pance practice exam b

A 33-year-old man presents for a follow-up to an outpatient psychiatry practice. He has previously been diagnosed with bipolar I disorder. His symptoms are currently stable on lithium and sertraline daily. His last lithium trough level was 1 mmol/L, and his last measured weight was 153 lbs. Today, he reports he has felt increasingly tired, has decreased concentration at work, and has decreased libido. His vital signs include a weight of 164 lbs, blood pressure of 115/77 mm Hg, heart rate of 59 bpm, respiration rate of 16/minute, temperature of 98.6°F, and oxygen saturation of 98% on room air. What would be the most appropriate next step in the management of this patient's condition? AAdd sildenafil as needed BDiscontinue sertraline and start escitalopram COrder prolactin level DOrder thyroid function tests ERefer the patient for cognitive behavioral therapy

Order thyroid function tests Lithium use can result in hypothyroidism.

You evaluate a 10-year-old girl in the ED presenting with headache. She reports that she has been having headache, nausea, and dizziness. She was seen in clinic yesterday and was diagnosed with a viral illness. Her symptoms have gotten worse since then. The patient reports no rhinorrhea, fever, loss of consciousness, trauma, or burns. Her mother and older brother also report having headaches. The patient appears confused. You order laboratory tests that show an elevated carboxyhemoglobin level. Which of the following is the most appropriate therapy? AAmyl nitrite BMethylene blue COxygen DSupportive care

Oxygen dx: Carbon monoxide (CO)

A 48-year-old man with a history of HIV presents to your office with complaints of fever, cough and shortness of breath. Laboratory testing reveals a CD4 count of 130 cells/microL. Which of the following findings is most likely to be seen on chest X-ray? AGround glass opacification BHampton's hump CHoneycombing DKerley B lines

Ground glass opacification 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 ------------------------------------------------------------ Honeycombing (C) is found with end-stage interstitial lung disease such as pneumoconiosis.

A 36-year-old G1P0 woman presents at 32 weeks gestation with right upper quadrant abdominal pain. She has no past medical history and her pregnancy has thus far been uncomplicated. Her vital signs on arrival are T 37.3°C, HR 110 bpm, BP 125/75 mm Hg, RR 24/min. Her physical exam is significant for moderate right upper quadrant tenderness to palpation. Her laboratory studies are remarkable for WBC 14 x 109/L, hemoglobin 9 g/dL, hematocrit 27%, platelets 70 X 109/L, AST 120 U/L, ALT 100 U/L, total bilirubin 1.5 mg/dL and LDH 1,000 U/L. Which of the following is the most likely diagnosis? ACholecystitis BCholedocholithiasis CFitz-Hugh Curtis syndrome DHELLP syndrome

HELLP syndrome H Hemolysis • LDH ≥ 600 IU/L E Elevated Liver enzymes • AST or ALT > 2x upper limit of normal L Low Platelet count • < 100,000/mm3 ------------------------------------------------------------------ Choledocholithiasis (B) refers to obstruction of the common bile duct with a stone. Presenting symptoms include right upper quadrant pain, nausea, and vomiting. While elevation of liver function tests can be seen with cholecystitis and choledocholthiasis, neither is associated with thrombocytopenia or anemia as shown above.

A 19-year-old woman presents with 2 days of pain and foreign body sensation in her right eye. She usually wears contact lenses but has her glasses on today. She takes no medications and has no chronic illnesses. Her vital signs are within normal limits except for a pulse of 102 bpm. Physical exam reveals erythema of the right conjunctiva with yellow-green purulent ocular discharge and photophobia. Extraocular muscle movements are within normal limits. Visual acuity is decreased in the right eye. Pupillary movement and reflexes are intact and normal. Fluorescein dye reveals a small round area of fluorescein uptake in the central cornea. Which of the following is the most likely diagnosis? AAcute angle-closure glaucoma BAnterior uveitis COptic neuritis DOrbital cellulitis EPseudomonas keratitis

Pseudomonas keratitis Contact lens users are at increased risk for acute bacterial keratitis. Common signs and symptoms include foreign body sensation, purulent ocular discharge, photophobia, and conjunctival erythema. A white, round ulceration may be noted on the cornea without the aid of fluorescein. Patients with acute bacterial keratitis may have decreased visual acuity and trouble keeping the involved eyelid open due to pain. Patients with Pseudomonas aeruginosa infection often have a yellow-green ocular discharge.

A 22-year-old woman with regular menstrual cycles presents with symptoms concordant with premenstrual syndrome. In evaluating the large differential of these symptoms, which one of the following serum laboratory tests is recommended? AEstrogen BFollicle-stimulating hormone CHuman chorionic gonadotropin DThyroid-stimulating hormone

Thyroid-stimulating hormone Premenstrual Syndrome 1-2 weeks prior to menstrual cycle Sleep disturbances, decreased focus, emotional lability, breast tenderness, or HA that resolves after menses begins Treatment is decreased caffeine intake, exercise, stress reduction, NSAIDs, SSRIs, OCPs Symptoms do not hinder personal or professional life (unlike premenstrual dysphoric disorder)

What is the most common site involved in oral cancer?

Tongue

A 3-day-old male neonate develops bilateral purulent eye discharge. He also exhibits a runny-nose as well as eyelid edema and redness. No other abnormalities on physical examination are noted. Which of the following could have been given as standard prophylaxis to prevent the development of this infant's condition? AIntravenous acyclovir BIntravenous ceftriaxone COral erythromycin DTopical erythromycin

Topical erythromycin dx: Neisseria gonorrhoeae Conjunctivitis Newborns ≤ 5 days old, sexually active adults Hyperpurulent discharge Corneal ulceration or perforation Admission Topical + IV antibiotics

A 46-year-old man presents to the emergency department reporting abdominal pain, bloating, nausea, anorexia, and vomiting. His symptoms have been worsening since onset three days ago. His last bowel movement was four days ago, but he continues to pass flatus. Which of the following tests has the highest sensitivity for confirming the most likely diagnosis? AAbdominal CT with contrast BAbdominal ultrasound CAbdominal X-ray DColonoscopy

Abdominal CT with contrast Small Bowel Obstruction History of prior abdominal or pelvic surgery Bilious vomiting PE may show high-pitched bowel sounds X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Diagnosis is made by imaging Treatment is NPO, IVF, NGT, surgery -------------------------------------------------------- vs Colonoscopy (D) has no role in assessment of a small bowel obstruction but may be used as a temporary treatment of sigmoid volvulus or to reduce intussusception. Abdominal X-ray (B) is frequently the initial imaging modality to detect small bowel obstruction, but it has a significantly lower sensitivity and specificity compared to CT and therefore is less likely to establish the diagnosis.

A 2-year-old previously healthy boy is witnessed having a tonic-clonic seizure in the emergency department. His parent originally brought him in due to a fever of 39°C. The episode lasted 5 minutes, and the patient returned to baseline mental status. Which of the following is the most appropriate next step in management? AAdminister antipyretics BInitiate anticonvulsant therapy CPerform a lumbar puncture DPerform an EEG

Administer antipyretics Febrile Seizure - Simple Common in children aged 6 months to 5 years History of fever > 38°C (especially sharp elevation in temp) Single tonic-clonic seizure lasting < 15 mins Treatment is supportive care If lasting > 5 min, a dose of diazepam gel, nasal, buccal, or suppository can be used

A 13-year-old boy is brought to the emergency room by his mother after a suicide attempt. She reports that he swallowed a bottle of pills but is unsure of what he ingested. His vital signs are BP 90/60, HR 135, RR 16, and T 100.3°F. On exam, the patient is somnolent, his pupils are dilated, mucous membranes are dry, and skin is warm and flushed. Which of the following substance did this patient most likely ingest? AAmitriptyline BMethylphenidate COxycodone DSertraline

Amitriptyline Tricyclic Antidepressants (TCA) Overdose Sodium channel blockade Worsened by acidosis QRS prolongation Anticholinergic Sxs Seizures Tx: sodium bicarbonate, benzodiazepines (if seizures) What are the two most common conduction abnormalities seen on ECG with TCA overdose? Answer: Widened QRS and prolonged QTc. ------------------------------------------------------------ vs Methylphenidate (B) is an amphetamine, and overdose leads to sympathomimetic symptoms such as tachycardia, hypertension, hyperthermia, psychosis, seizures, and mydriasis. Oxycodone (C) is an opiate and can lead to coma and respiratory depression if taken in high doses. Pinpoint pupils and hyporeflexia can also be seen. Sertraline (D) is a selective serotonin reuptake inhibitor and has a wide therapeutic window, so overdose typically does not cause life-threatening symptoms. However, vomiting, mild CNS depression, or tremor can occur.

What is the Cushing triad for increased intracranial pressure?

Answer: Irregular respirations, bradycardia, and hypertension.

A G2P1 woman at 13 weeks gestation presents for her initial prenatal visit. She has no ongoing medical conditions but previously underwent induction of labor due to preeclampsia with severe features. Today's vitals include HR of 91 bpm, RR of 18 breaths/min, BP of 129/87 mm Hg, T of 98.6°F, and SpO2 of 99% on room air. Exam reveals a palpable uterine fundus just superior to the pelvic rim with no other abnormal findings. Transvaginal ultrasound indicates a 13-week fetus with a fetal heart rate of 145 bpm. Which of the following is recommended to reduce the risk of preeclampsia in this pregnancy? AAspirin BFolic acid CLabetalol DMagnesium EPravastatin

Aspirin dx:Preeclampsia is an emergency pregnancy condition that consists of hypertension with proteinuria or hypertension with signs of severe end-organ involvement. Treatment: delivery at 37 weeks (without severe features) and 34 weeks (with severe features) AND prevention of seizures with magnesium sulfate and prevention of permanent maternal organ damage New-onset hypertension < 20 weeks gestation: suspect molar pregnancy ----------------------------------------------------------------- vs Magnesium (D) is used for seizure prophylaxis in patients diagnosed with preeclampsia with severe features. It is not an appropriate treatment for the prevention of recurrent preeclampsia.

