Internal med rosh questions

A 71-year-old man presents to the office for a routine exam. He has a history of a minor myocardial infarction without sequelae two years ago and hypertension, and he is obese, with a body mass index of 31 kg/m2. A prior chest X-ray revealed slight cardiomegaly, and an echocardiogram revealed left ventricular hypertrophy. He has had 2 admissions for heart failure exacerbations. At this time he reports feeling well and denies dyspnea, orthopnea, or fatigue. Physical exam reveals an obese man who appears otherwise healthy. Auscultation of the heart and lungs reveals no bibasilar crackles, pleural effusions, or tachycardia. There is no jugular venous distension or pitting edema. Palpation of the abdomen is grossly normal. What is the recommended maximum sodium intake per day for this patient? A) 2.0 g per day B) 2.5 g per day C) 3 g per day D) 4.5 g per day

A) 2.0 g per day

A 67-year-old man is admitted to the hospital for cough, hemoptysis, and dyspnea and is subsequently diagnosed with Legionnaires' disease. He is started on azithromycin. On the third day of admission, the patient begins to have nausea, vomiting, and mild confusion. A comprehensive metabolic panel is ordered, and the sodium level is 122 mEq/L. Serum osmolality is 210 mOsm/kg, urine osmolality is 450 mOsm/kg, and urine sodium is 40 mEq/L, indicating a hypotonic, euvolemic hyponatremia. After further testing, there is no indication of cardiac, thyroid, hepatic, renal, or adrenal disease. What is the most appropriate next step in the management of this patient? A) 3% hypertonic saline 100 mL over 10 minutes B) Demeclocycline 300 mg PO tid C) Fluid restriction and 2 g of sodium chloride tablets D) Furosemide 80 mg PO tid

A) 3% hypertonic saline 100 mL over 10 minutes Acute, symptomatic hyponatremia (duration < 48 hours), as seen in the vignette above, should be corrected quickly with 3% hypertonic saline 100 mL over 10 minutes.

A 60-year-old man presents to the clinic complaining of severe shortness of breath and orthopnea. An echocardiogram is significant for a pulmonary arterial pressure of 30 mm Hg, and his electrocardiography is significant for right ventricular and right atrial hypertrophy. Which of the following findings would you expect on this patient's physical exam? A) Accentuation of the pulmonic component of the second heart sound B) An opening snap C) Decreased jugular venous pressure D) No pitting edema

A) Accentuation of the pulmonic component of the second heart sound

A 32-year-old man with a history of type 1 diabetes presents with multiple complaints. He states that he has had a 15-pound unintentional weight loss over the last month and is feeling fatigued. He feels nauseous frequently and has had a loss of appetite. He has associated irritability and depression. His vital signs demonstrate a blood pressure of 89/52 mm Hg with orthostatic hypotension. You note hyperpigmentation of the elbows, knees, and knuckles. Which of the following is the most likely diagnosis? A) Addison disease B) Conn syndrome C) Gastric cancer D) Iron deficiency anemia

A) Addison disease

A 35-year-old woman presents with palpitations, dyspnea, and mild chest pain that started at rest. On physical exam, she is noted to be diaphoretic and tachycardic. Her blood pressure is 130/80 mm Hg, heart rate is 170 beats per minute, and respiratory rate is 22 breaths per minute. Her rhythm strip is shown above. The rhythm persists despite the initiation of the Valsalva maneuver. Which of the following is the most appropriate pharmacologic treatment to give next for this patient's condition? A) Adenosine B) Diltiazem C) Esmolol D) Procainamide

A) Adenosine The first-line medication of paroxysmal supraventricular tachycardia is intravenous adenosine.

A 32-year-old woman is being evaluated for infertility. She also complains of headaches and vision disturbance. On exam, she is noted to have bitemporal hemianopsia. Laboratory studies reveal a serum prolactin level of 210 ng/mL. Which of the following history findings would most likely be present? A) Amenorrhea B) Dysmenorrhea C) Increased libido D) Regular menses

A) Amenorrhea Pituitary adenoma

A 56-year-old man presents to the office with complaints of anal pain with bowel movements for the past 2 weeks. He reports there is no pain at rest, but he often has residual pain after defecating. He has noted a small amount of bright red blood on the toilet paper after having a bowel movement. His past medical history is significant for a prior work-related back injury, for which he takes hydrocodone with acetaminophen on a daily basis. On physical examination, the finding demonstrated above is noted. A digital rectal exam is not performed due to the patient's significant pain. What is the most likely diagnosis based on the provided information? A) Anal fissure B) External hemorrhoid C) Internal hemorrhoid D) Perianal abscess

A) Anal fissure

A 45-year-old woman with type 2 diabetes mellitus presents to your clinic for her diabetes exam. She was diagnosed 5 years ago and has been stable on oral medications. She wants to make sure she is up to date with her ongoing diabetes care. Which of the following is recommended for ongoing health maintenance in patients with diabetes mellitus? A) Annual dilated eye exam B) Annual lipid panel C) Exercise stress testing D) Hepatitis A vaccine

A) Annual dilated eye exam

A 45-year-old man presents to a primary care provider with fever, fatigue, worsening dyspnea, cough, and right-sided pleuritic chest pain for one week. Physical examination is significant for diminished breath sounds over the right lower lobe and dullness to percussion over the same area. A chest radiograph is ordered and shows a right-sided 15 mm pleural effusion over 35% of the hemithorax. He is transferred to the ED where a thoracentesis is performed. Pleural fluid analysis reveals a pleural fluid protein to serum protein ratio of 0.7 and a pleural fluid LDH to serum LDH ratio of 0.8. The pleural fluid is free-flowing and has a pH of 7.4. Gram stain and culture of the pleural fluid are negative.Which of the following is also indicated in the treatment of this patient? A) Antibiotics and supportive treatment B) Tube thoracostomy C) Tube thoracostomy and intrapleural fibrinolytic D) Tube thoracostomy with intrapleural fibrinolytic and deoxyribonuclease

A) Antibiotics and supportive treatment

A 76-year-old woman with congestive heart failure presents with palpitations and dyspnea. On exam, her pulse is irregular, with a rate of 78 beats/minute. Crackles at the lung bases are also present on lung auscultation. Her rhythm strip is shown above. Which of the following medications should be initiated? A) Apixaban B) Aspirin C) Enalapril D) Verapamil

A) Apixaban The patient in the vignette above has a CHA2DS2-Vasc score of 4 and requires anticoagulation for stroke prevention

A 78-year-old man presents with progressively worsening dyspnea on exertion over the last year. It is now beginning to interfere with his activities of daily living, which prompted his visit. His history includes hypertension and hyperlipidemia. He is a former smoker who quit approximately 10 years ago after he retired from working as an electrician. Physical exam is unremarkable except for some fine end-inspiratory crackles. A chest radiograph is obtained that shows bilateral parenchymal opacities. A computed tomography scan shows calcified pleural plaques. Which of the following is the most likely diagnosis? A) Asbestosis B) Emphysema C) Sarcoidosis D) Silicosis

A) Asbestosis Asbestosis is pneumoconiosis that is slowly progressive and caused by the inhalation of asbestos fiber particles. This causes diffuse pulmonary fibrosis. A high-resolution computed tomography scan will show characteristic findings of subpleural linear densities, parenchymal fibrosis, and pleural plaques.

A patient presents to the emergency department for dizziness and shortness of breath. The above electrocardiogram is obtained. His vitals are 88/40 mm Hg, pulse 45 bpm, respirations 16 per minute, and oxygen saturation 98%. Which of the following clinical interventions is indicated first? A) Atropine B) Defibrillation C) Observation D) Permanent pacemaker

A) Atropine This patient has a second-degree Mobitz type II atrioventricular (AV) block. If the patient is hemodynamically unstable, atropine and transcutaneous pacing are typically utilized first in the ED.

