MOCK PANCE EXAM-Block 2 (ROSH)

One Step Further Question: What is the etiologic factor for recurrent cellulitis?

Answer: Venous or lymphatic obstruction.

One Step Further Question: What two other criteria are used to diagnose an exudative effusion?

Answer: Pleural protein:serum protein > 0.5; Pleural LDH:serum LDH > 0.6.

One Step Further Question: What therapy may help patients with severe pain and erythema nodosum?

Answer: Potassium iodide.

One Step Further Question: What treatment for Enterobius vermicularis infection is recommended for pregnant patients?

Answer: Pyrantel pamoate.

One Step Further Question: Which two sensory organ deficits can be mistaken for dementia?

Answer: Problems with hearing and eyesight can be mistaken for dementia, therefore for any memory loss, hearing and vision screening tests should be performed.

One Step Further Question: What pulmonary bacterial infection is classically associated with cystic fibrosis?

Answer: Pseudomonas aeruginosa.

One Step Further Question: Which natural herb is commonly prescribed to patients in order to treat symptoms of benign prostatic hyperplasia?

Answer: Saw palmetto.

One Step Further Question: What type of cast is typical of pyelonephritis?

Answer: White blood cell cast.

One Step Further Question: What is the definitive treatment for acute cholecystitis?

Answer: Cholecystectomy

One Step Further Question: What medication must be initiated when prescribing oral isotretinoin?

Answer: Patients must be on a form of birth control before taking oral isotretinoin as it is known to be a teratogen

One Step Further Question: What are the most common organisms to cause cholangitis?

Answer: E. coli, Klebsiella, Enterococcus, Bacteroides.

One Step Further Question: What is the treatment for cardiac tamponade?

Answer: Emergent pericardiocentesis.

One Step Further Question: What is the treatment for oral candidiasis?

Answer: Fluconazole.

One Step Further Question: What medication is used first-line for patients who are exhibiting aggressive behavior during their episode of delirium?

Answer: Haloperidol.

One Step Further Question: What is the most common mechanism for the development of septic arthritis in children?

Answer: Hematogenous spread.

One Step Further Question: What retinal changes are seen in hyperviscosity syndrome?

Answer: "Sausage-link" or "boxcar" segmentation.

One Step Further Question: Elevated levels of what two laboratory values are usually diagnostic of cobalamin (vitamin B12) deficiency?

Answer: Homocysteine and methylmalonic acid (MMA)

One Step Further Question: Which hernia arises on the medial aspect of the inferior epigastric vessels?

Answer: A direct inguinal hernia.

One Step Further Question: How can one differentiate between elder abuse and senile pupura?

Answer: Bruises from physical abuse will evolve into brown patches and there will be multiple bruises in different healing stages.

One Step Further Question: For what coinfection should patients with tuberculosis be tested?

Answer: Human immunodeficiency virus (HIV) infection.

One Step Further Question: How is an insulinoma diagnosed and treated?

Answer: CT imaging of the pancreas and surgical resection of the tumor

One Step Further Question: What is a potentially dangerous side effect of the medication used for constipation known as Tegaserod?

Answer: Cardiovascular events

One Step Further Question: What laboratory study should be monitored in the setting of magnesium sulfate therapy?

Answer: Creatinine, as it can cause renal insufficiency.

One Step Further Question: What is the name of the maneuver used to observe a paroxysmal positional nystagmus to help diagnosis benign paroxysmal positional vertigo (BPPV)?

Answer: Dix-Hallpike test.

One Step Further Question: What diagnostic test is used for confirmation of ovarian torsion?

Answer: Laparoscopic visualization is the only confirmation of ovarian torsion

One Step Further Question: What medication is useful for long term chronic forms of cluster headaches?

Answer: Lithium.

One Step Further Question: Which intervention will most likely improve the long-term survival in a patient with severe COPD?

Answer: Long-term oxygen supplementation. It has been shown to improve survival and quality of life, decrease dyspnea, and decrease pulmonary artery pressure.

One Step Further Question: What is the life-threatening spread of a mandibular infection into significant submandibular cellulitis?

Answer: Ludwig's angina.

One Step Further Question: Which tendinopathy is associated with "golfer's elbow"?

Answer: Medial epicondylitis.

One Step Further Question: What common analgesics can alter lithium levels?

Answer: NSAIDs, with the exception of aspirin.

One Step Further Question: What is the best neck position and phase of respiration for obtaining a soft tissue neck X-ray when you are considering retropharyngeal abscess?

Answer: Neck extension and inspiration.

One Step Further Question: Which virus is the most common cause of infectious diarrhea in the United States?

Answer: Norovirus.

One Step Further Question: Other than neurogenic shock, what are the two other causes of distributive shock?

Answer: Septic shock (most common) and anaphylaxis.

One Step Further Question: What other gastrointestinal infections have been linked with hemolytic uremic syndrome?

Answer: Shigella and Salmonella.

One Step Further Question: What differentiates hypertensive emergency from hypertensive urgency?

Answer: Significantly elevated blood pressures and the presence of end organ damage such as acute aortic dissection.

One Step Further Question: How is scabies transmitted?

Answer: Skin-to-skin contact.

One Step Further Question: What are the symptoms of MAOI overdose?

Answer: Tachycardia, hypertension, hyperthermia, rhabdomyolysis, seizures, coma, cardiovascular collapse.

One Step Further Question: Which treatment can be used to improve tolerance to dietary phenylalanine?

Answer: Tetrahydrobiopterin

One Step Further Question: Which fractured bone is commonly referred to as a nightstick fracture?

Answer: Ulnar shaft fractures are commonly referred to as nightstick fractures and are caused by a direct blow to a raised forearm.

A 26-year-old African-American man presents with diffuse abdominal and back pain a few days after being diagnosed with streptococcal pharyngitis. He appears mildly ill, with slight scleral icterus. Laboratory findings are as follows: unconjugated bilirubin: 3.2 mg/dL (N < 0.2), hemoglobin: 9.6 g/dL (N 13.0-18.0), hematocrit: 29.4% (N 37.0-49.0), peripheral blood smear: keratocytes, blister cells, and polychromatic macrocytes. Which one of the following is the most likely diagnosis? Glucose-6-phosphate dehydrogenase deficiency Sickle cell anemia Spherocytic hemolytic anemia Thalassemia

Correct Answer ( A ) Explanation: Glucose-6-phosphate dehydrogenase deficiency (G6PD), the most common enzyme deficiency worldwide, causes a spectrum of diseases including neonatal hyperbilirubinemia, acute hemolysis, and chronic hemolysis. Persons with this condition also may be asymptomatic. This X-linked inherited disorder most commonly affects persons of African, Asian, Mediterranean, or Middle-Eastern descent. Acute hemolysis is caused by infection, ingestion of fava beans, or exposure to an oxidative drug. Clinically, acute hemolysis can cause back or abdominal pain and jaundice secondary to a rise in unconjugated bilirubin. Jaundice, in the setting of normal liver function, typically does not occur until greater than 50 percent of the erythrocytes have been hemolyzed. A peripheral blood smear revealing the presence of keratocytes, blister cells, and polychromatic macrocytes is consistent with an oxidative hemolytic process. Heinz bodies (inclusions within RBCs of denatured hemoglobin) are also present. A blood smear suggests the diagnosis even if an assay for G6PD is normal, which is frequently the case in heterozygous men of African ancestry. The main treatment for G6PD deficiency is avoidance of oxidative stressors. Rarely, anemia may be severe enough to warrant a blood transfusion. Splenectomy generally is not recommended. Folic acid and iron potentially are useful in hemolysis, although G6PD deficiency usually is asymptomatic and the associated hemolysis usually is short-lived. Antioxidants such as vitamin E and selenium have no proven benefit for the treatment of G6PD deficiency.

In the setting of hypertensive emergency, which of the following conditions necessitates the most rapid reduction of blood pressure? Acute aortic dissection Acute hemorrhagic stroke Acute hypertensive nephropathy Acute ischemic stroke

Correct Answer ( A ) Explanation: A hypertensive emergency with acute aortic dissection necessitates rapid reduction of blood pressure. Most patients in hypertensive emergency have significantly elevated blood pressure with systolic pressure ≥ 180 mm Hg and diastolic pressure ≥ 120 mm Hg. Patients with acute aortic dissection are treated to rapidly reduce the blood pressure to a goal systolic of 100 to 120 mm Hg within about 20 minutes of diagnosis. An intravenous beta blocker is given first to reduce the heart rate below 60 beats per minute and to reduce the shear stress on the aortic wall. In other settings of hypertensive emergency, the optimal therapy, including the choice of agent and the blood pressure goal, varies according to the specific hypertensive emergency. It is generally unwise to lower the blood pressure too quickly or too much, as ischemic damage can occur in vascular beds that have grown accustomed to the higher level of blood pressure due to autoregulation. For most hypertensive emergencies, mean arterial pressure should be reduced gradually by about 10 to 20% in the first hour and by a further five to 15% over the next 23 hours. Hypertensive emergency with acute hemorrhagic stroke (B), acute ischemic stroke (D) and acute hypertensive nephropathy (C) are all conditions in which the elevated blood pressures should be lowered slowly. In the setting of the acute phase of an ischemic stroke the blood pressure is usually not lowered unless it is ≥ 185/110 mm Hg in patients who are candidates for reperfusion therapy or ≥ 220/120 mm Hg in patients who are not candidates for reperfusion therapy.