Which of the following can cause a false positive rapid plasma reagin (RPR)? AAspirin use BAutoimmune disease COwning a pet cat DYoung age

Autoimmune disease Syphilis Primary: painless chancre Secondary: lymphadenopathy, condyloma lata, rash on palms and soles Tertiary: gummas VDRL and RPR positive 1-4 weeks after infection Primary or secondary: IM benzathine penicillin G, 1 dose Tertiary: IM benzathine penicillin G qwk for 3 weeks

A 20-year-old sexually active woman presents with dysuria and polyuria for a one-week duration. She has never had a urinary tract infection. She denies hematuria, flank pain, suprapubic pain, or fever. She denies itching or vaginal discharge. A urine specimen taken earlier in the week showed significant pyuria but a culture resulted in no growth. She has taken an antibiotic for 2 days without relief. Her only other medication is an oral contraceptive agent. Which one of the following is the most likely infectious agent? ACandida albicans BChlamydia trachomatis CEscherichia coli DStaphylococcus saprophyticus

Chlamydia trachomatis #obligate intracellular organism hence not found on culture Chlamydia Cervicitis Diagnosis is made by nucleic acid amplification testing (NAAT) Most commonly caused by Chlamydia trachomatis Treatment is doxycycline (100 mg BID x 7 days), azithromycin should be used in pregnancy Reinfection testing after treatment: Nonpregnant: three months after treatment or at the first visit in the 12 months after treatment Pregnant: four weeks after treatment Most commonly reported sexually transmitted disease in the United States Consider empirically treat for concomitant gonorrhea if high risk The USPSTF recommends routine screening for chlamydia and gonorrhea in sexually active women < 25 years of age and in women age ≥ 25 years who are at increased ri

A 40-year-old woman presents with acute onset right upper quadrant pain, nausea, and vomiting. It began 18 hours ago after a fatty meal, and has progressively worsened. She is febrile and has tenderness in the right upper quadrant. She is not jaundiced. Blood tests are significant for a leukocytosis but only mildly elevated liver enzymes, bilirubin, and amylase. Ultrasound examination reveals gallbladder wall thickening and pericholecystic fluid. The common bile duct is patent. Which of the following is the most likely diagnosis? ABiliary colic BCholangitis CCholecystitis DCholedocholithiasis

Cholecystitis Cholecystitis Sx: colicky, steadily increasing RUQ or epigastric pain after eating fatty foods, fever PE: Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula) DiagnosisInitial: U/S Gold standard: HIDA Most commonly caused by obstruction by a gallstone Acalculous disease can occur in critically ill Treatment is cholecystectomy, antibiotics; percutaneous cholecystostomy tube in critically ill

n the evaluation of a patient with nystagmus, you suspect the main cause is peripheral vestibular dysfunction. You decide to perform caloric testing. Which of the following physical exam findings is expected in a patient with normal vestibular function? ACold water in the right ear produces nystagmus to the left BCold water in the right ear produces nystagmus to the right CWarm water in the left ear produces nystagmus to the right DWarm water in the right ear produces nystagmus to the left

Cold water in the right ear produces nystagmus to the left

Which of the following describes the most common presentation of an acute bowel obstruction? AColicky abdominal pain, distention, and emesis BFever, crampy abdominal pain, nausea, vomiting, and diarrhea CNausea, anorexia, and pain in the right lower quadrant DWatery diarrhea with diffuse abdominal pain and weight loss

Colicky abdominal pain, distention, and emesis cardinal manifestations of acute intestinal obstruction. Patients may appear to be critically ill and if experiencing volume depletion, may also experience oliguria, hypotension, and tachycardia. Important elements of the history include prior surgeries or any history of cancer or inflammatory bowel disease. Small Bowel Obstruction History of prior abdominal or pelvic surgery Bilious vomiting PE may show high-pitched bowel sounds X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Diagnosis is made by imaging Treatment is NPO, IVF, NGT, surgery --------------------------------------------------------- Fever, crampy abdominal pain, nausea, vomiting, and diarrhea (B) is a typical presentation of acute gastroenteritis which is usually self-limited. However, it may be complicated by dehydration and last up to 14 days. Nausea, anorexia,and pain in the right lower quadrant (C) are findings consistent with acute appendicitis which is treated surgically. Watery diarrhea with diffuse abdominal pain and weight loss (D) can be seen with chronic diarrhea which is defined by frequent loose stools lasting four weeks or longer.

A 56-year-old man presents to the emergency department with a 5-day history of constipation. He has a history of seasonal allergies, hypertension, and ulcerative colitis. His vital signs are within normal limits. Laboratory studies reveal microcytic, hypochromic anemia. Physical exam reveals an empty rectal vault. A fecal occult blood test is positive. Which of the following is the most likely diagnosis? AColorectal carcinoma BDrug-induced constipation CIntestinal obstruction due to adhesions DToxic megacolon

Colorectal carcinoma Second leading cause of death Third most common cancer in men and women Adenocarcinoma Risk factors: age, IBD, adenomatous polyps, FAP, HNPCC Rectosigmoid > ascending > descending Left-sided cancer: tends to obstruct Right-sided cancer: tends to bleed Iron deficiency anemia Colonoscopy CEA ----------------------------------------------- . Toxic megacolon (D) is a potential complication of ulcerative colitis, but the most common presentation is severe, bloody diarrhea that is resistant to treatment. The majority of patients with toxic megacolon are febrile and have altered mental status, tachycardia, hypotension, and lower abdominal distension.

A 45-year-old woman presents to your office with a complaint of pain "all over." She tells you that over the past few years her pain has worsened and she also experiences daily fatigue, difficulty concentrating, and headaches. Physical exam reveals multiple points of tenderness to palpation. Which of the following lab results would be expected? ADecreased vitamin B12 BElevated erythrocyte sedimentation rate CElevated thyroid stimulating hormone DNormal complete blood count

Normal complete blood count dx: Fibromyalgia

Which of the following patients is at greatest risk of developing West Nile meningoencephalitis? A22-year-old man status post kidney transplant B3-year-old girl who is unvaccinated C58-year-old man with diabetes and hypertension D82-year-old woman with dementia

82-year-old woman with dementia West Nile Virus Mosquitos Summer and fall Flulike Sx, URI Sx, rash Complication: meningoencephalitis The biggest risk factor, by far, for neuroinvasive West Nile disease is advanced age.

acute prostatitis tx

< 35 years old: N. gonorrhoeae, C. trachomatis > 35 years old: E. coli Treatment < 35 years old: ceftriaxone IM and doxycycline > 35 years old: fluoroquinolone or TMP-SMX for 4 weeks Acute Bacterial Prostatitis Sx: fever, chills, perineal or pelvic pain, and dysuria PE: boggy and exquisitely tender prostate Most common causes

Lung cancer Hemoptysis Diastolic murmur: mitral stenosis Sudden SOB, chest pain: PE Trauma: pulmonary contusion Immunodeficiency, immigrant: TB Hx of TB or sarcoidosis: aspergilloma Kidney dysfunction: Goodpasture syndrome or granulomatosis with polyangiitis (GPA, previously Wegener) Hx of tobacco use, weight loss: malignancy Massive hemoptysis: ≥ 100 mL/hour or ≥ 500 mL over 24 hours Massive hemoptysis Rx: patient in bleeding side down position, mainstem bronchus intubation

A 55-year-old smoker presents to the ED with hemoptysis and dyspnea for four weeks. His vital signs are T 37°C, BP 146/76 mm Hg, HR 85 bpm, RR 20 per minute, and oxygen saturation 96% on RA. His lung exam reveals distant breath sounds on the left side. His chest X-ray is shown above. What is the most likely cause of his hemoptysis? ABronchitis BLung cancer CPneumonia DPulmonary embolism

Antagonizes the membrane actions of potassium Calcium gluconate antagonizes the membrane actions of potassium and also helps treat or prevent hypocalcemia, which can increase the effects of hyperkalemia on the heart allowing for stabilization of the cardiac membrane.

A 75-year-old man with poorly controlled advanced kidney injury presents to the emergency department via EMS from home in cardiac arrest. EMS reports the patient is on dialysis but has not been able to attend his last three appointments due to social complications. Your team continues the advanced cardiac life support algorithm for one more round when there is return of spontaneous circulation. An ECG of the patient's cardiac rhythm is shown above. Complete blood count, complete metabolic panel, venous blood gas, and cardiac enzymes are obtained. The complete blood cell count and cardiac enzymes are unremarkable. The complete metabolic panel shows the following: sodium 132 mEq/L, potassium 8.0 mEq/L, glucose 110 mg/dL, Cr 4.0 mg/dL, BUN 30 mg/dL. The venous blood gas shows the following: pH of 7.35, bicarbonate 33 mmol/L, anion gap 8 mEq/L, pO₂ 60 mm Hg, and PCO₂ 36 mm Hg. What is the mechanism of action of the first-line drug used to reverse the precipitating condition causing this patient's cardiac arrest? AAntagonizes the membrane actions of potassium BBinds potassium in exchange for other cations CEnhances the sodium-potassium pump of skeletal muscle DIncreases potassium excretion EIncreases systemic pH

10-week-old boy is brought to the emergency department in late December by his parent who reports that he has had difficulty breathing for the past 24 hours. His other parent has been sick with an upper respiratory tract infection. Vital signs are notable for a respiratory rate of 60/min and oxygen saturation of 99% on room air. Examination reveals significant rhinorrhea, intercostal retractions, bilateral expiratory wheezes, and crackles at the bases. Nasal suctioning is performed with minimal improvement. He has normal urine output. Which of the following is the most appropriate next step in management? AAdminister high-flow nasal cannula oxygen and admit to a monitored bed for continued respiratory support BAdminister nebulized albuterol with high-flow nasal cannula oxygen and admit to a monitored bed for continued respiratory support CAdminister prednisolone and albuterol nebulizer before discharging with recommendations for next-day pediatrician follow-up DPerform a chest X-ray and administer empiric antibiotics

Administer high-flow nasal cannula oxygen and admit to a monitored bed for continued respiratory support dx: bronchiolitis Occurs primarily in children ≤2 years old 1-3 day prodromal URI symptoms PE: tachypnea, retractions, polyphonic wheezing, and rales Diagnosis is made by history and physical exam Most commonly cause: respiratory syncytial virus (RSV) Treatment is supportive care Treatment Nonsevere bronchiolitis • Anticipatory guidance, nasal suctioning, hydration Severe bronchiolitis • Trial of inhaled bronchodilator (controversial) • Heated humidified high-flow nasal cannula • Continuous positive airway pressure • Endotracheal intubation

A 32-year-old woman presents with fever and lower abdominal pain. She has a history of pelvic inflammatory disease. Her vital signs are T 38.4°C, HR 133 bpm, and BP 101/60 mm Hg. On examination, the patient is toxic appearing and has marked lower abdominal tenderness to palpation with rebound and guarding. Pelvic examination reveals cervical motion tenderness, scant discharge, and left adnexal tenderness. The patient's urine pregnancy test is negative. A transvaginal ultrasound is performed and reveals a complex cystic, thick-walled, well-defined mass in the left adnexa. Which of the following is the most appropriate next step in management? AAdminister ceftriaxone and discharge home with a 14-day course of doxycycline BBegin intravenous antibiotics and admit for possible drainage CObtain a CT scan to rule out appendicitis DSend a serum pregnancy test to rule out ectopic pregnancy

Begin intravenous antibiotics and admit for possible drainage dx: tubo-ovarian abscess (TOA) Most commonly caused by a complication of pelvic inflammatory disease Sx: lower abdominal pain, fever, vaginal discharge PE: unilateral adnexal tenderness Dx: pelvic ultrasound Tx: intravenous antibiotics, surgical drainage, or both

Which of the following correctly describes physiologic changes that occur in pregnancy? ABlood volume increases BFunctional residual capacity increases CGastrointestinal motility increases DHemoglobin concentration increases

Blood volume increases ------->look at image------>

You are called to the emergency department to see a 5-year-old boy for ingestion. He was playing in the garage when his parent found him with an opened bottle of antifreeze. The liquid was all over his mouth and clothes. He had two episodes of vomiting and fell asleep on the way to the hospital. On physical examination, you note tachycardia. Which of the following laboratory abnormalities would you expect in this type of ingestion? ACalcium oxalate crystals in urine BDecreased lactate levels CHypercalcemia DNon-anion gap metabolic acidosis