A 35-year-old man presents to the clinic complaining of a retrosternal burning sensation after eating, with an occasional acidic taste in his mouth. Which of the following lifestyle modifications should be recommended for this patient? A) Avoid caffeine, chocolate, and carbonated beverages B) Avoid eating a meal six hours before bedtime C) Avoid foods containing tomatoes, onions, and garlic D) Sleep in a prone position

A) Avoid caffeine, chocolate, and carbonated beverages

A 65-year-old man with a past medical history of chronic kidney disease stage IV presents to the clinic to discuss his lab results. The patient does not report any symptoms or concerns at this time. His BMP results include glucose 140 mg/dL, creatinine 3.86 mg/dL, eGFR 21 mL/min, sodium 142 mmol/L, potassium 7.2 mmol/L, chloride 108 mmol/L, carbon dioxide 21 mmol/L, and calcium 9.7 mmol/L. The patient's ECG is noted above. Which of the following should be administered as the most appropriate next step in this patient's management? A) Calcium gluconate B) Insulin C) Kayexalate D) Sodium bicarbonate

A) Calcium gluconate Hyperkalemia

A 76-year-old woman presents to the emergency department after having a seizure. She has been vomiting for the past three days and has been lethargic since yesterday. A basic metabolic panel reveals a sodium level of 155 mEq/L. Which of the following complications should be considered when initiating volume repletion and serum sodium reduction? A) Cerebral edema B) Hypoglycemia C) Osmotic demyelination syndrome D) Prolonged QT interval

A) Cerebral edema

A 45-year-old woman presents to a primary care provider with fatigue, generalized joint pain and stiffness, and multiple nodules over the extensor surface of her forearms. A complete laboratory workup is ordered and is significant for elevated levels of anti-cyclic citrullinated peptide and C-reactive protein. She is started on appropriate pharmacologic therapy. Which of the following diagnostic studies will most likely be indicated as her condition progresses, in addition to routine preoperative tests for procedures requiring sedation? A) Cervical spine radiographs B) Dual-energy X-ray absorptiometry C) Pulmonary function testing D) Schirmer test

A) Cervical spine radiographs Rheumatoid arthritis

A 58-year-old woman with a history of choledocholithiasis presents to the emergency department with acute abdominal pain and altered mental status. Upon physical assessment, the patient is found to have a temperature of 102.8°F, blood pressure of 89/52 mm Hg, heart rate of 122 beats per minute, and oxygen saturation of 97% on room air. She has significant tenderness in the right upper quadrant. Initial laboratory assessment reveals an elevated white blood cell count, elevated serum alkaline phosphatase, elevated gamma-glutamyl transpeptidase, and elevated bilirubin. What other information would likely be gathered from her history and physical examination based on the suspected diagnosis? A) Concurrent jaundice B) History of inflammatory bowel disease C) Preceding pruritus D) Recent travel to Bolivia

A) Concurrent jaundice Jaundice is present in approximately 60-70% of patients with acute cholangitis. Acute cholangitis results from an ascending infection within the biliary tract.

A 67-year-old man with a history of congestive heart failure presents with dyspnea and a dry cough for the past two days, and it has been worsening. He denies any fever or other upper respiratory symptoms. Exam of the lower extremities reveals +1 pitting edema at the level of the ankles. A chest radiograph shows obliteration and opacification of the bilateral costophrenic angles visualized in two views. Which of the following would you expect to find on physical exam? A) Decreased tactile fremitus B) Hyperresonant percussion C) Increased chest expansion D) Tracheal deviation

A) Decreased tactile fremitus Pleural effusion

A 55-year-old man presents to a primary care provider for concerns about erectile dysfunction. He reports that he has had difficulty maintaining an erection for several months. He is currently on medication for depression, anxiety, benign prostatic hyperplasia, and angina. Which of the following medications is the most likely cause of his erectile dysfunction? A) Duloxetine B) Nitroglycerin C) Prazosin D) Selegiline

A) Duloxetine SNRIs can cause erectile dysfunction

A 68-year-old man presents with a substernal chest tightness that occurred while he was walking his dog this morning. The pain lasted approximately five minutes and was relieved by rest. Physical examination and laboratory studies are unremarkable. Resting ECG is normal. Which of the following is the most likely next step in diagnosis? A) Exercise ECG B) Myocardial perfusion scintigraphy C) Radionuclide angiography D) Stress echocardiography

A) Exercise ECG Stable angina pectoris

A 68-year-old man presents to the clinic complaining of abdominal distention and shortness of breath. He takes no daily medications, has not seen a healthcare provider in decades, and has consumed 12 beers per day for the past 20 years. On physical exam, vital signs are within normal limits. Skin is nonicteric, and body habitus demonstrates central adiposity. Physical exam reveals a firm, irregular liver border just below the right costal margin, abdominal fluid wave, and dullness to percussion with decreased breath sounds on the right chest. Which of the following represents appropriate initial management of this patient's complaints? A) Furosemide 20 mg daily and salt restriction B) Insertion of a thoracostomy tube in the right chest and abdominal paracentesis C) Liver transplantation D) Metoprolol tartrate 50 mg bid and potassium restriction

A) Furosemide 20 mg daily and salt restriction

A 68-year-old man with rheumatoid arthritis and Crohn disease presents with fatigue and exertional dyspnea. On exam, he is noted to be tachycardic and hypotensive. Laboratory studies show a serum hemoglobin level of 10 g/dL with an MCV of 90 fL, elevated CRP, and elevated ESR. Which additional finding is most likely to be present in this patient? A) High ferritin B) High iron C) High TIBC D) High transferrin

A) High ferritin Anemia of chronic disease

A 46-year-old woman presents to a primary care provider as a new patient. Her vital signs are T 98.8°F (37.1°C), BP 200/164 mm Hg, HR 98 bpm, RR 18 breaths per minute, and pulse oximetry 100% on room air. Her body mass index is 38. She is a heavy smoker and has a 35 pack-year history. On physical exam, she has a low hairline, low-set ears, webbed neck, and a broad chest. The patient reports that horseshoe kidneys were present on a previous renal ultrasound. While in the office, the patient suddenly experiences severe tearing chest pain that radiates to her back. Which of the following is the most common risk factor for the suspected diagnosis? A) Hypertension B) Marfan syndrome C) Smoking D) Turner syndrome

A) Hypertension Aortic dissection

A 28-year-old PA student presents to a primary care provider with fatigue and gross hematuria. He started having cold-like symptoms last night along with a mild sore throat and noticed bloody urine in the toilet this morning. He has not taken any recent medication other than pseudoephedrine. He reports no tobacco, alcohol, or drug use. The patient is of Chinese descent. A serum complement level is normal. What is the most likely cause of his hematuria? A) IgA nephropathy B) Postinfectious glomerulonephritis C) Pseudoephedrine D) Thromboangiitis obliterans

A) IgA nephropathy IgA nephropathy, also known as Berger disease, is a cause of nephritic syndrome and is the most common primary glomerular disease worldwide, particularly in those who are of East Asian (e.g., Chinese, Taiwanese, Korean) descent or are White.

