Comprehensive Review Test

In a patient with elevated blood pressure, which of the following physical exam findings most strongly indicates a need for workup for secondary hypertension? A.S3 gallop B.flank bruits C.CVA tenderness D.retinal exudates

B. flank bruits -- frequently caused by atherosclerosis of the renal vasculature. This is one of the most common causes of secondary hypertension.

A 5-year-old is brought to the clinic by his mother due to productive cough, sore throat, and mild fever for the past week. Sputum Gram stain and smear is inconclusive. Chest x-ray shows a subsegmental infiltrate. PCR is positive for Chlamydia. What is the recommended treatment? A. erythromycin B. penicillin C. tetracycline D. trimethoprim-sulfamethoxazole

A. erythromycin -- a macrolide or a tetracycline (doxycycline) is the treatment of choice for chlamydial pneumonia.

A patient with no known risk factors for colorectal cancer should begin screening at what age? A. 40 years B. 45 years C. 50 years D. 55 years

C. 50 years -- colorectal screening for those without any known risk factors is recommended to begin at age 50. For patients with a family history, screening should begin at age 40, or 10-years earlier than the age at which the family member was diagnosed.

A 62-year-old male with history of hypertension and hyperlipidemia presents with left-sided hemiplegia and an associated hemisensory loss along with homonymous hemianopia. What area of the brain has most likely been affected? A. right middle cerebral artery B. right posterior cerebral artery C. left middle cerebral artery D. left posterior cerebral artery

A. right middle cerebral artery -- occlusion of the MCA will result in contralateral hemiplegia with hemisensory loss as well as homonymous hemianopia.

An 8-year-old complains of nonspecific abdominal pain, cramps, flatulence, bloating, and occasional diarrhea. The symptoms seem to be related to the ingestion of dairy products. What is the next step in management? A. 2-week trial of lactose-free diet B. hydrogen breath test C. use of calcium and magnesium supplementation D. use of pancreatic enzyme replacement

A. 2-week trial of lactose-free diet -- this is a typical presentation of a patient with lactose intolerance. A practical approach in clinical practice is to eliminate dairy products for 2-weeks and look for symptom resolution. Note: a hydrogen breath test is helpful to diagnose lactose intolerance, but a 2-week trial of lactose-free diet is a more acceptable first approach.

A 26-year-old female with a history of systemic lupus erythematosus (SLE) for 5 years is found to have elevated blood pressure on three separate occasions. Labs reveal anemia and mildly elevated BUN and creatinine. Urinalysis shows proteinuria but no casts. Which of the following pharmacologic agents would be best to treat the hypertension? A. ACE inhibitor B. β-blocker C. calcium channel blocker D. diuretic

A. ACE inhibitor -- hypertension + kidney disease = ACE inhibitor or ARBs. They promote dilation of the efferent arterioles and, thus, reduction of intraglomerular pressure.

A 70-year-old female reports recurrent episodes of dyspnea, heaviness in the chest, and weakness for 3 days. Cardiac markers are elevated and she is admitted. Which of the following tests would be best to evaluate for reinfarction during her hospitalization? A.CK-MB B.LDH C.troponin I D.troponin T

A. CK-MB -- typically returns to normal within 24-48 hours of an infraction; any further elevation is indicative of reinfarction. Note: Troponin remains elevated for 5-14 days following infarction and therefore is not a good marker for reinfarction.

A 31-year-old female presents for evaluation of numbness and tingling of her right leg. History reveals similar symptoms 3 months ago in left arm that resolved after a week. Examination reveals full range of motion but weakness of motor strength. Which of the following is the most sensitive test for diagnosing the suspected disorder? A.MRI B.CT scan C.CSF analysis D.evoked potentials

A. MRI -- multiple foci are best demonstrated by MRI, supporting the clinical diagnosis of multiple sclerosis.

Abduction of the flexed hip of a 1-month-old elicits a "clunk." What test is this and what does it assess? A. Ortolani sign; developmental dysplasia of the hip B. Lachman test; slipped capital femoral epiphysis C. Galeazzi test; Legg-Calvé-Perthes disease D. Pavlik's sign; Osgood-Schlatter disease

A. Ortolani sign; developmental dysplasia of the hip -- in the Ortolani maneuver, abduction of the flexed hip results in the "clunk" which represents the reduction of the dislocated hip back into the acetabulum. Barlow maneuver reproduces slippage (clunk) on adduction.

A 38-year-old obese female presents with progressively worsening exertional dyspnea and a chronic cough productive of foul-smelling phlegm. She gives a history of recurrent pulmonary infections throughout her life. Examination reveals crackles heard throughout the lung fields and digital clubbing. What is the most likely diagnosis? A.bronchiectasis B.asthma C.emphysema D.chronic bronchitis

A. bronchiectasis -- obstructive lung disease that causes a chronic productive cough with purulent and foul-smelling sputum. A physical finding of persistent crackles over the affected lung region(s) is a diagnostic confirmation; clubbing confirms chronic pathology. Congenital or acquired etiologies are known.

Which of the following women has the greatest risk for developing endometrial hyperplasia? A. a 54-year-old woman with a long history of anovulatory cycles B. a 33-year-old woman with a 10-year history of oral contraceptive use C. a young woman suffering from anorexia nervosa D. an obese woman with normal menses occurring every 30 days

A. a 54-year-old woman with a long history of anovulatory cycles -- high risk for endometrial hyperplasia due to unopposed estrogen causing endometrial proliferation. Progesterone is only produced after ovulation, resulting in secretory endometrium that prevents further endometrial proliferation.

A 24-year-old G2P1001 female at 35 weeks' gestation complains of abdominal pain associated with moderate vaginal bleeding but no leakage of fluid and no history of trauma. She admits to using cocaine recently. Physical exam reveals blood pressure of 150/90 mm Hg and heart rate of 110 bpm. She has no peripheral edema. The fundus is tender and a moderate amount of dark blood is noted in the vagina. The cervix is 1.0 cm dilated. Fetal heart tones are in the 160 to 170 range. What is the most likely diagnosis? A. abruptio placentae B. placenta accreta C. placenta previa D. preeclampsia

A. abruptio placentae -- presents as painful vaginal bleeding during the third trimester. Cocaine use is assocaited with increased risk for abruptio placentae.

A child has a history of brief lapses in consciousness without involuntary movements or autonomic components. The episodes begin and end abruptly. Which of the following type of seizure is this child most likely exhibiting? A. absence B. myoclonic C. simple partial D. atonic

A. absence -- characterized by brief impairment of consciousness with an abrupt beginning and ending. At times, involuntary movements may occur, but they are uncommon and the patient has no recollection and witnesses commonly miss them.

A 65-year-old female has worked as a laundromat attendant for 25 years. She complains of pain in both knees which worsens with activity throughout the day. Radiography reveals osteophytes and joint narrowing. What is the recommended first-line treatment? A. acetaminophen B. COX-2 inhibitor C. intra-articular steroid D. salicylates

A. acetaminophen -- initial treatment for mild-to-moderate osteoarthritis. If response is inadequate, NSAIDs should be used. NSAIDs are more effective but also carry higher risk of adverse effects. Note: COX-2 inhibitors are effective but should be used judiciously due to the potential cardiac side effects.

A 32-year-old female who is 6 weeks postpartum complains of double vision that appears midmorning and worsens throughout the day. She has been easily fatigued and has had difficulty swallowing. Examination reveals ptosis and limited EOM movement. Pupillary reflexes and deep tendon reflexes are normal. Which of the following tests would best confirm the suspected diagnosis? A.acetylcholine receptor antibodies assay B.cerebrospinal analysis for elevated protein C.muscle tissue biopsy D.plasma electrophoresis

A. acetylcholin receptor antibodies assay -- up to 90% of patients with myasthenia gravis will demonstrate elevated acetylcholine antibodies in their circulation. Onset of symptoms after pregnancy or a stressful event is not unusual. Response to short-acting acetylcholine is also used to confirm the diagnosis. Note: if AChR antibodies are negative, MuSK-Antibodies can be obtained. Note: an endrophonium test (Tensilon test) inhibits Acetylcholinesterase which allows ACh to interact with receptors, therefore patients with MG will have improvement of symptoms. The ice pack test will also improve ocular symptoms.

A 63-year-old male presents with sudden onset of a painful, red left eye. He also reports a throbbing frontal headache, blurred vision with halos around lights, and nausea without vomiting. On examination, there is ciliary flush, a normal conjunctiva, and cloudiness of the cornea. The left pupil is mid-dilated and fixed. What is the most likely diagnosis? A. acute angle-closure glaucoma B. retinal detachment C. subarachnoid hemorrhage D. temporal arteritis

A. acute angle-closure glaucoma -- presents as a painful red eye. Abrupt onset of symptoms includes pain, injection, corneal edema, and blurred vision. In some patients, ocular symptoms are overshadowed by nausea, vomiting, or headache. Note: treatment --> combination topical agents (e.g., Timolol) and a systemic agent to lower intraocular pressure (e.g., PO or IV Acetazolamide).

A 63-year-old with a history of chronic atrial fibrillation complains of acute pain and numbness of the left arm. On examination, the limb is cool and pale, and distal pulses are absent. What is the most likely diagnosis? A. acute arterial occlusion B. Buerger disease C. Takayasu arteritis D. venous spasm

A. acute arterial occlusion -- results in paleness, pain, and pulselessness. Almost 90% of arterial emboli arise from the heart.

A 51-year-old female presents with a 2-day history of colicky right upper quadrant pain as well as nausea and bloating. Examination reveals temperature of 100.4°F and significant pain upon palpation of the right upper quadrant. Laboratory findings include elevated WBC and mild bilirubinemia. What is the most likely diagnosis? A.acute cholecystitis B.acute pancreatitis C.duodenal ulcer D.viral gastroenteritis

A. acute cholecystitis -- triad of RUQ tenderness, fever, leukocytosis is highly suggestive of acute cholecystitis. Serum bilirubin may be mildly elevated in one-quarter of patients. It is more common in women >40-years old and those who are overweight.

A 19-year-old male presents to the emergency department due to acute onset of fatigue, vomiting, diarrhea, and anorexia. He has postural dizziness, fever, and low blood pressure. Ten days ago, he had an acute nonbloody gastroenteritis that started abruptly and cleared after 48 hours. A chemistry panel shows decreased sodium, increased potassium, and a glucose of 50 mg/dL. What is the most likely diagnosis? A. adrenal insufficiency B. type 1 diabetes mellitus C. myxedema D. pheochromocytoma

A. adrenal insufficiency -- patients present with weight loss, fatigue, diarrhea, vomiting, anorexia, and salt cravings. They may have postural dizziness and pigmentation of the buccal mucosa, palms, face, and extensor surface. In addition, hyponatremia, hyperkalemia, and hypoglycemia may be present. Adrenal insufficiency is considered a medical emergency.

A 13-month-old is brought to the clinic with what her mother describes as intermittent episodes of abdominal pain. The infant cries and pulls her knees up and vomits during each episode. She has had one thick, brown-red, mucus-laden liquid stool. On examination, a sausage-shaped mass is found in the upper abdomen. What is the best treatment option? A.air enema B.Nissen fundoplication C.pyloromyotomy D.surgical resection

A. air enema -- air or barium enema not only confirms the diagnosis but, with appropriate hydrostatic pressure, will also reduce the intussusception in 75% of patients.

Seventy-two hours after total knee replacement, an otherwise healthy 57-year-old male develops tachycardia, hand tremor, and nausea. He becomes very anxious, agitated, and tells the nursing staff "millions of ants are crawling over his skin and sheets." An hour later, he has a new-onset tonic-clonic seizure. Which of the following is the most likely cause of this patient's condition? A. alcohol withdrawal B. acute delirium C. epileptic disorder D. hyperthyroidism

A. alcohol withdrawal -- often, alcohol dependence is uncovered during hospitalization and presents with seizure, increased heart rate, tactile hallucinzations, agitation, and anxiousness along with tremor, nausea, and vomiting. Symptoms generally appear within hours or days after cessation or reduced alcohol intake. Patients may not be forthright about their alcohol use during prehospitalization history.

A 63-year-old male presents with exacerbation of exertional dyspnea and peripheral edema. He has a long history of poorly controlled hypertension and a 50 or more pack-year history of smoking cigarettes. He has been hospitalized several times in the past with similar symptoms. Where is the apical pulse most likely located in this patient? A. along the left axillary border B. high in the epigastric region C. in the right second intercostal space D. under the left nipple

A. along the left axillary border -- chronic heart failure leads to cardiomegaly, which displaces the apical impulse laterally.

A 52-year-old male with no significant past medical history and no current complaints undergoes screening ECG. The rhythm strip shows multiple five to six beat runs of wide QRS complexes. Which of the following medications should be administered now? A.amiodarone B.atropine C.epinephrine D.verapamil

A. amiodarone -- ventricular tachycardia is defined as three or more consecutive ventricular premature beats. Amiodarone or lidocaine, given in a slow IV bolus followed by a slow infusion, is the recommended treatment for stable (nonsustained) ventricular tachycardia.

A 64-year-old male presents with worsening pain in his right calf that occurs after walking short distances and resolves with rest. Examination reveals loss of hair and thinned and darkened skin over the lower extremities; distal pulses are diminished. Which of the following diagnostic studies is most appropriate to perform at this time? A. ankle-brachial index B. arteriography C. lymphangiography D. magnetic resonance angiography

A. ankle-brachial index -- an ankle-brachial index is useful in gauging the degree of arterial insufficiency and should be performed prior to any additional imaging studies.

A 54-year-old male presents to the emergency department after a syncopal episode. The patient states that this is his third such episode in the past 4 weeks. He also describes episodes of dyspnea on exertion that occur with substernal chest pain. Physical exam reveals a harsh III/VI systolic crescendo-decrescendo murmur heard best at second right intercostal space that radiates to the carotid arteries. It is heard best when the patient is sitting forward. What is the most likely diagnosis? A. aortic stenosis B. mitral stenosis C. pulmonary stenosis D. tricuspid stenosis

A. aortic stenosis -- AS most commonly occurs due to a congenital unicuspid or bicuspid valve; rheumatic heart disease; or degenerative changes brought on by HTN, HLD, and smoking. Syncope is a late finding and occurs in associated with exertion. A systolic ejection murmur heard best in the aortic area with radiation to the neck is characteristic. The murmur peaks at midsystole.

A 20-year-old female has a chronic history of recurrent episodes of right lower quadrant pain and diarrhea. Which finding on colonoscopy would suggest a diagnosis of Crohn disease rather than ulcerative colitis? A. aphthoid ulcerations and focal crypt abscesses in all layers of the bowel wall B. erythematous mucosa with a fine granular surface that looks like sandpaper C. lumpy, bumpy appearance of mucosa due to areas of inflamed but intact mucosa contiguous with ulcerated areas D. mucosal disease limited to the rectum

A. aphthoid ulcerations and focal crypt abscesses in all layers of the bowel wall -- active Crohn disease is characterized by focal inflammation and formation of fistula tracts. It can affect any part of the GI tract from mouth to anus.

A 34-year-old male presents complaining of a painful mouth sore for 2 days. He denies any alcohol or tobacco use and otherwise feels fine. Examination is significant for a 2-mm round ulceration with a yellow-gray center surrounded by a red halo on the right buccal mucosa. What is the most likely diagnosis? A. aphthous ulcer B. glossitis C. herpetic stomatitis D. leukoplakia

A. aphthous culcer -- common and relatively straight-forward to recognize. They appear as described and are found on nonkeratanized mucosa. They may be solitary or multiple and are typically recurring. The are usually 1-2mm but can be larger.

A 44-year-old overweight female presents with acute sharp epigastric pain 2 hours after a large meal. She vomited once. Which of the following examination findings will most likely be found on this patient? A. arrested inspiration with deep palpation of the right upper quadrant B. nontender palpable gallbladder on palpation of the right upper quadrant C. referred pain to the left lower quadrant with right lower quadrant palpation D. elevated jugular venous pressure on compression of right upper quadrant

A. arrested inspiration with deep palpation of the right upper quadrant -- RUQ abdominal tenderness with inhibition of inspiration on palpation constitutes a Murphy sign, indicative of cholecystitis.

On postoperative day 2 after an exploratory laparotomy under general anesthesia, a patient has a low-grade fever, tachypnea, and scattered rales. The patient is not coughing and denies shortness of breath. What is the most likely cause? A. atelectasis B. pneumonia C. pulmonary embolus D. congestive heart failure

A. atelectasis -- occurs in about 25% of patients after abdominal surgery. The effects of mechanical ventilation and postoperative analgesia cause a depression of the respiratory reflexes such as coughing, yawning, and periodic deep breathing that would otherwise expand collapsed alveoli (atelectasis). It typically develops within the first 48-hours after surgery and accounts for the vast majority of postoperative fevers.

A 52-year-old postmenopausal woman develops chest pain suggestive of angina. Fasting labs reveal glucose of 92 mg/dL, total cholesterol of 271 mg/dL, LDL of 127 mg/dL, HDL of 31 mg/dL, and triglycerides of 375 mg/dL. An exercise stress test is positive. What is the best therapy for her dyslipidemia? A. atorvastatin (Lipitor) B. cholestyramine (Questran) C. estradiol D. niacin

A. atorvastatin (Lipitor) -- will decrease TG and LDL while increasing HDL without the side effects associated with niacin (hot flashes) and cholestyramine (GI distress)

A 35-year-old male presents after a near-syncopal episode. He describes a 2-week history of palpitations, weakness, and dyspnea on exertion. He has been drinking alcohol daily due to the recent loss of his job. The patient's pulse is irregularly irregular. Which of the following is the most likely diagnosis? A.atrial fibrillation B.paroxysmal supraventricular tachycardia C.ventricular bigeminy D.premature atrial complexes

A. atrial fibrillation -- acute alcohol excess and alcohol withdrawal in predisposed individuals may precipitate atrial fibrillation. This syndrome is often termed the "holiday heart".

A 36-year-old sustained a low back injury in a pickup basketball game. The pain has been somewhat relieved with over-the-counter topical analgesic patches and aspirin. Today, he presents with fatigue and darkened urine. He appears jaundiced. Labs reveal low hemoglobin and hyperbilirubinemia. Smear reveals Heinz bodies and bite cells. Which of the following recommendations should be given to this patient? A. Avoid known oxidant drugs. B. Obtain platelet transfusions as directed. C. Refrain from contact sports. D. Undergo elective splenectomy as soon as possible.

A. avoid known oxidant drugs -- this patient likely has glucose-6-phosphate dehydrogenase (G6PD) deficiency. All other choices are unnecessary as hemolytic episodes are self-limiting and the spleen is not the offending problem. Patients should be warned to avoid drugs, such as aspirin, that cause oxidative stress.

A 12-year-old is brought to the emergency department after an altercation at school. Examination reveals postauricular ecchymosis. What does this finding indicate? A. a basilar skull fracture B. a contrecoup head injury C. an epidural hematoma D. a depressed skull fracture

A. basilar skull fracture -- the clinical signs of a basilar skull fracture include periorbital brusiing (raccoon eyes), postauricular ecchymosis (Battle sign), and leakage of CNS fluid from the ear or nose.

A fair-skinned patient with a long history of biopsy-proven benign actinic keratoses presents with another steadily thickening lesion on her right temple. Despite recommendations to limit sun exposure, the patient plays golf daily, uses no sunscreen, and intends to continue enjoying her retirement. What is the preferred evaluation for this lesion? A.biopsy the lesion B.culture only if ulceration occurs C.continued clinical observation D.monitor for symmetry, color variation, or border irregularity

A. biopsy the lesion -- actinic keratoses (AK) are the most common precancerous lesions in humans, and there is no definite way to distinguish AK and squamous cell carcinoma (SCC) without a biopsy. There is a continuum of clinical signs that makes distinction difficult. Increasing thickness, redness, pain, ulceration, and size suggest progression to SCC, but a biopsy is needed to definitively differentiate.

A 42-year-old white female presents for well-woman examination. She has a BMI of 28 kg/m2. What additional risk factor would indicate a need for screening for type 2 diabetes mellitus at this time? A. blood pressure of 142/94 mm Hg B. chronic resistant dermatophytosis C. HDL cholesterol 52 mg/dL D. previous delivery of a small-for-gestational-age baby at 38 weeks

A. blood pressure of 142/94mmHg -- the ADA and USPSTF recommend fasting blood glucose screening for all individuals older than 45 with BP >135/80. Screening in younger adults with BMI >25 should be done in the presence of one additional risk factor. Risk factors include elevated BP, family history of DM2, non-Caucasian race, history of large for gestational age birth, low HDL, PCOS, acanthosis nigricans, history of vascular disease, and a history of impaired fasting glucose or impaired glucose tolerance.

A 55-year-old smoker presents with a chronic cough. Chest x-ray reveals a 2-cm solitary perihilar nodule. Which of the following would provide the most useful information? A. bronchoscopy with biopsy B. computed tomography C. magnetic resonance D. sputum cytology

A. bronchoscopy with biopsy -- biopsy is needed to evaluate a pulmonary nodule for malignancy, unless the lesion is calcified or has been stable for years. New lesions greater than 0.5cm carry a higher rate of malignancy, especially in a smoker. Perihilar nodes are also accessible by bronchoscopy. Alternatively, a transthoracic fine-neede aspiration could be done to obtain tissue.

A 63-year-old male complains of acute loss of vision in the right eye that lasted about 2 to 3 minutes and completely resolved. He denies pain, blurriness, and motor deficits. What diagnostic study would be most helpful at this time? A. carotid Doppler recordings B. 24-hour Holter monitor C. CT scan of head D. carotid angiography

A. carotid Doppler recordings -- noninvasive and very sensitive to the degree of plaque and stenosis of the carotid arteries. This patient likely has experienced amaurosis fugax. The most likely source is ipsilateral carotid artery.

A patient presents with unilateral hearing loss. Weber reveals lateralization to the right ear. Rinne test reveals the following: RIGHT: bone conduction = 10 seconds, air conduction = 5 seconds; LEFT: bone conduction = 5 seconds, air conduction = 10 seconds. Which of these other physical exam findings is to be expected? A.cerumen impaction in the right ear B.effusion in the left ear C.otitis media in the left ear D.pain on palpation of tragus or mastoid area

A. cerumen impaction in the right ear -- cerumen impaction will block the ear canal. This would result in lateralization of the Weber test to the affected ear and would also cause bone conduction to be greater than air conduction in the same ear.