Calcium oxalate crystals in urine dx:Ethylene glycol is commonly found in antifreeze. History of ingestion of antifreeze, solvents, windshield wiper fluid, cleaners, fuels, deicing solutions Flank pain, hematuria, and oliguria Labs: anion gap metabolic acidosis, ↑ osmol gap, hypocalcemia, acute kidney injury, calcium oxalate crystals in urine, fluorescent urine under Wood lamp Tx: fomepizole For severe metabolic acidosis, consider hemodialysis, sodium bicarbonate

A 47-year-old woman presents with several months of a persistent cough that recently resulted in hemoptysis. A review of system also confirms episodes of diarrhea, rash, and flushing. Physical exam is normal with the exception of focal wheezing over the right upper lobe. Which of the following is the most likely diagnosis? AAlpha-1-antitrypsin deficiency BCarcinoid tumor CPulmonary hypertension DPulmonary tuberculosis

Carcinoid Syndrome Patient presents with skin flushing, wheezing, and diarrhea Diagnosis is made by 24-hour excretion of 5-hydroxyindoleacetic acid in the patient's urine Most commonly caused by carcinoid tumors (neuroendocrine tumors that secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides)

A 60-year-old man presents to your clinic with uncontrolled diabetes and a history of chronic kidney disease. He is unable to tolerate metformin and wants to try another oral hypoglycemic drug rather than starting insulin. Which of the following sulfonylureas would put the patient at highest risk of hypoglycemia and should therefore be avoided? AGliclazide BGlimepiride CGlipizide DGlyburide

Glyburide What receptor on pancreatic beta cells do sulfonylureas bind to? Answer: The adenosine triphosphate potassium channel. Sulfonylurea Toxicity Mechanism: increase insulin secretion Can cause hypoglycemia 24 hrs after ingestion Can cause severe hypoglycemia in children Rx: charcoal, dextrose, octreotide

A 41-year-old previously healthy woman presents to the ED with gingival bleeding and epistaxis over the past four days. She takes no medications and has no recent travel. You note scattered petechiae, but otherwise physical exam is normal. Her hemoglobin is 12.5 g/dL, international normalized ratio 1.1, PTT 25 seconds, and platelets 14,000/µL. A peripheral blood smear shows few large, well-granulated platelets. Which of the following is the most appropriate initial treatment? ACorticosteroids and immunoglobulin BObservation CPlatelet transfusion DSplenectomy

Corticosteroids and immunoglobulin dx Immune thrombocytopenia (ITP)- Pediatric 2-6 years old Antiplatelet autoantibodies H/o recent viral infection Non-blanching petechiae/purpura, gingival bleeding Labs: platelets < 100,000/µL, normal WBC, normal hematocrit Tx: activity restriction, observation, glucocorticoids and IVIG or IV anti-D if severe

A patient was treated for an upper respiratory tract infection 2 weeks ago. She now presents with one day of 7/10 facial pain with bending forward, as well as difficulty blowing her runny nose. Examination reveals frontal bone tenderness to percussion and nasal erythema and drainage. Her temperature is 100°F. Which of the following is the most appropriate management option for this patient? AAntihistamines BComputed tomography of the frontal sinuses CDecongestants DOtolaryngological referral

Decongestants dx: Rhinosinusitis Treatment begins with analgesics, decongestants and saline nasal irrigation. If the presenting temperature is greater than 101°F, or symptoms are severe or worsening or last longer than 7 days, begin antibiotic treatment with amoxicillin-clavulanate. Acute Sinusitis Sx: nasal congestion, pain or pressure over sinuses, ear pain or pressure, headache, fever PE: purulent rhinorrhea Most commonly caused by viral URI If viral, tx: supportive care Bacterial sinusitis: purulent nasal secretions and severe symptoms for ≥ 10 daysAmoxicillin-clavulanate Complications: frontal bone osteomyelitis (Pott puffy tumor), orbital cellulitis, sinus venous thrombosis, extension into meninges/brain

Which of the following is most likely to be seen on the physical exam of a patient with hypothyroidism? AAlopecia areata BDelayed relaxation of deep tendon reflexes CLid lag DOnycholysis

Delayed relaxation of deep tendon reflexes Hypothyroidism Sx: generalized weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain PE: periorbital edema, dry skin, and coarse brittle hair Labs: high TSH and low free T4 Most commonly caused by Hashimoto thyroiditisDx: antithyroid peroxidase and antithyroglobulin autoantibodies Tx: levothyroxineTakes about 6 weeks to see treatment effects Monitor TSH Hashimoto: risk factor for non-Hodgkin lymphoma

A patient presents with excessive urination and thirst. A comprehensive metabolic panel is normal. Urinalysis is significant for a low specific gravity. Which of the following is the most appropriate next test to order for the evaluation of these symptoms? ACosyntropin stimulation test BDesmopressin stimulation test CDexamethasone suppression test DOctreotide suppression test

Desmopressin stimulation test dx: Diabetes insipidus is a disorder of antidiuretic hormone (ADH) function

A 62-year-old man with a past medical history of type 2 diabetes mellitus, asthma, and morbid obesity presents to the cardiology clinic for radionuclide myocardial perfusion imaging. He was referred to the clinic after he went to the emergency department complaining of chest pain, and acute coronary syndrome was ruled out. The patient is wheelchair bound and states he cannot walk for more than a minute or two due to his diabetic neuropathy. When asked, he also states he had a cup of coffee that morning with his breakfast. Which of the following agents is most appropriate for conducting a pharmacologic stress test in this patient? AAdenosine BAtropine CDipyridamole DDobutamine

Dobutamine Dobutamine is a selective beta-1 adrenergic agonist that increases heart rate and myocardial contractility to pharmacologically stress the heart. For myocardial perfusion imaging, dobutamine is considered a second-line agent in patients who cannot receive a vasodilator. Contraindications to the use of dobutamine include moderate-to-severe hypertension (i.e., systolic blood pressure > 180 mm Hg), unstable angina, infarction within the past three days, or dysrhythmias (e.g., atrial fibrillation with rapid ventricular response ------------------------------------------------------------------ Atropine (B) is a muscarinic antagonist used to increase heart rate. Atropine is useful as an adjunct to dobutamine when it is not able to stress the heart sufficiently to perform the exam, but is not used alone for this indication.

Which of the following is the most common location of aortoenteric fistula formation? ⭐️ ADuodenum BEsophagus CJejunum DSigmoid colon

Duodenum Aortoenteric Fistula History of AAA, aortic repair, aortic graft replacement Reports rectal bleeding PE will show signs of shock Management includes blood transfusion or resuscitation and emergent surgical consultation TRIAD • Gl bleeding • Abdominal pain • Palpable mass

Which of the following physical exam findings can aid in differentiating the cause of crackles or rales, heard on lung auscultation? AClubbing BEgophony CPercussion DRespiratory rate

Egophony Egophony is performed by asking the patient to say "EEE" while auscultating. If an "AH" sound is heard instead of "EEE", then this indicated an abnormal finding. This is secondary to the sound being transmitted through an area of consolidated parenchyma. This is present in pneumonia, but not in other conditions of abnormal alveolar filling such as interstitial fibrosis. This physical exam finding can help differentiate between pneumonia and other lung conditions such as bronchitis or emphysema. --------------------------------------------------------------- What other physical exam finding may be useful in differentiating the cause of rales? Answer: Whispered pectoriloquy.

A G2P2 46-year-old woman presents to her gynecologist's office with a six month history of irregular, heavy menses. She states her cramps are no worse than usual and she does not have dyspareunia or postcoital bleeding. On physical exam, she has a body mass index of 32 kg/m2. A bimanual examination reveals a normal-appearing cervix and a smooth, regularly-shaped uterus that is not enlarged. Which of the following is the most likely diagnosis? AAdenomyosis BCervical polyps CEndometrial hyperplasia DUterine leiomyoma

Endometrial hyperplasia most common cause of abnormal uterine bleeding in older, obese women

A patient complains of new onset hematuria, left flank pain and unintentional weight loss. Her past medical history is significant for chronic hypertension and tobacco use. Abdominopelvic imaging reveals a mass within the confines of the left renal capsule. A surgical biopsy is taken. When considering the most common kidney cancer in adults, the histology report of this patient's biopsy would most likely describe abnormalities of which of the following cells? AConnective tissue cells of the renal stroma BEpithelial cells of the proximal convoluted tubule CStromal cells of the metanephrogenic blastema DTransitional cells of the renal pelvis

Epithelial cells of the proximal convoluted tubule Renal Cell Carcinoma History of smoking Classic triad: Flank pain, palpable abdominal renal mass, hematuria Treatment is nephrectomy

44-year-old woman complains of progressive unilateral hearing loss. She now is almost deaf in her left ear. In addition, her physical examination is significant for balance deficits. MRI scanning shows a large tumor arising from the vestibular division of the eighth cranial nerve. Which of the following is the recommended management of this tumor? AChemotherapy BExcision microsurgery CSerial monitoring DStereotactic radiation

Excision microsurgery Vestibular Schwannoma Formerly known as acoustic neuroma Patient presents with gradual hearing loss, tinnitus, balance disturbance Diagnosis is made by MRI with gadolinium Most commonly caused by CN VIII tumor Management includes observation, microsurgical excision, or stereotactic radiotherapy

Tonya is a 35-year-old nurse who presented to the emergency department last week for a neurologic event. Today she presents with fatigue, generalized dull aching, decreased color vision in her left eye, and right arm and leg weakness that has lasted for 48 hours. A magnetic resonance imaging study of the brain showed no evidence of a stroke but revealed scattered T2 lesions. What is the treatment for this acute episode? AGlatiramer BHigh-dose corticosteroids CInterferon beta DLow-dose corticosteroids

High-dose corticosteroids dx: multiple sclerosis Multiple Sclerosis Demyelinating CNS lesions separated in space and time Risk factors: female sex, age < 30, birth at northern latitude (possibly linked to vitamin D deficiency) Sx: pain with eye movement, monocular vision loss, diplopia with lateral gaze, sensory abnormalities PE: afferent pupillary defect (Marcus Gunn pupil), spinal electric shock sensation with neck flexion (Lhermitte sign), impaired bilateral adduction (bilateral internuclear ophthalmoplegia) Dx: MRI: periventricular white matter lesions CSF: oligoclonal IgG bands, WBC pleocytosis Tx: Acute exacerbation: methylprednisolone Disease modifying: natalizumab, ocrelizumab, glatiramer acetate*, interferon beta-1a* Note: Natalizumab associated with PML, test for JC virus antibodies

Which of the following is the best initial diagnostic tool to assist in diagnosing the patient presenting with altered bowel habits? AAbdominal ultrasonography BFlexible sigmoidoscopy CHistory and physical examination DPsychometric screening

History and physical examination dx: Irritable bowel syndrome is one of the most common gastrointestinal illnesses and is characterized by abdominal pain and altered bowel habits (diarrhea, constipation, or both) in the absence of any organic cause. It is typically a diagnosis of exclusion based on history and physical and several negative diagnostic studies. -------------------------------------------------------- Flexible sigmoidoscopy (B) provides an internal exam of the lower part of the large intestine, allowing inspection of the rectum and sigmoid colon.