A 62-year-old man presents with a gradual onset of worsening dyspnea on exertion and dry cough over the last few months. A chest radiograph demonstrates increased reticular markings. A high-resolution computed tomography scan is completed and shows scattered ground-glass opacities superimposed on a fine reticular pattern. Pulmonary function studies are ordered and demonstrate a restrictive pattern. Which of the following diagnostic results would be most consistent with the diagnosis? A) Increased FEV1/FVC ratio B) Increased forced expiratory volume in one second C) Increased forced vital capacity D) Increased residual volume

A) Increased FEV1/FVC ratio Idiopathic pulmonary fibrosis

A 2-year-old girl presents for intermittent diarrhea, poor weight gain, and low appetite that has gotten worse over the past month, according to her mother. The patient's anti-tissue transglutaminase immunoglobulin A is elevated. Which of the following is the mainstay of treatment of this condition? A) Life-long avoidance of foods containing gluten B) Life-long avoidance of foods containing lactose C) Oral mesalamine D) Oral prednisone therapy

A) Life-long avoidance of foods containing gluten

A 38-year-old woman has been diagnosed with papillary thyroid cancer. The tumor is 2.3 cm in diameter with metastasis to regional lymph nodes and no distant metastasis. Which of the following best describes the stage of this cancer? A) Stage I B) Stage II C) Stage III D) Stage IV

A) Stage I If the age is less than 45 years, then patients with any tumor size and any node metastasis without distant metastasis are classified as stage I

A 23-year-old woman presents to her primary care provider with complaints of vaginal itching, dysuria, and odorless, white, curd-like discharge. Which of the following diagnostic study results is most consistent with the suspected diagnosis? A) pH of 4.0 and hyphae on potassium hydroxide prep B) pH of 4.7 and a positive whiff test C) pH of 5.2 and clue cells on wet mount D) pH of 5.5 and motile trichomonads on wet mount

A) pH of 4.0 and hyphae on potassium hydroxide prep

Which of the following patients meets the diagnostic criteria of diabetes mellitus, according to the American Diabetes Association? A) A patient with a fasting glucose level of 100 mg/dL and an A1C value of 5.5% B) A patient with polyuria, excessive thirst, and a random glucose level of 240 mg/dL C) An asymptomatic patient with a fasting glucose level of 136 mg/dL (day 1) and 110 mg/dL (day 2) D) An asymptomatic patient with a random glucose level of 220 mg/dL

B) A patient with polyuria, excessive thirst, and a random glucose level of 240 mg/dL

A 61-year-old woman presents to a primary care provider for routine management of hypertension, hyperlipidemia, and diabetes mellitus. Her vital signs are significant for a BP of 148/96 mm Hg. Her most recent hemoglobin A1C was 7.6%. While at the office, the patient suddenly exhibits slurred speech, left-sided facial weakness, and right arm weakness. The patient is immediately taken to the emergency department. While en route, the patient's symptoms resolve. A stroke protocol is initiated upon arrival to the ED. A noncontrast CT of the head is shown above. The patient's complete blood count, comprehensive metabolic panel, coagulation profile, and urinalysis are normal. Serial cardiac enzymes and ECGs are normal. The physical exam is significant for a left-sided carotid bruit. No focal neurologic deficits are present. What is the best next step in the management of this patient? A) Administer recombinant tissue plasminogen activator B) Admit and order a diffusion-weighted MRI C) Discharge on aspirin with outpatient evaluation within 72 hours D) Emergent left carotid endarterectomy

B) Admit and order a diffusion-weighted MRI The patient in the vignette above has an ABCD2 score of 6 (1 point for age, 1 point for BP, 2 points for unilateral weakness, 1 point for symptoms lasting 10-59 minute, and 1 point for diabetes mellitus) and should be admitted and further assessed with a diffusion-weighted MRI. A diffusion-weighted MRI is better than standard CT and MRI tests for evaluating ischemic damage and subsequent stroke risk after a TIA.

A 50-year-old woman presents with muscle weakness of the shoulder and pelvic girdles that has progressively worsened over the last several months. Physical exam reveals a three out of five muscle strength in the hip flexors and the deltoids. Laboratory studies demonstrate elevated aldolase and creatine kinase. Which of the following positive laboratory results would be expected? A) Anti-double stranded DNA antibodies B) Anti-Jo-1 antibodies C) Anti-La antibodies D) Anti-SCL-70 antibodies

B) Anti-Jo-1 antibodies Polymyositis

A 65-year-old man with a history of diabetes mellitus type 2 and heart failure presents with substernal chest pain, nausea, and diaphoresis. On exam, he is mildly tachycardic and hypertensive. His rhythm strip shows ST depression in leads II, III, and aVF. Laboratory studies demonstrate an elevation in the level of serum troponin. Which of the following medications should he be started on today? A) Alteplase B) Atorvastatin C) Metoprolol D) Verapamil

B) Atorvastatin High-dose statins (atorvastatin) are recommended in all patients with NSTEMI as they improve outcomes and delay death or major cardiovascular events by up to three months.

A 73-year-old man with a 20 pack-year history of cigarette use presents to the clinic complaining of a change in his urine color. The patient states he has noticed his urine has a slight red tinge. He denies any symptoms of flank pain, dysuria, malodorous urine, urethral discharge, or urgency. His urinalysis is positive for occult blood. Which of the following is the most likely diagnosis? A) Benign prostatic hypertrophy B) Bladder cancer C) Nephrolithiasis D) Wilms tumor

B) Bladder cancer

A 26-year-old man with a past medical history of cystic fibrosis presents to the clinic complaining of a chronic cough with purulent, foul-smelling sputum. The patient has crackles noted to bilateral bases of lungs. A CT scan is significant for abnormal dilation of bronchial walls. Which of the following is the most likely diagnosis? A) Asthma B) Bronchiectasis C) Chronic bronchitis D) Emphysema

B) Bronchiectasis

A 35-year-old woman is diagnosed with iron deficiency anemia and is being treated with ferrous sulfate. Which of the following foods has the highest iron content and thus should be recommended in her diet? A) Beef B) Calf liver C) Ham D) Lamb

B) Calf liver

A 30-year-old woman presents to the clinic complaining of a fever, cough, and shortness of breath. She reports associated symptoms of fatigue and chills. Her vital signs include blood pressure 126/84 mm Hg, heart rate 108 beats/minute, temperature 39°C, and oxygen saturation 96% on room air. Her physical exam is consistent with increased tactile fremitus and dullness to percussion over the left lower lung field. A sample of her sputum is obtained and observed with a Gram stain significant for gram-positive cocci in pairs. What is the appropriate treatment for this patient's suspected diagnosis? A) Azithromycin and ampicillin B) Clarithromycin C) Clindamycin D) Levofloxacin

B) Clarithromycin The patient in the vignette has community-acquired pneumonia, which is most commonly due to Streptococcus pneumoniae, which would appear on Gram stain as gram-positive cocci in pairs.

A 65-year-old woman with a history of deep vein thrombosis who is taking warfarin reports to her primary care provider with a three-week history of lower leg swelling, pain, and an itchy rash on the leg that was previously affected by the deep vein thrombosis. Physical exam reveals 2+ pitting edema of the affected leg, brownish discoloration, and a diffuse, flaking, weeping rash over her affected calf. Venous ultrasound does not show new deep vein thrombosis. What initial intervention is recommended? A) Altering anticoagulation therapy B) Compression stockings C) Radioablation therapy D) Warm compresses

B) Compression stockings Chronic venous insufficiency

A 32-year-old man presents to the clinic for treatment of newly diagnosed, asymptomatic HIV infection. His viral load is 200,000 copies/mL, and his CD4 cell count is 110 cells/microL. He is currently taking no medications and is allergic to sulfa drugs (generalized urticaria). A chest X-ray reveals no active pulmonary disease, and tuberculosis skin and sputum tests are negative. Which of the following antimicrobials should be prescribed prophylactically for this patient in addition to antiretroviral medication? A) Azithromycin 1,200 mg once weekly B) Dapsone 100 mg daily C) Rifabutin 300 mg daily D) Trimethoprim-sulfamethoxazole DS daily

B) Dapsone 100 mg daily

You respond to a code blue of a 45-year-old woman in the cardiac intensive care unit. Upon arrival in the room, a defibrillator has already been attached to the patient and a nurse is performing cardiopulmonary resuscitation. The ECG of the patient is shown above. Which of the following is the best next step in management? A) Cardiopulmonary resuscitation B) Defibrillation C) Epinephrine intravenous D) Intubation

B) Defibrillation

A 65-year-old woman with a history of Hashimoto thyroiditis presents to your office with complaints of an enlarged mass on her neck and unexplained weight loss over the past 3 months. She is now retired but previously worked as a hairdresser and is an avid gardener. Physical exam reveals cervical lymphadenopathy and splenomegaly. Which of the following is the most appropriate diagnostic test? A) Endoscopy B) Excisional lymph node biopsy C) Magnetic resonance imaging D) Neck ultrasound

B) Excisional lymph node biopsy Workup for patients suspected of having non-Hodgkin lymphoma includes laboratory testing, chest radiography, excisional lymph node biopsy, and computed tomography of the neck, chest, abdomen, and pelvis.

