PANCE Review Quiz

A 32-year-old woman presents for magnetic resonance imaging of the head due to visual changes and galactorrhea. A mass is found in the sella turcica. Based on the most likely diagnosis, what particular visual defect does this patient likely have? A. Binasal hemianopsia B. Bitemporal hemianopia C. Homonymous hemianopsia D. Quadrantanopsia E. Superior hemianopsia

B. Bitemporal hemianopia

A 70-year-old woman returns to the office for laboratory results one week after having had a temporal artery biopsy performed for suspected giant cell arteritis. Biopsy results confirm the suspected diagnosis. Which of the following is the most likely complication of this patient's condition? A. Alzheimer's disease B. Blindness C. Migraine headaches D. Trigeminal neuralgia

B. Blindness

Which of the following best describes the mechanism of action of ipratropium? A. Blockade of adenosine receptors leading to increase in cAMP and bronchioles smooth muscle relaxation B. Blockade of muscarinic receptors resulting in bronchodilation C. Inhibits leukotriene receptors D. Inhibition of release of histamine from mast cells

B. Blockade of muscarinic receptors resulting in bronchodilation

A 23-year-old woman presents to the emergency department after a baseball hit her in the right eye. She has double vision, pain upon moving the right eye, and numbness of the cheek, nose, and right side of the eye. Upon physical exam, swelling, tenderness, numbness of the nose, and epistaxis are present. What is the most likely diagnosis? A. Blepharitis B. Blowout fracture C. Corneal abrasion D. Stye

B. Blowout fracture

A 32-year-old man is being evaluated in the office for moderately severe claudication of the upper limbs. Thromboangiitis obliterans is suspected. A positive history of which of the following risk factors is most likely to be associated with this patient's condition? A. Alcohol use disorder B. Cannabis use disorder C. Cigarette smoking D. Cochin use disorder

B. Cannabis use disorder

A 46-year-old man returns to his primary care clinic for a follow up visit after beginning a new antihypertensive medication. He complains of a dry, nagging cough. Which of the following medications most likely caused this side effect? A. Lorsartan B. Captopril C. Propanolol D. Verapamil

B. Captopril

Which of the following antibiotic regimens is indicated in the treatment of a patient with cholecystitis? A. Azithromycin and amoxicillin/clauvulanate B. Ceftriaxone & metronidazole C. Vancomycin only D. Tetracycline & metronidazole

B. Ceftriaxone & metronidazole

A 25-year-old sexually active man notices that he has burning and pain while urinating. He also notices some urethral discharge. He sees you in your office for a consultation, and you order several laboratory tests. One of the tests that you order is a Gram stain and culture on a sample of the discharge. The results are negative, and gonorrhea is ruled out. Based on the most likely diagnosis, what is the most common etiology of his symptoms? A. Chlamydia psittaci B. Chlamydia trachomatis C. Ureaplasma urealyticum D. Trichomonas vaginalis E. Pneumocystis jirovecii

B. Chlamydia trachomatis

Each of the following findings would be common in patients with Parkinson disease EXCEPT: A. Bradykinesia B. Chorea C. Cogwheel rigidity D. Mask-like facies E. Resting tremor

B. Chorea

Each of the following is an intervention used in the treatment of excessive growth hormone production EXCEPT: A. Bromocriptine B. Desmopressin acetate C. Octreotide D. Surgery

B. Desmopressin acetate

Which of the following pathogens responsible for causing meningitis can be prevented by administration of a vaccine? A. E. Coli B. H. Influenzae type B C. Herpes simplex virus D. Staphylococcus aureus

B. H. Influenzae type B

The mother of a 3-year-old boy asks to have a blood test done on her son for lead poisoning. He has not been tested before. They have moved into an older home, built before 1960. She has noticed some peeling paint on windowsills and doors and has seen small paint chips on the floors. They are now having the house repainted and are staying with relatives. A careful environmental history is obtained, and risk reduction and nutrition education are provided. His fingerstick blood lead level comes back at 13 mcg/dL (normal < 10 mcg/dl). What is the next step in the management of this patient? A. Oral chelation therapy B. Home visit to identify potential lead sources C. Repeat lead level in 6 months D. Repeat lead level in 1 year E. Hospitalization and intravenous chelation therapy

B. Home visit to identify potential lead sources Oral chelation is advised if level is between 45-69 and then hospitalization with IV chelation >70

A 32-year-old man comes to your family medicine clinic with a painless lesion on his penis for the past week. On examination you determine that it is a chancre. Which of the following is the best next step in the treatment of this patient? A. Oral Doxycycline B. IM Penicillin C. IM Ceftriaxone D. Oral Clindamycin E. Amoxicillin/clauvulanate

B. IM Penicillin

A 40-year-old man presents with a 2-year history of severe, burning epigastric pain. A detailed history reveals that the pain is greatest in the early hours of the morning and wakes him up from sleep. The pain is also felt 2-3 hours after meals. He reports diarrhea for the past 2 years. On examination, his pulse is 74/min and blood pressure 136/84 mm Hg. There is slight epigastric discomfort on palpation. Lab examination shows hyperchlorhydria. What is a potential complication of this patient's diagnosis? A. Gallstones B. Intestinal ulcers C. Microcytic anemia D. Kidney stones

B. Intestinal ulcers

What is the most common causative organism of meningitis in college-aged persons? A. Streptococcus pneumoniae B. Neisseria meningitidis C. Haemophilus influenzae D. Group B streptococcus E. Escherichia coli

B. Neisseria meningitidis

A 32-year-old patient asks about vaccinations during pregnancy. Which of the following vaccines do you want to avoid giving during pregnancy? A. Influenza B. Rubella C. Diptheria D. Tetatnus

B. Rubella

A 20-year-old Caucasian male college student comes in with a complaint of hypopigmented patches that appeared gradually during the summer. He reports no history of unprotected sex. Scaly patches are present, but no pruritus. On examination, he has hypopigmented patches over the face and chest, but no vesicles or pustules. What is the most likely diagnosis? A. Leprosy B. Tinea versicolor C. Tinea cruris D. Vitiligo E. Tinea wapitis

B. Tinea versicolor Vitiligo presents as complete loss of pigmentation and is common in perioral regions, wrists and hands

Which of the following pathogens is most commonly associated with the risk of developing a hepatic abscess? A. Shigellosis B. Enterobiasis C. Amebiasis D. Cryptococcus

C. Amebiasis

A 22-year-old woman presents due to clogging of the right ear, hearing loss, dizziness, ringing of the ear, and ear pain. She was scuba diving in Florida last week. A thorough ear exam was conducted. The eardrum appears slightly pushed outward from where it normally sits. Laboratory results showed no abnormal findings. What is the most likely explanation of the findings? A. Acoustic neuroma B. Acute otitis media C. Barotrauma D. Otitis externa E. Otitis media w/ effusion

C. Barotrauma

What is the most common cardiac abnormality that develops in patients with undertreated acromegaly? A. Accessory conduction pathway B. Myocardial infarction C. Cardiomyopathy D. Myocardial wall rupture

C. Cardiomyopathy

Levine sign is most commonly described as which of the following? A. Mild stress applied to the skin causes bull to form B. Patient hesitation to inspire while the gallbladder is palpate C. Clenched fist held over the chest D. Compression of the calf causes the foot to plantar flex

C. Clenched fist held over the chest

You are evaluating a 24-year-old woman for bilateral eye pain. She describes red itching irritated eyelids for several weeks. She states she has had "several bouts" of similar symptoms over the last few years. Exam is consistent with blepharitis. She does not wear contacts, and she occasionally wears eye makeup. She denies any other infectious complaints. What is the most appropriate treatment? A. Start the patient on ophthalmic antibiotics B. Start the patient on ophthalmic steroids C. Discuss good eye hygiene and eyelid scrubbing D. Refer the patient to a ophthalmologist for surgical correction

C. Discuss good eye hygiene and eyelid scrubbing

A 34-year-old man presents for his first doctor's appointment. He had always neglected his health, but he finally sought medical attention at his wife's insistence. He explains that he was from an "unhealthy family" and that he was tired of being around doctors while growing up, so he avoided medical attention. His father died at the age of 30 of "very high blood pressure" and "heart failure." His older brother was recently operated on for the removal of a cancer from his neck. Prior to that, his brother had had surgery to remove a mass from his adrenal gland. He wants to know what he can do to be healthy. His blood pressure and BMI are within normal limits. He does not smoke or use alcohol, and he exercises regularly. What is the most appropriate next diagnostic step? A. Annual colonoscopy starting now B. Measurement of T3, T4 and TSH levels C. Genetic testing for possible familiar cancer syndrome D. Reassurance and return for yearly physical exam E. Renal ultrasound to look for renal cysts

C. Genetic testing for possible familiar cancer syndrome Pts symptoms are consistent with possible MEN2A syndrome - hyperparathyroidism, medullary carcinoma of thyroid, and pheochromocytoma

A 32-year-old man comes to your family medicine clinic with fever, productive cough, and mild shortness of breath for one week. On physical examination, you note that he has bilateral basilar crackles. What other physical examination findings would further increase your suspicion of community acquired pneumonia? A. Inc tactile fremitus, hyperresonance to percussion B. Dec tactile fremitus, dullness to percussion C. Inc tactile fremitus, dullness to percussion D. Dec tactile fremitus, hyperresonance to percussion E. Tracheal deviation

C. Inc tactile fremitus, dullness to percussion

Which of the following is the initial drug of choice for mood stabilization? A. Tricyclic antidepressants B. Olanzapine C. Lithium D. Benzodiazepines E. Fluoxetine

C. Lithium

Which of the following tick-borne diseases is classically associated with the presence of a bull's eye rash? A. Babesiosis B. Ehrlichiosis C. Lyme disease D. Rocky Mountain Spotted Fever

C. Lyme disease

A 65-year-old African American man with a past medical history of hypertension, hyperlipidemia, and diabetes experiences substernal chest pain while shoveling snow. The patient says the pain started after 10 minutes of shoveling wet snow and eventually resolved after he sat down and rested. The patient described the pain as a "heaviness" that did not radiate to any other part of his body and as a 4 or 5/10 on a subjective pain scale, and he experienced this discomfort for approximately 1-2 minutes total. The patient's current vital signs are blood pressure 168/98 mm Hg, pulse 92, and respirations 16. What drug would be the best choice to rapidly reduce the patient's chest pain in a future similar situation? A. Aspirin 81 mg PO B. Metoprolol 50 mg PO C. Nitroglycerine 0.4 mg PO D. Simvastatin 10 mg PO

C. Nitroglycerine 0.4 mg PO

What is the key finding in patients with orbital cellulitis that clinically distinguishes it from periorbital cellulitis? A. Blurry vision B. Fever C. Pain with EOMs D. Periorbital edema

C. Pain with EOMs

A 32-year-old patient at 33 weeks gestation presents to the clinic for evaluation of painless vaginal bleeding. Which of the following is the most likely diagnosis? A. Uterine leiomyoma B. Cervicitis C. Placenta previa D. Abruptio placentae

C. Placenta previa

Which of the following is the mainstay treatment for sarcoidosis? A. Albuterol B. I-atropine C. Prednisone D. Cyclophophamide

C. Prednisone

A 45-year-old obese male presents complaining of fatigue, muscle weakness, headaches, and multiple episodes of palpitations over the last few months. He takes metoprolol daily for his high blood pressure, and began treatment recently for high cholesterol, but doesn't remember the name of the medication. His blood pressure today is 157/110, and physical examination is unremarkable. Blood tests reveal the following:TSH 2.0 U/L (0.5-5.0 μU/mL), Calcium 8.5 mg/dl (8.4-10.2 mg/dL), Sodium 153 mEq/L (136-145 mEq/L), Chloride 92 mEq/L (95-105 mEq/L), Potassium 2.9 mEq/L (3.5-5.0 mEq/L), Bicarbonate 24 mEq/L (22-28 mEq/L), Magnesium 1.7 mEq/L (1.5-2.0 mEq/L).Which of the following is the most likely diagnosis? A. Heart failure B. Hyperthyroidism C. Primary hyperaldosteronism D. Cushing syndrome

C. Primary hyperaldosteronism

A 43-year-old Caucasian woman, previously in good health, presented to the emergency department with headache, blurred vision, and dizziness. Symptoms started 3 days ago and progressively worsened.Past medical history: hypertension, hypothyroidism, prior cholecystectomy. No known drug allergies. Medications: HCTZ 25 mg daily, diltiazem CD 120 mg daily, and levothyroxine 88 mcg daily. She ran out of all medications 2 weeks ago. Vital signs were normal, except for blood pressure 210/114 in the right arm, 215/115 left arm, 220/100 right leg, and 215/112 left leg. Physical exam: Heart - no visible or palpable PMI; normal S1 and S2 without murmur, rub, or gallop. Pulmonary - few faint RLL crackles, which cleared upon coughing. Remainder of the physical exam, including neurologic exam, was unremarkable. CBC and BMP were unremarkable except for K+ 2.3 mEq/L.EKG - NSR with one PVC. Chest X-ray - clear lung fields; normal pulmonary vasculature. CT head - no evidence of intracranial pathology. Renal artery sonogram - Unremarkable. Patient was treated with IV nitroprusside and IV KCl 40 mEq x 2 doses and was admitted for further treatment. Over the next 2 days, patient's blood pressures gradually normalized with medical therapy, but potassium levels remained low despite treatment. What is the most likely underlying cause of her symptoms? A. Cerebral anrusysm B. Pheochromocytoma C. Primary hyperaldosteronism D. Renal artery stenosis

C. Primary hyperaldosteronism Hyperaldosteronism can cause both hypertension and hypokalemia

In a patient undergoing total thyroidectomy for confirmed papillary carcinoma, what nerve may be at risk for damage incurred during this procedure? A. Vagus nerve B. Long thoracic nerve C. Recurrent laryngeal nerve D. Hypoglossal nerve

C. Recurrent laryngeal nerve

A 37-year-old man, with a longstanding history of asthma, presents to the urgent care with wheezing, shortness of breath and coughing which began while doing yard work this morning. His oxygen saturation is 91% on room air and his heart rate is 98 beats per minute. Which of the following is the most appropriate initial management of this patient? A. Oxygen therapy B. Intubation C. Short active beta agonist D. Long acting beta agonist

C. Short active beta agonist

A 7-year-old boy presents with a 3-day history of intense pruritus on his wrists, fingers, and antecubital fossae. It began on his fingers and has moved proximally. According to his mother, they are raised red eruptions and some have scabbed over. She states he has never had this before and it is keeping him up at night. He recently started at a new school. What procedure would be most helpful in confirming your diagnosis? A. Wood lamp inspection B. Skin scraping with KOH preparation C. Skin scraping with immersion oil D. Punch biopsy E. Skin culture with Gram stain

C. Skin scraping with immersion oil

A 75-year-old woman presents with heartburn and dyspepsia. She was diagnosed with osteoarthritis 4 years ago. For the past 18 months, she has been managing pain with naproxen. The gastroenterologist suggests that the patient be tested for Helicobacter pylori infection. What is the most sensitive and specific non-invasive method to diagnose this infection? A. Gastric biopsy B. Fecal antigen test C. Urea breath test D. Culture of H. Pylori

C. Urea breath test

In the treatment of pulmonary tuberculosis, what should be coadministered with isoniazid to reduce the risk of peripheral neuropathy? A. Zinc B. Rifampin C. Vitamin B6 D. Vitamin B12

C. Vitamin B6

A patient comes to your clinic with symptoms of asthma. Pulmonary function tests are performed before and after administration of a bronchodilator. What level of improvement should you see in the forced expiratory volume in one second (FEV1) of this patient in order to make the diagnosis? A. >3% B. >5% C. >7% D. >12% E. >25%

D. >12%

A 66 year old man, with history of arrhythmias well controlled on antiarrhythmic drugs for the last two years, presents to your clinic today complaining of feeling palpitations more often recently. He admits to a 15 pound weight loss over the last two months, despite the feeling that he is ravenously hungry. He has also noticed a fine tremor that has started over the last two weeks. Which of the following antiarrhythmics may have led to this man's symptoms? A. Nifedipine B. Lidocaine C. Digoxin D. Amiodarone

D. Amiodarone Digoxin causes arrhythmias, GI disorders and visual changes

A 66-year-old man with a past medical history of myocardial infarction 2 years ago, aortic regurgitation, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease is presently being monitored in the hospital. Myocardial infarction has been ruled out. An EKG performed upon admission revealed significant Q waves in the anterior leads but no evidence of an acute myocardial infarction. A diagnostic echocardiogram confirms moderate aortic and mitral valve regurgitation and a left-ventricular ejection fraction of 30%. He denies any complaints upon bedside evaluation. His physical exam reveals a blood pressure of 95/55 mm Hg and tachycardia. Continuous bedside ECG monitoring notes wide monomorphic QRS complexes with a heart rate of 160 beats per minute that spontaneously resolve within 20 seconds, reverting to the pattern identified upon admission. What antiarrhythmic agent would be the pharmacologic treatment of choice in the management of this patient? A. Lidocaine B. Procainamide C. Verapamil D. Amiodarone

D. Amiodarone Patient is presenting with monomorphic ventricular tachycardia

A 43-year-old woman comes to your office with Systemic Lupus Erythematosus (SLE). Which if the following thrombophilias is most closely associated with SLE? A. Protein C deficiency B. Protein S deficiency C. Factor V Leiden D. Antiphospholipid antibody syndrome

D. Antiphospholipid antibody syndrome

Propranolol is contraindicated in which of the following patients? A. Hypertensive patients B. Young, white males C. Elderly D. Asthmatics

D. Asthmatics

An 83-year-old man with a history of moderately controlled hypertension and coronary artery disease, comes to the emergency room today with orthopnea and dyspnea on exertion. He denies angina. Over the last few days he has noted a worsening of his dyspnea. Physical examination reveals him to be comfortably sitting. Though vital signs are within normal limits, you find 3 cm of jugular venous distention and 3+ pitting edema of the lower extremities. He is not using accessory muscles of respiration, and his oxygen saturation is 92% on room air. You note mild S4 gallop, and rales in the lower lung fields bilaterally. Which of the following diagnostic tests should be ordered to confirm the suspected diagnosis? A. Complete blood count B. Serum troponin levels C. Stress testing D. B-type natriuretic peptide E. Arterial blood gas

D. B-type natriuretic peptide

A 67-year-old man was cleaning out his garage and noticed a "bug" crawling on his leg. The bug bit him before the patient killed it. He discarded it and went about his business. 2 days later, he presents with pain, itching, and swelling of the affected leg. The bug had a violin-shaped pattern on its back. Based on the patient's symptoms and description, what was this "bug"? A. Black widow spider B. Wasp C. Scorpion D. Brown recluse spider

D. Brown recluse spider Black widow spiders have the red hour glass on their backs

Significant or irritating entropion is sometimes surgically corrected to prevent which of the following? A. Formation of cataracts B. Buildup of oils in the meibomian glands C. Formation of chalazions D. Corneal damage from chronic trichiasis

D. Corneal damage from chronic trichiasis

Which of the following conditions is most likely to be associated with the presence of asterixis? A. Ascending cholangitis B. Cholecysitis C. Hepatic Abscess D. Hepatic encephalopathy

D. Hepatic encephalopathy

The triad of "dermatitis, diarrhea, and dementia" (pellagra) results from a severe deficiency of which of the following vitamins? A. Thiamine B. Vitamin K C. Riboflavin D. Niacin E. Pyridoxine

D. Niacin Niacin is B3 which presents with he pellagra symptoms of dermatitis, diarrhea dnd dementia

Which of the following dermatologic conditions begins with a herald patch? A. Erythema multuforme B. Lichen plants C. Lyme disease D. Pityriasis rosea

D. Pityriasis rosea

A 69-year-old woman presents with shortness of breath. She states it has been worsening over the last 3-4 days; she also is experiencing increased fatigue. The patient is not on any daily medications other than over-the-counter multivitamins, and she has no pertinent past medical history. Physical examination is significant for an oral temperature of 101.5°F, and during auscultation, there are absent breath sounds noted in the right lower lung field. Tactile fremitus reveals an absent result in that same lung field, and percussion over that area creates a dull percussion note. What is the most likely diagnosis? A. Asthma B. COPD C. Early left-sided heart failure D. Pleural effusion E. Pneumothorax

D. Pleural effusion

Each of the following conditions can result in hydronephrosis EXCEPT: A. BPH B. Bladder cancer C. Neurogenic bladder D. Pre-renal acute kidney injury

D. Pre-renal acute kidney injury

Which of the following characteristics is classically associated with monomorphic ventricular tachycardia? A. Alternating QRS complex B. Intact AV conduction C. Narrow QRS complex D. Regular rhythm

D. Regular rhythm

A 32-year-old African American woman, who is being treated successfully for systemic lupus erythematosus, presents after having a miscarriage. Which of the following tests should be ordered to assess this patients risk for further miscarriage or blood clots? A. CBC B. Serum albumin levels C. Hemoglobin A1C D. Serum anti-phospholipid antibodies

D. Serum anti-phospholipid antibodies

Which of the following is the gold standard diagnostic study in a patient with suspected Celiac disease? A. Endoscopy with biopsy of gastric rugal folds B. Large bowel biopsy C. MRI of the abdomen D. Small bowel biopsy E. Tissue transglutaminase IgA

D. Small bowel biopsy Tissue transglutaminase IgA is the first step in evaluation as its sensitivity and specificity is high, but it is NOT the gold standard due to the biopsy giving the definitive diagnosis

Which of the following organisms is most commonly implicated in mastitis? A. Strep pneumo B. Salmonella C. E. Coli D. Staph aureus

D. Staph aureus

A 57-year-old man diagnosed with type 2 diabetes mellitus six months ago, comes to the office for follow-up visit and recheck of his blood lipid profile. He was started on metformin therapy, and given dietary counseling at his initial visit. Measurement of LDL-C at both his prior visit and today's visit is 140 mg/dL. Temperature is 37°C (98.6°F), pulse rate is 82/min, respirations are 16/min, blood pressure is 138/88 mmHg, and BMI is 31. Addition of which of the following medications to this patient's regimen is the most appropriate next step in management? A. Ezetimibe B. Vibrates C. Niacin D. Statins

D. Statins

A 26-year-old woman with a history of fatigue, intermittent fever, joint pain, and facial rash for the past two months, comes to the office for follow-up visit. At her initial visit, she stated that her normal exercise is martial arts, and she has noticed that her exercise tolerance has diminished. Additionally, she has had increasing pain and swelling of the joints in her hands, and mild diffuse muscle weakness. Temperature is 37.6°C (99.7°F), pulse rate is 86/min, respirations are 18/min, blood pressure is 116/68 mmHg. Physical examination shows a mild erythematous maculopapular rash overlying the cheeks and nasal bridge. Mild tenderness and edema is noted over the proximal interphalageal and metacarpophalangeal joints of both hands. Initial laboratory testing showed a positive anti-nuclear antibody test. Which of the following is the most likely diagnosis? A. Ankylosing spondilitis B. Polymyalgia rheumatica C. Reactive arthritis D. Systemic lupus erythematous

D. Systemic lupus erythematous

A 28-year-old man comes to the office because of itchy rash on his inner thighs for the past week. Physical examination shows several 2-3 cm scaling sharply marginated plaques in annular configurations on both medial thighs. Microscopic evaluation of skin scraping samples prepared with 10% potassium hydroxide solution shows septate branching hyphae. Which of the following is the most appropriate treatment for this patient's condition? A. Oral administration of dicloxacillin B. Oral administration of prednisone C. Topical application of hydrocortisone D. Topical application of clotrimazole

D. Topical application of clotrimazole

Which of the following is considered first line treatment for Bipolar Disorder especially for rapid cycling / aggression? A. Quietapine B. Fluoxetine C. Risperidone D. Valproic acid

D. Valproic acid Risperidone is used in bipolar one disorder whereas rapid cycling/aggression is seen in bipolar 2 more commonly.

All of these can cause cardiomyopathy EXCEPT: A. Chronic alcoholism B. Genetics C. Infections D. Postpartum E. Schizophrenia

E. Schizophrenia

A 54-year-old African-American man is seen in the office for follow-up visit after being diagnosed with hypertension three months ago. He is otherwise healthy. A trial of dietary modification and exercise has been only modestly successful, and a mutual decision has been made to introduce pharmacotherapy. Of the following classes of antihypertensive agents, which has a relative contraindication as a first line agent for this individual? A. ACE inhibitor B. Beta blocker C. CCB D. Loop diuretic

A. ACE inhibitor

This common malignancy is diagnosed in patients younger than 15 years of age, has an incidence peak during early childhood (2 to 4 years old), and is seen more prominently in industrialized nations. What is the name of this malignancy? A. ALL B. AML C. CLL D. CML E. Lymphoma

A. ALL

What is the hallmark finding seen in pemphigus vulgaris that distinguishes it from other blistering diseases? A. Acantholysis B. Bullae C. Concurrent autoimmune disease D. Presence of fever E. Presence of lesions on oral mucosa

A. Acantholysis AKA Nikolai's sign = superficial layers of epidermis separate from the deep layers when rubbed laterally by a finger or cotton swab

In addition to the regularly used muscles of respiration, which of the following muscles is also recruited, and used more prominently, in pathological lung diseases such as asthma? A. Accessory muscles (SCM and scalene) B. Erector spinae C. Pectoralis major and minor D. Latissimus dorsi

A. Accessory muscles (SCM and scalene)

Which of the following staining techniques is most appropriate to use on a sputum sample obtained from a patient suspected of being infected with Mycobacterium tuberculosis? A. Acid-fast staining B. Gram staining C. Periodic acid-Schiff reaction D. Wright staining

A. Acid-fast staining

A 43-year-old woman gravida 3 para 3 comes to the office because of worsening dysmenorrhea and menorrhagia for the past 6 months. She states that she has always had heavier than normal periods, often passes clots, and has painful menstruation. Pelvic examination shows a slightly soft, symmetrically enlarged uterus that is tender to palpation. Serum pregnancy test is negative. Which of the following is the most likely diagnosis? A. Adenomyosis B. Endocervical polyp C. Endometrial carcinoma D. Leiomyoma

A. Adenomyosis

A 52-year-old female comes to your office complaining of decreased appetite, trouble sleeping at night, feeling sad more days than not, and trouble concentrating at work and at home. The patient reports that her symptoms began after her divorce became final one month earlier. Which of the following is the most likely diagnosis? A. Adjustment disorder B. Major depressive disorder C. Normal grief reaction D. Post-traumatic stress disorder

A. Adjustment disorder

The nerve roots C5, C6, C7, C8 and T1 contribute to which of the following nerve plexuses? A. Brachial B. Cervical C. Coccygeal D. Lumbar

A. Brachial

A 17-year-old teenage boy comes to the clinic with an inflamed mass in the right axilla for five days. Physical examination shows a 4 cm indurated, deep-seated mass that is tender to palpation. The patient is afebrile. There is no streaking or fluctuance. He reports that he has had similar bumps in the area on and off over the past year, that usually resolve after about one week. Which of the following is the most likely diagnosis? A. Hidradenitis suppurativa B. Cellulitis C. Abscess D. Erysipelas E. Boils

A. Hidradenitis suppurativa

Which of the following best characterizes Tourette syndrome? A. Multiple complex motor and vocal tics B. Onset after age 65 C. Presence of focal dystonia D. Rapid response to electroconvulsive therapy

A. Multiple complex motor and vocal tics

An echocardiogram can assist in the diagnosis of all of the following EXCEPT: A. Supraventricular tachycardia B. Dilated cardiomyopathy C. Heart failure D. Myocardial infarction

A. Supraventricular tachycardia

In fetal heart monitoring, cord compression is most likely to cause which of the following? A. Variable decelerations B. Early decelerations C. Late decelerations D. Fetal demise

A. Variable decelerations Late decelerations are when there is uteroplacental insufficiency Early decelerations are with contractions

Which of the following is the most common cause of Vitamin B12 Deficiency? A. Alcoholism B. Atrophic gastritis C. Decreased ill absorption D. Dietary deficiency

B. Atrophic gastritis

Which of the following findings on physical examination best characterizes a second-degree burn of the skin? A. Erythematous, painful, and variably sized bullae B. Erythematous, painful, soft and dry C. Inelastic and leathery D. Pruritic, elevated papule and plaques with erythematous, sharply-defined borders and pale centers

A. Erythematous, painful, and variably sized bullae

Regular evaluation with a complete blood count for agranulocytosis must be performed when prescribing which of the following medications? A. Venlafaxine B. Clozapine C. Mirtazapine D. Sertraline

B. Clozapine

What is the treatment of choice for refractory schizophrenia? A. Haloperidol B. Clozapine C. Risperidone D. Seroquel E. Lithium

B. Clozapine

A 64-year-old man with a history of chronic kidney disease for the past five years, is found to have normochromic, normocytic anemia on routine laboratory testing. Deficiency in which of the following substances is the most likely cause of this patient's anemia? A. Erythropoietin B. Folic acid C. Thiamine D. Vitamin B12

A. Erythropoietin

A 56 year old female patient is admitted to your hospital service with a spontaneous left pneumothorax of 10%. You decide that the best treatment option at this point is which of the following? A. High flow oxygen and serial CXR B. Large bore needle inserted into the 2nd intercostal space, mid-clavicular line C. Chest tuber insertion at the 5th intercostal space, mid-axillary line D. Observation and serial CXR only

A. High flow oxygen and serial CXR

A 72-year-old man presents with low-grade fever, nausea, confusion, and lethargy. His past medical history is significant for hypertension, hypercholesterolemia, and diabetes. He had sinusitis approximately 1 week ago; otherwise, he has been healthy. Laboratory workup shows a CSF with elevated opening pressure and low blood glucose levels. A Gram stain on the CSF shows gram-positive cocci. CBC shows an elevation of PMNs, but it is otherwise normal. What is the most appropriate treatment in this case? A. Antibiotic therapy B. Steroids C. Supportive care D. Transfusion E. Antiviral treatment

A. Antibiotic therapy

A newborn that you are seeing in the hospital was born at 30 weeks gestation. Several hours after birth you note that he is taking rapid, shallow breaths at 60 per minute. You also observe grunting, intercostal and suprasternal retractions, and a dusky appearance to the skin. Chest radiography reveals air bronchograms most pronounced in the lower lobes bilaterally, and a reticular granularity to the parenchyma. Which of the following is this child's most likely diagnosis? A. Hyaline membrane disease B. Pneumothorax C. Tetrology of fallot D. Meconium aspiration syndrome

A. Hyaline membrane disease

A 2-week-old male infant presents with his father for evaluation of enlarged scrotum. The father states that the scrotum was a little larger in the first few days after birth than it is now, but it has not reduced in size enough to make him feel comfortable that it is normal. Physical examination reveals normally developed penis with abnormally large scrotum that transilluminates on the right side when light is shined on it. What is the most likely diagnosis? A. Hydrocele B. Inguinal hernia C. Spermatocele D. Testicular tumor E. Varicocele

A. Hydrocele

Which of the following is a pre-renal cause of acute kidney injury? A. Hypotension B. Nephrolithiasis C. Glomerulonephritis D. Acute tubular necrosis (ATN)

A. Hypotension Nephrolithiasis is post-renal Glomerulonephritis is intrarenal ATN is intrarenal

A 34-year-old man comes to the community clinic with a rash for the last month. Physical examination shows a greasy yellow papular rash with scaling along his forehead and into the nasolabial folds. Which of the following is the most likely diagnosis? A. Seborrheic dermatitis B. Seborrheic keratosis C. Tinea versicolor D. Tinea capitis

A. Seborrheic dermatitis

Which of the following blood vessels of the systemic circulation imposes the greatest resistance to blood flow? * A. Arteries B. Arterioles C. Lymphatic D. Veins E. Venules

B. Arterioles

A 2-year-old girl has developed a "barking" cough and a low-grade fever. She has some runny nose and her voice is somewhat raspy and hoarse. When approached by the PA, she becomes somewhat upset and exhibits mild inspiratory stridor. She appears otherwise well and has no drooling or dyspnea. What is the most likely etiology of this child's illness? A. Adenovirus B. Coxsackievirus C. Cytomegalovirus D. Parainfluenza virus E. Respiratory syncytial virus

D. Parainfluenza virus

All of the following a potential complications or sequela of ulcerative colitis EXCEPT: A. Toxic megacolon B. Colon cancer C. GI bleed D. Peptic ulcer disease

D. Peptic ulcer disease

A nurse working in your office thought that she was recently exposed to a patient with tuberculosis. This could not be confirmed, but you decide to perform a PPD test on the nurse. What results must you see for this test to be considered positive in a healthcare worker? A. 5 mm of erythema B. 5 mm of induration C. 10 mm of erythema D. 10 mm of induration E. 15 mm of induration

D. 10 mm of induration

In patients who are not considered high risk, surgical repair for abdominal aortic aneurysm becomes a viable option once the aneurysm diameter is greater than: * A. 1 centimeter B. 2 centimeters C. 4 centimeters D. 5 centimeters

D. 5 centimeters

A 15-year-old boy presents with abdominal pain and rectal bleeding. His family history is significant for the premature deaths of his mother and maternal grandmother from metastatic colon cancer. Both died before age 35; in both, autopsy findings included hundreds of colon polyps along with multiple primary colon cancers. Endoscopy of the boy also demonstrates extensive colonic polyp disease. What mutation in what is causing this patient's symptoms? A. BRCA1 B. BRCA2 C. MSH2 D. APC E. RET

D. APC BRCA1 & BRCA2 = breast & ovarian cancer; MSH2 = hereditary non-polyposis colon cancer syndrome; RET = medullary thyroid cancer

Which of the following is the primary mechanism by which benzodiazepines exert their sedative and anxiolytic effects? A. Acting as dopamine receptor agonists B. Acting as NMDA receptor antagonists C. Acting as serotonin receptor antagonists D. Increasing GABAA receptor mediated chloride conductance

D. Increasing GABAA receptor mediated chloride conductance

Which of the following is the most common site for aortic aneurysm? A. Ascending aortic arch B. Descending aortic arch C. Suprarenal aorta D. Infrarenal aorta

D. Infrarenal aorta

Which of the following Salter Harris classification fractures has the highest chance of resulting in growth disturbance? A. I B. II C. III D. IV E. V

E. V

A 50-year-old woman with a family history of colon cancer underwent a total colonoscopy per screening guidelines for colon cancer. 2 polyps, 1 cm each, were noted on exam. The doctor advises the patient to repeat her colonoscopy in 3 years due to her polyp pathology. What type of colon polyp does this patient likely have? A. Hyperplastic B. Hemartomatous C. Tubular adenoma D. Tubulovillous adenoma E. Villous adenoma

E. Villous adenoma Villous adenomas are at the HIGHEST risk of cancer and surveillance colonoscopy is in 3 years Hyperplastic and hemartomatous are benign with no malignant potential, no change in recommendation of follow-up colonoscopy Tubular adenoma are the MC neoplastic polyps, tubulovillous are at risk for cancer as well, repeat colonoscopy would be 5-10 years

A 35-year-old man presents with a groin mass. The patient states that the mass is painless; there is no known trauma to the region. The mass is present when the patient stands, and it disappears when the patient is lying flat. Past medical history is significant for obesity, hypertension, and hyperlipidemia. Past surgical history is significant for lipoma removal from the left shoulder. The patient denies tobacco use; he tells you that he drinks about 6 beers per week. In office ultrasound confirms diagnosis and surgical repair is scheduled. What is the most significant risk factor for this patient's condition? A. Obesity B. HTN C. Hyperlipidemia D. Lipoma removal E. Alcohol use

A. Obesity

A 1-year-old boy appears to be physically underdeveloped. His vital signs are not remarkable. His parents are concerned about his health because he seems to be weak and lethargic. The parents are recent immigrants from southern Italy. A brief history check reveals that both parents have a history of mild anemia. The child is afebrile. A complete blood count (CBC) is ordered and reveals: Low RBCs, Hb of 8.0 gm/dL (normal 11.3 - 13 g/dL) ; Hct of 24% (normal 33 - 38%); peripheral smear showed 1+ basophilic stippling; hypochromia; and the presence of codocytes. What is the most likely diagnosis? A. Thalassemia B. Sickle cell anemia C. Aplastic anemia D. Megaloblastic anemia

A. Thalassemia

A 20-month-old boy presents for a routine visit. He is eating well and drinking at least a bottle of cow's milk daily for the last several months. His history and physical are normal except for mild pallor. Urinalysis is normal, and the rest of his laboratory findings are below: Result Hemoglobin 9.5 (Normal 10.5-14.0 g/dL) RDW 52 (Normal 38.5-49.0%) MCV 72 (Normal 76.0-90.0 fl) Platelets 280,000 (Normal 150,000-450,000/μL) WBC 6.7 (Normal 5,000-14,500/μL) What additional finding might you expect in this child? A. Anisocytosis B. Depranocytosis C. Schistocytosis D. Elevated bilirubin

A. Anisocytosis

A positive Lachman test following a hyperextension injury to the knee most likely represents damage to which of the following structures? A. Anterior cruciate ligament B. Lateral collateral ligament C. Medical collateral ligament D. Meniscus

A. Anterior cruciate ligament

An 18-year-old woman is seen in the office for postprandial abdominal pain, bloating, and 10 pound weight loss over the past six months. She denies vomiting, diarrhea, and bloody stools. However, her stools have been foul-smelling, and pale in color. Her older sister was recently diagnosed with celiac disease. Which of the following is the most appropriate next step in diagnosis? A. Anti-transglutaminase antibody test B. Gluten-free elimination diet C. Small-bowel barium study D. Small-bowel biopsy

A. Anti-transglutaminase antibody test This is the most sensitive and specific blood test for celiac disease Positive serology is then confirmed with a duodenal biopsy

A 58-year-old man presents to the emergency department for a 4-hour history of chest pain and shortness of breath. He is a long-haul truck driver and noted the symptoms started while he was driving. He admits a mild cough with some blood in his sputum. The chest pain seems to be associated with breathing and gets worse with deeper inspiration. He denies fever or chills. He is a smoker. He reports no known medical conditions, no medication use, and no prior surgeries.On physical exam, the patient is mildly obese, tachypneic (respiratory rate of 22), and tachycardic (pulse of 112). He appears to be in mild distress. Lungs are normal to auscultation and percussion. Heart exam is normal. His left lower leg has some dependent edema and tenderness. The patient thinks he strained a muscle or bumped it, but he had been too worried about his shortness of breath and failed to mention this in his history. The remainder of his exam is normal.He was immediately placed on oxygen at arrival. Several tests results are available. SpO2 92% on oxygen; CBC, CMP, Troponin, CK-MB, ECG, and CXR are all normal. D-dimer is elevated. Assuming all modalities are available to this patient, what intervention is most appropriate for his current condition? A. Anticoagulation B. Chest tube decompression C. Hyperbaric oxygen therapy D. Inferior vena cava filter E. percutaneous coronary intervention (PCI)

A. Anticoagulation

A 13-year-old girl presents with a painful reddened lesion on the inside of her cheek. She noticed this lesion a few days ago and it will not go away. Upon physical exam, the inside of her right cheek has a yellow-grey appearance with an erythematous halo surrounding the lesion. Patient overall feels well besides this specific issue, and no other rashes or lesions are noted. All laboratory findings are within normal limits. HSV-1 and HSV-2 are both negative. What is the most likely diagnosis A. Aphthous ulcer B. Folate deficiency C. Herpangina D. Herpes labialis

A. Aphthous ulcer

A 48 year old alcoholic male presents with fever, dyspnea, and productive cough that contains both mucus and blood, which he describes as appearing like currant jelly. On x-ray there is no evidence of localized consolidation or pleural effusion, but you do notice what appears to be a cavitation in the right lung. What is the most likely causative organism of this man's pneumonia? A. Klebsiella B. Streptococcus C. Pseudomonas D. Chalmydophila

A. Klebsiella

An active 19-year-old male presents with dyspnea on exertion and pre-syncopal episodes. He has a positive family history of sudden cardiac death. Echocardiography demonstrates significant left ventricular hypertrophy. Which pharmacotherapeutic agent is the most appropriate initial therapy for this patient? A. Labetalol B. Nifedipine C. Aspirin D. Adenosine

A. Labetalol

A 56-year-old man is brought to the emergency department by ambulance because of altered mentation and confusion. Physical examination shows hyperreflexia, cerebellar ataxia, and asterixis. You also notice a musty breath odor. Administration of which of the following medications is most appropriate for this patient's underlying condition? A. Lactulose B. Lorazepam C. Mannitol D. Phenobarbital

A. Lactulose

A 32 year old female patient presents complaining of a rash on her wrists for the last two weeks. It has been unresponsive to both lotions and over-the-counter hydrocortisone. Though she thinks it is unrelated, she relates to you that she was treated last week for a pruritic vaginitis. Upon physical exam of the wrists you note violaceous planar papules on the flexor surface of the wrist. The most likely diagnosis is which of the following? A. Lichen planus B. Contact dermatitis C. Drug eruption D. Dyshidrosis E. Viral exanthema

A. Lichen planus

A 50-year-old man with a history of DM and CKD presents to your office for a follow-up appointment for his hypertension. He reports some non-specific muscle weakness, so you decide to perform an ECG. The ECG demonstrates peaked T waves in several leads without any other abnormality. His labs reveal BUN 12, CO2 22, creatinine 1.0, Glucose 97, K 7.2, Cl 101, and Na 137. What medication is most likely to cause this ECG finding? A. Lisinopril B. Furosimide C. Atenolol D. Hydrochlorothiazide