An 18-year-old man presents with questions about his diagnosis of sickle cell anemia. He has been managing his condition since childhood by treating his symptoms and having occasional blood transfusions. Now he is experiencing more frequent painful episodes and wants to know whether there are other treatment options. Which of the following is the most appropriate pharmacologic treatment? AFerrous sulfate BHydroxyurea COxycodone DPrednisone

Hydroxyurea

A 40-year-old woman presents with weakness, fatigue, nausea, and diarrhea. Physical exam reveals orthostatic hypotension and axillary fold hyperpigmentation. Which of the following laboratory abnormalities would you expect to find in this patient? AHypercalcemia BHypermagnesemia CHypokalemia DHyponatremia

Hyponatremia dx: Primary adrenal insufficiency (Addison disease), or hypocortisolism, most specific sign of primary adrenal insufficiency is hyperpigmentation, typically of the mucous membranes, axillary folds, and nipples. Another specific symptom of primary adrenal insufficiency is salt craving. Because the adrenal cortex is damaged, aldosterone levels are also affected. Primary Adrenal Insufficiency (Addison Disease) Sx: abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE: hyperpigmentation of skin and mucus membranes and hypotension Labs: hyponatremia and hyperkalemia Most commonly caused by autoimmune destruction of the adrenal cortex Tx: hydrocortisone or other glucocorticoid Most patients also require mineralocorticoid (fludrocortisone)

A 27-year-old woman presents in the fall for her first prenatal visit. Her last menstrual period started 8 weeks ago. The patient reports she is in a monogamous relationship with one male partner. She has a family history of diabetes mellitus but has never been diagnosed with diabetes herself. Her body mass index is 21 kg/m2. 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 findings include a soft and nontender abdomen, no blood in vaginal vault, and a closed cervical os. Transvaginal ultrasound shows an intrauterine fetal pole with a fetal heart rate. Which of the following is indicated at this prenatal visit? A24-hour urine collection for protein BFasting blood glucose level CGroup B Streptococcus screening DInactivated influenza vaccine ENucleic acid amplification testing for COVID-19

Inactivated influenza vaccine regardless of trimester. Influenza vaccination is particularly important for patients who are pregnant since they are at increased risk of hospitalization, intensive care unit admission, or death from seasonal influenza.

A newborn infant in the neonatal intensive care unit is being treated for neonatal sepsis with intravenous antibiotics, which include gentamicin every eight hours. Prior to the fourth dose, a gentamicin level of 5.5 µg/ml is obtained (range < 2 µg/ml). What is the next appropriate step in management? AIncrease interval of dosing to every 12 hours and recheck level BIncrease intravenous fluid administration CMaintain current dose and continue to monitor levels DReplace gentamicin with tobramycin

Increase interval of dosing to every 12 hours and recheck level Aminoglycosides are used in combination with other antibiotics in the treatment of neonatal sepsis. Trough levels are obtained before the fourth dose in order to monitor for toxicity. An aminoglycoside level > 2 µg/ml is associated with increased risk for ototoxicity, nephrotoxicity, and neuromuscular blockade. In cases of elevated trough levels, either the interval between doses can be increased, or the dose can be decreased. The trough level should be rechecked every three to five doses. Target peak levels of gentamicin are between eight to 10 µg/ml and are usually checked 30 minutes after the initial dose is given. In general, peak levels are related to efficacy and trough levels with the risk of toxicity. The data have shown that 24-hour dosing of gentamicin is more efficacious and less toxic. What is the mechanism of action of aminoglycosides? Answer: They inhibit protein synthesis by binding to the 30S subunit of the bacterial ribosome.

A 62-year-old man presents to the clinic for a physical exam. He smokes one pack of cigarettes per day, drinks four beers per day, and exercises once per week. He takes no medications and has not had a physical exam in years. Vital signs include a blood pressure of 150/90 mm Hg, heart rate of 80 bpm, respirations of 16/minute, and body mass index of 20 kg/m2. Physical exam reveals a well-nourished man with a slightly plethoric face, clear lungs, and normal cardiac rate and sounds. Pedal pulses are equal and strong. CBC and CMP are within normal limits with a fasting blood glucose of 80 mg/dL. Glycosylated hemoglobin is 5.5%. Lipid panel results are as follows: Total cholesterol: 161 mg/dL LDL: 82 mg/dL HDL: 36 mg/dL Triglycerides: 191 mg/dL VLDL: 43 mg/dL Which of the following risk factors is the most likely cause of this patient's primary diagnosis? AAge BGenetic disorder CHypertension DIncreased consumption of alcohol ESmoking

Increased consumption of alcohol dx: Hypertriglyceridemia is defined as elevated triglycerides in the bloodstream, the normal range being under 150 mg/dL. Serum triglyceride levels between 150 mg/dL and 499 mg/dL are considered high, while levels over 500 mg/dL are described as severely elevated. The most common risk factors for hypertriglyceridemia are obesity, metabolic syndrome, and type 2 diabetes mellitus. others= excessive consumption of alcohol, lack of exercise, use of certain medications, and genetic disorders. Lifestyle management is the first-line therapy for hypertriglyceridemia and includes weight loss, increased physical activity, and lower carbohydrate and fat intake. Medication is not indicated unless the patient is between 45 and 70 years old and also has elevated cholesterol and increased risk for cardiovascular disease, or the patient has triglyceride levels above 500 mg/dL First-line therapy for hypertriglyceridemia in the presence of elevated cholesterol and cardiovascular risk is statin drugs. First-line therapy for isolated severe hypertriglyceridemia is fibrates or omega-3 fatty acid derivatives.

A 17-year-old girl is seen in clinic due to complaints of excessive body hair. She denies taking any medication. She has irregular menses and denies sexual activity. On exam, her BMI is 31, with moderate hirsutism on upper lip and chest, moderate acne on her face, Tanner 5 breasts and pubic hair. The rest of her exam findings are normal. Which of the following is an expected laboratory finding? AIncreased cortisol BIncreased follicle-stimulating hormone CIncreased luteinizing hormone DIncreased thyroid-stimulating hormone

Increased luteinizing hormone dx:PCOs Polycystic Ovary Syndrome (PCOS) Ovulatory dysfunction, hyperandrogenism, and polycystic ovaries Common PE findings: bilateral ovarian enlargement, acanthosis nigricans, high BMI Laboratory evaluation: Oligomenorrhea: hCG, FSH, TSH, prolactin Hyperandrogenism: total testosterone and sex hormone-binding globulin or bioavailable and free testosterone, morning 17-hydroxyprogesterone Metabolic disease screening: 2-hour oral glucose tolerance test, fasting lipid panel Commonly associated with insulin resistance, which may be the central etiology Treatment is combination low-dose oral contraceptive pills, lifestyle changes, metformin Most common cause of infertilityLetrozole is first-line therapy for ovulation induction There is gonadotrophic dysregulation with increased luteinizing hormone (LH) pulsatility and abnormally high ratios of circulating LH to follicle-stimulating hormone (FSH).

A 35-year-old man presents to the emergency department four hours after being bitten on his left hand by a spider while cleaning out his shed. He currently complains of whole arm pain as well as headache, severe back spasms, and abdominal pain. What is the treatment of choice to control his symptoms? AIntravenous calcium gluconate BIntravenous diazepam CIntravenous ketorolac DIntravenous normal saline

Intravenous diazepam dx: black widow Treatment Mainly supportive (opioids and benzodiazepines) Antivenom Yes, but reserved for severe symptoms -------------------------------------------------------------- ntravenous ketorolac (C) is an analgesic which may provide some pain relief but does not adequately provide relief caused by severe muscle cramps and spasms associated with black widow bite envenomations.

A 10-year-old boy presents to the emergency department with nausea, vomiting, perioral numbness, blurry vision, and feeling his tactile sensation of hot temperature seems off. He reports eating out and having grouper at a local restaurant. No other family members report illness. Which of the following is the most appropriate treatment? AActivated charcoal BAntihistamine CHemodialysis DIntravenous fluids and antiemetics

Intravenous fluids and antiemetics dx:poisoning is most consistent with ciguatera toxicity.

A 60-year-old man presents to his primary care provider with complaints of left eyelid swelling and eye pain. Two weeks ago, he was treated at the clinic for sinusitis. Physical exam reveals a febrile man with a swollen and erythematous left eyelid. Extraocular movements are painful. Visual acuity is unaffected. Which of the following is the most appropriate management? ACiprofloxacin ophthalmic 0.3% ointment BHigh-dose oral amoxicillin-clavulanate CIntravenous vancomycin and ceftriaxone DOral cephalexin

Intravenous vancomycin and ceftriaxone dx:Orbital cellulitis

A 14-year-old girl presents with right thigh pain that has been going on for the last month. She recalls being kicked in the leg during soccer practice before her symptoms started. She was last seen in the ED 2 weeks ago and was diagnosed with a muscle contusion. On exam, there is a mass palpable over the anterior distal thigh. X-ray of the femur shows a distal femoral diaphyseal lesion with cortical destruction and periosteal reaction in a sunburst pattern. Which of the following is true regarding the most likely diagnosis? ABlunt trauma is associated with the pathogenesis BIonizing radiation for childhood cancer is a risk factor CIt most often involves the axial skeleton followed by the long bones DPathologic fracture is a common presenting sign

Ionizing radiation for childhood cancer is a risk factor Osteosarcoma Patient will be 10 to 20 years old or > 65 Pain, swelling that awakens at night X-ray will show Codman triangle, sunburst pattern Most common location: long bone metaphyses Most common malignant bone tumor

During a well-child visit, a 9-year-old boy and his father ask about health safety and sports activity. The boy wants to play baseball. His medical history is significant for tetralogy of Fallot, which was surgically corrected when he was 3-years-old. His last echocardiogram shows a right ventricular pressure to be < 50 mm Hg. Which of the following recommendations do you make? AA functional capacity evaluation is needed first BHe may only play leisure sports, like golf or cycling CIt is safe for him to play any sport, including baseball DThe boy should abstain from all sports and physical education class

It is safe for him to play any sport, including baseball There are no restrictions on any sport activity, including competition and contact sports, in patients who have had surgical correction of tetralogy of Fallot and whose right ventricular pressure is < 50 mm Hg. but otherwise maybe

A 59-year-old woman with a history of poorly controlled hypertension presents to the emergency room for a sudden, very severe headache that began 7 hours ago. She is disoriented and vomiting. A CT of her head showed no acute abnormalities. Which of the following is the next best step in her management? AElectroencephalogram BLumbar puncture CMRI head DSupportive care

Lumbar puncture dx: spontaneous subarachnoid hemorrhage (SAH) #berry aneurysm ---> If CT negative and performed within 6 hours of symptom onset, subarachnoid hemorrhage effectively ruled out ---> If CT negative and suspicion high, lumbar puncture or CT angiography Most commonly caused by a ruptured aneurysm Hunt & Hess classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm)

A patient diagnosed with sarcoidosis presents with erythema nodosum, hilar adenopathy and migratory polyarthralgia. This presentation is characteristic of which of the following syndromes? ABoerhaaves syndrome BCrigler-Najjar syndrome CHorner's syndrome DLöfgren syndrome