A 65-year-old man with a history of rheumatic fever presents with decreased exercise tolerance that has progressively worsened over the years. On exam, a low-pitched diastolic murmur is auscultated. The murmur is best heard at the apex with the patient in the left lateral decubitus position. An opening snap is also present. Which of the following is the most common presenting symptom based on the most likely diagnosis? A) Chest pain B) Exertional dyspnea C) Hemoptysis D) Hoarseness

B) Exertional dyspnea Mitral stenosis

A 20-year-old man presents to his primary care provider in July with complaints of fever, chills, headache, and muscle aches for four days. The patient recalls removing a tick on his arm several days before his symptoms began and is unsure how long the tick had been there. The patient reports that he has been dog sitting for the past week in North Carolina and noticed that one of the dogs had multiple ticks attached. He brought one of the ticks with him to the office today. Which of the following physical exam findings is most consistent with the suspected diagnosis? A) Erythematous circular rash with central clearing B) Facial flushing and abdominal pain C) Maculopapular rash on the trunk that spreads to the extremities D) Tic douloureux

B) Facial flushing and abdominal pain Rocky mountain spotted fever

A 58-year-old man with poor preventative care presents to the emergency department by ambulance due to worsening weakness in the context of vomiting blood for the past 5 hours. An accompanying family member reports they called 911 after the patient became confused at home. The family member cannot quantify the amount of blood or vomit. The patient does not smoke cigarettes. He drinks 1 pint of bourbon nightly and has done so for the past 20 years. The patient is tachycardic to 118 bpm, and his blood pressure is 88/60 mm Hg. Physical examination reveals ascites, temporal wasting, palmar erythema, and scleral icterus. Two large-bore intravenous catheters are placed. What intervention would be most appropriate at this time? A) Administration of octreotide B) Fluid resuscitation C) Packed red blood cell transfusion D) Transjugular intrahepatic portosystemic shunt

B) Fluid resuscitation

A 64-year-old man is diagnosed with pneumonia and admitted into the hospital. Which of the following findings supports Legionella as the pathogen causing pneumonia? A) Hypoglycemia B) Hyponatremia C) Infiltrate in the upper lobes D) Pleuritic chest pain

B) Hyponatremia

A 45-year-old Asian American man presents to the urgent care for one day of severe toe pain. He has a past medical history of obesity and hypertension. His current medications are chlorthalidone and a multivitamin. He reports his toe is painful, swollen, and sensitive to touch. On exam, the first metatarsophalangeal joint on his left foot is erythematous, swollen, and tender. Manipulation of the joint causes the patient distress. What is the first-line therapy for the suspected diagnosis? A) Allopurinol B) Indomethacin C) Observation D) Probenecid

B) Indomethacin Nonsteroidal anti-inflammatory drugs (e.g., indomethacin), colchicine, and glucocorticoids are the first-line therapy options for acute gout.

A 62-year-old man with chronic obstructive pulmonary disease uses an albuterol inhaler as needed for symptoms. Despite using the albuterol inhaler, the patient has frequent daily symptoms. He denies any exacerbations in the past year. Which of the following additions to his therapeutic regimen would be most appropriate? A) Inhaled ipratropium B) Inhaled tiotropium C) Oral prednisone D) Oral theophylline

B) Inhaled tiotropium Long-acting muscarinic antagonists (tiotropium or glycopyrrolate). Long-acting muscarinic-antagonists are preferred as the initial long-acting therapy because they are dosed once daily.

A 72-year-old man with a past medical history significant for hypertension presents for a routine yearly physical exam. He has been feeling well and has no complaints. His physical exam is benign, and a basic metabolic panel is ordered as part of a routine series of blood tests. The results show a calcium level that is 0.8 mg/dL above normal limits. When compared to last year's results, this is a new lab finding. Which of the following studies should be ordered next to confirm the most likely diagnosis? A) 1,25-dihydroxyvitamin D B) Intact parathyroid hormone C) Phosphate D) Thyroid ultrasound

B) Intact parathyroid hormone

A 54-year-old woman is being discharged on warfarin after being admitted for new-onset atrial fibrillation. Which of the following foods should she be advised to avoid while on warfarin? A) Bananas B) Kale C) Oats D) Pasta

B) Kale Patients on warfarin should avoid foods that are high in vitamin K such as kale and other dark leafy greens, ethanol, cranberry juice, and other foods high in vitamin E due to the risk of altering the efficacy of warfarin.

A 55-year-old woman presents with gradual onset of joint stiffness and swelling that has progressively worsened over the last two years. Joint stiffness often affects the metacarpophalangeal joints and proximal interphalangeal joints of the fingers and is worse in the morning, lasting more than 30 minutes. On exam, a bowstring sign is noted. Anti-cyclic citrullinated peptide antibodies are present in serum. She has never been on any medication for her condition. Which of the following medications slows the progression of the suspected disease and should be initiated at the time of diagnosis? A) Low-dose corticosteroids B) Methotrexate C) Nonsteroidal anti-inflammatory drugs D) Sulfasalazine

B) Methotrexate RA

A 68-year-old woman presents to urgent care with a rapid onset of symmetrical pain and stiffness of the shoulders, neck, and hip girdle that is worse in the morning and after prolonged inactivity. Because of the stiffness and pain, she is having difficulty with daily activities, such as combing her hair, taking a shower, putting on a coat, and driving. Which of the following is the most likely explanation for these findings? A) Giant cell arteritis B) Polymyalgia rheumatica C) Polymyositis D) Takayasu arteritis

B) Polymyalgia rheumatica Polymyalgia rheumatica is a clinical diagnosis based on pain and stiffness around the shoulder, neck, and hip area.

A 36-year-old diabetic health care worker is being treated for latent tuberculosis after a positive tuberculin skin test and a negative chest radiograph. The health care provider prescribes isoniazid daily for nine months. Which of the following medications should be prescribed in addition to this medication? A) Pyrazinamide B) Pyridoxine C) Rifampin D) Rifapentine

B) Pyridoxine

An 85-year-old man presents to the emergency department with new-onset fever and cough for one day. He lives in an assisted living facility and has a history of hypertension and COPD. His vitals are 88/42 mm Hg, pulse 122 bpm, temperature 101.5°F, respiration 22/min, and oxygen saturation 97% on room air. Lab work reveals a white blood cell count of 16,000 cells/HPF, creatinine of 1.9 mg/dL, and serum lactate of 6.5 mmol/L. While in the ER, he was given 2 L of 0.9% normal saline. A repeat blood pressure is 85/40 mm Hg. What is the most likely diagnosis? A) Sepsis B) Septic shock C) Severe sepsis D) Systemic inflammatory response

B) Septic shock This patient presents with septic shock. Septic shock is due to a systemic inflammatory response in the body that leads to abrupt peripheral vasodilation, causing a decrease in systemic vascular resistance.

