PANCE exam e part 1

What defines metabolic syndrome?

Answer: Three or more of the following: fasting blood glucose ≥ 100 mg/dL; high-density lipoprotein level < 40 mg/dL in men and < 50 mg/dL in women; triglyceride level > 150 mg/dL; waist circumference ≥ 102 cm in men and ≥ 88 cm in women; and hypertension ≥ 130/85 mm Hg.

A 19-year-old man presents with headache and a peripheral cranial nerve VII palsy. He states that he was recently hiking in Connecticut and had numerous tick bites. What CSF finding is most sensitive for Lyme meningitis? ABorrelia burgdorferi antibody BDecreased glucose level CDecreased protein level DPositive PCR assay

Borrelia burgdorferi antibody What is a Jarisch-Herxheimer reaction? Answer: The onset of fever, myalgias, headache, tachycardia, and tachypnea after initiation of antibacterial treatment of a spirochete illness.

An 85-year-old man was found unconscious in his home by emergency medical services and was brought to the hospital. He lives by himself and appears emaciated on physical exam. Bleeding of his gums and multiple chronic-appearing wounds on the extremities are also noted on physical exam. Which vitamin deficiency does this patient most likely have? AVitamin A BVitamin B CVitamin C DVitamin D

Vitamin C 4 HS Hemorrhage Petechiae, bleeding gums Hyperkeratosis Rough skin, loose teeth, poor wound healing Hypochondriasis Irritability, emotional changes Hematologic abnormalities Easy bruising

Systemic Inflammatory Response Syndrome (SIRS) No longer part of the sepsis continuum per SCCM and IDSA, but still used as an initial screening tool for early sepsis Accepted by the Centers for Medicare and Medicaid Services and other organizations Weak ability to predict in-hospital mortality Criteria (1 point for each, score ≥ 2 meets SIRS definition) T > 38°C or < 36°C RR > 20/min or PaCO2 < 32 mm Hg HR > 90 bpm WBC > 12,000/μL or < 4,000/μL or > 10% bands

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Referral for surgical consultation and pain medication as needed Cholelithiasis Risk factors: female sex, age 40-50 years old, pregnancy, obesity, rapid weight loss Sx: slowly resolving right upper quadrant pain that begins suddenly after eating a fatty or large meal Diagnosis is made by ultrasound Gallstones most commonly made of cholesterol Treatment is observation or cholecystectomy -------------------------------------------------------------------------------- vs Admission (A) and (B) is also not necessary as long as the patient with cholelithiasis has adequate pain control. The decision for cholecystectomy (B) can be made with outpatient surgical consultation in patients with cholelithiasis.

43-year-old woman presents with right upper quadrant abdominal pain for 3 weeks. She states that she intermittently gets sharp pain that occurs after eating and is associated with nausea and occasionally vomiting. The pain lasts for 10-15 minutes, and then spontaneously improves. Currently, she has no pain. Her vital signs and bloodwork are normal. A right upper quadrant ultrasound is shown above. What management is indicated? AAdminister antibiotics and admit for observation BAdmit patient for cholecystectomy CObtain CT scan of the abdomen and pelvis DReferral for surgical consultation and pain medication as needed

Renal cell carcinoma Renal Cell Carcinoma History of smoking Classic triad: Flank pain, palpable abdominal renal mass, hematuria Treatment is nephrectomy ------------------------------------------------------------------------------ vs Bladder cancer (B) also often presents with painless hematuria, which can be intermittent. The distinguishing feature in this vignette is the renal mass on the CT scan. Prostate cancer (D) is asymptomatic at the time of diagnosis in most cases. Less often, nonspecific urinary symptoms, hematuria, or hematospermia may be present, but these symptoms are more often due to other conditions. Prostate cancer is usually detected after an abnormal physical exam or when a prostate-specific antigen study is elevated. The mass on the CT scan makes renal cell carcinoma the most likely diagnosis. Furthermore, on the digital rectal exam, there were no asymmetric nodules.

70-year-old man with a history of cigarette smoking and BMI of 31.2 kg/m² presents to the clinic with gross hematuria for the past week. He reports unintentional weight loss of 15 pounds during the past 6 weeks. He has had no difficulty urinating, painful urination, or changes in urinary frequency. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a regular rate and rhythm with lungs clear to auscultation. His abdomen is soft and nontender without palpable masses. His prostate is enlarged but symmetric, and firm on a digital rectal exam. His urinalysis is negative for leukocyte esterase, nitrites, pyuria, and bacteriuria but shows 100 RBC/hpf. His CT is shown above. Which of the following is the most likely diagnosis? AAcute bacterial prostatitis BBladder cancer CPolycystic kidney disease DProstate cancer ERenal cell carcinoma

A 32-year-old man is admitted to the hospital for an asthma exacerbation. He is receiving 30 mg prednisone by mouth twice daily while admitted. The pharmacist calls you and states that due to drug shortages, prednisone is not available and the patient needs to be converted to dexamethasone. What is an appropriate equivalent dose of dexamethasone for this patient? A0.1 mg by mouth once daily B30 mg by mouth twice daily C60 mg by mouth four times daily D9 mg by mouth once daily

9 mg by mouth once daily 5 mg of prednisone is equivalent to 0.75 mg of dexamethasone. do the math 😭😭😭😭

Umbilical cord compression #VEAL CHOP What baseline fetal heart rate is considered normal? Answer: 110-160 bpm.

A 26-year-old G3P2 woman presents to the labor and delivery at 38 weeks and 6 days gestational age with contractions occurring every 5 minutes for the past 3 hours. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals her cervix to be dilated to 5 cm, cervical effacement of 90%, and fetal head station at 0. The patient is admitted, and her membranes rupture spontaneously with leakage of clear fluid seen from the vagina. The patient's fetal heart tracing is shown above. Which of the following is the most likely etiology of this fetal heart tracing? AFetal head compression BFetal movement CPlacental insufficiency DUmbilical cord compression EUterine contraction

Pneumocystis jiroveci history of weight loss and oral candidiasis points more likely to PCP. Pneumocystis Pneumonia (PCP) Caused by the fungus Pneumocystis jirovecii Risk factors: HIV, immunocompromised host, or immunosuppression Sx: gradual onset of dyspnea, nonproductive cough, fever Labs: ABG, CD4 < 200/mm3, increased LDH CXR: diffuse bilateral ground-glass opacities (batwing pattern), if CXR is nondiagnostic obtain CT Dx: confirm with staining or PCR of respiratory specimens (induced sputum or BAL) Tx: TMP-SMX, add corticosteroids for moderate to severe disease (air PO2 < 70 mm Hg or A-a gradient ≥ 35 mm Hg) Comments: can present with pneumothorax

A 33-year-old man presents with 5 days of gradual onset nonproductive cough, fatigue, and fever. He also notes a 15-pound weight loss over the last month. He is tachypneic with a heart rate of 105 beats/minute, a temperature of 38.2°C, and an oxygen saturation of 89% on room air. On examination, white plaques are noted on his tongue, and his lungs are clear on auscultation. His chest X-ray is shown above. Which of the following is the most likely causative agent? AInfluenza A BKlebsiella pneumoniae CPneumocystis jiroveci DStreptococcus pneumoniae

His-Purkinje system Second-Degree Heart Block (Mobitz II) PR interval will be fixed and consistent Notable feature: dropped QRS beats Immediate transcutaneous pacer pad placement with consideration for transvenous pacemaker Can progress to complete heart block

A 57-year-old man presents to the cardiology clinic for a 1-year follow-up appointment after his acute myocardial infarction. He reports no new symptoms and has taken his medications as prescribed, including carvedilol, aspirin, clopidogrel, and enalapril. Vital signs are HR 82 bpm, RR 16 breaths per minute, BP 133/84 mm Hg, T 98.2°F, and SpO299% on room air. Physical exam demonstrates an irregular radial pulse but is otherwise unremarkable. An ECG is obtained and is shown above. Which of the following is the most likely location of pathophysiologic conduction in this patient? AAtrioventricular node BHis-Purkinje system CLeft bundle branch DRight bundle branch ESinoatrial node

once u dx please determine if the patient is stable and has pulse Synchronized cardioversion dx:AFIB unstable Unstable: cardioversion Stable: rate control is mainstay (diltiazem, metoprolol) > 48 hours: anticoagulate for 21 days prior to cardioversion Determine the need for anticoagulation by using CHA2DS2-VASc score Most common sustained dysrhythmia in adults

A 72-year-old woman presents to the ED with an acute onset of dyspnea and palpitations that began 4 hours before arrival. Vital signs include an HR of 144 bpm, BP of 80/50 mm Hg, RR of 28/min, T of 98.6°F (37.0°C), and SpO2 of 92% on room air. The above 12-lead ECG is obtained. What is the most appropriate next step in management? AAnticoagulation with enoxaparin followed by warfarin BChemical cardioversion using procainamide CRate control using diltiazem DRate control using esmolol ESynchronized cardioversion

Multifocal Atrial Tachycardia Associated with older patients and those with COPD Rate will be 100-200 beats/min PR interval will differ Notable feature: at least three different P wave forms Treatment is to treat the underlying cause, calcium channel blockers

A 73-year-old man with a history of hypertension and COPD presents with the ECG seen above. Which of the following is the correct diagnosis? AAtrial fibrillation BAtrial flutter CMultifocal atrial tachycardia DWandering pacemaker

A 54-year-old man presents to the hospital in acute respiratory distress. He was released from the hospital 3 days ago after undergoing a cardiac stent placement secondary to an acute myocardial infarction. His hospital course was uncomplicated. On exam, his BP is 110/60 mm Hg, HR is 115 bpm, RR is 28/min, and oxygen saturation is 91% on room air. Cardiopulmonary exam reveals a midsystolic murmur with bibasilar crackles. An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis? AAcute aortic insufficiency BAcute mitral regurgitation CPostmyocardial infarction syndrome DVentricular aneurysm rupture

