ROSH questions (Cardio, Pulm, GI, MSK)

Which of the following is a risk factor for developing Kawasaki disease?

4 years of age

Which of the following is the most common surgical emergency in pregnant women?

Appendicitis

A 22-year-old woman with a history of homozygous sickle cell disease presents to the office with reports of slowly worsening pain in her right anterior groin for the past few months. She states her pain is worse with walking. All vital signs are within normal limits, and she is afebrile. On exam, the patient has an antalgic gait. Her range of motion is decreased overall and is most marked on abduction. Pain is noted with passive and active range of motion and is worse with internal and external rotation of the hip. She is nontender to palpation of the hip and knee joints. Which of the following is the most likely cause of her pain?

Avascular necrosis

Which of the following is a risk factor associated with the development of pancreatic cancer?

Cigarette smoking

Which of the following best describes the rhythm seen in the ECG above?

Complete heart block

Aortic stenosis can lead to which of the following general patterns of left ventricular remodeling?

Concentric left ventricular hypertrophy

A 35-year-old man with a history of gastroesophageal reflux disease presents to the emergency department with chest pain and fever. An outpatient esophagogastroduodenoscopy was performed three days ago and revealed no gastric ulcers. On exam, he is ill-appearing and tachycardic. Which of the following is the next best step in management of this patient?

Consult thoracic surgery

A 3-year-old boy presents after swallowing a quarter. He now feels it is stuck. At which location is an obstruction most likely to occur?

Cricopharyngeus muscle *esophageal ingestion not respiratory aspiration of foreign body

Of the following, which is the most common infectious etiology of diarrhea in patients with AIDS?

Cryptosporidium

You prescribe ramipril to a 65-year-old man with uncontrolled hypertension and severe renovascular disease. At a follow-up visit four weeks later his creatinine is noted to be 2.3. His creatinine before starting the ramipril was 1.0. By what mechanism did the ACE inhibitor cause this change?

Decreasing glomerular blood flow

A 67-year-old man with diabetes mellitus, chronic lower back pain and previously stable systolic heart failure now has increasing orthopnea and shortness of breath. Physical exam reveals pulmonary crackles, jugular venous distention and lower extremity edema. He is on carvedilol, lisinopril, furosemide, insulin and ibuprofen. Which of the following is appropriate for management of this patient?

Discontinue the ibuprofen Non-steroidal anti-inflammatory drugs (e.g. ibuprofen) can worsen symptoms of heart failure

25-year-old truck driver presents with a 1-day history of throbbing rectal pain. Your examination shows a large thrombosed external hemorrhoid. Which one of the following is the preferred initial treatment for this patient?

Elliptical excision of the thrombosed hemorrhoid <72 hours thats the 1st line treatment

Which one of the following tests can be used to confirm lactose intolerance?

Hydrogen Breath Test

An 80-year-old man who presents to the emergency department with a complaint of sudden onset left-sided abdominal pain and bloody diarrhea. Abdominal CT demonstrates thickening of the bowel wall and free peritoneal fluid. What is the most likely diagnosis?

Ischemic colitis

You perform an arthrocentesis on a patient with knee pain. Synovial fluid analysis reveals a WBC of 5,000 cells/µL with 70% polymorphonuclear leukocytes. Which of the following is the most likely diagnosis?

Inflammatory arthritis

Which of the following confirms an intrauterine pregnancy?

Intrauterine fetal pole and yolk sac

What is the most common cause of intestinal obstruction in children under two years of age?

Intussusception

52-year-old man with a long history of alcohol use disorder presents with epigastric pain and vomiting. You diagnose him with pancreatitis. Which of the following laboratory values is associated with an increased risk of mortality on admission?

LDH 400 IU/L

66-year-old woman has been on estrogen-replacement therapy for nine years. Her social history is significant for 20 years of heavy alcohol use and 30 years of tobacco use. Her family history is positive for familial adenomatous polyposis. Which of the following organs is most likely to undergo malignant transformation due to this patient's alcohol use?

Liver

Which of the following diagnostic studies has the highest sensitivity to evaluate for acute radiculopathy?

Magnetic resonance imaging

Which of the following is true regarding intestinal intussusception?

Most adult cases are in small intestine

A 51-year-old man presents to emergency room with severe pain in his right great toe. He has a history of chronic gout and has had multiple, similar flares. He recently began taking a new medication to control his cholesterol. Which of the following medications did this patient most likely begin taking?

Niacin

A woman complains of her heart racing, facial flushing and headache after taking an unknown pill in her purse. Which of the following is the most likely medication?

Nitroglycerin

Which of the following is true regarding diverticulitis?

Oral antibiotics can be held in uncomplicated diverticulitis

Which of the following correctly describes a positive straight leg raise?

Pain in the back which radiates past the knee when raising the symptomatic leg 45 degrees

Which of the following is the most predictive risk factor for cardiac ischemia?

Past medical history of coronary artery disease

A 14-year-old boy presents to clinic with a one month history of right shoulder pain. The patient is a competitive tennis player. Symptoms began during a match when the patient was serving. He experienced a pop in the shoulder and had immediate pain. Magnetic resonance imaging of the shoulder shows a superior labral tear from anterior to posterior (SLAP lesion). Which of the following is the most likely physical exam finding?

Positive O'Brien test

Which of the following conditions most commonly results in symptomatic hemorrhoids?

Pregnancy

An 81-year-old man presents to the Emergency Department in respiratory distress. He is sitting upright and appears anxious, dyspneic, and diaphoretic. Vital signs show blood pressure of 190/110 mm Hg, heart rate of 130 beats/minute, respiratory rate of 35 breaths/minute, and oxygen saturation of 85% on room air. Which of the following physical examination findings most strongly suggest heart failure as the cause of his respiratory distress?

Presence of a third heart sound

60-year-old woman with a history of heart failure presents with substernal chest pain that awoke her from sleep. She has dysphagia when swallowing solids and odynophagia when swallowing both solids and liquids. She reports a history of chest pain in the past but states that this pain is different in that it is sharp and occurs only after swallowing. Her medications include metoprolol succinate, furosemide, potassium chloride, simvastatin, isosorbide dinitrate, and levothyroxine. Which of the following is most likely to lead to the correct diagnosis?

Questioning her about her medication use

A 37-year-old man presents with cough and shortness of breath. Vital signs are T 102°F, BP 110/76, HR 108, RR 20, and oxygen saturation of 92% on room air. His chest X-ray is shown above. Which of the following helps determine the causative organism?

Recent influenza infection Lung abscess (cavitary lesion)

68-year-old woman presents with cough that has been present for the past several months. She describes it as a dry, hacking cough that she attributed to her cigarette smoking. A chest X-ray is completed that shows a 2.5 cm mass in the peripheral right lower lobe. Sputum cytology is performed and is negative for malignant cells. What is the next best step in managing this patient?

Refer for transthoracic needle aspiration

Which nerve root is affected in a patient with loss of the ankle jerk reflex?

S1

xray of distal tibial fracture, below the growth place Which one of the following best classifies this fracture?

Salter Harris Type III

Which of the following describes a burn that causes pressure and discomfort, extends into the dermis, and may have thick-walled blisters or be leathery white?

Second-degree deep partial-thickness burn

An 85-year-old nursing home patient presents with diffuse abdominal pain and distension and nausea, but no vomiting. The above abdominal radiograph is obtained. What is the management of this patient?

Sigmoidoscopy

For patients with lactose intolerance, in which of the following parts of the gastrointestinal tract does malabsorption of lactose occur?

Small intestine

Which of the following is a risk factor associated with the development of pancreatic cancer?