A 64-year-old janitor presents to your office with a complaint of bilateral knee pain. He says that he has worked in physically demanding jobs his entire life and is now experiencing knee pain that increases in severity at the end of his workday. Which of the following is the most appropriate initial treatment? Acetaminophen Glucocorticoids Glucosamine Oxycodone

Correct Answer ( A ) Explanation: Before beginning pharmacologic treatment of osteoarthritis, intervention should include educating the patient about weight loss, exercise and progression of the disease. Patients who do not respond to nonpharmacologic treatment and do not have signs or symptoms of inflammation should begin taking acetaminophen as needed. Acetaminophen is safer than NSAIDs with regards to cardiovascular and gastrointestinal risks, therefore is used as first-line therapy. Patients who do not respond to treatment with acetaminophen or with signs and symptoms of inflammatory osteoarthritis should be started on NSAIDs. Caution should be used when using NSAIDs in patients with a history of peptic ulcer disease or renal insufficiency, those at risk of cardiovascular disease and those taking aspirin or warfarin.

A 72-year-old man presents to your office complaining of increased awakenings due to the urge to urinate during the night. He notes that his urine stream is weak and notices that he is dribbling when he urinates. He denies burning or pain with urination, blood in his urine or any recent changes in his weight. He denies all constitutional symptoms. A digital rectal exam, urinalysis, and PSA were performed which confirmed the suspected diagnosis. Which of the following can be used for first-line treatment of the suspected disorder as well as for alopecia? Finasteride Phenoxybenzamine Prazosin Tamsulosin

Correct Answer ( A ) Explanation: Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. BPH is a common problem that affects the quality of life in approximately one third of men older than 50 years. BPH is histologically evident in up to 90% of men by age 85 years. Prostate enlargement causes urinary frequency, hesitancy, urgency, straining, dribbling and increases nighttime awakenings. History and physical exam are key elements to the diagnosis of BPH. Urinary analysis is needed in order to rule out any urinary tract infections and obtaining the prostate specific antigen level is controversial. Although BPH does not cause prostate cancer, men at risk for BPH are also at risk for prostate cancer and should be screened accordingly. Screening for prostate cancer remains controversial and should be done after an informed discussion between the physician and patient. Ultrasonography is useful to determine bladder and prostate size and the presence of hydronephrosis, however an ultrasound is not necessary for the initial workup of BPH. Initial treatment of symptomatic BPH includes many different classes of medications such as alpha-receptor blockade agents, phosphodiesterase-5 inhibitors, 5-alpha reductase inhibitors, combination therapies and dietary supplements. 5-alpha reductase inhibitors are the only class of medications that treat both BPH and alopecia. They inhibit the conversion of testosterone to DHT, causing DHT levels to drop, which, in turn, may decrease prostate size. These agents include finasteride and dutasteride.

The finding seen in the image above should raise suspicion for which of the following diagnoses in an adult? Acquired immune deficiency syndrome Diabetes mellitus Glucose-6-phosphate dehydrogenase deficiency Meningococcemia

Correct Answer ( A ) Explanation: Molluscum contagiosum infection on the face should raise concern for underlying HIV/AIDS infection. In fact, the severity of immunosuppression correlates with the number of lesions found on the face and there is an inverse relationship between the number of lesions and the patient's CD4 count. The infection is caused by a DNA poxvirus. The lesions are flesh-colored, dome-shaped and have a pearly appearance. They are papular and have a characteristic dimpled center. They are most commonly found on the trunk, axillae, extremities, face and genitalia. It spreads via autoinoculation, scratching, contact with lesions, and fomites. In immunocompetent individuals, the condition is generally self-limited and resolves spontaneously in six to nine months. Patients can be referred to a dermatologist for removal.

A 30-year-old man presents with fever, neck stiffness, and headache. He is lying supine on the bed. When you lift the patient's neck off of the stretcher, he flexes his hips and lifts his legs up off of the bed. Based on this information, which of the following signs is considered positive? Brudzinski's sign Kernig's sign Obturator sign Rovsing's sign

Correct Answer ( A ) Explanation: Brudzinski's sign is tested when the patient is lying supine. The test is considered positive if passive flexion of the patient's neck causes the patient to flex their hips and lift their legs off of the examination table or stretcher. This sign suggests that the patient may have underlying meningeal irritation due to acute meningitis, encephalitis, subarachnoid hemorrhage or other pathology. Kernig's sign (B) is tested when the patient is lying supine with the hip and knee flexed at 90 degrees. The test is considered positive if the patient experiences pain during knee extension from this position and suggests that the patient may have underlying meningeal irritation. Obturator sign (C) is suggestive of a pelvic appendix and is positive when the patient is lying supine and they experience pain when the right hip is flexed and internally rotated. Rovsing's sign (D) is positive when palpation of the left lower quadrant causes referred pain to the right lower quadrant. A positive Obturator or Rovsign's sign supports a diagnosis of acute appendicitis, although other pathologies can cause the test to be positive.

A 35-year-old diabetic woman was admitted for a rapidly progressive, exquisitely painful rash as seen in this image above. She reported a three-day history of fevers and chills but denies any history of travel or trauma. Which of the following is the most likely diagnosis? Cellulitis Erysipelas Necrotizing fasciitis Toxic epidermal necrolysis

Correct Answer ( A ) Explanation: Cellulitis is a non-necrotizing inflammation of the skin and subcutaneous tissue that results from a bacterial infection. It usually occurs secondary to a break in the skin and it is important to inquire about any history of trauma. Nonetheless, microabrasions in the skin can be enough to introduce bacteria that will cause cellulitis. The cardinal signs of cellulitis include erythema, pain, swelling and warmth. The leg is the most commonly involved site and regional lymphadenopathy is usually present. Systemic signs can be present such as fevers, malaise and chills. Severe infections can cause signs of sepsis. Patients with diabetes, immunodeficiency, cancer, venous stasis, chronic liver disease, peripheral arterial disease, and chronic kidney disease appear to be at higher risk for recurrent infection because of an altered host immune response. In individuals with normal host defenses, the most common causative organisms are group A streptococci and S aureus. Group B Streptococcus cellulitis occurs in infants younger than six months because their immune responses are not fully developed, and it may also be seen in adults with comorbidities such as diabetes or liver disease. Immunocompromised hosts may become infected from nontraditional cellulitis organisms, including gram-negative rods and anaerobes. The diagnosis is based on history and physical exam alone, however in cases with systemic signs a complete laboratory workup including a complete blood count with differential, blood cultures, and a CRP should be obtained. Antibiotics are the mainstay treatment for cellulitis. Draining cellulitis and abscesses will need drainage for full resolution. In cases of cellulitis without draining wounds or abscess, streptococci continue to be the likely etiology, and beta-lactam antibiotics are appropriate therapy. Clindamycin is a reasonable alternative for patients with a penicillin allergy. Infections with MRSA should be treated with trimethoprim/sulfamethoxazole, vancomycin or clindamycin; depending on the community resistance. Toxic epidermal necrolysis (D) is a severe dermatologic disorder that is usually drug induced. It is characterized by widespread erythema, necrosis, and bullous detachment of the epidermis and mucous membranes. By definition, it must involve at least 30% of the body surface. Necrotizing fasciitis (C) is a rapidly progressive infection of the fascia that spreads along the facia planes. Cellulitis is more localized and does not affect layers deeper than the subcutaneous tissues. Erysipelas (B) is a superficial infection of the skin that only affects the dermis and is characterized by sharply demarcated borders.

A 53-year-old man with a 30-pack-year smoking history presents complaining of progressive shortness of breath for the past four months. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50%. These findings are most consistent with which condition? Chronic bronchitis Congestive heart failure Interstitial lung disease Sarcoidosis

Correct Answer ( A ) Explanation: Chronic obstructive pulmonary disease (COPD) is a disease characterized by airflow limitation that is no longer fully reversible. COPD includes emphysema (destruction and enlargement of lung alveoli) and chronic bronchitis (chronic cough and phlegm for three months or more over two consecutive years). Chronic airflow obstruction must be present in order for the diagnosis to be made. Spirometry is used to differentiate obstructive vs. restrictive lung diseases. Spirometry measurements are used to calculate the FEV1 which represents the proportion of a person's vital capacity that they are able to expire in the first second of expiration. In obstructive lung disease, the FEV1 is reduced due to an obstruction of air escaping from the lungs. Since COPD is an obstructive lung disease, the diagnosis is made when the FEV1/FVC ratio is less than 0.7 and the FEV1 is less than 80% of predicted.