Acute mitral regurgitation is the result of rupture of the chordae tendineae, papillary muscle, or valve leaflet. Acute: unique, harsh, midsystolic murmur best heard at apex that radiates to the base rather than the axilla Chronic: blowing holosystolic murmur best heard at apex with radiation to axilla History Acute: ischemic heart disease, endocarditis, MI, traumaChronic: rheumatic heart disease Diagnosis is made by echo Treatment Acute: nitroprusside, dobutamine, intra-aortic balloon pump, emergency surgery Chronic: CHF Rx, valve repair or replacement

A 55-year-old man presents to the clinic for an annual follow-up of his well-controlled medical conditions. He is currently taking metformin, sitagliptin, lisinopril, aspirin, and atorvastatin. Vitals today include a HR of 87 bpm, RR of 17/min, BP of 139/81 mm Hg, T of 98.8°F, and SpO2 of 99% on room air. Which one of the following components of urine analysis is the best indicator of early-stage kidney disease in this patient? AAlbuminuria BCreatinine CKetones DRed blood cell concentration EWaxy casts

Albuminuria dx:Diabetic nephropathy

An 80-year-old man presents to your clinic with complaints of malaise, myalgias, fever, cough, and abdominal pain for the past three weeks. One month ago, he vacationed in Ohio on a bird watching trip. He is febrile with mild tachycardia and pulse oximetry of 90%. A chest X-ray shows mediastinal lymphadenopathy and a focal infiltrate. Which of the following is the most appropriate therapy? AAmphotericin B BAzithromycin CFluconazole DZidovudine

Amphotericin B Histoplasmosis History of travel to Ohio or Mississippi River valley and exposure to bird or bat droppings X-ray: pulmonary infiltrates (lobar or diffuse reticulonodular), hilar and mediastinal adenopathy Diagnosis: histopathology, antigen detection Tx (if indicated): itraconazole or amphotericin B

A 1-week-old boy born at term to a 16-year-old primigravida mother without complications presents to the ED for lethargy. In the ED, his vital signs include a T 37°C, HR 166 bpm, RR 82/min, and oxygen saturation of 80%. On exam, he is lethargic with diffuse pulmonary rales and rhonchi, cold extremities, and decreased peripheral pulses. Given concern for a ductal-dependent cardiac lesion, you administer an infusion of prostaglandin E1. Which of the following is a known adverse reaction of prostaglandin E1 infusion? AApnea BHypertension CHypothermia DThrombocytosis

Apnea ductal-dependent cardiac lesion that requires a patent ductus arteriosus (PDA) to preserve blood flow from the aorta to the pulmonary artery. This opening allows blood to flow from the right ventricle to the aorta( bypassing the non functioning lungs) in the baby this reverses once baby is born. It closes in response to higher oxygen concentration (chemoreceptors in the cardiac muscle)and the release of bradykinin.

A 55-year-old man involved in a motor vehicle collision reports shortness of breath during morning rounds. He incurred a left open tibial fracture as a result of the collision and underwent intramedullary rod placement 48 hours ago. Physical examination reveals a diaphoretic patient in mild distress, rales in the right lower lobe, tachycardia without murmurs, and a swollen left lower extremity. His vital signs are remarkable for a pulse of 110 beats per minute and respiratory rate of 26 breaths per minute. His medical history is remarkable for a recent diagnosis of lung cancer. Which of the following is most likely to confirm the diagnosis? AChest X-ray BCT pulmonary angiography CD-dimer DLupus anticoagulant

CT pulmonary angiography dx: Pulmonary Embolism Sx: dyspnea, pleuritic chest pain, cough, syncope PE: tachypnea, tachycardia, possible signs of DVT (calf pain or swelling) ECG: sinus tachycardia, nonspecific ST segment and T wave changes, RV strain, S1Q3T3 (classic finding) CXR: nonspecific abnormalities, Hampton hump (pleural-based wedge infarct), Westermark sign (vascular cutoff sign) US: right ventricle hypokinesis, flattened interventricular septum, diastolic septal bowing Dx: CT pulmonary angiography most preferred, VQ scan alternative Tx: Use Hestia criteria or PESI to determine risk of complications and help with disposition planning (outpatient vs inpatient) Anticoagulation: heparin, LMWH, warfarin, novel oral anticoagulants (NOAC) Thrombolytics, embolectomy in hemodynamically unstable patients Comment: in low clinical suspicion: negative D-dimer excludes PE ------------------------------------------------------------------ vs Chest X-ray (A) may be an appropriate test for a patient with a low pretest probability, but the findings are not sensitive or specific enough to be considered diagnostic. Chest X-ray may aid in identifying an alternative diagnosis. D-dimer (C)is a byproduct of fibrin degradation and in low or moderate pretest probability is an appropriate test. However, in this scenario, the patient has a high pretest probability score. Thrombosis is ruled out if the D-dimer is not elevated. It is important to remember that several factors alter the D-dimer reliability, specifically trauma, surgery, hemolysis, and factor VIII deficiency. Lupus anticoagulant (D) is an antibody that tends to attach to endothelial cells and cause thrombosis. Presence of lupus anticoagulant may predispose to the development of thromboembolism, however establishing the diagnosis of pulmonary embolism takes priority to establishing etiology.

26-year-old woman presents with a 5-month history of amenorrhea and bilateral galactorrhea. She denies the possibility of pregnancy. On physical exam, milk can be expressed from both breasts. Visual fields testing by confrontation reveals bitemporal field defects. Pelvic exam is normal and a pregnancy test is negative. After confirming the suspected diagnosis, which of the following is the most appropriate management? ABupropion BCabergoline COctreotide DTamoxifen

Cabergoline dx: prolactinoma Hyperprolactinemia Sx: infertility, galactorrhea, amenorrhea, headache, bitemporal hemianopsia Labs: elevated prolactin levels (> 200 ng/mL typically due to prolactinoma) MRI: may show a sellar mass Most commonly caused by pituitary adenoma Other causes: nipple stimulation, drugs (antipsychotic, antidepressant, antiemetic), hypothyroid, CKD, cirrhosis Treatment First line: dopamine agonists (e.g., cabergoline, bromocriptine) Surgery: indicated in adenomas refractory to medical management or with compressive effects (e.g., visual loss) Prolactinoma is the most common functioning pituitary tumor

Which of the following agents is first line for rate control in atrial fibrillation with rapid ventricular response in the setting of compensated systolic heart failure? AAmiodarone BCarvedilol CDigoxin DDiltiazem

Carvedilol first line agent in rate control of atrial fibrillation with rapid ventricular response in the setting of compensated systolic heart failure Atrial Fibrillation Rate will be irregular Rhythm will be irregular Notable feature: No defined P waves Labs: CBC, BMP, TSH & free T4 (especially for first Afib) Treatment:Unstable: cardioversion Stable: rate control is mainstay (diltiazem, metoprolol) > 48 hours: anticoagulate for 21 days prior to cardioversion Determine the need for anticoagulation by using CHA2DS2-VASc score Most common sustained dysrhythmia in adults

A 24-year-old woman presents to your office with a complaint of severe anxiety. Approximately three times per week she has episodes of sweating, chest pain, heart palpitations, shaking and fear of losing control or dying. The episodes seem to occur and resolve spontaneously. Which of the following is the most appropriate therapy? ACarbamazepine BCitalopram CImipramine DRisperidone

Citalopram dx: Panic disorder Initial treatment for panic disorder is with an antidepressant, cognitive behavioral therapy, or a combination of the two. When a decision is made to treat with medication, first-line treatment is with a selective serotonin reuptake inhibitor (SSRI), such as citalopram.

A patient is being discharged from the hospital after having an ST-elevation myocardial infarction. During his stay, he underwent percutaneous coronary intervention with placement of a drug eluting stent. The patient is being sent home on the following medications: aspirin 81 mg, metoprolol 50 mg, nitroglycerin 0.4 mg sublingual, and atorvastatin 40 mg. Which of the following should also be added to his regimen? AClopidogrel BFish oil CRanolazine DReteplase

Clopidogrel Dual antiplatelet therapy with aspirin and a platelet P2Y12 receptor blocker (such as clopidogrel) decreases the risk of coronary artery stent thrombosis and its consequences of myocardial infarction or death more than the use of aspirin alone.

Which of the following lab findings would you expect to find in a patient with beta-thalassemia? ACodocytes BDowney cells CEchinocytes DSmudge cells

Codocytes target cells, are cells that are named for their appearance. These appear like a bull's-eye with a dark center surrounded by a white ring Mediterranean or African origin

A 38-year-old man presents with the worst headache of his life. A magnetic resonance angiogram is obtained which demonstrates a large unruptured cerebral aneurysm of the posterior communicating artery. Which of the following are you most likely to find on physical examination? ACranial nerve III palsy BCranial nerve V palsy CCranial nerve VI palsy DCranial nerve VII palsy

Cranial nerve III palsy dx: subarachnoid hemorrhage due to a cerebral aneurysm Cranial nerve III is the oculomotor nerve which can become compressed when a cerebral aneurysm is present at the junction of the internal carotid artery and posterior communicating artery, causing a unilateral strict downward gaze, ptosis, anisocoria, and blurred vision. ----------------------------------------------------------------- vs Cranial nerve V palsy (B) is a palsy of the trigeminal nerve which controls sensation of the face and muscles of mastication and are rarely affected by a cerebral aneurysm. Typical findings of a cranial nerve V palsy include decreased sensation to the face and jaw deviation upon closure. Cranial nerve VI palsy (C) is a palsy of the abducens nerve which helps to control lateral movement of the eye. When this nerve is affected, the lateral rectus muscle becomes weak and the eye deviates inward towards the nose. The most common causes of a cranial nerve VI palsy include increased intracranial pressure, brain tumor, and stroke. Cranial nerve VII palsy (D) is a palsy of the facial nerve which innervates all facial musculature. When this nerve is affected there is drooping of the facial muscles and decreased taste on the anterior two-thirds of the tongue. An idiopathic cranial nerve VII palsy is most commonly known as Bell's palsy which is caused by a virus.

