Ultimate Board Review 1

Cytokine and inflammation inhibition

How do Inhaled Corticosteroids work?

Their antiprostaglandin action counters the underlying pathophysiology.

How do NSAIDs relieve the pain of dysmenorrhea?

They are Alpha-2-agonists that decrease aqueous fluid production. Note: Do not administer while wearing soft contact lenses. wait 10 min after use before inserting contact lenses. CONTRAINDICATED IN PATIENTS RECEIVING MAOI's

How do sympathomimetics help treat Glaucoma?

Increases GABA GABA is an inhibitory neurotransmitter in the CNS

How do the benzodiazepines work?

Forceful flexion of the neck results in involuntary flexion of the hips, knees, and ankles.

How is Brudzinski's sign performed?

*Metronidazole* or Tinidazole + *intraluminal antiparasitic* followed by *Chloroquine*. May need drainage if no response to medications after 3 days.

How is amebic liver abscess treated?

Three to eight years after vaccination and 15 years after clinical infection.

How long does immunity last after vaccination or clinical infection with pertussis?

Most experts recommend administering *a minimum of 5 days of therapy and continuing antibiotic use until the patient is afebrile for 48-72 hrs.*

How long should you maintain therapy for the treatment of outpatient CAP?

Inhibit MAO-B which an enzyme that normally breaks down dopamine → more available dopamine in the basal ganglia → inhibits Ach (excitation) in the basal ganglia = calms down the basal ganglia.

How the the MAO-B Inh. meds help treat parkinson disease?

Yes

Is azithromycin recommended in the treatment of pregnant women with chlamydia infection?

Serum glucose, creatinine, vitamin B12/folate, TSH, RPR, hepatitis panel, serum protein electrophoresis (SPEP).

If electrodiagnostic testing is unavailable, which laboratory tests offer the highest yield in evaluating distal symmetric polyneuropathy?

Mycoplasma Send serum cold agglutinins as part of diagnostic workup

Pneumonia: ear pain leads to bullous myringitis, erythematous pharynx or tympanic membranes, persistent nonproductive cough

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Most commonly caused by viral > bacterial (S. pneumoniae most common) Treatment is amoxicillin

What are the 3 most commonly identified bacterial agents in acute otitis media?

Milaria rubra Patho: A skin condition caused by blocked sweat ducts and trapped sweat beneath the skin. (Miliaria = Heat Rash) Tx: Cooling baths and avoidance of overheating

What condition is pictured

FTA-ABS test (detects antibodies to the bacteria Treponema pallidum)

What confirmatory test should be done next if a patient has a positive RPR?

Lung cancer

leading cause of cancer deaths worldwide in both men and women

AVNRT and AVRT

Name the 2 main types of PSVT

GBS, E. coli, Chlamydia pneumoniae

Name the 3 MC organisms in neonatal pneumonia

Alteplase (rTPA). Given if no evidence of hemorrhage. Alteplase is the only rTPA effective in ischemic stroke!!

Name the Tissue PlasminogenActivator we use for ischemic strokes

False Thimerosal was taken out of childhood vaccines in 2001, and multiple, large, well-designed epidemiological studies and systematic reviews have found no evidence of an association between thimerosal and autism or other developmental disorders. In fact, autism rates have continued to rise, which is the opposite of what would be expected if thimerosal caused autism.

T/F: Thimerosol in the measles vaccine ca cause autism?

Flumazenil

What is the antidote to benzodiazepine poisoning?

Ultrasonography

What is the imaging test of choice if a large or loculated pleural effusion is suspected?

A) Hypocalcemia = carpal spasm after occluding blood flow in forearm with blood pressure cuff

Trousseau's sign is usually associated with which of the following? A Hypocalcemia B Hypokalemia C Osteomalacia D Hyperparathyroidism

Increased follicle-stimulating hormone, decreased estrogens and decreased progesterone.

What are the classic hormone level alterations in menopause?

Flushing and pruritus mediated by prostaglandin release. Tx: Nonsteroidal anti-inflammatory agents may prevent or alleviate prostaglandin-mediated niacin flushing or pruritus.

What are two common side effects which limit the use of niacin in treating hypertriglyceridemia?

Begins in 30s; 50% of men affected by age 50 years; 75% affected by 80 years (with nearly half of these cases being clinically significant).

What is the epidemiology of benign prostatic hyperplasia?

The occurrence of the initial episode of acute rheumatic fever is unlikely after 15 years of age.

Why does a healthy adult with uncomplicated Group A strep pharyngitis generally not require antibiotic treatment?

D) Rocky Mountain spotted fever Based on the history and presentation, this patient most likely has Rocky Mountain Spotted Fever (RMSF) which is a tick-borne disease caused by the organism Rickettsia rickettsia. RMSF should be considered in patients with unexplained febrile illness even if they have no history of a tick bite or travel to an endemic area. The classic clinical triad of fever, headache, and rash should raise a high suspicion for RMSF, especially high fevers over 102°F. The rash begins as a maculopapular eruption on the wrists and ankles and spreads centripetally to involve the trunk and extremities. The face is usually spared. Antibiotic therapy should be initiated before laboratory confirmation is available. Doxycycline is the antibiotic of choice for RMSF. Doxycycline therapy also treats Lyme disease, ehrlichiosis, and relapsing fever; diseases often clinically confused with RMSF. Doxycycline should be initiated immediately in this patient. Babesiosis (A) is a tick borne illness that presents with Influenza-like symptoms, fever, sweating, myalgia, headache, hemolytic anemia, hemoglobinuria, jaundice, renal failure. Ehrlichiosis (B) is a tick-borne illness that presents with influenza-like syndrome, fever, chills, cough, malaise, headache, and myalgias. A rash is rare in this disease, differentiating this from RMSF. Lyme disease (C) is a tick borne illness that initially presents as an erythema migrans (target) rash at the bite site, influenza-like symptoms, fever, fatigue, arthralgias, headache, cough, and lymphadenopathy. A bull-eye lesion is pathognomonic for Lyme disease.

A 35-year old woman presents to your office with a 1-week history of high fevers, severe headaches and muscle pain. She also reports a rash. She denies any recent travel or changes in her diet. She is current on her immunizations. She currently lives in North Carolina and enjoys hiking in the outdoors. On physical exam her temperature is 102.3°F and she has a maculopapular rash on her extremities, including her hands and feet and sparing her face. She states the rash began a few days after her fever started and has progressively worsened. You decide to draw laboratory tests and titers in order to confirm the suspected disease. You also prescribe antibiotics immediately. Which of the following is most likely etiology of the disease? A) Babesiosis B) Ehrlichiosis C) Lyme disease D) Rocky Mountain spotted fever

immunosuppression, catabolism, hyperglycemia, fluid retention, osteoporosis, growth delays

Corticosteroid SE

Until it is no longer mutually desired by the mother and child.

How long should breastfeeding continue?

1) ↑ antistreptolysin (*ASO*) titers 2) low serum compliment (*C3*)

Lab values to check if you suspect Post Infectious Acute Glomerulonephritis (AGN)

- Beta-interferons to decrease teh number/severity of relapses - Amantadine = helpful for fatigue of MS - Baclofen and Diazepam = for spasticity

MS: treatment of Relapsing-Remitting/progressive disesase

B) Second trimester of pregnancy Diastolic blood pressure and the mean arterial pressure reach their nadir at 16-20 weeks of gestation.

Maternal blood pressure normally decreases the most during what period of pregnancy? A) First trimester of pregnancy B) Second trimester of pregnancy C) Third trimester of pregnancy D) During labor and delivery

Sensorineural Hearing Loss

Side Weber localizes to has normal Rinne = what type of hearing loss?

Basilar Artery Deficit

Stroke: ↡bilateral sensation

seminoma

Testicular Cancer: Most common tumor

nonseminomatous germ cell tumors (NSGCTs)

Testicular Cancer: inhomogeneous with calcifications, cystic areas, and indistinct margins

Large Cell (Anaplastic) Carcinoma

This type of lung cancer is very agressive

given at age 11 up to 26

What ages do we recommend giving the HPV vaccine?

1) SABA 2) Anticholinergics 3) Corticosteroids

What types of medications do we use for treatment of acute asthma exacerbation?

Functional asplenia Think Sickle Cell

What do Howell-Jolly bodies indicate

Approximate increase of 10 to 15 beats/minute in pregnancy.

What is the average difference in resting heart rate in a pregnant woman vs. a nonpregnant woman?

Breast and pelvic examination, pregnancy test, pelvic ultrasound and serum follicle-stimulating hormone.

What is the initial work-up of a patient with primary amenorrhea?

Adenocarcinoma of the lung.

What is the leading cause of cancer-related death overall?

↑LDH suggests ↑RBC destruction LDH is an enzyme found in abundance in RBC's

What is the main use of LDH in regard to hematologic disorders?

Bromocriptine

What is the medication of choice for the treatment of prolactinoma?

Janeway Lesions = infective endocarditis

painless erythematous macules in the palms and soles

Thrush using a spacer and rinsing mouth after inhaler use decreases risk of thrush.

side effect of ICS use for asthma

Bone mineral density loss.

Adolescent females taking injectable depomedroxyprogesterone acetate (Depo-Provera®) for a duration of 2 or more years should be monitored for which side effect?

Omalizumab

Anti-IgE antibody used in severe, uncontrolled asthma

Leukotriene Modifiers/Receptor Antagonists (LTRAs) Montelukast (Singulair), Zafirlukast (Accolate), Zileuton (Zyflo)

Asthma: useful in asthmatics with allergic rhinitis/aspirin induced asthma. ppx only.

No benefits have been shown on oxygen saturation, hospitalization rates, or duration of hospitalization by using β2-agonists (including salbutamol/albuterol, ipratropium bromide, and terbutaline), and they should not be given routinely. Inhaled epinephrine has not been shown to affect rates of admission from the ED or hospital length of stay among patients admitted for bronchiolitis; however, there may be a role in children with severe or acutely deteriorating bronchiolitis.

Benefits of β2-agonists for the treatment of bronchiolitis

Alpha Thalassemia

CBC: hypochromic, microcytic anemia (pronounced ↓MCV, more than iron deficiency), normal RBC count, normal serum iron stores, Hgb of 4.

Stage Ia1

Cervical cancer: microinvasion is what stage?

Aortic Regurgitation (AR) or aortic insufficiency (AI)

Diastolic. decrescendo. blowing murmur maximal @ LUSB [high-pitched], increased venous return increases murmur, decreased venous return decreases murmur A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

Yes

Does health care associated pneumonia have a higher mortality than community acquired pneumonia?

Bisphisphonates (-dronates) Slows bone loss by inhibiting osteoclast-mediated bone resporption. Take after overnight fast, with water (no food), remain upright for 30 mins, wait at least 30-60 min for breakfast

First line treatment for Osteoporosis

Renal biopsy

Gold Standard for diagnosing Acute Glomerulonephritis

Acid-Fast Bacteria (AFB) cultures TB ruled out after 3 negative smears. Early AM gastric specimens if unable to give sputum

Gold standard diagnosis of TB

flank ecchymosis sign of pancreatitis

Grety Turner sign

inhibits vitamin K-dependent coagulation factor synthesis (II, VII, IX, X, proteins C and S)

How does Warfarin (coumadin) work?

within first 3 hours of onset (4.5 hours in some cases)

How long do we have to give thrombolytics for ischemic stroke?

At least 6 - 12 weeks.

How long should a scaphoid fracture be immobilized?

prevent dopamine breakdown

How to COMT Inhibitors help in the management of Parkinson Disease?

Chlamydia trachomatis and Neisseria gonorrhoeae

most common organisms responsible for bacterial epididymitis in males younger than 35 years.

Sheehan's syndrome

partial or complete pituitary insufficiency due to postpartum necrosis of the anterior pituitary gland in women with severe blood loss and hypotension during delivery.

beta-blockers, ASA, NSAIDs, ACEIs

what medications tend to cause nonallergic airway hyperreactivity?

1) Allergic (EXtrinsic) 2) Idiosyncratic (INtrinsic) = nonallergic

Name the two main types of Airway hyperreactivity in asthma

Wet (neovascular or exudative) Macular Degeneration

New, abnormal vessels growing under the central retina which leak and bleed leading to retinal scarring

Polycythemia

Overproduction of all 3 myeloid cell lines (primarily ↑RBC's but also associated with ↑WBC's and ↑platelets)

seminomas (simple = lack markers; sensative = to radiation, slow growing, stepwise spread)

Testicular Cancer: well-defined hypoechoic lesions without cystic areas

*Pseudonormalization/↑CO2* During asthma attacks, respiratory drive is stimulated so pt hyperventilates to decrease CO2. So an increase in CO2 can mean resp failure

This ABG may indicated impending respiratory failure in asthma

Swan neck deformity.

What chronic finger deformity can result from an untreated mallet finger?

Reactive Arthritis = "Cant see, cant pee, cant climb a tree" Chlamydia

What is "Reiter Syndrome?" And what STD is it associated with?

A major exotoxin and virulence factor produced by Gram-negative B. pertussis organisms is known as lymphocytosis-promoting factor.

What is the mechanism responsible for the lymphocytosis seen in children with pertussis?

Chronic obstructive pulmonary disease.

What is the most common cause of cor pulmonale in the United States?

Ischemic cardiomyopathy.

What is the most common cause of heart failure with reduced ejection fraction?

- ↑reticulocytes, LDH, indirect bilirubin (jaundice) - ↓ Haptoglobin

What kind of labs will you see with Hemolytic Anemias?

Acute bronchiolitis with severe lung or heart disease or immunocompromised

What patients should you treat with Ribavirin

Liver function tests (LFTs).

What routine lab work should be considered before prescribing oral antifungal medications?

Broca Defect in expressing speech, writing or signs MCA Dominant (usually L-side) defect

What type of aphasia is "expressive"

Gonorrhea Esp of the knees

Which STI is associated with septic arthritis?

A) cavitation Cavitation is seen with lung abscess or progressive primary tuberculosis

Which of the following is the most common radiographic presentation of lung abscess? A cavitation B pleural thickening C hilar mass D hyperinflation

Fetal hemoglobin (HgbF) declines and the deficient hemoglobin takes over

Why do thalassemias and inheritied hemoglobinopathies start to show around 6 months.

Sickle Cell Disease spleen has atrophied following repeated infarction.

Functional asplenia early in life should make you think of what condition?

Mitral stenosis

PE will show loud S1, opening snap, low-pitched, rumbling diastolic apical murmur

Temporal Arteritis (Giant Cell Arteritis) Tx: is high dose steroids ASAP Comments: Associated polymyalgia rheumatica

Patient will be a woman > 50 y/o, Complaining of monocular visual loss, unilateral headache, jaw claudication, PE will show tender temporal Artery, Labs will show ESR > 50

*fosphenytoin* >> phenytoin Phenytoin infusion may result in venous irritation and tissue damage if the undiluted drug is administered through a small-bore venous catheter. In addition, a rare complication of intravenous phenytoin use is purple glove syndrome: a dark discoloration that extends from the injection site to the distal limb, and is associated with pain and swelling. Fosphenytoin is a water-soluble prodrug of phenytoin that has fewer infusion-related complications but is significantly more expensive. Hypotension and arrhythmias may result from phenytoin and fosphenytoin at high infusion rates.

If benzodiazepines do not abort seizures, the next step is _____________________.

*Pericardial Tamponade* muffled heart sounds, JVD, hypotension, pulsus paradoxus = Beck's triad Echocardiography will show diastolic collapse of RV Treatment is pericardiocentesis

Patient will be complaining of dyspnea and chest pain, PE will show muffled heart sounds, JVD, hypotension, pulsus paradoxus, ECG will show low voltage QRS, electrical alterans

Testicular Cancer Accounts for 1% of all cancers in males. Peak age: 32 years old (ranges 12 to 35). Incidence: Doubled since 1960s. Highest rates: Scandanavia and Germany; Lowest rates: Asia and Africa. Cryptorchidism (Undescended Testicle) Accounts for 10% of cases (Confers 2.5 to 11 fold increased risk).

MC solid tumor in young men

Diagnosis is made by T2-weighted MRI

MS: Diagnosis

Temporary pacing to bridge to permanent pacemaker (Permanent pacemaker is the definitive treatment)

Management of acute/symptomatic 3rd degree AV block

"rest the pancreas" or Supportive measeures only 90% recover without complications in 3-7 days and require supportive measures only. Supportive measures = NPO, IV fluids, anaglesia

Management of choice for acute pancreatitis

Eisenmenger syndrome is a general term applied to *pulmonary hypertension and shunt reversal* (causing a right-to-left shunt, bypassing the lungs and resulting in cyanosis and clubbing.) in the presence of a congenital defect, including VSD, ostium primum ASD, AV canal defect, aortopulmonary window, or PDA

What is Eisenmenger syndrome?

Vertebral tuberculosis

What is Pott's Disease?

Hypoglycemia

What is a common side affect of sulfonylureas when used in elderly patients?

12-22 mm Hg.

What is a normal intraocular pressure?

thirst, blurred vision, dry mouth, urinary retention, dysphagia, acute glaucoma, BPH Anticholinergic side effects.

SE of Ipratropium (Atrovent)

small cell carcinoma

SVC syndrome is MC with which type of lung cancer

LABA's for long term control of asthma Prevents symptoms, especially nocturnal asthma

Salmeterol (Serevent), Symbicort, Advair

MCA Dominant side (usually L-side)

Stroke: aphasia, math comprehension, agraphia (loss in the ability to communicate through writing)

Acquired (not hereditary)

What is meant by "Extrinsic" Hemolytic Anemia?

Pulmonary opacity on CXR or CT

This is required to establish a diagnosis of CAP

Metronidazole

What medication do we use for Giardia according to PPP?

Phenobarbital

What medication does PPP recommend for febrile seizures?

In most cases of EM, supportive treatment is all that is necessary. Oral antihistamines, steroids, and analgesics may be beneficial.

What is the treatment of choice in those who develop Erythema multiforme?

Hypertensive vasculopathy, the result of long-standing hypertension, is the leading cause of intracerebral hemorrhage. The result of degenerative changes and eventual rupture of small penetrating arteries that branch off major intracerebral arteries

What is the most common cause of nontraumatic intracerebral hemorrhage in adults?

Impaired consciousness without focal symptoms

What type of presentation should make you think / favors SAH

TB of the lymph nodes

What is scrofula?

- Anemia of chronic disease

Name the bolded Normocytic Anemia in PPP (1)

BP ≥ 185/110 recent bleed or trauma Bleeding disorder

Name the contraindications to Alteplase in ischemic stroke

Tonic-Clonic (Grand Mal) Seizure

Seizures: Loss of consciousness → Rigidity, sudden arrest of respiration → repetitive rhythmic jerking → post-ictal phase

Status Epilepticus

Seizures: repeated, generalized seizures without recovery >30 mins

Myoclonus

Seizures: sudden, brief, sporadic involuntary twitching, No LOC

Pseudomonas aeruginosa

45yo man who has been in the ICU for 2 weeks on vent support develops fever and chills with productive green sputum on suction

Strep pneumoniae

Pneumonia: rusty (blood-tinged) sputum

Migraine *with Aura*

Classic Migraine

SVC Syndrome MC with small cell carcinoma

Dilated neck veins, facial plethora, prominent chest veins

Polycythemia

Excessive Red Blood Cell production due to chronic myeloproliferative neoplasm

Acute Bacterial Endocarditis (ABE) (S. aureus)

Infection of NORMAL VALVES with a VIRULENT organism

4,1000 - 11,000

Normal lab value for WBC

150,000 to 450,000 platelets per microliter

Normal lab value for platelets

0.6 - 1.4 mg/dL (1.0 +/- 0.4)

Normal lab value for serum creatinine

Anti-IgE antibody used in severe, uncontrolled asthma - inhibits IgE inflammaton

Omalizumab

Erythromycin-Sulfisoxazole, Azithromycin, or TMP-SMX (*macrolide or Bactrim*)

Patient has AOM but is PCN allergic, what should you use?

50 cells/mcl = Valganiciclovir first; ganciclocvir + foscarnet second

Primary prophylaxis of CMV retinitis is recommended at what CD4 count?

Beta-1 cross reactivity tachycardia, arrhythmia, muscle tremors, CNS stimulation, Hypokalemia

SABA side effects

Osler Nodes

Tender nodules on the palms of pads of the digits

High dose corticosteroids + Cyclophosphamide + plasmapharesis (to remove the antibodies)

Treatment of Goodpasture's Disease

false

True or false: hypothyroidism is more common in men?

Strep pneumoniae

what is meant by "pneumococcal"?

*Acute angle closure glaucoma*

"Cupping" of optic nerve on fundoscopy

Sickle Cell Disease Microthrombosis causes avascular ischemic necrosis of the bone

"H"-shaped vertebrae

Bisphosphonates Slows bone loss by inhibiting osteoclast-mediated bone resporption. Think Osteoporosis.

-dronates

Asbestos

2nd MC cause of lung cancer after smoking.

SE Asians

Alpha Thalassemia MC in what population?

folate, avoid oxidative stress, avoid iron supplementation

Basic management of moderate alpha thalassemia

blood transfusions, iron chelating agents, possible splenectomy to stop RBC destruction, allogenic bone marrow transplant is definitive.

Basic management of severe alpha thalassemia

Macular degeneration

Central vision loss as well as detail and color vision

Tuberculosis (TB)

Chronic productive cough, chest pain,(often pleuritic), Hemoptysis if advanced, night sweatsh, fever/chills, fatigue,

Facial muscle spasm when facial nerve is tapped = hypocalcemia

Chvostek Sign

Migraine *without Aura*

Common Migraine

*Acute angle closure glaucoma*

Conjunctival erythema, "Steamy" cornea

>/= 15% decrease in FEV1

Exercise challenge test criteria for diagnosing asthma

Infective Endocarditis

Fever, anorexia, weight loss, fatigue, ECG abnormalities

Fluids

First line management of mild shigellosis

Dry (Atrophic) Macular Degeneration

Gradual breakdown of the macula leading to gradual blurring of central vision

99.7%

HPV is associated with what percentage of Cervical Cancer?

Amantadine Increases presynaptic dopamine release.

Improves long-term levodopa induced dyskinesia. May help early on with mild symptoms of parkinson disease.

Lactate Dehydrogenase It is found in all tissues, so an elevation of the blood level is a nonspecific indicator of tissue damage. Elevations of LDH suggest injury to the muscles, liver, hemolysis, or rapid cell division as in lymphomas.

LDH

Aztreonam (Azactam®)

Monobactam with gram-negative spectrum

C) Amlodipine Beta blocker or calcium channel blockers

Optimum therapy for hypertension on patient with angina A) Lisinopril (Zestril) B) Furosemide (Lasix) C) Amlodipine (Norvasc) D) Losartan (Cozaar)

Nystatin

PO and topical antifungal

Self-terminating withing 7 days (usually < 24 hrs)

Paroxysmal A fib = ____________________

Thalassemia

Peripheral blood smear shows "Target cells" , teardrop cells, basophilic stippling.

Persistent AF > 1 year refractory to cardioversion or cardioversion never tried

Permanent A fib = ____________________

Anaerobes

Pneumonia: ASPIRATION pneumonia

Mycoplasma pneumoniae

Pneumonia: pharyngitis, ear (bullous myringitis), URI symptoms

Typical pneumonia

Pneumonia: signs of consolidation, bronchial breath sounds, dullness on percussion, increased tactile fremitus, egophony, inspiratory rales

Sphenopalatine artery Tx: packing (foley, gauze pack, intranasal balloon device)

Posterior nose bleeds:

IM benzathine penicillin G *x 1 dose*

Primary/secondary syphilis treatmnet:

*Anti-HTN meds* (beta-blockers, CCBs) TCAs Anticonvulsants (Valproate, *Topiramate*) *** Topiramate is only drug with moderate evidence for prophylactic treatment in patients with chronic migraine and medication overuse headache***

Prophylactic management of migraine headaches

Fatty casts.

Proteinuria and nephrotic syndrome lead to what kinds of casts seen on microscopic examination of urine?

Usually <3g/day (but CAN be in the nephrotic range)

Proteinuria levels in glomerulonephritis

Chlamydia

Purulent or mucopurlent discharge, pruritis, dysuria, dyspareunia, hematuria

depression, B12 deficiency, syphilis, hypothyroidism, NPH, drug use, intracranial mass

Reversible causes of Dementia

bronchiolitis On chest examination, wheezing and crackles are heard diffusely throughout both lung fields.

Rhinorrhea, tachypnea, wheezing, and coughing. Use of accessory muscles, nasal flaring, and fever may also occur. These symptoms last on average 7 to 21 days and are often the worst in the first week of the illness.

Used for staging

Role of CT in diagnosis of lung cancer

retinal hemorrhages with pale centers, petechiae infective endocarditis

Roth Spots

ICS's for long term control of asthma

Salmetrol, Flunisolide, Triamcinolone

(1) nasal polyps, (2) asthma, (3) aspirin-sensitivity Such patients may have an immunologic salicylate sensitivity leading to potentially-severe bronchospasm. The presence of polyps in children should suggest the possibility of cystic fibrosis (So do some CF screening if you see this).

Samter's triad

False Needle biopsy is not indicated in the workup of suspected testicular cancer.

T/F: after suspected testicular cancer based on Physical Exam, the best next step in management is needle biopsy.

Isobiazid

TB: what medication is associated with drug-induced lupus, rash

Pyrazinamide (PZA)

TB: what medication is associated with hepatitis and hyperuricemia?

Arthritis-Dermatitis Syndrome (Gonorrhea)

Tendon pain, joint pain, maculopapular/petechial rash.

AFP

Testicular cancer: increased in many nonseminomatous germ cell tumors (NSGCT); not usually elevated in seminoma's or choriocarcinomas

1) Simple = lack tumor markers 2) Sensitive = to radiation 3) Slow = slow growing 4) Stepwise = spread in a stepwise manner

The 4 S's of Seminoma

Koebner phenomenon

The appearance of skin lesions on lines of trauma is known as...

Chancroid

The chancre begins as a soft papule surrounded by erythema. After 24-48 hours it becomes pustular, then eroded and ulcerated; vesicles are not seen. The edges of the ulcers are often ragged and undermined. The ulcer is usually covered by a necrotic, yellowish-gray exudate, and its base is composed of granulation tissue that bleeds readily on manipulation. usually tender and or painful not indurated (soft chancre).

20-40%.

The disabling symptoms of premenstrual syndrome mentally or physically incapacitate what percentage of affected women?

Chlamydia

Urethritis, PID, Reactive Arthritis, and Lymphogranuloma Venereum

Gentamicin

Used for gram negative coverage in infectious endocardidits

Penicillin or Vancomycin

Used for gram positive coverage in infectious endocarditis

Trousseau's Syndrome

Venous thrombosis associated with metastatic cancer

Conductive Hearing Loss

Weber: localizes to affected ear Rinne: abnormal (BC > AC) Side Weber localizes to has ABnormal Rinne = what type of hearing loss?

>70% predicted response sustained x 1 hr after treatment

What PEFR warrants ED discharge?

Parietal cells in the stomach

What cells produce "intrinsic factor" needed for B12 transport to terminal ileum?

Anticoagulation (heparin followed by warfarin).

What is the treatment of choice for a carotid artery dissection?

Alcohol

What substance must be avoided during metronidazole therapy?

"Erythromelalgia" = sign of Polycythemia

episodic burning/throbbing of hands and feet with edema

↓heme production

how does lead poinsoning lead to microcytic anemia?

↓globin production

how does thalassemia lead to microcytic anemia

Parkinson disease

resting tremor, rigidity, bradykinesia, and postural instability.

Roth Spots = infective endocarditis

retinal hemorrhages with pale centers, petechiae

community-acquired bacterial pneumonia (CAP).

the most common infectious cause of death in the United States.

Anticholinergic side effects

thirst, blurred vision, dry mouth, urinary retention, dysphagia, acute glaucoma, BPH

children/adolescents

what age group tends to get the allergic form of asthma?

Pseudomonas

in patients invaded by plastic (think nursing home, G-tube/ET tube, dialysis, hospitalized); cough, fever, dyspnea; gram-negative coccobacillus; CXR with patchy infiltrates; cystic fibrosis, hot tubs

D) Staccato cough

A 2-month-old boy presents with a fever and cough. Which of the following is suggestive of Chlamydial pneumonia? A) Bullous myringitis B) Diarrhea C) Rusty-colored sputum D) Staccato cough

Immediately reimplant the tooth and refer to an oral surgeon Avulsed permanent teeth should be cleansed, transported in Hanks solution or saline and reimplanted by an oral surgeon within one hour.

A 20 year-old presents 30 minutes after being struck by a hockey puck in the mouth. On physical examination a central incisor is missing from its socket. The patient has the tooth wrapped in tissue paper and the root appears intact. Which of the following is the most appropriate next step in the treatment of this patient?

This patient is exhibiting signs and symptoms consistent with thyroid storm. The most common precipitating factor is infection While medication noncompliance (B), myocardial infarction (C), and recent surgery (D) are all potential triggers of thyroid storm, they are far less common to do so than infection. Fever may be treated with acetaminophen as salicylates have the potential to increase T4 and T3 levels

A 65-year-old woman presents to the ED with a cough and rapid heart rate. She reports a history of hyperthyroidism. On physical exam, you note tachycardia and bilateral ocular proptosis. Which of the following is the most common trigger for this patient's disease process?

Vital signs (autonomic neuropathy), fundoscopy (retinopathy) and feet (diminished pulses, neuropathy).

A focused diabetic physical examination must include, at minimum, evaluation of which areas?

Multiple Sclerosis

CSF will show ↑ IgG protein, WBC pleocytosis (an increased white blood cell count in cerebrospinal fluid.)

IVb or recurrent

Cervical cancer: Distant mets is what stage?

Sulfa, Oral hypoglycemics, Anticonvulsants, Penicillin, NSAIDs (SOAPS)

Common drugs that cause EM

Thyroid and celiac disease

Patient with Osteoporosis should be screened for what?

Alpha-2 agonists Alpha 2 receptors in the brain stem and in the periphery inhibit sympathetic activity

These meds suppress aqueous humor production AND increase outflow

Replication and infectivity. Its presence represents high levels of DNA in the serum and higher rates of transmission.

What does the HBeAg serologic marker for hepatitis B indicate?

Streptococcus pneumoniae (same organisms seen in acute sinusitis = S. pneumo, H. flu, Moraxella, Strep pyo [GABHS])

What is the most common organism associated with acute otitis media (AOM)

friction rub.

What physical exam finding is a hallmark of pericarditis?

OA

joint space loss + osteophytes

D) Oral metronidazole (Flagyl) This is a classic description of trichomonas vulvovaginitis. This condition must be treated with oral metronidazole or tinidazole.

A 47 year-old perimenopausal female with vasomotor symptoms complains of vulvar itching and copious vaginal discharge with a rancid odor. Physical examination reveals erythema of the vulva and petechiae on the cervix. The pH of the vaginal discharge is five. Which of the following is the recommended treatment for this patient? A Topical metronidazole (Metrogel) B Oral fluconazole (Diflucan) C Topical estradiol (Estrace) cream D Oral metronidazole (Flagyl)

Palivizumab may be used in high risk groups.

Medication used as prophylaxis for acute bronchiolitis

Polycythemia Excessive Red Blood Cell production due to chronic myeloproliferative neoplasm

Pruritis (especially after a hot bath)

cryptorchidism

Testicular Cancer: Most common risk factor

<50% predicted

What PEFR warrants admission in asthma?

between -1.0 to -2.5

What T score defines osteopenia

Cooling baths and avoidance of overheating.

What is the treatment for Milaria rubra?

Treponema pallidum (syphilis).

Which organism causes condyloma latum?

hyperesthesia

exaggerated pain response to a painful stimulus), hypoesthesia (decreased sensation/numbness in a painful area

Bronchioalveolar has the best prognosis.

Lung cancer: Classically presents with voluminous sputum and an interstitial lung pattern on CXR.

Immunoglobulin E (IgE).

antibodies: If you have an allergy, your immune system overreacts to an allergen by producing antibodies called

RSV infection in children

associated with persistence of airway reactivity later in life.

Mycoplasma

atypical presentation; extra-pulmonary such as headache, malaise, bullous myringitis; CXR patchy interstitial pattern; hemolysis/cold agglutinins; rash; Guillain-Barre

Primary syphilis Tx: Benzathine penicillin G 2.4 million units IM, single dose, is nearly universally curative. Doxycycline for 2 weeks is an alternative for penicillin-allergic patients.

characterized by a small papule that develops at the site of inoculation (usually genital) that becomes a painless, indurated ulcer,

Fluorescent antibody to membrane antigen (but is not readily available)

gold standard for identification of varicella-zoster virus

2 to 10 years

how long on average does it take for cervical carcinoma to penetrate the basement membrane

Corticosteroid SE

immunosuppression, catabolism, hyperglycemia, fluid retention, osteoporosis, growth delays

Antidromic (5%) mimics VT

impulse goes down the accessory pathway first and returns via the normal pathway = WIDE COMPLEX TACHYCARDIA

apraxia MCA nondominant side (usually R-side)

inability to perform particular purposive actions

TZD's (thiazolidinediones) = "glitazones"

increases insulin sensitivity in adipose tissue, skeletal muscle, and liver

GLP-1 agonists = "-tides"

incretin analog that increases glucose-stimulated insulin secretion and decreases glucagon secretion. Slows gastric emptying and reduces appetite. Only available as subQ injections.

Francisella tularensis (tularemia)

infected animals (ex. rabbits); ulcerated skin lesion, lymphadenopathy

Gout Patho: Most commonly caused by uric acid crystals Clinical: acute onset of pain in the first MTP (Podagra) Tx: Acute = NSAID's; Chronic = allopurinol or colchicine Comments: can be triggered by loop and thiazide diuretics

needle-shaped crystal with negative birefringence

allodynia

pain felt from a nonpainful stimulus, such as clothes or bed sheets on the skin

Hantavirus

severe respiratory distress/shock; rodent urine/feces; Southwest; supportive care only

Typical pneumonia

sudden onset of fever, productive cough with purulent sputum, pleuritic chest pain, rigors (shaking chills), tachycardia, tachypnea

SABA side effects = Sympathomimetic symptoms

tachycardia, arrhythmia, muscle tremors, CNS stimulation, Hypokalemia

TTP Thrombotic thrombocytopenic purpura (TTP). It is characterized by small-vessel platelet-rich thrombi that cause thrombocytopenia, microangiopathic hemolytic anemia, and sometimes organ damage. TTP is a medical emergency that is almost always fatal if appropriate treatment is not initiated promptly. With appropriate treatment, survival rates of up to 90 percent are possible.

thrombotic microangiopathy caused by severely reduced activity of the von Willebrand factor-cleaving protease ADAMTS13.

Strep pneumoniae

typical presentation, rust-colored sputum, rigors, high WBC, gram-positive encapsulated diplococci

thalassemia

uniformly sized cells with increased numbers of *target cells and teardrop cells*

Nonsemanomatous Germ Cell Tumors (NSGCTs)

↑ serum AFP, ↑Beta-HCG, radioresistance

Primary Erythrocytosis = Polycythemia

↑hematocrit in the absence of hypoxia

lead poisoning anemia Looks similar to anemia of chronic dz (ACD) but ACD is associated with ↓serum iron

↑serum iron, ↓TIBC, ↑ferritin

Growth Hormone Deficiency Most common cause: pituitary tumor, The incidence of GH deficiency is estimated to be between 1:4000 and 1:3500, so the disorder should not be considered rare.

↓ Muscle mass,↓ Bone density, ↑ Lipids, ↓ Memory, ↓ IGF-1

sulfa drugs (part of management of moderate alpha thalassemia)

"Avoid oxidative stress", ex: avoid what type of medication?

Typhoid (enteric) fever Salmonella typhii

"Rose Spots"

>/= 30 seconds

"Sustained" VT

D) hematuria The most common presenting symptom/sign of renal cell carcinoma is hematuria (approximately 60%). Flank pain or abdominal mass is present in about 30% of new cases. Hint: Renal cell cancer may present with HYPERcalcemia Hint: Renal cell cancer may present with polycythemia, NOT ANEMIA.

*Renal cell carcinoma* most commonly presents with which of the following symptoms or signs? A hypocalcemia B inguinal pain C anemia D hematuria

Pericious Anemia

+ Intrinsic Factor Ab, Parietal Cell Ab, ↑gastrin levels, + Schilling Test (a medical procedure used to determine whether you're absorbing vitamin B-12 properly.)

*Sulfonylurea 1st gen* = antihyperglycemic MOA: stimulates pancreatic beta cell insulin release. NOTE: can lead to hemolytic anemia in patient with *G6PD* deficiency; use caution or consider other agents AE common: weight gain, fatigue, diarrhea, nausea, dyspepsia, rash AE serious: leukopenia, thrombocytopenia, liver problems, blood problems.

-amide (diabetes)

SGLT2 Inhibitors = anti hyperglycemic MOA: Inhibit sodium-glucose cotransporter 2 (SGLT2) which blocks the reabsorption of glucose from the kidneys and increases glucose loss in the urine (FLOZin = flow'n = urine) NOTE: DKA and euglycemic DKA reported. If s/s of acidosis then assess for ketoacidosis regardless of glucose levels. AE Common: genital fungal infections, UTI, increased urination, Increased LDL AE serious; hypotension, renal dysfunction, hypoglycemia

-gliflozin

Meglitinides = antihyperglycemics Ex: Repaglinide (Prandin) MOA: stimulate pancreatic beta cell insulin release AE common: arthralgia, URI, hypersensitivity AE serious: hypoglycemia, jaundice, cholestatic hepatitis, increased LFTs

-glinide

DPP4 Inhibitors (DiPeptidyl Peptidase 4) = antihyperglycemic MOA: Inhibits inactivation of incretin hormones (GLP-1) resulting in glucose-stimulated increased insulin secretion and decreased glucagon secretion. CI: don't mix with GLP-1 agonists (-tides)

-gliptin

*Beta-Blockers* Drops: Chronic open-angle glaucoma PO: HTN, Angina, Reduce perioperative cardiac events in high-risk patients undergoing noncardiac surgery, compensated heart failure, etc.

-olol

*Prostaglandin Analogs* for treatment of Chronic Open-angle Glaucoma MOA: Prostaglandin F-2 analog increases aqueous fluid flow Note: Do not administer while wearing soft contact lenses. Wait 10 min after use before inserting contact lenses. May aggravate intraocular inflammaton

-prost

Protect ear against moisture Drying agents include isopropyl alcohol and acetic acid (vinegar)

1st line management of Otitis Externa

Verapamil Preventive therapy should be started without delay at the onset of a cluster episode. The goal is to suppress attacks over the expected duration of the cluster period. An effective preventive regimen is of utmost importance because patients typically have one to eight cluster headaches a day, and repeated use of abortive medications may result in toxicity and/or rebound. For patients with chronic cluster headache and those with relatively long-lasting (ie, two months or longer) active periods of episodic cluster headache, we recommend initial preventive therapy with verapamil. The best evidence supporting its effectiveness comes from a randomized controlled trial involving 30 patients with cluster headache that compared verapamil with placebo. The following observations were reported: ● Overall, verapamil significantly reduced attack frequency and analgesic consumption during the 14 days of administration compared with placebo. ● During the first week of treatment, the median number of daily attacks, the primary outcome measure, was similar for patients treated with verapamil and placebo (1.1 versus 1.7). However, in the second week, the median number of daily attacks was significantly lower for patients treated with verapamil (0.6 versus 1.7). ● The number of responders in the verapamil and placebo arms was 12 of 15 (80 percent) and none of 15, respectively.

1st line prophylaxis of cluster headaches

*Topical FQ antibiotic drops* = Ofloxacin or Ciprofloxacin Ofloxacin otic is cheaper than Ciprofloxacin otic so start with ofloxacin if you have a choice Second line is an aminoglycoside combo (neomycin/polytrim-B/hydrocortisone otic). Avoid water/moisture/topical aminoglycosides in ear whenever there is TM rupture

1st line treatment for Chronic Otitis externa

Nitroglycerine and beta blockers NTG not used if suspected right ventricular infarction or PDE-5 inhibitor use w/in 48 hrs (ex. sildenafil)

1st line treatment for hypertensive emergencies with Acute Coronary Syndrome

Labetalol or Esmolol (Beta Blockers) Decreases shearing forces. Target SBP to 100-120 and pulse <60 bpm achieved within 20 minutes

1st line treatment for hypertensive emergencies with Aortic Dissection

Nicardipene or Labetalol Nicardipine is a dihydropyridine calcium channel blocker (like nifedipine) that can be given as an intravenous infusion. The initial dose is 5 mg/hour and can be increased to a maximum of 15 mg/hour. Nicardipine has a better safety profile and a similar antihypertensive effect when compared with nitroprusside. The major limitations are a longer onset of action, which precludes rapid titration, and a longer serum elimination half-life (three to six hours). Labetalol is a combined beta-adrenergic and alpha-adrenergic blocker. Its rapid onset of action (five minutes or less) makes it a useful intravenous medication for the treatment of hypertensive emergencies. However, one trial found that labetalol has less antihypertensive efficacy as compared with nicardipine. labetalol should be avoided in patients with asthma, chronic obstructive lung disease, heart failure, bradycardia, or greater than first-degree heart block.

1st line treatment for hypertensive emergencies with encephalopathy, hemorrhagic stroke, or ischemic stroke

Atropine or temporary pacing Progression to 3rd degree common so permanent pacemaker is definitive treatment

1st line treatment of Mobitz-II second degree AV block

Macrolide (Azithromycin or Clarithromycin) or Doxy

1st line treatment of OUTpatient CAP

*Ceftriaxone* 250 mg intramuscular in a single dose for treatment of gonococcal infection Due to rising rates of gonococcal resistance to other agents (sulfonamides, penicillins, tetracyclines, and fluoroquinolones), third generation cephalosporins had been considered first-line monotherapy. Of these, ceftriaxone is favored because drug resistance has been documented less frequently than for other cephalosporins. However, as more isolates with decreased susceptibility to both cefixime and ceftriaxone are being reported, the ability to effectively treat N. gonorrhoeae with a single agent has been threatened and is no longer recommended. For uncomplicated urogenital gonococcal infections, we suggest using Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection PLUS Azithromycin (1 gram in a single oral dose) for possible additional activity against N. gonorrhoeae and for treatment of potential chlamydia coinfection Doxycycline (100 mg orally twice daily for seven days) is an alternate option for a second agent to administer with ceftriaxone, but we reserve its use for patients allergic to or intolerant of azithromycin because of the increased prevalence of N. gonorrhoeae resistance to doxycycline compared with azithromycin.

1st line treatment of gonorrhea

B) threatened abortion Vaginal bleeding that occurs prior to the 20th week of gestation is classified as a threatened abortion. Pain is usually not a major feature and vaginal examination usually reveals a closed cervical os. Hint: Vaginal bleeding and cramp-like lower abdominal pain are usually present in an *inevitable abortion*. The cervical os is also frequently partially open. Hint: Vaginal bleeding accompanied by cramp-like pain, cervical dilatation, and passage of some products of conception constitutes an *incomplete abortion*. Hint: After all products of conception are passed, the uterus contracts and vaginal bleeding stops. The cervical os closes, but the uterus is smaller than the suspected gestational age following a *complete abortion*.

27 year-old G1P0 female presents complaining of painless spotting since this morning. She is known to be 12 weeks pregnant. Pelvic examination reveals the presence of blood within the vagina with a closed cervical os. The uterus is consistent with a 10-12 week gestation and nontender to palpation. Which of the following is the most likely diagnosis? A inevitable abortion B threatened abortion C incomplete abortion D complete abortion

B) Iron deficiency anemia The World Health Organization (WHO) estimates that anemia affects one quarter of the world's population and is concentrated within preschool-aged children and women. The majority of the anemia is due to iron deficiency. The most important screening test is a focused dietary history, and it is more useful than hemoglobin levels. The primary risk factors for iron deficiency are: history of prematurity or low birth weight, use of low iron formula, or feeding of non-formula cow's milk, goat's milk, or soy milk for the milk-based part of the diet before 12 months of age or fewer than two servings per day of iron-rich foods (meats or fortified infant cereal) after six months of age. Thalassemia (C) would also present with microcytic anemia with MCV less than 80 fL, and the family history may be positive. Iron stores are absent and serum ferritin levels are low in iron deficiency, while both are normal or elevated in the thalassemias. Folate deficiency (A) and vitamin B12 deficiency (D) would both reveal macrocytic anemia with MCV greater than 100 fL.

A 12-month-old girl is in the clinic for a well-child check. She can walk and is eating more table foods. The parents have given her goat's milk for two months. Physical examination is normal. Laboratory screening obtained shows hemoglobin of 10 g/dL, mean corpuscular volume 77 fL and elevated red cell distribution width. Which of the following is the most likely diagnosis? A) Folate deficiency B) Iron deficiency anemia C) Thalassemia D) Vitamin B12 deficiency

C coarctation of the aorta Coarctation is a discrete or long segment of narrowing adjacent to the left subclavian artery. As a result of the coarctation, systemic collaterals develop. X-ray findings occur from the dilated and pulsatile intercostal arteries and the "3"is due to the coarctation site with proximal and distal dilations. Hint: Thoracic outlet syndrome occurs when the brachial plexus, subclavian artery, or subclavian vein becomes compressed in the region of the thoracic outlet. It is the most common cause of acute arterial occlusion in the upper extremity of adults under 40 years old.

A 12-year-old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound. Femoral pulses are weak and delayed compared to the brachial pulses. Blood pressure obtained in both arms is elevated. Chest x-ray reveals rib notching. Which of the following is the most likely diagnosis? A abdominal aortic aneurysm B pheochromocytoma C coarctation of the aorta D thoracic outlet syndrome

B) Pityriasis rosea Pityriasis rosea is a classic childhood exanthem. The rash begins with the appearance of a characteristic herald patch, an erythematous, oval-shaped, sharply demarcated lesion that is most common on the upper back, chest, or neck. The rash subsequently spreads down the trunk in a "Christmas-tree" distribution along the cleavage lines of the skin. In children, it may also affect the face, scalp, and extremities. The lesions may desquamate and result in post-inflammatory hyperpigmentation. Many children may be asymptomatic, while others may experience intense pruritus. The typical course of pityriasis rosea is self-resolution, which may take weeks to months. Some patients may require topical steroids to control itching.

A 12-year-old girl presents with a rash. Erythematous papules and plaques are noted over her back. A prominent, oval-shaped, scaling papule is present on her right upper back. What is the most likely diagnosis? A) Atopic dermatitis B) Pityriasis rosea C) Tinea corporis D) Tinea versicolor

C) primary dysmenorrhea This patient most likely has primary dysmenorrhea supported by onset of pain within 1-2 years after onset of menarche and characteristic symptoms of low, mid-abdominal, spasmodic cramping pain that radiates to the back or inner thighs beginning on the first or second day of menstruation. Pelvic examination fails to reveal any pathological findings. Hint: Premenstrual syndrome is seen primarily in females that are 25-40 years old. Associated physical and emotional symptoms appear 7-14 days before the onset of menses and resolve once menstruation begins.

A 13 year-old female presents with a six month history of lower mid-abdominal pain that is spasmodic in nature and radiates to the inner thighs. The pain usually starts within a few hours of the onset of menses and lasts about 2 days. The patient's menarche began 2 years ago. She denies any sexual activity. Physical examination, including pelvic, is unremarkable. Which of the following is the most likely diagnosis? A) ovarian cyst B) endometriosis C) primary dysmenorrhea D) premenstrual syndrome

B) Ceftriaxone, metronidazole and neurosurgery consultation This patient presents with signs, symptoms and imaging consistent with an intracranial abscess. Immediate management involves administration of antibiotics covering the most likely pathogens and neurosurgical consultation. CNS abscess is unusual in immunocompetent hosts but can result from direct spread from other infections. The most common causes from direct spread are dental infections, otitis media and sinus infections. Patients with multiple abscesses should raise suspicion for endocarditis. *Streptococcus species and anaerobic bacteria are the predominant causative agents*. Patients with a history of trauma or intracranial surgery are also at risk for MRSA. CT scan is the diagnostic modality of choice and typically is followed by a lumbar puncture (unless there are signs of increased intracranial pressure), which aids in determining the etiologic agent. Location, size and number of abscesses dictate management. Patients with a single abscess are more readily treated with neurosurgical intervention while those with multiple abscesses are usually treated with antibiotics alone. Initial antibiotics in patients without a history of neurosurgery should be with a *third generation cephalosporin and an agent covering anaerobic bacteria like metronidazole*.

A 14-year-old boy presents with headache, fever and altered mental status. He was recently seen and evaluated for sinusitis 1 week ago, but was not given antibiotic treatment at that time. A non-contrast CT scan of the head is performed. What management is indicated? A) Ceftriaxone, metronidazole and admit B) Ceftriaxone, metronidazole and neurosurgery consultation C) Ceftriaxone, vancomycin and neurosurgery consultation D) Pyramethamine, sulfadiazine and admit

B) Brain CT scan with contrast This patient has a subdural empyema from direct extension of his sinusitis. Diagnosis of a brain abscess is challenging as the presentation is inconsistent. However, it should be considered in all patients with headache, fever, and focal neurological signs. Pain may be sudden or gradual in onset. Only half of these patients have fevers and some present without a headache. Frontal abscesses commonly cause generalized seizures and may be the only presenting sign. Meningeal signs are usually absent (unless an abscess is occipital), and signs of increased intracranial pressure usually take days to develop. The best test for diagnosing a brain abscess is magnetic resonance imaging with gadolinium contrast, however this is not always available in the emergency department. Brain CT with contrast is the next best test to confirm a brain abscess. A blood culture (A) may be helpful in determining the organism and should be obtained prior to starting antibiotics, if possible, but does not confirm the source of the infection. Patients with an intracranial abscess may present with seizures but in the setting of fever and focal neurologic findings, head imaging is indicated before an electroencephalogram (C). A lumbar puncture (D) is contraindicated in a patient with focal neurologic findings prior to head imaging.

A 14-year-old treated for sinusitis two weeks ago presents to your ED with worsening headache and fevers over the last week. His mother states that he has been sleeping most of the day and brought him in because he was having trouble walking. He has had no vomiting, vision changes, photophobia, neck pain, or trauma. His vital signs are within normal limits for his age. Your examination shows a pale appearing, somnolent male who wakes and answers questions appropriately. He has a normal cranial nerve exam, negative Kernig's and Brudzinski's signs, but is unable to heel-to-toe walk and has a foot drop on the left. Of the following, what is the next best step to establish the diagnosis? A) Blood culture B) Brain CT scan with contrast C) Electroencephalogram D) Lumbar puncture

Primary amenorrhea Dysfunctional uterine bleeding (A) is defined as nonpathologic, excessive and noncyclic bleeding mainly due to anovulation.Secondary dysmenorrhea (C) is abnormal uterine bleeding associated with non-midline pelvic pain, which can be due to endometriosis, uterine fibroids or pelvic inflammatory disease. Sheehan's syndrome (D) is a rare cause of amenorrhea in the complicated postpartum setting, in which severe hemorrhage and/or hypotension results in pituitary gland necrosis.

A 14-year-old woman presents to clinic with some frustration over never having a menstrual period. She is short in stature and has Tanner stage 2 breast development. As you begin a gynecological exam, you realize that you cannot pass a speculum into the vagina. Which of the following is the most likely diagnosis? Dysfunctional uterine bleeding Primary amenorrhea Secondary dysmenorrhea Sheehan's syndrome

C) Pelvic ultrasound This patient presents with a history concerning for ovarian torsion and should undergo a pelvic ultrasound. Ovarian torsion is an organ threatening disease, involving twisting of the ovary or fallopian tube or both on the vascular pedicle. It is more commonly seen on the right side (due to the effects of the sigmoid colon being on the left) and in women of childbearing age. Patients typically present with sharp, severe unilateral abdominal pain with nausea or vomiting. However, the classic presentation is often not present making diagnosis challenging. Risk factors for torsion include the presence of an ovarian mass or infertility treatment. Clinicians must maintain a high suspicion for this disease in order to make a timely diagnosis and prevent ovarian necrosis. Pelvic ultrasound, while imperfect, represents the best initial imaging modality. The classic ultrasound appearance in torsion is enlargement with a heterogenous stroma and peripherally displaced follicles. The most common findings are an increased ovarian size and an abnormal position in relation to the uterus. The addition of Doppler ultrasound may demonstrate decreased blood flow to the ovary but these findings are inconsistent. Additionally, Doppler ultrasound may be completely normal in intermittent torsion. Ultimately, patients with suspected ovarian torsion may require laparoscopy to confirm or rule out torsion.

A 15-year-old G1P0 woman at 23 weeks presents with sharp, left lower quadrant abdominal pain for 1 hour. She has had an ultrasound confirming the presence of a single intrauterine pregnancy. The pain is severe and associated with nausea. Pelvic examination reveals tenderness of the left adnexa. The patient's urinalysis is unremarkable. What test should be ordered to diagnose the patient? A) Abdominal X-ray B) CT scan of the abdomen and pelvis C) Pelvic ultrasound D) White blood cell count

A) Corticosteroids Fine serrations (ulcers) and pseudopolyps suggest ulcerative colitis. It is usually limited to the colon but occasionally, as in this case, the terminal ileum is also affected ("backwash" ileitis). In addition to sulfasalazine or 5-amino-salicylacid, more severe ulcerative colitis cases require corticosteroids. Corticosteroids are also helpful in Crohn's disease involving the small bowel. Metronidazole is helpful in treating the characteristic fistulas of Crohn's disease. Immunosuppressive agents, like with 6-mercaptopurine, are used in severe Crohn's disease cases. Diphenoxylate and loperamide provide only symptomatic relief. While surgical removal of the colon can give relief in ulcerative colitis, Crohn's disease tends to recur in about half of the cases involving removal of the diseased bowel.

A 15-year-old boy develops bloody diarrhea with abdominal cramping. Double contrast barium enema shows fine serrations and narrowing of the rectum and sigmoid. Stool contains mucus, blood, and white blood cells, but no parasites or bacterial pathogens. Endoscopy shows inflamed mucosa and pseudopolyps. Biopsy finds extensive inflammatory process in the mucosa and submucosa. Glands are filled with eosinophilic secretions. There is also mild involvement of the terminal ileum. Sulfasalazine treatment was attempted but failed to bring improvement. *What is the most appropriate next step in the management?* A) Corticosteroids B) Metronidazole C) 6-mercaptopurine D) Diphenoxylate E) Loperamide

C) Predominance of gram negative rods on gram stain vaginal pH of 5.5 (D) is characteristic of both bacterial vaginosis and trichmoniasis. Improvement on oral metronidazole (A) is characteristic of both bacterial vaginosis and trichmoniasis. Patients taking metronidazole should be cautioned about a disulfiram-like reaction if alcohol is consumed during a course of metronidazole. Multiple punctate hemorrhagic cervical lesions (B) describe the classic "strawberry cervix" that is associated with trichmoniasis.

A 15-year-old girl complains of vaginal discharge over the past two weeks. She reports recently becoming sexually active but uses condoms consistently during intercourse. Which of the following favors a diagnosis of bacterial vaginosis over trichmoniasis? A) Improvement on oral metronidazole B) Multiple punctate hemorrhagic cervical lesions C) Predominance of gram negative rods on gram stain D) Vaginal pH of 5.5

C) Predominance of gram negative rods on gram stain Improvement on oral metronidazole (A) is characteristic of both bacterial vaginosis and trichmoniasis. Patients taking metronidazole should be cautioned about a disulfiram-like reaction if alcohol is consumed during a course of metronidazole. Multiple punctate hemorrhagic cervical lesions (B) describe the classic "strawberry cervix" that is associated with trichmoniasis. A vaginal pH of <4.5 is normal, but a more basic vaginal pH of 5.5 (D) is characteristic of both bacterial vaginosis and trichmoniasis.

A 15-year-old girl complains of vaginal discharge over the past two weeks. She reports recently becoming sexually active but uses condoms consistently during intercourse. Which of the following favors a diagnosis of bacterial vaginosis over trichmoniasis? A) Improvement on oral metronidazole B) Multiple punctate hemorrhagic cervical lesions C) Predominance of gram negative rods on gram stain D) Vaginal pH of 5.5

A) Acetaminophen Acetaminophen is one of the most commonly used household medicines and is a frequently seen in intentional and unintentional ingestions in children. It is mainly metabolized by the liver, and overdose can lead to the production of the toxic metabolite, N-acetyl-p-benzoquinone imine (NAPQI). This can lead to cell necrosis when the antioxidant glutathione is depleted. Management includes early administration of N-acetylcysteine to prevent liver failure. The need to administer N-acetylcysteine is determined by the amount ingested (if known) or the acetaminophen level based on the Rumack-Matthew nomogram, which stratifies the risk of liver failure based on acetaminophen level and time since ingestion. N-acetylcysteine works mainly by increasing available glutathione, which then detoxifies the NAPQI. Dihphenhydramine (B) is an antihistamine and anticholinergic. Toxic manifestations may include mania, delirium, fever, erythema, dry skin, dry mucous membranes, tachycardia, mydriasis, or urinary retention. Ibuprofen (C), another common over the counter antipyretic and analgesic, can also cause nausea and vomiting when taken in large quantities. It can also lead to gastric ulceration and bleeding and can lead to kidney (not liver) injury. Pseudoephedrine (D) is commonly used as a nasal decongestant and is an alpha-adrenergic agonist. Overdose symptoms mimic other sympathomimetics and can include tachycardia, hypertension, hyperthermia, psychosis, paranoia, aggression, seizures, mydriasis, and diaphoresis.

A 15-year-old girl presents after a suicide attempt. She admits to taking a bottle of over the counter pills about 12 hours ago but does not remember the name of the drug. Her symptoms include nausea, vomiting, and diaphoresis. Initial lab work reveals mildly elevated AST and ALT. What drug did she most likely ingest? A) Acetaminophen B) Diphenhydramine C) Ibuprofen D) Pseudoephedrine

C) Recommend ibuprofen starting one day before menses Recommending acetaminophen (B) will not be as beneficial as ibuprofen since it does not directly affect the prostaglandins responsible for primary dysmenorrhea. Recommending oral ibuprofen starting one day before her menses is scheduled to begin typically provides modest relief for women with abdominal cramps due to primary dysmenorrhea. In the absence of a structural or infectious cause, this pain is caused primarily by uterine vasoconstriction, contractions, and anoxia brought on by prostaglandins present in the first few days of a menstrual cycle. As a result, NSAIDs are generally effective for reducing pain, as they are prostaglandin inhibitors.

A 15-year-old girl presents for severe lower abdominal pain that occurs for the first two days of her menstrual cycle each month. She has associated nausea and diarrhea. She denies menorrhagia. She had a normal menarche at age 13 and is not sexually active. Abdominal and pelvic exams are normal. Which of the following is the initial best step in management? A) Obtain a Pap smear and cervical cultures B) Recommend acetaminophen starting one day before menses C) Recommend ibuprofen starting one day before menses D) Referral for exploratory laparotomy

Azithromycin and ceftriaxone Azithromycin (A) ​alone is inadequate due to the high prevalence of chlamydia and gonorrhea co-infection. Amoxicillin (C) does not have a role in the treatment of cervicitis or urethritis. Fluoroquinolones (e.g. ciprofloxacin) (D) have high resistance to N. gonorrhoeae and is no longer recommended.

A 15-year-old girl presents to clinic with vaginal discharge. She recently became sexually active but states that her partner does not have any symptoms of infection. Speculum examination reveals white discharge and an erythematous cervix. Bimanual examination is unremarkable. Urine PCR is positive for Chlamydia trachomatis. Which of the following is the most appropriate treatment options? Azithromycin Azithromycin and ceftriaxone Ceftriaxone, amoxicillin and metronidazole Ciprofloxacin and ceftriaxone

Metronidazole Azithromycin (A) is the treatment of choice for chlamydial cervicitis. Chlamydia infection may cause vaginal discharge in females, but often the infection is asymptomatic. On speculum exam, the cervix is erythematous and friable. Ceftriaxone (B), a third generation cephalosporin, is the drug of choice for infections with Neisseria gonorrhoeae. Similar to chlamydial infection, gonorrheal infections may cause vaginal discharge, and, less commonly, may be asymptomatic. The cervix may also be erythematous and friable on speculum examination. No treatment (D) is inappropriate in a patient with symptoms and signs of bacterial vaginosis. Although bacterial vaginosis represents an overgrowth of normal anaerobic vaginal bacteria rather than an acquired infection, treatment is recommended. Adequate treatment is especially important for pregnant women, as bacterial vaginosis increases the risk of preterm delivery, chorioamnionitis, and endometritis.

A 15-year-old girl presents to the Emergency Department with complaints of vaginal pruritus and discharge. She denies sexual activity. Speculum examination reveals a homogenous, grey discharge with a pH > 4.5. A wet prep reveals stippled epithelial cells. What treatment is indicated? Azithromycin Ceftriaxone Metronidazole No treatment

B) Synchronized cardioversion Tachycardia can be classified based on the appearance of the QRS complex on the ECG as narrow and wide complex tachycardia. Narrow complex tachycardia consists of sinus tachycardia, atrial fibrillation, atrial flutter, AV nodal reentry, and atrial tachycardia (ectopic and reentrant). Wide complex tachycardia consists of ventricular tachycardia and supraventricular tachycardia with aberrancy. The patient presents with a tachycardia and associated serious symptoms of faintness, shortness of breath, chest pain and apprehension, mild hypotension, and peripheral vasoconstriction. Thus, while young patients can tolerate a rapid heartbeat for some time, this patient would be classified as hemodynamically unstable. The treatment of choice for unstable patients with a narrow complex tachycardia would be immediate synchronized cardioversion. However, whenever possible, it is advisable to provide analgesia and sedation for conscious patients before cardioversion.

A 15-year-old girl presents with a 1-hour history of rapid heartbeat, faintness, sweating, and nervousness. She is also experiencing shortness of breath and chest pain. The patient has no significant past medical history. There is no history of similar episodes. The patient is on no medications, and she denies illicit drug use. On exam, her vital signs are BP70/60 mmHg; pulse 200 bpm; RR 22/min, temperature afebrile. She looks pale, and her palms are slightly sweaty. She is not comfortable sitting up, so she prefers lying down. She looks slightly apprehensive. Her heart and lung exam are negative except for the tachycardia; except for cool sweaty hands, a brief abdominal and extremity exam are non-revealing. The physician quickly places the paddles on the patient's chest to record the rhythm; this shows a narrow-complex regular tachycardia at 210 bpm. He requests oxygen, IV line, and continuous monitoring. An EKG is in the process of being completed. *At this point, what should be done?* A) Carotid sinus massage B) Synchronized cardioversion C) Adenosine 6 mg IV push D) Diltiazem 10 mg IV push E) Verapamil 5 mg IV push

A) Begin work-up for primary amenorrhea Inducing a cycle with medroxyprogesterone (Provera) (C) is a strategy used for the treatment of secondary amenorrhea. Not initiating a work up (D) is inappropriate as primary amenorrhea is defined by age 14 if no secondary sexual characteristics have developed. Avid exercise (B) can be a cause of both primary and secondary amenorrhea, by causing functional hypothalamic amenorrhea, however this is only diagnosed after ruling out all other causes.

