#25 Rosh Review

Question: What is the 5-year survival rate for oral cancer?

Answer: 50-55%. Rapid Review Oral Hairy Leukoplakia EBV Lateral aspect of tongue Lesions do not scrape off (unlike thrush) HIV

Question: Approximately what is the prevalence of substance use disorders in the general population of the United States?

Answer: 8% of general adult populaiton. Rapid Review Substance Abuse Use → impairment or distress Not dependent

Question: How much toothpaste should a child younger than 2 years old use?

Answer: A smear or rice grain size.

Question: What is the antibody associated with Crohn's disease?

Answer: ASCA is present in 60-70% of patients with Crohn's disease.

Question: What is the mechanism of action of adenosine?

Answer: AV nodal conduction blockade. Rapid Review Supraventricular Tachycardia All tachydysrhythmias that arise above the bifurcation of the bundle of His Characteristics: Atrial rate 120-200 Rhythm: regular Narrow QRS Causes Pre-excitation syndromes (WPW) Mitral disease Digitalis toxicity Drugs and toxins Hyperthyroidism Treatment: Vagal maneuvers (Valsalva) Adenosine (first-line medication), ßBs, CCBs Unstable: synchronized cardioversion

Question: What medication (and dose) can be used to temporarily preserve patency of the ductus arteriosus?

Answer: Alprostadil (prostaglandin E1), 0.05-0.1 mcg/kg/min intravenously. Rapid Review Ductal Dependent Lesions Transposition of the great vessels (most common cause in newborns) Tetralogy of Fallot (most common in children >1 year old) Tricuspid atresia Interrupted aortic arch Coarctation of the aorta Hypoplastic left heart syndrome Shock, "gray baby" within hours to days after birth PGE1

Question: What is the first-line antibiotic for the treatment of bacterial rhinosinusitis?

Answer: Amoxicillin-clavulanate. Rapid Review Sinusitis Patient will be complaining of pain over sinuses PE will show purulent rhinorrhea Most commonly caused by viral URI Treatment is supportive care Comments: bacterial sinusitis - persistent symptoms for more than 10-14 days - amoxicillin-clavulanate

Question: What is an afferent pupillary defect?

Answer: An APD is present when the patient's pupil appears to dilate when the swinging light is moved from the unaffected to the affected eye. Common causes include central retinal artery or vein occlusion, optic neuritis, and retrobulbar neuritis. Rapid Review Optic Neuritis Idiopathic > MS Unilateral vision loss Pain with EOM Afferent pupillary defect Negative exam or optic disk swelling MRI to r/o MS Steroids

Question: What is Sampter's triad?

Answer: Asthma, nasal polyps and allergy to aspirin.

Question: When are teratogenic risks the greatest to the fetus?

Answer: At 4-12 weeks. Rapid Review FDA Pregnancy Categories A: No risk in controlled human studies B. No risk in controlled animal studies C: Small risk in controlled animal studies D. Strong evidence of risk to fetus X: Very high risk to fetus

Question: How long should a scaphoid fracture be immobilized?

Answer: At least 6 - 12 weeks. Rapid Review Scaphoid Fracture FOOSH Snuff box tenderness Possibly negative radiographs Complication: avascular necrosis Thumb spica splint

Question: Which congenital heart diseases cause right ventricular hypertrophy?

Answer: Atrial septal defect, Eisenmenger's syndrome and pulmonic stenosis. Rapid Review Coarctation of the Aorta PE will show higher blood pressure in the arms than in the legs EKG will show LVH CXR will show notching of ribs Diagnosis is made by echo Treatment is balloon angioplasty with stent placement, or surgical correction Comments: Associated with Turner's syndrome

Question: What antidote should be present during edrophonium administration?

Answer: Atropine can be used to counteract the cholinergic effects of edrophonium. Rapid Review Myasthenia Gravis Patient will be complaining of proximal muscle weakness, ptosis, and diplopia that is worse at the end of the day PE will show ice test improves sx Diagnosis is made by edrophonium (tensilon) test, EMG Most commonly caused by autoimmune destruction of acetylcholine receptors Treatment is acetylcholinesterase inhibitors, such as pyridostigmine Comments: associated with thymoma

Question: What two other disorders are associated with Tourette's syndrome?

Answer: Attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). Rapid Review Tourrette Syndrome Stereotyped motor + vocal tics for > 1 year Coprolalia Associated with OCD, ADHD Rx: antipsychotics, behavioral therapy

Question: What is the treatment for primary syphilis?

Answer: Benzathine penicillin G 2.4 million units IM, single dose, is nearly universally curative. Doxycycline for 2 weeks is an alternative for penicillin-allergic patients. Rapid Review Syphilis Primary: painless chancre Secondary: lymphadenopathy, comdyloma lata, rash on palms/soles Tertiary: gummas VDRL and RPR positive 4-6 weeks after infection Primary/secondary: IM benzathine penicillin G x 1 dose Tertirary: IM benzathine penicillin G x 3 weeks

Question: What is the prevalence of idiopathic pulmonary fibrosis in the U.S.A?

Answer: Between 14 and 43 per 100,000 persons in the US. Rapid Review Idiopathic Pulmonary Fibrosis Smoking males Unknown agent → repeated alveolitis → fibrosis Chronic cough, dyspnea Honeycombing Rx: O2, pulmonary rehabilitation

Question: What mineral typically needs to be supplemented in individuals who avoid lactose containing products?

Answer: Calcium supplementation is recommended to prevent osteoporosis. Rapid Review Lactose Intolerance Genetic condition or 2° to underlying conditions Dx: usually clinical, lactose tolerance test, lactose breath hydrogen test Rx: lactose restriction, calcium, vitamin D

Question: What is the formula for cardiac output?

Answer: Cardiac output (Q) = stroke volume (SV) x heart rate (HR). Rapid Review Cor Pulmonale Pulmonary HTN + RVH → right heart failure Most common chronic cause: COPD Most common acute cause: PE Right heart catheterization

Question: What is the most common cause of bowel obstruction in pregnancy?

Answer: Cecal volvulus. Rapid Review Sigmoid Volvulus Elderly bedridden patient or patient with psychiatric/neurological history History of constipation Sigmoidoscopy

Question: What is the most common presenting symptom in patients with acute ischemic heart disease?

Answer: Central-chest discomfort. Rapid Review Ischemic Heart Disease #1 cause of death in USA RFs: family hx, smoking, HTN, DM, cholesterol, male, age >55 Stable angina: activity → chest pain (CP), relieved by rest, NTG Unstable angina: CP at rest CP, dyspnea, diaphoresis, nausea, hiccups, radiation to shoulder/jaw/back Elderly, diabetics, females, hx of stroke or HF: ↑ risk for atypical presentation Earliest ECG sign of MI: hyperacute T waves Up to 50% of ECGs are negative or nonspecific Highest S/S: troponin I

Question: At what age do most bicycle deaths occur?

Answer: Children younger than 15 years.

Question: What X-ray finding is seen in patients with sigmoid volvulus?

Answer: Coffee bean sign.

Question: What chronic conditions predispose infants to chronic candidal diaper dermatitis?

Answer: Diabetes mellitus type 1, chronic mucocutaneous candidiasis, or immunodeficiency.

Question: What is the most common complication of measles?

Answer: Diarrhea. Rapid Review Rubeola (Measles) Fever 3 c's: cough, conjunctivitis, coryza Koplik's spots: red spots with blue/white center (pathognomonic) Rash spreads head to feet

Question: When does acute fatty liver of pregnancy typically occur?

Answer: During the third trimester. Rapid Review Appendicitis Patient will be complaining of fever, pain that began periumbilical then moved to RLQ, nausea and anorexia PE will show Psoas sign (RLQ pain on extension of right hip), Obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (right lower quadrant pain when the left lower quadrant is palpated) Diagnosis is made by ultrasound, CT Most commonly caused by fecalith Treatment is surgery

Question: Which extraintestinal symptoms may be seen in patients with irritable bowel syndrome?

Answer: Dyspareunia, dysmenorrhea, increased urinary frequency, and fibromyalgia symptoms. Rapid Review Irritable Bowel Syndrome Patient will be a woman With a history of constipation alternating with diarrhea Complaining of abdominal discomfort which is relieved with bowel movements Diagnosis is made by Rome criteria Treatment is symptomatic - dietary management and drugs

Question: What is the treatment for cholesteatomas?

Answer: Excision therapy. Rapid Review Acquired Cholesteatoma Patient will have a history of chronic ear infections or tympanostomy tubes Complaining of painless otorrhea PE will show yellow or white mass behind the tympanic membrane Treatment is tympanomastoid surgery

Question: What are the four types of clinical tetanus?

Answer: Generalized, localized, cephalic and neonatal. Rapid Review Tetanus Clostridium tetani Toxin mediated Trismus (lockjaw) Generalized tetanus is most common Strychnine can mimic Benzodiazepines, metronidazole (not penicillin), TIG, immunization

Question: What are the treatment options for non-pathologic bilateral tinnitus?

Answer: Hearing aids, amplification of normal sounds or "white noise" to mask symptoms, avoidance of excess noise and stress reduction. Rapid Review Acoustic Neuroma CN VIII tumor Hearing loss + tinnitus + vertigo MRI

Question: What is the most common manifestation of renal disease in patients diagnosed with Henoch-Schönlein Purpura?

Answer: Hematuria. Rapid Review Henoch-Schonlein Purpura (HSP) Patient will be 4-12 years old With a history of recent URI Complaining of abdominal pain, arthralgia, and a rash that began on buttocks and lower extremities PE will show maculopapular rash (palpable purpura) that is non-pruritic Most commonly caused by IgA mediated vasculitis Treatment is supportive care Comments: Complications include nephropathy, intussusception

Question: What is the name of the anatomic structure through which a direct inguinal hernia usually protrudes?

Answer: Hesselbach's triangle (bordered by the abdominus rectus muscle, inguinal ligament and inferior epigastric vessels). Rapid Review Inguinal Hernias Bimodal: < 1 and > 40 Direct: Protrudes directly through Hesselbach's triangle and medial to the inferior epigastric artery (IEA) Bulge ↓ upon reclining Indirect: Most common Protrudes through internal ring, lateral to IEA ​Medial to IEA: Direct; Lateral to IEA: Indirect (MDs dont LIe) Strangulation risk: indirect > direct Nonreducible hernia: emergent surgery consultation

Question: What is the most common cause of heart failure in the United States?

Answer: Ischemic heart disease Rapid Review Heart Failure Most common cause: ischemic heart disease Systolic dysfunction: ↓ EF Cardiac output (CO) dependent on afterload Diastolic dysfunction: Impaired myocardial relaxation → abnormal LV filling CO dependent on preload Left heart failure: ↑ LVEDV + ↑ LVEDP → blood backup into lungs → pulmonary edema Dyspnea, orthopnea, paroxysmal nocturnal dyspnea Crackles Right heart failure Most common cause: left heart failure JVD, peripheral edema, ascites S3 BNP: distinguishes between CHF and dyspnea of pulmonary etiology Most useful study: echocardiogram

Question: What is a Marcus Gunn pupil?

Answer: It is a relative afferent pupillary defect that results in bilateral pupil constriction when shining a light in the unaffected eye but an absent pupil response (or a paradoxial dilation) when a light source is directed toward the affected eye. Rapid Review Multiple Sclerosis Demyelinating disorder Caucasian females Optic neuritis (afferent pupillary defect, pain with eye movement, monocular vision loss, pale optic disc) Internuclear ophthalmoplegia Lhermitte's phenomenon: spinal electric shock sensation with neck flexion CSF: ↑ IgG protein, WBC pleocytosis Rx: methylprednisolone

Question: What criteria may be used to diagnosis irritable bowel syndrome?