A 24-year-old female presents for routine gynecologic examination. History is significant for first birth at age 16 years and second at age 18 years. Since separation from her husband at age 19 years, she has had several sexual partners. Pelvic examination reveals condylomata acuminata on the labia. For what gynecologic neoplasm is this woman at highest risk? A.cervical cancer B.endometrial cancer C.ovarian cancer D.rectal cancer

A. cervical cancer -- HPV types 16, 18, 31, 35, and 35 appear to have the most oncogenic potential. Infection is associated with cervical cancer.

A 45-year-old male smoker is obese, does not exercise, and consumes a high-fat and high-sodium diet. He was recently diagnosed with angina by his health care provider. What lifestyle change will have the best long-term improvement to his risk profile? A.cessation of smoking B.low-fat and low-sodium diet C.improvement in exercise D.weight loss

A. cessation of smoking -- #1 preventable cardiac risk factor; the risk decreased by 50% 1-year after complete smoking cessation.

A 28-year-old female at 33 weeks' gestation complains of leaking fluid from her vagina since she woke up this morning. Examination with a sterile speculum reveals a collection of fluid in the posterior fornix. Which of the following tests would best confirm the presence of amniotic fluid? A. Check for ferning under a microscope. B. Look for clue cells on microscopic examination. C. Perform a guaiac test on the fluid. D. Test the fluid with nitrazine paper to see if it turns red.

A. check for ferning under a microscope -- ferning is seen when amniotic fluid is air-dried on a microscope slide.

A 35-year-old female presents with wrist pain. Examination reveals swelling of the proximal interphalangeal (PIP) joints and mild ulnar deviation bilaterally. She mentions that her mother and sister have similar findings. She is currently using NSAIDs with minimal relief. Which of the following is an appropriate treatment regimen at this time? A.Combine glucocorticoids (up to 10 mg/day) with a DMARD such as methotrexate. B.Discontinue NSAIDs and start glucocorticoids at 10 mg/day, increasing to 40 mg/day. C.Maintain her on NSAIDs and add 20 mg/day of glucocorticoids. D.Substitute acetaminophen for NSAIDs and add glucocorticoids 10 to 20 mg/day.

A. combined glucocortioids (up to 10 mg/day) with a DMARD such as methotrexate -- in RA, glucocorticoids may be used in conjunction with DMARDs only up to 10mg/day. Once DMARDs are effective, steroids should be tapered and removed.

A 58-year-old obese female with stable exertional angina presents with an irregular, pruritic, weeping lesion just above the medial malleolus. The surrounding skin is hyperpigmented and slightly edematous. What is the most important intervention to minimize the incidence of similar lesions in the future? A. compression stockings B. daily topical steroids C. lower extremity elevation D. regular aerobic exercise

A. compression stockings -- frequent ambulation and wearing compression stockings will reduce edema, improve venous return, and minimize the risk of future leg ulcers from venous insufficiency. Note: regular aerobic exercise is important but will be leff effective than compression stockings as a preventative intervention against venous stasis ulcers.

A 30-year-old male complains of insidious yet progressive malaise, fever, weight loss, and dyspnea, which do not improve after three visits to primary care. He has been treated with a course of macrolide antibiotics and supportive measures. Lungs are clear. Chest radiography reveals bilateral hilar and right paratracheal adenopathy. Erythrocyte sedimentation rate is elevated; WBC count is low. What is the recommended treatment? A.corticosteroid B.cyclosporin C.minocycline D.thalidomide

A. corticosteroid -- first-line therapy for the treatment and suppression of sarcoidosis of the lungs.

A 56-year-old complains of eye pain and tearing as well as swelling and redness in the medial portion of his left eye. There is tenderness over the tear sac area with purulent material easily expressed. What is the best treatment for this condition? A. dacryocystorhinostomy B. probing of the nasolacrimal system C. systemic antibiotics D. topical antibiotics

A. dacryocystorhinostomy -- adults who develop dacryocystitis will respond to systemic antibiotics, but reccurence is the rule. Relief of obstruction is the only cure; dacryocystorhinostomy is the procedure of choice.

A 27-year-old presents with acute fever and headache. Examination reveals drowsiness, confusion, and nuchal rigidity. CSF analysis will most likely reveal which of the following? A. decreased glucose B. decreased protein C. elevated lymphocytes D. low opening pressure

A. decreased glucose -- CSF in bacterial meningitis would have decreased glucose secondary to consumption by the infecting organisms.

A 47-year-old male presents to the clinic complaining of severe pain in his lower jaw, fever, and facial swelling. He describes a constant, throbbing pain which prevents him from eating or sleeping because the pain intensifies if he tries to lie down. The patient's breath exhibits a foul odor and there is an erythematous, fluctuant, tender mass near the left lower third molar. What is the most likely diagnosis? A. dental abscess B. halitosis C. mumps infection D. sialadenitis

A. dental abscess - dental caries begin asymptomatically as a destructive process of the hard surface of the tooth. Over time, dental caries extend to the tooth pulp, which can lead to abscess formation. Abscesses are characterized by swelling, pain, and fever.

A 33-year-old presents complaining of cough. She had 2 days of cold symptoms (scratchy throat, congestion, postnasal drip) 6 days ago, which have cleared. She is left with an irritative cough that comes in spasms throughout the day. Which of the following is the recommended management at this time? A. dextromethorphan B. guaifenesin C. hydrocodone D. phenylephrine

A. dextromethorphan -- available without a prescription, is nonnarcotic, and may be useful in the treatment of patients with persistent coughing secondary to postviral bronchitis. Cough that persists longer than 2-weeks should prompt suspicion of pertussis.

A 29-year-old presents to primary care complaining of increased thirst and increased fluid intake. He has a history of significant head trauma due to a motor vehicle accident 6 months ago. He is drinking more than 90 oz of fluid per day and urinates frequently throughout the day and night. Physical exam is normal. Electrolytes are within normal limits. Serum osmolality is normal. BUN and creatinine are low. Random urine studies reveal the following: Urine dipstick: negative for heme, protein, ketones, and glucose Urine specific gravity: 1.000 (normal 1.002 to 1.035) Urine pH: 5.1 (normal 5.0 to 9.0) What is the most likely diagnosis? A. diabetes insipidus B. diabetes mellitus C. metabolic syndrome D. pituitary adenoma

A. diabetes insipidus -- central DI is caused by decreased ADH secretion and subsequent diuresis. This disease has many causes, including head trauma, brain surgery, TB. This patient has increased volume with decreased urine concentration. The next test to be completed would be a desmopressin challenge test. Note: lithium is the most common cause of nephrogenic DI

A 36-year-old with chronic temporomandibular joint disorder presents to the emergency department with acute pain and muscle spasm. What is the treatment of choice? A. diazepam (Valium) B. cyclobenzaprine (Flexeril) C. ketorolac (Toradol) D. amitriptyline (Elavil)

A. diazepam (Valium) -- using 10mg of diazepam IV will aid in muscle relaxation and decrease some of the patient's anxiety prior to manual reduction. Note: ketorolac (Toradol) will relieve the pain but not the muscle spasm; cyclobenzaprine is only PO and will not control the spasm associated with dislocation.

A 62-year-old male has had increasing shortness of breath over the past several months. He presents today because his feet are so swollen that he cannot wear shoes. He has a long history of hypertension, which has been erratically treated due to unacceptable side effects to most agents. Physical exam reveals elevated jugular venous pressure, rales throughout both lung fields, an S3 gallop, and 3+ pitting edema to the midcalf bilaterally. The cardiac apex is laterally displaced. ECG demonstrates sinus tachycardia and a left bundle branch block. What type of cardiomyopathy is most likely? A.dilated B.hypertrophic C.restrictive D.Takotsubo

A. dilated -- dilated cardiomyopathy account for about 90% of cases. It is more common in men and symptoms are those of left or biventricular failure.

A person with early Alzheimer disease will have difficulty with recent memory (word recall) on the Mini-Mental Status Examination. What other task would most likely be diminished as well? A. drawing a clock B. object naming C. reading comprehension D. writing a sentence

A. drawing a clock -- persons in the early stages of Alzheimer disease will typically have difficulties with memory and visuospatial abilities. The "mini-cog" test consists of a clock-drawing test and a three-item word recall. Note: object naming, reading comprehension, and writing a sentence are generally not affected in *early* Alzheimer disease.

Which of the following describes the triad of features that constitute the female athlete syndrome? A.eating disorder, low bone mineral density, amenorrhea B.eating disorder, dyspareunia, low bone mineral density C.menstrual dysfunction, depression, eating disorder D.menstrual dysfunction, low bone mineral density, hyperthyroidism

A. eating disorder, low bone mineral density, amenorrhea -- the classic *female athlete triad* syndrome is mentrual dysfunction (usually amenorrhea), an eating disorder, and low bone mineral density (osteopenia/osteoporosis). Note: on some board questions, the eating disorder aspect of the triad is replaced with patient complaints of "low energy".

A 46-year-old male has recently been diagnosed with metabolic syndrome. Extensive evaluation revealed no structural heart disease and he currently has no dyspnea on exertion, orthopnea, edema, or paroxysmal nocturnal dyspnea. His father, older brother, and paternal grandfather all died in their early 60s of heart failure. Of the following recommendations for prevention of heart failure, which is most appropriate at this time? A. encouraging regular exercise B. implanting a defibrillator C. initiating a β-blocker D. severely restricting dietary salt

A. encouraging regular exercise -- this man has stage A heart failure; that is, he is at risk for failure but without structural heart disease or symptoms of failure. Appropriate measures including encouraging exercise, treating lipid disorders, discouraging alcohol and smoking, and controlling hypertension and metabolic syndrome.

A 32-year-old male, a furniture mover by trade, presents with a history of left-sided scrotal pain. He states that 2 days ago, he noticed some soreness in his scrotum. The pain radiated to his left flank; he thought he had pulled a muscle. The pain gradually increased in intensity over the ensuing 48 hours. He has developed dysuria and subjective fever. On examination, his temperature is 39°C (102.2°F); there is some scrotal swelling present and a tender, enlarged scrotal mass. What is the most likely diagnosis? A.epididymitis B.hydrocele C.testicular torsion D.sliding inguinal hernia

A. epididymitis -- usually have a relatively acute onset, accompanied by fever, dysuria, and an enlargement of the epididymis. Most cases have an infectious etiology and/or can follow heavy physical strain. Early in the onset of symptoms, the epididymis may be palpated. As the condition or infection progresses, the epididymis becomes indistinguishable from the testis. Often, elevation of the scrotum will help relieve the pain.

A 23-year-old female presents with increasing cough for 3 weeks. The cough is worse at night and occurs in "waves" lasting 5 to 10 minutes and causing gasping inhalations. Posttussive vomiting has occurred on several occasions. The cough was preceded by mild cold symptoms. She completed all immunizations needed to begin public school and has no known drug allergies. What is the treatment of choice for her condition? A. erythromycin B. oral glucocorticoids C. supportive care D. trimethoprim-sulfamethoxazole

A. erythromycin -- macrolide antibiotics are the drugs of choice for treatment of pertussis. The incidence of pertussis has grown, prompting a recommendation to consider booster vaccines every 10-years.

Six weeks ago, a patient began multidrug treatment for pulmonary tuberculosis, which was contracted in an inner city homeless shelter. The patient now complains of difficulty seeing, dull eye pain exacerbated with eye movement, and loss of color discrimination. Which of the following is the most likely cause of this complaint? A.ethambutol B.rifampin C.isoniazid D.pyrazinamide

A. ethambutol -- optic neuritis is the most common adverse effect of ethambutol. The likelihood of occurrence is increased with higher doses and length of administration. Additional explanation: Rifampin = liver dysfunction, rash, flu-like syndrome. Isoniazid = hepatitis, peripheral neuropathy; optic neuritis is rare. Pyrazinamide = hyperuricemia and hepatitis.

A 64-year-old thin white female undergoes DEXA scan. Her T score is −2.3 SD (standard deviations). How frequently should this test be repeated to monitor her status? A.every 1 to 2 years B.every 3 to 5 years C.every 5 to 7 years D.every 7 to 10 years

A. every 1-2 years -- recommendations based on T-score: - T score: -1.0 to -1.5 = every 5 years - T score: -1.5 to -2.0 = every 3-5 years - T score: -2.0 or worse = every 1-2 years

An 8-year-old boy is brought in for evaluation of a chronic rash on his trunk. Examination reveals multiple erythematous, scaling plaques and papules with raised borders and some central clearing. What is the best next step in management? A.Examine scrapings in a 20% KOH solution by direct microscopy. B.Culture scrapings on Sabouraud glucose medium. C.Obtain multiple punch biopsies and submit for pathology. D.Culture scrapings on blood agar.

A. examine scrapings in a 20% KOH solution by direct microscopy -- in a suspected dermatophyte infection, it is appropriate to collect scales with a scalpel blade or edge of a glass microscope slide, place in a 5% to 20% KOH solution, heat gently, and examine for hyphae or mycelium.

A patient has a 4-mm flat lesion on her posterior lower thigh. Its color is variegated purple and black, and it has well-demarcated margins. What is the preferred evaluation method? A.excisional biopsy B.KOH prep C.punch biopsy D.Wood's lamp assessment

A. excisional biopsy -- any lesion suspected to be malignant melanoma must be biopsied. Excisional biopsy is preferred, especially with small focal lesions. Excision is also the first step in treatment. A lesion does not have to meet all criteria (asymmetry, borders, color, diameter) to be suspicious. Note: tumor thickness is the single most important prognostic factor for patients with localized melanoma.

A 43-year-old male complains of several episodes of chest pain. Each episode occurs with exertion and is relieved with rest. He denies cigarette smoking and alcohol abuse. His lipid profile is normal. What is the most appropriate diagnostic study for evaluating this patient? A. exercise stress test B. myocardial perfusion scintigraphy C. electrocardiography D. echocardiography

A. exercise stress test -- noninvasive, inexpensive, and has a 70% sensitivity and 75% specificity in diagnosing angina due to coronary artery disease.

A 16-year-old presents with abdominal pain that began periumbilical and has localized to the right lower quadrant. She is nauseous and has no appetite. What is the most likely precipitant of this event? A.fecalith B.neoplastic hyperplasia C.growth of intestinal polyp D.viral infection

A. fecalith -- obstruction due to a fecalith is the most common inciting event in appendicitis.

A patient presents after several episodes of recurrent diarrhea over the past 2 weeks. He describes one to two bulky, foul-smelling stools daily, followed by several days of more frequent watery episodes, then with several days of apparent resolution. Other than mild fatigue and some mucus passed with the stools, there are no other symptoms. What organism is most likely responsible? A. Giardia lamblia B. Campylobacter jejuni C. Salmonella spp. D. Bacillus cereus

A. giardia lamblia -- incubates for 1-3 weeks, causes foul-smelling bulky stools with few other symptoms, and may wax and wane over weeks before resolving. It is a parasite acquired through contaminated water. Campylobacter --> incubates 2-10 days + fever and bloody diarrhea. Salmonella --> incuates 8-48 hours + fever, nausea, and diarhea +/- blood x3-5 days. Bacillus cereus -- incubates <18 hours + vomiting and diarrhea, both of which resolve in 24-hours.

A 25-year-old inebriated man, who is otherwise healthy, presents to the ED with right upper chest pain after he fell against a coffee table. Chest x-ray shows a small pneumothorax. The patient is admitted for serial chest films and observation. Which of the following is the most appropriate initial therapy for this patient? A.high-flow oxygen B.albuterol metered-dose inhaler C.intravenous prednisone D.prophylactic heparin

A. high-flow oxygen -- if the pneumothorax is small but the patient is mildly symptomatic or unlikely to cooperate with follow-up, admit the patient and administer high-flow oxygen. The resulting nitrogen gradient will speed resorption.

A 53-year-old G7P7007 presents with complaints of urinary incontinence that has become progressively worse over the past 2 months. She states that the incontinence is made worse with coughing or sneezing and when going up stairs. She denies any muscle weakness or suprapubic discomfort. The patient states that she has not had a period in 5 months. Physical exam reveals no evidence of vaginal atrophy. Examination reveals good sphincter tone. Which of the following is the most appropriate intervention? A.instruction in pelvic muscle exercises B.intermittent urinary catheterization C.oxybutynin (Ditropan) D.topical estrogen cream

A. instruction in pelvic muscle exercises -- this patient most likely has stress incontinence due to laxity of the pelvic diaphragm as well as a lack of estrogen causing leakage from the bladder when there is an increase in intra-abdominal pressure. Pelvic muscle exercises (Kegel) are most helpful in the treatment of stress incontinence, by strengthening the pelvic musculature. Patients should perform Kegel 50-60 times per day in sets of 10-20. Note: the most common type of incontinence in the elderly is *urge incontinence*. Stress incontinence is the most common type in younger women, and the second most common type in the elderly.

A 27-year-old female presents with progressive unilateral loss of vision over the last 36 hours. She complains of mild pain in the eye, which worsens when performing extraocular movements. Examination reveals loss of color vision and a relative afferent pupillary defect. What is the most likely diagnosis? A. optic neuritis B. central retinal artery occlusion C. amaurosis fugax D. uveitis

A. optic neuritis -- has a mild to profound visual loss that develops over hours to a few days with visual field defects that are varied and common; extraocular movements often exacerbate the variable pain. Loss of color vision and a relative afferent pupillary defect are found on examination. The optic nerve is inflamed in about 1/3 of cases. Optic neuritis is strongly correlated with demyelinating diseases.

A 4-year-old girl is brought to the clinic by her mother who states that the child has been complaining of progressively worsening ear pain and itchiness over the past week. Examination reveals left tragal tenderness and an edematous and closed canal. Weber lateralizes to the left. What is the most likely diagnosis? A.otitis externa B.otitis media C.otosclerosis D.TM perforation

A. otitis externa -- OE is an infection of the external auditory canal secondary to trauma or a consistently moist environment, which favors growth of fungi or bacteria. It generally presents with canal itching and pain with movement of the ear. If the canal is closed, Weber is expected to lateralize to the side of the blocked canal. Note: Pseudomonas aeruginosa is the most common organism associated with OE. Treatment is generally a topical fluoroquinolone (e.g., Ciprodex -- $$, Ofloxacin).

A 64-year-old nursing home resident complains of pain and swelling of the penis. Examination reveals a swollen retracted foreskin with marked edema and mucopurulent drainage. What is the most likely diagnosis? A. paraphimosis B. penile carcinoma C. Peyronie disease D. urethritis

A. paraphimosis -- inability to retract the foreskin over the glans. In paraphimosis, the foreskin has been retracted over the glans but has failed to reduce to its normal position. This causes venous congestion, swelling, and eventually the arterial supply can be compromised. Surgical intervention is required if it fails to reduce manually.

A 48-year-old homeless male presents to the indigent care clinic with abdominal pain and tenderness, anorexia, and nausea. Examination is significant for palpation of the liver border 5 cm below the right inferior costal margin at the midclavicular line. He admits to drinking 1 to 3 bottles of liquor per day. His skin and sclerae are jaundiced. AST, ALT, and GGTP are elevated threefold above normal. Besides abstinence from alcohol, what is the most effective treatment measure for this patient? A. pentoxifylline B. cholestyramine C. immune globulin D. pegylated interferon

A. pentoxifylline -- the clinical presentation of alcoholic liver disease can vary from an asymptomatic hepatomegaly to a rapidly fatal acute illness or end-stage cirrhosis. A recent period of heavy drinking, complaint of anorexia and nausea, and the demonstration of hepatomegaly and jaundice strongly suggest the diagnosis. Abstinence is essential. Pentoxifylline reduces the risk of hepatorenal syndrome. Note: pentoxifylline (Trental) is a hemorheologic agent that lowers blood viscosity and has been shown to decrease portal hypertension in experimental animals with cirrhosis, as well as been found to have inhibitory effects on TNF.

A patient gives a history of vertigo episodes over the last several years. Each episode occurs about 10 seconds after quick movement of the head and lasts about 1 minute. An MRI done a year ago was negative. What is the recommended management? A. Perform maneuvers that provoke vertigo. B. Lie completely still and rest until the episode resolves. C. Continue normal activities as usual. D. Hyperventilate for 1 to 3 minutes when episodes begin.

A. perform maneuvers the provoke the vertigo -- patients with chronic positional vertigo may respond to habituation menuevers or PT routines. Dix-Hallpike maneuvers can be diagnostic as well as therapeutic.

A 45-year-old female presents for evaluation of pain in both hands. Examination reveals symmetric distal interphalangeal joint involvement. The nails are noted to be ridged with associated pitting and onycholysis. Erythrocyte sedimentation rate (ESR) and serum uric acid are elevated. What is the most likely diagnosis? A. psoriatic arthritis B. reactive arthritis C. rheumatoid arthritis D. systemic lupus erythematosus

A. psoriative arthritis -- characterized by silvery plaques on an erythematous base. Patients may develop joint disease. Nail pitting is common. Arthritis precedes or occurs simultaneously with skin disease in 20% of cases.

The Allen test should be performed prior to arterial puncture of which of the following arteries? A. radial B. carotid C. brachial D. femoral

A. radial

A patient is admitted to the hospital with an idiopathic spontaneous pneumothorax successfully treated with tube thoracostomy. The patient is interested to know if he will experience a recurrence of this disorder. What is the most accurate response? A. Recurrence occurs in up to 30% of patients and is treated by obliterating the pleural space. B. Recurrent spontaneous pneumothorax will heal more quickly with subsequent occurrences. C. He is more likely to develop a tension pneumothorax with subsequent occurrences. D. There is no data to support recurrence rates in idiopathic spontaneous pneumothorax.

A. recurrence occurs in up to 30% of patients and is treated by obliterating the pleural space -- spontaneous pneumothorax recurs in 30% of patients usually within 2-years. The majority are ipsilateral. Treatment in recurrent episodes is either administration of a noxious agent into the pleural space to obliteral the space or a partial pleurectomy with overseweing of apical blebs or abrasions of the space.