A 15-year-old woman presents to the office with her mother concerned that she has not had a menstrual cycle. She is an avid runner, logging 20 miles per week. On exam she exhibits no breast development or axillary or genital hair. Her mother was 15 when she started her menstrual cycle. What is your next step? A) Begin work-up for primary amenorrhea B) Encourage her to stop exercising for 3 months C) Induce cycle with medroxyprogesterone D) No work up, but provide education on the topic

B) Mittelschmerz (unilateral pelvic discomfort associated with ovulation and the production of progesterone) Women may experience pain at the time of ovulation, may alternate side to side. Hint: With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or "chocolate cyst". The patient with endometriosis also often has dysmenorrhea, dyspareunia, and dyschezia. Hint: Functional ovarian cysts occur from ovulation and are not usually symptomatic. Hint: Patients with pelvic inflammatory disease often present with fever, pain, and more acute symptoms.

A 16 year-old G0P0 patient presents complaining of lower pelvic pain that alternates from right to left side of her pelvis. She states that it is related to her cycle and occurs most commonly midcycle. She denies sexual activity. She reports that she has taken ibuprofen at the time of the discomfort with some relief. Her pelvic examination is unremarkable. Which of the following is the most likely diagnosis? A Endometriosis B Mittelschmerz C Functional ovarian cyst D Pelvic inflammatory disease

D) Hospitalization with parenteral doxycycline and cefoxitin This patient has pelvic inflammatory disease and most likely a tubo-ovarian abscess. It is recommended that the patient be hospitalized and treated with high-dose IV antibiotic therapy. For patients with tubo-ovarian abscesses, surgical drainage is often necessary.

A 16 year-old nulliparous acutely ill female presents with bilateral lower abdominal pain. She has a temperature of 100.4 degrees F and on examination has a tender, enlarged left adnexa. Cervical culture is positive for Chlamydia. Ultrasound reveals a complex tubular structure in the left adnexal area. What is the recommended treatment? A Outpatient treatment with IM ceftriaxone and oral doxycycline B Oral doxycycline C IM procaine penicillin D Hospitalization with parenteral doxycycline and cefoxitin

B) Topical tretinoin Topical retinoids, such as tretinoin, adapalene, and tazarotene, are effective first-line treatments for mild acne. Tretinoin is a comedolytic, which inhibits follicular canal obstruction by normalizing keratinocyte shedding, thereby inhibiting microcomedone formation. It also has anti-inflammatory properties. Adapalene has anti-inflammatory effects and normalizes follicular cell differentiation. The clinical presentation is that of acne vulgaris. Acne is a common skin condition that affects the pilosebaceous units. It usually begins in adolescence, though it also affects adults, especially women. Acne can be classified as mild, moderate, or severe. In mild acne, there are comedones, a few papules, and pustules without any nodules. In cases of moderate acne, patients have comedones, several papules and pustules, and a few nodules. In cases of severe acne, there are numerous comedones, papules, pustules, and nodules. Other topical agents such as benzoyl peroxide, topical sulfacetamide, and topical azelaic acid, are also effective first-line treatments for mild acne. Topical antibiotics, like erythromycin and clindamycin, are used in mild-to-moderate inflammatory acne because they have anti-inflammatory properties in addition to being effective against P. acnes. Benzoyl peroxide and topical antibiotics combinations reduce antibiotic resistance.

A 16-year-old Caucasian girl presents with a 6-month history of blackheads and whiteheads on her face. On examination, you find a few papules and pustules on her cheeks; there are no nodules. Her mother reports that she had similar spots on her face before she got married. What is an appropriate first-line medication for her? A) Oral isotretinoin B) Topical tretinoin C) Oral doxycycline D) Oral minocycline E) Intralesional triamcinolone

B) Serum Iron test A teenager who comes in frequently for a viral upper respiratory infection is a typical patient in any ambulatory practice. In many cases, the frequent infections can result from the busy lifestyles that many teenagers have. High school students are often involved in many extracurricular activities, miss sleep, and frequently obtain a less-than-nutritious diet. In this case, the physician ordering the tests has uncovered another reason for this young woman's frequent viral illnesses: subclinical iron deficiency. The patient's CBC demonstrates a borderline low hematocrit, which may be passed for normal. Her MCV is on the low edge of normal, suggesting microcytosis. Both these values suggest that this patient may suffer from subclinical iron deficiency, as her hematocrit is not overtly low. Iron deficiency on its own can lead to reversible abnormalities of immune function. Subclinical iron deficiency is diagnosed on the basis of reduced serum ferritin, decreased transferrin saturation, and decreased serum iron levels; however, normal hemoglobin has also been documented to impair immune responsiveness. In areas with prevalent nutritional deficiencies, milk fortification reduces morbidity due to respiratory disease. Although there have been conflicting reports on the value of iron supplementation in the prevention of infection, it appears that iron supplementation may benefit children with iron deficiency if they reside in a non-malarious region.

A 16-year-old girl presents for the third time in 2 months with symptoms of an upper respiratory tract infection. She has a blocked nose, tearing eyes, and appears exhausted. The first 2 times, she presented the same way and the diagnosis was a viral upper respiratory infection. At the 2nd presentation, she was given antibiotics in the vain hope that there was a superimposed sinus bacterial infection. When she presents the 3rd time, her mother comes in with her and demands to know what is making her daughter so susceptible to viral infections. The patient is a high school student and has a heavy study load. 2 months ago, she was studying for finals, and everyone believed the stress of exams was the cause of her illness. This time, she has been sick for 3 days with a bad cough, fever, runny nose, and throat pain; she denies that she has been overworked and says that she eats a good diet. On exam, you observe temperature 100.9°F; pulse 92 bpm; RR 18/min; BP 120/80 mm Hg. The head/ear/throat exam is unrevealing; the lung and heart exam is within normal limits. Her laboratory data reveals: What test is indicated at this time? A) Throat culture B) Serum Iron test C) Serum Immunoglobulin levels D) Folate level E) No test is indicated at this time

C) Start intravenous vancomycin and clindamycin Streptococcal Toxic Shock Syndrome (Strep TSS), as is true for any disease process manifesting with shock, is a medical emergency. One or more pyrogenic exotoxins secreted by Streptococcus pyogenes (Group A Strep) when it invades host tissues, is responsible for the syndrome. A similar but not identical pyrogenic exotoxin is produced by Staphylococcus aureus and may present with a similar clinical picture. It is, therefore, prudent to start antibiotics that cover both Strep and Staph, such as vancomycin, as soon as possible after treatment for shock is instituted. It has furthermore been demonstrated that treatment of toxic shock syndromes with a beta-lactam antibiotic such as penicillin or ampicillin is clinically inferior to a ribosomally active antibiotic such as clindamycin. This is thought to reflect the ability of clindamycin to turn off toxin production by the invasive bacteria. In addition to antibiotics, these patients often require surgical consultation for possible debridement. Vancomycin is bactericidal for most gram-positive organisms, particularly staphylococci and streptococci; it is, however, bacteriostatic for most enterococci. For systemic effect, the medication must be administered intravenously. Thrombophlebitis sometimes follows intravenous injection. The medication is infrequently reversibly ototoxic when given concomitantly with aminoglycosides or high-dose intravenous erythromycins; it increases aminoglycoside-induced nephrotoxicity with coadministration. Clindamycin is active against gram-positive organisms including S pneumoniae, viridans streptococci, group A streptococci, and S aureus, though resistance has been described in all of these pathogens. Common side effects are diarrhea, nausea, and skin rashes.

A 16-year-old male football player presents to the emergency room confused and in shock. There is no history of trauma, travel, preceding illness, or animal exposure. The young man appears pale, diaphoretic, and tachycardic, with a respiratory rate of 24 and a blood pressure of 95/55. Palpation of the slightly swollen right thigh is exquisitely painful, and there is slight erythema over that area. After aggressive fluid administration, an emergency MRI demonstrates a suppurative process involving the fascia of his right thigh. Which of the following is the most appropriate treatment at this time? A) Administer morphine for pain relief B) Obtain a CT scan with IV contrast of the right thigh C) Start intravenous vancomycin and clindamycin D) Start tetracycline orally

Once a diagnosis of testicular torsion is suspected, emergent surgery is indicated to have the best possible chance of salvaging the testicle (85-97% chance if less than 6 hours). Any other treatment measures delay the definitive treatment and increase the risk of testicular ischemia and infarction.

A 16-year-old male presents with increasing pain and swelling of his right scrotum. The right testicle is extremely tender to palpation on examination. A Doppler ultrasound demonstrates decreased blood flow. Which of the following is the most appropriate intervention?

B) emergent surgery Once a diagnosis of testicular torsion is suspected, emergent surgery is indicated to have the best possible chance of salvaging the testicle (85-97% chance if less than 6 hours). Any other treatment measures delay the definitive treatment and increase the risk of testicular ischemia and infarction.

A 16-year-old male presents with increasing pain and swelling of his right scrotum. The right testicle is extremely tender to palpation on examination. A Doppler ultrasound demonstrates decreased blood flow. Which of the following is the most appropriate intervention? A oral doxycycline B emergent surgery C incision and drainage D scrotal elevation and ice packs

D) Metronidazole Azithromycin (A) is macrolide that is not used in the treatment of bacterial vaginosis. Ceftriaxone (B), a third-generation cephalosporin, is administered parenterally and not appropriate for outpatient therapy. Doxycyline (C) is used in combination with ceftriaxone to treat gonorrhea and chlamydia but has no role in the treatment for BV.

A 16-year-old sexually active girl presents to your clinic with foul-smelling vaginal discharge. Examination of the vaginal fluid reveals clue cells. The vaginal pH is 5. Which of the following is the best course of treatment for this condition? A) Azithromycin B) Ceftriaxone C) Doxycline D) Metronidazole

Abruptio placentae Abruptio placentae, also called placental abruption, is defined as a premature separation of a normally implanted placenta from the uterus. Similar to placenta previa, it too causes third trimester bleeding, however unlike placenta previa, it is associated with significant pain, fetal stress and maternal complications. Vasa previa (D) is a condition in which the umbilical cord attaches into the placental membranes instead of the central placental tissue. This abnormal attachment generates an errant vessel which lies between the cervical os and the fetus, leading to the possibility of rupture and fetal demise.

A 16-year-old woman in her third trimester presents with acute onset of significant pelvic pain and blood per vagina. Thus far, her pregnancy has been normal. Her past medical history is significant for hypertension, asthma and recreational cocaine use. Examination reveals a tender, extremely tense uterus. Which of the following is the most like diagnosis? Abruptio placentae Preeclampsia Uterine atony Vasa previa

Bacterial vaginosis Bacterial vaginosis (BV) is an imbalance in the normal vaginal flora caused by a decrease in the concentration of hydrogen peroxide-producing lactobacillus and an overgrowth of several other microorganisms. These microorganisms vary but could include Gardnerella vaginalis, Mobiluncus spp., Peptostreptococcus spp., and several anaerobic gram negative rods (Prevotella spp., Porphyromonas spp., Bacteroides spp.). Patients usually complain of an amine odor and a grayish or milky, homogenous vaginal discharge. Diagnosis is made by using a diagnostic scale called Amsel's criteria. According to this scale, three of the four criteria must be met to diagnose BV. The four criteria are: an amine odor when potassium hydroxide solution is added to vaginal secretions (otherwise known as a positive whiff test), homogenous vaginal discharge, a vaginal pH >4.5, and the presence of clue cells on microscopy. Clue cells are epithelial cells that are coated with bacteria giving them a stippled appearance. Treatment involves metronidazole or clindamycin either orally or intravaginally. Recurrent BV is common.

A 16-year-old woman presents with vaginal discharge for 4 days. She describes the discharge as gray and malodorous. She denies any pain or itching. On exam, you note vaginal discharge, but no cervical or adnexal tenderness. Microscopy reveals clue cells. Which of the following is the most likely diagnosis? Atrophic vaginitis Bacterial vaginosis Candidiasis Trichomoniasis

B) Admit for further obstetrics evaluation Ultimately, delivery is the potentially curative therapy for preeclampsia but at this stage in pregnancy, an emergent cesarean section (D) would not be indicated. Phenytoin (B) is not indicated for seizure prophylaxis in preeclampsia. Instead, magnesium is the drug of choice for seizure prophylaxis when necessary. Patients with mild preeclampsia without symptoms or isolated maternal hypertension can be managed as outpatients (C) but not those with severe preeclampsia.

A 17-year-old G1P0 woman at 25-weeks gestation presents with intermittent blurred vision. On presentation, she is asymptomatic. Vital signs are HR 84, BP 175/113, oxygen saturation 97%. Physical examination reveals 2+ pitting edema on both lower extremities and urinalysis has 3+ protein on dip. Which of the following is most likely indicated? A) Administration of Phenytoin B) Admit for further obstetrics evaluation C) Arrange follow up with the patient's obstetrician D) Emergency cesarean section

D) Positive urine Chlamydia PCR Chlamydia trachomatis is the second most common sexually transmitted infection in both males and females in the United States (HPV is the first). The most common manifestation of chlamydial infection in males is urethritis, or the infection may be asymptomatic. However, infection may also lead to epididymitis, prostatitis, proctitis, and reactive arthritis. Nucleic acid amplification tests (NAAT)'s, such as polymerase chain reactions (PCR's) are sensitive and specific tests to establish a diagnosis of C.trachomatis. In the above case, a positive urine Chlamydia PCR is likely to be present.

A 17-year-old boy presents with dysuria and urethral discharge. He reports multiple female partners, but none of them are experiencing similar symptoms. Which of the following tests results are most likely to be present? A) Flagellated, motile protozoans on smear of a urethral swab B) Gram negative intracellular diplococci on smear of a urethral swab C) Positive HSV-2 IgG titer D) Positive urine Chlamydia PCR

C) Placental abruption Cigarette smoking during pregnancy is the most important modifiable risk factor associated with adverse pregnancy outcomes. Smoking and secondhand smoke exposure increase the risk of infertility, placental abruption, preterm premature rupture of membranes (PPROM), and placenta previa. Cigarette smoking also increases the risk of placental abruption. Dose-response curve analysis has consistently revealed that the risk of abruption is greatest among heavy smokers. Because PPROM is associated with both cigarette smoking and placental abruption, the relationship between cigarette smoking and abruption may be partially explained by the increased risk of PPROM. However, cigarette smoking appears to be a risk factor for placental abruption, independent of PPROM. Cigarette smoking has also been consistently associated with placenta previa. It is recommended that all pregnant women should be asked regularly about tobacco use. In clinical practice, screening for tobacco use is done by asking the patient if she has ever smoked cigarettes, if she smoked when she found out that she was pregnant, and whether she smokes now. Women who smoke should be asked the number of cigarettes smoked per day.

A 17-year-old girl is examined for a routine visit. She eats a healthy diet. She also stays active by playing volleyball three times a week. Her grades are mostly B's. She admits that she started to be sexually active for the past six months and has delayed periods for two months now. She had her menarche at 12 years old and has regular periods. She also smokes a quarter of a pack of cigarettes per day. Which of the following is an adverse pregnancy outcome due to maternal smoking? A) Hyperbilirubinemia B) Large for gestational age C) Placental abruption D) Respiratory distress syndrome

The patient has manifestations of hyperandrogenism and menstrual abnormalities that are suspicious for polycystic ovary syndrome (PCOS). There is gonadotrophic dysregulation with *increased luteinizing hormone (LH)* pulsatility and abnormally high ratios of circulating LH to follicle-stimulating hormone (FSH).

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

C) Increased luteinizing hormone LH:FSH > 3 : 1 (normal is 1.5 : 1) - LH is a pituitary hormone The patient has manifestations of hyperandrogenism and menstrual abnormalities that are suspicious for polycystic ovary syndrome (PCOS). Increased cortisol (A) is due to hypercortisolism (Cushings) that presents with facial plethora, supraclavicular fat pads, buffalo hump, truncal obesity, and purple striae, which the patient does not have. Increased follicle-stimulating hormone (B) is present in ovarian failure, which can be due to Turner syndrome, autoimmune disease, chemotherapy, or premature menopause. Increased thyroid-stimulating hormone (D) is due to hypothyroidism and commonly manifests as fatigue, constipation, weight gain, bradycardia, coarse hair and skin.

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

The patient has idiopathic intracranial hypertension (formally known as pseudotumor cerebri) as evidenced by papilledema, normal imaging and elevated opening CSF pressure Idiopathic intracranial hypertension has many drug-induced etiologies as well, including tetracyclines, oral contraceptives, sulfonamides, hypervitaminosis A, phenytoin, corticosteroids and nitrofurantoin. It is appropriate to stop doxycycline to determine if that is the underlying cause of her headaches.

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

B) Tenderness over the AC (acromioclavicular) joint Acromioclavicular (AC) separations typically occur as a result of a direct blow to the very lateral shoulder, usually a fall onto the shoulder. This AC separation is probably a Type I. Type I will have tenderness over the AC joint, no deformity and fair motion with some pain but the patient may still be able to play football with the shoulders padded and limited contact. Pain occurs with abduction mainly. They will typically hold their arm adducted and supported. Tenderness over the greater tuberosity would be seen with rotator cuff pathology or proximal humerus fractures. Crepitus would be seen with fracture or Type III AC separations. Nerve and/or vascular injuries are very rare with this injury.

A 17-year-old male high school football player presents after being tackled and slammed onto his right dominant shoulder forcefully 2 hours ago during a game. He had immediate pain, but was able to continue punting. He has full active and passive range of motion, but some pain (4/10) with abduction. There is no obvious deformity and the skin over the shoulder is intact and not tented. What would you expect to find on a physical exam? A) Tenderness over the greater tuberosity B) Tenderness over the AC (acromioclavicular) joint C) Crepitus with motion D) Decreased radial pulse E) Paresthesia over the elbow

A) Human papillomavirus vaccine Both types of the Human papillomavirus vaccine are given as a three-dose series in persons who initiated HPV vaccination at ages 15 through 26 years, so this patient is due for her third dose.

A 17-year-old presents for a well-child visit. She is healthy and has no complaints. A review of her past immunizations shows that she is up to date on all required immunizations at her 8-year-old well child visit. She also received the Human papillomavirus vaccine at age 15 and 16, and quadrivalent meningococcal vaccine and TdaP at age 12. Which one of the following vaccines should she receive at this visit? A) Human papillomavirus vaccine B) Inactivated poliovirus C) Measles D) Rubella

D) Obstetrics consultation "snowstorm" or "bag of grapes" appearance" = Hydatidiform mole or molar pregnancy This patient presents with vaginal bleeding and an ultrasound consistent with a hydatidiform mole or molar pregnancy requiring obstetrics consultation Methotrexate (A) is used for the medical management of early ectopic pregnancies. CT scan of the abdomen and pelvis (B) is unnecessary as the ultrasound confirms the diagnosis. Antibiotics (C) are unnecessary in the management of molar pregnancy.

A 18-year-old G1P0 woman at 16-weeks presents with vaginal bleeding. She had no prenatal care. Vital signs are unremarkable and physical examination only reveals a small amount of blood in the vaginal vault. A transvaginal ultrasound is performed and shows a "snowstorm" or "bag of grapes" appearance. Which of the following managements is most likely indicated? A) Administer methotrexate B) CT scan of the abdomen and pelvis C) Intravenous antibiotics D) Obstetrics consultation

B aortic root dilation his patient has the signs and symptoms consistent with Marfan's syndrome. Ectopia lentis, aortic root dilation and aortic dissection are major criteria for the diagnosis of the disease. Hint: Patients with Marfan's syndrome commonly have mitral valve prolapse and possibly aortic regurgitation (high frequency diastolic murmur at the third right intercostal space). Right atrial enlargement, pulmonic stenosis and ventricular septal defect are not commonly seen.

A 19 year-old female presents with complaint of palpitations. On examination you note the patient to have particularly long arms and fingers and a pectus excavatum. She has a history of joint dislocation and a recent ophthalmologic examination revealed ectopic lentis. Which of the following echocardiogram findings would be most consistent with this patient's physical features? A right atrial enlargement B aortic root dilation C pulmonic stenosis D ventricular septal defect

D) Anterior/Posterior (AP) and axillary or transscapular lateral radiographs AP and axillary lateral or transscapular lateral (Y-scapula) views should be obtained. It is imperative that a lateral view of the shoulder joint be obtained to assess the position of the humeral head. Posterior dislocations can be easily missed if the lateral view is not obtained.

A 19-year-old man presents with pain and deformity of his right dominant shoulder after a sudden jerking movement to the same 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 diagnostic studies should be performed? A) MRI stat B) CT of the shoulder C) Anterior/Posterior (AP) and internally rotated humeral view radiographs D) Anterior/Posterior (AP) and axillary or transscapular lateral radiographs E) Internal and external rotated views of the humeral head

D) Primary syphilis Chancroid (A) is caused by the organism Hemophilus ducreyi and often presents with multiple painful papules which subsequently ulcerate over days. Gram stain of an aspirate from the inguinal bubo will reveal short gram-negative bacilli in a linear or parallel formation—often described as a "school of fish." Granuloma inguinale (B) (donovanosis) is a rare STD caused by the Calymmatobacterium granulomatis. The lesions evolve and, depending on the stage, can be a painless papule, vesicle, or nodule on the genitalia or a beefy-red, velvety ulcer with a rolled border. Subcutaneous granulomas (pseudobuboes) in the inguinal nodes develop over the next few months. Lymphogranuloma vernereum (C) is caused by Chlamydia trachomatis and is characterized by unilateral tender inguinal and femoral lymphadenopathy. The genital lesion is a small, shallow, painless vesicle or ulcer.

A 19-year-old man who is a college student presents to the ED with concern for a lesion on his penis for the past two days. He began a relationship with a new sexual partner three weeks ago. On exam, there is a non-tender 2-cm ulcer on the dorsum of his glans. There is no inguinal adenopathy. An HIV ELISA and RPR are negative. What is the most likely diagnosis? A) Chancroid B) Granuloma inguinale C) Lymphogranuloma venereum D) Primary syphilis

D) Transmural inflammation There is a genetic predisposition (A) for both types of IBD. The lesions of ulcerative colitis affect only the colon while the lesions of Crohn's disease may affect any part of the GI tract including the colon (B). Symptoms of diarrhea and abdominal pain (C) are seen with both Crohn's disease and ulcerative colitis. Inflammatory bowel disease (IBD) is caused by an abnormal immune response to normal intestinal flora. There are two types of IBD, Crohn's disease and ulcerative colitis. Ulcerative colitis is limited to the colon. Crohn's disease can affect any part of the gastrointestinal (GI) tract from the mouth to the anus with "skip lesions." The inflammation of Crohn's disease is transmural, compared to affecting only the mucosa and submucosa in ulcerative colitis. Patients with IBD present with systemic symptoms such as fatigue, weight loss, sweats and malaise. GI manifestations occur based on the area of the GI tract affected and can include abdominal pain, cramping, irregular bowel habits, and the passing of mucus without pus or blood. Laboratory testing is not specific enough to provide the diagnosis of IBD, although can provide supporting information and help with management. Endoscopy may be used in evaluating Crohn's disease and colonoscopy is a valuable tool for both types of IBD.

A 19-year-old man with a previous history of abdominal pain and diarrhea presents to your office with complaints of fatigue, weight loss, sweats and malaise. He tells you that his mother has experienced similar symptoms, but doesn't like to go to the doctor so has never been evaluated. Which of the following is most suggestive of Crohn's disease rather than ulcerative colitis? A) Genetic predisposition B) Lesions affecting the colon C) Symptoms of diarrhea and abdominal pain D) Transmural inflammation

Initiate screening at age 21 with cytology only HPV testing is not recommended in women under age 30 (A). Younger women are more likely to have transient HPV infections and testing at a young age leads to unnecessary colposcopies. Cervical cancer screening with cytology only (D) or co-testing with HPV (C) is not recommended in women under age 21 regardless of sexual activity.

A 19-year-old sexually active woman presents to your office with questions about cervical cancer screening. She wants to know when she should start getting screened since she's been sexually active for two years. Which of the following is the most appropriate next step in management? Initiate screening at age 21 with cytology and human papillomavirus testing Initiate screening at age 21 with cytology only Initiate screening now with cytology and human papillomavirus testing Initiate screening now with cytology only

C) Multiple sexual partners

A 19-year-old woman presents with lower abdominal pain for 5 days. You consider pelvic inflammatory disease as a diagnosis. Which of the following is a likely contributor for this condition? A) Age over 25 years B) Barrier contraception C) Multiple sexual partners D) Pregnancy

E) Retinoblastoma Hint: Retrolental fibroplasia is an abnormal proliferation of fibrous tissue immediately behind the lens of the eye, leading to blindness. It affected many premature babies in the 1950s, owing to the excessive administration of oxygen. Hint: Phakomata are retinal findings hallmarking hamartomatous (A hamartoma is a mostly benign, focal malformation that resembles a neoplasm in the tissue of its origin) disorders such as tuberous sclerosis. The distinctive ocular lesion is a yellowish multinodular cystic lesion arising from the retina or disc. Similar lesions can occur in neurofibromatosis. Hint: Retinitis pigmentosa is a progressive degeneration of the retina. It is characterized by pigmentary changes, arteriolar attenuation, some degree of optic atrophy and progressively deteriorating visual impairment. Granularity or mottling of the retinal pigment pattern or distinctive focal pigment aggregates can be seen fundoscopically. Hint: Retinoschisis is a congenital disorder involving splitting of the retina into an inner and outer layer. Usually good vision is maintained. An elevation of the inner layer of the retina can be seen.

A 2 week old female infant is seen for her newborn well baby exam after a normal birth and delivery. She has been nursing well, has regained her birthweight and her development appears normal for her age so far. Physical examination is normal with the exception that ophthalmoscopic evaluation reveals a faint white reflex in her right eye. What is the most likely diagnosis? A) Retrolental fibroplasia B) Phakomata C) Retinitis Pigmentosa D) Retinoschisis E) Retinoblastoma

D) Recombinant human growth hormone Short stature, often called dwarfism, has a myriad of causes. A more correct medical term for stature three or more standard deviations below the age-appropriate norm is skeletal dysplasia. Achondroplasia and growth hormone deficiency are two of the more common etiologies of short stature, although malnutrition is the most common cause worldwide. There are several causes of growth hormone deficiency, with CNS tumor, surgery or radiation being the most common causes in the pediatric population. Stunted growth, failing to meet height norms or a delay in motor milestones are common presenting symptoms of growth hormone deficiency. Although somewhat controversial in the adults, growth hormone replacement, via recombinant preparations, is the standard of care in the pediatric population, and is most commonly given as a single daily subcutaneous injection. Monitoring of height and bone age is continued every 3-6 months until mature height and normal bone density is obtained. Bromocripitine (A), a dopamine agonist, is used in the treatment of hyperprolactinemia. Although this pituitary condition can be caused by a tumor, it is characterized by amenorrhea, galactorrhea and infertility, not stature abnormalities. Desmopressin (B) is used to treat central diabetes insipidus, not short stature. Pegvisomant (C) is a growth hormone receptor antagonist used in the treatment of acromegaly, a condition of excess, not deficient, growth hormone ie. would make it worse.

A 2-year-old boy fails to meet motor milestones. His height is more than 3 standard deviations below the norm on his age-matched growth chart. A brain CT reveals a pituitary gland mass. This patient may be a candidate for which of the following medications? A) Bromocriptine B) Desmopressin C) Pegvisomant D) Recombinant human growth hormone

A) Consultation with child services for suspected abuse This patient presents with a partial thickness second degree burn with a mechanism of injury that does not fit the injury pattern raising suspicion for child abuse. The most likely etiology of these burns is from a cigarette. Cigarette burns are typically round and sharply-demarcated. They are sometimes confused with healing impetigo. Child physical abuse refers to infliction of injury to any part of the child. This may present as bruising, fractures, brain injury, burns or internal hemorrhage. Often patients will present with multiple injuries in various stages of healing or patterned injuries (resembling objects). Burns may occur from contact with a hot object or with immersion in hot water. Although accidental hot water burns are common, those sustained from abuse will have characteristic patterns as well. Immersion injuries to extremities will present with glove-stocking distribution involvement. Additionally, intentional immersion injuries may present with burns to the anogenital area. Children with burn injuries with these patterns should always be investigated for possible abuse.

A 2-year-old boy presents with a burn to his right hand as seen above. The patient's mother states that he mistakenly got burned by hot water when she tipped a hot tea kettle over. What management is indicated? A) Consultation with child services for suspected abuse B) Consultation with plastic surgery for skin grafting C) Discharge home with silvadene and follow up D) Transfer to a burn center

*Streptococcus pneumoniae* is most common. Bullous myringitis is a direct inflammation and infection of the tympanic membrane caused by a viral or bacterial agent. Vesicles or bullae filled with blood or serosanguineous fluid on an erythematous tympanic membrane are the hallmark of bullous myringitis. Bullous myringitis was previously linked to Mycoplasma pneumoniae but it appears, based on middle ear aspirate culture results, that typical acute otitis media pathogens are the true cause.

A 2-year-old boy presents with right-sided ear pain. On otoscopy, you observe the image seen above. What organism is most commonly the cause of this condition?

B) Disruption of the extensor tendon mechanism at the distal interphalangeal phalangeal (DIP) joint The patient has a mallet finger. A mallet finger is characterized by a closed disruption of the distal extensor apparatus, often occurring when there is sudden forceful flexion of an extended finger, such as when struck by a ball. Because the disrupted extensor tendon no longer connects with the distal phalanx, the DIP joint is held in flexion due to unopposed action of the flexor digitorum profundus. A mallet finger injury is the most common hand injury seen in athletes. On examination, the distal tip of the finger is flexed at the DIP joint. Pain, swelling, and tenderness may be present over the DIP joint. Passive extension is usually intact, but patients are unable to actively extend the distal phalanx. Radiographs may show an associated dorsal avulsion fracture. The treatment involves immobilizing the DIP joint in slight hyperextension for 6-8 weeks to allow tendon healing. The proximal interphalangeal (PIP) joint and metacarpophalangeal (MCP) joints should be allowed to move freely.

A 20-year old man presents after jamming his index finger during a basketball game. When he tries to straighten his finger, the distal tip remains flexed as shown above. Which of the following describes the pathophysiology of this injury? A) Defect of the central slip causing volar migration of the lateral bands B) Disruption of the extensor tendon mechanism at the distal interphalangeal phalangeal (DIP) joint C) Disruption of the ulnar collateral ligament D) Inflammation of the abductor pollicis longus and extensor pollicis brevis tendons

B) a direct inguinal hernia. Hint: A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. *An indirect inguinal hernia is typically elliptic that does not reduce easily*. An obturator hernia is more commonly seen in elderly women and are rarely palpable in the groin. Femoral hernias are rare in males and do not typically reduce with lying down.

A 20-year-old male presents with a mass in the groin. On inspection with the patient standing a symmetric, round swelling is noted at the external ring. When the patient lies down the mass disappears. The patient denies any trauma. The most likely diagnosis is A) an indirect inguinal hernia. B) a direct inguinal hernia. C) an obturator hernia. D) a femoral hernia

B) NSAIDs and thumb spica splint The patient presents with de Quervain's disease, or tenosynovitis, and should be managed conservatively with splinting and NSAIDs. Surgical release of the dorsal extensor compartment (C) is indicated for patients with refractory symptoms.

A 20-year-old man who is employed in construction presents with pain to his thumb and wrist for 4 months. He states that the pain worsens while he is working. Examination reveals pain along the radial surface of the wrist with forced ulnar abduction. What management is indicated? A) MRI of the wrist B) NSAIDs and thumb spica splint C) Surgical release of the dorsal extensor compartment D) Wrist X-ray with ulnar deviation view

C) Free testosterone This patient presents like PCOS - Hyperandrogenism, as evidenced by elevated free testosterone, supports the diagnosis of polycystic ovarian syndrome. Hint: Prolactin level will not be elevated in a patient with polycystic ovarian syndrome. Hyperprolactinemia is associated with oligo- and amenorrhea and infertility. Hint: Endometrial Biopsy - Endometrial hyperplasia occurs secondary to anovulation, endometrial biopsy is mandatory for follow-up management but is not indicated at diagnosis.

A 21 year-old obese woman complains of menstrual irregularity since menarche at age 17. She is 5'5" and weighs 180 pounds. Exam of her face reveals excessive hair growth as well as acne. Her abdomen shows midline hair growth and truncal obesity. A previous pelvic ultrasound shows many small fluid filled ovarian cysts bilaterally. Which of the following is the most appropriate diagnostic study to make the initial diagnosis in this patient? A) Prolactin level B) Endometrial biopsy C) Free testosterone D) thyroid stimulating hormone

D) Fresh frozen plasma This patient has non-allergic angioedema, likely hereditary angioedema with his brother's history of the same reaction. Patients have a deficiency of the C1 esterase inhibitor causing an increased production of bradykinin due to activation of the kallikrein-kinin system. Fresh frozen plasma contains the C1 inhibitor and its administration may help stop the angioedema.

A 21-year-old man presents with severe swelling of the left side of his tongue and his left upper lip. He tells you his brother had the same problem 2 years ago. Which of the following is the most effective treatment? A) Cryoprecipitate B) Diphenhydramine C) Epinephrine D) Fresh frozen plasma

C) Hydralazine Magnesium sulfate (D) is used for seizure prevention in preeclampsia and for the treatment of eclampsia, but it is not specifically an antihypertensive. The patient has severe preeclampsia. Preeclampsia refers to the constellation of hypertension after 20 weeks of pregnancy (blood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic) plus proteinuria (> 0.3 g in a 24-hour collection period). Severe preeclampsia refers to marked hypertension with evidence of end-organ dysfunction. Diagnostic criteria include two or more of the following: blood pressure ≥ 160 mm Hg systolic or ≥ 110 mm Hg diastolic (measured on two occasions at least four to six hours apart), visual disturbances, mental status changes, pulmonary edema, epigastric or right upper quadrant pain, elevated liver function tests, thrombocytopenia, proteinuria, oliguria, or impaired fetal growth. If a patient with preeclampsia develops seizures, it is termed eclampsia. Delivery of the infant is the definitive treatment. Mild preeclampsia can be monitored without treatment, but severe preeclampsia should be treated with antihypertensives and magnesium for seizure prevention until delivery can be safely achieved. Antihypertensives of choice for severe preeclampsia include intravenous labetalol, hydralazine, and nifedipine. Patients presenting to the ED with signs and symptoms of preeclampsia should always be co-managed with an obstetric consultant.

A 21-year-old woman G1P0 at 35 weeks gestation presents with headache, blurry vision, and shortness of breath. Vital signs include a blood pressure of 195/110 mm Hg, heart rate of 90 beats per minute, respiratory rate of 21 breaths per minute, oral temperature of 37.1℃, and oxygen saturation of 90% on room air. Urinalysis reveals 3+ protein. A chest radiograph reveals pulmonary edema. Which of the following medications should be administered to reduce blood pressure? A) Enoxaparin B) Furosemide C) Hydralazine D) Magnesium sulfate

B) Fast inward sodium channel blockade This patient is exhibiting signs and symptoms of a tricyclic antidepressant (TCA) overdose. TCAs act by fast inward sodium channel blockade, causing QRS complex widening (> 100 ms) on ECG. Management of TCA toxicity includes administration of sodium bicarbonate to combat the sodium channel blockade if there is widening of the QRS complex on ECG or telemetry.

A 21-year-old woman presents to the Emergency Department after an intentional ingestion. On physical examination, she is lethargic, flushed, hot to the touch, and her pupils are dilated. Vital signs include BP 130/90 mm Hg, HR 130 beats/minute, and RR 22 breaths/minute. After several minutes, she has a generalized tonic clonic seizure. What is the mechanism by which this class of medications causes cardiac toxicity? A) AV nodal blockade B) Fast inward sodium channel blockade C) Inhibition of the sodium/potassium-ATPase pump D) Rapid outward potassium channel blockade

D) Metronidazole The patient's presentation is consistent with bacterial vaginosis (BV), which is the most common cause of vaginitis. BV is not a sexually transmitted disease; rather, it is caused by a change in the vaginal flora with the replacement of Lactobacillus species with high concentrations of a polymicrobial group including anaerobic bacteria, Gardnerella vaginalis, and Mycoplasma hominis. It is also associated with an increase in vaginal pH from 4.5 to as high as 7. The pathognomonic finding for BV is clue cells, which are bacteria that line the borders of the vaginal epithelial cells. Diagnosis can also be made using the Amsel criteria (see table). The recommended treatment regimen includes 1 week of metronidazole or clindamycin, either orally or intravaginally. Azithromycin (A) and doxycycline (C) are indicated to treat chlamydia cervicitis. Ceftriaxone (B) or other 3rd-generation cephalosporins can be used to treat gonorrheal cervicitis.

A 21-year-old woman presents with foul-smelling vaginal discharge for 5 days. Her urine pregnancy test is negative. On exam, she has no cervical or adnexal tenderness to palpation. A moderate amount of whitish-gray discharge is noted in the vault that you perform microscopy on, as seen above. What is the appropriate antibiotic choice for this patient? A) Azithromycin B) Ceftriaxone C) Doxycycline D) Metronidazole

B) Draw blood cultures and admit for intravenous antibiotics and transthoracic echo This patient's presentation is *concerning for infective endocarditis* and should have a minimum of three blood cultures drawn, started on intravenous antibiotics and ordered for a transthoracic echocardiogram (TTE). Although the patient has a predominance of respiratory features, the presence of fever and IVDA makes endocarditis a distinct possibility and the patient should not be discharged with the diagnosis of a respiratory infection (A). Valvuloplasty (C) uses a balloon catheter to open a stenotic valve. This is most often performed for aortic stenosis. Although this patient may one day require a valvuloplasty, it is not performed in the early stages of endocarditis. Fever, cough and chest pain may be consistent with pneumonia and early in the clinical course, the chest X-ray may not reveal an infiltrate. However, this patient is at high-risk for infective endocarditis and treatment for pneumonia (D) would not be appropriate.

A 21-year-old woman with a history of intravenous drug abuse presents with fever, dyspnea, cough and chest pain. Examination reveals an ill-appearing woman with track marks on both upper extremities. A chest X-ray reveals no infiltrate and urinalysis is unremarkable. What management is indicated? A) Discharge with a prescription for azithromycin for a respiratory infection B) Draw blood cultures and admit for intravenous antibiotics and transthoracic echo C) Draw blood cultures and admit for intravenous antibiotics and valvuloplasty D) Start antibiotics for community acquired pneumonia and admit

A) Chorioamnionitis Endometritis (B) in an infection of the uterine endometrium that affects between 2 and 8% of pregnancies. The infection develops on the second or third post-partum day and is characterized by fever, abdominal pain and foul-smelling lochia. Pelvic inflammatory disease (C) does not occur during this stage of pregnancy due to the mucous plug that seals the cervix. It may occur during the first trimester although it is quite rare. A urinary tract infection (D) does not cause systemic signs of infection as described in the patient unless it has moved to the upper urinary tract causing pyelonephritis. Beginning at 16 weeks, the membranes of the chorioamniotic sac adhere to the cervical os and are at risk for infection. Chorioamnionitis is an intra-amniotic infection of the chorion and amniotic layers of the amniotic sac. The placenta and fetal membranes may also be involved. It is caused by an ascending infection of normal vaginal flora.

A 21-year-old woman with no prenatal care presents for evaluation of lower abdominal pain and fever. She estimates that she is approximately 7.5 months pregnant. On questioning, she acknowledges intermittent pain for two days and a gush of fluid shortly after the pain began. Her temperature is 101.8°F. Physical examination is notable for purulent material in the vaginal vault. Which of the following is the most likely diagnosis? A) Chorioamnionitis B) Endometritis C) Pelvic inflammatory disease D) Urinary tract infection

A) Chorioamnionitis Pelvic inflammatory disease (C) does not occur during this stage of pregnancy due to the mucous plug that seals the cervix. It may occur during the first trimester although it is quite rare. Beginning at 16 weeks, the membranes of the chorioamniotic sac adhere to the cervical os and are at risk for infection. Chorioamnionitis is an intra-amniotic infection of the chorion and amniotic layers of the amniotic sac. The placenta and fetal membranes may also be involved. It is caused by an ascending infection of normal vaginal flora. This is a clinical diagnosis and patients require intravenous antibiotics, most commonly ampicillin and gentamicin.

A 21-year-old woman with no prenatal care presents for evaluation of lower abdominal pain and fever. She estimates that she is approximately 7.5 months pregnant. On questioning, she acknowledges intermittent pain for two days and a gush of fluid shortly after the pain began. Her temperature is 101.8°F. Physical examination is notable for purulent material in the vaginal vault. Which of the following is the most likely diagnosis? A) Chorioamnionitis B) Endometritis C) Pelvic inflammatory disease D) Urinary tract infection

A) fibroadenoma Fibroadenoma of the breast most commonly is seen in young females. Typical characteristics include a solitary 1-3 cm firm, painless, freely movable mass that does not change with the menstrual cycle and are slow growing. Most are found as an incidental finding on physical examination or during self-breast examination Hint: Intraductal papillomas are usually non-palpable. The patient presents with complaints of spontaneous onset of bloody, serous, or cloudy nipple discharge

A 22 year-old G0P0 asymptomatic female is seen for her yearly gynecologic examination. She denies performing self-breast exams and any family history of breast or gynecologic cancers. On palpation of her left breast, a solitary 1 cm rubbery, firm, well-circumscribed, non-tender breast mass is noted. In review of her records, similar findings were noted on last year's examination. Which of the following is the most likely diagnosis? A) fibroadenoma B) breast fat necrosis C) fibrocystic changes D) intraductal papilloma

B) Inevitable abortion Abortion is inevitable when cervical effacement, dilatation and rupture of membranes is noted. Hint: Threatened abortion (AB) implies the cervix remains closed with only slight bleeding

A 22 year-old G1P0 female presents at 12 weeks gestation with 24 hours of vaginal bleeding. She complains of continued cramping and bleeding requiring pad change every two hours. Vital signs are normal. Vaginal examination shows bleeding with a dilated cervix. Which of the following is the most likely diagnosis? A Threatened abortion B Inevitable abortion C Incomplete abortion D Complete abortion

C) Pseudomonas aeruginosa Pseudomonas aeruginosa is frequently associated with osteomyelitis involving puncture wounds of the foot. This is believed to result from direct inoculation with P. aeruginosa via the foam padding found in tennis shoes. Hint: Staphylococcus aureus is the most common infecting organism in cases of acute osteomyelitis, however, the mechanism of injury in this case suggests P. aeruginosa.

A 22 year-old female complains of worsening pain, swelling, and tenderness in her left heel for 1 week. She sustained a penetrating injury to the heel two weeks ago when she stepped on a nail while running in tennis shoes. Examination reveals a draining puncture wound with surrounding erythema and exquisite tenderness. X-ray of the left foot demonstrates periosteal reaction associated with the wound. Which organism is classically responsible for this infection? A Escherichia coli B Streptococcus pyogenes C Pseudomonas aeruginosa D Staphylococcus aureus

C) Open reduction and ulnar gutter splint immobilization *Open reduction is indicated with angulation of greater than 40 degrees*. Hint: Reduction followed by splinting is recommended for fifth metatarsal fractures with angulation of 15-40 degrees.

A 22 year-old male presents several hours after sustaining a hand injury when he punched a wall. X-rays of the hand demonstrate fracture of the fifth metacarpal neck with *65 degrees dorsal angulation* and a claw hand. What is the most appropriate intervention? A) Antibiotic treatment and ulnar gutter splint immobilization B) Closed reduction and ulnar gutter splint immobilization C) Open reduction and ulnar gutter splint immobilization D) Ulnar gutter splint immobilization only

A Prehn's sign. Prehn's sign is seen in epididymitis when elevation of the scrotum with the affected epididymis to the level of the symphysis pubis brings relief from the pain.

A 22 year-old male presents to the clinic complaining of scrotal pain that radiates into the groin. Patient admits to being a weightlifter and was lifting 24 hours prior to this pain developing into the scrotum. The patient admits to being sexually active with only his male partner. Examination reveals a reddened scrotum and it is difficult to distinguish the epididymis from the testes on the right side. Elevation of the right testicle brings relief of the pain. This is known as a positive A Prehn's sign. B Cullen's sign. C Rovsing's sign. D Murphy's sign.

*C) distended neck veins.* - Cardiac compression will manifest with distended neck veins and cold clammy skin Hint: widened pulse pressure is associated with aortic regurgitation Hint: Pulmonary edema not typically seen. More likely to see peripheral edema Hint: Early diastolic murmurs are associated with pulmonary regurgitation

A 22 year-old male received a stab wound in the chest an hour ago. The diagnosis of pericardial tamponade is strongly supported by the presence of A) pulmonary edema. B) wide pulse pressure. C) distended neck veins. D) an early diastolic murmur

C) needle thoracotomy right 2nd intercostal space Hint: This patient has a tension pneumothorax on the right, and insertion of the chest tube on the left would be life threatening. Pay attention to SIDE

A 22 year-old patient complains of sudden onset of chest pain accompanied by shortness of breath. The patient appears dyspneic. On examination, the trachea is deviated to the left, breath sounds are faint on the right, and the right chest is hyperresonant to percussion. The preferable treatment for this patient would be A) a tracheostomy. B) insertion of a chest tube with underwater seal, left 2nd intercostal space. C) needle thoracotomy right 2nd intercostal space D) a lung scan for pulmonary embolus and begin heparin sodium (Heparin) therapy

D) Ibuprofen PO The patient likely has viral pharyngitis. The examination demonstrates an erythematous pharynx without exudates and without adenopathy. In this case, the patient needs supportive care. NSAIDs, such as ibuprofen, will provide the most symptomatic relief. Acetaminophen (A) may provide some analgesic effect in this patient, but does not have the same effect as NSAIDs in improving resolution of symptoms as it lacks anti-inflammatory properties. Amoxicillin PO (B) may be helpful in the treatment of streptococcal pharyngitis although evidence does not suggest it improves time to resolution of symptoms or pain. In children, the use of antibiotics is recommended to prevent the possibility of later rheumatic heart disease. Ceftriaxone IM (C) is indicated for possible gonococcal pharyngitis, which does not have an exudative component. Clinicians cannot make the diagnosis without a careful sexual history.

A 22-year-old man presents with a sore throat. On examination, the pharynx is erythematous without tonsillar enlargement or exudate. There is no cervical adenopathy. The patient is not sexually active. Which of the following is likely to provide the most improvement? A) Acetaminophen PO B) Amoxicillin PO C) Ceftriaxone IM D) Ibuprofen PO

D) Microscopic evaluation of vaginal fluid Premature rupture of membranes (PROM) is the rupture of the fetal membranes before the onset of labor. In most cases, this occurs near term. When membrane rupture occurs before 37 weeks gestation, it is known as preterm PROM. It can lead to significant perinatal morbidity, including respiratory distress syndrome, neonatal sepsis, umbilical cord prolapse, placental abruption, and fetal death. The presence of amniotic fluid can be confirmed with nitrazine testing (a pH of 7.1-7.3 as opposed to a normal pH of 3.5-6.0), the presence of ferning on microscopic evaluation, or smear combustion (amniotic fluid turns white and crystalizes when flamed). Corticosteroids (A) can accelerate fetal lung maturation and are widely used in preterm labor. However, their routine use in PROM has not been established because rupture of the membranes also stimulates fetal lung development. Digital manipulation of the cervix (B) should be avoided because the incidence of infection increases with the number of examinations. Magnesium sulfate (C) inhibits calcium uptake by smooth muscle cells and is used as a tocolytic agent in preterm labor. However, it has not yet been established that this patient is in preterm labor and tocolysis should not be initiated at this time. In addition, any initiation of tocolysis should be coordinated with the receiving obstetrician.

A 22-year-old woman at 36 weeks gestation presents with complaints of feeling a sudden gush of water coming from her vagina. She has had regular obstetrical follow-up and a normally progressing pregnancy. Which of the following is the most appropriate next step in management? A) Administration of corticosteroids B) Immediate digital examination of the cervix C) Initiation of magnesium sulfate infusion D) Microscopic evaluation of vaginal fluid

C) Ceftriaxone plus doxycycline Neisseria gonorrhea and Chlamydia trachomatis are the pathogens most commonly identified in patients with PID. The most common presenting symptom is lower abdominal pain. Outpatient treatment for women with mild to moderate symptoms of PID includes a regimen of ceftriaxone plus doxycycline.

A 22-year-old woman presents to your office with complaints of pelvic pain and vaginal discharge. She admits to having recent unprotected intercourse with a new partner and her last menstrual period ended three days ago. Which of the following is the most appropriate pharmacologic treatment? A) Azithromycin B) Ceftriaxone C) Ceftriaxone plus doxycycline D) Metronidazole

Doxycycline 100 mg PO BID x 14 days A single 1-gram dose of azithromycin (A) is part of the regimen to treat cervicitis and urethritis in men. It can also be used for PID but should be administered once weekly for 2 weeks. The CDC no longer recommends fluoroquinolones (B) for the treatment of gonococcal infections and associated conditions such as PID due to high resistance. Metronidazole (D) is not required as part of the PID treatment regimen, but it is added sometimes to also treat trichomoniasis or vaginitis or if there is a concern for anaerobic infection.

A 22-year-old woman presents with lower abdominal pain and abnormal vaginal discharge for 4 days. She is sexually active with multiple partners and does not consistently use barrier contraception. She has bilateral adnexal tenderness and yellow discharge on pelvic exam. Her urine pregnancy test is negative. In addition to a 1-time dose of ceftriaxone, what is the most appropriate outpatient course of antibiotics for the patient? Azithromycin 1 gram PO x 1 Ciprofloxacin 500 mg PO BID x 14 days Doxycycline 100 mg PO BID x 14 days Metronidazole 500 mg PO BID x 14 days

Word catheter is placed for four to six weeks A Bartholin's abscess occurs with infection of an obstructed Bartholin gland, a pea-sized mucous secreting gland located on each side of the labia minora in the 4 and 8 o'clock positions. When the duct that drains fluid from the gland becomes blocked, a mucous-filled cyst forms and eventually, if not drained, bacterial overgrowth occurs leading to an abscess. It is also possible to have a primary infection of the Bartholin gland itself. Most commonly, the causative organism is normal vaginal flora of which E. coli is most prevalent in cultures. All patients do not require antibiotics (A). Like other abscesses, if adequate drainage is obtained in the immunocompetent host, antibiotics are not necessary. Many gynecologists recommend antibiotic therapy if cellulitis is present. Gonorrhea and chlamydia (B) are not the most common causes. Together they are responsible for approximately 10% of these abscesses. Incision is not performed in the OR (C) unless there is larger infection requiring anesthesia for facilitation of the drainage. Patients with recurrent abscesses may need marsupialization performed in the OR but this is not during the acute infection

A 22-year-old woman presents with pain and swelling to the vulva. On examination, you notice an area of swelling with induration and central fluctuance at the 8 o'clock position. Which of the following statements is true regarding this? All patients require antibiotics Gonorrhea and chlamydia are the most common causes Incision should be performed in the operating room Word catheter is placed for four to six weeks

D) Thyroid-stimulating hormone Serum sex steroids (A) and gonadotropins (B) are similar in women with or without premenstrual syndrome. A woman with current regular menstrual cycles is unlikely to be pregnant, as such, a human chorionic gonadotropin (C) level is unrevealing. It is important to remember that other common conditions, such as thyroid disorders and hypercortisolism, can mimic the behavioral and affective changes of premenstrual syndrome.

A 22-year-old woman with regular menstrual cycles presents with symptoms concordant with premenstrual syndrome. In evaluating the large differential of these symptoms, which of the following serum laboratory tests is recommended? A) Estrogen B) Follicle stimulating hormone C) Human chorionic gonadotropin D) Thyroid-stimulating hormone

D) Thyroid-stimulating hormone Thyroid abnormalities, both hyperthyroidism and hypothyroidism, can result in such mood symptoms. Although the initial laboratory evaluation of suspected premenstrual syndrome is limited, a serum thyroid-stimulating hormone level is recommended. Serum sex steroids (A) and gonadotropins (B) are similar in women with or without premenstrual syndrome. A woman with current regular menstrual cycles is unlikely to be pregnant, as such, a human chorionic gonadotropin (C) level is unrevealing.

A 22-year-old woman with regular menstrual cycles presents with symptoms concordant with premenstrual syndrome. In evaluating the large differential of these symptoms, which of the following serum laboratory tests is recommended? A) Estrogen B) Follicle stimulating hormone C) Human chorionic gonadotropin D) Thyroid-stimulating hormone

D) Uteroplacental insufficiency Hint: Fetal hypoxia would be a concern if deep late FHR decelerations were present with absent beat-to-beat variability. Hint: Early decelerations are due to head compression of the fetus. Pressure on the fetal head causes an alteration in cerebral blood flow causing a central vagal stimulation and subsequent FHR deceleration. The deceleration is a mirror image of the contraction. Hint: Variable decelerations are from cord compression. The decelerations have a sharp, angular, decline in FHR with duration less than 2 minutes.

A 23 year-old female is in active labor and has progressed from 3 cm to 6 cm in the last six hours. Fetal monitoring demonstrates mild repetitive late decelerations. Which of the following is the most likely cause of this finding? A) Fetal hypoxia B) Head compression C) Cord compression D) Uteroplacental insufficiency

B) Borderline Borderline personality disorder is characterized by unstable relationships, self image and affect. This instability is often marked with impulsiveness. In the Emergency Department, these patients will often "split" providers: they will act with affection and respect to some providers and anger and disregard to others. Substance abuse and drug seeking behavior are often seen in borderline patients as well. Antisocial personality disorder (A) is typified by a disregard and violation of the rights of others. Histrionic personality disorder (C) involves excessive emotionality and attention seeking. Narcissistic personality disorder (D) involves patterns of grandiosity and lack of empathy to others.

A 23-year-old man presents with leg pain for 3 months and requests hydromorphone for pain. The nurse approaches you because she believes the patient is "drug seeking" as he became extremely upset when she told him that he would have to wait for the doctor to evaluate him before pain medications could be given. Upon entering the room, the patient speaks pleasantly with you and compliments you on your kindness. He tells you that he only comes to this hospital because "it's the best in the world," and "none of the other doctors understand me." Upon informing the patient that you will not be prescribing hydromorphone, he becomes extremely upset and starts yelling. What personality disorder traits is this patient exhibiting? A) Antisocial B) Borderline C) Histrionic D) Narcissistic

C) Levonorgestrel intrauterine device Progestin-only pills (D) are most effective in women who are exclusively breastfeeding. They are not as effective in pregnancy prevention in other circumstances. Combined oral contraceptives (A) and the etonogestral/ethinyl estradiol vaginal ring (B) contain estrogen and therefore would be contraindicated in this patient whom is taking antiepileptic drugs. Certain antiepileptic drugs induce hepatic metabolism of estrogen (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, and topiramate). This can potentially lead to failure of any contraceptive that contains estrogen. Therefore progestin only birth control methods would be beneficial to this patient. The levonorgestrel intrauterine device and copper intrauterine device are acceptable choices even for a nulligravida. The levonorgestrel intrauterine device is a progestin only device that can be used for either 3 years or 5 years depending on if it is the Skyla® or the Mirena® device.

A 23-year-old nulligravida comes to your office for contraception counseling. She has a seizure disorder that is well controlled on carbamazepine. She is a nonsmoker and has no other medical problems or complaints. She is currently in a relationship and does not want to get pregnant in the next several years. Which one of the following contraceptives is the most appropriate? A) Combined oral contraceptives B) Etonogestrel/ethinyl estradiol vaginal ring C) Levonorgestrel intrauterine device D) Progestin-only pills

D) Levonorgestrel intrauterine device (Mirena) Progestin-only pills (D - Micronor) are most effective in women who are exclusively breastfeeding. They are not as effective in pregnancy prevention in other circumstances. Combined oral contraceptives (A) and the etonogestral/ethinyl estradiol vaginal ring (B) *contain estrogen and therefore would be contraindicated in this patient whom is taking antiepileptic drugs* Estrogens and progestogens are metabolized by cytochrome P450 3A4. Seizure meds induce cytochrome P450 3A4, leading to enhanced metabolism of either or both the estrogenic and progestogenic component of COC's, thereby reducing their efficacy. carbamazepine can markedly reduce levels of ethinyl estradiol when taken concurrently.

A 23-year-old nulligravida comes to your office for contraception counseling. She has a seizure disorder that is well controlled on carbamazepine. She is a nonsmoker and has no other medical problems or complaints. She is currently in a relationship and does not want to get pregnant in the next several years. Which one of the following contraceptives is the most appropriate? A) Combined oral contraceptives ("The Pill" B) Etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) C) Levonorgestrel intrauterine device (Mirena) D) Progestin-only pills (Micronor)

B) Chandelier sign Pelvic inflammatory disease (PID) is an acute infectious condition of the upper female genital tract that causes significant inflammation. The most common areas of infection include the uterus and fallopian tubes, although adjacent pelvic structures or areas in the abdomen may also be affected. Physical exam findings include cervical motion tenderness, also referred to as chandelier sign. Cervical or adnexal tenderness on bimanual exam is suggestive of PID and further workup including testing for the presence of Neisseria gonorrhea and Chlamydia trachomatis should be initiated.

A 23-year-old woman presents to your office with complaints of pelvic pain and vaginal discharge. She admits to having recent unprotected intercourse with a new partner and her last menstrual period ended three days ago. Which of the following physical exam findings supports the likely diagnosis? A) Chadwick sign B) Chandelier sign C) Goodell's sign D) Hegar's sign

E) Epinephrine Epinephrine has significant beta-agonistic effects, which cause bronchodilation, and alpha-agonistic effects, which can reverse systemic hypotension. IM route is preferred over SC, as time for maximum serum concentration is shorter by IM route. Hint: Theophylline may be required in resistant bronchospasm. Hint: Glucagon is required only if the patient is on beta-blockers. In such patients, it exerts its effects by inotropic and chronotropic properties, which are independent of beta-receptors. Hint: Cimetidine is an H2 blocker, which may have an additive effect with H1 blockers in anaphylaxis. Hint: Methyl prednisolone, a corticosteroid, is used in all generalized reactions for its anti-inflammatory property

A 23-year-old woman presents with an anaphylactic reaction after being stung by several bees. She complains of wheezing and shortness of breath. On examination, the client is in acute distress. BP is 98/56 mmHg, PR 110/min, RR 28/min, and temperature 98.7°F. She is immediately treated with supplemental oxygen. In treating this condition further, what drug is required most urgently? A) Theophylline B) Glucagon C) Cimetidine D) Methylprednisolone E) Epinephrine

D) Lactation mastitis This condition may progress into or present initially as an abscess (A), a more defined and localized pocket of infection which is usually discretely palpable. Postpartum women who do not breast feed may experience symmetric breast engorgement (B) typically within 3 days post-delivery, but usually do not have the associated inflammatory symptoms as above. Although breast cancer (C) can present at many different ages, the patient's young age makes inflammatory cancer less likely. Furthermore, inflammatory breast cancer is associated with skin thickening and dimpling, as well as axillary lymphadenopathy. A blocked breast duct, inspissation, can mimic mastitis, but usually does not have an associated fever.

A 23-year-old woman presents with concerns of tender breast enlargement. Two weeks ago, she gave birth to a healthy newborn, whom she currently breast feeds. Examination reveals general erythema, warmth and edema of the right breast. There are no superficial abnormalities, no palpable mass and no purulent nipple discharge is present. The left breast appears normal. Which of the following is the most likely diagnosis? A) Breast abscess B) Breast engorgement C) Inflammatory breast cancer D) Lactation mastitis

D) Urine beta-hCG All women of childbearing age presenting with pelvic complaints require a pregnancy test. Even though this patient reports that she had her menses one week prior to her presentation, ectopic pregnancy and even a normal pregnancy can be associated with vaginal bleeding that can be mistaken for normal menses. Since ectopic pregnancy is a life-threatening condition, it is important to rule it out early in this patient's workup. A urine beta-hCG is a rapid test that has a very high sensitivity that can rapidly determine if a woman is pregnant. A negative urine beta-hCG effectively rules out ectopic pregnancy. A urinalysis (C) may also be helpful in the evaluation of a woman with pelvic pain, however, it is not entirely specific to the cause of pain. Urine may be affected by other diagnoses including cervicitis, vaginitis, pelvic inflammatory disease, nephrolithiasis, or appendicitis.

A 23-year-old woman presents with pain in in the suprapubic area and right lower quadrant of her abdomen that began 4 hours ago. She denies vaginal discharge and vaginal bleeding. Her vital signs are BP 115/65, HR 60, RR 12, and T98.1°F. Her last menses was one week ago. Which of the following diagnostic tests should be obtained first? A) Complete blood count B) Gonorrhea and chlamydia DNA amplification C) Urinalysis D) Urine beta-hCG

Use of local irritants This patient's differential diagnosis is most concordant with vulvitis or vaginitis. A main differentiator between the two is the presence of increased or abnormal appearing vaginal secretions. Age of menarche (A), family history of endometrial cancer (B), and prior deliveries (C), although important in a complete gynecologic history, would not help to differentiate the above two conditions. it is important to investigate the use of any local irritants, like deodorants, perfumes, soaps, fabric softeners, tight fitting sportswear (like runner's synthetic shorts) and scented or dyed toilet paper. Visual inspection of the vulva and vagina, as well as palpation of the pelvic structures, are important parts of the physical examination.

A 23-year-old woman presents with vulvar itching and vaginal discharge. She is not currently sexually active, and does not use contraceptives. She works in an office, drinks 3 alcoholic beverages a week and recently took up long-distance running. Physical examination reveals a reddened vulva without surface ulcerations, the absence of lice or nits, normal appearing vaginal secretions and an unremarkable vaginal cavity. There is no adnexal tenderness. Which important item is missing from this patient's history? Age of menarche Family history of endometrial cancer Prior deliveries Use of local irritants

B) Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 14 days Ceftriaxone and azithromycin (A) are used in the treatment of cervicitis or urethritis. Clindamycin (C) and metronidazole (D) are used in the treatment of bacterial vaginosis.