Answer: Kruis Score, Manning Criteria or Rome Criteria. Rapid Review Irritable Bowel Syndrome Patient will be a woman With a history of constipation alternating with diarrhea Complaining of abdominal discomfort which is relieved with bowel movements Diagnosis is made by Rome criteria Treatment is symptomatic - dietary management and drugs

Question: What are other causes of macrocytic anemia not related to megaloblastic changes?

Answer: Liver disease (most common) and hypothyroidism. Rapid Review Vitamin B12 (Cobalamin) Deficiency Patient will be a vegan Complaining of fatigue, weakness and peripheral neuropathy PE will show pallor and glossitis Labs will show MCV > 100, hypersegmented neutrophils, elevated homocysteine, elevated methylmalonic acid Treatment is parenteral vitamin B12 Comments: only vitamin B12 deficiency results in neurological symptoms

Question: Which gender has a higher prevalence of conduct disorder?

Answer: Male. Rapid Review Conduct Disorder Pediatric version of antisocial personality disorder Violating human rights of others

Question: What is the treatment for gout in the acute phase?

Answer: Most commonly indomethacin, but any NSAID can be used. Rapid Review Pseudogout M=F, >50 years old Slower onset than gout Positively birefringent, rhomboid-shaped, calcium pyrophosphate crystals Knee Rx: NSAIDs

Question: Do all pericardial effusions cause tamponade?

Answer: No. Chronic effusions are less likely to cause tamponade than acute effusions. Rapid Review Pericardial Tamponade Patient will be complaining of dyspnea and chest pain PE will show muffled heart sounds, JVD, hypotension (Beck's triad), pulsus paradoxus ECG will show low voltage QRS, electrical alterans Echocardiography will show diastolic collapse of RV Treatment is pericardiocentesis

Question: A large, completely obstructing nasal polyp may cause a patient to present with symptoms of which condition?

Answer: Obstructive sleep apnea. Rapid Review Samter's Triad Asthma Aspirin sensitivity Nasal polyps

Question: What is Cullen's sign?

Answer: Periumbilical ecchymosis caused by subcutaneous intra/retro-peritoneal hemorrhage, rarely seen in acute hemorrhagic pancreatitis. Rapid Review Acute Pancreatitis Patient will be complaining of epigastric pain radiating to the back, nausea, and vomiting PE will show ecchymosis of left flank (GreyTurner sign), umbilical ecchymosis (Cullen sign) Labs will show elevated lipase (best) and amalyse Diagnosis is made by US and Ranson's criteria Most commonly caused by gallstones > alcohol Treatment is IV fluids

Question: What vascular emergency of the leg results from a large DVT?

Answer: Phlegmasia cerulea dolens. Rapid Review Deep Vein Thrombosis (DVT) Patient with a history of smoking, long distance travel, surgery, oral contraceptives use Complaining of unilateral leg edema, leg pain, tenderness and warmth PE will show positive Homan's sign Diagnosis is made by first ultrasound, Gold Standard: venography Most commonly caused by stasis, hypercoagulable state, trauma (Virchow's triad) Treatment is IV heparin and switch to warfarin Comments: Risk stratification by Well's criteria

Question: What is the diagnostic criteria for pre-eclampsia?

Answer: Preeclampsia refers to the syndrome of new onset of hypertension and either proteinuria or end-organ dysfunction during pregnancy.

Question: What hormone produced during pregnancy is responsible for the higher incidence of urinary tract infections?

Answer: Progesterone, which causes relaxation of the ureters.

Question: What is the name of the sign that refers to the lateral thinning of the eyebrows as seen in hypothyroidism?

Answer: Queen Anne's sign. Rapid Review Hypothyroidism 1° > 2° 1° previous radioactive iodine/thyroidectomy > autoimmune 2° most common cause: pituitary tumor Fatigue, weight gain, cold intolerance TSH: ↑ with 1°, ↓ with 2°

Question: What is the INR range in a patient taking warfarin for atrial fibrillation?

Answer: The INR range is 2-3. Rapid Review Atrial Fibrillation Alcohol Irregularly irregular No P waves Narrow QRS unless conduction block or accessory pathway Unstable: cardioversion Stable: Rate control with CCBs, ßBs <48 hours duration: cardiovert to sinus rhthym >48 hours duration: anticoagulate, echo to r/o thrombus, then cardioversion

Question: Examination of which structure is important in any suspected ankle fracture or injury?

Answer: The fibular head. External rotation forces at the ankle can cause a Maisonneuve fracture, a compilation of fibular head fracture, tear of the ankle's medial collateral ligament and disruption of the tibiofibular syndesmosis. Rapid Review Ankle Fractures Single malleolar: either distal fibula or tibia Bimalleolar: distal fibula + tibia Trimalleolar: bimalleolar fracture + posterior tibial involvement Rx: possible ORIF if unstable

Question: What is the significance of an elevated creatinine kinase- MB and normal troponin value?

Answer: The injury is likely due to release from non-cardiac tissue.

Question: Which pericarditis cases are most prone to develop tamponade?

Answer: Those which are idiopathic or due to malignancy or uremia. Rapid Review Pericardial Tamponade Patient will be complaining of dyspnea and chest pain PE will show muffled heart sounds, JVD, hypotension (Beck's triad), pulsus paradoxus ECG will show low voltage QRS, electrical alterans Echocardiography will show diastolic collapse of RV Treatment is pericardiocentesis

Question: The risk of death in unstable angina is four-fold increased if which three biomarkers are elevated?

Answer: Troponin I or T, high-sensitivity C-reactive protein and B-type natriuretic peptide. Rapid Review Ischemic Heart Disease #1 cause of death in USA RFs: family hx, smoking, HTN, DM, cholesterol, male, age >55 Stable angina: activity → chest pain (CP), relieved by rest, NTG Unstable angina: CP at rest CP, dyspnea, diaphoresis, nausea, hiccups, radiation to shoulder/jaw/back Elderly, diabetics, females, hx of stroke or HF: ↑ risk for atypical presentation Earliest ECG sign of MI: hyperacute T waves Up to 50% of ECGs are negative or nonspecific Highest S/S: troponin I

Question: Though primary adrenal insufficiency is usually due an autoimmune process in the United States, it is occasionally due to which infectious process world-wide?

Answer: Tuberculosis may result in development of primary adrenal insufficiency. Rapid Review Primary Adrenal Insufficiency (Addison's Disease) Patient will be complaining of abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE will show hyperpigmentation of skin and mucus membranes and hypotension Labs will show hyponatremia and hyperkalemia Most commonly caused by autoimmune Treatment is hydrocortisone

Social or medical problems that result from substance use are defined by which of the following terms? Abuse Dependence Intoxication Tolerance

Correct Answer ( A ) Explanation: According to the DSM-IV-TR guidelines, substance abuse is defined by any of the following behaviors: Dependence (B) can be physical or psychological. Physical dependence is the presence of tolerance or emergence of withdrawal symptoms. Psychological dependence is the craving experienced or drug-seeking behavior. Intoxication (C) is a reversible substance-specific syndrome, with maladaptive behavioral or psychological changes due to the effect of the substance on the central nervous system. Tolerance (D) occurs with repeated exposure and manifests as the requirement of a larger dose to produce intoxication. NOTE The psychiatric diagnoses, substance abuse and substance dependence, in DSM-IV-TR were replaced by one diagnosis, substance use disorder, in DSM-5. Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, substance dependence is approximately comparable to substance use disorder, moderate to severe subtype, while substance abuse is similar to the mild subtype. DSM-5 criteria for SUD are consistent across substances.

Which of the following is the most common surgical emergency in pregnant women? Appendicitis Cholecystitis Small bowel obstruction Uterine rupture

Correct Answer ( A ) Explanation: Acute appendicitis is the most common surgical emergency in pregnant women. The rate of acute appendicitis in pregnant patients is the same as seen in nonpregnant patients. Unfortunately, delays in diagnosis lead to an increased rate of perforation, increased morbidity and mortality. Physiologic changes during pregnancy make diagnosis difficult. As the uterus grows, the abdominal organs are more distant from the abdominal wall making it difficult to detect tenderness and peritoneal signs. Additionally, the location of the appendix later in pregnancy is variable as it can rest anywhere between the right lower quadrant to deep within the right upper quadrant. Ultrasound, CT scan and MRI are all viable diagnostic tests depending on availability. However, on occasion, patients will require exploratory laparoscopy. Cholecystitis (B) occurs at similar rates in pregnant as in nonpregnant patients. Small bowel obstruction (C) is relatively uncommon in pregnancy. Uterine rupture (D) is an uncommon but life threatening complication typically seen during labor.

A 74-year-old man is having a preoperative ECG performed. What is your interpretation of his ECG? Atrial fibrillation Atrial flutter Normal sinus rhythm Sinus tachycardia

Correct Answer ( A ) Explanation: Atrial fibrillation is an irregularly irregular rhythm due to uncoordinated atrial activation and random occurrence of ventricular depolarization. The atria are not contracting, but they do discharge electrical impulses to the ventricles. However, no single impulse depolarizes the atria completely, so only an occasional impulse gets through the AV node. It is the most common sustained dysrhythmia in clinical practice. Atrial flutter (B) is a rapid atrial rhythm, but due to nodal delay, ventricular response rate is slower. Therefore, atrial flutter always occurs with some sort of AV block so that not all impulses are conducted. The resulting block is often variable (2:1, 3:1, 4:1). P waves have a characteristic sawtooth pattern. In normal sinus rhythm (C) and sinus tachycardia (D), the SA node is the pacemaker that causes the atria to depolarize regularly and, thus, the ventricles to depolarize regularly. Therefore, the ECGs for both of these rhythms have P waves and QRS complexes that occur regularly. The difference between these two rhythms is with the rate. The rate of sinus rhythm is 60-99. The rate of sinus tachycardia is >100.

Which of the following is the most common cause of acute pancreatitis? Biliary tract pathology Endoscopic retrograde cholangiopancreatography (ERCP) Ethanol ingestion Medication side effect

Correct Answer ( A ) Explanation: Biliary tract pathology (gallstones) is the leading cause of acute pancreatitis, accounting for approximately 45% of cases. The incidence may be as high as 66% in some regions. Stones from the bile duct, pancreatic duct, or common bile duct can obstruct the pancreatic duct, resulting in bile reflux, increased pancreatic secretions, and pancreatic enzymes activation. Patients classically present following ingestion of a fatty meal or after binge drinking and complain of epigastric pain, nausea, and vomiting. The epigastric pain is constant in nature with radiation directly into the back and is often eased when the patient leans forward. Because of the retroperitoneal location of the pancreas, however, rebound is generally absent. Ethanol abuse (C) is the second most common cause (35%) and is seen in acute and chronic consumption of ethanol. Chronic alcoholics go on to develop chronic pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) (B) is associated with up to a 5% risk of acute pancreatitis within 30 days of the procedure. Some common medications (D) associated with pancreatitis include corticosteroids, HIV medications, valproic acid, and others. However, the incidence is much less than seen with biliary disease.

Which of the following is a marker of high ventricular filling pressures? Brain natriuretic peptide Creatine kinase-MB Creatinine Troponin

Correct Answer ( A ) Explanation: Brain natriuretic peptide is a marker of high ventricular filling pressures. It is a natriuretic hormone that was initially identified in the brain but is also released from the heart, particularly the ventricles. It is released in response to volume expansion and increased wall stress in the ventricles. Increased plasma concentrations are found in heart failure in response to increased ventricular filling pressures from volume overload. Troponin (D) and creatine kinase-MB (B) are markers for cardiac muscle damage as in an acute myocardial infarction or ischemia. Troponin is the preferred marker for the diagnosis of myocardial injury for all diagnostic categories because of its increased specificity and better sensitivity compared to creatine kinase-MB. Creatinine (C) is a marker of renal function, not increased ventricular filling pressures.