Smoking

What is the most common causative organism in community acquired pneumonia?

Streptococcus pneumoniae

A soccer player presents to the emergency department after being kicked in the shin by his opponent an hour ago. Upon presentation he is diaphoretic and screaming in pain. You assess his lower extremity range of motion and notice that he has extreme pain with passive range of motion of his foot. He complains of numbness and has 1+ distal pulses on the affected limb. What is the best treatment for this patient?

Surgical fasciotomy

Which of the following is used to measure the pulmonary artery wedge pressure?

Swan-Ganz catheter

Which one of the following cardiac dysrhythmias is associated with antipsychotic use?

Torsades de pointes

Which of the following treatments is contraindicated in the treatment of a 5-month-old with supraventricular tachycardia?

Verapamil

A 60-year-old missionary woman is being evaluated for dementia. She also has diarrhea. She was recently treated for tuberculosis with isoniazid. Physical examination shows a symmetric hyperpigmented rash on both arms. Deficiency of which of the following vitamins most likely resulted in this patient's condition?

Vitamin B3

Which one of the following groups of lab results is most consistent with a complication that commonly occurs 6 to 12 weeks after acute hepatitis?

WBC decreased, RBC decreased, platelets decreased Aplastic anemia can happen

54-year-old man presents to the clinic to establish care. His medical history includes diabetes mellitus, hypertension, COPD, and tobacco use disorder. Medications include enalapril, metoprolol, metformin, sitagliptin, formoterol, and as-needed albuterol. The patient does not recall receiving any vaccines in the past. Vitals reveal HR 94 bpm, RR 18/min, BP 122/85 mm Hg, T 98.8°F, and SpO2 95% on room air. Physical exam reveals a barrel-chested man in no acute distress without labored breathing. Which of the following vaccines is most appropriate for this patient to prevent pneumococcal disease?

20-valent pneumococcal conjugate vaccine

xray of fractured radius A 72-year-old woman presents to the emergency department after falling while she was leaving church this morning. She was holding a cane in her left hand and fell onto the dorsum of the hand. She reports pain and difficulty moving the left hand and wrist. On physical examination, she has moderate swelling and ecchymosis over the left wrist. There is tenderness to palpation over the distal radius. The radial pulse is intact, and there is normal capillary refill in her fingers. She has intact sensation to light touch and pin-prick over her fingers and is able to flex, extend, and abduct her fingers and oppose her thumb, although with pain. An X-ray of the wrist is obtained and is shown above. In addition to elevation, ice, and pain medication, application of which of the following is the most appropriate initial treatment?

A sugar tong splint

A 26-year-old-man with no significant medical history was jogging 3 days ago when he tripped and fell, hitting his chest on a concrete curb. He presents to urgent care with symptoms of continued discomfort over his chest and difficulty taking a deep breath due to pain. He reports no cough or fever. He has been using acetaminophen and ibuprofen for pain with minimal relief but takes no other medications. His blood pressure is 112/80 mm Hg, heart rate is 62 bpm, respirations are 18/min, SpO2 is 100% on room air, and temperature is 98.6°F. Breath sounds are clear without rales, rhonchi, or wheezing, but they are dull in the bilateral bases. His left anterior fifth to ninth ribs are tender to palpation. Chest X-ray shows a nondisplaced fracture of the anterolateral aspect of the left seventh rib and atelectasis in the lung bases bilaterally. What is the most essential intervention to prevent pulmonary complications in this patient?

Adequate pain control

A 10-week-old boy is brought to the emergency department in late December by his mother who reports that he has had difficulty breathing for the past 24 hours. His mother and sister have a history of asthma, and his father has been sick with an upper respiratory tract infection. Vital signs are notable for a respiratory rate of 70 breaths/min and an oxygen saturation of 99 percent on room air. Examination reveals significant rhinorrhea, intercostal retractions, bilateral expiratory wheezes and crackles at the bases. Nasal suctioning is performed with minimal improvement. He has normal urine output. Which of the following is the most appropriate next step in management?

Admission to monitored bed for continued supportive care bronchiolitis

A 25-year-old man presents to the emergency department with sudden onset of shortness of breath and pleuritic chest pain. He is taking no medications, reports no chronic illness, and smokes one pack of cigarettes per day. His vital signs include body mass index of 18 kg/m2, pulse of 70 bpm, temperature of 98.7°F, respirations of 21 per minute, blood pressure of 120/80 mm Hg, and oxygenation saturation of 97%. Physical exam reveals decreased breath sounds on the left with decreased tactile fremitus and hyperresonance to percussion. The patient's chest X-ray is shown above. Which condition most likely led to this patient's clinical presentation?

Apical subpleural bullae

55-year-old man presents with groin pain of insidious onset that began 5 months ago. His medical history includes sickle cell anemia. He currently abuses alcohol. Examination reveals painful hip rotation and decreased range of motion. There is no midline pelvic pain with resisted hip adduction. Pelvic radiographs reveal mild subchondral sclerosis about the femoral head, but no joint space narrowing or osteophytosis. Which of the following is the most likely diagnosis?

Avascular osteonecrosis *will have sclerosis in BOTH femoral head and acetabulum not just femoral head

A 60-year-old man presents to the office with a history of osteoporosis. Which of the following statements is correct as it relates to men with osteoporosis?

Back pain with vertebral compression fracture is the most common presenting complaint

A 23-year-old woman delivers her first child. Her family history is positive for three uncles who needed early-in-life surgery for "heart defects." You are asked to assess her 1-day-old infant who does not "appear well" according to the nursing staff. During your examination, which of the following findings most suggests the presence of congenital heart disease?

Basilar crackles and peripheral edema Congenital cardiac defects occur in 8 out of 1000 live births. Up to one third of infants born with a congenital cardiac defect develop life-threatening symptoms within the first few days of life, with 80% of infants presenting with congestive heart failure (pulmonary or peripheral edema or both).

A 27-year-old woman with no reported medical history presents to the emergency department after falling onto her left shoulder while playing soccer. Vital signs today include a heart rate of 70 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 22 breaths per minute, pulse oxygenation of 99% on room air, and temperature of 98.6°F. Physical examination reveals a regular heart rate and rhythm. She has tenderness, edema, and bruising at the mid-aspect of her left clavicle. Her sensation is intact in her bilateral extremities, and her radial pulse is noted to be decreased on the left side. A plain radiograph shows a displaced fracture of the left clavicle. Which of the following is the best next step in management?

CT angiogram of the left upper extremity Thoracic outlet syndrome

A 55-year-old man with a medical history of hypertension on hydrochlorothiazide presents to the ED with severe 10/10 chest pain. He describes the pain as tearing, radiating to his back, with associated nausea and vomiting. His vital signs are BP 152/91 mm Hg in his right arm and 140/87 mm Hg in his left arm, HR 85 bpm, RR 14 breaths per minute, and T 37.1°C. Physical exam reveals no tenderness to palpation of all four abdominal quadrants, and heart sounds are clear without murmurs, gallops, or rubs. Chest radiograph reveals a widened mediastinum. What is the best next step?

CT angiography

A young woman complains of daily diarrhea without abdominal pain. She brings in a sample that appears to contain much more fat than water. She has a family history of diarrhea. She denies any recent antibiotic therapy. Her vital signs are within normal limits and her physical exam is unremarkable. Laboratory testing reveals iron deficiency anemia, an elevated stool osmotic gap, and positive anti-endomysial antibodies. Which of the following is the most likely diagnosis?