A woman brings her elderly father to the emergency department due to bizarre motor activity. She states he has severe Alzheimer disease and was begun on haloperidol (Haldol) about 4 weeks ago due to increasing psychotic behavior. Which of the following is the most likely motor activity he is displaying? A.repetitive, rhythmic tongue protrusion and opening and closing of the mouth B.brief, repetitive localized muscle twitches commonly of the face C.occasional, brief sudden jerks of the extremities, especially when falling asleep D.brief, florid, irregular movements that interrupt normal motion

A. repetitive, rhythmic tongue protrusion and opening and closing of the mouth -- tardive dyskinesia often occurs after onths or years of psychotropic medications and is characterized by repetitive, rhythmic, stereotypic movements of the face, mouth, tongue, and sometimes, limbs and trunk. It can happen after a short trial or after chronic use of a psychotropic medication.

A man who was found unconscious is brought to the emergency department. He is hypotensive, tachycardic, and febrile. Laboratory findings include an elevated white blood cell count, elevated lactic acid, a low platelet count, and a normal hematocrit. Swan Ganz is placed and reveals decreased preload, decreased afterload, and decreased systemic vascular resistance. What is the most likely diagnosis? A.septic shock B.neurogenic shock C.cardiogenic shock D.hypovolemic shock

A. septic shock -- characterized by hypotension, tachycardia, decreased preload, decreased SVR, and often fever. Severe sepsis may present with hypothermia. Alkaline phosphatase will be elevated, whereas platelets and other coagulation factors are often decreased.

Which of the following laboratory results is most consistent with a diagnosis of primary hyperparathyroidism? A.serum calcium 11.5 mg/dL (normal 8.5 to 10.5 mg/dL) B.ionized calcium 3.2 mg/dL (normal 4.6 to 5.3 mg/dL) C.serum magnesium 1.1 mEq/L (normal 1.3 to 2.1 mEq/L) D.serum phosphate 3.0 mg/dL (normal 2.5 to 4.5 mg/dL)

A. serum calcium 11.5 mg/dL -- hypercalcemia (greater than 10.5 mg/dL) is the hallmark of primary PTH. Note: ionized calcium levels are also always increased (>5.3); serum magnesium is not affected by primary PTH; and serum phosphate is usually low.

A patient develops an acute onset of shaking chills 10 minutes into a random donor platelet transfusion. Other than a mild fever, vital signs are normal and there is no evidence of rash, urticaria, or respiratory difficulty. Which of the following would be the best course of action? A.Slow the transfusion and administer acetaminophen and diphenhydramine. B.Slow the infusion and administer dexamethasone (Decadron). C.Stop the transfusion and follow the acute transfusion reaction protocol. D.Stop the transfusion and begin a broad-spectrum intravenous antibiotic.

A. slow the transfusion and administer acetaminophen and diphenhydramine -- this is a common uncomplicated reaction that occurs in about 30% of platelet transfusions; it is due to the presence of donor white blood cells.

A 25-year-old female presents with multiple chronic complaints involving joints, gastrointestinal tract, and headaches. You are the fifth practitioner the patient has seen in the last 6 months; she brings her medical records to the appointment. The records include the appropriate medical workup for her complaints, and all results are negative. Which of the following is the most likely diagnosis? A.somatization disorder B.major depression C.conversion disorder D.obsessive-compulsive disorder

A. somatization disorder -- patient meets all criteria including age of onset, gender, and negative medical work-up. Note: conversion disorder is a monosymptomatic somatoform disorder wherein patients will experience a neurologic or medical deficity in which the etiology is psychological.

A 35-year-old female comes to the office complaining of acutely inflamed and painful left eye. Her symptoms began 2 days ago. There is some visual blurring associated with her symptoms. The patient wears contact lenses. Examination reveals diffuse inflammation of the left conjunctiva; fluorescein staining reveals a shallow, dendritic ulcer in the center of the cornea. What is the recommended management? A. trifluridine (Viroptic) B. moxifloxacin (Vigamox) C. olopatadine (Patanol) D. prednisolone (Pred Forte)

A. trifluridine (Viroptic) -- herpes keratitis in an ummunocompetent host typically resolves in 2-3 weeks. Antiviral treatment is used to prevent stromal damage and scarring. Referral to ophthalmology is warranted.

A 72-year-old female presents with fatigue, dyspnea, and angina. Physical exam reveals pale conjunctiva, a grade II pulmonary flow murmur, glossitis, and decreased vibratory sensation in the lower extremities. CBC shows macrocytic indices and pancytopenia with macro-ovalocytes and hypersegmented neutrophils. Reticulocyte count is less than 2%. What is the most likely diagnosis? A.vitamin B12 deficiency B.defect in hemoglobin synthesis C.folate deficiency D.iron deficiency

A. vitamin B12 deficiency -- the clinical picture and macro-ovalocyes and hypersegmented neutrophils suggest B12 deficiency. Note: folate deficiency also causes a macrocytosis and hypersegmented neutrophils but not peripheral neuropathy.

A patient has been diagnosed with schizophrenia that is resistant to conventional medication. He is started on clozapine. Which of the following laboratory values must be monitored weekly? A. white blood cells B. red blood cells C. platelets D. absolute lymphocytes

A. white blood cells -- agranulocytosis occurs in 1-2% of patients treated with clozapine. Risk is higher in those of Ashkenazi Jewish ancestry. Weekly white blood cell counts should be strictly monitored for the first 6-months of treatment; if WBC is stable, monitoring can be done less frequently after that. Weekly monitoring must resume when the drug is discontinued as well.

After his best friend had a myocardial infarction, a 49-year-old male comes in for medical care for the first time in many years. He is 72 inches tall and weighs 210 lb. His diet consists of a moderate amount of fat; he has never smoked, drinks alcohol only on rare occasions, and plays basketball or touch football on weekends. Blood pressure is 138/86 mm Hg. He thinks it would be easiest to embark on a program of more regular physical activity as a first step to lifestyle modification. How much is his systolic blood pressure likely to drop if he is able to walk briskly for 30 minutes on most days of the week? A. 2 to 4 mm Hg B. 4 to 9 mm Hg C. 5 to 20 mm Hg D. 8 to 14 mm Hg

B. 4 to 9 mmHg -- engaging in regular aerobic exercise for 30 minutes most days of the week results in a reduction of SBP of 4-9mmHg

In the newborn, failure to pass meconium is a common sign of Hirschsprung disease. Meconium should be passed within what time after birth? A.12 to 18 hours B.24 to 48 hours C.72 hours D.1 week

B. 24 to 48 hours -- Hirschsprung disease, the primary absence of parasympathetic ganglion cells in a segment of the colon, interrupts the motility of the intestine. The absence of peristalsis causes feces to accumulate proximal to the defect, leading to intestinal obstruction. Meconium should be passed within 24-48 hours.

What is the normal respiratory rate in the newborn? A. 20 to 30/min B. 30 to 60/min C. 50 to 70/min D. 60 to 90/min

B. 30 to 60/min

As a general rule, sutures in the face and neck should be removed in how many days? A.1 to 2 days B.4 to 5 days C.7 to 8 days D.10 to 14 days

B. 4 to 5 days

At 1 minute, a newborn displays the following signs: heart rate of 96 bpm; slow, irregular breathing; active motion; grimaces when catheter is inserted into nostril; and a pink body with slightly blue extremities. What is the Apgar score? A.5 B.6 C.7 D.8

B. 6 -- APGAR score for this newborn is calculated as followed: heart rate (1 point), respiratory effort (1 point), muscle tone (2 points), response to catheter in nostril (1 point), and color of extremities (1 point). The score should be recorded at 1 and 5 minutes after birth.

A known alcoholic is seen in the emergency department. Workup reveals inflamed gingivae; petechiae; rough, dry skin; anemia; and impaired wound healing. This patient is likely deficient in what vitamin? A.A B.C C.E D. K

B. C -- Vitamin C is necessary for biosynthesis of collagen, carnitine, bile acids, and norepinephrine; deficiency results in scurvy. It most commonly develops in alcoholics or elderly due to dietary inadequacy. Deficiency in: - Vitamin A = night blindless; loss of color vision. - Vitamin E = neuronal degeneration + areflexia/gait disturbances. - Vitamin K = bleeding.

A patient is brought to the emergency department after falling and hitting his head on the sidewalk. He has been unconscious for 8 minutes. Which of the following is the most important diagnostic test to do at this time? A.skull radiography B.CT scan of the head C.cervical spine radiography D.lumbar puncture

B. CT scan of the head -- CT scan will best identify potentially life-threatening intracranial bleeding as well as any fractures or mass effect caused by cerebral edema. Why not C? Although all patients with head injuries must have cervical spine fractures ruled out, neck films may be deferred by stabilizing the neck while more urgent conditions are addressed.

Which of the following ethnic groups in the United States have the highest incidence of Rh negativity? A.African Americans B.Caucasians C.Indo-Eurasians D.North American Indians

B. Caucasians -- 15-16% incidence

A 16-year-old presents with fever, sore throat, fatigue, malaise, anorexia, and myalgia. Examination reveals anterior and posterior cervical lymphadenopathy, exudative pharyngitis, and splenomegaly. What is the most likely etiologic agent? A. cytomegalovirus B. Epstein-Barr virus C. rubeola virus D. varicella virus

B. Epstein-Barr virus -- EBC is the cause of mononucleosis, a disease spread by salivary secretions. Lymphadenopathy (particularly the posterior chain) occurs in greater than 90% of patients, wehreas pharyngitis occurs in about 80%, and splenomegaly in 50%.

Which of the following indicates viral replication and infectivity for a patient with chronic hepatitis B? A. HBsAg (−); anti-HBs (+) B. HBsAg (+); HBeAg (+) C. HBcAg (+); anti-HBe (−) D. anti-HBs (+); anti-HBe (+)

B. HBsAg (+); HBeAg (+) -- chronic HepB with active viral replication.

A patient who has diabetes and known coronary heart disease has a fasting LDL cholesterol of 175 mg/dL, HDL cholesterol of 35 mg/dL, and a triglyceride level of 255 mg/dL. Which of the following is the first-line choice of pharmacotherapy for this patient's hyperlipidemia? A.nicotinic acid B.HMG-CoA reductase inhibitor C.fibric acid D.bile acid sequestrant

B. HMG-CoA reductase inhibitor -- "statis"; effective in lowering TG and LDL, and increasing HDL.

A 28-year-old presents with acute swelling of the cheek, which worsens with meals. Examination reveals an erythematous and edematous tender parotid duct; purulent material is expressed with massage. What is the most appropriate next step? A. fine-needle biopsy B. IV antibiotics C. lithotripsy D. supportive care

B. IV antibiotics -- treatment of sialadenitis includes IV antibiotics (i.e., nafcillin) and increasing salivary flow (hydration, warm compresses, sialogogues, gland massage).

Which of the following ECG findings is the most reliable indicator of myocardial ischemia during an exercise stress test? A. J-point elevation of the ST segment greater than 1 mm B. J-point depression of the ST segment greater than 1 mm C. a decrease in R-wave amplitude D. transient left-axis deviation

B. J-point depression of the ST segment greater than 1mm -- most reliable for ischemia. J-point elevation of the ST segment greater than 1mm is most suggestive of an infarct.

A 35-year-old skier reports knee pain and instability after a sudden stop. Which test would be best to confirm the suspected diagnosis? A. Apley B. Lachman C. McMurray D. Thompson

B. Lachman -- test assesses the anterior cruciate ligament which is commonly injured during sudden stress to the knee. Note: Lachman is more sensitive than the anterior drawer test for ACL rupture.

A 19-year-old male college student presents with an asymptomatic rash extending over his upper trunk, shoulders, and neck. The hypopigmented, annular lesions vary in size from 4 to 5 cm in diameter to larger, confluent areas. There is no visible scale associated with the lesions. What organism is the most likely cause of his symptoms? A. Candida albicans B. Malassezia furfur C. Staphylococcus aureus D. Trichophyton rubrum

B. Malassezia furfur -- the patient has tinea versicolor, which is caused by an overgrowth of the yeast organism Malassezia, a common skin colonizer of all humans.

A 55-year-old with mild osteoarthritis presents with swelling of the right knee. He describes intermittent pain and a feeling of locking or giving way over the past week. Physical exam reveals tenderness at the knee joint line. Which of the following maneuvers is the most reliable and useful in diagnosing the suspected disorder? A.Lachman test B.McMurray test C.Finkelstein test D.straight leg raise test

B. McMurray test -- typically positive in the presence of a medial meniscus injury. (Pearl: for ACL tear, the Lachman test -- pulling the tibia forward while holding the patient's thigh at 20-30 degree flexion -- is more sensitive than the anterior drawer test).

A 40-year-old "weekend" athlete presents with 3 weeks of worsening hip pain. Examination reveals tenderness at the greater trochanteric region at the lateral hip which exacerbates with external rotation of the hip. Which of the following is the best initial therapy? A. aspiration B. NSAIDs C. antibiotics D. injectable steroids

B. NSAIDs -- first line therapy for trochanteric bursitis caused by trauma or overuse.

A 14-year-old male is noted to be limping after track practice. Examination reveals swelling and tenderness of the left tibial tuberosity. Radiography is negative for fracture but reveals some overlying soft-tissue swelling and ossification of the tibial tuberosity. What is the most likely diagnosis? A. jumper's knee B. Osgood-Schlatter disease C. osteochondral fracture D. torn medial meniscus

B. Osgood-Schlatter disease -- typically seen in 12-14 year olds. It is a vriant of traction apophysitis and occurs when the muscle assocaited with the inserting tendon becomes tight. Stretching of the quadriceps muscle will reproduce the pain.

A 52-year-old male presents with unilateral left-sided hearing loss that has progressed over 2 months. His wife states that he has difficulty discriminating words, although he can hear the sounds. He has also experienced some imbalance lately, but he contributes this to trying to do too many things too quickly. Which of the following is the likely pattern of testing on physical exam? A. Rinne air conduction greater than bone conduction; Weber lateralizes to left. B. Rinne air conduction greater than bone conduction; Weber lateralizes to right. C. Rinne bone conduction greater than air conduction; Weber lateralizes to right. D. Rinne bone conduction greater than air conduction; Weber lateralizes to left.

B. Rinne air conduction greater than bone conduction; Weber lateralizes to the right -- this patient liekly has an acoustic neuroma. Sensorineural hearing loss will result in air conduction greater than bone conduction and a contralateral Weber.

A 10-year-old presents with his parents who are concerned about their son's school difficulties. He has consistently been unable to stay in his seat and has great trouble focusing on his school work. He also has difficulty following direction, is easily distracted, and is often forgetful about what he is assigned to do. What is the most appropriate pharmacologic choice for this patient? A. a benzodiazepine B. a methylphenidate preparation C. a sedative hypnotic D. a selective serotonin reuptake inhibitor

B. a methylphenidate preparation -- such as Ritalin, if the first-line pharmacologic treatment of attention-deficit hyperactivity disorder.

A 28-year-old was found unconscious on his back. It was unknown how long he had been down. A Foley catheter returns dark brown urine. Urinalysis reveals 4+ hemoglobin and 4+ protein. Microscopy reveals no RBCs; however, there are many granular casts. Serum creatinine is 3.5 mg/dL and K+ is 6.2 mEq/L. What is the most likely diagnosis? A. acute interstitial nephritis B. acute tubular necrosis C. postrenal azotemia D. prerenal azotemia

B. acute tubular necrosis -- ATN secondary to myoglobin release from being unconscious on his back for an unknown length of time (rhabdomyolysis). This is confirmed by the acute tubular epithelial cell (granular) casts, lack of RBCs in the urine with positive hemoglobin on urine dip, and an increase in the serum creatinine.

What is the most common cause of obstruction of the small intestine in adults? A.hernia B.adhesion C.neoplasm D.gallstones

B. adhesion -- cause 60% of all mechanical small bowel obstructions in adults

A local nursing home has reported that six patients have developed high fever, chills, headache, dry cough, and myalgia. Several other patients have not received the annual influenza vaccine due to religious preference. What is the recommended treatment for the unimmunized residents? A.Administer a single dose of amantadine followed by rimantadine for 5 days. B.Administer oral dose of oseltamivir daily for 7 days. C.Increase oral intake and supplement with high doses of vitamin C. D.Isolate the residents because no effective drugs are available.

B. administer oral dose of oseltamivir daily for 7-days -- oseltamivir or zanamivir is recommended as both treatment and prophylaxis in high-risk groups in times of outbreaks.

A 62-year-old female presents to the emergency room profoundly dehydrated after several bouts of watery diarrhea. She describes the diarrhea as "rice water" in color. She believes the shellfish she ate yesterday was improperly cooked. The diarrhea and dehydration associated with this disease are primarily the result of which of the following? A.an endotoxin component of the pathogen's cell wall B.an enterotoxin actively secreted by the pathogen C.direct destruction of the GI tissue by the pathogen D.the immune response of the body in eliminating the pathogen

B. an enterotoxin actively secreted by the pathogen -- cholera is an acute diarrheal disease that can, in a matter of hours, result in profound, rapidly progressive dehydration and death. The characteristic water diarrhea ("rice water") is due to the action of cholera toxin, a potent protein *enterotoxin* produced by the organism after is colonizes the small intestine. Local outbreaks in the United States are typically associated with consumption of contaminated, locally harvested shellfish.

A 25-year-old male presents with fatigue and weakness. Physical exam reveals temperature of 99.4°F, purpura, pallor, and traces of gingival bleeding. There is no hepatosplenomegaly. A CBC shows normochromic normocytic anemia, granulocytopenia, and thrombocytopenia. What is the most likely diagnosis? A.sideroblastic anemia B.aplastic anemia C.acute leukemia D.hemolytic anemia

B. aplastic anemia -- this is a classic presentation of aplastic anemia: a pancytopenia due to bone marrow failure. Patients experiencing idiopathic aplastic anemia are at high-risk to develop blood neoplasia.

A 28-year-old who is training for a marathon complains of progressively worsening pain in the left foot. Initially, it was relieved with rest but now is persistent. Examination reveals pain on palpation of the fifth metatarsal. Which of the following is the best test to confirm the suspected diagnosis? A.plain radiography B.bone scan C.CT scan D.MRI

B. bone scan -- most sensitive and definitive test for stress fractures. It will show uptake in the area of the stress fracture before anything appears on plan radiography. Plan radiography is usually negative early in the course of a stress fracture. Days or weeks may pass before the fracture line or new bone formation becomes visible. Note: UpToDate is not a fan of bone scans for stress fractures. They recommend initial plain radiographs which, if negative, can be followed by MRI (both sensitive and specific, versus a bone scan which has low specificity). UpToDate considers MRI to be the best imaging modality for stress fractures.

After 3 days of amoxicillin, a patient discontinued treatment for a sinus infection. Five days later, he is brought to the emergency department due to headaches of several days' duration, decreased sensorium, and new-onset seizure activity. Examination reveals focal neurologic signs and a temperature of 100.4°F. Pertinent laboratory values include elevated ESR and PMN leukocytosis. Which of the following is the most likely diagnosis? A. brain tumor B. brain abscess C. cerebral infarction D. encephalitis

B. brain abscess -- usually presents with headache, focal neurologic deficits, and seizures. Decreased sensorium, drowsiness, and confusion may also be present. Approximately 50% of patients have low-grade fever. Laboratory studies may show leukocytosis with a predominance of polymorphic nucelocytes and an elevated sedimentation rate.

A patient with a 10-year history of schizophrenia, currently on risperidone (Risperdal), presents because she has been feeling very sad. She states that she does not want to do her usual activities and just sits at home. She has had similar episodes in the past, but they resolved after several weeks. When she first presented 10 years ago, her symptoms included hearing voices that she believed came from God and getting messages from the radio and television. Pharmacologic treatment of this patient should include the addition of what medication? A.atomoxetine (Strattera) B.carbamazepine (Tegretol) C.nefazodone (Serzone) D.olanzapine (Zyprexa)

B. carbamazepine (Tegretol) -- mood stabilizer that has been shown to be effective in the treatment of schizoaffective disorder, particularly the depressive type.

A college student presents for evaluation of lower abdominal pain and increased vaginal discharge with "an embarrassing odor." A swab of mucopurulent cervical discharge is stained, and, when examined, reveals abundant neutrophils and Gram-negative intracellular diplococci. What is the recommended treatment? A. ceftriaxone (Rocephin) and acyclovir (Zovirax) B. ceftriaxone and azithromycin (Zithromax) C. ceftriaxone and ciprofloxacin (Cipro) D. ceftriaxone and penicillin G

B. ceftriaxone and azithromycin (Zithromax) -- this patient likely has gonorrhea. Appropriate treatment is ceftriaxone or cefixime. Infected patients should be empirically treated for chlamydia infection as well. Azitrhomycin and doxycycline are the recommended agents.

A 5-year-old male presents with crusting facial lesions present for 3 days. The mother reports that prior to the development of the facial lesions, her son was scratching at insect bites. Examination reveals confluent erosions with honey-colored crusts below the left nares and across each cheek. Temperature is 99.8°F. Which of the following is the most appropriate treatment? A.acyclovir B.cephalexin C.doxycycline D.hydrocortisone

B. cephalexin -- provides appropriate coverage for impetigo caused by Staphylococcus and Streptococcus species. Systemic antibiotics are recommended with widespread or complicated infections, or if systemic symptoms are present: fever, malaise, etc. Topical treatments (mupirocin, bacitracin) may be sufficiency for *very* mild cases that are limited in extent.

A 22-year-old with sickle cell anemia presents to the emergency department with acute pain and swelling of the lower tibia. He is febrile and lethargic and reluctant to move the leg. CT scan shows cortical bone destruction. Which of the following antibiotic regimens is indicated? A. ceftriaxone 1 g IV daily for 48 hours B. ciprofloxacin 400 mg IV three times a day for 6 weeks C. itraconazole 200 mg po twice a day for 6 months D. tetracycline 250 mg po three times a day for 3 months

B. ciprofloxacin 400mg IV TID x6-weeks -- Staphyloccocus aureus is a common cause of osteomyelitis in patients with sickle cell anemia. Suspected cases should be treated with a FQ for 4-6 weeks. It may be combined with rifampin. Salmonella is also a possible cause but less likely than Staph aureus. Treatment is the same.

A 54-year-old is brought to the emergency department after losing consciousness. Just prior to the event, he complained of an acute severe headache unlike anything he had ever experienced before. He is now conscious but likely displays which of the following symptoms? A.amnesia B.confusion and irritability C.weakness and lassitude D.parietal scalp tenderness

B. confusion and irritability -- most patients with SAH regain consciousness but display confusion and irritability. Other patients may progress to coma depending on the size of the hemorrhage.

