining of intermittent joint pain. The joint pain began about 13 months ago affecting primarily the joints in her hands, wrists, and feet. She expresses concern regarding worsening fatigue, muscle aches, and feelings of depression. The physical exam reveals tender, edematous bilateral wrists; painless oral ulcers; and erythematous maculopapular lesions on her face. Which of the following is the most specific antibody for the diagnosis of this condition? A Anti-Sm antibodies B Anti-Ro/SSA and anti-La/SSB antibodies C Anti-U1 RNP antibodies D Anti-ssDNA antibodies E Antinuclear antibody (ANA)

Candidal esophagitis Candidal esophagitis is a condition most commonly seen in the immunocompromised and those with esophageal motility disorders. Diagnosis of Candida esophagitis is made by demonstration of yeast or hyphal forms in plaque smears and exudate stained with periodic acid- Schiff or Gomori silver stains. The characteristic endoscopic finding is diffuse, linear, yellow-white plaques adherent to the mucosa.

A 45-year old HIV + patient presented to you with a one-week history of dysphagia, odynophagia, retrosternal pain, nausea, and vomiting. Esophagoscopy done showed small, yellow-white raised plaques with surrounding erythema. Brushings obtained were smeared and stained with periodic acid-Schiff revealed mycelia forms and masses of budding yeast. What is the most likely diagnosis? A Candidal esophagitis B Herpes esophagitis C CMV esophagitis D Tuberculosis esophagitis

Endoscopic mucosal biopsy of the small intestine Endoscopic intestinal mucosal biopsy of the proximal duodenum (bulb) and distal duodenum is the standard method for confirmation of the diagnosis in patients with a positive serologic test (IgA endomysial antibody) for celiac disease

A 45-year-old male from Ireland complains of diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distension. He reports having 3-5 loose stool per day for the last six months. The condition improves when he fasts. You suspect a diagnosis of celiac disease. The gold standard test to confirm the diagnosis of celiac disease is A Endoscopic mucosal biopsy of the small intestine B Antigliadin antibodies C Tissue Transglutaminase Antibodies (tTG-IgA) D IgA Endomysial antibody (EMA)

Tissue biopsy A clinical diagnosis of polyarteritis nodosa (PAN) is suspected based upon the presence of characteristic symptoms, physical findings, and compatible laboratory test results. However, because of the relative rarity of this disease and the potentially severe adverse effects related to treatment, the diagnosis should be confirmed by biopsy whenever possible. In the absence of an obvious site for biopsy, angiography sometimes reveals microaneurysms of blood vessels in the renal, hepatic, or mesenteric circulations.

A 45-year-old male with generalized symptoms such as malaise, fever, sore throat, joint, and muscle aches and pains. He also complains of numbness, tingling, sensory disturbances, and weakness. On physical examination, you notice the presence of tender lumps under the skin, especially on the thighs and lower legs. Laboratory testing is notable for a newly elevated creatinine of 2.6 mg/dL, erythrocyte sedimentation rate, and C-reactive protein. He is also seropositive for hepatitis B virus, ANCA-negative, and guaiac positive. Of the following diagnostic studies which will confirm your suspected diagnosis? A Testing for rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies B Chest radiography C Muscle enzyme concentrations D Tissue biopsy

Verapamil Cluster headaches are a neurological disorder characterized by severe, recurrent headaches that are focused on one side of the head, typically around the eye. Recommended primary prevention is verapamil. Inhalation of 100% oxygen at 6-12 L/min for 15 minutes via a nonrebreathing mask provides relief within 15 minutes but it does not help prevent future episodes. Subcutaneous sumatriptan (6 mg) is beneficial (ie, pain-free within 20 minutes) in about 75 percent of patients.

A 45-year-old man comes to your office with a four-week history of recurrent headaches that wake him up in the middle of the night. The headaches have been occurring every night and have been lasting approximately 1 hour. The headaches are described as a deep burning sensation centered behind the left eye. The headaches are excruciating (he rates them as a 15 on a 10-point scale) and are associated with watery eyes, "a sensation of heat and warmth in my face," nasal discharge, and redness of the left eye. Before the onset of these headaches 4 weeks ago, the patient describes no more than the occasional tension headache. Headaches were certainly never a problem. The patient describes no recent life changes and no major life stresses. He is happily married, has three children, and has a secure job that he enjoys. On examination, his blood pressure is 120/70 mm Hg. His pulse is 82 beats/minute and regular. How would you best treat his headache to help prevent future episodes? A Verapamil B Sumatriptan C Oxygen D Intranasal lidocaine

Thrombotic Thrombocytopenic purpura This clinical presentation is consistent with thrombotic thrombocytopenic purpura (TTP), which is associated with a pentad of signs and symptoms including fever, microangiopathic hemolytic anemia, thrombocytopenia (with associated petechiae), renal dysfunction, and neurological or mental status changes. Physical exam demonstrates petechiae, a result of thrombocytopenia, and his peripheral blood smear is positive for schistocytes (RBC fragments), which are seen in microangiopathic hemolytic anemias such as TTP.

A 45-year-old man is brought to the emergency room by his partner because he has been acting confused for the past day. He is febrile, with an oral temperature of 103.6 deg F; vital signs are otherwise stable. His physical exam is significant for the petechiae on the left foot; he has never noticed lesions like these before. He also has subtle right-sided weakness affecting upper and lower extremities. Labs reveal hemoglobin 7.0 g/dL, hematocrit 21%, white blood count of 10.2 x 10^3 µL, and platelet count of 20 x 10^3 per µL. PT/INR and PTT are normal. Schistocytes are noted on his peripheral blood smear. What is the most likely diagnosis? A Idiopathic thrombocytopenic purpura B Disseminated intravascular coagulation C Thrombotic thrombocytopenic purpura D Hemolytic uremic syndrome

Add ezetimibe (Zetia) 10 mg daily If LDL-C is not at goal after 6-12 weeks the next best step for the treatment of familial hypercholesterolemia is to add ezetimibe 10 mg daily and check again in 6-12 weeks. If at that time the patient's LDL is still not at goal (ideally < 150) refer to lipid specialist to consider adding a PCSK9 inhibitor.