Celiac disease

An elderly man presents with 4 episodes of angina in the past 24 hours. His medical history includes diabetes and advanced COPD. Based on initial testing, you diagnose non-ST-elevation myocardial infarction. You are waiting for the cardiac team to admit him to the critical care unit. In the interim, which of the following is the most appropriate medication to begin?

Clopidogrel

Which of the following is true regarding the management of a subungual hematoma?

Complete nail removal may be necessary if the nail bed has been significantly damaged IF its painful drain it, regardless of size

13-year-old boy presents to clinic for evaluation of flat feet. He does not complain of pain. On physical exam, the patient has bilateral pes planus when standing. He is able to recreate an arch when he stands on his toes and has normal subtalar motion bilaterally. Which of the following is the most appropriate course of action?

Counsel the family that painless flat feet is a normal finding and does not require treatment. (if not symptomatic do not need treatment)

A soccer player presents to the emergency department after being kicked in the shin by his opponent. Upon presentation, he demonstrates pain out of proportion as well as extreme pain with passive range of motion. You have a high suspicion for acute compartment syndrome. Which of the following laboratory findings, if elevated, is most closely associated with this disorder?

Creatine Kinase *Elevated in those with rhabdo which can be seen in acute compartment syndrome like with this patient

Over the last 7 months, a 13-year-old girl has had intermittent abdominal pain, which has made her quite irritable. The abdominal pain is associated with arthralgias and general malaise. Review of systems reveals that she has lost 5 kg (11 lb) and has painful bowel movements. Which one of the following is the most likely cause of these symptoms?

Crohn's disease

A patient with irritable bowel syndrome complains mainly of lower abdominal pain. She denies diarrhea or constipation, and rarely has problematic flatulence. For this patient's abdominal pain, which of the following medications do you recommend?

Desipramine

A patient with irritable bowel syndrome complains mainly of lower abdominal pain. She denies diarrhea or constipation, and rarely has problematic flatulence. For this patient's abdominal pain, which of the following medications do you recommend?

Despiramine

A 48-year-old right-handed woman presents to your office with a 6-week history of left shoulder pain and stiffness. She recalls shoveling snow prior to the pain starting but did not have any injury. She has difficulty putting on a bra or jacket, and sometimes the pain interferes with sleep. Her medical history is significant for type 2 diabetes mellitus, hypothyroidism, osteoporosis, and a 20 pack-year smoking history. On physical examination, she has no swelling over the shoulder or upper arm and no tenderness to palpation. Active range of motion of the shoulder is 100° of forward flexion, 45° of abduction, 30° of external rotation, and little internal rotation past neutral. Passive range of motion is identical to active and all motions have firm endpoints. She has good strength with resisted abduction, internal rotation, and external rotation with the arm at the side. Findings on neurovascular examination and X-rays of the shoulder are normal. Which of the following is the greatest risk factor for this patient's condition?

Diabetes mellitus

Which one of the following has been shown to render some improvement in individuals with borderline personality disorder?

Dialectic behavioral therapy

A 19-year-old man with no significant medical history presents to the emergency department for a shoulder injury. He states that he was playing basketball and experienced a blow to his extended right arm. He is now experiencing significant right shoulder pain. He does not take any medications. On presentation, vitals are temperature 37°C, BP 115/75 mm Hg, pulse 85 bpm, and SpO2 99%. Physical exam reveals a slightly abducted, externally rotated right arm. The acromion process is prominent in appearance. Range of motion is significantly limited in the right shoulder, but the right arm, wrist, and fingers are 5/5 in strength with normal range of motion. Bilateral arm sensation is normal. Distal pulses are intact. The remainder of the physical exam is normal. If left untreated, which of the following is a complication of the injury described above? xray of dislocated shoulder

Difficulty with shoulder abduction *anterior shoulder dislocation

You diagnose a 43-year-old man with alcohol withdrawal. Lab results reveal a hemoglobin of 12 g/dL and an MCV of 115 fL. Which of the following is the most likely cause of these findings?

Direct ethanol toxicity Ethanol affects practically every organ system in the body. This patient is suffering from a macrocytic anemia, most likely as a result of chronic alcohol abuse. Chronic ethanol intake directly suppresses bone marrow by impairing protein synthesis, causing anemia or even pancytopenia. Vit B12 is usually from dietary issues or malabsoprtion

A mom brings in her 16-year-old daughter, with concerns of increasing weight loss. Over the past 3 months, her weight went from 60 kg to 55 kg, placing her at the 10th percentile for weight and BMI. She states she is just very conscious of her food choices and wants a regimented exercise routine, as she is training for High School track. She does admit to irregular scant menstrual periods. What constellation of signs and symptoms should you be concerned about in this patient?

Disordered eating, amenorrhea, osteopenia Female Athlete Triad (altered body image could be considered but is NOT part of the triad)

Which of the following findings is most suggestive of Pneumocystis jirovecii pneumonia in a patient with suspected HIV infection and shortness of breath?

Elevated serum lactate dehydrogenase

An 18-year-old man is brought into the emergency room for evaluation after being the restrained passenger in a motor vehicle collision. He is alert and complains of severe right lower extremity pain. He was unable to bear weight on the extremity at the scene. On exam, there is presence of a transverse groove at the medial knee joint line. The extremity is pale and cold. Popliteal pulses are not palpable in the right lower extremity and 2+ in the left lower extremity. Which of the following is the most appropriate next step in the management of this patient?

Emergent open surgical reduction

A 47-year-old woman with a history of HIV infection, hypertension, and schizophrenia presents with a 1-day history of epigastric abdominal pain, nausea, and vomiting. Vital signs are notable for BP of 135/86 mm Hg, pulse of 104 bpm, RR of 14 breaths/minute, temperature of 37.9°C, and oxygen saturation of 98% on room air. On examination, she is exquisitely tender in the epigastrium. Lipase is elevated at 4,500 U/L. Which of the following of the patient's medications could most likely have caused her symptoms?

Enalapril

A 75-year-old woman with a history of hypertension presents to the ED with right upper quadrant pain that has been gradually worsening over the past day. Her vital signs are: T 103°F, BP 100/60, HR 100, RR 22, and oxygen saturation 97% on room air. Physical exam reveals scleral icterus and right upper quadrant tenderness without rebound or guarding. A bedside right upper quadrant ultrasound demonstrates a common bile duct measuring 1 cm. Laboratory results are pending. What is the definitive management of this condition?

Endoscopic retrograde cholangiopancreatography

3-day-old female developed a rash 1 day ago that has continued to progress and spread. The infant was born at term after an uncomplicated pregnancy and delivery to a healthy mother following excellent prenatal care. The infant was discharged 2 days ago in good health. She does not appear to be irritable or in distress, and she is afebrile and feeding well. On examination, abnormal findings are confined to the skin, including her face, trunk, and proximal extremities, which have macules, papules, and pustules that are all 2-3 mm in diameter. Her palms and soles are spared. A stain of a pustular smear shows numerous eosinophils. Which one of the following is the most likely diagnosis?

Erythema toxicum neonatorum

A 5-year-old boy presents to the emergency department complaining of right hip pain. He is febrile and refuses to bear weight on the right foot. There is no history of trauma. X-rays are obtained and are unremarkable. Which of the following diagnostic tests would best exclude a diagnosis of osteomyelitis?

Erythrocyte sedimentation rate

A 35-year-old man with no significant medical history presents to the emergency department after a high-mechanism motor vehicle collision. He reports that he has severe left-sided chest wall pain after his chest hit the steering wheel. Vital signs include a heart rate of 110 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 24 breaths per minute, pulse oxygenation of 93% on room air, and temperature of 98.6°F. Physical examination reveals left-sided chest anterolateral chest wall tenderness and part of his chest wall is moving inward during inspiration. The patient's rib radiograph is shown above. Which of the following is the most suspected diagnosis

Flail chest

A 17-month-old boy presents with bilious vomiting, fever, and abdominal distention for the past 3 days. The mother states she noticed blood in the last diaper she changed. What is the most likely diagnosis?