A 14-year-old girl complains of itchy, watery eyes and clear rhinorrhea that has continued 3 days since completing an overnight spring camping trip. Examination reveals hyperemia with clear, stringy discharge. The papillae on the upper tarsal conjunctivae are enlarged. Which of the following is most important to include in patient management? A. saline irrigation B. cool compresses C. soft eye patch D. frequent hand washing

B. cool compresses - supportive therapy for symptomatic relief of allergic eye disease +/- topical H1 receptor antagonists.

A 28-year-old G3P2002 at 29 weeks' gestation presents complaining of a gush of fluid from her vagina. Ferning test is positive. She is afebrile, and the fetal heart tracing is reactive and reassuring. Which of the following is the next step in management? A.cesarean section B.corticosteroids C.oxytocin D.send patient home on bedrest

B. corticosteroids -- recommended in PROM patients prior to 32-weeks' gestration to enhance fetal lung maturity.

A 59-year-old male with a 30-pack-year smoking history complains of painless hematuria that has been present for the past 3 weeks. He denies trauma. Urinalysis reveals gross hematuria. Which of the following is the best next step? A.CT of pelvis B.cystoscopy with biopsy C.intravenous pyelogram D.MRI of pelvis

B. cystoscopy with biopsy -- bladder carcinoma presents with painless hematuria in 85-90% of cases. Although bladder cancer can be detected by ultrasonography, CT sca, or MRI, only a cystoscopy with biopsy will establish the diagnosis with certainty.

A 43-year-old who is overweight complains of dull achiness of the lower legs whenever standing for prolonged periods of time. Which of the following is most likely to be found on physical exam? A.decreased posterior tibia and dorsalis pedis pulses B.dilated tortuous veins in posterior thigh and leg C.loss of pigment over the thighs and shins D.pitting edema in bilateral ankles

B. dilated tortuous veins in the posterior thigh and leg -- varicose veins are either asymptomatic or produce dull pain with exertion.

A 5-year-old girl presents with sore throat, sudden onset fever, and upper respiratory symptoms. On examination, she has mild inspiratory stridor and is leaning forward and drooling. She appears toxic. Vitals reveal a temperature of 102.5°F, respiratory rate of 26, and heart rate of 110 bpm. What is the next step in managing this patient? A. administration of aerosolized racemic epinephrine B. endotracheal intubation C. lateral neck radiography D. oropharyngeal examination using a tongue blade

B. endotracheal intubation -- epiglottitis constitutes a medical emergency in children . Direct fiberoptic laryngoscopy is frequently performed in a controlled environment (e.g., opeartive room) in order to visualize and culture the typical edematous "cherry red" epiglottis and to faciliate placement of an endotracheal tube. Immunization against H.flu has resulted in a dramatic decrease in incidence of epiglottitis; cases occur in underimmunized on in specific Streptococcus spp. pharyngitis.

A 12-year-old complains of sore throat. Examination reveals edema and erythema of pharyngeal mucosa with gray-white exudate, cervical adenopathy, and a temperature of 101.0°F. She is allergic to penicillin. What is the recommended management? A. supportive care only B. erythromycin ethyl succinate (EES) C. amoxicillin-clavulanate potassium (Augmentin) D. cephalexin (Keflex)

B. erythromycin ethyl succinate (EES) -- an effective alternative treatment for patients allergic to penicillin. PCN is first-line therapy for streptococcal pharyngitis.

A 52-year-old obese Caucasian male with a history of chronic gastroesophageal reflux presents with increasing dysphagia. He describes pain on swallowing and occasional regurgitation. He continues to smoke one pack of cigarettes daily, as he has for the past 30 or more years. He also enjoys a 4-oz glass of whiskey three times weekly. On examination, his weight is down 10 lb from a visit 1 month ago. What is the most likely diagnosis? A.Barrett esophagus B.esophageal cancer C.gastric adenocarcinoma D.infectious esophagitis

B. esophageal cancer -- progressive dysphagia and weight loss of short duration are the initial symptoms in the vast majority of patients with esophageal cancer. Dysphagia initially occurs with solid foods and gradually progresses to include semisolids and liquids. By the time these symptoms develop, the disease is usually incurable, because difficulty in swallowing does not occur until greater than 60% of the esophageal circumference is infiltrated with cancer.

A 30-year-old female complains of involuntary movements of her hands and head which have developed over the last 6 months. The movements are rhythmic and are worsened with emotional stress and lessened with alcohol intake. What else is likely in this patient's history? A. exposure to high-dose estrogen B. family history of similar complaints C. gait disturbances D. progressive hoarseness

B. family history of similar complaints -- essential tremor is an autosomal dominant disorder. The tremors can begin at any age and characteristically affect the hands, head, or voice.

A patient presents to the emergency department with constant epigastric pain for 6 hours with nausea and vomiting for 3 hours. The pain is not relieved with the vomiting. Abdomen is tender and bowel sounds are minimal; there are ecchymoses on the flanks. Which of the following laboratory findings would indicate the poorest prognosis? A. LDH greater than 350 U/L; white blood cell count greater than 12,000/µL; AST over 100 units/L B. glucose greater than 200 mg/dL; white blood cell count greater than 16,000/µL; LDH 400 mg/dL C. white blood cell count greater than 16,000/µL; serum LDH greater than 200 U/L; AST over 100 U/L D. white blood cell count greater than 16,000/µL; AST over 100 U/L; serum calcium less than 10 mEq/L

B. glucose >200; WBC >16k; LDH 400 -- Ranson Criteria is generally used to asses the severity of acute pancreatitis. When three or more of the following findings are present, a severe course of complicated pancreatitis can be predicted, placing the patient at risk for adverse outcome: - age > 55 - WBC > 16k - glucose >200 - serum LDH >350 - AST >250 Additionally, development of the following in the first 48-hours indicates a worsening prognosis: - HCT drop >10% - BUN rise >5 - arterial PO2 <60mmHg - serum Ca <8 - base deficit >4 - est. fluid sequestration >6L

An 8-month-old boy is brought to the rural clinic by his mother. He was born at home and has not been seen by a pediatrician. The child is irritable, is not eating well, and easily fatigues. He appears jaundiced. Fingerstick hemoglobin is 7.2 g/dL. Additional labs reveal an elevated reticulocyte count and a peripheral smear showing 20% nucleated RBCs/HPF and 10% sickled cells. Which of the following tests would be most appropriate to order next to confirm the diagnosis? A. IgG autoantibodies B. hemoglobin electrophoresis C. Coombs test D. osmotic fragility

B. hemoglobin electrophoresis -- in sickle cell anemia, the peripheral blood smear usually showed nucleated RBCs; greater than 5% sickled hemoglobin is highly suggestive of the disease. Confirmation is by hemoglobin electrophoresis to quantify the percentage of hemoglobin S.

A 67-year-old has been admitted to the hospital for community-acquired pneumonia. She is dehydrated, weak, hypotensive, and has a cough productive of thick, green phlegm. Examination reveals coarse lung sounds throughout all lung fields. She is started on IV levofloxacin at admission and develops diarrhea on day 4 of treatment. Which part of her history places her at greatest susceptibility for the development of Clostridium difficile infection? A.community-acquired pneumonia B.hospital admission C.history of diverticulosis D.patient's age

B. hospital admission -- antibiotic-associated colitis is a significant clinical problem almost always caused by Clostridium difficile infection. Hospitalized patients are most susceptible, especially those who are severely ill or malnourished. C. difficile colitis is the major cause of diarrhea in patients hospitalized for more than 3-days. Characteristically, the diarrhea occurs during the period of antibiotic exposure, is dose related, and resolved spontaneously after discontinuation of the antibiotic. Patients who develop severe diarrhea may benefit from a course of MTZ, vancomycin, or fidaxomicin.

A 4-month-old is brought to the office; mother describes 3 days of clear rhinorrhea and low-grade fever. Today, the child has developed rapid breathing and wheezes. Examination reveals shallow, rapid respirations; retractions; and nasal flaring. Lungs are clear. What is the cornerstone of management? A. antibiotics B. humidified oxygen C. racemic epinephrine D. glucocorticoids

B. humidified oxygen -- this child has severe bronchiolitis and meets criteria for hospitalization. The most important therapy for bronchiolitis is humidified oxygen delivers via mask, hood, or tent. The child may also benefit from a course of ribavirin.

A worried mother brings her 3-year-old son to the emergency department with fever of 104°F, sore throat, and refusal to eat. The parents are migrant farm workers who recently emigrated from Mexico. On physical exam, the patient is cyanotic and tachypneic and has obvious signs of respiratory distress, including inspiratory stridor and retractions. He is drooling. What is the first step in the management of this patient? A. direct visualization of the patient's throat using a tongue blade and laryngoscope B. immediate protection of his airway with intubation or tracheostomy C. intravenous administration of penicillin and gentamicin D. radiography of the lateral neck with soft-tissue window

B. immediate protection of his airway with intubation or tracheostomy -- once the airway is secured, blood and throat cultures should be obtained. Administration of a second or third-generation cephalosporin is indicated for coverage of Haemophilus influenzae. Mass vaccination has led to decrease incidence of H.flu in developed countries. Other pathogens include GAS, Strep pneumo, Haemophilus parainfluenza, and Staph aureus. This child, from Mexico, may be unvaccinated.

A 60-year-old male with a history of moderately severe chronic obstructive pulmonary disease has recently weaned off a long course of corticosteroids. He presents now with headaches that are worse with straining. He also complains of double vision and blurriness. What is most likely to be found on physical exam? A. carotid bruit B. papilledema C. positive Romberg sign D. resting tremor

B. papilledema -- pseudotumor cerebri (benign intracranial hypertension) may develop after stopping corticosteroids, as a complication of otitis or mastoiditis, with endorcine abnormalities, or with certain medications. Papilledema and blind spots are seen on physical exam.

A patient is 12 hours post closed reduction of a tibial fracture and is in a long leg cast. Despite an injection of meperidine (Demerol), the patient complains of unrelieved pain and cannot move his toes. What is the best option for the management of this problem? A. Elevate the leg on an extra pillow. B. Immediately split the cast medially and laterally. C. Explain that this pain is typical of an early fracture and observe for several hours. D. Remove the cast completely.

B. immediately split the cast medially and laterally -- the treatment of suspected compartment syndrome is to split or bivalve the cast immediately, allowing circulation to the distal aspect of the limb. Note: although complete removal could be done, the original application was required to the reduce the fracture. The removal of the cast completely could cause further injury to the fracture site.

What is the most common type of hernia? A.direct inguinal B.indirect inguinal C.umbilical D.femoral

B. indirect inguinal

The morning after an eating and drinking binge, a 39-year-old obese male presents with exquisite pain in the left ankle. Examination reveals a red, hot, swollen medial malleolus. He is afebrile. Which of the following is the treatment of choice? A. allopurinol (Zyloprim) B. indomethacin (Indocin) C. propoxyphene (Darvon) D. colchicine

B. indomethacin (Indocin) -- NSAIDs are the treatment of choice for acute gout. Indomethacin and naproxen are acceptable choices.

A 35-year-old G1P0 presents to labor and delivery at 38 weeks complaining of headache and right upper quadrant pain. Blood pressure is 160/110 mm Hg; cervix is 1 cm dilated, 50% effaced, and at −2 station. Urine dipstick shows +3 protein and negative for ketones and leukocytes. Fetal heart tracing is reactive and reassuring. Which of the following is the best intervention at this time? A. cesarean section B. induction of labor C. more labs are necessary to determine management D. send home on bed rest

B. induction of labor -- this patient has severe preeclampsia defined by elevated BP and proteinuria during pregnancy. It most commonly occurs in primiparous women who are close to term (but can occur any time after 20 weeks' gestation). Preeclampsia can progress to eclampsia (seizures) and death so it is managed aggressively. The best management is delivery of the fetus. Because both mom and fetus are stable, induction of labor is warranted. Note: although more labs are indicated, they are not necessary in making the diagnosis, and waiting for thei results could delay delivery of the fetus.

A 30-year-old obese white female presents with fatigue and generalized weakness for several weeks. Physical exam reveals mucosal pallor and an atrophic tongue. Laboratory data shows a microcytic, hypochromic appearance to the RBCs. Which of the following is the most likely diagnosis? A.pernicious anemia B.iron deficiency anemia C.folate deficiency D.β-thalassemia minor

B. iron deficiency anemia -- presents with fatigue/weakness; onset is often insidious. Laboratory values and physical presentation are consistent with iron deficiency anemia. Note: b-thalassemia minor also presents with microcystic, hypochromic anemia but physical exam abnormalities are unusual.

A 55-year-old who drinks alcohol daily and smokes 1 pack per day recently attended a high school reunion at a large hotel. During the reunion, the hotel experienced numerous problems with their air-conditioning system. Three days later, he began to experience nausea, vomiting, headache, fever, and productive cough associated with pleuritic chest pain and dyspnea. Examination reveals temperature of 103.8°F, pulse rate of 64 bpm, and scattered rales and rhonchi. What is the recommended treatment? A. doxycycline B. levofloxacin C. penicillin D. rifampin

B. levofloxacin -- azithromycin or a FQ are considered firstline treatment in Legionella pneumonia.

Which of the following is the best description of erysipelas? A. a group of small, pinpoint, follicular pustules found on the upper outer aspect of the upper arms or anterior thighs that often remain unchanged for years B. localized painful, distinctly demarcated, raised erythema and edema often with streaking and prominent lymphatic involvement C. one pustule or a group of pustules, usually without fever or other systemic symptoms, which may be found on any skin surface D. originates as a small vesicle or pustule that ruptures to expose a red, moist base; a crust of honey-yellow to white-brown firmly adheres as the lesion expands

B. localized painful, distinctly demarcated, raised erythema and edema often with streaking and prominent lymphatic involvement

A 16-year-old has had asthma since age 7 years. He uses combination fluticasone and salmeterol (Advair Diskus 100/50) twice per day. He has breakthrough wheezing requiring albuterol less than once per week. He claims his asthma does not interfere with daily activities. Lungs are clear on examination. What is the most appropriate recommendation? A. Perform spirometry every 6 months. B. Maintain a self-administered peak flow record. C. Instruct patient to call at onset of symptoms. D. Have patient schedule follow-up visits when needed.

B. maintain a self-administered peak flow record -- this patient has chronic stable persistent asthma. A peak flow record and a medication response are most important in managing asthma. Peak flow measurements are simple and can be self-administered. Any change from baseline should prompt adjustment in management and communication with the clinician.

A 10-year-old presents with ear pain. Examination reveals edema of the external auditory canal producing an anterior and inferior displacement of the auricle with percussion tenderness posteriorly. What is the most likely diagnosis? A.acute otitis externa B.mastoiditis C.otitis media D.malignant otitis externa

B. mastoiditis -- caused by an acute otitis media that was not treated adequately. auricular displacement = mastoiditis.

A 3-year-old girl is brought in by her mother who is concerned about a rash that started on her daughter's face 3 days ago and moved downward to her trunk and extremities including the palms and soles. The rash is starting to fade and flake from the head and face. Prior to the rash, the child had fever, runny nose, sneezing, and a dry cough. The mother states that the child has not been immunized due to religious beliefs. Examination reveals an erythematous maculopapular rash on the face, trunk, and extremities. There are discrete lesions on the trunk and extremities, whereas lesions of the face and neck appear confluent and with brownish discoloration and fine scaling. What is the most likely diagnosis? A. erythema infectiosum B. measles C. rubella D. scarlet fever

B. measles (rubeola) -- highly contagious; disease is characterized by fever, malaise, coryza, and cough. Koplik spots (bluish-white spots on the buccal mucosa) appear before the exanthem and are pathognomonic. The maculopapular lesions are erythematous and appear from a head-to-toe distribution; desquamation also occurs in a head-to-toe fashion.

A 62-year-old male with a 10-year history of diabetes mellitus type 2 complains of frequency and hesitancy. He states his urinary stream is decreased, and he often feels as if he has not emptied his bladder. He has had a few episodes of incontinence. Examination reveals an enlarged, smooth prostate. Urinalysis is positive for WBCs and blood; culture is negative. Which of the following measures is most appropriate? A.Refer for bladder biopsy. B.Measure postvoid residual volume. C.Schedule cystometric testing. D.Perform urine cytology studies.

B. measure postvoid residual volume -- the picture is suggestive of urinary tract obstruction. A bladder catheter should be inserted after voiding to measure postvoid residual volume. A high residual volume is worrisome. Diabetics may have the added insult of neurologic bladder which would also lead to retention.

A 42-year-old obese female has tried diet and exercise for the past 4 months after a diagnosis of type 2 diabetes. She returns to the clinic for follow-up. Her hemoglobin A1c is 7.0, and her serum creatinine is normal; however, she presents with a 10-lb weight gain since her last visit. BMI is 30.5 kg/m2. Which of the following treatment options would be most appropriate at this time? A. bedtime insulin (NPH) B. metformin (Glucophage) C. glipizide (Glucotrol) D. continuation of diet and exercise

B. metformin (Glucophage) -- along with diet and exercise, is recommended for the treatment of obese patients with type 2 diabetes and a normal serum creatinine.

A 25-year-old female undergoes echocardiography for nonspecific chest pain and palpitations. Results indicate a floppy mitral valve. What finding was most likely present on physical exam? A. fixed split S2 B. midsystolic click C. late diastolic rumble D. early systolic ejection sound

B. midsystolic click -- hallmark of prolapse of the mitral valve. The click may be followed by a mid-to-late systolic murmur, indicating mitral valve regurgitation.

A 28-year-old female from Bangladesh is brought to the United States for evaluation and repair of a heart valve problem. Since having a febrile illness with sore throat and skin rash at age 23 years, she has been experiencing increasing exhaustion, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Physical exam reveals an opening snap just after S2 and a low-pitched diastolic murmur heard best at the apex. CXR demonstrates an enlarged left ventricle. What is the most likely diagnosis? A.aortic regurgitation B.mitral stenosis C.pulmonic regurgitation D.tricuspid stenosis

B. mitral stenosis -- common after rheumatic fever. The murmur and opening snap are as described.

A 53-year-old male is admitted with a compression fracture of the lumbar vertebra. Radiography reveals punched-out lytic lesions of the vertebral column. What is the most likely diagnosis? A.chondroblastoma B.multiple myeloma C.osteoporosis D.amyloidosis

B. multiple myeloma -- punched-out lytic lesions are characteristic of multiple myeloma. They are best visualized using plain radiography. Pathologic fractures are a common initial presentation.

A 33-year-old female presents to the emergency department with severe right flank pain that radiates to the groin. She is nauseous but afebrile. She is anxious and unable to lie still. Urinalysis shows marked hematuria and no casts. What is the most appropriate next step in the management? A.lithotripsy B.narcotic analgesia C.intravenous fluids D.helical CT scan

B. narcotic analgesia -- analgesia is the most appropriate treatment. The pain of an obstructing stone is exquisite. Due to the common presence of nausea, parenteral narcotics are commonly required. Helical CT will be done but imaging is improved with analgesia.

A mother of a 4-year-old is concerned about a bump on the child's wrist. Examination reveals a 1-cm solitary, soft, mobile, nontender lesion on the dorsal wrist. It transilluminates symmetrically. What is the recommended management? A.aspiration B.observation C.immobilization D.cortisone injection

B. observation -- asymptomatic ganglions are left untreated. Indications for surgical intervention include limitation of motion, pain, weakness, and peresthesias.

A 17-year-old male college student complains of left ear pain. Physical exam reveals tenderness on palpation of the tragus. Otoscopic examination reveals the tympanic membrane to be intact, gray, and mobile without bulging or retraction. Which of the following is the treatment of choice? A.amoxicillin (Amoxil) B.ofloxacin solution (Floxin otic) C.carbamide solution (Murine, Debrox) D.pseudoephedrine (Sudafed)

B. ofloxacin solution (Floxin otic) -- antibiotic ear drops are the treatment of choice for acute inflammatory otitis externa. Solutions containing an aminoglycoside (neomycin, polymyxin) or a fluoroquinolone are first line. A topical corticosteroid is often added.

A patient presents with a spontaneous pneumothorax of 10% on the right with associated chest wall pain. There is neither dyspnea nor a history of pulmonary disease. Which of the following is the most appropriate management plan? A. simple aspiration, then outpatient bed rest B. outpatient treatment with bed rest C. thoracotomy tube D. pleurodesis

B. outpatient treatment with bed rest -- outpatient treatment is adequate if there is less than 15% pneumothorax, no signs of tension pneumothorax, and no underlying lung disease. Air is reabsorbed from a small, spontaneous pneumothorax in a few days.

A 32-year-old homemaker complains of anterior shoulder and arm pain which worsens when lifting her child or pushing large items. Examination reveals tenderness most pronounced 3 inches below the anterior acromion. Which of the following is also likely to be found on examination of this patient? A.inability to abduct the shoulder greater than 30 degrees B.pain with forearm supination against resistance C.pain with forearm extension resistance D.tingling with percussion of the anterior wrist

B. pain with forearm supination against resistance -- palpation of the tendon within the bicipital groove reproduces intense pain of bicipital tendonitis. Forearm supination, one of the main actions of the biceps, will also reduce pain, especially when resistance is applied.

A patient presents with epigastric pain described as boring and radiating to the back. It is relieved with leaning forward. What organ is most likely involved? A.gallbladder B.pancreas C.distal small bowel D.duodenum

B. pancreas - the major symptom of acute pancreatitis is midepigastric or LUQ pain. It is described as constant, boring pain that often radiates to the back as well as the flanks, chest, or lower abdomen. Relief is often found with leaning forward or lying in the fetal position.

A 52-year-old G1P0010 with chronic obesity and irregular menses presents for a checkup. She reports having mild hot flushes for 6 months. For the past 14 months, she has had some irregular bleeding, which she characterizes "like a period," which occurs at 2- to 4-week intervals and lasts up to 10 days. She believes that the bleeding has been brought on by stress; she has some difficulty sleeping and increased emotional lability. Physical exam: height, 5 ft 2 inches; weight, 234 lb; BP, 160/90 mm Hg; and pulse rate, 88 bpm and regular. External genitalia is mildly atrophic. Cervix is parous. A small amount of dark blood is noted in the cervical os. The uterus is about 12-week size, irregular in contour, but difficult to delineate due to the patient's body habitus. In what life stage would this patient be considered? A. menarchal B. perimenopausal C. premenopausal D. postmenopausal

B. perimenopausal -- considered perimenopausal because she is still having periods, although not regular, and she is also having other menopausal symptoms such as hot flashes, trouble sleeping, and increased emotional lability.