A 23-year-old, sexually active woman, presents with abdominal pain. Vital signs are normal. Pelvic examination reveals cervical motion tenderness and adnexal tenderness. Which of the following treatments is most likely indicated? A) Ceftriaxone 250 mg IM once + azithromycin 1000 mg PO once B) Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 14 days C) Clindamycin 300 mg PO BID for 7 days D) Metronidazole 500 mg PO BID for 7 days

A) valacyclovir (Valtrex) This patient most likely has herpes genitalis which may be treated with oral antivirals, such as valacyclovir, that will reduce the duration of viral shedding and shorten the duration of symptoms.

A 24 year-old female presents with complaints of dysuria associated with fever, malaise, myalgias and headache for the past 3 days. Today she noticed some lesions on her genitalia. Physical examination reveals the presence of multiple clear vesicles and erythematous ulcers with tender bilateral inguinal adenopathy. Which of the following is the most appropriate treatment for this patient? A valacyclovir (Valtrex) B metronidazole (Flagyl) C ceftriaxone (Rocephin) D benzathine penicillin G (Bicillin)

C) Laparoscopy with biopsy Diagnosis of endometriosis must be made by direct visualization. Laparoscopy with biopsy is the most appropriate diagnostic study in this patient

A 24 year-old sexually active woman presents to the clinic complaining of dysmenorrhea, dyspareunia and backache that occurs premenstrually. Pelvic examination shows pain upon uterine motion and uterosacral nodularity in the posterior vaginal fornix. The definitive diagnosis for this patient requires which of the following? A Pelvic ultrasound B CT of the abdomen C Laparoscopy with biopsy D CA-125 test

A) Gabapentin Complex regional pain syndrome (CRPS) is not commonly encountered in primary care. However, CRPS presents with profound signs and symptoms. CRPS-1 occurs after a noxious neurological event, such as soft tissue crush injury, immobilization, orthopedic surgery and podiatric surgery. Any insult to the integrity of peripheral nerves is a possible etiology. This condition is felt to be due to activation of peripheral nociceptors, causing an increase in neuroexcitatory agents in the spinal cord, leading to upregulation and sensitization of peripheral and central pain pathways. A classic presentation is post-surgical patients with days-to-weeks onset of distal extremity diffuse neuropathic pain, edema and erythema, as in the above patient. Most patients are treated with a mix of medication options: corticosteroid burst, intranasal calcitonin, NSAIDs, short course of opioids, gabapentin, tricyclic antidepressants and transdermal clonidine or lidocaine.

A 24-year-old athlete undergoes anterior cruciate ligament repair surgery. Two weeks later, he presents with excruciating pain distal to the knee. Fracture, soft tissue injury and intraarticular infection are ruled-out. Examination reveals a swollen, warm, red foot and ankle that is painfully sensitive to light touch. The other leg appears normal. The patient guards this area and active range-of-motion is restricted. Complete pinprick sensory testing is deferred as initial testing is too painful to continue. Vibration testing results in continued pain even after removal of the tuning fork. Which of the following medications will you most likely prescribe? A) Gabapentin B) Intranasal desmopressin C) Intravenous immunoglobulin D) Pyridostigmine

*C) do a fine needle aspiration.* *The combination of fine needle aspiration and radioisotope scanning of a solitary thyroid nodule provides the best diagnostic yield.* Because *cold nodules are highly suspicious for malignancy*, they are generally referred for surgical removal. It is not reasonable to delay the diagnosis. Hint: Ultrasound is preferred over MRI or CT scan of the thyroid

A 24-year-old male is initially found to have a single nodule in the right lobe of his thyroid gland. He is clinically and chemically euthyroid. The next step is to A reassure the patient and reassess yearly. B recheck in 1-3 months. C do a fine needle aspiration. D obtain a CT scan of the neck.

D) Thumb spica splint and orthopedics follow up The patient has an examination concerning for an occult scaphoid fracture and requires immobilization with a thumb spica splint and follow up with an orthopedic surgeon. The scaphoid bone is the most commonly fractured carpal bone. It typically occurs after a fall on an outstretched hand (FOOSH). There are three types of fractures: 1) fractures of the tuberosity and distal pole, 2) fractures of the waist and 3) fractures of the proximal pole. Patients present with pain at the anatomic snuff box or distal radius. Physical examination reveals tenderness and swelling of the anatomic snuff box and may have increased pain with axial compression of the first metacarpal (Watson's scaphoid shift test). Additionally, pain may be increased with thumb to index finger pinch. Diagnostic testing should begin with AP, lateral and oblique plain radiographs of the wrist. A scaphoid view (X-ray with wrist in ulnar deviation) can increase the likelihood of detecting small scaphoid fractures on X-ray. Unfortunately, plain radiographs miss 15% of scaphoid fractures. Patients with missed fractures that are not immobilized are at an increased risk for fracture nonunion and long-term chronic arthritis. Therefore, splint immobilization with a thumb spica is indicated in all patients who have a clinical suspicion for scaphoid fractures regardless of the X-ray findings.

A 24-year-old man presents with wrist pain after a fall on his outstretched right hand. Examination reveals tenderness at the base of the first metacarpal in the anatomic snuffbox and pain with axial load on the thumb. The patient's X-ray is shown above. What management is indicated? A) Acetaminophen and primary care follow up B) Removable soft wrist splint for 2 weeks C) Sugar tong splint and orthopedics follow up D) Thumb spica splint and orthopedics follow up

A) Ebstein's anomaly Although rare, Ebstein's anomaly is a congenital cardiac malformation that can in part be attributed to maternal lithium use during pregnancy, especially within the first trimester. Other causes are suspected to be multifactorial in nature, with genetics, environment, and other medications (benzodiazepines) during pregnancy shown to be possible contributors. During fetal development, there is a failure of the tricuspid valve to form properly, resulting in downward displacement of the leaflets and incompetency of the valve. This leads to a relatively small functional right ventricle, tricuspid regurgitation, and eventually symptoms of heart failure. Treatment options include observation and medical (heart failure management) for mild cases and surgical (valve replacement/repair, shunt repair) for more severe cases. Eisenmenger's syndrome (B) is the reversal of a left-to-right shunt due to increasing pulmonary pressures. Instead of simply recirculating oxygenated blood through the right side of the heart, the increased right-sided pressures causes a shunt of deoxygenated blood into the systemic circulation. Pulmonary atresia (C) refers to a constellation of congenital abnormalities that results in an unformed pulmonic valve. It presents acutely after birth as the ductus arteriorus closes, and blood is not able to be oxygenated. Tetralogy of Fallot (D) refers to four separate congenital abnormalities that are present in the same heart: ventricular septal defect (VSD), right ventricular hypertrophy, right ventricular output obstruction, and an overriding aorta.

A 24-year-old pregnant woman presents to the urgent care clinic where you are working. During your assessment, she states that she saw her obstetrician when she first became pregnant but has not had any follow-up care since. You also find out that she has bipolar disorder and took lithium throughout the first trimester. What congenital abnormality is the fetus at risk of developing? A) Ebstein's anomaly B) Eisenmenger's syndrome C) Pulmonary atresia D) Tetralogy of Fallo

D) Selective serotonin reuptake inhibitors Treatment of mild premenstrual syndrome symptoms, those considered to not alter daily socioeconomic function, includes stress reduction techniques and regular exercise. This patient reports historical points which reveal moderate to severe symptomatology. In women whose daily function is altered due to the cyclical, luteal phase symptoms of premenstrual syndrome, selective serotonin reuptake inhibitors (SSRIs) are recommend as first-line therapy. Anticholinergics (A) block central and peripheral nervous system acetylcholine transmission. Their common side effects of confusion, irritability, dysphoria, memory difficulty and poor concentration would not be recommended in a patient who is already cognitively and vocationally impaired. Surgery, consisting of hysterectomy (B) with bilateral oophorectomy, is reserved for rare refractory cases of severe disabling premenstrual syndrome symptoms. Oral contraceptive pills (OCPs) (C) are recommended as second line therapy in those women who cannot tolerate the side effects of, or do not respond to, SSRIs.

A 24-year-old woman presents for initial evaluation of cyclical symptoms of irritability, painful bloating and depression. These symptoms occur regularly 4-5 days prior to the beginning of menstruation. During these few days, this patient typically has to miss work due to the "awful pain and mental clouding." Which of the following treatment options do you recommend as first-line therapy? A) Anticholinergics B) Hysterectomy C) Oral contraceptive pills D) Selective serotonin reuptake inhibitors

D) Levonorgestrel releasing IUD IUD releases potent progestin only; is not a combination contraceptive. WHO rates progesterone only contraception as a "2". A 2 means that progesterone only contraception can general be used after DVT but should be monitored and followed up with caution. Hint: the vaginal ring has a 7% failure rate, must be removed during intercourse and replaced within 3 hours Hint: The risk of venous thromboembolism with combined hormone in ring is similar to the oral contraceptive pill (OCP). Hint: The risk of venous thromboembolism with combined hormone in patch is similar to OCP Hint: The use of oral OCPs triples a user's risk of venous thromboembolism.

A 25 year-old G2P2 married female presents to the clinic for birth control counseling. Her past history includes deep vein thrombosis with her last pregnancy. She does not want another pregnancy for at least 4 years. The birth control method that would be best for this patient is which of the following? A) Vaginal ring B) Transdermal patch C) Combined oral contraceptive pill D) Levonorgestrel releasing IUD

D) Endometriosis Hint: Leiomyomas of the uterus may present with abnormal uterine bleeding, but typically do not present with any symptoms. Hint: Endometrial polyps present with menorrhagia and intermenstrual and premenstrual bleeding, pain is not typical. Hint: Ovarian cysts present with adnexal mass and acute pain upon rupture.

A 25 year-old female presents with constant premenstrual pelvic pain. She also notes dysmenorrhea and dyspareunia. Which of the following is the most likely diagnosis? A Uterine leiomyoma B Endometrial polyps C Ovarian cysts D Endometriosis

C) acute pyelonephritis. Acute pyelonephritis presents with flank pain, fever, and generalized muscle tenderness. Urinalysis shows pyuria with leukocyte casts. Hint: Nephrolithiasis does not usually present with fever or casts. Urinalysis will have RBCs present. Hint: Acute salpingitis would be suggested if pelvic exam abnormalities were present

A 25 year-old female presents with right lower quadrant pain, right flank pain, nausea, and vomiting. Her temperature is 39.6 degrees C. There is right CVA tenderness and RLQ tenderness. Pelvic exam is unremarkable. Urinalysis reveals pH 7.0, trace protein, negative glucose, negative ketones, positive blood, and positive nitrates. Specific gravity is 1.022. Microscopic shows 102 RBCs/HPF, 50-75 WBCs/HPF, rare epithelial cells, and WBC casts. The most likely diagnosis is A) acute salpingitis. B) nephrolithiasis. C) acute pyelonephritis. D) appendicitis

A) KOH prep KOH prep is used to assist in the diagnosis of vaginal *candidiasis*, which presents with vulvar pruritus and white curd like, cheesy vaginal discharge. Hint: Gram stain is used in the diagnosis of *bacterial* infections. Hint: Tzanck smear is used to diagnose *herpes* infections. Multinucleated Giant Cells. Direct Fluorescent Antibody needed for definitive. Hint: FTA-ABS is used to diagnose *syphilis*. Gold Standard. Positive for life.

A 25 year-old female presents with vulvar pruritus and a thick, white vaginal discharge. Which of the following tests will be most helpful in making the correct diagnosis? A) KOH prep B) Gram stain C) Tzanck smear D) FTA-ABS

B) Inevitable abortion = the gross rupture of membranes in the presence of cervical dilation. Hint: Threatened abortion is characterized by bleeding in the first trimester without loss of fluid or tissue. Hint: Incomplete abortion is when the cervical os is open and allows passage of blood. The products of conception may remain in utero or may partially extrude through the open os. Hint: Complete abortion refers to a documented pregnancy that spontaneously passes all of the products of conception.

A 25 year-old female, G2 P1001, presents to your office at 11-weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, blood is noted at the dilated cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8-9 weeks gestation. No other abnormalities are found. Which of the following is the most likely diagnosis? A) Threatened abortion B) Inevitable abortion C) Incomplete abortion D) Complete abortion

D) Transvaginal ultrasound Transvaginal ultrasound is the best test to separate ectopic from intrauterine pregnancy. Hint: The use of laparoscopy in the diagnosis of an ectopic pregnancy has decreased, but is still useful when a definitive diagnosis is difficult. Hint: Culdocentesis is used in the diagnosis of intraperitoneal bleeding, which may or may not be present in an ectopic pregnancy. Hint: Dilation and curettage may confirm or exclude intrauterine pregnancy but is not the next best test in the evaluation of ectopic pregnancy.

A 25 year-old presents with pelvic pain and uterine bleeding. Her Beta-HCG was 1200 mIU/L six days ago. Her current Beta-HCG is 1600 mIU/L. What is the next best test in the evaluation of this patient? A Laparoscopy B Culdocentesis C Dilation and curettage D Transvaginal ultrasound

D) Papanicolaou test Routine screening for ovarian cancer by ultrasound (C), measurement of tumor markers, or pelvic exam is not recommended. The positive predictive value is low because of the low prevalence of ovarian cancer in the general population. The meningococcal vaccine (B) is only recommended for adults with asplenia, first-year college students living in dormitories or military personnel. Woman 50-74 years of age should receive a mammography (A) every two years for breast cancer screening. However, some women may require earlier screening based on patient context (family history, genetic make-up) and the benefits and harms should be discussed with the patient. Do not routinely screen women >75 years of age with mammography.

A 25-year old woman presents to her primary care physician for a routine annual visit. Her last Papanicolaou test was three years ago. She smokes cigarettes and is sexually active. Her mother was diagnosed with ovarian cancer at age 50. According to the current guidelines, which of the following should be offered to the patient? A) Mammography B) Meningococcal vaccine C) Ovarian ultrasound D) Papanicolaou test

D) There is an increased risk for fetal demise This woman has classic symptoms of intrahepatic cholestasis of pregnancy. It is characterized by pruritus which is often concentrated in the palms of the hands and soles of the feet. Serum bile acids are almost always elevated and there is a significant increase in intrauterine fetal demise. A widely accepted management approach is induction of labor between 36 and 37 weeks gestation as most fetal deaths occur after 37 weeks. Aminotransferases are often elevated (A) in this disease. The treatment of choice is ursodiol which helps increase hepatic bile flow and decrease bile acid levels. This improves pruritus and also helps lower aminotransferase levels. Cholestyramine (C), which decreases absorption of bile salts in the ileum, is not as effective as ursodiol in decreasing pruritus. Intrahepatic cholestasis of pregnancy will recur (B) in over half of subsequent pregnancies.

A 25-year-old G2P1 presents to your office at 32 weeks gestation with a complaint of severe itching, particularly on the palms of her hands and the soles of her feet. Lab results reveal elevated bile acids. Regarding this disease, which of the following statements is most correct? A) Aminotransferases are low B) Disease recurrence is rare in subsequent pregnancies C) The treatment of choice is cholestyramine D) There is an increased risk for fetal demise

A) Weber - sound is heard louder in right ear, Rinne - bone conduction exceeds air conduction in right ear *Weber* = lateralization (middle of head). In unilateral conductive hearing loss, sound is heard in the impaired ear. In unilateral sensorineural, sound is heard in the good ear. *Rinne* = AC vs BC (mastoid then air/ear) Otitis media and serous otitis are examples of causes of conductive hearing loss. When a conductive hearing loss exists, the Weber test will result in the appearance of a louder sound in the affected ear and the Rinne test will result in bone conduction exceeding air conduction in the affected ear. The other answers are incorrect because in a sensorineural hearing loss, the Weber test results in a louder sound in the unaffected ear and the Rinne test will result in air conduction exceeding bone conduction in the affected ear.

A 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. Which of the following results would you most likely expect to find? 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 E) Weber - sound is equal in both ears, Rinne - bone conduction greater than air conduction in right ear

A) Lithium Lithium, used in the treatment of bipolar disorder, is a common cause of diabetes insipidus. It is freely filtered through the glomerulus and reabsorbed in the proximal tubule along with sodium and water. Even small doses of lithium may cause diabetes insipidus. Lithium can also make the distal renal tubules resistant to the action of vasopressin. This patient had recently started this medication, which resulted in his new symptoms Vasopressin = anti-diuretic hormone (ADH) which would do the opposite; it causes the kidneys to reabsorb solute-free water and return it to the circulation. This person is dumping water.

A 25-year-old man presents with increased urination and thirst. Over the past 3 days, he has been unable to satisfy his thirst and has to urinate up to 20 times per day. He noticed that his urine is very clear and colorless. In general, he feels very weak. He has never had any problems with urination before. His medical history is remarkable for a recently diagnosed psychiatric condition for which he began medical treatment. On physical exam, he appears to be lethargic, dehydrated, and pale. His vital signs are as follows: blood pressure 96/52 mm of Hg, temperature 101.2 degrees Fahrenheit, pulse 108 beats per minute, and a respiratory rate of 26 per minute. *Which of the following is a common cause of diabetes insipidus?* A) Lithium B) Carbamazepine (Tegretol) C) Amitriptyline (Elavil) D) Valproic acid (Valproate) E) Vasopressin

Gram negative bacillus Chancroid is a common sexually transmitted disease in developing nations, but is relatively rare in the United States. Chancroid is caused by Haemophilus ducreyi, a gram negative bacillus, which has an incubation period of 4 to 10 days. Initially, a small pustule will form at the site of inoculation and progresses to multiple, painful ulcerations with sharply demarcated purulent bases. Chlamydia trachomatis is an obligate intracellular gram negative organism (C), the most commonly reported sexually transmitted disease in the United States, and the infectious cause of chlamydial infections. Chlamydia can cause Lymphogranuloma venereum, which manifest as painless genital ulcers and tender inguinal lymphadenopathy

A 25-year-old sexually active woman presents to the Emergency Department with a complaint of painful vulvar ulcers and a swollen inguinal lymph node. She denies dysuria and vaginal discharge. Which of the following is most consistent with the description of the offending infectious organism? Gram negative bacillus Gram negative diplococcus Obligate intracellular gram negative organism Spirochete

A) Hypertrophic Cardiomyopathy The clinical picture is suggestive of a Hypertrophic Cardiomyopathy (HCM). The age of presentation is usually in the mid-20's and the most frequent symptom is dyspnea although most patients are asymptomatic with a normal physical examination. Syncope may result from an arrhythmia due to abnormal myofibers. The transient increase in LV size during squatting reduces the LV outflow tract obstruction in HCM and softens the intensity of the murmur. The increase in QRS voltage indicates a hypertrophied heart and, depending on which leads (V1-V6), will tell you right or left heart. In Aortic stenosis, the murmur will get louder with squatting and in this patient the murmur gets softer. Mitral valve stenosis produces a diastolic murmur, while there is a systolic murmur in this patient. Mitral valve insufficiency (MVI) does produce a systolic murmur but it is described as pansystolic and the patient with MVI could have symptoms of shortness of breath, fatigue, palpitations, and orthopnea which is not present in this patient. Pulmonary stenosis is rare and would produce signs of jugular venous distention (JVD), cyanosis of nail bed, and general symptoms of hypoxia. There is no mention of JVD or cyanosis in this patient.

A 25-year-old woman presents to the ER after a syncopal episode. She had loss of consciousness 3 times over the past 12 months. Each event occurred during or just after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and a III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. The EKG shows a normal sinus rhythm with diffuse increased QRS voltage. What is the most likely diagnosis? A) Hypertrophic Cardiomyopathy B) Mild Mitral Valve Insufficiency C) Moderate Pulmonary Stenosis D) Severe Aortic Stenosis E) Moderate Mitral Valve Stenosis

Azithromycin Ciprofloxacin (B) is a quinolone which has not been shown to be effective against Chlamydia trachomatis. Penicillin (D) is used in the treatment of syphilis and is not used to treat chlamydia. Metronidazole (C) is used for the treatment of vaginal trichomoniasis and bacterial vaginosis, but is ineffective against Chlamydia.

A 25-year-old woman presents to your clinic with concerns about sexually transmitted infections. She admits to unprotected sex with multiple partners. She is asymptomatic, but her last partner told her that he recently tested positive for chlamydia. The most appropriate next step is administration of which of the following? Azithromycin Ciprofloxacin Metronidazole Penicillin

A) Inevitable abortion Threatened abortion (D) is diagnosed when the pregnant woman presents with vaginal bleeding, lower back discomfort, or midline pelvic cramping. On examination, the cervix is closed, and the pregnancy is viable. Inevitable abortion is associated with painful abdominal cramps, vaginal bleeding and a dilated cervix with gestational tissue often visible at the cervical os or on ultrasound. Dilatation and curettage is indicated for significant cramping or blood loss.

A 25-year-old woman presents to your office with amenorrhea, abdominal cramping, and irregular vaginal bleeding. She usually has monthly menstrual cycles, but has been intermittently spotting over the last 2 months. Her exam shows a firm uterus without tenderness and a dilated cervix with blood in the vaginal vault. Her beta HCG is positive and a bedside ultrasound reveals a yolk sac, fetal pole and no evidence of cardiac activity. What is the most likely diagnosis? A) Inevitable abortion B) Physiologic bleeding C) Septic abortion D) Threatened abortion

B) Secondary hyperparathyroidism This patient has *stage 3 kidney disease*, based on her glomerular filtration rate of 60 ml/min/1.73 m2 and her proteinuria. It is also likely that she has hyperparathyroidism. Disorders of calcium and phosphorus balance are common in kidney disease and should be evaluated starting early in the course of disease to prevent complications. Vitamin D levels, calcium and phosphorus levels, and parathyroid hormone levels (PTH) should be checked in all patients with stages 3 - 5 chronic kidney disease. Decreasing glomerular filtration rates lead to phosphorus retention. Decreased renal synthesis of hydroxylated vitamin D leads to decreased intestinal calcium reabsorption and hypocalcemia. Together, hyperphosphatemia, hypocalcemia, and hypovitaminosis D lead to hyperparathyroidism. Vitamin D usually suppresses PTH synthesis and secretion. Vitamin D deficiency removes this negative feedback, leading to hyperparathyroidism. Correction of calcium-phosphate balance is important; when it is abnormal, it can lead to vascular and valvular calcification and increased risk of cardiac death. Her phosphorus level is elevated, not low. Goal levels for patients with stages 3 and 4 kidney disease are 2.7 - 4.6 mg/dl. Her calcium level is low, not elevated. Her corrected level should be >8 mg/dl. Her PTH level is 150. Patients with stage 3 should have levels in the 35-70 pg/ml range (Brenner, ch. 52), according to National Kidney Foundation guidelines. No mention is made of Vitamin A levels in this vignette. Her vitamin D levels are low, which is consistent with impaired hydroxylation of the vitamin D compound by her kidneys. Patients with levels <30 ng/dl should be supplemented with ergocalciferol. Hypervitaminosis D (Vitamin D intoxication) occurs in the accidental or intentional intake of vitamin D or vitamin D compounds including vitamin D, vitamin D fortified milk, etc. High levels of vitamin D would be noted in this case. Additionally, since Vitamin D suppresses PTH, low levels of PTH would be noted. Vitamin D causes increased gastrointestinal calcium absorption and increased serum calcium levels. Symptoms are those of hypercalcemia (bone and abdominal pain, weakness, confusion, and possibly hematuria/flank pain/poor urine flow if renal stones develop). Treatment involves promoting kaliuresis (excreting potassium in the urine.) with volume expansion and possibly loop diuretics and steroids.

A 25-year-old woman presents with fatigue. She has been diabetic for 10 years, and she takes multiple injections of insulin a day. She has no other medical problems. She takes no other medications, and she is not sexually active. Her skin shows diffuse scratch marks. Her laboratory tests show below. What is the most likely diagnosis?: A) Hypervitaminosis D B) Secondary hyperparathyroidism C) Hypervitaminosis A D) Hypophosphatemia E) Hypercalcemia

A) Reassurance that the discoloration is an expected finding. This is indicative of migratory ecchymosis and expected after insertion of a pacemaker.

A 26 year-old female presents to clinic with a left arm that is swollen and non-tender with bluish discoloration along the upper arm and forearm. She is status post pacemaker insertion in the left upper chest for third degree heart block, one week ago. Pulses are present and the arm is warm, but not red. The pacemaker incision is healing well despite a hematoma and tenderness at the site. Which of the following statements would be appropriate patient education about this condition? A) Reassurance that the discoloration is an expected finding. B) Apply cold compresses to the site of the hematoma. C) Elevation of the involved extremity will increase the swelling. D) Aspirin should be taken to help manage pain.

B) disseminated intravascular coagulation Disseminated intravascular coagulation is characterized by bleeding from many sites as all *coagulation factors are consumed and then broken down*, leading to decreased fibrinogen level and platelet count, prolonged PT and PTT, and presence of fibrin split products. Hint: ABO incompatibility results in immediate hemolysis and shock. Hint: Idiopathic thrombocytopenia is characterized by decreased platelet count, but coagulation factors are normal. Hint: With inadequate repair of liver lac, Bleeding would be localized only and would result in shock if lacerations of the liver were not repaired properly.

A 26 year-old female required 12 units packed red blood cells during a trauma resuscitation and surgical repair of liver and splenic lacerations. The patient is now 6 hours postoperative and has blood oozing from the suture line and IV sites. There is bloody urine in the Foley bag. Laboratory evaluation demonstrates a platelet count of 10,000/microliter, prolonged prothrombin level, and the presence of fibrin split products. Which of the following is the most likely diagnosis? A) acute ABO incompatibility reaction B) disseminated intravascular coagulation C) exacerbation of idiopathic thrombocytopenia D) inadequate repair of the liver lacerations

High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain.

A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis?

A) Ectopic pregnancy High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain. Hint: In pelvic inflammatory disease the temperature is usually above 38 degrees C and pelvic pain usually follows onset of cessation of menses

A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis? A) Ectopic pregnancy B) Appendicitis C) Crohn's disease D) Pelvic inflammatory disease

A) Ectopic pregnancy High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain. Hint: In pelvic inflammatory disease the temperature is usually above 38 degrees C and pelvic pain usually follows onset of cessation of menses.

A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis? A) Ectopic pregnancy B) Appendicitis C) Crohn's disease D) Pelvic inflammatory disease

B) *Endometriosis* Remember the *3 D's* = Dysmenorrhea, Dyspareunia, Dyschezia!! associated with cyclic premenstrual pelvic pain / low back pain With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or *"chocolate cyst"*. The patient with endometriosis also often has dysmenorrhea, dyspareunia, and dyschezia.

A 26 year-old monogamous female presents with cyclic pelvic pain that has been increasing over the last 6 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis? A) Ovarian cancer B) Endometriosis C) Functional ovarian cyst D) Pelvic inflammatory disease

B) Syphilis The primary lesion of syphilis presents as a painless ulcer or chancre. Secondary syphilis presents with a skin rash lymphadenopathy and mucocutaneous lesions. Hint: The classic presentation of herpes is a painful vesicle. Hint: Granuloma inguinale presents with raised, red lesions that bleed easily. Hint: Chancroid presents with a painful genital ulcer and tender suppurative inguinal adenopathy.

A 26 year-old woman requests screening after her boyfriend was treated for a sexually transmitted infection recently. On examination you find a painless vulvar ulcer. Which of the following is the most likely diagnosis? A) Herpes B) Syphilis C) Chancroid D) Granuloma Inguinale

Dengue fever the second most important tropical, febrile illness after malaria. Dengue has a short incubation period of 4-7 days. It is also known as "breakbone fever" due to the severe myalgias.

A 26-year-old man presents with a severe retro-orbital headache, a sudden-onset fever of 103.3°F, nausea and severe myalgias six days after returning from Panama. On exam, he has a morbiliform rash on his abdomen and back. Which of the following is most likely responsible for his symptoms?

A) Blood culture positive for S.typhi Definitive diagnosis depends on a positive blood culture for Salmonella typhi. The term Enteric fever includes typhoid caused by Salmonella enterica serotype, Typhi (referred to as S.typhi), and paratyphoid caused by Salmonella paratyphi A, B, and C. *Isolation of S.typhi from stool and urine samples helps diagnosis, but could be positive in carriers as well*.

A 26-year-old man residing in Thailand presents with high-grade fever, dull, frontal headache, malaise, anorexia, and vague abdominal discomfort of 7 days duration. He had mild diarrhea, dry cough, and myalgia. On examination, his temperature was 39 degrees C. His pulse was 65 per minute. He had a coated tongue, tender abdomen, and a soft palpable spleen. Clinical diagnosis was Enteric fever. Appropriate clinical samples were sent for culture and serology. What laboratory data would be helpful in making a *definitive diagnosis?* A) Blood culture positive for S.typhi B) Stool culture positive for S.typhi C) Urine culture positive for S.typhi D) Serum titer of S.typhi O agglutinins 1: 80 E) Serum titer of S.typhi H agglutinins 1: 160

D) Weight reduction Clomiphene citrate (A) is the next line of treatment if weight loss does not lead to return of ovulation. Multiple studies have shown conflicting evidence comparing the efficacy of metformin and clomiphene for ovulation induction, however clomiphene remains the first line pharmacologic agent for ovulation induction in PCOS. Gonadotropin therapy (B) is used if clomiphene citrate fails. Low-dose gonadotropin therapy is recommended over high-dose therapy. Spironolactone (C) is the first-line agent to treat hirsutism in women with PCOS and has no role in ovulation induction. it is structurally similar to testosterone so will block testosterone receptors. Teratogenic so must be used with OCP's. Combination oral contraceptives are also used to prevent hirsutism and menstrual abnormalities in patients whom do not wish to conceive, however they are not first-line.

A 26-year-old obese woman with a 2-year history of increased acne, abnormal hair growth, and menstrual abnormalities presents to her obstetrician for an infertility workup. A pelvic ultrasound reveals enlarged cystic ovaries. She desires to become pregnant. Which of the following is the first line treatment? A) Clomiphene citrate B) Gonadotropin therapy C) Spironolactone D) Weight reduction

A) Consult Obstetrics and Gynecology Ectopic pregnancy is a life-threatening illness that must be considered in all women of childbearing age who present with abdominal pain, pelvic pain, abnormal vaginal bleeding, amenorrhea, or evidence of unexplained hypovolemia. Until pregnancy is ruled out or a uterine pregnancy is confirmed, ectopic pregnancy should remain high on the differential. An ectopic pregnancy is any pregnancy that implants outside of the uterine cavity. The vast majority of ectopic implantations occur in the fallopian tubes, although abdominal, cervical, and cesarean scar pregnancies can occur. Diagnosis is confirmed by a positive hCG test (either urine or serum) and evidence of implantation outside the uterus (either by ultrasound, laparoscopically or surgically). A positive pregnancy test with an unknown location of implantation does not confirm the diagnosis, but whenever an intrauterine pregnancy cannot be confirmed, ectopic implantation should be considered. Due to the life-threatening nature of the illness, any hypotensive patient with strong suspicion for an ectopic pregnancy warrants an emergent consult to Obstetrics and Gynecology for possible operative management. Although obtaining a complete blood count (B), serum human chorionic gonadotropin levels (C), and a pelvic ultrasound (D) can aid in the diagnosis of ectopic pregnancy, in an unstable patient with high suspicion for ectopic pregnancy, these diagnostic tests should not delay mobilization of resources that can provide definitive care.

A 26-year-old previously healthy woman presents to the Emergency Department with abdominal pain. She was at home when she developed sudden onset lower abdominal pain followed by a brief syncopal episode. Her vital signs include blood pressure of 88/46 mm Hg, heart rate of 112 beats/minute, respiratory rate of 18 breaths/minute, temperature of 37.6°C, and oxygen saturation of 98%. She had a positive home pregnancy test yesterday. After initiating aggressive resuscitation, what is the most appropriate next step in management? A) Consult Obstetrics and Gynecology B) Obtain a complete blood count C) Obtain a serum human chorionic gonadotropin (hCG) level D) Pelvic ultrasound

Uterine atony Amniotic fluid embolism (A) is a rare but often fatal obstetric complication in which amniotic fluid enters the maternal circulation, leading to cardiopulmonary collapse and disseminated intravascular coagulopathy. Dehiscence of a cesarean section incision (B) may also lead to hemorrhage in the postpartum state, but this patient delivered vaginally. In Rh sensitization (C), maternal antibodies are made against fetal red blood cells. With subsequent pregnancies, the placental transmission of these antibodies can lead to a devastating fetal, not maternal, anemia.

A 26-year-old woman just vaginally delivered twin, macrosomic newborn boys. This represents her fourth pregnancy, which has been the longest of them all at 43 weeks gestation. Her delivery was difficult and required forceps to complete. Estimated blood loss was 1100 ml. Currently, she is hypotensive, tachycardic and anemic. Which of the following is the most likely diagnosis? Amniotic fluid embolism Incision dehiscence Rh sensitization Uterine atony

Medroxyprogesterone acetate (Depo-Provera) History of migraines is a contraindication for estrogen use. Behavioral methods such as the withdrawal method and periodic abstinence (A) are not as effective as hormonal therapy and should not be used as first line pregnancy prevention. Norelgestromin/ethinyl estradiol transdermal (D) and etonogestrel/ethinyl estradiol vaginal (B) more commonly known as the are combined estrogen-progesterone birth control methods and because of the estrogen, are both contraindicated in this patient.

A 26-year-old woman presents for her annual exam and is inquiring about birth control. She is current on her immunizations and her last pap smear was 2 years ago. She is in a monogamous relationship with her boyfriend and does not have any immediate plans for pregnancy. She has a history of migraines with aura but does not require any prescription medication. Which of the following birth control methods is the best option for her? Behavioral methods such as the withdrawal method and periodic abstinence Etonogestrel/ethinyl estradiol vaginal Medroxyprogesterone acetate Norelgestromin/ethinyl estradiol transdermal

Discharge home with repeat beta hCG in 48 hours This ultrasound does not rule out the diagnosis of an ectopic pregnancy as an ectopic pregnancy can cause a decidual reaction in the uterus, which appears similar to an early gestational sac. The definitive ultrasound finding for an intrauterine pregnancy would be the presence of a yolk sac or fetal pole. It is expected that above the discriminatory hCG zone of 1500-2500 mIU, a definitive IUP should be identified. Patients with a beta hCG below the discriminatory zone without a definitive IUP can be managed conservatively with a repeat hCG level in 48 hours (the level should double every 48 hours) and repeat ultrasound. Rhogam (B & C) is recommended for patients who are Rh negative and have vaginal bleeding. If the mother is exposed to fetal blood, she may develop antibodies that threaten future pregnancies. This patient does not have vaginal bleeding and is Rh positive obviating the need for Rhogam

A 26-year-old woman presents with abdominal cramping after a positive home pregnancy test. Her vitals are T 98.7°F, HR 94, BP 110/66, RR 18, oxygen saturation 97%. Her exam is unremarkable. Labs reveal a serum beta HCG of 1000 mIU and she is Rh positive. She states that the pregnancy is wanted.The transvaginal ultrasound shows an early gestational sac without a yolk sac or fetal pole within the uterus. Which of the following is appropriate management for this patient? Administer methotrexate Administer Rhogam and discharge home with repeat beta hCG in 48 hours Administer Rhogam and methotrexate Discharge home with repeat beta hCG in 48 hours

C) Serum prolactin level In the absence of other breast signs or symptoms, breast imaging such as ultrasonography of the breasts (D) is not necessary. A brain MRI focusing on the pituitary sella is not needed until the diagnosis of hyperprolactinemia is confirmed. A MRI of the sella turcica (B) would be warranted if the prolactin level is elevated. Dynamic tests of the hypothalamic-pituitary-adrenal axis, such as a dexamethasone suppression test (A), are generally not indicated in the evaluation of amenorrhea. Dexamethasone suppression tests are indicated in disorders of glucocorticoid excess.

A 26-year-old woman reports a history of amenorrhea for the past year. She also had an increased amount of milky discharge from her nipples over the past several months and has lost all interest in sex for the past 6 months. She denies any drug or medication use other than occasional over-the-counter analgesics for frequent headaches. A physical examination confirms the presence of an easily expressed milky discharge, as well as vaginal dryness. A pregnancy test is negative. Which one of the following tests would be most appropriate at this point? A) Dexamethasone suppression test B) MRI of the sella turcica C) Serum prolactin level D) Ultrasonography of the breasts

C) MRI of the brain CT angiography (A) is useful in the detection of arterial aneurysms. CT venogram (B) is helpful in assessing the patency of venous sinuses if cerebral venous thrombosis is suspected. A noncontrast CT of the head (D) is less sensitive than MRI for the previously stated reasons. This patient presents with signs and symptoms concerning for a hemorrhage of the pituitary or pituitary apoplexy and should have an MRI for diagnosis. Pituitary apoplexy describes the presence of a pituitary infarction or hemorrhage leading to decreased pituitary function. Often, patients have a preexisting pituitary tumor. The most common symptoms seen in hemorrhagic pituitary apoplexy are sudden onset of headache caused by subarachnoid bleeding associated with nausea and vomiting. Fever may be present if the vascular supply of the hypothalamus is compromised. Patients typically have ophthalmologic symptoms including decreased visual acuity, opthalmoplegia and visual field defects. The classic visual field defect is bitemporal hemianopsia. Bleeding may cause abnormalities of cranial nerves III, IV and VI. These findings are typically due to leakage of blood into the subarachnoid space or due to mass effect (hemorrhagic or a rapidly expanding mass). Lab testing will reveal global panhypopituitary function. MRI is the optimal study for a number of reasons. The sella turcica, where the pituitary sits, is not imaged well by CT scan due to the amount of bone in the area. Additionally, MRI can differentiate between hemorrhagic and necrotic tissue, which CT cannot. Overall, MRI is 50% more sensitive for apoplexy than CT scan.

A 27-year-old man presents with a severe headache and blurred vision. Physical examination reveals bitemporal hemianopsia and an inability to abduct the left eye. What diagnostic modality will most likely yield a diagnosis? A) CT angiography of the head B) CT venogram of the head C) MRI of the brain D) Noncontrast CT scan of the head

D) Stop transfusion The patient developed an acute hemolytic reaction and the most important priority is stopping the transfusion. Acute hemolytic reactions are a medical emergency and occur from the rapid hemolysis of donor red blood cells from host antibodies. Symptoms occur within minutes of onset of the transfusion and include fever, chills, and back and joint pain. Uncontrolled hemolysis can lead to acute renal failure and DIC. The majority of acute hemolytic reactions occur because of transfusion of ABO incompatible blood (i.e. type A red cells transfused to a type O individual), usually due to human error.

A 27-year-old woman develops back pain, diffuse joint pain, headache, and dyspnea shortly after starting a blood transfusion for heavy vaginal bleeding. Vital signs are notable for fever, tachycardia and hypotension. Which of the following is the most important initial treatment? A) Administer antipyretics B) Administer IV fluids C) Repeat type and screen and cross-matching, serum haptoglobin, complete blood count and direct Coombs testing D) Stop transfusion

C) MRI MRI is the diagnostic modality of choice for multiple sclerosis (MS). Multiple sclerosis is characterized by demyelination of axons within the central nervous system. Patients present with symptoms that are "scattered in time and space" meaning that they have intermittent symptoms in anatomically disparate locations. Patients may have patchy motor and sensory deficits and bladder dysfunction. Spinal cord lesions typically involve the posterior columns, lateral spinothalamic tracts and the corticospinal tract. Spinal MRI is the diagnostic modality of choice because it can be used to rule out causes of cord compression while also show lesions diagnostic for MS.

A 27-year-old woman presents with a complaint of transient vision loss in her right eye. She states that she has had multiple similar episodes in the past 6 months. She also complains of incomplete bladder emptying, intermittent tremors and intermittent weakness in her left arm. The patient has a family history of multiple sclerosis. Which of the following is the best diagnostic test for the suspected diagnosis? A) CSF testing for myelin basic protein B) CT scan of the spine C) MRI D) Serum oligoclonal bands

D transfer to a burn center. Reasons for transfer to a burn center include a partial thickness burn covering greater than 10% of total body surface area. In addition, burns in patients with pre-existing medical conditions, such as diabetes, that could complicate their management, prolong recovery, or affect their outcome, is also a reason for transfer to a burn center Hint: If used in the care of a burn patient, the antibiotic selected should have activity against Pseudomonas and S. aureus. Cefazolin does not have any antipseudomonal activity

A 28 year-old female with diabetes mellitus type 2 sustains a partial thickness burn to her left upper arm and her chest when hot grease spilled on her at home. The burn to her arm is circumferential and the estimated total body surface burned is 18%. She has no allergies. The most appropriate treatment of this patient would include A outpatient application of silver sulfadiazine. B debridement of all intact blisters. C IV cefazolin (Ancef, Kefzol). D transfer to a burn center.

A) Myomectomy. Hint: Oral progesterone may be used to suppress menorrhagia preoperatively. Used alone, it would not be considered definitive treatment. Hint: GnRH agonists are used as an adjunct to surgery for treatment of uterine fibroids. Used alone, they would not be considered definitive treatment.

A 28 year-old woman is complaining of heavy uterine bleeding and pelvic pressure that has progressively worsened over the past year. Evaluation reveals multiple moderate-sized uterine fibroids. The patient desires to have more children. The most appropriate definitive treatment is A Myomectomy. B Hysterectomy. C GnRH agonists D Oral progesterone

A diastolic low-pitched decrescendo murmur best heard at the cardiac apex would be the most likely auscultatory finding on exam. This woman likely has mitral stenosis secondary to rheumatic heart disease.

A 28-year-old south Asian immigrant who is in her second trimester of her first pregnancy presents to the emergency department complaining of worsening dyspnea, orthopnea and lower extremity edema. She has never experienced anything like this before. She has no past medical history; however, she admits to frequent sore throats and ear infections as a child. Which of the following is most likely to be heard on auscultatory exam?

B) Continue breastfeeding to decrease the chance of the mastitis progressing to a breast abscess Discontinuing breastfeeding is not recommended (C) and (D) because breast milk helps improve the infant's immunity and provided the right amount of nutritional support. Breastfeeding also enhances the mother-infant bonding experience. The small bacteria load in the nipple will not help to develop the infant's immune system (A). The infant received passive immunity from direct immunoglobulins in the breast milk.

A 28-year-old woman who has been breastfeeding her baby for approximately 3 months visits her physician complaining of breast tenderness and fevers. After assessing the patient, the physician believes that she is experiencing mastitis. The patient is started on analgesics and antibiotics. What should the physician recommend in terms of breastfeeding from the affected breast? A) Continue breastfeeding since the small bacterial load can help develop the infant's immune system B) Continue breastfeeding to decrease the chance of the mastitis progressing to a breast abscess C) Discontinue breastfeeding to allow time for proper healing D) Discontinue breastfeeding to decrease bacterial spread to the infant

D) Topical tacrolimus Topical tacrolimus 0.1%, applied twice daily, is the first-line therapy for patients with vitiligo affecting less than 20% of the patient's body. The underlying cause of vitiligo is the destruction of melanocytes, or pigment cells. Often, there is an autoimmune component to this destruction and it may be seen in conjunction with diseases such as pernicious anemia, autoimmune thyroid disease, Addison disease, and type 1 diabetes. In the absence of an underlying autoimmune condition, other causes of hypopigmentation may be responsible. A history of using intralesional corticosteroids or liquid nitrogen over the affected skin may cause temporary loss of pigmentation, particularly in patients with a naturally olive or dark complexion. A Wood's lamp can be used to accentuate vitiligo, as the hypopigmentation following an inflammatory condition will not enhance readily. Treating vitiligo is often a long process of trial-and-error. Years of treatment are usually needed. Importantly, vitiligo increases a patient's risk of developing skin cancers, and more thorough skin screening methods should be considered. Narrowband UVB therapy (B) and oral PUVA therapy (C) are recommended treatments for vitiligo. However, these are not considered first-line treatments in patients with less than 20% skin involvement, as they carry an increased risk of phototoxic reactions

A 28-year-old woman with a history of pernicious anemia presents with significant depigmentation of the skin on her hands and forearms. She has no history of damaging events to the skin or prior dermatologic disorders. Which of the following interventions would be the best initial step in managing this patient? A) Local liquid nitrogen application B) Narrowband UVB therapy C) Oral PUVA therapy D) Topical tacrolimus

Measure Negative Inspiratory Force This patient is experiencing a myasthenic crisis, which is impending respiratory failure with an associated need for mechanical ventilation. An objective measure of respiratory status (i.e., negative inspiratory force [NIF] or forced vital capacity [FVC]) should be trended to evaluate the need for mechanical ventilation.

A 28-year-old woman with myasthenia gravis presents with progressive shortness of breath that started several hours ago. She takes pyridostigmine every 6 hours and has not missed any doses. Yesterday she was prescribed an unknown antibiotic for sinusitis at an urgent care clinic. On exam, her vital signs are within normal limits, and she does not appear in respiratory distress. What is the next immediate step in management?

C ) January 11 Nägele's rule is LMP minus 3 months plus 7 days. April 4 minus 3 months equals January 4 plus 7 days equals January 11.

A 29 year-old female G1P1 presents to the office with a one-month history of amenorrhea and a positive home pregnancy test. The first day of her last menstrual period (LMP) was April 4. Using Nägele's rule what is her EDC? A ) January 1 B ) January 7 C ) January 11 D ) January 18

Cholecystitis *Gallbladder disease represents one of the most common medical and surgical conditions seen during pregnancy*. This is thought to be due to a decrease in gallbladder contractility and lithogenicity of the bile. There is an increased risk in multiparous women.

A 29 year-old female G4P2Ab1 at 20 weeks gestation complains of nausea and vomiting with tenderness in the RUQ. Vital signs reveal the patient to be febrile. On physical examination, the abdominal examination reveals positive bowel sounds in all quadrants with a positive Murphy's sign. Fundus can be palpated at the level of the umbilicus. The skin is warm and dry with slight tenting. Oral mucosa is dry as well. What is the most likely diagnosis?

B) Clomiphene citrate (Clomid) SERM - selective estrogen receptor modulator, will block the feedback inhibition of estradiol on the hypothalamus and pituitary leading to an increase in FSH. Increase in FSH causes follicle and egg maturation in the ovary. Clomiphene citrate is the agent of choice for women younger than 36 years of age who need induction of ovulation. Hint: Medroxyprogesterone acetate inhibits pituitary gonadotropin release, it maintains a pregnancy; used for secondary amenorrhea Hint: Leuprolide inhibits gonadotropin release suppressing ovarian steroidogenesis and ovulation. Hint: Metformin decreases hepatic glucose, reduces body weight which in turn can improve ovulatory function in women with PCOS; it is sometimes used as an adjunct with clomiphene citrate in anovulation.

A 29 year-old female has been diagnosed with infertility due to anovulation. Her provider suggests using a medication that will block the feedback inhibition of estradiol on the hypothalamus and pituitary leading to an increase in FSH. Which of the following medications is the most appropriate for this patient? A) Leuprolide (Lupron) B) Clomiphene citrate (Clomid) C) Medroxyprogesterone acetate (Provera) D) Metformin (Glucophage)

D) 1-hour post-Glucola blood glucose Glucose screening, usually with a 1-hour Glucola, is routinely performed between 24-28 weeks gestation to evaluate for glucose intolerance Hint: A serological test for syphilis, usually the VDRL, is part of the routine obstetrical tests ordered at a patient's initial prenatal visit. Hint: Maternal serum alpha-fetoprotein testing is routinely done between 15-18 weeks gestation to screen for neural tube defects.

A 29 year-old female presents for routine prenatal visit at 26 weeks gestation. She has no complaints and has completed all the initial routine obstetrical diagnostic tests to date. Her physical examination and all initial diagnostic evaluations are unremarkable. Which of the following is the most appropriate diagnostic test to order at this time? A VDRL B amniocentesis C maternal serum alpha-fetoprotein D 1-hour post-Glucola blood glucose

Urethrogram A urethrogram is the only procedure that should be done to evaluate this type of injury as urethral integrity may have been compromised secondary to the pelvic fracture. Blood at the meatus is the most important finding of suspected urethral injury. Hint: An IVP can be done as part of an evaluation for hematuria however it is rarely used today. Hint: A VCUG is done to evaluate urinary reflux in children

A 29 year-old male is involved in a motor vehicle crash. On the secondary survey it is noted that there is blood at the meatus and the patient is suspected of having a pelvic fracture. The patient is otherwise stable. Which of the following tests should be done to evaluate the urinary system? A Voiding cystourethrogram (VCUG) B Intravenous pyelogram (IVP) C Urethrogram D Renal arteriography

D) G6PD deficiency G6PD deficiency is a very common X-linked hemolytic disorder affecting millions across the world. The highest incidence is among people of African, Asian, or Mediterranean descent. Glucose-6-phophate dehydrogenase is an enzyme in red cells that is vital to the integrity of the cell. Deficient individuals are susceptible to hemolysis under oxidant stress caused by drugs like sulfa and antimalarials, infections, or noxious agents like fava beans. Oxidant stress causes denatured hemoglobin, resulting in Heinz bodies (small round inclusions within the red cell body). During an acute event, as in this patient, rapid hemolysis causes acute anemia, hemoglobinuria (thus the dark urine), abdominal and back pain, jaundice, and even renal failure. G6PD levels are normal to low during an acute attack, since the replacement reticulocytes are young and have adequate enzyme levels. G6PD level should be measured after an acute attack is over. Removing the precipitating agent and getting oxygen and rest is usually sufficient during an acute attack.

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 trimethoprim-sulfamethoxazole (Bactrim), 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 4g/dl, reticulocyte count of 6%, and MCV of 93. Peripheral smear reveals cell fragments, microspherocytes, and blister or bite cells. Heinz bodies are also present. Based on these findings, which clinical entity is most likely? A) Hereditary spherocytosis B) Sickle cell anemia C) Porphyria D) G6PD deficiency E) Autoimmune hemolytic anemia

A) Daily use of intranasal corticosteroids Small nasal polyps can usually be managed initially for 1-3 months with daily intranasal corticosteroids to improve quality of life and reduce the need of an operation. Patients with significant impairment of nasal patency may also benefit from a short, tapered course of oral corticosteroids during this initial treatment phase. If patients fail to have improvement of symptoms after three months of intranasal steroids, surgery may be necessary. Daily use of a non-sedating antihistamine (B) may be appropriate for managing this patient's allergic rhinitis; however, it will not lead to a decrease in size of the polyps or reduce need for surgery. An ethmoidectomy (C) is usually only necessary for patients with nasal polyps if they have had recurrent polyp formation or have complicating medical issues such as asthma. A polypectomy (D) is not the initial best step for this patient, as several months of intranasal corticosteroids may be able to reduce the need of having the polyp surgically removed.

A 29-year-old man comes to the clinic complaining of several months of worsening nasal obstruction and poor sense of smell. He has perennial (continually recurring) allergic rhinitis, for which he takes diphenhydramine as needed. A nasal speculum exam shows a small, edematous, mucosa-covered mass in the left nasal passage. Which of the following is the best initial clinical intervention for this patient? A) Daily use of intranasal corticosteroids B) Daily use of non-sedating antihistamine C) Ethmoidectomy D) Polypectomy

C) Propranolol Ketorolac (Toradol) (A), a nonsteroidal anti-inflammatory drug, is not indicated for scheduled, daily use as a preventive for migraines. Promethazine (Phenergan) (B) is an antiemetic that helps with nausea and vomiting for people who suffer from migraines. It is not a preventive medication. Sumatriptan (Imitrex) (D) is rapidly effective agent for aborting attacks when given subcutaneously but it is not indicated for preventative treatment. Propranolol is one beta-blocker that is frequently used as a first-line prophylaxis for migraines. Once a prophylactic drug has been found to improve occurrence of migraines, it should be continued for several months. If a patient remains headache-free, the dose may gradually be tapered down and eventually withdrawn. Other medications shown to be successful in the prophylactic treatment of migraines include antiepileptics (topiramate, valproic acid), calcium channel blockers (verapamil), and antidepressants (amitriptyline). Recently, botulinum toxin type A injections have been approved by the US Food and Drug Administration (FDA) for migraine prevention.

A 29-year-old woman has a 10-year history of migraine headaches. She had been using ergotamine to abort her headaches, but is now having one or two headaches per week that are interfering with work. Which of the following is the most appropriate preventive therapy? A) Ketorolac B) Promethazine C) Propranolol D) Sumatriptan

C) Hysterosalpingogram Assessment of fallopian tube patency is by hysterosalpingography (first choice) or laparoscopy (if history strongly suggests prior tubal damage). Both CT scan (A) and pelvic ultrasound (D) will show the uterine and ovarian anatomy but neither test will determine fallopian tube patency which is integral in the work up of infertility. Dilatation and curettage (B) is used for the diagnosis and treatment of abnormal uterine bleeding and is not a diagnostic criteria for infertility. Initial laboratory testing for the female partner includes a CBC, urinalysis, STD screen, confirmation of rubella and varicella immunity, and Papanicolaou smear. Ovulation should be verified by urinary ovulation prediction kits that detect the LH surge, determination of the mid-luteal phase serum progesterone level (7 days before anticipated menses), or both.

A 29-year-old woman has been trying to get pregnant for 7 years. A previous physical exam and lab work were all within normal limits. An ovulation kit confirms that she is ovulating. She has never been pregnant before and her fiancé has fathered 2 children and recently had a semen analysis that indicated normal functioning sperm. Which of the following is the most appropriate test of choice? A) CT scan of the pelvis B) Dilatation and curettage C) Hysterosalpingogram D) Pelvic ultrasound

A) Immediately Breast cancer is recognized as both an increasingly common disorder and a potentially hereditary disorder. Furthermore, early detection will provide a woman with her best chance at a cure of breast cancer. Given the patient's genetic burden of having both her mother and her grandmother die of metastatic breast cancer at the relatively young age of 32 years, it is reasonable to provide her with immediate and periodic mammography combined with instruction in breast self-examination. Women at high risk require a more aggressive schedule, frequent examinations, and other procedures such as ultrasound and MRI. American Cancer Society Guidelines - Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. - Women age 45 to 54 should get mammograms every year - Women 55 and older should switch to mammograms every 2 years or can continue yearly screening. - Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age ACOG continues to recommend adherence to its current guidelines, which include the following: - Screening mammography every 1-2 years for women aged 40-49 years - Screening mammography every year for women aged 50 years or older

A 29-year-old woman inquires when she should have her first mammogram. Her family history is significant for the death of her mother and grandmother due to breast cancer at the age of 32 years. Presently, the woman is asymptomatic. What is the recommendation for mammography for this patient? If you have a strong family history, the National Comprehensive Cancer Network recommends, starting at age 30, you get a: - Clinical breast exam every 6-12 months - Mammogram every year - Breast MRI every year A) Immediately B) When she is 30 years old C) When she is 32 years old D) When she is 34 years old E) When she is 36 years old

Endometriosis "3 Ds," dysmenorrhea, dyspareunia, and dyschezia, as well as abnormal uterine bleeding are among the well-recognized manifestations. With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or "chocolate cyst." Imaging is of limited value and is only useful in the presence of pelvic or adnexal mass. Ultimately, a definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery. Functional ovarian cysts (B) occur from ovulation and form as a normal part of the menstrual cycle. They are usually not symptomatic. It is important to consider ovarian cancer in a patient with a pelvic mass however, ovarian cancer (C) usually occurs in older women over age 55 and patients are often asymptomatic until the disease is more advanced. With Pelvic inflammatory disease (PID) (D) the patient will have abdominal tenderness, adnexal tenderness, cervical motion tenderness and an elevated temperature.

A 29-year-old woman presents with cyclic pelvic pain that has been increasing over the last 7 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis? Endometriosis Functional ovarian cyst Ovarian cancer Pelvic inflammatory disease

C) Magnesium sulfate A pregnant or recently postpartum patient with new-onset seizure should be considered to have eclampsia. Most cases of eclampsia occur in the 3rd trimester, with approximately 80% occurring during delivery or within the first 48 hours after delivery, though seizures may occur as late as several weeks postpartum. Seizures are most commonly tonic-clonic and last 60 to 90 seconds. Magnesium sulfate is the drug of choice for eclamptic seizures. A loading dose of 4-6 g of magnesium sulfate should be administered over 15-20 minutes followed by a maintenance infusion of 1-2 g per hour. Most eclamptic seizures terminate with magnesium. Labetalol (A) may be used to control severe hypertension in a patient with preeclampsia or eclampsia, but does not treat seizures. Lorazepam (B) and phenobarbital (D) are second- and third-line choices, respectively, if eclamptic seizures are refractory to magnesium.

A 29-year-old woman who is two weeks postpartum following an uncomplicated pregnancy and delivery of a full-term infant is brought in by emergency medical services with an ongoing generalized tonic-clonic seizure. Which of the following medications should be administered first? A) Labetalol B) Lorazepam C) Magnesium sulfate D) Phenobarbital

E) Fasting prolactin, TSH, FSH, LH, hysterosalpingogram Fasting prolactin, TSH, FSH, and LH should all be obtained in the female patient as her irregular menses more or less indicate a high probability of oligomenorrhea. It is also important to evaluate by hysterosalpingogram to look for evidence of uterine and/or tubal defects. It is also important to evaluate the male patient's semen to investigate male infertility related to oligospermia or hypomotility

A 29-year-old woman, G0P0, and her husband present to your office after 1 year of infertility. Their histories elicit irregular menses in the woman and that the man is an avid cyclist. Apart from semen analysis in the man, what laboratory and/or diagnostic studies should be pursued in the woman to further evaluate this couple's infertility? A) Fasting prolactin, TSH B) TSH, LH, T3, T4 C) Fasting prolactin, FSH D) FSH, T3, T4 E) Fasting prolactin, TSH, FSH, LH, hysterosalpingogram

D) Ventricular septal defect Ventricular septal defects (VSD) present with a holosystolic murmur best heard at the left lower sternal border and is frequently accompanied by a thrill or displaced point of maximal impulse. A defect in the membranous (superior) portion of the ventricular septum is more common than in the muscular (inferior) portion. Auscultation is often sufficient to make the diagnosis of a VSD but confirmation can be obtained with echocardiography. If uncorrected, over time the left-to-right shunt can reverse to a right-to-left shunt (Eisenmeger phenomenon) and result in cyanosis. Smaller VSDs are associated with louder murmurs but larger defects may lead to tachypnea and sweating with feeds and failure to thrive. Most small VSDs close on their own while larger VSDs may require surgical intervention if there is associated aortic regurgitation, pulmonary hypertension, pulmonic stenosis or congestive cardiac failure resistant to medications.

A 3-day-old baby girl has a holosystolic murmur along the left lower sternal border. What is the most likely diagnosis? A) Aortic stenosis B) Atrial septal defect C) Patent ductus arteriosus D) Ventricular septal defect

D) Ehlers-Danlos syndrome There are several different types of Ehlers-Danlos syndrome (EDS). The clinical vignette above describes the classical, type I variant. The velvety, distensible skin, hyperextensibility of many joints, mitral valve prolapse, and hernia are all associated with the type I variant. Although the exact nature of the biochemical defect is just now being sorted out, all types of EDS are due to mutations in collagen genes. In recent experimental studies, a mutation in the gene encoding the α1(V)-chain of type-V collagen, was identified. Type- V collagen is associated with type-I collagen and is probably involved in assembly of type-I collagen fibers. Type-I collagen is abundant in ligaments of joints and in the dermis, thus the characteristic and unusual symptoms in the skin and joints

A 3-year-old boy has velvety lax skin, hyperextensible joints, and mitral valve prolapse. What is the most likely diagnosis? A) Marfan syndrome B) achondroplasia C) epidermolysis bullosa D) Ehlers-Danlos syndrome E) osteogenesis imperfecta

She may have a vaginal foreign body; consider a nasal speculum to attempt visualization and removal Children often fear parental disapproval of a vaginal foreign body placement. This often leads to a delay in diagnosis until secondary signs (such as vaginal bleeding, foul smelling discharge, or purulent drainage) are noted by parents. The physical exam is often quite difficult owing to patient anxiety, small anatomic size, and parental concerns about sexual or physical abuse. However, a thorough vaginal exam is indicated in patients with vaginal bleeding or discharge. Use of a nasal speculum, procedural sedation, or trained assistant (such as a child life specialist) may facilitate this exam.

A 3-year-old girl presents to the ED with her mom and grandmother for evaluation of vaginal spotting. The child has no other complaints and specifically denies sexual abuse or trauma when questioned alone. After watching a news special on sexual abuse, mom is concerned that her daughter may have been sexually assaulted, despite no specific concern. The child is acting appropriately and there are no external lesions or signs of trauma. Internal pelvic exam is difficult due to the patient's age. Which of the following statements is true? Obtain a pelvic x-ray prior to attempting a physical exam She is the victim of abuse; do no further evaluation without a trained nurse present and contacting authorities She may have a vaginal foreign body; consider a nasal speculum to attempt visualization and removal Vaginitis is an unusual diagnosis in this age group

E) Admit patient, start humidified oxygen and intermittent racemic epinephrine This is respiratory distress secondary to croup cuased by parainfluenza virus. This child is in acute respiratory distress as depicted by her stridor at rest, nasal flaring, and state of distress. The situation warrants admission, treatment, and careful observation. Corticosteroids via nebulizer may also be effective. Specific antiviral treatments and parainfluenza vaccines are not currently available. Parainfluenza virus will not respond to antibiotic treatment. Although home care with a vaporizer can be effective for patients with milder cases of croup, this child is severely ill.

A 3-year-old girl presents with a 2-day history of sore throat and fever. This morning, she was hoarse and seemed to be having more difficulty breathing. On exam, she appears to be in distress and has an oral temperature of 100.0 F. Tympanic membranes are pink but not bulging. Nares are patent without rhinorrhea. She has a barking cough, stridor at rest, and nasal flaring. What treatment is most appropriate in the care of this child? A) Start specific antiviral therapy B) Start broad spectrum antibiotic C) Administer parainfluenza vaccine D) Discharge home to use cool mist vaporizer E) Admit patient, start humidified oxygen and intermittent racemic epinephrine

D) Glucose testing ssevery 1-3 years is recommended Those with normal glucose should be reassessed every 3 years; those with prediabetes should be assessed annually Hint: Lifestyle modification may delay or prevent developing diabetes Hint: She has a 50-60% risk of developing diabetes within 10-15 years

A 30 year-old female presents to the clinic for her 6 week post partum examination. She was diagnosed with gestational diabetes mellitus during her pregnancy and was successfully treated with diet alone. Which of the following patient education statements is most appropriate for this patient? A The risk of gestational diabetes occurring in future pregnancies is very low. B The risk of developing diabetes in 10-15 years is relatively low. C Lifestyle modification, diet & exercise will not prevent her from developing diabetes D Glucose testing ssevery 1-3 years is recommended

B) ectopic pregnancy. Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis. Hint: Acute pelvic pain may occur secondary to bleeding from the rupture of a hemorrhagic *ovarian cyst*, *but no adnexal mass would be palpable on pelvic examination*.