A 34-year-old man presents with episodic, unilateral headaches. The pain occurs every night "like clockwork". It is described as a severe pain on the left side of his head. He has associated tearing and rhinorrhea on the left side when he gets the pain. It lasts for two hours and then subsides. He has never had anything like this in the past and denies any significant medical history. What is the most likely diagnosis? Cluster headache Temporal arteritis Tension headache Trigeminal neuralgia

Correct Answer ( A ) Explanation: Cluster headaches are typically a syndrome of severe unilateral headache accompanied by ipsilateral cranial autonomic symptoms that include rhinorrhea, lacrimation, ptosis, miosis, and conjunctival injection. Pain is located in the ocular, frontal, and temporal areas, but can be in the area of the trigeminal nerve as well. Each episode occurs one to three times daily, usually around the same time of day, and lasts up to three hours at a time for periods of two to 12 weeks. Treatment focuses on abortive therapies for acute pain and preventative treatments to inhibit recurrence. Acute attacks usually respond well to high-flow oxygen therapy for 15-20 minutes. Sumatriptan given subcutaneously can be used to shorten an acute attack. Short courses of steroids can limit future episodes. Verapamil is used as first-line treatment for prolonged bouts of attacks. Trigeminal neuralgia (D) causes unilateral pain that is often described as "electrical" or "lightning-like" pain, made worse with talking or chewing.

A 75-year-old woman with osteoporosis fell on her outstretched hand. Her X-ray is seen above. Which of the following is the most likely diagnosis? Distal radius fracture Olecranon fracture Scaphoid fracture Ulnar fracture

Correct Answer ( A ) Explanation: Distal radius fractures occur in young adults due to high-impact injuries and from falls on an outstretched hand in older adults due to the fact that older adults have weaker bones. Radial fractures are commonly seen in patients with osteoporosis. The median nerve is at risk for injury so its function should also be assessed. A Colles' fracture is an eponym for a dorsally displaced distal radius fracture. Fractures are diagnosed on plain film, although often times individuals with a distal radius fracture will present with a wrist deformity (e.g. dinner fork deformity for a Colles' fracture). Distal radius fractures that are minimally displaced or impacted can be treated with immobilization for four to eight weeks. Younger patients with good bone health and non-displaced fractures often can be treated with a volar splint, whereas patients with minimal displacement or osteoporotic bone should have the extra protection of a short arm cast. It is imperative to perform weekly radiography for the first three weeks because even fractures that appear stable may displace during early treatment, particularly in older patients. Traditionally, surgical treatment has been reserved for displaced, irreducible fractures or reducible but unstable distal radial fractures.

A five-year-old boy presents to your office to follow up on a positive pinworm paddle test. Which of the following is the most appropriate therapy? Albendazole Clotrimazole Metronidazole Piperazine

Correct Answer ( A ) Explanation: Enterobius vermicularis (pinworm) is one of the most common nematode infections in the world. Many infections are asymptomatic, but when symptoms present the most common is perianal itching. Autoinfection occurs after scratching the perianal area and transferring eggs to the mouth with infected hands. Infection can occur via contact with environmental surfaces that contain eggs. Person-to-person transmission occurs after eating food prepared by contaminated hands or handling contaminated clothes or bedding. Enterobius is diagnosed using the pinworm paddle test. An adhesive surface is pressed onto the perianal area, then viewed under a microscope where eggs can be visualized. Treatment is with 400 mg of oral albendazole once, then repeated in two weeks.

A 65-year-old man presents with increased shortness of breath. He began antibiotics three days prior to arrival for pneumonia. His chest X-ray is shown above. Which of the following findings most strongly suggests an empyema? Bacteria on Gram stain of pleural fluid Blood-tinged thoracic fluid LDH greater than 2/3 upper limit of serum LDH Pleural fluid pH of 7.25

Correct Answer ( A ) Explanation: Patients with pneumonia may develop parapneumonic effusions as a result of the inflammatory changes taking place within the lung. It is important to identify an empyema early because of the increased morbidity and mortality in these patients. A diagnostic thoracentesis is frequently performed first identifying the characteristics of the pleural fluid suggestive of an empyema. The definition of an empyema is the presence of bacteria on Gram stain of the pleural fluid after it has been drained. On gross inspection the fluid is purulent and cloudy, suggesting pus in the pleural space. Additional analysis will typically show an elevated white blood cell count of the pleural fluid as well as a decreased glucose level. Once an empyema is identified, it requires drainage typically through tube thoracostomy. Placement of a tube will prevent the formation of loculations. Empyemas do not develop solely as a result of pneumonia and are seen after penetrating thoracic trauma, esophageal rupture, surgical complications or after chest tube placement. A pH of 7.25 (D) is more consistent with an effusion from a cause other than empyema such as: parapneumonic effusion, malignant effusion, rheumatoid effusion, tuberculosis, or systemic acidosis. A pH less than 7.20 is strongly suggestive of an empyema. Blood-tinged thoracic fluid (B) is more consistent with neoplasm, pulmonary infarction or trauma. LDH greater than 2/3 the upper limit (C) of serum LDH is suggestive of an exudative effusion. This is not part of the diagnostic criteria for empyema.

Which of the following describes the most common oral infection following radiotherapy for cancer? Candida albicans Herpes simplex Staphylococcus aureus Streptococcus viridians

Correct Answer ( A ) Explanation: Radiotherapy contributes to the development of oral candidiasis, an opportunistic fungal infection caused by Candida albicans. Individuals with oropharyngeal candidiasis (OPC) usually have a history of HIV infection, wear dentures, have diabetes mellitus, or have been exposed to broad-spectrum antibiotics, radiation therapy or inhaled steroids. Radiotherapy is one of the treatment modalities used in the treatment of oral cancer. Approximately 90% of oral cancers are squamous cell carcinoma (SCC), which is seen typically on the lip or lateral part of the tongue usually as a lump or ulcer that is white, red, or mixed white and red. Longer-term complications of radiotherapy, such as dry mouth (xerostomia), loss of taste, osteoradionecrosis (ORN) (less commonly), and other problems also may be distressing. Radiotherapy also complicates further surgery, because in particular, the endarteritis impoverishes healing

Which of the following is an increased risk factor for the condition depicted in the image above? Aspirin Gender Viral Infections Vitamin D deficiency

Correct Answer ( A ) Explanation: Solar or actinic purpura (also known as senile purpura) is a common and benign condition of extravasated blood in the dermis characterized by ecchymotic, purpuric patches on the forearms, arms, or legs of older persons. This extravasation is secondary to the fragility of the blood vessel walls caused by chronic sun exposure with the resultant ultraviolet radiation, which induces dermal tissue atrophy. As a person becomes older, collagen and elastic fibers in the dermis become frayed; elastic tissue loses its integrity and sags, clinically appearing as wrinkles; and connective tissue weakens and predisposes to traumatic solar purpura. Unlike other ecchymoses, which evolve into brown patches, senile purpura tends to fade to fainter shades of purple, although residual brown pigmentation may persist for weeks to months, or may be permanent. The condition usually follows minor trauma and commonly affects those who take aspirin or other blood thinners such as coumadin or heparin. In the United States, the occurrence of senile purpura is almost exclusively limited to the elderly population, commonly found in approximately 12% of those older than 50 years. Treatment is unnecessary and the extravasated blood is eventually reabsorbed. Viral infections (C) are not a risk factor for senile purpura. Herpes Zoster virus is a common viral skin manifestation in the elderly, however it appears as a painful vesicular rash in a dermatome distribution. Both genders (B) are equally affected in senile purpura. Vitamin D deficiency (D) is not a risk factor in senile purpura, instead multiple theories exist that vitamin C deficiency may be a risk factor as it is one of the precursors for collagen formation.

A 55-year-old woman with a history of gallstones presents to the ED with right upper quadrant abdominal pain. Her blood pressure is 98/64 mm Hg, heart rate is 110 beats per minute, respiratory rate is 22 breaths per minute, and temperature is 39.8°C. She has scleral icterus and appears jaundiced. She is also mildly confused. She is tender in the RUQ with guarding. What is the most likely diagnosis? Acute cholangitis Acute cholecystitis Acute pancreatitis Spontaneous bacterial peritonitis

Correct Answer ( A ) Explanation: The patient is suffering from acute cholangitis, which occurs when there is concomitant common bile duct obstruction (often secondary to a stone) and retrograde ascending bacterial infection. The signs and symptoms include nausea, vomiting, fever and abdominal pain. Classically patients will have Charcot's triad of fever, RUQ pain, and jaundice or Reynolds pentad, which is Charcot's triad plus hypotension and altered mental status. Common laboratory abnormalities include leukocytosis, hyperbilirubinemia, elevated alkaline phosphatase and elevated liver transaminases. RUQ ultrasound, CT scan and ERCP can be performed for diagnosis. The patient should be aggressively resuscitated with intravenous fluids and started on broad-spectrum antibiotics with Gram-positive, Gram-negative, and anaerobic coverage. General surgery should be emergently consulted for decompression and the patient should be admitted to an intensive care unit.