A 38-year-old female G4P3003 at 27 weeks' gestation has a low hemoglobin and hematocrit and a serum ferritin of 10 µg/L. She admits to palpitations and dyspnea on exertion and greater fatigability than she remembers from prior pregnancies. What additional finding is most likely in this patient? A.paresthesias B.pica C.pruritus D.purpura

B. pica -- fairly common in iron deficiency anemia. Ice chips, chalk, or specific foodstuffs are common cravings.

A 56-year-old sustains a fracture of the left femur from a fall. While awaiting surgery, he suddenly complains of chest pain and severe dyspnea. SaO2 has fallen to 86%. ECG shows sinus tachycardia and nonspecific ST- and T-wave changes. Chest x-ray is normal. D-dimer is elevated. What type or description of the chest pain is this patient most likely experiencing? A. burning or gnawing B. pleuritic C. squeezing D. stabbing

B. pleuritic -- the pain of a PE is most likely pleuritic and increases with respiratory movement.

A 62-year-old female complains of pain and stiffness of the shoulders and hips along with malaise, weight loss, and lowgrade fever over the past month. Muscle strength is normal on examination. Passive range of motion is limited in all directions. Erythrocyte sedimentation rate is elevated. What is the best choice for treatment? A. ibuprofen B. prednisone C. indomethacin D. aspirin

B. prednisone -- symptoms of polymyalgia rheumatic respond quickly and dramatically to steroid administration. Because of this, dosages can usually be rapidly weaned to low-maintenance levels, minimizing side effects. Treatment may need to be continued for a year.

What is the hallmark electrocardiographic finding in Mobitz type I (Wenckebach) atrioventricular block? A. accordion-appearing QRS morphology B. progressive lengthening of the PR interval C. ventricular rate of less than 50 bpm D. widened QRS complexes

B. progressive lengthening of the PR interval.

A 63-year-old male who smokes complains of insidious onset of vague epigastric pain over the past several months. He also complains of anorexia, diarrhea, malaise, and difficulty sleeping. Labs reveal anemia, hyperglycemia, and elevated alkaline phosphatase and bilirubin. What is the most likely description of the pain? A.cramping quality after eating B.relief with sitting and leaning forward C.radiation to the left shoulder D.referral to the right lower quadrant

B. relief with sitting and leaning forward -- pain of pancreatic cancer may be lessened by sitting up and leaning forward. This indicates that the lesion has spread beyond the pancreas and is inoperable.

A 40-year-old man has one episode of painless gross hematuria. What is the initial management? A.Tell him to return if the bleeding recurs. B.Send urine sample for urinalysis and culture. C.Schedule him for IVP and cystoscopy. D.Prescribe antibiotics for probable UTI.

B. send urine sample for urinalysis and culture -- results will help guide further workup. (Note: cystoscopy is a component of second-line evaluation. It is indicated if bladder neoplasm or BPH is suspected as the cause based on urinalysis findings. IVP has been replaced to CT or MRI to image the upper urinary tract).

A 78-year-old male with a history of COPD is diagnosed with influenza and treated with supportive care and oseltamivir (Tamiflu). Three days later, the fever returns along with increased cough, sputum production, and sharp chest pain. Chest x-ray reveals consolidation in the right lower lobe. Which of the following organisms is a likely etiologic agent? A.Pneumocystis jiroveci (nee carinii) B.Staphylococcus aureus C.Klebsiella pneumoniae D.Mycoplasma pneumoniae

B. staphylococcus aureus -- bacterial pneumonia following influenza is most common in the elderly or in patients with chronic pulmonary, cardiac, or metabolic disease. Staphylococcus aureus, Strep pneumo, and H. flu are the most frequent pathogens.

A 68-year-old female is brought to the clinic by her husband with complaints of severe episodes of vertigo. This is her fourth attack this week. She is nauseous but has not vomited. She also reports fullness in her left ear accompanied by a low-tone blowing tinnitus and sensation of "fullness." Which of the following represents an appropriate treatment for this patient? A.oral steroids on an as-needed basis B.symptomatic care with antihistamines and diuretics C.topical antibiotic drops for 7 days D.vestibular suppressant medication until symptoms subside

B. symptomatic care with antihistamines and diuretics - antihistamines and diuretics (acetazolamide) in addition to a low-salt diet are the mainstays of treatment for Meniere disease.

What is the most common site of pathology in Crohn disease? A. the proximal jejunum B. the terminal ileum C. Auerbach plexus D. rectosigmoid junction

B. the terminal ileum -- regional enteritis, Crohn disease, can affect any site along the entire GI tract. The terminal ileum is most commonly involved.

At the age of 1 year, a child's weight should be how much compared to birth weight? A. twice his or her birth weight B. three times his or her birth weight C. four times his or her birth weight D. five times his or her birth weight

B. three times his/her birth weight -- a child should double weight by 6-months and triple by 1-year.

A 22-year-old female is complaining of a rash around her mouth. She describes a feeling of mild burning or tension but denies pruritus. Examination reveals papulopustules on erythematous bases; the vermillion border is spared. A culture is negative. What is the recommended management? A. ketoconazole cream B. topical metronidazole C. topical steroids D. warm compresses

B. topical metronidazole -- perioral dermatitis most often occurs in young women and is treated with topical MTZ. Topical erythromycin is also effective. If the lesions do not clear, systemic treatment with minocycline, doxycycline, or tetracycline may be tried.

A 58-year-old female is brought to the emergency room for recurrent episodes of severe right upper quadrant pain that lasts for hours. Ultrasonography has failed to show any abnormality on previous evaluations. She has a fever of 103.5°F and appears jaundiced. She is morbidly obese at 295 lb. Which of the following would be the most appropriate next step? A.abdominal plain film B.colonoscopy C.endoscopic retrograde cholangiopancreatography (ERCP) D.HIDA scan

C. ERCP -- fever, pain, jaundice = Charcot triad for ascending cholangitis. ERCP provides the most direct and accurate means of determining the cause, location, and extent of obstruction. If a stone or presence of cholangitis is suspected, ERCP is the procedure of choice because it permits sphincterotomy with stone extraction or stent placement. Note: the treatment of choice for cholangitis is always ERCP. Treatment with immediate cholecystectomy is associated with increased mortality. ERCP allows for decompression of the gallbladder. Removal comes later.

A 21-year-old male comes to the university health services because of a persistent lump in his neck. It has been present for about 4 months. The lump usually does not bother him, but he has experienced pain episodes intermittently, the most recent was the previous weekend after attending an end-of-term party. What is the most likely diagnosis? A. acute infectious mononucleosis B. acute lymphoblastic leukemia C. Hodgkin lymphoma D. lymphadenitis

C. Hodgkin lymphoma -- the presence of an enlarged lymph node that is painful after alcohol ingestion suggests Hodgkin lymphoma.

A 17-year-old male with type 1 diabetes mellitus presents with acute pain in the left knee, fever, chills, malaise, and anorexia. He denies trauma. On examination, the knee is warm, swollen, and red. Range of motion is severely limited secondary to pain. Which of the following is the most appropriate initial therapy? A. IV vancomycin B. po dicloxacillin C. IV ceftriaxone D. po ciprofloxacin

C. IV ceftriaxone -- 2nd or 3rd generation cephalosporins, such as ceftriaxone, provide good coverage for Staph and Neisseria gonorrhea -- the two most likely causative agents in this age group. It will also cover gram-negative enteric rods which may be the cause of nontraumatic septic arthritis in the ummunocompromised. Urgent drainage and debridement is also necessary.

Which of the following is the most appropriate test to differentiate chronic sinusitis from a tumor? A. CT without contrast B. sinus radiographs C. MRI with contrast D. sinus endoscopy

C. MRI with contrast -- MRI with gadolinium is much more sensitive than CT to differentiate tumor from fluid, inflammation, and inspissated mucus.

A patient presents with concerns of thickening of fingers, oily skin, and coarsening voice, which has progressed over the past 1 to 2 years. Further questioning reveals shrinking testicles with loss of libido as well. Which of the following imaging tests is recommended? A. cerebral angiography B. CT of the head C. MRI of the head D. radiographs of the skull

C. MRI of the head -- the history is consistent with acromegaly which is caused by a pituitary tumor in 90% of cases. MRI is the preferred imaging modality.

A 25-year-old female with a history of chronic alcohol abuse presents with mild hematemesis and melena. Examination reveals a slightly overweight female with erosion of the front teeth and enlarged salivary glands. Bowel sounds are normal; abdomen is soft and nontender. What is the most likely cause of the bleeding? A. erosive esophagitis B. erosive gastritis C. Mallory-Weiss tear D. portal hypertension

C. Mallory-Weiss tear -- lacerations of the gastroesophageal junction. Most patients have a history of retching, vomiting, or heavy alcohol use. This patient also shows signs of bulimia, which is characterized by bing-purge behavior.

A 23-year-old male presents for evaluation of a productive cough that has been present for the past 3 weeks. He has additional complaints of fever and night sweats, weight loss, anorexia, general malaise, and weakness. Sputum Gram stain fails to reveal any organisms. What is the most likely etiologic agent? A. Bordetella pertussis B. Mycoplasma pneumoniae C. Mycobacterium tuberculosis D. Streptococcus pneumoniae

C. Mycobacterium tuberculosis -- rod-shaped, non-spore-forming, obligate aerobic bacterium. It is assocaited with negative gram staining and positive acid-fast staining. Presumptive diagnosis is made until cultures return.

A 62-year-old male with a history of stable angina presents with mild chest pain and shortness of breath. Pulse rate is 142 bpm and irregularly irregular, and BP is 90/50 mm Hg with mild orthostatic changes. ECG reveals erratic, disorganized atrial activity between discrete QRS complexes, which also occur in an irregular pattern. What is the immediate treatment of choice? A.β-blocker B.digoxin C.electric cardioversion D.pacemaker placement

C. electric cardioversion -- treatment of choice in an urgent situation with an unstable patient with shock and ischemia. A shock with 100-200J administered at the R-wave is the initial trial.

Which of the following histories best describes a presentation consistent with multiple sclerosis? A. a 35-year-old male with an acute 4-day history of bilateral leg weakness beginning in the feet and now extending as far as the thighs B. a 60-year-old female with a 2-month history of slowly increasing dysphagia, weakness in the extremities, ptosis, and diplopia C. a 32-year-old female with a several month history of recurrent, brief episodes of extremity weakness and tingling, diplopia, and vertigo D. a 50-year-old male with a 3-month history of weakness, stiffness, and loss of muscle mass in the arms and legs

C. a 32-year-old female with a several month history of recurrent, brief episodes of extremity weakness and tingling, diplopia, and vertigo -- MS is a disease with primary onset between 30-50 years of age characterized by recurrent episodes of sensory abnormalities, blurred vision, and weakness with or without spasticity. It is more common in females.

A 23-year-old male complains of frequency, urgency, and dysuria associated with fever and chills for 2 days. The patient states that he has difficulty starting his stream. Physical exam reveals a febrile patient with minimal suprapubic tenderness and moderate perineal tenderness. The remainder of the examination is unremarkable. What is the most likely diagnosis? A. acute cystitis B. acute epididymitis C. acute prostatitis D. acute pyelonephritis

C. acute prostatitis -- presents with irritative voiding symptoms and fever accompanied by perineal, sacral, or suprapubic pain.

A 38-year-old male continues to experience progressive dyspnea, wheezing, cough, and sputum production despite cessation of smoking 5 years ago. His father suffered from the same chronic respiratory problems until his death due to liver failure at age 52 years. The patient is on several bronchodilators including ipratropium, albuterol, and fluticasone. Which of the following should be recommended to this patient at this time? A. lung transplantation B. oral prednisone C. α1-antitrypsin D. supplemental oxygen

C. alpha-1-antitrypsin -- this patient is likely a-1-antitrypsin deficiency. Alpha-1-proteinase inhibitor (Prolastin) is a human protein that helps prevent breakdown of lung tissue, thereby reducing symptoms and prolonging life. Note: definitive treatment is liver transplant.

Which of the following medications has the greatest potential to trigger an acute asthma attack? A.narcotics B.chemotherapeutic agents C.aspirin D.ACE inhibitors

C. aspirin -- NSAIDs and aspirin can precipitate an acute asthma attack

A 23-year-old presents with a 2-day history of conjunctival injection, discomfort, and a yellow-green discharge from the eyes. Physical exam reveals bilateral conjunctival injection, clear lungs, and no lymphadenopathy. Which of the following is the most appropriate management? A. Begin topical antihistamines for allergic conjunctivitis. B. Begin warm compresses and advise good hand washing hygiene for viral conjunctivitis. C. Begin topical sulfonamide for bacterial conjunctivitis. D. Begin topical steroids and refer to an ophthalmologist for uveitis.

C. begin topical sulfonamide for bacterial conjunctivity -- bacterial conjunctivitis presents with a purulent discharge; typically there is no preauricular adenopathy. Treatment is with topical sulfonamide, gentamicin, tobramycin, norfloxacin, or trimethoprim polymyxin B sulfate. Good hand washing is advised, and contaminated pillows, makeup, and towels should be avoided to prevent reinfection.

The crystals of pseudogout are composed of what substance? A. calcium-containing salts B. monosodium urate monohydrate C. calcium pyrophosphate D. calcium oxalate

C. calcium pyrophosphate

A 14-year-old female presents to the emergency department with acute abdominal pain which began diffusely and has settled in the right lower quadrant. Examination reveals tenderness, rigidity, and rebound. Which of the following diagnostic tests would provide the highest accuracy rate for the most likely diagnosis? A.abdominal ultrasonography B.CBC with differential C.computed tomography of abdomen D.plain films of the abdomen

C. computed tomography of abdomen -- several studies demonstrated benefit over U/S and plain radiography in diagnosis of acute appendicitis. Nonvisualization of the appendix on CT is associated with a normal appenxid 98% of the time.

Which of the following pulmonary function test results is consistent with a diagnosis of emphysema-predominant COPD? A.decreased total lung capacity (TLC) B.increased diffusing capacity (DLCO) C.decreased ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC ratio) D.markedly decreased residual volume (RV)

C. decreased FEV1/FVC -- the ratio is reduced in all types of COPD.

A 31-year-old female complains of weakness and fatigue progressing over the last 3 months. Laboratory studies reveal a hemoglobin of 10.6 g/dL and a hematocrit of 37%. Which of the following lab results is also most likely present in this patient? A. decreased TIBC B. increased platelet count C. decreased serum ferritin D. increased reticulocyte count

C. decreased serum ferritin -- with iron deficiency anemia, depletion of iron stores occurs first, then iron reserves are lost, as indicated by reduced serum ferritin. Erythropoiesis is stimulated, TIBC rises, and serum iron is low. An increased platelet count may accompany an iron deficiency anemia but is not specific for diagnosis.

A 38-year-old female with a resolving upper respiratory infection develops fever, pleuritic substernal chest pain, and shortness of breath that is worse while lying down and better while sitting. A pericardial friction rub is noted on physical exam. Which of the following would most strongly support the suspected diagnosis? A.positive ASO titer B.cardiomegaly on chest x-ray C.diffuse ST elevation on ECG D.Gram-positive diplococci on sputum smear

C. diffuse ST elevation on ECG -- characteristic of pericarditis. As the disease progresses, the ST elevations return to baseline followed by T-wave inversion.

When visual acuity is recorded, what does the numerator indicate? A. number of items in the chart line incorrectly identified B. percentage of items in the chart line incorrectly identified C. distance in feet of the patient from the eye chart D. distance in feet at which a patient with normal vision can read the chart line

C. distance in feet of the patient from the eye chart

A 27-year-old elementary school teacher returns to clinic for reevaluation of a severe sore throat. She was seen earlier in the week, diagnosed with tonsillitis, and prescribed amoxicillin. Today, she reports she is still febrile and has malaise, odynophagia, dysphagia, and otalgia. She speaks with a "hot potato" voice and is drooling. Physical exam reveals tonsillar displacement, palatal edema, and uvular deviation. What additional intervention is most appropriate at this time? A.addition of oral steroids B.change of antibiotic to clindamycin C.emergent ENT referral for abscess drainage D.immediate intubation for airway maintenance

C. emergent ENT referral for abscess drainage -- appropriate antibiotic coverage for tonsillitis includes penicillins, macrolides, or clindamycin. For this patient, antibiotic coverage should be continued with the addition of abscess drainage. Change of antibiotics is not indicated.

A 13-year-old has been coughing for 10 days. It began as a dry cough but has now become productive of small amounts of white sputum. He also complains of headache, sore throat, and a pressure feeling in his ears. Examination reveals injected pharynx, no cervical adenopathy, and scattered rales. What is the treatment of choice? A. ampicillin B. gentamicin sulfate C. erythromycin D. supportive therapy only

C. erythromycin -- macrolides have highly specific activity against Mycoplasma pneumoniae. Although newer macrolides offer some advantages, erythromycin is effective and less expensive.

A 22-year-old male awoke with stiffness and pain on the left side of his face. Examination reveals drooping of the lower eyelid and loss of the nasolabial fold. Which nerve is affected? A. abducens B. trigeminal C. facial D. hypoglossal

C. facial -- Bell palsy is an idiopathic paresis of the facial nerve secondary to an inflammatory reaction. It may represent a reactivation of herpes simplex infection, but this has not been proven.

A 27-year-old male has a solitary, solid, 1-cm, firm nodule in the right side of his thyroid which was picked up on routine examination. Ultrasonography confirms a single solid mass with microcalcifications. What is the best next step? A.MRI of the neck B.excisional biopsy C.fine-needle aspiration and biopsy D.observation and reassess in 3 months

C. fine-needle aspiration and biopsy -- should be obtained for cytological evaluation of the thyroid mass tissue. It is minimally invasive and cost-effective

A patient complains of a strange motor phenomenon involving her left arm. The fingers of her left hand begin to jerk spasmodically, which progressively involves the forearm, upper arm, and shoulder, until the whole left upper extremity displays this activity. She does not lose consciousness. This is characteristic of which of the following types of seizure? A. grand mal B. petit mal C. focal motor D. myoclonic

C. focal motor -- a common type of focal motor seizure (previously referred to as simple partial seizure) involves motor symptoms that begin distally and progress to involve an entire limb or body. Other types of focal seizures invovle sensory or autonomic symptoms or affective disturbances or hallucinations. All focal seizures share the feature of no loss of consciousness.

A previously healthy 37-year-old businessman complains of a 1-week history of fever and abdominal pain. Further questioning reveals a prodrome of decreased appetite, nausea and vomiting, and general malaise. He denies diarrhea. He took a vacation to Mexico 5 weeks ago and business trip to the U.S. West Coast 2 weeks ago. He also ate at a new steak and seafood restaurant in town last week. He is in a heterosexual monogamous relationship of 4 years. Examination reveals a flat abdomen, normoactive bowel sounds, right upper quadrant tenderness, and negative Murphy sign. What is the most likely diagnosis? A.enterotoxigenic Escherichia coli B.giardiasis C.hepatitis A D.salmonellosis

C. hepatitis A -- transmitted via fecal-oral route. A common source is undercooked shellfish. The incubation period is about 30-days. Patient could have contracted this during his trip to Mexico. His symptoms are characteristic of HAV infection.

In early intestinal obstruction, what are the characteristic initial findings on abdominal auscultation? A. absent bowel sounds B. diminished bowel sounds C. hyperactive bowel sounds D. low-pitched, rumbling bowel sounds

C. hyperactive bowel sounds -- very common early in the course of intestinal obstruction. They are describes as high-pitches with occasional rushes (crescendo-decrescendo).

A 53-year-old male with diabetes type 2 has blood pressure readings in the 125/84 to 134/92 mm Hg range. Urinalysis is negative. He is prescribed an ACE inhibitor. This patient is at risk for which of the following serum chemistry abnormalities? A.hypernatremia B.hyperglycemia C.hyperkalemia D.hypomagnesemia

C. hyperkalemia -- a common side effect of ACE inhibitors due to increased potassium retention.

A 34-year-old previously healthy male presents with pleuritic chest pain relieved by sitting forward. He has a temperature of 102.5°F. Auscultation reveals a biphasic scratching sound heard best in the supine position. ECG reveals diffuse ST-segment elevations. What is the treatment of choice? A.acetaminophen B.broad-spectrum antibiotics C.ibuprofen D.nitroglycerin

C. ibuprofen -- NSAIDs are the treatment of choice in inflammatory pericarditis.

A 14-year-old boy sustains an inversion injury of the left ankle while playing basketball. Swelling and pain were immediate. Examination on the field reveals mild swelling and tenderness with full range of motion and a mild limp with weight bearing. What is the recommended treatment? A.early aggressive range of motion B.heat alternating with ice for the first 24 to 48 hours C.ice with progressive exercise against resistance as tolerated D.return to full use as soon as weight bearing is tolerated

C. ice with progressive exercise against resistance as tolerated -- radiographs are warranted if there is localized tenderness over the malleoli, tenderness beyond the ligament attachements, or excessive/unrelenting swelling or inability to bear weight.

A 79-year-old male with a history of mild COPD and hypertension controlled with hydrochlorothiazide presents with dyspnea. He states it began 2 days ago on exertion and has progressed over the last 12 hours to dyspnea at rest. Physical exam reveals an S3 and 2+ pitting edema to the ankles. Which of the following is also likely to be present? A. an ejection click B. the presence of a thrill C. jugular vein distention D. a fourth heart sound (S4)

C. jugular vein distention -- distention of the jugular vein indicates congestion due to RV failure. The most common cause of RV failure is LV failure.

A 13-year-old male complains of knee pain that gets worse throughout the day. Examination reveals tenderness and swelling over the proximal anterior tibia. Which of the following is also likely to be found in this patient? A.hip and knee pain that is worsened with internal rotation B.warm, swollen, painful knees C.knee pain that is exacerbated by descending stairs D.increased pain when walking on flat surfaces

C. knee pain that is exacerbated by descending stairs -- activity dependent on quadriceps muscle movement, such as ascending and descending stairs, exacerbates the knee pain experiences in Osgood-Schlatter disease, in inflammatory process of the tibial tuberosity.