A. Lisinopril ACE inhibitors have the potential to cause hyperkalemia due to blockage of aldosterone production

A 36-year-old woman presents with a 24-hour history of sudden severe diarrhea described as profuse, gray, cloudy, watery stools without blood or fecal odor. She was recently in Bangladesh for work and returned yesterday, which was when the diarrhea began. She is also experiencing a mildly elevated temperature with a very dry mouth, headache, and severe fatigue. What is the most likely offending organism? A. Enterotoxigenic E. Coli B. Vibrio cholerae C. Norwalk virus D. Shigella dysenteriae E. Clostridium difficile

B. Vibrio cholerae Shigella causes bloody diarrhea w/ abdominal cramping and fever; enterotoxigenic E. Coli and norwalk have fever and cramping and c. Diff is associated with antibiotic use

An 85-year-old woman presents to your clinic for routine checkup. The patient has no symptoms or complaints. During her physical examination, you notice a pulsatile abdominal mass. Which of the following is the best initial study to confirm your suspected diagnosis? A. Abdominal CT scan with IV contrast B. Abdominal ultrasound C. MRI scan D. Plain abdominal x-ray study

B. Abdominal ultrasound

A 22 year old woman who is 36 weeks pregnant presents with severe lower abdominal cramping-like pain and extensive vaginal bleeding. What is the most likely diagnosis? A. Placenta Previa B. Abruptio Placentae C. Ectopic Pregnancy D. Ovarian Torsion E. Preelampsia complications

B. Abruptio Placentae

Early one afternoon, a 15-year-old boy presents with abdominal pain, nausea, and vomiting. The pain has been worsening since the onset of symptoms in the morning. There is no known gastrointestinal disease in the history; no one in the immediate environment has one, either. Physical examination finds no abdominal tenderness, but Psoas sign and tenderness on rectal examination are detected. Temperature and pulse are slightly elevated. Skin turgor is reduced, and there is a 10 mm Hg drop in postural blood pressure. Laboratory studies find 18,000 white blood cells per microliter. What is the most likely diagnosis? A. Acute mesenteric lymphadenitis B. Acute appendicitis C. Salmonella gastroenteritis D. Meckel's diverticulitis E. Regional enteritis

B. Acute appendicitis

A 27-year-old woman presents due to labial pain and burning and reportedly noticed a cluster of blisters in the area 2 days ago. She had myalgia, malaise, and a temperature of 100.5°F a few days prior to appearance of the blisters, which kept her home from work. She is monogamous and her partner denies similar symptoms.On physical examination, inguinal lymphadenopathy is noted in addition to the presence of multiple vesicles on the labia and perineum; some are ruptured and some are crusted. There is no vaginal discharge, and the rest of the pelvic exam is unremarkable. What is the proper treatment for this condition? A. Penicillin B. Acyclovir C. Fluconazole D. Metronidazole

B. Acyclovir

A healthy 20-year-old man comes to the clinic to be tested for tuberculosis. Which of the following is the most sensitive test for tuberculosis in this patient population A. Acid-fast bacillus test B. Administration of a PPD test C. Quantiferon gold serum test D. Sputum culture

B. Administration of a PPD test

Which of the following diseases is associated with the development of nasal polyps? A. Amyloidosis B. Allergic rhinitis C. Chronic sinusitis D. COPD

B. Allergic rhinitis

A 55 year old male, who worked as an insulation installer for more than 30 years, presents with dyspnea and a dry cough. On physical exam you note clubbing of the fingers and inspiratory crackles diffusely throughout both lungs. Chest x-ray reveals pleural plaques with a reticular pattern through both lung bases. What is the most likely diagnosis for this patient? A. Idiopathic pulmonary fibrosis B. Asbestosis C. Silicosis D. Sarcoidosis

B. Asbestosis

A newborn girl is diagnosed with phenylketonuria following routine screening, and confirmatory testing. When providing dietary counseling to the girl's parents regarding use of artificial sweeteners, which of the following must the girl avoid ingesting? A. Acesulfame potassium B. Aspartame C. Stevia D. Sucralose

B. Aspartame

A 5-year-old boy presents with an erythematous skin rash associated with intense itching. The boy's mother has noticed that her son's rash has been recurrent, with 3-4 episodes per year. The itching and rash increases after consumption of certain foods. On examination, erythematous raised papules are seen on the cheek, trunks, and upper arms. What is most likely associated with the boy's condition? A. Gluten enteropathy B. Asthma C. Vitamin A deficiency D. Psoriasis E. Raised dengue titers

B. Asthma

A 2-year-old boy is brought to the office by his parents for evaluation. They state that their son often times speaks in a language that appears to be nonsensical. When his daily routine is disrupted, he often has tantrum like outbursts. Additionally, he rarely makes eye contact when spoken to. During the physical examination, he seems to ignore the other individuals in the room. Which of the following is the most likely diagnosis? * A. ADHD B. Autism spectrum disorder C. Conduct disorder D. Personality disorder

B. Autism spectrum disorder

A 21-year-old woman comes to the office seeking advice because of feelings of inadequacy for the past five years. She states that she is extremely sensitive to what other think about her, and consequently, avoids any activities that involve socializing or interacting with others. Which of the following personality disorders is most likely in this patient? A. Antisocial B. Avoidant C. Borderline D. Paranoid

B. Avoidant

A 23 year old female G1P1 presents to the emergency department with her breastfed 2 month old daughter complaining of breast tenderness and swelling. Her temperature is elevated at 101.6 F (38.7 C) and physical exam reveals erythema and swelling of the left lower quadrant of the left breast. The patient states she has never had this before and has no drug allergies. Which of the following is the most appropriate medical intervention at this time? A. Penicillin VK B. Dicloxacillin C. Doxycycline D. Reassurance and warm compresses

B. Dicloxacillin

A 66-year-old man with a chronic dysrhythmia comes into the clinic complaining of visual changes. He states he sees halos around lights and notices a yellowish discoloration to his vision. This patient is most likely being treated with which of the following dysrhythmic agents? A. Amiodarone B. Digoxin C. Propanolol D. Lidocaine E. Isoproterenol

B. Digoxin

A 52-year-old Caucasian man who frequently visits the emergency department presents due to "being short of breath." He is currently homeless, in and out of shelters. Past presenting problems that have brought him to the emergency department indicate that he has a chronic issue with alcohol overuse. Today, the patient is experiencing severe shortness of breath at rest. Physical examination findings reveal rales auscultated in bilateral lung fields, an S3 gallop, and elevated JVP. What is the most likely diagnosis? A. Angina pectoris B. Dilated cardiomyopathy C. Essential hypertension D. Hypertrophic cardiomyopathy E. Restricted cardiomyopathy

B. Dilated cardiomyopathy

A 48-year-old previously healthy African American woman was involved in a severe motor vehicle accident, sustaining multiple injuries. She was stabilized in the emergency department but is now bleeding extensively from her laceration sites, her IV catheter site, and from mucous membranes. Laboratory results show thrombocytopenia, fragmented red blood cells, and low fibrinogen levels. What is the most likely diagnosis? A. Factor V deficiency B. Disseminated intravascular coagulation C. Factor XI deficiency D. Protein C and S deficiency E. Acute idiopathic thrombocytopenia purpura

B. Disseminated intravascular coagulation

Which of the following anatomical locations does Crohn's disease most commonly affect? A. Sigmoid colon B. Distal ileum C. Distal jejunum D. Transverse colon

B. Distal ileum

One of your patients who is 32 weeks pregnant presents to the clinic complaining of dizziness, fatigue and headache. Her blood pressure has been elevated during the pregnancy but today seems abnormally high at 180/110 mmHg. She is mildly confused and seems lethargic. You order some blood work which reveals thrombocytopenia, anemia, and elevated levels of ALT and AST. For which of the following complications are you concerned? A. Dresser syndrome B. HELLP syndrome C. Disseminated intravascular coagulopathy D. Idiopathic thrombocytopenia

B. HELLP syndrome

Ischemia is the cause of cerebrovascular accident (CVA) in approximately 85% of cases. When it is suspected that a patient has had a CVA, which of the following studies should be used to determine whether ischemia is indeed the cause, or if their symptoms are due to hemorrhage? A. Head CT with contrast B. Head CT without contrast C. Carotid artery ultrasound D. Electroencephalogram

B. Head CT without contrast

Which of the following is the most common presenting symptom of concussion? A. Dizziness B. Headache C. Loss of consciousness D. Nausea and vomiting E. Amnesia

B. Headache

For routine vaccination, each of the following immunizations generally requires a booster dose to be administered between 4-6 years of age except: * A. DTaP B. Hib C. Inactivated poliovirus D. Varicella

B. Hib

A 44-year-old Caucasian woman is admitted to the hospital with a severe nosebleed. The patient states that there was no history of trauma, and she has never had nosebleeds before. She also reports a history of upper respiratory infection (URI) symptoms 1 week ago. The patient's blood work is notable for a platelet count of 10,000/mm3. The patient is treated with steroids for her presumptive diagnosis. The patient's platelet count is refractory, and a splenectomy is performed. After a few months, what would you expect to see in this patient's peripheral blood smears? A. Burr cells B. Howell-Jolly bodies C. Hypersegmented neutrophils D. Schistocytes

B. Howell-Jolly bodies

A 27-year-old woman comes to the office because of perianal itching and irritation for the past two weeks. She has tried application of over-the-counter hemorrhoid creams without relief. She is sexually active, and takes oral contraceptive pills. Physical examination of the perianal area shows multiple soft, moist cauliflowerlike lesions. Which of the following is the most likely causative organism of this patient's condition? A. Herpes simplex virus B. Human papilloma virus C. Klebsiella granulomatis D. Molluscum contagiosum virus

B. Human papilloma virus

A 57-year-old woman who was recently diagnosed with primary hyperparathyroidism due to an adenoma is admittted to the hospital for a parathyroidectomy. Forty-eight hours after the surgery, she becomes markedly anxious and develops paresthesias in her fingers and toes, muscle cramps, and carpopedal spasm. What is the most likely cause of her symptoms? A. Hypercalcemia B. Hypocalcemia C. Hypermagnesemia D. Hypokalemia

B. Hypocalcemia

A 36-year-old woman with a diagnosis of vitiligo is seen in the office for evaluation of comorbid autoimmune disease. Which of the following autoimmune conditions is most likely to occur as a comorbid condition of vitiligo? A. Addison disease and Conn disease B. Hypothyroidism and hyperthyroidism C. Multiple sclerosis D. Ulcerative colitis and Crohn's disease

B. Hypothyroidism and hyperthyroidism

A 39-year-old previously well Caucasian man presents to the emergency department with a 10-day history of fever >101°F and acute dyspnea with pleuritic chest pain. His past medical history is notable only for childhood asthma (no recurrences since age 12) and appendectomy. He has no known drug allergies. He denies taking prescribed medications on a regular basis.Vital signs show: Temperature 100.8°F, pulse 108, respirations 24, and blood pressure 98/60. O2 saturation is 90% on room air. Physical examination reveals mild crackles of the mid-lung fields bilaterally and a grade II/VI soft systolic murmur, loudest at the left lower sternal border. Oral exam shows overall poor dentition. Skin exam shows non healed puncture wound in left antecubital region surrounded by old granulomas and scarring.A spiral CT reveals evidence of multiple pulmonary emboli. He is admitted to the general medical floor of an acute care hospital. Additional diagnostic tests are ordered; preliminary results of blood cultures showed 4+ growth of gram-positive cocci. Infectious Diseases is consulted and he is started on an IV antibiotic regimen. What is the most likely causative risk factor for this patient's underlying diagnosis A. Dental infection B. IV drug use C. Kawasaki disease D. Rheumatic heart disease E. Valvular heart disease

B. IV drug use

A 48-year-old man comes to his internal medicine clinic for a routine checkup. His only concern at this time is that he has noted increased flushing in his face, mild headaches, and fatigue on and off for the last few months. Blood testing reveals a hemoglobin of 19 g/dL, and a hematocrit of 57%. Which of the following is the treatment of choice for this patient's condition? A. Induction chemo B. Phlebotomy C. Decreased meat consumption D. Blood transfusion

B. Phlebotomy

A 32-year-old woman is brought in via ambulance due to a fast heart rate. Her blood pressure is 114/76 mm Hg, and her heart rate is 156 bpm. She reports mild chest pain and shortness of breath. Her 12-lead EKG reveals retrograde P-waves that occur simultaneously with the QRS complexes but appear "hidden." After mechanical measures fail, what pharmacologic agent should be tried first? A. Amiodarone 150 mg IV B. Verapamil 5 mg IV C. Adenosine 6 mg IV D. Lidocaine 5 mg IV

C. Adenosine 6 mg IV

What is the most common cause of viral conjunctivitis? A. Coronavirus B. Influenza virus C. Adenovirus D. Parainfluenza virus E. Human herpes virus

C. Adenovirus

A 19-year-old man presents with pain and deformity of his right dominant shoulder after a sudden jerking movement to the same shoulder from a wrestling competitor approximately 1 hour ago. He states he felt a clunking sensation when it happened. He was unable to continue wrestling and has pain with movement of the right shoulder. What initial imaging should be the next step in this patient? A. CT of the shoulder B. Anterior/posterior and internally rotated humeral view radiographs C. Anterior/posterior, scapular lateral, and axillary radiographs D. MRI of the shoulder E. Internal and external radiographs of the humeral head

C. Anterior/posterior, scapular lateral, and axillary radiographs

A 57-year-old woman who is otherwise healthy comes to the clinic because of increasing vaginal dryness, and increasing pain with sex over the past two years. Her last menstrual period was five years ago. She had initially used over-the-counter vaginal lubricants with some success, but they have become less effective over time. Physical examination shows recession of the labia minora, dry, pale vulvovaginal mucosa, and loss of mucosal ridges and folds. Which of the following is the most appropriate next step in management? A. Administration of Dana zoo B. Administration of tamoxifen C. Application of vaginal estrogen preparation D. Application of progesterone cream

C. Application of vaginal estrogen preparation

A patient has a positive direct Coombs test. Which of the following is the most likely diagnosis? A. G6PD deficiency B. Sickle cell anemia C. Autoimmune hemolytic anemia D. Hereditary spherocytosis

C. Autoimmune hemolytic anemia

Which of the following is the pharmacologic therapy of choice for Mycoplasma pneumoniae? A. Penicillin G B. Ampicillin C. Azithroymcin D. Ceftriaxone

C. Azithroymcin

A 45 year old male is brought to the emergency room because of delirium, high fever, and tachycardia. Labs drawn show a TSH of 0.25 U/ml and a T4 level of 18 mg/dl. Which of the following is the next best step in the evaluation and treatment of this patient? A. Administer radioactive iodine in preparation for thyroid scan B. Begin therapy with aspirin and prednisone C. Begin immediate therapy with PTU and propranolol D. Thyroid US

C. Begin immediate therapy with PTU and propranolol This is the initial treatment of a thyroid storm***

A 32-year-old African American woman comes to the clinic with a one month history of fever, malaise, non-productive cough, joint pain and weight loss. Chest radiograph reveals bilateral hilar adenopathy. Which of the following tests will give a definitive diagnosis of the suspected disease in this patient? A. Bronchoalveolar lavage B. Administration of an intradermal PPD test C. Biopsy of mediastinal nodes D. Spiral CT

C. Biopsy of mediastinal nodes

A 24-year-old man undergoes a routine medical check-up to become a volunteer in the ER. PPD skin test shows an induration diameter of 9 mm. Sputum and chest X-ray are done; they are negative for tuberculosis. He is otherwise healthy and has no fever, cough, or other symptoms of Mycobacterium tuberculosis infection. What is the most appropriate explanation for the doubtful tuberculin test in this patient A. Sputum and CXR report could be wrong B. Adequate sputum samples were not supplied C. He was given BCG vaccinations earlier in life D. He may suffer from chronic cavitation lesion in the lung E. He has an active tubercular infeciton

C. He was given BCG vaccinations earlier in life

When reading the radiology report for one of your patients, you notice that the radiologist documented Ghon complexes (can also be referred to as Ranke complexes) in the right upper lobe. This finding is consistent with which of the following? A. Progressive pulmonary fibrosis B. A common finding in interstitial lung disease C. Healed primary pulmonary tuberculosis D. Latent tuberculosis

C. Healed primary pulmonary tuberculosis

Which of the following is the most likely cause of pseudo-hyperkalemia? A. Acute kidney injury B. Angiotensin converting enzyme inhibitors C. Hemolysis of blood specimen D. Metabolic acidosis E. Rhabdomyolysis

C. Hemolysis of blood specimen

A 23-year-old man presents with a 2-day history of watery nasal discharge, malaise, sneezing, and nasal congestion. On examination, you notice inflammation of the nasal mucosa; pulse is 80/min, BP is 130/84 mm Hg; temperature is 98.8°F. The rest of the examination is normal. What is the appropriate treatment for this patient? A. Azithromycin, nasal decongestants, ibuprofen B. Ibuprofen only C. Nasal decongestants and non-pharmacologic remedies D. Antiviral agents, nasal decongestants & ibuprofen E. Antiviral agents only

C. Nasal decongestants and non-pharmacologic remedies

Which of the following organisms is best characterized as a gram-negative diplococcus? A. Bacillus anthraces B. Clostridium botulinum C. Neisseria gonorrheae D. Staphylococcus aureus

C. Neisseria gonorrheae

An 18-year-old man is seen in the urgent care clinic for a rash that developed on his right ring finger one day after he started wearing his new high school graduation ring. He states the finger is itchy, and the affected skin is slightly red with some small blisters. Allergy to which of the following metals is the most likely cause of this patient's condition? A. Cobalt B. Gold C. Nickel D. Silver

C. Nickel

A 22-year-old woman who is 16 weeks pregnant comes into your clinic complaining of burning with urination and increased frequency over the last few days. Physical examination reveals suprapubic tenderness and urinalysis reveals positive nitrites and positive leukocyte esterase. Which of the following represents the best pharmacological intervention at this time? A. Azithromycin B. Ciprofloxacin C. Nitrofurantoin D. Trimethoprim-sulfamethoxazole

C. Nitrofurantoin

An 18-year-old man presents with multiple painful vesicles on an erythematous base on the right side of his lower lip. He experienced similar symptoms a month ago with an associated sore throat. He has an oral temperature of 101°F and positive tender cervical lymphadenopathy. What is the most appropriate clinical intervention? A. Oral amoxicillin/clauculanic acid for 10 days B. Punch biopsy of 1 of the lesions C. Oral valcyclovir D. IV acyclovir

C. Oral valcyclovir Symptoms consistent with herpes virus, oral systemic treatment has been proven to help clear the lesions

A 54-year-old woman presents to your office complaining of a severe unilateral headache with associated photophobia, nausea, and vomiting. While eliciting her history you discover that she has never had headaches like this before. The next best step in the evaluation and treatment of this patient would be? A. Prescribe sumatriptan B. Prescribe an NSAID C. Order a head CT D. Advise her to try heat packs on her neck and to take ibuprofen as needed

C. Order a head CT

A 36-year-old man with a history of asthma comes to the urgent care clinic because of acute onset of high fever, headache, upper respiratory symptoms, myalgias, and malaise for the past one day. A rapid diagnostic test confirms the presence of influenza, but the type is not specified. Which of the following is the most appropriate treatment for this patient's condition? A. Amantadine B. Azithromycin C. Oseltamivir D. Zanamivir

C. Oseltamivir

A newly graduated physician assistant is working in a vascular surgery practice. The PA is replacing a practitioner with 10 years of experience. The collaborating physician asks the PA to place a central line. The PA has done this once before, but the doctor states their previous PA did it all the time. The PA is uncomfortable doing this procedure. What is the determining factor in this situation? A. Collaborating physician's scope of practice B. Previous PA's scope of practice C. PA's experience D. State laws

C. PA's experience

A 44-year-old man comes to the emergency department because of nausea, vomiting, and mid-epigastric pain for the past two days. Physical examination shows corneal arcus, and mild tenderness over the epigastric area. The remainder of the examination shows no abnormalities. Measurement of serum triglycerides is 1,250 mg/dL. Which of the following conditions, as a complication of hypertriglyceridemia, is most likely in this patient? A. Atrophic gastritis B. Mesenteric artery occlusion C. Pancreatitis D. Portal hypertension

C. Pancreatitis Hypertrigluceridemia can cause acute pancreatitis***

A 4-year-old girl is brought to the clinic by her mother because of a swollen, tender thumb. The child sucks her thumb, and for the past week has felt increasing pain around the nail, and has had a red, swollen area that has drained pus once. Physical examination reveals a significant area of erythema, edema, and fluctuance at the nail fold. Which of the following is the most likely diagnosis? A. Felon B. Onychomycosis C. Paronychia D. Hermetic whitlow

C. Paronychia

A 25-year-old woman has a 2-month history of "episodes" that occur more than 3 times a week. She describes the episodes as a pounding heartbeat, breaking out in a sweat, and difficulty catching her breath. Occasionally, she will feel dizzy and faint with a "tingling" sensation throughout her body. Based on the suspected diagnosis, what is the first-line drug used in management of this disorder? A. Alprazolam B. Clonazepam C. Paroxetine D. Imipramine E. Clomipramine

C. Paroxetine

An 18-year-old man with no significant past medical history presents with pain and swelling over the upper right knee for 5 months. The pain was initially insidious, dull, and achy. Over the past several weeks, however, it has gradually become progressively more severe and unremitting, often waking the patient at night. He also notes increased swelling, warmth, and erythema. He denies a history of injuries, accidents, trauma, surgeries, or sexual encounters.His physical exam reveals a noticeable limp, reduced right knee range of motion, and localized tenderness and swelling to the distal anterior femur. What is the next step in the management of this patient? A. Begin physical therapy 3 times a week for 6 weeks B. Begin a xanthine oxidase inhibitor and indomethacin C. Perform a right knee radiograph D. Prescribe trial of ibuprofen and observe for 2 weeks E. Refer the patient for a bone scintigraphy scan

C. Perform a right knee radiograph

A 16-year-old girl presents to her primary care physician after having discovered a breast mass while bathing. She reports no symptoms of any kind; the mass was discovered while taking a shower. There is no history of chest trauma. Exam reveals Tanner stage IV breast development, appropriate to age, and a 2 cm mass in the upper outer quadrant of the right breast. The mass is rubbery in character, mobile, with distinctly palpable borders, non-tender, not fixed to adjacent tissue, and without change in surface anatomy of the breast. What is the most likely diagnosis? A. Breast abscess B. Phyllodes tumor C. Juvenile fibroadenoma D. Giant fibroadenoma E. Malignancy

C. Juvenile fibroadenoma

A 43 year old female G4P4 presents to the clinic complaining of wetting herself. She is very concerned as this has led to some very embarrassing moments. A further history reveals this usually happens when she coughs or sneezes. The initial treatment of choice for this patient is which of the following? A. Anti-cholinergic medications B. Injectable bulking agents C. Kegal exercises D. Vaginal pessary

C. Kegal exercises

Which lab test provides the most useful information when evaluating a patient for choledocholithiasis? A. CBC B. PT/PTT C. LFTs D. Lipase

C. LFTs

A 76-year-old man presents with acute myocardial infarction. He quickly develops hypotension, altered mental status, cold clammy skin, and metabolic acidosis evident on laboratory tests. Based on the most likely diagnosis, what diagnostic study will be most helpful in demonstrating the severity of this patient's condition? A. CBC B. ABG C. Lactate levels D. Cortisol level E. Blood culture

C. Lactate levels Pt is experiencing cardiogenic shock

Upper gastrointestinal bleeding is defined as bleeding that occurs proximal to which of the following anatomic sites? A. Gastroesophageal sphincter B. Hesselbach triangle C. Ligament of Treitz D. Pyloric sphincter

C. Ligament of Treitz

A 55-year-old African American man, with a 60 pack year smoking history, presents to the clinic for evaluation of a 30 pound weight loss over the last 8 weeks. The patient is otherwise asymptomatic. Chest x-ray reveals a hilar mass and mediastinal widening. Old chest x-ray films are reviewed and appear normal. Which of the following is the most likely diagnosis? A. Tuberculosis B. COPD C. Lung cancer D. Pulmonary metastases

C. Lung cancer

A female patient presents to the emergency department for evaluation of vaginal bleeding and crampy abdominal pain at 16 weeks gestation. Patinet states that she has passed some type of clot just prior to coming to the emergency department. Pelvic examination reveals a dilated cervical os with visible tissue in the endocervical canal. Which of the following types of abortion is best represented in this case? A. Inevitable abortion B. Threatened abortion C. Complete abortion D. Incomplete abortion

D. Incomplete abortion

A 78-year-old man with known left-sided congestive heart failure presents due to cough, worsening dyspnea with exertion, and orthopnea. What is the most direct cause of his symptoms? A. Tricuspid insufficiency B. Left ventricular hypertrophy C. Decreased peripheral vascular resistance D. Increased pulmonary venous pressure

D. Increased pulmonary venous pressure Left sided heart failure has a low cardiac output and elevated pulmonary venous pressure resulting in dyspnea

A 23-year-old woman comes to the urgent care clinic complaining of 1 week of malaise, generalized fatigue, and muscle aches. She was out hiking last week, and symptoms began the morning after she returned from the hike. Today she noticed a rash to her left lower leg, which prompted her to be evaluated. Physical examination reveals a low grade fever, mildly elevated heart rate, and a small erythematous ring surrounding a central clearing and an erythematous puncta in the center. Which of the following is the most likely causative organism in this patient's condition? A. Treponema pallidum B. Rickettsia rickettsia C. Plasmodium falciparum D. Borrelia burgdorferi

D. Borrelia burgdorferi

An 18-year-old man presents for a screening physical exam prior to joining his college's freshman lacrosse team. He reports no medical complaints, and he does not take any medications. Physical exam is unremarkable. His immunizations are up-to-date, and he denies sexual activity or smoking. Review of routine labs reveals an elevation in unconjugated bilirubin. Liver enzymes, serum electrolytes, and complete blood count are within normal limits, as is conjugated bilirubin level. What is the most likely diagnosis? A. Alcoholic hepatitis B. Critter-Najjar syndrome C. Dubin-Johnson syndrome D. Gilbert's Syndrome

D. Gilbert's Syndrome

Which of the following would be the most prudent advice you could give to a patient who has diabetic peripheral neuropathy? A. Restrict protein intake B. Restrict fluid intake C. Have regular eye exams D. Have regular foot exams

D. Have regular foot exams

A 14 year old female is brought to your clinic by her mother with a complaint of a bump on her right eyelid times two days. She admits to pain, light sensitivity, lid heaviness, and increased tearing in the affected eye. Her vision is unaffected. On physical exam there is a small, erythematous mass that is tender to the touch. What is the most likely diagnosis? A. Blepharitis B. Dry eye syndrome C. Chalazion D. Hordeolum

D. Hordeolum

A 63-year-old male with chronic kidney disease is in the ICU with bradycardia, flaccid paralysis, and an ileus. A stat work-up includes an ECG showing peaked T waves. Which lab finding would you suspect? A. Hypomagnesemia B. Hypercalcemia C. Hypokalemia D. Hyperkalemia

D. Hyperkalemia

A 33-year-old man presents for an initial visit to a new primary care office. He has not seen a healthcare provider at all in the past 5 years. His past medical history reveals a coarctation of the aorta repair at age 13, after which he saw a cardiologist yearly until age 18. Since then, he has not had insurance and has only sought care for urgent problems in acute care clinics. What is a common complication of coarctation that primary care should regularly monitor this patient? A. Anemia B. Palpitations C. Orthostatic hypotension D. Hypertension E. Hypertriglyceridemia

D. Hypertension

A 16-year-old girl has just been diagnosed with severe allergic rhinitis caused by ragweed and dust mite. She is a candidate for allergy immunotherapy, which will involve weekly subcutaneous delivery of the offending allergens in increasing concentrations. What is the ultimate goal of this type of immunotherapy for this patient? A. Immunity B. Hypersensitization C. Immune suppression D. Hyposensitization E. Eradication of infection

D. Hyposensitization

A 16-year-old girl presents with a 4-hour history of loss of consciousness. Her older sister states that the patient has been depressed and was found with an empty bottle of tuberculosis medication. The patient has now begun having generalized tonic-clonic seizures. Examination reveals a developed teenage girl responsive only to painful stimuli; there are intermittent tonic-clonic movements of the extremities. Besides the general care of an unconscious patient with seizures, what should be given as a specific antidote? A. Atropine B. Diphenylhydantoin C. Methylene blue D. Pyridoxine E. Vitamin K

D. Pyridoxine The reversal agent of Isonazid is pyridoxine

A 48-year-old man presents for an annual physical exam. He has a past medical history of obesity and a 5-year history of hypertension that is currently not well-controlled. He was also recently diagnosed with type 2 diabetes mellitus (DM). He is a 20 pack-year smoker and drinks 2-3 beers per night. On exam, his BMI is 41, and BP is 145/92 mm Hg. The remainder of his exam is unremarkable. What is the most important matter to address with this patient concerning the prevention of morbidity and mortality? A. Obesity B. Alcohol use C. Lack of exercise D. Hypertension E. Cigarette smoking

E. Cigarette smoking

A 35-year-old Hispanic man presents due to a sore that will not heal around his rectum and anal area. This lesion has been draining pus consistently for the last week. He has had intermittent pain with this lesion (4/10 on a 0-10 pain scale) that is made slightly worse when he has a bowel movement (ranking it a 6/10). More recently, especially in the last few days, he has noted pain increases with just sitting. The patient also admits to intermittent periods of itching. He denies fever or diarrhea. No past medical history of inflammatory bowel disease. Physical examination of the anorectal area reveals excoriated and inflamed perianal skin with a palpated induration. What is the patient's most likely diagnosis? A. Anal fistula B. Anal tissue C. Anal cancer D. Internal hemorrhoid

A. Anal fistula

25-year-old man presents to you with an acute otitis media with serous otitis in the right ear. You perform the Weber and Rinne tests. What results would you expect? A. Weber—sound is heard louder in right ear; Rinne—bone conduction exceeds air conduction in right ear B. Weber—sound is heard louder in left ear; Rinne—bone conduction exceeds air conduction in right ear C. Weber—sound is heard louder in right ear; Rinne—air conduction exceeds bone conduction in right ear D. Weber—sound is heard louder in left ear; Rinne—air conduction exceeds air conduction in right ear

A. Weber—sound is heard louder in right ear; Rinne—bone conduction exceeds air conduction in right ear

A 31-year-old HIV-positive woman presents for ongoing care. She was diagnosed with HIV 2 years ago, and she began antiretroviral therapy. Her CD4 T cell count is 400 cells/mL, and she has a history of oral candidiasis. As part of her evaluation, a tuberculin skin test (TST) is performed using 5 TU of purified protein derivative (PPD). The test site is examined 48 hours later and the skin reaction is measured. What is the minimum diameter of induration at which this test result should be considered positive in this patient? A. 2 mm B. 5 mm C. 10 mm D. 15 mm E. 20 mm

B. 5 mm 5 mm - HIV, positive CXR findings consistent with prior TB, organ transplant or IC pts 10 mm - medical comorbidities, residents/employees of high-risk congregate settings, IVDU 15 mm - healthy persons without risk factors

A 63-year-old woman presents with acute onset of abdominal pain that describes as a steady deep discomfort in the left lower quadrant. She was constipated initially, but she is now experiencing diarrhea. On physical examination, she has a temperature of 38°C. The abdomen is tender in the LLQ with guarding and rebound tenderness. She has positive fecal occult blood. What is the best test to determine the most likely diagnosis? A. Abdominal ultrasound B. Abdominal CT C. Barium enema D. Colonoscopy

B. Abdominal CT

A 13-year-old girl presents to the emergency department with febrile episodes (Tmax 102°F), joint aches in her knees and wrists, chest pain, and a raised red rash. She denies sexual activity or intravenous drug use. Vital signs are BP 90/60 mm Hg, HR 115/min, T 101°F, RR 25/min. Physical exam is remarkable for diffuse scattered ring-shaped macules on her extremities, a III/VI systolic ejection murmur, and guarded passive range of motion in wrists and knees bilaterally with no apparent swelling. Laboratory findings: WBC 16,000 mcL, Hematocrit 35%, Platelets 350,000 mcL, ESR 65 mm/h, positive antistreptolysin O titer. What is the most likely diagnosis? A. Still's disease B. Acute rheumatic fever C. Septic arthritis D. Systemic lupus erythematous E. Lyme disease

B. Acute rheumatic fever

A 61-year-old man presents with a recent history of increased fatigue with mildly increased exertional dyspnea. The patient denies any significant past medical history but states that he had some heart problems as a child; he was never clear as to what the problem was. On cardiac examination, you hear an early diastolic soft decrescendo murmur with a high-pitched quality, especially when the patient is sitting and leaning forward. No thrill is felt. What is the most likely diagnosis? A. Tricuspid stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral valve prolapse E. Pulmonic stenosis

B. Aortic regurgitation

During a routine X-ray examination for employment insurance purposes, the radiologist notices a rounded lesion in a pulmonary cavity on the right upper lobe of the pulmonary X-ray of a middle-aged man. The patient was treated for pulmonary cavitary tuberculosis (TB) 2 years ago; he has completed treatment, and he has not had any problems since. What late complication of TB is seen in this patient? A. Fibrothorax B. Aspergilloma C. Broncholithiasis D. Reactivation of TB E. Bronchiectasis

B. Aspergilloma

A 3-year-old girl presents with a 1-day history of irritability and weakness in her legs. Neurologic exam reveals an ascending symmetrical paralysis with cranial neuropathy. A lumbar puncture is performed and cerebrospinal fluid is found to have a normal glucose level, <10 leukocytes/mm3, and elevated protein. Medical history shows the child recently recovered from a mild diarrheal illness. What organism is triggering this syndrome? A. Shigella dysenteriae B. Campylobacter jejuni C. Clostridium botulinum D. Escherichia coli

B. Campylobacter jejuni

A 78-year-old Caucasian man presents with unilateral painless loss of vision in the right eye of 3 hours duration. Examination reveals an elderly man who is anxious but in no acute distress. Visual acuity is light perception only in the right eye and 20/30 in the left eye. Pupillary examination is significant for an afferent pupillary defect on the right side. Penlight examination of the eyes is otherwise unremarkable. Retinal examination of the right eye reveals a cherry-red spot. Retinal examination of the left eye is unremarkable. What disease process most likely accounts for the patient's presentation? A. Open-angle glaucoma B. Central retinal artery occlusion C. Trauma D. Cataract

B. Central retinal artery occlusion

A 28-year-old woman with a past medical history of well-controlled asthma presents with recurrent sneezing episodes, nasal itching, congestion, and headache. Her physical exam reveals post-nasal drip, a transverse nasal crease, and bilateral infraorbital cyanosis. What additional finding supports an allergic etiology on this patient's presentation? A. Associated manifestations including malaise, body aches and cough B. Pale bluish nasal mucosa on speculum examination C. Provocation of changes in temperature or exposure to odors and chemicals D. An erythematous and edematous nasal septum and turbinates

B. Pale bluish nasal mucosa on speculum examination

A 16-year-old girl with a 2-year history of ulcerative colitis presents with signs of an acute exacerbation: abdominal pain and frequent passing of large quantities of blood and mucus from the rectum. It is treated with sulfasalazine, glucocorticoids, and intravenous alimentation. Diarrhea decreases markedly, but her status continues to deteriorate. Tachycardia, volume depletion, and electrolyte imbalance develop; temperature is 101.8° F. Physical examination finds abdominal tenderness but no mass. Plain radiography shows the transverse colon is dilated up to 7 cm. What is the most appropriate next step in management for this patient? A. Stop sulfasalazine B. Perform colectomy C. Perform colonoscopy D. Perform barium enema

B. Perform colectomy

A 17-year-old boy was in your clinic 4 days ago for evaluation of a 101.8°F fever and was diagnosed with acute pharyngitis. You prescribed penicillin VK 250 mg TID for 10 days. The patient returns today because his sore throat is now worse. He has not been able to drink fluids and he has excruciatingly severe pain with swallowing. You recognize the muffled "hot potato" voice. On re-examination, you identify a right medial deviation of the soft palate with a 4+ right tonsillar swelling. What is the most likely diagnosis? A. Oral candidiasis B. Peritonsillar abscess C. Laryngitis D. Mononucleosis E. Dental abscess

B. Peritonsillar abscess

A 17-year-old girl presents with a rash. She states she noted a single oval patch several days before a more generalized rash erupted. She indicates that the rash mildly itches. On physical examination, the initial lesion appears as an erythematous (salmon-colored) plaque with a collarette on the trailing edge of the advancing border. You note a fawn-colored rash that follows the cleavage lines on the posterior trunk. This rash is most prevalent on the trunk, and the proximal upper and lower extremities. What is the most likely diagnosis? A. Atopic dermatitis B. Pityriasis rosea C. Psoriasis D. Tines corporis

B. Pityriasis rosea

A 45-year-old man is admitted to the hospital with fever, weakness, weight loss, extremity pain, and a rash on his legs. He states that his symptoms began about 1 week ago. He denies recent illness or injury and states that he has been in good health for as long as he can remember. On physical exam, the patient was well-developed, well-nourished, and in mild physical distress. His lower extremities have ulceration near his medial malleoli and a diffuse lace-like purplish discoloration on his bilateral lower extremities. His blood pressure was elevated at 152/94 mm Hg, and a chest radiograph was negative. Laboratory analysis revealed an elevated sedimentation rate and C-reactive protein, elevated BUN, and creatinine. His red blood cell count was decreased, and his ANCA was negative. Hepatitis B tests were also negative. Biopsy of the leg ulceration reveals a fibrinoid necrosis of an arterial wall with a leukocytic infiltrate. What is the most likely cause of this patient's symptoms? A. Systemic lupus erythematous B. Polyarteritis nodosa C. Rheumatoid arthritis D. Sjögren syndrome E. Kawasaki disease

B. Polyarteritis nodosa

Hypovolemic shock

D/t decreased intravascular volume, leading to decrease in preload and cardiac output Can be hemorrhagic or non-hemorrhagic (Ex: burns, severe diarrhea and vomiting)

A 77-year-old man presents with significant persistent hypotension that has been worsening for 1 hour. Further investigation of this patient reveals a significant increase in heart rate and substantial tachypnea. Urinary output is too minimal to measure, and upon quick physical examination, the patient's extremities are cool to touch. After beginning fluid resuscitation for shock protocol, the patient's symptoms appear to be worsening. Bedside ECG indicates ST elevation in leads II and III and aVF. Hemodynamic monitoring indicates large V waves on PCWP tracing, suggesting severe mitral regurgitation. Based on this scenario, how would this patient's shock be categorized? A. Obstructive shock B. Distributive shock C. Cardiogenic shock D. Septic shock E. Hypovolemic shock

C. Cardiogenic shock

A 58-year-old man presents with a recent episode of rectal bleeding. A brief history reveals that his bowel patterns have been increasingly erratic over the past 6 weeks. He reports periods of 2-6 days without bowel movements followed by copious production of thin coils of stool. He has lost 10 lb over the last month. His family history is significant for the death of his cousin from colon cancer. Physical exam reveals the patient is pale and febrile (temperature 101°F); the rectal exam is heme-positive with scant stool, and his prostate is soft and moderately enlarged. What is the most appropriate evaluation method in the diagnosis of colorectal cancer? A. Abdominal plain film B. Barium enema C. Colonoscopy D. Anoscopic examination

C. Colonoscopy

A 17-year-old boy presents for a follow-up regarding fatigue and dizziness. After his initial presentation, he had some general blood work drawn, including a complete blood count, which shows a low hemoglobin and hematocrit. MCV is low. What detail from the patient's history would support your suspected diagnosis? A. Heart palpitations B. History of lymphoma C. Craving to eat ice D. Systemic lupus erythematous

C. Craving to eat ice

A 9-year-old girl presents with a sore throat. The mother states that she began to run a fever a few days ago, and she complained that her throat hurt. On physical exam, you note a red throat, a red and beefy tongue, tonsillar exudates, and swollen anterior cervical lymph nodes. It is noted in the patient's records that she has had a severe anaphylactic reaction to penicillin. What antibiotic would treat this infection while minimizing the risk of invoking an allergic reaction? A. Augmenting B. Cephalexin C. Erythromycin D. Ciprofloxacin

C. Erythromycin Strep bacterial infections TOC is Penicillin, when C/i, treat with macrolide

A 43-year-old woman presents with a 6-month history of vague right upper quadrant discomfort. The patient denies any relation of pain to meals and describes it as a dull constant discomfort. The patient was diagnosed with type 2 diabetes mellitus 1 year ago, which is controlled with diet. She does not smoke but admits to drinking a glass of wine occasionally. She denies any medications except for over-the-counter acetaminophen, which she takes occasionally for joint pains. She does not have any family history of chronic liver disease. There is no history of blood transfusions in the past.On physical examination, the patient is obese with a BMI of 31; BP 140/90 mm Hg. The liver is palpable 3 cm below the right costal margin and is slightly tender. No other signs of chronic liver disease are evident. Hemoglobin 13.2 g/dL (normal 13 - 17 g/dL), Platelet 160,000 (150,000 - 400,000), AST 64 u/L (normal <40), ALT 70 u/L (normal <40), alkaline phosphate: normal, serum total bilirubin 1.0 mg/dL (normal <1.9 mg/dL), Ferritin: normal, Iron: normal, Total Cholesterol: 220 mg/dL (normal <200 mg/dl), triglycerides: 350 mg/dL (normal <150 mg/dl), HBsAg: negative, anti-HBs: positive, anti-HBc: negative, anti-HCV: negative. What is the most likely diagnosis? A. Hemochromatosis B. Chronic Hepatitis B C. Non-alcoholic steatohepatitis D. Alcoholic hepatitis