A 65-year-old woman comes to the clinic with a three month history of weakness, fatigue, easy bruising, and numbness and tingling in the lower extremities. She tells you she has been on a "tea and toast" diet for the past several months and is a strict vegetarian. She lives alone and has no past medical history. Physical examination shows bilateral absent reflexes and diminished vibration sensation over the lower extremities. Laboratory studies show elevated serum levels of homocysteine and methylmalonic acid. A peripheral blood smear shows a macrocytic megaloblastic anemia. Which of the following deficiencies is this patient most likely suffering from? Cobalamin Folate Niacin Thiamine

Correct Answer ( A ) Explanation: This patient most likely has vitamin B12 (cobalamin) deficiency. Animal products (e.g. meat and dairy products) are the most common sources of cobalamin. Because this patient is not consuming any animal products (e.g. tea and toast diet, strict vegetarian), she subsequently developed cobalamin deficiency. Vitamin B12 deficiency typically presents with paresthesias, ataxia, and megaloblastic anemia (e.g. weakness, fatigue, easy bruising). Additionally, laboratory studies will show increased serum levels of both homocysteine and methylmalonic acid (MMA). Folate (vitamin B9) deficiency (B) typically presents with a sore tongue or glossitis, weakness, fatigue, and anemia. Although megaloblastic anemia is also seen in folate deficiency, there are no associated neurologic symptoms, unlike with vitamin B12 deficiency. Niacin (vitamin B3) deficiency (C) typically presents with pellagra (e.g. dermatitis, diarrhea, and dementia). Thiamine (vitamin B1) deficiency (C) typically presents with beriberi (neurological and cardiovascular disease), Wernicke-Korsakoff syndrome (neuro-psychiatric disorder), and optic neuropathy (bilateral visual loss or impaired color perception). Thiamine deficiency is most commonly seen in chronic alcoholics.

A 35-year old female nurse with a history of borderline personality disorder presents to the emergency department for the second time with an acute hypoglycemic episode. These episodes have no relation to meals or fasting. She does not have a history of diabetes; however, her husband is an insulin dependent diabetic. Which of the following laboratory results aids in the confirmation of the suspected diagnosis in this patient? Plasma neuropeptide Y level Serum C-peptide level Serum chromogranin A level Urinary vanillylmandelic acid level

Correct Answer ( B ) Explanation: A Plasma C-peptide level aids in the diagnosis of factitious hypoglycemia. Plasma C-peptide is a measure of endogenous insulin secretion and distinguishes endogenous from exogenous hyperinsulinemia. Factitious hypoglycemia occurs in nondiabetic patients who knowingly self-administer hypoglycemic agents for the purpose of causing hypoglycemia. It is more common in women, occurs most commonly in the third or fourth decades of life, and, among nondiabetic subjects, is often found in those in health-related occupations. The possibility of factitious hypoglycemia should be considered in every patient undergoing evaluation for a hypoglycemic disorder, especially when the hypoglycemia has no relation to meals or fasting. When hypoglycemic symptoms occur in a patient without diabetes, the differential diagnosis includes the presence of an insulin-secreting tumor, or insulinoma, which is exceedingly rare, the surreptitious injection of insulin, or the ingestion of a sulfonylurea or meglitinide. The diagnosis of factitious hypoglycemia can usually be established by documenting the presence of hypoglycemia and by simultaneously measuring plasma insulin, C-peptide, proinsulin, and insulin secretagogues. If the results indicate exogenous injection of insulin or surreptitious ingestion of sulfonylureas, a psychiatric evaluation may be appropriate, especially in patients with a history of a mood or psychiatric disorder.

A 45-year-old man presents with severe dental pain that acutely developed several hours ago. Three days ago he had an extraction for severe caries. Which of the following is the most likely diagnosis? Abscess Acute alveolar osteitis Acute necrotizing ulcerative gingivitis Pulpitis

Correct Answer ( B ) Explanation: Acute alveolar osteitis is also called dry socket. This typically occurs three to five days after a dental extraction. For the first couple of days after the procedure, the patient is pain free and then abruptly has severe pain associated with a foul odor from the surgical site. The healing blood clot over the surgical site dislodges causing a localized infection and inflammation of the bone in the socket. Treatment includes irrigation of the socket and then packing with iodoform gauze and dental paste. Most dentists also recommend oral antibiotics. An abscess (A) is possible after any surgical procedure although would more likely have a more gradual onset of pain with associated fever and facial swelling. Acute necrotizing ulcerative gingivitis (C) occurs when bacteria invade and infect non-necrotic gingival tissue. Patients also develop systemic signs of infection with fever, malaise, and adenopathy. A classic gray pseudomembrane may cover the tissue and bleed when scraped off. Pulpitis (D) is an infection of the pulp of a tooth seen in association with dental caries. In early pulpitis patients reports sensitivity to hot and cold substances in the mouth and with advanced pulpitis pain and sensitivity even to air.

A newborn infant presents with meconium ileus. Which of the following genetic disorders should be screened for? Congenital hypothyroidism Cystic fibrosis Phenylketonuria Sickle cell anemia

Correct Answer ( B ) Explanation: Cystic fibrosis should be suspected when a newborn presents with meconium ileus. Meconium ileus is characterized by obstruction of the bowel by meconium, or infant stool, in a newborn infant. Infants generally present during the first three days of life with abdominal distension with or without vomiting and failure to pass meconium. It is the presenting problem in 10 to 20% of newborns with cystic fibrosis. Conversely, 80 to 90% of infants with meconium ileus have cystic fibrosis. Patients with meconium ileus should undergo sweat testing to clarify a diagnosis of cystic fibrosis. Symptomatic presentation of cystic fibrosis in infants and children includes meconium ileus, respiratory symptoms and failure to thrive.

A patient presents to the clinic complaining of worsening edema and foamy urine. Urine microscopy is performed and urine sediment casts have a characteristic Maltese cross appearance under polarized light. Which of the following is mostly likely described on urine microcopy? Broad casts Fatty casts Granular casts Hyaline casts

Correct Answer ( B ) Explanation: Fatty casts on urine microscopy have the appearance of a Maltese cross under polarized light and are characteristic of nephrotic syndrome, which is the most likely diagnosis in this patient with edema and frothy urine. Lipiduria is usually present in nephrotic syndrome and urinary lipid may be present in the sediment, entrapped in fatty casts, enclosed by the plasma membrane of oval fat bodies or free in the urine. Fat droplets are round and may be confused with red cells. They can be differentiated from red cells under routine light microscopy by their variable size, their dark outline, and the Maltese cross appearance under polarized light. Broad casts (A) are wider than other casts due to their formation in large dilated tubules with little flow. The presence of broad casts is typically associated with advanced chronic kidney disease. Granular casts (C) represent degenerated cellular casts or the aggregation of proteins within a cast matrix. Coarse, deeply-pigmented granular casts, often called muddy brown casts are characteristic of acute tubular necrosis. Hyaline casts (D) have a transparent and empty appearance and may be observed with small volumes of concentrated urine or with diuretic therapy and are generally nonspecific.

A 47-year-old multiparous woman comes to the emergency department complaining of lower pelvic pain. She says the pain is worse when lifting a heavy object or when standing for prolonged periods of time. She is 162.6 cm (5 ft 4 inches) tall and weighs 133.8 kg (295 lbs). No visible bulge is seen on physical examination when the patient is in the supine position. Which of the following is the most likely diagnosis? Direct inguinal hernia Femoral hernia Incarcerated hernia Incisional hernia

Correct Answer ( B ) Explanation: Increasing age, female gender, obesity, and multiparity are all risk factors for developing a femoral hernia. Femoral hernias are located inferior to the inguinal ligament and protrude through the femoral ring, which is medial to the femoral sheath and lateral to the lacunar ligament. Although femoral hernias only represent about 3% of all hernias, they are most commonly seen in women. Usually women often do not have a visible bulge on physical examination. This can be misleading, therefore, follow up with ultrasonography (or diagnostic laparoscopy) is typically done. Direct inguinal hernias (A) protrude medial to the inferior epigastric vessels and are more commonly seen in men.

A 35-year-old woman presents with recurrent bouts of tinnitus, dizziness and hearing loss. She reports that the episodes are incapacitating and cause her to become nauseous. The attacks last about one hour and the symptoms disappear after a few hours. The last two episodes were treated with meclizine and prochlorperazine in the emergency department. Audiology testing reveals low-tone frequency hearing loss. Which of the following is the most appropriate long-term management for this patient? Broad-spectrum antibiotics and ibuprofen Diuretics and low-sodium diet Epley maneuver Scopolamine transdermal patch

Correct Answer ( B ) Explanation: Meniere's disease, also known as endolymphatic hydrops, is a disorder of the inner ear. Endolymphatic hydrops refers to a condition of increased hydraulic pressure within the inner ear endolymphatic system. Excess pressure accumulation in the endolymph can cause a tetrad of symptoms including fluctuating hearing loss, episodic vertigo, tinnitus, and aural fullness. These symptoms can last for hours at a time and occur as remitting and relapsing episodes. Diagnosis is made on clinical history and detailed audiological tests, however other investigations may be required to exclude other causes. Dietary changes and diuretics are the mainstay of treatment of Meniere's disease used to decrease the fluid pressure in the inner ear. High-salt intake is thought to alter the concentrations of fluid in the inner ear thereby worsening Meniere's severity and frequency.