A 30 year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The most likely diagnosis is A) placenta abruptio. B) ectopic pregnancy. C) pelvic inflammatory disease. D) ruptured ovarian cyst.

C) Laparotomy Laparotomy is indicated with presumptive diagnosis of ectopic pregnancy in an unstable patient. Hint: Culdocentesis has been replaced by transvaginal ultrasound as diagnostic procedure for suspected ectopic pregnancy.

A 30 year-old female presents to the emergency room having passed out at home 30 minutes prior to arrival. Her last menstrual period was 6 weeks ago and pregnancy test was reported positive 5 days ago. She started having vaginal bleeding last night. Vital signs are BP 70/40 mmHg, P 140 bpm, R 22. She is pale and diaphoretic. The next step in the evaluation of this patient's condition should be which of the following? A Abdominal ultrasound B Culdocentesis C Laparotomy D Magnetic resonance imaging

C) Trichomoniasis Trichomoniasis presents with vulvar pruritus and a profuse, frothy, greenish, foul-smelling vaginal discharge with a pH usually exceeding 5.0. Hint: Bacterial vaginosis presents with malodorous, gray-white discharge. The pH is typically 5.0-5.5. Hint: Vulvovaginal candidiasis presents with a thick, curd-like discharge and vulvar pruritus. Hint: Atrophic vaginitis is usually without discharge, but presents with vaginal dryness.

A 30 year-old presents with persistent vaginal discharge and vulvar pruritus. The discharge is profuse, frothy, greenish, and foul smelling. pH of the vagina is 6.0. Which of the following is the most likely diagnosis? A) Vulvovaginal candidiasis B) Bacterial vaginosis C) Trichomoniasis D) Atrophic vaginitis

Fasting glucose less than 95 mg/dL Universal screening for gestational diabetes is recommended between 24-28 weeks of gestation. Screening is a two-step process that initially involves a 50-gram oral glucose load and measurement of plasma glucose one hour later. If the plasma glucose is > 130-140 mg/dL, the 100-gram three-hour glucose tolerance test is recommended. Medical nutrition therapy, exercise, and insulin are first-line treatment options for gestational diabetes. The American Diabetes Association and the American College of Obstetrics and Gynecology recommended the following glucose targets: fasting blood glucose < 95 mg/dL, one-hour postprandial blood glucose level < 140 mg/dL, and two-hour postprandial blood glucose level < 120 mg/dL.

A 30-year-old Gravida 2, Para 1 woman at 12 weeks of pregnancy presents for routine prenatal care. She has a history of gestational diabetes mellitus managed with diet alone during her previous pregnancy. She denies any episodes of hypoglycemia. Today, her fasting blood glucose is 145 mg/dL and her hemoglobin A1C is 7.5. Which of the following represents an ideal intrapartum glycemic target for this woman? Fasting glucose less than 110 mg/dL Fasting glucose less than 95 mg/dL One-hour postprandial glucose level less than 200 mg/dL Two-hour postprandial glucose level less than 200 mg/dL

C) 200 cells/mcL = TMP/SMX first; Dapsone, atovaquone, Pentamidine second Primary prophylaxis for pneumocystosis in a patient with HIV infection should be initiated when CD4 cells counts drop to 200 cells/mcL or less. When CD 4 levels drop to 50 cells/mcL, primary prophylaxis for mycobacterium avium complex should be initiated. The other cell counts listed are not levels at which primary prophylaxis should be initiated.

A 30-year-old HIV-positive man presents to your clinic for the first time with a history of pneumocystosis, and he is on trimethoprim/sulfamethoxazole for secondary prophylaxis. *Primary prophylaxis of Pneumocystis pneumonia is recommended for patients at what CD4 cell count?* A) 50 cells/mcL B) 100 cells/mcL C) 200 cells/mcL D) 350 cells/mcL E) 500 cells/mcL

E) Ethambutol his patient has all the complaints and symptoms of pulmonary tuberculosis (TB). Direct sputum examination by Ziehl-Nielsen stain also helps the diagnosis, but it is still not confirmatory. Sputum needs to be cultured to check what kind of mycobacterium is causing this disease. It is important to start the treatment as soon as the culture is sent. The standard treatment for adult respiratory/pulmonary TB includes a complete 6-month regimen comprising of 2 months initial phase with 4 drugs, which include rifampin, isoniazid, pyrazinamide, and ethambutol. This is followed by a 4-month continuation phase consisting of 2 drugs: rifampin and isoniazid. Irrespective of the bacteriological status of the sputum, this is the recommended standard treatment for respiratory tuberculosis (including isolated pleural effusion or mediastinal lymphadenopathy). The 4th drug, ethambutol, may be omitted in patients with a low risk of resistance to isoniazid. Ethambutol should be started in individuals who are known or suspected to be HIV positive, in those who have had previous treatment, and in immigrants and refugees of any ethnic group who are considered to have a significantly higher risk of resistance to isoniazid and other drugs. Like most medications, antituberculosis drugs also have some side effects. Since treatment is long-term, it is essential that patients are warned about and checked for side effects. If side effects are not explained well to the patient, it will decrease the compliance. The adverse effect of ethambutol is retrobulbar neuritis. The important side effects of anti-tubercular drugs are: INH: Hepatotoxicity, peripheral neuritis, cutaneous hypersensitivity, rarely can cause optic neuritis RMP: Hepatotoxicity, nephrotoxicity, red discoloration of the body fluids, 'Flu-syndrome,' and thrombocytopenic purpura PZA: Hepatotoxicity, hyperuricemia ETH: Retrobulbar neuritis STM: Nephrotoxicity, ototoxicity

A 30-year-old man presents with a 2-month history of coughing and a 2-day history of coughing blood. He has been losing weight and sweating at night. On physical examination, the patient appears wasted, tachypneic, has bronchial breath sounds on the right upper lobe, and crepitations on the left upper lobe and right mid zone. His direct sputum result comes back positive for acid-fast bacilli with Ziehl-Neelsen stain. His sputum is sent for culture, and treatment is started. Refer to the image. *Retrobulbar neuritis is the predominant adverse effect of what drug?* A) Isoniazid B) Rifampin C) Pyrazinamide D) Streptomycin E) Ethambutol

A) Polyarteritis nodosa Polyarteritis nodosa is a systemic vasculitis of small to medium vessels. It represents an autoimmune inflammatory disorder of unknown origin. It results in transmural fibrinoid necrosis. It typically affects younger males. Symptoms include proximal myalgia and weakness (similar to polymyalgia rheumatica, and commonly expressed as difficulty climbing stairs), arthralgias, tender subcutaneous palpable nodules, abdominal pain with diarrhea or GI bleeding and glomerular ischemia with hypertension, renal failure, and hematuria. Compared to other vasculitides, polyarteritis nodosa does not affect the pulmonary vasculature, however it is accompanied by systemic inflammatory signs such as low grade fever, malaise, unintentional weight loss, and night sweats. Treatment includes prednisone and cyclophosphamide

A 30-year-old man presents with asymmetric myalgias and arthralgias. He also complains of difficulty climbing stairs. You note fever, hip, and shoulder muscle weakness but no atrophy, scattered extremity numbness, and tender palpable purpura. However, there is no facial or truncal rash. Laboratory testing reveals a low hematocrit, a high creatinine kinase, a negative antinuclear antibody titer, and an elevated erythrocyte sedimentation rate. Which of the following is the most likely diagnosis? A) Polyarteritis nodosa B) Polymyalgia rheumatica C) Polymyositis D) Pseudogout

*growth hormone deficiency.* Causes are congenital, acquired (head trauma or radiation) and idiopathic, with the most common cause being a pituitary tumor. It is diagnosed by a *low level of serum insulin-like growth factor-1*, an insulin tolerance test or a GHRH-arginine test. Random serum GH (C) levels are useless in the work-up due to its pulsatile release.

A 30-year-old man presents with progressive memory impairment and mental fatigue after sustaining head trauma during a motorcycle accident. He also reports significant weight gain even though his diet is unchanged. Physical exam reveals generalized muscle weakness and a loss of muscle bulk but no dry mucous membranes or peripheral edema. A basic metabolic panel is normal. Electrodiagnostic testing shows no evidence of myopathy or neuropathy. A DEXA scan uncovers the presence of low bone mineral density. Which of the following serum laboratory tests would help you in securing a diagnosis?

D) Topical 4% cocaine solution Balloon devices (A) are usually reserved for posterior epistaxis. These patients require ICU monitoring. Larger or multiple bleeding sites may require electrocautery (B), however, this practice is rarely recommended due to the risk of destroying normal tissue and septal perforation. If the above local treatments fail, then posterior-to-anterior packing with ribbon gauze (C) impregnated with petroleum jelly, bacitracin, neomycin, and polymyxin B or 3% bismuth tribromophenate, or the use of a nasal tampon, is recommended. Packing involves the use of a nasal speculum and Bayonet forceps to secure the gauze in a tightly packed, accordion-like arrangement.

A 30-year-old man with chronic rhinitis presents with 3 hours of epistaxis. He denies hemoptysis or a history of coagulopathy. Inspection reveals an anterior single vessel bleed. You place gauze in the affected nostril and hold compression for 10 minutes. You remove the gauze and he begins to bleed again. Use of which of the following is the most appropriate next step in managing this patient? A) Double-balloon device B) Electrocautery C) Ribbon gauze packing D) Topical 4% cocaine solution

C) Oral ibuprofen This patient's working diagnosis is most concordant with primary dysmenorrhea, in which there is significant pain associated with the first few days of menses which alters normal activity or requires pain medication to control. Although secondary causes such as endometriosis and pelvic inflammatory disease are the most common misdiagnosis of primary dysmenorrhea, her stable presentation in this specialized setting, in conjunction with a normal initial diagnostic test, favors symptomatic control and follow-up evaluation. To treat dysmenorrhea, non-steroidal antiinflammatory medications (NSAIDs) and acetaminophen are helpful. Opioid analgesics (A) are considered second line if NSAIDs and acetaminophen fail to relieve the pain. Consider parenteral pain control if oral medications fail. Abdominopelvic heat is also beneficial.

A 30-year-old woman misses work and presents to the Emergency Department with severe pelvic pain rated at 6/10. She states it began yesterday with the onset of menstruation. She has regular cycles with normal blood flow amount, but has not had this pain before. She denies spine, urologic and rectal symptoms. Vital signs are normal, and physical examination as well as pelvic ultrasound is unremarkable. Serum beta-hCG is negative. Other than referral to a gynecologist for further evaluation, which of the following is the most appropriate initial treatment? A) Intravenous morphine B) Oral contraceptive pills C) Oral ibuprofen D) Oral pregabalin

Surgical visualization Definitive diagnosis is surgical. Doppler ultrasound showing absence of flow within the ovary is highly specific, however, the presence of blood flow does not rule out ovarian torsion, as the ovary has a dual blood supply and may maintain blood flow even in the presence of torsion. The most common finding in ovarian torsion is an enlarged, edematous ovary. Treatment is immediate and emergent surgical intervention in order to salvage the ovary and prevent secondary adverse events such as hemorrhage, peritonitis, and adhesions. Due to its enlarged tubo-ovarian ligament length, the right ovary is the most common side of torsion. Presenting history will include sudden onset and severe, unilateral pelvic pain, commonly during strenuous activity, as well as nausea and vomiting

A 30-year-old woman presents to the Emergency Department with left lower quadrant pain. The pain started suddenly while she was sleeping and is rated a 10/10 in severity. Which of the following tests will yield a definitive diagnosis of an ovarian torsion? Computed tomography Magnetic resonance imaging Surgical visualization Ultrasound

D) Pelvic ultrasonography Determining the source of abnormal uterine bleeding is a difficult task when caring for gynecologic patients. This evaluation begins with a detailed history and physical followed by laboratory tests and pelvic ultrasound. Common initial laboratory tests include a complete blood count, serum prolactin level, serum ß-hCG and serum thyroid stimulating hormone level. Pelvic ultrasonography may reveal uterine lining abnormalities, including irregularities, polyps, fibroids and masses. The results of the above will guide the clinician down a non-gynecologic versus gynecologic pathway.

A 30-year-old woman presents with abnormal menstrual bleeding. Her history and physical are unrevealing. Other than laboratory testing, which of the following is the next best step in evaluating this patient? A) Dilatation and curettage B) Endometrial biopsy C) Hysteroscopy D) Pelvic ultrasonography

D) Pelvic ultrasonography Determining the source of abnormal uterine bleeding is a difficult task when caring for gynecologic patients. This evaluation begins with a detailed history and physical followed by laboratory tests and pelvic ultrasound If a gynecologic source is suggested, endometrial biopsy (B), which can be accomplished via many different curette procedures, is then recommended. If the source of bleeding is still not found, hysteroscopy (C), which allows direct visualization of the uterine cavity, is then recommended. If the diagnosis is still unclear, the patient may be sent for dilatation and curettage (A). This procedure's sedation allows for muscular relaxation which may increase diagnostic yield.

A 30-year-old woman presents with abnormal menstrual bleeding. Her history and physical are unrevealing. Other than laboratory testing, which of the following is the next best step in evaluating this patient? A) Dilatation and curettage B) Endometrial biopsy C) Hysteroscopy D) Pelvic ultrasonography

This patient presents with endometritis and should be treated with broad-spectrum antibiotics and admitted to the hospital. Clindamycin IV and gentamicin IV are typically recommended.

A 30-year-old woman presents with fever and abdominal pain. She is 3 days postpartum after cesarean section. Physical examination reveals lower abdominal tenderness to palpation and foul smelling vaginal discharge. What management is indicated?

B) Clindamycin IV + gentamicin IV This patient presents with endometritis and should be treated with broad-spectrum antibiotics and admitted to the hospital. Endometritis affects 1 in 20 vaginal deliveries and 1 in 10 cesarean sections. There are a number of associated risk factors including operative delivery, prolonged rupture of membranes, lack of prenatal care and frequent vaginal examinations. Endometritis is a polymicrobial infection with gram-positive cocci and gram-negative coliforms involved. Patients typically present with abdominal pain, fever and foul-smelling lochia or discharge. It commonly develops the second or third day post partum. Clindamycin IV and gentamicin IV are typically recommended.

A 30-year-old woman presents with fever and abdominal pain. She is 3 days postpartum after cesarean section. Physical examination reveals lower abdominal tenderness to palpation and foul smelling vaginal discharge. What management is indicated? A) Ceftriaxone IM and Azithromycin PO B) Clindamycin IV + gentamicin IV C) Fluconazole D) Metronidazole

B) Suction curettage Adjuvant interventions include establishing large-bore intravenous access, uterine massage, oxytocin, methylergonovine maleate and alerting the operating room. If curettage fails, then one should consider a more advanced hemostatic treatment like uterine artery or hypogastric artery ligation (C) or arterial embolization. Obtaining a blood type (A) and alerting the blood bank is wise in managing any patient with hemorrhage. However, in this case, it should not supersede a definitive treatment like curettage. Packing the uterine cavity with gauze (D), once commonplace, is seldom used today as it is only a temporizing maneuver.

A 30-year-old woman, who had an uncomplicated pregnancy, delivered a healthy newborn a few minutes ago. She just now delivered a placenta with absent cotyledons. Copious amounts of blood begin to flow from the vaginal orifice. Within minutes, the patient becomes lightheaded but maintains consciousness. You attempt manual extraction but the bleeding continues and the blood pressure decreases to 98/68 mmHg. Which of the following is the next best step in management of postpartum hemorrhage? A) Blood type and cross-match B) Suction curettage C) Uterine artery ligation D) Uterine packing with gauze

Transvaginal ultrasound (TVUS) Administration of betamethasone to hasten fetal lung maturity (A) is indicated for women with preterm labor (contractions resulting in cervical dilatation) prior to 37 weeks gestation. Sterile speculum examination (C) and sterile digital cervical exam (B) are contraindicated until placenta previa is ruled out as this can lead to significant hemorrhage.

A 31-year-old woman at 35-weeks gestation presents with brief painless, bright red vaginal bleeding. In addition to fetal monitoring, which of the following is the most important initial management? Administration of betamethasone to hasten fetal lung maturity Sterile digital cervical exam Sterile speculum examination Transvaginal ultrasound

Visual evoked potential testing - may detect abnormalities even when an MRI is normal.

A 31-year-old woman presents with acute onset eye pain, followed by unilateral blurred vision. Which of the following tests may confirm a diagnosis of optic neuritis?

D) colposcopy with endocervical curettage Colposcopy with endocervical curettage and directed biopsy of suspicious lesions is the appropriate evaluation of a high grade squamous intraepithelial lesions (HSIL) Pap smear result. Hint: HPV DNA testing is recommended for initial evaluation of an ASC-US result on a Pap smear. If HPV testing is positive, colposcopy is then indicated. If negative, the Pap smear is repeated in 12 months. Hint: A pelvic ultrasound or abdominopelvic CT scan is indicated when repeat abnormalities are seen on a Pap smear, however all diagnostic studies have failed to reveal the source of cellular abnormality. Hint: Repeat Pap smears in 4-6 months may be done in evaluation of ASC-US Pap smear results after treatment with either appropriate therapy for vaginal infection or intravaginal estrogen therapy for menopausal patients with atrophic changes.

A 32 year-old female G4P4 with a history of multiple sexual partners is seen in follow-up for recent findings of high grade squamous intraepithelial lesions (HSIL) on a Pap smear. Which of the following is the most appropriate next step? A HPV DNA testing B pelvic ultrasound C repeat Pap smear in 4-6 months D colposcopy with endocervical curettage

Placental abruption Uterine rupture is a catastrophic tearing open of the uterus into the abdominal cavity. Classic signs for uterine rupture (C) include sudden tearing uterine pain with contractions with resolution of pain between contractions, vaginal hemorrhage and regression of the fetal parts. It is much less common than placental abruption in patients with no acute trauma or prior uterine scarring. Fetal distress has been found to be the most reliable presenting clinical symptom in uterine rupture. Placenta previa is diagnosed by ultrasound and occurs when the placenta tissue completely or partially covers the internal cervical os. Symptomatic placenta previa (A) usually manifests as painless vaginal bleeding in the late second or third trimester, often after sexual intercourse. This initial sentinel bleed usually is not sufficient to produce hemodynamic instability or to threaten the fetus in the absence of cervical instrumentation or cervical digital examination. Vasa previa (D) is the velamentous insertion of the umbilical cord into the membranes in the lower uterine segment resulting in amniotic blood vessels presenting in front of the fetal head. Vasa previa typically manifests as onset of hemorrhage at the time of amniotomy or spontaneous rupture of membranes. The hemorrhage is fetal blood, and exsanguination can occur rapidly resulting in immediate fetal distress.

A 32-year-old gravida 2 para 1 at 33 weeks gestation presents to the emergency room for sharp abdominal pain. She has not had any prenatal care during this pregnancy. Her symptoms include vaginal bleeding, uterine pain between contractions, and fetal distress. Her first pregnancy was uncomplicated, with a vaginal delivery at term. Which one of the following is the most likely diagnosis? Placenta previa Placental abruption Uterine rupture Vasa previa

A) Nontender and firm Testicular cancer can occur at any age, but most commonly is seen at ages 20-35 years. Risk factors include cryptorchidism, family history, infertility, tobacco use, and exposure to DES in utero. The clinical presentation may be asymptomatic or present with a painless mass in the scrotum. Patients may complain of a dull ache or pain, swelling, or hardness in the lower abdomen or scrotum. Exam reveals a firm, hard, or fixed nodular mass on the testis that does not transilluminate. All patients with a testicular mass need to be evaluated for testicular cancer. Workup should include testicular ultrasound and serum tumor markers: beta-hCG, LDH, and alpha-fetoprotein.

A 32-year-old man presents with a left testicular mass. Which of the following examination characteristics is most suggest a primary testicular cancer? A) Nontender and firm B) Nontender and fluctuant C) Tender and soft D) Tender and transilluminates

Treat her laceration as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound In addition to caring for her laceration, the patient requires further workup of her pregnancy. A beta-hCG level should be obtained to correlate with her stated dates and to help identify an intrauterine pregnancy, miscarriage, ectopic pregnancy, or molar pregnancy. A pelvic ultrasound should also be performed to evaluate for ectopic pregnancy, given the severity, prevalence, and difficulty of diagnosis without the ultrasound. A type and screen should also be obtained to determine her Rh status and the potential need for RhoGam administration. Delay of treatment is not necessary (A) in this patient. If her vital signs were unstable, then priority would be given to treating a life-threatening condition. The patient should not be discharged (D) without further investigation into her pregnancy-related complaints. Determining the beta-hCG level (B) alone is insufficient to investigate the state of her pregnancy and the cause of her vaginal bleeding.

A 32-year-old woman 8 weeks pregnant by dates presents to the ED with a 2-cm laceration to her index finger sustained while she was cutting a tomato. On review of systems, she also notes 2 days of vaginal spotting and lower abdominal cramping. Vital signs are within normal limits. Physical exam is consistent with a simple 2-cm laceration. The pelvic exam reveals a closed os and no adnexal tenderness or masses. Which of the following statements best describes the next step in management? Delay treating her laceration until her pregnancy status is further clarified Treat her laceration as indicated, and perform a beta-hCG quantitative level Treat her laceration as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound Treat her laceration as indicated, then discharge with outpatient obstetrical follow-up

C) *Ibuprofen* *Tension-type headaches* cause pain that is mild or moderately intense and is described as tightness, pressure, or a dull ache. The pain is usually experienced as a band extending bilaterally back from the forehead across the sides of the head to the occiput. Patients often report that this tension radiates from the occiput to the posterior neck muscles. In its most extensive form, the pain distribution is "cape like," radiating along the medial and lateral trapezius muscles covering the shoulders. Tension-type headaches can last from 30 minutes to several days and can be continuous in severe cases. In addition to its characteristic distribution and intermittent nature, the history obtained from patients with tension-type headache discloses an absence of signs of any serious underlying condition. Patients with tension-type headache do not typically report any visual disturbance, fever, stiff neck or recent trauma. Treatment goals for patients with tension-type headache should include recommending effective over the counter analgesic agents and discovering and ameliorating any circumstances that may be triggering the headaches. Research confirms that NSAIDs, such as Ibuprofen, and acetaminophen are effective in reducing headache symptoms. Patients with chronic tension-type headache should limit their use of analgesics to two times weekly to prevent the development of chronic daily headache. Repeated use of analgesics, especially ones containing caffeine or butalbital, can lead to "rebound" headaches as each dose wears off and patients then take another round of medication. Common features of chronic daily headache associated with frequent analgesic use are early morning awakening with headache, poor appetite, nausea, restlessness, irritability, memory or concentration problems, and depression. If the patient requires analgesic medication more frequently, adjunctive headache medications can be initiated. Smoking cessation is an important issue to address in patients with chronic tension-type headache. The number of cigarettes smoked has been "significantly related" to the headache index score and to the number of days with headache each week.

A 32-year-old woman complains of a band-like pressure around her forehead that radiates down to the back of her neck. These headaches occur twice a week on average and last for approximately 1 hour in duration. Her neurological exam is within normal limits and she has no other associated symptoms. What is the best initial abortive treatment? A) Amitriptyline B) Caffeine C) Ibuprofen D) Promethazine

D) Repeat Pap smear and human papillomavirus testing in one year All patients should be counseled on safe sex practices (A) regardless of lab results. Patients with significantly abnormal cytology require further evaluation with repeat cytology and HPV testing or colposcopy (B). Negative cytology would not require immediate referral for colposcopy. For women aged 30 years and older, the recommendation for a Pap smear with negative cytology and negative HPV is repeat co-testing in five years (C).

A 32-year-old woman presents to your office for a physical exam including a Papanicolaou test (Pap smear). Lab results reveal negative cytology and positive human papillomavirus (HPV). Which of the following is the most appropriate next step in management? A) Counsel patient on safe sex practices B) Order colposcopy C) Repeat Pap smear and human papillomavirus testing in five years D) Repeat Pap smear and human papillomavirus testing in one year

D) Repeat Pap smear and human papillomavirus testing in one year

A 32-year-old woman presents to your office for a physical exam including a Papanicolaou test (Pap smear). Lab results reveal negative cytology and positive human papillomavirus (HPV). Which of the following is the most appropriate next step in management? A) Counsel patient on safe sex practices B) Order colposcopy C) Repeat Pap smear and human papillomavirus testing in five years D) Repeat Pap smear and human papillomavirus testing in one year

B) Odor A common office test is the KOH "whiff" wet preparation test, in which a secretion sample is mixed with saline and 10-20% potassium hydroxide. The presence of a "fishy" amine odor represents a positive test, while the absence of this abnormal amine-like odor represents a negative result. Color (A) is visually inspected, pH (C) is tested via an indicator strip and viscosity (D) is evaluated by rubbing the secretion between the fingers.

A 32-year-old woman presents with an increase in vaginal secretions. You decide to perform a potassium hydroxide wet preparation of a sample. This test evaluates which of the following secretion qualities? A) Color B) Odor C) pH D) Viscosity

B) Begin intravenous antibiotics and admit for possible drainage A tubo-ovarian abscess (TOA) typically results as a complication of pelvic inflammatory disease (PID) and is most commonly seen in sexually active women. Since it is a complication of PID, patients typically present with lower abdominal and pelvic pain, fever, vaginal discharge, and cervical motion or adnexal tenderness. Pelvic exam may reveal a palpable mass in the adnexa. Ultrasound is the test of choice for suspected TOA, and transvaginal is best for visualizing the adnexa. Ultrasound findings typically include identification of a complex cystic, thick-walled, well-defined mass in the adnexa or retrouterine area. The mass is usually multiloculated with air-fluid levels. If ultrasound is equivocal, a CT scan can aid in the diagnosis. Treatment involves administration of intravenous antibiotics. Some abscesses require surgical drainage. Tubo-ovarian abscesses can result in irreversible tubal and ovarian damage and pose a serious threat to fertility. Although ceftriaxone and doxycycline (A) is the treatment for PID, patients with a TOA require a prolonged course of intravenous antibiotics and possible surgical drainage. This requires inpatient management.

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

C) Propranolol, propylthiouracil, iodide, hydrocortisone This patient is presenting with symptoms consistent with thyroid storm, a life-threatening form of hyperthyroidism. Although it may be a patient's initial presentation, it more often is precipitated by an acute stressor such as infection, myocardial infarction, surgery, or trauma in a patient with known hyperthyroidism. The goal of management of thyroid storm is fourfold - decrease sympathetic hyperactivity, block synthesis of thyroid hormone, block release of thyroid hormone and block the conversion of T4 to T3. The first medication given should be a beta-blocker, preferably propranolol. Propranolol decreases the sympathetic hyperactivity resulting in improvement of tachycardia, hypertension, hyperpyrexia and tremor. This should be followed by medications which decreased thyroid hormone synthesis, such as propylthiouracil (PTU) and methimazole. PTU has the added benefit of also decreasing conversion of T4 to T3 and is preferred in pregnancy. Iodide, which blocks the release of stored thyroid hormone, should only be administered after giving either PTU or methimazole (approximately one hour later) as iodide can increase synthesis of thyroid hormone. Lastly, corticosteroids can be given which also help block the conversion of T4 to T3. Patients should also receive supportive care such as cooling measures and acetaminophen to control hyperpyrexia, benzodiazepines as needed to control agitation, respiratory management and fluid resuscitation.

A 32-year-old woman presents with tachycardia, palpitations, nausea, vomiting, and fever. She was recently diagnosed with Grave's disease. On examination, she is diaphoretic and mildly agitated with heart rate 132 beats per minute, blood pressure 189/91 mm Hg, and temperature 39.4ºC. What is the correct order of treatment for this patient? A) Hydrocortisone, iodide, propylthiouracil, propranolol B) Iodide, propranolol, propylthiouracil, hydrocortisone C) Propranolol, propylthiouracil, iodide, hydrocortisone D) Propylthiouracil, hydrocortisone, propranolol, iodide

B) *Combination oral contraceptives* This patient presents with *non-life threatening abnormal vaginal bleeding (previously called dysfunctional uterine bleeding)*, which can initially be managed with combination oral contraceptives. DUB is typically split into anovulatory (90%) and ovulatory (10%). In patients with vaginal bleeding of childbearing age, the most important first step in diagnosis is to rule out pregnancy. After this, it is important to explore other causes including medications, genital tract pathology and systemic disease. Once these are excluded, a diagnosis of DUB can be reached. Dilation and curettage (A) is typically offered to patients with heavy vaginal bleeding evidenced by hemodynamic instability. A hysterectomy (C) is rarely needed in the treatment of DUB but is indicated for patients with heavy bleeding and hemodynamic instability in which conservative management fails. Intravenous estrogen therapy (D) is effective in stopping heavy bleeding, but is not considered first line therapy.

A 32-year-old woman presents with vaginal bleeding for 2 weeks. She states she has about 1 pad of bleeding every 2-3 hours. Vital signs are stable and physical exam only reveals blood from the cervical os. The patient's hemoglobin is 12 g/dl and her pregnancy test is negative. What treatment is indicated for this patient? A) Admission for dilation and curettage B) Combination oral contraceptives C) Hysterectomy D) Intravenous estrogen therapy

B) Functional ovarian cyst most ovarian enlargements (75%) are caused by functional ovarian cysts, which actually are not a result of neoplasia but rather represent anatomical variations of normal ovarian function. These cysts are commonly asymptomatic, being only discovered during routine examination. The remaining 25% is represented by the ovarian neoplasms, categorized by the cell line of origin: epithelial (most common overall), germ cell (most common in the reproductive years, with the most common type being a benign cystic teratoma (A), which is also known as a dermoid cyst) or stromal cell (D). Overall, 90% of ovarian neoplasms in the reproductive years are benign (C), but decreases to 75% in the postmenopausal years (i.e., 25% of all ovarian tumors in postmenopausal women are malignant). This 15% increased incidence of ovarian malignancy denotes the importance of palpable ovarian enlargement in the postmenopausal population.

A 32-year-old woman with fluctuating menstrual intervals comes to your primary care clinic for a pelvic examination. She is not currently pregnant, but has had two normal pregnancies and healthy deliveries. During adnexal palpation, you notice that one ovary is appreciably larger than the other. In your discussion with the patient, you explain that this ovarian enlargement most likely represents which of the following conditions? A) Benign cystic teratoma B) Functional ovarian cyst C) Ovarian carcinoma D) Stromal cell ovarian neoplasm

D) Colposcopy-directed biopsy A colposcopy-directed biopsy *is the first diagnostic evaluation* indicated for cervical dysplasia Hint: A cervical cone biopsy may be indicated in further evaluation of this patient, but it is *dependent on the results of the colposcopy* Hint: An aspiration needle biopsy has no role in the evaluation of cervical dysplasia.

A 33 year-old female presents for follow-up of her Pap smear that showed cervical dysplasia. Which of the following is the most appropriate next diagnostic procedure? A) Cone biopsy B) Aspiration needle biopsy C) Dilation and curettage D) Colposcopy-directed biopsy

Complex regional pain syndrome = chronic pain in a body region, but it most commonly affects the extremities. It is characterized by pain, swelling, skin changes, vasomotor instability, limited range of motion, and patchy bone demineralization. It frequently occurs after a soft tissue injury, surgery, or vascular event such as a myocardial infarction or stroke.

A 33-year-old woman is being evaluated in clinic for pain in her left lower leg. She underwent an arthroscopic meniscus repair of the left knee three months ago. She denies any recent trauma. Patient reports sudden onset of pain and burning sensation in her leg. It does not worsen with physical activity or elevation. She denies fever or chills. On physical exam her left leg is extremely erythematous, warm, swollen and tender to the lightest touch. Lower extremity pulses are 2+ bilaterally. Initial lab work reveals a normal complete blood count, erythrocyte sedimentation rate, and C-reactive protein. What is the most likely diagnosis? A) Cellulitis B) Complex regional pain syndrome C) Erysipelas D) Peripheral vascular disease

D) Administer sodium bicarbonate The patient has taken amitriptyline, which is a tricarboxylic acid antidepressant (TCA); her set of symptoms are consistent with TCA toxicity. The mechanisms of action of TCA are via anticholinergic effects, norepinephrine reuptake blockade, a quinidine effect, a sodium channel blocker, and peripheral alpha blockade. TCA-cardiotoxicity may be demonstrated on an electrocardiogram via sinus tachycardia, QRS complex prolongation > 100 milliseconds, right bundle branch block, ventricular tachycardia, ventricular fibrillation, and QT prolongation. Sodium bicarbonate is the drug of choice for the treatment of ventricular dysrhythmias and/or hypotension, secondary to tricarboxylic acid antidepressant (TCA) poisoning.

A 33-year-old woman presents after being found unresponsive in the bedroom of her home. She has a past medical history of depression, and her mother found an *empty bottle of amitriptyline* by her bedside. Otherwise, she has no other medical or surgical history. The patient is a non-smoker and does not drink alcohol. On physical exam, her pulse is 138/minute, blood pressure is 80/60 mm Hg, temperature is 101.2°F (38.4°C), and respirations 6/minute. Her heart sounds are normal and she has thready pulses. Her breath sounds are normal, but with shallow effort. The abdomen is soft and nontender. Neurologically, she moves her limbs from painful stimuli. Her skin is flushed with no needle marks. Her chest X-ray is normal, and the electrocardiogram demonstrates a wide complex tachycardia without ectopy. The patient is intubated and hyperventilated. What is the *next* appropriate step of the patient's management? A) Administer intravenous lactated Ringer's solution B) Administer phenytoin C) Administer physostigmine D) Administer sodium bicarbonate E) Hemodialysis

C) Threatened abortion If bleeding occurs in the first 20 weeks of pregnancy and the cervix is closed, threatened abortion is the diagnosis. Hint: Inevitable abortion is when the patient presents during the first 20 weeks of pregnancy with bleeding and crampy abdominal pain, also associated with a dilated cervix or a gush of fluid without the passage of the products of conception.

A 35 year-old G2P1001 female presents to the office at 11 weeks gestation with vaginal bleeding, mid-lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, bright red blood is seen coming from the cervical os. The cervix is closed. The uterus is 9-11 weeks in size by palpation. Her blood pressure is 120/70 mmHg and her pulse rate is 96. What is the patient's most likely diagnosis? A Inevitable abortion B Incomplete abortion C Threatened abortion D Missed abortion

A) Herpes Simplex Virus (HSV) This patient has genital herpes. Most often HSV 2 but can be HSV 1 as well. PCR is the most sensitive and specific test for HSV. Multinucleated giant cells and intranuclear inclusion bodies seen on the Tzanck preparation is characteristic of HSV- however, this is no longer widely performed due to lower sensitivity than new testing methods

A 35 year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis? A) Herpes Simplex Virus (HSV) B) Molluscum Contagiosum Virus (MCV) C) Human Papilloma Virus (HPV) D) Syphilis

C) Cauda equina syndrome Cauda equina syndrome is a massive central disc protrusion that causes variable degrees of paralysis. Bowel and bladder function may be impaired with saddle anesthesia. This condition is a surgical emergency

A 35 year-old female who was a back seat passenger in a vehicle which was involved in a head-on collision is brought to the ED. She is able to tell you that she is having difficulty moving both of her legs and is experiencing bilateral leg pain as well. She is embarrassed because she has "wet myself." Physical examination reveals markedly diminished sensory and motor function of both legs and decreased rectal sphincter tone. Which of the following is the most likely diagnosis? A) Herniated disc at L5-S1 and L4-L5 B) An anterior cord lesion C) Cauda equina syndrome D) An L2 lesion

Loss of two-point discrimination (dorsal columns) can be the earliest sign of compartment syndrome

A 35 year-old male placed in a thumb spica cast for a scaphoid fracture presents complaining of forearm and hand pain that is not relieved with pain medication and elevation. Which of the following is the earliest physical exam sign for his current condition?

B) Loss of two-point discrimination Loss of two-point discrimination can be the earliest sign of compartment syndrome Hint: Peripheral pulses are poor indicators of compartment syndrome as they remain intact until late. Hint: Pain with passive stretch is a subjective finding early and must be differentiated from pain of the original injury. Although a reliable finding it may be difficult to reproduce in the cast.

A 35 year-old male placed in a thumb spica cast for a scaphoid fracture presents complaining of forearm and hand pain that is not relieved with pain medication and elevation. Which of the following is the earliest physical exam sign for his current condition? A Slow capillary refill B Loss of two-point discrimination C Absent peripheral pulses D Pain with passive stretch

A) Colonoscopy The best test to recommend is a colonoscopy since it detects both polyps and cancer. Colorectal cancer is the 4th most common form of cancer in the United States; it arises from adenomatous polyps in the colon. Familial adenomatous polyposis (FAP) has different inheritance patterns and different genetic causes. In this patient, the pattern is probably autosomal dominant which puts him at a risk of nearly 100% for developing colorectal cancer by the age of 40. That means that screening tests for colorectal cancer must be performed earlier than suggested for the rest of the population (i.e., before the age of 50). A fecal occult blood test, fecal immunochemical test, and stool DNA test (sDNA) find cancer, not polyps. The AFP (alpha-fetoprotein) tumor marker is a useful marker for hepatocellular carcinoma and germ cell tumors, but not for colorectal cancer.

A 35-year-old man has a routine physical examination with no abnormal findings. His family history, however, is positive for familial adenomatous polyposis. What screening test would be best for him to obtain? A) Colonoscopy B) No screening necessary before the age of 50 C) Fecal occult blood test D) Stool DNA test (sDNA) E) AFP tumor marker

C) Pneumocystis pneumonia Hint: TB not the answer because the sputum cytology was negative for acid-fast bacilli. Hint: *Secondary syphilis* would present as a *maculopapular rash involving the palms/soles*, *Condyloma lata* (wart-like, moist lesions involving mucous membranes and other moist areas, especially near the chancre site and systemic symptoms,fever, lymphadenopathy, arthritis, meningitis, headache, and/or hepatitis Hint: *Lung cancer* typically does not show diffuse bilateral interstitial infiltrates. It would typically manifest with cough, hemoptysis, dyspnea, anorexia and weight loss. Might see hypercalcemia (especially with SCC), may see SIADH, Cushing's (ectopic ACTH MC with small cell); Lambert-Eaton Syndrome (Small cell - weakness similar to myasthenia gravis but *IMPROVES* with continued use); or Pancoast Syndrome Hint: Legionella presents in immunocompromised, smokers, or chronic lung disease, scant sputum production, pleuritic chest pain, toxic appearnce, *focal patchy infiltrates*, with *polymorphonuclear leukocytes and no organisms* on gram stain of sputum.

A 35-year-old man is admitted to the hospital with progressive shortness of breath, fever, and worsening cough. The patient had been in good health until 2 months ago, when he began losing weight. This was associated with anorexia, intermittent diarrhea, night sweats, and then a nonproductive cough. He had lost more than 20 pounds by the time he was admitted to the hospital. His past medical history is unremarkable. He has been divorced for 5 years, and he has 1 child. He is employed as a medical equipment salesman, traveling extensively in the Midwest. He admits to drinking alcohol in large amounts on weekends, but he denies tobacco and intravenous drug use. He gives history of a previous homosexual encounter. Physical examination shows that the chest was normal to percussion and clear by auscultation, except for a few scattered ronchi. The heart is normal except for tachycardia. The abdomen is soft with normal bowel sounds. Genitalia are normal; however, there is a painful 2 cm ulceration at the anal verge. The neurologic exam is unremarkable. Chest radiological findings show *diffuse bilateral interstitial infiltrates*. Arterial blood gases on room air show pO2- 57mmHg, pCO2 31 mmHg, and pH 7.45. His alveolar-arterial O2 gradient is 55mmHg. *Bronchoalveolar lavage fluid with lung biopsy shows the presence of cysts*. Sputum cytology is *negative for acid-fast bacilli*. What is the most likely diagnosis? A) AIDS-related tuberculosis B) Secondary syphilis C) Pneumocystis pneumonia D) Lung cancer E) Legionella pneumonia

C) Pneumocystis pneumonia Whenever a young patient presents with fever, progressive exertional dyspnea, hypoxia, and loss of weight, the possibility of Pneumocystis jiroveci pneumonia complicating acquired immunodeficiency syndrome (AIDS) should be considered, especially when diffuse interstitial infiltration (or patchy shadows) are found on chest radiological study. The history of a homosexual encounter favors this diagnosis. This should be followed by tests to confirm HIV. The increased alveolar-arterial O2 gradient indicates severe respiratory dysfunction. Bronchoalveolar lavage with lung biopsy is an appropriate early step in his evaluation. Finding pneumocystic cysts in the alveolar lavage is a confirmatory diagnosis for Pneumocystis jiroveci pneumonia. Treatment is based on the alveolar-arterial O2 gradient, which is considered mild when the value is less than 35mmHg, moderate when it is 35-45mmHg, and severe disease when more than 45mmHg. The mainstay of treatment is given intravenously or orally. Combined therapy of trimethoprim-sulfamethoxazole and corticosteroids is necessary in the treatment of a severe case of pneumocystis in AIDS. Administration of corticosteroids helps to prevent respiratory failure and death in AIDS patients. When Pneumocystis jiroveci Pneumonia is found in the absence of underlying immunosuppression from malignancy or drug, the patient fulfills the definition of AIDS.

A 35-year-old man is admitted to the hospital with progressive shortness of breath, fever, and worsening cough. The patient had been in good health until 2 months ago, when he began losing weight. This was associated with anorexia, intermittent diarrhea, night sweats, and then a nonproductive cough. He had lost more than 20 pounds by the time he was admitted to the hospital. His past medical history is unremarkable. He has been divorced for 5 years, and he has 1 child. He is employed as a medical equipment salesman, traveling extensively in the Midwest. He admits to drinking alcohol in large amounts on weekends, but he denies tobacco and intravenous drug use. He gives history of a previous homosexual encounter. Physical examination shows that the chest was normal to percussion and clear by auscultation, except for a few scattered ronchi. The heart is normal except for tachycardia. The abdomen is soft with normal bowel sounds. Genitalia are normal; however, there is a painful 2 cm ulceration at the anal verge. The neurologic exam is unremarkable. Chest radiological findings show *diffuse bilateral interstitial infiltrates*. Arterial blood gases on room air show pO2- 57mmHg, pCO2 31 mmHg, and pH 7.45. His alveolar-arterial O2 gradient is 55mmHg. *Bronchoalveolar lavage fluid with lung biopsy shows the presence of cysts*. Sputum cytology is *negative for acid-fast bacilli*. What is the most likely diagnosis? A) AIDS-related tuberculosis B) Secondary syphilis C) Pneumocystis pneumonia D) Lung cancer E) Legionella pneumonia

B) Anemia of chronic disease This patient most likely has anemia of chronic disease secondary to his chronic kidney disease. Anemia of chronic disease is characterized by normochromic normocytic anemia, decreased reticulocytes, low iron levels, normal-to-increased ferritin levels, and low soluble transferrin receptor to log ferritin ratios (Weiss). It is the second most common cause of anemia after iron deficiency anemia (Weiss), and it may complicate a variety of diseases, including infections, cancers, autoimmune diseases, chronic kidney disease, and transplant rejection. In anemia of chronic disease, high cytokine production leads to decreased gastrointestinal iron absorption, decreased regulation of iron transporters, decreased erythropoietin production, and decreased proliferation and differentiation of erythroid precursor cells. The result is normochromic normocytic anemia. Patients may complain of fatigue and decreased quality of life. Treatments include erythropoietin and iron to support hemopoiesis. Treatments may correct anemia and improve symptoms, but they will unlikely correct chronic kidney disease.

A 35-year-old man with known stage 3 chronic kidney disease due to diabetes presents with fatigue. His blood sugars are acceptable; his mood is euthymic, and he is sleeping and eating well. He does not smoke, and he has no known toxic environmental exposures. Work up shows normochromic normocytic anemia, with a hemoglobin of 11 g/dl, which is decreased from 12 g/dl 6 months ago. Medications include lisinopril, furosemide, and insulin. What is the most likely diagnosis? A) Iron deficiency anemia B) Anemia of chronic disease C) Thalassemia D) Myelodysplasia E) Pernicious anemia

C) Reassure her that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance Drugs can be screened in animals for abuse potential. Abusable drugs are rewarding (animals will self-administer them in preference to eating/drinking) and tend to induce both tolerance and withdrawal. The more rapid the onset of the sought for changes, the more likely the drug will be abused. Rapidity of onset is related to the particular drug taken and to the mode of administration. Drugs that are injected or inhaled are especially quick in action. Inhalation, in particular, bypasses first pass metabolism in the liver. Thus, IV use of heroin or snorting of cocaine (especially highly concentrated forms known as crack) quickly leads to abuse. Conversely, patients may be reassured that most prescribed medications, even psychotropics except benzodiazepines, are not abusable drugs and patients do not become addicted to them. Giving lower doses of antidepressants or prescribing them for a few weeks would be incorrect, since the onset of action is delayed up to 3 or 4 weeks and the drugs should be continued for at least 4 months. (Short courses followed by tapering would be correct for a benzodiazepine). Antidepressants, especially cyclic antidepressants, may precipitate a withdrawal syndrome if stopped abruptly, but this alone does not make them abusable.

A 35-year-old woman is reluctant to try an antidepressant for fear of becoming a drug addict. How should the physician respond? A) Respect her concerns and treat her with psychotherapy alone B) Give her the medication and refer her to a twelve step program C) Reassure her that antidepressants are not drugs of abuse because of oral administration, lack of immediate reward, and lack of tendency to cause tolerance D) Prescribe lower than recommended doses to avoid inducing a "high", explain to the patient she will not become addicted as long as she stops the drug after a few weeks E) Tapering to avoid withdrawal symptoms

A) Magnesium sulfate Magnesium sulfate is indicated in this patient with preeclampsia to reduce the risk of seizures Hint: Diazepam may cause respiratory depression, hypotonia, and thermoregulatory problems in the newborn and should be avoided. Hint: Captopril and other ACE inhibitors should be avoided in pregnant patients due to side effects. Hint: Nifedipine can lead to severe hypotension and should be avoided in this case.

A 36-week pregnant patient presents to the ED with hypertension. Physical examination reveals 2+/4+ edema in the lower extremities with hyperreflexia and clonus bilaterally. A urinalysis reveals 3+ protein. Which of the following is the best treatment option for this patient? A) Magnesium sulfate B) Nifedipine (Procardia) C) Diazepam (Valium) D) Captopril (Capoten)

C) CT scan of the sinuses This patient is suffering from chronic sinusitis. Repeated regimens of different antibiotics have not provided him relief, and now he fits the criteria for chronic sinusitis, including 12 weeks of symptoms. Chronic sinusitis is most commonly caused by streptococcus pneumoniae, Haemophilus influenzae, and moraxella catarrhalis. Together, these 3 bacteria account for 70% cases. A limited CT scan of the sinuses defines the location and extent of disease and helps in deciding further management. It is quick, low cost, and sensitive. CT scanning also helps in delineating anastomotic blockage of the osteomeatal complex; therefore, there is a role for it in cases of endoscopic surgery. Hint: Plain X-rays are no longer recommended; they are not sensitive enough in the visualization of the sinuses, and they often miss findings Hint: MRI of the sinuses tells us more about the soft tissue pathology, but bony structures cannot be studied in detail. MRI is done if malignancy is suspected or there are signs and symptoms of possible intracranial extension. Hint: Nasal cultures can be contaminated with colonized organisms in the nose, such as staphylococcus aureus, and do not correlate well with culture obtained from the sinuses. Endoscopically-guided cultures of secretions in the middle meatus or within a sinus are usually not done in clinical practice, even though occasionally it may provide the exact causative pathogen. Hint: A 3-week course of antibiotics may relieve symptoms briefly, but it is unlikely to cure him, especially since he already has had several courses. Amoxicillin-clavulanate or cefuroxime are traditionally used for 3 weeks. In intractable cases, a 6-week course may also be given. Clarithromycin and clindamycin are used for patients who are allergic to penicillin. Quinolones are only used if cultures show Gram-negative bacteria.

A 36-year-old man presents with nasal stuffiness, headache, fatigue, facial pain, and chronic post-nasal drip. He has had similar episodes in the past; on average, they have occured 2 - 3 times a year for the last several years. He has been diagnosed with acute sinusitis, and antibiotics have been prescribed; they have provided him with relief for a brief period. This time, however, his symptoms have bothered him on and off for the last 3 months; he was given a 14-day course of antibiotics, but he experienced only partial relief. He is tired of the recurrent episodes, and he wants a cure. On exam, he is afebrile; nasal mucosa is inflamed, and there is mucopurulent secretion in the nasal cavity. The right maxillary sinus is tender on palpation. Lungs are clear. What is the best next step in the management of this patient? A) A 3-week course of antibiotics B) Plain X-ray views of the sinuses C) CT scan of the sinuses D) Nasal and sinus cultures E) MRI of the sinuses

Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency.

A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done?

C) Rest and NSAIDs The clinical picture is suggestive of acute pericarditis. Most cases are due to viral infections with the treatment being rest and non-steroidal agents, e.g. aspirin or indomethacin. If this pericarditis progressed to tamponade, pericardiocentesis would be indicated. Symptoms of tamponade are not seen in this patient (dyspnea, elevated jugular venous pressure, hypotension, paradoxic pulse, and muffled heart sounds). Beta blockers are not indicated for treating pericarditis. Corticosteroids are usually given in cases unresponsive to rest and NSAIDs. Most cases of pericarditis are self-limiting and usually run their course from 1-3 weeks but initial treatment consists of rest and NSAIDs.

A 39-year-old man presents with a 1-week history of severe chest pain. He states that the pain seems to worsen when he lies down. He describes the pain as radiating to the back, and it also worsens when he takes a deep breath. His vital signs are as follows: blood pressure 124/ 84 mm Hg, respiratory rate 18/ min, temperature 101°F, and pulse 74 beats per minute. On auscultation of the chest, you cannot distinguish a S1 or S2 but hear a scratching or grating sound. *What is the first step in the treatment of this patient?* A) Pericardiocentesis B) Beta blockers C) Rest and NSAIDs D) Corticosteroids E) No treatment necessary

D) Placenta previa One of the common causes of third trimester bleeding is placenta previa, in which the placenta improperly implants over or in close proximity to the cervical os due to abnormal vascularization. Risk factors include increased maternal age, multiparity, prior placenta previa and prior cesarean delivery. Incidence in nulliparas is about 1 in 1500, and increases to 1 in 20 in grandmultiparas. Bleeding, which is variable in amount and maternal in origin, typically presents in the 29th-30th gestational week. There typically is no pain associated with the bleeding. Diagnosis is made via ultrasonographic examination. Treatment consists of hospitalization, bed rest, hemodynamic stabilization if necessary and observation with expectant management until fetal maturity occurs (typically >36 weeks gestation).

A 39-year-old woman in her third trimester presents with two days of bloody "spotting" on her underwear. This is her third pregnancy, which thus far has been uncomplicated. Her initial delivery was vaginal and her second delivery was via cesarean section. She is currently sexually active, and has a history of trichomoniasis. She denies pelvic pain. Laboratory examination reveals hematocrit of 32%, white blood cell count of 10,000, platelet count of 260,000 INR of 1.1 and aPTT of 32 seconds. Pelvic examination shows a nonerythematous cervix with clear mucus. Which of the following is the most likely diagnosis? A) Cervicitis B) HELLP syndrome C) Maternal coagulopathy D) Placenta previa

B) Placenta previa Painless third-trimester bleeding was a common presentation for placenta previa in the past; however, now most cases of placenta previa are detected antenatally with ultrasound before the onset of significant bleeding. This patient has had no prenatal care and is at increased risk for complications. Placenta previa is characterized by placental tissue that overlies or is adjacent to the cervical os. Placenta previa typically presents as painless vaginal bleeding in the second or third trimester. Between 70% and 80% of patients with placenta previa will have at least one bleeding episode. Patients at risk of placenta previa include increasing parity or maternal age, cigarette smoking, and prior uterine surgery. About 10% to 20% of patients present with uterine contractions before bleeding, and fewer than 10% remain asymptomatic. Of patients with bleeding, one third will present before 30 weeks' gestation, one third between 30 and 36 weeks' gestation, and one third after 36 weeks' gestation. Patients with early-onset bleeding (<30 weeks' gestation) have the greatest risk for blood transfusion and associated perinatal morbidity and mortality. The bleeding is believed to occur from disruption of placental blood vessels in association with the development and thinning of the lower uterine segment. Patients with placenta previa who present preterm with vaginal bleeding require hospitalization and immediate evaluation to assess maternal-fetal stability. In at least 50% of women who present with asymptomatic previa, delivery can be delayed for more than 4 weeks, including patients with initial bleeding episodes greater than 500 mL.

A 39-year-old woman presents to the office with painless vaginal bleeding in the third trimester (32 weeks) of pregnancy. She has had no prenatal care and a history of tobacco use. She denies any lower extremity edema, and her vital signs are normal. She has five other children, all of whom were delivered via Cesarean section. Which of the following conditions should you be most concerned about? A) Labor B) Placenta previa C) Placental abruption D) Preclampsia

A) Fine needle aspiration Fine needle aspiration is fairly accurate, easily performed, and has minimal morbidity Hint: Although BRCA 1 and BRCA 2 genetic tests are used in the risk assessment for possible breast and ovarian cancer, it would not replace the need to perform a more definitive evaluation of an identified breast mass. Hint: Serum CA-125 is a tumor marker for ovarian, not breast, cancer Hint: Radiation therapy is only indicated after a diagnosis of breast cancer is proven and may be used as adjunctive therapy.

A 40 year-old female presents with a 1.5 cm well-circumscribed mass noted on mammography in the right upper, outer quadrant. Which of the following procedures is most appropriate and should be done next? A) Fine needle aspiration B) BRCA 1 and BRCA 2 genetic testing C) Serum CA-125 D) Radiation therapy

D) Colposcopy and endometrial sampling this is the appropriate workup for *glandular cell abnormalities* One of the 4 Bethseda system subgroups of *cervical adenocarcinoma*. Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix. Colposcopy and endometrial sampling are important to perform in patients with AGUS Pap results because glandular cells are associated with squamous and glandular precursor lesions and carcinoma. Hint: Colposcopy with ECC would be recommended in patients with ASCUS, LGSIL, HGSIL, or squamous cell findings on a Pap smear Hint: Repeat Pap smear would be recommended in patients with ASCUS, not AGUS, results on a Pap smear. Hint: HPV DNA testing is recommended to further evaluate patients with Pap smears with dysplasia.

A 40 year-old female presents with a Pap smear abnormality revealing atypical glandular cells (AGUS). What is the most appropriate intervention? A) HPV DNA testing B) Colposcopy with endometrial curretage(ECC) C) Repeat Pap smear in 3 months D) Colposcopy and endometrial sampling

B) Shock wave lithotripsy Extracorporeal shock wave lithotripsy is indicated in patients with stones greater than 6 mm in size or intractable pain. Hint: While fluid hydration is indicated, a stone greater than 6 mm will typically not spontaneously pass and surgical therapy is indicated.

A 40 year-old patient with a history of recurrent kidney stones presents with acute onset of right flank pain and hematuria. The patient is afebrile and pain is poorly controlled on oral medications. On CT scan a 1 cm stone is noted in the renal pelvis. Which of the following is the most appropriate intervention for this patient? A Antibiotics B Shock wave lithotripsy C Ureterolithotomy D Fluid hydration

D) maintain nasal patency and nasal cosmesis (u) A. Septal hematoma is less likely due to the finding of epistaxis, and is not of highest priority. (u) B. Reconstructive nasal surgery is a delayed procedure. (u) C. Open reduction is not indicated for nasal trauma. (c) D. Maintain nasal patency until closed reduction can be attempted in 1 week

A 40-year-old male is hit in the face with a baseball. There is nasal deformity with bleeding. The most appropriate initial management is to A) treat the hematoma with I&D and antibiotics. B) consult with an ENT for immediate reconstructive nasal surgery. C) reduce septal defect using open technique. D) maintain nasal patency and nasal cosmesis

D) maintain nasal patency and nasal cosmesis (u) A. Septal hematoma is less likely due to the finding of epistaxis, and is not of highest priority. (u) B. Reconstructive nasal surgery is a delayed procedure. (u) C. Open reduction is not indicated for nasal trauma. (c) D. Maintain nasal patency until closed reduction can be attempted in 1 week

A 40-year-old male is hit in the face with a baseball. There is nasal deformity with bleeding. The most appropriate initial management is to: A) treat the hematoma with I&D and antibiotics. B) consult with an ENT for immediate reconstructive nasal surgery. C) reduce septal defect using open technique. D) maintain nasal patency and nasal cosmesis

C) 100 Joules Of all of the arrhythmias, both supraventricular and ventricular, atrial flutter is the easiest to cardiovert back to a regular sinus rhythm. The temptation, especially when using front-to-back paddles, is to use the lowest voltage setting (e.g., 50 Joules, or 25 Joules, or even 10 Joules). That temptation needs to be resisted; if the initial electric shock is ineffective, then the circulating catecholamine levels of the patient become markedly increased, which thereby places the patient at risk of developing potentially fatal ventricular fibrillation and cardiac arrest with subsequent electric shocks. In contrast, there is no need to apply higher energies such as 200 Joules, 300 Joules, or 360 Joules as the initial energy for cardioversion in case of atrial flutter. The most reasonable approach is to provide a 100 Joules direct current countershock which will have a high probability of returning the patient with atrial flutter to a regular sinus rhythm while maintaining a low probability of causing burns or broken bones with 1 and only 1 direct current moderate-energy 100 Joules electric shock.

A 40-year-old man presents with atrial flutter with 2:1 atrioventricular (AV) conduction, giving him a pulse of 150 per minute, which is perfectly regular. He takes no medications regularly. You plan to provide him with urgent direct current cardioversion with conscious sedation. What should be used as the initial energy for cardioversion in order to restore sinus rhythm in patients with atrial flutter? A) 10 Joules B) 25 Joules C) 100 Joules D) 200 Joules E) 300 Joules

C) Treat her asthma as indicated, if improved, discharge with outpatient obstetrical follow-up Treatment should not be delayed (A). In fact, the most important aspect to assuring the health of the fetus is to ensure the health of the mother. No further workup of the patient's pregnancy is required (B and D). Her respiratory complaints are unrelated to her pregnancy. As a good public health practice, many EDs offer routine screening for pregnancy using point-of-care testing. In this patient—with isolated respiratory complaints and lack of findings on physical or pelvic exam that indicate anything other than a normal pregnancy—an incidental positive beta-hCG does not warrant any further attention other than a referral for follow-up with an obstetrician. The patient's asthma is the treatment priority. Standard therapy should be administered even in the setting of pregnancy.

A 40-year-old woman with a history of asthma presents to the ED with symptoms of wheezing and shortness of breath similar to previous exacerbations. Her vital signs are BP 115/70, HR 80, RR, 14, and pulse oximetry is 99% on room air. The patient is offered and agrees to a point-of-care beta-hCG test that returns positive. Upon further questioning, patient denies any vaginal or urinary complaints. On exam, you note mild bilateral wheezing with good air movement. Which of the following is the most appropriate next step in management? A) Delay treating her asthma until her pregnancy status is further clarified B) Treat her asthma as indicated, and perform a beta-hCG quantitative level C) Treat her asthma as indicated, if improved, discharge with outpatient obstetrical follow-up D) Treat her asthma as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound

D) Tricuspid This patient most likely has bacterial endocarditis. Endocarditis is more common in patients with valvular abnormalities, prosthetic valves, and IV drug users. Common pathogens include Staphylococcus aureus and viridans group streptococci. Of note, viridans streptococcus endocarditis commonly presents after dental work. Endocarditis presents most commonly with fever and malaise, although other signs and symptoms may be present. Although the classic triad is fever, anemia, and a heart murmur, this rarely presents clinically. *IV drug users usually have right-sided endocarditis, most commonly affecting the tricuspid valve*. The murmur noted on exam is usually *tricuspid regurgitation*. Labs should be ordered for those with suspected endocarditis, as one would expect leukocytosis, anemia, increased ESR, and increased CRP. Three blood cultures from three separate venipuncture sites should be taken, with the first and last draw occurring at least one hour apart. The most useful diagnostic imaging is an echocardiogram, especially a TEE, demonstrating vegetations. The *Duke criteria* are the most widely used and accepted criteria to clinically diagnose bacterial endocarditis. Empiric antibiotics should be initiated in those with suspected or confirmed endocarditis once cultures have been drawn, with antibiotics being altered as needed once the pathogen and susceptibility return.

A 40-year-old woman, who actively uses intravenous drugs, presents to the ED with fever and fatigue for the past 3 days. In the ED, her vital signs are BP 126/82, HR 90, RR 16, oxygen saturation 99% on room air, and temperature 101.6°F. On exam, a murmur is noted. A transesophageal echocardiography is ordered for suspected endocarditis. Which of the following valves is most likely to be affected? A) Aortic B) Mitral C) Pulmonic D) Tricuspid

Screening colonoscopy now and repeat every 3-5 years if normal Hereditary factors are believed to contribute to up to 30% of colorectal cancers. Relative risk is 3.8 times if the family member's cancer was diagnosed at less than 45 years of age. *Recommended screening in a single first degree relative with colorectal cancer diagnosed before age 60 is* *beginning colonoscopy at age 40 or ten years younger than age at diagnosis of youngest affected first-degree relative*. Then if negative, every 5 years

A 41 year-old female presents to you for medical screening advice. Her 44 year-old sister passed away recently 18 months after diagnosis of metastatic colon cancer. Which of the following is the most appropriate advice for this patient?

D) Uterine ablation Colposcopy (A) is a gynecologic procedure in which the cervix, vagina and vulva are directly visualized under illumination and magnification. Hysteroscopy (C) is the current gold standard for evaluating uterine pathology. Both of these diagnostic tests would not treat nor prevent further menstrual bleeding. Hysterectomy (B) may be a last resort, but endometrial ablation is usually attempted first as hysterectomy has a high risk of perioperative complications and prolonged recovery.