Which of the following disorders causes a normal anion gap metabolic acidosis? ACyanide exposure BDiabetic ketoacidosis CDiarrhea DSalicylate ingestion

Diarrhea Acute Respiratory and Metabolic Acidosis and Alkalosis (Normal ABG values pH 7.35-7.45; PaCO2 35-45 mm Hg; bicarbonate 22-26 mEq/L) --------------------------------------------------------------- vs Cyanide (A), diabetic ketoacidosis (B), and salicylate ingestion (D) are all causes of increased anion gap metabolic acidosis.

Which of the following is associated with an organic cause of psychosis? AAuditory hallucinations BDisorientation CNormal vital signs DSlow onset of symptoms

Disorientation Organic Psychosis Older patient Sudden onset Waxing and waning cognition Disoriented Aphasia Visual hallucinations Abnormal vital signs, physical exam ------------------------------------------------------------ vs Patients with functional or psychiatric etiologies of psychosis are more likely to have auditory hallucinations (A) instead of visual ones, slow onset of symptoms (D), and normal vital signs (C).

Which of the following is a late complication of acute myocardial infarction? ACardiogenic shock BComplete heart block CDressler syndrome DPulmonary edema

Dressler syndrome Dressler Syndrome History of MI Pleuritic chest pain radiating to the back, worse when lying back, improved when leaning forward PE will show tachycardia and pericardial friction rub ECG will show PR depression, PR elevation (aVR), diffuse ST segment elevation (concave) Treatment is NSAIDs, colchicine, steroids ---------------------------------------------------------------- vs Complete heart block (B) may occur within hours of an acute myocardial infarction (AMI). This is most commonly associated with an inferior wall MI because the right coronary artery which is most commonly affected supplies the inferior wall of the heart as well as the sino-atrial node. It is usually transient and may require a temporary transvenous pacemaker. Cardiogenic shock (A) occurs within hours of an AMI. This is characterized by hypotension and signs of heart failure. These patients may require inotropic support and or an intra-aortic balloon pump. Pulmonary congestion and pulmonary edema (D) can occur within hours if there is sufficient insult to the myocardium. In severe cases patients may require noninvasive positive pressure ventilation or invasive ventilation support.

A 65-year-old woman with a medical history of rheumatoid arthritis on disease-modifying antirheumatic drugs presents to the clinic for a routine annual examination. The patient reports a 25 pack-year smoking history but stopped smoking cigarettes when she was 45 years of age. Vital signs today include a heart rate of 80 bpm, blood pressure of 125/80 mm Hg, respiratory rate of 20 breaths per minute, pulse oxygenation of 99% on room air, and temperature of 98.6°F. Physical examination reveals a normal rate and rhythm and lungs that are clear to auscultation. Which of the following screening tests is indicated in this patient? AAbdominal ultrasonography BCancer antigen 125 CChest radiograph DDual-energy X-ray absorptiometry ELow-dose CT chest

Dual-energy X-ray absorptiometry Osteoporosis is characterized by low bone density, which results in decreased bone strength and an increased risk of low-trauma or atraumatic fractures. Women who are postmenopausal are at an increased risk of osteoporosis due to decreased estrogen production after menopause. ---------------------------------------------------------------

A 63-year-old man with a 40-year history of alcohol and tobacco abuse presents with solid food dysphagia. The patient has also had a 21 lb weight loss over the past 7 months. Which of the following studies should be performed for a definitive diagnosis? ABarium esophagram BChest X-ray CCT Scan DEndoscopy

Endoscopy Esophageal Neoplasm Risk factors: male sex, chronic GERD, tobacco and alcohol use, HPV infection Sx: progressive dysphagia to solid foods, weight loss Diagnosis is made by endoscopy with biopsy Most common type is adenocarcinoma, second is squamous cell carcinoma Adenocarcinoma usually a complication of GERD or Barrett esophagus Chronic alcohol and tobacco use are strongly associated with an increased risk of squamous cell carcinoma. The majority of adenocarcinomas develop as a complication of Barrett's metaplasia due to chronic gastrostroesophageal reflux (GERD) -------------------------------------------------------------- vs\ Barium esophagram (A)is obtained as the first study to evaluate the dysphagia. The appearance of a polypoid, obstructive, or ulcerative lesion is suggestive of carcinoma and requires endoscopic evaluation.

A 31-year-old man presents with 10/10 flank pain that radiates to his testicle. He has no significant past medical history. Temperature and vital signs are normal. Examination reveals no edema or skin lesions. Urinalysis is positive for a microhematuria. Further evaluation would most likely reveal which of the following abnormalities? ACalcium deposition in the renal parenchyma BEnlarged renal pelvis and proximal ureter CGlomerular capillary angiopathy DParenchymal hemorrhage, neutrophil casts and suppurative necrosis

Enlarged renal pelvis and proximal ureter

A previously healthy 52-year-old woman presents to your office with a complaint of diffuse pruritus. She is concerned about insects under her skin. She brought a sample of her skin mixed with debris that she believes are the insects. She is requesting that you send it to the lab. Physical exam reveals scattered ulcers and erosions in varying stages of healing with excoriations all over her body. Which of the following is the most effective management?😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️ AEstablish a strong therapeutic alliance BPermethrin cream as needed CReferral to psychiatry DReferral to substance abuse treatment

Establish a strong therapeutic alliance dx:Delusions of parasitosis (DoP) Erotomanic: belief that another person is in love with the individual Grandiose: conviction of having some great talent or insight Jealous: delusion that partner is unfaithful Persecutory: belief that being conspired against, spied on, poisoned, etc. Somatic: delusion about bodily functions or sensations With bizarre content: delusions are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., belief that a stranger removed one's internal organs and replaced with another's organs without leaving a scar) --------------------------------------------------------------- vs n treating DoP, it is important that the medical provider does not offer treatment that will strengthen the patient's delusion, such as prescribing permethrin as needed (B). A referral to psychiatry (C) is an appropriate part of the management of DoP, but should only be done once a therapeutic alliance has been established since initially patients will not accept that their symptoms are due to a psychiatric etiology. Substance abuse should be ruled out as a possible cause of symptoms, but this may be done as part of the history in the outpatient setting and a referral to substance abuse treatment (D) is only necessary if the patient has a substance abuse disorder per DSM-5.

With which of the following air-filled structures does the middle ear communicate anteriorly? AEthmoid air cells BEustachian tube CMastoid air cells DSigmoid sinus

Eustachian tube What are the three auditory ossicles? Answer: Malleus, incus, and stapes.

A 21-year-old man presents to the emergency department after a boxing match in which his opponent repeatedly punched him in the head and face. He is experiencing pain on the left side of his face and over his left ear. He also states he is having trouble hearing out of his left ear. His vital signs are a BP of 118/80 mm Hg, HR of 115 bpm, RR of 28/min, oxygen saturation of 99%, and T of 98.6°F. The physical exam reveals edema and bruising around bilateral eyes, the nose, and on the left side of the face. The patient is tender to palpation over the left temporal bone. An otoscopic examination reveals a hemotympanum in the left ear. A temporal bone CT is performed and reveals a fracture of the left temporal bone. Which cranial nerve is most at risk for injury in this patient?😩😩😩😩😩😩 AFacial nerve BOculomotor nerve COlfactory nerve DTrigeminal nerve ETrochlear nerve

Facial nerve

What is the main feature that distinguishes pyelonephritis from cystitis? ADysuria BFever CLow back pain DNausea

Fever Acute Pyelonephritis Sx: fever, dysuria, and flank pain PE: CVA tenderness Labs: UA + leukocyte esterase, nitrites, microscopy +WBCs, Gram stain, urine culture and susceptibility testing Most commonly caused by Escherichia coli Treatment depends on infection severity and community/host risk factors for resistant pathogens Fluoroquinolones TMP-SMX 3rd/4th gen cephalosporins For critical illness or risk for multidrug-resistant organisms: consider coverage for MRSA, VRE Cystitis Sx: increased urinary frequency, dysuria, and suprapubic pain Labs: positive leukocyte esterase and nitrites Definitive diagnosis is made by urine culture Most commonly caused by Escherichia coli Treatment varies on age and risk of MDR infection Pregnancy: asymptomatic bacteriuria should be treated Complications: ↑ risk of preterm birth, low birth weight, perinatal mortality

A 23-year-old man presents in status epilepticus by EMS. They have given multiple doses of benzodiazepines without response. Which of the following tests is most important at this time? AFingerstick glucose BLumbar puncture CNoncontrast head CT DSerum sodium level

Fingerstick glucose should be part of the immediate workup of any patient who presents with altered mental status. Status Epilepticus PE will show ≥ 5 minutes of continuous seizure activity or more than one seizure without recovery from the postictal state between episodes Most commonly caused by a change in the medication regimen of someone with a seizure disorder Treatment First-line: benzodiazepines (e.g., lorazepam) Second-line: phenytoin or fosphenytoin, valproic acid, levetiracetam Third-line: pentobarbital, propofol, phenobarbital

A 30-year-old woman presents to her primary care physician with concerns that she has been exposed to syphilis by her partner. She was treated for syphilis in the past. Which of the following diagnostic tools would show a false-positive result due to her prior infection and cannot be used alone to provide a diagnosis of syphilis? ADirect fluorescent antibody (DFA) BFluorescent treponemal antibody absorption (FTA-ABS) CPolymerase chain reaction (PCR) DRapid plasma reagin (RPR)

Fluorescent treponemal antibody absorption (FTA-ABS) will remain positive after a person's first infection with syphilis leading to a false-positive results and inaccuracy in diagnosing syphilis. • Used to confirm the diagnosis in patients with positive VDRL/RPR • ElA may be used for screening • Higher sensitivity/specificity than nontreponemal tests • False positive (FTA-ABS) in patients with lupus or Lyme disease . Initial screening is performed with a nontreponemal test (eg, RPR). This is a quantitative test (reported as a titer of antibody) and reflects the activity of the infection. A reactive nontreponemal test is then confirmed with a treponemal test, such as the fluorescent treponemal antibody absorption (FTA-ABS). ------------------------------------------------------------------ VDRL RPR • False positives due to pregnancy, autoimmune disorders, other infections • Decreased sensitivity in early primary syphilis and late syphilis • Usually become negative after successful treatment