Intussusseption

Which of the following statements is true concerning aspiration pneumonitis?

It is caused by an inflammatory chemical injury

A 27-year-old man presents to his primary care provider complaining of intermittent, burning, substernal chest pain for three months. Symptoms are exacerbated by lying flat after meals, drinking coffee and eating fried foods. He also complains of worsening halitosis but denies regurgitation of undigested food, excessive burping, nausea or vomiting. Physical exam is unremarkable. What is the most likely diagnosis?

Gastroesophageal reflux *Halitosis but with CP so that's why it wasn't Zenker's Diverticulum

58-year-old man presents with shortness of breath for two days. He complains of a six-month history of a dry cough, unintentional weight loss, and night sweats. He has no past medical history, but he has a 40 pack-year smoking history. In the ED, his vital signs are BP 132/76, HR 72, RR 16, oxygen saturation 96% on room air, and temperature 98.8°F. An ECG reveals no acute abnormality and a chest X-ray shows a right middle lobe irregular mass and a right-sided pleural effusion. A thoracentesis is performed. What findings would be expected on pleural fluid analysis?

Glucose < 60 mg/dL

A 65-year-old man presents with hematemesis. His past medical history includes heavy alcohol use, tobacco use, Helicobacter pylori infection, heavy intake of smoked fish, and diabetes mellitus. Endoscopic examination reveals a large pyloric mass. Which of the following is the most common cause of this type of gastric cancer?

H pylori

A 31-year-old woman, newly diagnosed with rheumatoid arthritis, presents to the clinic to start treatment for her disease. Other than her joint pain and fatigue, she is otherwise healthy and denies any other complaints. She has two children and, although not currently trying to conceive, she is considering having one more child in the near future. What is the most likely medication you would start her on?

Hydroxychloroquine Methotrexate and Deflunomide teratogenic*

A 2-year-old boy presents to the urgent care clinic with his mother after an incident at the grocery store 30 minutes ago. The boy was attempting to run away from his mother, and the mother grabbed onto the boy's left arm to pull him back to her. The boy immediately started crying and is now holding his left arm to his side with his forearm in a pronated position and refuses to move it. Upon physical examination, no edema is noted in the left elbow or forearm. Palpation of the elbow is positive for tenderness at the lateral aspect of the elbow joint. Attempts at supinating the elbow are met with cries from the child. The rest of the patient's exam is normal. What is the best treatment method for this patient's symptoms?

Hyperpronation of the forearm (this is the preferred method ove rthe supination and flexion)

A 32-year-old woman presents with abdominal pain, nausea, vomiting, and change in skin color for 6 days. She states that she had unprotected intercourse 4 weeks ago. Which one of the following tests indicates acute infection with hepatitis B as the cause of the patient's symptoms?

IgM antibody to B core antigen (Anti-HBc-IgM) surface antigen is used for acute infection and chronic and cannot r/o chronic surface antibody shows if they have immunity (either by vaccine or natural infection)

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

Increased consumption of alcohol (Hypertriglyceridemia)

A 60-year-old woman with a history of well-controlled diabetes mellitus presents to your office with a complaint of constipation. She has a bowel movement about twice per week with straining and hard stools. She has had intermittent constipation for many years, but over the past four months it has been constant. Which of the following is the most appropriate initial management?

Increased fiber intake

A 7-year-old boy accompanied by his mother presents to your office, complaining of a rash and bilateral knee and ankle pain. He also notes some mild crampy abdominal pain associated with nausea but denies vomiting, diarrhea, and fever. On exam you note the rash seen above. He has swelling around his patellar joints bilaterally, and the area is very painful. There are no palpable abdominal masses. His lungs are clear and the remainder of the physical examination is unremarkable. What complication is this patient at greatest risk for?

Intussusception Patient has Henoch-Schönlein Purpura (HSP). Henoch-Schönlein Purpura is the most common systemic vasculitis of childhood and is characterized by a rash (palpable purpura), arthritis, abdominal pain, and renal involvement.

A 4-year-old boy presents to your office with watery nonbloody diarrhea for the last three months. He has occasional abdominal pain prior to the onset of the diarrhea and his mother noted worsening flatulence, especially after meal times. Mom denies any recent travel or camping and the patient does not go to school or daycare. On exam, he is 60th percentile for weight and height (similar to his last well-child check), appears well, and has a normal abdominal exam. What is the most likely diagnosis?

Lactose Intolerance No signs of failure to thrive

A nine-year-old girl is seen in the clinic for a well child visit and is found to have a body mass index in the 94th percentile. What additional studies should be ordered according to the American Academy of Pediatrics?

Lipid panel and complete metabolic panel

An 83-year-old man from a nursing home is sent for evaluation of abdominal distention and vomiting. Nursing home records report no bowel movement for two days and no fevers. His X-ray is shown above. On CT scan, no obstructing lesion is identified. What of the following may be beneficial in relieving this condition?

Neostigmine Oglive Syndrome when the xray shows obstruction in large bowel but CT shows none, pseudo obstruction, autonomic destruction

A 50-year-old man with a medical history of alcohol use disorder and chronic obstructive pulmonary disease on prednisone presents to the orthopedic clinic with progressive left hip pain for the past 3 months. Vital signs today include a heart rate of 80 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 20 breaths per minute, pulse oxygenation of 99% on room air, and temperature of 98.6°F. Physical examination reveals a regular rate and rhythm and lungs are clear to auscultation. The left hip pain is exacerbated with left hip internal rotation and abduction. Hip radiographs are unremarkable. What is the best next step in the management of this patient's condition?

Obtain MRI of the left hip

A 55-year-old man with a history of alcohol use disorder and cirrhosis presents to the emergency department reporting abdominal distension and weight gain. He states that his symptoms have been slowly progressing over the past 3 weeks. He is not taking any medications and reports no orthopnea, abdominal pain, lethargy, or confusion. Vitals are temperature 37°C, blood pressure 120/80 mm Hg, pulse 89 bpm, and SpO2 98% on room air. Physical exam reveals a man with jaundice in no acute distress. His abdomen is markedly distended and nontender to palpation in all four quadrants with bulging flanks. There is dullness to percussion in the flank region. The remainder of the physical exam is unremarkable. Which of the following is the best next step in management?

Obtain abdominal ultrasound *paracentesis after obtaining US

A 25-year-old man presents to the clinic reporting sudden shortness of breath and pain with breathing. He reports no preexisting medical conditions or current medication use but is a current smoker. Vital signs include HR 143 bpm, RR 27 breaths per minute, BP 102/71 mm Hg, T 98.1°F, and SpO2 87% on room air. Physical examination demonstrates a tall, thin man with diminished breath sounds and decreased tactile fremitus on the right side. Chest radiograph results are shown above. Which of the following is the best initial treatment?

Perform chest tube thoracostomy large pneumothorax (over half of lung margin)

Which of the following is a contraindication to the use of air-contrast enema in the reduction of pediatric intussusception?

Peritonitis

A 55-year-old woman with a medical history of obesity and bilateral knee osteoarthritis presents to the orthopedic clinic with medial knee pain for the past month. The patient reports the pain came on spontaneously without associated trauma. Vital signs today include a heart rate of 70 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 22 breaths per minute, pulse oxygenation of 99% on room air, and temperature of 98.6°F. Physical examination of the left knee reveals tenderness of the proximal medial left tibia but no edema or induration. The patient has full range of motion of the knee without ligamentous laxity. She has intact dorsalis pedis and posterior tibialis pulses, and her sensation is intact to light touch. Which of the following is the most likely diagnosis?