A 45-year-old obese Caucasian gentleman arrives at your clinic for a routine check-up after having some blood work done during a workplace health screening. He is found to have an LDL cholesterol level of 550 mg/dL. He states that his father and brother had high cholesterol and both died at a young age from a heart attack. He has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes. He is started on high dose statin and his LDL at 12 weeks is 350 mg/dL. What is the next best step in this patient's management? A Continue high dose statin, the patient's LDL is at goal B Add niacin 100 mg three times daily C Add ezetimibe (Zetia) 10 mg daily D Add a PCSK9 inhibitor E Refer to a lipid specialist

Venodilation Stable angina pectoris results when myocardial oxygen demand exceeds oxygen supply. Nitrates, the first-line therapy for acute episodes and they act principally through smooth muscle relaxation and venodilation which causes blood pooling in the peripheral vasculature with a concomitant reduction in preload. Decreased preload decreases cardiac contractility and oxygen demand.

A 46-year-old man comes to the office because of a four-month history of intermittent episodes of chest discomfort and tightness. His symptoms typically occur only on exertion, such as when gardening or playing with his children, and are relieved by rest. He says the episodes last less than 20 minutes. He has otherwise been healthy and his personal medical history is noncontributory. His father has coronary artery disease but is alive and well. Physical exam, laboratory studies and ECG are normal. The medication most appropriate for treating his acute episodes acts by which of the following mechanisms? A Blocking calcium channels B Controlling coronary artery vasospasm C Decreasing heart rate D Venodilation E Arteriolodilation

Trimethoprim-Sulfamethoxazole (Bactrim) TMP-SMX is the drug of choice for all forms of pneumocystis. Prophylaxis is provided for high-risk patients with a CD4 count of less than 200 or with a history of PJP infection. Daily Bactrim is the prophylaxis antibiotic of choice.

A 47-year-old HIV positive female presents with a complaint of nonproductive cough. She is febrile, tachypneic, and tachycardic. Lung exam reveals bilateral rales. Chest x-ray shows diffuse interstitial infiltrates. What is the recommended treatment for this patient? A Trimethoprim-Sulfamethoxazole (Bactrim) B Tetracycline (Sumycin) C Amantadine (Symmetrel) D Ticarcillin (Ticar)

Acute myelogenous leukemia Acute myelogenous leukemia (AML) is a leukemia that presents in adults with a cell lineage of the immature granulocytic cells seen in the peripheral blood e.g. myeloblasts, promyelocytes. Auer rods are commonly seen in this condition.

A 48-year-old male complains of weakness and general malaise for about 2 months. Patient denies any recent illness and does not take any medications. Physical examination reveals a pale looking male in no acute distress. His heart rate is 110 beats/minute without a murmur and his abdominal examination reveals hepatosplenomegaly. A CBC reveals the WBC to be 62,000/microliter, Hgb is 8.3 gms/dl, Hct is 24.6%. A differential reveals a predominance of monoblasts and promyelocytes with Auer rods present. What is the most likely diagnosis? A Acute lymphocytic leukemia B Acute myelogenous leukemia C Chronic lymphocytic leukemia D Chronic myelogenous leukemia

Cornea Involvement of the tip of the nose with herpes virus is known as Hutchinson's sign. It is suggestive of involvement of the cornea with herpes and urgent referral to an ophthalmologist is recommended. The patient has shingles (herpes zoster) which follows dermatomes and is generally unilateral. Involvement of the tip of the nose or lid margins should lead one to suspect corneal involvement.

A 48-year-old male patient is diagnosed with shingles involving cranial nerve V. During the examination you note that the tip of his nose is involved. At this point, it is crucial to rule out involvement of: A The opposite pinna B Cornea C Nasal septum D Tympanic membrane

Electrocardiogram Electrocardiogram is the gold standard for diagnosing myocardial infarction within the first 6 hours of symptom onset. Electrocardiogram changes will include ST-segment elevation (signifying transmural infarct), ST-segment depression (signifying subendocardial infarct), and Q waves (signifying transmural infarct).

A 48-year-old man comes to the emergency department because of severe substernal chest pain radiating to his left arm that began 1.5 hours prior to arrival. The pain is accompanied by diaphoresis and shortness of breath. His blood pressure is 165/94 mm Hg, pulse is 82/min, and respiratory rate is 18/min. An acute myocardial infarction is suspected. Which of the following tests is the most important tool in the initial evaluation of this patient? A Aspartate aminotransferase B Creatine kinase-myocardial bound C Electrocardiogram D Echocardiogram E Lactate dehydrogenase

Colonoscopy The diagnostic procedure of choice in this patient is a total colonoscopy to confirm a mass lesion, to determine the location of that lesion, and to obtain a biopsy specimen of the lesion if possible.

A 48-year-old man comes to your office with a vague lower right-sided abdominal fullness (not pain). He describes to you a general feeling of "not feeling well," fatigue, and a somewhat tender area "down near my appendix." He states, "I have no energy. I'm tired all the time." He also suspects that his skin changed color, first to a pale color and then to slightly yellow. On direct questioning, he admits to anorexia, weight loss of 30 pounds in 6 months, nausea most of the time, vomiting twice, some diarrhea that seems to be mucus, and blood in the stool almost every day for the past 3 months. When you ask him what he makes of all of this, he tells you, "Maybe a very bad flu." On examination, the patient looks very pale. Examination of the abdomen reveals abdominal distention. You record the abdominal girth as a baseline. There is a sensation of "fullness" in the right lower quadrant of the abdomen. This area is also dull to percussion and is slightly tender. There is definite percussion of tympani on both sides of the area of dullness. The liver span is 20 cm. The sclerae are yellow. What is the definitive diagnostic procedure of choice in this patient? A Complete blood count (CBC) B Fecal occult blood samples C Air-contrast barium enema D Colonoscopy

Prednisone The most likely diagnosis in this patient is polymyositis. This is supported by the finding of a gradual progressive proximal muscle weakness and elevation of creatinine phosphokinase level. The finding of lymphoid inflammatory infiltrates on muscle biopsy confirms the diagnosis. Initial treatment of choice in this condition is the use of a corticosteroid (prednisone). Patients who do not respond to prednisone may then benefit from the use of methotrexate or azathioprine. Both intravenous immune globulin and hydroxychloroquine are effective for the treatment of patients with dermatomyositis that is resistant to prednisone therapy.