C. Non-alcoholic steatohepatitis Non-alcoholic fatty liver disease includes this. It represents the hepatic component of metabolic syndrome

Mandatory newborn screening has been completed on a Caucasian infant who was born 36 hours ago. The birth was relatively benign without any complications; the newborn was born at exactly 40 weeks gestation. An abnormal result found in the screening tests has resulted in you ordering required counseling for the parents to initiate lifelong modification in their child's diet to decrease the incidence of abnormal intellectual development. What disease state was most likely found during the screening? A. Classic galactosemia B. Congenital hypothyroidism C. Phenylketonuria D. Sickle Cell Disease

C. Phenylketonuria

You are a PA assisting an orthopedic surgeon with a total knee arthroplasty (TKA). You reviewed the knee X-ray prior to the case and confirmed on the consent the correct side. A surgical time out was performed, and all agreed that the patient is having a left TKA. There is no mark on either leg by the surgeon to identify the correct leg. The surgery is completed, and the patient is transferred to the recovery room. Upon waking, the patient reports that they were supposed to have a right TKA. The consent is reviewed and does read as left, the side that was amputated. Which of the following CME activities based on this case presentation is performance improvement and not self assessment? A. Assess your communication skills with the surgeon B. Assess the surgeon's diagnostic skills C. Re-evaluate the consent procedure D. Review your knowledge of the consent procedure

C. Re-evaluate the consent procedure

A 46-year-old woman underwent elective cholecystectomy. The attending nurse noted mild bleeding at the site of IV line and the incision site during dressing. The patient also reported bleeding from the gums and nose. Coagulation profiles revealed prolongation of aPTT, PT, and TT; decreased fibrinogen level; and increased levels of fibrinogen degradation product (FDP). Platelet count was also decreased. The patient was not experiencing any bleeding disorder before her hospitalization. What is the most likely cause of this patient's bleeding tendency? A. Deficiency of clotting factors of the intrinsic pathway B. Deficiency of clotting factors of the extrinsic pathway C. Platelet functional defect D. Disseminated intravascular coagulation E. Underlying liver disease

D. Disseminated intravascular coagulation

A 54-year-old man presents after having a generalized seizure. The patient is HIV-positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inquiry, the patient also notes that he has become short-tempered and hypercritical; at times he seems confused. An MRI of the brain is performed, and it reveals several cortical ring-enhancing lesions. What is the most likely diagnosis? A. Isoniazid B. Rifampin C. Pyrazinamide D. Ethambutol

D. Ethambutol

A 30-year-old immigrant worker presented 4 weeks ago with a chronic cough, blood-stained sputum, and night sweats. His PPD was 15 mm and pulmonary tuberculosis was diagnosed. Treatment was started at that time and today he is back for a checkup with the complaint of "pins and needles" sensation in his hands. What drug is causing this type of side effect? A. Ethambutol B. Rifampin C. Streptomycin D. Isoniazid

D. Isoniazid

A new female patient presents to your clinic to discuss upcoming travel plans. She was born in the Dominican Republic and emigrated the United States 10 years ago. She is planning on returning the Dominican Republic to visit relatives. She plans to spend some time outdoors trekking near her family's home. She is up-to-date on her influenza vaccination and other age-appropriate preventative health screenings and vaccinations. She is not pregnant or trying to become pregnant. She is otherwise healthy without any chronic medical conditions. What should you recommend for this patient? A. Cancellation of travel plans B. Dengue fever vaccination C. Hepatitis B vaccination booster D. Malaria prophylaxis E. Yellow fever vaccination

D. Malaria prophylaxis

A 30-year-old man presents with a 1-week history of a painful tongue. He has been having diarrhea and forgetting things more easily. He recently emigrated from India and lives alone on a maize-based diet. On examination, you note that the tip and margins of his tongue are a bright scarlet color. He also has a symmetrical erythematous rash on his forearms. What is the most likely diagnosis? A. Vitamin A deficiency B. Pyridoxine deficiency C. Vitamin C deficiency D. Niacin deficiency E. Vitamin E deficiency

D. Niacin deficiency Niacin = pellagra - symmetrical dermatitis, scarlet glossitis & stomatitis

An 88-year-old man with abdominal pain presents to the emergency room with his wife. A mini-mental status exam reveals pronounced forgetfulness and confusion. The patient is discovered to have acute appendicitis requiring immediate surgery. He is unable to understand the situation and cannot provide informed consent. What further action should the physician take? A. Do not perform the surgery B. Have another doctor confirm the necessity of surgery C. Obtain a court order to perform surgery D. Obtain consent from his wife to perform surgery E. Try to persuade the patient to consent to surgery

D. Obtain consent from his wife to perform surgery

A 16-year-old boy presents with a general itching of his hands and wrists. It started a few weeks after he went to play in a high school soccer tournament. On physical exam, you note several wavy skin-colored ridges on his hands and wrists with excoriations. There are multiple small erythematous papules on flexor surface of wrists. You note that the intertriginous areas of the hands are involved. What is the most likely diagnosis? A. Ringworm B. Spider bite C. Body lice D. Scabies

D. Scabies Treatment is permethrin

A 50-year-old woman presents with a 4-month history of well-defined white patches distributed symmetrically over her face, hands, and neck. The patches of discoloration easily burn when exposed to sun but otherwise are not painful. Physical exam reveals white macules along with large areas of white patches. There is no evidence of erythema, crusting, or drainage. What is the most likely diagnosis? A. Alopecia B. Psoriasis C. Melasma D. Vitiligo

D. Vitiligo

Pyridoxine (vitamin B6 deficiency) symptoms

Peripheral neuropathy, seborrheic dermatosis, glossitis & cheilosis

Obstructive shock

Secondary to an extracardiac cause - obstructing right ventricular output (Ex: tension PTX, hemodynamically significant PE)

Distributive shock

Secondary to severe peripheral vasodilation, d/t systemic infection The MC bacterial organisms are gram-positive bacteria (pneumococcus and enterococcus)

A 19 year old female presents to your clinic because she has missed her last two menstrual cycles and has noticed some spotting on her underwear. She states that she has been nauseated and vomited a few times. On physical exam you notice a bluish discoloration of the vaginal wall. You perform a urine pregnancy test which comes back positive. The bluish discoloration is known as which of the following? A. Chadwick's sign B. Hangars sign C. Good Ella sign D. Braxtons sign

A. Chadwick's sign

The classic clinical manifestations of acute cholangitis that include the triad of right upper quadrant pain, fever and jaundice, is best known by which of the following eponym signs? A. Charcot B. Cullen C. Grey Turner D. Rovsing

A. Charcot

A 66-year-old man comes to the office for evaluation of gradual central vision loss over the past two years. Amsler grid testing shows several blurry spots in the field of vision. Fundoscopy reveals discrete yellow deposits on the retina. Which of the following is the most likely diagnosis? A. Age-related macular degeneration B. Amaurosis fugax C. Anterior uveitis D. Glaucoma

A. Age-related macular degeneration

A 74-year-old man with a history of hypertension, coronary artery disease, supraventricular tachycardia, hyperlipidemia, and type 2 diabetes mellitus, seeks evaluation for a bluish-gray discoloration of his face and hands that has been progressively worsening over the past year. Which of the following medications in this patient's drug regimen is most likely to cause this discoloration? A. Amiodarone B. Atorvastatin C. Metformin D. Metoprolol

A. Amiodarone

A 47-year-old man presents to an urgent care center with 18 hours of abdominal pain, nausea, vomiting, and chills. He is a single construction worker, denies smoking, and has at least a 10-year history of drinking 2-4 alcoholic beverages daily. A series of lab work is performed on the patient to evaluate his abdominal pain prior to abdominal imaging. What laboratory results would be most indicative of the patient suffering from acute pancreatitis? A. Amylase 310 U/L and lipase 760 U/L B. Amylase 50 U/L and lipase 10 U/L C. Aspartate aminotransferase 32 U/L and alanine aminotransferase 29 U/L D. Aspartate aminotransferase 120 U/L and alanine aminotransferase 40 U/L E. White blood cell count 14,000/mm3 and total bilirubin 1.8 mg/dL

A. Amylase 310 U/L and lipase 760 U/L

A 32-year-old woman comes to the office for evaluation of persistent pain of the left wrist since accidently falling on her outstretched hand three days ago. She applied an elastic wrap, and has been using over-the-counter anti-inflammatory agents with some relief. Physical examination of the wrist shows decreased range of motion due to pain, and point tenderness over the anatomic snuff box. X-ray study of the wrist shows nondisplaced fracture of the middle-third of the scaphoid. Which of the following is the most appropriate next step in management? A. Application of thumb spica splint B. Corticosteroid injection at site of maximal pain C. CT scan of wrist D. Immediate open reduction and internal fixation

A. Application of thumb spica splint

57-year-old man is brought to the emergency department by his partner because of worsening pain in the right upper abdomen, and fever for the past two days. Temperature is 38.1°C (100.6°F), pulse rate is 102/min, respirations are 18/min, and blood pressure is 130/80 mmHg. Physical examination shows mild icterus, and moderate tenderness over the right upper quadrant of the abdomen. Ultrasound study shows dilation of the common bile duct in addition to the presence of three stones. Which of the following is the most likely diagnosis? A. Ascending cholangitis B. Cholecystitis C. Primary biliary cirrhosis D. Primary sclerosis cholangitis

A. Ascending cholangitis Ascending cholangitis AKA acute cholangitis are these symptoms Primary sclerosis cholangitis is a AI disease, strongly associated with ulcerative colitis

The presence of which of the following conditions is a contraindication to the use of non-selective beta-adrenergic blocking agents? A. Asthma B. Glaucoma C. Migraine headaches D. Type 2 diabetes mellitus

A. Asthma

A 42-year-old woman with a history of dizziness and difficulty exercising presents seeking help. She reports fatigue, shortness of breath, and weakness for the past month. Upon physical exam, an EKG is conducted and an irregularly irregular heartbeat of 90 beats a minute. Laboratory findings showed no abnormal findings. Upon ECHO, there do not appear to be any abnormalities. What is the most likely explanation of the findings? A. Atrial fibrillation B. CHF C. Embolic stroke D. Mitral valve regurgitation

A. Atrial fibrillation

A 47-year-old Caucasian woman presents for evaluation of a 4-week history of dyspnea. Symptoms started when on vacation in Colorado. She initially attributed the symptoms to the altitude, but she continued to have shortness of breath with mild activity after returning home: walking more than 100 feet, walking up one flight of stairs. Symptoms resolve with rest. She also reports mild exertional chest tightness and easy fatigability. She denies paroxysmal nocturnal dyspnea, orthopnea, edema, palpitations, and syncope.Past medical history includes usual childhood illnesses, no previous surgeries, and no known allergies. She takes a daily multivitamin and occasional Tylenol for headache. She does not smoke, rarely drinks alcohol, and denies use of recreational drugs. Physical exam shows temp 96.9°F, pulse 80 and regular, respirations 16, and BP 136/82. O2 sat is 96% on room air. The patient is an alert Caucasian woman in no acute distress, with no obvious jugular venous distention; non-labored respirations; lung fields clear to auscultation and percussion; and no rhonchi, rales, or wheezes. Heart shows RV heave present; normal S1 with fixed, split S2 with prominent P2 component; and grade II/VI systolic murmur at the left upper sternal border at the second intercostal space. The remainder of exam is within normal limits.CBC and BMP are unremarkable. Free T4 and TSH are within normal limits. EKG shows normal sinus rhythm with right ventricular hypertrophy, right atrial enlargement, and right axis deviation. There is an RSR in leads v1 and v2. What congenital heart defect does this patient most likely have? A. Atrial septal defect B. Coarctation of the aorta C. Patent foramen ovale D. Ventricular septal defect

A. Atrial septal defect ASD causes a widely split fixed S2

A 24-year-old man with schizophrenia is brought to the office by his mother because he has become increasingly socially withdrawn, and has been exhibiting poor self-care over the past week. He states that he is also experiencing auditory hallucinations, and is having difficulty sleeping. When interviewing him, he has a monotone and monosyllabic speech pattern, and psychomotor retardation. Typical antipsychotic medications, such as haloperidol, are most effective at treating which of this patient's signs or symptoms? A. Auditory hallucinations B. Monotone and monosyllabic speech C. Psychomotor retardation D. Social withdrawal

A. Auditory hallucinations

A 65-year-old man presents with gradual increase of urinary frequency over the past few months. Most recently, he has difficulties starting to urinate and the stream seems slow. Despite waking up several times a night to release his bladder, he continues to have a sensation of incomplete emptying. He has no history of sexually transmitted diseases, surgeries, or urinary tract infections. Upon examination, he is slightly overweight and his vitals are normal. His abdomen feels soft, the genitals are benign, and his prostate is non-tender and moderately enlarged (35-40 g). Lab tests are negative for blood presence in urine and indicate a protein-specific antigen (PSA) of 1.3 ng/mL. What is the most likely diagnosis? A. BPH B. Overactive bladder C. Prostate cancer D. Prostatitis E. Urinary tract infection

A. BPH

A 61-year-old woman presents a 1-week history of intermittent episodes of feeling like she was spinning. She states the episodes are brief, but they occur 2-3 times per day. It is worse when she turns to her right side while lying in bed. Even when she is not dizzy, she feels off balance. She denies tinnitus, decreased hearing, fever, syncope, nausea, vomiting, diplopia, or any other related symptoms. During the Dix-Hallpike maneuver, the patient exhibits nystagmus, with her eyes beating laterally when the right ear is turned downward. The nystagmus diminished with each time the maneuver was performed. What is the most likely diagnosis? A. BPPV B. Labyrinthiritis C. Meniere's Disease D. Vestibular schwannoma E. Brain stem infarction

A. BPPV

A 51-year-old man who is otherwise healthy comes to the office for follow-up appointment regarding hypertension. On two previous visits his blood pressure had been elevated. He was resistant to beginning medication, and wanted to try lifestyle modification first. He states that he has cut back on smoking, but has not quit completely. He has not been successful in losing weight, and current BMI is 38. His blood pressure measurement today is 162/94 mmHg. After discussing his options, the patient agrees to try medication while continuing to work on lifestyle changes. You prescribe chlorthalidone 12.5 mg once daily. Which of the following tests should be done within 4-6 weeks of initiating this medication? A. Basic metabolic panel to assess electrolytes Complete blood count to assess for neutropenia C. Hepatic panel to assess live function D. Serum uric acid level

A. Basic metabolic panel to assess electrolytes It is a thiazides diuretic and can cause hypokalemia, low mag and low sodium

A full-term newborn girl who was delivered vaginally 18 hours ago is being evaluated in the nursery. There were no complications with either the pregnancy or delivery. The mother is breastfeeding, and feeding is going well. However, the mother states that her baby looks yellow. Physical examination shows jaundice. The remainder of the examinaiton show no abnormalities. Laboratory studies show a total bilirubin level of 12 mg/dL (normal = 0.1 to 1.0 mg/dL), and the direct bilirubin level is 3.5 mg/dL (normal =0.00 to 0.03 mg d/L). Which of the following is the most appropriate next step? A. Begin work-up for pathological cause of hyperbilirubinemia B. Perform an exchange transfusion C. Reassure the mother that the jaundice is most likely physiologic and will resolve over the next week D. Reassure the mother that the jaundice is related to breast feeding and will resolve over the next week

A. Begin work-up for pathological cause of hyperbilirubinemia

A 72-year-old man presents with an 8-month history of progressive exertional dyspnea accompanied by a dry and persistent hacking cough. He now feels slightly dyspneic at rest. He denies fever, chills, palpitations, chest pain, or peripheral edema. He denies any recent travel history, exposure to chemicals, and is a lifelong non-smoker. He is retired but previously worked as a school principal and teacher. His physical exam is remarkable for digital cyanosis and clubbing. Normal S1 and S2 without murmurs or gallops. Normal peripheral pulses bilaterally. A chest X-ray noted small lung volumes. Pulmonary function testing shows reduced TLC, FEV1, and normal FEV1/FVC ratio. What finding would you expect to find on pulmonary exam? A. Bibasilar dry inspiratory crackles B. Dullness to percussion bilaterally C. Exploratory wheezing D. Hyperresonance to percussion E. Inspiratory and expiratory wheezing

A. Bibasilar dry inspiratory crackles Symptoms are consistent with idiopathic pulmonary fibrosis, which is a restrictive lung disease.

A 68-year-old man with a history of hypertension, hyperlipidemia, and myocardial infarction presents to the emergency room with a 3-day history of shortness of breath at rest. He has found it difficult to walk short distances due to shortness of breath. He reports orthopnea, nocturnal dyspnea, and generalized abdominal discomfort. He denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, cough, nausea, vomiting, diarrhea, rashes, lightheadedness, and syncope. Upon physical examination, the patient is acutely dyspneic. He is afebrile but tachypneic and diaphoretic. There is a diminished first heart sound, S3 gallop, and laterally displaced PMI. The abdominal exam reveals distension with hepatomegaly in the right upper quadrant. There is 2+ pitting edema of the lower extremities to the level of the mid-calf. A bedside chest X-ray revealed pulmonary vascular congestion and Kerley B lines. What additional finding is expected on physical examination of this patient? A. Bibasilar rales B. Hyperresonance to percussion C. Warm and dry skin D. Depressed jugular venous pressure E. Bradycardia

A. Bibasilar rales

A 30-year-old African American man is admitted to the hospital to undergo stapedectomy for the treatment of otosclerosis. He had been experiencing increased hearing loss in the right ear over the past few years. His mother had suffered from the same condition when she was in her 40s and had been successfully operated upon. You perform an assessment using the Weber and Rinne tests. What physical exam finding do you expect? A. Bone conduction of the affected side is greater than air conduction B. Bone conduction of the affected side is equal to air conduction C. Air conduction of the affected side is greater than bone conduction D. Sound lateralizes tot he unaffected ear E. Bone conduction of the unaffected ear is greater than air conduction

A. Bone conduction of the affected side is greater than air conduction

While performing a routine breast exam on a 57 year old woman, retractions are noted in the upper outer quadrant of the left breast. This physical exam finding is most suggestive of which of the following diagnosis? A. Breast cancer B. Fibrocystic changes C. Fibroadenoma D. Normal postmenopausal changes

A. Breast cancer

What is the diagnostic test of choice in a patient suspected to have mastoiditis? A. CT B. Radiographs, including Water's view C. MRI D. Lumbar puncture with cerebrospinal fluid analysis

A. CT

A 30-year-old woman presents because she recently had a PPD skin test; the transverse diameter of the induration was 14 mm. The patient denies ever having tuberculosis and she is asymptomatic now, but she expresses some anxiety about the result of the skin test. For the last 6 months, she has worked as a nurse for a long-term care facility. Her patient is a vent-dependent tetraplegic. On clinical examination, there are no abnormalities. What is the most appropriate next step? A. CXR B. Isoniazid prophylaxis C. Reassurance D. Respiratory isolation E. Sputum examination

A. CXR

A 24-year-old woman was diagnosed with anorexia nervosa one month ago. The most common cause of death in patient's with this condition involve complications of which of the following systems? A. Cardiovascular B. Endocrine C. Gastrointestinal D. Neurological E. Pulmonary

A. Cardiovascular

A 66-year-old man is seen in the office because of persistent productive cough for the past four months. Sputum is typically yellowish-white in color. While the cough comes and goes and is usually worse during the winter months, he has been coughing this way for the past three years. He has smoked one pack of cigarettes daily for the past 40 years. Temperature is 37°C (98.6°F), pulse rate is 92/min, respirations are 24/min, blood pressure is 148/88 mmHg, and BMI is 31. Physical examination shows mild cyanosis of the hands and feet, and scattered coarse rhonchi and wheezes in both lung fields. Which of the following is the most likely diagnosis? A. Chronic bronchitis B. Cystic fibrosis C. Hypersensitivity pneumonitis D. Sarcoidosis

A. Chronic bronchitis

A 34-year-old multiparous woman presents for a routine Pap smear after being "too busy" to have annual exams for the past 7 years. Three Pap smears in her 20s have all been normal. She has had one episode of venereal warts in her late teens; there was no recurrence. She had two vaginal deliveries. She does not smoke. Remainder of her history is negative. Her Pap smear is reported as "atypical squamous cells of undetermined significance." The HPV test is positive. What is the most appropriate next step in regards to evaluating the patient? A. Colposcopy B. Cone biopsy C. Hysterectomy D. Loop electrosurgical excision procedure (LEEP) E. Repeat Pap in one year

A. Colposcopy

A 62-year-old man presents with a 2-month history of worsening fatigue and shortness of breath. He has a past medical history of emphysema attributable to his 85 pack-year smoking history. The patient complains of nearly passing out while climbing the stairs in his house. He tells you that he feels like his heart races. He reports chronic shortness of breath and cough, but he now he feels like his dyspnea is dramatically worse; he can no longer sleep in his bed. He has been trying to sleep propped up in a chair at night. He is also experiencing fatigue. He has gained about 15 pounds, and he notes that he can no longer lace up his shoes. He denies fever, chills, and chest pain. His cough produces some mucus, but no hemoptysis. Vital Signs: Wt: 212 lbs, HR: 108, BP: 149/88, SpO2 88%. On physical exam, you see a man in mild respiratory distress; he is sitting upright and leaning forward, and he uses accessory respiratory muscles for breathing. The exam is significant for reduced air movement and mild rales bilaterally in the lungs; distended neck veins; mild tachycardia with prominent P2; lower extremity edema; and right upper quadrant abdominal tenderness with hepatomegaly. Based upon this patient's history and physical, what is the most likely diagnosis? A. Cor pulmonale B. Hepatitis C. Lung abscess D. Pneumonia E. Pulmonary embolism

A. Cor pulmonale

A 36-year-old African American woman presents with a nonproductive cough, malaise, mild fever, and mild dyspnea. She also indicates that she has some lesions around her nose. Upon physical exam, you note red-brown dermal papules around her nares. A chest X-ray demonstrates a right hilar mass. A pulmonologist is consulted and performs a biopsy during bronchoscopy. The report reveals that the mass is a non-caseating granuloma. What initial therapy should be prescribed? A. Corticosteroids B. Inhaled beta agonists C. Methotrexate D. Amphotercin B E. Cyclosporine

A. Corticosteroids

Upon inspection of an 18-year-old man's scrotum, you note that the left side is underdeveloped and a testis is not palpable. There is no scrotal tenderness, swelling, or nodularity. Considering this is not an acute finding, what is the most likely diagnosis? A. Cryptorchidism B. Acute epididymitis C. Hydrocele D. Testicular cancer E. Strangulated inguinal hernia

A. Cryptorchidism

A 1 day-old boy develops progressing abdominal distension, bilious vomiting and failure to pass a meconium stool. Abdominal radiographs show dilated loops of small bowel. Which of the following is the most likely diagnosis in this patient? A. Cystic fibrosis B. Hypothyroidism C. Intussusception D. Pyloric stenosis

A. Cystic fibrosis The patient is presenting with meconium lieu's which is consistent with the diagnosis of cystic fibrosis

A 19-year-old woman comes to the student health center because of palpitations that occurred after drinking five cups of coffee 30 minutes ago. Electrocardiogram shows suprventricular tachycardia. Carotid sinus massage is planned. Which of the following best describes the physiologic mechanism of action of this procedure? A. Decreased depolarization rate of the sinoatrial node via stimulation of the vagus nerve B. Increased impulse conduction rate through the atrioventricular node via stimulation of the vagus nerve C. Positive chronological effect D. Positive inotropic effect

A. Decreased depolarization rate of the sinoatrial node via stimulation of the vagus nerve

A 5-year-old boy is brought to the urgent care clinic by his mother because he has not been urinating for the past day, and his face and feet appear swollen. Two weeks prior, he was treated for streptococcal pharyngitis with penicillin. The mother states that she stopped giving him the medication after a couple of days because she thought the child was better. Vital signs are, temperature 37°C (98.6°F), heart rate 78 beats/min, respirations 15 breaths/min, and blood pressure 120/90 mmHg. Physical examination shows swelling in the periorbital regions of the face, and in both lower extremities. Laboratory analysis shows a low serum albumin and total protein concentration, and the presence of protein and blood in the urine. Which of the following is the most likely cause of edema in this patient? A. Decreased serum albumin concentration B. Effects of gravity C. Hematuria D. Increased arterial blood pressure

A. Decreased serum albumin concentration Patient is presenting with symptoms of acute glomerulonephritis.

A 29-year-old woman presents to the clinic with a complaint of severe diarrhea occurring over the last 3 to 4 days. Upon examination, the patient displays poor skin turgor and has a temperature of 100.2°F. In the supine position, the patient's blood pressure is 88/64 mm Hg and her heart rate is 112 beats/min. Upon standing, her heart rate further increases to 126 beats/min. Which of the following accounts for the further increase in the patient's heart rate upon standing? A. Decreased systemic vascular resistance B. Decreased venous return C. Increased preload D. Increased myocardial contractility

A. Decreased systemic vascular resistance

A 47-year-old man is being evaluated in the clinic because of a four day history of pain, tenderness, and itching of his glans penis and foreskin. Physical examination shows erythema of these structures, and a curd-like exudate in the sulcus between the glans and foreskin. In addition to a presumptive diagnosis of candidal balanitis, which of the following additional comorbid conditions must be excluded? A. Diabetes mellitus B. Hypertension C. Peyronie disease D. Priapism

A. Diabetes mellitus

A 16-month-old girl is brought to the office by her mother because she is concerned about a delay in her daughter's developmental milestones. The mother states that her child is able to sit alone and crawl, but has only just started to stand one week ago. Physical examination shows bilateral epicanthal folds with upslanting palpebral fissures, a tongue that is wrinkled and protruded, short and broad hands with a single palmar flexion crease, and increased spacing between the great and second toes. Which of the following is the most likely diagnosis? A. Down syndrome B. Ehlers-Danlos syndrome C. Huntington disease D. Klinefelter syndrome

A. Down syndrome

A 33-year-old woman presents to the office with multiple vesicles with associated intense itching on her hands and feet. Her past medical history is negative. The patient is a waitress who takes no medication and does not work with chemicals. The vesicles are tense with some scales. There is no erythema or initial incidence of itching. The vesicles have responded well to a limited treatment with a high steroid cream. What is this patient's most likely diagnosis? A. Dyshidrotic eczema B. Tinea pedis C. Contact dermatitis D. Bullous pemphigoid E. Bullous diabeticorum

A. Dyshidrotic eczema

A 58-year-old man with a history of COPD, hyperlipidemia, a 40 pack-year smoking history, and obesity is being evaluated at his primary care office for complaints of post-prandial regurgitation that is associated with an acidic sensation in his mouth and a chronic, nonproductive cough, all of which have been occurring over the past year. He has taken over the counter famotidine (Pepcid) without any relief. He denies any fever, chills, changes in weight, diaphoresis, chest pain, shortness of breath, sputum, palpitations, abdominal pain, or changes in bowel habits. His physical exam reveals an obese BMI, but it is otherwise unremarkable. His stool hemoccult is negative. Bloodwork reveals an iron-deficiency anemia; a chest radiogram was without pulmonary disease. An upper barium esophagram noted an outpouching of barium at the lower end of the esophagus and a wide hiatus through which gastric folds are visible above the diaphragm. H. pylori antibody testing and urea breath tests were negative. What is th A. Esomeprazole B. Ranitidine C. Nitroglycerine D. Metronidazole

A. Esomeprazole

A 63-year-old woman presents with a blood pressure of 171/93 and returns for a follow-up appointment with a blood pressure of 181/94. The patient states she has a past medical history of alcohol abuse and high sodium intake. Additionally, the patient reports never using any antihypertensive medications. Upon physical exam, S2 heart sound is increased. The patient overall feels well besides her specific issue, and no other abnormal findings are found. Blood is not found in the urine, she presents with no flank pain, and she has a normal CT scan. Additionally, her T3 of 120 nanograms per deciliter and T4 levels of 5.0 micrograms per deciliter are in normal range. What is the most likely diagnosis? A. Essential hypertension B. Hypertensive emergency C. Hyperthyroidism D. Polycystic kidney disease E. Resistant hypertension

A. Essential hypertension

A 16-year-old female has tried topical clindamycin and tretinoin. In addition, she recently finished a six-month course of doxycycline 100 mg bid. She has not noticed much improvement in her acne. The patient continues to complain of large, painful lesions, as well as numerous comedonal lesions. What is the next appropriate step in treatment? A. Isotretinoin 0.5 mg/kg/day B. Clotrimazole cream bid C. Reflex 500 mg bid D. Elides cream bid

A. Isotretinoin 0.5 mg/kg/day

The incidence of infection with Norwalk-like virus is most common in which of the following months? A. January B. April C. July D. August E. September

A. January

A 5-year-old child presents for her kindergarten checkup. The clinician notes that over the past couple of years, her height decreased from the 50th percentile to the 5th percentile. On examination, the clinician also notes truncal adiposity. Her CBC and lead levels were normal. Which of the following is the most likely diagnosis? A. Growth hormone deficiency B. Cushing disease C. Congenital hypothyroidism D. Congenital adrenal hyperplasia

A. Growth hormone deficiency

A 50-year-old man presents with a 4-day history of increasing exertional dyspnea. He has had a chronic cough for the past 3 years and attributes it to cigarette smoking. The cough had been productive of watery sputum, but it has changed to a yellowish color over the past week. He has no known allergies and reports no family history of asthma. On general appearance, he is wheezing. His temperature is 101°F, P 105/min, BP 136/86 mm Hg, and RR 30/min.Respiratory system examination reveals decreased chest wall excursion. Auscultation reveals a prolonged expiratory phase with crepitations and generalized rhonchi. Chest X-ray reveals irregular bronchovascular markings. Laboratory results reveal Hb 15 g/dL (13.8 - 17.2 g/dL), WBC 12,000/uL (normal 4500 - 10,500), and platelets 300 x 109/L (normal 150,000 - 400,000). What group of pathogens is most commonly associated with an acute exacerbation of the patient's most likely diagnosis? A. Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis B. Pseudomonas aeruginosa, Moraxella catarrhalis, Chlamydia pneumoniae C. Legionella pneumophila, Chlamydia pneumoniae, Mycoplasma pneumoniae D. Mycoplasma pneumoniae, Legionella pneumophila, Pseudomonas aeruginosa E. Legionella pneumophila, Streptococcus pneumoniae, Haemophilus influenzae

A. Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis These are the MC pathogens of acute exacerbation of chronic bronchitis

A 32-year-old man is admitted to the hospital following loss of consciousness. The patient had been ill with fever and headache for several days, then developed double vision, confusion, and loss of consciousness. He has been otherwise healthy with no past medical conditions. Imaging reveals edema of the frontal lobe. What virus most likely caused this patient's infection? A. Herpes Simplex Virus B. Adenovirus C. Influenza A D. West Nile Virus E. Epstein-Barr virus

A. Herpes Simplex Virus Herpes simplex virus is the most common viral cause of encephalitis

A 66-year-old man comes to the office for evaluation because of progressive shortness of breath and dry cough over the past three years. He has a 15-pack-year history of smoking, but quit 30 years ago. Although he used to be physically active, now he feels breathless walking to the mailbox. He denies exposure to chemicals or fumes. He has no other health problems, and takes no medications. Vital signs are normal. Oxygen stauration is 92% on room air. Physical examination shows clubbing of the fingernails, and bibasilar crackles in the lungs. Results of spirometry show reduced forced vital capacity (FVC), but normal ratio of forced expiratory volume in one second (FEV1/FVC). Chest x-ray study shows extensive bilateral reticulonodular opacities in both lower lobes. Which of the following is the most likely diagnosis? A. Idiopathic pulmonary fibrosis B. Silicosis C. Sarcoidosis D. Emphysema

A. Idiopathic pulmonary fibrosis

Hemolytic uremic syndrome (HUS) may be a complication of which of the following disease states? A. Infection with E. Coli B. Disseminated intravascular coagulation C. Infection with parvovirus B19 D. G6PD deficiency

A. Infection with E. Coli

A 67-year-old woman with moderately severe chronic obstructive pulmonary disease comes to the office because of increasing dyspnea for the past two weeks. Prior to this, she has been well-controlled with formoterol over the past year. She quit smoking one year ago. She has not been hospitalized, or had any exacerbations in the past year. Oxygen saturation on ambient air is 92% by pulse oximetry. Forced expiratory volume in one second shows a slight decline compared to one year ago. Which of the following additions to her current treatment is the most appropriate next step in treating this patient's symptoms? A. Inhaled anticholinergic B. Inhaled corticosteroid C. Oral PDE-4 inhibitor D. Oral theophylline E. Oxygen

A. Inhaled anticholinergic

A 28 year old female comes into the clinic for evaluation of chronic pelvic pain. She states that she has a history of anxiety and depression, but is concerned about the increased frequency of urination that she has been experiencing over the last few months. She also complains of pelvic pain and tells you that nothing seems to aggravate this, but she does feel relief when she urinates. Urinalysis reveals squamous epithelial cells, and trace blood. Which of the following is the most likely diagnosis? A. Interstitial cystitis B. Ovarian cyst C. Nephrolithiasis D. Pyelonephritis

A. Interstitial cystitis

A 17-year-old boy presents with pain in his wrists, elbows, and knees bilaterally. He has felt fatigued, and he has been unable to work his summer job as a cashier and bagger in his family's community grocery store for the past 2 weeks. He also reports intermittent fevers and a large rash on his back in the area of his right shoulder.All of these symptoms have emerged in the last 4 weeks after a week-long backpacking trip in upper state New York. He has no significant past medical history. His only medication is acetaminophen daily for joint pain. He does not use tobacco, alcohol, or illicit drugs. He has no known allergies.Physical examination reveals a thin male adolescent in no acute distress.Temp 99.1°F, P 100 bpm, RR 14, BP 120/70 mm Hg.Small non-tender mobile lymph nodes are palpable in the neck and axilla bilaterally. There is a large warm erythematous patch with central clearing at the patient's posterior right shoulder region; it extends across the arm and axilla and measures approximately 25 cm in diameter. There is limited range of motion in his right wrist and left elbow. There were no gross focal neurologic deficits. What is the most likely cause of these symptoms? A. Lyme disease B. Pityriasis rosea C. Pityriasis versicolor D. Rocky Mountain spotted fever E. Secondary syphilis

A. Lyme disease

A 38-year-old male patient with HIV develops diabetes; he takes stavudine. What diabetes medication is most likely to exacerbate potential acid-base disorders of his antiviral therapy? A. Meformin B. Glyburide C. Glipizide D. Exanatide E. Insulin

A. Meformin

An otherwise healthy 50-year-old man is brought to your office, located in a small town in the foothills of the Appalachian mountains, by his daughter. The daughter reports that her father has been more lethargic than usual, and she states that she has seen him go into the backwoods and return obviously inebriated. You suspect that he is drinking moonshine from a homemade still and that it is leaching poisonous metals/substances into the distillate.The patient is morose and has difficulty answering questions. The rest of the physical exam uncovers no other abnormalities.The blood gas analysis shows a pH of 7.3, a pCO2 of 30 mm Hg, and a bicarbonate of 15 mEq/L. Further laboratory testing revealed sodium of 140 mEq/L and a chloride of 100 mEq/L. What is the most likely diagnosis? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis E. Mixed pattern

A. Metabolic acidosis

A 35-year-old Costa Rican woman emigrated to the United States 5 years ago. She presents to the office due to chronic progressive dyspnea. She reports no chest pain, fever, or cough and is a non-smoker. Her daily activities are becoming increasingly limited due to her shortness of breath. On auscultation, she has an accentuated S1, a loud opening snap, and a diastolic murmur heard best at the apex in the left lateral decubitus position. She has 1+ ankle edema bilaterally. What is the most likely diagnosis? A. Mitral stenosis B. Mitral valve prolapse C. Tricuspid stenosis D. Aortic stenosis E. Aortic regurgitation

A. Mitral stenosis

A 22 year old sexually active male present to your clinic complaining of urethral burning during urination and a purulent, foul-smelling discharge. For this patient, which of the following is the best test to order to confirm this patient's likely diagnosis? A. NAAT B. Urethral swab cx C. UA D. Urine gram stain

A. NAAT

A 13-year-old girl presents 2 weeks after an upper respiratory infection with diarrhea, sweating, and increased heart rate. Physical examination reveals a tremor and a swollen, tender, painful thyroid gland. Pulse rate is 110/min and blood pressure is 130/60 mm Hg. Labs: Serum T4 = increased; Serum T3 = increased; T3 resin uptake = increased; TSH = decreased; Radioactive iodine uptake = very low. What is the appropriate treatment? A. Naproxen B. Levothyroxine C. Thyroidectomy D. Methimazole E. Propylthiouracil

A. Naproxen

A 48-year-old man with a history of type 2 diabetes mellitus comes to the office because of acutely painful left great toe for the past two days. He states that he was otherwise in good health until a few nights ago, when he attended a wedding where, "I drank too much wine." Vital signs are normal. Physical examination of the foot shows maximal point of tenderness at the left metatarsophalangeal joint. Serum uric acid level is elevated. X-ray study of the left foot shows no abnormalities. Arthrocentesis of the left metatarsophalangeal joint is performed, and the synovial fluid is sent to the laboratory for analysis. Which of the following findings on analysis of this fluid confirms the suspected diagnosis? A. Negative bifringent crystals B. Positive Alizarin red stain C. Positive gram stain D. Positive bifringent crystals

A. Negative bifringent crystals

An 8-year-old boy presents with his father on a Sunday afternoon with left ear pain. His father reports that he had 2 ear infections as a baby, but he cannot remember in which ear. The visit occurs during the summer months, and the patient's father says that the boy has been swimming almost daily in a neighbor's pool. Physical examination of the ears bilaterally reveals left ear canal erythema and edema, and pain with manipulation of the left pinna. No other physical examination findings are abnormal. What is the most likely treatment? A. Neomycin/polymyxin B/hydrocortisone topical solution B. Clotrimazole 1% topical solution C. Ciprofloxacin oral suspension D. Triamcinolone 0.1% topical solution E. Amoxicillin oral suspension

A. Neomycin/polymyxin B/hydrocortisone topical solution

An afebrile 76-year-old man has a history of pain and stiffness in his knees bilaterally and in his right hip. The pain is worse after an activity or first thing in the morning. Otherwise, he is healthy and has no other complaints. Upon physical exam, the patient has limited range of motion, joint line tenderness of knees, and mild swelling in the painful joints without warmth. 2 of 18 "tender points" are tender to palpation. A synovial fluid analysis was conducted and it was negative for urate crystals. X-rays of the knees and right hip do not show sclerosis of the bone. Additionally, a Gram stain was conducted and was negative for any bacteria. What is the most likely diagnosis? A. Osteoarthritis B. Gouty arthritis C. Fibromyalgia D. Avascular necrosis E. Septic arthritis

A. Osteoarthritis Pt is experiencing pain first thing in the morning and after activity, not many tender points - consistent with osteoarthritis

A 6-year-old boy presents with a 2-day history of fever followed by cough, coryza, and conjunctivitis. He has also developed a rash that started behind the ear and is starting to spread downwards towards the trunk. On examination, you notice erythematous maculopapular blanching rash with coalescence in some areas. The palm and soles are spared. On oral examination, you notice 1-3 mm bluish lesions surrounded by an erythematous base. He is not up to date with his immunizations. What virus is most likely responsible for this patient's condition? A. Paramyxovirus B. Togavirus C. Human parvovirus B19 D. Human herpes virus 6 E. Varicella virus

A. Paramyxovirus Rubeola/measles has the 3 C's and Koplik spots. It is caused by this virus

Which of the following characteristics distinguishes Obsessive Compulsive Personality Disorder from Obsessive Compulsive Disorder? A. Patient generally lacks insight B. Symptoms often impair social and family activities C. Patient exhibits perfectionism and the need for organization D. Symptoms interfere with task completion

A. Patient generally lacks insight

Which of the following is a potential complication of acute pyelonephritis? A. Perinephric abscess B. Renal vein thrombosis C. Allergic interstitial nephritis D. Hepatic failure

A. Perinephric abscess

A 66-year-old man comes to the office because of progressively worsening pain in his right calf for the past four months. The pain occurs after he walks a distance of about one-half a city block, and steadily intensifies. When he stops walking, the pain gradually disappears. Which of the following is the most likely diagnosis? A. Peripheral arterial occlusive disease B. Polymyositis C. Raynaud disease D. Superficial thrombophlebitis E. Varicose veins

A. Peripheral arterial occlusive disease

A 4-year-old boy presents with a rash on his feet, ankles, wrists, and gluteal areas; the rash is accompanied by severe itching, particularly at night. His 6-month-old sister has a similar rash on her neck and head. On examination, you find pruritic erythematous papular and papulopustular skin changes between the web spaces of the fingers; changes are also seen on the flexor aspects of the wrists and in the genital and gluteal areas. On superficial epidermis, you find several short elevated red tortuous lines; they have a small vesicle at the tip. What is the recommended treatment for the suspected diagnosis? A. Permethrin cream B. Hydrocortisone cream C. Clindamycin lotion D. Selenium sulfide lotion E. Tar soap