A 27-year-old woman presents with vaginal bleeding. Her last menstrual period was eight weeks ago. On physical examination, there is a small amount of blood in the vaginal vault with an open internal cervical os. Bedside ultrasound reveals an intrauterine pregnancy with a fetal pole but no heartbeat. Which of the following is the most likely diagnosis? Incomplete miscarriage Inevitable miscarriage Missed abortion Threatened miscarriage

Correct Answer ( B ) Explanation: Spontaneous miscarriage before 20 weeks of gestation is the most common serious complication of pregnancy. Most miscarriages (80%) occur in the first trimester of pregnancy and almost all occur before 20 weeks gestation. Up to 25% of pregnant women experience bleeding during pregnancy so the evaluation of threatened miscarriage or abortion is common. The ultimate risk of fetal demise in threatened abortion decreases substantially once a fetal heart beat is visible on ultrasound. The results of the physical examination and ultrasound classify the type of miscarriage. In the case presented, the presence of an open internal os defines the miscarriage as inevitable. Additionally, patients will typically have vaginal bleeding and products of conception can often be felt or visualized through the internal cervical os. An incomplete miscarriage (A) is one in which the products of conception are visible either in the os or vaginal canal. Once all products are expelled and the uterus contracts with a closed cervical os, the miscarriage is complete. A missed abortion (C) is a term that encompasses several clinical scenarios when the pregnancy does not progress but the uterus has not expelled the products of conceptions and the cervical os remains closed. These scenarios include: failure of the uterus to grow over time; an anembryonic gestation where no fetus develop; and fetal death when the age/size of the fetus would have a heart beat but none is detected on ultrasound. A threatened miscarriage (D) is the presence of vaginal bleeding in pregnancy with a closed cervical os. Between 35% and 50% of women will ultimately lose the pregnancy when they have experienced a threatened miscarriage.

A 14-year-old basketball player presents to the emergency room with a tender swollen left knee after taking a fall during her game. During the basketball game she came to an abrupt stop and fell on her knee and heard a "pop." Subsequently, she was unable to bear weight. On physical exam the right knee is swollen and there is asymmetry on side-to-side laxity and 8 mm of tibial displacement on the anterior drawer test. Which of the following should be performed in order to diagnose this injury? Arthrocentesis Magnetic resonance imaging Ultrasound X-ray series

Correct Answer ( B ) Explanation: The anterior cruciate ligament (ACL) is the most frequently injured major ligament of the knee. An ACL tear commonly presents with a noncontact deceleration force or falling on a knee that is internally rotated. A "popping sensation" is often felt at the time of injury. Pain and swelling occur immediately after the injury. Instability of the knee or a "wobbly" feeling is also a common finding during the injury. The anterior drawer test and Lachman test are the two most common physical exams that are sensitive for this injury. The most specific imaging study used to confirm the diagnosis of an ACL tear is an MRI. Surgical treatment is indicated and physical rehab is important in order to regain strength and function, however surgical treatment has better outcomes in younger, active patients and therefore older patients may opt to not go through with surgery and will have satisfactory outcomes with physical rehab alone.

A 42-year-old man presents with low back pain and a normal neurologic examination. Which of the following would prompt emergent imaging of the lumbosacral spine? History of heavy lifting History of intravenous drug use Positive straight leg raise Radicular pain

Correct Answer ( B ) Explanation: The evaluation of acute low back pain must eliminate the presence of red flags suggesting serious etiologies requiring urgent evaluation. Multiple causes of low back pain exist including vascular, visceral, musculoskeletal, infectious, mechanical, and rheumatologic. Pain may originate from the vertebral column, spinal cord, nerve roots, musculature, or abdominal and thoracic organs. A history of intravenous drug use should raise the index of suspicion for an infectious etiology (e.g. epidural abscess, osteomyelitis, discitis) and imaging with MRI to evaluate the lower back is indicated. Many patients expect imaging during their evaluation and higher patient satisfaction is linked with performance of the ancillary testing. However, most patients do not require emergent diagnostic imaging studies.

A two-year-old boy is brought to the ED because he refuses to walk for the last two days. His blood pressure is 90/40 mm Hg, heart rate 140 beats/minute, respiratory rate is 24 breaths/minute and his oral temperature is 39.2°C. On examination, he is holding his left hip flexed with slight abduction and external rotation. He has pain with passive movement of the left hip. His bloodwork is significant for a WBC count of 13,000 and ESR of 50. What is the most likely diagnosis? Legg-Calvé-Perthes Disease Septic arthritis Slipped capital femoral epiphysis syndrome Transient synovitis

Correct Answer ( B ) Explanation: The patient likely has septic arthritis, a microbial invasion (most commonly S. aureus) of the joint space secondary to hematogenous or local spread or a traumatic or surgical infection. The disease most commonly occurs in males younger than four years of age (peak incidence six to 24 months). The knee is the most commonly affected joint in children and the hip is the second most common. It generally presents with acute onset of fever, irritability, pain, and refusal to bear weight or move the affected joint. Generally the area is warm, erythematous, and swollen. In cases of hip involvement, it is often held in flexion, abduction and external rotation. Younger children will have more nonspecific symptoms. Generally the WBC count, ESR and CRP will be elevated. Arthrocentesis and synovial fluid analysis should be performed. In cases of septic arthritis, the synovial fluid is turbid or purulent, WBC count > 50,000 cells/mL with a PMN predominance, low glucose, elevated protein and lactate. The patient should be immediately started on intravenous antibiotics, evaluated by orthopedics for surgical intervention and admitted to the hospital. Legg-Calvé-Perthes disease (A) or idiopathic avascular necrosis of the proximal femoral epiphysis, most commonly occurs in male children between the ages of three and 12 years with a peak between five and seven years of age. It often presents with a limp that has an insidious or stuttering onset. The associated pain is generally mild, refers to the groin, anteriomedial aspect of the thigh or knee, and is often relieved by rest, and generally worse at the end of the day. Slipped capital femoral epiphysis (SCFE) syndrome (C) occurs with posterior and inferior slippage of the proximal femoral epiphysis on the metaphysis and is most common in overweight, adolescent males between 12 and 16 years of age. Patients with SCFE present with progressive limp and pain localized to the groin, thigh or knee. Transient synovitis (D) is a self-limited non-pyogenic inflammation of the synovium that most commonly occurs in boys between the ages of three and six years of age. The exact etiology is unknown although in many cases follows a mild upper respiratory infection. Children will complain of hip pain, walk with a limp or refuse to bear weight. They are generally otherwise well.

Which of the following is true regarding traveler's diarrhea? Bacterial enterotoxins block glucose and water resorption in the intestines which means that oral rehydration is ineffective Infection with invasive bacteria such as C. jejuni, Shigella and Salmonella is more common in travelers to Southeast Asia Metronidazole is the treatment of choice for traveler's diarrhea The pathophysiology of traveler's diarrhea involves increased osmotic load to the colon

Correct Answer ( B ) Explanation: While the majority of infectious diarrhea in the United States is caused by viruses, a history of foreign travel is associated with an 80% risk of bacterial diarrhea. The destination of travel is the most important risk factor for traveler's diarrhea, with countries in South America, Asia, Africa, and parts of the Middle East considered high-risk destinations. E. Coli is the most commonly identified bacterial agent causing traveler's diarrhea among travelers to Mexico and South America, whereas invasive bacteria like C. jejuni, Shigella, and Salmonella are more commonly seen among travelers to southern Asia. Most cases of traveler's diarrhea are caused by contaminated food and drink. Travelers to high-risk destinations should be counseled to drink only bottled water or water that has been boiled. Most cases of traveler's diarrhea are self-limited. The treatment for traveler's diarrhea includes oral rehydration with glucose-containing fluids, ciprofloxacin, and consideration of anti-motility agents like loperamide. Anti-motility agents should not be used in patients with bloody diarrhea or suspected inflammatory diarrhea owing to risk of complications like prolonged fever, toxic megacolon, or hemolytic uremic syndrome in children. Metronidazole (C) is the treatment of choice when parasitic infection like Giardia or Entamoeba histolytica is suspected. However bacteria are the most common cause of traveler's diarrhea and ciprofloxacin is recommended as the first-line agent. The pathophysiology of traveler's diarrhea (D) does not involve increased osmotic load to the colon. Bacterial enterotoxins block passive sodium and water resorption and stimulate sodium excretion, resulting in a net loss of fluid. Laxatives are an example of increased osmotic load to the colon causing diarrhea.

A 76-year-old woman suffers from chronic constipation. Secondary causes such as hypothyroidism and diabetes have been ruled out. The only medications she takes are a daily multivitamin and ibuprofen occasionally for her osteoarthritis. Which of the following medications should be added to her daily regimen in order to help her with her constipation? Docusate sodium Enema Psyllium Senna

Correct Answer ( C ) Explanation: As an initial step in treatment, the patient should be advised to follow a diet rich in fiber. Strong epidemiologic evidence has shown that greater amounts of crude dietary fiber are associated with a lesser prevalence of constipation and other gastrointestinal disorders, including diverticular disease and colorectal cancer. Fiber appears to increase stool bulk and weight and to speed intestinal transit time. Fiber is a good first step in the treatment of constipation. Psyllium is a form of supplemental fiber and also has the benefit of reducing lipids and improving glucose control in diabetics. Docusate sodium (A), commonly referred to as Colace, is a stool softener but is less effective than fiber in preventing constipation. Enemas (B) should only be used in acute situations as they can cause colonic perforations. Senna (D) is a common stimulant laxative, which has the potential to cause severe electrolyte imbalances in the elderly and can also cause abdominal pain.

Which of the following is the drug of choice in the prevention of seizures in the setting of pre-eclampsia? Diazepam Lorazepam Magnesium sulfate Phenytoin

Correct Answer ( C ) Explanation: Magnesium sulfate is the drug of choice to prevent and treat eclamptic seizures. Pre-eclampsia refers to the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman. It is a multi-system, progressive disorder with a disease spectrum that ranges from mild to severe. Delivery results in resolution of the disease. Major medical organizations worldwide consistently recommend magnesium sulfate as the drug of choice for the prevention of eclampsia. Studies have found magnesium sulfate to be safer and more effective for prevention of recurrent seizures than phenytoin or diazepam. The drug is usually initiated at the onset of labor or induction, or prior to a cesarean delivery.