A 48-year-old woman presents with a chief complaint of gradually progressing difficulty in climbing stairs over the past 3 months. The physical examination shows there is notable proximal muscle weakness of the upper and lower extremities. The remainder of the examination is unremarkable. The laboratory evaluation shows an elevated serum creatinine phosphokinase level, and a muscle biopsy reveals lymphoid inflammatory infiltrates. Which of the following is the appropriate initial treatment of choice in this patient? A Prednisone B Azathioprine C Methotrexate D Immunoglobulin E Hydroxychloroquine

Surgical excision A 49-year-old with a cold nodule and follicular architecture is suspicious for follicular adenoma or adenocarcinoma. Surgical excision is necessary to determine whether the neoplasm exhibits signs of capsular or vascular invasion for this determination.

A 49-year-old woman comes to your office with complaints of a "lump" she found on her neck while bathing. She denies any other symptoms and states that she has not gained any weight. On exam, you notice a 2 cm nodule on her anterior neck. Her TSH level is normal, and a radionucleotide scan reveals a cold nodule. Fine needle aspiration biopsy (FNAB) reveals follicular architecture suspicious for malignancy. What is the next best step? A Punch biopsy B Surgical excision C Thyroxine administration D Ultrasound E CT scan

Hyperestrinism Cirrhosis of the liver can cause elevated circulating estrogens, leading to features such as palmar erythema, gynecomastia, spider angiomas, and testicular atrophy.

A 53-year-old alcoholic man comes to the emergency department because of an episode of hematemesis. The patient looks disheveled and is disoriented to time and place. Past medical history includes hepatitis C infection. Abdominal examination shows abdominal distension with a fluid wave and caput-medusae. Examination of the extremities shows a bilateral "flapping" tremor, red palms, and bilateral 2+ lower extremity edema. What is responsible for this patient's palmar erythema? A Hyperammonemia B Hyperbilirubinemia C Hyperestrinism D Portal hypertension

Renal cell carcinoma Given the patient's presentation (flank pain, hematuria) and history of smoking, the most likely diagnosis is renal cell carcinoma. Renal cell carcinoma most commonly presents with a combination of hematuria, an abdominal mass, and flank discomfort, although many patients are asymptomatic and are diagnosed incidentally. Patients may also have an elevated hematocrit from elevated erythropoietin production. Risk factors for renal cell carcinoma include smoking, hypertension, obesity, acquired cystic kidney disease, and genetic factors such as von Hippel Lindau.

A 55-year-old male presents to your office for abdominal discomfort. The patient states he first noticed pain on his right flank several months ago, and it has been gradually getting worse. For the past week, he has also noticed blood in his urine. Prior to this episode, he has been healthy and does not take any medications. The patient denies fever, chills, and dysuria. He has a 40 pack-year smoking history. Vital signs are T 37 C, HR 140/90 mmHg, HR 84/min, RR 14/min, O2 98%. Physical exam is unremarkable. CBC reveals a hemoglobin of 17 and hematocrit of 51%, and urinalysis is positive for red blood cells, negative for leukocytes. Which of the following is the most likely diagnosis? A Renal cell carcinoma B Polycystic kidney disease C Abdominal aortic aneurysm D Pyelonephritis

Cytomegalovirus infection Cytomegalovirus (CMV) is the most common viral infection in solid organ transplant recipients. CMV infection usually develops during the first few months post-transplantation and is associated with clinical infectious diseases and acute and/or chronic graft injury and dysfunction. It often presents with fever, fatigue, arthralgias, pneumonia, GI ulcers, and hepatitis.

A 63-year-old man with a history of alcohol use disorder presents with a chief complaint of stabbing chest pain on inspiration for the last 48 hours. The patient also complains of cough, fever, fatigue, and joint pain for the last week. He received a liver transplant 5 weeks ago with no surgical complications. On physical examination, the patient is found to have a fever of 100.8°F and is otherwise unremarkable. Chest radiographs show interstitial infiltrates predominantly in the lower lobes. Given the time frame, which of the following best explains this patient's symptoms? A Acute graft-versus-host disease B Chronic graft-versus-host disease C Parvovirus B19 infection D Cytomegalovirus infection

Infective Endocarditis Infective endocarditis (IE) is an infection of the endocardial surfaces of the heart, most commonly the heart valves. IE occurs when a microorganism begins to invade the heart valves causing an inflammatory reaction that damages the valve - sometimes leading to stenosis and sometimes leading to regurgitation. This patient developed a new cardiac murmur in recent weeks that is described as a faint systolic murmur heard over the lower left sternal border. This is most consistent with tricuspid regurgitation. She also has distended neck veins and hepatomegaly, both of which suggest right-sided heart failure which can result from tricuspid regurgitation. Small infectious emboli can break away from the primary lesion on the tricuspid valve and go into the pulmonary vasculature causing shortness of breath and pleuritic chest pain. Most cases of IE are caused by Staphylococcus aureus and Viridans streptococci, and diagnosis is confirmed by obtaining multiple blood cultures that show that there is continuous bacteremia.

A 55-year-old woman is admitted to the hospital because she has shortness of breath and pain on both sides of her chest with deep breathing which has worsened over the past 5 days. In recent weeks, she has been feeling fatigued and has had low grade fevers and night sweats, and was found to have a new cardiac murmur on examination. Her temperature is 38.1°C (100.6°F), pulse is 106/min, respirations are 26/min, and blood pressure is 136/88 mm Hg. She appears diaphoretic and is in mild respiratory distress. Cardiac auscultation reveals a faint systolic murmur heard over the lower left sternal border. Her neck veins are distended and abdominal examination shows hepatomegaly. Which of the following is the most likely cause of her clinical presentation? A Fat embolism B Infective endocarditis C Myocardial infarction D Rheumatic fever E Small cell lung cancer

IV Hydrocortisone This patient is presenting with toxic megacolon secondary to ulcerative colitis (UC). The first-line treatment for patients with toxic megacolon from UC is IV glucocorticoids to reduce inflammation and the need for surgical intervention.

A 55-year-old woman with a history of ulcerative colitis presents to the emergency department with a severe flare. The patient reports numerous bloody loose stools and has been febrile for two days. Vital signs are T 102.0 HR 98 BP 131/86 RR 17 Sat 100%. The abdominal exam is notable for markedly distended abdomen with tympani and tenderness to palpation without guarding or rebound. A CT scan shows a markedly dilated descending and sigmoid colon with no perforations. What is the next best step in management for this patient? A Oral prednisone B IV hydrocortisone C Rectal 5-ASA D IV Metoclopramide E IV Ondansetron

Immediately consult vascular surgery Peripheral vascular disease with intermittent claudication and signs of decreased perfusion should be examined using Doppler ultrasound and the ankle-brachial index (ABI). An ABI of <0.41 is grounds for the immediate surgical consultation.