A 45-year-old woman presents with recurrent reflux and dysphagia. She reports that her fingers become cyanotic when she is exposed to cold temperatures and then hyperemic with rewarming. On exam, skin thickening and thickness over the extensor surfaces of the digits are noted. Which of the following positive laboratory results is most specific for the suspected diagnosis? A) Anti-Jo-1 antibody B) Anti-Smith antibody C) Anticentromere antibody D) Antinuclear antibody

C) Anticentromere antibody Scleroderma

A 40-year-old woman presents to her primary care provider with right leg pain that has been persistent for the past seven months. The patient has a history of a right tibial shaft stress fracture that was diagnosed two years ago. The patient reports sensations of burning, tingling, and severe muscle aches over the site of the previous fracture. She reports her right leg seems to be a different color and is painful to move at times. On physical examination, the right leg is pale and dusky in appearance. The patient has pain out of proportion to light touch over the anterior tibialis muscle. Ankle dorsiflexion is limited due to pain. AP and lateral radiographs of the right tibia are normal. What is the most likely diagnosis? A) Arterial ulcer B) Chronic osteomyelitis C) Complex regional pain syndrome D) Exertional compartment syndrome

C) Complex regional pain syndrome

A 30-year-old man presents to a primary care provider with fatigue, decreased appetite, and a diffuse maculopapular rash involving his palms and soles. He reports that he is currently sexually active with both men and women and has had four different partners in the last year. He also reports that he had a painless sore on his penis about two months ago that healed spontaneously after a few weeks. A rapid plasma reagin test is positive. A follow-up fluorescent treponemal antibody absorption test is also positive. Which of the following physical exam findings is most consistent with the patient's diagnosis? A) Chancre B) Condyloma acuminata C) Condylomata lata D) Gummas

C) Condylomata lata The patient in the vignette above has secondary syphilis which is characterized by a diffuse maculopapular rash commonly found on the palms and soles, condylomata lata, and systemic signs and symptoms (e.g., fever, headache, sore throat, lymphadenopathy, decreased appetite).

55-year-old man presents with abdominal discomfort and pain for the last year. He had previously been taking naproxen 500 mg twice daily for arthritic pain in his knees but stopped after the epigastric pain started becoming intolerable. His esophagogastroduodenoscopy report details a shallow ulcer in the antrum of the stomach. He is prescribed 40 mg of omeprazole once daily. Helicobacter pylori testing is negative at this time. Which of the following represents the most appropriate therapy at this time? A) Add bismuth subsalicylate, metronidazole, and tetracycline and continue omeprazole B) Add clarithromycin and amoxicillin and continue omeprazole C) Continue omeprazole 40 mg once daily as monotherapy D) Replace omeprazole with sucralfate

C) Continue omeprazole 40 mg once daily as monotherapy If testing for H. pylori is negative, monotherapy with a proton pump inhibitor (PPI) such as omeprazole is sufficient for healing.

A 55-year-old woman presents to the clinic with acute onset of cough, shortness of breath, and fever. Based on the clinical manifestations and above image, which of the following exam findings would further support the most likely diagnosis? A) Decreased tactile fremitus B) Diffuse end-expiratory wheezing C) Dullness to percussion of the right lower lobe D) Hyperresonance to percussion of the right lower lobe

C) Dullness to percussion of the right lower lobe

A 26-year-old man who uses intravenous drugs presents with an acute onset of fever, chills, malaise, and anorexia. On physical exam, his temperature is 101.4°F, BP 98/50 mm Hg, HR 120 beats per minute, and RR 22 breaths per minute. Splinter hemorrhage and Osler nodes are present. Which of the following diagnostic tests would confirm the suspected diagnosis? A) Chest radiography B) Computed tomography C) Echocardiography D) Electrocardiogram

C) Echocardiography

A 62-year-old obese woman with diabetes presents to the office complaining of worsening dyspnea and dizziness. She has a longstanding history of alcohol use and currently reports decreasing her alcohol consumption to 12 beers per week. On physical exam, she appears to be in no acute distress. Cardiovascular exam reveals jugular venous distention and rales bilaterally on auscultation of the lungs. Which initial diagnostic study is most helpful for eliminating a valvulopathy as the possible cause of her symptoms? A) Cardiac magnetic resonance imaging B) Chest radiography C) Echocardiography D) Electrocardiography

C) Echocardiography

A 58-year-old cachectic man with a 40 pack-year history of tobacco use presents to the clinic with severe shortness of breath and a cough. He is tachypneic and is using accessory muscles to breathe. A chest X-ray shows flattened diaphragm and an increase in anteroposterior diameter. Which of the following would you expect to find on this patient's pulmonary function test? A) Decreased expiratory reserve volume B) Decreased total lung capacity C) FEV1/FVC less than 70% D) Increased diffusing capacity of the lungs for carbon monoxide

C) FEV1/FVC less than 70% Emphysema which is a form of COPD

Which of the following is the first step in the pathogenesis of primary pulmonary tuberculosis infection? A) Creation of the Ranke complex B) Development of regional lymphadenopathy C) Formation of a tubercle D) Formation of the Gohn focus

C) Formation of a tubercle Tuberculosis (TB) is spread by small aerosol droplets. These droplets reach the alveolar space and activate the host's defense system. If the defense system fails to eradicate the infection, then the infection can begin to grow within the alveolar space. Eventually, the infection may spread to extrapulmonary tissues. Macrophages create cytokines and chemokines that, in turn, attract alveolar macrophages and neutrophils. These cells combine to form a granulomatous nodule called a tubercle. As the tubercle grows, the infection spreads to local lymph nodes, creating lymphadenopathy.

A 50-year-old man presents with a gradual onset of weight loss, malaise, and abdominal pain. On exam, he is noted to have painful violaceous plaques surrounded by livedo reticularis on the extremities. Laboratory studies demonstrate elevated C-reactive protein and erythrocyte sedimentation rate. Which of the following diseases should be screened for based on the suspected diagnosis? A) Acute cholecystitis B) Hepatitis A C) Hepatitis B D) Hepatitis E

C) Hepatitis B Polyarteritis nodosa

A 68-year-old man with sickle cell anemia has painful episodes that are becoming more frequent. He is currently pain-free but wants to be started on a therapy that can improve his painful crisis. Which of the following therapies should be initiated to improve his painful episodes? A) Bone marrow transplant B) Gene therapy C) Hydroxyurea D) L-glutamine oral powder

C) Hydroxyurea Hydroxyurea is the only pharmacologic agent that has consistently demonstrated improvements in episodes of pain and survival rates for patients with sickle cell anemia. It increases hemoglobin F and reduces the production of HbS, thereby reducing the number of red cells that are susceptible to sickling.

A 32-year-old man presents to the office for a routine physical exam. He has a history of seasonal allergies but is otherwise healthy. He takes no medications, does not smoke, and drinks beer occasionally in social situations. He has an athletic build, however, he reports not exercising much due to shortness of breath while exercising. His vital signs show a blood pressure of 112/72 mm Hg, pulse of 87 bpm, temperature of 98.2°F, and respirations of 10 breaths per minute. On cardiac exam, you hear a crescendo-decrescendo systolic murmur beginning slightly after S1 that is best heard at the apex and left lower sternal border. The murmur increases with the Valsalva maneuver. His electrocardiogram is shown above. What is the most likely diagnosis? A) Aortic regurgitation B) Aortic stenosis C) Hypertrophic cardiomyopathy D) Patent ductus arteriosus

C) Hypertrophic cardiomyopathy

A 35-year-old man with a past medical history of hypertension presents to the urgent care clinic with intermittent left-sided lower back pain with radiation to his flank, hematuria, nausea, and increased urinary frequency. He denies any recent trauma or falls. He is not sexually active. Vital signs are heart rate of 68 bpm, blood pressure of 132/81 mm Hg, O2 saturation of 98% on room air, respiratory rate of 16 breaths per minute, and temperature of 98.1°F. Physical exam shows mild tenderness to palpation of the left lower back and left flank without bruising. There is no hernia present, and a genital exam is unremarkable. What is the initial management of choice for this patient, based on the most likely diagnosis? A) Cystoscopy B) Foley catheter placement C) Intravenous fluids and anti-inflammatory medications D) Reassurance and follow-up

C) Intravenous fluids and anti-inflammatory medications

A 65-year-old man with a history of poorly controlled type 2 diabetes mellitus and hypertension presents to your office for his diabetes visit. Routine laboratory testing reveals elevated serum creatinine and blood urea nitrogen levels, increased from the previous year. Which of the following is the most appropriate diagnostic study to evaluate this patient? A) Intravenous urogram B) Kidney computed tomography C) Kidney ultrasound D) Kidney, ureter, bladder radiography

C) Kidney ultrasound Azotemia is defined as elevated serum creatinine and blood urea nitrogen levels, which are markers of kidney function. The most effective initial diagnostic tool is kidney ultrasound due to its ease of use, lack of radiation, cost, and ability to detect a number of abnormalities causing the kidney dysfunction.