A 41-year-old woman suffers from heavy and irregular menses, which at times leads to fatigue, lightheadedness and dyspnea. She has had three hospitalizations in the past year for such episodes. Her gynecologic evaluation has not revealed any pathological cause. The heavy menses continue despite hormonal therapy. She states she is done with child bearing. Which of the following treatment options should be considered next? A) Colposcopy B) Hysterectomy C) Hysteroscopy D) Uterine ablation

D) Tube thoracostomy This patient has a hemothorax. Drainage of a hemothorax is best obtained through insertion of a chest tube (tube thoracostomy).

A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention? A Thoracotomy B Needle aspiration C Close observation D Tube thoracostomy

B) Nephrolithiasis A sudden onset of severe colicky flank pain associated with nausea and vomiting as well as the absence of rebound or direct testicular tenderness makes nephrolithiasis the most likely diagnosis. This is further supported by the presence of hematuria on the urinalysis. Hint: The absence of fever, as well as non-tenderness to palpation of the testes, suggests a renal rather than gonadal cause of the patient's symptoms. Hint: While bladder cancer may have associated microscopic hematuria, it presents with painless hematuria or irritative voiding symptoms.

A 42 year-old male presents complaining of a sudden onset of a severe intermittent pain originating in the flank and radiating into the right testicle. He also complains of nausea and vomiting. On examination the patient is afebrile, but restless. Examination of the abdomen reveals tenderness to palpation along the right flank with no rebound or direct testicular tenderness. Urinalysis reveals a pH of 5.4 and microscopic hematuria, but is otherwise unremarkable. Which of the following is the most likely diagnosis? A Bladder cancer B Nephrolithiasis C Acute appendicitis D Acute epididymitis

B) Anal fissure Anal fissures are easily diagnosed from history alone with the classic finding of severe pain upon defecation. Constipation is also a common cause of the trauma that leads to development of a fissure. Hint: While internal hemorrhoids may cause rectal bleeding, tearing pain is an uncommon complaint unless there is evidence of thrombosis of irreducible tissue.

A 42 year-old male with a history of constipation presents with complaints of severe pain with defecation described as feeling like he is "tearing apart." He has also noted occasional small amounts of blood on toilet paper. External examination of the rectum is unremarkable and an internal rectal exam cannot be performed due to severe pain when attempted. Which of the following is the most likely diagnosis? A) Proctitis B) Anal fissure C) Rectal prolapse D) Internal hemorrhoids

C) ondansetron (Zofran) Ondansetron selectively blocks 5-HT3 receptors in the periphery (visceral afferent fibers) and in the brain (chemoreceptor trigger zone). It is indicated for use in chemotherapy induced nausea and vomiting. Hint: Scopolamine and meclizine are effective against motion sickness, but ineffective against substances that act directly on the chemoreceptor trigger zone

A 42 year-old patient who is being treated for colon cancer with chemotherapy develops nausea and vomiting. Which of the following drugs would be the most effective in controlling the nausea and vomiting? A) scopolamine (Scopace) B) meclizine (Antivert) C) ondansetron (Zofran) D) loperamide (Imodium)

C) The condition is most common after 40 years of age Dysfunctional uterine bleeding (DUB) is a condition of irregular uterine bleeding in a patient who does not have an anatomic uterine lesion. It is most common above the age of 40 years (50% of the cases), but it is also seen in adolescents (20%), in whom it is associated with anovulatory cycles. Anovulatory cycles are characterized by abnormal levels of estrogen and may be due to estrogen withdrawal or breakthrough. A deteriorating ovarian follicular function is responsible for anovulatory bleeding during the climacteric. Other etiologies, such as polycystic ovarian disease, fibroids, and thyroid disease need to be ruled out before making the diagnosis. An endometrial biopsy or dilation and curettage (if the patient cannot undergo an endometrial biopsy in the office) can be diagnostic, but it is not curative or even therapeutic in a patient with DUB. Medical therapy, including estrogens, progestational agents, progesterone-impregnated intrauterine devices, and combination oral contraceptives are used to treat the condition.

A 42-year-old gravida 1, para 1 presents with a 4-month history of menorrhagia. She is having shortened menstrual cycles that are sometimes only 15 days in length, with menstrual bleeding for 5 - 6 days. She is using approximately 12 - 14 pads or tampons per day. She admits to fatigue, headaches, and occasional dizziness, but denies syncope. There is no dysmenorrhea. A thyroid-stimulating test last month was within normal limits. Abdominal and pelvic exams are normal. What statement is true regarding dysfunctional uterine bleeding? A) It is seen in all age groups equally B) Dilatation and curettage is the only treatment C) The condition is most common after 40 years of age D) The condition is not seen in adolescents E) It is never associated with ovulatory cycles

infectious endocarditis. Risk factors for infectious endocarditis include rheumatic heart disease, congenital or acquired valvular disease, and intravenous drug use. In an IV drug user, coverage should include methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa in addition to the typically implicated organisms. The most appropriate antibiotics for this patient would include cefepime and vancomycin.

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 103.4°F. Chest X-ray is shown above. Which of the following is the most likely diagnosis

C) Aspartate transaminase 250 U/L and alanine transaminase 120 U/L Liver transaminases, alanine transaminase (ALT) and aspartate transaminase (AST) are typically elevated 2-10 times normal. Unlike hepatitis due to other causes, AST is predominantly elevated, often with a AST:ALT ratio of 2:1.

A 42-year-old man presents to the Emergency Department with nausea, vomiting, and right upper quadrant abdominal pain. He drinks alcohol daily. Which of the following laboratory results would be most consistent with alcoholic hepatitis? A) Alkaline phosphatase 350 U/L B) Aspartate transaminase 1000 U/L and alanine transaminase 1200 U/LY C) Aspartate transaminase 250 U/L and alanine transaminase 120 U/L D) Mean corpuscular volume 60 fL

C) Oxymetazoline (*Afrin* = sympathomimetic) and pseudoephedrine (*Sudafed* = sympathomimetic) This patient has rhinosinusitis. Viral upper respiratory infections and allergic rhinitis are the most common causes of acute rhinosinusitis. Symptoms of acute sinusitis typically progress over the first several days and spontaneously resolve after 7 to 10 days. It is difficult to distinguish clinically between a viral and bacterial infection in the first several days of illness and antibiotic therapy is not recommended at this time. Management focuses on symptomatic treatment with pain management and decongestant therapy. Antihistamines may provide some benefit for patients with allergic rhinosinusitis. Decongestant therapy is available topically with agents like oxymetazoline. Systemic therapy includes pseudoephedrine. Saline nasal irrigation is beneficial for all forms of acute rhinosinusitis. Topical and systemic steroids are no longer recommended for acute sinusitis. A CT scan of the sinuses (A) is not necessary in this patient. Imaging is indicated when there are concerns for complications of cellulitis (e.g. cavernous sinus thrombosis, abscesses, orbital involvement) or invasive fungal infections. ENT consultation (B) is not necessary for uncomplicated sinusitis. A prescription for amoxicillin/clavulanic acid (D) is not indicated in the first several days of illness because of the likelihood this is viral. *Without improvement after symptomatic therapy or progression to chronic sinusitis, antibiotics are indicated.*

A 42-year-old man presents with facial pain. He reports pain over his cheeks and forehead with associated fever for the last 24 hours. On inspection of his nasal passages you note inflamed turbinates with green discharge. He is tender over palpation of the frontal and maxillary sinuses. Which of the following is the most appropriate course of action? A) CT scan of the sinuses B) ENT consultation C) Oxymetazoline and pseudoephedrine D) Prescription for amoxicillin/clavulanic acid

D) Sialogogues This patient has obstructive sialoadenitis, which occurs from outflow obstruction by a stone or calculus in the salivary gland or duct. The submandibular location is most commonly involved because it is has more viscous secretions and runs an uphill course. Patients with sialolithiasis note xerostomia (dry mouth) along with increasing swelling and pain during mealtime. Most salivary stones pass spontaneously. To aid in passage, patients should be started on sialogogues (e.g., sour lozenges), which stimulate salivary secretions and help expel the stone. Palpable stones may also be "milked" from the duct, if they are distal enough, by gentle stroking in a posterior to anterior direction. Antihistamines (A) can worsen this condition by decreasing saliva production and are contraindicated. If the sialoadenitis does not resolve with conservative therapy, dilation and incision (B) of the salivary duct is required to remove the stone. Oral antibiotics (C) are not required in simple obstructive sialoadenitis. However, when suppurative sialoadenitis is present, oral antibiotics with staphylococcal coverage are recommended.

A 42-year-old woman complains of two days of pain and swelling in the right submandibular area. She complains of dry mouth and worsening of the swelling and pain during mealtime. Which of the following is the first-line treatment for this condition? A) Antihistamines B) Dilation and incision C) Oral antibiotics D) Sialogogues

Hyperthyroidism When considering irregular menses in a middle-aged woman, a clinician should remember there are conditions other than menopause which can be causative. In any woman with changes in menstruation, consider pregnancy, and obtain a human chorionic gonatropin (hCG) level. A woman over age 45 who presents with menstrual irregularities plus common menopausal symptoms (such as palpitations, hot flashes, vaginal dryness and dyspareunia, as in the patient above), is more likely transitioning into menopause than presenting with a new endocrine disorder, and as such, no further diagnostic evaluation is recommended. For women under 45 years of age with menstrual irregularities, consider hyperthyroidism, especially if the patient also demonstrates mood changes and hot flash type symptoms, like sweating

A 42-year-old woman presents for evaluation of irregular menses, associated with episodes of excessive daytime sweating and palpitations. She has not had a hysterectomy or oophorectomy. She is currently sexually active, although intercourse has been more uncomfortable lately. Which of the following disorders would you consider in this patient's differential diagnosis? Hyperaldosteronism Hyperprolactinemia Hyperthyroidism Hypokalemia

A) Carbamazepine prescription Trigeminal neuralgia = is manifested by intermittent episodes of severe pain in the distribution of the fifth cranial nerve. The antiepileptic carbamazepine is the medical treatment of choice for this condition.

A 42-year-old woman presents with severe facial pain. The patient reports she has had episodes of severe, shooting pain on the lower half of the left side of her face. Her neurologic examination is normal. She cannot identify any triggers for the episodes of pain. Which of the following is the appropriate next step? A) Carbamazepine prescription B) CT scan of the head C) Prednisone prescription D) Referral for EEG

A) Myxedema Myxedema is one of the metabolic predisposing causes for carpal tunnel syndrome. The patient's clinical presentation is suggestive of carpal tunnel syndrome. Carpal tunnel syndrome is a median nerve compressive neuropathy. Patients with myxedema or hypothyroidism have accumulation of myxedemateous tissue under the transverse carpal ligament, which causes compression of the median nerve in the carpal tunnel resulting in the manifestations of carpal tunnel syndrome. In carpal tunnel syndrome the median nerve is compressed in the wrist. The neurological distribution of her complaints corresponds to the distribution of the median nerve. The median nerve innervates the palmar surface of the thumb, index, middle, and radial half of the ring fingers and the motor branch innervates the thenar muscles. Electromyography and nerve conduction studies help in confirming the diagnosis of carpal tunnel syndrome. Patients can be managed with analgesics for pain, corticosteroids which can be administered orally or as local injection, and splint to prevent wrist flexion and further compression of the carpal tunnel. The other metabolic causes of carpal tunnel syndrome include acromegaly, diabetes mellitus, and amyloidosis. None of the other choices listed, which include hypoadrenalism, hypoprolactinemia, hypoglycemia, and Cushing syndrome, are associated with an increase in the occurrence of carpal tunnel syndrome.

A 42-year-old woman works full-time as a data entry clerk and often puts in many hours of overtime. She has started to notice numbness and tingling in her right thumb, index finger, middle finger, and half of her ring finger; symptoms are especially severe at night The numbness and tingling were intermittent for months, but they have become persistent during the past few days. What could be considered a predisposing factor for this patient's condition? A) Myxedema B) Hypoadrenalism C) Hypoprolactinemia D) Hypoglycemia E) Cushing syndrome

B) Hyperparathyroidism (stones, bones, groans, moans) The presence of elevated total and ionized calcium are consistent with hyperparathyroidism. High calcium, low phosphate.

A 43 year-old male is found to have an elevated serum calcium on routine pre-employment laboratory testing. Further laboratory testing demonstrated: Calcium 11.3 mg/dL (8.8 - 10.2 mg/dL) Ionized Calcium 6.2 mg/dL (4.6 - 5.3 mg/dL) Phosphorus 2.1 mg/dL (3.0 - 4.5 mg/dL) What is the most likely diagnosis? A) Adrenal insufficiency B) Hyperparathyroidism C) Osteoporosis D) Paget's disease

A) Candidiasis Oral candida or "thrush" is characterized by painless, confluent white plaques that can be removed with scraping. Candidiasis is often the first manifestation of HIV infection and should be considered in patients with no known predisposing cause of Candida overgrowth. Definitive diagnosis is made by wet preparation using potassium hydroxide revealing oval budding cells and hyphae of Candida albicans. Effective antifungal therapy may be achieved with oral fluconazole, clotrimazole troches, or nystatin mouth rinses. HIV patients may require longer courses of fluconazole of oral itraconazole.

A 43-year-old HIV positive man presents with a 3-day history of painless, confluent white plaques, adherent to the oral and pharyngeal mucosa. The plaques reveal a raw, bleeding mucosa when scraped with a tongue depressor. What is the most likely diagnosis? A) Candidiasis B) Kaposi's sarcoma C) Leukoplakia D) Oral lichen planus

D) Neovascularization Neovascularization is the hallmark of proliferative diabetic retinopathy. New vessels can appear at the optic nerve and the macula as a result of retinal hypoxia. They are susceptible to rupture, resulting in vitreous hemorrhage, retinal detachment, and blindness. Proliferative retinopathy requires urgent referral to an ophthalmologist and is usually treated with pan retinal laser photocoagulation. The risk of developing diabetic retinopathy is related to the extent of glycemic control and the duration of diabetes. It is classified as nonproliferative and proliferative. Blot hemorrhages, cotton wool spots, and microaneurysms are indicative of nonproliferative diabetic retinopathy, which is usually seen 10 to 20 years after the onset of diabetes. Nonproliferative retinopathy does not always progress to proliferative retinopathy, but if it becomes extensive, it can result in retinal ischemia, which increases the likelihood of proliferative disease. Flame-shaped hemorrhages are indicative of hypertensive retinopathy.

A 44-year-old man presents for follow-up of poorly controlled type I diabetes mellitus, which was diagnosed 32 years ago. What change on his funduscopic examination would indicate a need for urgent referral to an ophthalmologist? A) Blot hemorrhages B) Cotton wool spots C) Microaneurysms D) Neovascularization E) Flame-shaped hemorrhages

B) Excision microsurgery Acoustic neuromas, - Sensorineural hearing impairment is the main symptom, while tinnitus, balance disturbance and headache is somewhat common and vertigo is rare. - There are three general management steps: monitoring, surgery or stereotactic radiation. If the tumor is slow growing and causing minimal, non-progressive symptoms, it may be monitored.

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

C) Initiate metoprolol Long QT syndrome = Beta-blockade with medications such as metoprolol may be appropriate in patients who are hemodynamically stable. Cardiology consult or referral is recommended because implantation of a cardiac defibrillator can be beneficial for those at risk of sudden cardiac death.

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 and blood pressure is 117/82. Her medications include lisinopril and metformin. She took lorazepam yesterday for anxiety related to the loss of her mother. What is the most appropriate therapy? A) Administer adenosine B) Discontinue lorazepam C) Initiate metoprolol D) Perform vasovagal maneuvers

A) Ectopic pregnancy Risk factors for an ectopic pregnancy are history of pelvic inflammatory disease, current use of an intrauterine device, prior tubal ligation, prior ectopic pregnancy, and in vitro fertilization. Gestational trophoblastic disease (B) is a spectrum of obstetric diseases that includes partial and complete hydatidiform mole, invasive mole, and choriocarcinoma. Gestational trophoblastic disease is characterized by excessive nausea and vomiting, larger than expected uterus, and extremely high levels of HCG. The woman in this case had lower than expected HCG level for her six-week gestational age. A heterotopic pregnancy (C) is a combined intrauterine pregnancy and an ectopic pregnancy. The incidence of heterotopic pregnancy has been increasing in the United States as the result of increased assisted reproductive technology use. A patient with a heterotopic pregnancy can present with signs and symptoms of a ruptured ectopic pregnancy if the ectopic implanted fetus has ruptured. In this case, the intrauterine pregnancy will still be visible on ultrasound. A threatened abortion (D) typically presents with lower abdominal cramping and vaginal bleeding within the first 20 weeks of pregnancy. On pelvic exam, the cervix will be closed. A threatened abortion will show an intrauterine pregnancy on transvaginal ultrasound.

A 44-year-old woman with a history of hypertension presents to her primary care provider's office with complaints of nausea and vomiting. Her last menstrual cycle was six weeks ago. Two years ago she had a bilateral tubal ligation performed. On physical exam, her abdomen is nontender and her uterus is not enlarged. Pelvic exam is unremarkable. Her serum human chorionic gonadotropin level is 5,000 mIU/mL. A transvaginal ultrasound does not demonstrate an intrauterine gestational sac. Which of the following is the most likely diagnosis? A) Ectopic pregnancy B) Gestational trophoblastic disease C) Heterotopic pregnancy D) Threatened abortion

C) Propranolol This patient is showing symptoms of benign essential (familial) tremor, for which the best initial treatment option in lifestyle-limiting disease is the beta-blocker propranolol. Essential tremor usually presents with a postural tremor of the hands or head that is often worsened by psychic stress. When laryngeal muscles are involved, the patient's voice may shake as well. Of note, the legs are usually spared in this condition. Though the cause is uncertain, there appears to be an autosomal-dominant inheritance pattern in some cases. Patients may be initially affected at any age. Essential tremor usually becomes more prominent with age, though significant disability is rare. Symptomatic treatment is limited to patients with lifestyle-limiting tremors. In addition to propranolol, other therapies include primidone, alprazolam, topiramate, or gabapentin.

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

C) Emphysema The classical symptomatology includes prolonged progressive dyspnea with late-onset non-productive cough, occasional mucopurulent relapses, and eventual cachexia and respiratory failure. The patients are usually thin and have a barrel-shaped chest. There is tachypnea with pursed lip breathing and use of accessory muscles; they may also adopt a tripod sitting position. Hint: Chronic bronchitis produces obstructive changes and bronchial inflammation. Chronic bronchitis is characterized by *chronic productive cough for at least 3 or more months in each of 2 successive years for which other causes, such as infection with Mycobacterium tuberculosis, carcinoma of the lung, or chronic heart failure, have been excluded*. Chest X-ray shows increased bronchovascular markings and cardiomegaly. Hint: Bronchiectasis is a condition characterized by abnormal permanent distortion of the conducting bronchi or airways, most often secondary to an infectious process. Patient with bronchiectasis often present with *chronic cough with mucopurulent sputum production, which lasts months to years*. CT, especially HRCT (high-resolution computed tomography), helps in confirming the diagnosis.

A 45-year-old man presents with a 2-year history of worsening dyspnea and a 1-month history of a dry cough. The patient gives no history of fever, chills, chest pain, or wheeze. History is significant for smoking (25 cigarettes/day for more than 22 years). A chest X-ray shows hyperinflated lungs with bullae, tubular heart, flattened diaphragm, and no areas of consolidation. Pulmonary function tests (PFT) reveal a decrease in forced expiratory volume in 1 second (FEV1) along with reduction of FEV1/FVC (forced vital capacity) ratio. These findings are characteristic of what condition? A) Congestive cardiac failure B) Chronic bronchitis C) Emphysema D) Bronchiectasis E) Diffuse alveolar damage

C) Excision of thrombosed external hemorrhoid The clinical case described most likely represents a patient with a thrombosed external hemorrhoid. External hemorrhoidal thrombosis is not infrequent and can be seen in patients with no prior history of hemorrhoidal disease. The cause is thought to be from elevated venous pressures related to excess straining with constipation and physical exertion following a bout of diarrhea or change in diet. It is an acute painful event with the pain generally lasting 7-14 days and resolving with resolution of the thrombosis. The clinical presentation is usually as described above, with acute swelling and pain located at or around the anal verge. When the overlying skin of the thrombosed hemorrhoid is eroded, bleeding occurs. The pain usually lasts for a few days and then spontaneously resolves. The swelling may take several weeks to resolve. Treatment depends on the time of presentation and the severity of the condition. Acute thrombosed external hemorrhoid presenting within 72 hours of onset of symptoms should be excised. Excision of the thrombosed external hemorrhoid can be performed under local anesthesia and is associated with a low recurrence and complication rate. Patients presenting after 72 hours of onset of symptoms should be managed by conservative/symptomatic medical therapy.

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

B) Microalbuminuria Microalbuminuria is the first sign of diabetic nephropathy. Screening for microalbuminuria, a marker of kidney disease, is recommended annually for patients with type I diabetes of greater than 5 years duration; it is recommended annually for all patients with type II diabetes. This screening test is most easily obtained with a first void morning urine "spot" albumin to creatinine ratio. Normal levels for spot samples are <10 mg/g for men and <15 mg/g for women. Since kidney diseases other than diabetic kidney disease may cause proteinuria and albuminuria, evaluating the urine sediment of diabetics with presumed diabetic kidney disease is advised. Normal = <10 Micro = 20-200 Macro = >200 Nephrotic = >3000

A 45-year-old woman with a 25-year history of type I diabetes presents for follow-up of her diabetes. Her spot albumin/creatinine ratio was 100 mg/g 4 months ago, and it was confirmed at 100 mg/g yesterday. Her urinary analysis shows no cells, casts, or blood. Her creatinine is 0.7mg/dl, and her estimated glomerular filtration rate is 95 ml/min/1.73m2. How would her proteinuria be described? A) Normoalbuminuria B) Microalbuminuria C) Minialbuminuria D) Macroalbuminuria E) Nephrotic syndrome

C) Sclerotherapy This patient's diagnosis is varicose veins. Sclerotherapy can be used to treat varicose veins. It involves the injection of an irritating solution into the varicose vein to promote an inflammatory response, scarring, and obliteration of the lumen Hint: Warfarin is indicated for myocardial infarction or cerebrovascular accident prevention and in patients with atrial fibrillation, mechanical heart valves, or deep venous thrombosis Hint: Cilostazol and clopidogrel both inhibit platelets. Clopidogrel is used in CAD and CVA prevention, as well as post-ST-segment MI. Cilostazol lowers lipid levels and is indicated in peripheral arterial disease.

A 45-year-old woman with a no significant past medical history presents with a 4-month history of dull, aching heaviness sensation in her proximal right leg. She notes that this sensation is provoked by extended periods of standing and walking, and is relieved when she lies in a recumbent position. Her past medical history is remarkable for pregnancy 4 times, the most recent being approximately 2 years ago. She denies a history of smoking, trauma, injuries, fever, chills, chest pain, shortness of breath, hemoptysis, cough, skin changes and coolness, and peripheral edema. Her physical exam reveals several dilated, tortuous, elongated veins along the medial right thigh, which are especially pronounced upon standing. The remainder of the physical exam is normal. *What will be the most appropriate therapeutic approach for this patient at this time?* A) Warfarin (Coumadin) B) Clopidogrel (Plavix) C) Sclerotherapy D) Furosemide (Lasix) E) Cilostazol (Pletal)

C) Hysterectomy Large leiomyomas are the most common indication for hysterectomy in this age group. Hint: Myomectomy is not an option for this large of an intramural fibroid.

A 46 year-old G4P4 African American female presents to the clinic complaining of heavy and prolonged menstrual flow over the past 6 months. Gynecological history includes menarche age 12 and LMP 3 weeks prior. Pelvic exam reveals a 14-week size, irregular uterus. Pelvic ultrasound shows the presence of a large intramural fibroid with normal endometrial lining. Which of the following is the most appropriate management for this patient? A Oral contraceptive pill B Levonorgestrel-releasing IUD C Hysterectomy D myomectomy

A) Menorrhagia Hint: Metrorrhagia is bleeding that occurs at any time between menstrual periods. Hint: Oligomenorrhea describes menstrual periods that occur more than 35 days apart. Hint: Hypomenorrhea is usually light flow, sometimes only spotting.

A 46 year-old woman describes her menstrual periods as regular (occurring every 30 days), prolonged, and with a heavy flow. You document this finding as which of the following? A Menorrhagiaw B Oligomenorrhea C Metrorrhagia D Hypomenorrhea

A) Ethambutol Ethambutol can cause optic neuritis resulting in decreased visual acuity and possible blindness. The medication should be discontinued immediately at the first sign of visual loss. Because of the difficulty in monitoring vision in children, ethambutol is not recommended in this population. Side effects of isoniazid (B) include hepatitis and peripheral neuropathy, the latter of which can be prevented with coadministration of pyridoxine. Pyrazinamide (C) may cause hepatotoxicity and polyarthralgias. Rifampin (D) causes an orange discoloration of body fluids, including urine, tears, sweat and sputum.

A 46-year-old man presents with right eye pain and a change in his vision. He was recently diagnosed with tuberculosis and started on a 4-drug regimen. Based on his history and physical exam findings, you are concerned for optic neuritis. Which of the following medications is likely responsible for his symptoms? A) Ethambutol B) Isoniazid C) Pyrazinamide D) Rifampin

B) Pantroprazole, amoxicillin, and clarithromycin twice daily for 2 weeks There are several regimens recommended for H. pylori infection, which is an important cause of peptic ulcer disease and should be treated if found associated with symptoms. The choice of the regimen depends on considerations such as cost, side effects, and ease of administration. Allergy to one of the medications, as well as intolerance, should also be taken into account. Any proton pump inhibitor (PPI) with amoxicillin 1000 mg twice daily and clarithromycin 500 mg twice daily for 2 weeks or PPI with metronidazole 500mg twice daily and clarithromycin 500mg twice daily for 2 weeks are recommended. These are the triple drug therapies available. The other regimens suggested are bismuth, metronidazole, and tetracycline 4 times daily for 2 weeks along with PPI twice daily for 2 weeks or H2 receptor antagonist twice daily for 4 weeks (quadruple drug therapy). Dual therapy with a proton pump inhibitor and an antibiotic (amoxicillin or clarithromycin) is not recommended as primary therapy, since eradication rates are much lower than the above regimens. The most common side effect is a metallic taste in the mouth due to clarithromycin or metronidazole. Amoxicillin can cause diarrhea or a rash. Clarithromycin can also cause nausea, vomiting, abdominal pain, and (rarely) QT prolongation. Metronidazole can cause peripheral neuropathy, seizures, and a disulfiram-like reaction when taken with alcohol. Tetracycline is teratogenic and causes photosensitivity.

A 46-year-old woman presents with a 2-month history of heartburn, epigastric discomfort, nausea, and occasional vomiting. She has a history of hyperlipidemia, controlled with diet and exercise, as well as asthma, for which she takes inhalers as needed. She takes no other medications, including over-the-counter analgesics. Family history is noncontributory. On exam she is afebrile, BP120/70 mm Hg, pulse 74/min, and SPO2 92%. Lungs are clear, and she has minimal epigastric tenderness. Otherwise, physical examination is unremarkable. She is advised by her physician to take lansoprazole once daily, which provides only partial relief. Endoscopy is then recommended, which shows a duodenal ulcer. Biopsy reveals infection with Helicobacter pylori. What would be the recommended regimen at this time? A) Lansoprazole, amoxicillin, and metronidazole twice daily for 2 weeks B) Pantroprazole, amoxicillin, and clarithromycin twice daily for 2 weeks C) Omeprazole, tetracycline, and clarithromycin twice daily for 2 weeks D) Bismuth, metronidazole, and lansoprazole twice daily for 2 weeks E) Bismuth, metronidazole, and tetracycline 4 times daily for 2 weeks

A) Leiomyoma Abnormal uterine bleeding and irregular enlargement of the uterus are most consistent with leiomyoma. Pain is rarely present unless vascular compromise occurs. Hint: While adenomyosis may present with hypermenorrhea, dysmenorrhea is often also present. Physical examination would reveal the presence of diffuse globular uterine enlargement, not the irregular enlargement as noted in the case presented Hint: Endometriosis presents with dyspareunia, dysmenorrhea, and infertility. If the pelvic exam were abnormal, uterine findings would include tender nodules in the cul de sac, not the uterus.

A 47 year-old female presents to the clinic with complaints of prolonged, heavy menses that have been getting progressively worse for 3 years. She denies any pain. On physical examination, enlargement of the uterus with multiple smooth, spherical, firm masses is noted. A CBC is consistent with a mild anemia. Which of the following is the most likely diagnosis? A Leiomyoma B Adenomyosis C Endometriosis D Endometrial polyps

C) Uterine leiomyomata Uterine leiomyomata (fibroid) typically presents with severe dysmenorrhea and menorrhagia. An enlarged, irregular uterus is noted on examination. Hint: endometritis = Fever (>38 C or 100.4 F), tachycardia, abdominal pain, and uterine tenderness after c-section Hint: Endometriosis = Cyclic premenstrual pelvic pain, Dysmenorrhea, Dyspareunia, Dyschezia Hint: Endometrial hyperplasia can cause menorrhagia but is not usually a cause of dysmenorrhea. Endometrial stripe > 4 mm. Due to continuous unopposed estrogens, ex: within 3 years of estrogen only therapy in postmenopausal women.

A 48 year-old G3P3003 female presents to the office complaining of severe secondary dysmenorrhea and menorrhagia over the last 6 months. On physical examination her uterus feels enlarged and irregular. Which of the following is the most likely diagnosis? A) Endometritis B) Endometriosis C) Uterine leiomyomata D) Endometrial Hyperplasia

A) CT urography CT urography with and without contrast should be done to evaluate the upper and lower urinary tract for neoplasms, and benign conditions such as urolithiasis. This has replaced IVP for imaging of the upper tracts. Abdominal ultrasound will not help in this scenario and the role of renal ultrasound in evaluation of hematuria is unclear. Cystoscopy will help to assess the bladder and urethra but will not help with evaluation of the upper urinary tract.

A 48 year-old female presents to the clinic complaining of hematuria. The patient states that she was found to have hematuria during an insurance physical examination. The patient denies dysuria or frequency. She also denies pain in the abdomen, flank or meatus. She denies any history of previous nephrolithiasis. Urinalysis reveals the urine to be yellow and slightly hazy with a positive dipstick for hemoglobin. Microscopic reveals 5-7 RBCs/HPF without WBCs, bacteria, casts, or crystals. What is the next diagnostic study this patient should undergo? A CT urography B Intravenous pyelogram C Abdominal ultrasound D Cystoscopy

D) Purpura Hemolytic-uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are microvascular thrombotic disorders associated with platelet aggregation, thrombocytopenia, erythrocyte injury, and elevated serum lactate dehydrogenase levels. They both present with microangiopathic hemolytic anemia, thrombocytopenia, and renal failure, but TTP may have concurrent neurologic abnormalities and fever. Both diseases are associated with thrombocytopenia that often leads to purpura, petechiae, and bleeding. HUS usually occurs in children 5-10 days after an episode of E. coli-induced bloody diarrhea, in which the shiga toxin activates platelets and renovascular cells leading to thrombosis. TTP usually occurs in adults and can be idiopathic or secondary to drugs, autoimmune disease, pregnancy, or HIV. In TTP, the pathophysiology is based on an inhibition of the enzyme ADAMTS13, which leads to large multimers of von Willebrand factor. The exact distinction between HUS and TTP can be difficult; they share common symptoms. As in any hemolytic state, the peripheral blood smear will have schistocytes (fragmented erythrocytes, also called helmet cells). If either condition is suspected, urgent plasmapheresis (remove plasma and replace with fresh frozen plasma) is performed daily for 1-8 weeks until the lactate dehydrogenase or hemoglobin normalizes. Consider administering corticosteroids for inadequate response to plasmapheresis and splenectomy for recurrent cases. Prompt recognition of TTP is important because the disease responds well to plasma-exchange treatment but is associated with a high mortality rate when untreated.

A 49-year-old man presents with mental status changes and fever. Brain CT scan is normal. His urine toxicology screen is negative. Laboratory findings show a serum sodium of 137 mEq/L, serum potassium of 5.1 mEq/L, serum creatinine of 1.9 mg/dL, WBC of 9 000/L, hemoglobin of 9.3 g/dL, and platelets of 19 000/L. Which of the following would you expect to see on skin examination? A) Acanthosis nigricans B) Erythromelalgia C) No abnormalities D) Purpura

C) Post-streptococcal glomerulonephritis Post-streptococcal glomerulonephritis classically presents as hematuria that begins 1-2 weeks after an episode of streptococcal pharyngitis or 3-6 weeks after a streptococcal skin infection. Often the initial infection is mild and thus does not lead to medical evaluation or recognition. Affected children are typically 5 - 12 years old with a mean age of 7 years old. Treatment is supportive. Although > 60% of patients briefly develop hypertension, > 95% make a full recovery. Inherited or acquired coagulopathy (A) may also present with acute hematuria. However, other symptoms of coagulopathy almost always occur prior to the onset of microscopic or gross hematuria. IgA nephropathy (B) may also cause gross hematuria. However, hematuria caused by IgA nephropathy begins within 1-2 days of the onset of upper respiratory or gastrointestinal infection. Urinary tract infection (D) may cause hematuria, but symptoms of dysuria, urinary frequency, and urinary urgency are more common. Moreover, urinary tract infections are rare in school-aged boys.

A 5-year-old boy has acute onset of hematuria, periorbital edema, and hypertension. He has no other complaints and review of systems is unremarkable. Recent medical history is significant for a "cold" last week. What is the most likely etiology of his hematuria? A) Coagulopathy B) IgA nephropathy C) Post-streptococcal glomerulonephritis D) Urinary tract infection

E) Polymerase Chain Reaction assay and antigen detection he characteristics presented by this child suggest B. pertussisor parapertussis infection. The diagnosis of pertussis is still primarily clinical, and laboratory results only play a small role in the diagnostics. Chest X-ray cannot confirm the suspected diagnosis. WBC count is likely to be elevated, with the lymphocytes composing 70 - 80% of the total count. The infection can be directly confirmed by culture for Bordetella pertussis, but it takes several days, and there is a high rate of false negative results. Immunofluorescent staining of nasopharyngeal washing can be done, and it is significantly more sensitive than culture. Although culture used to be the gold standard, PCR assay and antigen detection are now considered more reliable. PCR assay and antigen detection are increasingly used to assist in diagnosing pertussis. Advantages include greater sensitivity, more rapidly available results, and use later in the disease course or after antimicrobial therapy because the tests do not rely on the isolation of viable organisms. Their use is limited by lack of standardization and incomplete understanding of the correlation between test results and the course of the illness.

A 5-year-old girl has paroxysms of cough that increase in severity and duration. Some coughing episodes are followed by a whooplike, high-pitched inspiratory noise, and vomiting has also occurred after paroxysms. What laboratory test could lead to the earliest confirmation of the likely diagnosis? A) Chest X-ray B) Blood cell analysis C) Culture D) Immunofluorescent antibody staining E) Polymerase Chain Reaction assay and antigen detection

A) Hepatocellular carcinoma This patient has signs and symptoms consistent with *hemochromatosis*, which is associated with hepatocellular carcinoma. Hemochromatosis is due to an increase in iron within the tissues. Hemochromatosis is a disorder of iron overload; it could be due to genetic or non-genetic causes. In hereditary hemochromatosis, there is absorption of a few milligrams of iron each day, in excess of need. As such, clinical manifestations often occur only after the age of 40 years, when body iron stores have reached 15 to 40 g. The symptoms of hemochromatosis are nonspecific and include arthralgia; abdominal pain; fatigue, weakness; impotence; weight loss; amenorrhea and early menopause; abnormal skin pigmentation; damage to the pancreas leading to diabetes; cardiomyopathy; and cirrhosis. The liver is commonly affected with hemochromatosis, and hepatosplenomegaly is commonly seen. There is an abnormal skin pigmentation that is seen with hemochromatosis. In hemochromatosis, the plasma iron will be elevated; total iron binding capacity will be normal or low; and transferrin saturation will be elevated. Hepatocellular carcinoma is the most serious complication, and it is a major cause of death in patients with hemochromatosis. A large percentage of patients with hemochromatosis will develop problems with their pancreas; however, the pancreatic pathology commonly seen with hemochromatosis is insulin dependent diabetes, not pancreatic cancer.

A 50-year-old man presents with a 3-month history of weakness, fatigue, and abdominal discomfort. Upon further questioning, he acknowledges a lack of sexual desire. He denies any photosensitivity. On physical examination, his liver is enlarged, and his spleen is palpable. He has abnormal skin pigmentation on his face, neck and his elbows and which gives his skin a *metallic gray hue*. His laboratory results are in the chart. *What serious complication is associated with the patient's condition?* A) Hepatocellular carcinoma B) Bronchogenic carcinoma C) Pancreatic carcinoma D) Lymphoma E) Leukemia

A) Direct inguinal hernia Direct inguinal hernia is correct because the direct inguinal hernia enters through the weakened abdominal fascia and into the anatomic region known as Hesselbach's Triangle. This area is bordered by the rectus abdominus, the inferior epigastric artery, and the inguinal ligament. Femoral hernias, indirect inguinal hernias, and umbilical hernias do not traverse through Hesselbach's triangle. There was no previous surgery for an incisional hernia to occur.

A 50-year-old man presents with a lump in his groin for 2 weeks. He states he was lifting an air conditioner and he felt a pop in his groin and began to notice an outpouching in his lower abdomen that has become mildly tender over the last week. Resting and lying flat appears to help, and standing and lifting aggravates it. He denies any fevers, nausea, vomiting, or changes in bowel habits. Patient denies any previous abdominal surgeries or procedures. Upon examination, you identify a soft, reducible mass in the lower abdomen and hernia examination reveals a mass pushing against the side of your finger. You order an ultrasound of the lower abdomen and find the intestinal sac has traversed through a weakened area of the abdominal wall and through Hesselbach's Triangle. This type of hernia is referred to as a(n) A) Direct inguinal hernia B) Femoral hernia C) Indirect inguinal hernia D) Umbilical hernia E) Incisional hernia

B) No diagnostic tests are necessary This patient's diagnosis is a posterior anal fissure. Along with a history, the diagnosis can usually be made based on findings from a gentle perianal examination with inspection of the anal mucosa. In this case, no diagnostic procedures are required. A digital rectal examination is painful and often can be deferred. Anoscopy may be required for lesions that are not well-visualized; however, this is not well tolerated by a patient with an acute anal fissure. In this case, anoscopy can often be deferred; the patient can be treated based only on the symptoms. If an ordinary anal fissure is suspected, and if it is located in the posterior or anterior midline, then no laboratory or imaging tests are necessary. If the fissure is off the midline or irregular, or if an underlying illness (e.g., Crohn disease, squamous cell cancer, AIDS) may be present, then the appropriate tests should be ordered. These tests include erythrocyte sedimentation rate, stool and viral cultures, human immunodeficiency virus (HIV)testing,and biopsy of the lesion/fissure.

A 51-year-old man presents with a 3-day history of severe pain associated with bowel movements. The pain lasts up to 1 hour following each bowel movement. His stools are described as "hard", but they retain their normal brown color, with the occasional presence of a few drops of bright red blood. His dietary history is remarkable for a low-fiber diet lacking in raw fruits and vegetables. He denies any sexual contact, drug use, or other gastrointestinal symptoms. He takes ferrous sulfate for anemia and oxycodone for chronic joint pain. His rectal exam reveals a small tear in the lining of the anus. What is the most appropriate diagnostic test to order at this time? A) CT scan of the abdomen and pelvis B) No diagnostic tests are necessary C) HIV ELISA test D) Anoscopy E) Rectal biopsy

A) Total abdominal hysterectomy Atypical adenomatous hyperplasia contains cellular atypia and mitotic figures in addition to glandular crowding and complexity. This has a 20-30% risk of progression to endometrial cancer and the recommendation is hysterectomy. Hint: C) Endometrial curettage would remove the hyperplasia and progesterone will decrease the endometrial glandular proliferation. This would be appropriate management in a patient with endometrial hyperplasia without atypia. Hint: Observation and biopsy again in 3 months would increase the risk of endometrial cancer for this patient. Hint: Oral progesterone for 10 days of the month will cause the patient to have a withdrawal bleed every month. This would be an appropriate treatment in a premenopausal patient with endometrial hyperplasia without atypia

A 52 year-old obese patient with persistent heavy menses undergoes an endometrial biopsy and is diagnosed with atypical adenomatous hyperplasia. What is the next step in the management of this patient? A) Total abdominal hysterectomy B) Observation and endometrial biopsy in 3 months C) Endometrial curettage followed by progesterone daily D) Oral progesterone days 16-25 of the month for 6 months and repeat biopsy

Intestinal obstruction Intestinal obstruction without complications is suggested by crampy pain, abdominal distention, hyperactive bowel sounds, visible peristalsis, and minimal tenderness.

A 52-year-old female presents with diffuse abdominal pain accompanied by distention and visible peristalsis. Ausculation reveals hyperactive bowel sounds. Percussion is tympanic throughout. Palpation reveals mild diffuse tenderness without masses. The most likely diagnosis is

No intervention Telemetry observation (C) is not required in type 1 second-degree heart block because it does not typically progress into other forms of heart block.

A 52-year-old man presents from his primary care physician's office for evaluation of an abnormal electrocardiogram. His ECG reveals Type 1 second-degree atrioventricular (AV) block. He has no symptoms. What is the appropriate intervention?

C) NSAIDs (Non-steroidal anti-inflammatory drugs) The patient has pleuritis without effusion. Pleuritis is inflammation of the pleura. It may occur with or without effusion and is characterized by a sharp pain worsened by cough and inspiration. The pain may radiate to the shoulder if the diaphragmatic pleura is affected and pressure around the area of inflammation may produce pain. Friction rub is heard on auscultation. The pleuritic chest pain causes shallow rapid breaths. The presentation with flu-like illness, malaise, absence of history of collagen vascular disease, and CXR findings makes the most likely etiology viral in this case. Pleuritis is treated with NSAIDs. Ibuprofen can be given in the dose of 400 - 800 mg orally 3 times daily for pain management in case of pleurisy due to viral etiology. Other examples of etiologic agents are rheumatoid arthritis, systemic lupus erythematosus, radiation, pneumonia, acute pulmonary embolism, and pneumothorax.

A 52-year-old woman living a non-sedentary lifestyle presents with a 5-day history of low-grade fever, flu-like syndrome, sore throat, and malaise. She is mostly bothered by the fact that she has to "catch" her breath because of pain on inspiration and when coughing. She has no known past medical or surgical history; she is not on any medication, and she has no pertinent family history. She denies any medication use, including over-the-counter medicines. On physical examination, her vitals are: Temperature 100.6 F, pulse 86/min, BP133/75 mm Hg, and RR 20cycles/min. She has shallow breathing, resonant percussion notes, fair air entry with vesicular breath sounds, and friction rub. Her blood gas on room air is: pH 7.36, PCO2 44 mmHg, PO2 100 mmHg, HCO3 26 mEq\L, O2 saturation 99.8%. Her chest X-ray (CXR) is normal and the D-dimer assay is also normal. What is the most appropriate management modality for this patient? A) Reassurance B) IV heparin C) NSAIDs (Non-steroidal anti-inflammatory drugs) D) V/Q scan (ventilation/perfusion scan) E) CT scan (Computed Tomography)

B) 10 years Small hyperplastic polyps, which are defined as less than 10 mm in size, are not neoplastic and are considered low risk. For patients at low risk the recommended interval between screening colonoscopies in 10 years. Adenoma polyps are the most common sub-classification of neoplastic polyps and always need more frequent monitoring. Patients with only 1 to 2 small (<1cm) tubular adenomas should undergo repeat colonoscopy in 5-10 years (B). Patients with 3-10 adenomas or any adenoma greater than 1 cm, displaying high-grade dysplasia or with villous features, should undergo a repeat colonoscopy at 3 years (C). The interval for more extensive disease is best individualized but can be as often as annually (A) in unusual cases such as sessile adenomas or a familial syndrome.

A 53-year old previously healthy woman visits her primary care physician to review the results from the biopsy obtained from the solitary 8 mm polyp discovered in her colon by a routine colonoscopy. The report confirms that this is a hyperplastic polyp. Her family history is negative for colon cancer. Which one of the following is the most appropriate interval for follow-up colonoscopy in this patient? A) 1 year B) 10 years C) 3 years D) 5 years

A) Arthrocentesis and fluid analysis The patient presents with atraumatic, monoarticular arthritis with warmth and swelling and must have an arthrocentesis to rule out a septic joint. Patients with septic arthritis will typically present with fever, joint pain, swelling and effusion in a single joint. Additionally, patients frequently have warmth of the joint and decreased range of motion. Involvement of multiple joints raises the possibility of meningococcal disease and sepsis. Most septic joints are caused by gram-positive bacteria (75-90%) with Staphylococcus aureus being the most common. Although there are a number of serum lab tests that are often requested in the workup of a possible septic joint (WBC, ESR, CRP) systematic reviews show little evidence that these tests can rule in or out the disease. The only way to obtain a definitive diagnosis is with arthrocentesis and fluid analysis. A synovial fluid WBC count is traditionally considered the most useful test. A WBC >50,000 cells is highly suggestive of a septic joint. Synovial lactate level >5.6 mmol/L has been found to be highly predictive of a septic joint, as well. Treatment of a septic arthritis involves antibiotics and orthopedic consultation for possible open drainage. A serum uric acid level (B) is helpful in the diagnosis of gouty arthritis but not in septic arthritis. Serum WBC count (C) is neither sensitive nor specific for this diagnosis. Radiographs (D) are often performed and may shows effusion or possibly osteomyelitis but are not diagnostic.

A 53-year-old man presents with a swollen, painful left knee. He denies trauma or fever. Examination reveals decreased range of motion of the left knee with swelling and warmth. What test is likely to be diagnostic? A) Arthrocentesis and fluid analysis B) Serum uric acid level C) Serum white blood cell count D) X-ray of the knee

D) Post-operative adhesions Small bowel obstruction commonly presents with abdominal pain, vomiting, and a distended abdomen. Plain radiographs are helpful in making the diagnosis and may show air-fluid levels and dilated loops of bowel. CT scan is more accurate for both confirming the location of the obstruction, as well as helping to identify the cause of the obstruction. Treatment of a partial small bowel obstruction requires that the patient be NPO (without oral intake), placement of a nasogastric tube, and fluid resuscitation with monitoring and correction of electrolytes as needed. A complete bowel obstruction usually requires surgical treatment. Post-operative adhesions are one of the most common causes of all small bowel obstructions. Differential diagnoses of small bowel obstruction include postoperative ileus, large bowel obstruction, acute appendicitis, acute pancreatitis, and infectious causes of abdominal pain.

A 53-year-old woman presents complaining of abdominal pain and vomiting that is worsening over the last 2 days. She denies chronic medical issues. She has a history of an appendectomy and cholecystectomy, as well as two vaginal deliveries. Her exam is remarkable for abdominal rushes, gurgles and high-pitched sounds, as well as abdominal tenderness to palpation. Plain abdominal radiography shows dilated loops of small bowel with air-fluid levels. What is the most likely etiology of her diagnosis? A) Abdominal hernia B) Diverticulosis C) Intussusception D) Post-operative adhesions

D) Chronic bronchitis he clinical picture is suggestive of chronic bronchitis. Chronic bronchitis is defined by a clinical history of productive cough for 3 months of the year for 2 consecutive years. Smoking is the leading cause. The principle pathologic feature is airway injury and narrowing, hypertrophy of the airway mucous glands, infiltrate of inflammatory cells, and loss of ciliated epithelium. The cough produces thick, often purulent sputum because of the ongoing local inflammation and the high likelihood of bacterial colonization and infection. The increased mucous production and defective mucociliary escalator function leads to inspiratory and expiratory crackles. On imaging, common findings are hyperinflation of lung volumes, depressed diaphragm, and parallel linear densities known as tram track lines. Asthma produces wheezing lung sounds. They are not heard in this patient. A productive cough is not a clinical manifestation of emphysema. Pulmonary edema may present with mild exertional dyspnea or a nonproductive cough, although a frothy or blood-tinged sputum may be seen. Pulmonary fibrosis is a restrictive lung disease with the clinical features of progressive dyspnea. It is typically accompanied by a dry, persistent hacking cough.

A 53-year-old woman presents with a 1-year history of chronic cough. The cough produces large volumes of grossly purulent sputum. She has a history of recurrent respiratory infections; they resulted in 5 hospitalizations in the past year. She also had similar complaints during the previous year.. Shortness of breath limits her daily activity considerably. Upon pulmonary examination, bilateral breath sounds are audible, with inspiratory and expiratory crackles at the lung bases. Chest X-rays reveal increased lung volumes, flattened diaphragm, and tram track lines. *What is the initial diagnosis?* A) Asthma B) Emphysema C) Pulmonary edema D) Chronic bronchitis E) Pulmonary fibrosis

B) Atrophic vaginitis Atrophic vaginitis is typically caused by reduced estrogen levels producing intense itching and thin vaginal mucosa with a resultant yellowish discharge that has a pH > 5.5. Hint: Lichen sclerosis is a benign, chronic inflammatory process and the most common vulvar dermatologic disorder. During the acute phase the lesions appear red or purple and involve the non hair bearing areas of the vulva and perianal areas. Erythema and edema of the skin occur.

A 54 year-old female comes to your office with the complaint of vaginal itching. Her last menstrual period was three years ago. On examination the patient's vulva is smooth and somewhat shiny; her vaginal mucosa is pale and thin with a mild yellowish discharge with a pH of 6.0. The most likely cause of these symptoms is which of the following? A) Lichen sclerosis B) Atrophic vaginitis C) Contact Dermatitis D) Candidiasis

C) Adenocarcinoma of esophagus Barrett's esophagus is an abnormality of the distal esophagus characterized by the replacement of normal squamous epithelium by metaplastic columnar epithelium with goblet cells, as a result of continuous inflammation most commonly from acid reflux. This is a premalignant condition with potential to develop into adenocarcinoma over time. Surveillance with screening endoscopy and mucosal biopsy is indicated to detect early onset of high grade dysplasia, which is then treated with esophagectomy. Failure to be compliant with the screening regimen may lead to adenocarcinoma of the esophagus, which has a poor prognosis as it presents late.

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 unexceptional. 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. This screening was recommended to him because he is in danger of developing A) Achalasia of the cardia B) Esophageal stricture C) Adenocarcinoma of esophagus D) Squamous cell carcinoma of esophagus

C) Diabetes mellitus Diabetes mellitus (DM) is an independent risk factor for atherosclerosis. The risk of myocardial infarction (MI) in a patient with diabetes is the same risk as someone without diabetes who has had a previous MI. The risk of death from cardiac events is also the same between the 2 groups. Patients with diabetes mellitus should be advised to stop smoking and aggressively control other risk factors, such as glucose, hypertension, and dyslipidemia, in order to reduce the risk of ischemic heart disease.

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 126/80, pulse 100, respirations 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 largest risk factor for an acute myocardial infarction?* A) Alcohol use B) Cigarette smoking C) Diabetes mellitus D) Hypertension E) Obesity

A) Atrophic vaginitis It is unlikely that a patient with a normal temperature and absence of vaginal discharge has any of the common vaginal infections, including bacterial vaginosis (B) and candidiasis (C). Vulvar lichen planus (D) commonly occurs in postmenopausal women, but manifests as an erosive dermatitis associated with intense pruritus, burning and vulvar pain. Menopause can be defined as amenorrhea for greater than 12 months. Atrophic vaginitis, also referred to as urogenital atrophy, is a major cause of vaginal dryness in postmenopausal women, occurring in about 40% of this population. The generalized loss of estrogens, which is the hallmark hormone alteration associated with menopause, causes thinning of the urogenital epithelium. Vaginal dryness ensues, as well as burning, pruritus, discharge, bleeding and possibly dyspareunia (painful sexual intercourse subsequent to decreased vaginal lubrication).

A 54-year-old woman, whose last menstrual period was more than 2 years ago, complains of vaginal dryness and irritation. She denies any recent infection or sexual activity. She is afebrile with normal vital signs. Visual inspection of the vaginal canal reveals pale, dry and shiny epithelium without frank discharge or superficial lesions. Which of the following conditions is the most likely diagnosis? A) Atrophic vaginitis B) Bacterial vaginosis C) Candidiasis D) Vulvar lichen planus

B) If the fluid has a protein concentration below 3 g/dL After the diagnosis of ascites is made by physical examination, all patients with new-onset ascites should undergo abdominal paracentesis and ascitic fluid analysis. The most important tests to order for fluid analysis include protein concentration and cell count. Fluids with protein concentration above 3 g/dL are designated as exudates. Those with values below 3 g/dL are designated as transudates. Diseases usually associated with transudates include congestive heart failure, cirrhosis, constrictive pericarditis, inferior vena cava obstruction, hypoalbuminemia, Meigs syndrome, and some cases of nephrotic syndrome. The amount of albumin in the ascitic fluid compared to the serum albumin (the Serum Ascites Albumin Gradient, SAAG) can be indicative of the cause of ascites. Ascites related to hypertension, cirrhosis, or congestive heart failure generally shows a SAAG greater than 1.1 g/dL. Exudates are more commonly seen with peritoneal neoplasm, pancreatic ascites, myxedema, and tuberculous peritonitis. A large number of red blood cells in the fluid or grossly bloody ascites suggests a diagnosis of neoplasm. An acidic fluid and leukocyte count of more than 500/mm3 strongly suggests a peritoneal infection or inflammatory process. Other tests that should be ordered in the appropriate clinical setting include cytologic examination, lactic dehydrogenase (LDH), specific tumor markers, glucose, and cultures for bacteria, mycobacteria, and fungi.

A 55-year-old African-American man presents as febrile with massive swelling of the abdomen and diarrhea. He has a 20-year history of heavy alcohol use. A fluid wave is elicited on physical examination of the abdomen by striking one flank and feeling the transmitted wave on the opposite flank. *In what case would ascitic fluid analysis suggest cirrhosis as a cause of ascites in this patient?* A) If the acidic fluid and leukocyte count is more than 500/mm3 B) If the fluid has a protein concentration below 3 g/dL C) If there is a large number of red blood cells in the fluid D) If fluid is designated as an exudate E) If the Serum Ascites Albumin Gradient is lower than 1.1 g/dL

D) A 2 mm ST-segment depression is seen on the ECG at peak exercis u) A. An increase in systolic blood pressure is an expected normal response during this test. (u) B. Heart rate should reach maximal value during exercise. (u) C. Random premature ventricular beats are not uncommon during peak exercise and do not indicate CAD. (c) D. A 2 mm ST-segment depression is suggestive of cardiac ischemia and is considered to be an abnormal finding

A 55-year-old male presents complaining of episodic substernal chest pain that occurs especially during strenuous exercise. Suspecting coronary artery disease (CAD), an exercise stress test is ordered. The test is considered to be abnormal if which of the following occurs? A) Systolic blood pressure increases during exercise. B) The heart rate reaches maximal value during exercise. C) Random premature ventricular beats occur at peak exercise. D) A 2 mm ST-segment depression is seen on the ECG at peak exercis

C) 5 years to 10 years Colonic polyps occur in 30-50% of adults. Risk factors include age, genetic predisposition, a diet high in fat, red meat and low in fiber, tobacco use and obesity. There are three main types of polyps: hyperplastic (no risk of malignant transformation), adenomatous (most common; possible risk of malignant transformation) and malignant (already cancerous). Polyps may cause rectal bleeding (frank or occult), but typically, they are asymptomatic. They are commonly detected on sigmoidoscopy or colonoscopy, and usually removed if found. Microscopic examination is then performed to evaluate for the presence of malignant cells. Polypectomy carries the complication risks of bleeding and perforation. After polypectomy, for 1-2 small (<10 mm) tubular adenomas, repeat colonoscopy is recommended within 5 to 10 years.

A 55-year-old patient just had his first colonoscopy and uncomplicated polypectomy for 1-2 small (<10 mm) tubular adenomas. He has no family history of cancer. In the majority of patients, what is the time frame recommended for a repeat colonoscopy after an initial colonoscopy and polypectomy is performed? A) 1 year to 3 years B) 3 years to 5 years C) 5 years to 10 years D) 6 months to 1 year

B) Endometrial biopsy Abdominal ultrasound (A) is not recommended for women with postmenopausal vaginal bleeding. If ultrasound needs to be used, transvaginal ultrasound is the appropriate diagnostic test to order. Postmenopausal women with an endometrial thickness < 3-4 mm on transvaginal ultrasound are unlikely to have endometrial carcinoma. Hysterectomy (C) may be indicated based on the results of the diagnostic imaging, but is not an initial step in management of postmenopausal vaginal bleeding. All women who present with postmenopausal vaginal bleeding should be evaluated with either endometrial biopsy or transvaginal ultrasound, there is no role for watchful waiting (D).

A 55-year-old postmenopausal woman presents to your office with a complaint of vaginal bleeding. Which of the following is the most appropriate next step in management? A) Abdominal ultrasound B) Endometrial biopsy C) Hysterectomy D) Watchful waiting

E) Low sodium diet he clinical picture is suggestive of *Meniere's disease*. The classic syndrome consists of episodic vertigo lasting 20 minutes to several hours associated with fluctuating low-frequency sensorineural hearing loss, tinnitus, and a sensation of aural pressure. The Dix-Hallpike maneuver is a diagnostic maneuver for benign paroxymal positional vertigo. Treatment involves a low sodium diet and diuretics. Restricting water intake will lead to dehydration and an increase in sodium levels, worsening the symptoms of Meniere's disease. Diazepam can be used for Meniere's disease but is usually used for severe vertigo. The question is indicating initial treatment. Diazepam is used in the treatment of vestibular neuronitis. In vestibular neuronitis, a paroxymal, usually single attack of vertigo occurs without accompanying impairment of auditory functions and will persist for several days to weeks before clearing. Examination reveals nystagmus. These symptoms are not present in this patient. Antibiotics are not indicated for Meniere's disease. Fluticasone propionate is an anti-inflammatory nasal spray used to treat the nasal symptoms of indoor and outdoor nasal allergies and year-round nonallergic nasal symptoms. Fluticasone helps reduce the inflammation that leads to nasal symptoms that include congestion, sneezing, and itchy, runny nose which are not indicated in this patient

A 55-year-old woman comes to your clinic presenting with episodic vertigo, tinnitus, hearing loss, and ear fullness. Her ear and eye physical examination are unremarkable. You perform a Dix-Hallpike maneuver which is negative. There are no carotid bruits noted on auscultation. Which of the following is the best initial treatment for this patient? A) Restrict water intake B) Diazepam 10 mg BID C) Antibiotics D) Fluticasone propionate E) Low sodium diet

D) Mitral stenosis In mitral regurgitation (C) patients will display a systolic murmur, most often holosystolic, high-pitched and present at the apex with radiation to the axilla, left scapula, middle back, or left sternal border, depending on the direction of the regurgitant jet. The main symptoms of mitral stenosis (MS) are slowly progressive dyspnea and fatigue. Most auscultatory signs of MS are missed if not performed in the left lateral decubitus position. Typically, the first heart sound (S1) is accentuated. A low-pitched diastolic rumble, heard with the bell of the stethoscope over the apex is also present. The high-pitched opening snap (OS) is caused by the abrupt stopping of the domed mitral valve into the left ventricle. Mitral valve stenosis (MS) is predominantly caused by rheumatic carditis and is more prevalent in female patients.

A 55-year-old woman presents to the office with progressive dyspnea, paroxysmal dyspnea, orthopnea, and fatigue over the last several months. On auscultation of her heart you hear a low-pitched diastolic rumble best heard in the left lateral decubitus position along with a high-pitched opening snap. Which type of valvular abnormality is associated with these findings? A) Aortic regurgitaion B) Aortic stenosis C) Mitral regurgitation D) Mitral stenosis

C) Lisinopril Lisinopril, an ACE Inhibitor, should help decrease albuminuria, prevent progression of diabetic kidney disease from micro to macroalbuminuria, and prevent a decline in glomerular filtration rate. This class of medications has been studied extensively for these purposes. Angiotensin II receptor blockers (e.g., irbesartan) may also reduce urinary albumin to normal levels. Monotherapy with either of these classes of medications should be attempted first in patients with microalbuminuria. This will test tolerance, effectiveness, and adverse reaction such as hyperkalemia. For patients with greater degrees of albuminuria (e.g., 1 g/day), poor response to monotherapy and blood pressure control, and no hyperkalemia associated with therapy, combination therapy should be considered. Combination therapy with both ACE inhibitors (e.g., lisinopril) and angiotensin II receptor blockers (e.g., irbesartan) is used to treat both diabetic and non-diabetic kidney disease. These medications act on different parts of the renin angiotensin system. In combination, irbesartan could block the effect of angiotensin produced by non-ACE pathways and lisinopril could block the production of angiotensin stimulated by irbesartan in a negative feedback system; however, combination therapy is usually preceded by monotherapy. Although combination therapy is currently being used in both diabetic and non-diabetic kidney disease, this therapy still being researched. It is unknown whether monotherapy alone is sufficient. It does not appear to be sufficient in all patients, particularly those with persistent micro and macroalbuminuria despite monotherapy.

A 55-year-old woman with a 15-year history of type II diabetes presents for follow-up of her diabetes. Her spot albumin/creatinine ratio was 100 mg/g 4 months ago and was confirmed at 100 mg/g yesterday. Her urinary analysis shows no cells, casts, or blood. Her creatinine is 0.7mg/dl and her estimated glomerular filtration rate is 95 ml/min/1.73m2. *What medication(s) should you prescribe to help prevent her progression from micro to macroalbuminuria and to help prevent a progressive decline in glomerular filtration rate?* A) Potassium chloride B) Calcium carbonate C) Lisinopril D) Sodium bicarbonate E) Calcium citrate

MVR is the definitive intervention to correct MR caused by papillary muscle rupture.

A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 *pansystolic murmur radiating to the axilla*. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention?

B Mitral valve replacement MVR is the definitive intervention to correct MR caused by papillary muscle rupture Hint: CABG may be necessary if significant blockage is found, but it will not correct the mitral regurgitation.

A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention? A Intra-aortic balloon counterpulsation B Mitral valve replacement C Coronary artery bypass surgery D Immediate fluid bolus

A) Topical estrogen (Estrace) cream This patient has atrophic vaginitis which is very common in postmenopausal patients. The vagina will appear atrophied, will look pale, and thin and dry in appearance. Best to treat with topical or oral estrogen preparations. Hint: MetroGel is the drug of choice for bacterial vaginosis.