Löfgren syndrome

A 32-year-old G1P0 woman presents to labor and delivery at 37 weeks gestation for elevated blood pressure and proteinuria noted in her obstetrician's office. The patient endorses a mild temporal headache and nausea. Blood pressure is found to be 168/102 mm Hg. On physical examination, there is edema of bilateral hands and hyperreflexia. On laboratory studies, the patient has 4+ protein on urine dipstick. There is no evidence of hemolytic anemia or thrombocytopenia, but liver enzymes are elevated. In addition to urgently preparing for delivery, which of the following would be the most appropriate next step in the patient's management? ABetamethasone to promote fetal lung maturity BIntravenous nitroprusside to reduce blood pressure CMagnesium sulfate for seizure prophylaxis DVigorous intravenous hydration to prevent renal failure

Magnesium sulfate for seizure prophylaxis #but not prevention =use ASA for prevention Preeclampsia Pregnancy > 20 weeks gestation or postpartum Visual disturbances, severe headaches, or asymptomatic Evaluation will show new-onset hypertension (≥ 140/90 mm Hg) with either proteinuria (≥ 300 mg/24 hr or urine protein: creatinine ratio ≥ 0.3) OR significant end-organ dysfunction Treatment: delivery at 37 weeks (without severe features) and 34 weeks (with severe features) AND prevention of seizures with magnesium sulfate and prevention of permanent maternal organ damage New-onset hypertension < 20 weeks gestation: suspect molar pregnancy

A 66-year-old man with Type 2 diabetes presents complaining of right ear pain and drainage for the past 3 weeks. He states the pain is deep in the ear and that the drainage is greenish and foul-smelling, and has increased over the past 3 weeks. He denies cough, congestion, fever, or placing anything in his ear. On physical examination, the patient is afebrile. Otoscopic examination reveals a markedly edematous right ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Examination of the left ear is unremarkable. Which of the following is the most likely diagnosis? AAcute mastoiditis BAuricular cellulitis CChronic otitis externa DMalignant otitis externa

Malignant otitis externa 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 -------------------------------------------------------- Chronic otitis externa (C) presents commonly with pruritus and rarely is associated with ear pain. It is usually caused by irritation from repeated minor trauma to the ear canal or drainage from a chronic middle ear infection.

Which of the following drugs can cause mydriasis in overdose? AHydromorphone BLorazepam CMeperidine DParaquat

Meperidine However, unlike most other opioids, meperidine can cause mydriasis (dilated pupils) in cases of toxicity. Increased muscle tone, twitching, and tremors may also be seen with meperidine overdose. The half-life of normeperidine is up to 48 hours and subsequent hallucinations, seizures and psychosis may result. Therefore, meperidine is not routinely used for the management of acute pain in the emergency department. Meperidine can also potentially interact with monoamine oxidase inhibitors and cause serotonin syndrome. ------------------------------------------------------------- vs Hydromorphone (A) is a semisynthetic morphine derivative. Like most other opioids, it causes miosis (pinpoint pupils) in cases of overdose. Lorazepam (B) and other benzodiazepines do not cause pupillary changes in overdose. Paraquat (D) is a herbicide that is activated by sunlight and primarily affects the lungs, causing pulmonary fibrosis and respiratory failure. It typically does not have effects the central nervous system.

A 27-year-old man with a history of asthma presents to your office for his annual exam. He reports that in the past month he has experienced wheezing and shortness of breath about once per week which resulted in using his rescue inhaler. He woke up once because of coughing. He has a peak flow meter and home readings have been 85-90% of his personal best. Which of the following best describes the classification of his asthma? AMild intermittent BMild persistent CModerate persistent DSevere persistent

Mild intermittent Intermittent Symptoms ≤ 2 days/week≤ 2 nighttime awakenings/monthFEV1 > 80% of predicted Mild persistent Symptoms > 2 days/week but < daily> 3-4 nighttime awakenings/monthFEV1 ≥ 80% of predicted Moderate persistent Symptoms daily> 1 nighttime awakening/week but not nightlyFEV1 60-80% of predicted Severe persistent Symptoms throughout the dayNightly awakenings commonFEV1 < 60% of predicted

In addition to stool softeners, which of the following can be used topically in the management of midline anal fissures? AFentanyl BMupirocin CNitroglycerin DSucrose

Nitroglycerin Its vasodilatory properties increase blood flow to injured tissue, and it also reduces pressure in the internal anal sphincter, which decreases pain during defecation. The ointment is applied two to three times daily at the anal opening. Other treatment modalities include fiber diets, sitz baths, laxatives, botulinum toxin, topical nifedipine (a calcium channel blocker), and surgery. Anal Fissure Patient presents with rectal pain and bleeding that occurs with or shortly after defecation PE will show fissure located in the posterior midline Diagnosis is made by visual inspection Treatment is stool softeners, protective ointments, sitz baths, topical nitroglycerin or nifedipine If fissures are located laterally, search for pathologic etiologies

A 67-year-old woman with no significant medical history presents to her gynecologist's office for her routine annual exam. The patient's last Pap smear and HPV cotesting were negative 2 years ago. She has not had any previous abnormal Pap smears. The patient smokes tobacco daily and uses alcohol socially. She continues to be sexually active with her partner of 33 years. Her vital signs are a HR of 74 bpm, RR of 17/min, SpO2 of 99% on room air, BP of 128/86 mm Hg, T of 98.1°F, and BMI of 33.6 kg/m2. On physical exam, her vaginal canal is slightly atrophic, the cervix visualized without scarring or erythema, and there is no tenderness on bimanual exam. What is the most appropriate recommendation for cervical cancer screening for this patient? ANo further testing BPap smear and HPV testing at this visit CRepeat Pap test and HPV testing in 5 years DRepeat Pap test in 3 years ERepeat Pap test in 5 years

No further testing According to the United States Preventative Services Task Force (USPSTF), cervical cancer screening should be done between 21 and 65 years of age, regardless of the patient's sexual activity and HPV vaccine status. Screening should stop after age 65 if the patient has a history of negative Pap smears previously. Therefore, this patient requires no further testing. The only exception to discontinuing Pap testing before the age of 65 is if the patient has had a hysterectomy. What is the most common cause of cervical carcinoma? Answer: HPV, especially types 16 and 18.

A 10-year-old boy presents to the clinic with easy bruising and frequent prolonged epistaxis. He has a family history of a bleeding disorder. Vital signs include a HR of 90 bpm, BP of 100/60 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination findings include a regular rate and rhythm, lungs clear to auscultation bilaterally, and several bruises on the skin. Laboratory evaluation reveals a von Willebrand factor antigen and activity level of 20 IU/dL. Which of the following additional laboratory findings would be most consistent with the suspected diagnosis? ADecreased platelets, normal prothrombin time, and normal activated partial thromboplastin time BIncreased platelets, normal prothrombin time, and prolonged activated partial thromboplastin time CNormal platelets, normal prothrombin time, and normal activated partial thromboplastin time DNormal platelets, prolonged prothrombin time, and normal activated partial thromboplastin time ENormal platelets, prolonged prothrombin time, and prolonged partial thromboplastin time

Normal platelets, normal prothrombin time, and normal activated partial thromboplastin time Clinical • Easy bruising • Skin bleeding • Prolonged bleeding from mucosal surfaces (oropharyngeal, GI, uterine) Laboratory • Normal platelet count (mild thrombocytopenia in type 2B) • Normal PT/INR • Normal aPTT (prolonged if very low factor VIll) von Willebrand Disease Most common inherited bleeding disorder due to reduced, dysfunctional, or absent von Willebrand factor Sx: increased mucocutaneous bleeding, heavy menses, excessive postpartum bleeding Labs: aPTT may be prolonged (if factor VIII low), VWF antigen, platelet-dependent VWF activity (ristocetin cofactor assay), factor VIII activity Tx options: desmopressin (DDAVP), von Willebrand factor concentrate Most cases autosomal dominant, consider genetic counseling and testing of 1st degree relatives

A 38-year-old man with a history of heavy alcohol use presents with hematemesis. After obtaining a history and performing a physical exam, a Mallory-Weiss tear is suspected. The patient's vital signs are stable with a normal heart rate and blood pressure. Which of the following is the next best step in caring for this patient? AAdminister an antiemetic BObtain intravenous access CPlace a nasogastric tube DPrepare the patient for emergent upper endoscopy

Obtain intravenous access Mallory-Weiss Syndrome History of drinking alcohol and forceful vomiting Hematemesis Diagnosis is made by upper endoscopy Caused by an incomplete tear in the esophagus mucosa and proximal stomach Tx: acid suppression, endoscopic therapy Management • Supportive • Endoscopic therapy (active bleeding) • Acid suppression (no active bleeding) -----------> . Once the patient is stabilized, an esophagoduodenoscopy (EGD) can confirm the diagnosis and allows for treatment options if the bleeding has not resolved spontaneously. Epinephrine injection, embolization, or coagulation therapy can be used to stop the bleeding although most cases resolve spontaneously as the mucosa heals over 48 to 72 hours. -------------------------------------------------------- Administering an antiemetic (A) is important to prevent further vomiting and subsequent worsening of the bleeding; however, this is not the most important first step in a patient that is actively bleeding and has the potential to become hemodynamically unstable. Preparing the patient for an emergent upper endoscopy (D) may be necessary if the bleeding is severe and the patient requires the procedure; however, it is not the first step before obtaining IV access.

A 32-year-old man with a history of intravenous drug use presents to the emergency department with complaints of chest pain, shortness of breath, cough and fever. Physical exam reveals a temperature of 102F, new heart murmur, diffuse petechial rash and subungual hemorrhages. Which of the following is the most appropriate next step in management? ABegin anticoagulation therapy BBegin empiric antibiotic therapy CObtain three sets of blood cultures DOrder cardiovascular surgical consult

Obtain three sets of blood cultures dx: Bacterial Endocarditis Most commonly caused by: IVDA: Staphylococcus aureus, tricuspid Native valve: Staphylococcus aureus, viridans streptococci (most common in previously diseased), mitral PE: fever, Roth spots, Osler nodes, murmur, Janeway lesions, anemia, nailbed hemorrhages, emboli (FROM JANE) Diagnosis is made by echocardiography and Duke criteria

A 7-day-old infant presents for eye discharge. He was born at home with the aid of a midwife. On exam, the infant has copious mucopurulent discharge from both eyes, swollen eyelids, and chemosis. Which of the following is the most appropriate treatment? ACiprofloxacin ophthalmic BErythromycin ophthalmic CIntramuscular ceftriaxone DOral erythromycin

Oral erythromycin dx treatment of choice for neonatal chlamydial conjunctivitis. Chlamydial Conjunctivitis Patient will be a neonate 5-14 days after delivery PE will show mucopurulent ocular discharge, eyelid swelling, and erythematous conjunctiva Diagnosis is made by culture Most commonly caused by Chlamydia trachomatis Treatment of choice is oral erythromycin or azithromycin --------------------------------------------------------------- Erythromycin ophthalmic (B) is not an effective treatment due to high failure rate.