Which of the following conditions is a result of a rapid increase in pericardial pressure and a clinical picture of acute restrictive cardiomyopathy? Cardiac tamponade Constrictive pericarditis Pericardial effusion Pneumopericardium

Correct Answer ( A ) Explanation: Cardiac tamponade results from acute compression of the myocardium by rapid fluid (or gas) accumulation in the pericardial sac. Tamponade develops when fluid filling the pericardial sac accumulates faster than the rate of stretch in the parietal pericardium. The resulting extrinsic pressure on the myocardium exceeds right atrial pressure leading to a reduction in right ventricular filling. With a continued rise in pericardial pressure, cardiac compliance decreases. Flow of blood into the right side of the heart ceases, leading to a precipitous decline in cardiac output. Key to remember: the rate of fluid accumulation, not the absolute volume, is the important factor in the development of tamponade. Constrictive pericarditis (B) usually results from fibrous reaction of the pericardium and is characterized by impaired diastolic filling from external cardiac compression caused by a thickened pericardium. It is usually due to a late consequence of viral pericarditis, or even tuberculosis, and presents with a more indolent course than tamponade. A characteristic auscultatory finding is a pericardial knock in early diastole. A friction rub may also be heard. Pericardial effusions (C) are often asymptomatic and are due to a variety of diseases such as malignancy, renal failure, uremia, trauma, and radiation therapy. If the pericardial effusion accumulates rapidly, it can result in pericardial tamponade. Pneumopericardium (D) is a rare disorder that results in air around or within the pericardial space. It is classically associated with Hamman's sign, which is a loud crunching sound—best heard with the patient in a left lateral recumbent position—and is pathognomonic for mediastinal air.

Which of the following is an acyanotic congenital cardiac defect? Coarctation of the aorta Ebstein's anomaly Hypoplastic left heart syndrome Pulmonary atresia

Correct Answer ( A ) Explanation: Coarctation of the aorta is an acyanotic congenital heart lesion. Acyanotic congenital heart defects (CHD) should be divided into obstructive lesions and lesions with left-to-right shunts and increased pulmonary blood flow. Acyanotic lesions typically present in the first 6 months of life with congestive heart failure. Obstructive CHD includes pulmonic stenosis, aortic stenosis and coarctation of the aorta. Left-to-right shunt CHD includes VSD, ASD, patent ductus arteriosus and endocardial cushion defects. Coarctation of the aorta accounts for approximately 8% of all CHDs. Ebstein's anomaly (B), hypoplastic left heart syndrome (C) and pulmonary atresia (D) are cyanotic heart lesions.

Which of the following findings on X-ray is suggestive of colorectal cancer? Apple core sign Bird's beak sign Egg-on-a-string sign String sign

Correct Answer ( A ) Explanation: Colorectal cancer is the third most common type of cancer for both men and women in the United States. It is most commonly seen in adults aged 50 years or older. Risk factors for the development of colorectal cancer include family history of colorectal cancer, inflammatory bowel disease, cigarette smoking, obesity and lack of physical activity. Screening is recommended for all adults starting at age 50 years; earlier depending on risk factors. The majority of patients with colorectal cancer are asymptomatic in the early stages of the disease and are often identified through screening. Later in the disease process, patients with colorectal cancer can present with complications such as large bowel obstruction or perforation. Plain abdominal radiography is a helpful first step in evaluation. Findings include the apple core sign, which occurs when circumferential masses severely constrict the bowel lumen. Establishing the diagnosis requires examination of tissue, which is best accomplished through colonoscopy. Treatment depends on the severity of the disease. Bird's beak sign (B) is an X-ray finding seen with achalasia, which is an esophageal motility disorder. Radiographs of neonates with Transposition of the Great Arteries will have the egg-on-a-string sign (C). The heart is globular or egg-shaped and the mediastinum is narrowed, giving the appearance of a string. Narrowing of the bowel lumen caused by Crohn's disease or pyloric stenosis results in the string sign (D) on X-ray.

A 76-year-old man with colorectal cancer presents to the ED with dyspnea and fatigue. He is hypotensive, tachycardic, tachypneic and afebrile. The jugular venous pulse rides high on lateral neck inspection. Cardiac sounds, but not breath sounds, are distant. There is no discernable friction rub or murmur, however, his blood pressure decreases during inspiration. An ECG reveals normal rhythm, increased rate and decreased voltages. Which of the following treatments is most appropriate in this patient's plan of care? Cardioversion Endarterectomy Hemodialysis Pericardiocentesis

Correct Answer ( D ) Explanation: This scenario most likely represents cardiac tamponade. Pericardial tamponade refers to the dampening effect of rapidly accumulating pericardial effusion. An increase in intrapericaridal pressure compresses the heart chambers, decreases venous return and ultimately decreases cardiac output. As this occurs, it becomes ever more difficult for blood to flow from chamber to chamber. Causes include pericarditis, traumatic aortic dissection and myocardial rupture. Patients usually present with severe dyspnea, fatigue and hypotension. Typical exam findings include Beck's triad of hypotension, distant heart sounds and increased jugular venous pressure. Tachycardia and clear-sounding tachypnea are common. Pulsus paradoxus, a decrease in systolic blood pressure more than 10 mm Hg during inspiration, is also commonly present. However, pulsus paradoxus also accompanies constrictive pericarditis, congestive heart failure, pulmonary embolism, and end-stage obstructive pulmonary disease. Distant heart sounds and friction rubs may be present. Chest radiographs show large cardiac silhouettes, and ECGs may reveal a widespread decrease in voltage with an effusion and electrical alternans in tamponade. Classic echocardiographic findings are effusion, interventricular septal shift during inspiration, diastolic collapse of the right atrium and respiration-timed alterations in transvalvular flow. This medical emergency is treated with cardiopulmonary stabilization, pericardiocentesis (percutaneous drainage of pericardial fluid), cautious volume replacement and inotropic medications such as dobutamine. Cardioversion (A) is an electrophysiological treatment used to reverse arrhythmias, such as atrial fibrillation. This patient has a normal rhythm. Endarterectomy (B) is a surgical procedure used to remove atheromatous plaque from within a vessel. It is commonly used in the carotid arteries and aorta of patients with chronic atherosclerosis and distal ischemia, such as stroke symptoms or painful distal vasculopathy. This patient does not present with neurologic or peripheral arterial disease complaints. Hemodialysis (C) is used for patients with end-stage renal failure.

A 39-year-old woman presents with palpitations and lightheadedness. Her rhythm strip is shown above. Which of the following treatments is indicated? Adenosine Defibrillation Procainamide Sedation with etomidate following by electrical cardioversion

Correct Answer ( A ) Explanation: The electrocardiogram reveals a supraventricular tachycardia (SVT). Most cases of SVT result from sustained reentry occurring within the atrioventricular (AV) node, with a minority of cases of SVT resulting from a reentry loop from an ectopic atrial focus. The electrocardiographic hallmarks of SVT are a fast, regular rhythm with a narrow QRS complex. Since the depolarization does not come from the sinoatrial node, P waves do not precede each QRS complex, though P waves may be buried within or seen immediately before or after each QRS complex, known as "retrograde" P waves. Paroxysmal SVT is more common in females than males, with a peak incidence in the late teenage and young adult years. Most patients with SVT do not have underlying heart disease. Common symptoms include palpitations, lightheadedness, and dyspnea. Vagal maneuvers, such as carotid sinus massage and valsalva, are often successful in terminating SVT, especially early in the dysrhythmia course. If vagal maneuvers are ineffective, adenosine is the treatment of choice. The initial dose of adenosine is 6 mg rapid intravenous push, followed by a dose of 12 mg if the first dose is ineffective. Beta-blockers and calcium channel-blockers are alternative agents. Electrical cardioversion is used for refractory SVT or patients who are clinically unstable. Defibrillation (B) is the treatment for pulseless ventricular tachycardia and ventricular fibrillation. Sedation with etomidate following by cardioversion (C) is the treatment for refractory SVT or unstable patients. Procainamide (D) is not a first-line treatment for SVT.

A 32-year-old woman presents with intermittent double vision for 1 week. The patient states that she woke up this morning with no symptoms but now has double vision and this pattern has been going on for the last week. The patient states symptoms get better with rest. Physical examination reveals drooping of the upper eyelids and the left eye is unable to abduct. What is the next best step in management of this patient? Administer edrophonium Intravenous immunoglobulin MRI of the brain Noncontrast CT of the head

Correct Answer ( A ) Explanation: This patient presents with signs and symptoms concerning for myasthenia gravis (MG) and can have edrophonium administered to confirm the diagnosis. MG is an uncommon disease that affects women more commonly than men. The disease results from the presence of autoantibodies directed against nicotinic acetylcholine receptors (AChR) at the neuromuscular junction. This leads to destruction of AChRs resulting in muscle weakness. Muscle weakness that gets worse with use is the hallmark of MG. Patients will complain of weakness in muscle groups with repeated use. Ocular symptoms often manifest early and include ptosis, diplopia and blurred vision. These symptoms are typically worse at the end of the day. Respiratory failure presents later in the disease and may lead patients with a diagnosis of MG to present to the ED. The quality of respiration and ventilation can be quantified using a negative inspiratory flow (NIF) measurement. Patients with symptoms concerning for MG can be diagnosed using the edrophonium test. Edrophonium is a short acting acetylcholinesterase (ACh)-blocking agent which leads to increased ACh in the presynaptic cleft. Administration in patients with MG should lead to decreased symptoms. Use of edrophonium can result in potentially significant complications, such as symptomatic bradycardia and bronchospasm. It should be used with caution, if at all, in older patients, those with asthma/COPD and those with underlying cardiac disease. IV immunoglobulin (IVIG) (B) is used in the treatment of Guillan-Barre disease and multiple sclerosis. MRI of the brain (C) and noncontrast CT of the head (D) will not show abnormalities in MG as it is a disease of nerve endings.

A young boy suffers from involuntary tics. During a detailed speech evaluation, you detect the intermittent use of varying obscenities. Which of the following speech disorders, which is associated with Tourette's syndrome, describes this finding? Coprolalia Echolalia Glossolalia Palilalia

Correct Answer ( A ) Explanation: Tics are repetitive, sterotyped movements or vocalizations. The most common forms are blinking, sniffing, grimacing, throat-clearing and throwing the head sideways or backward. Tourette's syndrome is a combination of multiple tics, including involuntary vocalizations and coprolalia, the involuntary, compulsive use of obscenities. One-third of cases are familial, and the underlying pathology is felt to lie within the caudate nucleus. There are no strong associations with psychiatric illness except for a small tie to obsessive-compulsive personality disorder. Treatment includes benzodiazepines or clonidine. Microdosing of haloperidol may be useful in severe cases. Echolalia (B) is involuntary repetition of words or phrases spoken by others. Glossolalia (C) is speaking elaborate but meaningless speech, or speaking an unknown language. Palilalia (D) is involuntary repetition or echoing of one's own words.

Which of the following will help to classify heart failure as being systolic or diastolic? Afterload Ejection fraction Heart rate Preload

Correct Answer ( B ) Explanation: Ejection fraction is the percentage of blood that is ejected from the ventricle during systole. A normal ejection fraction is 55% or greater. Systolic dysfunction typically results from ischemic heart disease and myocardial cell death. It results in impaired contractility with an ejection fraction < 40%. Cardiac output is dependent on resistance (afterload) to emptying the ventricle. Diastolic dysfunction typically results from chronic hypertension and left ventricular hypertrophy. It results in impaired relaxation and ventricular filling with a normal ejection fraction. Output is dependent on ventricular filling (preload). Afterload (A) is the force needed to overcome both the volume of blood in the ventricle and the peripheral vascular resistance during ventricular contraction. The afterload is not specific for different types of heart failure. Heart rate (C) can also be variable in different types of heart failure. Preload (D) is the force or volume stretching the myocytes before contraction. It also can be thought of as the volume in the ventricle at the end of diastole just before the ventricle contracts. Output is dependent on preload in diastolic dysfunction, but it poorly differentiates diastolic from systolic heart failure.