A. Permethrin cream

A 71-year-old woman presents to the emergency department complaining of weakness, fatigue, and a near syncopal episode at home. Further workup reveals an atrioventricular block on ECG. Which of the following medications likely caused her AV block? A. Propanolol B. Cholestyramine C. Lisinopril D. Methotrexate

A. Propanolol

A 19-year-old woman presents with a 4-day history of fever accompanied by chills, nausea, vomiting, and back pain. She denies any chest pain, cough, or urinary symptoms. On further questioning, she said she had 2 episodes of diarrhea yesterday with vague abdominal discomfort. She has no other significant past medical history, is on no medications, and has no allergies. Family history is significant for hypertension in father and arthritis in mother. She is single, has no children, does not smoke or drink, and works part time as a waitress. On exam, she has a temperature of 102.4°F, pulse of 110/min, BP 110/60 mm Hg, and SPO2 of 92%. Mucous membranes are dry, and sclera is clear. Lungs are clear, and heart sounds are normal. There is mild left flank tenderness and tenderness in the left costovertebral angle. Labs: Hb 12g/dL, WBC 17,000/uL, bands were 18% and platelets 350,000/uL. Chest X-ray and EKG are normal. Urinalysis shows 35 WBC, 6 RBC, and no casts. What is the most likely diagnosis? A. Pyelonephritis B. Salpingitis C. Cystitis D. Gastroenteritis E. Diverticulitis

A. Pyelonephritis

A 23-year-old man who you recently diagnosed and treated for chlamydial urethritis, returns to the clinic today with visual disturbances and aches and pains in his knees, elbows, and wrists. He also has some abdominal pain and nausea. Laboratory studies reveal an elevated sedimentation rate, but are otherwise normal. Which of the following is the most likely diagnosis? A. Reactive arthritis B. Systemic lupus erythematosus C. HIV D. Septic arthritis

A. Reactive arthritis

A 16-year-old slightly overweight girl presents because she wants to lose weight. She read online that drugs for ADD can help with weight loss. She is unsure of the name of the drug she read about but wonders if she can use them as diet pills instead. Since she was told that drugs like meth have similar properties, she also wants to know if these are safe to take for weight loss. She is told to avoid them because they can become habit-forming and their effectiveness is short-lived. What is the mechanism of action of the drug she is referring to? A. Releases dopamine and norepinephrine B. Enhances effect of GABA C. Interferes with sodium and potassium transport D. Blocks the effect of serotonin E. Blocks binding of acetylcholine to nicotinic receptors

A. Releases dopamine and norepinephrine

A 72-year-old woman presents with a severe unilateral headache, jaw pain, and scalp tenderness. The patient states the headache is of a piercing quality; her jaw hurts only when she chews, and feels better a few minutes after she stops chewing. A pulsation of the temporal artery on the same side as her headache cannot be appreciated, and prednisone is prescribed until the patient can see a specialist. What is the reason prednisone is prescribed in this case? A. Risk for blindness B. Stenosis of the contralateral temporal artery C. As treatment of pseudo tumor cerebri D. Edema reduction for berry aneurysm E. Angioedema in the oropharynx

A. Risk for blindness

A 47-year-old man presents with numbness, tingling, and pain anterior and to the left side of his left thigh. Pain is provoked even with light touch, and tingling continues for several minutes after the touch. Symptoms started a couple of months ago and worsen when he wears a belt and walks down slopes and stairs, as well as after prolonged standing. Symptoms are relieved when he puts a pillow between his thighs. Patient also assumes hunched posture while standing to avoid unpleasant sensory symptoms. His BMI is 40, and he has a protruding pendulous abdomen. What else do you expect to find on examination? A. Sensory loss in anterolateral thigh down to the left upper knee B. Sensory loss on the dorsum of the foot C. Food drop D. Loss of foot inversion in plantar flexion E. Loss of left quadriceps reflex

A. Sensory loss in anterolateral thigh down to the left upper knee Patient is experiencing compression of their lateral femoral cutaneous nerve

What is the most common organism implicated in causing blepharitis? A. Staphylococcus aureus B. Propionibacterium acnes C. Neisseria gonorrhea D. Escherichia coli

A. Staphylococcus aureus

A 43-year-old man without any significant PMHx presents with acute onset of a productive cough, shortness of breath, pleuritic chest pain, and fever. His sputum is described as "thick, brown-colored, and mucoid" but without blood. He also notes associated fatigue and night sweats. He denies chills, changes in weight, a history of travel, sick or confined contacts, exposure to animals, cigarette smoking, otalgia, sore throat, swollen glands, abdominal pain, diarrhea, rashes, myalgias, and arthralgias. His physical exam is remarkable for fever, tachycardia, and tachypnea. The lung exam is noteworthy for right lower lung field increased tactile fremitus, dullness to percussion, inspiratory crackles, and bronchial breath sounds. What is the most likely etiologic responsible for this patient's presentation? A. Streptococcus pneumoniae B. Histoplasmosis capsulatum C. Chlamydia psittaci D. Pseudomonas aeruginosa E. Mycobacterium tuberculosis

A. Streptococcus pneumoniae MCC of CAP, classically causes rust-colored sputum Histoplasmosis is from bird/bat droppings Pseudomonas occurs in IC pts mcly and causes greenish sputum Tuberculosis will have weight loss, fatigue, malaise and night sweats

Which of the following physical exam findings would you expect to find in a patient with pelvic inflammatory disease? A. Tenderness of cervix B. Adnexal mass C. Chadwick's sign D. Positive Murphy's sign

A. Tenderness of cervix

A 29-year-old Caucasian man with a prior history significant for right cryptorchidism presents for a routine physical examination. His prior cryptorchidism was corrected by orchiopexy at the age of 6 months. He has no complaints at present. His physical exam reveals no abnormalities other than bilateral gynecomastia and a right testicular mass that is painless and firm; it measures approximately 1.5 cm in diameter. The right testicular mass does not transilluminate, nor does it disappear when the patient lies supine. There is no femoral or inguinal lymphadenopathy, nor are there palpable hernias. What is the most likely diagnosis? A. Testicular malignancy B. Scrotal hydrocele C. Epididymitis D. Orchitis

A. Testicular malignancy

Which of the following is the appropriate treatment for acute Clostridium tetani infection? A. Tetanus immune globulin, tetanus toxoid & metronidazole B. Tetanus immune globulin & penicillin C. Tetanus toxins & penicillin D. Tetanus immune globulin and tetanus toxins

A. Tetanus immune globulin, tetanus toxoid & metronidazole

A 30-year-old woman gravida 1 para 0 at 14 weeks' gestation presents to the emergency department with mild cramping pain in the lower abdomen, and vaginal bleeding for the past hour. Temperature is 37°C (98.6°F), pulse rate is 82/min, respirations are 16/min, and blood pressure is 128/88 mmHg. Physical examination of the abdomen is soft and nontender to palpation. Pelvic examination shows a small amount of bright red blood in the vagina. The cervical os is closed, and no cervical motion tenderness or adnexal tenderness is elicited. An ultrasound study shows a gestational sac, and a fetal heart rate of 92 beats per minute. Which of the following is the most likely diagnosis? A. Threatened abortion B. Inevitable abortion C. Incomplete abortion D. Complete abortion

A. Threatened abortion

A 70-year-old woman presents to the ER with a 1-week history of palpitations, dyspnea, and generalized weakness. She also gives history of decreased oral intake and weight loss. The patient has no significant previous medical history. On exam, the patient is afebrile. Pulse is 130/min, BP is 100/68 mm Hg, RR is 14/min, oxygen saturation of 97% on room air. Skin appears warm and smooth without cyanosis or edema. Cardiovascular exam reveals normal S1 and S2, no murmurs, rubs, or gallops. Lung sounds are clear bilaterally. Chest X-ray shows no acute cardiopulmonary disease. Electrocardiogram shows atrial fibrillation with rapid ventricular rate of 135 bpm. Normal QRS and QT intervals. What is the next step in management of this patient? A. Thyroid function tests B. Echocardiogram C. Adrenal functional tests D. Sleep study E. No further testing indicated

A. Thyroid function tests A fib is the MC cardiac arrhythmia in pts with hyperthyroidism. Since the patient is otherwise healthy with no other abnormalities, a thyroid issue should be ruled out at this time

A 32-year-old man with a past medical history of allergic rhinitis and asthma that is well-controlled complains of recurrent pruritus associated with an erythematous rash in the flexural areas of his elbows and knees. The lesions seem to become worse when he scratches them and when he is under stress. He denies any recent insect bites, travel, fever, chills, new clothing, or detergent use. Physical examination reveals rough-appearing erythematous plaques in the bilateral antecubital and popliteal fossae, with areas of excoriations within the lesions. What intervention is most appropriate at this time? A. Triamcinolone 0.1% applied to the lesions once or twice daily B. Cephalexin 500 mg by mouth every 12 hours C. Acyclovir 200 mg by mouth 5 times a day D. Tacrolimus ointment 0.03% applied to the lesions twice daily E. Prednisone 40 mg by mouth family tapered over 2-4 weeks

A. Triamcinolone 0.1% applied to the lesions once or twice daily

A 6-year-old boy presents due to lethargy, polyuria, nocturnal enuresis, and polydipsia. His mother tells you that he reports being tired and thirsty all the time. You note that he has lost 5 lb since his last visit 6 months ago. What is the most likely diagnosis? A. Type 1 diabetes mellitus B. Type 2 diabetes mellitus C. Leukemia D. Diabetes insipidus

A. Type 1 diabetes mellitus

A 75-year-old woman, mother of four, presents to your office to establish care. Appearing healthy, she reports a past medical history positive for hypertension and denies any additional problems. However, when specifically asked she admits to having urinary incontinence for "a couple of years" and now describes symptoms that have recently worsened, with the patient experiencing the need to void almost hourly. These desires to urinate are so severe that she is now using four to five adult incontinence pads per day to manage the urine she leaks. What is the most likely diagnosis? A. Urge incontinence B. Stress incontinence C. Overflow incontinence D. Functional incontinence

A. Urge incontinence

Which of the following Vitamin deficiencies is most likely to present with poor wound healing? A. Vitamin C B. Vitamin D C. Vitamin A D. Niacin

A. Vitamin C

A 62-year-old man with a 15-year history of hypertension presents with severe tearing chest pain radiating through to the back. Blood pressure is 180/110 mm Hg, heart rate is 120 bpm, and respiratory rate is 34/min. Physical examination findings include neck negative for bruits/JVD, lungs clear to auscultation, regular heart rhythm, normal S1/S2 with an S4 present, and a grade III/IV diastolic rumbling murmur noted with the patient leaning forward. Radial pulses are 1+ on right and 3+ on left. EKG reveals a sinus tachycardia and evidence of left ventricular hypertrophy. A STAT chest X-ray is obtained. What finding is most consistent with the presumptive diagnosis? A. Widening of the superior mediastinum B. Kerley B lines C. Right-sided pulmonary effusion D. Prominent right cardiac shadowing

A. Widening of the superior mediastinum

Which of the following is used to treat benzodiazepine overdose? A. Disulfiram B. Flumazenil C. Mirtazapine D. Naloxone

B. Flumazenil

A 12-year-old boy is brought to the office by his father for routine sports physical. He is healthy, and takes no medications. A review of his health record shows that at his last well-child examination at age 6 years, he completed the recommended schedule of vaccines, and is current on all immunizations. Which of the following immunizations is recommended at today's visit A. DTaP B. 9vHPV C. MMR D. Varicella

B. 9vHPV

Which of the following valvular lesions of the heart produces a murmur that is characterized as diamond-shaped, systolic, and heard best at the right upper sternal border? A. AR B. AS C. MR D. MS

B. AS

Your patient is taking atorvastatin 40 mg daily for her history of hyperlipidemia. Based on the potential side effects of this medication what labs are indicated for periodic monitoring? A. HGB/HCT B. AST/ALT C. WBC count D. TSH/T4 E. B12

B. AST/ALT Statin medication have the potential to cause liver injury so liver enzymes are to be monitored regularly

A 28-year-old man presents with a 2-week history of a non-painful non-pruritic rash. He is negative for any other rashes, dysuria, urinary frequency, penile discharge, erectile dysfunction, diarrhea, constipation, change in stool, nausea, or vomiting. He does recall having had a penile "scab" approximately 4 weeks ago that healed; he never sought medical attention. He is not aware of having been exposed to anyone with any illnesses in the past few months. Social history is positive for unprotected anal sex with multiple male partners in the past 6 months, with the last sexual encounter occurring 4 days ago. He states that he has not engaged in any recreational drug use or cigarette smoking. Skin exam reveals a pink-red papulosquamous eruption with scattered discrete coppery papules on the palms of his hands. What treatment is the best choice for the patient's condition? A. Ceftriaxone 150 mg IM once B. Benzathine penicillin G 2.4 million units IM once C. Azithromycin 250 mg daily for 7 days D. Doxycycline 100 mg twice daily for 7 days E. Ciprofloxacin 500 mg twice daily for 7 days

B. Benzathine penicillin G 2.4 million units IM once

Patients with atrial fibrillation lack a synchronized and physiologically useful contraction of the atria. While not always producing symptoms, it may cause shortness of breath, weakness, decreased exercise tolerance, lightheadedness, and fatigue. Which of the following best describes the pathophysiologic mechanism of atrial fibrillation? A. Afterload is increased B. Blood volume sent to the left ventricle by atrial kick is lost C. Increased stroke volume D. Venous return is increased

B. Blood volume sent to the left ventricle by atrial kick is lost

A 60-year-old man with a history of heart failure is being evaluated in the emergency department because of worsening shortness of breath over the past two days. Chest x-ray study is interpreted as congestive heart failure with pleural effusion. Which of the following findings on chest x-ray study best characterizes the presence of pleural effusion? A. Air bronchogram B. Blunting of the costophrenic angle C. Kerley B lines D. Peribronchial cuffing

B. Blunting of the costophrenic angle

An 8-month-old girl is brought to the emergency department by her parents because she has had fever, runny nose, and cough for the past three days. Over the past day, she has also had progressive difficulty feeding. Temperature is 38.3°C (101°F). Physical examination shows an infant in moderate respiratory distress with nasal flaring and expiratory wheezing. Chest x-ray study shows hyperinflation and peribronchial thickening. Which of the following is the most likely diagnosis? A. Asthma B. Bronchiolitis C. Pertussis D. Pneumonia

B. Bronchiolitis

A 55-year-old man comes to the emergency department complaining of fatigue, night sweats, an unintentional 15 pound weight loss over the course of the last two months. He also has diffuse body aches, and recurrent fevers. He reports mild anorexia, and early satiety. Physical examination is unremarkable except for a palpable spleen tip. Blood testing shows increased granulocytes: primarily mature neutrophils and low blast cells. Philadelphia chromosome is also found. Which of the following is the most likely diagnosis? A. ALL B. CML C. CLL D. AML

B. CML

A 65-year-old man is brought to the emergency room because of sudden vision loss in his right eye earlier that day. He denies trauma, or even pain in the eye. On fundoscopy, the retina appears pale with a central area of redness. Which of the following is the most likely diagnosis? A. Central retinal vein occlusion B. Central retinal artery occlusion C. Acute angle closure glaucoma D. Open angle glaucoma

B. Central retinal artery occlusion

A 62-year-old female with a known history of hypertension presents due to the abrupt onset of a severe headache, marked vertigo, nausea, vomiting, and ataxia. On physical exam, you note nystagmus, sensory loss, and weakness of the right face. What is the most likely diagnosis? A. Cervical artery dissection B. Cerebellar hemorrhage C. Internal auditory artery occlusion D. Spinal cord compression

B. Cerebellar hemorrhage

A 43-year-old male presents as planned to your family practice clinic for follow up. He was diagnosed with a left lower lobe pneumonia one month prior, caused by Streptococcus pneumoniae, and was successfully treated as an outpatient. Which of the following diagnostic tests is most appropriate at this time? A. Blood cultures B. Chest x-ray C. Intradermal PD D. Urinalysis

B. Chest x-ray

A 21-year-old woman, gravida 1 para 0 at 38 weeks' gestation comes to the emergency department because of fever and abdominal pain for the past six hours. She states that her "water broke" approximately 48 hours ago. However, she did not seek attention at that time because she did not have any pain, and did not think she was in labor. Temperature is 38.9°C (102°F), pulse rate is 122/min, respirations are 18/min, and blood pressure is 108/70 mmHg. Physical examination shows uterine contractions occurring every five minutes. The uterus is tender to palpation. Fetal heart rate is 172 beats/min. Which of the following is the most likely diagnosis? A. Abruptio placenta B. Chorioamnionitis C. Eclampsia D. Placenta previa E. Premature rupture of membranes

B. Chorioamnionitis

Which of the following conditions has a pathophysiology that is most likely to result in pulmonary hypertension as a complication? A. Atypical pneumonia B. Chronic obstructive pulmonary disease C. Pectus carinatum D. Sarcoidosis

B. Chronic obstructive pulmonary disease

A 35-year-old man presents due to headaches. He describes them as only occurring on one side of his head; they tend to have the sensation of a sharp stabbing pain just above his left eye. Each headache lasts for 2 hours; they have been occurring daily for 2-3 weeks, and they have had the same pattern every 3-4 months for the past 2 years. During these periods, the patient admits to his nose feeling congested; his left eye appears red, and it excessively waters. Aggravating factors appear to be alcohol and stressful situations. He denies any known family history of headaches similar to his or migraines. The physical examination is within normal limits. What is the most likely diagnosis? A. Tension headache B. Cluster headache C. Cerebral aneurysm D. Hemicrania continua E. Classic migraine

B. Cluster headache

A 69-year-old man presents with dyspnea on exertion that has been slowly progressive over the course of the last year. He notes impairment in climbing stairs and walking short distances. His review of systems is positive for fatigue, palpitations, intermittent retrosternal chest pain, swelling of his lower extremities, dizziness, and "feeling faint." His associated symptoms are also known to occur upon exertion.He denies any fever, chills, weight changes, cough, abdominal pain, early satiety, nausea, vomiting, diarrhea, changes in his urine color or odor, flank pain, hematuria, or dysuria. He denies any cigarette, alcohol, or drug use. His cardiac exam is remarkable for an increased pulmonic component of the second heart sound (P2), wide, inspiratory splitting of S2 over the cardiac apex, right-sided S3 and S4 gallops, a left parasternal lift, a loud diastolic murmur that increases with inspiration and diminishes with the Valsalva maneuver, prominent "A" waves in jugular venous pulsations, and increased JVD. He has an enlarged liver with hepatojugular reflux, peripheral edema, and ascites. A bedside EKG analysis revealed peaked P waves, rightward axis deviation, and prominent R waves in the early V leads. What is the most likely diagnosis? A. Myocardial infarction B. Cor pulmonale C. Primary biliary cirrhosis D. Left ventricular heart failure E. Pulmonary embolism

B. Cor pulmonale

A 23-year-old woman comes to her primary care office for the evaluation of chronic diarrhea and intermittent right lower abdominal pain for the last six months. She also complains of fatigue and diffuse body aches. The patient undergoes colonoscopy as part of the evaluation, which shows irritation and mild ulcerative lesions in the terminal ileum as well as the splenic flexure. Both lesions appear to have a cobblestone-like pattern to them. Which of the following is the most likely diagnosis? A. Celiac disease B. Crohn disease C. Fibromyalgia D. Ulcerative colitis

B. Crohn disease

A 32-year-old woman comes to the office because of pain in her right thumb and wrist for the past month. The pain has increased in severity, and has made it difficult for her to pick up her toddler-aged child. She states the pain is reproduced when she tucks her thumb into her palm underneath the remaining fingers. She denies any trauma. Physical examination of the wrist shows mild prominence and tenderness at the radial styloid. Neurovascular examination shows no abnormalities. X-ray study of the hand and wrist are normal. Which of the following is the most likely diagnosis? A. Carpal tunnel syndrome B. De Quervain tenosynovitis C. Dupuytren disease D. Gamekeeper thumb

B. De Quervain tenosynovitis

A 66-year-old man is being evaluated in the office for a murmur that was found incidentally two weeks ago when he was seen at a local urgent care clinic for an unrelated problem. Physical examination shows a grade II-III systolic murmur best heard over the second intercostal space adjacent to the right border of the sternum. Aortic stenosis is suspected. You ask the patient to perform a Valsalva maneuver, then reauscultate over this same area. Which of the following effects upon the murmur is most likely to occur as a result of performing the Valsalva maneuver? A. Conversion of the systolic murmur to a machinery-type murmur B. Decrease intensity C. Increased intensity D. No change intensity

B. Decrease intensity

A 27-year-old mildly obese woman comes to the clinic complaining of ongoing flatulence and bloating for several months. She states that her stools are very foul smelling. She says this is usually worse when eating foods that contain wheat. She then goes on to state that she wouldn't have come in to be evaluated except she has now noticed a blister-like rash over the trunk of her body. It is very pruritic in nature. Which of the following dermatologic conditions is most likely occurring in this patient? A. Herpes zoster B. Dermatitis herpetiformis C. Viral exanthem D. Secondary syphilis

B. Dermatitis herpetiformis

Which of the following best describes a stage 4 pressure injury of the skin? A. Callous formation B. Full-thickness skin and tissue loss C. Full-thickness skin loss D. Non-blanchable erythema of intact skin E. Partial-thickness skin loss with exposed dermis

B. Full-thickness skin and tissue loss Stage one - non-blanchable erythema of intact skin Stage two - partial-thickness skin loss with exposed dermis Stage three - full thickness skin loss

A 25-year-old man presents after experiencing pronounced shortness of breath while at the gym. You cannot obtain satisfying information from him during the interview, and you think that he may have an intellectual disability disorder. On examination, he appears short for his age and you notice webbed neck, dental malocclusion, antimongoloid slanting of the eyes, and hypogonadism. Auscultation reveals high-pitched systolic ejection murmur maximal in the second left interspace with radiation to the left shoulder and ejection click that decreases with inspiration. His second heart sound (P2) is delayed and soft. The impulse of right ventricle is increased, and you palpate a thrill at second left intercostal space. What will be your best next diagnostic step? A. Intellectual disability assessment B. Echocardiography/Doppler C. Cardiac catheterization D. Cardiac MRI E. Karyotyping

B. Echocardiography/Doppler You are testing for congenital heart disease since the patients symptoms represent Turner syndrome

A 40-year-old Asian American man presents with a 3-day history of nausea and vomiting. He also reports mild fatigue and lost of appetite. He reports he is in good health besides having a positive PPD test 2 months ago. He was started on a medication after the positive test. Surgical history includes an appendectomy. He is a non-smoker, drinks 7 alcohol beverages a week, and exercises 4 times a week. What lab values would you anticipate in this patient? A. Low BUN and creatinine B. Elevated AST and ALT C. Low GGT D. Elevated gastric E. Low alkaline phosphatase

B. Elevated AST and ALT Isoniazid hepatitis should be expected in any patient on this medicine who presents with these symptoms

What is the most important recommendation that should be given to a patient with chronic simple silicosis in order to halt the progression of their disease? * A. Annual bonchoalveolar lovage B. Eliminate exposure to offending agent C. Advise smoking cessation D. Lung transplantation E. No recommendations exist that will halt progression

B. Eliminate exposure to offending agent

A 33-year-old woman, gravida 0 para 0, has been unable to conceive a child with her husband for the past two years despite having regular menstrual cycles. She has a history of dysmenorrhea, premenstrual low back pain, and dyspareunia for the past three years. Her last Pap smear was normal one year ago. Physical examination shows a retroverted uterus with normal size and shape. There is tenderness of the uterosacral ligament. Several tender nodules are palpated in the posterior vaginal fornix. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis? A. Cervical cancer B. Endometriosis C. Polycystic ovarian syndrome D. Uterine leiomyoma

B. Endometriosis

A 57-year-old man comes to the community free clinic because of fever, chills, sore throat, and swollen glands in his neck for the past three days. He is homeless, and has not received preventive healthcare in over 30 years. Temperature is 39.0°C (102.2°F), pulse rate is 102/min and regular, respirations are 20/min, and blood pressure is 146/94 mmHg. Physical examination shows a disheveled, somewhat toxic-appearing thin man. Examination of the oropharynx shows pharyngeal erythema and edema, and a thick, gray membrane overlying the soft palate, uvula, and tonsils. Anterior and submandibular cervical lymphadenopathy is also noted. Which of the following antibiotics A. Cephalexin B. Erythromycin C. Gentamicin D. Tetracycline

B. Erythromycin

A 13-year-old boy presents with pain in his right leg. The pain has been present for about 2 months, but it has worsened with time; he has also developed a low-grade fever. He denies any known injury to the area. On examination, there is tenderness and mild swelling near the right fibula. X-ray reveals an invasive lesion involving the right fibula, with a periosteal onion-skin reaction. What is the most likely diagnosis? A. Plasmacytoma B. Ewing's sarcoma C. Multiple myeloma D. Endochondroma E. Osteochrondroma

B. Ewing's sarcoma

A 46-year-old woman presents because she has not had her period for almost a year, has hot flashes, and feels fatigued most of the time. She complains of insomnia, and states that she keeps smoking despite trying many times to quit. Her libido is low and she does not use any hormone-based birth control. Her blood analysis indicates a TSH (thyroid-stimulating hormone) level of 3.1 mcU/mL (normal 0.4 - 4 mcU/mL) and a FSH (follicle-stimulating hormone) level of 55.3 mIU/mL (normal <35 mIU/mL). What is the most accurate conclusion regarding the menstrual status of this patient? A. TSH level is consistent with menopause B. FSH level is consistent with menopause C. Blood results are consistent with primary ovarian insufficiency D. TSH is consistent with hypothyroidism E. TSH is consistent with perimenopause

B. FSH level is consistent with menopause

A 24-year-old woman G1P0 comes to the clinic after noticing a breast lump. She states she has had cyclic breast pain for a few years now, however she has recently noticed a unilateral mass. She has no fever and physical examination reveals a mobile, non-tender, firm, 1.5cm mass. Which of the following is the most likely diagnosis given the clinical presentation? * A. Breast abscess B. Fibroadenoma C. Fibrocystic changes D. Intraductal carcinoma

B. Fibroadenoma

What is the therapy of choice for a patient diagnosed with Coccidioidomycosis? A. Ampho B B. Fluconazole C. Azithromycin D. Trimethroprin/sulfamethoxazole

B. Fluconazole

A 73-year-old man with no significant past medical history presents with a 1-month history of light-headedness, dizziness, and near syncope; it has been occurring in response to sitting up and standing from a supine position. He denies chest pain, palpitations, shortness of breath, cough, loss of consciousness, vision or speech changes, nausea or vomiting, numbness, tingling, paresthesias, and focal weakness. His physical exam is noteworthy for a drop in systolic blood pressure of 24 mm Hg from a supine to standing position. What clinical intervention should be recommended to this patient? A. Begin clonidine or a diuretic B. Fludrocortisone and compression stockings C. Large, carbohydrate meal consumption D. Sodium and water restrictions E. Rise rapidly from seated and supine positions

B. Fludrocortisone and compression stockings

Which of the following agents is a benzodiazepine receptor antagonist, and may be used to reverse the clinical effects of benzodiazepines? A. Acetylcysteine B. Flumazenil C. Glucagon D. NAloxone

B. Flumazenil

A 50-year-old man is brought to the emergency department by his friend because of severe, constant, deep, epigastric pain that radiates to his mid-back for one day. He states he has nausea, and has vomited three times today. Temperature is 38.4°C (101.2°F), pulse rate is 120/min, respirations are 22/min, and blood pressure is 140/90 mmHg. Physical examination shows an ill appearing man in moderate discomfort. Examination of the abdomen shows epigastric tenderness to palpation, without rebound tenderness. Laboratory studies show an elevated lipase, and normal triglyceride levels. Administration of which of the following is the most appropriate initial step in management? A. IV antibiotics B. IV normal saline C. Oral antipyretic agent D. Oral pancreatic enzymes

B. IV normal saline

A 60-year-old man with a history of well-controlled hypertension comes to the office because of progressive dyspnea, dry cough, and fatigue for the past six months. He has worked as a barber for 30 years. He has no history of smoking, and his only medication is lisinopril. Temperature is 37°C (98.6°F), pulse rate is 78/min, respirations are 20/min, and blood pressure is 138/88 mmHg. Auscultation of the lungs show fine, bibasilar crackles. The remainder of the physical examination shows no abnormalities. Chest x-ray study shows reticular opacities in the lower lung bases. Pulmonary function tests show reduced lung volumes, and reduced forced vital capacity. Which of the following is the most likely diagnosis? A. Alpha-1-antitrypsin deficiency B. Idiopathic pulmonary fibrosis C. Mesothelioma D. Sarcoidosis

B. Idiopathic pulmonary fibrosis

A 61 year old male presents to the clinic with complaint of chest pain for the last 30 minutes, the onset of pain began after drinking his routine morning coffee, he describes the pain as pressure over the chest which radiates to the left neck and arm. He also states that he vomited in the car on the ride to the hospital. He is uncomfortable and diaphoretic. You order an electrocardiogram which shows ST elevation in leads II, III, and AVF what is your most likely diagnosis? A. Anteroseptal MI B. Inferior MI C. Prinzmetal angina D. Unstable angina

B. Inferior MI

A 32-year-old man presents due to occasional shortness of breath and associated cough, especially when he is working outside. He has associated chest tightness that resolves within minutes when he sits down and rests. These symptoms occur 1-2 days a month. He is otherwise healthy and does not smoke. Blood pressure is 128/74 mm Hg, and pulse is 76, respiration is 14, and pulse oximetry is 100% on room air. His FEV1 is 96%. What is the treatment of choice? A. Inhaled corticosteroid B. Inhaled short-acting beta agonist C. Inhaled anticholinergic D. Oral beta agonist

B. Inhaled short-acting beta agonist

A 36-year-old man comes to the emergency department because of profuse diarrhea for the past 36 hours. He states that he recently returned from a trip to Haiti when the diarrhea started. He describes the diarrhea as severe, frequent, and watery with characteristics of rice water. Temperature is 37.3°C (99.2°F), pulse rate is 116/min, respirations are 20/min, blood pressure is 100/50 mmHg. Physical examination shows dry mucous membranes, and slightly decreased skin turgor. Which of the following is the most appropriate next step in management A. Emergent consultation with a gastroenterologist B. Intravenous administration of lactated Ringer solution C. Obtain stool specimen for ova and parasite analysis D. Oral administration of metronidazole

B. Intravenous administration of lactated Ringer solution Cholera symptoms are classically watery diarrhea which lasts a few days, vomiting and muscle cramps. Diarrhea can lead to severe dehydration and electrolyte imbalance requiring IV lactated Ringer solution rather than isotonic sodium chloride solution

A 55-year-old man presents with severe central chest pain. Pain started suddenly and it radiates to the back and neck. He is unable to lie flat. He feels sick but has not vomited. He has no major illnesses and knows of none that run in his family. He does not use alcohol, tobacco, or illicit substances. He is allergic to sulfa drugs.On physical exam, he appears in extreme pain and is lying on his side. Temperature is 98.6°F, heart rate is 110, blood pressure is 180/105 mm Hg, and respiratory rate is 20. Cardiac exam reveals normal S1 and S2 without rubs or gallop. The top of his internal jugular venous column is present at 2-3 cm above the sternal notch. Chest auscultation shows normal vesicular breathing. He has normal active bowel sounds tympanic to percussion. Extremity exam is normal, and the lower motor and sensory function are intact.ECG shows left ventricular hypertrophy. Chest X-ray shows widened mediastinum. What treatment should be given immediately to this patient? A. Nitroglycerin spray B. Intravenous labetalol C. Streptokinase D. Angioplasty E. Surgery

B. Intravenous labetalol

A 52-year-old man had abdominal surgery to remove a portion of his stomach. He subsequently developed a megaloblastic anemia. A deficiency in which of the following substances is the most likely cause of this patient's anemia? A. Gastrin B. Intrinsic factor C. Pepsin D. Prostaglandin

B. Intrinsic factor

You are rounding on one of your patients that was admitted to the hospital over the weekend for shortness of breath and chest pain. His electrocardiogram this morning shows inverted P-waves in the inferior leads. Which of the following would be this patient's most likely rhythm? A. Atrial tachycardia B. Junctional rhythm C. Ventricular tachycardia D. Atrial fibrillation

B. Junctional rhythm Junctional rhythm - p wave invention is due to retrograde depolarization of the atria Atrial fibrillation shows no distinguishable P waves

A 44-year-old man comes to the emergency room with epistaxis for the last hour. It started after blowing his nose. What is the most common and likely site of bleeding for this patient? A. Carotid artery B. Kisselbach's plexus C. Pharyngeal artery D. Posterior nasal artery

B. Kisselbach's plexus

A 27-year-old male accident victim with a head injury is admitted to the ICU and kept on mechanical ventilatory support. On the seventh day after admission, he is clinically diagnosed with pneumonia. Blood samples and lower respiratory secretions are submitted to the laboratory for culture; empiric antimicrobial therapy is started. What is the most likely etiologic agent of pneumonia in this patient A. Streptococcus pnuemoniae B. Klebsiella pneumoniae C. Mycoplasma pneumoniae D. Moraxella catarrhalis E. Haemophilus influenzae

B. Klebsiella pneumoniae Patients on ventilators are at risk for pseudomonas, klebsiella, etc.

A 15-year-old girl is referred to a cardiologist's office for workup of hypertension. Her mother reports a normal pregnancy and birth. There is no family history of heart disease. On physical exam, you note the following: BP 140/70 left and right upper extremities, 90/70 left and right lower extremities, HR 85/min, RR 20/min. Brachial and femoral pulses are incongruent. You note pulsations in the suprasternal notch. Cardiac auscultation reveals a III/VI systolic ejection murmur. What would you expect to see on chest radiography? A. Right ventricular hypertrophy and large pulmonary arteries B. Left ventricular hypertrophy and a notch in the aorta C. Boot-shaped heart with right ventricular prominence D. Prominence of the aorta, pulmonary artery and left atrium

B. Left ventricular hypertrophy and a notch in the aorta

A 46-year-old woman comes to the urgent care clinic because of anxiety for the past two days. She has a history of heavy, daily alcohol use, but decided to quit "cold turkey" two days ago. Temperature is 37.3°C (99.1°F), pulse rate is 104/min, respirations are 18/min, and blood pressure is 154/92 mmHg. On physical examination she appears flushed, diaphoretic, and tremulous. Laboratory studies show low serum albumin, and low protein levels, as well as elevated prothrombin time value. She is admitted for alcohol detoxification. Which of the following medications is most appropriate for treating this patient's symptoms? A. Haloperidol B. Lorazepam C. Naloxone D. Phenobarbital

B. Lorazepam

A 9-year-old boy presents with episodes of severe impulsivity, lack of attention, poor listening skills, and obsessive and compulsive characteristics; symptoms have been evident to his mother and multiple teachers at school. There have been numerous episodes. The patient has had mild evidence of these signs since he was in kindergarten, but they have become substantially worse in the last 4 months. Considering the differential diagnosis, what is an associated feature that would support the most likely diagnosis? A. Weight loss B. Low frustration tolerance C. Racing heart D. Headache

B. Low frustration tolerance

A 50-year-old woman with no significant past medical history presents for an annual pelvic examination. She states her last menstrual period was over 6 months ago; the last few occurrences of menses were extremely irregular. The patient also describes having the sensation of intense heat in her face and trunk, and the sensation is accompanied by sweating. She also states that her "heat episodes" have been occurring 1 or 2 times a week for the last several months. Patient denies any other symptoms at this time. She has received her annual pap and pelvic examination yearly, as well as a clinical breast exam, without any issues.On pelvic examination, you note obvious vaginal thinning, excessive dryness, and apparent vaginal wall atrophy. Based on the history and physical examination findings, what is most likely occurring in this patient? A. Ovarian failure B. Menopause C. Pregnancy D. Cervical cancer

B. Menopause

A 52-year-old woman comes to your clinic with bilateral knee and wrist pain with stiffness for the past 3 months. She admits that her stiffness is worse upon first waking in the morning, and that it usually doesn't go away for at least an hour. She also states that for the last couple of months she has felt excessively tired, and overall unwell. Laboratory testing reveals normal thyroid studies, a mildly elevated erythrocyte sedimentation rate (ESR) and positive rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibodies (anti-CCP). Which of the following is the treatment of choice in this patient to slow the progression of her disease? A. Aspirin B. Methotrexate C. Naproxen sodium D. Oral glucocorticoids

B. Methotrexate

A 65-year-old woman presents with fatigue, loss of energy, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. She has a glucose-6-phosphate dehydrogenase (G6PD) deficiency and a history of coronary artery disease. On examination, you find swollen, painful, and tender small joints in a symmetrical pattern. Using the history, physical, and X-rays, as well as the presence of rheumatoid factor and antibodies to cyclic citrullinated peptides, you conclude that she has a flare-up of a chronic diagnosis. What long-term therapy should be recommended in order to modify the course of the disease? A. NSAIDs B. Methotrexate C. Sulfasalazine D. Corticosteroids E. Selective COX-2 inhibitors

B. Methotrexate

What is the most common cause of nephrotic syndrome in children? A. Post-streptococcal glomerulonephritis B. Minimal change disease C. Diabetes Mellitus D. Polycystic kidney disease

B. Minimal change disease

A 65-year-old woman presents with general weakness for the past few days; it gets worse as the day progresses. She says she has been having double vision, and you notice she has poor posture. A blood test reveals the presence of antibodies to acetylcholine receptor. A repetitive nerve stimulation test showed a decremental response. What is the most likely diagnosis? A. Marfan syndrome B. Myasthenias gravis C. Duchenne muscular dystrophy D. Rheumatoid arthritis E. Systemic lupus erythematosus

B. Myasthenias gravis

A 25-year-old man presents with back pain and stiffness. He states he has had longstanding issues with back pain. He denies any trauma to his back. He has noticed associated increasing stiffness and general fatigue. He feels that these issues have gradually worsened over the last several months and are more persistent recently. He notes that the pain is much worse first thing in the morning, rating it a 6-7/10. Radiation occasionally occurs into the buttock areas and the patient feels the symptoms actually lessen with activity. Physical examination shows marked forward stooping of the thoracic and cervical spine with the lower spine showing the presence of a substantial reduction in lateral flexion. What would be the first-line pharmaceutical treatment to consider in this patient? A. TNF inhibitors B. NSAIDs C. Sulfasalazine D. Etanercept E. Corticosteroids

B. NSAIDs

A 26-year-old male presents to your clinic with 2 weeks of joint pain. He reports symptoms consistent with a migratory arthritis, but for the past three days he says that the pain and swelling is worse in his left knee. On further questioning he reveals that three weeks ago he had burning upon urination with some milky discharge from his penis, but the symptoms have since resolved. On physical exam the left knee is erythematous, swollen, tender to palpation, and has decreased range of motion. Genitourinary exam is unremarkable. What is the most likely causative organism A. Chlamydia trachomas B. Neisseria gonorrhoeae C. Salmonella D. Clostridium tetani

B. Neisseria gonorrhoeae Gonorrhea is the most likely causative agent with penile drainage, migratory arthralgias and single large joint infections — gonococcal arthritis

An otherwise healthy 43-year-old woman at 8 weeks gestation presents for routine prenatal care. Everything appears to be healthy with both mother and baby. Which of the following is considered the next best step in the management of this patient? A. Continue with routine prenatal visits B. Offer prenatal screening for aneuploidy C. Perform a non stress test D. Check alpha-fetoprotein levels

B. Offer prenatal screening for aneuploidy

What diagnostic finding would confirm a suspicion of Multiple Sclerosis? A. Intracellular Lewy bodies B. Oligoclonal bands C. CT shows cerebral and caudate nucleus atrophy D. Increased serum ceruloplasmin concentration

B. Oligoclonal bands

A 23-year-old woman presents due to palpitations, numbness, shortness of breath, and sweating. She reports that these episodes have been occurring once or twice a week for the past several months and that she cannot discern any consistent pattern or trigger. Although the symptoms occur seemingly at random and independent of social situations, she reports that she has begun to limit her social activities for fear of having an episode while she is away from home. Physical exam and laboratory findings are within normal limits. What is the most likely diagnosis? A. Generalized anxiety disorder B. Panic disorder C. Post-traumatic stress disorder D. Social phobia E. Panic attack

B. Panic disorder

Which of the following is the initial therapy of choice for generalized anxiety disorder? A. Atomoxetine B. Paroxetine C. Alprazolam D. Buspirone

B. Paroxetine

A 55-year-old man presents with a COPD exacerbation managed with a ventilator. The patient's blood pressure drops and the ventilator alarm goes off. The only medication being administered is amlodipine via nasogastric tube. This patient is afebrile, even though the hospital has been having problems with pseudomonas infection in ventilated patients.On examination, there is a middle-aged orally-intubated man with temperature 99.4°F, pulse 145/min, and BP 62/34 mm Hg; he breathes above the ventilator at a rate of 36 cycles/min. His breathing is shallow, and there are diminished breath sounds in the right hemithorax. What is the most appropriate next step? A. Add positive end-expiratory pressure B. Perform needle thoracotomy, chest tube placement C. Start antibiotics D. Give IC fluid bonuses E. Start pressor agents

B. Perform needle thoracotomy, chest tube placement Symptoms are consistent with a right tension pneumothorax

A 42-year-old female presents to your office complaining of intermittent bouts of balance problems, focal weakness, and the occasional episode of intense right sided facial pain. You suspect multiple sclerosis. Which of the following would you expect to see on MRI if this presumptive diagnosis is correct? A. Cerebral and caudate nucleus atrophy B. Periventricular white matter plaques C. Intracellular neuroribrillary tangles D. Extracellular neuritis plaques

B. Periventricular white matter plaques

A 41-year-old woman presents due to worsening symptoms. She was diagnosed with idiopathic pulmonary hypertension about 2 years prior to presentation; she is on home oxygen therapy. She has longstanding fatigue and dyspnea, but she is now experiencing profound dyspnea with exertion, swelling in her ankles, some discomfort in her right upper abdomen, and the inability to breathe well when lying down. She has always been thin, but her weight has increased by 10 pounds in the last month. She denies fever and chills.She recently had an electrocardiogram (ECG), but she has not seen a healthcare provider to discuss the results. The ECG report indicates peaked p waves, right axis deviation, and tall r wave in V1. What is the most appropriate intervention for her current condition? A. Prescribe a CCB, such as verapamil B. Prescribe a diuretic, such as furosimide C. Prescribe a fluoroquinolone, such as levofloxacin D. Prescribe a thiazolidinedione, such as poiglitazone

B. Prescribe a diuretic, such as furosimide Patient is presenting with pulmonary hypertension and transitioning into cor pulmonale. They will develop symptoms of heart failure thus fluid overload needs to be treated

A 25-year-old woman presents to discuss her available contraception options. You review her history and note menses onset at age 12, duration of menses typically around 6 days, occurring every 30 days. She is G0P0, and she has no history of abnormal pap smears or diagnosed STIs. The patient is a non-smoker in a monogamous relationship with one partner for the past year. All other medical history is non-contributory with the exception of the patient having a deep venous thrombosis at age 19 and a pulmonary embolism at age 21. Other than anticoagulation therapy for the appropriate amount of time, no other hematological evaluation was pursued after these events. Given the patient's history, what form of contraception would you select? A. Estrogen/progestin combination oral contraception pill B. Progestin-only oral contraception pill C. Etonogestrel/ethinyl estradiol vaginal ring D. Norelgestromin/ethinyl estradiol patch-transdermal E. Estradiol/medroxyprogesterone monthly injection

B. Progestin-only oral contraception pill Estrogen is contraindicated in patients with hx of DVT, smokers, breast feeding mothers and other hypercoagulable states

Parents bring their 4-year-old daughter in because of knock-knee. She is otherwise healthy, and her height is in the 50th percentile for age. On examination, she has about 10 degrees of valgus. What should you recommend? A. X-rays of the lower extremities B. Reassurance that this is normal for age C. Orthopedic shoes D. Long leg braces E. Lab tests for markers of bone turnover

B. Reassurance that this is normal for age

A 32-year-old nulliparous woman presents for a routine gynecological exam. She has been married for 5 years and plans to start a family in the near future. Menarche occurred at age 11. Menstrual cycles are regular, occurring every 28-30 days, and lasting for 4-5 days each. She denies menorrhagia and dysmenorrhea. She has used oral contraceptive pills since age 18; she recently discontinued them and began taking prenatal vitamins.On physical examination, you palpate a mass on the left side. A transvaginal ultrasound confirms a 3 cm complex cystic mass on the left ovary, without free fluid detected within the pelvis. The patient has no family history of any malignant tumors. What is the best therapeutic approach for this patient? A. Resume oral contraceptive pills B. Repeat ultrasound in 2-3 months C. Plan an oophorectomy D. Schedule a cystectomy

B. Repeat ultrasound in 2-3 months

A 24 year old female patient presents to your clinic complaining of a non-productive cough, nasal congestion and rhinorrhea, and a sore throat for the last four days. Upon physical exam you find a temperature of 100.8 F (38.2 C), an erythematous oropharynx, and lungs that are clear to auscultation. A rapid streptococcal swab performed in the office is negative. What is the most likely etiology of the patient's suspected diagnosis? A. Streptococcus pyogenes B. Rhinovirus C. Adenovirus D. Respiratory syncytial virus

B. Rhinovirus

A 34 year old male presents to the clinic complaining of feeling emotionally unstable, and having frequent headaches. He also states that he has noticed a resting tremor that improves with purposeful actions, and some stiffness or rigidity to his movement. These symptoms have gradually worsened over the last few months. Examination of the eyes is remarkable for dark rings that appear to encircle each iris. Which of the following tests, if abnormal, confirms this patient's likely underlying condition? A. Complete blood count B. Serum ceruloplasmin concentration C. MRI of the brain D. Urine drug screen E. Ultrasound of the kidneys

B. Serum ceruloplasmin concentration The onset of Parkinsonism symptoms in a patient younger than 40 should have prompt evaluation for Wilson's disease.