Pes anserinus pain syndrome

A 45-year-old man presents complaining of three days of fever and myalgias, as well as sores on both of his shins. Physical exam reveals tender, nodular lesions surrounded by a starburst pattern of erythema. What is his most likely diagnosis?

Polyarteritis nodosa

A 10-year-old boy presents to clinic with complaints of right posterior heel pain. There was no preceding injury. The pain has been ongoing for four months. He is a soccer player and notices the pain primarily when wearing his cleats during soccer. On physical exam, the patient has pain with medial-lateral compression of the calcaneus. Which of the following is the most likely diagnosis?

Sever disease

A 32-year-old man presents with right upper quadrant pain that started earlier today. His symptoms initially included mild generalized abdominal discomfort and nausea before localizing to the right side of his abdomen. He has a low-grade fever but his vital signs are otherwise unremarkable. He has minimal tenderness in the right lower quadrant to palpation. Which of the following signs would be indicative of a retrocecal location of the appendix?

Psoas sign

A 60-year-old woman with a history of heart failure presents with substernal chest pain that awoke her from sleep. She has dysphagia when swallowing solids and odynophagia when swallowing both solids and liquids. She reports a history of chest pain in the past but states that this pain is different in that it is sharp and occurs only after swallowing. Her medications include metoprolol succinate, furosemide, potassium chloride, simvastatin, isosorbide dinitrate, and levothyroxine. Which of the following is most likely to lead to the correct diagnosis?

Questioning her about her medication use

A patient presents to the emergency department with wrist and hand weakness. He is holding his wrist in flexion and his hand is hanging limply. He is unable to extend his wrist against resistance. Which of the following nerves is most likely injured?

Radial nerve

A 43-year-old woman presents with right upper quadrant abdominal pain for 3 weeks. She states that she intermittently gets sharp pain that occurs after eating and is associated with nausea and occasionally vomiting. The pain lasts for 10-15 minutes, and then spontaneously improves. Currently, she has no pain. Her vital signs and bloodwork are normal. A right upper quadrant ultrasound is shown above. What management is indicated?

Referral for surgical consultation and pain medication as needed *can be managed outpt if noncomplicated and stable

A 40-year-old woman with a history of anemia presents to your office with complaints of abdominal bloating and pain with defecation. When she was younger she had daily bowel movements. Now she has a bowel movement every 3-4 days that is hard. She has to strain and has even had to use her finger to get the stool out. Which of the following historical factors is most important to discuss at this time?

Review of current medications

A track-and-field athlete presents to orthopedic clinic with insidious onset anterior knee pain. Examination reveals tenderness over the lateral patella. Which of the following radiographic findings suggests bipartite patella over patellar fracture?

Rounded patellar fragment vs sharp demarcated borders with a patellar fracture

A 55-year-old man presents to your office with gradual onset atraumatic low back pain, leg pain, and numbness. The pain is most often bilateral, involving the buttocks and thighs, and spreads distally towards the feet. The leg pain begins and worsens with walking and standing and is relieved by sitting or lying down with hips and knees drawn up in a sitting posture. Which of the following is the most likely diagnosis?

Spinal stenosis

A 32-year-old man presents to the emergency department with palpitations and occasional non-exertional chest pain. Physical examination reveals a tall, thin man with pectus excavatum. A late systolic murmur with a midsystolic click is heard on auscultation. Which of the following maneuvers will result in movement of the click later into systole?

Squatting

A 72-year-old man presents with vague upper abdominal pain that has been ongoing for the past month. He has associated anorexia and mild nausea. He notes that he has had an unintentional 10-pound weight loss since the pain began. His past medical history is significant for hypertension and hyperlipidemia. He currently takes lisinopril and atorvastatin. His social history includes tobacco use with a 50 pack-year history. He reports drinking two glasses of gin per night. His vital signs are as follows: HR of 67 bpm, BP of 128/73 mm Hg, SpO2 of 95% on room air, and T of 98.5°F. A physical examination is unremarkable except for mild hepatomegaly. Considering the most likely diagnosis, which of the following lymph nodes is most likely to reveal malignant cells?

Supraclavicular *Virchow node: seen in elft supraclavicular node and represents abd CA whether gall, pancreas, gastric, or even pelvic organs

A 12-month-old boy is brought to the emergency department by his mother for three days of intermittent episodes of inconsolable crying. This morning the boy became lethargic and difficult to awaken. He has had several episodes of nonbilious vomiting and grossly bloody stools. His vital signs are T 38.3°C, HR 140, BP 80/50, RR 22. On examination, he is lethargic but diffusely tender on abdominal palpation with involuntary guarding. His abdominal X-ray reveals free air under the diaphragm. Which of the following is the most appropriate definitive management of this patient's condition?

Surgical reduction Air contrast enema is contraindicated in intussuseption when peritonitis is suspected

A 51-year-old man presents with low back pain that has been worsening over the past several years. Radiographs of the spine demonstrate fusion of the sacroiliac joints and a "bamboo spine." Blood tests reveal that he is human leukocyte antigen B27 positive. Which of the following findings on physical exam would be most consistent with the suspected diagnosis?

Tenderness over the spine and sacroiliac joints

A 21-year-old woman is brought in by ambulance from a soccer game where she was kicked by a teammate as her left leg was planted. Per the ambulance report, the patient was found with the knee bent completely under her, crying in severe pain. She was unable to bear weight on the extremity at the scene. On examination, there is no gross bony deformity of the left leg, knee, or thigh. Peri-patellar ecchymosis and a significant effusion are noted. The knee hyperextends when the leg is lifted by the heel and the knee joint is extremely unstable on valgus and varus stress. Femoral, patellar, posterior tibial, and dorsalis pedis pulses are present. Which of the following is the most likely diagnosis in this patient?

Tibiofemoral dislocation *Not ACL bc

Which of the following disorders is associated with celiac disease?

Type 1 diabetes mellitus

An 18-month-old boy is brought to the emergency department by his mother for two days of intermittent episodes of inconsolable crying. During these episode, the child is noted to stop playing, lay down, and draw his legs up to his chest. His mother denies any emesis or bloody bowel movements. Physical examination and vital signs in the emergency department are normal. Which of the following is the most appropriate imaging modality for the confirmation of a diagnosis of intussusception in this patient?

Ultrasonography No GI sxs so uncertain if this is intusseption off the bat, therefore have to start with an US and not go right to air contrast enema

What is the most common extra-articular manifestation of ankylosing spondylitis?

Uveitis HLAB27 bamboosign spine worse in morning better with exercise pain over SI joints and spine

A 54-year-old man with a history of type 2 diabetes mellitus controlled by dapagliflozin, hypertension controlled by lisinopril, and injection drug use presents to the emergency department, brought by his sister, for progressively worsening low back pain for the past 4 weeks. Vital signs are a HR of 98 bpm, BP of 128/88 mm Hg, RR of 20/min, oxygen saturation of 99%, and T of 100.8°F. Upon physical examination, tenderness is noted over the lumbar spine with percussion. Range of motion in the lumbar spine is limited due to pain. The patient does not report pain with hip extension. Neurological examination of the lower extremities is normal. Laboratory testing is obtained and is significant for erythrocyte sedimentation rate 102 mm/h, C-reactive protein 150 mg/L, and white blood cell count 13,000 mm3. Which of the following is the most likely diagnosis?