Which of the following sources of fluoride has the highest risk of causing dental fluorosis? Community water fluoridation with 0.7 ppm fluoride Fluoride drops and tablets Fluoride gel and varnish Tooth brushing with 1000 ppm fluoride toothpaste

Correct Answer ( B ) Explanation: Fluoride is highly beneficial in primary and secondary prevention of dental decay. It is incorporated into tooth enamel and also helps incorporate calcium and phosphate into enamel. While insufficient fluoride intake can increase the risk of dental caries, too much fluoride can result in fluorosis. Fluorosis can result from systemic fluoride consumption >0.05 mg/kg/day during enamel formation. This high fluoride consumption can be caused by residing in an area of high fluoride content in the drinking water (>2.0 ppm), swallowing excessive fluoridated toothpaste, or inappropriate fluoride prescriptions. Excessive fluoride during enamel formation affects ameloblastic function, resulting in inconspicuous white, lacy patches on the enamel to severe brownish discoloration and hypoplasia. Therefore, topical fluoride through low levels in water and toothpaste is favored to systemic fluoride through drops and tablets. Community water fluoridation is considered a highly successful public health achievement. The US Department of Health and Human Services recently updated their optimal fluoride concentration recommendation from 1 ppm to 0.7 ppm (A) to account for the fluoride exposure from other sources. Fluorosis can occur at levels >2.0 ppm. Fluoride gel and varnish (C) are very effective in preventing caries as they leave a fluoride-calcium compound on tooth enamel that releases fluoride when the pH decreases from plaque. Varnish is preferred over gel as it adheres better to the teeth and requires little training to be applied. Starting in the first year of life, fluoride varnish should be applied to the teeth of children twice yearly. Toothbrushing with fluoridated (1000 ppm) toothpaste (D) twice a day is recommended for proper hygiene. Fluoride remains in the saliva after brushing at low concentrations for two to six hours. Fluoride levels less than 1000 ppm in toothpaste do not consistently prevent caries.

Which U.S. Food and Drug Administration (FDA) category is defined by the following: Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. Category A Category B Category C Category D

Correct Answer ( B ) Explanation: In 1979, the United States Food and Drug Administration (FDA) introduced a classification of fetal risks due to pharmaceuticals. The pregnancy category is an assessment of the risk of fetal injury due to the pharmaceutical if it is used as directed by the mother during pregnancy. It does not include any risks conferred by pharmaceutical agents or their metabolites present in breast milk. Category B agents are presumed to be safe. Category A (A) correlates with agents known to be safe. The FDA requires a relatively large amount of high-quality data on a pharmaceutical for it to be defined as Pregnancy Category A. As a result of this, the FDA allocates many drugs that would be considered Pregnancy Category A in other countries to Category B. Category C (C) correlates with agents that have possible adverse effects. Their use should be considered only if the benefits outweigh the risks. Category D (D) correlates with agents that have known fetal risks and should be used only in life-threatening emergencies where there is no alternative agent.

In a patient with chronic abdominal pain, which additional finding suggests a diagnosis of irritable bowel syndrome? Decreased hemoglobin Improvement with defecation Nocturnal or progressive abdominal pain Weight loss

Correct Answer ( B ) Explanation: Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that has no organic etiology. It is one of the most commonly diagnosed gastrointestinal disorders and is more frequently seen in women and younger patients. Symptoms include chronic abdominal pain described as crampy and varying in intensity, accompanied by altered bowel habits. Patients complain of diarrhea, constipation, both diarrhea and constipation, or normal bowel movements that alternate with diarrhea and constipation. Symptoms usually improve with defecation. Because there is no biologic marker for IBS, a symptom-based criteria system was developed to assist in the diagnosis. The Rome III criteria confirms a diagnosis of IBS in patients with recurrent abdominal pain at least three days per month for the past three months associated with at least two other criteria. These additional criteria include improvement with defecation, onset associated with a change in the frequency of stool and onset associated with a change in the appearance or form of stool. Management of IBS includes psychological support, dietary measures and adjunctive pharmacologic treatment aimed at reducing symptoms. Symptoms that are not found in patients with IBS include laboratory evidence of anemia such as decreased hemoglobin (A), nocturnal or progressive abdominal pain (C) and weight loss (D). These are considered to be alarm or atypical symptoms and require colonoscopy or other imaging studies.

Which of the following tests can be used to confirm lactose intolerance? Anti-Gliadin antibodies Breath hydrogen test Sweat test Urea breath test

Correct Answer ( B ) Explanation: Lactose breath hydrogen test will show a rise in breath hydrogen >20 ppm within 90 min of ingestion of 50 g of lactose and is positive for lactase deficiency. This test is positive in 90% of patients with lactose malabsorption. Common causes of false-negative results are recent use of oral antibiotics or recent high colonic enema. The diagnosis can usually be made on the basis of the history and improvement with dietary manipulation. Lactose intolerance is a prototypical carbohydrate malabsorption disorder. Individuals with the condition may experience diarrhea, cramps, abdominal pain, and flatus following ingestion of milk products. Symptom severity depends on the amount of lactose ingested and the fat content of the product (ie skim milk empties from the stomach faster, causing more symptoms). Diagnostic workup may include confirming the diagnosis with hydrogen breath test and excluding other conditions listed in the differential diagnosis that may also coexist with lactase deficiency. Imaging studies are generally not indicated. A small bowel series may be useful in patients with significant malabsorption. Nearly 50 million people in the United States have partial or complete lactose intolerance. There are racial differences, with <25% of white adults being lactose intolerant but >85% of Asian Americans and >60% of African Americans having some form of lactose intolerance. Anti-Gliadin antibodies (A) are used in the diagnosis of celiac disease and not associated with lactose intolerance. Sweat test (C) is associated with the diagnosis of cystic fibrosis and urea breath test (D) is used to confirm eradication of H. Pylori infection.

A 27-year-old woman presents with visual changes. She notes progressive worsening vision in her right eye over the last two days. She reports pain with movement of her eye. On examination, she has an afferent pupillary defect in that eye and a swollen optic disk on fundoscopy. What is the most likely diagnosis? Macular degeneration Optic neuritis Papilledema Retinal detachment

Correct Answer ( B ) Explanation: Optic neuritis results in monocular vision loss from demyelination of the optic nerve. Most commonly, patients are between the ages of 15 and 45 years and there is a 30-40% association with multiple sclerosis. Examination reveals decreased visual acuity and an afferent pupillary defect. Fundoscopic examination demonstrates a normal or swollen optic disk. Without treatment, patients progress to their poorest vision in approximately one week with slow improvement over the next several weeks. Steroid therapy may be started however its long-term benefit remains unclear. Macular degeneration (A) characteristically causes progressive loss of central vision. The most common form is age-related macular degeneration although it may result from trauma, radiation exposure, inflammatory or infectious disease, vascular disease or hereditary disease. Visual loss continues and it is the leading cause of legal blindness in the US. Papilledema (C) may appear similar to optic neuritis on fundoscopic examination although more commonly is bilateral. In papilledema, swelling of the optic disk results from increased intracranial pressure. The pupil examination and visual acuity should remain normal and ocular pain is typically absent. Retinal detachment (D) may cause visual loss classically beginning with flashes of light or floaters followed by a falling curtain over their visual field. Bedside ultrasound can demonstrate the separation of retinal layers from accumulation of fluid aiding in the diagnosis.

Which of the following is most likely to present as a ductal-dependent cardiac lesion? Atrial septal defect Coarctation of the aorta Isolated ventricular septal defect Mitral valve prolapse

Correct Answer ( B ) Explanation: Patients with coarctation of the aorta may present with circulatory failure and shock upon closure of a patent ductus arteriosus (PDA). In many cases, the coarctation of the aorta occurs juxtaductal (adjacent to the PDA). The PDA may serve to widen the juxtaductal area of the aorta so that blood may flow forward from the left ventricle. However, in other cases, the PDA serves as a conduit for right-to-left shunted blood from the right ventricle. In the latter case, infants classically present with differential cyanosis due to well-oxygenated blood reaching the upper body (pink) from the ascending aorta, and deoxygenated blood reaching the lower body (blue) via the PDA and descending aorta. This is because the PDA often inserts distal to the origin of the left subclavian artery from the aorta. When the ductus arteriosus closes, this can lead to circulatory failure and shock. Atrial septal defects (A) and isolated ventricular septal defects (C) typically feature left-to-right shunting of blood and do not require PDAs for pulmonic or systemic circulation. Although mitral valve prolapse (D) increases one's risk for cardiovascular complications in adulthood, it is not progressive in childhood and requires no specific therapy.

The emergency department staff began treatment for a woman who presented with chest pain. The pain is described as retrosternal, worse with minimal activity, better with rest, sharp in character and 9/10 in intensity. You are paged to admit her to the intensive care unit under the working diagnosis of unstable angina. Her vitals have remained stable after beginning antiplatelet, antihypertensive and antithrombotic medications. Two hours after admission, a repeat history and physical and review of available test results offers the following information: Serial electrocardiograms reveal increasing R wave amplitude; An echocardiogram calculates an ejection fraction of 50%; Angina is reported as 9/10 in intensity; Atrial natriuretic peptide levels are elevated. Which of the following historical facts would prompt you to immediately consult interventional cardiology for invasive coronary revascularization? 50% ejection fraction Continued chest pain Elevated atrial natriuretic peptide R wave progression

Correct Answer ( B ) Explanation: Patients with unstable angina are mostly admitted to a critical care unit after initial presentation. There, an anti-ischemic regimen, if not already begun, is initiated. This typically includes oxygen, nitrates, analgesics and beta-blockers. Serial monitoring for new dysrhythmias, recurrent ischemia, dynamic electrocardiography, changing laboratory results and worsening angina is necessary to maximize patient outcomes. Further management includes risk stratification to determine if early invasive treatment is appropriate. High-risk indicators that favor early invasive treatment strategies include hemodynamic instability, elevated troponin I or T levels, a history of CABG, a history of percutaneous coronary intervention (PCI) within the past 6 months, recurrent angina despite anti-ischemic therapy, symptoms of congestive heart failure (S3, pulmonary edema, crackles, mitral regurgitation) or an ejection fraction < 40%. An ejection fraction < 40%, not 50% (A), favors early invasive treatment of unstable angina. Whereas elevated B-type natriuretic peptide is associated with poor outcomes in patients with unstable angina, atrial natriuretic peptide (C) is not. It is however responsible for water, sodium and potassium homeostasis. Its action is opposite of aldosterone. R wave progression (D) is not indicative of invasive management of unstable angina. New or presumably new ST depression is, however.

A 17-year-old boy presents to his pediatrician complaining of persistent drainage from his ear. He has a history of chronic ear infections and, one month prior, was started on amoxicillin secondary to symptoms of ear pain, hearing loss, and drainage along with physical exam findings of an inflamed, bulging tympanic membrane. When his symptoms failed to resolve, his medication was changed to amoxicillin-clavulanate; however, the patient is still experiencing symptoms. Given his history and the persistence of symptoms despite antibiotic therapy, what diagnosis should be considered? Benign necrotizing otitis externa Cholesteatoma Foreign body Mastoiditis

Correct Answer ( B ) Explanation: The development of an acquired cholesteatoma should be considered in a patient with a history of frequent ear infections and persistent ear drainage despite appropriate antibiotic therapy. A cholesteatoma is a cystic structure typically located within the middle ear or mastoid process. It is the result of keratinizing squamous epithelial cells and may cause symptoms of otorrhea, hearing loss, and dizziness. It also has the potential to continue to grow and invade surrounding structures. A cholesteatoma may be congenital or acquired. Acquired cholesteatomas are most common among those who have chronic otitis media; however, it is also seen in those with tympanic perforation or unintentional surgical placement of skin into the middle ear. Benign necrotizing otitis externa (A) is most commonly seen in immunocompromised individuals and insulin dependent diabetics. Granulations in the external canal would be present on exam. Mastoiditis (D) can also be a complication of otitis media. However, it also often presents with a fever as well as redness and swelling behind the affected ear. While a foreign body (C) may be a reasonable concern in a younger patient, his age makes this much less likely.