A 57-year-old man comes to the emergency department because of intermittent, severe leg pain in both his calves for 2 weeks. He has a history of untreated high blood pressure, diabetes, and high cholesterol. For the past 3 years, the pain started after walking three blocks and only going away upon resting. In the past 2 weeks, he has had the same pain at rest. His temperature is 36.5°C (97.7°F), pulse is 78/min, respirations are 17/min, and blood pressure is 160/89 mm Hg. Examination shows both calves are atrophied and there is a paucity of hair, but no swelling or discoloration. Additionally, his lower calves are cool to the touch and dusky in appearance. Doppler ultrasound shows perfusion to both feet, and with its assistance blood pressures of 35/20 mm Hg in the posterior tibial artery are obtained bilaterally. Which of the following is most appropriate next step in management? A Immediate high-dose statin therapy B Immediately consult vascular surgery C Intravenous alteplase D Pain control and discharge; refer to vascular surgery as an outpatient E Rest, elevate, and compress the affected leg

Hepatomegaly Hepatomegaly is not a component of Charcot's triad which consists of Fever + Jaundice + Right upper abdominal pain. The full triad present in only 70% of cases. Reynolds' pentad, which occurs in severe suppurative cholangitis consists of Charcot's triad plus altered mental status and hypotension.

A 58-year-old male with acute onset of abdominal pain associated with fever and shaking chills. The patient is hypotensive and febrile with a temperature of 102.2 ° F. Although he is confused and disoriented, he complains of right upper quadrant pain during palpation of the abdomen. His sclerae are icteric and the skin is jaundiced. Which of the following is not a component of Charcot's triad of symptoms used in the identification cholangitis? A Right upper quadrant pain B Hepatomegaly C Fever D Jaundice E Altered mental status

Vitamin B12 deficiency Vitamin B12 deficiency can cause megaloblastic anemia and peripheral neuropathy. Patients with a vegan diet are prone to vitamin B12 deficiency as it can only be obtained through animal sources.

A 58-year-old man comes to the emergency department because of bilateral numbness in his feet for the past 2 months. He has a long history of type 2 diabetes mellitus controlled with metformin. He states that his blood sugars have been well controlled ever since he switched to a vegan diet 3 years ago. Physical examination shows decreased pinprick and vibratory perception bilaterally. Motor function and ankle reflexes were intact. A peripheral blood smear shows megaloblastic and macrocytic anemia. Which of the following is the most likely diagnosis? A Celiac disease B Folic acid deficiency C Diabetic neuropathy D Vitamin B12 deficiency

Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z-thumb deformity Rheumatoid arthritis's early signs include soft tissue swelling, osteopenia, erosions, and joint space narrowing. Later changes include subluxation causing ulnar deviation, z- thumb, boutonniere, and swan neck deformities, and ankylosis.

A 63-year-old woman presents with pain in her hands for three years. She describes the pain as progressive - coming on slowly and worsening over the course of the three years. She says that her aunt and wheelchair-bound grandmother had problems with their hands as well. A hand X-ray is obtained which shows soft tissue swelling and marked juxta-articular osteopenia in her metacarpophalangeal and proximal interphalangeal joints, and minor bony erosions. Which of the following will most likely be present on her plain film ten years from now? A Pencil-in-cup deformity, ankylosis, periostitis, dactylitis B Subchondral sclerosis, subchondral cysts, osteophytes, joint space narrowing C Subperiosteal bone resorption D Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z- thumb deformity

Positive A reaction size of greater than or equal to 5 mm in an HIV positive patient is considered a positive tuberculin skin test reaction.

An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result? A Positive B Negative C Active infection D Falsely negative

Colchicine Calcium pyrophosphate deposition (CPPD), more commonly known as pseudogout, commonly presents as sudden onset, severe pain of a joint, much like gout. However, aspiration of the synovial fluid in pseudogout demonstrates rhomboid-shaped, weakly positively birefringent crystals. The pathogenesis of CPPD is similar to that of gout. Calcium pyrophosphate crystals cause joint synovial cells to secrete proinflammatory cytokines such as IL-1, which recruits neutrophils and macrophages, further promoting the inflammatory process. Colchicine is an inhibitor of microtubule assembly. It is therefore hypothesized that the drug inhibits crystal endocytosis and/or presentation to intracellular inflammasomes, which helps prevent the propagation of the inflammation process. Daily, low-dose colchicine, therefore, will help reduce future episodes of pseudogout attacks.

A 59-year-old woman complaining of severe left hip pain for the past day. She states the hip feels warm and looks enlarged. The patient has had multiple similar episodes in her knees, hips, and wrists over the last few years, for which she took ibuprofen as needed. Past medical history is significant for hypertension and type II diabetes mellitus, which are well managed with lisinopril and metformin, respectively. Vital signs are within normal limits. Physical examination shows an erythematous and swollen left hip joint. It is tender to palpation with decreased active and passive range of motion. Arthrocentesis of the left hip is performed. Gram stain is negative. Polarized light microscopy shows rhomboid-shaped, weakly positively birefringent crystals. Long-term therapy with which of the following medications is most helpful in reducing the recurrence rate of similar episodes? A Aspirin B Allopurinol C Indomethacin D Colchicine

Long-term penicillin Rheumatic heart disease is caused by autoimmune cross-reactivity following a Streptococcal infection. Development of antibody-mediated mitral valve damage is common. Long-term penicillin is suitable for acute treatment and prophylaxis from complications.

A 6-year-old boy comes to the pediatric clinic because of 4 weeks of fatigue and shortness of breath. His medical history is notable for poor follow-up with yearly check-ups, but his mother notes that he has been fairly healthy for the duration of his life, except for a "bad sore throat that needed antibiotics" about 6 months ago. On examination, the boy appears fatigued, but is appropriately oriented and responsive, and is generally non-toxic appearing. He is afebrile. Cardiac examination is notable for a widely split S2, a quiet S1, and point of maximum impulse displaced to the left. Which of the following is the next best step in the management of this patient? A Digoxin B Long-term penicillin C Short-term course of clindamycin D Reassurance & routine care E Intramuscular ceftriaxone

Broad-spectrum antibiotic 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.