A 58-year-old man presents with shortness of breath for 2 days. He reports a 6-month history of a dry cough, unintentional weight loss, and night sweats. He has no significant medical history, but he has a 40 pack-year smoking history. In the ED, his vital signs are BP 132/76 mm Hg, HR 72 bpm, RR 16/min, SpO2 96% on room air, and temperature 98.8°F (37.1°C). An ECG reveals no acute abnormality, and a chest X-ray shows a right middle lobe irregular mass and a right-sided pleural effusion. A thoracentesis is performed. What findings would be expected on pleural fluid analysis? AGlucose < 60 mg/dLCorrect Answer BLactate dehydrogenase < 66 U/LYour Answer CPleural fluid:blood lactic dehydrogenase ratio < 0.6 DPleural fluid:blood protein ratio < 0.5

Glucose < 60 mg/dL a transudative effusion by lactate dehydrogenase (LDH) of less than two-thirds of the upper limit of the normal serum LDH level, a fluid:blood LDH ratio < 0.6, and a pleural fluid:blood protein ratio < 0.5. In an exudative effusion, the glucose level is < 60 mg/dL. Pleural Effusion PE will show ↓ breath sounds + dull percussion + ↓ tactile fremitus CXR will show blunting of the costophrenic angle Can also use CT or US to diagnose Most common causes Transudate: heart failure Exudate: infection > malignancy, PE Management includes treating underlying cause, therapeutic thoracentesis, tube thoracostomy Light criteria are used to differentiate between transudative and exudative effusions

A 36-year-old woman presents to the ED concerned about decreased hearing and increased fullness to the right ear. Over the last week, she has used cotton-tipped applicators to attempt to remove cerumen from her right ear. On exam, you notice a cerumen-impacted external canal on the right. You irrigate the right ear with warm saline using an 18-gauge IV catheter and a plastic curette to remove the cerumen. During the procedure, the patient has sudden decreased hearing in the right ear. Which of the following is the most appropriate next step in management? AAdmit the patient to the hospital and arrange for an otolaryngology consultation BDischarge home with a course of otic antibiotics drops CHave the patient keep the ear dry and arrange otolaryngology follow-up DPlace a cotton ball in the ear and discharge home

Have the patient keep the ear dry and arrange otolaryngology follow-up tympanic membrane perforation

49-year-old woman presents with headaches that occur nearly every afternoon since she switched jobs 6 months ago. She describes squeezing pain at her forehead, accompanied by fatigue and poor concentration. Her exam is normal except for posterior neck tenderness, which she attributes to stress at work. Which of the following interventions would be most helpful to this patient? AHeadache abortive therapy with sumatriptan BHeadache prevention with amitriptyline CHeadache prevention with daily verapamil DHigh dose prednisone taper

Headache prevention with amitriptyline Tension Headache Patient presents with bilateral, nonpulsating, band-like pain PE will show neck muscle tenderness Most commonly caused by stress Treatment is NSAIDs (abortive), tricyclic antidepressants (preventive) Most common type of headache

Which of the following meets the criteria for a diagnosis of systemic inflammatory response syndrome? AHeart rate > 80 bpm and respiratory rate > 16/min BHeart rate > 90 bpm CHeart rate > 90 bpm and temperature > 100.4°F (38°C) DTemperature > 100.4°F (38°C) and WBC > 10,000/µL

Heart rate > 90 bpm and temperature > 100.4°F (38°C) Systemic Inflammatory Response Syndrome (SIRS) No longer part of the sepsis continuum per SCCM and IDSA, but still used as an initial screening tool for early sepsis Accepted by the Centers for Medicare and Medicaid Services and other organizations Weak ability to predict in-hospital mortality Criteria (1 point for each, score ≥ 2 meets SIRS definition) T > 38°C or < 36°C RR > 20/min or PaCO2 < 32 mm Hg HR > 90 bpm WBC > 12,000/μL or < 4,000/μL or > 10% bands

A 16-year old boy presents with a superficial bite to his right arm. He states he was camping in the woods and a bat flew into his tent. Which of the following treatments should this patient receive? AHuman rabies immunoglobulin and 3 doses of inactivated rabies vaccine over 7 days BHuman rabies immunoglobulin and 4 doses of inactivated rabies vaccine over 14 days CHuman rabies immunoglobulin only DInactivated rabies vaccine only

Human rabies immunoglobulin and 4 doses of inactivated rabies vaccine over 14 days Rabies History of exposure to raccoons, bats, or skunks Hydrophobia, agitation, spasms Treatment is wound care (scrubbing), rabies immune globulin at wound site (if indicated), vaccination --------------------------------------------------------------- vs The inactivated rabies vaccine (D) is used as pre-exposure prophylaxis. Human rabies immunoglobulin (C) is never given alone. Human rabies immunoglobulin and 3 doses of inactivated rabies vaccine over 7 days (A) is incorrect since 4 doses of inactivated rabies vaccine over a 14-day duration is required for post-exposure prophylaxis.

A 47-year-old man presents with hiccups for three days. He is unable to stop them with any home remedies. His physical examination is benign. Which of the following is a potential cause of hiccups?😨😨😨 AHypercalcemia BHyperkalemia CHypoglycemia DHyponatremia

Hyponatremia & hypocalcemia are two possible causes of hiccups.

A 65-year-old man presents with acute onset of low back pain. His temperature is 98.3°F, blood pressure is 150/90 mm Hg and his heart rate is 110 bpm. Physical examination is notable for equal peripheral pulses in all extremities and a normal neurologic examination. A CT scan is performed which reveals a true and false lumen of the aorta and an intimal flap at the level just below the aortic arch. In addition to pain control, which of the following is the best management strategy? AGradual return to activity and primary care follow up BInitiate esmolol drip and obtain vascular surgery consultation CRecommend outpatient, interval imaging DStart packed red blood cell transfusion and obtain vascular surgery consultation

Initiate esmolol drip and obtain vascular surgery consultation Aortic Dissection Risk factors: advancing age, male sex, HTN, Marfan syndrome Sx: acute onset of "ripping" or "tearing" chest pain or back pain PE: asymmetric pulses or SBP difference of > 20 mmHg CXR: widened mediastinum Dx: CT angiography or transesophageal echocardiogram (TEE) Treatment: reduce BP and HR (beta-blockers), pain control, emergency surgery (Type A dissection) Type A: involves ascending aorta Type B: involves only descending aorta

A 15-year-old boy presents to the emergency department with lower back pain. He reports heavy lifting 3 weeks ago, with gradual onset of pain and no relief with symptomatic care, including over-the-counter medication. The pain is localized to the paraspinal muscles over his lumbar back. He reports normal urine output. Baseline laboratory tests are notable for a serum sodium of 140 mEq/L, potassium of 5.2 mEq/L, chloride of 110 mEq/L, bicarbonate of 25 mEq/L, BUN of 20 mg/dL, and creatinine of 2.3 mg/dL. A urinalysis shows hyaline casts, 5 white blood cells/hpf, and 1+ protein. Which of the following is the most likely pathophysiology of his laboratory findings? AAcute interstitial nephritis BAcute tubular necrosis CHypovolemia DObstructive nephropathy Which one of the following is the most likely cause of acute kidney injury in a patient with eosinophiluria? AAcute interstitial nephritis BEthylene glycol poisoning CPoststreptococcal glomerulonephritis DRhabdomyolysis

Interstitial Nephritis Sx: fever, rash Labs: ↑Cr, eosinophiluria, WBCs, white blood cell casts Caused by medications (NSAIDS, antibiotics, PPIs, others), infections, autoimmune disorders Tx: discontinue offending medication, if kidney function does not improve consider biopsy and glucocorticoids Urinalysis may show white blood cells and hyaline or granular casts, as well as mild proteinuria. Removal of the offending agent often leads to recovery. This patient has intrinsic renal disease, as his BUN to creatinine ratio is less than 15 and his urine output is normal. The most likely etiology of his intrinsic renal disease is acute interstitial nephritis (AIN) secondary to overuse of nonsteroidal anti-inflammatory drugs for back pain. Many drugs and toxins can cause AIN. It typically presents 1 to 2 weeks following onset of the inciting agent, and may be associated with fever, rash, arthralgias, and eosinophilia. Urine output is typically preserved

A 77-year-old man presents with syncope. He states he was walking to the bus when he felt chest pain, had shortness of breath, and passed out. The patient has a history of hypertension. Examination reveals dry mucous membranes and a systolic murmur that radiates to the carotids bilaterally. The patient continues to complain of chest pain. Vitals are unremarkable, and the ECG reveals left ventricular hypertrophy. What management is indicated? AIntravenous fluids and cardiology consultation BMorphine sulfate and admit to telemetry CSublingual nitroglycerin and activation of the cardiac catheterization lab DSublingual nitroglycerin and admit for telemetry

Intravenous fluids and cardiology consultation dx:aortic stenosis. Management should focus on restoring preload and cardiology consultation. Aortic stenosis is the most common cardiac valve lesion in the US. ----------------------------------------------------------- vs Patients with symptomatic aortic stenosis exhibit an extreme sensitivity to vasodilators. Morphine (B) causes vasodilation through histamine and is contraindicated. Sublingual nitroglycerin (C and D) treats typical anginal symptoms by vasodilation, leading to decreased preload and decreased cardiac workload. In aortic stenosis patients, this vasodilation can precipitate worsening symptoms.