A 65-year-old man presents with a painless, enlarging ulcerative lesion on the penis that he noticed approximately 4 months prior. His medical history is significant for hypertension and a 20 pack-year smoking history. A sexual history reveals that he is in a monogamous relationship, married to his wife for the past 35 years. A physical exam is completed and demonstrates a 1 cm in diameter, nontender, shallow ulceration with crusting at the borders on the coronal sulcus. Palpation of the inguinal area bilaterally reveals several enlarged, firm, mobile lymph nodes. Which of the following is the most likely diagnosis? ABehçet syndrome BGenital herpes CHaemophilus ducreyi infection DPenile cancer ESyphilitic chancre

Penile cancer Penile Cancer Most common type is squamous cell Risk factors are HIV, HPV, phimosis, trauma Typically in older men Diagnosis is made by biopsy TNM staging The mean age at diagnosis is age 60. Risk factors for developing penile cancer include a history of genital warts, penile tear or injury, chronic penile rash, phimosis, or urethral stricture. Physical examination may reveal an ulcerative lesion or a mass on the glans, coronal sulcus, or the prepuce. The mass or ulcer is typically painless and is associated with inguinal adenopathy that either represents an inflammatory reaction or malignant infiltration. Human papillomavirus (HPV) is identified in approximately 30-50% of all penile cancers, and HIV infection is also a risk factor for developing the disease. Tobacco exposure may increase the risk of penile cancer by inhibiting the function of antigen-presenting Langerhans cells. ---------------------------------------------------------- Syphilitic chancre (E) is a sign of primary syphilis following infection with the spirochete, Treponema pallidum. The chancre is often painless and has a raised and indurated margin. These chancres typically heal within 3-6 weeks.

An 80-year-old man reports three months of high pitched ringing in his ears. He denies head trauma, fever, change in medications or diet, gross hearing loss, dizziness or vertigo, focal neurologic deficits, or vision changes. Which of the following is the most likely diagnosis? AAcoustic neuroma BMénière disease CPrimary tinnitus DVestibular neuritis

Primary tinnitus vs Acoustic neuroma: CN VIII, hearing loss + tinnitus + disequilibrium Ménière disease: recurrent vertigo + tinnitus + hearing loss =====classically described as a tetrad of symptoms: vertigo, tinnitus, hearing loss, and aural fullness.========== ​Ramsay Hunt syndrome: facial paralysis, zoster lesions, tinnitus Labyrinthitis: sudden severe vertigo, hearing loss, tinnitus, not recurrent Head trauma Electrical injury Diving Ototoxic agents ---Salicylates: respiratory alkalosis + anion gap metabolic acidosis + tinnitus ----NSAIDs ----Quinine -----Abx (aminoglycosides, erythromycin, vancomycin) Chemotherapeutic agents ---------------------------------------------------------

A 66-year-old man with a medical history significant for hypertension and chronic kidney disease presents for a routine examination. Laboratory tests are available and include an estimated glomerular filtration rate of 31 mL/min/1.73 m2, potassium of 4.1 mmol/L, magnesium of 2 mEq/L, calcium of 10 mg/dL, and parathyroid hormone level of 160 pg/mL. A physical exam is completed and is unremarkable. Vital signs are a BP of 132/82 mm Hg, HR of 87 bpm, SpO2 of 97% on room air, and T of 98.4°F. Decreasing the intestinal absorption of which of the following will benefit the patient the most? ACalcium BMagnesium CPhosphate DPotassium ESodium

Phosphate dx: Chronic kidney disease leads to hyperphosphatemia Stage 1: normal kidney function (eGFR ≥ 90) and ≥ 3 months of proteinuria Stage 2: mild reduction in kidney function (eGFR 60-89) and ≥ 3 months proteinuria Stage 3: moderate reduction in kidney function (eGFR 30-59) Stage 4: severe reduction in kidney function (eGFR 15-29) Stage 5: kidney failure (eGFR < 15) - requires dialysis or transplant for survival (ESRD) Chronic Kidney Disease Definition: permanent loss of kidney function > 3 months Most commonly caused by DM, HTN PE: uremic frost, HTN, pulmonary edema, pericardial rub, encephalopathy Complications: Volume overload Electrolyte imbalance (hyperkalemia, hyperphosphatemia, hypocalcemia) Normocytic anemia: ↓ EPO + anemia of chronic disease Secondary hyperparathyroidism, mineral bone disorder Acidosis Platelet dysfunction, bleeding Cardiovascular disease and dyslipidemia Increased risk of infection

35-year-old G2P1 woman at 28 weeks gestation presents to the Emergency Department with abdominal pain, continuous uterine contractions, and decreased fetal movement. She has a history of hypertension and endorses a 1.5 pack per day smoking history. She denies any vaginal bleeding or rush of water. Her vital signs upon arrival are T 37.2°C, HR 130, BP 80/50, RR 22. Fibrinogen is 200 mg/dL. A fetal heart rate by bedside Doppler is 100. Physical exam reveals a rigid, tender uterus. An ultrasound shows a normally implanted posterior placenta with diffuse thickening. Which of the following is the most likely diagnosis? AChorioamnionitis BPlacenta accreta CPlacental abruption DUterine rupture

Placental abruption Placental Abruption Risk factors: hypertension, trauma, or cocaine use Painful vaginal bleedingMost often during the third trimester Labs will show hypofibrinogenemia Tx: fetal monitoring, hemodynamic stabilization, delivery

An elderly woman underwent cataract surgery last week. Today, she complains of central vision loss and peripheral flashing lights. This patient is likely to emergently require which of the following procedures? ABlepharoplasty BCanaloplasty CLaser assisted in-situ keratomileusis DPneumatic retinopexy

Pneumatic retinopexy dx: Retinal detachment Retinal Detachment Patient presents with painless loss of vision, floaters, flashing lights, curtain-lowering sensation PE: retina appears hazy gray with white folds Management is stat ophthalmology consult Risk factors include prior cataract surgery, head or eye trauma, family history and severe myopia. Considered an emergency, the most common symptoms are acute vision loss

A male child born at 40 weeks of gestation has an Apgar score of 4 at birth. He is gasping for air and has a pulse of 68 despite positioning and airway clearance. Which of the following would be the best choice for initial clinical intervention in this patient? AIntubation BPositive pressure ventilation CSupplemental oxygen by facemask DWarming, drying, and close observation

Positive pressure ventilation If a neonate has a pulse, but it is less than 100 beats per minute, this is most often indicative of respiratory distress, not cardiac pathology. A neonate who demonstrates a weak cry with gasping and a pulse less than 100 beats per minute should receive positive airway pressure within one minute of birth. After 30 seconds of positive airway pressure, the heart rate is reassessed. If the heart rate is over 100 beats per minute and spontaneous breathing has begun, positive airway pressure can be discontinued. If the pulse continues to be under 100 beats per minute, the neonate should be reassessed for adequacy of ventilation. Repositioning, suction, mask adjustment, or pressure increases may need to be made. While Apgar scores at one minute and five minutes after birth are not accurate predictors of neonatal morbidity and mortality, they are useful in assessment of the neonate's need for further clinical intervention. ------------------------------------------------------- intubation is not initial If the pulse remains under 100 beats per minute after positive airway pressure has been given and adjustments have been made (e.g., repositioning, increased pressure, suction) then intubation (or a laryngeal mask airway) should be performed. Neonates who persistently show respiratory distress and a heart rate under 60 beats per minute despite positive airway pressure or intubation should receive chest compressions and may also need intravenous epinephrine

A 58-year-old woman with no significant medical history presents for an annual wellness physical. She says it has been 16 months since she had any menstrual bleeding and notes moderate vaginal discomfort that makes coitus difficult for her. She has tried vaginal lubricants with minimal improvement. Which of the following recommendations would be most appropriate for this patient? AAvoidance of vaginal intercourse BPrescribe a vaginal ring containing estradiol CPrescribe an oral conjugated estrogen preparation

Prescribe a vaginal ring containing estradiol

A 61-year-old man presents to the clinic for evaluation. His medical history includes chronic obstructive pulmonary disease with an ongoing 25 pack-year history of tobacco use. The patient takes albuterol as needed in addition to his daily medications, which include salmeterol and budesonide. Following a thorough history and physical exam, the patient undergoes diagnostic colonoscopy, which identifies a polypoid, endoluminal mass in the ascending colon. Subsequent biopsy indicates colorectal adenocarcinoma. Which of the following does this patient most likely report during the initial evaluation? AColicky abdominal pain, distention, and nausea BCrampy abdominal pain with intermittent bloody diarrhea CHematochezia and recent change in bowel habits DProgressive fatigue and weight loss ETenesmus and diminished caliber of stools

Progressive fatigue and weight loss According to the US Preventive Services Task Force (USPSTF) guidelines, patients at average risk for colorectal cancer should begin screening at age 50 years and may discontinue screening when the estimated life expectancy is < 10 years. The USPSTF recommends that patients age 70 to 75 years should be screened as clinically deemed necessary, and screening should be discontinued in all patients over age 85. ---------------------------------------------------------- Patients frequently report hematochezia and recent change in bowel habits (C) with colorectal cancer, but this presentation is more often found in patients with rectosigmoid cancer and those with left-sided colorectal tumors. Tenesmus and diminished caliber of stools (E) is more likely to be associated with rectal cancer. Colicky abdominal pain, distention, and nausea (A) are less commonly associated with colorectal carcinoma. These symptoms indicate intestinal obstruction secondary to the tumor. Crampy abdominal pain with intermittent bloody diarrhea (B) is more suspicious for Crohn disease than colorectal carcinoma.

A 67-year-old man presents after being in a motor vehicle collision 20 minutes ago. His wife reports that there was a brief period of unconsciousness followed by a lucid interval. Past medical history is significant for cardiac stents to the left anterior descending coronary artery, and the patient has been on warfarin ever since stent placement. Vital signs include temperature 98.6°F, respiratory rate 18 breaths/minute, blood pressure 120/65 mm Hg, heart rate 90 beats/minute, and oxygen saturation 98% on room air. Physical examination shows no neurological deficits. Glasgow Coma Scale score is 12. Complete blood count shows white blood cell count 5.8/L, hemoglobin 15 mg/dL, hematocrit 45%, and platelet count 265,000. The comprehensive metabolic panel reveals no abnormalities. Prothrombin time is 16 seconds, and international normalized ratio is 4.0. Computed tomography shows a 15 cm3 lens-shaped pattern with clot thickness of 8 mm and no midline shift. Which of the following is the most appropriate next step in management? ACraniotomy BMannitol CProtamine DProthrombin complex concentrate

Prothrombin complex concentrate #similar concept to one w/ gastric ulcer dx: Epidural hematoma History of a head injury with a loss of consciousness followed by a lucid interval CT will show a biconvex opacity Most common artery ruptured is the middle meningeal artery Treatment is emergent evacuation . Reversal of anticoagulation in patients taking anticoagulants (warfarin) must be done before surgical intervention. The approach to warfarin reversal includes immediate cessation of further warfarin therapy, slow infusion of vitamin K, and infusion of prothrombin concentrate complex. If prothrombin concentrate complex is not available, fresh frozen plasma may be used instead. International normalized ratio (INR) goal in this setting is typically less than 1.2