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 A brief course of oral theophylline

Chronic lymphocytic leukemia Chronic lymphocytic leukemia presents with a WBC count greater than 20,000/microliter and an absolute lymphocyte count of greater than 5000/microliter.

A 60-year-old presents with fatigue and splenomegaly. CBC reveals the following: WBC- 24,000/microliter, Hgb- 13.5 g/dl, Hct- 40%, MCV- 87 fL, MCHC- 34 g/dl, MCH- 28 pg, and platelets- 380,000/mL. The differential reveals neutrophils- 11%, lymphocytes- 80%, monocytes- 8%, and basophils- 1%. What is the most likely diagnosis? A Acute lymphocytic leukemia B Acute myelogenous leukemia C Chronic lymphocytic leukemia D Chronic myelogenous leukemia

Serum calcium 11.5 mg/dL (normal 8.5 to 10.5 mg/dL) Hypercalcemia (greater than 10.5 mg/dL) is the hallmark of primary hyperparathyroidism.

A 62-year-old female complaining of joint pain, polyuria, polydipsia, and generalized fatigue. The patient reports a history of recurrent kidney stones and depression. Radiographs show osteopenia and subperiosteal resorption on the phalanges. Which of the following laboratory results is most consistent with a diagnosis of primary hyperparathyroidism? A Serum calcium 11.5 mg/dL (normal 8.5 to 10.5 mg/dL) B Ionized calcium 3.2 mg/dL (normal 4.6 to 5.3 mg/dL) C Serum magnesium 1.1 mEq/L (normal 1.3 to 2.1 mEq/L) D Serum phosphate 3.0 mg/dL (normal 2.5 to 4.5 mg/dL)

Oseltamivir (Tamiflu) When at least 2 patients are ill within 72 hours of each other and at least one resident has laboratory-confirmed influenza, the facility should promptly initiate antiviral chemoprophylaxis with oral oseltamivir to all non-ill residents living on the same unit as the resident with laboratory-confirmed influenza (outbreak affected units), regardless of whether they received influenza vaccination during the current season. Consideration may be given for extending antiviral chemoprophylaxis to residents on other unaffected units or wards in the long-term care facility based upon other factors (e.g. unavoidable mixing of residents or healthcare personnel from affected units and unaffected units). Oseltamivir is the recommended antiviral drug for chemoprophylaxis of influenza in long-term care settings. Baloxavir is not approved for chemoprophylaxis of influenza and is not recommended for chemoprophylaxis of influenza in long term care facility residents. Amantadine and rimantadine are NOT recommended for use because of high levels of antiviral resistance to these drugs among circulating influenza A viruses.

A 62-year-old female is admitted to a nursing home during an outbreak of influenza. In review of her records, you note that she did not receive the flu vaccine this year. Which of the following is the most appropriate drug of choice for influenza prophylaxis in this patient? A Amantadine (Gocovri) B Rimantadine (Flumadine) C Baloxavir (Xofluza) D Oseltamivir (Tamiflu)

Recommend influenza and pneumococcal vaccines In addition to smoking cessation, patients with COPD may benefit from vaccination against both influenza and pneumococcal disease.

A 62-year-old male presents with a history of dyspnea on exertion and chronic cough worse with arising in the mornings. He has a 40-year-pack history of cigarette use. On examination there is increased AP diameter and decreased breath sounds with a prolonged expiratory phase. Pulse oximetry reveals an oxygen saturation of 93% on room air. In addition to smoking cessation, which of the following is an appropriate intervention at this time? A Home oxygen therapy B Maintenance oral steroids C Prophylactic antibiotic therapy D Recommend influenza and pneumococcal vaccines

Methotrexate This patient is suffering from megaloblastic anemia secondary to folic acid deficiency. Medications commonly associated with this condition include methotrexate, phenytoin, and trimethoprim. Folic acid deficiency leads to a decreased production of DNA synthesis, resulting in megaloblastic anemia. Folic acid deficiency differs from vitamin B12 deficiency in 2 ways: 1) Neurologic symptoms (demyelination and subacute combined degeneration of the spinal cord) are seen with vitamin B12 deficiency but not with pure folate deficiency; 2) Folic acid deficiency is associated with normal serum methylmalonic acid (MMA) and increased homocysteine, whereas vitamin B12 deficiency leads to increases in both MMA and homocysteine. It is important to always obtain a TSH level to rule out hypothyroidism in the setting of megaloblastic anemia. Additionally, folic acid levels are of particular importance in pregnant patients, who have a higher folic acid requirement; low folic acid during pregnancy can lead to fetal neural tube defects.

A 64-year-old female presents to her primary care physician with complaints of fatigue, a sore mouth, as well as occasional abdominal pain, and diarrhea for the past several months. She denies any loss of balance, trouble walking, numbness, pain, or tingling in her hands or feet. Physical examination is significant for mild hyperpigmentation of the dorsal aspect of the hands as well as a red, swollen tongue. A complete blood count reveals a hematocrit of 31 with a low reticulocyte count; in addition, a peripheral smear of the patient's blood is shown here. Further testing reveals normal serum methylmalonic acid levels and increased homocysteine levels. Which of the following medications likely increased this patient's risk of developing this presenting condition? A Hydralazine B Warfarin C Prednisone D Hydrochlorothiazide E Methotrexate

Esophageal varices Esophageal varices occur as a result of portal hypertension due to chronic liver disease. History of prolonged excessive alcohol ingestion is a risk factor for alcoholic liver cirrhosis which is a chronic liver disease. When they hemorrhage, treatment focuses on hemostasis, replacing lost blood volume, and prevention of complications.

A 64-year-old man with a history of alcoholism, tobacco use, and hypertension presents with hematemesis, fatigue, and anorexia. He reports occasional abdominal pain relieved transiently with meals and one episode of painful vomiting. Recently, his stools have been black. Spider angiomas, but no palmar erythema or hepatosplenomegaly are observed on the exam. Laboratory studies show a hemoglobin of 7.5g/dL, platelet count of 160,000/mm3, and a leukocyte count of 8,000/mm3. ECG shows normal sinus rhythm without axis deviation. What is the most likely cause of his hematemesis? A Mallory-Weiss syndrome B Peptic ulcer disease (PUD) C Esophageal varices D Boerhaave syndrome

Clostridium difficile Clostridium difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C. difficile, and the release of toxins that cause mucosal inflammation. Antibiotic therapy is the key factor that alters the colonic flora.