Vertebral osteomyelitis (type of spinal abscess infection)

A 38-year-old woman presents to your office with complaints of wrist pain and swelling. Physical exam findings include a flesh-colored, smooth, firm, rounded swelling on the dorsal aspect of her wrist. Which of the following is the most appropriate first step in management?

cyst aspiration

A 42-year-old man presents to the emergency department with fever, chills, cough, and hemoptysis. He has a history of intravenous opioid use. Vital signs include BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4F. Chest X-ray is shown above. Which of the following is the most likely diagnosis?

Septic emboli

Which of the following HIV-positive patients suspected of having Pneumocystis pneumonia should receive prednisone before treatment with trimethoprim/sulfamethoxazole?

A 10-year-old with a normal chest X-ray and a PaO2 of 65 mm Hg HIV-positive patients with moderate to severe Pneumocystis jiroveci pneumonia, defined by a room air arterial oxygen partial pressure (PaO2) of less than 70 mm Hg (severe disease is less than 60 mm Hg) or an alveolar-arterial oxygen gradient that exceeds 35 mm Hg

A 17-year-old girl with a history of asthma presents to your office with complaints of wheezing and shortness of breath. She says that in the past month she has experienced symptoms approximately 3-4 times per week requiring use of her short-acting beta agonist inhaler. She has also woken up at night four times during the month with shortness of breath and occasionally gets dyspneic on her daily walk. Which of the following is the most effective management?

Add a low dose inhaled glucocorticoid Mild is 3-4 x month nightly awakenings, mod is weekly but not nightly, nightly is severe and includes LRTA, montelucast, theophyline, ect

A 53-year-old man presents with abdominal pain for 2 days that he localizes to the left side of the abdomen. He has associated nausea and loss of appetite. He reports that his last bowel movement was yesterday and was normal for him. His medical history is significant for obesity and type 2 diabetes mellitus. A physical examination is performed, and there is left lower quadrant tenderness to palpation without peritoneal signs. Bowel sounds are auscultated and consist of clicks and gurgles at a rate of 20 per minute. His vital signs are as follows: BP of 118/65 mm Hg, HR of 68 bpm, T of 100.6°F, and an SpO2 of 99% on room air. A CT scan is performed and shows pericolonic stranding and thickening of a portion of the sigmoid colon wall with pericolonic bubbles. Which of the following is the best next in the management of this patient's condition?

Admit for intravenous antibiotics, intravenous fluids, and bowel rest

Which of the following best describes cor pulmonale?

Altered structure and function of the right ventricle result of pulm HTN, not due to left sided heart disease

A 12-year-old previously healthy girl presents to the clinic with acute onset of productive cough, fever to 102°F, and extreme fatigue over the past 3 days. She is awake and alert but appears tired. Her oxygen saturation is 96%, and respiratory rate is 15 breaths per minute. Lung auscultation reveals fine crackles in the left upper lobe. A chest radiograph reveals localized alveolar infiltrates with consolidation. Which of the following is the first-line treatment for this patient's most likely diagnosis based on her clinical presentation?

Amoxicillin

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

Apnea

A 45-year-old man with a history of paroxysmal atrial fibrillation presents to the ED with acute onset of severe pain and paresthesias in his right calf. On exam, you note lower extremity pallor and an absent dorsalis pedis pulse. Which of the following is the most likely diagnosis?

Arterial thromboembolism A thrombus is a blood clot that forms in a vein. An embolus is anything that moves through the blood vessels until it reaches a vessel that is too small to let it pass. Can sometimes be a product that broke off of a thrombus (Deep VT--> VTE)

Which of the following best describes the physiologic process responsible for the fourth heart sound heard in patients with advanced aortic stenosis?

Atrial contraction against a noncompliant left ventricle

A 76-year-old woman with a history of chronic obstructive pulmonary disease presents to your office in December with complaints of fever, muscle aches, headache and malaise that started yesterday. Which of the following is the most appropriate next step in management?

Begin a course of oseltamivir < 48 hrs

A 33-year-old man with no significant medical history presents to the primary care clinic for decreased exercise tolerance for the past month. While taking his medical history, he notes that his father has a congenital condition affecting his heart. He does not take any medications on a regular basis and is a nonsmoker. His heart rate is 72 beats/minute, blood pressure is 115/74 mm Hg, respiratory rate is 16 breaths/minute, oxygen saturation is 99%, and temperature is 98.6°F. His physical exam reveals a midsystolic murmur that is best heard over the right second intercostal space. His lung exam is without rales. He has no peripheral edema. Based on this information, a nonurgent echocardiogram is ordered. Which of the following is the most likely finding in this patient?

Bicuspid aortic valve

A 60-year-old man presents with nighttime dyspnea. His medical history is significant for chronic hypertension. A recent echocardiogram showed an increase in left ventricular chamber volume but normal ventricular wall thickness. Based on this finding alone, which of the following medications is the most appropriate treatment for this patient's dyspnea?

Bisoprolol

Closure of the ductus arteriosus begins when levels of which of the following substances increases in the immediate post-natal period?

Bradykinin early on prostaglandin E1 is responsible for keeping the ductus arteriosus open Which medication is used to close a patent ductus arteriosus, especially in a premature infant? -Indomethacin a prostaglandin inhibitor.

A 10-year-old boy presents to your office with elbow pain. The pain is located along the medial aspect of the elbow and is exacerbated while pitching during his Little League games. Your examination reveals mild swelling along the medial aspect of the right elbow. Radiographs show mild hypertrophy of the medial epicondyle. What is the initial treatment of choice for this condition?

Complete rest from throwing for four to six weeks

The emergency department staff began treatment for a woman who presented with chest pain. The pain is described as retrosternal, worse with minimal activity, better with rest, sharp in character and 9/10 in intensity. You are paged to admit her to the intensive care unit under the working diagnosis of unstable angina. Her vitals have remained stable after beginning antiplatelet, antihypertensive and antithrombotic medications. Two hours after admission, a repeat history and physical and review of available test results offers the following information: serial electrocardiograms reveal increasing R wave amplitude; an echocardiogram calculates an ejection fraction of 50%; angina is reported as 9/10 in intensity; atrial natriuretic peptide levels are elevated. Which of the following historical facts would prompt you to immediately consult interventional cardiology for invasive coronary revascularization?

Continued chest pain

A 28-year-old man presents with 2 months of nonbloody diarrhea and abdominal pain. Stool culture is negative for an infectious etiology. Endoscopic examination reveals small and large bowel fissuring and cobblestoning. Microscopic examination shows a transmural inflammatory infiltrate, but no crypt hyperplasia or villous atrophy. Hydrogen breath testing is negative. Which of the following is the most likely diagnosis?

Crohn's disease

A bicuspid aortic valve is often associated with which of the following findings?

Dilation of the ascending aorta Bc bicuspid aortic valve can lead to aortic stenosis

A 36-year-old veterinarian presents with myalgias, dry cough, and severe headache. His vital signs include blood pressure 138/74 mm Hg, heart rate 82 beats/minute, temperature 39°C, and oxygen saturation 94% on room air. He has hepatosplenomegaly on abdominal exam. His chest X-ray shows patchy perihilar infiltrates. What of the following is the most appropriate antibiotic for this patient?

Doxycycline Psittacosis

An elderly man presents with 6 months of progressive positional dyspnea. Nine months ago, he had a mild heart attack and was properly treated. Today, you appreciate a new loud, blowing holosystolic murmur heard at the apex. Which of the following color Doppler echocardiography findings would you most expect to find based on these signs and symptoms?

During systole, blood is seen flowing from the left ventricle into the left atrium mitral regurgitation

A patient with acute pancreatitis is noted to have a pleural effusion on chest radiography. Which of the following findings would you expect to find on pleural fluid analysis?