An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. The facility nurse notes that he seems to have the most abdominal pain and blood in his stools after eating. On examination, he is afebrile and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient's bleeding? AAngiodysplasia BDiverticular bleeding CIschemic colitis DPeptic ulcer disease

Ischemic colitis Ischemic Colitis History of atherosclerotic disease, aortoiliac surgery, cardiopulmonary bypass Acute onset of crampy abdominal pain CT imaging will show bowel wall edema Most commonly caused by inadequate blood flow through the mesenteric vessels Treatment: most cases resolve with supportive care

A patient who is undergoing a transesophageal echocardiogram suddenly develops profound hypoxemia and cyanosis. His respiratory rate is 18 breaths/minute, but his saturation remains at 80% despite adequate application of supplemental oxygen by non-rebreather mask. A quick review of the medication record reveals that he received benzocaine, fentanyl, midazolam, and propofol during the procedure. What substance should you administer to treat his underlying condition? AFlumazenil BMethylene blue CNaloxone DPhenylephrine

Methylene blue This patient has methemoglobinemia. Methemoglobin is a substance that is present in the conversion pathway of iron to deoxyhemoglobin. It is always present in red blood cells, but it is constantly enzymatically metabolized under normal circumstances. Certain medications, including benzocaine, can disrupt this pathway, leading to an accumulation of methemoglobin and reducing the oxygen-carrying capacity of the blood. It may also alter the appearance of the arterial blood and make it appear chocolate colored. Methemoglobinemia Fe3+ → Hgb can't bind O2 Leftward shift of oxyhemoglobin dissociation curve (impaired oxygen delivery to tissues) Pulse ox in high 80s, Normal PaO2, unresponsive to O2, SOB + clear lungs on PE + normal CXR Cyanosis Brown blood Causes: dapsone, nitrates, antimalarials, -aines, naphthalene (moth balls) Treatment: Methylene blue What is the normal level of methemoglobin in arterial blood? Answer: Less than 2%.

A 60-year-old man with insulin-dependent diabetes mellitus, gastroparesis, hypertension, and congestive heart failure has just received a new diagnosis of pheochromocytoma. Which of the following medications should be discontinued?😎😎😎😎😎👀👀👀😨😨😨😨😨😨😨😨❤️ AFurosemide BInsulin lispro CLisinopril DMetoclopramide

Metoclopramide as well as beta-blockers (in the absence of alpha-blocking agents), glucagon, metoclopramide, and histamine. in preparatuion for surgery Metoclopramide blocks the inhibitory effects of dopamine receptor activation on sympathetic nerves, which can potentially lead to catecholamine release in the setting of a pheochromocytoma. Beta-blockers are routinely administered to patients with pheochromocytoma, but only after they have been established on treatment with alpha-adrenergic blocking agents such as phenoxybenzamine. If beta-blockers are administered prior to alpha-adrenergic blockade, the result can be further elevation in blood pressure due to unopposed alpha-adrenergic action in the peripheral blood vessels. What is the mechanism of action and clinical application of metyrosine? Answer: Metyrosine is an inhibitor of catecholamine synthesis and is sometimes used preoperatively in patients with pheochromocytoma. To prepare for surgical excision, medications which cause stimulation of pheochromocytoma activity must be discontinued. These medications include beta-blockers (in the absence of alpha-blocking agents), glucagon, metoclopramide, and histamine. Surgical excision of a pheochromocytoma is a high-risk procedure and must be performed by a skilled surgical team. Proper preoperative medical preparation to ensure volume expansion and blood pressure control is essential. Pheochromocytoma Catecholamine-secreting tumor located in the adrenal glands Sx: paroxysmal headaches, diaphoresis, palpitations, tremors, and vision changes PE: hypertension, orthostasis Dx: ↑ 24h urinary catecholamines and metanephrines, or ↑ plasma metanephrine levels, adrenal CT or MRI Tx: alpha-blocker (phentolamine, phenoxybenzamine) prior to beta-blockade to prevent unopposed alpha-agonism surgical resection Associated with MEN2 (medullary thyroid cancer, pheochromocytoma, +/- primary hyperparathyroidism)

A previously healthy 28-year-old woman presents to your office with complaints of worsening overall muscle weakness and drooping eyelids for the past month. Physical exam reveals a mask-like face with ptosis. Sensory exam and deep tendon reflexes are normal. Which of the following is the most likely diagnosis? ABell's palsy BGuillain-Barré syndrome CMultiple sclerosis DMyasthenia gravis

Myasthenia gravis Sx: ocular or generalized muscle weakness, bulbar weakness (dysarthria, dysphagia), ptosis and diplopia that is worse at the end of the day or following exertion PE: applying ice pack to eyelid improves diplopia Serologic testing for autoantibodies: anti-nAChR, anti-MuSK Electrophysiologic studies: repetitive nerve stimulation, single-fiber electromyography Tx: acetylcholinesterase inhibitors (pyridostigmine) Acute myasthenic crisis: plasmapheresis, IVIG In critical care: adjust RSI medication doses Increase dose of depolarizing NMB Decrease dose of nondepolarizing NMB

A 60-year-old woman presents with a neck and chest rash. Review of systems is significant for proximal weakness and myalgias for 3 months. Examination of the skin reveals a violet hue on both eyelids, reddened macules on the neck, shoulders, and chest, and thick, scaly skin on the dorsal surfaces of the metacarpophalangeal and proximal interphalangeal joints. However, there are no tender subcutaneous nodules. You send the patient for electromyography and nerve conduction testing. Which of the following pathologies would you would expect the findings to be most consistent with? AMyopathy BNeuropathy CRetinopathy DVasculopathy

Myopathy dx: Polymyositis Dermatomyositis Risk factors: female sex, age 40-60, occult malignancy Sx: insidious, painless, proximal muscle weakness (polymyositis) and a rash, dysphagia PE: heliotrope rash, Gottron papules, mechanic's hands, photodistributed poikiloderma (shawl sign, v-sign) Labs: ↑ CK and aldolase Dx: MRI, EMG, muscle biopsy Tx: steroids, methotrexate or azathioprine Antisynthetase syndrome: anti-Jo-1 antibodies, interstitial lung disease, worse prognosis Age-appropriate screening for malignancy

A 24-year-old woman presents to the clinic with intermittent vertigo for the past three weeks. She complains of episodic vertigo that lasts from 20 minutes to several hours. Associated symptoms include tinnitus and decreased hearing. Which of the following is the most likely diagnosis? ABenign paroxysmal positional vertigo BMénière's disease COtitis media DVestibular neuronitis

Ménière's disease Ménière Disease Patient presents with episodic low-frequency hearing loss, tinnitus with aural (ear) fullness, and vertigo lasting 20 minutes up to 24 hours Diagnosis is made clinically Most commonly caused by too much inner ear endolymph and increased pressure within the inner ear Treatment is low-salt diet, diuretics (HCTZ + triamterene) ----------------------------------------------------------- Benign paroxysmal positional vertigo (A) is associated with brief episodes of vertigo brought on by movement of the head. Otitis media (C) can cause dizziness along with ear pain but it typically does not cause vertigo. Vestibular neuronitis (D) can cause severe vertigo, nausea and vomiting and typically follows a viral infection. Auditory symptoms are not seen with vestibular neuronitis.

A 36-year-old woman presents to your clinic with low back pain that began 4 days ago. She was moving some heavy furniture and felt her back "give out." Physical exam reveals muscle spasm in the lumbar paraspinal muscles and decreased range of motion with back flexion, extension, and rotation. Which of the following is the most appropriate therapy? AAmitriptyline BNaproxen COxycodone DPrednisone

Naproxen Back Strain or Sprain History of repeated lifting and twisting PE will show diffuse tenderness in the lower back or SI region, with decreased ROM, especially flexion X-ray only needed if atypical symptoms present (pain at rest, pain at night, significant trauma, red flags) Most commonly caused by injury to the paravertebral spinal muscles NSAIDs are first line ------------------------------------------------------------- vs Amitriptyline (A) is a tricyclic antidepressant sometimes used in the treatment of chronic back pain. Oxycodone (C) is an opioid analgesic and may provide some benefit in patients with acute low back pain whose symptoms are not relieved with NSAIDs and muscle relaxers. Due to concerns about high misuse potential and drug diversion, these agents should be used with caution and are not considered first-line therapy. Systemic corticosteroids such as prednisone (D) are not recommended in the treatment of acute low back pain due to a number of adverse effects including mood lability, insomnia, and poor glycemic control in patients with diabetes.

A 56-year-old man presents to the emergency department with right upper quadrant pain that radiates to the right scapula. His pain increases with deep respiration, and he reports associated nausea and multiple episodes of vomiting. His medical history includes hypertension, atherosclerosis, and gout with medical treatment involving lisinopril, atorvastatin, aspirin, and allopurinol. Vital signs include a HR of 104 bpm, RR of 18/min, BP of 156/99 mm Hg, T of 101.9°F, and SpO2 of 98% on room air. The patient has a nondistended abdomen that is tender to palpation in the right upper quadrant. Abdominal ultrasound findings are equivocal, and cholescintigraphy is ordered. Which of the following findings from this diagnostic study are considered diagnostic of the suspected diagnosis? AGallbladder wall thickening and edema BNonvisualization of the gallbladder on delayed images CPresence of pericholecystic stranding DSmall amount of fluid in the gallbladder fossa EVisualization of contrast within the common bile duct and gallbladder

Nonvisualization of the gallbladder on delayed images dx:Acute cholecystitis -------------------------------------------------------------- vs Gallbladder wall thickening and edema (A) is commonly found on ultrasound and computed tomography scans. This is not the diagnostic finding of interest with a HIDA scan. Presence of pericholecystic stranding (C) is most commonly found with computed tomography scans in patients with acute cholecystitis. Small amount of fluid in the gallbladder fossa (D) can be demonstrated on ultrasound imaging and may also be found on computed tomography scans. This finding is not diagnostic by itself with imaging and commonly occurs in conjunction with other indicative findings, such as gallbladder wall thickening and pericholecystic stranding. Visualization of contrast within the common bile duct and gallbladder (E) during a HIDA scan indicates a patent duct and helps rule out acute cholecystitis.