A 25-year-old female presents for an ultrasound after having a positive home pregnancy test. She has an unremarkable past medical history and physical exam. She states she has been feeling fine without any abdominal discomfort or vaginal bleeding noted. On ultrasound you determine she is 10 weeks pregnant. You note a noncomplex unilateral mass on her left ovary measuring 2 cm in diameter. Which additional history would support your suspected diagnosis? A. Hx of HSV B. She used Clomiphene to conceive C. Two previous Caesarian sections D. 20 lb unintentional weight loss E. Previous miscarriage at 7 weeks gestation

B. She used Clomiphene to conceive Pts with ovarian cysts frequently require assisted reproduction due to ovarian hyper stimulation during first trimester

Which of the following symptoms or physical examination findings would most help you differentiate an otitis externa from an otitis media? A. Fever B. Tragal tenderness C. Ear pain D. Hearing loss E. Bulging tympanic membrane

B. Tragal tenderness

A woman presents with her 6-year-old adopted daughter due to excessive scratching of the scalp and ears. The woman states that she washes the girl's hair frequently, but it hasn't been helpful; the woman is very frustrated for her daughter. On examination of the scalp, excessive excoriations are noted on the posterior neck and postauricular regions bilaterally. No cervical lymphadenopathy is noted. Nits are also observed on the shaft of the hair. What is the appropriate treatment for this patient? A. Remove all household pets B. Treat with permethrin C. Treat with topical steroid D. Treat with oral antibiotics E. Treat with oral antifungals

B. Treat with permethrin

A 39-year-old previously well Caucasian man presents to the emergency department with a 10-day history of fever >101°F and acute dyspnea with pleuritic chest pain. His past medical history is notable only for childhood asthma (no recurrences since age 12) and appendectomy. He has no known drug allergies. He denies taking prescribed medications on a regular basis. Social history is notable for use of IV drugs.Vital signs show temperature 100.8°F, pulse 108, respirations 24, blood pressure 98/60. O2 saturation is 90% on room air. Physical examination reveals mild crackles of the mid-lung fields bilaterally and a grade II/VI soft systolic murmur, loudest at the left lower sternal border. A spiral CT reveals evidence of multiple pulmonary emboli. He is admitted to the general medical floor of an acute care hospital. Additional diagnostic tests are ordered; preliminary results of blood cultures showed 4+ growth of gram-positive cocci. Infectious Diseases is consulted and he is started on an IV antibiotic regimen. what is the most likely source of the multiple pulmonary emboli in this patient? A. Deep vein thrombosis B. Tricuspid valve vegetation C. Left atrial thrombosis from atrial fibrillation D. Disseminated intravascular coagulation E. Metastatic cancer

B. Tricuspid valve vegetation

In a suspected complete tear of the medial collateral ligament, which physical examination finding would confirm your suspicions? A. Unilateral laxity with varus stress testing B. Unilateral laxity with valgus stress testing C. Locking of the knee with McMurray testing D. Reproduction of pain with Thessaly test

B. Unilateral laxity with valgus stress testing

Your supervising physician warns you that a patient on your schedule for today has been diagnosed with Histrionic personality disorder. Which of the following characteristics would you expect that patient to exhibit? A. Feels a sense of entitlement B. Use of physical appearance to attract attention C. Tendency to break the law D. Fears the dissolution of relationships

B. Use of physical appearance to attract attention

A 4-year-old boy presents with a 3-day history of fever with chills, cough, and fast breathing. His parents report decreased oral intake and increased difficulty breathing with retractions over the last 24 hours. His initial vital signs are heart rate 144 bpm; respiratory rate 32/min; temperature 101.3°F (38.5°C); oxyhemoglobin saturation 89% on room air. He is immediately started on supplemental oxygen, and his oxyhemoglobin saturation improves to 95%. Subsequent evaluation, including a chest X-ray, is suggestive of right middle and lower lobe pneumonia. What is the mechanism for the low oxyhemoglobin saturation in this patient? A. Hypoventilation B. Ventilation-perfusion mismatch C. Diffusion block D. Shunt E. Increased dead space in lungs

B. Ventilation-perfusion mismatch Hypoventilation - causes elevated CO2 before hypothermia Diffusion block - associated with lung disorders causing reduced gas exchange Shunt - Tetrology of fallout, etc.

A 3-year-old infant is brought to the emergency room by his parents. They state that he has been coughing with a fever for the last week, and they think he has pneumonia again. This would be his third time in the past twelve months. Physical examination shows what appears to be an undernourished child, lung sounds are coarse with peripheral wheezing, and you notice a blowing holosystolic murmur at the left sternal border. Which of the following is this patient's most likely underlying diagnosis? A. Cystic fibrosis B. Ventricular septal defect C. Asthma D. Pulmonary fibrosis

B. Ventricular septal defect I'm children with large VSD they will have FTT, recurrent respiratory infections and audible murmur on exam

An 8-month-old female infant presents with a 2-day history of increasing irritability and decreased appetite. She has also had some diarrhea and low-grade fever. On exam, she is afebrile, fussy, and hard to console, but she appears alert and active. She lies with her hips and knees flexed, crying harder with any movement. A few petechiae are noted on her skin. Leg X-rays are done to look for a possible fracture that shows a pencil-thin cortex and a ground glass appearance of the bones. Further history reveals that she has been given evaporated milk since birth to save money, and she has not yet been started on solids. What vitamin deficiency would most likely cause this infant's symptoms? A. Vitamin B6 B. Vitamin C C. Vitamin A D. Vitamin B2 E. Vitamin E

B. Vitamin C Scurvy aka vitamin C deficiency is characterized by petechiae, joint pain, bleeding from mucous membranes and thin hair B6 deficiency - seizures, peripheral neuritis, dermatitis, microcytic anemia Vitamin A deficiency - leading cause of preventable blindness in children, follicular hyperkaratosis, eye dryness Vitamin B12 deficiency (Riboflavin) - cheilosis, glossitis, keratitis, photophobia, blurred vision, seborrheic dermatitis and anemia Vitamin E deficiency - muscle weakness, double vision, loss of position sense, hemolytic anemia, decreased reflexes and constricted visual fields

What is the most common cause of a Mallory-Weiss tear? A. FB aspiration B. Vomiting C. Iatrogenic trauma with instrumentation during a procedure D. Coughing

B. Vomiting

A 40-year-old man presents with irregular heartbeats over the course of several days. His past medical history is significant for the presence of mitral valve stenosis and atrial fibrillation (AF). He takes beta blockers regularly. His ECG shows atrial fibrillation with an irregular heart rhythm around 80 bpm. What pharmacologic agent should be prescribed prior to cardioversion in this patient to restore sinus rhythm and prevent further complications? A. Heparin B. Warfarin C. Digoxin D. Amiodarone

B. Warfarin

A 32 year old female, with a significant history of IV drug use, presents to the emergency department with complaint of muscle aches and pains, hot and cold flashes, fever, and painful nodes in the pads of her fingers. She has also noticed weight loss over the past four weeks. During physical exam a new murmur is noted on auscultation. What is the recommended duration of antibiotic therapy? A. 1 week B. 3 weeks C. 6 weeks D. 12 weeks

C. 6 weeks

A 74 year old patient presents for evaluation of dysphagia to both solids and liquids. He also states that he has a history of heartburn and acid reflux. You order an upper GI series, which demonstrates a bird beak sign. Which of the following is the most likely diagnosis? * A. Schatzki ring B. Esophageal cancer C. Achalasia D. Peptic ulcer disease

C. Achalasia

A 54-year-old man with a history of chronic alcohol abuse presents to the emergency department with complaints of a subjective fever and severe epigastric pain radiating to the back. The pain has been present for the past 8 hours and is associated with nausea and vomiting, which has not relieved the pain. Laboratory data reveal a WBC of 14,000/mm 3 and a serum amylase of 500 U/L (reference range 0-286 U/L). Plain films of the abdomen were unremarkable. Which of the following is the most likely diagnosis? A. Perforated duodenal ulcer B. Acute cholecystitis C. Acute pancreatitis D. Mesenteric ischemia E. Choledocholithiasis

C. Acute pancreatitis

A 54-year-old male has had long term GERD symptoms. He has been on proton pump inhibitors and has had fair control of his symptoms. Other past history is unremarkable. He is a nonsmoker and drinks socially. Family history is significant for hypercholesterolemia in his father. Physical examination is unremarkable. An endoscopy a few years ago, revealed Barrett's esophagus by biopsy of the esophageal mucosa. He was recommended to have follow-up endoscopy every 2-3 years with mucosal biopsy. The screening was recommended to him because he is in danger of developing which of the following? A. Achalasia B. SCC of esophagus C. Adenocarcinoma of esophagus D. Esophageal stricture E. Esosinophillic esophagitis

C. Adenocarcinoma of esophagus

A 77-year-old Caucasian woman is admitted to the hospital for episodes of dizziness. Her symptoms have been present for approximately 4 months, and they have been progressively worsening. She has no dizziness when sitting or lying down. She does note some rapid heart rate associated with her dizzy spells. The dizziness becomes severe enough that she must sit down and is unable to proceed with walking, which is now significantly interfering with her functional activities. She denies associated chest pain, shortness of breath, or nausea.Past Medical History: Hypothyroidism, single episode of atrial fibrillation 2 years ago.Usual home medications: Aspirin 81 mg daily, Levothyroxine 88 mcg daily.Social History: Patient is married and has 2 adult children. She denies any history of smoking, alcohol use, or use of recreational drugs.Review of systems: Notable only for occasional cough, occasional headache, and mild anxiety.Vital signs: Temp 98.2°F, pulse 98 and regular, respirations 16, blood pressure 94/62 mm Hg (sitting, right arm). What exam finding will most likely establish the diagnosis? A. Assessment for pallor of the skin and nails B. Assessment of skin turgor C. Blood pressures lying, sitting, and standing D. Cardiac auscultation E. Romberg test

C. Blood pressures lying, sitting, and standing

A 28-year-old man with no significant past medical history is rushed to the local trauma center following a stab wound to his chest. Paramedics report that there was significant blood loss. The patient has lost consciousness. He is oliguric and his extremities are cool and moist to touch. His physical exam is also remarkable for tachycardia, tachypnea, a depressed systolic pressure, an immeasurable diastolic blood pressure. What is the preferred initial pharmacologic agent of choice for this patient? A. Epinephrine B. Normal saline C. Blood products D. Somatostatin E. Vasopressin

C. Blood products Hypovolemic shock

A 19-year-old female student is referred for psychiatric assessment after an attempted suicide 2 days ago. On questioning, the patient informs that the precipitant to her attempted suicide was a recent breakup with her boyfriend. Her history is significant for multiple suicide attempts since the age of 12. On further questioning, the patient informs that she has a chronic feeling of emptiness and sometimes feels disconnected from reality. She also gets into fights with her boyfriends, as she has difficulty controlling her anger. The patient admits that she has had highly problematic relationships with men and that she falls quickly in and out of love. Examination reveals several cuts on the wrists and arms. What personality disorder does the patient have A. Narcissistic B. Dependent C. Borderline D. Histrionic E. Paranoid

C. Borderline

A 19-year-old woman presents to your office with a chronic cough, productive of foul smelling purulent sputum for the last year. She denies having fevers, but admits to occasional episodes of hemoptysis. She has been diagnosed with cystic fibrosis, and treated multiple times for pneumonia. On chest x-ray you note dilated, thickened airways. Which of the following is the most likely diagnosis? A. Chronic bronchitis B. Asthma C. Bronchiectasis D. Interstitial pulmonary fibrosis

C. Bronchiectasis

Administration of an inhaled anticholinergic agent (eg. ipratropium) is most likely to cause which of the following physiologic responses? A. Bradycardia B. Bronchoconstriction C. Bronchodilation D. Increased mucus production E. Increased urinary urgency and frequency

C. Bronchodilation

A 27-year-old woman comes to the emergency department because of pain in the right lower abdomen that began 8 hours ago. The pain has steadily worsened, and she is now nauseous and has vomited twice. She does not have an appetite. Temperature is 37.0°C (98.6°F), pulse rate is 92/min, respirations are 20/min, and blood pressure is 128/82 mmHg. Physical examination of the abdomen shows mildly decreased bowel sounds, mild to moderate tenderness in the right lower quadrant, and no rebound tenderness. Mild tenderness is noted in the right adnexa on pelvic examination. Urine pregnancy test is negative. Results of transvaginal ultrasound are equivocal. Which of the following is the most appropriate next imaging study to obtain? A. Anterior-posterior view of the abdomen B. Barium enema x-ray study C. CT scan of the abdomen and pelvis D. MRI of the abdomen E. Radionuclide scanning

C. CT scan of the abdomen and pelvis

A 1-month-old full-term male infant has been diagnosed with tetralogy of Fallot. His disease is being classified as moderate, and he has been admitted to the neonatal intensive care unit for monitoring. He is now stable and is doing well. During a consultation between the infant's parents and the pediatric cardiologist, treatment options are being discussed. What is the pediatric cardiologist likely to recommend as definitive treatment? A. Chronic oral beta blocking agents B. No treatment, this disease is self-limiting C. Closure of ventricular septal defect & pulmonary valvulotomy D. Closure of atrial septal defect and aortic valvulotomy E. Closure of atrial septal defect and pulmonary valvulotomy

C. Closure of ventricular septal defect & pulmonary valvulotomy

A 55 year old female patient presents to your clinic in Arizona complaining of a productive cough, shortness of breath, and fever for the last 12 days. Over the last 24 hours she has developed a rash. Upon inspection the rash is symmetrically distributed on her legs in spreading, concentric, erythematous, and raised patches. On your charts you describe the rash as target lesions and document a suspected diagnosis of which condition? A. Viral PNA with concurrent exanthema B. CAP and unrelated eczematous lesions C. Coccidiomycosis infection D. Histoplasmosis infection

C. Coccidiomycosis infection

A 19-year-old man presents with pain and deformity of his right dominant shoulder after a sudden jerking movement to that shoulder from a wrestling competitor approximately 1 hour ago. He was unable to continue wrestling and has pain with any movement of the right shoulder. On exam, you see a loss of normal shoulder contour anteriorly. There is no focal joint or bony tenderness. What is the most likely diagnosis? A. Rotator cuff tear B. Acromioclavicular separation C. Glenohumeral dislocation D. Fractured clavicle E. Sternoclavicular subluxation

C. Glenohumeral dislocation

A 35-year-old woman comes to the office for evaluation of intermittent hearing loss over the past 12 months. Physical examination shows lateralization to the right ear with Weber test, and bone conduction greater than air conduction in the right ear with Rinné test. Which of the following is the most likely explanation for these findings? A. Conductive loss in both ears B. Conductive loss in left ear C. Conductive loss in right ear D. Sensorineural loss in left ear

C. Conductive loss in right ear

A 62-year-old man is brought to the office by his wife because he has had fatigue, and shortness of breath for the past week. He has also had a nonproductive cough which is made worse by lying down. Temperature is 37.4°C (99.3°F), pulse rate is 94/min, respirations are 24/min, and blood pressure is 152/94 mmHg. Physical examination shows scattered bibasilar crackles. Chest x-ray study shows mild cephalization of the pulmonary vasculature, and peribronchial cuffing. Which of the following is the most likely diagnosis? A. Bacterial pneumonia B. Chronic obstructive pulmonary disease C. Congestive heart failure D. Idiopathic pulmonary fibrosis

C. Congestive heart failure

You notice during a pre-kindergarten exam that your patient doesn't appear to have binocular fixation. Which of the following is the most appropriate physical exam test to perform next? A. Red reflex B. Corneal reflex C. Cover-uncover test D. Visual field testing

C. Cover-uncover test

A chronic AIDS patient presents to the emergency room with meningoencephalitis. You are familiar with the causative organisms in this patient population, and therefore order a cerebrospinal fluid analysis in India Ink. What organism do you expect that test to reveal? A. Cytomegalovirus B. Candida albicans C. Cryptococcus neoformans D. Toxoplasmosis gondii

C. Cryptococcus neoformans Cytomegalovirus causes central and peripheral enceophalitis in AIDS patients

A 16-year-old boy presents for a physical. His mother is concerned that he is gaining weight but not growing taller. She has noticed his face is more round and he now has stretch marks on his abdomen. The physician notices a large amount of truncal fat and relatively thin limbs. The patient has acne on his cheeks bilaterally. What is the most likely diagnosis? A. Turner syndrome B. Marfan syndrome C. Cushing syndrome D. Klinefelter's syndrome E. Male hypogonadism

C. Cushing syndrome

Which of the following clinical conditions is best characterized as an acute, fluctuating disturbance in attention and cognition due to an underlying general medical condition? A. Autism spectrum disorder B. Bipolar C. Delirium D. Delusional disorder E. Dementia

C. Delirium

A 54-year-old man presents with chest pain. He has a past medical history of hypertension and diabetes mellitus. The pain is located in the middle of his chest and radiates to his jaw. The pain began about 20 minutes ago, and he rates the pain as a 10 on a 0-10 point scale, with 10 being the worst pain he has ever felt. He has had 3 similar episodes, but they have always resolved after 5 minutes or so of rest. He has smoked 1 pack of cigarettes a day for the past 36 years. He drinks 2 or 3 beers on Friday nights. Review of systems (ROS) is positive for diaphoresis, acute dyspnea, and impending doom. ROS negative for fever, chills, and malaise. Physical exam shows an obese, middle-aged man in moderate distress. BP is 126/80 mm Hg, pulse is 100, and respirations are 26. Heart and lung exams are normal, except for tachycardia and tachypnea. He has no pedal edema. What aspect of the patient's history is the most influential risk factor for an acute myocardial infarction? A. Alcohol use B. Male sex C. Diabetes mellitus D Hypertension E. Obesity

C. Diabetes mellitus

A 4 year old male is brought into the clinic by his mother because he has had ear pain and a fever for the last two days. You diagnose an acute otitis media. Mom is frustrated because this is the fourth time in the past year that he has received that diagnosis. In addition to antibiotic treatment, what is the next best step in the management of this patient A. Discharge with follow up with pediatrician as scheduled next year B. Admit for surgical consultation C. Discharge child with ENT referral for possible myringotomy tube placement D. Reassure mom that it is very common for children of his age group to have multiple episodes and no treatment is necessary

C. Discharge child with ENT referral for possible myringotomy tube placement

A 60-year-old woman presents to be evaluated for bizarre behavior. Her daughter arrives with her and speaks with you alone; she describes her mother's behavior as consisting of mood swings, lavish trips, spending foolishly, staying up at night, and being hyper. According to her daughter, her mother has been diagnosed with bipolar disorder in the past. She feels her mother needs a mood stabilizer, but you would rather not try lithium because of excessive weight gain. What drug might you consider starting on this patient? * A. Trifluoperazine (Stelline) B. Trazodone (Desyrel) C. Divalproex (Depakote) D. Haloperidol (Haldol) E. Risperidone (Risperdal)

C. Divalproex (Depakote) Depakote is the preferred mood stabilizer

A 3 year old boy is brought to the clinic by his mother. Up to this point he has been developmentally normal, but is now having trouble rising from the floor. Physical exam shows hip girdle weakness, enlargement of the distal muscles of the leg, and atrophy of the proximal thigh muscles. Lab studies reveal an elevated serum creatinine kinase. Which of the following is this boy's most likely diagnosis? A. Polymyositis B. Cerebral palsy C. Duchenne's muscular dystrophy D. Multiple sclerosis

C. Duchenne's muscular dystrophy

A 40 year old male presents to the emergency department with complaints of nausea, vomiting and severe upper abdominal pain since last night. While taking a history on the patient you find out that this is not the first time that this has happened. Three years ago, he was prescribed omeprazole. He cannot recall, however, the last time he took the medicine, nor why he was prescribed it. He states that when he ate dinner last night, his pain was worse a few hours after his meal. Physical exam reveals localized, moderate mid-epigastric tenderness. Which of the following is the most likely diagnosis? A. GERD B. Gastric ulcer C. Duodenal ulcer D. Gastric perforation E. Esophagitis

C. Duodenal ulcer Patient presentation is consistent with PUD of the duodenum; painful a few hours after meal Epigastric tenderness and lack of heartburn symptoms in history veer away from GERD

A 52-year-old man with no past medical history is referred to the office by an urgent care clinic for further evaluation of heart failure. He states that for the past month, he has had fatigue, shortness of breath, ankle swelling that gets worse during the day, and he sleeps on two pillows at night. He denies syncope or palpitations. Physical examination shows jugular venous distension, S3 gallop, hepatomegaly, and 2+ pitting edema of both legs and ankles. Chest x-ray study taken at the urgent care clinic showed cardiomegaly. Electrocardiogram showed low limb lead voltage, and precordial lead criteria for left ventricular hypertrophy. Which of the following is the most appropriate next imaging study to obtain? A. Aortogram B. Cardiac MRI scan C. Echocardiography D. Ventilation—perfusion scan

C. Echocardiography

A 44 year old female, with a history of amyloidosis, presents today complaining of decreased exercise tolerance, some orthopnea, and lower extremity swelling. Echocardiography shows diastolic dysfunction. Which of the following is the diagnostic test of choice for confirming this patient's suspected diagnosis? A. Echocardiography is definitive, no further testing is needed B. Coronary angiography C. Endomyocardial biopsy D. CXR

C. Endomyocardial biopsy

A 22-year-old woman at 24 weeks gestation presents with a 3-day history of a nonproductive cough and fever. She states she has been battling an upper respiratory infection that does not seem to go away. Initially, she thought that she had a cold, but the symptoms persisted. She was told by her obstetrician that she has the flu and to drink plenty of fluids and get some rest. Vital signs reveal temperature 101.2°F, blood pressure 120/80 mm Hg, heart rate 110/bpm, and respiratory rate 22 breaths/min. On physical examination, she appears ill; lungs exhibit wheezing. What would be an appropriate treatment for this patient? A. Doxycycline B. Ciprofloxacin C. Erythromycin D. Amoxicillin E. Penicillin

C. Erythromycin

A 45-year-old man presents with a 24-hour history of severe anal pain and swelling. The pain started after straining at defecation and has worsened over the course of the day. There is no history of fever. Examination of the anal area reveals a swollen ecchymotic mass in the perianal skin, very close to the anal verge. What is the treatment of choice for this condition? A. Immediate surgical drainage in the operating room B. Antibiotics C. Excision of thrombosed external hemorrhoid D. Immediate colonoscopy E. Internal sphincterotomy

C. Excision of thrombosed external hemorrhoid

A 43-year-old woman is seen in the office for post-surgical follow-up after thyroidectomy two weeks ago. She has no pain at the surgical site, but does state that she has been feeling fatigued and anxious for the past week. She also has tingling in her lips, fingers and toes, and intermittent muscle cramping of her legs and feet. Temperature is 37°C (98.6°F), pulse rate is 80/min, blood pressure is 120/82 mmHg. Examination of the neck shows a well approximated incision site with no drainage or erythema. The trachea is midline. Which of the following additional physical examination findings is most likely to also be present? A. Carpal spasm with arm elevation B. Costoverebral angle tenderness C. Facial spasm D. Hand tremor

C. Facial spasm

A 20-month-old boy is brought into the emergency department by his parents. They state he has not been feeling well for 2 days and this morning noted he was "shaking all over" and was not responding to commands. This went on for less than 10 minutes and has never happened before. His current rectal temperature is 100.7°F. The seizures are characteristic of... A. Absence seizures B. Lennox-Gastaut syndromes C. Febrile seizures D. Infantile spasms

C. Febrile seizures

An 11-year-old boy presents with a chronic history of mild hemolytic anemia, intermittent jaundice, and right upper quadrant pain. He denies any shortness of breath, muscle aches, or joint pain. Supplementation with what should be given to the patient as part of the treatment plan? A. Thiamine B. Cyanocobalamin C. Folic acid D. Niacin E. Riboflavin

C. Folic acid

A 28-year-old man is seen in the office because of persistent diarrhea since returning from a camping trip five days ago. He characterizes the stool as malodorous, and greasy-appearing. He also has some abdominal cramping, bloating and foul flatus, and has lost 5 pounds since returning from his trip. Physical examination shows no abnormalities. Microscopic examination of a stool specimen shows several oval cysts. Which of the following is the most likely diagnosis? A. Crohn disease B. Diverticulitis C. Giardiasis D. Viral gastroenteritis

C. Giardiasis

A 58-year-old woman with a past medical history of hypertension, hyperlipidemia, breast cancer, hip fractures, and coronary artery disease is being evaluated for acute-onset severe left-sided pleuritic chest pain over the course of the last 2 hours. The pain is associated with feelings of anxiety, hemoptysis, shortness of breath, and nausea. She "feels warm" but denies chills, palpitations, wheezing, edema, vomiting, abdominal pain, abnormal bowel habits, or dietary intolerances. She admits to a 30 pack-year smoking history but denies drug or alcohol use. Upon physical exam, she is found to be febrile, hypotensive, tachycardic, tachypneic, diaphoretic, and in acute painful distress. There are perioral cyanosis and a pleural friction rub to the left lung fields; the remainder of the exam is normal. What is the most appropriate therapeutic intervention for this patient at this time? A. Indomethacin B. Doxycycline C. Heparin D. Prenisolone E. Albuterol

C. Heparin

A 50-year-old man presents with a 2-week history of not being able to see well. He is not on any medications. He has been smoking 2 packs of cigarettes a day for the past 30 years. On examination of his right eye, there is ptosis and miosis. A chest radiograph reveals a rounded opacity in the right lung field. What is the most likely diagnosis? A. Lambert-Eaton syndrome B. Superior vena cava syndrome C. Horner syndrome D. Cushing syndrome E. Syndrome of inappropriate antidiuretic hormone secretion

C. Horner syndrome

A 41-year-old man, with past history of gouty attacks, presents to your clinic shortly after beginning therapy for elevated blood pressure. He woke up this morning with excruciating pain in his right great toe, and hasn't been able to move around comfortably since due to the continued pain. He admits that this is just as bad as the gouty attacks that he suffered years ago. Which of the following blood pressure medications was he most likely to have started? A. Lisinopril B. Metoprolol C. Hydrochlorothiazide D. Lorsartan

C. Hydrochlorothiazide

A 55-year-old woman presents with bumps around her eyes. She states they have been worsening over the past 3-4 months. They are not painful, but she is worried they may be something serious, especially since they seem to be increasing in size. The patient is currently taking a regular dose aspirin, which was suggested by her gynecologist, but she is not on any other daily medications. Family history is pertinent for her father dying at age 82 due to a heart attack and her mother still living at the age of 79 with a known medical history of hypertension and high cholesterol. On physical examination, slightly raised yellowish well-circumscribed plaques along the nasal portion of both eyelids are noted. What is the most likely diagnosis? A. CHF B. DM C. Hypercholesterolemia D. Hypertension E. Lupus

C. Hypercholesterolemia

A 22-year-old woman presents with an 8-month history of amenorrhea. Further questions elicit additional pertinent positives of backaches, headaches, and acne. Physical examination reveals a female patient with a moon-shaped face, multiple purple striae, and significant central obesity (body mass index of 36). Considering the given history and physical exam discoveries above, what is the main cause of these findings? A. Hyperglycemia B. Hypothyroidism C. Hypercortisolism D. Hyperthyroidism

C. Hypercortisolism

Which of the following thrombophilias may result from B 6 , B 12 , or folate deficiency? A. Protein C B. Antithrombin III C. Hyperhomocysteinemia D. Antiphospholipid antibody syndrome (APS) E. Factor IX deficiency

C. Hyperhomocysteinemia

All of the following are causes of Torsades de Pointes EXCEPT: A. Hypomagnesemia B. Antipsychotic medications C. Hyperkalemia D. Prolonged QT interval E. Head injuries

C. Hyperkalemia

Which of the following is the most common cause of pulseless electrical activity? A. Hypertension B. Digitalis toxicity C. Hypovolemia D. Hypokalemia

C. Hypovolemia

A lateral wall myocardial infarction will show abnormalities in which of the following ECG leads? A. V1-V2 B. V1-V3 C. I, aVL, V5 and V6 D. II, III and aVF

C. I, aVL, V5 and V6

What is the drug treatment of choice for tetany associated with hypoparathyroidism? A. Oral calcium carbonate B. Vitamin D C. IV calcium gluconate D. Botulinum toxin

C. IV calcium gluconate

A 5-year-old boy has three honey-colored crusted lesions with surrounding erythema on his legs. The swabs taken from the lesions were sent to the microbiology laboratory. The results show yellow colonies grown on blood agar with hemolysis. The colonies are coagulase-positive and mannitol-positive. What is the most likely diagnosis? A. Molluscum contagiosa B. Varicella zoster C. Impetigo D. Herpes Zoster E. Erythema infectious

C. Impetigo

A 54-year-old man presents complaining of severe right knee pain that woke him from sleep last night. He denies history of trauma, recent illness, or fever. Physical exam reveals a tender, erythematous, and edematous joint. Range of motion is greatly decreased due to pain. Joint fluid analysis shows needle shaped crystals. Which of the following is the treatment of choice for this patient's condition? A. Allopurinol B. Colchicine C. Indomethacin D. Probenacid

C. Indomethacin

A 45-year-old man comes to the office for evaluation because he has noticed that his forehead and jaw seem more prominent than in the past, and his nose, lips and tongue also seem to have become larger over the past year. He also states that his rings no longer fit, and that he requires a larger shoe size. Physical examination of the head shows enlargement of the forehead, nose, lips, and mandible. The mouth shows widening of spaces between teeth, and an enlarged tongue. The hands show enlarged digits with widening of the distal ends of the fingers. In addition to obtaining a MRI study of the head, which of the following laboratory tests is the most approprite next step in diagnosis? A. Cortisol B. Glucagon C. Insulin-like growth factor 1 D. Testosterone E. Vanillylmandelic acid

C. Insulin-like growth factor 1

You are evaluating a 34-year-old African American man for a 5-week history of increasing right groin pain. He denies any injury or history of similar pain. The pain is worse with movement and has progressed to the point that the patient has severe pain with bearing weight. He denies fever, chills, urinary symptoms, or any other issue at this time. He has a past medical history of sickle cell disease and hypothyroidism. Physical exam reveals tenderness upon palpation of the groin with increased pain on both active and passive range of motion of the hip. Homan's sign is negative. Distal pulses and sensation are intact and normal. What diagnostics study should be ordered at this time? A. Ultrasound of the right lower leg B. CBC C. MRI of the right hip with and without contrast D. CXR E. Urinalysis

C. MRI of the right hip with and without contrast Pt is presenting with avascular necrosis secondary to his sickle cell disease

A 56 year old female presents to the urgent care complaining of two days of high fever, muscle aches, and a stiff neck. Today she admits that she has been a little confused, which is unlike her. Which of the following must be ruled out first from your differential diagnosis? A. Influenza A B. Influenza B C. Meningitis D. Pneumonia

C. Meningitis

An adult patient in the medical intensive care unit has an arterial blood gas that reveals a pH of 7.25, a HCO3 of 16mEq/L, and a PaCO2 of 40mmHg. Which of the following acid-base disorders is most likely in this patient? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C. Metabolic acidosis

A 54-year-old woman comes to the emergency department because of shortness of breath, and right-sided lower chest pain for the past five days. One year ago, she had a right mastectomy for breast cancer. Chest x-ray study shows opacification of the lower one-third of the right hemithorax. Thoracentesis is performed and shows a thick aspirate containing increased concentrations of protein, and lactate dehydrogenase. Which of the following is the most likely diagnosis? A. Chylothorax B. Congestive heart failure C. Metastatic breast cancer D. Nephrotic syndrome

C. Metastatic breast cancer

A 76-year-old woman presents because her children are concerned that she might have dementia. She states that she is doing reasonably well, except that she sometimes sleeps less deeply and wakes up more often than she did several years ago. According to her children, she is slower than before, and her memory has been getting worse over the last 3 years; she has difficulties recalling the specific date of an event (although she can describe the event itself). She also has a great deal of trouble with names, but she can easily recognize people. She always says, "It is on the tip of my tongue, but..." Aside from hypertension that is under control, she does not have any other health problems. She has been a widow for about 10 years. Her older brother was diagnosed with dementia. Physical examination today is within normal limits for the age, and neurological examination is non-focal. What should be your next diagnostic step? A. EEG B. Stanford-Binet Intelligence Test C. Mini-mental status examination D. MRI of brain E. TSH and T4

C. Mini-mental status examination

A 33-year-old G5P4 woman presents to her gynecologist. She has been using condoms and would like to discuss alternative birth control options. She has regular periods and is not currently trying to get pregnant. She is sexually active with one partner. Past medical history includes asthma, deep vein thrombosis during her first pregnancy, and a C-section for her fourth pregnancy. She has no known drug allergies. What is the best birth control option for this patient? A. Combination estrogen-progestin pill B. Ortho Eva (ethinyl estradiol/norelgestromin) patch C. Mirena (levonogestrel) IUD D. Tubal ligation

C. Mirena (levonogestrel) IUD

A 22-year-old woman presents for a physical examination. When questioning her for medical history, you discover that she has a history of rheumatic fever. Upon listening to her heart, you detect a diastolic murmur. The murmur is low-pitched and begins with a loud snapping sound. What valvular abnormality is most likely present in this patient? A. Mitral regurgitation B. Aortic regurgitation C. Mitral stenosis D. Aortic stenosis E. Tricuspid stenosis

C. Mitral stenosis

A 43-year-old woman comes to the office with a complaint of chronic muscle pain, and progressive muscle weakness for the past six months. Her weakness has made it more difficult for her to climb the stairs in her home. On physical examination you find no tenderness to palpation, but you do note marked proximal muscle weakness. Which of the following is the best test to confirm the diagnosis in this patient? A. Muscle creatinine phosphokinas B. Erythromycin sedimentation rate C. Muscle biopsy D. Radiographs of the affected joints

C. Muscle biopsy

A 60-year-old woman with a history of type 2 diabetes mellitus is brought to the emergency department by ambulance because of altered mental status that has worsened over the past two days. Temperature is 38.3°C (100.9°F), pulse rate is 102/min, respirations are 18/min, and blood pressure is 122/78 mmHg. Physical examination shows a drowsy, but arousable woman. Initial laboratory results show plasma glucose of 1,000 mg/dL, and pH of 7.32. Hyperosmolar hyperglycemic state is suspected. In addition to treating any underlying illnesses that may have precipitated this metabolic decompensation, intravenous administration of which of the following is the most appropriate initial intervention for this patient's condition? A. 5% dextrose in water B. Insulin C. Normal saline D. Sodium bicarbonate

C. Normal saline Normal saline —> insulin —> D50 once 150

A 34-year-old woman presents with a 2-week history of severe fatigue, increased swelling in both feet, and slight pain in the right abdomen. She gives a history of shortness of breath on severe exertion.Exam reveals an afebrile patient with pedal edema and hepatomegaly. There are prominent A waves on the jugular venous pulsations (JVP). Auscultation reveals a tricuspid opening snap. A diastolic murmur is heard over the left sternal border, which increases on inspiration. A widely split S1 is also heard.Diagnostic tests reveal a normal CBC. Right atrial enlargement is seen on the chest X-ray, and the echocardiogram shows thickened tricuspid leaflets with limited mobility with increased velocity rough diastolic flow and prolonged pressure half-time. What is the cutes of hepatomegaly in this patient? A. Metastasis of tumor from the right atrial sarcoma B. Primary hepatic tumor C. Obstructed venous flow to the right ventricle D. Backflow pressure due to inferior vena cava obstruction

C. Obstructed venous flow to the right ventricle

A 63-year-old woman presents with a 6-month history of worsening difficulty in swallowing. Shortly after swallowing, she feels like something is getting stuck in her upper chest, and the sensation lasts long enough to begin causing significant chest discomfort just behind her breastbone. The difficulty swallowing is often extremely variable and intermittent; it has not been progressive. It gets to the point that she feels like she is going to regurgitate her food, and she is also experiencing substantial episodes of acid reflux. The difficulty swallowing seems to be worsened by when the patient is extremely stressed and when she eats hot or cold food. She denies any weight loss, night sweats, or other significant issues. Physical examination of the patient is otherwise noncontributory. An extensive gastrointestinal evaluation, which included a comprehensive endoscopic evaluation, is negative. What is first-line for this patient's symptoms? A. Injected botulinum toxin B. IV Nitroglycerine C. Oral Diltiazem D. Oral Prednisone E. Oral Metoclopramide