Elevated amylase concentrations

A 30-year-old woman presents to her primary care physician with concerns that she has been exposed to syphilis by her partner. She was treated for syphilis in the past. Which of the following diagnostic tools would show a false-positive result due to her prior infection and cannot be used alone to provide a diagnosis of syphilis?

Fluorescent treponemal antibody absorption (FTA-ABS)

A 35-year-old man presents to the emergency department after a motor vehicle collision with prolonged extrication. He complains of severe pain in his leg, which was trapped under the car for 3 hours. A 12-lead ECG obtained in triage is shown above. Which of the following interventions will decrease total body potassium stores? EKG was hyperkalemia

Furosemide

25-year-old man presents for evaluation of fever and cough. He reports last week that he was diagnosed with influenza. In the last two days he developed a worsening cough productive of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95% oxygen saturation on room air. His chest X-ray demonstrates a lobar infiltrate in the left lower lobe. Which of the following would you most likely expect to see on the patient's Gram stain?

Gram positive cocci in clusters

A 62-year-old man with a history of chronic obstructive pulmonary disease presents with cough, headache, dyspnea, and watery diarrhea that started six days ago. He was seen at a local urgent care four days ago and prescribed amoxicillin-clavulanate without improvement. He is ill-appearing with a fever of 38.7C and inspiratory rales on auscultation. Which of the following results would be most consistent with his diagnosis?

Serum sodium 128 mEq/L

A 44-year-old woman presents to the Emergency Department with palpitations following the death of her mother 2 days prior. Her ECG is consistent with normal sinus rhythm with a QTc interval of 520 msec. Her heart rate is 86 bpm and blood pressure is 117/82 mm Hg. Her medications include lisinopril and metformin. She took lorazepam yesterday for anxiety related to the loss of her mother. What is the most appropriate next step?

Initiate propranolol

A continuous systolic-diastolic murmur is auscultated in a 3-week-old dyspneic infant. She is tachypneic and diaphoretic. Her mother reports weight loss and poor feeding. Doppler color-flow imaging reveals high velocity jets in the pulmonary artery. This patient will most likely undergo which of the following corrective surgeries?

Ligation

A 62-year-old man with no significant medical history presents to the emergency department with progressively worsening shortness of breath and pleuritic chest pain for the past month. The patient reports having no cough, fever, or chills. He reports that he drinks about eight beers per day and has for the past 40 years. Vital signs include a heart rate of 82 bpm, blood pressure of 135/92 mm Hg, respiratory rate of 22 breaths per minute, pulse oxygenation of 95% on room air, and temperature of 98.6°F. Physical examination reveals trace bilateral lower extremity pretibial edema, moderate ascites, and decreased breath sounds in the right lower lung fields. Laboratory evaluation reveals a white blood cell count of 11,000 cells/μL, hemoglobin of 11 g/dL, platelet count of 125,000 platelets per microliter, aspartate aminotransferase of 152 U/L, alanine aminotransferase of 65 U/L, troponin of < 0.012 ng/mL, D-dimer of 0.37 μg/mL, and B-type natriuretic peptide of 99 pg/mL. The patient's chest X-ray is shown above. Which of the following would be an expected finding of pleural fluid analysis for this patient?

Low lactate dehydrogenase pleural effusion

A 33-year-old man presents to the ED with several weeks of cough, pleuritic chest pain, weight loss, and night sweats. The patient drinks a six-pack of beer daily. Vital signs are BP 145/75 mm Hg, HR 88 bpm, RR 18 breaths/min, and T 37.7°C. Pulmonary exam reveals crackles and decreased breath sounds on auscultation. You obtain the radiograph seen above. Which one of the following is the most likely diagnosis?

Lung abscess

21-year-old patient who is otherwise healthy presents to the clinic with reports of wheezing, dyspnea on exertion, and frequent night-time cough. He does not take any medications. Vital signs demonstrate HR 67 bpm, RR 17 breaths per minute, BP 117/76 mm Hg, T 98.7°F, and SpO2 98% on room air. Chest auscultation reveals diffuse, high-pitched, musical expiratory wheezes, while skin examination demonstrates lichenified plaques in a flexural distribution over the antecubital and popliteal fossae. Spirometry results are within the normal range. Which medication is most useful for further diagnosis of this patient's condition?

Methacholine

A four-year-old girl is brought to the ED by her parents due to lethargy. A week prior, the girl had a cough and cold. Later, symptoms progressed to include fever and malaise. She has been less active with decreased appetite. A few hours prior to arrival in the ER, she was having difficulty breathing. On exam, temperature is 38.3°C, respiratory rate is 35, heart rate is 126, blood pressure is 90/60, with clear breath sounds, hepatomegaly, and poor pulses. Which of the following is the most likely diagnosis?

Myocarditis There is usually a history of a recent respiratory or gastrointestinal illness within the previous weeks. There is a prodrome of fever, myalgia, and malaise several days prior to the onset of symptoms of heart dysfunction. Then, patients present with heart failure symptoms that include dyspnea at rest, exercise intolerance, syncope, tachypnea, tachycardia, and hepatomegaly.

An 8-month-old previously healthy boy presents with fever, cough, and wheezing for the last two days. Physical exam reveals prolonged expiration and mild subcostal retractions. Lung auscultation reveals diffuse expiratory wheezing and tachypnea. His immunizations are up-to-date. Which of the following tests is most likely to confirm the suspected diagnosis?

Nasopharyngeal swab for fluorescent antibody staining CXR will not confirm like this will***

A 7-year-old boy presents to the emergency department for recurrent abdominal pain. The patient has been seen several times for the same complaint with no etiology identified. After consulting with a gastroenterologist, they recommend performing a computed tomography scan of the abdomen to evaluate the patient for bowel obstruction. The patient is very anxious and is unlikely to remain still for the scan. Which of the following medications for procedural sedation would be contraindicated in this patient?

Nitrous oxid

A 35-year-old woman presents to her primary care physician for follow up of an incidental finding on chest CT found during a workup for possible pulmonary embolism. She is a non-smoker and has a negative family history for lung cancer. A solid, solitary pulmonary nodule of 4 mm was seen on chest CT. The scan was otherwise unremarkable. Which of the following is the next best step?

No further follow-up

A 78-year-old woman presents to the emergency department via ambulance after having a generalized seizure at home. Per her accompanying family member, the patient developed a fever and headache earlier today. She was acting strange before the seizure started. There is no recent head injury or illness, but she had a cold sore a few days ago. The patient's medical history is pertinent for hyperlipidemia and glaucoma, for which she takes atorvastatin, latanoprost eye drops, and timolol eye drops. Vital signs reveal a blood pressure of 108/72 mm Hg, heart rate of 112 bpm, respiratory rate of 24/min, oxygen saturation of 97%, and temperature of 101.7°F. The patient is obtunded and confused on examination. Deep tendon reflexes are 4+. A right-sided hemiparesis is noted. Kernig sign and Brudzinski sign are negative. An MRI of the brain is performed and is shown above. Given the suspected diagnosis, which of the following will CSF analysis reveal, in addition to CSF protein content?

Normal glucose, increased lymphocyte count, increased erythrocyte count Encephalitis

Which of the following complications can be prevented by simultaneously administering pyridoxine and isoniazid in a patient with tuberculosis exposure

Peripheral neuropathy

Which of the following is the most common opportunistic respiratory infection in patients with acquired immunodeficiency syndrome?