A 65-year old man who is being managed for lung cancer on the ward makes a complaint of a 2-day history of the passage of nonbloody watery stool up to 4 times per day, anorexia, cramping abdominal pain, and fever. Meanwhile, he had a 10-day course of antibiotics 4 weeks ago on account of a lung infection. Which of the following is the most likely cause of his diarrhea? A Salmonella B Rotavirus C Clostridium difficile D E. coli

Right-sided heart failure This patient has a right ventricular myocardial infarction leading to right-sided heart failure, which explains the increase in the jugular venous pressure. The external jugular vein pulsation should normally be <3 cm vertical height above the sternal angle.

A 65-year-old man comes to the emergency department because of a sudden onset of chest pain and dizziness. He has a history of uncontrolled hypertension, hyperlipidemia, alcohol abuse, and a family history of coronary artery disease. He currently takes enalapril, simvastatin, and low-dose aspirin. His temperature is 35.3°C (95.5°F), the pulse is 110/min, respirations are 30/min, blood pressure is 80/60 mm Hg, and pulse oximetry on room air shows an oxygen saturation of 90%. He looks pale and diaphoretic and when his head is positioned at 45°, the filling level of the external jugular vein is 9 cm vertical height above the sternal angle. His heart sounds are clear and he has no extra cardiac sounds on examination, nor rales on pulmonary examination. There is no change in blood pressure on inspiration. An electrocardiogram reveals ST-elevation in the right precordial leads. This clinical presentation is most consistent with which of the following conditions? A Anterior cardiac wall rupture B Cardiac tamponade C Pulmonary edema D Right-sided heart failure E Diastolic heart failure

Esophageal cancer Esophageal cancer occurs in the elderly population. Presents as dysphagia initially to solids then weeks later to liquid. Prolonged histories of tobacco use, and alcohol ingestion are strong risk factors for esophageal cancer.

A 65-year-old man presents to you with 3 months history of dysphagia initially to solid food, and then 4 weeks later to liquid. There is a history of tobacco use and excessive alcohol ingestion for over 20 years. He says he has lost 22 lbs. in the past 2 months. What is the most likely diagnosis? A Zenker's diverticulum B Achalasia C Esophageal cancer D Diffuse esophageal spasm (DES)

Dilated Cardiomyopathy The correct answer is dilated cardiomyopathy. Left ventricular dilation (as seen in the radiograph) and systolic dysfunction (shortness of breath, murmur) must be present for diagnosis. Most cases are idiopathic. The two most common causes of secondary dilated cardiomyopathy are ischemia and long-standing hypertension. An S3 gallop signifies the end of rapid ventricular filling in the setting of fluid overload and is often associated with dilated cardiomyopathy.

A 65-year-old patient comes to the office because of increased shortness of breath for 3 months. His symptoms are particularly bad at night. Medical history includes long-standing hypertension and alcoholism. Examination shows a displaced apex beat and normal breath sounds. Cardiac auscultation shows an S3 gallop and a pan-systolic murmur radiating to the axilla. The chest X-ray is shown here. Which of the following is the most likely diagnosis? A Deep venous thrombosis B Dilated cardiomyopathy C Hypertrophic cardiomyopathy D Infective endocarditis E Myocarditis

Measurements of prostate-specific antigen PSA measurement correlates well with volume and stage of disease and is the recommended examination for monitoring disease progression. It is recommended that serial PSA testing be performed no more often than every six months and repeat digital rectal examination (DRE) no more often than every 12 months unless clinically indicated.

A 65-year-old patient with prostate cancer has a nonpalpable, focal lesion, and is reluctant to have surgery at this time. Which of the following would best monitor disease progression? A Periodic rectal exams B Transrectal ultrasonography C Measurements of serum acid phosphatase D Measurements of prostate-specific antigen

Hypocalcemia due to hypothyroidism Hypocalcemia is defined as a decrease in total plasma calcium concentration < 8.8 mg per dL in the presence of normal plasma protein concentration. Causes include hypoparathyroidism, vitamin D deficiency, renal tubular disease, magnesium depletion, acute pancreatitis, hypoproteinemia, septic shock, hyperphosphatemia, and drugs, including phenytoin, phenobarbital, and rifampin. Most patients are asymptomatic. Symptoms, when present, include muscle cramps involving the legs and back, mental status changes, dry skin, depression, and psychosis. Papilledema may occasionally occur, and cataracts may develop after prolonged hypocalcemia. Severe hypocalcemia (< 7 mg per dL) may cause tetany, laryngospasm, or generalized seizures. With hypocalcemia giving rise to latent tetany, the patient may exhibit a positive Chvostek's sign (involuntary twitching of the facial muscles caused by a light tapping of the facial nerve just anterior to the exterior auditory meatus) or a positive Trousseau's sign (carpopedal spasm caused by reduction of the blood supply to the hand with a blood pressure cuff inflated to 20 mm Hg above the systolic BP applied to the forearm after

A 65-year-old woman with a seizure disorder controlled with phenytoin presents to your office complaining of muscle cramps, dry skin, and depression. On physical examination, she is noted to have a twitch in her cheek when the facial nerve is tapped. Which of the following is the most likely cause of her symptoms? A Hyponatremia due to adrenal insufficiency B Hypocalcemia due to hypothyroidism C Hyperkalemia due to kidney failure D Hypervitaminosis D due to hyperparathyroidism

Administer high-dose prednisone This patient is suffering from temporal (giant cell) arteritis. For a patient with suspected temporal arteritis, the first step in management should be immediate administration of high-dose steroids.

A 66-year-old female presents to the emergency department with a chief complaint of a throbbing, right-sided headache for the past 5 days. She states that the pain is worse when eating. Earlier today, she also had a transient 5 second period of blindness of her right eye. The patient describes a multiple-year history of pain and weakness of her bilateral shoulders and hips. Physical examination is significant for extreme tenderness to palpation of the right scalp. Serology reveals an elevated WBC count and an ESR of 111 mm/h. Which of the following is the best next step in the management of this patient? A Administer high-dose prednisone B Consult ophthalmology C Obtain a non-contrast CT of the head D Perform temporal artery biopsy

CT scan Diverticulitis presents with left lower quadrant abdominal pain, systemic symptoms (such as fever), nausea, vomiting, and leukocytosis on lab values. It typically occurs in a patient with a history of diverticulosis. The most accurate test for diverticulitis is a CT scan. Colonoscopy is contraindicated as it could cause rupture. Further management is keeping the patient NPO and administering ciprofloxacin, metronidazole, and IV fluids. Patients who can not tolerate oral antibiotics should be started on IV antibiotics.