C. Oral Diltiazem Pt is suffering from esophageal spasm most likely. The TOC for this is an oral CCB. Oral nitrates can also be helpful, but not IV

A husband and wife recently returned from a vacation to Mexico, and now present to the emergency room because he has developed severe headaches over the last two days, has been extremely nauseous, and felt shaky and sweaty. Physical examination reveals a 46-year-old febrile man in obvious distress, with mild scleral icterus, and diffuse abdominal tenderness. Initial laboratory studies reveal a normocytic, normochromic anemia, as well as a slight metabolic alkalosis. You suspect that this patient may have malaria. Which of the following is the diagnostic test of choice for this condition? A. Head CT B. Microhematocrit centrifugation C. Peripheral blood smear with Giemsa staining D. Lumbar puncture with cerebrospinal fluid analysis

C. Peripheral blood smear with Giemsa staining

The second heart sound (S2) is caused by vibrations that are produced by closure of the aortic and pulmonic valves. During inspiration, the aortic valve closes just before the pulmonic valve. Which of the following best characterizes the S2 produced by this asynchronous valve closure? A. Gallop B. Murmur C. Physiologic splitting D. Valvular incompetence

C. Physiologic splitting

A 25-year-old woman is admitted to the hospital due to a 3-week history of episodic headaches; they are accompanied by palpitations and sweating. The episodes occur several times daily; each episode lasts about 15 minutes. On examination, the patient is diaphoretic and has elevated blood pressure, which prompted her admission. Her blood pressure is currently 220/100 mm Hg. Past medical history is significant for exercise-induced asthma, for which she takes albuterol. What test would be useful in the diagnosis of this patient? A. Cosyntropin stimulation test B. Dexamethasone suppression test C. Plasma fractionated metanephrine D. Electrocardiogram

C. Plasma fractionated metanephrine

A 32 year old female presents complaining of chronically itchy, burning, and dry eyes. She admits that they feel very tired in the afternoon and evening. She has tried artificial tear drops without significant relief. What physical exam findings would support your suspected diagnosis? A. Subconjunctival hemorrhage B. Unequal pupil size C. Poor tear film with punctuate epithelial erosions D. Lisch nodules found on the iris

C. Poor tear film with punctuate epithelial erosions

A 42-year-old man presents to your clinic complaining of shoulder pain and weakness that began after a heavy workout at the gym two days ago. At that time he felt a tearing sensation in the left shoulder and has had severe pain ever since, especially if he brings his arm up over his head. Along with tenderness to palpation in the affected shoulder, and restricted range of motion, what additional physical examination finding would you expect in this patient to help confirm your suspected diagnosis? A. A step-of at the AC joint B. Radiculopathy in the left arm C. Positive drop arm D. Localized edema and ecchymosis overlying the proximal humerus

C. Positive drop arm

A 62-year-old woman comes to the office for evaluation of a painful rash on her face for the past three days. Her symptoms began with fever, malaise and fatigue, followed by left-sided scalp tenderness, and an ache around her left eye. She denies visual changes. Yesterday, she developed a blistering rash on her nose. She confirms that she had chicken pox as a child. Physical examination of the face shows a cluster of vesicles on the left side of the nose, and hyperesthesia of the left side of her forehead and scalp. Which of the following is the most appropriate next step in management? A. Prescribe a topical antiviral medication B. Prescribe an analgesic, supportive care & watchful waiting C. Prescribe an oral antiviral medication, analgesic and refer the patient to an opthamologist D. Prescribe an oral antiviral medication and analgesic

C. Prescribe an oral antiviral medication, analgesic and refer the patient to an opthamologist

A 45-year-old woman presents with diarrhea and vomiting that started last evening. She says she warmed up leftover rice for supper last night and symptoms began shortly thereafter. She has no fever, and her blood pressure and pulse are within normal limits. What would be the best next step in management of this patient? A. Admit for observation B. Start oral fluids and metronidazole C. Reassure and send home with oral rehydration D. Send stool specimen to the lab and follow up tomorrow E. Admit for parenteral fluids and antibiotics

C. Reassure and send home with oral rehydration

The treatment for Factor IX deficiency is which of the following? A. Vitamin K B. Fresh frozen plasma C. Recombinant factor concentrate D. Desmopressin acetate

C. Recombinant factor concentrate

Which of the following best describes the term "tenesmus"? A. Severe constipation in an obstructed colon B. Bloody diarrhea with colonic spasms C. Rectal urgency and straining in an empty colon D. Inability to pass impacted stool in rectum

C. Rectal urgency and straining in an empty colon

A 42-year-old man with a known past medical history of schizophrenia has begun to demonstrate new and unusual behavior over the past 2 weeks. The patient has been compliant with taking risperidone 2 mg for the past year. The patient's son reports that his father has been acting "silly" and exhibiting inappropriate behavior, such as removing his clothes, repeating odd noises and gestures, and speaking incoherently with random loud and violent outbursts. This morning, the patient was observed to have used a knife to cut himself; his son stopped him. What is the next step in the management of this patient at this time A. Increase the risperidone to 4 my per day B. Draw a CBC, chemistry panel and UA C. Refer the patient to the hospital for inpatient monitoring D. Discontinue risperidone and begin quetiapine E. Prescribe both diazepam and paroxetine

C. Refer the patient to the hospital for inpatient monitoring

A 55 year old obese male comes to your clinic for his annual physical exam with no new complaints. On routine testing, his fasting blood glucose is 135 mg/dl. You suspect that he may have diabetes mellitus. What is the next best step in the evaluation of this patient? A. Random blood sugar measurement B. 4-hour oral glucose tolerance test C. Repeat fasting blood glucose D. No further testing is required with the given test results

C. Repeat fasting blood glucose Fasting blood glucose of >126 on two separate occasions are recommended in the absence of symptoms in order to confirm the diagnosis

Which acid-base abnormality is most commonly associated with chronic obstructive pulmonary disease? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis E. Mixed acidosis

C. Respiratory acidosis

Which of the following diseases of childhood is characterized by the sudden onset of high fever, followed several days later by a rash that begins on the trunk, and spreads to the limbs? A. Erythema infectiosum B. Pityriasis rosea C. Roseola D. Rubella E. Toxoplasmosis

C. Roseola

A 24-year-old man comes to the office because of scrotal swelling that he has noticed over the past week. He says that it has not been painful, but he is worried that it might be cancer. He states that his friend was recently diagnosed with testicular cancer, and had found a lump in his scrotum. Which of the following physical examination findings suggests a malignant etiology in this patient? A. Bag of worms B. Positive Phren sign C. Rubbery fixed nodule on testis D. Transilluminating soft mass

C. Rubbery fixed nodule on testis

A 32-year-old woman is brought to the emergency department by paramedics after being found unconscious on her sofa by her husband at home. CT scan of the head shows extensive subarachnoid hemorrhages at the base of her brain. Which of the following pathophysiologic mechanisms is the most likely cause of this patient's condition? A. Acute occlusion of the middle cerebral artery B. Acute occlusion of the middle meningeal artery C. Rupture of a berry aneurysm D. Rupture of a meningeal bridging vein

C. Rupture of a berry aneurysm Rupture of berry aneurysm - subarachnoid hematoma MMA - epidural hematoma Bridging veins - subdural hematoma

A 7-year-old boy is brought into your urgent care clinic because of a red and swollen ankle for 4 days. Upon eliciting the history, you discover that about one week prior he sustained a minor injury to the right ankle, breaking the skin. Over the past couple of days, his parents have noticed him walking with a limp that has gradually worsened until this morning when he refused to bear weight on that leg. Physical examination reveals a temperature of 103.2 F (39.6 C), and an erythematous and edematous right ankle. Range of motion is decreased when compared to the left, and it is exquisitely tender to palpation and with motion. Ultrasound reveals effusion around the joint. Other laboratory results are pending. Which of the following is the most likely diagnosis? A. Superficial cellulitis B. Osteomyelitis C. Septic arthritis D. Gout

C. Septic arthritis

A 33-year-old woman at 29 weeks of gestation comes to your office complaining of generalized malaise, chills, and fatigue for the past week. Her past medical history is unremarkable, and her pregnancy is uneventful so far. She works at a cat adoption center. Temperature is 37.6 C (99.7 F). Physical examination shows generalized lymphadenopathy without splenomegaly or hepatomegaly. Which of the following is the most appropriate next step in management? A. Amniocentesis B. CT scan of the fetus in Uterine C. Serologic testing for Toxoplasma gondii D. Supportive care E. Termination of pregnancy

C. Serologic testing for Toxoplasma gondii

A 48-year-old obese woman who underwent a gastrectomy two weeks ago presents to the emergency department complaining of periumbilical abdominal pain for the last 48 hours. She states that she has not had a bowel movement or passed gas in five days, which is very unusual for her. She also states that she had one episode of vomiting on her way to the hospital. She denies any dysuria, chest pain or shortness of breath. Physical examination reveals abdominal distention with high pitched bowel sounds. Which of the following is the most likely diagnosis? A. Paralytic ileus B. Volvulus C. Small bowel obstruction D. Toxic megacolon

C. Small bowel obstruction

Which of the following organisms is the causative agent of rheumatic fever? A. Streptococcus agalactiae B. Streptococcus mutants C. Streptococcus pyogenes D. Streptococcus viridans

C. Streptococcus pyogenes

A 25-year-old man has a long history of criminal behavior, and he has been in and out of prison for assaultive behavior, theft, armed robbery, and sexual assault. He shows no remorse for his behavior and states that he is the real victim. He also shows little emotion regarding his family history, and he prefers to brag about his sexual exploits. The patient denies a history of mood disorders or schizophrenia. What disorder commonly co-occurs with this patient's symptoms? A. Agoraphobia B. Binge eating disorder C. Substance abuse disorder D. Schizophrenia

C. Substance abuse disorder

A 62-year-old man presents for evaluation of facial swelling that feels worse with bending forward. He states he has also experienced headaches, shortness of breath, and visual problems over the past few weeks. He admits that he has a 70 pack-year smoking history. Upon examination, you note swelling of the face and distention of neck and chest veins. You appreciate diminished breath sounds and tactile fremitus in the right upper lobe. what is the most likely diagnosis? A. Interstitial lung disease B. Spontaneous primary pneumothorax C. Superior vena cava obstruction D. Pneumonia E. Chronic bronchitis

C. Superior vena cava obstruction

A 76-year-old man presents with substernal chest pain; it is associated with progressive exertional dyspnea, easy fatigability, and dizziness. These symptoms are exacerbated by walking short distances, and they are relieved with rest. He denies fever, chills, cough, wheezing, pleurisy, calf pain, abdominal problems, peripheral edema, cigarette, drug use, alcohol use, sick contacts, or travel. His physical exam reveals a normal blood pressure and a rough, harsh, low-pitched crescendo-decrescendo systolic murmur beginning after the first heart sound; it is best heard at the second intercostal space in the right upper sternal border. Its intensity is increased toward midsystole; the murmur radiates to both carotid arteries and is accentuated upon squatting, and it is reduced during Valsalva strain. His lungs are without adventitious sounds. What is correct regarding the management of this patient? A. β-adrenergic blocker therapy is contraindicated in this patient. B. An increase in aerobic activity to improve conditioning is recommended. C. Surgical intervention provides the only definitive treatment D. Bacterial endocarditis prophylaxis is required in patients with this diagnosis

C. Surgical intervention provides the only definitive treatment

Which of the following is a late finding in carpal tunnel syndrome? A. Decreased grip strength B. Pain C. Thenar atrophy D. Paresthesias in the median nerve distribution

C. Thenar atrophy

A 30-year-old man comes to the office because of a scaly rash on his trunk and upper arms for the past two months. He states that the rash does not tan like the surrounding skin with exposure to the sun. Physical examination shows multiple hypopigmented macules on the trunk and arms, with some areas of confluence. Which of the following is the most likely diagnosis? A Guttate psoriasis B. Plaque psoriasis C. Tinea versicolor D. Vitliligo

C. Tinea versicolor Hypopigmented macules with patches, whereas vitiligo does not have patches

A 35-year-old man presents for medical care, but he is too embarrassed to tell the nurse his chief symptom. Eventually, he admits to severe, intense itching around his anus; it has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He ranks this pain as a 10/10 on a pain scale. This intense pain makes him try to avoid having bowel movements regularly. He admits to one episode of a small amount of bright red blood on the toilet paper and on the stool itself. Reviewing documentation on this patient reveals that this is the fourth similar episode in the last 14 months. The patient denies fever and diarrhea; according to him, he has never been diagnosed with inflammatory bowel disease. Considering the most likely diagnosis, what pharmaceutical intervention should be initiated? A. Topical lidocaine 5% B. Topical prilocaine 2.5% C. Topical nitroglycerin 0.2-0.4% D. Topical bacitracin ointment E. Topical hydrocortisone cream 1%

C. Topical nitroglycerin 0.2-0.4% Anal fissures are treated with topical nitro, topical digital em, or infection of botulinum. Sitz baths and no straining are also recommended

While in the lab you are looking under the microscope at a saline wet mount prep of a vagial specimen. You immediately identify motile organisms and therefore your suspected diagnosis is which of the following A. Candidiasis B. Bacterial vaginosis C. Trichomoniasis D. Chlamydia

C. Trichomoniasis

A 20-year-old athlete with no known allergies comes to clinic with a tender bump on his right thigh that has been present for 4 days. He has had fevers and chills for the past 24 hours, and he states that a few of the athletes at his gym have had similar lesions lately. Physical examination reveals a temperature is 101.5 F (38.6 C), pulse is 78 beats per minute, and blood pressure is 118/78. There is a 4 centimeter, round area of erythema that is slightly raised and appears to be fluctuant. The area is warm and tender to the touch. Also noted are red streaks radiating proximally from the lesion. History and physical examination are consistent with methicillin-resistant Staphylococcus Aureus skin infection. Which of the following would be an appropiate treatment in the management of this patient? A. Amoxicillin-clavulanate B. Cefepime C. Trimethoprim-sulfamethoxazole D. Vancomycin

C. Trimethoprim-sulfamethoxazole

A 20-year-old woman presents with intermittent nose bleeds for the past 2 weeks. She also reports that her menstrual periods have increased in number in the past 2 months. She recently underwent surgery for small bowel resection and eats only one meal a day. Laboratory investigations reveal prolonged prothrombin time, prolonged activated partial thromboplastin time, and a normal platelet count. What is the most likely diagnosis? A. Thiamine deficiency B. Riboflavin deficiency C. Vitamin K deficiency D. Vitamin D deficiency E. Iron deficiency

C. Vitamin K deficiency

A 34-year-old construction worker comes to your family medicine clinic with a lump on his right wrist that has increased in size over the last week. He denies pain, redness, or itching. On physical examination you note a firm, round, and smooth growth on the dorsal right wrist which transilluminates with a pen light. Which of the following is the most likely diagnosis? A. Lipoma B. Giant cell tumor C. Radial artery aneurysm D. Ganglion cyst E. Synovial sarcoma

D. Ganglion cyst

A 70-year-old woman with long-standing type 2 diabetes mellitus presents due to pain in the left ear along with purulent drainage. On physical examination, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal. What organism is most likely to grow from the purulent drainage? A. Candida albicans B. Haemophilus influenza C. Moraxella catarrhalis D. Pseudomonas aeruginosa E. Streptococcus pneumoniae

D. Pseudomonas aeruginosa

What is likely the latest finding that presents in compartment syndrome? A. Pain B. Paresthesias C. Pallor D. Pulselessness

D. Pulselessness

Physical examination of an 88-year-old man shows the following findings: unilateral muscle weakness, some spasticity, hyperreflexia, and impaired fine motor skills. When you examine his gait, you note that his forearm is flexed and pronated while his leg remains extended. Based upon this information alone, which of the following is the most likely etiology? A. A cerebellar lesion B. A lesion in the basal ganglia C. A lesion in the dorsal columns D. A upper motor neuron lesoin

D. A upper motor neuron lesoin Upper motor neuron - weakness, hyperreflexia, spasticity, increased tone, impairment of fine motor skills Cerebellar lesion - scanning speech, nystagmus, abnormal finger-to-nose test, rapid alternating movement test, wide-based gait Basal ganglia- involuntary movements and tremors, increased tone, slow or awkward find finger movements or toe tapping without weakness Dorsal columns- position sense (proprioception), vibration sensation and light tough, two point discrimination

A 70-year-old woman presents with shortness of breath at rest over the past 3 days. She has found it difficult to walk short distances due to shortness of breath. Additionally, she is experiencing confusion, orthopnea, nocturnal dyspnea, and lightheadedness. She denies cough, fever, chills, diaphoresis, anxiety, chest pain, pleurisy, nausea, abdominal pain, vomiting, diarrhea, rashes, and syncope.On physical examination, the patient is short of breath, requiring numerous pauses during conversation. She is afebrile, but she is tachycardic, diaphoretic, and her extremities are cool. There is a diminished first heart sound, S3 gallop, laterally displaced PMI, bibasilar rales, and dullness to percussion and expiratory wheezing noted. An elevated JVD and 2+ pitting edema of the lower extremities is evident. What statement regarding this patient's condition is correct? A. The MC etiology of this condition is infiltrative diseases B. Increased caloric and sodium intake improves patient outcomes C. Confusion is the MC presenting complaint in older patients D. Activation of the renin-angiotensin-aldosterone system occurs E. The electrocardiograph is the most useful diagnostic test

D. Activation of the renin-angiotensin-aldosterone system occurs

A 32-year-old man presents to your office for evaluation. For the last eight months he describes being depressed on most days, and feeling especially irritable. On further examination you find the patient is unable to focus the conversation, and sometimes uses disorganized speech patterns, including echolalia. He admits that at times he hears voices, but cannot make out what they are saying. The patient is unkempt, and you cannot ascertain exactly where he sleeps at night. No evidence of a medical condition or substance abuse can be found upon laboratory testing. What is the next best step in the management of this patient? A. Discharge home and initiate antidepressant therapy B. Discharge home and follow-up for individual psychotherapy C. Discharge home on a course of antipsychotic medications D. Admit for observation and start antipsychotic therapy E. Admit to hospital and order restraints

D. Admit for observation and start antipsychotic therapy Patient had schizophrenia and is clearly not caring for his own needs. He requires hospitalization and medications to stabilize him prior to discharge

A 21 year old female presents to the clinic complaining of an ongoing dry cough for the last few months. She also complains of trouble breathing, and progressive shortness of breath. On physical exam you note that she does not have a fever, but she is using some accessory muscles of respiration and is purse-lipped on expiration. Labs and chest x-ray are ordered. Chest x-ray results show mild flattening of the diaphragms, and labs are normal other than mildly elevated liver enzymes. Which of the following is the most likely diagnosis in this patient? A. Emphysema B. Acute bronchitis C. Chronic bronchitis D. Alpha-1-antitrypsin deficiency

D. Alpha-1-antitrypsin deficiency This is an autosomal recessive d/o seen in younger patients. Results in emphysema like symptoms in the younger population.

A 66 year old man, with history of arrhythmias well controlled on antiarrhythmic drugs for the last two years, presents to your clinic today complaining of feeling palpitations more often recently. He admits to a 15 pound weight loss over the last two months, despite the feeling that he is ravenously hungry. He has also noticed a fine tremor that has started over the last two weeks. Which of the following antiarrhythmics may have led to this man's symptoms? A. Nifedipine B. Lidocaine C. Digoxin D. Amiodarone

D. Amiodarone Amiodarone - induce hypo or hyperthyroid like symptoms Digoxin - arrhythmias, GI d/o and visual changes

A 15-year-old boy with a diagnosis within autism spectrum disorder presents for a follow-up appointment. He is considered high-functioning; he attends a public school, goes to daily cognitive/behavioral sessions, and attends weekly counseling sessions with a provider who specializes in treating adolescent patients with a diagnosis within autism spectrum disorder. Despite these interventions and activities, his mother states that she has noted a significant increase in episodes of what she can only describe as temper tantrums; there is also severe irritability and quickly changing moods. The occurrences have become so severe that they have begun to disrupt the patient's daily routine. What would be the most appropriate pharmacologic agent to treat this patient? A. Paroxetine B. Atomoxetine C. Clonidine D. Aripiprazole E. Sertraline

D. Aripiprazole

A 21-year-old man presents with acute onset of pleuritic chest pain accompanied by 2-3 days of fever, chills, arthralgias, and myalgias. Upon further questioning, the patient notes that he had a severe sore throat and fever 4 weeks ago, but he was not evaluated for these symptoms. Physical examination reveals a febrile patient in mild distress. A systolic murmur is noted in the left fourth/fifth intercostal space that radiates to the left axilla. A friction rub is also appreciated on exam. Laboratory results reveal an elevated erythrocyte sedimentation rate (ESR) and antistreptolysin antibodies. What is the most appropriate initial management of this patient? A. Tetracycline B. Ciprofloxacin C. Amantadine D. Aspirin E. Prednisone

D. Aspirin Patient is presenting with symptoms consistent with acute rheumatic fever, treatment is supportive with aspirin

A 34 year old overweight female is brought to the Emergency Department in a stuporous state. Primary survey is intact. An IV is placed and cardiac monitor is unremarkable. While pending vital signs, which of the following diagnostic studies is the next best step in the management of this patient? A. TSH level B. EKG 12-lead C. Drug screening D. Blood glucose point of care test

D. Blood glucose point of care test

Which of the following is a common side effect of angiotensin-converting enzyme (ACE) inhibitors? A. Deep venous thrombosis B. Supraventricular tachycardia C. Lung Cancer D. Cough

D. Cough

A 10-year-old girl presents with recurrent bronchitis. Her past history is significant for polypectomy, nasal polyps, failure to thrive, and repeated attacks of bronchitis. Examination reveals clubbing and diffuse rhonchi on respiratory auscultation. Investigations reveal subnormal lung function, decreased exercise tolerance, and a sweat chloride concentration of 62 mEq/L (normal: <40 mEq/L). What is the most likely diagnosis? A. Pulmonary aspergilloma B. Bronchial asthma C. Pulmonary tuberculosis D. Cystic fibrosis E. Primary ciliary dyskinesia

D. Cystic fibrosis

A 40-year-old man presents with stage 4 liver cancer. The patient, despite the diagnosis, continues to make business transactions over the hospital telephone and tells everyone he is fine. He gets angry with the nurses for thinking he is sick and giving him medicine. What is this man experiencing? A. Anger B. Acceptance C. Grieving D. Denial E. Impotence

D. Denial

A 35-year-old woman notices a change in the appearance of a mole on her neck. Physical examination reveals that the lesion is an irregular nodular superficial mass with a variegated appearance. Biopsy demonstrates a primary malignant tumor. What characteristic of the malignant skin lesion is most predictive of the patient's long-term prognosis? A. Sharpness of border B. Diameter C. Color Variation D. Depth E. Asymmetry

D. Depth

A 60-year-old man presents with difficulty climbing stairs, dyspnea, and fatigue. He has gained 30 lb over the past year. On examination, he is found to have edema, pigmentation of the skin, palmar creases, and proximal muscle weakness. Chest X-ray shows an irregular mass in the right upper lobe. Lab values show an increase in evening cortisol levels and an increase in ACTH. What is the next step in diagnosis? A. MRI of the brain B. Adrenal venous sampling C. Repeat serum ACTH level D. Dexamethasone suppression test E. ACTH stimulation test

D. Dexamethasone suppression test

A 34-year-old woman presents with worsening headaches. She says that the headaches are present throughout the day and that she has been feeling nauseous. She has also noticed difficulty in seeing vehicles on the freeway lately. She has had several close calls due to this impairment. Her periods, which were previously regular, are now irregular, with heavy bleeding every 3-4 months. She has also noticed a milky discharge from both nipples. Her pregnancy test is negative. An MRI of the brain confirms the diagnosis. What would be the best initial treatment for the most likely diagnosis? A. Irradiation of the tumor B. Surgical excision C. Dopamine antagonists D. Dopamine agonists

D. Dopamine agonists Dopamine agonists (Bromocriptine) —> surgical excision

All of the following clotting factors are vitamin K dependent EXCEPT: A. Factor X B. Factor IX C. Factor VII D. Factor XI

D. Factor XI

A 66-year-old man presents with a 2-month history of fatigue. He reports that he has recently joined Alcoholics Anonymous. On examination, he is malnourished and pale, but his neurological examination is essentially normal. A peripheral blood smear reveals macrocytic red cells. What is the most likely diagnosis? A. Iodine deficiency B. Zinc deficiency C. Copper deficiency D. Folic acid deficiency E. Cobalamin deficiency

D. Folic acid deficiency

All of the following symptoms are typically seen in patients with Schizophrenia - Catatonic type EXCEPT: A. Motoric immobility B. Extreme negativism or mutism C. Echolalia D. Folie de deux

D. Folie de deux A rare syndrome in which two persons share common delusion beliefs

A 29-year-old African American man develops dysuria and increased frequency of micturition. In the emergency room, he is found to have a urinary tract infection and is treated with Nitrofurantoin, as well as recommended to follow up with his primary care physician in the office. Over the next few days, the patient experiences fatigue, fever, jaundice, abdominal and back pain, and dark urine. Blood tests show Hb of 4 g/dL, reticulocyte count of 6%, and MCV of 93. Coombs test is negative and bilirubin is normal. Peripheral smear reveals cell fragments, microspherocytes, and blister or bite cells. Heinz bodies are also present. Based on these findings, what clinical entity is most likely? A. Hereditary spherocytosis B. Sickle cell anemia C. Porphyria D. G6PD deficiency E. Autoimmune hemolytic anemia

D. G6PD deficiency

You are currently on an inpatient hospitalist team in a local pediatric hospital. First thing this morning, your team is called in to evaluate an infant born at 27 weeks gestation 50 minutes ago. Upon initial inspection of the newborn, you observe rapid labored grunting respirations, flaring nostrils, and retractions that are present above and below the breastbone. Auscultation reveals diminished air movement, and a chest radiograph reveals a ground glass appearance in the lung fields bilaterally. What pharmacological agent should be initiated to help alleviate these signs and symptoms? A. Intravenous antiviral B. Hepatitis B immunoglobulin C. Intravenous antibiotic D. Inhaled surfactant replacement E. Inhaled corticosteroids

D. Inhaled surfactant replacement

A 55-year-old man got drunk at a pub after a serious argument with his wife about his diet and habits (he is overweight and a heavy smoker). On the way back home, he felt sudden chest pain radiating to the left shoulder, shortness of breath, sweating, and anxiety. His ECG shows pathological Q wave and ST elevation. Laboratory results show that troponin levels are elevated. What caused the rise in troponin levels in this patient? A. Fatty changes in myocardial cells B. Increased synthesis of adhesion molecules C. Long-term destruction of alcohol D. Injury of myocardial cell membrane

D. Injury of myocardial cell membrane

A mother comes to the emergency department with her 8-month-old son. She states that he has been more fussy than normal and has been having intermittent screaming episodes while drawing his legs up to his chest. She states that she wasn't too concerned until he started vomiting four hours ago and then had a bowel movement that appeared to look like currant jelly. Which of the following is the most likely diagnosis? A. Anal fissure B. Gastroenteritis C. Hirschsprung enterocolitis D. Intussusception

D. Intussusception

Which of the following is the correct description of a positive Brudzinski's test? A. Involuntary neck flexion when the leg is extended with the hip at 90 angle B. Sharp inspiration upon deep palpation in the right upper quadrant C. Pain in lower back that travels down the posterior thigh when the hip is flexed and the leg is extended D. Involuntary leg and hip flexion with passive neck flexion

D. Involuntary leg and hip flexion with passive neck flexion

On physical examination you find a patient to have great toe extensor weakness and numbness of the dorsal aspect of the foot. Which nerve root is most likely to be injured in this patient? A. L2 B. L3 C. L4 D. L5 E. S1

D. L5

A 45-year-old African American man with no significant past medical history presents with a 1-hour history of left retro-orbital headache. The headache was of a sudden onset, and it began upon waking this morning. It is described as excruciating, stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any preceding infections, nausea, vomiting, fever, chills, focal weakness, numbness, tingling, hearing, gait, or speech changes. He recalls a similar episode several months ago; it lasted about 3 hours and dissipated without complications. His physical exam is remarkable for painful distress, nasal congestion with rhinorrhea, left ocular miosis, and left forehead flushing diaphoresis. What is an additional expected manifestation in this patient? A. Cervical muscle tenderness B. Temporal artery tenderness C. Visual scintillations and scotomas D. Lacrimation and conjunctival injection E. Papilledema

D. Lacrimation and conjunctival injection

A 47-year-old man with advanced cirrhosis of the liver is admitted to the hospital for evaluation of altered mental status including lethargy, disorientation, and slurred speech. Vital signs are within normal limits. Physical examination shows tenderness to palpation of the abdomen, and asterixis. Laboratory studies show evidence of chronic but stable liver disease, and elevated serum ammonia level. Administration of which of the following agents is most likely to have the greatest effect on improving this patient's mental status? A. N-Acetylcysteine B. Naloxone C. Bisacodyl D. Lactulose

D. Lactulose

A 74-year-old woman presents for management of an ischemic stroke. She reports difficulty seeing objects on her right side. You perform confrontational visual field testing as part of your neurological examination and you discover she has a right inferior homonymous quadrantanopsia. The lesion localizes to what part of the body? A. Left optic tract B. Optic chiasm C. Left optic nerve D. Left parietal lobe E. Right optic tract

D. Left parietal lobe https://upload.medbullets.com/topic/120488/images/visual%20field%20defects%20by%20moises%20dominguez.jpg

A 56-year-old man with history of chewing tobacco use comes to your family medicine clinic because he noticed a white spot on the inside of his lip about a week ago. He denies pain at the site, oral discomfort, or hot or cold sensitivity. On physical examination, the lesion is on the inside of the right lip and extends slightly onto the buccal mucosa. The lesion remains intact upon inspection and scraping with a tongue blade. No erosions are present. Which of the following is the most likely diagnosis? A. Diphtheria B. Mononucleosis C. Oral lichen planus D. Leukoplakia

D. Leukoplakia

A 70-year-old woman comes to her primary care provider for a routine checkup. On physical examination, a holosystolic murmur heard best at the apex and radiates to the left axilla is auscultated. Which heart murmur is most often associated with this description? A. AR B. TS C. AS D. MR

D. MR

A 52-year-old man comes to the emergency department because of decreased vision in the temporal fields of both eyes for the past three hours. He also states that he has had a headache for the past month that has steadily worsened. Over the past six months, he has also noticed a signigicant decline in his libido, and worsening erectile dysfunction. Physical examination shows decreased vision by confrontation in both temporal fields, and decreased size of both testes. Serum testosterone measurement obtained one week earlier at another clinic showed his level to be below the normal limit. Which of the following studies is the most appropriate next step in diagnosis? A. Bone scan B. Chest x-ray study C. CT scan of the pelvis D. MRI of the head

D. MRI of the head

A 54-year-old man, found to have elevated serum cholesterol at a health fair screening booth, comes to the office for further evaluation. Pulse rate is 84/min, respirations are 14/min, blood pressure is 152/94 mmHg, and BMI is 31. Physical examination shows a waist circumference of 44 inches. Results of laboratory analysis of fasting blood sample show HDL cholesterol of 35 mg/dL, triglycerides of 180 mg/dL, and blood glusose of 110 mg/dL. Which of the following best characterizes this patient's condition? A. Diabetes mellitus B. Hypertensive urgency C. Insulinoma D. Metabolic syndrome

D. Metabolic syndrome

A 7-year-old boy presents with his parents for evaluation of behavior problems in school; the problems have been ongoing for over 6 months. The boy's teacher recommended he be evaluated. The teacher reports that he tests at grade level, but he seems to make careless mistakes on schoolwork and has trouble maintaining attention to instruction; he does not finish his homework, and he often loses his homework, pencils, and books. The boy is seen often fidgeting at his desk; he blurts out answers and has difficulty waiting his turn. The parents agree that they have seen similar traits at home for several years, such as forgetting to do daily activities and being easily distracted. They view him as a bright happy boy who is very active. He has had normal vision and hearing screenings. The father reports that he was very similar as a child and still struggles with focus and concentration as an adult, but he never received any help. The parents deny any major changes in the family situation. They would like medical help to improve their son's performance in school. The boy has been seen regularly for his well-child exams and has always met milestones and had normal exams. Today, he is quickly moving about the exam room; he looks at a book for a few moments, and he then looks to the window for a short while before interrupting his parents. In addition to behavioral intervention, and assuming the parents agree to medication for their son, what medication is the most appropriate initial treatment A. Amitriptyline B. Bupropion C. Clonazepam D. Methylphenidate

D. Methylphenidate

A 27-year-old man with Marfan syndrome presents due to exercise intolerance and heart palpitations. On exam, you note a mid-systolic click and late systolic murmur heard at the apex of the heart. The click and murmur are noted later in systole with squatting and earlier in systole with sudden standing. What is the most likely diagnosis? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral valve prolapse E. Aortic dissection

D. Mitral valve prolapse

A 27 year old female presents with extreme nausea and vomiting for the last 2 weeks. Today she also complains of severe abdominal cramping. Physical exam reveals diffuse guarding and intense right lower quadrant tenderness. Ultrasound is ordered and it reveals a snowlike pattern grouping of vesicles. Fetal heart tones are absent. Which of the following is the most likely diagnosis? A. Acute Appendicitis B. Ectopic pregnancy C. Diverticulitis D. Molar pregnancy

D. Molar pregnancy

A 6-year-old girl, with history of eczema and seasonal allergies, is brought to the emergency room by her parents because they are concerned that she is not breathing well since this afternoon. Upon entering the room you notice audible wheezing, especially on expiration, and the child appears to be in acute distress. After ensuring that her airway is intact, what therapy should be started immediately in this child? A. IV magnesium B. Oral prednisolone C. Humidified air D. Nebulized albuterol E. IM dexamethasone

D. Nebulized albuterol

A 30-year-old woman presents for routine analysis of cholesterol levels. The results show plasma cholesterol levels of 300 mg/100 mL. You prescribe the drug simvastatin (Zocor). She is reluctant to take drugs to treat her hypercholesterolemia. After further discussion, she agrees to take a vitamin to treat the elevated cholesterol. She also has questions concerning familial hypercholesterolemia. What vitamin is effective in reducing circulating cholesterol levels when given in pharmacological doses? A. Riboflavin B. Thiamin C. Vitamin K D. Nicotinic acid E. Pantothenic acid

D. Nicotinic acid

A 20-year-old woman comes to the student health center because of dysuria, urinary urgency and frequency for the past two days. She denies fever, chills, and flank plain. Results of dipstick urinalysis are positive for nitrites, and leukocyte esterase. Urine pregnancy test is negative. Which of the following is the most appropriate initial treatment for this patient's condition? A. Ampicillin B. Ciprofloxacin C. Metronidazole D. Nitrofurantoin

D. Nitrofurantoin

Which of the following is most likely a feature that is characteristic of bulimia nervosa compared with anorexia nervosa? A. Anxiety B. Depression C. Obsessed with weight and appearance D. Normal body weight or overweight

D. Normal body weight or overweight

A 56-year-old man is hospitalized with sudden onset of symptoms of chest pain, sweating, palpitation and shortness of breath. ECG showed ST elevation of 3 mm above isoelectric ECG line, and troponin I of 6 ng/mL. His BP is 130/75 mm Hg, and HR is 65 bpm. The next morning, Doppler and transesophageal echocardiography were performed following new onset of chest pain, shortness of breath and systemic hypotension, which established mitral regurgitation with papillary muscle rupture. What would be the most appropriate therapeutic intervention at this point? A. Increase the dose of nitrates B. Initiate treatment with a beta blocker C. Perform surgery to insert a ventricular assist device D. Perform mitral valvuloplasty E. Postpone the intervention until acute phase is over

D. Perform mitral valvuloplasty

An 80-year-old man with no significant medical history is brought to the clinic by his daughter because of concerns about dementia. The daughter states that she has noticed a steady decline in his cognitive abilities over the past year. Prior to that, he was quite active and independent. Specifically, his memory is poorer, and he has had difficulty concentrating and accomplishing simple tasks. She has also noticed that his gait has become very slow, and his feet drag along the floor. Two months ago, he began experiencing urinary incontinence, and now has to wear urinary pads. On physical examination his gait is bradykinetic, broad-based, shuffling, and magnetic. He does not have tremor or rigidity. He has impaired recall, decreased fine motor skills, and difficulty with attention. Which of the following is the most likely diagnosis? A. Alzheimer's disease B. Dementia and Lewy bodies C. Frontotemporal dementia D. Normal pressure hydrocephalus E. Parkinsons disease

D. Normal pressure hydrocephalus Classic symptoms of this are abnormal gait, urinary incontinence and dementia.

A 49-year-old morbidly obese man comes to the clinic because of chronic fatigue despite a full night of sleep. He also reports a sore throat and headache upon waking each morning. He is currently taking lisinopril for hypertension. He also has taken some sleeping pills to help with sleep, but they seem to worsen his fatigue. Which of the following conditions is most likely present in this patient? A. Depression B. DMT2 C. Hypothyroidism D. Obstructive sleep apnea

D. Obstructive sleep apnea

A 66-year-old non-smoking man presents to the family practice clinic due to chronic cough. He notes shortness of breath on exertion. On physical exam, an increased respiratory rate with shallow breathing is noted. Dry crackles are auscultated bilaterally over the lungs. No clubbing or cyanosis is noted. The remainder of the exam and vitals are normal.This patient has the following test results: Pulse oximetry: slightly hypoxic; Chest x-ray: Small opacities; Pulmonary Function Tests (PFTs): Restrictive Pattern. In evaluation of this patient's chronic cough, what aspect of his history is most helpful in distinguishing idiopathic pulmonary fibrosis from the various types of pneumoconioses? A. Character of cough B. Duration of cough C. Family history of pulmonary disease D. Occupational exposure history E. Past surgical history

D. Occupational exposure history

Your patient that was recently diagnosed with granulomatosis with polyangiitis (Wegener's granulomatosis) presents to the clinic complaining of severe nausea and vomiting since starting on high dose cyclophosphamide therapy. Which of the following treatment regimens would best relieve this patient's symptoms? A. Lorazepam B. Metoclopramide and dexamethasone C. Prochlorperazine D. Ondansetron and dexamethasone

D. Ondansetron and dexamethasone

A 36-year-old female presents to your emergency department showing symptoms of delusions and hallucinations. She denies any trauma or recent illness, and is alert.. It is unknown how long this has been occurring. Additional history is limited but a complate physical ecamination reveals no abnormalities. What is the next best step the evaluation and management of this patient? A. Administer Haloperidol and admit for observation B. Obtain a Head CT C. Obtain collateral information concerning the patients medical state for the past 3 weeks D. Order a urine drug screen

D. Order a urine drug screen

A 20-year-old man is brought to the emergency department by his brother because of coughing, increased salivation, nausea, vomiting, blurry vision, and muscle twitching for the past 45 minutes. He states that the symptoms began when he returned home after setting off flea bombs in his apartment one hour before. Temperature is 37°C (98.6°F), pulse rate is 56/min, respirations are 20/min, blood pressure is 106/58 mmHg, and O2 saturation of 95% on room air. Exposure to which of the following is the most likely cause of this patient's condition? A. Amphetamines B. Carbon monoxide C. Lead D. Organophosphates D. Petroleum distillates

D. Organophosphates

A 23-year-old pregnant woman comes to the urgent care with sudden onset of fever, chills, and myalgias which began 24 hours ago. She also has a headache, sore throat and has had a non-productive cough. She is currently in her second trimester and has had a normal pregnancy thus far. A nasopharyngeal swab is performed, and culture results are positive for Influenza A. Which of the following is indicated in the treatment of this condition for this patient? * A. Influenza vaccine B. Supportive therapy only C. Amantadine D. Oseltamivir

D. Oseltamivir

A 56-year-old woman, gravida 0 para 0, comes to the office for evaluation of lower abdominal pain, and increased urinary urgency and frequency that began six weeks ago. She states that she has also had early satiety, and that has resulted in a 15 pound weight loss during this time. Menarche was at age 10 years, and menopause at age 50 years. She has been in a monogamous lesbian relationship for 25 years, and has never used any form of contraception. She denies any prior sexually transmitted infections. She has never smoked cigarettes, rarely drinks alcohol, and has no chronic health problems. Her last Pap smear was 10 years ago, and was normal. Physical examination, including pelvic examination, is normal. Dipstick urinalysis is normal. Pelvic ultrasound study shows a unilocular solid mass with increased vascularity in the left adnexal area. Serum CA125 level is 100 IU/mL (normal range = 0-35 IU/mL). Which of the following cancers is most likely in this patient? A. Bladder B. Cervical C. Endometrial D. Ovarian

D. Ovarian

A 57-year-old man is being treated in the emergency department for ST segment elevation myocardial infarction of the inferior wall. His electrocardiogram shows third degree atrioventricular block with narrow QRS complexes. Pulse rate is 40/min, respirations are 24/min, blood pressure is 90/60 mmHg. Which of the following is the most appropriate intervention for this patient's dysrhythmia? A. Cardioversion B. Intravenous administration of adenosine C. Intravenous administration of epinephrine D. Pacemaker

D. Pacemaker

Which of the following is the most common type of thyroid cancer? A. Anaplastic B. Follicular C. Medullary D. Papillary

D. Papillary Anaplastic is not common but is the most aggressive Follicular has Hutchel cells, second MC Medullary is associated with MEN2A and 2B syndromes