An 18-year-old woman with a history of asthma presents to her primary care provider for follow-up. Currently she experiences symptoms of coughing, wheezing and shortness of breath 3 days a week and uses her rescue inhaler 3 days a week. She awakens at night with similar symptoms 3 times a month. She reports some minor interference with her daily routine. Which of the following options is an appropriate management plan at this time? High dose inhaled corticosteroid and short-acting beta-agonist as needed Low dose inhaled corticosteroid and short-acting beta-agonist as needed Oral corticosteroid and short-acting beta-agonist as needed Short acting beta-agonist as needed

Correct Answer ( B ) Explanation: This patient can be classified as having mild persistent asthma. The recommended regimen for her includes a low dose inhaled corticosteroid (ICS) and short-acting beta-agonist (rescue inhaler). Asthma is a type of obstructive lung disease marked by chronic inflammation of the lower airways. Classic symptoms include recurrent episodes of cough, shortness of breath and wheezing. A pulmonary function test is initially obtained to confirm diagnosis. Test results demonstrate a decreased FEV1 (forced expiratory volume in 1 second) to FVC (forced vital capacity). Administration of a short acting beta agonist shows some reversibility. A step-wise approach is used in treating symptoms of asthma based on the severity. Inhaled corticosteroids are useful in reducing airway inflammation and bronchial hyper-responsiveness. Peak flow monitoring is an effective way to assess asthma control at home. In addition, it is important to reduce airway irritants and triggers to avoid exacerbation of symptoms. High dose inhaled corticosteroid and short-acting beta-agonist as needed (A) is appropriate in the management of severe persistent symptoms of asthma. Oral corticosteroid and short-acting beta-agonist as needed (C) can be used short-term in acute exacerbations and to manage symptoms of severe persistent asthma. Short acting beta-agonist (rescue inhaler) as needed (D) is only appropriate for symptomatic relief during acute exacerbations. Rescue inhalers are bronchodilators that help relax smooth muscles and provide quick relief.

A 19-year-old woman presents to the ED with pain and dyschromatopsia in her right eye. She also describes varying degrees of intermittent paresthesias over the previous month and occasional transient gait disturbance. An MRI shows white matter pathology. Which of the following lumbar puncture findings is associated with her condition? IgM and IgG antibodies to B. burgdorferi Pleocytosis and oligoclonal bands of immunoglobulin G Positive VDRL Xanthochromia

Correct Answer ( B ) Explanation: This patient has multiple sclerosis, which is a neurologic disorder that causes variable motor, sensory, visual, and cerebellar dysfunction as a result of multiple focal areas of CNS demyelination. The patient's orbital pain is likely due to optic neuritis. Dyschromatopsia is the change in color perception and may be more prominent than visual disturbance. Although MRI is the gold standard, lumbar puncture can aid in the diagnosis. The lumbar puncture in approximately 50% of the cases will show pleocytosis, which is an increased number of lymphocytes. In 85%-95% of cases, there will be oligoclonal bands of immunoglobulin G. IgM and IgG antibodies to B. burgdorferi (A) is seen in the CSF in patients with secondary Lyme disease. A positive CSF VDRL (C) is seen in patients with tertiary syphilis. Xanthochromia (D) is a yellow discoloration of the CSF sometimes seen in patients with a subarachnoid hemorrhage.

A 34-year-old man presents with a deep laceration to the left leg after falling off a motorcycle. The wound is contaminated with rocks and dirt. He states that he has not received a tetanus shot since completing vaccinations as a child. After irrigation and repair, which of the following should be administered? No tetanus prophylaxis needed Tdap Tdap and Tetanus immune globulin Tetanus immune globulin

Correct Answer ( B ) Explanation: This patient presents with a dirty wound and no tetanus booster in the last 5 years and thus requires a tetanus booster during this presentation. Tetanus is a toxin-mediated disease that is characterized by uncontrollable skeletal muscle spasms. It can cause hypoventilation, hypoxia and death if the toxin affects the muscles of respiration. Tetanus is a relatively rare disease particularly in developed countries where vaccination programs have been successful. Primary immunization confers protective antibodies to nearly 100% of patients. Immunity wanes between 5 and 10 years after completion of the initial vaccination series and so patients should have a booster shot every 10 years. It typically affects patients who have sustained a deep, penetrating wound. In adult patients with a history of a primary series in the past, any wound that is not a clean/minor wound should be given a tetanus shot (Tdap) if their last booster was >5 years ago. If the patient has a history of not completing a primary series, they should be given a Tdap regardless of the wound depth or size. The patient requires prophylaxis (A) as it has been more than 5 years since their last tetanus shot. Tetanus immune globulin (C & D) should be given to patients with an unknown, incomplete or lack of primary tetanus immunization series.

Which of the following statements is most accurate regarding acute ischemic heart disease? Elderly patients more often present with typical chest pain than atypical chest pain Reproducible chest wall tenderness excludes ischemia as a cause of chest pain Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation Women rarely present with atypical features of acute coronary syndrome

Correct Answer ( C ) Explanation: A typical feature of acute coronary syndrome is crushing retrosternal chest pain or pressure. Often this is lacking, and patients present with atypical features of the pain or the presence of angina equivalent symptoms (e.g., dyspnea, nausea, vomiting, dizziness). Many patients with a diagnosis of ACS have pain that is pleuritic, positional, or reproduced by palpation. One large study showed that up to 33% of patients diagnosed with acute myocardial infarction did not have chest pain on presentation. Atypical complaints include dyspnea; nausea; diaphoresis; syncope; and pain in the arms, epigastrium, shoulder, or neck. Atypical features of ACS are present with increasing frequency in older populations. In patients older than 85 years (A), atypical symptoms are more common than typical chest pain, with dyspnea being the most common. Isolated physical exam findings are rarely diagnostic of the origin of chest pain. Palpation of the chest wall (B) may reveal localized tenderness, but 5%-10% of patients with ACS have chest pain and associated palpable chest wall tenderness. Being female (D) is a risk factor for an atypical presentation of ACS.

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

Correct Answer ( C ) Explanation: According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), conduct disorder is characterized by behavior which violates the basic rights of others, societal norms, or age-appropriate rules in a repetitive and persistent manner. At least 3 criteria need to be present for the past 12 months, including bullying or threatening others, deliberate fire setting or destruction of property, staying out past curfew, and truancy from school. These behaviors cause significant impairment in academic, social and occupational functioning and may be specified as occurring with limited pro-social emotions, such as lack of remorse or empathy. Antisocial personality disorder (A) is a diagnosis given to individuals 18 years of age or older who have a history of at least some symptoms of conduct disorder before age 15. Individuals with attention deficit/hyperactivity disorder (B) exhibit behaviors that interfere with functioning, such as inability to pay attention in school or avoiding tasks that require sustained concentration, but do not act in a manner that violates other individual's rights. Conduct disorder and oppositional-defiant disorder (D) may present similarly, but individuals with oppositional-defiant disorder do not engage in destruction of property such as fire setting or graffiti. Symptoms of oppositional-defiant disorder are also less severe than those of conduct disorder.

A five-year-old boy presents with a progressive rash on his legs and buttocks over the past two days along with intermittent abdominal pain and anorexia. His mother states he has not been as active lately because of pain in his knees and ankles. He was otherwise healthy up until a week ago when he started complaining of intermittent headache and fever which she treated with acetaminophen. Which of the following is a known complication of the patient's diagnosis? Appendicitis Hypertrophic pyloric stenosis Intussusception Necrotizing enterocolitis

Correct Answer ( C ) Explanation: Henoch-Schönlein Purpura (HSP) is the most common vasculitis affecting children. It is usually self-limiting and resolves after approximately four weeks. It is often preceded by a prodrome of headache, pharyngitis, fever, and anorexia. The clinical presentation is influenced by the deposition of IgA in blood vessel walls, which leads to the triad of a palpable purpuric rash seen on the legs and buttocks, abdominal pain, and arthritis. Intussusception is a known, but rare, complication of HSP and occurs more commonly at the ileo-ileal junction, as opposed to the ileo-colic location seen in typical intussusceptions. For this reason, ultrasound is the preferred imaging modality over contrast enema in HSP intussusception. Intussusception occurs when one piece of bowel invaginates and telescopes into a more distal segment, causing intermittent abdominal pain whenever there is bowel peristalsis. Multiple studies have demonstrated ultrasound to be highly accurate in the diagnosis of intussusception. It is often the initial diagnostic test since it is non-invasive, does not require radiation exposure and can be reproduced at the bedside. On ultrasound, the intussuscepted bowel commonly has a sonodense center (bowel contents) surrounded by a sonolucent ring (bowel wall), giving a "donut appearance" or "target sign." Appendicitis (A), hypertropic pyloric stenosis (B), and necrotizing enterocolitis (D) are not known complications of HSP. Appendicitis can also give a "target sign" appearance on ultrasound due to periappendiceal inflammation. However, the more tubular structured appendix is non-compressible because of inflammation and appendicoliths and does not exhibit peristalsis like the small bowel in intussusception.

A 40-year-old woman presents to the office complaining of fatigue, dry hair, constipation, weight gain, and poor memory for about six months. On further questioning, she even states that in the summer she likes to wear a jacket. What condition do you suspect based on the above presentation? Dementia Depression Hypothyoidism Iron deficiency anemia

Correct Answer ( C ) Explanation: Hypothyroid patients generally present with the following signs and symptoms: fatigue, lethargy, weakness, constipation, weight gain, cold intolerance, muscle weakness, slow speech, and slow cerebration with poor memory. The patient typically has dry, coarse, thick, cool, sallow skin and brittle, coarse hair, with loss of outer third of eyebrows. Incidence of hypothyroidism increases with age; among persons older than 60 years, 6% of women and 2.5% of men have laboratory evidence of hypothyroidism (thyroid-stimulating hormone [TSH] more than twice normal level). Primary hypothyroidism (thyroid gland dysfunction) is the cause in >90% of the cases of hypothyroidism. Increased antimicrosomal and antithyroglobulin antibody titers are useful when autoimmune thyroiditis is suspected as the cause of the hypothyroidism. Although poor memory, cerebellar ataxia, and dulled expression is associated with neurologic processes such as dementia (A) or depression (B), the findings of dry hair, constipation, and fatigue are more consistent with hypothyroidism. Isolated fatigue may be associated with iron deficiency anemia (D).