A 55-year-old man presents to a primary care provider with complaints of depression, resting tremor, slowed movements, and problems with balance. Physical examination is significant for rigidity, a shuffling gait, and masked facies. Which of the following pathologic findings is associated with the patient's condition? A) Atrophy of the caudate nucleus and putamen B) Increase in dopaminergic neurons in the substantia nigra C) Lewy bodies in the substantia nigra D) Tau tangles in the intercellular spaces of neurons

C) Lewy bodies in the substantia nigra

A 78-year-old woman presents to the emergency department with sudden-onset dyspnea, weakness, and altered mental status. Her vital signs show a blood pressure of 78/45 mm Hg, pulse of 117 bpm, temperature of 100.4°F, and respirations of 19 breaths per minute. She is alert and oriented to person and place but appears confused about time and situation. Physical exam reveals a thin woman in acute distress complaining of chest pain. Arterial pulses are rapid and thready with low amplitude. Auscultation along the left sternal border and apex of the heart reveals a systolic, soft, low-pitched decrescendo murmur without thrill radiating to the axilla. Which acute issue is the most likely diagnosis? A) Aortic dissection B) Aortic stenosis C) Mitral regurgitation D) Mitral valve prolapse

C) Mitral regurgitation Mitral regurgitation is the most prevalent valvular disorder in the United States. It refers to the abnormal reversal of blood flow from the left ventricle to the left atrium. Mitral regurgitation can lead to increased intracardiac pressure, left ventricular dysfunction, and the inability of the mitral valve leaflets to close appropriately.

A 52-year-old woman presents to a primary care provider with photosensitivity, foreign body sensation, and eye fatigue bilaterally. She also reports a sore tongue and dry, peeling lips. A Schirmer test and rose bengal stain are positive in both eyes. What is the most likely finding on salivary gland biopsy? A) Decreased salivary output B) Increased salivary output C) Mononuclear cell infiltration D) Polynuclear cell infiltration

C) Mononuclear cell infiltration Mononuclear cell infiltration seen on salivary gland biopsy is a hallmark of Sjögren syndrome. Sjögren syndrome is an autoimmune condition characterized by B cell hyperreactivity and T cell infiltration of the exocrine glands.

A 62-year-old woman with a history of hypertension presents to the emergency department for new-onset headache and blurry vision that started one hour ago. Vital signs are BP 220/120 mm Hg, HR 100 bpm, and RR 16 breaths per minute. Physical exam is significant for flame hemorrhages on funduscopy. Lab work reveals anemia, thrombocytopenia, and an acutely elevated serum creatinine. The patient is admitted to the ICU for blood pressure stabilization. Which of the following is the most appropriate pharmacologic therapy? A) Captopril B) Clonidine C) Nicardipine D) Nifedipine

C) Nicardipine Dihydropyridine calcium channel blockers (e.g., nicardipine) and labetalol have been shown to be the most effective at lowering blood pressure in most clinical scenarios.

A 74-year-old man with a 35 pack-year smoking history presents to a primary care provider with shortness of breath, nonpleuritic right-sided chest pain, fatigue, generalized weakness, and a 12-pound weight loss over the past three months. He denies any sick contacts, travel, or changes in daily activities. He typically spends most of his time volunteering at Habitat for Humanity since he is a retired construction worker but has been unable to volunteer in the past month because of his worsening symptoms. His father and two older brothers passed away from complications due to lung cancer. His chest radiograph is shown above. Pleural fluid to serum protein ratio is 0.7, and pleural fluid to serum lactate dehydrogenase ratio is 0.66. A red blood cell count of the pleural fluid reveals 230,000 cells/µL. Cytology of the pleural fluid is unremarkable. A video-assisted thoracoscopic surgery is performed to obtain a biopsy of the pleural lining. Histology of the specimen confirms the diagnosis. Which of the following is an independent risk factor for the patient's condition? A) Elderly age B) Family history C) Occupation D) Smoking history

C) Occupation Mesothelioma is an aggressive primary tumor that typically occurs in the pleural lining of patients who have been exposed to asbestos. Asbestos is the only independent risk factor of mesothelioma and is associated with occupational exposures from industries such as construction.

A 44-year-old obese woman presents to the clinic to discuss the results of her recent upper endoscopy. Several confluent, erosive, and exudative lesions were noted in the distal esophagus. Biopsies of the inflamed tissue were negative for dysplasia and Helicobacter pylori. Which of the following initial treatment options is best for this patient? A) Amoxicillin 1 g bid, omeprazole 40 mg bid, and clarithromycin 500 mg bid for 14 days B) Famotidine 20 mg bid for 6 months C) Omeprazole 40 mg daily for 8 weeks D) Sucralfate 1 g qid and calcium carbonate 8 g daily for 4 weeks

C) Omeprazole 40 mg daily for 8 weeks Reflux esophagitis—are treated with proton pump inhibitors (such as omeprazole) as first-line therapy. After eight weeks of therapy, a repeat upper endoscopy should be performed to evaluate the mucosal response to treatment.

A 32-year-old pregnant woman presents to the clinic complaining of acute onset myalgias, cough, and fever. She states she woke up this morning feeling okay and then all of a sudden felt as if she were "hit by a truck." She notes her coworker was just diagnosed with the flu a couple of days ago. Her vitals today are as follows: weight 158 pounds, body mass index 27 kg/m2, temperature 102°F, O2 98% on room air, and blood pressure 120/86 mm Hg. What is the most appropriate treatment for this patient? A) Azithromycin B) Baloxavir C) Oseltamivir D) Penicillin

C) Oseltamivir

A 66-year-old woman presents with a sensation of pulsation in her neck and abdomen. The patient reports that she has also had progressively worsening dyspnea on exertion and peripheral edema that began two months ago. She had a pacemaker placement nine months ago for a chronic bifascicular block. Physical exam is significant for distended, pulsatile neck veins, hepatomegaly, and 1+ generalized pitting edema. Palpation of the liver results in increased distension of the neck veins. Which of the following findings on physical exam would most likely correlate with the patient's condition? A) Harsh midsystolic crescendo-decrescendo murmur radiating to the left shoulder B) Loud midsystolic murmur best heard with the patient sitting and leaning forward C) Pansystolic murmur that becomes louder with inspiration D) Pansystolic murmur with prolonged apical impulse

C) Pansystolic murmur that becomes louder with inspiration Tricuspid regurgitation

A 68-year-old man with a past medical history of diabetes mellitus and hypertension presents to the emergency department with acute onset of chest pain. The ECG is shown above. The initial troponin is elevated. Which of the following is the best treatment? A) Coronary artery bypass graft surgery B) Fibrinolysis C) Percutaneous coronary intervention D) Pharmacologic treatment without further intervention

C) Percutaneous coronary intervention

A 44-year-old woman presents with complaints of gradually worsening dyspnea on exertion, fatigue, and dry cough over the course of several months. Her vital signs are within normal limits. A chest radiograph is obtained that shows symmetric, bilateral hilar adenopathy. Which of the following would be the most likely finding on physical exam? A) Digital clubbing B) Erythema nodosum C) Peripheral lymphadenopathy D) Rales

C) Peripheral lymphadenopathy Sarcoidosis: Peripheral lymphadenopathy is present in approximately 40 percent of patients.