A 15-year-old boy presents for a high school basketball physical. After his mother leaves the room, he asks if you can "take a look at something." He then lifts his shirt and tells you that he is developing "man breasts." He is very embarrassed. There is firm mobile tender tissue palpable under both nipples. This tissue is approximately 75 mm in size on the right side and 1 cm on the left. There is no nipple discharge on either side. The patient's height is 66", weight is 125 lb (BMI 20.2). What is the most important next step in the diagnostic workup? A. Check testosterone level B. LFTs and abdominal CT scan C. Mammogram of both breasts D. Physical examination including genitalia E. Thyroid function tests

D. Physical examination including genitalia

A 75-year-old woman with a past medical history of hypertension, hyperlipidemia, and obesity presents with insidious but progressive bilateral knee pain for the past several months. She states that her pain is worsened with movement and relieved by rest. She reports "cracking" sounds in her knees upon ambulation and minimal stiffness lasting 10 minutes. Her physical exam is remarkable for bilateral knee crepitus, joint line tenderness, and an antalgic gait; there is no swelling, erythema, or warmth noted. What is an expected diagnostic test result in this patient? A. Elevated ESR B. Just a-articulate demineralization on x-rays C. Negatively birefringent crystals D. Plain radiography subchondral sclerosis E. Synovial fluid leukocytosis

D. Plain radiography subchondral sclerosis

A 22-year-old man presents with sudden onset of shortness of breath and right-sided chest pain. Symptoms began abruptly yesterday. He felt well prior to the onset of symptoms. He denies fever, hemoptysis, and upper respiratory symptoms. He smokes one pack per day; he has an otherwise non-contributory past medical history.On physical exam, the patient is in mild respiratory distress. He has a slightly elevated heart rate and respiratory rate. He is normotensive. His trachea appears deviated to the left. On pulmonary exam, breath sounds are diminished on the right. Hyperresonance is noted on percussion of the right chest compared to the left. Other than tachycardia, his cardiovascular exam is normal. What test finding is most diagnostic for your suspected diagnosis of this patient? A. Blunting of costophrenic angles on chest x-ray B. Increased pH on arterial blood gas C. Oxygen saturation less than 90% on pulse oximetry D. Pleural line on chest x-ray E. Sputum smear positive for acid-fast bacilli

D. Pleural line on chest x-ray

A 51 year old male, with a long-standing history of smoking and who worked during his early career as a pipefitter, presents with progressive dyspnea over the past six months. He has also had a persistent dry cough that has not responded to over the counter cough suppressants. On physical exam you notice diffuse crackles as well as mild clubbing of his fingers. Which finding on chest x-ray is most consistent with your suspected diagnosis? A. Eggshell calcification B. Hilar adenopathy C. Granulomas D. Pleural plaques E. Honeycombing

D. Pleural plaques

Which of the following hematologic abnormalities is most likely to be present in patients with chronic obstructive pulmonary disease? A. Anemia B. Eosinophilia C. Leukocytosis D. Polycythemia

D. Polycythemia

Which of the following is the most common complication associated with Herpes Zoster infection? A. Secondary bacterial infection B. Meningoencephalitis C. Disseminated herpes zoster D. Post-herpetic neuralgia

D. Post-herpetic neuralgia

A 27-year-old woman is brought to the ER by her husband because of bizarre behavior 4 days after the uncomplicated delivery of a full-term healthy boy. Her personal and family history of mental illness is negative. The second day after delivery, she accused her husband of poisoning her food. She has problems falling asleep, generally sleeping only 2-3 hours nightly and complaining of unpleasant smells waking her up. She started arranging toys and the newborn's things in a specific symmetrical order and became aggressive when someone moved them. She would stop the ongoing activity from time to time with a blank expression and was found several times staring at the wall and silently counting. Even simple tasks require the help of others, and she often forgets what she started doing. This makes her irritable and sometimes tearful. She feels guilty about being a terrible mother and states that she did not deserve to have a baby. The morning when her husband asked for your advice, she told him that she hears voices telling her to take her son and jump out the window. What is the most likely diagnosis? A. Maternity blues B. Psychomotor epilepsy C. Postpartum depression D. Postpartum psychosis E. Obsessive-compulsive disorder

D. Postpartum psychosis

A 52-year-old woman presents with left hip pain. There is no known history of trauma to the area. Her past medical history includes Crohn's disease, type 2 diabetes, and hypertension. She is currently taking metformin, metoprolol, and mesalamine. She recently completed a prednisone taper for her Crohn's disease. She also finished a course of ciprofloxacin, which she took for a urinary tract infection. An X-ray is obtained, revealing a collapsed left femoral head. What medication likely contributed to her current condition? A. Metoprolol B. Metformin C. Mesalamine D. Prednisone E. Ciprofloxacin

D. Prednisone Pt is presenting with avascular necrosis; causes of this are extensive steroids use and alcoholism

A 63-year-old man with type 2 diabetes mellitus comes to the office because of severe burning sensation in both feet for the past month. The pain is worse at night, and prevents him from sleeping well. Additionally, he has not been able to comfortably wear his socks and shoes, and has not been at work for the past week. Physical examination of both feet shows hypersensitivity to light touch in a stocking-glove distribution. Which of the following is the most appropriate initial drug therapy for this patient's condition? A. Fluoxetine B. Lamotrigine C. Lidocaine patch D. Pregabalin E. Tramadol

D. Pregabalin

Which of the following patient-specific factors is most likely to cause a false-positive reaction to tuberculin skin testing? A. Cutaneous anergy B. HIV infection C. Patient taking oral steroids for one month or longer D. Prior vaccination with BCG vaccine

D. Prior vaccination with BCG vaccine

A 24-year-old woman comes to your office stating that her hands shake uncontrollably when she tries to do things like write or tie her shoes. After a full work up, the patient is diagnosed with inherited essential tremor. Which of the following is the first line treatment for this condition? * A. Metoprolol B. Nimodipine C. Primidone D. Propanolol

D. Propanolol

A 70-year-old man with type 2 diabetes mellitus, hyperlipidemia, homocysteinemia, and metabolic syndrome presents with a 5-month history of excessive daytime sleepiness, a lack of refreshing sleep, a depressed mood, and an inability to focus at work and while driving. Additionally, he has been told by his wife that he snores rather loudly while sleeping. He denies fever, chills, headache, cold intolerance, weight loss, hair changes, hoarseness, dysphagia, chest pain, edema, palpitations, or changes in his bowel habits. On physical exam, he is found to be hypertensive. He has elevated BMI with abdominal obesity, and he has an enlarged neck circumference; no other abnormalities are noted. What pathological mechanism best accounts for this patient's presentation? A. Bacterial overgrowth of Streptococcus, causing pharyngeal inflammation B. Lymphocytic infiltration of the thyroid, causing fibrosis of the thyroid follicles C. Compression of the superior vena cava by an infiltrating mediastinal neoplasm D. Reduced inspiratory patency of the airway due to relaxation of the muscles E. Lower airway inflammation with mucosal thickening and mucus

D. Reduced inspiratory patency of the airway due to relaxation of the muscles

A 27-year-old woman presents to the OB/GYN clinic complaining of dyspareunia and pain in her left lower abdominal region for the last 2 weeks. She states her menses is normal and regular. She has no chronic medical problems and takes no daily medications. Ultrasound is ordered and reveals a simple 4cm left sided ovarian cyst with normal blood flow. Pregnancy test is negative. Which of the following is the most appropriate therapy at this time? A. Laparoscopy B. Biopsy C. Emergency oophorectomy D. Repeat US in one month

D. Repeat US in one month

A 27-year-old man is seen in the emergency department for a panic attack that he has had for the past two hours. Blood gas analysis shows: pH - 7.56, PCO2 - 20 mmHg, bicarbonate - 22 mEq/L, PO2 - 98 mmHg, and SaO2 - 97%. Which of the following is the most likely diagnosis? A. Hypoxia B. Metabolic acidosis with respiratory compensation C. Metabolic alkalosis D. Respiratory alkalosis

D. Respiratory alkalosis

An 18-month-old boy presents with a 2-day history of runny nose, slight cough, and low-grade fever. Over the last 24 hours, however, his condition has worsened; the child is tachypneic on exam. He is wheezing, and his breaths are associated with nasal flaring and chest retraction. What is the most common etiology of this patient's condition? A. Adenovirus B. Haemophilus influenzae C. Influenza virus D. Respiratory syncytial virus E. Streptococcus pneumoniae

D. Respiratory syncytial virus

A 23-year-old woman comes to the office for follow-up visit to review ultrasound results one week after she was evaluated because of lower abdominal bloating. Her last normal menstrual period was one month ago. Pelvic examination performed at the time of the initial evaluation showed some fullness of the right adnexa. Urine pregnancy test was negative. Results of transabdominal ultrasound obtained five days ago shows a single 4 cm diameter, thin rounded wall unilocular anechoic mass in the right ovary. Which of the following is the most appropriate next step in management? A. CT of the abdomen and pelvis B. Emergent referral to a gynecologist C. MRI of the pelvis D. Schedule a follow-up visit with repeat ultrasound in 8-12 weeks

D. Schedule a follow-up visit with repeat ultrasound in 8-12 weeks Pt is presenting with a functional ovarian cyst, which usually does not require surgery

A 24-year-old man is brought to the office by his girlfriend because she is concerned that he has been hearing voices for the past two months. She states that over the past six months, he has had episodes where he felt the presence of someone in a room when there was no one there, and that he often mumbles in public. Additionally, she states that he has been having increasing difficulty concentrating, and maintining a train of thought. He often responds to questions with an unrelated answer, and will at times speak incoherently. Which of the following is the most likely diagnosis? A. Bipolar disorder B. Delusional disorder C. Personality disorder D. Schizophrenia disorder

D. Schizophrenia disorder

A 64-year-old woman comes to the office because of constipation, vague abdominal pain, and mild fatigue for the past three weeks. Vital signs are normal, and physical examination shows no abnormalities. Laboratory tests of serum show a calcium level of 11.3 mg/dL (normal = 8.7-10.4 mg/dL); phosphorus 2.2 mg/dL (normal = 2.5-4.5 mg/dL), and albumin 4.0 g/dL (normal = 3.5-4.5 g/dL). Repeat testing of albumin level confirms the prior test results. Electrocardiogram shows shortening of the QT interval. Which of the following is the most appropriate next step in evaluation of this patient? A. Chest CT scan to rule out malignancy B. Measurement of 24-hour urine calcium excretion C. Serum measurement of calcitonin D. Serum measurement of parathyroid hormone

D. Serum measurement of parathyroid hormone

A 19-year-old woman comes to the office because of localized pain and swelling within the floor of the left side of her mouth and jaw for the past 3 days. She states that the pain increases whenever she eats, particularly after eating something that is sour. Physical examination shows a firm mass in the submandibular area with mild to moderate tenderness. Scant pus is expressed from the openning of the submandibular duct when the gland is gently compressed. Which of the following is the most likely diagnosis? A. Infected branchial cleft cyst B. Infected thyroglossal duct cyst C. Peritonsilar abscess D. Sialadenitis

D. Sialadenitis

A 3 year old female presents to the emergency department with development over the last few hours of fever, confusion, dysphagia, drooling, and has a toxic appearance. Which of the following imaging studies is indicated in this patient? A. Head CT B. CXR C. AP neck x-ray D. Soft tissue lateral neck x-ray

D. Soft tissue lateral neck x-ray

A 7-year-old girl who is otherwise healthy is brought to the urgent care by her mother because she has had fever, sore throat, and decreased appetite for the past two days. She is up to date with her immunizations. Temperature is 103.2 F (39.6 C). On physical examination, her pharynx has a whitish exudate in patches over the tonsils, and she has tender cervical lymphadenopathy. You also note palatal petechiae, and an absence of a cough. Which of the following is the most likely diagnosis? A. Diptheria B. Epiglottitis C. Mononucleosis D. Streptococcal pharyngitis

D. Streptococcal pharyngitis

A 28-year-old woman comes to the emergency department with fever, chills, mild dyspnea, pleuritic chest pain, and productive cough for the past two days. A chest radiograph reveals consolidation of the right lower lung field. Which of the following is the most likely cause of her pneumonia? A. Mycoplasma pneumoniae B. Legionella pneumoniae C. Staphylococcus aureus D. Streptococcus pneumoniae

D. Streptococcus pneumoniae

Primary spontaneous pneumothorax most often occurs in which of the following patient populations? A. Elderly B. Obese individuals of any sex C. Pre-menopausal women D. Tall thin males E. Those with history of chronic lung conditions

D. Tall thin males

A 5-year-old boy is brought to the office by his mother because she has noticed a persistent lump in his neck for the past month. Physical examination shows a midline 2 cm rubbery mass located just inferior to the hyoid bone. When he is asked to swallow or protrude his tongue, the mass transiently moves upward. Which of the following is the most likely diagnosis? A. Bronchial cleft cyst B. Goiter C. Submental lymph node D. Thyroglobulin duct cyst

D. Thyroglobulin duct cyst

A 23-year-old man comes to the student health center for evaluation of a painless mass on his right testicle that he has noticed over the past month. Physical examination shows a 2-cm moderately firm, fixed, non-tender mass on the right testicle. The mass does not transilluminate. Which of the following is the most appropriate initial diagnostic study to obtain? A. Alpha-fetoprotein B. Beta-human chorionic gonadotropin C. Biopsy D. Ultrasound

D. Ultrasound

A 70-year-old man with a history of well-controlled hypertension and osteoarthritis comes to the office for routine visit. He has a 40 pack-year history of smoking, but quit 10 years ago. Temperature is 37°C (98.6°F), pulse rate is 78/min, respirations are 16/min, and blood pressure is 118/76 mmHg. Physical examination shows slight kyphosis, and Heberden nodes at the distal interphalangeal joints of both hands. Which of the following screening tests is recommended for this patient? A. Carotid ultrasound B. CXR C. DEXA scan of the hip D. Ultrasound of the abdominal aorta

D. Ultrasound of the abdominal aorta USPTF recommends one-time screening for AAA by ultrasonography in men ages 65-75 who have ever smoked

A 15-year-old boy presents with a 2-month history of intermittent burning pain in the epigastrium. Pain is felt more during the night and between meals; it is partly relieved by eating food or by taking antacids. Pain usually lasts 30-60 minutes and is accompanied by nausea and vomiting. He often has a feeling of bloating and burping. He remains asymptomatic for several days between. There is no history of taking analgesics or anti-inflammatory drugs. Physical examination shows epigastric tenderness. The rest of the examination is essentially normal. Stool examination for occult blood is positive. What is the investigation of choice for establishing the diagnosis? A. Abdominal US B. Upper GI barium studies C. CT scan abdomen D. Upper GI endoscopy E. Stool microscopy

D. Upper GI endoscopy

In adults, which of the following causative agents are the most common etiologic agent of acute bronchitis? A. Bacteria B. Fungi C. Parasites D. Viruses

D. Viruses

A 12-year-old girl, who is otherwise healthy, is brought to the office by her mother because of heavy menstrual bleeding for the past two months. She started her menstrual periods six months ago, but the mother only recently noticed the heavy bleeding. She does not take any medications. Physical examination shows no abnormalities. Results of laboratory studies show a mildly prolonged activated partial thromboplastin time, and normal prothrombin time. Which of the following is the most likely diagnosis? A. Hemophilia A B. Hemophilia B C. Protein C deficiency D. Von Willebrand disease

D. Von Willebrand disease

A 3-year-old girl is brought to the clinic by her mother, who tells you that the child has not been eating well over the past month and has developed swelling in the abdomen. On exam, the child has a smooth abdominal mass that is the size of a baseball on the left side. Vital signs reveal a blood pressure of 134/82 mm Hg, temperature of 99.8°F, and respirations of 16 breaths per minute. Urinalysis shows only 1+ red blood cells, and CBC and CMP are within normal limits. What is the most likely diagnosis? A. Multicystic dysplastic kidney disease B. Splenomegaly C. Lymphoma D. Wilms tumor E. Renal cell carcinoma

D. Wilms tumor

A 12-year-old boy has jaundice, non-tender hepatomegaly and splenomegaly, and tremor. He has been healthy and is on no medications. He is afebrile. Golden-brown rings on the peripheral corneas are noted on slit lamp eye exam. Laboratory studies reveal low levels of serum ceruloplasmin and elevated 24-hour urine copper excretion. What is the most likely diagnosis? A. Reye syndrome B. Autoimmune hepatitis C. Drug-induced hepatitis D. Wilson disease E. Acute hepatitis A virus

D. Wilson disease

A 34-year-old woman who works as a medical transcriptionist seeks evaluation for pain in her right wrist and hand for the past six months. Over the past month, the pain has been more consistent, and has also been associated with numbness in her hand. The pain is worse at night, and shaking her hand helps alleviate the pain. Which of the following findings on physical examination would suggest a diagnosis of carpal tunnel syndrome? A. Decreased sensation over the fourth and fifth fingers B. Pain and swelling over the radial stolid C. Wrist drop D. Wrist pain when the patient presses her palms together with the elbows flexed to ninety degrees

D. Wrist pain when the patient presses her palms together with the elbows flexed to ninety degrees

A 32-year-old woman comes to the emergency department for evaluation of right-sided lower abdominal pain that has worsened over the past day. For the past three days, she has also had watery, brown diarrhea. There is no blood in her stool. This entire episode began after eating pork chops at her in-laws house one week ago. She denies recent international travel, antibiotic use, and pregnancy. Temperature is 39°C (102.2°F), pulse rate is 80/min, blood pressure is 114/76 mmHg. Abdominal examination shows hyperactive bowel sounds, and point tenderness in the right lower quadrant. Which of the following pathogens is the most likely cause of her diarrhea? A. Salmonella enterica B. Staphylococcus aureus C. Vibrio cholera D. Yersinia enterocolitica

D. Yersinia enterocolitica Yersinia is the cause of inflammatory diarrhea that is watery and brown, RLQ pain and fever are common = raw undercooked pork Salmonella - watery diarrhea, nausea, vomiting, stomach cramps = raw undercooked chicken, eggs, beef Staphylococcal enterotoxins- abrupt intense vomiting = meat, dairy, mayonnaise

A 36-year-old G1P1001 woman presents with a 4- to 5-week history of pain along her right lateral wrist; the pain worsens when she tries to grasp something. There was no trauma. She gave birth 6 weeks ago and carrying her baby is difficult secondary to pain. She is right-handed and has never had any issues like this before. On exam, there is tenderness and edema over the radial styloid. You then have the patient fully flex her thumb, adduct, and grasp it with that hand. You then place her hand in ulnar deviation, which reproduces the pain described above. What is the most likely diagnosis? A. Rheumatoid arthritis B. Ganglion cyst C. Scaphoid fracture D. de Quervain tenosynovitis E. Radial nerve entrapment

D. de Quervain tenosynovitis

A 35-year-old woman who recently finished a round of oral antibiotics for pneumonia presents due to her tongue having "a thick white coating"; she adds that it is "also red and irritated." She is able to "scrape the white stuff off" some areas of her tongue, which she reports have become raw and more erythematous. What is the most likely diagnosis? A. Hairy leukoplakia B. Atrophic glossitis C. Hairy tongue D. Geographic tongue E. Candidiasis

E. Candidiasis Hairy leukoplakia is common in HIV/AIDS patients and is characterized by White patches that CANNOT be scraped off

In a patient requiring aortic valve replacement, at which age threshold is a bioprosthetic valve recommended over use of a mechanical valve? A. <29 years B. 30-39 years C. 40-49 years D. 50-59 years E. >60 years

E. >60 years

Which of the following adolescent girls should be evaluated for primary amenorrhea? A. A 12-year-old girl without secondary sex characteristics or menarche B. A 13-year-old girl with axillary or pubic hair development without menarche C. A 14-year-old girl with secondary sex characteristics without menarche D. A 15-year-old girl with secondary sex characteristics who previously had periods, but now has not had one in 3 months E. A 16-year-old girl with secondary sex characteristics who has never had a menstrual cycle

E. A 16-year-old girl with secondary sex characteristics who has never had a menstrual cycle

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never had this as bad as she does currently. The patient denies any other significant past medical history and is currently taking only a multivitamin daily. She admits to recently having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days. She hopes that after finals are over her headaches will subside. She also states she was given a 10-day course of amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stools, use of tobacco/alcohol, or coughing up blood. Physical examination is unremarkable for any abnormalities. What medication would you suggest for the patient to begin for her headaches at this time? A. Antibiotics B. Anticholinergics C. Proton pump inhibitor D. H1 receptor antagonist E. Acetaminophen

E. Acetaminophen

A 26-year-old woman at 29 weeks gestation presents with a 1-week history of vaginal discharge and dysuria. On genital exam, she has mucopurulent cervicitis. A cervical swab is obtained and results are positive for Chlamydia trachomatis infection. What is the best course of treatment? A. Doxycycline B. Metronidazole C. Levofloxacin D. Fluconazole E. Azithromycin

E. Azithromycin

A 65-year-old woman presents with weight gain, fatigue, and aching limbs that have been bothering her for the past 2 months. Further questioning reveals that she has also been having intermittent runny noses, constipation, and dry skin. She drinks about 80 oz of water daily. She denies fever, night sweats, hematochezia, melena, abdominal pain, or headaches.Physical exam reveals heart rate 56, respiratory rate 18, blood pressure 138/102, temperature 97.9°F, and weight 210 lb. HEENT exam is unremarkable. On heart exam, there is a grade II systolic murmur heard best at the right sternal border, second intercostal space. No rubs or gallops are heard. Lungs are clear to auscultation bilaterally. Abdomen is soft with no distension, tenderness, or organomegaly. Neurologic exam shows good coordination, normal sensation and strength, intact cranial nerves, and 2+ reflexes that are symmetric in upper and lower extremities. Skin exam shows cool dry somewhat pale skin with scattered cherry angiomas. What physical exam finding is caused by this patient's most likely diagnosis A. 2+ reflexes in the upper and lower extremities B. Scattered cherry angiomas C. Respiratory rate of 18 D. Grade II systolic murmur E. Blood pressure of 138/102

E. Blood pressure of 138/102 Symptoms are suggestive of hypothyroidism

A 23-year-old woman comes to the urgent care clinic complaining of 1 week of malaise, generalized fatigue, and muscle aches. She was out hiking last week, and symptoms began the morning after she returned from the hike. Today she noticed a rash to her left lower leg, which prompted her to be evaluated. Physical examination reveals a low grade fever, mildly elevated heart rate, and a small erythematous ring surrounding a central clearing and an erythematous puncta in the center. Which of the following is the most likely causative organism in this patient's condition? A. Treponema pallidum B. Rickettsia rickettsii C. Plasmodium falciparum D. Babes microti E. Borrelia burgdorferi

E. Borrelia burgdorferi

An 84-year-old woman presents with a 6-hour history of dyspnea, non-productive cough, hemoptysis, and a "sharp, stabbing" pleuritic chest pain. Her review of systems is negative for any fever, chills, palpitations, wheezing, abdominal pain, nausea, vomiting, diarrhea, and rashes. She has a past medical history of myocardial infarction, congestive heart failure, dyslipidemia, asthma, and lung cancer. Social history is significant for a 50 pack-year smoking history, but she quit 10 years ago. She denies any alcohol or recreational drug use, sick contacts, or recent travel. She also denies any recent hospitalizations or surgeries.On physical exam, skin is warm and dry without rashes. There is abdominal distension, hepatosplenomegaly, supraclavicular lymphadenopathy, and 2+ lower extremity pitting edema (right greater than left) noted. The cardiac exam reveals tachycardia, jugular venous distension of 6 cm, and an S3 gallop. Pulmonary exam reveals tachypnea, diffuse dullness to percussion, decreased tactile fremitus, and absent breath sounds.She undergoes diagnostic thoracentesis. Laboratory findings of pleural fluid are listed below. Pleural fluid LDH: 160 units/liter; Pleural-to-serum protein: 0.2; pleural-to-serum LDH: 0.3; pleural fluid glucose: negative; pleural fluid WBCs: negative; pleural fluid pH: within normal limits; pleural fluid RBCS: negative. What is the most likely contributory etiology? A. Pulmonary embolism B. Lung cancer C. Cirrhosis D. Bacterial pneumonia E. Congestion heart failure

E. Congestion heart failure

A 40-year-old man with no significant past medical history presents with a 2-day history of alternating fever and rigors, diaphoresis, fatigue, and a productive cough. He admits to mucoid sputum of moderate quantities. He denies a history of smoking, alcohol use, recent travel, or sick contacts. He further denies chest pain, palpitations, hemoptysis, rashes, abdominal pain, nausea, vomiting, or diarrhea. On physical exam, he is found to be tachypneic and was observed to be intermittently coughing. The pulmonary exam was notable for bronchial breath sounds over the right anterior fourth, fifth, and sixth intercostal spaces. A chest radiograph revealed a right middle lobe consolidation. What additional physical exam finding would be consistent with this patient's most likely diagnosis? A. Cheyenne-Stokes respiration B. Bradycardia C. Decreased tactile fremitus D. Decreased whispered pectoriloquy E. Dullness to percussion

E. Dullness to percussion

A 74-year-old man with a history of diabetes mellitus, hypertension, and hyperlipidemia presents with severe chest pain and dyspnea. On exam, he is confused, agitated, pale, apprehensive, and diaphoretic. His pulse is weak and tachycardic; systolic blood pressure is 80 mm Hg. He has a narrow pulse pressure, tachypnea, a weak apical impulse, significant jugular venous distention, and pulmonary crackles. Bedside electrocardiogram reveals ST-segment elevations in the anterior and septal leads, while a portable chest X-ray notes diffuse pulmonary congestion. What is the most appropriate step in the management of this patient? A. Immediate crystalloid infusion B. Initiate intravenous beta blocker therapy C .Begin urgent phenylephrine D. Quickly administer nitrates and morphine E. Emergent percutaneous coronary intervention

E. Emergent percutaneous coronary intervention Pt is experiencing cardiogenic shock d/t myocardial infarction w/ pulmonary edema

A 67-year-old man presents with dyspnea and chest pain 3 days after flying home from Europe. Workup reveals a pulmonary embolism. The patient has required 6 L of O2 to maintain a saturation above 90% and has continued to remain tachycardic. The remainder of his past medical history is unremarkable. What therapy should you initiate at this time? A. Aspirin plus rivaroxaban (Xarelto) B. Warfarin plus clopidogrel C. Clopidogrel plus apixaban (Eliquis) D. Enoxaparin sodium (Lovenox) plus aspirin E. Enoxaparin sodium (Lovenox) plus warfarin

E. Enoxaparin sodium (Lovenox) plus warfarin American College of Chest Physicians recommends anticoagulation be initiated with either low molecular weight heparin (Lovenox), unfractionated heparin or fondaparinux (Arixtra) in ADDITION to coumadin. Discontinuation of the first medication when INR is >2.0

A 2-year-old girl is brought to an otolaryngologist by her mother for chronic ear infections. The patient is otherwise healthy, with the exception of recurrent episodes of otitis media (OM). Examination and history show that the child has had average growth and development; she has not had invasive infections, skin disorders, or hospitalization. The child's mother is concerned about the risk of hearing loss and its effects on development. What patient education information can you give the child's mother? A. Hearing loss does not result from OM, except in rare cases. B. Sensorineural hearing loss, not conductive, is more commonly associated with OM. C. Hearing loss during OM will not adversely affected speech and language. D. Van der Hoeve syndrome, a sequela of OM, can cause hearing loss. E. Hearing loss associated with OM is conductive and most commonly temporary.

E. Hearing loss associated with OM is conductive and most commonly temporary.

A 12-year-old Jewish girl is brought in by her father. The father reports that the child started to bleed profusely following tooth extraction 2 hours ago. Further questioning reveals that there is a history of bleeding disorder in the child's maternal uncle and aunt. Examination reveals tachycardia and bleeding from the site of tooth extraction. Coagulation profile reveals prolonged activated partial thromboplastin time (aPTT), normal prothrombin time (PT) and thrombin time (TT), and deficiency of factor XI. The child was treated with fresh frozen plasma (FFP) and fibrin glue. What is the likely diagnosis? A. Thrombocytopenia B. Hemophilia B C. Von Willebrand disease D. Hemophilia A E. Hemophilia C

E. Hemophilia C

A previously healthy 35-year-old man has had right flank pain radiating to his right groin for the past 3 hours. CT shows a 11 mm uric acid stone in his right proximal ureter. What is the best option of treatment in this patient? A. NSAIDs B. Prednisone C. Open stone surgery D. Tamsulosin E. Lithotripsy

E. Lithotripsy Stones >10 mm are unlikely to pass spontaneously

47-year-old obese woman presents with left non-dominant shoulder pain and limited motion. The pain began about a month ago but has reduced over time. Her shoulder has progressively lost motion during that time; she cannot reach overhead with that arm. There is no history of trauma, it does not wake her at night, and she can sleep on the left side. Her past medical history is significant for type 1 diabetes and hypothyroidism. She is on regular insulin, NPH insulin, and levothyroxine. what diagnostic study would best help evaluate the suspected diagnosis? A. Plain radiographs B. CT C. EMG D. Ultrasound E. MRI

E. MRI Patient is presenting with adhesive capsulitis (frozen shoulder); common in middle aged pts with hypothyroidism and diabetes. They will have shoulder pain and limited of ROM. Will have decreased active and passive ROM

A 20-year-old female college student presents due to a 7-day history of daily heartburn. She has never experienced heartburn as bad as she does currently. She is treating it with over-the-counter histamine-2 receptor antagonist, famotidine, 1 tablet daily. The patient denies any other significant past medical history and is currently taking a daily multivitamin and an antihistamine for seasonal allergies. She recently admits to having increased episodes of headaches that she believes are due to stress. For this reason, she has been taking ibuprofen 600 mg every 8 hours. She states that she has been taking this consistently every 8 hours for the last 10 days; she hopes that her headaches will subside after finals are finished. She also states that she was given amoxicillin 2 weeks ago for a middle ear infection, which resolved without any further intervention. She denies any difficulty swallowing, weight loss, night sweats, chest pain, black tarry stool, use of tobacco or alcohol, or coughing up blood. Physical examination is unremarkable. What medication is most likely causing her increased gastrointestinal symptoms? A. Antibiotic B. H2-receptor antagonist C. Multivitamin D. H1-receptor antagonist E. NSAID

E. NSAID

A 17-year-old boy presents with intermittent bouts of shortness of breath, coughing, and chest tightness. The symptoms most often occur during football practice, sometimes when he is just standing outdoors in cold weather. He denies palpitations, fever, and chills. Past medical history is non-contributory. He is a non-smoker. Physical exam is unremarkable. Vital signs are as follows: BMI 19 kg/m2, BP 116/70 mm Hg, HR 80 bpm, SpO2 99% on room air.His physician orders pulmonary function testing (PFT) and a chest X-ray (CXR). Based on the most likely diagnosis, what chest x-ray finding is most likely? A. Hyperinflation B. Ground glass shadowing C. Bronchial wall thickening D. Perihilar fluffy infiltrate E. Normal CXR

E. Normal CXR

A 73-year-old male presents reporting that his toenails are thick, hard to cut, discolored, and dystrophic. A KOH culture confirmed a fungal infection. What is the most likely diagnosis? A. Onychocryptosis B. Onychauxis C. Onychogryphosis D. Onycholysis E. Onychomycosis

E. Onychomycosis

Which of the following diseases is most commonly associated with detection of intracellular Lewy bodies? A. Myasthenia gravis B. Huntington's disease C. Multiple sclerosis D. Essential tremor E. Parkinson's disease

E. Parkinson's disease

A 45-year-old man who works as a carpenter comes to your clinic complaining of right shoulder pain that is worse in the evenings for the past month. On physical examination he has pain on range of motion, a positive Neer and Hawkins tests, but strength appears to be normal bilaterally. Which of the following is the most appropriate initial diagnostic study to obtain in this patient? A. MRI B. CT C. Ultrasound D. MR arthrogram E. Plain x-ray

E. Plain x-ray

A 67-year-old male post office worker presents with a 3-week history of increasing shortness of breath; it occurs even while he is at rest. The patient was diagnosed with congestive heart failure in the past year and he has been well controlled on oral medication. He has no history of tobacco use. He has gained 10 pounds since his last exam 2 months prior to presentation. On physical exam, there are diminished breath sounds and decreased tactile fremitus bilaterally at the base of the lungs. Dullness to percussion is also noted in the same area. He has 3+ bilateral pitting lower extremity edema. What is the most likely diagnosis? A. Lung malignancy B. Tuberculosis C. Empyema D. Spontaneous pneumothorax E. Pleural effusion

E. Pleural effusion

A 66-year-old man presents with monoarticular arthritis. He has stage 3 chronic kidney disease. His affected joint is warm to the touch. You suspect gout. He is allergic to aspirin. What anti-inflammatory should be prescribed A. Acetaminophen B. Aspirin C. Ibuprofen D. Metformin E. Prednisone

E. Prednisone Prednisone does not cause a decline in renal function.

A 40-year-old male recreational tennis player presents with pain in his playing-side elbow since a tournament last weekend. He played five matches of singles and two matches of doubles games. He cannot even hold a pen without pain. He says he needs to get better fast because he has another tournament coming in a week. On exam, he has pain with extension against resistance of his affected side wrist. What treatment options should be recommended on this first visit? A. Start strengthening exercises now to get ready for next tournament B. Prescribe him muscle relaxants since spasms cause the pain C. Tell him he should switch arms to give his normal playing arm a rest D. Inject him today with long-acting anesthetic agent to relieve his pain E. Prescribe an NSAID of choice and recommend skipping the next tournament

E. Prescribe an NSAID of choice and recommend skipping the next tournament

A 32-year-old woman comes to the office because irregular periods over the past six months. She also states that her sex drive is diminished. For the past two months, she has noticed a milky breast discharge, and has also had vaginal dryness. Which of the following is the most likely diagnosis? A. Dysfunctional uterine bleeding B. Endometriosis C. Functional ovarian cyst D. Polycystic ovary syndrome E. Prolactinoma

E. Prolactinoma

An 8-year-old boy sustained a puncture wound to his right foot by stepping on a nail through his sneaker 4 days ago. His mother said the wound bled profusely but the nail did not go completely through his foot. They washed the wound at home with soap and water, wrapped it in a bandage, and did not seek further care. This morning, he complained that it was very painful and his mother noted that his foot looked red and swollen. On exam, his temperature is 99°F; pulse is 114 BPM, and his BP is 104/68 mm Hg. The plantar surface of his right foot has a small 2 mm scabbed entry wound that is surrounded by a 5-6 cm area that is erythematous, swollen, and quite tender. There is a scant amount of thin seropurulent material from the entry wound on examination. What bacteria is most likely the cause of the suspected complication the patient is experiencing? A. Streptococci B. Eikenella C. Pasteurella D. Clostridium E. Pseudomonas

E. Pseudomonas

A 2-year-old boy with his parents presents with colicky pain, a history of irritability, and a 2-day history of lethargy. There is also history of rectal bleeding and passage of "currant jelly" stool for the past 2 days. Vital signs reveal blood pressure of 105/70 mm Hg, heart rate of 90 bpm, respiration of 18/minute, and temperature 99.2°F. Plain abdominal film shows evidence of obstruction, and barium enema detects coiled-spring appearance to the bowel. Based on the most likely diagnosis, what is the best next step in management of this patient? A. Resection of the bowel B. Reduction by contrast enema C. Observation for spontaneous reduction D. Manual reduction E. Reduction by air enema

E. Reduction by air enema Pt is experiencing intussusception,

A 42-year-old man presents with a 3-day history of "not being able to hear in my right ear." He is otherwise healthy and is not taking any medications. There is no history of trauma. On physical exam, the whisper test is decreased on his right, the Weber test lateralizes to the right ear, and the Rinne test is as follows: right ear bone conduction is greater (lasts longer) than air conduction; left ear air conduction lasts longer than bone conduction. What is the most likely diagnosis? A. Right ear sensorineural hearing loss, possibly due to Ménière's disease B. Left ear sensorineural hearing loss, possibly due to Ménière's disease C. Left ear conductive hearing loss, possibly due to middle ear disease D. Right ear sensorineural hearing loss, possibly due to acoustic neuroma E. Right ear conductive hearing loss, possibly due to cerumen impaction

E. Right ear conductive hearing loss, possibly due to cerumen impaction

A 73-year-old man presents with worsening shortness of breath on activity over the last few months. Another issue he mentions is not being able to complete as many physical activities during the day as he could perform 3 months ago. He states he has to use at least three pillows to allow him to sleep at night; otherwise, he cannot breathe. Physical examination confirms the suspected diagnosis. What sign would be consistent with this patient's most likely diagnosis? A. Diminished lower extremity pulses B. Diminished second heart sound C. Hypertension D. Non-healing ulcer E. S3 gallop

E. S3 gallop

Which of the following infectious agents is the most common cause of impetigo? A. Candida albicans B. Human papilloma virus C. Malassezia furfur D. Pox virus E. Staphylococcus aureus

E. Staphylococcus aureus

A 28-year-old woman comes to the emergency department with fever, chills, mild dyspnea, pleuritic chest pain, and productive cough for the past two days. A chest radiograph reveals consolidation of the right lower lung field. Which of the following is the most likely cause of her pneumonia? A. Mycoplasma pneumoniae B. Legionella pneumoniae C. Staphylococcus aureus D. Haemophilus influenzae E. Streptococcus pneumoniae

E. Streptococcus pneumoniae

A 62-year-old man who has worked as a coal miner for 20 years comes to the clinic because of progressive shortness of breath, and dyspnea on exertion over the past two months. He denies any past medical history, and does not smoke or use recreational drugs. Vital signs are blood pressure 142/86 mmHg, heart rate 97 beats/min, respirations 20 breaths/min, and oxygen saturation is 92% on room air. Physical examination shows normal jugular venous pulsations, and diffuse fine dry crackles over both lung fields. Heart sounds are normal, and there is no edema in either lower extremity. Chest x-ray study shows diffuse interstitial infiltrates, and honeycombing. Which of the following is the most appropriate management of this patient's condition? A. Administration of albuterol B. Administration of furosemide C. Administration of nitroglycerin D. Incentive spirometry E. Supportive care, including home oxygen

E. Supportive care, including home oxygen

A 24-year-old man who is otherwise healthy is diagnosed with acute, uncomplicated hepatitis A infection. Which of the following is the most appropriate initial treatment for this patient's condition? A. Administration of a broad-spectrum antibiotic B. Administration of glucocorticoids C. Administration of immune globulin D. Administration of Ribavarin E. Supportive therapy

E. Supportive therapy

A 32-year-old woman comes to the office for evaluation of redness and pressure in both eyes for the past 2 months. She initially attributed her symptoms to poor sleep and fatigue as the result of caring for her 11-month-old son, whom she breastfeeds at night. She reports no other concerns, and in fact is very happy to have lost 15 pounds in the past 2 months after struggling to lose weight from her pregnancy. She also states having a return of her menses 3 months ago, but none since then. Temperature is 37.3°C (99.1°F), pulse rate is 104/min, respirations are 16/min, and blood pressure is 138/82 mmHg. Physical examination shows redness, tearing and proptosis of both eyes. The thyroid gland is slightly enlarged. Which of the following is the most appropriate diagnostic study to obtain in this patient? A. Anti-thyroid peridoxase antibodies B. CT scan of the neck C. Radioactive iodine uptake and scan D. Serum human chorionic gonadotropin E. TSH receptor antibodies

E. TSH receptor antibodies

A 38 year old transgender patient presents to your office with varied somatic complaints. During the mental status exam you observe that the patient loses the thread of conversation and discusses irrelevant topics based on an external stimuli. The patient never returns to the main point he was trying to express. Which of the following speech patterns is this patients exhibiting? A. Circumstantiality B. Word salad C. Looseness of association D. Neologisms E. Tangentiality

E. Tangentiality

A 38 year old transgender patient presents to your office with varied somatic complaints. During the mental status exam you observe that the patient loses the thread of conversation and discusses irrelevant topics based on an external stimuli. The patient never returns to the main point he was trying to express. Which of the following speech patterns is this patients exhibiting? A. Circumstantiality B. Word Salad C. Looseness of association D. Neologisms E. Tangentiality

E. Tangentiality Circumstantiality - eventually gets to the point after a delay in thought process Word salad - mixture of words and phrases, making no sense Looseness of association - ideas shift between subjects and are unrelated to each other Neologisms - creation of new words

A 32-year-old man presents with pain in his right shoulder. He tells you he plays softball every weekend and does a lot of shoveling around his house. The shoulder has been sore for some time, but now it hurts to the point where he tries to avoid using it. The drop arm test is negative, and there is no redness, warmth, or obvious swelling, but the patient is unable to lift his arm up to 90° without pain. What is the most likely diagnosis? A. Bursitis B. Fibromyalgia C. Gout D. Rotator cuff tear E. Tendinitis

E. Tendinitis

A 64-year-old Caucasian woman who takes no medications and has had no recent medical attention presents to establish care. She says high cholesterol "runs in her family," and she admits to eating fast food for lunch most days of the week. In light of her family history and current habits, what might be incidentally found on her physical exam? A. Acanthosis nigricans on her neck B. Buffalo hump on her back C. Lipoma on the trunk D. Systolic heart murmur E. Xanthelasma over both eyes