A 42-year-old man with no significant medical history presents to his primary care office for his routine annual exam. He has no concerns during his visit. His vital signs are a HR of 77 bpm, RR of 17/min, oxygen saturation on room air of 99%, BP of 122/84 mm Hg, T of 97.8°F, and a BMI of 24.6 kg/m2. On physical exam, there is a large amount of cerumen in bilateral ear canals; otherwise, his exam is normal. The patient reports no hearing loss or tinnitus. Which of the following is the best next step in the management of this patient's exam findings? AManual removal with a curette BObservation only CReferral to otolaryngologist for removal DRemoval with cerumenolytic agent ERemoval with irrigation

Observation only dx:bilateral cerumen impaction symptoms such as decreased hearing, ear pain or fullness, itchiness, dizziness, and tinnitus. For asymptomatic patients, such as the one in the above vignette, one should continue to observe only as cerumen removal is not indicated. However, if a patient is reporting symptoms or if the patient is unable to express symptoms, then cerumen removal is indicated by either cerumenolytic agents, irrigation, or manual removal. The most common complications after cerumen removal include ear pain, bleeding, and perforation of the tympanic membrane. ------------------------------------------------------------- vs Referral to otolaryngologist for removal (C) is rarely necessary and should only be done if the patient has a history of chronic cerumen impaction, a perforated tympanic membrane, or a history of ear surgery. Patients can also be referred to otolaryngology if they have persistent ear symptoms after removal of cerumen.

A 52-year-old woman with a history of unprovoked deep vein thrombosis at the age of 45 and treated with anticoagulation presents to her gynecologist with concerns for frequent hot flashes. She states her hot flashes mostly occur at night. The patient reports her last period was 2 years ago before having a hysterectomy for uterine fibroids. Her vital signs are a HR of 81 bpm, RR of 18/min, SpO2 of 99% on room air, BP of 126/82 mm Hg, T of 98.8°F, and BMI of 31.6 kg/m2. Her physical exam is normal. What is the best next step in management for this patient's presentation? AIntravaginal estrogen BOral clonidine COral estrogen and progestin therapy DOral paroxetine EWeight loss and vitamin E supplementation

Oral paroxetine dx: hot flashes due to menopause

You are called to examine a 3-year-old boy in the emergency department for possible ingestion. He was found by his father drooling and playing with an opened drain cleaner. After suspecting a caustic ingestion, he immediately called poison control and was advised to bring the boy to the emergency department. The boy is irritable and drooling. His physical examination is otherwise normal. Which of the following is the most appropriate next step in management? AGive activated charcoal BGive prophylactic antibiotics COrder an upper endoscopy DPerform gastric lavage

Order an upper endoscopy Caustic materials cause tissue injury. Caustic alkaline materials are found in drain cleaners, various cleaning agents, hair relaxers, dishwasher agents, and disk batteries. Alkalis produce liquefaction necrosis that allows further tissue penetration of the toxin and setting the stage for possible perforation. acids in household products include toilet bowl cleaners, swimming pool cleaners, and rust removers. Acids produce a coagulative necrosis that limits further tissue penetration, though perforation can still occur. Ingestion of caustic materials can produce injury to the oral mucosa, esophagus, and stomach. The symptoms include pain, drooling, vomiting, abdominal pain, and difficulty swallowing. Initial treatment of caustic exposures includes thorough removal of the product from the skin or eye by flushing with water. Endoscopy should then be performed within 12 to 24 hours of ingestion in symptomatic patients or those in whom injury is suspected in order to assess severity which will then guide the prognosis and treatment of the patient. ----------------------------------------------------------------- vs # subsequent aspiration Giving activated charcoal (A) is not appropriate because it does not bind the caustic agents and can predispose the patient to vomiting and subsequent aspiration. Giving prophylactic antibiotics (B) does not improve the outcome of caustic ingestion. Performing gastric lavage (D) is contraindicated because it can lead to emesis and subsequent aspiration.

A two-year-old boy develops pallor following a viral upper respiratory tract infection. His mother reports a family history of "some kind of low blood levels". His serum studies reveal a normocytic anemia and the presence of spherocytes on the peripheral blood smear. Which of the following tests can be done to confirm the diagnosis? ADirect Coombs test BHemoglobin electrophoresis COsmotic fragility test DSerum reticulocyte count

Osmotic fragility test Hereditary Spherocytosis Patient presents with symptoms of anemia: fatigue or pallor Positive family history Labs will show microcytic or normocytic anemia and is the only disorder that will cause an increase in mean corpuscular hemoglobin concentration (MCHC) Peripheral smear will show spherocytes and Howell-Jolly body Most commonly caused by an autosomal dominant genetic disease Treatment includes daily folic acid

A 26-year old woman presents to urgent care with a fever of 101.4°F, dysuria and nausea for the past 24 hours. On physical exam, exquisite pain is elicited on palpation of the right flank. She does not appear toxic. She is able to eat and drink, despite her nausea. Her pregnancy test is negative and her urinalysis is pending. What is the best management and treatment for this patient? AInpatient management with intravenous ceftriaxone BInpatient management with intravenous vancomycin COutpatient management with oral ciprofloxacin DOutpatient management with oral trimethoprim/sulfamethoxazole

Outpatient management with oral ciprofloxacin dx; Acute pyelonephritis Acute Pyelonephritis Sx: fever, dysuria, and flank pain PE: CVA tenderness Labs: UA + leukocyte esterase, nitrites, microscopy +WBCs, Gram stain, urine culture and susceptibility testing Most commonly caused by Escherichia coli Treatment depends on infection severity and community/host risk factors for resistant pathogens Fluoroquinolones TMP-SMX 3rd/4th gen cephalosporins For critical illness or risk for multidrug-resistant organisms: consider coverage for MRSA, VRE What is the management and treatment for pyelonephritis in pregnancy? Answer: Inpatient management with an intravenous second- or third-generation cephalosporin. ------------------------------------------------------------ vs Due to increased resistance, outpatient management with oral trimethoprim/sulfamethoxazole (D) is usually reserved for cases where susceptibility results for the urine isolate are known and indicate likely activity. For women with complicated acute pyelonephritis, inpatient therapy with intravenous ceftriaxone (A) is recommended. Other options for inpatient management with intravenous antibiotics include a fluoroquinolone, an aminoglycoside, an extended-spectrum penicillin, or a carbapenem. Inpatient treatment with intravenous vancomycin (B) is not recommended because this antibiotic does not have gram-negative coverage.

A previously healthy 3-year-old girl is brought to the clinic due to a nose bleed. Her mother states she has been applying pressure for 10 minutes, but the bleeding has continued. Vital signs include a HR of 118 bpm, RR of 19/min, BP of 90/53 mm Hg, T of 97.9 °F, and SpO2 of 100% on room air. On physical exam, the child has no sign of respiratory distress. Bleeding is noted from the anterior nasal vault, but the source cannot be readily identified. Which of the following is the best next step in treatment? AAnterior nasal packing with a vaseline-covered sponge BContinued direct pressure to the nasal alae CFibrin glue application DOxymetazoline application with a gauze pledget ESilver nitrate application

Oxymetazoline application with a gauze pledget dx:epistaxis ---------------------------------------------------------- vs Anterior nasal packing with a vaseline-covered sponge (A) may be attempted if the application of a topical vasoconstrictor (e.g., oxymetazoline) does not control the bleeding. Packing should be placed by an otolaryngologist. Continued direct pressure to the nasal alae (B) is unlikely to resolve this bleeding episode as direct pressure had already been applied for 10 minutes without tamponade. The patient should be treated instead with a topical vasoconstrictor. Fibrin glue application (C) should be attempted after direct pressure or application of a topical vasoconstrictor is unsuccessful in resolving the epistaxis. This treatment is less painful than nasal packing or cautery and is particularly useful in patients with coagulopathies or hereditary hemorrhagic telangiectasia. Silver nitrate application (E) should not be attempted prior to less invasive strategies such as topical oxymetazoline. Additionally, cautery techniques are best utilized if the source of bleeding can be localized and hemostasis is achieved.

An 82-year-old man presents with slurred speech and unilateral arm weakness that have resolved. His noncontrast head CT is negative. Which of the following is the most appropriate management plan? ADischarge home with primary care follow-up BGive low molecular weight heparin CPerform MRI and MRA of the head and neck DPerform transcranial Doppler studies

Perform MRI and MRA of the head and neck dx: transient ischemic attack (TIA), neurologic deficits that occur and resolve within a few minutes. Patients who have a TIA are at high risk for stroke in the period immediately following a TIA. Thus, further testing is warranted in a timely fashion. ------------------------------------------------------------------- vs Without further testing, it is inappropriate to discharge the patient home with primary care follow-up (A). Some data in Europe suggest that referral to a stroke neurologist for prompt follow-up and coordinated care may be a safe alternative. However, in the US, the vasculature is typically exonerated prior to discharge. Low molecular weight heparin (B) is not a standard treatment for TIA. In cases in which atrial fibrillation is identified, patients will begin anticoagulation in the absence of contraindications. Transcranial Doppler studies (D) are sometimes used to evaluate the posterior circulation. However, this patient's symptoms are not consistent with a posterior stroke. Furthermore, the sensitivity of transcranial Doppler ultrasound is poor for the identification of critical vascular stenosis

An otherwise healthy 38-year-old man reports 6 days of a painful boil on his upper back. Vital signs are BP 128/82 mm Hg, HR 70 bpm, RR 16/min, T 98.6°F. He has been applying warm compresses to the area, but it is increasing in size, and the pain is worsening. On exam, you palpate a 1 x 1 cm erythematous, tender, fluctuant abscess without induration or surrounding cellulitis. What is the most appropriate treatment? AContinue warm compresses and discharge home BPerform incision and drainage and prescribe IV antibiotics CPerform incision and drainage and prescribe oral antibiotics DPerform incision and drainage only EPrescribe antibiotics only

Perform incision and drainage only dx: simple abscesses --------------------------------------------------------------- vs Only prescribing antibiotics (E) is not effective therapy for a simple abscess since incision and drainage optimizes the likelihood of cure. IV antibiotics (B) are indicated only in the most severe cases in immunocompromised individuals or when there are signs of serious systemic infection. In these cases, IV antibiotics are started prior to incision and drainage. Appropriate IV antibiotics include vancomycin and daptomycin.