Pneumocystis jiroveci

A patient presents to the clinic complaining of a tearing pain with bowel movements and reports small streaks of blood on the toilet paper. A physical examination of the patient's anus reveals a lesion most likely in which of the following anatomic locations?

Posterior midline

patient presents to the clinic complaining of a tearing pain with bowel movements and reports small streaks of blood on the toilet paper. A physical examination of the patient's anus reveals a lesion most likely in which of the following anatomic locations?

Posterior midline

Which of the following diagnoses should be considered when an unexplained isolated pleural effusion is found on chest radiograph?

Pulmonary embolism

A 65-year-old man presents to the clinic with a history of hypertension, hyperlipidemia, peripheral arterial disease, and atrial fibrillation. His current medications include metoprolol, lisinopril, and rosuvastatin. The patient complains of acute left leg pain and reports no recent trauma. He is afebrile with a blood pressure of 165/90 mm Hg and a pulse of 105 bpm. Physical exam reveals a man who appears uncomfortable and in mild distress. He is tachycardic, with an irregularly irregular rhythm. Lungs are clear to auscultation bilaterally without wheezes, rhonchi, or rales. His left leg is cool and pale, with decreased distal pulses. Ultrasound reveals an occlusion of the left popliteal artery. In addition to the above, which of the following exam findings would you expect to observe?

Reduced sensation of the distal left leg This patient presents with an acute arterial occlusion, or acute limb ischemia, of the left popliteal artery. This can occur in any peripheral artery of the upper or lower extremities.

A 59-year-old woman has furosemide-resistant peripheral edema and ascites. Her medical history is significant for sarcoidosis. You order an echocardiogram which reveals increased wall thickness and decreased cavity size of the right ventricle, enlarged atria and a normal appearing left ventricle. Cardiac MRI shows no fatty deposition in the ventricular walls. Which of the following is the most likely diagnosis?

Restrictive cardiomyopathy

A 55-year-old woman who is otherwise healthy presents to the office with reports of worsening fatigue and frequent lightheadedness. A complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone are obtained, which are all normal. You obtain an ECG, and it is shown above. In chart review, her prior heart rates have been around 80 beats per minute at rest. She is referred to a cardiologist who performs an exercise stress test where the patient has suboptimal heart rate response to exercise. What is the location of the underlying pathology of this patient? EKG was sick sinus syndrome

Right atrial wall

A 4-year-old patient is brought to the emergency department by his parents after a choking incident that occurred one hour ago. The parents tell you that their son was eating steak, started to laugh and then began choking. Since the incident, he has been coughing and wheezing. Physical exam reveals unilateral diminished breath sounds with auscultation of the lungs. Which of the following is the most appropriate next step in management?

Rigid bronchoscopy

16-year-old boy presents to the office with lower back and buttock pain for 3 months. He is a football lineman on his high school team. The pain is worse with activity and improves with rest and anti-inflammatory medications. He reports that the pain is getting worse, and he had a recent episode of pain and tingling in his left leg while kicking a ball. On physical examination, he walks with a normal gait. He has a mildly increased thoracic kyphosis and a decreased lumbar lordosis. There is tenderness to palpation over the lower lumbar area in the midline and the paraspinal muscles and a palpable step-off between the spinous processes of the L5 and S1 vertebrae. He has no pain with forward bending but does have pain with extension of the spine. Straight leg raise test is positive for pain radiating to the left leg and tight hamstrings. Neurologic examination is normal. Which of the following is the most likely diagnosis?

Spondylolisthesis

A 74-year-old woman presents with complaints of fever, productive cough with bloody sputum, shortness of breath, and headache. These symptoms developed and worsened drastically over the past 3 days. She recently recovered from an influenza infection 1 week ago. Her medical history otherwise includes only well-controlled hypertension. Vital signs on presentation are as follows: T 39°C, HR 106, BP 110/75, RR 30, oxygen sat 95% RA. A chest radiograph is obtained and a subsequent CT scan of the chest demonstrates multiple cavitary lung lesions. Which of the following organisms is most likely responsible for this patient's presentation?

Staphylococcus aureus

Persistent fever and bacteremia are found in a 28-year-old woman with new onset murmur. She does not use intravenous drugs, and does not have any prosthetic heart valves or history of congenital heart disease. However, she has significant dental disease and poor dentition. What is the most common organism responsible for bacterial endocarditis in this patient?

Streptococcus viridans

A 33-year-old woman with no past medical history presents with a cough and fever for one week. Her cough is productive of green sputum. Auscultation of the chest is normal. Vital signs are: T 100.2°F, BP 120/72, HR 88, RR 12, and 100% saturation on room air. She is otherwise well-appearing. What is the most appropriate management of this patient?

Supportive care

29-year-old woman presents to the ED complaining of pain on inspiration. Over the previous three days, she has experienced a low-grade fever, sore throat, and body aches. She denies any medical history and takes no medications. Her vital signs are normal and auscultation of her lungs reveals normal breath sounds. Her upright chest radiograph is seen above. Which of the following is the most appropriate next step in management?

Supportive care viral pleuritis chest xray normal

A 59-year-old man with a history of hypertension, dyslipidemia, and chronic low back pain presents for evaluation of sudden-onset abdominal pain that radiates to his right shoulder. His current medication regimen includes enalapril, propranolol, aspirin, ibuprofen, and atorvastatin. He describes intense, diffuse abdominal pain that began 2 hours ago and has since decreased in severity. Vital signs are HR 133 bpm, RR 20/min, BP 102/82 mm Hg, T 95.7°F, and SpO2 95% on room air. Physical exam reveals an ill-appearing man with a weak radial pulse and cool extremities. Abdominal palpation demonstrates marked abdominal rigidity and right lower quadrant tenderness. Cardiac biomarkers are within normal limits, and initial ECG monitoring reveals left ventricular hypertrophy without signs of ischemia or infarct. Abdominal radiograph images are shown above. Which of the following is the best next step in intervention following initial stabilization?

Surgical consultation Pic of ruptured peptic ulcer with air under diaphragm due to it

A 32-year-old woman presents to your office with a complaint of productive cough that started 6 days ago. She reports occasional wheezing, chest wall tenderness, and has been afebrile since the onset of symptoms. Her husband had similar symptoms and was prescribed azithromycin by his primary care provider. Which of the following is the most appropriate next step in management?

Symptomatic treatment

Which of the following is true about myasthenia gravis?

Symptoms are decreased by cooling

Which of the following is the most common sign seen in patients presenting with a pulmonary embolism?

Tachypnea

You are concerned with hearing a new diastolic, rumbling murmur in one of your patients. This murmur is best heard with the bell over the left sternal border at the fourth intercostal space and is louder during inspiration. Which of the following is the most likely diagnosis?

Tricuspid stenosis

A 63-year-old man presents to your office complaining of episodic diarrhea and wheezing. His wife also mentions that his skin will occasionally look flushed. You suspect carcinoid syndrome. What initial diagnostic study is most appropriate to confirm this condition?

Twenty four hour urine excretion of 5-hydroxyindoleacetic acid

neonate is born at 32 weeks gestation, and you are immediately called to the delivery room to examine the patient. The neonate is tachypneic, and you notice nasal flaring and grunting on examination. The patient also appears cyanotic. You obtain a chest X-ray and, after reviewing the results, determine the patient's symptoms are due to a deficiency of surfactant. Which cell type is responsible for this pathologic process?

Type II pneumocytes

A 64-year old man presents with right-sided abdominal pain and the following rash. Which of the following is the most likely diagnosis?

Varicella zoster Pic of shingles

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

Venous hum

Which one of the following is the most common atypical presenting complaint in an elderly patient diagnosed with acute coronary syndrome?

dyspnea