A 45-year-old man comes to the office with a chief complaint of ringing in his right ear with decreased hearing on the right side. On exam there is no cerumen impaction or carotid bruits. Audiographic evaluation confirms right-sided hearing loss only. What is the next step in evaluation and treatment? Audiology appointment for hearing aid Carotid doppler of the neck Magnetic resonance imaging of the internal auditory canal Nasolaryngoscopy

Correct Answer ( C ) Explanation: If tinnitus is accompanied with hearing loss that is asymmetric or unilateral, this requires further evaluation with magnetic resonance imaging of the internal auditory canal to rule out acoustic neuroma. If the tinnitus is bilateral, not particularly intrusive, not pulsatile, and associated with symmetric hearing loss, it is likely secondary to the hearing loss itself. Tinnitus is a term used to describe an internal noise perceived by the patient. It is usually, but not always, indicative of an otologic problem. Tinnitus is most often subjective, that is, heard only by the patient. However, it can be objective and heard by the patient and the examiner. In most cases, tinnitus is secondary to bilateral sensorineural hearing loss and requires no further evaluation. In rare cases, tinnitus can be a symptom of a vascular abnormality (aneurysm or arteriovenous malformation), hypermetabolic state, or intracranial mass. In the presence of pulsatile tinnitus suggestive of a vascular etiology, carotid doppler or MRI angiography is warranted. "Clicking" tinnitus may be due to palatal myoclonus. Middle ear and rarely external ear pathology can also cause tinnitus, as can numerous medications such as aspirin. AUDIO OF TINNITUS 00:0000:00 Audiology appointment for hearing aid (A) would be considered the next step if this was bilateral hearing loss with tinnitus as the tinnitus would likely be secondary to the hearing loss itself. Carotid doppler (B) would be considered if a bruit was auscultated or the tinnitus was described as pulsatile. Nasolaryngoscopy (D) is warranted if there is suspicion for a nasopharyngeal mass or eustachian tube dysfunction.

A 33-year-old woman is seen in clinic for pregnancy induced hypertension. Which of the following antihypertensives is considered safe during pregnancy? Lisinopril Losartan Methyldopa Nitroprusside

Correct Answer ( C ) Explanation: Methyldopa is a drug of first choice for control of mild to moderate hypertension in pregnancy and is the most widely prescribed antihypertensive for this indication. Gestational hypertension refers to elevated blood pressure first detected after 20 weeks of gestation in the absence of proteinuria or other diagnostic features of preeclampsia. When hypertension is diagnosed in a pregnant woman, the major issues are establishing a diagnosis, deciding the blood pressure at which treatment should be initiated and avoiding drugs that may adversely affect the fetus. Methyldopa has been widely used in pregnant women and its long-term safety for the fetus has been demonstrated. During long term use in pregnancy, methyldopa does not alter maternal cardiac output or blood flow to the uterus or kidneys and for all these reasons is generally considered the agent of choice for blood pressure control in pregnancy. Labetalol, hydralazine and long-acting nifedipine are also acceptable oral antihypertensive options. Angiotensin converting enzyme inhibitors such as lisinopril (A), angiotensin II receptor blockers such as losartan (B), and nitroprusside (D) are contraindicated in all stages of pregnancy because of the risk of teratogenicity and toxic side effects.

A 7-year-old boy presents to your office for a well-child check. His mother has concerns regarding his car booster seat. Which of the following is the most accurate statement regarding car safety seats? All children should be restrained in the rear seats of vehicles for optimal protection until they have outgrown the highest weight or height allowed by the manufacturer of their belt-positioning booster seat, typically after 12 years of age. All children should be transitioned to belt-positioning booster seats as early as possible for optimal protection. All children should use a belt-positioning booster seat until the vehicle lap-and-shoulder seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age. All infants and toddlers should ride in a rear-facing car safety seat until they are 1 year of age or older.

Correct Answer ( C ) Explanation: Motor vehicle crashes continue to be a leading cause of death in children ages 4 and older. As such, the AAP released a policy statement with evidence-based guidelines for child restraint systems. These guidelines recommend that children should continue to use belt-positioning booster seats until the lap-and-shoulder seat belt fits properly; this generally occurs when the child is at least 4 feet 9 inches in height as well as at least 8 years of age. The middle seat is the safest seat. Children should not be sitting in the front seat until at least age 13, regardless of weight. The guidelines recommend that all children regardless of height or weight should be restrained in the rear seats (A) until age 13. There is greater safety advantage for children to remain in car safety seats for as long as possible before transitioning to booster seats (B) per the AAP policy statement. Children should ride in rear-facing car seats until age 2 years of age (D) or older, or children younger than 2 years who have outgrown the height or weight limit for their car safety seat.

A 65-year-old smoker with no documented cardiac disease presents with several months of worsening cough and exertional dyspnea. He denies exposure to inhalation toxins or dusts. Examination reveals bibasilar inspiratory crackles and fingernail clubbing. Spirometry reveals a restrictive lung pattern. A chest computed tomography scan is read as "honeycombing in the periphery and bases." A bronchoalveolar lavage report is only significant for lymphocytosis and a histological classification of usual interstitial pneumonia. Which of the following is the most likely diagnosis? Chronic obstructive pulmonary disease Community-acquired pneumonia Idiopathic pulmonary fibrosis Pneumoconiosis

Correct Answer ( C ) Explanation: Nomenclature of restrictive pulmonary disease can be confusing. It can be simplified if one first dissects the lung into airspace (mostly obstructive diseases), parenchyma (the lung "meat" which doesn't contain air, aka interstitium) and chest wall (the mechanism that runs the airspaces and parenchyma). Restrictive disease encompasses abnormalities of the parenchyma and chest wall. Idiopathic pulmonary fibrosis (IPF) represents a main subclassification of the more than 200 interstitial lung diseases. IPF is a chronic progressive, and often fatal, interstitial lung disease which affects adults over 50 years of age (men > women and smokers > non-smokers). Although linked to tobacco, occupational toxin exposure, gastroesophageal reflux and genetic predisposition, the exact etiology remains unknown, hence the term idiopathic. It is felt the pathology is based on abnormal wound healing, oxidant-antioxidant imbalance and excessive deposition of collagen. Patients experience a progressive dry cough, exertional dyspnea, inspiratory "velcro-like" crackles and fingernail clubbing. Radiography is nonspecific, but high resolution computed tomography reveals the diagnostic findings of fibrotic changes referred to as "honeycombing" (small cystic spaces enveloped by thick, fibrotic, well-defined walls, mainly occurring in the periphery and bases). Bronchoalveolar lavage (BAL) is an important diagnostic test, however, it is mainly used to rule-out other pulmonary disease such as malignancy and infections. In IPF, the tissue obtained from lung washings will show a histological appearance of usual interstitial pneumonia, the classic pathological description of IPF. Chronic obstructive pulmonary disease (A) results in obstructive, not restrictive, spirometry results. Community-acquired pneumonia (B) can be clearly defined by cytology analysis, bronchoalveolar washings, and has a distinctive pattern on chest radiography. This patient's BAL result does not report infectious findings. In addition, an infectious process would more than likely result in neutrophilia, while lymphocytosis is more common in IPF. Pneumoconiosis (D) does result in a restrictive lung pattern, but it is unlikely given the absence of exposure to inhaled toxins.

A laboratory report after an arthrocentesis returns with a finding of calcium pyrophosphate crystals that are rhomboid shaped. What is the most likely diagnosis? Cellulitis Gout Pseudogout Rheumatoid arthritis

Correct Answer ( C ) Explanation: Pseudogout is a disorder caused by deposits of calcium pyrophosphate dihydrate crystals in and outside the fluid of the joints, leading to intermittent attacks of painful joint inflammation. It most commonly affects the large joints (knees and wrists). The clinical presentation of pseudogout is similar to gout. However, distinguishing features of pseudogout include chondrocalcinosis of the affected joint, calcium pyrophosphate crystals that are positively birefringent and rhomboid shaped, and normal serum uric acid levels. Pseudogout is managed with NSAIDs for acute episodes and colchicine for prevention of attacks. Cellulitis (A) is associated with pain around a joint, not within the joint. Cellulitis is associated with erythema that blanches and warmth. Gout (B) is associated with needle-shaped sodium urate crystals that are negatively birefringent on arthrocentesis. Rheumatoid arthritis (D) is not associated with calcium pyrophosphate crystals.

Which one of the following is contraindicated in the second and third trimesters of pregnancy? Ampicillin Ceftriaxone Doxycycline Nitrofurantonin

Correct Answer ( C ) Explanation: Tetracyclines, such as doxycycline, are contraindicated throughout the duration of pregnancy due to the risk of permanent discoloration of tooth enamel in the fetus. Fluoroquinolones are also contraindicated in pregnancy due to the harmful risks to the fetus. Trimethoprin should be avoided in the first trimester due to the potential of neural tube defects as this medication acts a folic acid antagonist. Sulfonamides should be avoided in the third trimester because they may cause jaundice. Historically, ampicillin has been the drug of choice for many infections in pregnancy, particularly urinary tract infections, but in recent years E. coli has become increasingly resistant to ampicillin. Ampicillin (A) does not cause harm to the patient or the fetus, however it is not widely used secondary to resistance. Ampicillin resistance is found in 20 to 30 percent of E. coli cultured from urine. Of note, Ampicilin may be used to treat Group B streptococcus as an alternative to Penicillin. Cephalosporins such as ceftriaxone (B) are usually considered safe to use during pregnancy. Cephalosporins have a wide range of bacterial coverage and can be given as outpatient and inpatient treatment. Nitrofurantonin (D) is one of the first line agents used to treat bacterial infections in pregnancy because it does not cause harm to the fetus. Some clinicians avoid nitrofurantoin in the third trimester due to a risk of kernicterus.

A 4-month-old female presents with a diaper rash following four days of loose stools. The rash consists of erythematous, raised plaques and papules over the labia, inguinal folds, perineum and buttocks. What treatment is indicated? 1% hydrocortisone ointment Mupirocin ointment Nystatin ointment Zinc oxide ointment

Correct Answer ( C ) Explanation: The infant has classic findings of candidal diaper dermatitis, including beefy red plaques and satellite lesions. In contrast to the rash of irritant diaper dermatitis, the inguinal folds are usually involved. Candidal diaper dermatitis results from fungal invasion of superficial microtears in the skin. Candidal diaper dermatitis is usually clinical apparent, but potassium hydroxide preparation of skin scrapings may be used to confirm a diagnosis in unclear cases. The treatment of choice for candidal diaper dermatitis is a topical antifungal such as nystatin ointment. Other topical antifungal options include azoles such as clotrimazole, miconazole, or ketoconazole. Antifungal ointment should be applied at least two to three times per day and continued until the rash has fully resolved for 48 hours. 1% hydrocortisone ointment (A) is a useful adjunct in the treatment of severe irritant diaper dermatitis, but it is not indicated for candidal diaper dermatitis. Mupirocin ointment (B) can be used to treat mild bacterial superinfections of irritant diaper dermatitis, but it is not effective in treating candida. Zinc oxide (D) ointment is a barrier cream used to treat irritant diaper dermatitis but is ineffective in the treatment of candida.

A 85-year-old nursing home patient presents with diffuse abdominal pain and distension, nausea, but no vomiting. The above abdominal radiograph is obtained. What is the best management of this patient? Enema Nasogastric tube and bowel rest Sigmoidoscopy Surgical intervention

Correct Answer ( C ) Explanation: The radiograph demonstrates a markedly dilated single loop of colon consistent with a sigmoid volvulus. This is a closed-loop obstruction that results from twisting of a mobile segment of bowel. These occur almost entirely in two populations: (1) elderly, bed-ridden patients with debilitating comorbid disease and (2) patients of any age with profound neurologic or psychiatric illness. Almost all patients have a history of chronic severe constipation. Although spontaneous reduction of a sigmoid volvulus can occur, it is infrequent enough to mandate procedural intervention. Sigmoidoscopy is used to decompress and detorse the bowel. An enema (A) can be used in constipated patients to help expel stool from the colon, but this is not useful in patients with a known volvulus and can delay definitive therapy. Though often used, nasogastric tube and bowel rest (B) are usually inadequate. Decompression with a sigmoidoscope or even surgery may be necessary for definitive treatment. Surgical intervention (D) with resection and fixation is reserved for failed attempts at decompression with sigmoidoscopy and when there is evidence of bowel gangrene.