A 72-year-old woman with a history of atrial fibrillation presents to a rural hospital with sudden onset of severe epigastric pain. For the last 4 days, her stool has been black. The patient reports taking warfarin and metoprolol for atrial fibrillation, and her most recent doses were this morning. Vitals are BP of 100/60 mm Hg, HR of 110 bpm, RR of 18 bpm, oxygen saturation of 95%, and T of 98.0°F. Her heart has a tachycardic rate, regular rhythm, breath is shallow, and skin shows some pallor but no blueing. Standing chest X-ray shows free air under the diaphragm. Complete blood count shows hemoglobin of 11.0 g/dL and platelets of 105,000/μL. Her INR is 3.0. A nasogastric tube is placed, intravenous fluids and antibiotics are administered, and surgery is consulted. What is the best next step in management? ADesmopressin BOral vitamin K administration CPlatelet transfusion DProtamine sulfate infusion EProthrombin complex concentrate

Prothrombin complex concentrate This patient has experienced gastric ulcer perforation and is in need of immediate surgery. Thus, warfarin reversal is indicated. gastric perforation and emergent surgery, such as this, warfarin's effect must be directly reversed. This is most efficiently achieved by infusion of prothrombin complex concentrate, which contains activated factors II, VII, IX, and X and activated proteins C and S. Fresh frozen plasma has traditionally been used to provide this complement of factors in emergent cases. However, prothrombin complex concentrate does not need to be thawed before use and does not pose the risks of infection, fluid overload, or transfusion-related acute lung injury associated with plasma transfusion. Prothrombin complex concentrate is given with a slow infusion of 10 mg vitamin K. Vitamin K can be repeated every 12 hours, as needed, to ensure the body's continued manufacture of the key clotting factors LOOK AT IMAGE -------------------------------------------------------------------- Oral vitamin K administration (B) is used in nonemergent warfarin reversal, such as cases of excessively elevated INR with bruising. Even intravenously, supplementation by vitamin K alone here would be insufficient due to the physiological delay needed to manufacture the vitamin K-dependent factors. Platelet transfusion (C) is not immediately necessary in this patient, whose platelet count is close to normal and whose bleeding is not related to a platelet deficiency.

An otherwise healthy 4-year-old boy presents with his parents for vomiting and diarrhea. Several kids at his school have had similar symptoms. He began to have nonbloody, nonbilious vomiting yesterday and this morning began to have nonbloody diarrhea. He felt warm at home, but he is currently afebrile. He is well-appearing and playful. He is able to drink water without difficulty. Which of the following is the next best step? AAdminister intravenous fluids BAdmit for observation CProvide reassurance and discharge home DSend stool cultures

Provide reassurance and discharge home dx: Viral gastroenteritis

A patient's arterial blood gas is noted to have a pH of 7.32, pCO2 of 32 mm Hg, and bicarbonate of 16 mmol/L. Which of the following is the correct interpretation of this arterial blood gas? AMetabolic acidosis with respiratory alkalosis BPure metabolic acidosis CPure respiratory acidosis DRespiratory acidosis with metabolic alkalosis

Pure metabolic acidosis look at image for calculations ---------------------------------------------------------------- This patient does not have a metabolic acidosis with a respiratory alkalosis (A) because the calculated pCO2 and the measured pCO2 are the same. A measured pCO2 less than the expected pCO2 calculated using Winter formula would indicate a concomitant respiratory alkalosis.

A 30-year-old woman presents for follow-up after dilation and curettage for a partial hydatidiform mole. Which of the following laboratory studies is the best method for identifying persistent or recurrent gestational trophoblastic disease?

Quantitative beta-human chorionic gonadotropin Molar Pregnancy Sx: nausea, vomiting, abdominal pain, and vaginal bleeding PE: uterine size > than expected for dates Labs: beta-hCG higher than expected for dates Ultrasound may reveal snowstorm or bag of grapes appearance Tx: dilation and curettage New-onset hypertension < 20 weeks gestation: suspect molar pregnancy

Which of the following is the location of the mechanism of action of furosemide?

Thick ascending loop of Henle normally pumps sodium, potassium, and chloride out of the lumen and into the blood. Loop diuretics such as furosemide compete for the chloride site on the sodium-potassium-chloride pumps, which prevents the reabsorption of these ions, thus promoting diuresis of these electrolytes into the urine. What are common pathologies that may be treated with furosemide? Answer: Acute pulmonary edema and congestive heart failure.

An unimmunized child has had a mild fever for several days. Today, the child is brought to the clinic because of the development of a rash. The rash is a pink discrete macular eruption mostly on the face and trunk. Postauricular and suboccipital lymph nodes are palpable. The child has a low-grade fever, but does not appear sick. Which of the following is the most likely diagnosis? AErythema infectiosum BMeasles CRoseola DRubella

Rubella Rubella (German Measles) Patient presents with fever, sore throat, headache PE will show prominent lymphadenopathy (occipital, cervical, postauricular) and a rash that spreads from face down Treatment is only supportive care First-trimester pregnancy: congenital defects ---------------------------------------------------------------- erythema infectiosum ("fifth disease) (A), which typically presents with fiery red "slapped cheek" appearance, circumoral pallor, and subsequent lacy, maculopapular, evanescent rash on the trunk and limbs. High fever and lethargy are prominent features of measles (B) and help distinguish it from rubella. Measles presents with a prodrome of high fever, coryza, conjunctivitis, irritability, and Koplick spots (small, irregular, and red with whitish center on the mucous membranes). The rash is brick red, irregular, maculopapular beginning on the face and preceding downward, similar to rubella. Continued fever after rash onset and lymphadenopathy are not consistent with roseola (C). Roseola begins with a sudden high fever which subsides in a few days, and just as the child appears to be recovering, a red rash appears. This usually begins on the trunk, spreading to the legs and neck.

A 45-year-old man presents to the clinic for an annual physical examination. He has a previous medical history of hypertension, well controlled on losartan. He reports no previous surgical history or urinary complications. He reports having mild right-sided back pain for the last 3 months with no aggravating or alleviating factors. His sexual history is negative, and his family history is unknown. Vital signs include a HR of 62 bpm, BP of 110/75 mm Hg, RR of 14/min, oxygen saturation of 99% on room air, and T of 98.6°F. Physical examination is within normal limits. An ultrasound is ordered to evaluate his back pain and reveals three renal cysts on the right kidney and two renal cysts on the left kidney. What is the most serious extrarenal complication that can arise from the patient's most likely diagnosis? AAortic regurgitation BIncarcerated abdominal wall hernia CMitral valve prolapse DRenal cell carcinoma ERuptured cerebral aneurysm

Ruptured cerebral aneurysm Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the progressive formation of cysts on bilateral kidneys ultimately leading to loss of kidney function. What is the most common type of kidney cancer in adults? Answer: Renal cell carcinoma.

Which of the following should be monitored to evaluate for medullary thyroid cancer recurrence? AAnti-thyroid peroxidase antibodies BSerum calcitonin CSerum thyroxine DThyroid-stimulating hormone EThyrotropin-releasing hormone

Serum calcitonin What is the most aggressive type of thyroid cancer? Answer: Anaplastic.

A 28-year-old man presents to the emergency department with severe upper abdominal pain, nausea, and vomiting for 8 hours. Vital signs today include a heart rate of 112 bpm, blood pressure of 125/85 mm Hg, respiratory rate of 20/minute, oxygen saturation of 98% on room air, and temperature of 99.2°F. Physical examination reveals a man in acute distress with epigastric tenderness but no abdominal rigidity, rebound tenderness, or bruising. Laboratory findings include a white blood cell count of 7,000/μL, lipase of 2,200 U/L, aspartate aminotransferase of 35 U/L, alanine aminotransferase of 42 U/L, alkaline phosphatase of 85 U/L, and total bilirubin of 0.8 mg/dL. Gallbladder ultrasound reveals a diffusely enlarged and hypoechoic pancreas but no gallstones or gallbladder wall thickening. Which of the following additional studies may reveal the cause of this condition? ACFTR genetic testing BSerum ceruloplasmin CSerum gamma-glutamyl transpeptidase DSerum lipid profile EUrine drug screen

Serum lipid profile dx: Acute pancreatitis

A 24-year-old woman who first saw you 4 years ago for persistent acne, for which you prescribed a topical steroid, now presents in your office discouraged after 12 months of trying to conceive. Her vital signs are a BP of 120/80 mm Hg, HR of 87 bpm, RR of 14/min, T of 98.6°F, and a BMI of 22 kg/m2. Her last period was 1 week ago, but her periods are irregular. Her acne is still present, and she states she no longer takes medication for it. You verify her current medications and perform a vaginal exam, which is normal. All other signs are normal. Urine test is negative for pregnancy. What laboratory test would be the best next step for the suspected diagnosis? AHemoglobin A1C BSerum follicle-stimulating hormone CSerum prolactin level DSerum thyroid level ESerum total testosterone

Serum total testosterone -->Of the three Rotterdam criteria, this patient appears to experience ovarian dysfunction, as indicated by oligomenorrhea and infertility. Her acne suggests hyperandrogenism but is not definitive for a diagnosis of PCOS. High serum total testosterone levels would confirm hyperandrogenism. dx:PCOs Polycystic Ovary Syndrome (PCOS) Ovulatory dysfunction, hyperandrogenism, and polycystic ovaries Common PE findings: bilateral ovarian enlargement, acanthosis nigricans, high BMI Laboratory evaluation: Oligomenorrhea: hCG, FSH, TSH, prolactin Hyperandrogenism: total testosterone and sex hormone-binding globulin or bioavailable and free testosterone, morning 17-hydroxyprogesterone Metabolic disease screening: 2-hour oral glucose tolerance test, fasting lipid panel Commonly associated with insulin resistance, which may be the central etiology Treatment is combination low-dose oral contraceptive pills, lifestyle changes, metformin Most common cause of infertilityLetrozole is first-line therapy for ovulation induction There is gonadotrophic dysregulation with increased luteinizing hormone (LH) pulsatility and abnormally high ratios of circulating LH to follicle-stimulating hormone (FSH)

What finding is commonly seen in primary adrenal insufficiency but is not seen in secondary adrenal insufficiency? AFever BHypoglycemia CHyponatremia DSkin hyperpigmentation

Skin hyperpigmentation Primary Adrenal Insufficiency (Addison Disease) Sx: abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE: hyperpigmentation of skin and mucus membranes and hypotension Labs: hyponatremia and hyperkalemia Most commonly caused by autoimmune destruction of the adrenal cortex Tx: hydrocortisone or other glucocorticoid Most patients also require mineralocorticoid (fludrocortisone)

Which of the following counseling statements should be given regarding tobacco use and smoking cessation? ACurrently, there are more active smokers in the U.S. than former smokers BHeart disease risk is reduced within six months of smoking cessation CSmoking increases the risk for infertility DThere is no benefit to smoking cessation over the age of 80

Smoking increases the risk for infertility dx;Tobacco Use and Cessation Motivational interviewing Nicotine replacement Bupropion (avoid with seizure or eating disorders) Varenicline Consider combination therapy USPSTF, Jan 2021: insufficient evidence to recommend for or against pharmacotherapy for smoking cessation in pregnant people Nicotine is excreted in breast milk? true

Which of the following is considered a contraindication to the administration of succinylcholine? ARenal failure with a serum potassium of 3.8 mEq/L BSpinal cord injury sustained one month earlier CStroke with onset 24 hours prior to arrival DThird degree burns sustained one hour prior to arrival

Spinal cord injury sustained one month earlier is too early to give succinylcholine due to the risk of severe hyperkalemia. Chronic and indefinite denervation syndromes, such as multiple sclerosis or amyotrophic lateral sclerosis, have inherent risk at the onset of the illness that continues indefinitely. Thus, succinylcholine should be avoided in these patients. Succinylcholine is the agent of choice for rapid sequence intubation in acute burn, trauma, stroke, spinal cord injury and sepsis if given less than five days after onset. Acute denervation syndromes, such as stroke and spinal cord injury, are stabilized after 3-6 months. Therefore, succinylcholine can be administered after this period.