A 27-year-old female complains of worsening dysmenorrhea and dyspareunia for the last 2 years. The pain has become constant and aching and is worse around the time of menses. Which of the following tests would provide the most definitive diagnosis? A. abdominal CT scan B. hysteroscopy C. laparoscopy D. pelvic ultrasonography

C. laparoscopy -- diagnostic laparscopy is the only way to definitively diagnosis endometriosis because many patients do not have abnormal findings on physical exam. Visualization is diagnostic.

. A 26-year-old female presents with a rash consisting of hypopigmented macules and papules with fine scales located on the lower back and abdomen. Which of the following laboratory findings is consistent with the most likely diagnosis? A. elevated white blood cell count with eosinophilia B. multinucleated giant cells C. large blunt hyphae with budding spores D. grapelike clusters of Gram-positive cocci on microscopy

C. large blunt hyphae with budding spores -- tinea versicolor is a yeast infection caused by Malassezia furfur. A scraping of the lesion placed on a slide with 10% KOH should reveal the classic large hyphae with budding spores ("spaghetti and meatballs") on micrscopic examination.

A 45-year-old with multiple health problems is concerned with an unintentional 10-lb weight gain and extreme fatigue that has progressively worsened over the last 4 months. History and physical exam findings are suspicious for hypothyroidism and are substantiated with the laboratory evaluation. Which of the following currently prescribed medications taken for other disorders should this patient discontinue, if possible? A. fluoxetine (Prozac) B. hydrochlorothiazide (HydroDIURIL) C. lithium (Lithobid) D. propranolol (Inderal)

C. lithium (Lithobid) -- medication used for controlling bioplar disorder, is a potential goitrogen and should be discontinued under the careful supervision of a psychiatrist until the exact cause of this patient's hypothyroidism is established.

A 42-year-old female presents for evaluation of asthma symptoms. She reports awakening one to two nights per week due to cough; she uses her β-agonist daily due to shortness of breath. She uses a β-agonist preexercise but has needed it during exercise as well for the past month. She is currently taking a low-dose inhaled corticosteroid daily in addition to the β-agonist. Besides continuing the short-acting β-agonist as rescue treatment and reevaluating in 2 weeks, what is the preferred treatment for this patient? A. high-potency inhaled corticosteroid B. low-potency inhaled corticosteroid plus a leukotriene receptor antagonist C. low-potency inhaled corticosteroid plus a long-acting β-agonist D. short course of oral steroids plus a medium-potency inhaled corticosteroid

C. low potency ICS + LABA -- preferred Step 3 treatment includes use of a low-potency ICS with the addition of a LABA. A medium-potency ICS would also be an option. Note: ICS + a leukotriene receptor antagonist, like montelukast (Singulair), is also an option but LTRAs are not the preferred treatment option.

A 32-year-old female presents to the office complaining of left lower extremity swelling and pain. She denies any history of trauma. Examination reveals a swollen left lower extremity that is 7 cm greater in size than the right at the level of the calf. What is the best next step in the diagnosis of this patient? A. bilateral lower extremity venography B. D-dimer blood assay C. lower extremity venous Doppler studies D. spiral CT of the chest

C. lower extremity venous Duppler studies -- diagnosis of DVT requires clinical suspicion as well as carefully chosen appropriate diagnostic studies. Currently, Doppler ultrasonography is the first step in making the diagnosis. It has a high sensitivity and high specificity.

A 65-year-old who presents with progressive, bilateral, central visual loss is found to have retinal drusen deposits on funduscopic examination. This finding is most consistent with which of the following diagnoses? A. cataract B. open-angle glaucoma C. macular degeneration D. vitreous hemorrhage

C. macular degeneration -- the precursor is age-related macular degeneration is age-related maculopathy, of which the hallmark is the development of retinal drusen.

A 52-year-old male was well until 2 days ago when he experienced a sudden onset of fever, shaking chills, and myalgias. Today, he also complains of headache and abdominal pain but no nausea, vomiting, or diarrhea. He denies stiff neck, photophobia, or altered mental status. He returned home 2 days ago after completing an extended photo safari trip to several countries in Central Africa. What is the most likely diagnosis? A.amebiasis B.dengue fever C.malaria D.toxoplasmosis

C. malaria -- protozoan disease transmitted by the bite of infected Anopheles mosquitoes. Malaria is a very common cause of febrile illness in tropical countries. Symptoms begin as nonspecific, then fever develops along with more toxic signs and symptoms. Diagnosis rests on demosntration o the parasite in stained peripheral blood smears ("thick and thin blood smears"). Note: Plasmodium falciparum infection can cause recurrent fever every 36-48 hours -- often referred to as falciparum malaria.

A 27-year-old male presents to the urgent care facility following a jamming injury to his second right digit while playing volleyball. He is unable to extend the finger at the DIP. Radiographs are negative. What is the name of this injury? A.boutonnière deformity B.gamekeeper thumb C.mallet finger D.trigger finger

C. mallet finger -- results from an object striking the end of the finger, resulting in forced flexion. Patients present with pain at the dorsal DIP joint, inability to actively extend the joint, and often a flexion deformity. An associated avulsion fracture may require surgical intervention.

A 9-year-old being treated for acute bacterial ethmoid sinusitis returns to the clinic 2 days later with complaints of pain and swelling in the left eye. Visual acuity is normal. Mental status is intact. Examination reveals periorbital edema and pain on movement of the extraocular muscles. The patient is febrile. What is the most likely diagnosis? A. conjunctivitis B. endophthalmitis C. orbital cellulitis D. uveitis

C. orbital cellulitis -- often rises from contigious spread of infection from the ethmoid sinus. Patients present with pain, lid erythema, proptosis, conjunctival chemosis, fever, leukocytosis, decreased acuity, and restricted extraocular muscle movement.

A 4-year-old is brought to the office by his mother because the day care teachers noticed he is unusually restless at school. The mother also noticed that he has not been sleeping well lately and has started wetting the bed at night. The child is alert and cooperative but scratches his buttocks while you are interviewing. Cellophane tape applied to the perianal area reveals football-shaped ova under the microscope. What is the medication of choice? A. fluconazole (Diflucan) B. itraconazole (Sporanox) C. mebendazole (Vermox) D. metronidazole (Flagyl)

C. mebendazole (Vermox) -- mebendazole, albendazole, or pyrantel is the treatment of choice for pinworm infections. Enterobius vermicularis is commonly diagnosed by identifying the eggs on cellophane tape applied to the perianal area.

A lesion involving which of the following will result in decreased sensation along the palmar aspect of the right thumb, second and third fingers, and half of the fourth finger? A. radial nerve B. ulnar nerve C. median nerve D. brachial plexus

C. median nerve -- the median nerve supplies the palmar aspect of the right thumb, second and third digits, and half of the fourth digit.

A patient with chronic renal failure secondary to diabetes mellitus has developed chronic constipation unresponsive to dietary changes and increased fluids. Which of the following should be avoided in attempts to relieve the constipation? A.docusate sodium (Colace) B.lactulose (Chronulac, others) C.milk of magnesia (MOM) D.psyllium (Metamucil, others)

C. milk of magnesia (MOM) -- patients with chronic renal insufficiency should avoid magnesium-containing compounds as they will not be able to readily excrete the magnesium. Excess magnesium will result in hypermagnesemia. Note: docusate sodium, lactulose, and psyllium are all safe to use in patients with chronic renal insufficiency.

A 28-year-old female aerobics instructor complains of intermittent chest pain for the past 2 months. The pain is sharp, lasts several hours, and has no apparent relationship to meals, activity, or stress. Physical exam is remarkable only for auscultation of a midsystolic click. Which of the following is the most likely diagnosis? A.esophageal reflux B.angina pectoris C.mitral valve prolapse D.costochondritis

C. mitral valve prolapse Note: beta-blockers are the treatment of choice for a young, healthy person with MVP

A 6-year-old girl recently immigrated with her parents to the United States from Central America. Last year, she had a severe febrile illness that kept her in bed for several weeks with a "heart problem" that began after she had a bad sore throat. She was treated with aspirin and penicillin. In addition, she had painful joints that improved rapidly once treatment started. Today, the child is well and physical exam is normal. In order to prevent recurrence of this disease, what is the recommendation for this child? A. antibiotic prophylaxis prior to dental procedures B. immediate antibiotic treatment of any episode of pharyngitis C. monthly injections of benzathine penicillin D. no prophylaxis is needed

C. monthly injections of benzathine penicillin -- recommended in children who had rheumatic fever with carditis. This may be discontinued after 5-years of no recurrent symptoms.

A 74-year-old with moderate to severe COPD presents for routine checkup. ECG reveals a heart rate of 120 bpm, three distinct P waves, and variable PP intervals. What is the most likely arrhythmia? A. atrial fibrillation B. atrial flutter C. multifocal atrial tachycardia (MAT) D. wandering atrial pacemaker (WAP)

C. multifocal atrial tachycardia (MAT) -- almost exclusively seen in patients with severe COPD.

A 3-year-old child playing in an abandoned shed is bitten by a black widow spider. The mother rushes the child to the emergency department within 20 minutes of the incident. What is the initial treatment? A. intramuscular steroids B. administration of antivenin C. narcotic analgesic and methocarbamol D. pain relief with acetaminophen

C. narcotic analgesic and methocarbamol -- the black widow injects a neurotoxin, which causes depletion of achetylcholine at the neuromuscular junction. Initial treatment in a child consists of administration of strong analgesics, methocarbamol to relax muscles, and possibly calcium gluconate to relive rigidity, although its effectiveness is controversial. If the ptaient does not response to treatment, antivenom may be initiated.

A 46-year-old woman presents with a chief complaint of burning and tingling on the plantar aspect of the right foot. She has a history of recurrent ankle sprains on the same foot. The area has reduced sensitivity to light touch. Tinel sign is present at the posterior tibial nerve adjacent to the medial malleolus. Which of the following diagnostic tests will confirm the tentative diagnosis? A.Schilling test B.peripheral blood smear C.nerve conduction velocity D.magnetic resonance imaging

C. nerve conduction velocity -- or electromyography, are diagnostic to confirm tarsal tunnel syndrome.

A 2-year-old boy presents to the emergency department with elbow pain. While playing in the park, his father pulled him up by his arm to catch him from falling off the jungle gym. The child immediately cried out in pain and now his arm is hanging by his side with limited mobility. On physical exam, the child has limited supination and swelling is absent. What is the most likely diagnosis? A. elbow tendonitis B. ganglion cyst C. nursemaid's elbow D. Salter-Harris I fracture

C. nursemaid's elbow -- result of subluxation of the annular ligament. The injury occurs with longitudinal pulling of the elbow, often when a child is lifted by one arm. This is easily reduced by supination of the elbow with pressure on the radial head.

A 40-year-old professional comes to see you because his business partner is ready to dissolve their partnership due to his behavior. The patient is unmarried and lives alone. At work, he is very rigid and perfectionist. He can multitask easily, has great attention to detail, works very long hours, and expects others to do the same. He is often displeased with the work of others and has difficulty delegating when he should. He has had a steady stream of assistants because it is so difficult to work for him. He almost never takes a vacation. This patient most likely has which personality disorder? A. avoidant B. narcissistic C. obsessive-compulsive D. paranoid

C. obsessive-compulsive personality disorders is characterized by traits seen in this patient: a pattern of preoccupation with orderliness, perfectionism, and interpersonal control. Note: differ between OCD and OCPD? OCD is characterized by ego-dystonic features and patients are often distressed, whereas OCPD is ego-syntonic.

A 32-year-old male presents to the emergency department complaining of unilateral scrotal swelling with pain radiating to the ipsilateral groin. Examination reveals exquisite left testicular tenderness, scrotal edema, and erythema of the overlying skin. Urinalysis is normal. What is the most likely diagnosis? A.Fournier gangrene B.hydrocele C.orchitis D.prostatitis

C. orchitis -- unilateral painful testicular swelling associated with edema and inflammatory changes is typical for orchitis. It more commonly occurs in younger patients. Causes include mumps virus or enterovirus. Doppler ultrasonography or nuclear scintigraphy will differentiate orchitis from testicular torsion.

A patient presents to labor and delivery at 38 weeks stating her contractions have begun. She has no history of prenatal care. She complains that she has had episodes of painless, bright red vaginal bleeding about once per week since the 27th week of her pregnancy. What is the initial step in management? A. Artificially rupture her membranes and induce labor. B. Insert an internal monitor and perform fetal scalp blood monitoring. C. Order an ultrasound to determine placental location. D. Perform a vaginal examination to determine cervical effacement and dilation.

C. order an ultrasound to determine placental location -- third-trimester painless bleeding should be considered placenta previa until proven otherwise. Abruptio placentae presents with painful third-trimester bleeding. Ultrasonography will determine the location of the placenta and should be done before anything, including a bimanual or speculum examination.

A 61-year-old Asian American female presents to the emergency department after falling on her front porch. She has pain in her left hip and is unable to bear weight. She has been previously healthy without significant medical history. Thyroid studies, CBC with differential, urine studies, and blood chemistries are normal. Radiographs of the left hip show a femoral neck fracture. What is the most likely underlying contributor to this patient's fracture? A. hypoparathyroidism B. osteosarcoma C. osteoporosis D. Paget disease

C. osteoporosis -- often diagnosed following an acute fracture or with a bone mineral densitometry assessment. The World Health Organization defines osteoporosis as a bone mineral density below -2.5 SD.

A 33-year-old male presents with unilateral periorbital pain with ipsilateral nasal congestion, rhinorrhea, and lacrimation. He gives a history of multiple attacks occurring in groups about three times per year. What is the acute treatment? A.lithium B.methysergide C.oxygen D.viscous lidocaine

C. oxygen -- the most effective treatment for acute cluster headache. Injectable or nasal triptan may also be effective.

A 63-year-old male presents with sudden onset of left-sided facial droop and inability to fully close his left eye or raise his left eyebrow. He states that his face feels stiff. What other complaint is commonly present in patients with this disorder? A. facial pruritus B. nostril flaring C. periauricular pain D. scalp tenderness

C. periauricular pain -- patients with Bell palsy will often complain of pain about the ear, which precedes or accompanies the onset of facial weakness.

A patient presents with numbness of the anterolateral aspect of the right calf. Exam reveals ipsilateral foot drop. She states that she has recently started meditation classes and has been spending long periods of time sitting cross-legged on the floor. Which of the following is the most likely diagnosis? A.femoral neuropathy B.meralgia paresthetica C.peroneal nerve contusion D.tarsal tunnel syndrome

C. peroneal nerve contusion -- often secondary to compression of the nerve at the head and neck of the fibular. It presents with foot drop and lateral paresthesias. Note: meralgia paresthetica involves the lateral femoral cutaneous nerve and presents with pain or paresthesia around the out aspect of the thigh.

A 43-year-old female presents with a tremor, irritability, and nervousness. She states that despite the fact that she has an increased appetite and food intake, she has lost 8 lb over the last 4 weeks. Thyroid studies show TSH of 6.8 µU/mL (normal 0.34 to 4.25 µU/mL), T4 of 12.9 µg/dL (normal 5.4 to 11.7 µg/dL), and T3 of 4.3 nmol/L (normal 1.2 to 2.1 nmol/L). What is the most likely diagnosis? A. Graves disease B. Hashimoto disease C. pituitary adenoma D. thyroid storm

C. pituitary adenoma -- these symptoms are likely to be caused by a TSH-producing pituitary adenoma. This will produce an elevated T4, T3, *and* TSH compared to typical cuases of hyperthyroidism where TSH is low.

An HIV-positive patient with a CD4 count of 174 cells/µL presents with a 4-week history of fever, shortness of breath which worsens with exertion, and a nonproductive cough. Chest x-ray reveals bilateral interstitial infiltrates. What is the most likely diagnosis? A. histoplasmosis B. pneumococcal pneumonia C. pneumocystis pneumonia D. tuberculosis

C. pneumocystic pneumonia -- most common with cellular and humoral immune defects. The risk of PCP among HIV-infected patients rises markedely as circulating CD4 counts fall below 200 cells/µL. Classic findings on chest radiography in active disease consist of bilateral diffuse infiltrates beginning in the perihilar regions. Prophylactic therapy with trimethoprim-sulfamethoxazole is warranted with CD4 counts <200. Note: allergic to bactrim? Use Dapsone.

A 32-year-old with chronic asthma presents to the emergency department with an acute exacerbation. As you are completing the initial intake, she stops talking and her lips take on a bluish hue. Lungs are silent. What should the next course of action be in this case? A.Give dexamethasone IM STAT. B.Give oxygen with a nonrebreather mask. C.Prepare to intubate. D.Start nebulized albuterol.

C. prepare to intubate -- patient is in status asthmaticus and must be intubated immediately.

A 30-year-old female who is 32 weeks pregnant begins to experience tremors, heat intolerance, and irritability along with some fatigue, tachycardia, hypertension, and lower abdominal pain. Labs reveal the following: Hct 33%; Hgb 12.8 g/dL; WBC 14,600/µL AM cortisol 42 µg/dL (normal 5 to 20 µg/dL) Total thyroxine 13.1 µg/dL (normal 5 to 12 µg/dL) Total T3 225 ng/dL (normal 70 to 205 ng/dL) TSH 0.4 µU/mL (normal 2 to 10 µU/mL) Which of the following therapies is the treatment of choice? A.amiodarone B.propranolol C.propylthiouracil D.radioactive iodine

C. propylthiouracil (PTU) -- hyperthyroidism results in low TSH and elevated T3 and thyroxine (free T4). It may cause IUGR, prematurity, or transient thryotoxicosis in the newborn. PTU is the only drug recommended for treatment of hyperthyroidism during pregnancy and lactation. This drug does cross the placenta, and although rare, may result in excess TSH secretion and goiter in the fetus. Therefore, the smallest possible dose should be used. Very little is secreted in breast milk; adverse effects in the fetus have not been demonstrated.

A 25-year-old male presents to the clinic complaining of mild dyspnea on exertion. Examination reveals a prominent jugular pulsation and a palpable parasternal lift. There is a harsh systolic murmur best heard at the second and third left intercostal space; it radiates to the left shoulder. An early systolic sound precedes the murmur during expiration. ECG demonstrates right-axis deviation. What is the most likely diagnosis? A.aortic stenosis B.mitral regurgitation C.pulmonic stenosis D.tricuspid regurgitation

C. pulmonic stenosis -- classic description. Mild forms of this congenital disorder may not be apparent until adulthood when left-sided heart failure develops. (Note: tricuspid regurgitiation is heard at the 3rd-5th intercostals, and although may also show right-axis deviation, it is not associated with an ejection click).

A 27-year-old female presents complaining of left flank pain that has been present for the past 8 hours. She states that for the past couple of days, she has been experiencing frequency and dysuria and today began to experience fever and chills. Examination reveals a fever of 102.0°F with left costovertebral angle tenderness. What is the most likely diagnosis? A. glomerulonephritis B. nephrolithiasis C. pyelonephritis D. urinary tract infection

C. pyelonephritis -- an infection involving the renal parenchyma or renal pelvis. Patients experience fever, flank pain, shaking chills, and voiding symptoms. Exam reveals CVA tenderness. Urinalysis may show white cell casts.

A 32-year-old male presents with a complaint of conjunctivitis and a monoarthritis involving the left knee. Past medical history is significant for chlamydial urethritis, which was treated with doxycycline 3 weeks ago. What is the most likely diagnosis? A.Behçet syndrome B.psoriatic arthritis C.reactive arthritis D.systemic lupus erythematosus

C. reactive arthritis -- formerly known as "Reiter Syndrome", is characterized by urtheritis, conjunctivitis, mucocutaneous lesions, and septic arthritis. Cases develop after dysenteric infections or sexually transmitted infections, commonly chlamydia. Antibiotics treat the infection but have no effect on alleviating the symptoms or preventing the development of the disorder.

A 14-year-old girl presents for a health maintenance visit. Her mother is concerned that her daughter has not begun to menstruate. The mother's menarche was at age 13 years. Medical history and complete physical exam are normal with breast development and pubic hair (Tanner 3). She began pubertal changes at the age of 12.5 years. What is the most appropriate course of action? A. chromosomal analysis B. laboratory evaluation including TSH and T4 C. reassurance that she likely will begin menstruating within a year D. urinary estriol determination

C. reassurance -- menarche typically happens 2-2.5 years after the onset of pubertal changes. The mean age of menarche is 12.75 years; however, there is a wide variation in this age and range. This girl is within the normal range and has the appropriate physical changes and should be observed.

A 23-year-old female presents with a history of recurrent lower abdominal pain associated with alternating diarrhea and constipation for the past 4 months. Pain is temporarily relieved with defecation. She has had increased levels of stress at work, which seems to correlate with the appearance of her symptoms. She describes her symptoms as mild but is concerned about their recurring nature. She denies fever or weight loss; she has maintained normal menses. The entire abdomen is mildly tender on examination. What is the initial step in management of this disorder? A. anticholinergic medications B. antidiarrheal medications C. reassurance and dietary/lifestyle changes D. serotonin receptor antagonists

C. reassurance and dietary/lifestyle changes -- initial treatment of IBS involves education, reassurance, and dietary/lifestyle changes unless alarm symptoms are present (weight loss, acute onset, fever, nocturnal diarrhea). Patients should be instructed to increase water intake, avoid caffeine, and monitor their diet for triggering foods (legumes, fructose, lactose).

A 9-month-old is brought to the clinic after 3 days of cough, low-grade fever, congestion, and runny nose. She attends day care, and a number of the children are experiencing similar symptoms. Examination finds an active child who appears well with a temperature of 100.4°F and a respiratory rate of 20. Clear discharge is present at the nares; lungs are clear bilaterally. What is the best management? A. Initiate a broad-spectrum antibiotic. B. Prescribe an over-the-counter antihistamine and decongestant. C. Recommend nasal saline drops and a cool-mist humidifier. D. Suggest 1 teaspoon of honey every 4 to 6 hours to control the cough.

C. recommend nasal saline drops and a cool-mist humidifier -- the symptoms suggest a viral URI which a child in daycare may experience 8-12 times per year. Cool mist humidifiers and nasal saline drops provide symptomatic relief. Note: per the AAP, no OTC cough/cold preparations in children <6 years old.

A 57-year-old male with diabetes mellitus presents for a physical exam. A slight decline in this patient's visual acuity and the presence of microaneurysms and small hemorrhages are noted. Which of the following is the most appropriate management option at this time? A. Perform visual field testing. B. Prescribe artificial teardrops. C. Refer to an ophthalmologist. D. Prescribe glaucoma eye drops.