A 26-year-old woman presents with worsening fatigue over the last 2 weeks. She became concerned today when she noticed tingling in her feet bilaterally. She changed her diet 4 months ago and became a vegan. Which of the following would you expect to find on her laboratory studies? Decreased mean corpuscular volume Decreased reticulocyte count Increased mean corpuscular volume Spherocytosis

Correct Answer ( C ) Explanation: This patient likely has megaloblastic anemia due to her recent change to a vegan diet. Megaloblastic anemia is the result of an alteration of DNA synthesis caused by a deficiency of B12 or folate. Folic acid is found in green vegetables, cereals, and bread. Folic acid deficiency is typically due to a dietary deficiency or to increased use, such as in pregnancy. Vitamin B12 is only found in foods of animal origin. Patients at risk for B12 deficiency include those with chronic malabsorption or inadequate dietary intake (e.g. vegans). Symptoms of B12 deficiency include those typical of anemia (e.g. fatigue, pallor, dyspnea with exertion) as well as neurologic symptoms (e.g. paresthesias of the distal extremities, decreased proprioception, and weakness of the lower extremities). Laboratory studies will show a macrocytic anemia characterized by an increased mean corpuscular volume (MCV) as well as a decreased B12 level. Treatment consists of supplementation with parenteral therapy in cases due to malabsorption or oral therapy in cases of dietary deficiency. A decreased mean corpuscular volume (A) is seen in microcytic anemia caused by iron deficiency. A decreased reticulocyte count (B) indicates that red blood cells are not being produced in the marrow at a normal rate. This can be seen in cases of aplastic anemia. Spherocytosis (D) is seen in cases of extravascular hemolysis.

An 8-year-old boy presents with fever for 3 days. He had a fever, cough and nasal congestion 2 days ago and this morning began with a rash. Examination reveals maculopapular, red lesions over the face, neck and chest. You also note conjunctivitis. He is otherwise well appearing. What management is indicated? Ceftriaxone Isolation of patient from family Supportive care Tetracycline

Correct Answer ( C ) Explanation: This patient presents with symptoms consistent with measles requiring supportive care. Measles is a highly contagious viral illness spread by infectious droplets. The incubation period for the virus is 10-14 days and patients are contagious 2 days prior to the onset of symptoms to 4 days after the rash appears. The rash is typically preceded by fever, which increases daily for 5-6 days, and malaise. Cough, coryza and conjunctivitis begin about 24 hours after the onset of fever. Koplik's spots, a pathognomonic finding, appear on the second day of illness. They are small, bright red spots with blue-white centers appearing the buccal mucosa. Rash follows on the fourth to fifth day of the illness. The rash is characterized by maculopapular lesions beginning on the forehead and face and spreading to the trunk, arms and legs. Treatment for measles focuses on supportive care and recognition of bacterial complications. Isolation of infected patients is usually not helpful as exposure usually occurs prior to identification of the disease. Additionally, patients are not contagious after the rash has been present for 5 days. Administration of human immune serum globulin (ISG) can modify the course of disease if given within 6 days of exposure. Live measles virus vaccine may prevent measles if given within 72 hours of exposure. Ceftriaxone (A) may be helpful if a post-measels bacterial pneumonia is suspected. Otherwise, it does not play a role in treatment. Isolation (B) is likely to be unhelpful, as the family has already been exposed during the infectious period. Tetracycline (D) is the treatment of choice for Rocky Mountain spotted fever which is characterized by a rash, which spreads from extremities centrally.

Which of the following is most closely associated with the development of acute cor pulmonale? Acute bronchitis Health care associated pneumonia Heart failure Pulmonary embolism

Correct Answer ( D ) Explanation: Cor pulmonale is defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. Pulmonary hypertension is the common link between lung dysfunction and the heart in cor pulmonale. Cor pulmonale is usually a chronic condition, but acute pulmonary embolism (more common) and acute respiratory distress syndrome are associated with acute cor pulmonale. The underlying pathophysiology in massive pulmonary embolism causing cor pulmonale is the sudden increase in pulmonary resistance. In chronic cor pulmonale, RV hypertrophy (RVH) generally predominates. In acute cor pulmonale, right ventricular dilation mainly occurs. Acute bronchitis (A) is not associated with cor pulmonale. Heart failure (C) results from an abnormality in systolic or diastolic cardiac function. Chronically increased left heart pressures in poorly controlled heart failure can lead to cor pulmonale, but in most patients, this does not occur. Pneumonia (B) can increase cardiac demands but generally does not lead to pulmonary hypertension or right ventricular dilation.

A young woman presents with ankle pain and edema. While wearing high-heel shoes, she twisted her ankle upon stepping off a curb. She is tender about the lateral malleolus. Skin and neurovascular examination are normal. She has no medial tenderness. Ligament testing is negative. Radiographic examination reveals a non-displaced lateral malleolar fracture below the ankle joint. The tibia is unaffected. Which of the following is the most appropriate treatment at this time? Closed reduction Debridement Non-weight-bearing orthosis Weight-bearing cast

Correct Answer ( D ) Explanation: Fracture of the ankle may include injury to the medial malleolus (tibia), the lateral malleolus (fibula), the posterior malleolus (tibia), the talus and the collateral ligaments. Stability of the fracture depends on how many sides are injured. Stable fractures involve only one side of the joint, whereas unstable fractures include both sides of the joint. Stable fractures are treated with 4-6 weeks of a weight-bearing cast or brace. Unstable, displaced fractures require open or closed reduction (A). Open fractures require surgical debridement (B). Her skin is intact. Unstable, nondisplaced fractures require a non-weight-bearing cast (C). Since she has no radiographic or physical evidence of medial joint involvement, this ankle fracture could be considered stable. Even if you decide this is unstable, a non-weight-bearing cast, not brace (orthosis), is the treatment of choice.

A young adult with a family history of type 1 diabetes mellitus presents to the emergency room severely weak with altered mental status, nausea, and vomiting. On exam, she is hypotensive with increased pigmentation at her mucus membranes and palmar creases. Which of the following laboratory findings would you expect in this patient? Hyperglycemia Hypocalcemia Hypokalemia Hyponatremia

Correct Answer ( D ) Explanation: Hyponatremia is an expected laboratory finding in patients with acute adrenal insufficiency, of which this patient is showing signs and symptoms. Acute adrenal insufficiency is a medical emergency caused by insufficient plasma cortisol. It may occur for many reason, such as pituitary hypofunction, rapid withdrawal of steroid medications, or following extreme physiologic stress. However, this patient is most likely suffering from primary adrenal insufficiency, or Addison disease, as evidenced by the hyperpigmentation at this patient's skin and mucus membranes. Her family history of type 1 diabetes mellitus, an autoimmune condition, also increases her risk of Addison's disease. Other signs and symptoms of primary adrenal insufficiency include hypotension, abdominal pain, nausea, vomiting, diarrhea, fever, and confusion. Coma may result if untreated. Lab findings can include persistent hypoglycemia, eosinophilia, and hypercalcemia. Hyponatremia and hyperkalemia will result if there is a chronic mineralocorticoid deficiency. Differentiation of primary adrenal insufficiency from secondary adrenal insufficiency is accomplished with a cosyntropin, or ACTH, stimulation test. Though both types will present with depressed plasma cortisol, administration of synthetic ACTH will prompt a cortisol increase in patients with secondary adrenal insufficiency as their adrenal cortex is intact. However, this test will not result in a cortisol increase in primary adrenal insufficiency due to the lack of a functional adrenal cortex. Treatment of secondary adrenal insufficiency is dependent on the cause. Treatment of primary adrenal insufficiency generally requires daily hormone replacement with oral hydrocortisone, dexamethasone, or prednisone to prevent future adrenal crises. Hyperglycemia (A) should not be present in a patient with adrenal insufficiency. Rather, hypoglycemia is a common finding. The presence of hypokalemia (C) is more consistent with mineralocorticoid excess, as seen in Cushing syndrome or primary aldosteronism. Hypokalemia would not indicate adrenal insufficiency. Hypocalcemia (B) does not occur in adrenal insufficiency. Rather, hypercalcemia is an expected finding.

A 27-year old man presents with a 2-day history of right maxillary pain associated with nasal congestion and clear rhinorrhea. The only significant findings on examination are a low-grade fever and subjective tenderness with palpation over the right maxillary sinus. Which one of the following treatments is most supported by current evidence? Antibiotics Mucolytics Nasal saline Oral analgesics

Correct Answer ( D ) Explanation: Inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa; therefore, rhinosinusitis is a more accurate term for what is commonly called sinusitis. The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which can lead to over diagnosis of acute bacterial rhinosinusitis. Facial pain, purulent rhinorrhea, maxillary toothache and nasal obstruction are some of the signs and symptoms of rhinosinusitis however, the duration of symptoms is important in determining bacterial versus viral etiology. In most patients, viral rhinosinusitis improves in 7 to 10 days. Diagnosis of acute bacterial rhinosinusitis requires that symptoms persist for longer than 10 days or worsen after 5 to 7 days. Although oral antibiotics are overwhelmingly prescribed as initial treatment in acute sinusitis, it has been shown that the majority of acute illnesses are viral in origin and that 98% of cases will resolve spontaneously. Analgesics are considered the mainstay of therapy for acute sinusitis. Analgesic treatment is often necessary for patients to relieve pain, get adequate rest, and resume normal activities. Selection of analgesics should be based on the severity of pain. Acetaminophen or an NSAID are appropriate for mild to moderate pain. Antibiotics (A) may be considered in patients with symptoms or signs of acute rhinosinusitis that do not improve within seven days or that worsen at any time; in those with moderate to severe pain or a temperature of 38.3°C or higher; and in those who are immunocompromised. Antibiotics are not the treatment of choice for viral rhinosinusitis. The effect of nasal saline (C) does not extend to the paranasal sinuses. There are no randomized controlled studies that evaluate the effectiveness of nasal saline in patients with sinusitis. Mucolytics (B) have been used to thin mucus and improve nasal drainage. However, because they have not been evaluated in clinical trials, they are not recommended as an adjunct treatment for rhinosinusitis.

A 43-year-old woman presents with a several year history of irregular bowel habits characterized by alternating diarrhea and constipation and associated with intermittent, occasional crampy abdominal pain and bloating. She denies loss of appetite, weight loss or vomiting, and she has never seen blood in her stools. The pain does not awaken her at night, and she has been unable to identify any particular dietary triggers. Her body mass index (BMI) is 24, she is afebrile, and her abdominal exam is unremarkable. A series of three fecal occult blood tests are all negative. What is the most likely diagnosis? Abdominal migraine Acute diverticulitis Crohn's disease Irritable bowel syndrome