A 21-year-old college student presents after vomiting blood the last time he vomited. He reports that he has been vomiting and retching all morning. His vital signs are normal and his stool is occult blood negative. What is the most likely cause of the bleeding? Dieulafoy lesion Gastritis Partial thickness tear of the esophagus Peptic ulcer disease

Correct Answer ( C ) Explanation: Mallory-Weiss syndrome is upper gastrointestinal bleeding as a result of a longitudinal partial thickness tear of the distal esophageal mucosa. It can also involve the mucosa of the gastric mucosa near the gastroesophageal junction. Patients classically describe hematemesis after episodes of retching. The amount of blood varies and ranges from specks of blood to several ounces. Up to 40% of patients experience lower chest and epigastric pain. Most patients remain hemodynamically stable and are discharged after a period of observation. If the diagnosis is unclear, upper endoscopy is performed for direct visualization of the esophagus. It is rare that patients with a Mallory-Weiss tear need treatment beyond observation A Dieulafoy lesion (A) is a rare cause of upper gastrointestinal hemorrhage causing significant, life-threatening bleeding. It is a vascular malformation of the proximal stomach in which an arteriole runs a tortuous course through the submucosa. On endoscopy, a large ulcerated vessel is visible in the submucosa.

26-year-old woman with a history of dysmenorrhea and depression presents to the ED after having a seizure witnessed by her husband. He reports finding her on the bedroom floor with an empty pill bottle. Which of the following non-steroidal anti-inflammatory (NSAIDs) medications did she most likely ingest? Celecoxib Ibuprofen Mefenamic acid Rofecoxib

Correct Answer ( C ) Explanation: Overdose of mefenamic acid is associated with seizure activity. This typically occurs two to seven hours following the acute ingestion. Mefenamic acid is a fenamate that is marketed under the trade name Ponstel® in the United States as an analgesic used for pain associated with menstruation. Seizures are generally well controlled with benzodiazepine administration. A complete and rapid recovery is expected following overdose.

A 24-year-old pregnant woman presents with a rash on her hands with itching that is worse at night. Physical exam shows excoriations over the web spaces of the hands with tiny burrows noted. Several members in her household have similar symptoms. Which of the following is the most appropriate treatment? Ivermectin Lindane 1% cream Permethrin 5% cream Sulfur in petroleum 5%

Correct Answer ( C ) Explanation: Permethrin 5% cream is a safe treatment for scabies during pregnancy. Less than 2% of an applied dose is absorbed systemically although residual effects of the drug remain for up to ten days after application. Scabies is caused by a mite infestation with Sarcoptes scabiei. These mites burrow under the skin of infested individuals leaving behind eggs and feces in the small epidermal tunnels that they create. These burrows are usually found in the web spaces between digits, intertriginous areas, and flexor creases. Symptoms include itching that is worse at night and a rash or itching that is worse in web spaces or intertriginous areas. History will often reveal others in the household with similar symptoms. Diagnosis of scabies is usually clinical, however, skin scrapings can reveal microscopic confirmation of adult mites or their eggs. Treatment includes permethrin 5% cream, lindane 1% cream (not available in the USA due to side effects), ivermectin, or crotamiton 10% cream. Permethrin 5% cream is safe during pregnancy and is applied over the entire body from the neck down and left on for eight hours. Afterwards, it is washed off entirely. Patients should also be instructed to launder all clothing and bed linen in hot water to prevent reinfestation. Ivermectin (A) should not be used during pregnancy and is not safe to use in children less than five years. It is a pregnancy category C drug and has shown to be teratogenic in studies using mice, rats, and rabbits. Lindane 1% cream (B) is a pregnancy category C drug and has been shown to be absorbed systemically in studies. There are concerns regarding neurotoxicity and hematotoxicity with its use making it an unsuitable choice for pregnant females or young children. Lindane is no longer available in the USA. Sulfur in petroleum 5% (D) is safe during pregnancy, however, the unpleasant odor and staining associated with this drug make it a less attractive choice for treatment.

A 42-year-old man is diagnosed with acute pericarditis complicated by a pericardial effusion. He suddenly develops dyspnea and orthopnea. On physical exam he is tachycardic, hypotensive and has distant heart sounds. He is noted to have jugular venous distension and his lungs are clear to auscultation. Which of the following is an important physical finding associated with this patient's condition? Pulsus alternans Pulsus bisferiens Pulsus paradoxus Pulsus parvus et tardes

Correct Answer ( C ) Explanation: Pulsus paradoxus is an important physical finding in cardiac tamponade, which is the most likely diagnosis in this rapidly deteriorating patient. Among patients with pericardial effusion, the sensitivity of pulsus paradoxus for cardiac tamponade exceeds 80% and is higher than any other single physical finding. Pulsus paradoxus is an exaggerated drop in systemic blood pressure of greater than 10 mm Hg during inspiration. Several complex mechanisms generate pulsus paradoxus in cardiac tamponade, the most important of which is an amplified interdependence between the right and left sides of the heart inside a restricted pericardial space. Pulsus alternans (A) is a variation in pulse amplitude occurring with alternate beats due to changing systolic pressure and almost exclusively occurs in systolic heart failure. Pulsus alternans is rarely encountered in patients with cardiac tamponade. Pulsus bisferiens (B) is characterized by two systolic peaks of the aortic pulse during left ventricular ejection separated by a midsystolic dip. It is frequently observed in patients with hemodynamically significant aortic regurgitation. Pulsus parvus et tardus (D) is a sign of aortic stenosis where, upon palpation, the pulse is weak and late relative to its usually expected character. Neither is associated with cardiac tamponade.

A 19-year-old man presents after getting tackled in a football game. He complains of pain in the right shoulder. On physical examination, you palpate mobility of the right distal clavicle. His X-ray is shown below. What is the appropriate next step? Figure of eight sling Shoulder MRI Sling and orthopedic follow-up Surgery

Correct Answer ( C ) Explanation: The acromioclavicular (AC) joint is one of three joints making up the shoulder along with the glenohumeral and sternoclavicular joints. The AC joint attaches the lateral portion of the clavicle to the acromion. The AC joint most commonly becomes injured in contact sports after a fall or direct blow to the shoulder. The acromioclavicular and coracoclavicular ligaments are relatively weak and susceptible to injury. Injuries are divided into six types. In type I (most common), the AC joint is sprained and there is no separation of the two bones. In Type II injuries, the joint space is widened with minimal upward displacement of the clavicle. Type III injuries involve complete disruption of the joint and more significant upward displacement. Types IV, V and VI have more significant displacements of the clavicle in other parts of the axis. Type I and II AC joint separations are managed with a sling and orthopedic follow-up within a couple of weeks. Type III is also managed with a sling but more expeditious orthopedic follow-up because of the possible need for surgical management.

A two-week-old child is brought to the pediatrician's office for their first well-child visit. The child was born overseas and did not receive the standard post-natal testing that is performed in the United States. While in the office, the mother states that she has noticed a musty odor in the child's diaper, and that the child has begun to develop a rash on his forearms. The pediatrician is immediately concerned that the child may be suffering from an accumulation of which of the following amino acids? Citrulline Leucine Phenylalanine Valine

Correct Answer ( C ) Explanation: This child is suffering from phenylketonuria (PKU), which presents with the classic symptoms of musty odor and eczema. Classical PKU results from a deficiency in the enzyme phenylalanine hydroxylase. Screening for PKU is commonly performed as part of the newborn screen. Newborn screening in the United States has largely eliminated the development of intellectual disability from this disorder. Once identified, patients with PKU are instructed to consume a diet low in phenylalanine. Foods high in phenylalanine include meat, fish, eggs and legumes. If this diet is not followed, it can lead to progressive neurologic deterioration. The musty odor is secondary to phenyl acetate accumulation in the urine and sweat. Pharmacologic and nutritional management of PKU includes glycomacropeptide to improve bone health

A 60-year-old homeless man with a history of diabetes presents with a four-week history of low-grade fever, night sweats, and productive cough. Treatment with isoniazid, rifampin, pyrazinamide and ethambutol is initiated. Which of the following medications should also be prescribed to prevent adverse events? Biotin Cyanocobalamin Pyridoxine Thiamine

Correct Answer ( C ) Explanation: Tuberculosis is caused by Mycobacterium tuberculosis and the lungs are the major site of infection. The initial infection (primary tuberculosis) causes low-grade fever and only rarely other symptoms. In 90% of otherwise healthy infected individuals, the immune system will suppress further bacilli replication. Years later, when chronic disease and age weaken the immune system, reactivation tuberculosis may develop. Patients present with a weeks-to-months long history of fever, weight loss, night sweats, and fatigue. Chest pain, productive cough and hemoptysis may also be present. Patients should undergo chest X-ray which commonly reveals anterior lobe infiltrates, sometimes with cavitation. Three sputum specimens should be evaluated for acid-fast bacilli. Treatment consists of isoniazid, rifampin, pyrazinamide, and ethambutol for two months, followed by a minimum four-month continuation period with isoniazid and rifampin. Isoniazid use is associated with an increased risk of peripheral neuropathy. Patients at risk for peripheral neuropathy, such as those with a history of alcoholism, nutritional deficiencies, or diabetes, should take pyridoxine to help reduce the risk of neuropathy. Other side effects of isoniazid include hepatotoxicity and seizures if supratherapeutic doses are ingested