C. refer to an ophthalmologist -- nonproliferative retinopathy is the most common cause of legal blindness in type 2 diabetes mellitus. Visual loss develops due to edema, ischemia, or excudates at the macula.

A 50-year-old patient has a screening intraocular pressure of 20 mm Hg bilaterally. Remainder of examination is normal. Which of the following is the best management for this patient? A. Order a fluorescein angiography. B. Refer to an ophthalmologist emergently. C. Rescreen in 6 to 12 months. D. Begin topical pilocarpine 1%.

C. rescreen in 6-12 months -- intraocular pressure of 20mmHg by tonometry is within normal limits (10-21mmHg). An examination of the optic disc and visual fields is also necessary.

A 17-year-old male presents with pain and swelling of the right testis. He is febrile and nauseous. There is marked swelling of the parotid glands and enlargement of the submaxillary lymph nodes. Which of the following is the most effective treatment? A. systemic steroids B. surgical referral C. scrotal support D. antiviral therapy

C. scrotal support -- will provide pain relief while the condition (orchitis due to mumps) runs its course. Treat symptomatically with fluids, analgesics and antipyretics.

The presence of which of the following distinguishes eclampsia from preeclampsia? A.hypertension B.proteinuria C.seizure D.thrombocytopenia

C. seizure -- symptom that marks transition of preeclampsia to eclampsia.

A generally healthy, well-developed 18-year-old female presents to the emergency department with chest pain, which has recurred three times during the past week. The chest pain is accompanied by palpitations and is not brought on by exertion. She explains that she has been very anxious about leaving for her first year of college in a couple of days and feels like she is having a heart attack now. A year ago, she experienced similar pain events while preparing for the college placement examinations. She denies tobacco or illicit drug use and takes no medications or supplements. Which of the following additional symptoms is most likely to be found in this patient? A.bradycardia B.hyperreflexia C.sensation of breathlessness D.vertigo

C. sensation of breathlessness -- typical presentation of a panic attack includes unexpected, untriggered episodes of intense anxiety and fear with associated physiologic changes including palpitations, sweating, tremulousness, breathlessness sensation, chest pain, GI distress, and faintness.

A 45-year-old female presents to the emergency department complaining of chest pain. Which of the following descriptions would best suggest a diagnosis of pericarditis rather than myocardial ischemia? A.pain lasting for over an hour B.retrosternal location C.sharp, stabbing pain D.radiation of pain into the neck

C. sharp, stabbing pain -- pericardial pain differs in that it is far more likely to be sharp and stabbing (pleuritic), becoming worse with coughing or inspiration. All other symptoms are characteristic of both MI and pericarditis.

A 35-year-old female presents with fever, petechiae, and headache. A companion reports exhibiting two episodes of confusion. Labs reveal marked anemia, thrombocytopenia, and reticulocytosis. PT and PTT are normal; LDH, BUN, and creatinine are elevated. Peripheral smear shows fragmented RBCs with schistocytes and helmet cells. What is the most likely diagnosis? A.disseminated intravascular coagulation (DIC) B.immune thrombocytopenic purpura (ITP) C.thrombotic thrombocytopenic purpura (TTP) D.von Willebrand disease

C. thrombotic thrombocytopenic purpure (TTP) -- the clinical picture of petechiae, renal involvement, and microangiopathic anemia with schistocytes and helmet cells is indicative of TTP. Neurologic abnormalities range from mild disorientation to severe focal deficits, seizures, coma, or death. Hemolytic anemia and elevated LDH strongly suggest TTP.

A 35-year-old female presents with wrist pain. Four days ago, she fell on an outstretched hand while rollerblading. She did not seek care immediately because there was no swelling or bruising. Now, she complains of lateral wrist pain that is most pronounced when gripping glasses or the car steering wheel. She has pain with ulnar deviation and tenderness over the snuffbox. Radiographs are normal. What is the most appropriate management at this time? A. elastic wrap with ice and analgesics B. immediate referral to orthopaedic surgery C. thumb spica cast with repeat radiographs in 2 weeks D. volar wrist splint with ice and analgesics

C. thumb spica cast with repeat radiographs in 2-weeks -- a scaphoid fracture results from a fall on an outstretched hand with forced dorsiflexion. Disruption of blood flow to the scaphoid bone may occur, resulting in avascular necrosis. Initial radiographs may be negative; accepted treatment of suspected cases is to apply a thumb spica cast and repeat films after 2-weeks. Note: the fracture may not be evident for up to 2-weeks, but if snuffbox tenderness is present then it should be treated as fracture because of the high-incidence of avascular necrosis or nonunion (blood supply is distal to proximal). Splint + ortho referral.

A 28-year-old male presents to the emergency department with confusion and agitation. He appears intoxicated. He is unable to provide a useful history. Vitals reveal temperature of 39°C, pulse rate of 174 bpm, respiratory rate of 29, and blood pressure of 136/68 mm Hg. He has mild proptosis, is tachycardic with regular rhythm, and has fullness in his neck. He has a fine tremor, brisk reflexes, and mild to moderate weakness of all four extremities. While in the emergency department, he vomits three times. Serum electrolytes, kidney function, liver function, thyroid studies, and toxicology screen are all within normal limits. What is the most likely diagnosis? A. Addison disease B. diabetic ketoacidosis C. thyroid storm D. toxic adenoma

C. thyroid storm -- life-threatening complication of hyperthyroidism. Patients may develop fever, tachycardia, agitation, restlessness, delirium, and even coma. GI symptoms include abdominal pain, vomiting, diarrhea, and dehydration. Patients often have tachycardia with widened pulse pressure, which may progress to atrial fibrillation and cardiac failure. Thyroid storm is often a clinical diagnosis as thyroid studies may be normal. Therefore, index of suspicion must remain high. Acute management consists of close monitoring, fluid replacement, cooling, antithyroid drugs, and glucocorticoids.

A young man was hospitalized for several weeks following a motor vehicle accident. He was on mechanical ventilation for several days. Three weeks after discharge, he presents with shortness of breath and cough with an inability to clear secretions. Examination reveals coarse breath sounds throughout both lung fields. He is afebrile. What is the most likely cause? A. atelectasis B. pneumonia C. tracheal stenosis D. vocal cord paralysis

C. tracheal stenosis -- develops secondary to trauma, especially endotracheal intubation. Patients develop progressive respiratory distress weeks or months after the trauma. Note: atelectasis and vocal cord paralysis would present almost immediately after extubation.

A 36-year-old male presents with fever, nonproductive cough, and burning chest pain that worsens with inspiration. He has had these symptoms and general malaise off and on for several weeks as well as night sweats and fever. He admits to having several male sexual partners in the past year; he is unaware of his HIV status. Examination reveals a temperature of 99.8°F, respiratory rate of 22, heart rate of 100 bpm, and a loss of 5 lb since his last visit. Chest x-ray shows diffuse interstitial infiltrates. What is the recommended treatment? A. clindamycin-primaquine B. dapsone-trimethoprim C. trimethoprim-sulfamethoxazole D. intravenous pentamidine

C. trimethoprim-sulfamethoxazole -- TMP-SMX is the standard for both treatment and prophylaxis of Pneumocystic pneumonia. Most commonly, the CXR shows bilateral infiltrates but can also be focal, nodular, cystic, or cavitary.

A 23-year-old female is beginning treatment with isotretinoin (Accutane) for her cystic acne. What is the recommended frequency of serum pregnancy testing during treatment? A. one test prior to starting and one test monthly B. one test prior to starting and two tests monthly C. two tests prior to starting and one test monthly D. two tests prior to starting and two tests monthly

C. two tests prior to starting and one test monthly -- isotretinoin is highly teratogenic and therefore is absolutely contraindicated during pregnancy. Standard recommendations call for two serum pregnancy tests prior to initiating treatment and then one monthly for the duration of treatment.

A 23-year-old female who smokes 1/2 pack per day complains of a bluish lacy rash that appears on her lower extremities when exposed to the cold. The rash disappears once the area is rewarmed. What is the most likely etiology of this condition? A. atheromatous process of the superficial arteries B. inflammatory process affecting small and medium arterioles C. vasomotor instability of dermal blood vessels D. venous spasm throughout the saphenous system

C. vasomotor instability of dermal blood vessels -- livedo reticularis is caused by vasomotor instability. It can be a benign phenomenon but may be an indication of vascular disease, in particular anti-phospholipid antibody syndrome.

A 28-year-old female undergoes cholecystectomy. Preoperative CBC, platelet count, and international normalized ratio (INR) were normal. Excessive bloody drainage is noted 8 hours postoperative. Repeat CBC, platelet count, and INR continue to be normal; PT and PTT are normal, but bleeding time is prolonged. What is the most likely diagnosis? A. factor IX deficiency B. disseminated intravascular coagulation C. von Willebrand disease D. sepsis

C. von Willebrand disease -- autosomal dominant family trait. Mildly affected patients may not exhibit excessive bleeding tendencies until undergoing major surgical procedures or experiencing major physical trauma. Routine preoperative laboratory values are typically normal, and diagnosis is made by obtaining a bleeding time, factor, and von Willebrand factor levels.

Five days following a blood transfusion of 2 units of packed red blood cells, a patient complains of fever, chills, nausea, and myalgias. What is the recommended management? A. mannitol B. an antihistamine C. watchful waiting D. prednisone

C. watchful waiting -- therapy is rarely necessary for delayed hemolytic reactions to minor antibodies, which occur 3-21 days (most commonly 5-10 days) after the transfusion. Note: prednisone is indicated in more severe or acute reactions.

A positive Myerson sign is most commonly seen in persons with which of the following disorders? A. Bell palsy B. Guillain-Barré syndrome C. multiple sclerosis D. Parkinson disease

D. Parkinson disease -- Myerson sign is reflexive, sustained eye blinking in response to repetitive tapping just above the nasal bridge between the eyes (also referred to as the glabellar reflex). This sign can frequently be observed in persons with Parkinson disease.

Which type of leukemia is associated with the Philadelphia chromosome? A.acute lymphoblastic B.chronic lymphocytic C.acute myelocytic D.chronic myelogenous

D. chronic myelogenous -- the Philadelphia chromosome (BCR/ABL gene) results from reciprocal translocation between the long arms of chromosome 9 (ABL) and 22 (BCR). It is most frequently seen in chronic granulocytic (myelogenous) anemia.

The first stage of labor is considered complete when the cervical os opening measures how many centimeters? A.4 B.6 C.8 D.10

D. 10 cm -- full cervical dilation stares the second stage of labor.

A 46-year-old construction worker complains of pain when moving his right thumb or wrist. Examination reveals thickening and tenderness over the radial stylus. What physical exam technique will best confirm the suspected diagnosis? A. Lachman test B. Phalen test C. Allen test D. Finkelstein test

D. Finkelstein test -- in deQuervain tenosynovitis, the abductor pollicis longus and the extensor pollicis brevis tendons become inflamed. Finkelstein maneuver is accomplished by placing the thumb in the palm and enclosing the thumb with the fingers. The wrist is then placed in ulnar deviation, stretching the tendons; pain is a positive finding. Treatment --> thumb spica splint, NSAIDs, PT +/- corticosteroids; surgical release reserved for refractory cases.

It has been established that a 3-year-old has respiratory syncytial virus (RSV) bronchiolitis. He has no past medical history and is eating well despite his cough and congestion. Examination reveals temperature of 100.9°F, pulse rate of 100 bpm, respiratory rate of 22, and SaO2 of 97%. There is a slight wheeze but no stridor; skin turgor is good. What is the best course of action at this time? A.Give 5 days of azithromycin. B.Hospitalize and begin treatment with ribavirin. C.Initiate oxygen and bronchodilators. D.Give supportive therapy and fluids.

D. Give supportive therapy and fluids -- recommended for uncomplicated bronchiolitis. Note: ribavirin (antiviral medication) is useful in severe cases of RSV or when the child has other risk factors such as prematurity or immunocompromise.

A 32-year-old male presents with complaints of recurrent, episodic vertigo lasting up to 8 hours per episode for 6 months. The vertigo is associated with unilateral, low-frequency hearing loss and tinnitus. Caloric testing reveals impairment of thermally induced nystagmus on the involved side. What is the most likely diagnosis? A.labyrinthitis B.multiple sclerosis C.acoustic neuroma D.Ménière syndrome

D. Meniere syndrome -- disorder of the endolymphatic compartment with episodic vertigo, unilateral low-frequency sensorineural hering loss, and tinnitus.

A 55-year-old male presents with excruciating pain in the right metatarsophalangeal (MTP) joint. On examination, it is swollen and erythematous. The patient reports two prior episodes in the last 2 years. Joint aspiration reveals urate crystals. His past medical history includes hypertension and type 2 diabetes. Which of the following would be most useful in the long-term management of this patient? A.Discontinue his insulin regimen and substitute with non-insulin hypoglycemic agents. B.Place him on an angiotensin-converting enzyme inhibitor. C.Place him on a thiazide diuretic. D.Restrict purines in his diet.

D. Restrict purines in his diet -- may help reduce the risk of recurrent gouty attacks by decreasing the urate load.

A 27-year-old injection drug user presents with fever, chills, and a new murmur. Examination reveals track marks on the forearms and petechiae on the palate and beneath the fingernails. Which of the following agents is most likely responsible? A. HACEK organisms B. non-albicans Candida C. Serratia marcescens D. Staphylococcus aureus

D. Staphylococcus aureus -- in injection drug users, Staph aureus accounts for over 60% of endocarditis cases.

A 25-year-old female presents with paroxysmal episodes of palpitations and rapid heart rate that occur in no particular pattern. She has no current symptoms, and her ECG shows a sinus rhythm with a rate of 72 bpm. There are no pathologic Q waves and no ST-segment elevation or depression. The PR interval is 0.11 second with a delta wave at the onset of a slurred QRS complex. What is the most likely diagnosis? A. first-degree AV block B. paroxysmal atrial tachycardia (PAT) C. Lown-Ganong-Levine syndrome D. Wolff-Parkinson-White syndrome

D. Wolff-Parkinson-White syndrome -- hallmark is a short PR with a delta wave. It frequently causes palpitations. Note: the accessory pathway of WPW is known as the Bundle of Kent.

A 50-year-old male gives a history of shooting pain that begins at the side of his mouth and radiates to his ear. Episodes occur several times per day with several days between clusters. What is the recommended treatment? A.aspirin B.acetaminophen C.phenytoin D.carbamazepine

D. carbamazepine -- (or oxcarbamazapine) drug of choice in trigeminal neuralgia.

After bathing, a 65-year-old male notes intense, whole body pruritus that is unrelieved with a variety of over-the-counter medications. He gives a history of intermittent headaches with a sensation of fullness of his face and head, weakness, fatigue, and dizziness. Physical findings included systolic hypertension, splenomegaly, and facial plethora. Which of the following diagnostic tests is most appropriate at this time? A.abdominal ultrasonography B.arterial blood gas C.carotid Doppler scan D.complete blood count

D. complete blood count -- first step in diagnosing polycythemia vera. Erythrocytosis, thrombocytosis, and leukocytosis will be found.

A 15-year-old presents with fever, malaise, and sore throat with difficulty swallowing. Physical exam reveals enlarged anterior and posterior cervical nodes, palatal petechiae, and severely enlarged "kissing" tonsils without exudate. What is the recommended treatment? A. amoxicillin B. acyclovir C. interferon-α D. corticosteroids

D. corticosteroids -- advised specifically for reducing lymphoid enlargement threatening to compromise the airway in patients with mononucleosis. A maximum of 10-days with tapering dose is advsied.

Which of the following descriptors suggests a diagnosis of paranoid personality disorder? A.dependent, immature, egocentric, and emotionally labile B.perfectionist, indecisive, egocentric, and needs to control C.shy, introverted, withdrawn, and avoids close relationships D.defensive, oversensitive, secretive, and has limited emotional responses

D. defensive, oversensitive, secretive, and has limited emotional responses

An 18-year-old asymptomatic male presents for college entrance physical exam. His body mass index is 33 kg/m2. Vitals include BP of 156/84 mm Hg, pulse rate of 88 bpm, and respiratory rate of 16. He has a family history of diabetes mellitus, hypertension, and coronary artery disease. Which of the following laboratory studies is indicated at this time? A.C-reactive protein B.fasting aldosterone levels C.random plasma glucose D.hemoglobin A1c

D. hemoglobin A1c -- a HgbA1c >/=6.5 is presently recommended by the ADA as diagnostic for diabetes mellitus. (Note: the Comprehensive Review test answer states that >6.0 is diagnostic, but this is probably at typo. Page 219 of the textbook states 6.5 or higher is diagnostic).

A 35-year-old overweight female presents to the clinic complaining of tender inflammatory nodules and abscesses in her axillae and anogenital area. The lesions have waxed and waned over the past few years but have become more painful and bothersome in the past month. Some of the larger lesions are draining a purulent material. What is the most likely diagnosis? A. chronic chafing B. contact dermatitis C. drug reaction D. hidradenitis suppurativa

D. hidraadenitis suppurative -- i.e., acne inversa, is a disease of the apocrine glands (axilla, anogenital, and scalp). It affects females between pubery and menopause more often than males. Predisposing factors include obesity, history of acne, apocrine duct obstruction, and bacterial infection. There appears to a be a genetic tendency. Abscesses tend to recur. Old scars and sinus tracts may be found.

A 29-year-old multipara presents to a rural clinic. She successfully delivers a baby boy; a continuous, rough, machinery-like murmur is heard on cardiac auscultation of this newborn. What is the drug of choice to administer to the newborn? A.ampicillin B.β-blocker C.heparin D.indomethacin

D. indomethacin -- a prostaglandin inhibitor that is routinely administered to help close a PDA. Want to keep a PDA open instead? Use a PGE-1 analog (alprostadil).

During the winter semester, a 20-year-old student complains of abrupt onset of sore throat, fever, malaise, headache, nasal congestion, myalgias, and dry cough. Examination reveals pharyngeal injection and clear lungs. What is the most likely diagnosis? A. bacterial pneumonia B. severe acute respiratory syndrome (SARS) C. mononucleosis D. influenza

D. influenza

A 52-year-old presents for evaluation of decreased visual acuity, which he describes as a general blurring which has progressed over the past few months. Further questioning reveals increased difficulty driving at night due to glaring lights. Which of the following pieces of historical information would lead to a consideration of cataracts as the cause of the visual changes? A. history of rubella at 5 years of age B. contact lens use for 25 years C. family history of senile cataracts D. inhaled corticosteroid use for asthma

D. inhaled corticosteroid use for asthma -- risk factors for the development of cataracts include congenital rubella, trauma, systemic disease such as diabetes, systemic or inhaled corticosteroid use, uveitis, and excessive sun exposure.

Which of the following is the drug of choice in the urgent treatment of a panic attack? A.amitriptyline (Elavil) B.propranolol (Inderal) C.buspirone (BuSpar) D.lorazepam (Ativan)

D. lorazepan (Ativan) -- effective as urgent treatment. Buspirone and antidepressants have a role in chronic treatment only. Beta blockers can be used in conjunction with other therapies.

A 24-year-old presents complaining of malodorous, frothy, thin, gray vaginal discharge. Clue cells are present on wet mount. What is the best treatment? A. miconazole vaginal suppository for one dose B. miconazole cream for 7 days C. metronidazole po for one dose D. metronidazole po for 7 days

D. metronidazole PO for 7 days -- treatment of choice for bacterial vaginosis, but the recommended regimen is 500mg PO *BID* for 7 days, not the single 2g oral dosing. The single dosing is more appropriate for Trichomonas vaginalis.

A 61-year-old female complains of insidious, bilateral, progressive muscle weakness of her legs, which has caused inability to climb stairs or rise from a seated position without difficulty. What is the most likely diagnosis? A.Sjögren syndrome B.polyarteritis nodosa C.polymyalgia rheumatica D.polymyositis

D. polymyositis -- characterized by proximal muscle weakness of insidious onset. The LE are usually affected first with progression to the upper arms and sometimes the next. (Versus polymyalgia rheumatic which is often characterized by fever, weight loss, and malaise in addition to pelvic girdle/shoulder pain (does not cause weakness).

Which of the following is an indication to refer an asymptomatic adolescent for colonoscopy? A. brother who is 25 years old has been diagnosed with ulcerative colitis B. father developed multiple strictures after bowel resection at age 32 years C. family history of colon cancer in maternal uncle at age 36 years D. mother had colorectal adenomatous polyps removed at 19 years of age

D. mother had colorectal adenomatous polyps removed at 19-years of age -- Familial Adenomatous Polyposis (FAP) is characterized by the development of hundreds-to-thoursands of colonic adenomatous polyps. Colorectal polyps develop by a mean age of 15-years and cancer at 40-years. First-degree relatives of patients with FAP should undergo genetic screening after age 10. If the assay cannot be done or is not informative, family members at risk should undergo yearly sigmoidoscopy beginning at 12-years of age.

A 75-year-old with a history of Parkinson disease presents with minimally pruritic facial lesions present for 1 week. Examination reveals scattered discrete macules approximately 1 cm in size, with an orange-red greasy scale on the cheeks and nasolabial folds. What is the most appropriate treatment? A.benzoyl peroxide gel B.hydrocortisone cream C.metronidazole gel D.mupirocin ointment

D. mupirocin ointment -- effective topical treatment for limited impetigo.

A 29-year-old female who is 24 weeks pregnant presents complaining of a sudden onset of a severe, intermittent pain originating in the right flank and radiating into the right groin. She also complains of nausea and vomiting. Fundal height is consistent with her dates. She exhibits tenderness to palpation along the right flank with no rebound. Urinalysis reveals microscopic hematuria. Ultrasonography reveals right hydroureter and hydronephrosis. What is the most likely diagnosis? A.acute appendicitis B.acute cholecystitis C.bladder cancer D.nephrolithiasis

D. nephrolithiasis -- a sudden onset of severe colicky flank pain associated with nausea and vomiting as well as the absence of rebound makes nephrolithiasis the most likely diagnosis. This is further supported by the presence of hematuria and likely also calcium oxalate crystals on urinalysis. Note: stones <5mm in diameter have an 80% chance to pass spontaneously; >5-10mm most likely requires intervention (e.g., shock-wave lithotripsy, ureteroscopy with or without stenting, or percutaneous nephrolithotomy).