A 56 year-old female patient comes to the office for evaluation. She complains of dyspareunia and a thin vaginal discharge. On physical examination atrophic vulvar changes are noted associated with vaginal petechiae and a thin clear discharge. What medication is recommended to treat this patient's symptoms? A) Topical estrogen (Estrace) cream B) Topical hydrocortisone (Gynecort) C) Metronidazole (MetroGel) vaginal gel D) Terconazole (Terazol) vaginal suppository

C ultrasound of the abdomen An abdominal ultrasound can delineate the transverse and longitudinal dimensions of an abdominal aortic aneurysm and may detect mural thrombus. Abdominal ultrasound is best used to screen patients at risk for the development of this condition Hint: Although some abdominal aortic aneurysms are calcified, abdominal radiography may demonstrate the calcified outline of the aneurysm. However, about 25% of aneurysms are not calcified and cannot be visualized by plain x-ray. Hint: Contrast aortography is used commonly for the evaluation of patients with aneurysms before surgery, but it has no role in the serial assessment of patients being followed on a chronic basis.

A 56 year-old male presents to the office with a history of abdominal aortic aneurysm. He was told that he will need on going evaluation to assess whether the aneurysm is expanding. What is the recommended study to utilize in this situation? A plain film of the abdomen B serial abdominal exam C ultrasound of the abdomen D angiography of the abdominal aorta

B) Arterial thrombosis Arterial thrombosis has occurred and is evidenced by the loss of the popliteal and dorsalis pedis pulse. This is a surgical emergency. Venous occlusion and thrombophlebitis do not result in loss of arterial pulse.

A 56 year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities has 2+/4+ pulses throughout. Given these findings what is the most likely diagnosis? A Venous thrombosis B Arterial thrombosis C Thromboangiitis obliterans D Thrombophlebiti

B) Computerized tomographic angiography (CTA) The clinical picture is most compatible with a diagnosis of pulmonary embolism (PE). Pulmonary embolism is a condition in which there is sudden lodgment of a blood clot in a pulmonary artery with cause subsequent obstruction of blood supply to the lung parenchyma. The clinical manifestations of PE are usually nonspecific and vary in frequency and intensity depending on the extent of pulmonary vascular occlusion, pre-embolic cardiopulmonary function, and the development of pulmonary infarction. Small thromboemboli may be asymptomatic. The most common symptoms of PE include dyspnea, pleuritic chest pain, cough, and hemoptysis. Based on the acuity and severity of pulmonary arterial occlusion, PE can be categorized into 4 types as massive PE, acute pulmonary infarction, acute embolism without infarction, and multiple pulmonary emboli. CTA is the initial imaging technique of choice in stable patients. The ventilation perfusion scanning (V/Q)/lung scan is also an important diagnostic modality for the diagnosis of PE with a reasonable possibility of either confirming the diagnosis (with a "high-probability" scan) or ruling it out (with a normal scan). However, CTA has largely replaced it as the initial modality of imaging in stable patients and V/Q scanning is usually done if CT is not available or the person has a contraindication to CT or the intravenous dye.

A 56-year-old man presents with moderately severe chest pain. His pain is substernal and left anterolateral; there is some exacerbation on inspiration, and it has been increasing in severity over the last 36 hours. He works as a truck driver and has a history of heavy cigarette smoking, hypertension, and obesity. Over the past week, he has experienced swelling and discomfort in his right calf. Examination shows: BP - 90/55 mm Hg, P - 122/min, RR - 40/min, and temp - 37.6° C. He is mildly agitated and confused. Systemic examination reveals: heart: tachycardia, soft systolic murmur, questionable ventricular gallop. Chest: dullness to percussion left base with scattered crackles and wheezes throughout. Abdomen: negative. Extremities: right calf is 0.5 cm larger than left with some deep tenderness and a trace of ankle edema. Neurologic: no deficits. Laboratory: Hgb- 16.4g/dL, Hct 51%, WBC 12,300 cells/ µL, PaO2 52 mmHg, PaCO2 38 mmHg, and pH 7.35. Chest radiograph: borderline cardiomegaly and a prominent aorta; scattered patchy infiltrates bilaterally, small left pleural effusion. *What is the most accurate diagnostic modality for diagnosing this patient's condition?* A) Impedance plethysmography B) Computerized tomographic angiography (CTA) C) Spirometry D) Myocardial scan E) Cardiac ultrasound

Surgery Cauda equina syndrome is a rare but serious surgical emergency because the duration of nerve compression is inversely correlated with the likelihood of full neurologic recovery. Hint: While epidural steroids can be effective in treating lumbar disc herniation, in the case of cauda equine syndrome, immediate surgical decompression is mandatory.

A 57 year-old male presents with acute bilateral lower extremity weakness and urinary incontinence that began after he fell earlier today. His examination is significant for bilateral lower extremity sensory deficits and weakness along with decreased rectal sphincter tone. Which of the following is the most appropriate intervention?

C) Membrane stabilization is a critical first step Calcium directly antagonizes the membrane actions of hyperkalemia. Further calcium beyond first 1-2 doses are ineffective. (Caution in Digoxin Toxicity, may worsen, Consider Magnesium as alternative to Calcium) Calcium is recommended for the treatment of moderate to severe hyperkalemia (>6.5 mEq/L) where ECG changes are present or the risk of dysrhythmia is present. Calcium's effect is rapid but transient. It provides membrane stabilization within 1 to 3 minutes of administration. Calcium antagonizes the effects of hyperkalemia at the cellular level. In the setting of hyperkalemia, the resting membrane potential is shifted to a less negative value, that is, from −90 mV to −80 mV, which in turn moves the resting membrane potential closer to the normal threshold potential of −75 mV, resulting in increased myocyte excitability. *When calcium is given, the threshold potential shifts to a less negative value (that is, from −75 mV to −65 mV), so that the initial difference between the resting and threshold potentials of 15 mV can be restored*. The onset of action is less than 3 minutes, and it lasts for about 60 minutes. Calcium gluconate is less tissue toxic than calcium chloride if extravasation occurs.

A 57-year-old man presents to the ED for shortness of breath. He has a history of hypertension, diabetes, and end-stage renal disease. His ECG is seen above. Which of the following is true regarding his management? A) A normal ECG rules out hyperkalemia B) Calcium chloride administration will decrease the serum potassium concentration C) Membrane stabilization is a critical first step D) Repeated doses of IV sodium bicarbonate are recommended until the QRS complex narrows

D) Transvaginal ultrasound (Endometrial Cancer) Transvaginal ultrasound is the *preferred initial diagnostic test of choice* to evaluate painless vaginal bleeding in a postmenopausal patient in order to rule out endometrial (uterine) carcinoma. Transvaginal ultrasonography is used to measure the endometrial thickness, which should be less than 5 mm in a healthy patient. Colposcopy (A) is not indicated given the patient's normal Papanikolaou smear. Hysteroscopy (B) should be performed in the operating room if an office endometrial biopsy is not obtainable. A repeat Papanikolaou smear (C) is used to diagnose cervical cancer but not endometrial cancer. This patient also has a history of negative smears in the past, including one only a year ago.

A 58-year old postmenopausal woman presents with painless vaginal bleeding. Her last menses occurred 5 years ago. She reports that her Papanikolaou smears have always been normal; the last one was obtained a year ago. Which of the following is the next step in management? A) Colposcopy with endocervical curettage B) Hysteroscopy C) Repeat Papanikolaou smear D) Transvaginal ultrasound

B) Dilated cardiomyopathy The cause of the patient's dyspnea and fatigue is dilated cardiomyopathy. Dilated cardiomyopathy is caused by diminished cardiac contractility secondary to myocyte destruction.1 Multiple conditions can result in the death of the myocytes including chronic alcohol abuse and ischemia.1 The findings of an elevated BNP, cardiomegaly on CXR with decreased contractility, left ventricular enlargement, and systolic dysfunction on echo provide the diagnosis of dilated cardiomyopathy.

A 58-year-old man with a history of alcoholism presents with a 3-week history of dyspnea and fatigue. He has not seen a medical provider in multiple years and has no known medical diagnoses. He takes no daily medications. Work up reveals a normal troponin, elevated BNP, lateral T wave inversion on EKG, and evidence of cardiomegaly on CXR. You order a stat echo, which shows enlarged left ventricle and systolic heart failure evidenced by decreased contractility. What is the *most likely cause of the patient's dyspnea and fatigue?* A) Acute myocardial infarction B) Dilated cardiomyopathy C) Acute pericarditis D) Cardiac ischemia E) Chronic obstructive pulmonary disease

A) Administration of 60 mg of prednisone and referral to ophthalmology Giant cell arteritis is a vascular syndrome characterized by inflammation of medium and large-sized arteries. Also called temporal arteritis, this vasculitis involves arteries in multiple locations including the temporal artery. Clinical manifestations include headache, fever, polymyalgia rheumatica, systemic inflammation, anemia, and elevated erythrocyte sedimentation rate. Risk factors include age greater than 50 years, female sex and Scandinavian background. The primary goals of treatment are to reduce systemic symptoms and prevent vision loss, therefore immediate administration of high-dose prednisone with referral to ophthalmology is indicated. Diagnosis is confirmed by temporal artery biopsy, however treatment should be administered as soon as symptoms occur and not wait for biopsy results.

A 58-year-old woman presents to your office with complaints of headache, a temperature of 101.1°F, anorexia, and morning stiffness in her hips and shoulders. She indicates that this morning her vision was blurry, whereas yesterday it was normal. Which of the following is the most appropriate next step in management? A) Administration of 60 mg of prednisone and referral to ophthalmology B) Administration of 800 mg of ibuprofen and referral to neurology C) Administration of 800 mg of ibuprofen and referral to rheumatology D) Supportive care only

Phalen's Test - this is carpal tunnel

A 58-year-old woman who works on an assembly line complains of bilateral wrist pain for the last several months. She describes pain, numbness, and paresthesias in her thumb, index, and long fingers. Which of the following tests is most likely to be positive?

Prescribe a vaginal ring containing estradiol Avoidance of vaginal intercourse (A) may actually be harmful to patients with vaginal atrophy, as continuing to engage in intercourse usually helps prevent further tissue shrinkage. Recommending use of over-the-counter lubricants can aid patients in continuing coitus. Gabapentin taken nightly (D) will not benefit women with complaints of vaginal atrophy. This treatment would be more effective if the patient's post-menopausal symptoms manifested primarily as hot flushes. Oral conjugated estrogen preparations (C) are an inappropriate choice to manage this patient's symptoms due to the risks associated with using systemic, unopposed estrogen. In women with an intact uterus, estrogen should always be prescribed with an opposing progestin regimen to prevent endometrial hyperplasia and consequently endometrial carcinoma.

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

Anticoagulation = prevents further clots (LMWH, UFH) Hint: Thrombolysis - Dissolves active clots - (Streptokinase, Urokinase, Alteplase) is contraindicated in patients within 10 days of having major surgery.

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain *one week post total abdominal hysterectomy*. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient?

*Erythromycin* This is *pneumonia caused by Chlamydia trachomatis.*

A 6-week-old infant is brought to the Emergency Room with parental concern for one week of cough and congestion. Although her *cough has worsened*, she *remains afebrile*. Chest radiography reveals *bilateral interstitial infiltrates* and hyper-expansion. What is the cause and treatment of choice?

C) Generalized non-bullous, non-vesicular rash A type of acute, self-limiting, mucocutaneous vasculitis Kawasaki disease is the leading cause of acquired heart disease in children in the USA. Also an elevated ESR and CRP levels would suggest Kawasaki. Occurs significantly more often in Asians or native Pacific Islanders than in whites and mainly in children between 3 months and 5 years, boys more than girls. The presence of a generalized non-bullous, non-vesicular rash raises the suspicion for Kawasaki disease. (B) Other conditions that can present with a similar rash include *streptococcal disease*, which can present with tonsillar exudates (Strep. pharyngitis) or a fine maculopapular "sandpaper" rash (B) as in Scarlet fever. However, conjunctivitis and swelling or erythema of the hands and feet are uncommon. *(D) Measles* presents with similar symptoms (fever, red eyes, erythematous oropharynx, and rash), however it is rare in vaccinated children and it has a characteristic macular papular rash that starts at the head and spreads caudally. *(A) Rocky Mountain spotted fever* is usually characterized by a centripetally spreading rash that eventually becomes petechial.

A 6-year-old boy presents with fever and on physical exam has a strawberry tongue, red cracked lips, bilateral conjunctival injection, and palmar erythema. Which of the following increases suspicion for Kawasaki disease? A) Centripetally (tending to move toward a center) spreading petechial rash B) Fine "sand paper" maculopapular rash C) Generalized non-bullous, non-vesicular rash D) Macular papular rash starting at the head and spreading caudally

CABG indicated in patients with stenosis of the left main coronary artery and those with three-vessel CAD. Hint: Percutaneous transluminal coronary angioplasty is not the management of choice in left mainstem artery disease because of increased potential complications and mortality. Hint: Medical management is appropriate only for patients who are not surgical candidates.

A 60 year-old male has unstable angina, but is otherwise healthy. A 90% lesion is found in the left main coronary artery. Which of the following interventions is most appropriate?

A) Aortic dissection (The scenario presented here is typical of an ascending aortic dissection.) Hint: In an acute myocardial infarction the pain builds up gradually. Hint: Cardiac tamponade may occur with a dissection into the pericardial space; syncope is usually seen with this occurrence. Hint: Pulmonary embolism is usually associated with dyspnea along with chest pain.

A 60 year-old male is brought to the ED complaining of severe onset of chest pain and intrascapular pain. The patient states that the pain feels as though "something is ripping and tearing". The patient appears shocky; the skin is cool and clammy. The patient has an impaired sensorium. Physical examination reveals a loud diastolic murmur and variation in blood pressure between the right and left arm. Based upon this presentation what is the most likely diagnosis? A) Aortic dissection B) Acute myocardial infarction C) Cardiac tamponade D) Pulmonary embolism

Atelectasis MC cause of fever <48 hrs after surgery!!! Atelectasis is the most common pulmonary complication, affecting 25% of patients with abdominal surgery. It is more common in elderly and overweight patients and occurs within the first 12 to 24 hours postoperatively. Hint: Wound infection does not present this early

A 60 year-old patient returned from the recovery room to the floor following a subtotal gastrectomy. At 3 AM the next morning, the patient's temperature is 102° F (39° C) and pulse is 112/min. Which of the following is the most likely cause?

Combination chemotherapy Combination chemotherapy is the treatment of choice for a patient with small-cell carcinoma of the lung.

A 62 year-old male presents with a right hilar mass. Needle-biopsy of the mass reveals the presence of small-cell carcinoma and a bone scan reveals the presence of scattered hot spots throughout the skeleton. Which of the following is the most appropriate treatment?

Pancreatic cancer Pancreatic cancer is suggested by the *vague epigastric pain with the jaundice* resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (*Courvoisier's sign*) also indicates obstruction due to the cancer.

A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis?

A) Euthyroid sick syndrome Euthyroid sick syndrome can be described as abnormal findings on thyroid function tests that occur in the setting of a nonthyroidal illness, without preexisting hypothalamic-pituitary and thyroid gland dysfunction. This is most commonly diagnosed in a hospitalized patient and after recovery from the underlying illness. The thyroid function test abnormalities subsequently resolve. The most prominent alterations are low serum triiodothyronine (T3). Thyroid-stimulating hormone (TSH), thyroxine (T4), and free T4 (FT4) are also affected in variable degrees based on the severity and duration of the nonthyroidal illness. As the severity of the underlying illness increases, both serum T3 and T4 levels drop and gradually normalize as the patient recovers.

A 62-year-old man is admitted to the hospital for sepsis secondary to a urinary tract infection. His medical history is significant only for hypertension. On examination he has a temperature of 36.5°C, a TSH level of 0.2 μU/mL (N 0.4-5.0), and a free T4 level of 0.4 ng/dL (N 0.6-1.5). Which one of the following is the most likely explanation for these findings? A) Euthyroid sick syndrome B) Graves' disease C) Subacute thyroiditis D) Subclinical hyperthyroidism

D) Place the patient on a cardiac monitor, give the patient oxygen if hypoxic and administer aspirin This patient has an acute myocardial infarction (MI), An ischemic right ventricle becomes preload dependent because it can no longer pump blood to the left side of the heart. Administering nitroglycerin (C) (a preload reducer) to a patient having ischemia of the right ventricle can lead to severe hypotension. Because the right coronary artery often supplies the inferior aspect of the heart and the right ventricle, whenever there is evidence of ST-segment elevation in the inferior leads (II, III, aVF), it is important to exclude a right ventricular infarct by obtaining "right-sided leads." This is performed by placing the precordial leads on the right side of the patient's chest instead of the left. Lead rV4 is thought to be the most sensitive in identifying a right ventricular infarct. Similarly, labs, including serial cardiac biomarkers (troponin) should be drawn; however, this is not the most appropriate next step. It is important to notify the cath lab (B) of the patient's need for percutaneous intervention, but the first priority are the ABCs and administering an aspirin. The cath lab should be notified immediately after this is performed. Although a stress test (A) would be useful in a patient with cardiac risk factors, this patient has active cardiac symptoms and the ACC/AHA guidelines recommend such testing be performed when patients are free of ischemic or heart failure symptoms for at least 8-12 hours. In addition, this patient has evidence for a STEMI and should undergo percutaneous intervention in the cath lab.

A 62-year-old man reports to the ED with new-onset, crushing, left-sided chest pain, radiating to the left arm that began suddenly 35 minutes prior to arrival. The patient has a history of hypertension, hypercholesterolemia, diabetes mellitus, and a 60-pack-year smoking history. His EMS ECG demonstrates ST-segment elevation in leads II, III, and aVF. In the ED, his vital signs are BP 135/75, HR 98, and RR 18. What is the most appropriate next step? A) Arrange for the patient to have an emergent stress test B) Call the cath lab emergently and prepare the patient for transport C) Give the patient nitroglycerin and draw labs, including troponins D) Place the patient on a cardiac monitor, give the patient oxygen if hypoxic and administer aspirin

*Legionella pneumonia* - also associated with *hyponatremia* (also associated with anorexia, n/v/d, and increased LFT's) Legionella is an intracellular gram-negative facultative bacillus and is found in aquatic environments. Patients at risk include smokers, those with underlying respiratory disease (e.g. COPD) or immunosuppression, and men > 50 years of age. Hint: Cavitary lesions (A) are associated with Klebsiella pneumonia Hint: Bullous myringitis (B) is associated with Mycoplasma pneumonia Hint: O2 desaturation with ambulation is associated with Pneumocystis Jirovecci Pneumonia (PCP)

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 38.7°C and inspiratory rales on auscultation. What is the diagnosis and which of the following results would be most consistent with his diagnosis? A) Cavitary lesions B) Bullous myringitis C) Hyponatremia D) O2 desaturation with ambulation

Abnormal vaginal bleeding Presenting as asymptomatic with an abnormal Pap smear (B) is not likely in endometrial cancer. Rather, though atypical endometrial cells are occasionally seen on a Pap smear, most women will have a negative smear. Bloating and frequent urination (C) is characteristic of ovarian cancer, not early endometrial cancer. Marked lower abdominal pain (D) would not be the first symptom of endometrial cancer. Usually women with endometrial cancer do not develop pain until the cancer has metastasized or a superimposed infection has resulted.

A 62-year-old woman presents for her annual well woman exam. She wants to discuss her risk of endometrial cancer, given a personal history of polycystic ovarian syndrome and prolonged tamoxifen use during her 50's. Given these risk factors she should be cautioned that early endometrial cancer normally presents in which of the following manners? Abnormal vaginal bleeding Asymptomatic with an abnormal Pap smear Bloating and frequent urination Marked lower abdominal pain

*B) Apneusis* In the hypertensive patient with sudden loss of consciousness and decerebrate response (extensor posturing), you should consider brain stem hemorrhage. Abnormal breathing patterns can be observed in both pontine and medullary lesions; they sometimes can be prognostic. Her breathing pattern is apneustic. Apneustic breathing pattern characterizes deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release and the end-inspiration pause before expiration. Lesion in the pons or upper medulla causes the removal of input from the vagus nerve and the pneumotaxic center. Normally, apneustic center of the lower pons promotes inspiration by stimulation of the dorsal respiratory center in the medulla to delay the 'switch off' signal of the inspiratory ramp provided by the pneumotaxic center of pons. Therefore, athe pneustic center controls the intensity of breathing. Apneusis is an ominous sign, with a generally poor prognosis.

A 62-year-old woman with a long-standing history of hypertension presents with a severe headache; it started this morning and is rapidly worsening. During the interview, she suddenly collapses. Your brief examination shows that she responds with extensor posturing on external stimuli. Her deep tendon reflexes are 3, and you elicit Babinski bilaterally. You also notice that her breathing has a peculiar pattern: deep inspiration with a pause at full inspiration, followed by a brief insufficient release and the end-inspiration pause. *How do you best describe her respiratory pattern?* A) Cheyne-Stokes B) Apneusis C) Ataxic D) Cluster E) Kussmaul

B) Full colonoscopy Iron-deficiency anemia in an adult should prompt for evaluation of a gastrointestinal source of bleeding. This is especially important because a malignant etiology, particularly colorectal cancer, is possible. The signs and symptoms of colon cancer vary according to the tumor's site in the colon. Distal tumors are more frequently associated with hematochezia and obstruction, while proximal neoplasia tends to produce more chronic obstruction with proximal dilatation, intermittent bleeding with iron-deficiency anemia, and a palpable mass. Recurrent infarctions lead to intermittent luminal obstruction and episodic diarrhea. Some lesions grow to a considerable size before diagnosis. In this patient, the diagnostic technique with the highest yield is full colonoscopy. It permits visualization of the whole colon; it also permits performing a biopsy for histopathologic confirmation of the diagnosis. In selected cases, colonoscopic dilatation or stent placement can alleviate obstruction before surgery is performed. Some authorities recommend routine upper endoscopy while investigating lower gastrointestinal bleeding. In some series, upper endoscopy revealed a missed bleeding source in as many as 10% of patients, and altered management in nearly 50% cases. A fecal occult blood test (FOBT) is redundant, given the presence of active bleeding and the overt signs of iron-deficiency anemia. FOBT is useful in colon cancer screening, despite its high false-positive rates (e.g., from non-cancer bleeding or foods reactive with the test reagent). Another caveat is that cancers may bleed intermittently, thereby yielding a false-negative result on a random FOBT. Barium enema is less sensitive than colonoscopy and is unable to perform biopsy. Despite these disadvantages, some authorities recommend its use for colon cancer screening.

A 63-year-old Hispanic-American man presents with a 3-month history of chronic intermittent diarrhea with 5 - 6 watery stools per day; some are tinged with blood. During this period, he has had progressive fatigue and intolerance to exercise; he has lost 15 pounds (6% of body weight). Vital signs are within normal ranges. On physical examination, there is noticeable pallor. Heart sounds are regular and of normal frequency, both lung fields are clear to auscultation, the abdomen is soft and diffusely tender to palpation, particularly in the right quadrants. Rectal examination is painless, and an enlarged prostate is palpated, but there are no masses or blood. Anoscopy shows grade I hemorrhoids. There is no peripheral edema. A complete blood count shows the following: Ht 30% Hb 9.4 g/dL MCV 77 fl MCHC: 25 g/dL WBC 8.600 /mm3. w/ normal differential, platelets 460.000 /mm3; iron 56 µg/dL ferritin 5.5 µg/dL What is the most appropriate next step in management? A) Fecal occult blood test B) Full colonoscopy C) Barium enema D) Sigmoidoscopy E) Computed tomography of the abdomen

This patient presents with prostatitis requiring 4-6 weeks of antibiotic therapy Ciprofloxacin (C) is an appropriate antibiotic for prostatitis but needs to be continued for 30 days. Appropriate regimens include ciprofloxacin, ofloxacin or trimethoprim/sulfamethoxazole for 30 days. Fluoroquinolones and third-generation cephalosporins are appropriate for inpatient therapy as well.

A 63-year-old man presents with fever, chills, low back and perineal pain. His pain is increased with urination and he has both frequency and incomplete voiding. On exam, you note a tender prostate. Which of the following treatments is most likely indicated?

D) Vancomycin, ceftriaxone, ampicillin This patient presents with symptoms concerning for meningitis and should immediately have antibiotics started covering the most likely pathogens. There are a number of causative organisms but the most common are Streptococcus pneumoniae, Neisseria meningitidis and Listeria monocytogenes. A non-contrast head CT should be performed in patients with suspected meningitis if they have signs of increased intracranial pressure or mass effect (focal neurologic findings, altered mental status or papilledema) and in those with significant immunocompromise (i.e. HIV/AIDS). The diagnosis of meningitis is made by analysis of the CSF after lumbar puncture. Antibiotics should not be withheld from patients while waiting for CT scan or lumbar puncture. While awaiting the results of CSF and blood cultures, broad-spectrum antibiotics covering the most likely pathogens should be started. *Vancomycin* is administered to cover resistant S. pneumoniae (gram-positive, oval cocci typically arranged end to end in pairs - most common organism in all adults,) *third generation cephalosporin* (ceftriaxone) for N. meningitidis (aerobic gram-negative diplococci which are irregular but usually quiescent members of the nasopharyngeal flora - more likely to be encountered in younger adults.) *Ampicillin* should be given for patients who are at risk for L. monocytogenes (gram-positive rods - extremes of age (neonates and the elderly) and in patients with immunosuppression and alcoholism). Hint: Cefazolin (B) is a first generation cephalosporin and will not cover N. meningitidis.

A 63-year-old man with a history of alcoholism presents with fever, headache and altered mental status. What antibiotics should be administered? A) Ceftriaxone, ampicillin B) Vancomycin, cefazolin, ampicillin C) Vancomycin, ceftriaxone D) Vancomycin, ceftriaxone, ampicillin

D) Ceftriaxone, vancomycin and ampicillin This patient presents with signs and symptoms concerning for meningitis. The most common organisms in healthy adults are Streptococcus pneumoniae and Nisseria meningitides. Both of these organisms are covered by *ceftriaxone* however there is a small percentage of resistant S. pneumoniae requiring treatment with *vancomycin*. Listeria monocytogenes is a more common cause of meningitis in very young infants, elderly patients and those with chronic alcoholism or immunosuppression. L. monocytogenes is typically treated with *ampicillin.*

A 63-year-old man with chronic alcoholism presents with headache, fever and neck pain. Physical examination reveals neck stiffness. What antibiotics should be administered? A) Ampicillin alone B) Ceftriaxone alone C) Ceftriaxone and vancomycin D) Ceftriaxone, vancomycin and ampicillin

C) Ibuprofen This patient presents with monoarticular arthritis and a synovial fluid sample consistent with gout. Gout is a systemic disorder that manifests with joint inflammation. It is caused by precipitation of uric acid crystals from extracellular fluid. During an episode of gout, polymorphonuclear cells ingest the crystals and release cytokines leading to an inflammatory reaction within the synovium. The most commonly affected joint is the first metatarsophalangeal (MTP) joint followed by the knee. It is important to consider that patients with gout are at a higher risk of developing septic arthritis because the joints are chronically damaged. In patients with a history of gout that present with symptoms concerning for septic arthritis (pain, fever, decreased range of motion) arthrocentesis should be performed to rule out the presence of infection. Management of gout should be split into acute gouty attack treatment and long-term prophylaxis. The mainstay of acute therapy is NSAIDs and colchicine. Indomethacin, naproxen and ibuprofen all may be used in acute treatment. Colchicine inhibits microtubule formation reducing the inflammatory response to uric acid crystals. Unfortunately, the drug has a number of side effects that are almost universally experienced at therapeutic doses (nausea, vomiting, diarrhea). Acetaminophen (A) does not have anti-inflammatory properties and offers little benefit in acute gouty attacks. Allopurinol (B) is a xanthine oxidase inhibitor that prevents production of uric acid. It is useful in patients with increased synthesis and decreased clearance of uric acid. Allopurinol should not be started at the time of an acute attack of gout because it can lead to a transient increase in uric acid levels. However, patients already prescribed allopurinol should continue to take it at the same dose during acute episodes. Probenecid (D) is useful in prophylaxis but not for acute episodes.

A 63-year-old man with hypertension and dyslipidemia presents with pain and swelling of his left great toe. He denies trauma or fever. Examination reveals an exquisitely tender and swollen first metatarsophalangeal (MTP) joint on his left foot. Arthrocentesis yields fluid as shown above. What is the first line therapy for this patient? A) Acetaminophen B) Allopurinol C) Ibuprofen D) Probenecid

B) Atrial fibrillation This patient has a history of hyperthyroidism, an irregularly irregular pulse, and an EKG finding of varying R-R interval and fibrillatory F waves in place of P waves, which is consistent with atrial fibrillation. Irregular rhythm, as well as lack of P waves, is particularly noted in leads II, III, and aVF. AF is typically treated with rate control in stable patients (not pharmaceutically) or cardioversion in an unstable patient.

A 64-year-old woman with a past medical history of hyperthyroidism presents with new-onset palpitations. The patient states that she has intermittent palpitations, and she is worried about heart disease. She is currently asymptomatic and reports no chest pain or shortness of breath. An EKG is obtained. Vital signs reveal a T 98.6° F, BP 134/88 mm Hg, P 119 beats/min R 12/min. The pulse is noted to be irregular. The EKG is shown. What arrhythmia does the patient likely have? A) Atrial flutter B) Atrial fibrillation C) Supraventricular tachycardia D) Ventricular tachycardia E) Torsades de pointes

A) endoscopy with biopsy Endoscopy with biopsy establishes the diagnosis of esophageal cancer with a high degree of reliability Hint: Chest x-ray may show adenopathy, a pulmonary or bony metastases or sign of tracheoesophageal fistula. Barium esophagogram is obtained as the first study to evaluate the dysphagia. CT scan should be obtained once the diagnosis of carcinoma has been made to evaluate for pulmonary or hepatic metastases, lymphadenopathy, and local tumor extension. None of these tests will reveal the diagnosis of carcinoma.

A 65 year-old patient with known history of alcohol and tobacco abuse presents with solid food dysphagia. The patient also has a 24 lb weight loss over the past 6 months. Which of the following is the most appropriate intervention? A) endoscopy with biopsy B) chest x-ray C) barium esophagogram D) CT scan of the thorax

B) endometrial biopsy Postmenopausal bleeding is a primary complaint in patients with endometrial cancer. The only reliable method of diagnosis is by endometrial biopsy. Hint: Pap smears are the diagnostic tool of choice to evaluate for cervical cancer. The Pap smear is not reliable in diagnosing endometrial cancer, but in a small percentage of patients may show atypical endometrial cells which necessitates follow-up with an endometrial biopsy.

A 65 year-old postmenopausal female presents with complaints of new onset of vaginal bleeding. She relates a history of two episodes of vaginal bleeding during the past month, each lasting about four days. Which of the following diagnostic evaluations is the *most reliable* to evaluate the suspected diagnosis? A) Pap smear B) endometrial biopsy C) serum prolactin level D) serum FSH and LH levels

Total abdominal hysterectomy Stage I = involvement limited to uterus Stage II = Extension to and involvement of the cervix *Stage III = local spread* Stage IV = Distant spread Chemotherapy (A) with doxorubicin and cisplatin is associated with poor long-term remission. Recurrence rates are significantly decreased with the use of postoperative external beam radiation, while patient's with significant tumor bulk benefit from preoperative radiation. However, any radiation (B) is considered adjuvant therapy to surgical excision. Vaginal hysterectomy (C) is reserved for patients with stage I disease, especially if they cannot tolerate the rigors of abdominal surgery

A 65-year-old patient is diagnosed with stage III endometrial adenocarcinoma. You decide to refer her to a gynecologic oncologist. She asks you to explain the "best treatment available." In your counseling, you discuss which of the following treatment options? A) Chemotherapy B) External beam radiation C) Partial vaginal hysterectomy D) Total abdominal hysterectomy

A) Klebsiella pneumoniae Klebsiella pneumoniae is a gram-negative encapsulated organism. It occurs most commonly in alcoholic or chronically debilitated patients. Patients with klebsiella pneumonia commonly present with shaking chills, cyanosis, pleuritic chest pain, and a productive cough with characteristic currant-jelly sputum. Chest radiography reveals an infiltrate that is often in the upper lobes (most commonly the right) and is associated with a bulging fissure. If untreated, the infiltrate will progress into a necrotizing lesion with air-fluid levels, and can ultimately lead to development of an empyema.

A 65-year-old undomiciled man presents to your emergency department with complaints of fever, productive cough, and shortness of breath. He has a 40-pack-year history of smoking and daily alcohol consumption. His chest radiograph demonstrates a right upper lobe lung infiltrate with an air-fluid level. What is the most likely etiology for this finding? A) Klebsiella pneumoniae B) Legionella pneumophilia C) Mycoplasma pneumoniae D) Streptococcous pneumoniae

A) *Erythromycin* Intertrigo is a superficial inflammatory dermatitis occurring on two closely opposed skin surfaces as a result of moisture, friction, and lack of ventilation. Bodily secretions, including perspiration, urine, and feces, often exacerbate skin inflammation. Physical examination of skin folds reveals regions of erythema with peripheral scaling. Excessive friction and inflammation can cause skin breakdown and create an entry point for secondary fungal and bacterial infections, such as Candida, Group A beta-hemolytic streptococcus, and Corynebacterium minutissimum. Cutaneous erythrasma is caused by Corynebacterium minutissimum and presents as small reddish-brown macules that may coalesce into larger patches with sharp borders. They may be asymptomatic or pruritic and fluoresces coral-red on Wood lamp examination. Intertrigo complicated by erythrasma is treated with topical or oral erythromycin.

A 65-year-old woman who is morbidly obese presents to your office with intertrigo in the axilla. On examination you detect small, reddish-brown macules that are coalescing into larger patches with sharp borders. You suspect a secondary infection complicating the intertrigo. What is the most appropriate topical treatment for this condition? A) Erythromycin B) Mupirocin C) Nyastatin D) Ninc oxide

The varicella zoster vaccine is a live attenuated vaccine and therefore is contraindicated in this patient due to her immunocompromised state. This patient is considered immunocompromised since she is taking infliximab.

A 65-year-old woman with Crohn's disease that is well controlled on infliximab presents to her primary care physician. As you are updating her immunization status, which one of the following should be noted?

C) Diabetes mellitus The correct answer is diabetes mellitus since the presence of polyuria would indicate hyperglycemia and the associated erectile dysfunction and/or balanitis may be the only other presenting symptom or sign of diabetes mellitus in a male patient. Erectile dysfunction is a common vascular and neurological complication of diabetes and occurs in up to 75% of male diabetics. Elevated blood sugars result in autonomic neuropathy of the cavernous nerve of the penis so that erectile dysfunction serves as one of the earliest indications of neuropathy. Likewise, hyperglycemia results in microvascular damage to the dorsal and cavernous arteries, in the same way retinopathy, nephropathy, and neuropathy develop, further contributing to poor perfusion and erectile dysfunction. Hyperglycemia also results in the colonization of skin organisms, commonly Candida, resulting in typical superficial yeast infections seen in diabetics such as balanitis in men and vulvovaginitis in women.

A 66-year-old man presents to the office with polyuria and erectile dysfunction. He denies any other symptoms or significant past medical history. Physical examination reveals Tanner stage 5 of the external genitalia, balanitis of an uncircumcised penis, and slightly enlarged, symmetrical and smooth prostate. His condition is most likely the result of: A) Benign prostatic hypertrophy B) Diabetes insipidus C) Diabetes mellitus D) Hypogonadism E) Prostate cancer

C) Severe conductive Hearing impairment is described as conductive or sensorineural. In conductive hearing impairment, there is a fundamental problem with the mechanical passage of sound waves from the external auditory canal through the tympanic membrane, ossicles, oval window, cochlear ducts, perilymph and endolymph. Comparatively, sensorineural hearing impairment occurs when pathology affects the cells of the organ of Corti, the vestibulocochlear nerve (cranial nerve 8), pons or brain. Two tests, the Weber and Rhinne tests, can assist in determining the type of unilateral hearing loss. During Weber testing, a vibrating tuning fork is placed on the skull's vertex. If the fork's vibrations are heard better in the affected ear, conductive impairment of the affected ear is present; if it is heard better in the normal ear, sensorineural impairment of the affected ear is present. During Rhinne testing, a vibrating tuning fork is placed on the mastoid process on the same side as the affected ear. When the patient reports he or she cannot hear it any longer, the fork is moved beside the external auditory canal to allow sound to pass thru the air. The patient is then asked to determine at which site they heard the sound better. If it was heard better when the fork was on the mastoid process, there is conductive impairment of the affected ear; if it was heard better through the air, sensorineural impairment is present in the affected ear. Hearing impairment can be further defined as mild, moderate and severe, based on the amount of loss measured in decibels. A deficit of 26-40 decibels is considered mild, while a loss of 41-70 decibels is considered moderate. Hearing loss >70 decibels is referred to as severe.

A 66-year-old man presents with difficulty hearing with the left ear. You begin a physical examination. He hears vibration more in the left ear during a Weber test. During Rhinne testing of the left ear, he reports hearing vibration better when the tuning fork was placed on the mastoid process than when it was placed next to the ear canal. You send him to the audiology lab. They report he has a 78 decibel loss in the left ear. Which of the following types of hearing impairment is present in this patient? A) Mild conductive B) Mild sensorineural C) Severe conductive D) Severe sensorineural

C) Decreased serum phosphate level Chvostek's sign (A) can be present in hypocalcemia. Serum magnesium (B) is directly related to serum calcium levels, not inversely related. Hypertension, not hypotension (D), can be related to hypercalcemia. Calcium and phosphate have an inverse relationship with one another. As serum calcium levels increase, an increase in parathyroid hormone (PTH) levels will promote the renal excretion of phosphate, causing serum levels of phosphate to decrease. Hyperparathyroidism is the most common cause of hypercalcemia and can be classified as primary, secondary, or tertiary. Primary hyperparathyroidism is typically due to a defect in the parathyroid glands that cause PTH release in the setting of elevated calcium levels. Normally, additional PTH release is inhibited when serum calcium levels rise. Causes include parathyroid cancer, adenoma, or dysfunctional calcium sensing receptors on the surface of chief cells. Other lab abnormalities include serum hypophosphatemia and an increased urine calcium level. Surgical intervention with a parathyroidectomy is the mainstay of therapy.

A 68-year-old woman is diagnosed with hyperparathyroidism. Both her serum calcium level and parathyroid hormone level are elevated. Which of the following findings would be most consistent with the diagnosis? A) Chvostek's sign B) Decreased serum magnesium level C) Decreased serum phosphate level D) Hypotension

B) Colonic diverticula To make the diagnosis of acute diverticulitis, an abdominal/pelvic CT scan, an abdominal ultrasound, or an MRI of the abdomen/pelvis may be performed. CT scan demonstrates colonic bowel wall thickening, fat stranding, and colonic diverticula. Treatment of acute uncomplicated diverticulitis involves a short-course of antibiotics and dietary changes that focus on decreased fiber during the acute period and long term increased intake of fiber. Complications of the disease, if left untreated, include diverticular abscesses, colonic obstruction, and complete perforation of the diverticulum with peritonitis. Dilated loops of small bowel (C) is a finding on an abdominal CT scan or abdominal X-ray that is indicative of a bowel obstruction. Patients suspected of bowel obstruction present with nausea, vomiting, and cramping abdominal pain. Imaging demonstrates dilated loops of bowel proximal to the site of obstruction, along with bowel wall thickening, and air-fluid levels. Enlarged pericolonic lymph nodes (D) may be indicative of colorectal cancer. Patients diagnosed with colorectal cancer can present with a change in bowel habits, hematochezia, or abdominal pain, or they may present asymptomatically. Imaging should initially be performed and findings of enlarged pericolonic lymph nodes and a mass may be indicative of colorectal cancer. If acute diverticulitis is not suspected or a patient is out of the acute inflammatory window, a colonoscopy should be performed as this is the most accurate diagnostic test of choice for colorectal cancer.

A 69-year-old woman presents to the emergency department with a complaint of three days of left lower quadrant abdominal pain, nausea, vomiting, and a sudden change in bowel habits. What are you most likely to find on an abdominal and pelvic computed tomography scan? A) Appendiceal wall thickening B) Colonic diverticula C) Dilated loops of small bowel D) Enlarged pericolonic lymph nodes

Oral erythromycin (Erythromycin ophthalmic (B) is not an effective treatment due to high failure rate.)

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

Staphylococcal scalded skin syndrome (SSSS) = a toxin-mediated type of exfoliative dermatitis that causes separation of the epidermis from the dermis. ( Toxic epidermal necrolysis (TEN) is characterized by erythema, necrosis and bullous detachment of the epidermis from the dermis. It also includes mucous membranes and can even lead to gastrointestinal hemorrhage. While SJS typically involves less than 10% of the body surface, TEN involves more than 30% of the body surface.)

A 7-week-old boy born at 34 weeks gestation presents to the emergency department with a rash. Two weeks prior to presentation he was treated with mupirocin for a skin infection. One day prior to presentation he had nasal congestion. On exam, he is noted to be febrile to 38.4ºC and very irritable. His skin is diffusely erythematous and tender when touched. There is a sloughing rash on the anterior folds of his neck, the diaper region, and lips. What is the most likely diagnosis?

Polyethylene glycol an osmotic laxative, and reasonable first line oral medication to use for maintenance therapy of constipation, defined as a two week history or more of delay or difficulty in defecation.

A 7-year-old boy is contipated. Everything else fine. What is the most appropriate initial intervention for this child?

A) Asthma The spirometry result in this patient shows reduction in both forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), but FEV1 is more affected than FVC. Therefore, there is a decrease in the FEV1/FVC ratio below the predicted levels. The TLC is normal (80-120%). This concludes that this is an obstructive disorder and excludes the restrictive diseases listed. There is a marked improvement with bronchodilators. In reversible airway obstruction such as in asthma, there is a rise in the FEV1 and/or FVC by approximately 12% from pre- to post-bronchodilator testing. This reversibility is characteristic of bronchial asthma. The spirometry findings are not suggestive of restrictive lung diseases such as pneumonia, pleural effusion, kyphoscoliosis, and tuberculosis.

A 7-year-old boy presents with a 1-week history of wheezing and dyspnea on any exertion (with productive cough). On physical examination, bilateral rhonchi are heard. After a few days of treatment, spirometry is done on the patient. The findings are shown in the table. Total lung capacity (TLC) is 111% on spirometry. What is the most likely diagnosis? A) Asthma B) Pneumonia C) Pleural effusion D) Kyphoscoliosis E) Tuberculosis

A) Amoxicillin Lyme disease is the most common vectorborne disease in the United States. Pregnant or lactating women and children younger than 8 years of age should receive amoxicillin. Advanced or severe disease should be treated with intravenous ceftriaxone or penicillin. B) Azithromycin is a macrolide antibiotic, is not recommended as a first-line agent for early Lyme disease. It should be reserved for those who cannot tolerate doxycycline or amoxicillin. C) Cephalexin is a first-generation cephalosporin that is ineffective against Lyme disease. D) Doxycycline is the drug of choice for men, nonpregnant and nonlactating women, and children older than 8 years of age. Doxycycline is a tetracycline that is readily bound to calcium deposited in newly formed bone or teeth in young children. When administered during pregnancy, it can be deposited in the fetal teeth, leading to fluorescence, discoloration, and enamel dysplasia. It can also be deposited in bone, where it may cause deformity or growth inhibition

A 7-year-old girl presents with the rash seen above. Her mother states it appeared 7 days after hiking through the woods near their home in New Jersey. She has no known drug allergies. Which of the following is the most appropriate treatment for this patient? A) Amoxicillin B) Azithromycin C) Cephalexin D) Doxycycline

B) Angiography In patients with acute or chronic intestinal ischemia, a CTA or MRA can demonstrate narrowing of the proximal visceral vessels. In acute intestinal ischemia from a nonocclusive low flow state, angiography is needed to display the typical "pruned tree" appearance of the distal visceral vascular bed.

A 70-year-old male presents to your clinic complaining of an acute onset of severe periumbilical pain with nausea and vomiting. Past medical history is remarkable for coronary artery disease with atrial fibrillation. Physical examination is remarkable for minimal abdominal distension and guaiac positive stool. *The suspected diagnosis is acute mesenteric ischemia. Which is the gold standard diagnostic imaging study to confirm the suspected diagnosis?* A) Doppler ultrasound B) Angiography C) Computed tomography D) Plain radiography E) Colonoscopy

C) Hyperparathyroidism The majority of patients with hyperparathyroidism are asymptomatic. *Recurrent nephrolithiasis may be one of the presentations of primary hyperparathyroidism*. Measurement of parathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia.

A 72 year-old female is being evaluated for recurrent kidney stones. PE reveals no abnormal findings. Laboratory findings show elevated calcium and decreased phosphate levels. Which of the following is the most likely diagnosis? A) Pheochromocytoma B) Adrenal insufficiency C) Hyperparathyroidism D) Breast Cancer

C Hyperparathyroidism The majority of patients with hyperparathyroidism are asymptomatic. Recurrent nephrolithiasis may be one of the presentations of primary hyperparathyroidism. Measurement of parathyroid levels would be the initial laboratory test for the evaluation of hypercalcemia. Hint: Hypercalcemia may be the earliest manifestation of a malignancy and this must be investigated. Most often the signs and symptoms of a malignancy will cause the patient to seek medical care. Malignancy is the second leading cause of hypercalcemia, behind hyperparathyroidism. Nulliparity is a risk factor for breast cancer and the most common presenting sign in a breast mass.

A 72 year-old female is being evaluated for recurrent kidney stones. PE reveals no abnormal findings. Laboratory findings show elevated calcium and decreased phosphate levels. Which of the following is the most likely diagnosis? A Pheochromocytoma B Adrenal insufficiency C Hyperparathyroidism D Breast cancer

A) Refer to a gynecologist for biopsy Vulvular squamous cell hyperplasia causes thickening and hyperkeratosis of the vulva. The lesions are red and moist and cause intense pruritus over time the area becomes thickened and a white plaque may develop. Biopsy must be done to evaluate for intraepithelial neoplasm or invasive tumor.

A 72 year-old female presents with vulvular pruritus for the last nine months, which has progressively worsened over the last two months. She states that she went through menopause at age 54 and has been on estrogen and progesterone therapy since that time. Physical examination reveals red lesions with white plaques on the vulva. What should the next course of management include? A) Refer to a gynecologist for biopsy B) Refer to a dermatologist for antifungal therapy. C) Treat with a topical steroid. D) Treat with estrogen cream.

C) Transesophageal Echocardiogram

A 72 year-old male with a new diagnosis of congestive heart failure and atrial fibrillation, develops episodes of hemodynamic compromise secondary to increased ventricular rate. A decision to perform elective cardioversion is made and the patient is anticoagulated with heparin. Which test should be ordered to assess for atrial or ventricular mural thrombi? A) Electrocardiogram B) Chest x-ray C) Transesophageal Echocardiogram D) C-reactive protein

Acute diverticulitis Acute abdominal pain, fever, left lower abdominal tenderness, and leukocytosis are hallmark signs of acute diverticulitis.

A 72 year-old man presents with acute left lower quadrant abdominal pain. He has nausea, vomiting, and constipation. He has a fever of 101° F and guarding and rebound tenderness in his left lower quadrant. His white blood cell count is elevated. He has no prior history of gastrointestinal disease. Which of the following is the most likely diagnosis?

*Fusion Beats* Fusion beats occur when impulses from two different locations (one within the ventricle and one in a supraventricular location) activate the ventricle. The result is a QRS complex with morphology resembling a hybrid of a sinus beat and intraventricular beat. These are diagnostic of VT because they represent AV dissociation.

A 72-year-old man presents for evaluation of palpitations. He has a regular, wide complex tachycardia at a rate of 140. Which of the following supports a diagnosis of ventricular tachycardia?

B) Lytic lesions on plain film The patient's clinical presentation is suggestive of multiple myeloma. Multiple myeloma is on the differential of older patients with atraumatic back pain. It is caused by the proliferation of plasma cells causing a monoclonal immunoglobulin. Plasma cells rapidly proliferate in the bone marrow causing extensive skeletal destruction and osteolytic lesions on imaging studies. These lesions are often described as "punched out," particularly on the skull. The bony destruction also leads to hypercalcemia. Additionally, deposition of the immunoglobulin in the renal tubules begins to cause renal insufficiency. The elevated total protein is secondary to the circulating immunoglobulin in the blood. PLASMA CELL MYELOMA (FORMERLY MULTIPLE MYELOMA)

A 72-year-old man presents with lower back pain and significant weakness. Laboratory analysis is notable for a creatinine of 1.9 mg/dL, calcium of 10.7 mg/dL and total protein of 9.2 gm/dL. Which of the following might you expect to find? A) Hyperreflexia B) Lytic lesions on plain film C) Polycythemia D) Urinary retention

D) MRI This elderly man probably has a torn rotator cuff. If surgical treatment is being considered, MRI is the imaging study of choice because it can provide additional information on the status of the muscle and the size of the rotator cuff tear. Electromyelogram is used to assess the nerves. Ultrasound doesn't give as clear a picture of the tear due to the bony interference. Plain films can assess only the boney picture.

A 73-year-old man presents with the inability to actively raise his left non-dominant arm to retrieve plates from the kitchen cabinet. This began a month ago after his shoulder pain improved. He had a history of pain in that shoulder for over 6 months that kept him from sleeping on the left side and the pain would wake him often. There was no specific injury he can recall although he felt a pop a month ago while taking out the trash. What is the diagnostic study of choice if surgery is indicated? A) CT without contrast B) Electromyelogram (EMG) C) Ultrasound D) MRI E) Plain films

D) Septic arthritis Any patient with an acute monoarticular arthritis should be considered to have septic arthritis until proven otherwise. Patients at increased risk for septic arthritis include the elderly, those with prosthetic joints, IV drug abusers, and the immunocompromised. Septic arthritis often occurs in patients with a history of chronic arthritis, complicating the diagnosis. In healthy adults, the knee is the most commonly affected joint, but in IV drug abusers, common sites include the sacroiliac, sternoclavicular, and intervertebral joints. In children, the knee and hip are most commonly affected. Synovial fluid results in this case are consistent with a bacterial rather than inflammatory etiology (see table below). Fluid culture will help confirm the diagnosis of septic arthritis, but such results take time to complete. Empiric treatment should be initiated.

A 73-year-old man with a history of arthritis presents with complaints of a low-grade fever and severe right knee pain for the past three days, with an inability to bear weight since this morning. On exam, you note exquisite right knee tenderness and a large effusion. There is limited range of motion both actively and passively, and he refuses to ambulate. You perform an arthrocentesis and drain 20 mL of turbid fluid. Laboratory analysis of the joint fluid reveals the following: WBC of 55,000/µL with 95% neutrophils and a glucose level of 60 mg/dl (serum glucose is 140 mg/dl). Gram stain and crystal analysis are not immediately available. Which of the following is the most likely diagnosis? A) Acute gout B) Osteoarthritis C) Rheumatoid arthritis D) Septic arthritis

B) Foley catheter placement The patient presents with symptoms and signs consistent with acute urinary obstruction requiring placement of a Foley catheter to relieve the obstruction. Postrenal or obstructive renal failure is a reversible cause of acute kidney injury (AKI) and should always be considered in patients with new azotemia. Benign prostatic hyperplasia (BPH) is a common cause of urinary obstruction. Treatment of obstructive uropathy focuses on relieving the obstruction. There is no contraindication to placing a Foley catheter in patients with BPH and it should be done emergently to relieve obstruction. Suprapubic catheterization (D) should be attempted if placement of a Foley catheter fails. Emergency dialysis (A) should only be undertaken for pulmonary edema, severe uncontrollable hypertension, hyperkalemia, severe electrolyte or acid-base disturbance, specific overdoses and severe, symptomatic uremia.

A 73-year-old man with benign prostatic hyperplasia presents with a failure to void for 3 days and lower abdominal pain. Physical examination reveals lower abdominal distension and moderate tenderness to palpation. His BUN/Creatinine is 8/1.6. What management is indicated? A) Emergency hemodialysis B) Foley catheter placement C) Intravenous fluids D) Suprapubic catheterization

C) Malignant mesothelioma His work history predisposed him to asbestos. Mesothelioma can take more than 40 years to surface, and the most common industries that expose people to asbestos are construction, mining, brake linings, roofing, and working in shipyards. This patient worked in both construction and a car garage shop, which would have likely exposed him routinely to asbestos

A 75-year-old man presents with a 4-month history of dyspnea on exertion and a productive cough. He also unintentionally lost 10 pounds in 2 months. His past medical history is significant for coronary artery disease and a myocardial infarction. He has smoked an occasional cigar the last few years. He has been retired for 12 years, but for 30 years he worked odd jobs in the construction industry. He also helped his father in the family's car garage shop. Vital signs are normal. His physical exam is remarkable for decreased breath sounds in left lower lung fields and dullness to percussion. A chest radiograph is ordered, and it shows a left sided pleural effusion. What condition does this patient have? A) Lung cancer B) Congestive heart failure C) Malignant mesothelioma D) Pneumonia E) Recurrent postmyocardial infarction pericarditis

C) Endoscopic retrograde cholangiopancreatography The patient presents with severe (suppurative) ascending cholangitis, and requires biliary decompression with endoscopic retrograde cholangiopancreatography (ERCP). Ascending (or acute) cholangitis is a bacterial infection of the biliary system and is most frequently associated with common bile duct stones and obstruction. The disease classically presents with Charcot's triad (fever, jaundice, and right upper quadrant pain); however, only 50-75% of patients present classically, so clinicians must maintain a high index of suspicion for this life-threatening condition. While administration of broad spectrum antibiotics is appropriate, those with signs of severe disease—including persistent abdominal pain, hypotension despite adequate fluid resuscitation, fever greater than 102°F, and confusion—warrant urgent ERCP. Cholecystectomy (B) may be required after disease resolution to prevent recurrent episodes, but is no longer part of the definitive management of ascending cholangitis due to its highly associated mortality.

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? A) Broad spectrum antibiotics B) Cholecystectomy C) Endoscopic retrograde cholangiopancreatography D) Percutaneous transhepatic cholangiography

D) Mini-mental status examination Hint: Stanford-Binet Intelligence Scales cannot be used to score adults. Hint: MRI of the brain is indicated when structural changes are suspected; however, they are not likely in this patient due to her normal neurological examination. Hint: Electroencephalography (EEG) is recording of spontaneous electrical activity of the brain; it is primarily used in the diagnosis of epilepsy, and it is sometimes used in the diagnosis of coma, encephalopathies, sleep disorders, and brain death. Your patient's sleep complaints are normal in advanced age. Hint: You should perform a thyroid function test if you find out that a patient has dementia - slowness is a part of normal aging.

A 76-year-old woman presents because her children are concerned that 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 nonfocal. *What should be your next diagnostic step*? A) EEG B) Stanford-Binet Intelligence Test C) MRI of the brain D) Mini-mental status examination E) TSH and T4

D) Permethrin This patient presents with pediculosis capitis or head lice and should be treated with permethrin. These parasitic lice infest and lay eggs at the base of the hair shaft. Transmission is from person-to-person. It is common in children but uncommon after puberty. Patients will present with intense pruritus, which coincides with the lice feeding and inspection reveals nits (immature lice) firmly attached to the base of hair shafts. The heaviest infection is typically seen behind the ears. Diagnosis is made on clinical grounds or with microscopy. The preferred treatment for pediculosis capitis is with permethrin, which kills the adult louse. Subsequently, the nits must be removed with a vinegar solution and fine-tooth comb. The scalp should be reexamined one week later and repeat therapy at this point may be required. Clotrimazole (A) is an antifungal medication that does not play a role in the treatment of pediculosis. Ivermectin PO (B) is a second-line therapy for pediculosis capitis and should be reserved for cases in which topical therapy fails. Ivermectin is given as a single dose and repeated 10 days later but it is a second line treatment. There is also a topical ivermectin that can be used first line. In the past, lindane (C) was indicated as first line treatment but now is reserved for treatment failures.

A 9-year-old girl presents with scalp itching. Physical examination reveals the finding seen in the image above. What treatment is indicated? A) Clotrimazole B) Ivermectin PO C) Lindane D) Permethrin

B) Start antibiotics and continue breastfeeding with either breast This woman most likely has a breast abscess due to breastfeeding-associated lactation mastitis. The recommended treatment plan for breast abscess involves drainage and antibiotics. Drainage can be accomplished via small incision or needle aspiration. First-line antibiotic choices include dicloxacillin, cephalexin or clindamycin. Antibiotics (A and D) are recommended in breastfeeding-associated lactation mastitis. Breastfeeding (C) should continue.

A breastfeeding 28-year-old woman presents for evaluation of a painful right breast "lump" three weeks after delivery of a healthy newborn. Examination reveals localized erythematous edema of the right breast, a 7/10 painfully palpable discrete induration and thick, yellow nipple discharge. The nipple and areola are not excoriated. The left breast is unremarkable. You refer the patient for a drainage procedure. In the meantime, which of the following is the most appropriate initial plan? A) Continue breastfeeding with the left breast only; antibiotics are not recommended B) Start antibiotics and continue breastfeeding with either breast C) Start antibiotics and stop breastfeeding D) Stop breastfeeding; antibiotics are not recommended

*Complex regional pain syndrome (CRPS)(formerly called reflex sympathetic dystrophy)* Patho: rare disorder of the extremities characterized by autonomic and vasomotor instability. Most cases are preceded by surgery or direct physical trauma, often of a relatively minor nature, to the soft tissues, bone, or nerve. Clinical: The cardinal symptoms and signs are pain localized to an arm or leg, swelling of the involved extremity, disturbances of color and temperature in the affected limb, dystrophic changes in the overlying skin and nails, and limited range of motion. Pain is often burning in quality, intense, and often greatly worsened by minimal stimuli such as light touch. There are no systemic symptoms. I Dx: In the early phases of the syndrome, bone scans are sensitive, showing diffuse increased uptake in the affected extremity. Radiographs eventually reveal severe generalized osteopenia. Tx: Early mobilization after injury or surgery reduces the likelihood of developing the syndrome. For mild cases, NSAIDs can be effective. For more severe cases associated with edema, prednisone can be effective. Pain management is important and facilitates physical therapy, which plays a critical role in efforts to restore function. Some patients will also benefit from antidepressant agents (eg, nortriptyline) or from anticonvulsants (eg, gabapentin)

A classic presentation is post-surgical patients with days-to-weeks onset of distal extremity diffuse neuropathic pain, edema and erythema

E) Kussmaul seen often in severe metabolic acidosis (diabetic ketoacidosis, renal failure). In metabolic acidosis, breathing is first rapid and shallow, but later on, as acidosis worsens, breathing gradually becomes Kussmaul breathing.

A deep, labored, and gasping breathing pattern. What is the breathing pattern? A) Cheyne-Stokes B) Apneusis C) Ataxic D) Cluster E) Kussmaul

B) Gemfibrozil The management of dyslipidemia is controversial. Treatment begins with lifestyle modification. Most authorities recommend focusing on lowering LDL levels first. Secondary goals include lowering non-high density lipoprotein levels. If serum triglycerides are elevated, a tertiary goal may include screening for metabolic syndrome, a cardiac risk assessment and anti-hypertriglyceridemic medications. Gemfibrozil, a fibrate, is thought to have the greatest effect at lowering serum triglycerides. Statins (A and C) have the lowest effect on reducing triglyceride levels. Sitagliptin (D) is a DPP-4 inhibitor used in managing diabetes. Although optimizing glycemic control is recommended in those with hypertriglyceridemia, DPP-4 inhibitors do not directly lower triglyceride levels.

A diabetic patient with secondary dyslipidemia has a triglyceride level not at goal. Which of the following medications offers the highest reduction in serum triglyceride levels? A) Atorvastatin B) Gemfibrozil C) Lovastatin D) Sitagliptin

E) Carboxyhemoglobin level The family has CO poisoning. Carboxyhemoglobin is formed when inhaled CO binds to hemoglobin after being absorbed into the bloodstream. CO has an affinity for hemoglobin that is 250 times that of oxygen. Both oxygen transport and delivery to tissues are reduced as carboxyhemoglobin interferes with the dissociation of oxygen that should be provided until symptoms resolve and carboxyhemoglobin levels decrease to 5% or less. Delivery of 100% oxygen reduces the elimination half-life of CO to 1 hour from 4-5 hours. Hint: Hemoglobin level gives no indication of how much is bound to oxygen versus how much may be bound to CO. Thus, a hemoglobin level may be normal, and yet most of it may be bound to CO as carboxyhemoglobin Hint: Pulse oximetry that measures oxygen saturation is falsely normal because oxyhemoglobin and carboxyhemoglobin cannot be differentiated. Pulse oximeters use 2 light emitting diodes (a red one and an infrared light). Oxygenated hemoglobin absorbs infrared light and nonoxygenated hemoglobin absorbs red light. The pulse oximeter determines the relative absorption of each and gives the percentage of oxygenated versus nonoxygenated hemoglobin present. With significant carboxyhemoglobinemia, the oximeter will reflect only the oxygen saturation of normal hemoglobin and not the percentage of hemoglobin bound to carbon monoxide. Hint: Blood gas analysis may show metabolic acidosis with a normal arterial oxygen tension (PaO2) as measurement of dissolved oxygen, and it can overestimate the true oxygen saturation of hemoglobin. Hint: Urinalysis may show myoglobinuria due to eventual muscle necrosis as CO binds to myoglobin, decreasing its oxygen-carrying capacity.

A family presents in the middle of winter. They live in a low-income housing development. Their gas furnace is broken, and they have been using a kerosene heater at night. For the last 3 days, they have all been experiencing varying degrees of headache, dizziness, nausea, vomiting, and fatigue; symptoms are particularly severe at night. A 4-year-old child has also been very lethargic; occasionally, she seems to black out or fall asleep very soundly. She and her 9-year-old sibling have also had a cough, runny nose and sore throat for the past week. On exam, other than seeming tired, findings are nonspecific. Both children have a runny nose but their lungs and ears are clear. What is the best test to confirm exposure of the most likely diagnosis in this case? A) Hemoglobin level B) Pulse oximetry C) Blood gas analysis D) Urinalysis E) Carboxyhemoglobin level

C) Metronidazole treatment of choice for bacterial vaginosis. Bacterial vaginosis presents with a vaginal discharge with a fishy odor and clue cells on wet mount exam. Hint: Nonoxynol-9 is a spermicidal agent and not used to treat bacterial vaginosis. Hint: Ceftriaxone is used in the treatment of Neisseria gonorrhoeae Hint: Clotrimazole is used in the treatment of candidiasis

A female patient presents with a vaginal discharge that has a fishy odor. On wet mount examination of the discharge a few white blood cells and many stippled epithelial cells are noted. Which of the following is the treatment of choice for this patient? A Nonoxynol-9 B Ceftriaxone C Metronidazole D Clotrimazole

70%

A fib: anticoagluation therapy can reduce embolic risk by how much?