A 65-year-old man with a medical history of atherosclerosis, hypertension, and stable angina presents to the clinic for routine follow-up. Current medications include lisinopril, atorvastatin, aspirin, and propranolol. Vital signs are HR 76 bpm, RR 17 breaths per minute, BP 142/88 mm Hg, T 97.6°F, and SpO2 97% on room air. During cardiac auscultation, a harsh crescendo-decrescendo systolic ejection murmur is heard over the right upper sternal border with radiation to the carotids bilaterally. Which of the following maneuvers is most likely to accentuate this murmur? AAbrupt standing BForceful expiration CHand grip DSquatting EValsalva maneuver

Squatting dx:Aortic Stenosis Risk factors: advancing age, diabetes, hypertension Sx: dyspnea, chest pain, syncope PE: crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop. Murmur decreases with Valsalva Most commonly caused by degenerative calcification Treatment: aortic valve replacement

A 30-year-old woman with a history of Crohn disease presents to the emergency department with a report of rectal pain for about 2 weeks. She states she has pain with sitting and bowel movements and has noticed some discharge from her rectal area. She reports no fevers. Her vital signs show a heart rate of 80 bpm, blood pressure 119/75 mm Hg, respiratory rate 17 breaths/min, and SpO2 of 98% on room air. On physical exam, her abdomen is soft with mild tenderness to palpation in the suprapubic region. On rectal exam, there is scant purulent drainage with a small pustule noted in the perianal region. There is a palpable cord felt from the external surface to the anal canal. Imaging and labs are pending. What is the most appropriate management for the suspected diagnosis? AEmpiric antibiotics BIncision and drainage CSitz baths DStool test for ova and parasites ESurgical referral for evaluation

Surgical referral for evaluation dx: Anorectal fistula

A 52-year-old man presents with decreased sensation in the upper extremities and chronic neck pain. He states that the loss of sensation has been progressive for months. On physical examination, he has decreased sensation to pain over the upper back, shoulders, and arms with intact proprioception and light touch. What is the likely diagnosis? AAnterior cord syndrome BBrown-Séquard syndrome CCentral cord syndrome DSyringomyelia

Syringomyelia CSF cavity in spinal cord Most common location: cervical spine Arnold-Chiari malformation Loss of pain and temperature sensation with preservation of proprioception and light touch in cape-like distribution MRI Syringomyelia is defined as the presence of a cavitary lesion in the spinal cord. The lesion is chronic and progressive and symptoms vary based on the location of the syrinx. . When the syrinx occurs in the upper portions of the cord (specifically the neck), patients present with a cape-like distribution of loss of pain and temperature sensation in the upper extremities with preservation of light touch and proprioception. Physical examination shows sensory loss along with muscle wasting and weakness in the hands and arms. Symptoms may be worsened by a Valsalva maneuver. It is best imaged by MRI. ------------------------------------------------------------------ Anterior cord syndrome (A) is characterized by loss of motor function below the lesion and preservation of position, touch, and vibration sensation. Brown-Séquard syndrome (B) presents with ipsilateral motor function loss and contralateral pain and temperature sensation loss. Patients with central cord syndrome (C) present with bilateral motor paresis and sensory impairment.

A 32-year-old man presents to the county health department with complaints of a painless sore on his penis. He reports having unprotected sexual intercourse 2 weeks ago. Physical exam reveals a single 2 cm nontender ulcer with a raised, indurated margin on the shaft of his penis. Which of the following is the most likely causative organism? AHaemophilus ducreyi BHerpes simplex virus CNeisseria gonorrhoeae DTreponema pallidum

Treponema pallidum Penile chancre Painless, indurated ulcer

A 40-year-old woman who actively uses intravenous drugs presents to the ED with fever and fatigue for the past 3 days. In the ED, her vital signs are BP 126/82 mm Hg, HR 90 bpm, RR 16/min, SpO2 99% on room air, and T 101.6°F (38.7°C). On exam, a murmur is noted. Transesophageal echocardiography is ordered. Which of the following valves is most likely to be affected? AAortic BMitral CPulmonic DTricuspid

Tricuspid dx: bacterial endocarditis. Bacterial Endocarditis Risk factors: injection drug use, valvular heart disease Sx: fever, rash, cough, and myalgias PE: fever, Roth spots, Osler nodes, murmur, Janeway lesions, anemia, nailbed hemorrhages, emboli (FROM JANE) Diagnosis is made by echocardiography and Duke criteria Most commonly caused by: IVDA: Staphylococcus aureus, tricuspid Native valve: Staphylococcus aureus, viridans streptococci (most common in previously diseased), mitral Tx: antibiotics GI malignancy: Streptococcus bovis #Colorectal cancer. Dental prophylaxis in some cases

A 21-year-old woman presents to the emergency department with fever, malaise, and chest pain. Her vital signs in triage are T 39.0°C, HR 122, BP 110/60, RR 30. Physical examination reveals cellulitis along the antecubital area of the left arm, jugular venous distention, a holosystolic murmur best heard at the left sternal border, right upper quadrant tenderness, and 2+ bilateral lower extremity edema. Which of the following is the most likely cause of the patient's symptoms? AAortic regurgitation BMitral stenosis CPulmonic stenosis DTricuspid regurgitation

Tricuspid regurgitation Patient presents with signs of right-sided heart failure: ascites, edema, RUQ pain PE will show JVD and a blowing holosystolic murmur best heard at the left sternal border that becomeslouder during inspiration Diagnosis is made by echo Most commonly caused by RV dilatation ---------------------------------------------------------------- vs Pulmonic stenosis (C) is much more commonly congenital than acquired. The murmur of pulmonic stenosis is a systolic ejection murmur best heard at the left upper sternal border. Like all right heart murmurs, it increases with inspiration. aortic regurgitation (A). The murmur of aortic regurgitation is an early diastolic, decrescendo murmur best heard at the third left intercostal space.

A 26-year-old woman at 32 weeks gestation reports swelling and discomfort in her right leg. Ultrasound of the leg reveals a noncompressible vein. Which of the following treatments is contraindicated? AInferior vena cava filter BLow molecular weight heparin CUnfractionated heparin DWarfarin

Warfarin first-line treatment of VTE in pregnancy includes anticoagulation with heparin or low-molecular-weight heparin. Deep Vein Thrombosis (DVT) History of smoking, immobilization, surgery, oral contraceptive use Unilateral leg edema, leg pain, tenderness, and warmth Physical exam may show a positive Homan sign Diagnosis is made by ultrasound, gold standard is venography; D-dimer used in low-risk cases Most commonly caused by stasis, hypercoagulable state, endothelial dysfunction (Virchow triad) Treatment is anticoagulation Warfarin is contraindicated in pregnancy Pretest probability by modified Wells score

A man presents to the office for a wellness visit for the first time in 14 years. He has recently turned 65 years old and now has medical insurance. He reports no symptoms today. He has no significant medical history, and his medications include acetaminophen and ibuprofen as needed for occasional headaches. He reports smoking 10 cigarettes per day for the last 40 years. Home blood pressure measurements range from 146/88 mm Hg to 168/96 mm Hg. On exam, his BMI is 35 kg/m2. His blood pressure is 162/94 mm Hg, heart rate is 88 bpm, respirations are 18 breaths/min, SpO2 is 96% on room air, and temperature is 98.6°F. Cardiac, pulmonary, and abdominal exams are within normal limits. Bilateral pedal pulses are 2+ and equal bilaterally. ECG shows normal sinus rhythm. CBC and blood chemistries are unremarkable. Which of the following is the best next step in the management of this patient's condition? AAbdominal ultrasound BBrain natriuretic peptide CRenal arteriogram DUrinalysis and lipid profile EUrine metanephrines

Urinalysis and lipid profile dx: essential hypertension, Workup for a new diagnosis of hypertension should include a CBC, basic metabolic panel, lipid panel, thyroid-stimulating hormone, urinalysis, and an electrocardiogram. ------------------------------------------------------------- vs Renal arteriogram (C) is an imaging modality in which the renal artery is accessed via the femoral artery, contrast is injected, and images are taken. This is the gold standard for detecting renal artery stenosis. However, this type of imaging is rarely used due to the high sensitivity of other less invasive tests. In this patient, it is unnecessary as he has no clinical features of renovascular disease.

A 4-year-old girl presents for her annual well-visit. She is generally healthy, with normal growth and development. At today's visit, her heart rate is 88 beats/minute, blood pressure is 100/66 mm Hg, respiratory rate is 20 breaths/minute, oxygen saturation is 100%, and temperature is 98.5°F. With the patient seated on the exam table, a continuous murmur that is best heard in the supraclavicular region is auscultated. With the patient in a supine position, the murmur is not appreciated. The rest of her physical exam is unremarkable. What is the most likely etiology of this exam finding? AAortic regurgitation BAtrial septal defect CMitral regurgitation DStill murmur EVenous hum

Venous hum --------------------------------------------- Mitral regurgitation (C) is a holosystolic murmur that is best auscultated over the cardiac apex and is often heard radiating to the left axillary region Still murmur (D), is typically auscultated over the left lower sternal border and does not typically radiate. This murmur is thought to be a result of normal blood flow, but the exact anatomic etiology is uncertain. Unlike venous hum, Still murmurs are most prominent when patients are in the supine position.

A 55-year-old man with a history of alcohol use disorder presents with an unsteady gait. He is slightly confused, with ophthalmoplegia noted on neurologic examination. Which of the following is the primary treatment of this syndrome? ADextrose BFolic acid CMagnesium DVitamin B1

Vitamin B1 (thiamine deficiency) dx: Wernicke-Korsakoff syndrome i Associated with chronic alcohol use Ataxia and confusion PE will show nystagmus, lateral rectus palsy Most commonly caused by thiamine (B1) deficiency Treatment is aggressive thiamine repletion Replace thiamine BEFORE glucose Korsakoff (irreversible memory loss) ---------------------------------------------------------------- Folic acid (B) is another vitamin frequently deficient in those with alcohol use disorder and poor nutritional status. While important for multiple metabolic functions in the body, folic acid deficiency does not cause an acute clinical syndrome.

A patient presents with back pain. Radiographic findings include a herniated nucleus pulposus between L5 and S1. What are you most likely to find on physical examination if the patient has an S1 radiculopathy? ADecreased lateral leg sensation BUrinary incontinence CWeak dorsiflexion of the foot DWeak plantarflexion of the foot

Weak plantarflexion of the foot