A 40-year old man presents to the emergency department with a severe headache. His skin is flushed and diaphoretic. His blood pressure is 220/90 mm Hg. He went to a party at a friend's house this evening where he sampled several red wines and aged cheeses. He tells you that he recently had a MRSA skin infection and is currently taking "a strong antibiotic" for the infection. What is the most likely diagnosis? Malignant hyperthermia Neuroleptic malignant syndrome Serotonin syndrome Tyramine reaction

Correct Answer ( D ) Explanation: A tyramine reaction occurs when patients taking a non-selective monoamine oxidase inhibitor (MAOI) consume foods containing high levels of tyramine, such as aged cheeses, red wines, and smoked, pickled or aged meats. Linezolid, an oral antibiotic that is used in the treatment of MRSA infection, is known to have MAOI effects. Tyramine, an indirectly acting sympathomimetic amine is metabolized in the gut and liver by monoamine oxidase. Monoamine oxidase is blocked in patients taking MAOIs. When MAO-A is inhibited, the tyramine is absorbed systemically, causing a release in norepinephrine and serotonin causing a hypertensive crisis. Treatment is aimed at blood pressure control with alpha-blocking agents, such as oral terazosin or intravenous phentolamine. Malignant hyperthermia (A) occurs with the use of certain anesthetic agents (halothane and succinylcholine) and manifests as severe muscle rigidity and hyperthermia. Neuroleptic malignant syndrome (B) is a life-threatening condition characterized by muscle rigidity, autonomic instability, altered mental status, and hyperthermia that occurs soon after initiation or dose adjustment of a dopaminergic or antipsychotic drug. Serotonin syndrome (C) results from excessive serotonin accumulation in the synaptic cleft and manifests as a triad of altered mental status, autonomic instability and neuromuscular abnormality. Serotonin syndrome often occurs as the result of a drug-drug interaction between medications that increase the amount of serotonin in the synaptic cleft, however can occur following an overdose with an SSRI.

A 75-year-old woman has been in the hospital for the past five days due to a hip fracture. Her daughter came to visit her and noticed that her mom was extremely confused and would ramble statements that did not make any sense. She also appears drowsy. These symptoms last for about 30 minutes to an hour and then the woman returns back to her normal self. Her mental status waxes and wanes more during the evening. Which of the following medications should be discontinued in the patient, as it will worsen this clinical state? Ciprofloxacin Docusate Levothyroxine Prednisone

Correct Answer ( D ) Explanation: Delirium is defined by acute changes in mental status, that are marked by decreased ability to focus attention, confusion, incoherent speech, increase or decrease in arousal, and agitation. These symptoms are marked by periods of fluctuation. Causes of delirium include but are not limited to pain, sleep deprivation, medications, electrolyte abnormalities, infections, and intracranial pathologies. Delirium occurs more commonly in elderly patients that are hospitalized. It is important to identify and treat the underlying causes of delirium because patients with delirium during hospitalization have longer hospital stays, increased mortality, increased risk for deconditioning and pressure ulcers. Medications that can cause delirium include benzodiazepines, narcotics, anticholinergics, tricyclic antidepressants, and steroids. These medications should be avoided in patients with delirium. Prednisone should be discontinued or slowly weaned in this patient. Physical and chemical restraints should be avoided in these patients as well. Adding familiar objects to the hospital room such as calendars, clocks, items from the patient's house and encouraging family members to visit often can help prevent delirium. Medications for delirium should be targeted towards specific behaviors such as physical aggression, and distressing hallucinations. Low-dose antipsychotics such as haloperidol can be used in these situations, however their use should be limited. Benzodiazepines are last-line therapy for delirium as they can often times worsen the patient's confusion.

A 42-year-old woman presents to the emergency department complaining of right upper quadrant pain that radiates to her right shoulder and is associated with nausea, vomiting and anorexia. She appears ill, is febrile to 100.7°F and tachycardic. Which of the following is most likely to be elevated on laboratory evaluation? Alkaline phosphatase Amylase Bilirubin White blood cells

Correct Answer ( D ) Explanation: Elevated white blood cell count with a left shift is most likely be seen in this woman with symptoms concerning for acute cholecystitis. Acute cholecystitis should be suspected in a patient presenting with right upper quadrant pain, fever and leukocytosis. Patients typically have a leukocytosis with an increased number of band forms, or a left shift. Patients with acute cholecystitis typically complain of abdominal pain, most commonly in the right upper quadrant or epigastrium. The pain may radiate to the right shoulder or back. Characteristically, acute cholecystitis pain is steady and severe. Associated complaints may include fever, nausea, vomiting and anorexia. There is often a history of fatty food ingestion one hour or more before the initial onset of pain. Patients with acute cholecystitis are usually ill appearing, febrile and tachycardic. Elevation of amylase (B) is associated with acute pancreatitis, not uncomplicated acute cholecystitis. Elevation of alkaline phosphatase (A) and elevation of bilirubin (B) are not common in uncomplicated acute cholecystitis since biliary obstruction is limited to the gallbladder. If present, they should raise concerns about complicating conditions such as cholangitis, choledocholithiasis or, ascending cholangitis, gallstone pancreatitis, or Mirizzi syndrome. Mirizzi syndrome occurs when a gallstone becomes impacted in the distal cystic duct causing extrinsic compression of the common bile duct.

A 27-year-old woman presents with a painful rash on both of her legs as seen above. What is the most common cause of this condition? Allergy Drug hypersensitivity reaction Herpes virus Streptococcal infection

Correct Answer ( D ) Explanation: Erythema nodosum is a condition in which patients develop painful red/violet nodules deep under the skin. It develops as a result of an inflammatory reaction between the dermis and adjacent adipose tissue. It is thought to be a delayed hypersensitivity reaction to various infections, drugs or systemic disease. Most commonly the lesions develop over the anterior tibia but can appear anywhere on the body. Before the development of the rash, the patient often complains of fever and arthralgias, particularly of the ankles. There are multiple diseases or infections associated with erythema nodosum, the most common of which are Streptococcal infections. Others include: tuberculosis, sarcoidosis, coccidioidomycosis, histoplasmosis, ulcerative colitis, enteritis, pregnancy, Yersenia enterocolitica, and Chlamydia. The disease is treated symptomatically (NSAIDs, elevation, stockings) and is typically self-limited.

A nine-year-old boy presents with weakness and diarrhea. Mom reports he has had diarrhea for several days with a fever. His laboratory testing is notable for a hemoglobin of 8.3 g/dL and a creatinine of 2.4 mg/dL. Which of the following will be helpful to confirm the diagnosis? Fibrinogen level Iron level Leukocytosis Peripheral smear

Correct Answer ( D ) Explanation: Most cases of hemolytic uremic syndrome (HUS) occur in children after a diarrheal illness caused by E. coli O157:H7. In these cases, the E. coli produces a toxin that damages the endothelial cells, especially those in the colon and kidney. The first symptoms of the illness are related to the diarrheal illness and may involve a hemorrhagic colitis as a result of the bacterial invasion of the intestinal wall. The clinical syndrome involves the development of a microangiopathic hemolytic anemia and renal failure. The peripheral smear demonstrates a decreased number of red blood cells (anemia) and fragmented red blood cells as a result of the microangiopathic hemolytic anemia. These abnormal red blood cells include: schistocytes, spherocytes, segmented red blood cells, burr cells and helmet cells. Thrombocytopenia is common as a result of the microthromboses occurring in the syndrome. Fever is often present. The syndrome mimics thrombotic thrombocytopenic purpura (TTP) in adults, but does not typically have altered mental status as a symptom, which is common in TTP.

Which of the following is characteristic of neurogenic shock? Areflexia Flaccid paralysis Tachycardia Warm, dry extremities

Correct Answer ( D ) Explanation: Neurogenic shock is a type of distributive shock that can be found in patients with central nervous system and spinal cord injuries. Vasodilation occurs secondary to loss of sympathetic vascular tone causing pooling of blood in the distal extremities. Depending on the level of injury, loss of sympathetic cardiac innervation can result in bradycardia and loss of reflex tachycardia. Patients present with hypotension, relative bradycardia and warm, dry extremities. As neurogenic shock typically occurs in trauma patients, it is imperative to rule out other, more common forms of shock (e.g. hemorrhagic shock) before making a definitive diagnosis. Often confused with neurogenic shock, spinal shock is defined as temporary areflexia (A) and flaccid paralysis (B) below the level of a complete or incomplete spinal cord injury. Spinal shock typically lasts hours to days. Return of the bulbocavernosus reflex is one of the first signs of resolution of spinal shock. Patients with neurogenic shock usually present with a relative bradycardia, not tachycardia (C).