A 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, midabdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC. Which of the following is the most accurate test for this patient's condition? A Barium enema B Colonoscopy C CT scan D Sigmoidoscopy

Bronchiectasis This patient has signs and symptoms consistent with bronchiectasis including CXR findings of dilated and thickened bronchi that may appear as tram-tracks or as ring-like markings.

A 69-year-old male with a history of chronic lymphocytic leukemia presents to the clinic complaining of cough, dyspnea, and production of copious amounts of foul smelling sputum. Physical examination reveals crackles at the lung bases. Chest x-ray shows dilated and thickened bronchi that appear as ring-like markings. Which of the following is the most likely diagnosis? A Bronchiectasis B Tuberculosis C Adenocarcinoma D Pulmonary fibrosis

Administration of prednisone Polymyalgia rheumatica affects patients greater than 50 years of age and causes proximal bilateral aching and morning stiffness, along with elevated erythrocyte sedimentation rate. This inflammatory condition can be treated with low-dose glucocorticoids.

A 69-year-old woman comes to the office because of a 3-month history of neck and shoulder pain. She initially noticed symptoms only on the left side but has experienced bilateral pain and stiffness for the past two months. The stiffness is worst in the morning and lasts more than an hour. She reports a 4.5-kg (10-lb) weight loss during the past three months. Physical examination shows swelling of shoulders with limited range of motion. Muscle strength is normal in all extremities. Laboratory studies show an erythrocyte sedimentation rate of 70 mm/h. Which of the following is the most appropriate next step in management? A Administration of prednisone B Muscle biopsy C Measurement of creatine kinase levels D Temporal artery biopsy

Troponin I Troponin I is an enzyme that's useful in evaluating a myocardial infarction (MI). Troponin I levels begin to rise within 2-3 hours post-MI, peak at about 2 days, and continue to stay elevated for about 7 days.

A 71-year-old woman comes to the emergency department because of severe central chest pain for 30 minutes this morning. She says the pain was cramping in nature and radiated down her left arm. She has a history of atrial fibrillation and type 2 diabetes mellitus. Her temperature is 36.8°C (98°F), pulse is 97/min, respirations are 18/min, and blood pressure is 163/91 mm Hg. An ECG is obtained and shows ST elevations in II, III, and aVF. Which of the following biochemical measures would most likely be elevated and remain elevated for a week after this acute event? A Alanine aminotransferase B Aspartate transaminase C Creatinine kinase-MB D Lactate dehydrogenase (LDH) E Troponin I

Pulmonary fibrosis Pulmonary fibrosis presents with ground-glass infiltrates on CXR and is often associated with certain medication use. In this case, amiodarone.

A 74-year-old male with a history of coronary artery disease and atrial fibrillation presents to the clinic for follow-up of his shortness of breath. The patient's medications include amiodarone (Cordarone) and metoprolol (Lopressor). His chest x-ray reveals patchy ground-glass infiltrates. Which of the following is the most likely diagnosis? A COPD B Tuberculosis C Bronchiectasis D Pulmonary fibrosis

overflow incontinence Prolonged uncontrolled glycemic control predisposes patients to develop autonomic dysfunction that can affect multiple organ systems. These include cardiovascular, gastrointestinal, pupillary, and genitourinary systems such as neurogenic bladder than can lead to overflow incontinence. 45% of patients with diabetes and 75-100% of patients with diabetic peripheral neuropathy will develop bladder dysfunction, specifically urinary retention.

A 75-year-old female with a past medical history of obesity, coronary artery disease status post stent placement, hypertension, hyperlipidemia, and insulin-dependent diabetes presents for her regular checkup. She has not been very adherent to her diabetes treatment regimen and frequently forgets to administer her mealtime insulin. Her Hemoglobin A1c three months ago was 14.1%. As a result, she has developed worsening diabetic retinopathy and neuropathy. Based on her clinical presentation, which of the following is the patient most at risk for developing? A Stress incontinence B Overflow incontinence C Uterine prolapse D Hemorrhoids

Hyponatremia All SSRIs and SNRIs, as classes, can cause hyponatremia. The mechanism of action is believed to be syndrome of inappropriate antidiuretic hormone (SIADH). The hyponatremia can be profound with an incidence of 9% of all SSRIs prescribed with a higher incidence of hyponatremia in the elderly and those with compromised kidney function.

A 75-year-old male is brought by his son for mental status changes. He was recently started on oxycodone and duloxetine (Cymbalta) for diabetic neuropathy. Past medical history (PMH) includes chronic kidney disease (CKD) with eGFR = 28 mL/min/1.73 m2, peripheral vascular disease, gout, congestive heart failure, and coronary artery disease. He has been unable to eat due to nausea but has been able to take fluids. What metabolic abnormality would you expect to see on his labs? A Hyponatremia B Hypokalemia C Metabolic acidosis D Hypercalcemia

Hypercalcemia Multiple myeloma is a monoclonal plasma cell cancer that arises in the bone marrow. It often leads to numerous lytic bone lesions, as well as anemia, thrombocytopenia, hypercalcemia, and renal insufficiency.

A 75-year-old male journalist comes to the office for a routine check-up. He reports feeling a number of symptoms, but says that none of them "seem worth complaining about." He specifically says he has had a loss of appetite, nausea, constipation, generalized weakness, and fatigue as well as right hip pain. He reports that he has noticed these symptoms for the past 2-3 months, and thinks they may be getting a bit worse. Past medical history and examination are non-contributory. A hip X-ray is obtained demonstrating a lytic lesion on the femur. Which of the following additional laboratory abnormalities might you expect to find in this patient? A Hypercalcemia B Hypernatremia C Hyperkalemia D Hyperchloremia

Loss of neurons in the substantial nigra pars compacta Parkinson's disease results from a depletion of dopamine in neurons located in the substantia nigra pars compacta and results in characteristic movement disorders of pill-rolling tremor, bradykinesia, gait instability, and rigidity. Dementia may develop as the disease progresses. Histologically, Parkinson's disease features Lewy bodies: intraneuronal aggregates of alpha-synuclein.