Which of the following is a contraindication to the use of air-contrast enema in the reduction of pediatric intussusception? AAir contrast enema for a prior episode of intussusception in the last 24 hours BFever greater than 39°C CLethargy DPeritonitis

Peritonitis Intussusception (Telescoping Bowel) Patient will be a child 6 months to 3 years old Colicky abdominal pain, vomiting, and bloody stools (currant jelly) Diagnosis is made by ultrasound (target sign) Most common cause is idiopathicAlthough less common, it is important to be vigilant for pathologic lead points in children of any age Treatment is air or hydrostatic (contrast or saline) enema What rash is associated with Henoch-Schonlein purpura, a common cause of intussusception? Answer: Palpable purpura. Contraindications to the use of air-contrast enema include hemodynamic instability with shock, free air under the diaphragm, and peritonitis. Children with these features need emergent surgical intervention. ------------------------------------------------------------------ vs Lethargy (C) is a common presentation of intussusception and is not a contraindication to the use of air-contrast enema for reduction. Intussusceptions often recur in 12-24 hours and prior reduction with air-contrast enema (A) is not a contraindication to its use. Fever (B) is not a contraindication to the use of air-contrast enema and may be seen after reduction of the intussusception due to bacterial translocation or release of endotoxins or cytokines

A 35-year-old hair stylist presents to her physician for ongoing heel pain that is exacerbated by standing on her feet all day at work. She complains that the pain is worse in the morning upon getting out of bed but subsides within 30-45 minutes. On physical exam, pain is elicited by dorsiflexion of the toes. Which of the following is the most likely diagnosis? ACalcaneal bursitis BMorton neuroma CPlantar fasciitis DTarsal tunnel syndrome

Plantar Fasciitis Sx: heel and foot pain when first stepping out of bed or after period of inactivity, improves with walking orstretching the calf PE: tenderness over the sole of the foot near the calcaneus Tx: stretching plantar fascia and calf, heel inserts ------------------------------------------------------------- vs Reproduction of pain in the forefoot by compressing together the metatarsal heads of the second and third or the third and fourth toes suggests the presence of a Morton neuroma (C) and is not a typical finding in plantar fasciitis. Tarsal tunnel syndrome (D) can be ruled out by percussing over the tarsal tunnel behind the medial malleolus. This test produces no pain in patients with plantar fasciitis. Inflammation of the calcaneal bursae (B) is most commonly caused by repetitive overuse and cumulative trauma, as seen in runners wearing tight-fitting shoes. Inflammation of one or both of these bursae can cause pain in the posterior heel and ankle regions.

A 7-year-old boy presents complaining of occasional intermittent lower abdominal pain over the last several weeks associated with a decline in the frequency of bowel movements to one every third day. When he does defecate, stools are hard to pass and sometimes painful. There is no blood in the stools. He has no chronic medical problems, has never had surgery, and takes no medications. Review of systems are negative and physical exam is normal. What is the most appropriate initial intervention for this child? ABisacodyl BPhosphate enema CPolyethylene glycol DReferral to gastroenterologist ESoap suds enema

Polyethylene glycol first line oral medication to use for maintenance therapy of constipation, defined as a two week history or more of delay or difficulty in defecation. Other options include magnesium hydroxide, lactulose and sorbitol. The most common cause of constipation in children is functional constipation, meaning constipation without objective evidence of a pathological condition. ---------------------------------------------------------- vs Referral to a gastroenterologist (D) should be considered for patients who do not respond to therapy as expected, for those with symptoms, exam findings or other evidence to suggest organic disease, or for those whose management is complex due to other medical or social factors.

A 43-year-old man is admitted to the intensive care unit for refractory status epilepticus. He was intubated in the emergency department due to continued seizure activity and airway compromise. Currently, he is on levetiracetam and fosphenytoin for seizure prevention, a propofol infusion for sedation, and lorazepam as needed for seizure activity. On day four of his admission, the patient develops bradycardia and hypotension. Laboratory findings also indicate that the patient has a lactic acidosis. Which of the following medications is most likely to have caused this patient's current clinical picture? AFosphenytoin BLevetiracetam CLorazepam DPropofol

Propofol dx:propofol-related infusion syndrome (PRIS) Common findings of PRIS include bradycardia, metabolic acidosis, cardiovascular collapse, rhabdomyolysis, and renal failure. PRIS has most often been associated with prolonged use of greater than 48 hours, high doses > 4 mg/kg/hr, critical illness, age (i.e. more common in children) and concomitant vasopressor use. Treatment of PRIS includes providing supportive care and discontinuing propofol for another sedative, such as midazolam. -------------------------------------------------------------------- vs Fosphenytoin (A) and levetiracetam (B) are not associated with metabolic acidosis and rhabdomyolysis. Fosphenytoin (A) can cause bradycardia and hypotension, but this is seen with large parenteral doses administered too quickly. Lorazepam (C) can cause a metabolic acidosis due to the propylene glycol contained in the parenteral formulation being converted to lactic acid, but this is seen with high dose, long duration infusions, and not with single, intermittent doses.

A 45-year-old businessman presents for "shakiness" of his hands for several months. He notices it most when giving a presentation at work, and adds that his voice "quivers" at those times too. No other symptoms are present. He says his father had a similar problem for most of his adult life. Which of the following medications is the best initial selection for this condition? ABotulinum toxin A BDonepezil CPropranolol DRasagiline

Propranolol dx:Essential Tremor History of a family member with similar symptoms Hand tremor that is exacerbated by action and improved after alcohol consumption Most commonly caused by autosomal dominant gene Treatment is propranolol

A 57-year-old woman with a history of type 2 diabetes mellitus has had two weeks of worsening erythema and edema of the ear canal with deep otalgic pain. Copious granulations are present in the canal and a foul aural odor is noted. Which of the following organisms most likely caused this infection? AHaemophilus influenza BPseudomonas aeruginosa CStaphylococcus aureus DStreptococcus pyogenes

Pseudomonas aeruginosa Otitis Externa History of swimming or moisture exposure Malodorous discharge and pruritus PE will show pain with palpation of tragus or pinna Most commonly caused by Pseudomonas aeruginosa Treatment is topical antimicrobials with or without steroids Necrotizing otitis externa: a complication seen in those with diabetes or immunocompromise

An obese 34-year-old woman is brought to the emergency department with respiratory distress. Two months ago, she was in the hospital for knee surgery. Paramedics report an acute onset of dyspnea and pleuritic chest pain. She also complains of a tender thigh on the same side of her knee surgery. She is tachycardic and tachypneic, and mildly hypotensive. Examination reveals decreased breath sounds but no hyperresonance. An emergent chest radiograph is relatively normal except for some mild atelectasis. Which of the following is the most likely diagnosis? AAcute bronchitis BPleural effusion CPneumothorax DPulmonary embolism

Pulmonary embolism

A 55-year-old business executive comes to the emergency department with a 6-hour history of shortness of breath, cough, and chest pain. He smokes 1 to 2 packs of cigarettes daily and drinks 2 to 3 alcoholic beverages every night. He occasionally uses cocaine for recreational purposes. Physical examination reveals an erythematous and edematous right calf and a palpable cord. Auscultation of the lungs reveals rales and decreased breath sounds on the right side. Which of the following is the most likely diagnosis? AAcute myocardial infarction BGastroesophageal reflux disease CPulmonary embolism DVenous thrombosis

Pulmonary embolism Sx: dyspnea, pleuritic chest pain, cough, syncope PE: tachypnea, tachycardia, possible signs of DVT (calf pain or swelling) ECG: sinus tachycardia, nonspecific ST segment and T wave changes, RV strain, S1Q3T3 (classic finding) CXR: nonspecific abnormalities, Hampton hump (pleural-based wedge infarct), Westermark sign (vascular cutoff sign) US: right ventricle hypokinesis, flattened interventricular septum, diastolic septal bowing Dx: CT pulmonary angiography most preferred, VQ scan alternative Tx: Use Hestia criteria or PESI to determine risk of complications and help with disposition planning (outpatient vs inpatient) Anticoagulation: heparin, LMWH, warfarin, novel oral anticoagulants (NOAC) Thrombolytics, embolectomy in hemodynamically unstable patients Comment: in low clinical suspicion: negative D-dimer excludes PE

A 48-year-old man presents to the office with right shoulder pain that has been worse over the last 3 months. He has positive Hawkins and Neer signs. Drop-arm test produces pain but no weakness. Which of the following is the most likely diagnosis? ACervical nerve impingement with radiculopathy BGlenohumeral osteoarthritis CRotator cuff impingement DSuprascapular nerve entrapment

Rotator cuff impingement Rotator Cuff Impingement and Tear Supraspinatus (abduction) Infraspinatus (external rotation) Teres minor (external rotation) Subscapularis (internal rotation) Pain with brushing hair or teeth Pain at night when rolling onto shoulder Baseball pitchers

HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Rapidly progressive, most commonly seen in 28-36th week of pregnancy Sx: RUQ abdominal pain, nausea Labs:microangiopathic hemolytic anemia (low hemoglobin and schistocytes on blood smear)low platelets (<100,000 cells/microL)elevated liver enzymes (≥2x upper limit of normal) Management is blood pressure management, magnesium sulfate for prevention of eclamptic seizures, and delivery of the fetus

Schistocytes, thrombocytopenia, and elevated aspartate aminotransferase and alanine aminotransferase greater than twice normal

A 76-year-old man with a history of hypertension and hyperlipidemia presents to the office for evaluation of changes in his vision. The vision changes have been gradual, occurring in both eyes over the past 6 months. He first noticed it when he had to buy books in a larger print. He has smoked one pack of cigarettes per day for the past 55 years. His current medications are atorvastatin and hydrochlorothiazide. His vital signs are significant for a blood pressure of 128/78 mm Hg and heart rate of 72 bpm, and his BMI is 27.3 kg/m2. On physical examination, the conjunctivae are noninjected and sclera are anicteric. Lenses are without opacity. Funduscopic examination reveals patchy areas of depigmentation and atrophy and bright yellow drusen. What is the best initial management for this patient's suspected condition? AAggressive hypertension management BBevacizumab injections administered monthly CLaser photocoagulation therapy DPhacoemulsification ESmoking cessation

Smoking cessation Macular degeneration is an age-related retinal disorder. It is the leading cause of blindness in the older adult population. Risk factors include older age, hypertension, hyperlipidemia, cardiovascular disease, and cigarette smoking. What tool can patients use daily to monitor for progression of dry to wet macular degeneration? Answer: Amsler grid. Dry macular degeneration is associated with atrophic changes to the retina, while wet macular degeneration is characterized by the presence of neovascularization. Dry AMD can progress to wet AMD. The disease is usually bilateral. In early disease, dry AMD may be asymptomatic. As the disease progresses, gradual loss of vision occurs. In wet AMD, patients may experience visual distortions, metamorphopsia, and loss of central vision. Peripheral vision is spared. Macular degeneration can be diagnosed via dilated eye examination using a slit lamp. In dry AMD, atrophy and hard drusen are observed. In wet AMD, soft drusen, retinal hemorrhage, and evidence of neovascularization may be seen. Patients who smoke cigarettes should be counseled on tobacco cessation due to the increased risk of disease progression. Antioxidant treatment with vitamin C, vitamin E, zinc, copper, and carotenoid supplements is also recommended. Intravitreal injections of anti-vascular endothelial growth factors (anti-VEGFs), such as ranibizumab, bevacizumab, aflibercept, are used in wet AMD to reduce neovascularization and improve vision.