26-year-old woman presents to the emergency room with severe right sided lower quadrant pain and vomiting. The pain started two days ago and has progressively worsened. Her current medications include clomiphene citrate. On physical exam the patient is constantly changing positions in an attempt to relieve the pain. There is a small mass felt on deep palpation in the right lower quadrant. Which of the following is considered first-line in diagnosing the suspected condition? Abdominal ultrasound Computed tomography Magnetic resonance imaging Transvaginal ultrasound

Correct Answer ( D ) Explanation: Right-sided pelvic pain is especially challenging and can be confusing because of the close proximity of the appendix, uterus, right fallopian tube, and right ovary. Typically, it requires imaging to determine the etiology. The goal of imaging is to make the most accurate diagnosis using the least amount of radiation; therefore, transvaginal ultrasonography is the imaging modality of choice in the initial evaluation of pelvic pain. Ovarian torsion (adnexal torsion) is an infrequent but significant cause of acute lower abdominal pain in women. Ovarian torsion is the twisting of the ovary and or fallopian tube and its vascular support, thereby it can result in necrosis. It is most often seen in women of reproductive age (15-30 years of age). It commonly presents with intense abdominal pain, nausea, vomiting and an abdominal mass. Pregnancy, tumors, cysts and ovulation induction with gonadotropins increase the risk of torsion. Definitive diagnosis is surgical; however the initial imaging choice should be transvaginal ultrasound. Laparoscopic surgery with detorsion is the preferred treatment to preserve normal ovarian function and fertility. It is considered a surgical emergency

A five-year-old boy presents to the emergency department with fever, sore throat, and difficulty swallowing. He has been complaining of a mild sore throat for the last one week. He refuses to extend his neck or turn his head from side to side, however is not currently experiencing respiratory distress. A soft tissue radiograph of the neck reveals widening of the space anterior to cervical vertebral bodies. Which of the following is the most likely diagnosis? Bacterial tracheitis Epiglottitis Peritonsillar abscess Retropharyngeal abscess

Correct Answer ( D ) Explanation: The patient has a retropharyngeal abscess based on the clinical scenario and lateral soft tissue neck X-ray findings. Retropharyngeal abscess is a pediatric disease that occurs most commonly under the age of six, as the retropharyngeal space begins to obliterate beyond this age. Symptoms include fever, neck stiffness, refusal to turn the head and neck, sore throat, stridor, difficulty breathing and handling secretions. The retropharyngeal space on X-ray should be less than 7 mm at the level of C2 and less than 14 mm at the level of C6 in children. Anything larger suggests retropharyngeal abscess in the appropriate clinical setting. Bacterial tracheitis (A) generally occurs between three to four years of age and starts with a prodrome of fever, barking cough and stridor and is followed by acute decompensation with toxic appearance. In this case, the soft tissue neck x-ray should be normal. Epiglottitis (B) is less common with the development of the Hib vaccine, however can be seen in unvaccinated children. It is characterized by abrupt onset of fever and sore throat and children classically present with difficulty breathing, anxiety, stridor and drooling. The soft tissue neck x-ray should show a thumb-print sign consistent with an enlarged, inflamed epiglottis. Peritonsillar abscess (C) occurs more commonly during adolescence and presents with trismus, unilateral sore throat, fever, tonsillar asymmetry, and uvula deviation away from the affected tonsil. Radiographs may show tonsil enlargement, however ultrasound and CT-scan are better diagnostic modalities.

Which of the following laboratory studies are routinely monitored in a patient with bipolar disorder on lithium therapy? Complete blood counts Liver functions tests Pulmonary function tests Thyroid function studies

Correct Answer ( D ) Explanation: Thyroid function studies are routinely monitored in patients on lithium therapy. Lithium is a mainstay of treatment for bipolar disorder and may reduce the risk of suicide. The two most common long-term adverse effects of lithium involve the kidneys and thyroid gland. Thyroid function is adversely affected by lithium and thus monitored with laboratory tests; lithium can cause goiter, hypothyroidism, chronic autoimmune thyroiditis, and possibly hyperthyroidism. It is one of many medications that can be selected to treat acute mania, hypomania, and bipolar depression, and maintenance treatment of bipolar disorder. Prior to beginning lithium, clinicians should obtain a urinalysis, blood urea nitrogen, creatinine, thyroid function studies, calcium, pregnancy test for women of childbearing potential, and an ECG for patients over age 40. Complete blood counts (A), liver function tests (B) and pulmonary function tests (C) are not routinely monitored in the setting of lithium therapy. Complete blood counts are monitored in the setting of clozapine therapy as it can cause agranulocytosis, liver function tests are monitored in the setting of statin therapy as it can cause hepatic dysfunction and pulmonary function tests are monitored in the setting of amiodarone therapy as it can cause pulmonary fibrosis. Thyroid studies are also monitored in the setting of amiodarone therapy.

Which of the following is the most common cause of hyperviscosity syndrome? Chronic myeloid leukemia Multiple myeloma Sickle cell disease Waldenstrom's macroglobulinemia

Correct Answer ( D ) Explanation: Waldenstrom's macroglobulinemia is the most common cause of hyperviscosity syndrome. This syndrome is associated most commonly with the plasma cell dyscrasias during which there is abnormal synthesis of IgM paraproteins. Other conditions that lead to increased production of blood components may also lead to hyperviscosity including erythrocytosis and thrombocytosis. Additionally, during the blastic phase of leukemias, the overproduction of white blood cells leads to increased viscosity of the blood. In the early stages of the syndrome, patients experience vague constitutional symptoms including fatigue, anorexia and weight loss. As more paraproteins are produced, the classic symptoms include mucosal bleeding, visual disturbances and neurologic manifestations. The definitive treatment of hyperviscosity syndrome is leukapheresis or plasmapheresis. Prior to this treatment, hydration is critical in order to attempt to dilute the viscosity. Chronic myeloid leukemia (A) is the least common form of leukemia. In CML, the white blood cell count is often over 50,000 with polymorphonuclear neutrophils and metamyelocytes elevated on the differential. In some cases, CML converts to an acute leukemia with a blast crisis and may lead to a hyperviscosity syndrome. Multiple myeloma (B) is caused by proliferation of a single clone of plasma cells. The most common symptom is bone pain from proliferation of the plasma cells in the bone marrow. Skeletal X-rays demonstrate lytic lesions (on the skull often described as punched out lesions). With increased production of plasma cells circulating in the serum, hyperviscosity syndrome develops. Sickle cell disease (C) is caused by a substitution of valine for glutamate on the β-globin chain leading to sickled red blood cells. The abnormal shape of the red blood cells leads to vaso-occulsive emergencies where the circulation through smaller branches of the vasculature is impaired.

A 14-year-old has open and closed comedones without evidence of surrounding inflammation on his face and upper back. Which one of the following is the most appropriate initial treatment? Oral antibiotics Oral isotretinoin Topical antibiotics Topical retinoids

Treatment goals include scar prevention, reduction of psychological morbidity, and resolution of lesions. Topical retinoids are versatile agents in the treatment of acne. They are indicated as monotherapy for noninflammatory acne. They prevent the formation and reduce the number of comedones, making them useful against noninflammatory lesions. Topical retinoids also possess anti-inflammatory properties, making them somewhat useful in the treatment of inflammatory lesions as combination therapy with antibiotics. Additionally, they are useful for maintenance after treatment goals have been reached and systemic drugs are discontinued. The spectrum of acne lesions ranges from noninflammatory open or closed comedones such as blackheads and whiteheads to inflammatory lesions, which may be papules, pustules, or nodules. Lesions are most likely to occur on the face, neck, chest, and back, where there is a higher concentration of sebaceous glands. Comedones are noninflammatory acne lesions. Grading acne based on the type of lesion and severity helps guide therapy. Therapy targets the four factors responsible for lesion formation: increased sebum production, hyperkeratinization, colonization by Propionibacterium acnes, and the resultant inflammatory reaction.

Which one of the following activities is most likely to be impaired in early dementia? Cooking Dressing Grooming Toileting

orrect Answer ( A ) Explanation: Dementia interferes with daily functioning and behavior in many ways. The hallmark of dementia is loss of memory function, or amnesia. The person experiences forgetfulness, inability to remember old information or learn new content. Several other areas of mental function may be impaired in dementia. At early stages, concentration is usually impaired, and memory for recent events is limited. Memory of details of personal history may also be lessened. Affected persons can no longer perform complex tasks accurately and efficiently. Difficulty performing instrumental activities of daily living may become apparent. Examples of instrumental activities of daily living include management of household tasks such as grocery shopping, cooking, cleaning, doing laundry, paying bills or handling personal finances Individuals may show little emotion and withdraw from challenging situations. Some persons do not recognize their deficits. However, persons at the early stage remain well aware of time and place. They readily distinguish familiar persons and faces from strangers and can still travel to familiar locations without getting lost. As the early stage progresses, people begin to require some assistance. They may become unable to recall important information related to their current life situation, such as home address, telephone number, or names of grandchildren; though they still know the names of their spouses and children. They may have difficulty recalling important information from their past, such as the name of the high school or college they attended, military service, or occupation. Persons become disoriented to time, sometimes to place. A well-educated person may have difficulty counting backward from 40 by fours or from 20 by twos. Toward the end of this stage, they may have difficulty choosing proper clothing, but do not require assistance with personal care, such as toileting (D), (basic ADLs). Basic activities of daily living, such as dressing (B), eating, and grooming (C) are generally intact in early dementia.