A 75-year-old man is brought to your office by his wife. She states that he has just been "staring into space" for the past 2 months. He has been unable to move around the house without falling over. Also, his movements appear to be very slow. According to his wife, he has been very depressed, is drooling, has difficulty swallowing, and is losing weight. On examination, the patient has a slow, shuffling gait and walks in a stooped-over position. His blood pressure (lying) is 140/90 mm Hg. His standing blood pressure is 100/70 mm Hg. He has marked rigidity of his upper extremities. He also has a tremor that appears to be present only at rest. Which of the following is a pathological hallmark of this patient's disease? A Visual hallucinations B Beta-amyloid plaques C Loss of neurons in the caudate nucleus and putamen D Loss of neurons in the substantia nigra pars compacta

Hallucinations Features of delirium include a fluctuating level of consciousness, the presence of hallucinations, disorientation, and abnormal vital signs. Delirium involves a waxing and waning course and is caused by reversible entities such as infections, medications, postoperative periods, alcoholism, electrolyte imbalances, and other medical conditions. In dementia, the level of consciousness is usually preserved. There are usually no hallucinations or abnormal vital signs. The course is usually insidious and progressive, and symptoms are typically reversible. This patient is exhibiting signs and symptoms of delirium, and therefore, hallucinations are the most likely to be present because all the other choices are features of dementia.

A 77-year-old female for the past 4 days, has been crying easily, confused, and rambling incoherently. Her medical history is remarkable for mild dementia and well-controlled hypertension. She has never had anything like this in the past and she has not had any recent changes to her medications. When questioned, she has no difficulty articulating a sentence but difficulty remembering what she was asked. Laboratory testing is significant for leukocytosis. Which of the following is most likely to be seen? A Normal vital signs B Irreversibility C Hallucinations D Insidious course

Infuse D5W The next best step in the management of this patient is to infuse 5% dextrose solution as it is the fluid of choice in treating hypernatremia that has been symptomatic for >48hr. It is important to ensure a gradual decline in serum sodium. Ideally, aim for a rate less than 10 mEq/L /day (about .4mEq/L/h). Decreasing serum sodium too quickly increases the risk of cerebral edema.

A 79-year-old woman is brought to the ER lethargic, confused, and febrile. She has had a progressive mental status decline in the last 5 days and was sent in by the nursing facility for evaluation. Examination shows a BP of 132/75. Neurological examination revealed disorientation and confusion, with no focal cranial nerve deficits. She demonstrates normal strength in upper and lower extremities bilaterally. Her current medications include Losartan for hypertension and pregabalin for post-herpetic neuralgia. Her basic metabolic panel shows significant hypernatremia, mild hyperchloremia, all other values within normal ranges. Which of the following is the next best step in the management of this patient? A Observe and reassess in 3 hours B Infuse .45NS C Infuse D5W D CT Head

metabolic acidosis

A patient with the following ABG has what type of acid-base disorder? ph 7.30, PCO2 40, Bicarb 16 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal) A Respiratory acidosis B Respiratory alkalosis C Metabolic acidosis D Metabolic alkalosis

Respiratory acidosis

A patient with the following ABG has what type of acid-base disorder? ph 7.30, PCO2 60, Bicarb 22 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal) A Respiratory acidosis B Respiratory alkalosis C Metabolic acidosis D Metabolic alkalosis

Respiratory alkalosis

A patient with the following ABG has what type of acid-base disorder? ph 7.52, PCO2 25, Bicarb 22 PH (7.35-7.45 normal) CO2 (35-45 normal) HCO3 (20-26 normal) A Respiratory acidosis B Respiratory alkalosis C Metabolic acidosis D Metabolic alkalosis

Heterophile test The heterophile test (AKA Monospot) is used for the diagnosis of infectious mononucleosis in children and adults.

An 18-year-old female presents to the office with fever, fatigue, and sore throat. Physical examination reveals an erythematous pharynx, cervical lymphadenopathy, and splenomegaly. CBC reveals an increased white blood cell count with atypical lymphocytes, normal hemoglobin, and hematocrit, and normal platelet count. What additional laboratory test will help you make the diagnosis in this patient? A Heterophile test B Lymph node biopsy C Serum antibody screening D Serum transaminase

Give tissue plasminogen activator (tPA) IV tissue plasminogen activator ( tPA ) is given in patients presenting within 4.5 hours of the symptoms of an acute stroke without contraindications. Is necessary to be aware of the risk of symptomatic intracranial hemorrhage.

An 83-year-old man is brought to the ED because he suddenly started "acting odd during dinner." His daughter says that 45 minutes ago he was "completely normal." Medical history is noncontributory. His temperature is 37.8°C (100°F), pulse is 85/min, respirations are 12/min, and blood pressure is 162/90 mm Hg. Oxygen saturation is 98% on room air. Physical examination shows a right facial droop and right arm weakness, as well as expressive aphasia. Laboratory studies show an INR of 1.0 IU and undetectable troponin levels. An electrocardiogram is interpreted as within normal limits. A non-contrast head CT scan is obtained and is read as normal. Which of the following is the most appropriate next step in management? A Start IV labetalol to lower blood pressure to < 140/90 mm Hg B Initiate mannitol to decrease ICP C Administer 325 mg of Aspirin, then give IV Tissue plasminogen activator D Give tissue plasminogen activator ( tPA )

IV fluids IV fluids are the first treatment for diabetic ketoacidosis, as these patients typically present with a 5-10% volume deficit. Intravenous fluid can also help to correct the acidemia and hyperglycemia before insulin therapy is initiated

Susie is a 17 year with no past medical history, how presents to your clinic complaining of "feeling horrible." She has a 13-pound weight loss in the last 1.5 months and has increased thirst and urination. She has felt tired and nauseous. On examination her weight is below the 5th percentile, she looks thin, and her skin is pale. her blood pressure is 100/70 and her pulse is 104 bpm. Her respirations are deep at a rate of 28 breaths/minute and her breath smells fruity. Laboratory studies show elevated blood glucose (460mg/dL) with significant metabolic acidemia (pH 7.15). Urinalysis is positive for ketones. Which of the following is the next best step in the management of this patient? A IV fluids B IV insulin C IV sodium bicarbonate D Ondansetron (Zofran)