An 18-year-old man comes to your clinic after having a positive HIV rapid test result. You proceed to order the appropriate follow-up diagnostic test that turns out to be negative. When disclosing the results to the patient, he doesn't understand and asks for the meaning of the follow-up test. What statistical measure is discussed with the patient regarding the follow-up test? AConfidence interval BNumber needed to treat CSensitivity DSpecificity

Specificity Biostatistics Standard deviation: variability from mean Standard error of the mean: variability between sample mean and true mean Positive skew: mean > median > mode Negative skew: mean < median < mode Type I error: H0 incorrectly rejected Type II error: H0 incorrectly accepted Alpha: probability of type I error Beta: probability of type II error Power: probability of correctly rejecting H0 Increase power and decrease beta: increase sample size, increase expected effect size, increase precision of measurement Confidence interval: range in which real mean expected to fall t-test: compares means of two groups ANOVA: compares means of three groups chi-square: ≥ 2 percentages or proportions of categorical outcomes ---------------------------------------------------------------

A 57-year-old woman with cirrhosis complains of worsening distension of the abdomen and edema up to her lower legs despite compliance with eating less than 2 grams daily of sodium. She denies abdominal pain, constipation, dyspnea or fevers. On exam, her abdomen is distended and has a notable fluid wave. She has 2+ pitting edema to the level of her ankles. Which medication is the most appropriate next step in the management of this patient?😩🎍 AHydrochlorothiazide BLactulose COmeprazole DSpironolactone

Spironolactone ascites Cirrhosis PE: gynecomastia, palmar erythema, ↑ bleeding Hepatic encephalopathy: asterixis, confusion Portal hypertension: caput medusae, splenomegaly, ascites Most commonly caused by alcohol, hepatitis, autoimmune ↑ risk for HCC, screen with ultrasound +/- AFP every 6 months ------------------------------------------------------------------ vs Hydrochlorothiazide (A) is a thiazide diuretic, used as first-line therapy in the management of benign essential hypertension. Though this patient may also have hypertension for which hydrochlorothiazide might be effective, it is not the first choice for the management of ascites secondary to portal hypertension as a result of cirrhosis. Lactulose (B), is a synthetic disaccharide containing glucose and fructose, used for the management of hepatic encephalopathy, a complication of cirrhosis. It works by reducing the level of ammonia and other cerebral toxins in the circulation. It does not have a role in reducing ascites.

Which of the following correctly matches the stage with the clinical finding in a patient with chronic lymphocytic leukemia? AStage 0 - No findings, just family history BStage 1 - Lymphocytosis only CStage 2 - Lymphocytosis and splenomegaly with no anemia DStage 3 - Lymphocytosis, splenomegaly, thrombocytopenia, and hemoglobin >15 g/dL

Stage 2 - Lymphocytosis and splenomegaly with no anemia Low 0 Intermediate 1-2 High 3-4 Rai Staging of Chronic Lymphocytic Leukemia Stage Features 0 Lymphocytosis only (blood or marrow) 1 Lymphocytosis + lymphadenopathy 2 Lymphocytosis + hepatomegaly or splenomegaly Ill Lymphocytosis + anemia (hemoglobin < 11 g/dL) IV Lymphocytosis + thrombocytopenia (platelets < 100,000/mcL) Chronic Lymphocytic Leukemia (CLL) Most common adult leukemia in resource-rich countries Risk factors: male sex, age > 60 years old PE: asymptomatic, generalized lymphadenopathy Labs: isolated lymphocytosis, smudge cells

A 17-year-old girl presents to your office with a complaint of worsening headaches. The headaches occur most days of the week, worsen with activity, and are sometimes associated with vomiting. She denies a family history of headaches. She is taking ibuprofen for her headaches and doxycycline for acne. Exam is significant for papilledema. A brain MRI is normal, and on lumbar tap the opening pressure is elevated. What is the best next step in treatment? AStart acetazolamide BStart rizatriptan CStop doxycycline DStop ibuprofen

Stop doxycycline Idiopathic intracranial hypertension has many drug-induced etiologies as well, including tetracyclines, oral contraceptives, sulfonamides, hypervitaminosis A, phenytoin, corticosteroids and nitrofurantoin. It is appropriate to stop doxycycline to determine if that is the underlying cause of her headaches. Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Risk factors: female sex, obesity, meds (tetracycline, OCPs, vitamin A, steroids) Sx: diffuse headache and visual blurring, peripheral vision loss PE: bilateral papilledema, CN VI palsy Elevated opening pressure on LP Treatment is acetazolamide, serial LPs, weight loss

A 34-year-old woman presents to a local urgent care clinic with insidious onset of right foot pain that has been getting worse over the past two weeks. She denies any known trauma to the foot, but mentions she is training for a marathon. On physical exam, she is moderately tender to palpation over the second right metatarsal. An X-ray of the foot is normal. What is the most likely diagnosis? ACompartment syndrome BLigament sprain COsteomyelitis DStress fracture

Stress fracture

A 55-year-old woman presents to your office with complaints of fatigue, dry skin, constipation and weight gain. Physical exam results include a heart rate of 58 bpm and diminished deep tendon reflexes. Laboratory testing reveals an elevated TSH. Which of the following is the most appropriate next step in management?😩😩😩😩😩 ABegin treating patient with a beta-blocker BBegin treating patient with levothyroxine CTest serum free T3 DTest serum free T4

Test serum free T4 dx: hypothyroidism, ------------------------------------------------------------- vs Beta-blockers (A) are used to treat symptoms of hyperthyroidism and have no role with hypothyroidism. Treatment with levothyroxine (B) should begin once serum free T4 is evaluated and primary hypothyroidism diagnosed. Serum T3 (C)is tested when hyperthyroidism is suspected based on clinical symptoms. Patients with hyperthyroidism caused by Graves' disease will have a higher serum T3 level than serum T4.

A newborn is being evaluated for cyanosis. Physical examination shows a prominent right ventricular impulse and a systolic thrill. A crescendo-decrescendo murmur with a harsh systolic ejection quality is heard along the left upper sternal border. Based on these findings, which of the following is the most likely diagnosis? ATetralogy of Fallot BTransposition of the great arteries CTricuspid atresia DTruncus arteriosu

Tetralogy of Fallot Tetralogy of Fallot Most common cyanotic congenital heart disease in childhood History of episodes of cyanosis (tet spells) and squatting for relief (decrease R➔L shunt, increase oxygenation) Echo: pulmonic stenosis, right ventricular hypertrophy, overriding aorta, and VSD CXR: boot-shaped heart Mnemonic: PROVe: pulmonic stenosis, right ventricular hypertrophy, overriding aorta, VSD

An 18-year-old man presents with painful penile lesions for the past two days. He has associated general malaise and chills. Physical exam reveals shallow ulcerations on an erythematous base on the shaft of the penis. Which of the following is the best way to confirm the suspected diagnosis? ASerum herpes simplex virus antibody test BTissue biopsy CTzanck smear DViral culture and polymerase chain reaction testing

Viral culture and polymerase chain reaction testing dx: gold standard for diagnosing herpes simplex virus (HSV) Genital Herpes Simplex Sx: painful genital rash, may be asymptomatic PE: grouped erythematous shallow cluster of vesicles and lymphadenopathy Labs: multinucleated giant cells on Tzanck smear (poor sensitivity) Dx: tissue PCR or viral culture Most commonly caused by herpes simplex virus (HSV) type 2, but HSV-1 infections are increasing in frequency Tx: acyclovirPregnancy: acyclovir or valacyclovir for 7-10 days after primary infection and from 36 weeks to delivery

Vitamin decifiency😎😎😎😎😎

Vitamin Deficiencies A: night vision loss, xerophthalmia, dry skin (xerosis), growth retardation, Bitot spots on the conjunctivae B1 (thiamine): beriberi, Wernicke-Korsakoff syndrome, cardiac failure; alcoholism, malnutrition B2 (riboflavin): cheilosis, corneal vascularization (the two Cs of B2) B3 (niacin): dermatitis, dementia, diarrhea; corn-based diet (pellagra) B6 (pyridoxine): sideroblastic anemia, convulsions, peripheral neuropathy; INH use B12 (cobalamin): megaloblastic anemia + neurological symptoms, hypersegmented neutrophils C (ascorbic acid): scurvy (↑ bleeding, anemia, loose teeth) 4H: Hemorrhage Petechiae, bleeding gums Hyperkeratosis Rough skin, loose teeth, poor wound healing Hypochondriasis Irritability, emotional changes Hematologic abnormalities Easy bruising D: rickets (children), osteomalacia, tetany E: anemia, peripheral neuropathy, ataxia K: ↑ bleeding, ↑ PT/INR, ↑ PTT if severe Folate: megaloblastic anemia, sensory neuropathy