Correct Answer ( D ) Explanation: Irritable bowel syndrome (IBS) is the most likely diagnosis based on this patient's chronic history of the above described symptoms, as well as her normal physical examination. IBS is the most commonly diagnosed GI condition, is more common in women, and presents most often between the ages of 30 and 50. Diagnosis of IBS is based on clinical features, though patients with features such as rectal bleeding, weight loss, iron deficiency anemia, nocturnal symptoms, or those with a family history of colorectal cancer, inflammatory bowel disease or celiac disease should undergo additional testing such as endoscopy and laboratory assessment to rule out more serious pathology. Differentials to consider include inflammatory bowel disease, colon cancer, hyper- or hypothyroidism, chronic diarrhea, chronic constipation, or celiac sprue. Studies suggest avoiding foods that trigger symptoms, as well as regular exercise may help reduce symptoms of IBS. Antispasmodics and antidepressants may be helpful in reducing symptoms for some patients, and loperamide hydrochloride may be used to reduce episodes of diarrhea specifically. Lubiprostone is indicated for constipation-predominant IBS. 5-hydroxytryptamine 4 agonists and 3-hydroxytryptamine 3 antagonists are reserved for severe forms of constipation-predominant and diarrhea-predominant forms of IBS, respectively, due to the severe side effects associated with their use. Acute diverticulitis (B) occurs when a diverticula (a pouch or sac formed at a weak point along the digestive tract) becomes inflamed. Symptoms include the acute onset of abdominal pain in the right or left lower quadrants, loss of appetite, constipation or diarrhea and nausea. Exam findings include abdominal tenderness, distension and sometimes fever. Complications may include abscess formation, peritonitis, bowel obstruction, fistula formation and occasionally hemorrhage. Treatment includes broad-spectrum antibiotics to cover aerobic and anaerobic gram-negative organisms, and hospitalization may be required depending on a patient's clinical presentation. This patient's long-term symptoms of mild abdominal pain that is intermittent are not consistent with acute diverticulitis. Abdominal migraine (A) is a condition primarily of children and young adults, characterized by attacks of dull abdominal pain that is midline, peri-umbilical or poorly localized, and of at least moderate intensity. It may be associated with anorexia, nausea, vomiting, and pallor. Abdominal migraine is not diagnosed until other conditions causative of abdominal pain have been ruled out, and changes in stool pattern are not included with a part of the formal diagnosis. Crohn's disease (C) is an inflammatory condition of the colon characterized by abdominal pain, diarrhea, fatigue, fever, gastrointestinal bleeding, and weight loss. It is diagnosed by clinical symptoms, laboratory studies, and findings on endoscopy including skip lesions, cobblestoning, ulcerations and stricture. Treatment includes sulfasalazine (Azulfidine), 5-aminosalicylic acid (5-ASA), antibiotics and corticosteroids. For more severe disease, methotrexate and treatment with immunomodulators may be required and in some cases, surgical treatment is necessary. There are many complications of Crohn's disease including abscess, stricture, fistula, toxic megacolon, an increased risk for colonic cancer, and several extra-intestinal manifestations. This patient's symptoms are not consistent with inflammatory disease of the bowel.

A long-term tobacco and alcohol user presents with three months of a white patch on the floor of his mouth. Which of the following is the most likely diagnosis? Leukocytosis Leukomalacia Leukopenia Leukoplakia

Correct Answer ( D ) Explanation: Leukoplakia is a premalignant white patch or plaque that may eventually progress to an ulcer or mass. It is a pre-malignant oral lesion. The biggest risk factors are tobacco and alcohol use. If oral leukoplakia persists for more than 2 weeks, biopsy and treatment is required. These precancerous lesions are typically surgically removed with cryotherapy and laser ablation. Oral leukoplakia is also associated with HIV/AIDS. Unlike oral candidiasis (thrush) the white plaques of oral leukoplakia cannot be scrapped off. Leukocytosis (A) and leukopenia (C) refer to an increased and decreased number of white blood cells in the blood, respectively. Leukomalacia (B) may refer to brain white-matter necrosis which occurs near the lateral ventricles in infants.

A patient presents with wheezing and dyspnea. His medical history is significant for asthma, seasonal allergies and rotator cuff repair. You notice that he has aspirin and nonsteroidal anti-inflammatories listed under allergies. If this patient's medical history also included "Samter's triad", which of the following would you expect to find during physical examination? Blood clot Hypertension Jaundice Nasal polyps

Correct Answer ( D ) Explanation: Nasal polyps commonly occur in patients with environmental allergies, but the underlying etiology is widely unknown. These inflammatory masses also commonly occur in patients with cystic fibrosis and aspirin sensitivity. Samter's triad is a condition consisting of asthma, aspirin or NSAID sensitivity and nasal polyposis. Nasal polyps cause obstruction, nasal congestion, hyponosmia to anosmia, altered taste, headaches, facial pain and postnasal drainage. Inspection usually reveals single or multiple fleshy, translucent masses. Treatment mainly consists of oral, intranasal and topical corticosteroids. Virchow's triad explains the basis of thrombosis: hypercoagulability, which may present as a blood clot (A), hemodynamic stasis or turbulence and endothelial injury or dysfunction. The Cushing triad, also known as the Cushing reflex, occurs in states of increased intracranial pressure. The three symptoms are hypertension (B), bradycardia and irregular breathing. Charcot's triad of pain, fever, and jaundice (C) is common in ascending cholangitis.

A 19-year-old man who is a college student presents to the ED with concern for a lesion on his penis for the past two days. He began a relationship with a new sexual partner three weeks ago. On exam, there is a non-tender 2-cm ulcer on the dorsum of his glans. There is no inguinal adenopathy. An HIV ELISA and RPR are negative. What is the most likely diagnosis? Chancroid Granuloma inguinale Lymphogranuloma venereum Primary syphilis

Correct Answer ( D ) Explanation: Primary syphilis is characterized by a small papule that develops at the site of inoculation (usually genital) that becomes a painless, indurated ulcer, often described as the classic chancre. The chancre develops after an incubation period of 10-90 days, is present for 3-6 weeks, and resolves spontaneously. Serologic tests (VDRL and RPR) can be falsely negative for up to four weeks after the chancre appears and should not be relied upon to rule out primary syphilis. They are, however, quite sensitive for ruling out the diagnosis in later stages. Chancroid (A) is caused by the organism Hemophilus ducreyi and often presents with multiple painful papules which subsequently ulcerate over days. Gram stain of an aspirate from the inguinal bubo will reveal short gram-negative bacilli in a linear or parallel formation—often described as a "school of fish." Granuloma inguinale (B) (donovanosis) is a rare STD caused by the Calymmatobacterium granulomatis. The lesions evolve and, depending on the stage, can be a painless papule, vesicle, or nodule on the genitalia or a beefy-red, velvety ulcer with a rolled border. Subcutaneous granulomas (pseudobuboes) in the inguinal nodes develop over the next few months. Lymphogranuloma vernereum (C) is caused by Chlamydia trachomatis and is characterized by unilateral tender inguinal and femoral lymphadenopathy. The genital lesion is a small, shallow, painless vesicle or ulcer.

An overweight 29-year-old roofer presents with acute groin swelling after lifting an 80-pound sack of shingles. Examination reveals a minimally tender mass in the right scrotum. There is no mass in the proximal thigh or abdomen. Which of the following types of hernia do you most likely suspect? Direct inguinal Epigastric Femoral Indirect inguinal

Correct Answer ( D ) Explanation: The inguinal canal is formed by the inguinal ligament and the lower abdominal muscles. It is a tube from the abdominal cavity into the scrotum, allowing the testicles a passageway to descend through. It has two openings called the deep (internal) and superficial (external) inguinal rings. Hernia is the general term used to describe the passage of tissue or organ from its cavity of origin into a different body cavity. Hernias are common in the inguinal region. A direct inguinal hernia is passage of the abdominal contents straight through a weakened portion of the abdominal wall, usually occurring medial to the inferior epigastric vessels and superior to the inguinal ligament. An indirect inguinal hernia is the passage of abdominal contents through the internal inguinal ring, through the inguinal canal, and out through the external inguinal ring into the scrotum. Indirect inguinal hernias are more common than the direct type. Some risk factors that predispose a patient to have an inguinal hernia are obesity, heavy lifting, coughing, straining, and chronic lung disease. A direct inguinal hernia (A) occurs medial to the inferior epigastric vessels in the low abdomen. It causes a mass or bulging in the abdominal wall, a sign which is absent in the above patient. Periumbilical and epigastric hernias (B) typically occur through a weakened portion of the anterior abdominal wall, usually in the midline, through the linea alba. This patient has no abdominal bulging typical of an epigastric hernia. A femoral hernia (C) occurs inferior to the inguinal ligament, causing a mass, edema or bulging in the proximal thigh. It is rare and usually occurs in females.

A 24-year-old man presents with wrist pain after a fall on his outstretched left hand. Examination reveals tenderness at the base of the first metacarpal in the anatomic snuffbox and pain with axial load on the thumb. The patient's X-ray is shown above. What management is indicated? Acetaminophen and primary care follow up Removable soft wrist splint for 2 weeks Sugar tong splint and orthopedics follow up Thumb spica splint and orthopedics follow up

Correct Answer ( D ) Explanation: The patient has an examination concerning for an occult scaphoid fracture and requires immobilization with a thumb spica splint and follow up with an orthopedic surgeon. The scaphoid bone is the most commonly fractured carpal bone. It typically occurs after a fall on an outstretched hand (FOOSH). There are three types of fractures: 1) fractures of the tuberosity and distal pole, 2) fractures of the waist and 3) fractures of the proximal pole. Patients present with pain at the anatomic snuff box or distal radius. Physical examination reveals tenderness and swelling of the anatomic snuff box and may have increased pain with axial compression of the first metacarpal (Watson's scaphoid shift test). Additionally, pain may be increased with thumb to index finger pinch. Diagnostic testing should begin with AP, lateral and oblique plain radiographs of the wrist. A scaphoid view (X-ray with wrist in ulnar deviation) can increase the likelihood of detecting small scaphoid fractures on X-ray. Unfortunately, plain radiographs miss 15% of scaphoid fractures. Patients with missed fractures that are not immobilized are at an increased risk for fracture nonunion and long-term chronic arthritis. Therefore, splint immobilization with a thumb spica is indicated in all patients who have a clinical suspicion for scaphoid fractures regardless of the X-ray findings. Acetaminophen and primary care follow up (A) is inadequate because of the risk of a missed scaphoid fracture. A removable splint (B) does not guarantee proper immobilization and will not prevent nonunion. A sugar tong splint (C) extends from the elbow to the mid hand but does not immobilize the first metacarpal joint.

A 65-year-old woman with Crohn's disease that is well controlled on infliximab presents to her primary care physician. As you are updating her immunization status, which one of the following should be noted? Hepatitis A vaccine is contraindicated Pneumococcal vaccine is contraindicated Tetanus toxoid is contraindicated Zoster vaccine is contraindicated

Correct Answer ( D ) Explanation: The varicella zoster vaccine is a live attenuated vaccine and therefore is contraindicated in this patient due to her immunocompromised state. This patient is considered immunocompromised since she is taking infliximab. Hepatitis A vaccine (A) is recommended for any person with chronic liver disease or traveling and working in endemic areas. This vaccine is not a live attenuated vaccine and therefore can be given to patients that are immunocompromised. The pneumoccocal vaccine (B) is recommended for all patients greater that 65 years of age or patients who are immunocompromised or who have a chronic disease. This patient should therefore receive the pneumococcal vaccine. The tetanus toxoid (C) is not routinely given unless the patient has a contraindication to receiving the diptheria component.

A 35-year-old woman on oral contraceptives presents for evaluation of thigh pain and swelling. She was seen 6 days ago for the same complaint and had a negative compression ultrasound. Which of the following is the most appropriate plan? CT venogram Diuretic therapy Reassurance Repeat Doppler ultrasound

Correct Answer ( D ) Explanation: Venous doppler ultrasound performed by a qualified sonographer has a sensitivity and specificity of approximately 95% in the detection of deep vein thrombosis (DVT) of the proximal leg. The evaluation typically includes three different points: common femoral vein, superficial femoral vein and the popliteal vein. In patients with a high pre-test probability (as in this case of a woman on oral contraceptive medication), a repeat doppler ultrasound is indicated in patients with persistent symptoms. An alternative approach on the initial visit is to also perform a d-dimer which if negative in combination with the three-point ultrasound excludes the diagnosis of DVT. CT venogram (A) is not routinely performed in the evaluation of a patient for DVT. Some centers combine CT venogram of the legs with CT angiogram of the chest performed for the evaluation of pulmonary embolism. Using this in combination does increase the overall sensitivity of CT imaging for these diagnoses. Diuretic therapy (B) would not be initiated by the physician for unilateral leg swelling. A patient needs follow-up with a provider in order to monitor the effects of diuretic and also a complete evaluation to look for other causes of the leg swelling. While reassurance (C) should always be provided to patients, in this case, a diagnosis has not yet been made and further testing is indicated.