A 19-year-old female college student is brought to the office over Christmas break because her mother is very concerned about her despondent mood. She is not going out, not seeing her old friends, and stays in her room alone. You learn that last year, the patient went through a period of time where she was having trouble sleeping and was caught shoplifting. She tells you that she had collected almost 100 key chains from area stores during the months that she was feeling good. She also tells you that shortly before this episode, she had been feeling down for a few months and was relieved when she started to feel more energetic. About a month ago, she started to feel hopeless about everything. She denies any hallucinations and managed to pass all her courses even though she felt badly. She denies any suicidal ideation. Along with psychotherapy, which of the following is appropriate treatment for this patient? A. clonazepam (Klonopin) and carbamazepine (Tegretol) B. divalproex sodium (Depakote) alone C. haloperidol (Haldol) alone D. olanzapine and fluoxetine combination (Symbyax)

D. olanzapine and fluoxetine combination (Symbyax) -- olanzapine is a mood stabilizer; fluoxetine is an antidepressent. Together (available as Symbyax), they are very effective in treating bipolar depression. Note: divalproex sodium (Depakote) has surpassed the use of lithium in the treatment of acute mania but is not generally used for bipolar depression.

A 25-year-old student presents with acute onset (<24 hours) of high fever, chills, myalgias, severe malaise, and nonproductive cough. Rapid antigen testing supports the diagnosis of influenza type A. What is the recommended treatment? A. amantadine (Symmetrel) B. rimantadine (Flumadine) C. valacyclovir (Valtrex) D. oseltamivir (Tamiflu)

D. oseltamivir (Tamiflu)

The straight leg raise test is used to evaluate possible disk disease of the lower back. What is considered a positive straight leg raise test? A.pain radiating along the sciatic nerve at 20 degrees of active elevation of the ipsilateral leg B.pain radiating along the sciatic nerve at 60 degrees of active elevation of the ipsilateral leg C.pain radiating along the sciatic nerve at 20 degrees of passive elevation of the ipsilateral leg D.pain radiating along the sciatic nerve at 60 degrees of passive elevation of the ipsilateral leg

D. pain radiating along the sciatic nerve at 60 degrees of passive elevation of the ipsilateral leg -- positive straight leg raise is done by passively elevating the ipsilateral leg 30-60 degrees. Further support can be elicited by lowering the leg 10 degrees below the level of pain and dorsiflexing the foot.

A 25-year-old female with sickle cell trait plans to participate in a marathon in Mexico City. What symptom related to this trait is she most likely to experience? A.abdominal pain B.jaundice C.long bone pain D.painless hematuria

D. painless hematuria -- persons with sickle cell trait are usually asymptomatic; however, they may experience episodes of painless hematuria, particularly under extreme conditions. Individuals are also at risk for rhabdomyolysis during vigorous exercise, especially when at high altitude. (Note: bone pain, primarily in the long bones and back, occurs during a sickle cell crisis).

An otherwise healthy 70-year-old presents with a painful vesicular eruption spread throughout the left mid lower back. She has been taking 600 mg of ibuprofen every 6 hours with minimal relief. Which of the following would best confirm the suspected diagnosis? A. Complete a Tzanck smear. B. Measure IgG for varicella. C. Obtain a fungal culture. D. Perform PCR of skin scraping.

D. perform PCR of skin scraping -- herpes zoster is typically a clinical diagnosis. If testing is deemed necessary, a PCR or direct immunofluorescence are the tests of choice.

A 13-year-old female is brought in for evaluation by her father who claims to hear the child vomiting after eating large volumes of food. The patient repeatedly denies vomiting and "feels fine." What physical sign or symptom is most likely present in this patient? A. emaciated physical appearance B. eruption of wisdom teeth C. lymphadenopathy D. petechial hemorrhages of the soft palate

D. petechial hemorrhages of the soft palate -- petechial hemorrhages of the cornea, conjunctivia, soft palate, or face may be noted after self-induced vomiting.

A G3P2002 presents at 33 weeks' gestation. She has had two 30-second contractions within 10 minutes; cervix is 3 cm dilated. Nitrazine test is negative. She has no vaginal bleeding. What is the most likely diagnosis? A. Braxton-Hicks contractions B. abruptio placentae C. premature rupture of membranes D. preterm labor

D. preterm labor -- distinguished from Braxton-Hicks contractions by changes in cervical dilation in response to contractions.

A 32-year-old male presents for an occupational physical exam. His past medical history is significant for ulcerative colitis; however, he has not had any significant problems in more than 5 years. He describes worsening symptoms of fatigue, pruritus, anorexia, and indigestion over the past 6 months. His wife has commented to him that his skin and eyes appear "yellow" and has questioned him about his alcohol consumption, which he adamantly denies. Labs reveal a significantly elevated alkaline phosphatase level. AST and ALT are only mildly elevated. ERCP fails to show common bile duct obstruction. What is the most likely diagnosis in this patient? A.acute pancreatitis B.chronic cholecystitis C.choledocholithiasis D.primary sclerosing cholangitis

D. primary sclerosis cholangitis -- occurs commonly in patients with ulcerative colitis. It is more common in males than females. Pruritis with progressive jaundice is key to the diagnosis. Cholangiography wound show fibrosis of the bile ducts with dilations between strictures.

A 40-year-old female presents for evaluation of a fine tremor in both hands, which she says has been present for years but has become more noticeable in the last few years. Her father and sister have the same tremor. Which of the following is the best treatment to recommend to help control the tremor? A. alcohol B. alprazolam C. primidone D. propranolol

D. propranolol -- effective against benign familial tremor. It can be used intermittently or on a continious basis.

A 41-year-old male presents complaining of easy fatigability. On physical exam, a wide fixed split S2 and a Grade II/VI systolic murmur is heard over the pulmonic region. Which of the following will be most beneficial in the diagnostic evaluation? A. Obtain an ECG. B. Obtain a chest x-ray. C. Refer for cardiac catheterization. D. Refer for echocardiography.

D. refer for echocardiography -- direct visualization of the atrial septal defect by two-dimensional echocardiography and demonstration of a left-to-right shunt through the defect by color-flow Doppler confirms the diagnosis of atrial septal defect.

A 60-year-old awoke with acute unilateral visual loss. He denies pain, headache, and nausea or vomiting. Funduscopic examination reveals vessel dilation, intraretinal hemorrhages, and cotton-wool spots. What is the most likely diagnosis? A. retinal artery occlusion B. hypertensive retinopathy C. macular degeneration D. retinal vein occlusion

D. retinal vein occlusion -- venous dilation and tortuosity, hemorrhages, and cotton-wool spots with acute painless unilateral visual loss are the expected findings in retinal vein occlusion. Occlusion is most common in older patients with chronic atherosclerotic disease or hyperviscosity.

A 39-year-old female presents for evaluation of vague constitutional complaints and cold hands. Examination reveals a three-phase color change of her hands when exposed to cold water. The fingers of both hands are diffusely swollen; her lips appear thinned. What is the most likely diagnosis? A.polyarteritis nodosa B.polymyalgia rheumatica C.polymyositis D.scleroderma

D. scleroderma -- characterized by diffuse fibrosis involving the skin and internal organs. Raynaud's phenomenon and polyarthralgia are present in 90% of patients. Constitutional symptoms may be due to the presence of a mild anemia and systemic involvement. Note: Limited Scleroderma -- CREST Syndrome (calcinosis, Raynaud's, esophageal dysmotility, sclerodactyly, telangiectasias); associated with anti-centromere antibodies. Diffuse Scleroderma -- tight, shiny, thickened skin involving the trunk and proximal extremities; associated with greater internal organ involvement; associated with Anti-SCL-70 antibodies (anti-topoisomerase). ANA nonspecific but present in 90% of scleroderma patients.

A 56-year-old male complains of a nonhealing lesion on his left cheek. Examination reveals a 6-mm pearly papule with surface telangiectasias and a central erosion. What is the most appropriate next step in management? A. curettage B. electrodesiccation C. excision D. shave biopsy

D. shave biopsy -- all lesions suspicious for basal cell carcinoma should undergo either shave or punch biopsy prior to initiating curative treatment. Note: shave or punch biopsy should be performed before excision.

A mother states that her 9-year-old child has abrupt episodes of diminished attention where he "disconnects" briefly from conversations yet has no awareness of these lapses. What EEG pattern would you expect to find in this child during a typical episode? A.generalized rapid spiking B.localized disturbances C.normal EEG pattern D.spike-and-wave activity

D. spike-and-wave activity -- this child is experiencing absence (petit mal) seizures. EEG during an event would show symmetric 3-Hz spike-and-wave activity. Note: pediatric absense seizures is classically treated with ethosuximide.

A 17-year-old male with a family history of hereditary spherocytosis recently experienced his second aplastic crisis. Which of the following interventions is recommended for this patient to prevent future episodes of hemolysis? A. allogeneic bone marrow transplantation B. lifelong supplementation with folic acid C. red blood cell transfusion D. splenectomy

D. splenectomy -- young patients with repeated aplastic anemia and spherocytosis should be referred for splenectomy. Splenectomy will not correct the underlying membrane defect in this disorder but will prevent hemolysis and thus another aplastic crisis.

What is the most common pathogen implicated in acute osteomyelitis after total joint replacement? A.Enterococcus B.Pseudomonas C.Streptococcus D.Staphylococcus

D. staphylococcus

Which of the following is the most appropriate step in managing a patient with papillary thyroid cancer? A. chemotherapy B. radioactive iodine C. propylthiouracil D. surgical removal

D. surgical removal -- treatment of choice.

A 72-year-old with adenocarcinoma of the lung presents with headache, dizziness, visual loss, stupor, and near syncope. Which of the following is most likely on physical exam? A. bradycardia B. rhinophyma C. scattered rhonchi and wheeze D. swelling of the face and neck

D. swelling of the face and neck -- the patient has developed superior vena cava syndrome secondary to obstruction from the mediastinal mass. Swelling of the face and neck are characteristic as well as HA, dizziness, vusual loss, stupor, and syncope. The tumor is likely located in the superior mediastinum.

A 42-year-old female presents with intermittent joint pain that causes her to miss work at times. This joint pain began about a year ago involving primarily the joints in her hands, wrists, and feet. She is also concerned about her progressively worsening fatigue, muscle aches, and feelings of depression. Physical exam reveals tender, edematous bilateral wrists; painless oral ulcers; and erythematous maculopapular lesions on her face. What is the most likely diagnosis? A. systemic sclerosis B. osteoarthritis C. rheumatoid arthritis D. systemic lupus erythematosus

D. systemic lupus erythematosus -- SLE has various presentations. Characteristically, patients present initially with one or two symptoms such as fatigue, myalgias, and arthritis and later develop additional features of SLE. Maculopapular "butterfly" rash is characteristic, although if manifests in only half of affected individuals.

A 15-year-old boy presents for examination after being hit in the groin during a football game. Examination reveals the absence of his right testicle, with no masses, transillumination, or surgical scars noted on either side of his scrotum. His left testicle is present, and although tender to palpation, is of appropriate size. Which of the following is your greatest concern? A. hydrocele B. penile cancer C. spermatocele D. testicular cancer

D. testicular cancer -- testicles generally descend into the scrotum by 12-months of age. A "missing" testicle, with no sign of orchiectomy, could indicate cryptorchidism. Cryptorchidism is a risk factor for testicular cancer. It should also be noted that the descended testicle is also at increased risk for developing cancer.

A 17-year-old male complains of sudden unilateral left-sided groin pain. Examination reveals a markedly tender left scrotum with high-riding horizontal testicle. Elevation of the testicle does not reduce the pain. What is the most likely diagnosis? A.epididymitis B.orchitis C.prostatitis D.testicular torsion

D. testicular torsion -- common in younger males; peak incidence 13-years old. Severe testicular pain is present and not relieved with elevation (negative Prehn sign). The testicle rides high and lies horizontal. The cremasteric reflex is lost on the affected side. (Pearl: the cremasteric reflex is mediated by the internal oblique muscle).

An African American male presents after repeated outbreaks of tender, red, facial pustules that seem to have hairs embedded in them. He changes his razor blade regularly and shaves twice per day to prevent the "five o'clock shadow" look. What type of facial hair does this patient likely have? A.dyed or bleached B.electrolysis treated C.straight and thick D.tightly curled or spiral

D. tightly curled or spiral -- pseudofolliculitis barbae more commonly presents on the cheeks and neck of individuals with tightly curled, spiral hair. It is more common in blacks. Close shaving may induce the whisker to irregularly curve into and out of the follicular wall, leaving a tender, painful red papule or pustule at the point of hair entry. It may also occur in the axillae, pubic region, or legs.

A 68-year-old female presents after a syncopal episode that lasted less than 1 minute. She states she felt nauseous prior to losing consciousness. She has no significant past medical history. Resting blood pressure is 132/84 mm Hg. ECG is normal. Which of the following diagnostic tests is indicated at this time? A. basal metabolic temperature B. electrophysiologic testing C. exercise stress testing D. tilt-table testing

D. tilt-table testing -- the tilt-table test and event recorder placement are useful in diagnosis patients (especially middle-aged and older) with syncope due to vasovagal events, bradycardia, or hypotension. It should be done prior to invasive studies.

A patient is brought into the emergency room appearing quite ill. He has a fever of 103.2°F, dry skin and oral mucosal membranes, and abdominal distention and tenderness. His medical history is significant for ulcerative colitis. Given his history and physical exam findings, which of the following would be highest on the differential diagnosis? A.ileitis B.mesenteric ischemia C.small bowel obstruction D.toxic megacolon

D. toxic megacolon -- fulminant colitis and toxic megacolon are complications of severe ulcerative colitis. Patients have a more fulminant course with rapid progression of symptoms over 1-2 weeks and signs of severe toxicity. These patients appear quite ill, with fever, prominent hypovolemia, hemorrhage requiring transfusion, and abominal distention with tenderness. Patients with active UC are at higher risk of perforation or development of toxic megacolon and must be followed closely.

A 4-year-old girl presents with a 4-day history of limp. She has no history of trauma. She had a viral upper respiratory infection about 1 week ago that resolved without consequence. She is currently afebrile and has no other symptoms. Examination is unremarkable with full range of motion in all joints but a limp favoring the left leg. CBC with differential, ESR, and CRP are within normal limits. Radiographs are negative. What is the most likely cause? A.avascular necrosis of the hip B.slipped capital femoral epiphysis C.septic arthritis of the knee D.transient synovitis

D. transient synovitis -- most prevalent from 3-10-years of age, presenting 1-2 weeks following a URI. Children with this condition walk with a painful limp and often complain of anterior thigh pain. Treatment is symptomatic. Note: avascular necrosis would present with an antalgic gait, hip motion limited in abduction and internal rotation, +/- gluteal muscle wasting and positive Trendelenberg. Diagnosis with plain radiographs.

A 53-year-old male was diagnosed with a UTI and started on a fluoroquinolone 3 days ago. Today, he presents with fever, chills, low back pain, and perineal pain for the past 6 hours. He has not been able to urinate for that time despite multiple attempts. Examination reveals a boggy and tender prostate. Urinalysis via percutaneous suprapubic catheterization reveals numerous leukocytes. Prostate-specific antigen (PSA) is acutely elevated. What is the most appropriate next step? A. computed tomography of pelvis B. continue antibiotics for 7 more days C. prostate massage and cultures D. transrectal ultrasonography

D. transrectal ultrasonography -- patients with prostatitis will present with irritative voiding symptoms. Many will complain of low back pain, perineal pain, or suprapubic pain. Exam should proceed with caution as vigorous massage is contraindicated. An enlarged, boggy, or indurated prostate gland is characteristics. In cases of treatment failure, transrectal ultrasonography of the prostate may help detect prostate calculi or abscess.

A 45-year-old woman presents with a 1-week history of sudden episodes of lancinating right facial pain that radiates toward the ear. These episodes last anywhere from seconds to minutes. The pain is triggered by touch or eating. What is the most likely diagnosis? A.sinus infection B.cluster headache C.migraine headache D.trigeminal neuralgia

D. trigeminal neuralgia -- pain in the distribution of the trigeminal nerve is pathognomonic for trigeminal neuralgia. The pain is often triggered by touch, movement, and draft. The patient may try to hold her face still while talking.

An adult presents with right-sided facial fullness with purulent nasal discharge and fever for 10 days. He states symptoms began as a simple cold but have progressed. He has taken no medications and is allergic to penicillin. Sinuses are tender. Pharynx is edematous with purulent postnasal drip. What is the most appropriate antibiotic treatment? A.amoxicillin-clavulanate B.levofloxacin C.telithromycin D.trimethoprim-sulfamethoxazole

D. trimethoprim-sulfamethoxazole -- first-line therapy for sinusitis in patients with PCN allergy. Patients should also be treated with intranasal corticosteroids. (Note: levofloxacin is an acceptable treatment of sinusitis in patients with a history of recent antibiotic use).

A 22-year-old inner city social worker presents to the office with a 2-week history of fatigue, anorexia, a 10-lb weight loss, a low-grade fever, and intermittent night sweats. He has a nonproductive cough that has recently become somewhat productive. What is the most likely diagnosis? A. influenza B. Pneumocystis jiroveci pneumonia C. costochondritis D. tuberculosis

D. tuberculosis -- these symptoms represent the classic presentation of a patient with TB. He is at higher risk due to his occupation.

A 26-year-old male presents with four episodes of diarrhea per day, rectal bleeding, tenesmus, passage of mucus, and crampy abdominal pain for 1 week. He has experienced intermittent episodes of bloody diarrhea over the past 6 months. What is the most likely diagnosis? A. Crohn disease B. diverticulitis C. infectious diarrhea D. ulcerative colitis

D. ulcerative colitis -- although UC can present acutely, symptoms usually have been present for weeks to months. Occasionally, diarrhea and bleeding are so intermittent and mild that the patient does not seek medical attention. Tenesmus indicates rectal involvement which is always present in UC.

A 42-year-old male presents to the emergency department with edema, hypertension, microproteinuria, and bilateral palpable flank masses. He states he was diagnosed with hypertension 2 years ago, which has been resistant to medical management. His father died from complications of chronic kidney disease. Urinalysis is positive for blood and protein. What imaging modality will best confirm the suspected diagnosis? A.computed tomography B.intravenous pyelography C.magnetic resonance D.ultrasonography

D. ultrasonography -- polycystic kidney disease presents frequently with abdominal or flank pain with microscopic or gross hematuria. A family history is present in up to 75% of cases; an autosomal dominant inheritence is known. Whenever patients present with persistent hypertension and a palpable abdominal mass, the diagnosis should be entertained. Renal ultrasonography is the test of choice to confirm.

A 40-year-old female presents for an annual visit. When you ask how she has been, she starts to tell you but then breaks down in tears. She tells you that her sister died a few months ago after a long battle with breast cancer, and since that time, she has been sad and cries whenever she thinks of her sister. She has continued in her job at a local school and goes out with her family and friends. She can enjoy herself as long as she does not think about how much she misses her sister. What is the most likely diagnosis? A. complicated bereavement B. major depression C. posttraumatic stress disorder D. uncomplicated bereavement

D. uncomplicated bereavement -- patient is not functionally impaired.

A 24-year-old patient has a 3-year history of GERD symptoms. He has failed multiple pharmacologic treatment regimens, including H2 blockers, proton pump inhibitors, and metoclopramide. What is the next best step? A.24-hour pH probe B.barium esophagography C.esophagectomy D.upper endoscopy

D. upper endoscopy -- allows for visualization of the esophagus, stomach, and duodenum. Biopsies are readily obtained.

A 41-year-old female with long-standing GERD undergoes endoscopy, which reveals orange, gastric type epithelium present in tongue-shaped lesions extending upward from the distal end of the esophagus. How often and by what method should this patient undergo screening for cancer? A. ambulatory pH monitoring every 1 to 3 years B. ambulatory pH monitoring every 3 to 5 years C. upper endoscopy every 1 to 3 years D. upper endoscopy every 3 to 5 years

D. upper endoscopy every 3-5 years -- once Barrett esophagus has been identified, screening every 3-5 years by upper endoscopy is recommended to look for dysplasia or adenocarcinoma. There is an 11-fold increase in esophageal adenocarcinoma in patients with Barrett esophagus.

A 25-year-old male presents concerned about a mass that he found on his left testicle. Examination reveals a thickened spermatic cord that enlarges when a Valsalva maneuver is performed. The right testicle is significantly smaller than the left. What is the most likely diagnosis? A.epididymitis B.hydrocele C.inguinal hernia D.varicocele

D. varicocele -- "bag of worms" but may have a more subtle presentation. More commonly found on the left and its presence may affect testicular growth on the contralateral side. Maneuvers that increase intra-abdominal pressure will cause the pampiniform plexus to also increase in size, making its palpation easy. (Pearl: isolated right-sided varicoceles could be an indication of vena cava obstruction such as from a right renal cancer/venous tumor thrombus).

A 4-year-old girl presents for a routine checkup. She is new to the practice. Physical exam reveals a harsh, holosystolic grade III/VI cardiac murmur at the left sternal border with wide radiation and fixed split S2. There is no change with position or respiration. What is the most likely diagnosis? A.innocent murmur B.aortic regurgitation C.patent ductus arteriosus D.ventricular septal defect

D. ventricular septal defect -- small ventricular septal defects typically cause harse, *holosystolic* murmurs best heard at the left sternal border. The fixed, split S2 has a louder pulmonary component and indicates a septal defect. Why not PDA? The murmur of a patent ductus arteriosus is continuous, not holosystolic. The murmur accentuates in late systole.

A 48-year-old female presents for annual gynecologic examination. External inspection reveals several areas of low, irregularly outlined, flat-topped, white, well-defined plaques on the perineum and labia majora. The patient states she has had no symptoms and previous clinicians have never mentioned anything abnormal to her. What is the recommended management at this time? A.endometrial biopsy B.Pap smear C.Schiller test D.vulvar biopsy

D. vulvar biopsy -- a vulvar lesion, especially one with a change in color, needs to be biopsied to make an accurate diagnosis. This must be differentiated from chronic vulvar dermatitis.

A 47-year-old male presents with worsening irritation of his hands that started as dryness and progressed to chapping and erythema and now has fissuring. He works as a janitor in the local hospital cleaning the operating rooms. His symptoms become less severe on his days off. What advice should be offered? A. Wash and dry hands well after exposure to cleaning agents. B. Switch jobs as the problem will not otherwise resolve. C. Use emollient creams several times per day. D. Wear appropriate protective clothing and equipment.

D. wear appropriate protective clothing and equipment.