A) Obtain X-ray of the neck, chest, and abdomen Any history of foreign body ingestion should be taken seriously and investigated. The majority (80 percent) of foreign body ingestions occur in children between six months and three years of age. Coins and small toy items are the most commonly ingested foreign bodies. Symptoms of cervical swelling, erythema, or subcutaneous crepitations suggest perforation of the oropharynx or proximal esophagus. (B) Ordering barium contrast studies may be helpful in an occasional asymptomatic patient with negative plain films. However, their use is discouraged because of the potential for aspiration and in making subsequent visualization and removal of the object more difficult. (C) Providing reassurance to the mother is not appropriate because the patient needs further investigation. (D) Requesting an urgent endoscopy may be the next step after plain films are obtained. Urgent endoscopy is not needed if plain films fail to visualize the object and the patient remains asymptomatic.

A five-year-old boy is playing with his two-year-old sister when he calls to tell his mother that the girl put a dime in her mouth. The mother could not find anything in the girl's mouth so she brings her to the emergency department. Your physical examination is normal. Which of the following is the next best step? A) Obtain X-ray of the neck, chest, and abdomen B) Order barium contrast studies C) Provide reassurance to the mother D) Request for urgent endoscopy

A) *Amoxicillin-clavulanate* (Augmentin) *Pasteurella* is the first organism to consider in any patient who presents with a soft tissue infection following cat scratches or cat or dog bites or licks. Pasteurella are small gram-negative coccobacilli that are primarily commensals or pathogens of animals. However, these organisms can cause a variety of infections in humans, usually as a result of cat scratches, or cat or dog bites or licks. Wound infections characteristically have a very rapid development of an intense inflammatory response. Most patients develop symptoms within 24 hours of the initial injury, and as early as three hours after a cat bite. Pain and swelling are prominent. Purulent drainage is noted in about 40 pecent of patients, lymphangitis in about 20 percent, and regional adenopathy in 10 percent. Cellulitis often occurs within 24 to 48 hours. Necrotizing fasciitis may occur. Pasteurella multocida are usually resistant to clindamycin (B), erythromycin (C), and vancomycin (D) and are not the best therapy for this infection.

A five-year-old girl is brought by her father to the clinic because of a cat bite. Yesterday, she was playing with a neighbor's cat that suddenly bit the girl's left hand. Her wound was immediately cleaned. The following day, the father noted increased swelling and redness of the girl's left hand. On physical examination, she has normal vital signs, and on the left hand are two puncture wounds with a surrounding 1 cm diameter of erythema and swelling. Which of the following is the best treatment for a suspected Pasteurella sp. soft tissue infection? A) Amoxicillin-clavulanate B) Clindamycin C) Erythromycin D) Vancomycin

B) Immune thrombocytopenia The girl has symptoms and laboratory findings consistent with immune thrombocytopenia (ITP). ITP is one of the most common causes of symptomatic thrombocytopenia in children. There may be a history of a prior infection within the past month. Other than the prior history of infection, the history generally does not reveal any significant findings. There are no systemic symptoms, nor any prior history of bleeding or significant disease. Almost all patients diagnosed with ITP have signs of cutaneous bleeding that include petechiae, purpura, and ecchymoses. Mucosal bleeding that involves the nasal passages, buccal and gingival surfaces may also be present. Other than mucocutaneous bleeding, patients usually appear well. On physical examination, there is no significant enlargement of lymph nodes, liver, or spleen. Laboratory findings reveal thrombocytopenia that is usually the only abnormality detected. *A platelet count of < 100,000/microL is used to define thrombocytopenia* in ITP. The white blood cell count and differential, hemoglobin concentration, and other red cell indices are generally normal.

A five-year-old girl is brought to the clinic for evaluation of petechiae. The parents deny fever, decreased appetite, bone or joint pain, or weight loss. She did have a cold and runny nose about a month ago. On physical exam, the girl appears well with normal vital signs, petechiae and purpura on the upper and lower extremities. There are no signs of mucosal bleeding with normal lymph nodes, liver, or spleen. Laboratory studies reveal platelet count of 60,000/microL and an otherwise normal complete blood count. Which of the following is the most likely diagnosis? A) Hemolytic uremic sydrome B) Immune thrombocytopenia C) Leukemia D) Thrombotic thrombocytopenic purpura

B) Human-derived botulism immune globulin Infant botulism, while rare, is the most common form of botulism seen in the United States. Raw honey is a frequently mentioned etiology of infant botulism. Other causes include corn syrup and soil and vacuum dust. The initial clinical manifestation is constipation, followed by motor function symptoms such as ptosis, facial and generalized weakness. Clinical presentation and electromyography findings consistent with infant botulism allow for a presumptive diagnosis while confirmatory stool studies are pending. Treatment in infants younger than age one is with human-derived botulism immune globulin (BabyBIG) and should be administered as early as possible in the course of the infection. Equine-derived heptavalent botulinum antitoxin is used in non-infant cases of botulism. Bisacodyl (A) and senna (D) are stimulant laxatives that are not recommended for children younger than three years old. Cathartics containing magnesium, such as magnesium citrate (C) should not be used in the treatment of infant botulism

A four-month-old baby presents to your office with symptoms of worsening constipation, poor feeding, listlessness, and generalized weakness for two weeks. Physical exam findings include temperature of 98.6°F, ptosis, poor head control, and poor ability to suck. Which of the following is the most appropriate initial therapy? A) Bisacodyl B) Human-derived botulism immune globulin C) Magnesium citrate D) Senna

Rickets Rickets refers to deficient mineralization at the growth plate. The boy in the vignette has calcipenic rickets that is caused by calcium deficiency. This is due to insufficient intake or metabolism of vitamin D.

A four-year-old boy is new to your practice and comes into the clinic with his mother for a health supervision visit. The family recently migrated from the Middle East. The mother does not have any concerns. On exam, you note height at 5th percentile, enlargement of the costochondral junction, widening of the wrist and varus deformities of the legs. X-ray shows osteopenic epiphyseal centers. Laboratory tests reveal elevated alkaline phosphatase and low serum phosphorus and calcium. Which of the following is the most likely diagnosis? A) Blount disease B) Hypophosphatasia C) Rickets D) Skeletal dysplasia

A) Continue breastfeeding from both breasts Maternal mastitis is common during breastfeeding and is not a contraindication to continued breastfeeding. While the mother is on antibiotics, she should be instructed to continue to fully empty the breast with each feed. The mother should not be instructed to feed only from the contralateral breast (B), as the risk of transmission of infection from the affected breast is negligible. Pumping and discarding breast milk (D) is unnecessary. Finally, discontinuation of breastfeeding (C) is not recommended. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of the infant's life.

A mother calls the office concerned that she was diagnosed with mastitis while she is still breastfeeding her 1-month-old infant. What is the most appropriate recommendation? A) Continue breastfeeding from both breasts B) Continue breastfeeding from the contralateral breast C) Discontinue breastfeeding, as exclusive breastfeeding is only recommended for one month D) Pump and discard all breast milk until the mastitis is resolved

A) Education on positioning Topical remedies such as hydrogel dressing (C) and tea bag compresses (D) may also be effective, although no one topical agent has been shown to be clearly superior, and none is as effective as education on positioning and latch-on. Areolar engorgement is treated by the manual expression (B) or pumping of milk to soften the areola and allow better latch-on. Nipple pain with breastfeeding is extremely common, with some studies reporting a prevalence of up to 96%. Preventing or alleviating nipple pain is important for comfort, but also for promoting breastfeeding in general. The best intervention for nipple pain is education on proper positioning and attachment of the infant. This position may be lying on her side on the hospital bed or sitting in a comfortable chair. The most common position involves cradling the infant next to the breast from which he or she will feed, with his or her head propped up by the mother's arm. The infant should be placed with his or her stomach flat against the mother's upper abdomen, in the same plane.

A new first-time mother calls for advice on nipple pain with breastfeeding. She is 6 days post partum after an uncomplicated delivery. Which one of the following is most effective for reducing the pain? A) Education on positioning B) Expressed breast milk C) Hydrogel dressing D) Tea bag compresses

A) Acne neonatorum Acne neonatorum occurs in up to 20% of newborns. It typically consists of closed comedones on the forehead, nose, and cheeks, and is thought to result from stimulation of sebaceous glands by maternal and infant androgens. Open comedones, inflammatory papules, and pustules can also develop. Erythema is generally not seen. Acne neonatorum is a clinical diagnosis and parents should be counseled that lesions usually resolve spontaneously within 4 months without scarring. Treatment generally is not indicated, but infants can be treated with a 2.5% benzoyl peroxide lotion if lesions are extensive and persist for several months. Parents should apply a small amount of benzoyl peroxide to the antecubital fossa to test for local reaction before widespread or facial application. Findings in erythema toxicum neonatorum (B) include papules, pustules, and erythema. Erythema toxicum neonatorum is the most common pustular eruption in newborns. Typical lesions consist of erythematous, 2- to 3-mm macules and papules that evolve into pustules. Each pustule is surrounded by a blotchy area of erythema, leading to what is classically described as a "flea-bitten" appearance. Herpes simplex (C) lesions usually present in an ill-appearing neonate with vesiculopustular lesions. Milia (D) consists of 1- to 2-mm pearly keratin plugs without erythema, and may occur on the trunk and limbs.

A newborn male has a skin eruption on his forehead, nose, and cheeks. The lesions are mostly closed comedones with a few open comedones, papules, and pustules. No significant erythema is seen. Which one of the following is the most likely diagnosis? A) Acne neonatorum B) Erythema toxicum neonatorum C) Herpes simplex D) Milia

C) Pericardial knock = an accentuated heart sound occurring slightly earlier than a third heart sound. This would not be expected in restrictive cardiomyopathy. Conversely, an audible S3 is frequently present in persons with restrictive cardiomyopathy because of the abrupt cessation of the rapid ventricular filling.

A patient is being evaluated for dyspnea and lower extremity swelling. On physical exam the patient has jugular venous distention with inspiration and 2 + pedal edema. Hepatojugular reflex is present. The patient has clear lung fields and no murmur is appreciated. Which of the following findings would support the diagnosis of constrictive pericarditis over restrictive cardiomyopathy? A) Cardiomegaly B) Left bundle branch block C) Pericardial knock D) S3 heart sound

B) increased dietary fiber and sitz baths Most hemorrhoids respond well to conservative treatment such as fiber and sitz baths. Hint: Banding and injection of sclerosing agents are used if mild prolapse, enlargement, or intermittent bleeding is present. Hint: Hemorrhoidectomy should be used for permanently prolapsed internal hemorrhoids.

A patient presents complaining of vague anal discomfort. On examination, the patient is noted to have a few small external hemorrhoids and edema in the anal region. Which of the following is the most appropriate intervention? A) proctoscopy followed by a hemorrhoidectomy B) increased dietary fiber and sitz baths C) hemorrhoidal banding D) inject a sclerosing agent

Volkmann's contracture This patient has classic findings of acute compartment syndrome. Volkmann's contracture may occur from an untreated compartment syndrome or an arterial injury

A patient presents to the Emergency Department with complaints of increasing pain in the right lower extremity. He has a history of a non-displaced proximal tibial fracture treated with application of a long leg cast 2 days prior. On exam there is marked swelling of the toes and the patient refuses to move them secondary to pain. An injection of meperidine fails to relieve the patient's pain. Clinical intervention is needed to prevent what complication?

C) Volkmann's contracture This patient has classic findings of acute compartment syndrome. Volkmann's contracture may occur from an untreated compartment syndrome or an arterial injury. *Hint*: Osteomyelitis results from a source of infection that may include an open fracture, but not a closed fracture. *Hint*: Traumatic arthritis only occurs as a result of fractures that involve the articular surface. *Hint*: Malunion of the fracture fragments occur when there is poor reduction of the fracture fragments. Non-displaced fractures do not require reduction.

A patient presents to the Emergency Department with complaints of increasing pain in the right lower extremity. He has a history of a non-displaced proximal tibial fracture treated with application of a long leg cast 2 days prior. On exam there is marked swelling of the toes and the patient refuses to move them secondary to pain. An injection of meperidine fails to relieve the patient's pain. Clinical intervention is needed to prevent what complication? A) osteomyelitis B) traumatic arthritis C) Volkmann's contracture D) malunion of fracture fragments

A positive Rovsing's sign can be elicited in a patient with appendicitis when increased pain occurs in the right lower quadrant upon palpation of the left lower quadrant.

A patient presents with abdominal pain in the right lower quadrant, examination reveals increased pain in the right lower quadrant on deep palpation of the left lower quadrant. This commonly known as which of the following?

B) Clomiphene citrate = first drug of choice in patients with infertility due to anovulation with normal hormone levels. Hint: Dehydroepiandrosterone sulfate is an androgen and has no role in stimulating ovulation. Hint: Bromocriptine is used to induce ovulation in patients with pituitary tumors. Hint: Human menopausal gonadotropin is used in patients who do not respond to clomiphene or have a pituitary insufficiency.

A patient presents with infertility due to chronic anovulation. Laboratory testing reveals a normal follicle stimulating hormone, estradiol, and prolactin levels. The patient's progestin challenge test was positive. Which of the following is the drug of choice for the treatment of infertility in this patient? A) Dehydroepiandrosterone sulfate (DHEA) B) Clomiphene citrate (Serophene) C) Bromocriptine (Parlodel) D) Human menopausal gonadotropin (Repronex)

C) nafcillin, gentamicin, and metronidazole Nafcillin provides treatment for penicillinase-resistant organisms Gentamicin covers many gram negative aerobes, and metronidazole is effective against a wide variety of anaerobic bacteria. Hint: Metronidazole, clindamycin, and cefoxitin essentially have the same spectrum of activity. They are effective against gram-negative anaerobes

A patient with a bowel perforation secondary to a gunshot wound is being prepped for surgery. Appropriate antibiotic prophylaxis and treatment includes which of the following? A cefoxitin and gentamicin B vancomycin and penicillin G C nafcillin, gentamicin, and metronidazole D metronidazole, clindamycin, and cefoxitin

Dumping syndrome typically occurs after Billroth type I (antrectomy + gastroduodenostomy) surgeries as well as gastric bypass surgeries when the patient attempts to eat a large amount of simple sugars.

A patient with a history of severe peptic ulcer disease is 5 weeks status post Billroth I surgery. One week ago he restarted his normal diet and has had the onset of severe nausea, abdominal cramping, and light-headedness that occur approximately thirty minutes after eating. The abdominal exam reveals a healing surgical scar without areas of unusual tenderness or any palpable masses. Which of the following is the most likely diagnosis?

B) decreased CVP; decreased BP; increased pulse rate Hypovolemic shock is a condition with a decrease in the amount of circulating blood volume in the intravascular system. A decrease in the amount of circulating volume will result in a decrease in the CVP pressure which is an indirect measurement of the amount of blood in the right ventricle. Less blood in the vascular system means decreased blood pressure. Since there is less blood in the circulation, the body will attempt to compensate for this by increasing the number of contractions (pulse rate) and the force of those contractions due to increased sympathetic stimulation.

A patient with hypovolemic shock would most likely exhibit which of the following signs? A) increased CVP; decreased BP; increased pulse rate B) decreased CVP; decreased BP; increased pulse rate C) increased CVP; increased BP; decreased pulse rate D) decreased CVP; increased BP; decreased pulse rate

A) *Desipramine* (TCA) Irritable bowel syndrome is considered an intestinal motility disorder in which chronic diarrhea is the main symptom. Rome III diagnostic criteria are based on symptom presence on >3 days per month over the past 3 months plus 2 or more of the following: defecation decreases symptoms, a change in the frequency of stooling or a change in the shape of stool. Treatment regimens are geared toward which of the symptoms a patient with irritable bowel syndrome suffers from most: pain, diarrhea, bloating or constipation. The pain associated with irritable bowel syndrome can be treated with selective-serotonin reuptake inhibitors like citalopram, tricyclic antidepressants like desipramine, and antispasmodics such as atropine, hyoscyamine, dicyclomine or scopolamine. B) Loperamide (B), a opioid piperidine-derivative, is used to treat diarrhea, not pain, associated with irritable bowel syndrome. C) Lubiprostone (C) is a prostaglandin E1 derivative. Its chloride channel agonism is used in treating the constipation, not pain, associated with irritable bowel syndrome. D) Bloating and flatulence that are associated with irritable bowel syndrome can be treated with rifaximin (D), a semisynthetic antibiotic.

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? A) Desipramine B) Loperamide C) Lubiprostone D) Rifaximin

C) enhance fetal lung maturity. Corticosteroids may be given from 24-34 weeks in patients with preterm labor or who have pregnancy complications which may cause premature birth. The corticosteroids enhance pulmonary maturity.

A patient with preterm labor may be given corticosteroids to A) decrease uterine activity. B) prevent chorioamnionitis. C) enhance fetal lung maturity. D) prevent the development of gestational diabetes

Measurements of prostate-specific antigen PSA measurement correlates well with volume and stage of disease and is the recommended examination formonitoring disease progression.

A patient with prostate cancer has a nonpalpable, focal lesion, and the patient is reluctant to have surgery at this time. Which of the following would best monitor disease progression?

A) Stenting of the renal artery Hint: Lifestyle modifications in patients who are unresponsive to medical therapy prior to stenting will not change the natural course of the disease. This is recommended following stenting or surgery

A patient with renal artery stenosis is unresponsive to medical therapy. Which of the following is the next most appropriate intervention? A Stenting of the renal artery B Nephrectomy C Radioactive iodine D Lifestyle modifications

This patient has a pH 7.32 with a decreased serum bicarbonate and therefore has a metabolic acidosis.

A patient's arterial blood gas is noted to have a pH 7.32, pCO2 32 mm Hg, HCO3 16 mmol/L. Which of the following is the correct interpretation of this arterial blood gas?

B) Octreotide (Sandostatin) Octreotide (somatostatin analog) is a vasoactive drug used in the treatment of GI bleeding - will decrease portal venous flow - as well as somatostatin, vasopressin, and terlipressin. Somatostatin and octreotide are preferred due to safety and less incidence of serious side effects. Hint: Enoxaparin will increase bleeding and therefore contraindicated in GI bleeding

A person presenting with bleeding esophageal varicies should be treated with which of the following while awaiting arrival of endoscopy? A) Carafate (Sucralfate) B) Octreotide (Sandostatin) C) Omeprazole (Prilosec) D) Enoxaparin (Lovenox)

*HLA-B27* "Seronegative spondyloarthropathies" = any chronic disease of the joints of the vertebral column without rheumatoid factors in the blood. They include ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and other disorders.

A positive ______________ suggests a presence of the *seronegative spondyloarthropathies*: ankylosing spondylitis (spine and sacroiliac pain), reactive arthritis (conjunctivitis, urethritis, arthritis), psoriatic arthritis (skin and nail findings) and enteropathic arthropathy (history of Crohn's or ulcerative colitis).

C) Vaginal estrogen Oral estrogen (A) should be reserved for systemic menopausal symptoms other than vaginal dryness, such as hot flashes. Progesterone (B & D) is not used to improve the lubrication or elasticity of the vaginal epithelium.

A postmenopausal patient of yours is diagnosed with atrophic vaginitis and dyspareunia. She denies other menopausal complaints. Vaginal lubricants and moisturizers are not helping to decrease her symptoms. Which of the following would be most appropriate to prescribe next? A) Oral estrogen B) Oral progesterone C) Vaginal estrogen D) Vaginal progesterone

B) Estrogen During menopause, the ovary becomes less sensitive to circulating follicle-stimulating hormone, and as such, produces less estrogen. Estrogen is largely responsible for the health of the female urogenital epithelium, acting on receptors located in the vagina, vulva, urethra and urinary bladder. It maintains the proper amount of collagen, mucopolysaccharides and hyaluronic acid in the epithelium of these organs. As estrogen levels decrease significantly as a woman passes thru menopause, urogenital epithelial changes occur, and as a result, vaginal dryness and irritation can occur. The subsequent decrease in vaginal lubrication can cause painful sexual intercourse. Also, thinning and irritation of the urinary epithelium can lead to recurrent urinary tract infections.

A postmenopausal woman presents to the clinic worried about her and her husband's sexual health. As of late, sexual intercourse has been very uncomfortable for the both of them. She thinks it has to do with her recurrent urinary tract infections, however, you explain that as a woman ages, vaginal atrophy occurs due to a significant decrease in which of the following hormones? A) Androstenedione B) Estrogen C) Progesterone D) Testosterone

D) Suction curette Colposcopy (A) utilizes illumination and magnification of the vulva, vagina and cervix to evaluate the presence of premalignant and malignant lesions of these structures, but does not evaluate the endometrial cavity. Dilation and curettage (B) is reserved for patients with difficult or nondiagnostic outpatient biopsies. The results of a Papanicolaou test (pap smear) (C) may suggest endometrial abnormalities, but are unreliable in diagnosing endometrial cancer.

A postmenopausal woman presents with abnormal vaginal bleeding. You suspect endometrial malignancy, and refer the patient for further investigation. Which of the following modalities is *initially used in determining a diagnosis*? A) Colposcopy B) Dilation and curettage C) Papanicolaou test D) Suction curette

D) Suction curette The most important condition to evaluate in a woman with postmenopausal pelvic bleeding is endometrial cancer. The cornerstone of diagnosis is based on endometrial sampling. Several modalities are available, but the easiest, most convenient and most cost-efficient process is accomplished in the outpatient setting through the use of an aspiration device, such as suction curette.

A postmenopausal woman presents with abnormal vaginal bleeding. You suspect endometrial malignancy, and refer the patient for further investigation. Which of the following modalities is used in determining a diagnosis? A) Colposcopy B) Dilation and curettage C) Papanicolaou test D) Suction curette

A) Iron deficiency Iron deficiency anemia is responsible for 95% of anemias during pregnancy Hint: Folic acid deficiency anemia is common where nutrition is inadequate

A pregnant 28 year-old female presents at 30 weeks gestation complaining of fatigue and headache. Her vital signs and physical examination are normal. Routine hemoglobin screening is 10.1 g/dL. Peripheral smear shows microcytic, hypochromic red blood cells. Besides the physiologic dilution of pregnancy, what type of anemia is most likely in this patient? A Iron deficiency B Folic acid deficiency C Thalassemia D Hereditary spherocytosis

C) Psyllium (Metamucil) Hint: Hemorrhoidectomy and sclerotherapy are reserved for severe Grade III and IV hemorrhoids. Hint: because these are PAINLESS they are likely INTERNAL. rectal pain with interal would suggest complication

A pregnant female presents at 32 weeks gestation with painless rectal bleeding and a bulging perianal mass when straining which goes away. Which of the following is the most appropriate management of this patient? A) Hemorrhoidectomy B) Metronidazole (Flagyl) C) Psyllium (Metamucil) D) Sclerotherapy

B) Administer intravenous ceftriaxone and vancomycin This patient is presenting with severe meningococcal septicemia caused by the aerobic gram-negative diplococcus N. meningitidis, a natural organism living in the nasopharynx of humans, its only host. Patients with this infection may progress rapidly. The lumbar puncture may be deferred until the patient is stable and should not delay antibiotic administration. Although N. meningitides continues to be sensitive to penicillin, ceftriaxone and vancomycin should be administered to cover for N. meningitides and resistant pneumococcal meningitis, which may also cause purpura fulminans.

A previously healthy 17-year-old boy is brought to the ED by ambulance. He became very ill over the past few hours. His vital signs are T 39.4ºC, HR 142, BP 90/52, RR 20, and a pulse oximetry of 94% on room air. On exam, he has a stiff neck and the rash seen above on his leg. You establish an intravenous line, draw a blood culture, order a complete blood count and electrolyte assessment, and administer a fluid bolus. Which of the following is the most appropriate next step? A) Administer hydrocortisone to treat hemorrhagic adrenalitis (Waterhouse-Friderichsen syndrome) B) Administer intravenous ceftriaxone and vancomycin C) Perform a CT scan of the head D) Perform a lumbar puncture

Pelvic inflammatory disease Appendicitis (A) and ectopic pregnancy (B) are surgical emergencies that must be ruled out in a young female patient with lower abdominal pain, but the patient history of unprotected sexual encounters with multiple partners points to a diagnosis of PID. A thorough sexual and menstrual history should be completed, and a pregnancy test (D) is indicated, however lower abdominal pain and vaginal discharge are not indicative of pregnancy.

A previously healthy 21-year-old woman presents to your office with a complaint of lower abdominal discomfort and vaginal discharge for the past 2 weeks. She is currently single, but admits to occasionally "fooling around" with men she meets at parties. She expresses concern that she might be pregnant because of increasing tenderness in her lower abdomen for the past 3 days. Which of the following is the most likely diagnosis? Appendicitis Ectopic pregnancy Pelvic inflammatory disease Pregnancy

E) Lithotripsy This patient has a 7mm ureteral stone and will likely require surgical intervention, such as lithotripsy, for this stone to pass. Peitrow and Micali note that 90 to 98% of stones <5 mm are likely to pass on their own, although sometimes >30 days are needed for this to occur. A variety of agents may assist in stone passage. Deflazacort, a steroid, decreases ureter edema and may facilitate stone passage through the ureter. Nifedipine and tamsulosin decrease ureter spasm, facilitating smoother stone passage through the ureter. Analgesics, particularly opioids and non-steroidals, decrease the pain associated with stones lodging in the ureter. In the case of larger stones (>5 mm), passage is unlikely. Surgical interventions for stone removal include lithotripsy, a procedure which uses sound waves to break stones into smaller pieces which can be passed. Other procedures to assist in stone management include ureteral stenting, percutaneous nephrostomy tube placement, open surgical stone removal, and retrograde ureteral stone removal. However, since open surgical removal is an invasive procedure, lithotripsy is the first choice. Lithotripsy involves the usage of shock waves to crush stones in the renal calyx. It may be done as an outpatient procedure. Extracorporeal shock wave lithotripsy involves waves directed from outside; whereas intracorporeal shock wave lithotripsy consists of insertion of a percutaneous nephroscope and then crushing of the stones.

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 7 mm stone in his right ureter. What is the best option of treatment in this patient? A) Opioid analgesics B) Deflazacort C) Open surgical stone removal D) Tamsulosin E) Lithotripsy

Initiate screening mammography at age 50 Screening mammography for women may start at age 40 (B) in individualized cases based on risk factors. Magnetic resonance imaging (A) is not recommended as a diagnostic tool in breast cancer screening since there is not enough evidence to support its use. Ultrasound (D) is not used as a screening tool in breast cancer screening. Women who have suspicious lesions on mammography are generally sent for ultrasound to better visualize the lesions and determine next steps.

A previously healthy 35-year-old woman presents to your clinic with questions about breast cancer screening. She has no family history of breast cancer and wants to know when she should start screening. Per the United States Preventive Services Task Force, which of the following is the most appropriate next step in management? Initiate screening magnetic resonance imaging at age 40 Initiate screening mammography at age 40 Initiate screening mammography at age 50 Initiate screening ultrasound at age 50

C) Initiate screening mammography at age 50 Screening guidelines for cancer are developed after consideration of a number of factors including the benefits and harms of screening, scientific evidence of the risks of the condition and cost. Guidelines for breast cancer screening have more scientific evidence than any other type of cancer screening and have changed in recent years. There remain some discrepancies between different medical groups regarding recommendations for screening. The United States Preventive Services Task Force recommends screening mammography for women every two years from ages 50-74 years. Earlier and more frequent screenings may be individualized based on patient risk factors such as family history of breast cancer.

A previously healthy 35-year-old woman presents to your clinic with questions about breast cancer screening. She has no family history of breast cancer and wants to know when she should start screening. Per the United States Preventive Services Task Force, which of the following is the most appropriate next step in management? A) Initiate screening magnetic resonance imaging at age 40 B) Initiate screening mammography at age 40 C) Initiate screening mammography at age 50 D) Initiate screening ultrasound at age 50

D) Topical ciprofloxacin 0.3% - dexamethasone 0.1% drops Remember: (1) It is the aminoglycosides (Neomycin) that can be ototoxic. (2) acetic acid is a drying agent. (3) Topical treatment is standard, with oral medications reserved for febrile patients or those with involvement of the periauricular soft tissues. Topical acetic acid 2% solution (C) is an accepted treatment for otitis externa, but is not safe with tympanic membrane perforations. Since the tympanic membrane cannot be visualized to rule out a perforation, acetic acid should be avoided. Oral amoxicillin/clavulanate (A) is reserved for febrile patients or those with extensive periauricular soft tissue involvement. The patient has *otitis externa*, which refers to infection and inflammation of the external auditory canal. Factors which predispose to otitis externa include local trauma (often from scratching or attempted cerumen removal) and elevation of the local pH (frequent contact with water from swimming in pools or freshwater lakes). The clinical presentation of otitis externa includes erythema and edema of the external canal. Clear or purulent otorrhea and crusting exudate may be present. The inflammation may spread to the tragus and auricle, and in severe cases, to the periauricular soft tissues. The treatment for bacterial otitis externa should be aimed at treating the most common organisms causing otitis externa: *Pseudomonas aeruginosa, Staphylococcus aureus, Enterobacteriaceae, and Proteus species*. If the tympanic membrane is ruptured or external canal inflammation precludes visualization of the tympanic membrane such that perforation cannot be ruled out, non-ototoxic topical medications should be used in order to avoid causing damage to the inner ear. In this case, the best choice is topical ciprofloxacin 0.3% - dexamethasone 0.1% drops.

A previously healthy 37-year-old man presents with right ear pain which has been present for the past 3 days. On examination, the external canal is erythematous and edematous. A crusted exudate is present. The external canal is so swollen that it will not allow passage of an otoscope to visualize the tympanic membrane. Which of the following is the most appropriate treatment? A) Oral amoxicillin/clavulanate B) Oral fluconazole C) Topical acetic acid 2% solution D) Topical ciprofloxacin 0.3% - dexamethasone 0.1% drops

Bradycardia Cushing's triad is usually a pre-terminal event seen in patients with increased intracranial pressure and cerebral herniation through the foramen magnum. It is associated with decreased level of alertness, hypertension, bradycardia, and irregular respirations. *Bradycardia is the first sign and is therefore the most sensitive indicator.*

A seven-year-old boy is involved in a rollover motor vehicle collision. He arrives intubated by the paramedic service. On exam, you note him to be flexing both upper extremities. Which of the following is the most sensitive indicator of herniation? A) Bradycardia B) Hypertension C) Hypotension D) Irregular respiration

D) Wilms tumor Nephroblastoma, or Wilms tumor, is the most common abdominal malignancy in children, affecting 1 out of 100,000 children under the age of 15 years. It accounts for 7% of all childhood cancers. It is caused by alterations in the genes responsible for genitourinary development. The most common presenting symptom is an asymptomatic abdominal mass (80% of cases) and abdominal pain (25% of cases). Hematuria, hypertension and fever affect 5-30% of cases. Examination usually reveals a palpable abdominal mass. Work-up includes CBC, BMP, UA, coagulation studies and cytogenetic studies for 1p and 16q chromosomal deletions. Imaging begins with renal ultrasound, but may eventually include chest radiographs, abdominal CT or abdominal MRI. Treatment usually consists of nephrectomy followed by chemotherapy, with or without post-operative radiotherapy.

A seven-year-old boy, with a history of hypospadia, presents with abdominal pain. Examination reveals normal temperature, stable weight, and a nontender left abdominal mass. Further abdominopelvic, cranial nerve and neuromuscular examination is unremarkable. Urinalysis reveals scant red blood cells. Which of the following is the most likely diagnosis? A) Ewing sarcoma B) Hodgkin lymphoma C) von Hippel-Lindau syndrome D) Wilms tumor

A) Bordetella pertussis-specific polymerase chain reaction (PCR) B. pertussis PCR performed on a properly obtained nasopharyngeal specimen processed by an experienced lab is currently the method of choice. Although some false positive PCR results have been reported, it is much more sensitive than the difficult to obtain bacterial culture of this fastidious organism. Results can also be obtained fairly rapidly.

A two-month-old male infant presents in August with a copious, bubbly, tenacious mucous discharge from his nose and mouth. He also has a repetitive paroxysmal cough terminated by an inspiratory "whoop" and followed by a tussive episode. The infant had upper respiratory symptoms for the past two weeks. His parents report a possible seizure before taking him to the emergency room. Other infants in his day care center have been diagnosed with respiratory infections associated with a "prolonged" cough. The infant is pale and cyanotic, tachypnic and bradycardiac as well as anxious looking. Physical examination of his chest is consistent with a lobar pneumonia. What is the diagnostic method of choice in this patient? A) Bordetella pertussis-specific polymerase chain reaction (PCR) B) Bordetella pertussis-specific serology C) Culture for Bordetella pertussis D) Lymphocyte count

A) Administer antipyretics Febrile seizures are seizures that occur between the ages of six months and 60 months with a temperature of 38°C or higher, that are not the result of a central nervous system infection or any metabolic imbalance and that occur in the absence of a history of prior afebrile seizures. Treatment is mainly supportive for simple febrile seizures and involves evaluation of the fever source, control of fevers with antipyretics such as acetaminophen (not aspirin), and reassurance of the parents. An EEG (D) is not indicated unless the seizure is focal or atypical (complex febrile seizure). Moreover, if an EEG is indicated, it is usually delayed two weeks after the initial event. Anticonvulsant therapy (B) is not indicated for children with one or more simple febrile seizures. A lumbar puncture (C) should be strongly considered in children ages six to 12 months with a febrile seizure who have not received or are behind on immunizations, have been exposed to other children with serious bacterial infections, or who have been pretreated with antibiotics. The identification of a source of fever, such as UTI or otitis media, does not eliminate the possibility of meningitis. For children > 18 months of age, a lumbar puncture is only indicated in the presence of clinical signs and symptoms of meningitis or other intracranial infection.

A two-year-old previously healthy boy is witnessed having a tonic-clonic seizure in the emergency room. Mom originally brought him in due to a fever of 39°C. The episode lasted five minutes, and the patient returned to baseline mental status. Which of the following is the most appropriate next step in management? A) Administer antipyretics B) Initiate anticonvulsant therapy C) Perform a lumbar puncture D) Perform an EEG

Acute tubular necrosis (ATN) responsible for more than 50% of cases of acute kidney injury in the hospital setting. ATN occurs when there is decreased blood flow to the kidney usually secondary to a drop in blood pressure. The most significant finding on urine microscopy is muddy brown cellular casts, but additionally, there may be fine granular casts as well as renal tubular epithelial cells.

A urine microscopy of a patient with an elevated creatinine reveals muddy brown cellular casts. What is the most likely diagnosis?

C) Conjunctivitis Conjunctivitis can be caused by bacterial, viral, allergic, and irritant etiologies. Clients usually complain of red eyes and a sticky or watery discharge. The type of discharge helps to determine the etiology-watery in viral, and sticky green or yellow, in bacterial conjunctivitis. Irritation is common, but severe pain and photophobia are not. Bacterial or viral conjunctivitis is usually self-limited, but it may be treated with a topical antibiotic, without steroids, such as sulfacetamide (10% 3-4 times/day). Topical aminoglycoside should be reserved for more refractory disease. Allergic conjunctivitis may be effectively treated with a new class of non-steroidal topical anti-inflammatory agents. Irritant conjunctivitis, including dry eyes, may be treated with topical, non-preserved lubricants.

A white female comes into the evening clinic with a complaint of red eyes with a sticky discharge. Her eye feels irritated, the pain is mild. She tells you she shared towels with her boyfriend who had a red eye. She asks you if you think her boyfriend gave her an infection. What is your working diagnosis? A) Blepharitis B) Chalazion C) Conjunctivitis D) Ectropion E) Foreign Body

E) Foreign Body Foreign Body sensation is most commonly due to corneal or conjunctival foreign bodies. Other causes are disturbances of the corneal epithelium and rubbing of eyelashes against the cornea (trichiasis).

A white male comes into the ER with the complaint of pain in his right eye. He was whittling and felt like something went into his eye. This happened four hours ago. He has washed his eye with water, but it still feels funny. What is your working diagnosis? A) Blepharitis B) Chalazion C) Conjunctivitis D) Ectropion E) Foreign Body

Staphylococcus aureus It is important to distinguish mastitis (cellulitis) from an abscess (requires surgical drainage) and inflammatory breast cancer (rare, but deadly). In addition to antibiotics such as dicloxacillin or cephalexin that cover for Staphylococcus aureus, the patient should be encouraged to apply warm compresses and continue breastfeeding. If the patient does not respond to antibiotics within 72 hours, the patient should be evaluated again for the possibility of breast abscess.

A woman presents with right breast pain, fever, and malaise for 3 days. She has been breastfeeding her newborn child for the last 3 weeks. On exam, there is an area of focal erythema and tenderness. No mass or fluctuance is noted. What is the most likely pathogen responsible for causing her condition? Escherichia coli Staphylococcus aureus Streptococcus agalactiae Streptococcus pyogenes

C) Sialadenitis Stones in the salivary ducts are called sialolithiasis. The exact cause is unknown. Partial obstruction leads to increased saliva production, pain, and swelling during eating. Symptoms are usually transient and resolve within an hour, but often recur with each meal. When a stone completely obstructs a duct it can cause sialadenitis which is marked by constant pain, swelling and infection. Complications include scarring with stenosis and fistula formation. Diagnosis is clinical but is aided by radiographs (low yield) and CT scan. Treatment is supportive with sialogogues and local massage. If persistent, stone removal is necessary via extracorporeal shock wave lithotripsy. Antibiotics are prescribed for signs of infection. Lofgren syndrome (A), a type of acute sarcoidosis, consists of erythema nodosum, bilateral hilar lymphadenopathy and arthralgia, but no salivary gland findings. Sarcoidosis (B) is a disease of abnormal collections of granulomas. Salivary gland dysfunction is possible. Nontender, smooth, bilateral parotid gland enlargement is typical. Sarcoidosis almost never affects the other salivary glands. Xerostomia (dry mouth) is associated with sarcoid parotitis. Sjogren's syndrome (D) is an autoimmune disorder of the exocrine glands, leading to inflammation of the tear and salivary ducts, which results in decreased tears, dry eyes, decreased (not increased) saliva and dry mouth.

A young woman complains of two months of pain and swelling under her tongue. It occurs with every meal, and typically subsides within an hour. On examination, you appreciate submandibular edema and warmth. Palpation under the jaw reproduces pain. While her tongue is lifted up, you see an excess of saliva and mucopurulent discharge coming from Wharton's ducts. Which of the following is the most likely diagnosis? A) Lofgren syndrome B) Sarcoidosis C) Sialadenitis D) Sjogren's syndrome

A) CA-125 Desmin (B) is elevated in endometrial and muscle sarcomas. Inhibin (C) is increased in adrenocortical carcinoma, but also in stromal ovarian cancer, which is the least common of the three histological subtypes of ovarian cancer and not common in younger patients. The S-100 (D) protein biomarker is elevated in melanomas and sarcomas While ovarian cancer represents the fifth most common gynecologic malignancy, it carries the highest mortality of all such malignancies. Two thirds of patients have advanced disease upon diagnosis. The disease is usually widespread at presentation due to the ease of direct extension into the peritoneal cavity. Risk is decreased in anovulatory patients who take chronic oral contraceptive pills.

A young woman has a significant family history of gynecologic malignancy. She refuses oophorectomy at this time. In addition to serial ultrasound screening, which of the following serum levels will you monitor? A) CA-125 B) Desmin C) Inhibin D) S-100

B) Microscopic examination Infective vaginitis is very likely given the above clinical description. In the initial evaluation of these symptoms, it is important to determine the causative agent. A KOH "whiff" test can be performed to detect the amine-like "fishy" odor of bacterial vaginosis or trichomonas vaginitis. However, direct microscopic examination of the discharge suspended in saline (termed wet preparation, or 'wet prep') will reliably establish the diagnosis, and subsequently direct proper therapy.

A young woman presents with a complaint of "stained underwear." She reports that for the last three days she has noticed a malodorous, greenish discharge emanating from her "groin." You take a thorough history and perform a pelvic examination. Which of the following is the next best step in evaluating this complaint? A) Bacterial culture B) Microscopic examination C) Pelvic ultrasonography D) Serum complete blood count and chemistries

November to March.

Although bronchiolitis can be seen throughout the year, its peak occurrence in North America is from _________________.

Gentamicin

Aminoglycoside used to treat gram- negative bacteria; nephrotoxic, ototoxic; blood peak/trough levels should be monitore

Gentamicin, Amikacin, Tobramycin ("GAT")

Aminoglycosides for Pneumonia

Esophagoscopy for removal

An 18 month-old female presents to the Emergency Department having possibly swallowed a hearing aid battery within the past hour. She is drooling and appears anxious but parents have noticed no stridor or dyspnea. She has no history of previous esophageal injury. Physical examination is unremarkable. Chest radiograph reveals a radiopaque round object at the distal esophagus. Which of the following is the most appropriate treatment option?

A) Admit to hospital and prepare for delivery *Severe preeclampsia* mandates hospitalization. Delivery is indicated if gestational age is 34 weeks or greater. Severe Preeclampsia in this scenario indicated by the SBP >160 (or if DBP >110), and the headache with the vision changes after 20 weeks. Other factors would include progressive renal insufficiency, thrombocytopenia, HELLP syndrome, epigastric pain, clonus, irritability, or pulmonary edema. Hint: Antepartum fetal surveillance and close monitoring in hospital is appropriate for pregnant female with unfavorable cervix and mild preeclampsia.

An 18 year-old G1P0 female presents for her 35 week prenatal visit with complaints of headache, blurred vision and right upper quadrant discomfort. Vital signs show BP of 170/100 mmHg and brisk patellar reflexes. Urinalysis shows 3+ proteinuria. Fetal heart tones are 150. What is your next step in the care of this patient? A) Admit to hospital and prepare for delivery B) Admit to hospital with antepartum fetal surveillance and close monitoring of maternal conditions C) Order bed rest at home with daily fetal movement counts and twice weekly antepartum care D) Order bed rest at home with administration of prophylactic magnesium sulfate

C) Trichomonas vaginitis Signs of trichomonas include: thin frothy or bubbly, pale yellow-green to gray adherent vaginal discharge, can have erythema of vulva and vagina, may have petechiae on the cervix, amine odor may be present, may also complain of dysuria and dyspareunia, pH 5 to 6.5 (basic). Hint: Symptoms from bacterial vaginosis include ivory to gray discharge, thin, homogeneous, adherent, often increased pH 5-6.5 (basic), distinctive "fishy" odor, itching may be present. Malodorous discharge is especially noticeable by the patient after menses or intercourse.

An 18 year-old female comes to the clinic with the complaint of increased vaginal discharge and vaginal odor. She also complains of urinary frequency. On physical examination there is evidence of thin, gray, frothy discharge in the vagina. The cervix appears erythematous and the vaginal pH is 6. Which of the following is the most likely diagnosis? A) Candida vaginitis B) Bacterial vaginosis C) Trichomonas vaginitis D) Chlamydia trachomatis

D) mobile flagellated protozoa on a normal saline preparation Trichomonas presents with a frothy discharge, irritative symptoms of pruritus, dysuria, and frequency, and the flagellated protozoa are demonstrated on a saline preparation. Hint: Clue cells are seen in Gardnerella vaginalis infections, but the vaginal discharge is grayish and has an unpleasant fishy odor.

An 18 year-old female presents with 2-day duration of dysuria, vulvovaginal pruritis, and a frothy clear to white discharge. Which of the following results would be expected? A) clue cells on normal saline preparation B) hyphae and budding yeast on a KOH preparation C) intracellular gram negative diplococci on Gram stain D) mobile flagellated protozoa on a normal saline preparation

D) Lateral radiograph Cervical spine x-rays are most commonly used as the initial screen for cervical spine injury. A cervical spine series consists of a lateral view, anteroposterior (AP) view, and an odontoid view. The lateral view detects up to 80% of traumatic spine injuries.

An 18 year-old male is involved in a motor vehicle accident with a question of cervical spine fracture. What is the imaging test of choice to initially evaluate this patient and clear his cervical c-spine? A Positron emission tomography B Magnetic resonance imaging C Computed tomography D Lateral radiograph

D) Periapical abscess Acute pain, swelling, and mild tooth elevation is characteristic of a periapical abscess. Exquisite sensitivity to percussion or chewing on the involved tooth is a common finding. Periapical abscesses occur when there is significant erosion of the pulp with bacterial overgrowth and are usually associated with dental caries or nonviable teeth. Treatment is with antibiotics (penicillin), appropriate analgesia, and dental follow-up within 48 hrs.

An 18-year-old man presents to the ED with acute tooth pain. He has a history of multiple dental caries, but this pain has been gradually worsening over the past two days. On exam, tooth #31 is exquisitely tender to percussion and has a large eroded area of enamel. There is swelling seen in the surrounding gingiva but not in the buccal or submandibular soft tissues. The patient is afebrile with no other complaints. What is the most likely diagnosis? A) Acute tooth fracture B) Alveolar osteitis C) Ludwig's angina D) Periapical abscess

Compartment syndrome characterized by a pathological increase of pressure within a closed space and results from edema or bleeding within the compartment. It may occur as an early local complication of fracture.

An 18-year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis?

C) compartment syndrome Compartment syndrome is characterized by a pathological increase of pressure within a closed space and results from edema or bleeding within the compartment. It may occur as an early local complication of fracture. *Hint*: Avascular necrosis occurs primarily in muscles post-traumatically and may not arise for several months after an injury. *Hint*: Myositis ossificans is a late complication of fracture resulting from disruption of the blood supply to the bone. *Hint*: Reflex sympathetic dystrophy is characterized by painful wasting of the hand muscles that may be secondary to injury and could occur as a late complication.

An 18-year-old patient has a tibia/fibula fracture following a motorcycle crash. Twelve hours later the patient presents with increased pain despite adequate doses of analgesics and immobilization. Which of the following is the most likely diagnosis? A avascular necrosis B myositis ossificans C compartment syndrome D reflex sympathetic dystrophy

B) Admit to obstetrics for delivery Corticosteroids (A) have not been shown to be effective in patients with PROM (as opposed to those with preterm PROM). Amoxicillin (C) should be considered in PROM if there are signs of infection. Tocolysis (D) is controversial and delivery is preferred. No pharmacologic agents are completely effective and there is no evidence that tocolytic therapy directly improves neonatal outcome.

An 18-year-old woman at 37 weeks gestation presents with a spontaneous leakage of fluid from the vagina. She has no other signs of active labor. Vital signs are unremarkable and the patient has no complaints except for the leakage of fluid. What management is indicated? A) Administer corticosteroids B) Admit to obstetrics for delivery C) Amoxicillin IV D) Tocolysis (Mag sulfate, terbutaline, nifedipine, endomethacin)

D) Widely split and fixed S2 In the vast majority of cases, an atrial septal defect results in an intracardiac left-to-right shunt, which typically manifests as right ventricular overload and increased stroke volume. ASDs are associated with some physical examination abnormalities, depending on the degree of shunting and the compliance of the ventricles, systemic vasculature and peripheral vasculature. A hyperdynamic right ventricular impulse may be appreciated. Pulmonary artery dilation may produce an ejection click. Splitting of S1 and S2 is also common. In fact, a widely split and fixed S2 is very common in large left-to-right shunts. Large shunts can also produce a left sternal murmur, heard higher as a systolic crescendo-decrescendo murmur, and lower as a middiastolic rumble. Bradycardia (A) is not a common finding in symptomatic ASDs. The majority of ASDs result in left-to-right shunting. As such, there typically is no pulmonary bypass, and therefore, no resulting cyanosis (B). Prominent right, not left (C), ventricular impulse is commonly associated with the left-to-right shunting of an ASD.

An 8-month-old boy fails to obtain age-appropriate milestones. His mother feels that he is too fatigued to properly feed. An echocardiogram reveals a large atrial septal defect. Which of the following physical examination abnormalities would you most expect to find in this infant? A) Bradycardia B) Cyanosis C) Prominent left ventricular impulse D) Widely split and fixed S2

Measles Patho: Measles virus (rubeola) Clinical: conjunctivitis, coryza, and cough - The prodromal period lasts approximately 3 days and is characterized by fever, malaise, and anorexia, followed by the 3 C's. The rash first appears behind the ears and at the hairline of the forehead and then spreads cephalocaudally (head to tail) and centrifugally (tending to move away from a center.) to involve the neck, upper trunk, lower trunk, and extremities sparing the palms and soles. It initially consists of erythematous blanching maculopapular lesions but rapidly coalesces, especially where the first lesions appeared on the face Tx: Treatment is supportive. Recognition is of the utmost importance in preventing the spread of the disease and associated morbidity and mortality.

An 8-month-old child presented with fever, coryza, and marked conjunctivitis associated with intense photophobia. Confluent, erythematous, and maculopapular rash on the face developed on the fourth day of fever.

D) Surgical repair Infants or children with ventricular septal defects (VSDs) may or may not have symptoms based on the size of the defect. Smaller defects do not allow for a significant left-to-right cardiac shunt, therefore, many of these infants are asymptomatic and carry an excellent prognosis. For small defects, medication is usually not necessary. However, moderate and large defects typically require medication management for congestive heart symptoms. Options include diuretics and digoxin. If these patients fail medication management, surgical repair is recommended. Surgery is also recommended for any VSD that is associated with growth failure or recurrent respiratory infections. Indomethacin (C) is not a recommended treatment of VSD. It is however used in treating a different congenital heart defect called patent ductus arteriosus.

An 8-month-old infant with a ventricular septal defect has significant growth failure. He also suffers from recurrent pneumonia. Which of the following is the best management of this patient? A) Atenolol B) Furosemide C) Indomethacin D) Surgical repair

B) Grab as close to the tick's head with forceps and pull upward use tweezers or forceps, grab the tick's head as close to the skin as possible, and gently pull upward. The goal is to avoid crushing or tearing the tick's head or body because this can induce regurgitation of infectious contents or leave behind its body parts, a possible nidus for infection or a granulomatous reaction.

An 8-year-old boy is brought to the ED by his parents after they discovered a tick attached to his right armpit. What is the best way to remove the tick? A) Coat the tick in petroleum jelly B) Grab as close to the tick's head with forceps and pull upward C) Immerse the tick in isopropyl alcoholYour Answer D) Immerse the tick in normal saline E) Tie a suture around the tick's body and pull upward

B) Resistance training can begin as early as age 6 with appropriate supervision Most injuries related to resistance training (A) are secondary to improper lifting technique or inadequate supervision. Incorporating weightlifting movements into resistance training has been shown to significantly increase strength without report of injury. Resistance training may begin as early as ages 6 to 8 (C) with proper technique and appropriate supervision by a qualified instructor. The mechanical stress from heavy resistance training (D) in the context of proper technique has not been shown to have an impact on linear growth in any prospective youth resistance training study. Substantial concern exists within the general public that any type of strength training is an unsafe practice for the developing child, and specifically that it may stunt growth. There is no evidence to suggest that appropriate strength-training programs negatively impact linear growth. Rather, the mechanical stress of resistance training may actually support childhood bone formation as well as have a beneficial effect on overall cardiovascular fitness, lipid profiles, bone mineral density, and mental health. Proper weight training involves many reps with low resistance.

An 8-year-old boy presents for a well-child check. He wants to join his school's basketball team that involves weightlifting. His mother has concerns regarding whether this is appropriate for a child his age. Which of the following is the most accurate statement regarding resistance training? A) Most injuries related to resistance training are the result of weightlifting movements such as modified cleans, pulls, and presses B) Resistance training can begin as early as age 6 with appropriate supervision C) Resistance training is appropriate for children who are at least 10 years of age or are at least 4 feet 5 inches in stature D) The mechanical stress from heavy resistance training can negatively impact linear growth during childhood and early adolescence

C) Procainamide This question addresses issues related to the treatment of arrhythmias and lupus-like side effects. The initial treatment should control arrhythmias using lidocaine, unload the heart using a balanced vasodilator such as nitroglycerin or nitroprusside, and use aspirin and heparin to prevent further clot formation. Once discharged, patients are frequently placed on atenolol to control catecholamine-induced arrhythmias. Finally, long-term control of arrhythmias is accomplished using drugs such as procainamide or quinidine. Unfortunately, procainamide can cause lupus-like side effects. The use of thrombolytics has reduced myocardial damage caused by thrombus formation. Streptokinase, urokinase, and tissue plasminogen activator (tPA) all will lyse clots. This leads to coronary reperfusion. If performed within the first several hours post-clot, myocardium will be spared. The use of aspirin and heparin are directed at prevention of platelet aggregation and clot stabilization.

An 80-year-old man was treated for ventricular arrhythmias. He presents 1 month later with joint pains. He also has an unusual mask-like rash over his face and body. Discontinuation of drug therapy causes the symptoms to abate. What drug was most likely administered to this patient? A) Tocainide B) Quinidine C) Procainamide D) Phenytoin E) Propranolol

C) Ischemic colitis Ischemic colitis is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and possible gangrene of the bowel wall. Patients typically present with fairly acute onset crampy abdominal pain with tenderness over the affected bowel. Patients may have bloody diarrhea or passage of frank blood although it is not usually enough to warrant transfusion. The presentation with ischemic colitis differs from acute mesenteric ischemia which presents as pain that is disproportionate to physical examination findings. Risk factors include a history of atherosclerotic disease at other sites, such as coronary artery disease or cerebrovascular disease, advanced age, sepsis and extreme exercise. Bowel wall edema is the most common finding on CT imaging. All cases of ischemic colitis with signs of peritonitis or possible bowel infarction, generally warrant immediate surgical intervention for the resection of the ischemic or necrotic bowel, although this only occurs in about 20% of cases. Most cases resolve with supportive care (eg. IV fluids and bowel rest). Diverticular bleeding (B) is the most common cause of lower gastrointestinal hemorrhage. Patients with diverticular bleeding usually present with an abrupt onset of painless rectal hemorrhage. Occasionally, patients may present with mild abdominal cramping or the urge to defecate, secondary to blood within the colon

An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient's bleeding? A) Angiodysplasia B) Diverticular bleeding C) Ischemic colitis D) Peptic ulcer disease

A) Cheyne-Stokes Increased CO2 during the period of apnea causes compensatory hyperventilation. Hyperventilation in turn causes the decrease in CO2, which causes apnea and the cycle to restart. Causes include CNS dysfunction, cardiac failure with low cardiac output, sleep, hypoxia, or profound hypocapnia.

An abnormal pattern of breathing characterized by repetitive progressively deeper and sometimes faster breathing, followed by a gradual decrease in breathing that results in temporary apnea. Cycles usually take 30 seconds to 2 minutes. What is the breathing pattern? A) Cheyne-Stokes B) Apneusis C) Ataxic D) Cluster E) Kussmaul

Hypoparathyroidism (Hypocalcemia secondary to hypoparathyroidism) Hypocalcemia secondary to hypoparathyroidism is commonly seen as a complication of thyroidectomy. Hypocalcemia + Low intact PTH + High Phosphate is diagnostic

An adult presents with a three month history of *progressive severe muscle cramps*, extremity *paresthesias* and *lethargy* which began shortly after a thyroidectomy for a malignant thyroid lesion. Which of the following is the most likely diagnosis?

A) Dullness to percussion Early inspiratory crackles (B) is an exam finding that suggests small airway disease like bronchiolitis. Trachea deviating away from affected side (C) is a finding seen in tension pneumothorax. Vesicular breath sounds (D) is a normal physical examination finding. The causative organisms have changed over time with Streptococcus pneumoniae as the predominant organism. In addition, community-acquired Staphylococcus aureus is also becoming more common. The presentation of pleural effusion or empyema may depend upon when the child presents for medical attention. Some children present with symptoms related to empyema while others have been seen earlier in the course and appropriately treated for pneumonia but fail to respond. On physical examination, children may appear ill or occasionally be toxic-appearing. The majority are tachypneic, with fever and cough present in approximately 90 percent of patients. There may also be dullness to percussion, decreased air exchange, and possibly a pleural rub, on the side of the fluid collection.

An eight-year-old boy comes in your clinic for follow-up. Two days ago, he was diagnosed with pneumonia and started on amoxicillin-clavulanic acid. However, fever and cough persisted and is accompanied by decreased appetite, chest pain, and difficulty breathing. You suspect a complicated pneumonia. Which of the following physical exam findings is consistent with pleural effusion? A) Dullness to percussion B) Early inspiratory crackles C) Trachea deviates away from affected side D) Vesicular breath sounds

Hashimoto's thyroiditis. Hashimoto's thyroiditis (chronic autoimmune thyroiditis) is the most common cause of hypothyroidism in iodine-sufficient areas of the world.

An elevated thyroid peroxidase antibody (TPO) level is diagnostic for which thyroid disorder?

amiodarone but also with the highest risk of long-term complications. n addition, a 2014 report raises the possibility that amiodarone use in patients taking warfarin is associated with an increased risk of stroke compared to those not taking the drug.

Atrial Fib: Compared to other agents, ____________________is associated with the greatest likelihood of maintaining sinus rhythm

beta blockers (followed by sotalol and amiodarone.)

Atrial Fib: For patients with adrenergically-mediated AF (eg, occurring during exercise or other activity), we suggest _____________________ as first-line therapy,

B) ACEI

Cardioprotecitve, synergystic effect when used with thiazided in treating hypertension A) ARBs B) ACEI C) CCBs D) Beta Blockers

Essential tremor tends to temporarily improve after patients consume a small amount of alcohol.

Consumption is which type of beverage may transiently improve symptoms of benign essential tremor?

Rapidly Progressive Glomerulonephritis (RPGN)

Crescent formation on renal biopsy

*Paroxysmal Nocturnal Hemoglobinuria* Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired hematopoietic stem cell disorder with an unusual constellation of clinical findings. The rarity of the disease and nonspecific clinical features can result in significant delays in diagnosis. The importance of a prompt and accurate diagnosis has increased as effective therapies have become available, and diagnostic testing has evolved significantly as the molecular basis of the disease and pathogenesis of hemolysis become better understood. Screening for PNH is appropriate in patients with a direct antiglobulin (Coombs) negative hemolytic anemia, aplastic anemia, refractory anemia, or unexplained thrombosis in conjunction with cytopenias or hemolysis. The typical evaluation involves initial testing to determine that the patient has a hemolytic anemia; and to eliminate autoimmune, microangiopathic, and mechanical causes of hemolysis. Flow cytometry is then used to confirm or exclude the diagnosis of PNH.

Dark urine (Worse in the morning)

C) Protein C deficiency Deficiency of pro-coagulants causes bleeding diathesis while deficiency of anti-coagulants causes recurrent episodes of thrombosis. Protein C is a potent anti-coagulant. Both protein C and co-factor protein S are vitamin K dependent peptides. Protein C, which is produced by the liver, is a powerful naturally occurring anti-coagulant and is activated by thrombin. Thrombin (a powerful pro-coagulant) activates protein C after binding with a factor known as thrombomodulin. Activated protein C digests factor VIIIA and Va. Protein S is produced by endothelial cells and acts as a co-factor for protein C.

Deficiency of what factor may predispose a person to recurrent thrombosis? A) Platelet deficiency B) Factor VIIIC deficiency C) Protein C deficiency D) von Willebrand factor deficiency E) Factor VII deficiency

Laser Peripheral iridotomy This procedure creates a tiny hole in the peripheral iris through which aqueous humor can flow and reach the angle. Avoid anticholinergics and sympathomimetics.

Definitive treatment of Acute angle closure glaucoma

A normal reflex during which the eyes conjugately move in an opposite direction to head rotation, thus maintaining fixation on an object. If absent, consider a vestibular cause of nystagmus.

Describe the oculocephalic reflex (doll's head phenomenon).

Yes

Do all family members need to be treated if one person is diagnosed with pinworms?

D) 35 year-old woman with regular cycles Women with regular menstrual cycles are most likely to have dysmenorrhea. Dysmenorrhea is caused by a excess of prostaglandin F 2 alpha. Prostaglandin production increases under the influence of progesterone, reaching a peak at, or soon after, the start of menstruation. Hint: Young teenagers who have just started their menses are unlikely to have dysmenorrhea, because they usually are anovulatory for up to one year. Hint: Marathon runners are often amenorrheic or have oligoamenorrhea. They do not have dysmenorrhea because dysmenorrhea is a function of ovulatory cycles.

Dysmenorrhea would most likely occur in which of the following patients? A A young teenager who just started having her menses B A woman on birth control pills C A marathon runner with one menses per year D A 35 year-old woman with regular cycles

SIADH

Ectopic ADH production

Amoxicillin 2g 30-60 minutes before procedure

Endocarditis prophylaxis regimen

Clindamycin 600mg (Macrolides or Cephalexin are other options)

Endocarditis prophylaxis regimen if PCN allergic

pancreatitis

Epigastric pain, constant, boring, radiating to back, relieved with leaning forward or sitting in fetal position, Facial muscle spasm when facial nerve is tapped (Chvostek Sign).

*D) Squamous cell lung cancer* Squamous cell cancer is common in patients with a smoking history and presents with a central mass, hilar adenopathy and mediastinal widening. *Hint: Adenocarcinoma* typically presents with peripheral masses. *Hint: Large cell* lung cancer typically presents with peripheral masses

Episodes of hemoptysis. Chest x-ray reveals a hilar nodule with hilar adenopathy and mediastinal widening. What is the most likely diagnosis? A Large cell lung cancer B Adenocarcinoma C Bronchiectasis D Squamous cell lung cancer

Low iron because iron is hidden away (lots of passengers riding the bus [↑ferritin] so no seats are available [↓TIBC]) thought to be part of the body's defense system against invasion of organisms such as bacteria (which also rely on iron by obtaining it from the human host).

Explain anemia of chronic disease findings (Iron, ferritin, TIBC)

1) Lower IOP = acetazolamide, beta-blockers, mannitol 2) Open the angle = cholinergics

Explain the 2 steps in management of *Acute angle closure glaucoma*

DMARDs (Methotrexate) Early RA appears to be a "window of opportunity" in which aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) leads to better long-term outcomes. Therapy should be escalated to ensure maximal suppression of disease while making efforts to minimize toxicity and expense. aggressive therapy is important because once deformities are present the mechanical component is refractory to medical therapy. Almost all patients require more than one type of medication and, with rare exceptions, all patients should receive DMARD therapy. There are three broad categories of medications that are effective in managing RA: synthetic DMARDs, biologic DMARDs, and low-dose glucocorticoids. Prior to starting DMARD therapy, patients should receive vaccinations. live attenuated vaccines are contraindicated once individuals have started biologic DMARDs. The well-documented excess mortality (median life years lost: 8 years for males and 10 years for females) associated with RA is due largely to cardiovascular disease that is not explained by the traditional risk factors. RA is a systemic inflammatory disease, and chronic systemic inflammation has complex, deleterious effects on lipoproteins and the vascular system. Observational studies suggest that methotrexate and use of anti-TNF agents reduce cardiovascular events and mortality.