A 42-year-old woman presents with neck pain and tenderness, palpitations, and anxiety. She states that the symptoms have been present for the past two weeks. A review of systems is insignificant except for a viral upper respiratory infection a few weeks ago that resolved. Physical exam reveals a mildly diffusely tender, symmetrically enlarged thyroid gland. Which of the following would be the best next step in managing this patient's care? A) Begin levothyroxine B) Order a radioiodine imaging study C) Prescribe naproxen D) Refer for fine-needle aspiration biopsy

C) Prescribe naproxen Subacute thyroiditis is typically associated with neck pain with a tender goiter and abnormal thyroid function tests. Nonsteroidal anti-inflammatory medications, such as naproxen, or oral steroids can help decrease neck pain.

A 53-year-old man presents to his primary care provider for his annual physical. His blood pressure reading is 131/83 mm Hg at this visit. He returns to the clinic 2 weeks later for a second blood pressure measurement, and his BP at this time is 135/80 mm Hg. Which of the following is the most appropriate diagnosis according to ACC/AHA guidelines? A) Elevated blood pressure B) Normal blood pressure C) Stage 1 hypertension D) Stage 2 hypertension

C) Stage 1 hypertension

A 40-year-old Black man presents to a primary care provider for a follow-up visit to discuss his laboratory results. On the previous visit, a nontender, nodular prostate was palpated on digital rectal examination. His prostate-specific antigen level is 12.4 ng/mL. A transrectal ultrasound-guided biopsy is ordered. Which of the following is most likely present in the patient's history? A) Bone pain B) Painless hematuria C) Weak urinary stream D) Weight loss

C) Weak urinary stream

A 45-year-old man is screened for tuberculosis with a tuberculin skin test. He had recent close contact with an individual with active and contagious tuberculosis. Which of the following induration measurements is the minimum induration for a positive tuberculin skin test in this patient? A) 10 mm B) 15 mm C) 2 mm D) 5 mm

D) 5 mm

A 58-year-old man presents to the office with frequent heartburn, difficulty swallowing, and a sensation of pressure and mild pain in his chest after every meal. More recently, he has been having difficulty swallowing liquids as well. He has been taking ranitidine daily for years but continues to have worsening symptoms. Which of the following is the best initial test to diagnose the suspected condition? A) Chest radiograph B) Computed tomography of the chest C) Esophageal manometry D) Esophagogastroduodenoscopy

D) Esophagogastroduodenoscopy Esophageal strictures

A 45-year-old woman presents to her primary care provider with painful discoloration of her fingers and nose when cold. She states her fingers become pale when cold and then become red and painful when they begin to warm up. She also complains of difficulty swallowing and early satiety. On physical exam, she has tight, shiny skin and multiple telangiectasias. She currently smokes one pack per day and has no significant past medical history. What clinical intervention should be recommended first? A) Initiate methotrexate B) Initiate nifedipine C) Initiate sildenafil D) Initiate varenicline

D) Initiate varenicline Scleroderma

A 58-year-old man presents to a primary care provider with increasing right leg pain for the past four months. He reports that the pain is deep and achy and worse at night. The pain initially seemed to be localized to his upper thigh but is now also affecting his leg just above the knee. He also reports that his teeth have become more misaligned over the past few months and is wondering if that may be associated with the intermittent headaches he started having four months ago. He denies any falls, trauma, or changes in his daily activity. On physical examination, dilated scalp veins are present. Range of motion, strength, and stability of the lower extremities are within normal limits. A radiograph of the right femur is shown above. What is the most likely diagnosis? A) Osteoarthritis B) Osteochondritis dissecans C) Osteoid osteoma D) Paget disease

D) Paget disease

A 22-year-old man with no past medical history presents to the clinic complaining of sudden-onset shortness of breath and right-sided pleuritic chest pain. He reports his symptoms "came out of nowhere." His vitals are as follows: weight 155 pounds, body mass index 21 kg/m2, O2 90% on room air, and blood pressure 120/86 mm Hg. His lung exam is consistent with decreased breath sounds, decreased tactile fremitus, and hyperresonance to percussion over the right upper lung field. The remainder of the lung exam is normal. Which of the following is the most likely diagnosis for this patient? A) Asthma B) Pleural effusion C) Pneumonia D) Pneumothorax

D) Pneumothorax

A 44-year-old woman presents to the emergency department with chest pain, nausea, and diaphoresis. She reports multiple episodes of early morning chest pain for the past three weeks. She has a 20 pack-year smoking history and reports cocaine use in the last month. The initial ECG obtained shows ST elevations in the inferior leads. Serial troponins and CK-MB are negative. No stenotic lesions are seen on coronary angiography. Which of the following medications would be inappropriate in the management of the suspected diagnosis? A) Amlodipine B) Isosorbide dinitrate C) Lisinopril D) Propranolol

D) Propranolol Beta-blockers (e.g., propranolol, nadolol, sotalol, timolol) exacerbate coronary vasospasm and should be avoided in patients with Prinzmetal angina in the absence of coronary stenosis.

A 7-year-old boy is brought into the clinic for a cough. His mother states that she has noticed the cough has gotten more frequent over the past few months and is worse at night. The cough is dry. She has also noticed occasional wheezing and coughing when he has participated in baseball practice. He denies fever, rhinorrhea, headache, chest pain, or shortness of breath but does state that occasionally after practicing sports, his chest feels "tight." Which of the following is the most appropriate diagnostic test to order? A) Chest radiograph B) Complete blood count C) IgE antibody tests D) Pulmonary function studies

D) Pulmonary function studies

A 67-year-old man with a history of alcohol use disorder is admitted to the hospital and subsequently diagnosed with cirrhosis. His chemistry panel and blood gas show the following results: Sodium: 142 mmol/L Potassium: 4.0 mmol/L Chloride: 110 mmol/L Albumin: 4.0 g/L pH: 7.55 PaCO2: 32 mm Hg PaO2: 90 mm Hg Bicarbonate: 23 mmol/L What is the most likely diagnosis? A) Anion gap metabolic acidosis B) Metabolic alkalosis C) Non-anion gap metabolic acidosis D) Respiratory alkalosis

D) Respiratory alkalosis An increased pH, a decreased PaCO2, and a decreased or normal bicarbonate are indicative of respiratory alkalosis.

A 65-year-old woman with a past medical history of chronic obstructive pulmonary disease presents to her primary care clinic with worsening dyspnea, orthopnea, and lower extremity edema. On physical exam, you hear an accentuated S2 and observe elevated jugular venous pressure, peripheral edema, and ascites. An ECG is shown above. Which of the following is the pathophysiology behind this patient's symptoms? A) Acute pulmonary embolism from a deep vein thrombosis B) Left ventricular failure in the setting of acute myocardial infarction C) Right ventricular dilation in the setting of untreated coarctation of the aorta D) Right ventricular hypertrophy in the setting of increased pulmonary hypertension

D) Right ventricular hypertrophy in the setting of increased pulmonary hypertension Cor pulmonale is the hypertrophy or dilation of the right ventricle with or without associated dysfunction, most commonly in the setting of pulmonary hypertension from chronic obstructive pulmonary disease (COPD) or hypoxemia. Other causes of pulmonary hypertension include pulmonary artery hypertension (group 1), left heart disease (group 2), pulmonary artery obstructions (group 4), and unclear or multifactorial mechanisms (group 5).