E. Xanthelasma over both eyes

A 72-year-old man presents due to worsening shortness of breath, orthopnea, and chest pain; symptoms have been occurring for the past few weeks. The patient admits to some chronic heart problems, as well as fatigue, dyspnea, and a non-productive cough. He feels like symptoms have worsened recently. He denies fever, chills, and a productive cough.On physical exam, the man has mildly increased respiratory effort, but he does not appear in distress. He is barrel-chested. His breath sounds are diminished bilaterally, with dullness to percussion over the right and left lower lungs. No pleural friction rub is noted. On cardiovascular exam, an S3 gallop and mild tachycardia (110 bpm) are noted. Clubbing of the fingers, dependent edema in the lower extremities, and jugular venous distention are also noted. His cardiac enzymes and electrocardiogram demonstrate no acute cardiac pathology. Pleural fluid and cardiomegaly are found on the chest X-ray, and a thoracentesis is performed. The pleural fluid is generally clear in color, testing negative for chylomicrons and triglycerides. It has low levels of red blood cells, white blood cells, protein, and lactate dehydrogenase (LDH). What is the likely underlying mechanism for the pleural effusion in this patient? A. Chylothorax from disruption of the thoracic duct B. Empyema from infection in the pleural space C. Exudates from local inflammation in capillary beds D. Hemothorax E. Transudates from increased hydrostatic pressure or decreased oncotic pressure

E. Transudates from increased hydrostatic pressure or decreased oncotic pressure

A 28-year-old man comes to the urgent care center because of severe pain in his left thumb after he accidentally hit it with a hammer 30 minutes ago. Physical examination shows an intact nail plate with subungual hematoma occupying approximately one-third the diameter of his nail. X-ray study of the thumb shows no fracture. Which of the following is the most appropriate treatment for this patient's condition? A. Application of a compression dressing to the thumb B. Digital nerve block followed by removal of the nail plate C. Immobilization of the thumb in a short arm thumb spica cast D. Prescribe prophylactic antibiotics to reduce the risk of infection E. Trephination with electric cautery

E. Trephination with electric cautery

A 24-year-old female HIV-positive patient, who is not currently on medication, presents to the emergency department with acute dyspnea, tachycardia, fever, nonproductive cough, and a room air oxygen saturation of 92%. She admits feeling poorly for the past five days. A physical exam reveals bilateral basilar crackles. An x-ray reveals Pneumocystis jiroveci pneumonia. The patient has no drug allergies. Which of the following is the first-line treatment of choice? A. Amphotericin B B. Clarithromycin C. Clindamycin D. Pentamidine E. Trimethoprim-Sulfamethoxazole

E. Trimethoprim-Sulfamethoxazole

A 78-year-old man comes to the emergency department because of inability to urinate for the past six hours. He has a history of benign prostatic hyperplasia, but has always been able to void in the past. He has a history of hypertension which is well-controlled with hydrochlorothiazide. Physical examination shows suprapubic fullness and tenderness. Digital rectal examination shows an enlarged, nontender prostate. Which of the following is the most appropriate next step in management? A. Administration of oral doxazosin B. Administration of oral finasteride C. Follow up with urologist in 24 hours D. Insertion of a suprapubic catheter E. Urethral catheterization of the bladder

E. Urethral catheterization of the bladder

A 20-year-old woman presents with a rapid onset of nausea, headaches, fast breathing, and dilated pupils. Her sister thinks that the patient is exhausted from staying up several nights to study for final exams. The patient refused food several times, arguing that she did not have time to spend on anything but her studying; she even became aggressive when her roommates insisted on her going out to dinner with them. Upon physical examination, the patient seems tired and has a dry mouth; her body temperature is 99.8°F and her blood pressure is 135/85. The patient states that she took 2 acetaminophen pills the night before and in the morning to get rid of her headaches. What is the next step in the management of this patient? A. Rapid influenza test B. N-acetylcysteine C. Oral rehydration solution D. Urine HCG E. Urine drug test

E. Urine drug test

A 57-year-old female flight attendant comes to clinic with gradual onset of left leg pain, swelling and warmth. Physical exam reveals left calf tenderness with a palpable cord and increased warmth to the touch when compared to the right calf. Which of the following is the next best step in the evaluation of this patient? * A. ABI B. Contrast venography C. D-diner D. Impedance plethysmography E. Venous ultrasound

E. Venous ultrasound

Vitamin E deficiency symptoms

Hemolytic anemia in infants Labs showing low plasma tocopherol levels, low hemoglobin, reticulocytosis, hyperbilirubinemia and creatinuria

A 55-year-old Caucasian man was brought to the emergency department for evaluation of sudden chest pain. He was at a barbecue eating ribs when he developed sudden substernal chest pain with nausea and left arm numbness. An EKG demonstrated 2 mm ST elevations in leads V3, V4, and V5. He was diagnosed with acute myocardial infarction. Cardiology was consulted and angioplasty was recommended. The procedure and potential risks were explained in detail to the patient. The patient declined angioplasty, opting for medical therapy alone. He is discharged and dies a few hours after discharge. His family sues the PA and cardiologist for malpractice. What would need to be proven first for this malpractice case to be valid? A. Breach of duty B. Damage C. Establishment of care D. Incompetence E. Intent

A. Breach of duty

A 62-year-old woman well known to you presents with a severely itchy rash. The patient's medical history includes Parkinson's disease that was diagnosed around 7 years ago. The patient thought that the rash was just eczema initially, but the areas have morphed into severely tense, large blisters; they are extremely pruritic to the patient. On examination, you note multiple bullae 1-3 cm in size that are tense and appear to be sitting on an erythematous base. The bullae are located on the patient's lower abdomen in both lower quadrants and in the bilateral axillary and inguinal folds. What is the most likely diagnosis? A. Bullous pemphigoid B. Herpes Zoster C. Pemphigus vulgaris D. Tines corporis

A. Bullous pemphigoid

A 67-year-old man is recovering following an uncomplicated total hip arthroplasty. His past medical history is significant for hypertension and mild asthma. On postoperative day 2, he begins to note stiffness in his right leg. On exam, his right calf is noted to be swollen and slightly warmer than the left leg. The remainder of the exam is unremarkable. He is afebrile, and his vital signs are stable. What diagnostic evaluation is most appropriate in this situation? A. Compression ultrasonography B. Contrast venography C. Contrast-enhanced MRI D. Lower extremity x-ray E. Serum BNP measurement

A. Compression ultrasonography

A 3-year-old boy is admitted to the emergency room in acute respiratory distress. The patient has a body temperature of 40°C, a respiratory rate of 70/min, and a pulse of 130/min. Auscultations of the lungs are unremarkable. An examination of the throat reveals an exudate in the posterior pharynx that is yellowish and membranous. Bleeding occurrs when it is scraped and removed. The parents of the child reveal that the child has no prior immunizations. A throat culture was ordered and worked up specifically for an organism that selectively grows on cystine tellurite agar. What organism is causing this child's disease? A. Corynebacterium diptheriae B. Haemophilus influenza Type B C. Respiratory syncytial virus D. Bordatella pertussis E. Streptococcus progenies

A. Corynebacterium diptheriae

A family friend calls you for medical advice. She just gave birth to her third child 1 week ago. She is worried after a nurse from the hospital called her. The nurse said the baby tested high on a newborn screening for phenylalanine and that she would set up an appointment at a specialty center for the family. Your friend could not remember the name of the disorder, but she was told that it could prevent the infant from normal neurological development if left untreated. The friend reports that her pregnancy was uncomplicated and that the infant appears healthy so far. No one in the infant's immediate family has any health problems. What will most likely be the recommended treatment for the newborn's condition? A. Dietary restriction B. Oxygen therapy C. Surgery D. Administration of growth hormone

A. Dietary restriction

You are employed as a PA in a large fast-paced high-volume hospitalist practice that employs several PAs. The practice's patients include a mix of 60% covered by commercial insurance, 30% by Medicare, 5% by Medicaid, and 5% uninsured. One of your primary responsibilities is performing initial assessments of new patients admitted to the hospital in collaboration with a physician whose documentation is sufficient to permit shared billing. Although you dictate or record the patient's admission history and physical exam, the collaborating/supervising physician submits and determines the billing charges for the hospital admission. The practice administrators have instructed all of the PAs to always perform a complete review of systems so that the physician is free to bill the H&P at the highest level of medical complexity, if merited.One of your colleagues admits that they seldom perform a complete review of systems, instead only asking the patient, "Do you have any other symptoms?" If the answer is "No", your PA colleague indicates in their written note/dictation that "Twelve systems were reviewed and found to be negative, except as detailed in the history of present illness and past medical history." You PA colleague is in violation of a federal law regulating which general area of concern? A. False or fraudulent claims B. Hospital emergency departments C. Patient privacy D. Payment in exchange for referrals

A. False or fraudulent claims

A 5-year-old girl presents with a rash of clear and grayish vesicles on a reddened base. Her hands and feet are affected, including her palms and soles. She reports sores in her mouth. There is no desquamation to the rash. Her heart and lungs are clear. She is febrile, and there is an accompanying tachycardia. Her blood pressure is normal. Her oral cavity shows ulcerations. What is the most likely diagnosis? A. Hand-Foot-Mouth Disease B. Measles C. Kawasaki Disease D. Rocky Mountain Spotted Fever

A. Hand-Foot-Mouth Disease Kawasaki will have onset of fever before the rash and will have desquamation and eye involvement

A 24-year-old woman is evaluated in the endocrinology clinic. She is on 100 mcg of thyroxine per day for treatment of Hashimoto's thyroiditis and receives oral steroids for autoimmune adrenal insufficiency. In addition, she complains of fatigue, numbness, and tingling in her feet. When routine labs were drawn, the following values were noted: Hb: 9.9 g/dLMCV: 102 Iron indices: normal Folate: normal B12: low Parietal cell antibodies: high. What would prevent the development of megaloblastic anemia in this patient? A. Intramuscular injection of B12 B. Intravenous Folate C. Small dose of oral B12 D. Prescribed dose of oral ferrous sulfate

A. Intramuscular injection of B12

A 70-year-old African American man with a PMH of HTN x 23 years and type 2 DM x 20 years was admitted to the hospital due to a high-grade fever, nausea, infection, and severe back pain. Nearly 2 years prior, while walking down his steps, he fell without incurring any apparent fractures. Since then, he has been experiencing mild back pain that worsens when coughing.Physical exam is significant for pallor and hepatosplenomegaly. Skin exam is normal. Lab reports reveal low red blood cell count but normal neutrophil and platelet count. Renal function is decreased. The serum protein electrophoresis reveals the presence of paraprotein. Bone marrow biopsy reveals 50% infiltration by plasma cells. What is the most likely diagnosis? A. Multiple myeloma B. Waldenstrom's macroglobulinemia C. Monoclonal gammopathy of unknown significance D. Primary amyloidosis E. Polyclonal hypergammaglobulunemia

A. Multiple myeloma

A 43-year-old man visits the internal medicine clinic of a university hospital presenting with a 3-week history of shortness of breath, fever, and chills. Examination shows a temperature of 100.4 F. Laboratory results suggest hypoxemia with PO2 of 74. Previous history shows the patient has been HIV-1 positive for 4 years and presently has a CD4+ T-cell count of 50/mm3. A presumptive diagnosis of Pneumocystis carinii pneumonia (PCP) is made, which is confirmed by bronchoalveolar lavage. What would be expected from chest auscultation in this patient? A. No findings B. Tactile fremitus C. Bilateral rales D. Egophony E. Prolonged expiration

A. No findings

A 70-year-old African American man presents to his primary care provider with a complaint of gradual but progressive dyspnea and fatigue on exertion. He notes difficulty in climbing stairs with associated lightheadedness, increased abdominal girth, and swollen bilateral lower extremities. He admits to chronic alcohol use but denies any heart disease, chest pain or pressure, diaphoresis, palpitations, a history of diabetes, cigarette smoking, or claudication. His physical exam reveals sinus tachycardia, bibasilar rales, a laterally-displaced PMI, an elevated JVP, an S3 gallop, a mitral regurgitation murmur, peripheral edema, and abdominal ascites. What is the next step in the management of this patient? A. Obtain an echocardiogram B. Refer the patient for cardiac catheterization C. Perform cardiac biopsy D. Order cardiac troponin levels

A. Obtain an echocardiogram

A 21-year-old man presents with itchy skin changes. He works as a lifeguard. About a week ago, he noticed a round red patch on his belly that spread to his trunk and legs. He denies recent infections, allergies, and illnesses; he does not take any medications, and he admits that he occasionally smokes marijuana. The rest of his personal and family history is non-contributory. On examination, you find round annular scaly pruritic papulosquamous changes on his torso and legs. There are no changes on his mucosa, and the rest of physical examination is within normal limits. What is the next step in making the diagnosis? A. Potassium hydroxide preparation B. Skin biopsy C. Venereal disease research laboratory test D. I trader all prick test E. Tzank smear of lesion

A. Potassium hydroxide preparation

A 20-year-old woman presents to urgent care with the chief complaint of diarrhea for 4 days' duration. She describes the stool as greasy and foul-smelling. She has also experienced nausea, mild weight loss, and abdominal cramps. She denies tenesmus, urgency, or bloody diarrhea. She has no relevant past medical history. What might be elicited on further questioning? A. She drank steam water from a recent camping trip B. She visited Mexico for the weekend C. She was recently hospitalized for community-acquired pneumonia D. She went on a cruise ship for a 1-day excursion

A. She drank stream water from a recent camping trip Giardiasis - common in poor sanitary conditions and poor water treatment. Sxs are diarrhea,malaise, foul-smelling stools, nausea,flatulence and abdominals cramps

A 75-year-old African American man presents with a 5-month history of gradually progressive dyspnea that is especially pronounced when climbing stairs. He also has been noticing that his ankles and lower legs have "gotten larger" over roughly the same time period, which no longer allows him to fit into his sneakers. He denies fever, chills, chest pain, palpitations, cough, pleurisy, calf pain, abdominal complaints, sick contacts, or travel. His psychosocial history is noteworthy for chronic alcohol use. His physical exam reveals bibasilar rales, JVD of 5 cm, an S3 gallop, a holosystolic murmur at the apex that radiates to the left axilla, and 2+ pitting edema to the level of the mid-calves bilaterally. A bedside echocardiogram was remarkable for biventricular enlargement. What additional physical exam finding would be expected in this patient? A. Tachycardia B. Fever C. Warm, moist skin D. Acanthosis nigricans

A. Tachycardia

A 16-year-old Caucasian girl presents with a 6-month history of blackheads and whiteheads on her face. On examination, there are a few papules and pustules on her cheeks; there are no nodules. Her mother reports having similar spots on her face at this age. What is an appropriate first-line medication for this patient? A. Tretinoin B. Isotretinoin C. Doxycycline D. Triamcinolone

A. Tretinoin

A 28-year-old woman presents with bloody diarrhea for 1 week. After further questioning, she reveals that she had similar attacks in the past that subsided on their own. Her stool specimen is negative for ova and parasites. Stool culture did not grow any pathogens. A sigmoidoscopy is performed. There is friable erythematous mucosa extending from the rectum to the mid-descending colon, with broad-based ulcers in the descending colon. A biopsy taken from the rectum shows diffuse mononuclear inflammatory infiltrates in the lamina propria with crypt abscesses, but no granulomas are seen. What is the most likely diagnosis? A. Ulcerative Colitis B. Crohn's Disease C. Ischemic Colitis D. Amebic Colitis

A. Ulcerative Colitis

A 40-year-old woman is seen in the emergency department because of right upper quadrant pain and fever. She has been experiencing episodic epigastric pain over the past few months, but this is the worst her symptoms have been. She also reports anorexia and vomiting. She is in obvious distress. On physical examination, her doctor notes the presence of jaundice. Her lab results are as follows: Alkaline phosphatase: 89 U/L (normal: 20-70 U/L); Bilirubin (total): 3.8 mg/dL (normal: 0.2-1.5 mg/dL); AST: 50 U/L (normal: 10-40 U/L); ALT 70 U/L (normal: 10-60 U/L); amylase 35 U/L (normal 25-85 U/L); lipase: 80 U/L(normal: 0-160 U/L). What diagnosis is most likely to be the cause of. her symptoms? A. Cholelithiasis B. Cholangitis C. Pancreatitis D. Hepatocellular carcinoma

B. Cholangitis

A 6-week-old boy presents at your pediatric practice office, brought by his mother. She reports that for the past week he has not been feeding well and he breaks out into a cold sweat on his forehead while feeding. Upon further questioning, she reports that he becomes extremely breathless, irritable, and extremely pale after extended periods of crying.The mother reports a normal vaginal delivery and denies any problems with her son at the time of discharge from the hospital following his birth. She reports a family history of congestive heart failure. Vitals are as follows: pulse 130-regular, respiration 34-regular, blood pressure R arm 96/62 L arm 92/54 and R leg 70/42 L leg 74/40. Cardiac exam reveals 4+ carotid pulses bilaterally, 2+ brachial pulses bilaterally and absent femoral pulses bilaterally. A loud harsh systolic ejection murmur is noted at the base of the heart. The EKG reveals normal sinus rhythm with left ventricular hypertrophy. What is the most likely diagnosis? A. ASD B. Coarctation of the Aorta C. Pulmonary stenosis D. Tetralogy of Fallot E. VSD

B. Coarctation of the Aorta

A 35-year-old woman presents to your outpatient clinic due to left knee pain. She slipped on ice and struck her knee several days ago; pain has persisted since her fall. Her physical exam is remarkable for a large knee effusion, tenderness to palpation, and decreased range of motion. As part of your investigation, you decide to obtain an X-ray of her left knee. When ordering her X-ray, you inadvertently order an X-ray of her right knee. What is the most appropriate action to take regarding this error? A. Contact the patient and explain the error was with the radiology service B. Contact the patient yourself and explain the imaging order error C. Contact your medical legal department for the advice before proceeding D. Instruct your staff to contact the patient to obtain new imaging E. Order new images without disclosing the error to the patient

B. Contact the patient yourself and explain the imaging order error

An 86-year-old man was recently admitted to the hospital for diastolic congestive heart failure exacerbation. His code status was not addressed before his admission. He was later intubated due to cardiogenic shock and his family was notified of his admission. A meeting was convened with the patient's hospitalist team, his close friend, and his family to discuss the patient's medical wishes.His recently divorced wife brought in his will expressing his wishes not to be intubated.His close friend brought a document expressing that the patient wants all lifesaving measures.His son expressed that the patient does not want to be intubated in past conversations.His daughter believes that the patient wants to be intubated to "live as long as he can." What should occur regarding this patient's care? A. Continue all care B. Discuss with hospital ethics committee C. Extubate and start ACLS D. Keep him incubated E. Withdrawal all care

B. Discuss with hospital ethics committee

A 62-year-old woman presents to her physician with persistent reflux symptoms despite medical management. An upper endoscopy is performed, revealing the attached image. Biopsy findings reveal replacement of the esophageal squamous epithelium with columnar epithelium. What is the most serious complication of her disorder? A. Peptic stricture B. Esophageal adenocarcinoma C. Esophageal rupture D. Gastric adenocarcinoma

B. Esophageal adenocarcinoma

An obese 45-year-old woman presents with intermittent epigastric pain of 3 weeks duration. She explains that her pain worsens in the evenings and when lying down in bed. Her pain worsens when she eats chocolate. Upon physical exam, temperature is 98.1°F, blood pressure is 120/80 mm Hg, and there are no signs of epigastric pain on light or deep palpation. What is the most likely diagnosis? A. Esophageal spasm B. Gastroesophageal reflux disease C. Stable angina D. Zenker's diverticula

B. Gastroesophageal reflux disease

A 42-year-old man presents with a 10-day history of worsening headache, stuffy nose, greenish nasal discharge, and a low grade fever. He has body aches and facial pain, as well as a dry cough. He denies shortness of breath, abdominal pain, nausea, or vomiting. He is a non-smoker, has no significant past medical history, and is only taking acetaminophen. On exam, he has a temperature of 100.9°F taken orally. Pulse is 86/min, BP is 120/76 mm Hg left arm sitting, and SPO2 is 94% on room air. Lungs are clear and abdomen normal. Nasal mucosa appears boggy, and there is tenderness with palpation over the facial bones (maxillary area). Pharynx is without exudates. What component of the history supports your decision to prescribe antibiotics for this patient? A. Facial pain, body aches and SpO2 of 94% B. Length of time the symptoms have been present C. Boggy nasal mucosa and facial tenderness D. Low-grade fever

B. Length of time the symptoms have been present

A 24-year-old man presents with a 2-day history of skin rash on his back. He notes pain in his joints and tiredness. He has just returned from a camping trip. Vital signs are normal. Examination reveals an expanding lesion with a concentric circle of erythema. If left untreated, what is a complication of early dissemination of this condition? A. Endocarditis B. Myocarditis C. Restrictive cardiomyopathy D. Fibromyalgia

B. Myocarditis

A physician assistant has just joined a family medicine practice that has been around for more than a decade. This practice consists of a family medicine physician and a nurse practitioner. The physician assistant was asked to review two candidate applications for the position of receptionist. He notices that one candidate has the same last name as the physician. The candidates are both reviewed by the physician. The next morning, the new receptionist reveals that the physician is their cousin. What best describes this scenario? A. Fraud B. Nepotism C. Outside employment D. Recusal

B. Nepotism

A 39-year-old Caucasian man presents with a "lump in his left ear canal." He just wants to confirm it is not a type of tumor. Otoscopic examination reveals a single discrete pedunculated flesh-colored bony mass located at the 7 o'clock position in the left external auditory canal. The right external ear canal was unremarkable. You tell the patient that the lump in his ear canal is indeed classified as a tumor but is completely benign. What is this lump called? A. Keratoacanthoma B. Osteoma C. Pilomatrixoma D. Sebaceous adenoma E. Squamous papilloma

B. Osteoma

A 50-year-old woman has had a facial rash and a 10-year history of reddening of her face that comes and goes. On physical exam, you note erythema, telangiectasia, red papules, and tiny pustules on both cheeks. What is the most likely diagnosis? A. Personal dermatitis B. Rosacea C. Seborrheic dermatitis D. Atopic dermatitis

B. Rosacea

An 8-month-old male infant presents with rashes over the scalp and eyebrows. Physical examination shows a dry scaly crusting lesion over the scalp, eyebrows, and nape area. He is comfortable, so his mother presumed that it was not itchy at all. He has been breastfed up to this point, and he started solid food at about 5 months. There are no other signs or symptoms noted. Bowel movement and urination are normal. Developmental milestones are consistent with age. What is the most likely diagnosis? A. Atopic dermatitis B. Seborrheic dermatitis C. Psoriasis D. Candidiasis

B. Seborrheic dermatitis

A 29-year-old man is seen in the clinic for groin pain. He works as a cashier at a local supermarket. The pain increases through the day. When asked to point out its location, he localizes it to his left groin fold. Examination of his inguinoscrotal region reveals an ill-defined tortuous swelling that increases with standing. What is the next step in diagnosis? A. Diagnostic laparoscopy B. Ultrasound C. Venography D. CT E. MRI

B. Ultrasound

A 47-year-old Latina woman presents with a 2-month history of persistent abdominal pains. She becomes uncomfortable after eating, especially after consuming fats, eggs, chocolate, fried foods, fatty foods, and rich desserts. Her pains are primarily located in her right upper abdominal quadrant and often radiate to her right shoulder blade. Physical examination is essentially unremarkable. Blood pressure is 122/82 mm Hg, she has a pulse of 72 per minute, and a temperature of 98.6°F with respirations 16 per minute. Her abdominal examination reveals no tenderness, no guard, no rebound, and normally active bowel sounds. Her liver and spleen are not palpable. She has no readily palpable abdominal masses. She is not jaundiced. She has no scleral icterus. What test should be given to confirm the probable diagnosis? A. Oral cholecystogram B. Ultrasound abdomen C. CT scan abdomen D. Biliary scintigraphy E. MRI abdomen

B. Ultrasound abdomen

A 43-year-old man arrives at the emergency department via ambulance. His wife indicated that she found him lying on the living room floor when she came home from running errands around town. She also stated that he seemed "fine" before she left approximately 2 hours prior. He has a history of acid peptic disease. Upon arrival, he is conscious and indicates that he became dizzy upon standing. For the last couple of days, his stools have been coffee ground in color and he has had increasingly worse upper middle abdominal pain and nausea. His vitals are BP 90/48 mm Hg, pulse 145/min and thready, respirations 24/min, and pulse oximetry 88%. You order a hemoglobin and hematocrit, and the results are 8.2 g/dL and 24.8%, respectively. You review his records and find that 2 weeks ago his H&H was 15.6 g/fL and 48.2%, respectively. What is your initial assessment? A. Acute upper GI bleed d/t noncompliance with treatment B. Stool color change due to Pepto-Bismol treatment C. Acute massive hemorrhage due to perforation D. Diverticula bleed

C. Acute massive hemorrhage due to perforation A complication of peptic disease is commonly perforation, and given the patients dramatic drop in Hgb and HCT, this is consistent with significant blood loss

An 80-year-old woman has a history of a myocardial infarction about 5 weeks ago. The patient now presents to the ED with a history of congestive heart failure with symptoms of shortness of breath and peripheral edema, which appear to be worsening since her MI. An ECG is conducted, which reveals a prior inferior wall infarct. Cardiology is consulted where a 2-dimensional echo is conducted, displaying severe leaflet tethering and an enlarged left ventricle. What structure is most likely to be affected? A. Chordae tendineae B. Intraventricular septum C. Mitral valve D. Pulmonic valve E. Tricuspid valve

C. Mitral valve

A 24-year-old Muslim woman with no past medical history presents to establish care. She is dressed in a burka. She is given paperwork but does not fill it out. She enters the room and waits for the provider. A physician assistant enters the room several minutes later and introduces themselves. In presence of a nurse, the PA instructs the patient to change into a gown. The physician assistant returns several minutes later with the nurse and sees that the patient is still in her burka. She asks the patient why she did not change into the gown, but the patient does not respond. What should be done next? A. Allow the nurse to speak with the patient privately B. Enunciate more slowly for the patient to understand C. Find an interpreter for the patient D. Offer to reschedule the appointment E. Proceed with the physical exam

C. Find an interpreter for the patient

An 8-year-old girl presents with a 3-day history of fever, generalized muscle weakness, bilateral knee pain, and chest pain. You suspect acute rheumatic fever (ARF). What illness, contracted about 1 month ago, would support the suspected diagnosis of Acute Rheumatic Fever? A. E. coli infection B. Haemophilus influenza infection C. Group A Streptococcus infection D. Helicobacter pylori infection

C. Group A Streptococcus infection

An 8-year-old child is brought to your office because of swelling of the left upper eyelid; the swelling is associated with redness and tolerable pain. No fever is noted. Physical examination shows a localized swelling and redness on the upper middle lid of the left eye; there is slight tenderness on palpation. Vital signs are within normal limits. What is the most likely diagnosis? A. Chalazion B. Blepharitis C. Hordeolum D. Ectropion

C. Hordeolum

A 66-year-old man presents with a 2-month history of bone pain and weight loss. Lytic lesions were discovered on a routine X-ray. You order additional lab work. What electrolyte imbalance would you most likely find in this patient? A. Hypokalemia B. Hyponatremia C. Hypercalcemia D. Hypocalcemia

C. Hypercalcemia

A 49-year-old man presents with chronic fatigue, headache, fevers, and muscle and joint pain. He describes the initial rash occurred on his arm with a red circular rash with central clearing. He describes transient "reddish spots" that can be quite large and have appeared on his skin then faded away. His symptoms developed about 4 months ago with no apparent cause; they have gradually gotten worse with the recent addition of the musculoskeletal pains. He is married and monogamous, and he lives in a small rural community; nevertheless, he is concerned that he may have somehow contracted a communicable STD. What condition is causing the patient's symptoms? A. Acute rheumatic fever B. Lyme disease C. Malaria D. Polymyalgia rheumatica

C. Lyme disease

A 36-year-old woman presents with chronic dyspnea that is worse while lying prone. The patient reports progressive worsening of the symptoms. On physical examination, a heart murmur is detected upon cardiac auscultation, heard best with the bell over the apex. The murmur is a non-radiating low-pitched diastolic rumble. A loud S1 and opening snap can also be heard in addition to an apical thrill and decreased pulse pressure. An EKG is done and shows atrial fibrillation. What is the patient's most likely underlying condition? A. Aortic regurgitation B. Pulmonic stenosis C. Mitral stenosis D. Hypertrophic subaortic stenosis E. Mitral valve prolapse

C. Mitral stenosis

You are employed as a PA in a large fast-paced high-volume hospitalist practice that employs several PAs. The practice's patients include a mix of 60% covered by commercial insurance, 30% by Medicare, 5% by Medicaid, and 5% uninsured. One of your primary responsibilities is performing initial assessments of new patients admitted to the hospital in collaboration with a physician whose documentation is sufficient to permit shared billing. Although you dictate or record the patient's admission history and physical exam, the collaborating/supervising physician submits and determines the billing charges for the hospital admission. The practice administrators have instructed all of the PAs to always perform a complete review of systems so that the physician is free to bill the H&P at the highest level of medical complexity, if merited.One of your colleagues admits that they seldom perform a complete review of systems, instead only asking the patient, "Do you have any other symptoms?" If the answer is "No", your PA colleague indicates in their written note/dictation that "Twelve systems were reviewed and found to be negative, except as detailed in the history of present illness and past medical history." You PA colleague is in violation of a federal law regulating which general area of concern? A. Apply TCA or BCA B. Cryotherapy of bullous lesions C. Oral Prednisone D. Topical Acyclovir

C. Oral Prednisone

A 45-year-old man is evaluated for a 6-month history of palpitations, easy fatigability, and chest pain on exertion. He does not smoke or consume alcohol; he has no significant past medical history. His body weight has remained stable. He has spent the last 2 years traveling the world. His wife says that he eats "unhealthily." He is a strict vegan, consumes a lot of snacks, and has never taken any vitamin supplements. Examination shows a 5'7" male with a BMI of 19. His BP is 130/70 and pulse 90/min; his temperature is 98.4°F. Conjunctival pallor is present. Auscultation shows a grade 2/6 murmur ejection systolic murmur heard all over the precordium. Lab investigations are sent and are given below: Hb: 8.8 g/dL (normal 13 - 17 g/dL) WBC: 6000/mm3 (Normal 4500 - 10,500 cells/mm3) MCV: 72 (Normal 80 - 100_ Ferritin: low TIBC: elevated Stool occult blood: negative ESR: 8 mm/hour (normal < 17 mm/hr) TSH: normal What is the most appropriate medical therapy? A. Oral folate with B12 B. Intramuscular iron dextran C. Oral ferrous sulfate D. Packed red cell transfusion

C. Oral ferrous sulfate

A 67-year-old woman presents; according to her, her husband says she never listens to anything he says. The patient states that occasionally she has to ask people to repeat themselves when sitting to her right. She denies any dizziness, headaches, or visual disturbances. Her current medication is furosemide. On physical examination, the Weber test reveals lateralization to the left ear. On the left ear, air conduction lasted for 15 seconds and bone conduction lasted 10 seconds. On the right ear, air conduction lasted for 22 seconds and bone conduction lasted 10 seconds. What is the most likely cause of this hearing loss? A. Cerumen impaction B. Otosclerosis C. Ototoxicity D. Ménière's disease E. Middle ear effusion

C. Ototoxicity

A 48-year-old Caucasian man presents with acute onset of blurring of vision and severe pain in the left eye that began 30 minutes ago. He notes seeing halos with his left eye. He is also experiencing nausea and vomiting. These symptoms started at the same time as the pain. The patient reports that he was relaxing on his porch when the pain started. His temperature is 36.9°C, pulse 90/min, BP 130/90 mm Hg, and respirations 20/min. Physical examination reveals a shallow anterior chamber, a hazy cornea, a fixed, moderately dilated pupil, and ciliary injection. What would be the next step in the management of this patient A. X-ray to rule out foreign body B. Topical atropine to the eye to facilitate ophthalmoscopy C. Tonometry D. Discharge with topical antibiotic drops for the eye

C. Tonometry

A 32-year-old woman presents with a 1-month history of bleeding gums when brushing her teeth. She also reports that her wounds are taking longer than usual to heal. She is a stay-at-home mother and is breastfeeding her 6-month-old twins. On examination, you note multiple splinter hemorrhages on her nails and ecchymoses over her lower limbs. What is the most likely diagnosis? A. Vitamin A deficiency B. Pyridoxine deficiency C. Vitamin C deficiency D. Niacin deficiency E. Vitamin E deficiency

C. Vitamin C deficiency Bleeding tendencies and impaired wound healing d/t impaired formation of connective tissue (Ex: bleeding gums with teeth brushing, splinter hemorrhage's on nails and ecchymoses); d/t inadequate dietary intake (fruits, tomatoes and potatoes)

An 18-year-old woman presents with chronic fatigue and menorrhagia. Menorrhagia has been present since her first menstrual cycle, but it has recently become worse; she sometimes uses 20 tampons per day. About a year ago, she started using contraceptive pills but is now considering stopping using them because of migraine-like headaches. Her headaches are sometimes so severe that she has to take aspirin or other painkillers several times a day. The rest of her past medical history is unremarkable.Physical examination reveals pale skin and mucosa, pulse rate of 100 beats per minute, and a systolic ejection murmur 1/3 intensity over the precordium. Laboratory findings include a normal white blood count, a decreased hemoglobin of 10, a normal platelet count of 250 K, normal prothrombin time, slightly prolonged partial thromboplastin time, and normal fibrinogen. Her bleeding time is prolonged. Blood smear shows microcytic hypochromic anemia. What is the most likely diagnosis? A. Endometriosis B. VSD C. Von Willebrand Disease D. Hemolytic uremic syndrome E. Hemophilia A

C. Von Willebrand Disease

Cardiogenic shock

Causes: myopathy, mechanical or arrhythmic issues Lack of blood to pump through the circulatory system Sxs of MI as well as condition worsens after fluid resuscitation

A 66-year-old woman with a history of a multinodular goiter presents to the office after a recent hospitalization for a newly diagnosed cardiac arrhythmia. She relates that she has continued to see the cardiologist and is being treated with an oral medication. She denies any symptoms of hyper or hypothyroidism. She denies any change in the size of her gland or associated dysphagia or dyspnea. Thyroid function studies continue to remain in the normal range. When following this patient with multinodular goiter, what cardiac drug should be avoided or monitored closely? A. Propranolol B. Flecainamide C. Sotalol D. Amiodarone E. Mexiletine

D. Amiodarone It is an iodine-containing class III antiarrhythmic and inhibits peripheral conversion of T4 to T3 as well as exposes the thyroid to a potentially large source of iodine

A healthy mother with no known medical illnesses presents her 6-month-old male infant due to a 1-day history of poor feeding, lethargy, and weak cry. At first, the infant had difficulty sucking and swallowing and was not opening his eyes. This was followed by loss of head control, weakness of the trunk, arms, and then legs. The infant is constipated and has had decreased tears and saliva since yesterday. The infant was healthy before the onset of these symptoms. There is no history of fever, vomiting, cough, seizures, or difficulty in breathing. The infant has weak gag and pupillary reflexes, generalized hypotonia, loss of head control, ptosis, and diminished deep tendon reflexes. Blood counts and CSF examination are within normal limits. What is the most likely diagnosis? A. Myasthenia Gravis B. Spinal muscular atrophy C. Guillain-Barré syndrome D. Botulism

D. Botulism

A 27-year-old man presents with the "flu." He says that he has felt feverish, tired, and mildly nauseated for the past few weeks. He mentions a headache and non-pruritic rash. He denies any past medical history or medication use.On exam, he is afebrile. Examination reveals diffuse mild lymphadenopathy with mild hepatosplenomegaly; his soft palate has a few scattered shallow ulcerations. The palmar and plantar surfaces have a scattered papular rash that is copper colored, with a few papules on the flexor surfaces of the arms, legs, and trunk. Laboratory evaluation reveals hemoglobin of 12.8 g/dL (normal 13.8 - 17.2 g/dL), hematocrit of 38% (normal 41-50%), and white blood cell count of 11.1 cells/mm3 (normal 4.5 - 10.4 cells/mm3). What is the most likely diagnosis? A. Influenza B. Rocky Mountain Spotted Fever C. Hand-Foot-and-Mouth Disease D. Secondary syphillis E. Streptococcal pharyngitis

D. Secondary syphillis

A 28-year-old man presents with a rash. The lesions, which are mildly pruritic, are located on his arms and legs. They have been present for about 3 days without change or resolution. He has tried over-the-counter anti-itch creams, but they have been ineffective. The patient reports that he was seen approximately 1 week ago for some blister-like lesions on his penis. He was given an antiviral medicine, and those lesions resolved. He is wondering if he was misdiagnosed and if the two rashes are related. He admits to feeling some malaise over the last 2 weeks, but he is otherwise healthy. He denies fevers, unusual travel, medication use (except for as listed above), and known allergies. He has no known chronic conditions.On physical exam, vitals are normal; the patient is in no apparent distress. A pink-to-red papular rash is observed on the backs of the hands and feet and extensor surfaces of the arms and legs. The individual lesions are quite distinct; they have a red center, and they are surrounded by a pale ring and then another outer ring of red, inflamed tissue. The remainder of his physical exam is normal. What test will confirm the suspected diagnosis? A. Fungal culture B. Herpes culture C. Heterophile antibody D. Skin biopsy

D. Skin biopsy Pt has erythema multuforme

A 38-year-old man presents with a 2-day history of a mass and severe pain in his scrotum. Physical examination reveals that his right testicle appears much larger than his left. On palpation, you note a small hole in his inguinal canal, and you are unable to place the contents into the canal. The contents of the hernia appear ischemic. What is the best description of this hernia? A. Reducible B. Recurrent C. Irreducible D. Strangulated E. Incarcerated

D. Strangulated

A 10-year-old boy presents with a 1-week history of a rash on his scalp. His mother states that the boy has been scratching his head often, and she notes that there are areas where his hair appears to have fallen out. She attempted to treat it with over-the-counter preparations, but his condition has not improved. The boy is active and otherwise healthy.The rash appears as erythematous, circular, scaly patches. There are areas where the hairs have become brittle and broken off. A scraping of one of the patches is placed in potassium hydroxide solution and shows hyphae. What is the most likely diagnosis? A. Vitiligo B. Tinea versicolor C. Psoriasis D. Tinea capitis E. Seborrheic dermatitis

D. Tinea capitis

A 54-year-old man presents after having a generalized seizure. The patient is HIV-positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inquiry, the patient also notes that he has become short-tempered and hypercritical; at times he seems confused. An MRI of the brain is performed, and it reveals several cortical ring-enhancing lesions. What is the most likely diagnosis? A. AIDS dementia complex B. Cryptococcal meningitis C. Cytomegalovirus encephalitis D. Toxoplasma encephalitis

D. Toxoplasma encephalitis

You are a PA in the emergency department (ED) of a community hospital. A 70-year-old woman comes in for evaluation of hematochezia for 1 day associated with dizziness. She is found to have a blood pressure of 100/55 mm Hg, heart rate 110 bpm. Her hemoglobin is 6.0 g/dL, and hematocrit is 20.1%. In the ED, she is observed to have several bloody bowel movements of hematochezia. She presents a durable power of attorney card that states she declines transfusion and identifies her as a Jehovah's Witness. After a lengthy discussion about the diagnosis of gastrointestinal (GI) bleed and the risk of death if she does not receive a transfusion, she still declines blood. What is the most appropriate next step in her management? A. Call hospital administrator to discuss transfusion B. Call hospital legal team to discuss implications of transfusion C. Discuss with family privately to obtain their consent D. Order whole blood and transfuse patient E. Treat with supportive measures

E. Treat with supportive measures

A 6-year-old boy presents with his mother who is concerned because he wets his bed 2-3 times a week at night. He has no urinary symptoms during the daytime. He is the second child of three. He is in the first grade and is struggling with his performance. He has had no medical problems; there is no history of developmental delay, and he was the product of a normal uncomplicated pregnancy and delivery. Since the birth of the third child, his behavior has been poor. The vital signs are normal, and examination of other body systems is unremarkable. What investigation is most important in this child's workup? A. GU referral B. Intravenous pyelography (IVP) C. Renal ultrasound D. Urine culture E. Urinalysis

E. Urinalysis

An 18-month-old child presents with a 2-day history of fever that is currently 101°F rectally. You symptomatically treat the patient and ask the mother to return if the condition worsens. he mother returns 2 days later because the child has developed small red spots that became bumps and are now blisters. The mother also noted the child was scratching the lesions. Physical exam reveals macules, papules, and vesicles are on the face and thorax bilaterally. Each vesicle resides on its own erythematous base. What is the most likely diagnosis? A. Shingles B. Ramsey-Hunt syndrome C. Erythema infectiosum D. Primary herpes simplex E. Varicella

E. Varicella

A 72-year-old man is admitted with an acutely severe myocardial infarction. His status quickly deteriorates. His symptoms include hypotension, altered mental status, cold clammy skin, and metabolic acidosis seen on laboratory tests. What is the most appropriate initial pharmaceutical choice for a patient in this type of shock? A. Aspirin B. Clopidogrel C. Lidocaine D. Beta blockers E. Vasopressors

E. Vasopressors

Vitamin A deficiency symptoms

Inability to see well in dim light or night blindness Conjunctival and corneal xerosis Hyperkaratotic skin lesions