A 66-year-old man presents to your clinic for a preventive exam. Screening fasting blood work shows a blood sugar of 116 mg/dL and LDL-C of 191 mg/dL. What is the most appropriate medical treatment for primary prevention of atherosclerotic cardiovascular disease for this patient, using the 2018 ACC/AHA guidelines on blood cholesterol management? A) Atorvastatin 20 mg B) Lovastatin 20 mg C) Pravastatin 80 mg D) Rosuvastatin 20 mg

D) Rosuvastatin 20 mg

A 45-year-old woman presents to the clinic. She appears quite somnolent and states she is in pain. She reports pain in her hands, forearms, and knees, along with abdominal discomfort. She also describes sensitivity to cold in her hands, which she says makes her hands turn white and become painful. She reports her symptoms have been present on and off for the last few years but have begun to significantly worsen. Her medical history is significant for hypertension and interstitial lung disease with home oxygen use. The patient reports no tobacco or illicit drug use. She takes lisinopril, metoprolol, hydrochlorothiazide, and mycophenolate. Physical exam reveals puffy, thickened skin over the fingers on both hands, tenderness over multiple joints, rales, labored respirations, general body atrophy, abdominal rigidity, and a systolic regurgitation murmur of grade 3 over the tricuspid area. Her vitals are a temperature of 99.5°F, HR of 95 bpm, RR of 20/minute, BP of 140/100 mm Hg, oxygen saturation of 93%, and body mass index of 14 kg/m2. Which of the following is the most likely diagnosis? A) Acromegaly B) Polymyalgia rheumatica C) Polymyositis D) Scleroderma

D) Scleroderma Systemic sclerosis (scleroderma) is classically defined as a chronic, progressive, fibrotic disease that affects multiple systems. Broadly, it commonly involves vascular dysfunction (leading to ischemia) and fibrosis of skin and internal organs.

A 26-year-old woman presents to the emergency department with a chief complaint of hematemesis. Emesis is described as bright red blood. She had two episodes prior to presenting to the hospital. She reports no known history of stomach ulcer. She denies abdominal pain. Vital signs indicate a blood pressure of 102/76 mm Hg and heart rate of 52 bpm. Her body mass index is 16.6 kg/m2. Physical examination reveals lanugo, calluses on the dorsum of the right hand, and a small left subconjunctival hemorrhage. An endoscopy is performed that demonstrates a longitudinal tear in her esophagus with minimal active bleeding. Which of the following would you expect to learn from her history, given her history and likely underlying medical condition? A) She has a history of alcohol use disorder B) She has a history of chronic NSAID use C) She has a history of rumination syndrome D) She has a history of self-induced vomiting

D) She has a history of self-induced vomiting Mallory-Weiss syndrome

A 24-year-old man presents to the office complaining of worsening epigastric pain (especially at night) pain after eating spicy foods, and a metallic taste in his mouth that occurs on a daily basis. He only takes calcium carbonate tablets as needed and does not take any other medications. A chest radiograph is performed, which shows evidence of a hiatal hernia. Which of the following is the best initial approach to treating this condition? A) Encourage lifestyle changes, such as weight loss and avoidance of spicy foods B) Perform Nissen fundoplication C) Start treatment with an H2 receptor blocker D) Start treatment with an oral proton pump inhibitor

D) Start treatment with an oral proton pump inhibitor Lifestyle changes, such as weight loss and avoidance of spicy foods (A), is encouraged in all patients with hiatal hernias with symptoms of GERD. However, the patient in the vignette above has worsening symptoms that will require medications in addition to lifestyle changes for relief.

A 61-year-old man who does not have housing presents to an urgent care with reports of facial and lower extremity swelling. He states his face and eyes appear puffy in the morning and his feet and ankles seem swollen in the evening. He also reports he has been urinating less frequently and his urine is darker than normal. He had a sore throat and abdominal pain 2 weeks ago that resolved on its own. He was diagnosed with hepatitis 6 months ago. He cannot recall his childhood medical history. His blood pressure is 148/98 mm Hg. A urinalysis is obtained and reveals a cola-colored specimen with 11 RBCs/high-powered field and 3+ protein. Serum complement C3 is significantly low. Anti-DNase B antibodies are positive. Which of the following conditions in the patient's past medical history would be most consistent with the suspected diagnosis? A) Focal segmental glomerulosclerosis B) Hepatitis A infection C) Minimal change disease D) Streptococcal infection

D) Streptococcal infection Poststreptococcal glomerulonephritis is an acute, immune-mediated inflammatory disorder of the glomerulus, typically occurring 1 to 3 weeks after a group A beta-hemolytic streptococcal infection.

A 28-year-old woman with no past medical history presents to the clinic with complaints of chronic headaches. She states her current headache started this morning and feels like there is a "sweat band" tightly wrapped around her head. She notes she is in finals week for her master's program, and she has been very stressed lately. The patient denies any other symptoms at this time, including nausea, vomiting, or photophobia. Which of the following is the most likely diagnosis? A) Cluster headache B) Migraine headache C) Rebound headache D) Tension headache

D) Tension headache

A 53-year-old man with a past medical history of hypertension and insulin-dependent type 2 diabetes presents to his primary care clinic with 12 hours of increasing weakness, fatigue, and shortness of breath. Vitals show a heart rate of 34 bpm, blood pressure of 89/43 mm Hg, respiratory rate of 20 breaths per minute, O2 saturation of 95% on room air, and temperature of 97.5°F. Physical exam shows a pale, diaphoretic, and lethargic man with cool skin. An ECG is obtained and shows the above rhythm. What is the most likely diagnosis? A) First-degree atrioventricular block B) Second-degree type 1 atrioventricular block C) Second-degree type 2 AV block D) Third-degree atrioventricular block

D) Third-degree atrioventricular block

A 35-year-old man presents with epigastric pain, which radiates to the back, accompanied by nausea and vomiting. On exam, he is noted to have cream-colored retinal vessels. Laboratory studies demonstrate elevated amylase and lipase. Which of the following findings is most likely to also be elevated? A) High-density lipoprotein B) Lipoprotein(a) C) Low-density lipoprotein D) Triglyceride

D) Triglyceride HLD

A 65-year-old man presents with acute onset of severe muscle cramps and extremity spasms. QT prolongation is seen on ECG. Laboratory studies are remarkable for a serum calcium level of 7.3 mg/dL. Carpopedal spasm is witnessed with inflation of the sphygmomanometer. Which of the following best describes this physical exam finding associated with the underlying diagnosis? A) Band keratopathy B) Chvostek sign C) Decreased deep tendon reflex D) Trousseau sign

D) Trousseau sign Trousseau sign may also be induced by voluntary hyperventilation for one to two minutes after the cuff is removed and is more specific than Chvostek sign for hypocalcemia

A 30-year-old woman with a recent diagnosis of HIV and history of smoking presents to your office for her annual exam. She wants to make sure she is up to date with the screenings recommended with her new diagnosis. Which of the following preventive screening tests should be done? A) Fecal occult blood test B) Low-dose computed tomography of the chest C) Mammogram D) Tuberculin skin test

D) Tuberculin skin test Tuberculosis screening after HIV diagnosis should be done in all patients

A 20-year-old unvaccinated college student is brought in by his roommate to the college infirmary for altered mental status. The roommate reports the patient began complaining of fever, headache, and stiff neck yesterday. This morning, he was found in bed and was difficult to wake up. On evaluation, the patient only moans to painful stimuli, has a fever of 101.7°F, and is unable to put his chin to his chest. He has a diffuse purple rash that is nonblanching. You perform a lumbar puncture. What are the most likely cerebrospinal fluid results? A) Bloody color, elevated opening pressure, normal lymphocytes, normal protein, and normal glucose B) Clear color, high opening pressure, normal lymphocytes, normal protein, and normal glucose C) Clear color, normal opening pressure, normal lymphocytes, normal protein, and normal glucose D) Turbid color, elevated opening pressure, elevated lymphocytes, elevated protein, and low glucose

D) Turbid color, elevated opening pressure, elevated lymphocytes, elevated protein, and low glucose

According to the US Preventive Services Task Force, what is the appropriate lung cancer screening method for patients who are aged 50-80, currently smoke tobacco or those with a former heavy history of smoking? A) Low-dose helical computed tomography every three years B) Magnetic resonance imaging of chest every two years C) Yearly chest X-ray D) Yearly low-dose helical computed tomography

D) Yearly low-dose helical computed tomography