First line management of RA

Cefazolin (Ancef ®)

First-generation cephalosporin; surgical prophylaxis for skin flora

*Acetazolamide* Oral, IV decreases IOP by decreasing aqueous humor production. Reversible inhibition of the enzyme carbonic anhydrase resulting in reduction of hydrogen ion secretion at renal tubule and an increased renal excretion of sodium, potassium, bicarbonate, and water. Decreases production of aqueous humor and inhibits carbonic anhydrase in central nervous system to retard abnormal and excessive discharge from CNS neurons. Initial: 250 to 500 mg; maintenance: 125 to 250 mg (half the initial dose) every 4 hours (250 mg every 12 hours has been effective in short-term treatment of some patients).

First-line treatment of acute narrow angle-closure glaucoma

Noncontrast CT Do not perform LP if ICH is suspected. Mass effect may cause herniation if LP is done

Firstline test for hemorrhagic stroke

lipase

For acute pancreatitis which is more specific, amylse or lipase?

surgery

For early stage invasive cervical cancer, treatment is

chemoradiation significantly superior to radiation therapy alone.

For locally advanced cervical cancer, treatment is

conization

For microinvasive cervical cancer, treatment is

Metronidazole

For patients <12 months of age what medicaion is preferred for Giardia?

Lymphogranuloma Venereum (Chlamydia) Caused by Chlamydia trachomatis. General symptoms: Fever and chills, Headache or meningismus, Anorexia, Arthralgias and Myalgias.

Genital/rectal lesions with softening, suppuration (pus forming) and lymphadenopathy.

*Pulmonary Function Test* Reversible obstruction (↓FEV, ↓FEV/FVC)

Gold Standard diagnostic study for asthma

Tension Headache Tension-type headache (TTH) is the most prevalent headache in the general population, and the second-most prevalent disorder in the world. Path: Pain associated with myofascial (muscular) cause Tx: Nonpharmacologic interventions for TTH include heat, ice, massage, rest, and biofeedback. Analgesics (Tylenol, NSAIDs, Aspirin).

Headache is bilateral, tight, band-like, vise-like, constant, daily, NOT worsened with activity, usually not pulsatile. NO n/v or focal neuro symptoms

Migraine Headache Females more commonly affected. New data suggests as high as 25% of U.S. population affected. Path: CNS Platelet and mast cell aggregation, Increase then decrease in blood brain Catecholamines, Alternating Vasoconstriction and Vasodilatation, Serotonin release from synaptic nerve endings

Headache is lateralized, pulsatile, throbbing, associated with n/v, and worse with physical activity

Atypical pneumonia

Headache, fever, non-productive cough, myalgias, infiltrates on CXR

*DIC* *Disseminated intravascular coagulation* (DIC, also called consumption coagulopathy and defibrination syndrome) is a systemic process with the potential for causing thrombosis and hemorrhage. It can present as an acute, life-threatening emergency or a chronic, subclinical process, depending on the degree and tempo of the process and the contribution of morbidities from the underlying cause. Identifying DIC and the underlying condition responsible for it are critical to proper management. In DIC, the processes of coagulation and fibrinolysis become abnormally (and often massively) activated within the vasculature, leading to ongoing coagulation and fibrinolysis. Tissue or organ damage may result from reduced perfusion, thrombosis, and/or bleeding. Often, contributions from DIC itself and the condition that precipitated it are intertwined. Organ failure may result in significant morbidity and mortality.

Hemolytic Anemia (RBC destruction) + abnormal coags (Prolonged PT & PTT = bleeding problems)

Osteoarthritis

History suggests mechanical pain (ie, worse with activity, better with rest). Examination suggests joint line tenderness and boney enlargement. Radiographs demonstrate joint space narrowing, osteophytes, sclerosis, and bone cysts.

Vitamin C supplementation

How can we improve iron absorption

Blocks Na+ channels in the CNS

How does Phenytoin work?

Stool ova and parasites

How is Amebiasis diagnosed?

Days to weeks.

How long after an acute myocardial infarction does a left ventricular aneurysm occur?

years

How long do B12 stores in the body last?

6 weeks or longer

How long until clearing of pulmonary opacities is seen with CAP?

Seven times (1 mg of hydromorphone = 7 mg of morphine).

How much more potent is hydromorphone than morphine?

reduce MAP 25% in first hour, normalize BP over the next 8 to 24 hours Reduction of MAP > 25% may cause end-organ ischemia IV antihypertensives (labetalol or nicardipine)

Hypertensive Emergency: BP goals

Labetalol or esmolol Labetalol is an alpha-1-blocker and nonselective beta-blocker, which decreases systemic vascular resistance, mean arterial pressure, and heart rate, and causes a decrease or no change in cardiac output. Onset of action: 5 to 10 minutes. Duration of action: 3 to 8 hours.

Hypertensive emergencies: aortic dissection - 1st line treatment

Nicardipine Nicardipine is a second-generation dihydropyridine derivative calcium-channel blocker with high vascular selectivity and strong cerebral and coronary vasodilatory activity. The onset of action of IV nicardipine is from 5 to 15 minutes, with a duration of action of 4 to 6 hours. 5 mg/hour intravenously initially, increase by 2.5 mg/hour increments every 15 minutes according to response, maximum 15 mg/hour

Hypertensive emergencies: increased intracranial pressure or renal disease - 2nd line treatment after Labetalol

Ischemic Colitis Patho: Low-flow state → Large bowel ischemia. Ischemic colitis, a variant of mesenteric ischemia, usually occurs in the distribution of the inferior mesenteric artery. The intestinal mucosa is the most sensitive to ischemia and will slough if underperfused. The clinical presentation is similar to inflammatory bowel disease. Ischemic colitis can occur after aortic surgery, particularly aortic aneurysm resection or aortofemoral bypass for occlusive disease, when there is a sudden reduction in blood flow to the inferior mesenteric artery. Dx: Contrast-enhanced CT is highly accurate at determining the presence of ischemic intestine. In patients with acute or chronic intestinal ischemia, a CTA or MRA can demonstrate narrowing of the proximal visceral vessels. In acute intestinal ischemia from a nonocclusive low flow state, angiography is needed to display the typical "pruned tree" appearance of the distal visceral vascular bed. Ultrasound scanning of the mesenteric vessels may show proximal obstructing lesions. In patients with ischemic colitis, colonoscopy may reveal segmental ischemic changes, most often in the rectal sigmoid and splenic flexure where collateral circulation may be poor. Tx: Address underlying cause, surgery consultation. Any patient in whom there is a suspicion of intestinal ischemia should be urgently referred for imaging and possible intervention. The mainstay of treatment of ischemic colitis is maintenance of blood pressure and perfusion until collateral circulation becomes well established. The patient must be monitored closely for evidence of perforation, which will require resection.

Hypotension, Severe abdominal pain, Bloody stools

Beta-lactam + Macrolide or Doxy (*Ceftriaxone*, 1 g intravenously every 24 hours or ampicillin, 2 g intravenously every 6 hours) plus *azithromycin*, 500 mg intravenously every 24 hours) OR Broad spectrum respiratory FQ (Levofloxacin 750 mg/day, moxifloxacin 400 mg/day.)

INpatient CAP treatment

Amphotericin

IV antifungal antibiotic associated with renal toxicity, hypokalemia

Mycoplasma pneumonia AOM

If bullae on TM suspect...

Methotrexate Destroys trophoblastic tissue (disrupts cell multiplication) CI: ruptured ectopic pregancy, h/o TB, beta-hCG >5,000, + fetal heart tones, noncompliant patient.

In a hemodynamically stable pregnant patient with an ectopic pregnancy, what medication is recommended for medical management?

No, because the chloride level is similarly diluted.

In cases of hyperglycemia, should the sodium level be corrected prior to calculating the anion gap?

respiratory syncytial virus (RSV) or adenovirus infection

In infants and children, bronchiolitis is common and usually caused by _____________________.

Amebiasis

In most symptomatic individuals, mild initial diarrhea progresses to dysentery with blood and mucus in the stool and crampy abdominal pain, often with tenesmus.

Panretinal laser photocoagulation indicated for preservation of vision in patients with diabetic retinopathy.

In patents with diabetic retinopathy, what clinical intervention is most successful in preserving vision?

Aspirin, beta-blockers, and ACE-inhibitors. NOTE: The Air Versus Oxygen in ST-elevation Myocardial Infarction (AVOID) trial compared supplemental oxygen vs no oxygen unless oxygen fell below 94%. The AVOID study found in patients with ST-elevation myocardial infarction who were not hypoxic, administration of oxygen may increase myocardial injury, recurrent myocardial infarction, and major cardiac arrhythmia and may be associated with greater infarct size at 6 months

In patients with a myocardial infarction, which three drugs have been shown to decrease mortality?

C) lumbar puncture Although 95% of subarachnoid hemorrhages show blood on head CT, the remaining do not show evidence of hemorrhaging. A *lumbar puncture should then be performed and the fluid examined for red blood cells or xanthochromia*.

In suspected subarachnoid hemorrhage with a negative head CT, which of the following studies should be used to help establish the diagnosis of subarachnoid hemorrhage? A complete blood count B lipid profile C lumbar puncture D electrocardiogram

C) Provide her with reassurance Advising her to stop using tampons (A) is not needed since tampon use would not affect her vaginal discharge. The girl's vaginal discharge is physiologic leukorrhea and therefore she should be reassured that this is normal. Normal vaginal discharge is composed of 1 to 4 ml fluid per day that is white or transparent, thick or thin, and usually odorless. The pH of normal vaginal secretions is 4.0 to 4.5. This is formed by mucoid endocervical secretions in combination with sloughing of epithelial cells and normal vaginal flora. The discharge may become more noticeable during the middle of menstrual cycle, during pregnancy, or with the use of estrogen-progestin contraceptives. The normal discharge may be yellowish, slightly malodorous, accompanied by mild irritative symptoms, but it is not accompanied by pruritus, pain, burning, erythema, or local erosion. The absence of these signs and symptoms distinguishes it from pathologic discharge like vaginitis or cervicitis.

In the clinic, you are evaluating a 15-year-old girl who is complaining of increased vaginal discharge. She had her menarche at 12 years of age and since then has had irregular periods. She uses tampons during her menses. She notes thick yellowish vaginal discharge in between her periods. She denies burning, pain, or pruritus. She started to be sexually active for the past month with one partner. She uses condoms for contraception. On examination, you note Tanner 5 pubic hair and white discharge. You examine the discharge and obtain pH of 4, with negative whiff test and absence of clue cells on microscopy. You perform a pregnancy test, which is negative. Which of the following is the next best step? A) Advise her to stop using tampons B) Encourage her to douche after her period C) Provide her with reassurance D) Send culture for Gardnerella vaginalis

A) Cold water in the right ear produces nystagmus to the left Vestibulo-ocular reflex = COWS: Cold Opposite, Warm Same Any patient with nystagmus requires a complete neuro-ophthalmic examination, notably, visual acuity, pupillary reaction to light, extraoccular muscle function, confrontational testing and measuring intraocular pressure. Certain specifics to look for in a patient with nystagmus include if it changes with gaze directions, if it dampens with fixation, the fast phase direction and the presence of tinnitus, hearing impairment, vertigo and torticollis. Another test commonly used in the evaluation of nystagmus is called caloric testing, in which the external auditory canals are irrigated with cold and warm water or air. Caloric testing, normally a part of a full electro-, or video-, nystagmography test, is another way the peripheral vestibular system is tested. When cold water is used, it mimics a head rotation to the opposite side; warm water mimics head rotation to the same side. Normally, when the head turns right, the eyes turn left and exhibit horizontal nystagmus to the right. The opposite corollary holds true: head turns left, eyes turn right, brief horizontal nystagmus to left. Therefore, if a patient has normal peripheral vestibular function, warm water in the right ear produces left turning eyes with a right horizontal nystagmus, and cold water in the right ear produces right turning eyes with a left horizontal nystagmus. A helpful mnemonic, describing the direction of expected nystagmus during caloric testing, is COWS: Cold Opposite side, Warm Same side. If this is not seen, consider vestibular dysfunction of the side being tested.

In the evaluation of a patient with nystagmus, you suspect the main cause is peripheral vestibular dysfunction. You decide to perform caloric testing. Which of the following physical exam findings is expected in a patient with normal vestibular function? A) Cold water in the right ear produces nystagmus to the left B) Cold water in the right ear produces nystagmus to the right C) Warm water in the left ear produces nystagmus to the right D) Warm water in the right ear produces nystagmus to the left

A) Electrodiagnostics, then laboratory testing In the workup of suspected polyneuropathy, first assess for possible common underlying causes, such as diabetes mellitus, alcohol abuse, medication side effects, chronic renal impairment (uremia) and HIV by taking a complete detailed history. In those patients with common known underlying conditions and mild symptomatology, extensive initial diagnostic work up may be unnecessary. In those patients with unknown underlying conditions, or those with moderate, severe or progressive symptoms, initial diagnostic work-up begins with electrodiagnostic testing, such as electromyography and/or nerve conduction studies. Laboratory studies can be ordered based on electrodiagnostic testing results and history and examination findings.

In the initial diagnostic evaluation of a patient with undifferentiated polyneuropathy, which of the following approaches is most appropriate? A) Electrodiagnostics, then laboratory testing B) Electrodiagnostics, then nerve biopsy C) Laboratory testing, then electrodiagnostics D) Laboratory testing, then nerve biopsy

C) Ectopic pregnancy An ectopic pregnancy will have an abnormally low hCG level because the hCG will not double every 48 hours as a normal pregnancy would. Hint: Quantitative hCG levels are excessively elevated for the gestational age of the pregnancy. in hydatidiform mole Hint: Choriocarcinoma is a persistent form of gestational trophoblastic neoplasia and will have an elevated hCG level. Hint: A twin gestation will have a higher hCG level because of the presence of two fetuses.

In which of the following conditions would human chorionic gonadotropin (hCG) level be lower than expected for gestational age? A Choriocarcinoma B Hydatidiform mole C Ectopic pregnancy D Twin gestations

*Acute angle closure glaucoma* (>21 mmHg)

Increased intraocular pressure on tonometry

Parkinson Disease

Increased resisitance to passive movement, increased speed while walking, normal deep tendon reflexes, usually no muscle weakness.

Subacute Bacterial Endocarditis (SBE) (S. viridans)

Indolent (causing little or no pain) infection of ABNORMAL VALVES with LESS VIRULENT organism

Inhaled epinephrine has not been shown to affect rates of admission from the ED or hospital length of stay among patients admitted for bronchiolitis; however, there may be a role in children with severe or acutely deteriorating bronchiolitis.

Inhaled epinephrine for the treatment of bronchiolitis

BRONCHIOLITIS Bronchiolitis is a generic term applied to varied inflammatory processes that affect the bronchioles, which are small conducting airways less than 2 mm in diameter.

Insidious onset of cough and dyspnea, Minimal findings on chest radiograph.

B) Permethrin topical The patient has Scabies. Topical Permethrin is treatment of choice. Lindane is 2nd line. Can also try 6-10% sulfur in petroleum jelly for pregnant women/infants or oral Ivermectin if extensive infection. All clothing, bedding, etc should be placed in a plastic bag for at least 72 hours then wanted and dried using heat. Hint: Lindane is cheaper but not first choice. DO NOT use after bath/shower (may cause seizures due to increased absorption through open pores). Hint: Griseoflilvin is an antifungal. It can treat fungal infections such as ringworm, "jock itch," and athlete's foot. Hint: topical Clindamycin is used for mild hydradenitis supperativa

Intensely pruritic lesions:* papules, vesicles & linear burrows* Intense pruritus with minimal skin findings increased intensity at night*. What is the treatment of choice? A) Lindane B) Permethrin topical C) Griseoflilvin D) topical Clindamycin

Paroxysmal, persistent, or permanent WITHOUT EVIDENCE OF HEART DISEASE

Lone A fib = ____________________

Osteoporosis MC in upper lumbar and thoracic area

Loss of vertebral height, kyphosis

Cryptosporidium The coccidian parasite Cryptosporidium causes diarrheal disease that is self-limited in immunocompetent human hosts but can be severe in persons with AIDS or other forms of immunodeficiency. Cryptosporidium species infect a number of animals, and C. parvum can spread from infected animals to humans. Since oocysts are immediately infectious when passed in feces, person-to-person transmission takes place in day-care centers and among household contacts and medical providers. Waterborne transmission (especially that of C. hominis) accounts for infections in travelers and for common-source epidemics. Oocysts are quite hardy and resist killing by routine chlorination. Both drinking water and recreational water (e.g., pools, waterslides) have been increasingly recognized as sources of infection. Nitazoxanide, approved by the U.S. Food and Drug Administration (FDA) for the treatment of cryptosporidiosis, is available in tablet form for adults (500 mg twice daily for 3 days) and as an elixir for children. To date, however, this agent has not been effective for the treatment of HIV-infected patients, in whom improved immune status due to antiretroviral therapy can lead to amelioration of cryptosporidiosis. Otherwise, treatment includes supportive care with replacement of fluids and electrolytes and administration of antidiarrheal agents.

MC Cause of chronic diarrhea in patients with AIDS

Macular degeneration Age-related macular degeneration, often called "AMD," is a disease that causes vision loss. It mostly affects your central vision, so that things in the center look blurry. It is most common among people age 65 and older. There are 2 types of AMD, wet and dry: Dry AMD is the most common type. It affects 85 to 90 percent of people with the condition. It causes gradual vision loss. Wet AMD is less common. It affects 10 to 15 percent of people with the condition. But it moves more quickly and can cause severe vision loss or even blindness. Some people can start out with dry macular degeneration and then develop the wet type. Both wet and dry AMD can be treated with a special combination of vitamins and minerals, called the "AREDS formula." This formula seems to protect the eye from the damage caused by AMD. There are no treatments for dry AMD besides the AREDS formula. But there are other treatments for wet AMD. Treatments for wet AMD work by destroying abnormal blood vessels in the retina, or by preventing new blood vessels from forming there. That's important, because much of the damage of wet AMD is caused by abnormal blood vessels in the retina.

MC cause of permanent legal blindness and visual loss in the elderly

Gonorrhea

MC cause of urethritis in men <30y

Staph aureus Treat with Nafcillin + Gentamicin x 4-6 weeks

MC organism in ACUTE bacterial endocarditis

Pseudomonas Ubiquitous in the environment. P. aeruginosa is often an opportunistic pathogen, causing infections in patients with physical, phagocytic, or immunologic defects in host defense mechanisms. Historically, P. aeruginosa has been a major burn wound pathogen, a serious cause of bacteremia in neutropenic patients, and the most important pathogen in cystic fibrosis (CF) patients. The ideal antibiotic regimen should have coverage against the most common pathogens, S. aureus and P. aeruginosa

MC organism in Otitis Externa

*Staph epidermis* Early (w/in 60 days), later resembles native valve endocarditis

MC organism in prosthetic valve endocarditis (PVE)

Staph aureus, especially MRSA

MC organism ins ACUTE bacterial endocarditis in IV drug user

S. pneumoniae M. pneumoniae C. pneumoniae Influenza

MC organisms in CAP in outpatients who do not require hospitalization.

Chlamydia Chlamydia infection is 6 to 10 times more common than Gonorrhea.

MC overall bacterial cause of STD in the United States

Tension Mean onset ~30y. Thought to be due to mental stress.

MC overall type of headache

Microaspiration of oropharyngeal secretions

MC route of infection for pneumonia

Post-coital bleeding/spotting Symptoms at presentation often indicate at least locally advanced disease.

MC symptom of cervical carcinoma

Infections

MC trigger for G6PD deficiency acute hemolytic anemia episode

AVNRT = both pathways are WITHIN the AV node (one fast, one slow)

MC type of PSVT

Adenocarcinoma

MC type of lung cancer in smokers, women, and nonsmokers

Germ cell (sperm) tumors (GCTs) Germ cell tumors (GCTs) account for 95 percent of testicular cancers. For treatment purposes, two broad categories of testis tumors are recognized: pure seminoma (no nonseminomatous elements present) and all others, which together are termed nonseminomatous germ cell tumors (NSGCTs). Testicular germ cell tumors (GCTs) are one of the most curable solid neoplasms due to remarkable treatment advances that began in the late 1970s.

MC type of testicular cancer

Mitral valve (M>A>T>P) ***Exception is IVDA (Tricuspid)

MC valve involved in infective endocarditis

Vancomycin

MRSA: skin and soft-tissue infection: first-line therapy.

- IV corticosteroids (high dose), - Immunomodulators (Cyclophosphamide), - Plasmapharesis if not responsive to corticosteroids

MS: treatment of Acute Exacerbations

Clarithromycin or Azithromycin

Macrolides for treatment of pneumonia

Humidified O2

Mainstay of treatment for acute bronchiolitis

*>/= 20% decrease in FEV1* Methacholine stimulates cholinergic receptors. Methacholine is a bronchoconstrictor agent for diagnostic purposes only and should not be used as a therapeutic agent.

Methacholine challenge test criteria

X-ray (radiographic changes) Of all the laboratory tests, radiographic changes are the most specific for rheumatoid arthritis. Radiographs obtained during the first 6 months of symptoms, however, are usually normal. The earliest changes occur in the hands or feet and consist of soft tissue swelling and juxta-articular demineralization. Although both MRI and ultrasonography are more sensitive than radiographs in detecting bony and soft tissue changes in rheumatoid arthritis, their value in early diagnosis relative to that of plain radiographs has not been established.

Most specific test for RA

RSV, Mycoplasma pneumonia, Chlamydia pneumoniae, Strep pneumoniae

Name the MC organisms in pneumonia in children (5 weeks - 18 yrs)

Bevacizumab Off-label for Age-related macular degeneration. Bevacizumab is a recombinant, humanized monoclonal antibody which binds to, and neutralizes, vascular endothelial growth factor (VEGF), preventing its association with endothelial receptors, Flt-1 and KDR. VEGF binding initiates angiogenesis (endothelial proliferation and the formation of new blood vessels). The inhibition of microvascular growth is believed to retard the growth of all tissues (including metastatic tissue).

Name the VEGF = Vascular Endothelial Growth Factor listed in PPP

Phen*azo*pyridine (Azo) Not used more than 48 hrs d/t increase S/E: methemoglobinuria, hemolytic anemia

Name the bladder analgesic used for cystitis that turns urine orange

- Iron deficiency - Lead - Thalasemia - EARLY anemia of chronic dz

Name the bolded Microcytic Anemias in PPP (4)

"PEAR" Psoriatic Arthritis Enteropathic Arthritis Ankylosing Spondylitis Reactive Arthritis Arthritis of the axial skeleton (ie, the sacroiliac joints and spine), enthesitis (inflammation of the insertion sites of tendons to bone), asymmetric oligoarthritis or symmetric polyarthritis of peripheral joints, and the absence of rheumatoid factor are shared characteristics of the spondyloarthropathies.

Name the seronegative spondyloarthropathies

Small Cell and Non-Small Cell

Name the two broad categories of lung caner

37 The average normal body temperature is generally accepted as 98.6°F (37°C). Some studies have shown that the "normal" body temperature can have a wide range, from 97°F (36.1°C) to 99°F (37.2°C).

Normal temperature range in Celsius

A) Ovarian cancer Ovaries should not be palpable in the postmenopausal patient. Consider ovarian cancer until proven otherwise. Hint: Functional ovarian cysts occur in women who are ovulating. Hint: An endometrioma is an endometriosis cyst of the ovary. The cyst is filled with thick, chocolate-colored fluid, often called a "chocolate cyst". These cysts occur in menstruating women.

On rectovaginal examination of a 72 year-old post-menopausal female a 3 cm by 3 cm right adnexal mass is palpated. The rest of her physical examination is unremarkable. Her last gynecological examination was last year and was unremarkable. Which of the following is the *most likely diagnosis*? A) Ovarian cancer B) Endometrioma C) Uterine cancer D) Functional ovarian cyst

Allogenic stem cell transplant But this is associated with significant side effects. The use of HCT in sickle cell disease (SCD) is evolving. In several series of patients who have undergone HCT for SCD, five-year survival rates were 90 to 97 percent, and transplant-related mortality was 7 to 10 percent. SCD recurred in some patients, resulting in a SCD-free survival of 80 to 90 percent. We recommend HCT for patients with severe symptoms of SCD that are unresponsive to treatment with transfusions and hydroxyurea if an HLA-matched sibling is available as a donor (Grade 1B).

Only possible curative management for sickle cell disease

Vagal Maneuvers

Orthodromic (narrow) Wolff-Parkinson-White syndrome: Acute termination, First line

IV procainamide OR IV beta blocker

Orthodromic (narrow) Wolff-Parkinson-White syndrome: Acute termination, Other therapies

IV adenosine

Orthodromic (narrow) Wolff-Parkinson-White syndrome: Acute termination, Second line (after vagal maneuvers)

The rate of congenital malformations (namely neurologic, cardiovascular, gastrointestinal and respiratory) doubles with placenta previa.

Other than peripartum hemorrhage, name a fetal complication of placenta previa.

Otitis Externa

Pain on traction of the ear canal/tragus

A) Rifampin may decrease the effectiveness of the oral contraceptives. Hint: Progestin only oral contraceptives are less effective at inhibiting ovulation than the combination oral contraceptive. Hint: Coronary artery disease is a contraindication to the use of oral contraceptives Hint: Acetaminophen levels or effects may be decreased by oral contraceptives.

Patient education for a 23 year-old using oral contraceptives should include which of the following? A Rifampin may decrease the effectiveness of the oral contraceptives. B Acetaminophen may decrease the effectiveness of the oral contraceptives. C Oral contraceptives may provide some protection from coronary artery disease. D Changing to the "minipill" (progestin only) will inhibit ovulation more consistently than combination oral contraceptives.

*Ramsay-Hunt Syndrome* = Herpes Zoster Oticus *Patho*: reactivation of latent varicella zoster virus (HHV-3) in the facial nerve and geniculate ganglion..The second most common cause of facial paralysis. *Clinical*: Consists of a severe facial palsy associated with a vesicular eruption in the external auditory canal and sometimes in the pharynx and other parts of the cranial integument; often the eighth cranial nerve is affected as well. *Tx*: Oral Acyclovir and Corticosteroids. It is important to protect the involved eye from corneal abrasions and ulcerations by using lubricating drops.

Patient first noted pruritus. Developed facial and neck pain out of proportion to the physical examination, auditory symptoms, and facial palsy.

*Ramsay-Hunt Syndrome* = Herpes Zoster Oticus ***Note the vesicular eruptions on the neck*** *Patho*: reactivation of latent varicella zoster virus (HHV-3) in the facial nerve and geniculate ganglion..The second most common cause of facial paralysis. *Clinical*: Consists of a severe facial palsy associated with a vesicular eruption in the external auditory canal and sometimes in the pharynx and other parts of the cranial integument; often the eighth cranial nerve is affected as well. *Tx*: Oral Acyclovir and Corticosteroids. It is important to protect the involved eye from corneal abrasions and ulcerations by using lubricating drops.

Patient first noted pruritus. Developed facial and neck pain out of proportion to the physical examination, auditory symptoms, and facial palsy.

IgA nephropathy IgA nephropathy is the most common lesion found to cause primary glomerulonephritis throughout most developed countries of the world. Patients may present at any age, but there is a peak incidence in the second and third decades of life. An initial episode of gross hematuria at age 40 years or older is rarely due to IgA nephropathy, and other diagnoses must be assessed. Dx: The presence of IgA nephropathy is established only by kidney biopsy. Given the generally benign course of patients with IgA nephropathy who have isolated hematuria, a renal biopsy is usually performed only if there are signs suggestive of more severe or progressive disease, such as persistent urine protein excretion of at least 500 mg/day (which may increase over time) or an elevated serum creatinine concentration

Patient is a 26 year old male who presents with gross (visible) hematuria accompanying an upper respiratory infection, flank pain, and Low-grade fever.

*Lambert-Eaton myasthenic syndrome* Note: Approximately half of patients have concurrent small-cell lung cancer. The syndrome can precede detection of malignancy by several years. predominantly a disease associated with older men with a history of cigarette smoking and lung cancer. Patho: an autoimmune disorder Clinical: *may show some improvement in strength with sustained or repeated exercise.* Dx: Diagnosis is confirmed by electromyography. Tx: Treatment is mostly supportive. Neuromuscular transmission can also be enhanced with 3,4-diaminopyridine, which is considered first-line treatment. Immunosuppression with corticosteroids, IV immunoglobulin, guanidine, aminopyridines, and azathioprine also can be used to reduce symptom severity.

Patient is a 70 y/o male, former smoker who presents with fluctuating weakness and fatigue, especially of the proximal limb muscles, myalgias, muscle stiffness (especially in the hip and shoulders), paresthesias, a metallic tastes, and dry mouth. On PE when the patient is asked to grasp the examiner's hand, the squeeze becomes more forceful over several seconds. Eye movements are unaffected. Sensory examination is normal,

laparoscopic cholecystectomy The proper treatment for acute cholecystitis is IV fluids, antibiotics, pain control, and surgery. Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice.

Patient presents to the emergency department with right upper quadrant pain over eight hours, nausea, and vomiting. On exam there is a fever of 101.2 degrees F. Ultrasound shows a distended gallbladder. What is the most appropriate management of this patient?

Varicella, or chickenpox Cases generally occur in late winter and early spring. Successive fresh crops may appear for a few days. Low-grade fever, malaise, and headache are frequently present but are usually mild. The diagnosis of varicella is usually made clinically based on its distinctive rash. Dx: A Tzanck smear of the vesicle contents may demonstrate varicella giant cells with inclusion bodies Gold: Fluorescent antibody to membrane antigen testing is regarded as the gold standard for identification of varicella-zoster virus antibodies but is not readily available Tx: Uncomplicated varicella requires no specific therapy. Acetaminophen may be used as needed. Do not give aspirin because it may predispose to the development of Reye's syndrome. Oral antihistamines may be useful to reduce itching. Over-the-counter oatmeal-based baths may provide temporary symptomatic relief.

Patient presents with a low-grade fever, malaise, and headache and the rash pictured. Began on the trunk and rash consists of teardrop vesicles on an erythematous base, which then dry and crust over. Successive fresh crops may appear for a few days. Palms and soles are spared.

D) Referral for surgical consultation and pain medication as needed Laboratory studies are usually non-contributory but can be useful in ruling out common duct obstruction (elevated bilirubin and alkaline phosphatase) and pancreatitis (elevated lipase) which can occur when gallstones move out of the gallbladder.

Patient presents with biliary colic as a result of cholelithiasis (gall stones). What management is indicated? A) Administer antibiotics and admit for observation B) Admit patient for cholecystectomy C) Obtain CT scan of the abdomen and pelvis D) Referral for surgical consultation and pain medication as needed

*D) Rheumatoid Arthritis* RA is a lifelong, progressive disease that can produce significant morbidity and premature mortality. Morning stiffness is a hallmark of inflammatory arthritis and is a prominent feature of RA. Patients with RA are characteristically at their worst upon arising in the morning or after prolonged periods of rest. Of particular importance, RA almost always spares the distal interphalangeal (DIP) joints (in contrast, these joints are often involved in OA and psoriatic arthritis). The hands are involved in almost all patients with RA; The feet, particularly the MTP joints, are involved early in almost all cases of RA and are second only to hand involvement in terms of the problems they cause. Radiographs can detect evidence of articular damage early in the course of RA and long before the appearance of joint deformities. Anemia of chronic disease is seen in most patients with RA, and the degree of anemia is proportional to the activity of the disease. Unfortunately, there is no one single finding on physical examination or laboratory testing that is diagnostic of RA. Instead, the diagnosis of RA is a clinical one, requiring a collection of historical and physical features, as well as an alert and informed clinician. While a history of arthralgias is important, the diagnosis of RA requires the objective evidence of joint inflammation (swelling or warmth or both) on examination. Early treatment helps limit the number of joints involved.

Patient presents with fatigue and low-grade fevers, pain, stiffness, and swelling in multiple joints but is worst in the hands, especially the MCP joints. Labs are consistent with anemia of chronic disease. What is your diagnosis? A) Psoriatic Arthritis B) Osteoarthritis C) Reactive Arthritis D) Rheumatoid Arthritis

Subdural empyema. Headache is the most common complaint at the time of presentation; initially it is localized to the side of the subdural infection, but then it becomes more severe and generalized. Dx: MRI is superior to CT in identifying SDE and any associated intracranial infections. The administration of gadolinium greatly improves diagnosis by enhancing the rim of the empyema and allowing the empyema to be clearly delineated from the underlying brain parenchyma.

Patient presents with fever and a progressively worsening headache after history of sinusitis.

*Roseola* infantum, or exanthem subitum, was previously called sixth disease *Patho*: The most likely cause is the human herpesvirus 6, although other viruses have been associated with a roseola-like illness.There is no seasonal association. *Clinical*: febrile period of 3 to 5 days. The appearance of the rash immediately following a nonspecific febrile illness is characteristic and aids in the diagnosis. Primarily, young children are affected, with most patients being between 6 months and 3 years of age. The illness begins abruptly with high fever, sometimes as high as 40.6°C (105°F). The child is usually alert and active but may be irritable, especially with very high fever. Associated symptoms are usually mild and may include cough, coryza, anorexia, and abdominal discomfort. Lymphadenopathy may be present. The fever persists for 3 to 5 days, and the child rapidly becomes well. Tx: There is no specific therapy.

Patient presents with history of fever for past 4 days, The rash is an erythematous macular or maculopapular eruption that consists of discrete, rose or pale-pink lesions 2 to 5 mm in size. It is most prominent on the neck, trunk, and buttocks, but the face and proximal extremities may also be involved. The lesions blanch with pressure. There is no mucous membrane involvement.

*Ramsay-Hunt Syndrome* = Herpes Zoster Oticus *Patho*: reactivation of latent varicella zoster virus (HHV-3) in the facial nerve and geniculate ganglion..The second most common cause of facial paralysis. *Clinical*: Consists of a severe facial palsy associated with a vesicular eruption in the external auditory canal and sometimes in the pharynx and other parts of the cranial integument; often the eighth cranial nerve is affected as well. *Tx*: Oral Acyclovir and Corticosteroids. It is important to protect the involved eye from corneal abrasions and ulcerations by using lubricating drops.

Patient presents with otalgia, lesions pictured on the neck with facial palsy and tinnitius. On closer examination, the vesicles extend up the neck to the external auditory canal. What is this condition?

*Hutchinson sign* Herpes Zoster Ophthalmicus. A vesicular rash in the distribution of the ophthalmic division (V1) of the trigeminal nerve is seen. The presence of the lesion near the tip of the nose (Hutchinson sign) increases the risk of ocular involvement. The most common corneal lesion is punctate epithelial keratitis, in which the cornea has a *ground-glass appearance* because of stromal edema. Pseudodendrites, also very common, form from mucous deposition, are usually peripheral, and stain moderate to poorly with fluorescein. These may be differentiated from the dendrites of herpes simplex in that the pseudodendrites lack the rounded terminal bulbs at the end of the branches, and are broader and more plaquelike. Treat patients with epithelial defects with topical broad-spectrum antibiotics to prevent secondary infection. Initiate oral antivirals within 72 hours of onset, and treat for 7 to 10 days. Use cycloplegics if an iritis is present (Cycloplegia is paralysis of the ciliary muscle). Artificial tears or ointment may be helpful and narcotic analgesics may be required. Ophthalmologic consultation is indicated.

Patient presents with periocular rash and an injected eye, along with a watery discharge.

Acute Glomerulonephritis

Patient presents with peripheral edema, new HTN, fever, abdominal pain, flank pain, malaise, oliguria, and dark colored urine

PITUITARY APOPLEXY Patho: an infarction or hemorrhage of the pituitary gland. This often occurs in the setting of a preexisting pituitary tumor such as an adenoma. Although several hormone deficiencies are often present, adrenal insufficiency is the most life-threatening complication and requires immediate attention. Dx: MRI is the imaging study of choice for diagnosis of pituitary apoplexy. Tx: stabilization of the patient with electrolyte balance, fluid replacement, and collection of blood samples for baseline hormonal evaluation. After initial resuscitation, hydrocortisone 100-200 mg bolus intravenously should be given to all patients suspected of having pituitary apoplexy to treat frequently concurrent and potentially lethal acute adrenal insufficiency. Definitive treatment for pituitary apoplexy is usually neurosurgical decompression

Patient presents with severe sudden onset headache, cranial nerve defects including ophthalmoplegia, and bitemporal hemianopia

*Idiopathic Thrombocytopenic Purpura (ITP)* Immune thrombocytopenic purpura (ITP; also termed idiopathic thrombocytopenic purpura) is an acquired disorder in which there is immune-mediated destruction of platelets and possibly inhibition of platelet release from the megakaryocyte. In children, it is usually an acute disease, most commonly following an infection, and with a self-limited course. Tx: The diagnosis of ITP does not necessarily mean that treatment must be instituted. Patients with platelet counts >30,000/μL appear not to have increased mortality related to the thrombocytopenia. Consult hematology for medical management guidance. Treatment can include IV corticosteroids, IVIg, or IV Rho (D) immune globulin alone or in combination. If life-threatening hemorrhage is present, IV methylprednisolone and IVIg should be initiated along with platelet transfusions. For adult patients with longstanding, recalcitrant disease, splenectomy may be recommended.

Patient will be a child 2 - 6 yrs old With a history of recent viral infection Complaining of red spots on skin or easy bleeding; PE will show petechiae, purpura, and gingival bleeding; Labs will show platelets < 50,000 µL

Testicular Cancer Dx: starts with ultrasound Comments: - Most common risk factor: cryptorchidism, - Most common tumor: seminoma

Patient will be a man 20 - 35 years old Complaining of a testicular lump, PE will show painless, hard, fixed mass, Labs will show increased beta-hCG, alpha-fetoprotein (AFP), or lactate dehydrogenase (LDH)

Polyarteritis Nodosa Dx: is confirmed by biopsy showing necrotizing arteritis or by arteriography Tx: is steroids Comments: "starburst" livedo (painful violaceous plaques that are surrounded by livedo reticularis) is pathognomonic

Patient will be a man 40 - 50 years old, Complaining of malaise, fever, sore throat, joint and muscle aches and pains, PE will show tender lumps under the skin, especially on the thighs and lower legs, Labs will show ↑ ESR, ANCA negative

Testicular Torsion Dx: is made by ultrasound with Doppler Tx: is manual detorsion or surgical

Patient will be a young male complaining of intense scrotal pain, PE will show exquisite tenderness of the testicle and no cremasteric reflex

Erythema Multiforme (EM) Most commonly caused by herpes simplex virus (HSV) Tx: is usually self-limiting, supportive Comments: Common drugs that cause EM: Sulfa, Oral hypoglycemics, Anticonvulsants, Penicillin, NSAIDs (SOAPS)

Patient will be complaining of acute onset of a symmetric target lesions on palms and soles, face and trunk may also be involved. PE will show target-like with a central dark papule surrounded by a pale area and a "halo" of erythema

Crohn's Disease Path: Can occur anywhere on GI tract from mouth to anus Dx: is made by colonoscopy. Labs will show ASCA positive, p-ANCA negative Tx: is mesalamine (5-ASA). Surgery will not be curative. Crohn disease is a chronic lifelong illness characterized by exacerbations and periods of remission. As no specific therapy exists, current treatment is directed toward symptomatic improvement and control of the disease process. Over 50% of patients will require at least one surgical procedure.

Patient will be complaining of chronic nonbloody diarrhea, crampy abdominal pain, Right lower quadrant mass and tenderness.and weight loss PE will show aphthous ulcers, anal fissures, perirectal abscesses, anorectal fistulas

Hyperthyroidism Labs will show low TSH and high free T4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Treatment is methimazole or PTU Comments: Propylthiouracil (PTU) P for pregnancy

Patient will be complaining of heat intolerance, palpitations, weight loss, tachycardia, and anxiety, PE will show hyperreflexia

Bacterial Vaginosis Patho:Most commonly associated with Gardnerella vaginalis Dx: is made by KOH smear → fishy odor, whiff test, Amsel criteria Tx: is metronidazole

Patient will be complaining of malodorous vaginal discharge, PE will show thin, gray/white discharge, Labs will show pH > 4.5, clue cells

*Sialolithiasis* Salivary Gland (sialo-) stones (lithiasis). Treatment is gland massage, sialogogues (e.g., sour lozenges)

Patient will be complaining of mouth swelling and pain that is worse with meals

*CRAB*: hyper*C*alcemia, *R*enal insufficiency, *A*nemia, lytic *B*one lesions/*B*ack pain

Patient will be elderly, Complaining of back pain PE will show: hypercalcemia, renal, insufficiency, anemia, lytic bone lesions/back pain, Labs will show monoclonal antibody spike, X-ray will show lytic lesions, Peripheral blood smear: Rouleaux formations, Serum protein electrophoresis: M spike, Protein electrophoresis urine analysis: Bence-Jones proteins

Acute Angle-Closure Glaucoma Dx: Labs will show ↑ IOP ( > 21 mm Hg) Tx: is topical ßBs, carbonic anhydrase inhibitors, steroids, miotics (pupil constrictors)

Patient will be entering a dark room or movie theater, Complaining of acute unilateral painful vision loss, vomiting, and seeing halos around lights, PE will show cloudy cornea and fixed mid-dilated pupil

*Intertrigo* A *dermatitis* occurring on opposed surfaces of skin, such as the creases of the neck, folds of the groin and armpit, or a panniculus. It is *characterized by a tender, red patch or plaque with a moist, macerated surface*. The juxtaposed skin surfaces create a chronic friction and this can easily become suprainfected with candida, fungal, or bacterial infections. Caused by the macerating effect of heat, moisture, friction.

Patient will be obese, PE will show regions of erythema with peripheral scaling by skin folds, Most commonly caused by moisture, friction, and lack of ventilation, characterized by a tender, red patch or plaque with a moist, macerated surface

Benign Prostatic Hyperplasia (BPH) Patho: Most commonly caused by stromal and epithelial cell growth in the transitional zone of the prostate Dx: is made by digital rectal exam Tx: is α-blockers, 5α-reductase inhibitors, surgery (TURP)

Patient will be older, Complaining of Hesitancy, Intermittence/Incontinence, Frequency/Fullness, Urgency, Nocturia (HI FUN), PE will show a soft, smooth and mobile prostate without any nodules or indurations

Complex regional pain syndrome (CRPS) Tx: NSAIDs, gabapentin, sympathectomy (the surgical cutting of a sympathetic nerve or removal of a ganglion to relieve a condition affected by its stimulation.)

Patient will have a history of previous extremity injury or fracture, Complaining of light touch causing extreme pain and allodynia (pain felt from a nonpainful stimulus, such as clothes or bed sheets on the skin)

Essential Tremor Patho: Most commonly caused by autosomal dominant. ET is the most common movement disorder, Tx: is propanolol

Patient with a history of a family member with similar symptoms, Complaining of hand tremor that is exacerbated by action and improved after alcohol consumption

Pityriasis Rosea Treatment is self-limiting disease, treat itching with antihistamines. The rash resolves within 3-8 weeks and is not contagious.

Patient with a history of a larger lesion 1 week prior, ​"Herald Patch", Complaining of rash on the back, PE will show diffuse papulosquamous rash on the trunk, "Christmas tree-like" distribution

*Allergic Rhinitis* = Hx of allergic things with runny/sneezy nose - Labs will show elevated serum IgE - Treatment is glucocorticoid nasal spray - Comments: nasal polyps, asthma, and aspirin-sensitivity = Samter's triad (Such patients may have an immunologic salicylate sensitivity leading to potentially-severe bronchospasm.)

Patient with a history of asthma, atopic dermatitis and sinusitis Complaining of sneezing, rhinorrhea, and nasal congestion. PE will show infraorbital edema and darkening, transverse nasal crease, cobblestoning of the posterior pharynx

Lyme Disease Treatment = doxycycline. Kids/pregnant = amoxicillin Stage I: erythema migrans (pathognomonic), viral-like syndrome (fever, fatigue, malaise, myalgia, headache) Stage II: arthritis, myocarditis, bilateral Bell's palsy Stage III: chronic arthritis, chronic encephalopathy

Patient with a history of being in the woods hiking or camping Complaining of erythema migrans (pathognomonic), viral-like syndrome (fever, fatigue, malaise, myalgia, headache). PE will show slightly raised red lesion with central clearing, erythema migrans (bulls-eye) rash

Pertussis (Whooping Cough) Treatment is a macrolide - azithromycin

Patient with a history of nasal congestion, cough, and low-grade fever, Complaining of "rapid fire," repetitive coughing followed by an inspiratory "whoop" and post-tussive emesis

Small Bowel Obstruction Dx: is made by imaging Tx: is NGT, surgery

Patient with a history of pelvic surgery, Complaining of bilious vomiting, PE will show high pitched bowel sounds, X-ray will show dilated bowel, air fluid levels, "stack of coins" or "string of pearls" sign

Rocky Mountain spotted fever (RMSF) Patho: Most commonly caused by Rickettsia rickettsia Dx: is made by skin biopsy. The only diagnostic test that has proven useful during the acute illness is immunohistologic examination of a cutaneous biopsy sample from a rash lesion for R. rickettsii. Examination of a 3-mm punch biopsy from such a lesion is 70% sensitive and 100% specific. The most common serologic test for confirmation of the diagnosis is the indirect immunofluorescence assay. It is important to understand that serologic tests for RMSF are usually negative at the time of presentation for medical care and that treatment should not be delayed while a positive serologic result is awaited. Tx: is ALWAYS doxycycline, even in children

Patient with a history of recently in the woods hiking or camping, Complaining of abrupt onset of severe headache, photophobia, vomiting, diarrhea, and myalgia, PE will show maculopapular eruption on the palms and soles

Mitral stenosis Most commonly caused by rheumatic heart disease

Patient with a history of rheumatic heart disease, Complaining of exertional dyspnea, hemoptysis, PE will show loud S1, opening snap, low-pitched, rumbling diastolic apical murmur

*Otitis Externa* - Most commonly caused by Pseudomonas aeruginosa - Treatment is *topical antimicrobials with or without steroids* - Comments: Necrotizing otitis externa = a complication seen in diabetics/immunocompromised

Patient with a history of swimming or moisture exposure, Complaining of malodorous discharge and pruritus, PE will show pain with palpation of tragus/pinna

Otitis Externa Patho: Most commonly caused by Pseudomonas aeruginosa Tx: is topical antimicrobials with or without steroids Comments: Necrotizing otitis externa - a complication seen in diabetics/immunocompromised

Patient with a history of swimming or moisture exposure, Complaining of malodorous discharge and pruritus, PE will show pain with palpation of tragus/pinna

Increase the dose to 50 mg daily until the illness resolves. To better mimic the normal physiologic response the baseline dose should be doubled for the duration of the illness. Doses should be increased 5-10 fold with major events such as surgery. Hint: Stopping the hydrocortisone would cause adrenal crisis

Patient with adrenal insufficiency is taking hydrocortisone 25 mg daily. What should the patient do with the hydrocortisone dose when they develop a minor illness such as a cold?

hydrocortisone The acute phase of adrenal crisis is treated with IV saline and hydrocortisone. Hint: The shock that results from adrenal crisis is not responsive to vasopressors. Hint: Fludrocortisone may be utilized in treating the convalescent phase, but not acute phase, of adrenal crisis.

Patient with chronic rheumatoid arthritis on maintenance prednisone and methotrexate undergoes surgery. She develops hyponatremia, hypoglycemia, and hypotension. In addition to IV fluid therapy, which of the following is the best initial therapy?

C) Hydrocortisone The acute phase of adrenal crisis is treated with IV saline and hydrocortisone. Hint: Fludrocortisone may be utilized in treating the convalescent phase, but not acute phase, of adrenal crisis Hint: The shock that results from adrenal crisis is not responsive to vasopressors.

Patient with chronic rheumatoid arthritis on maintenance prednisone and methotrexate undergoes surgery. She develops hyponatremia, hypoglycemia, and hypotension. In addition to IV fluid therapy, which of the following is the best initial therapy? A Epinephrine B Fludrocortisone (Florinef) C Hydrocortisone D Glucagon

slipped capital femoral epiphysis (SCFE). SCFE is characterized by displacement of the capital femoral epiphysis from the femoral neck through the growth plate. The slipped epiphysis resembles "ice cream falling off the cone" and an abnormal Klein line. A straight line drawn along the lateral aspect of the femoral neck normally intersects the femoral head, whereas this line passes outside of the epiphysis in patients with SCFE.

Patients present with dull, aching hip, groin, thigh or knee pain, typically without any significant preceding trauma. Physical exam reveals external rotation and adduction at the hip. It affects predominantly obese adolescents. Males and African-American children are more commonly affected.

Chronic Otits Media

Perforated TM + persistent or recurrent purulent otorrhea with/without pain, possibly with varying degrees of conductive hearing loss

Lasts > 7 days. Requires termination

Persistent A fib = ____________________

Cryptogenic Organizing Pneumonia (COP) Formerly known as Bronchiolitis Obliterans with Organizing Pneumonia (BOOP), Resembles pneumonia on CXR but does not respond to antibiotics. Often idiopathic or occurs after pneumonia. Tx = Corticosteroids

Persistent alveolar exudates lead to inflammation and scarring of the bronchioles AND alveoli

*Class 1A's = Procainamide preferred!* amiodarone, flecainide, Ibutilide

Pharmacologic treatment of WPW

Klebsiella

Pneumonia: CXR shows upper lobe (esp R upper lobe) with bulging fissure, cavitations

*Legionella pneumophila* Gram negative aerobic bacilli that hangs out around warm stagnant water. More severe disease than other Atypical Pneumonia. Antibiotic course for 21 days = start with Azithromycin (macrolide) or a respiratory tract quinolone. Remember, this one typically is associated with GI type symptoms as well. (you can have "legions" around = no person to person)

Pneumonia: No person to person transmission

Mycoplasma

Pneumonia: Send serum cold agglutinins as part of diagnostic workup

S. aureus Klebsiella anaerobes

Pneumonia: abscess formation associated with these 3 types organisms

Legionella

Pneumonia: associated with GI symptoms, increased LFTs and HYPOnatremia

Haemophilus Influenza

Pneumonia: children <6y or elderly

Klebsiella Pneumonia

Pneumonia: debilitates, chronic illness, aspirators

Anaerobes

Pneumonia: foul smelling sputum

H. flu Pseudomona

Pneumonia: green sputum

Atypical pneumonia

Pneumonia: often normal PE, signs of consolidation usually absent

Legionella pneumophila

Pneumonia: outbreaks related to contaminated water supplies, ex: air contidioners, cooling towers, etc

pericarditis and pleuritis. Dressler's syndrome is the occurrence of pericarditis and pleuritis several days to weeks following an MI

Post-infarction syndrome (Dressler's syndrome) occurs after acute myocardial infarction presenting as A ventricular aneurysm. B pericarditis and pleuritis. C cardiac tamponade. D pleural effusion and rash.

B tamoxifen Tamoxifen is the adjuvant therapy of choice in post-menopausal estrogen receptor positive axillary node negative breast cancer. Hint: Bisphosphonate therapy is used in breast cancer patients with metastasis disease for the bone. Hint: While ovarian ablation is a form of hormonal therapy, it is not the initial treatment of choice. Hint: Chemotherapy is indicated in breast cancer with tumors larger than 1 cm in size.

Postmenopausal patient is diagnosed with grade I breast cancer. The tumor is 0.7 cm in size, estrogen-receptor positive, and axillary nodes are negative. After undergoing a lumpectomy, which of the following adjuvant therapy is indicated for this patient? A chemotherapy B tamoxifen C ovarian ablation D bisphosphonate therapy

*Transabdominal ultrasound* Sensitivity in detecting gallstones in the setting of pancreatitis is 62-95%. Is noninvasive, easy to perform at the bedside and inexpensive. May find a *sentinel loop* (isolated dilatation of a segment of gut) adjacent to the pancreas, gas distending the right colon that abruptly stops in the mid- or left-transverse colon (cut-off sign), or calcifications. Limited by obesity, bowel gas, and is operator dependent.

Preferred study for pancreatitis if biliary etiology is suspected

a SERM used in treatment of osteoporosis is PROTECTIVE against breast cancer and NOT associated with risk of endometrial cancer (in contrast to estrogen therapy with increase risk of both). Like tamoxifen, raloxifene has antagonist effects in breast tissue and reduces the incidence of breast cancer in women who are at very high risk. Unlike tamoxifen, the drug has no estrogenic effects on endometrial tissue. Adverse effects include hot flushes (an antagonist effect) and an increased risk of venous thrombosis (an agonist effect).

Raloxifene

Beta Blockers

Rate control: Cautious use in patients with reactive airway disease

Digoxin

Rate control: preferred in patients with hypotension or CHF, elderly, not generally used in active patients

2 doses at least 6 months apart

Recommendation for HPV vaccine if <15y

visual changes and lens opacity

Side effects of miotics/cholinergics for Acute angle closure glaucoma

Basilar Artery Deficit

Stroke: Cerebellar dysfunction, CN palsies, ↡ vision, ↡bilateral sensation

*"Crossed Sx"* = Posteror Cerebral Artery (*PCA*) Just past the basilar artery, supplies mainly inferior/posterior portions of the brain

Stroke: Ipsilateral (same side) cranial nerve deficits and contralateral (opposite side) muscle weakness mainly of the muscles of the tongue and swallowing.

ACA

Stroke: Personality changes

Lacunar Infarct Lacunar infarcts are small (0.2 to 15 mm in diameter) noncortical infarcts caused by occlusion of a single penetrating branch of a large cerebral artery. These branches arise at acute angles from the large arteries of the circle of Willis, stem of the middle cerebral artery (MCA), or the basilar artery.

Stroke: Pure motor symptoms (Hemiparesis, hemiplegia)

MCA nondominant side (usually R-side)

Stroke: Spatial deficits, dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal.), anosognosia (inability or refusal to recognize a defect or disorder that is clinically evident.), apraxia (inability to perform particular purposive actions)

ACA

Stroke: Urinary incontinence

posterior cerebral artery stroke the posterior cerebral artery supplies the occipital lobe and cerebellum. The classic symptoms and signs of posterior circulation strokes include ataxia, nystagmus, altered mental status, and vertigo. Motor dysfunction, although common, is typically minimal, which can keep some patients from realizing they have had a stroke.

Stroke: Visual hallucinations, contralateral homonymous hemianiopsi

MCA MC type (70%)

Stroke: deficits greater in face/arm > leg/foot

Anterior cerebral artery Occlusion of the anterior cerebral artery is uncommon but when unilateral occlusion occurs, it can cause contralateral sensory and motor symptoms in the lower extremity, with sparing of the hands and face.

Stroke: motor weakness, leg is weaker than his arm and face with minimal sensory findings

Lacunar Infarct Lacunar infarcts are small (0.2 to 15 mm in diameter) noncortical infarcts caused by occlusion of a single penetrating branch of a large cerebral artery. These branches arise at acute angles from the large arteries of the circle of Willis, stem of the middle cerebral artery (MCA), or the basilar artery.

Stroke: pure sensory loss (numbness, paresthesias)

Vertebral artery stroke

Stroke: vertigo, nystagmus, n/v, diplopia, ipsilateral ataxia

Glomerulonephritis

Sudden onset of hematuria, proteinuria, and RBC casts, often accompanied by HTN, edema, and impaired renal function

Vancomycin + Gentamicin

Suggested empiric therapy for ACUTE native valve infective endocarditis if suspected MRSA or PCN allergic

PCN or Ampicillin + Gentamicin

Suggested empiric therapy for SUBACUTE native valve infective endocarditis

Vancomycin

Suggested empiric therapy for SUBACUTE native valve infective endocarditis in IVDA

Nafcillin + Gentamicin x 4-6 weeks

Suggested empiric therapy for acute native valve infective endocarditis

Amphotericin B x 6-8 weeks Patients often need surgical intervention

Suggested empiric therapy for valve infective endocarditis with FUNGAL organism

Vancomycin + Gentamicin + Rifampin (For staph aureus)

Suggested empiric therapy for valve infective endocarditis with PROSTHETIC VALVE

*Triptans or Ergotamine* MOA: Sertotonin-1 agonists → vasoconstriction SE: chest tightness CI: CAD or PVD, Uncontrolled HTN, Hepatic or renal dz or pregnancy.

Symptomatic (abortive) management of migraine 1st line

Aortic Stenosis (AS)

Systolic "Ejection" Crescendo-decrescendo murmur at RUSB ratdiates to carotid (neck), decreases with decreased venous return, increases with increased venous return. A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

IM benzathine penicillin G *x 3 weeks*

Tertiary syphilis treatment:

Leydig cell tumors Leydig cells are the principal testicular source of androgens and are also capable of estrogen production. These tumors may produce either virilizing or feminizing symptoms. In boys with precocious puberty, Leydig cell tumor should be considered if asymmetric testicular enlargement is present. Even if a distinct mass cannot be palpated and is not detectable by ultrasonography, the larger testis should be biopsied if it enlarges during follow-up.

Testicular Cancer: may be benign, may secrete hormones which may lead to precocious puberty in children or gynecomastia/loss of libido in adults

The treatment of SCFE is operative stabilization, and children with SCFE should be referred promptly to an orthopedic surgeon.

The clinical presentation of the girl is consistent with slipped capital femoral epiphysis (SCFE). Nothing has been done yet. next best step in management?

infusion of isotonic saline to expand extracellular volume and stabilize cardiovascular status. This also increases insulin responsiveness by lowering the plasma osmolality (Posm), reducing vasoconstriction and improving perfusion, and reducing stress hormone levels.

The first step in the treatment of DKA or HHS is....

nasogastric decompression. Nasogastric decompression is indicated in all but mild cases of obstruction to prevent distal passage of swallowed air and minimize distension. Hint: Antibiotics are given only if surgery is to be done.

The first step in the treatment of a patient with an intestinal obstruction and no comorbid diseases is

*increased risk of encephalopathy* TIPS procedures involve the placement of a stent in the liver in order to shunt blood away from the portal vein into the hepatic vein which bypasses the cirrhotic liver parenchyma. Its main complication is encephalopathy from the accumulation of toxic substances in the brain since the liver no longer acts as a filter. *Hint*: Budd-Chiari syndrome is a thrombosis of the hepatic vein. It is not a common complication of the TIPS procedure. *Hint*: TIPS procedures are performed in order to shunt blood away from the liver parenchyma which in essence lowers portal pressures lessening the risk for esophageal varices.

The main complication with the use of transjugular intrahepatic portosystemic shunt (TIPS) procedure is which of the following? A) increased portal pressures resulting in further esophageal varices B) increased portal pressures resulting in a worsening of cirrhosis C) Budd-Chiari syndrome D) increased risk of encephalopathy

Macrolides (erythromycin and azithromycin), doxycycline, or a fluoroquinolone such (levofloxacin or moxifloxacin). Mycoplasma pneumoniae don't have cell walls so beta lactams wont work

The mainstays of therapy for possible M. pneumoniae infection are...

venography = the most accurate method for diagnosis in the lower leg Hint: While impedance plethysmography (non-invasive medical test that measures small changes in electrical resistance; These measurements reflect blood volume changes), physical exam findings, and Doppler ultrasound are useful in diagnosing thrombophlebitis, venography is the most accurate method for diagnosis in the lower leg.

The most accurate method of diagnosing thrombophlebitis of the lower leg is A) impedance plethysmography. B) physical exam findings. C) Doppler ultrasound. D) venography

A) increase in hydration Keeping the urine dilute is the most effective strategy to prevent crystal accumulation in the urine and the development of urinary stones.

The most effective preventive strategy to prevent recurrence of renal lithiasis is which of the following? A increase in hydration B early treatment of urinary tract infection C limitation of calcium intake D use of probenecid

D) bone Samples from needle aspiration of pus in the bone, or from a bone biopsy, are essential to determine the exact causative agent. Hint: While blood cultures are indicated in acute cases of osteomyelitis, they are only positive in 25-50% of pediatric hematogenous osteomyelitis and 10% of other forms of bone infection. Hint: Taking specimens for culture from a sinus tract or the base of an ulcer correlate poorly with organisms infecting the bone

The most reliable site from which to identify the causative organism in cases of osteomyelitis is the A base of ulcer. B blood. C sinus tract. D bone

D) Repeat capillary samples, confirming with venous sample within 1 month A blood lead level of 10-14 mcg/dL is considered moderate risk II and warrants, in addition to reporting to the local health department, repeating all capillary samples and confirming with a venous sample within 1 month for new cases and 1-3 months for known cases. As this is a new case, venous testing should be done within 1 month after repeating capillary sample. Lead based paint in older housing currently is the most important source of lead exposure. Young children's mouthing behavior and pica are widely recognized as causes of elevated blood lead concentrations. Lead is toxic to most body systems, including the nervous system, liver, and hematopoietic and renal systems. Lead irreversibly binds and impairs function of enzymes in the pathway to heme synthesis. Blood levels at which lead poisoning is defined and corresponding interventions has changed several times over the past decades. Improved understanding of subclinical toxicity on neurodevelopment has led to proactive screening and environmental intervention to prevent elevated lead levels. Treatment of lead poisoning varies with the blood lead level, though all management should focus on nutritional and environmental intervention. Chelation therapy is the mainstay of treatment for lead levels greater than 45 mcg/dL.

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, risk reduction and nutrition education is provided. His fingerstick blood lead level comes back at 13mcg/dL. Which additional management should be done at this level? A) Collaborate with lead poisoning preventive program to provide home inspection and other services B) Repeat with a venous sample within 1-3 months C) Obtain abdominal radiographs and order bowel decontamination if indicated D) Repeat capillary samples, confirming with venous sample within 1 month E) Consider retesting within 3 months

A) "What disturbs you about this behavior?" Before the physician can provide guidance for the parents, the parents' concerns need to be understood. While the described behavior is perfectly normal for a 5-year-old, and it is appropriate for parents to knock on the door of their child's room before entering to teach children respect for privacy through modeling, the parents' concerns must first be understood. To immediately assume there is something physically wrong with the child, or that the child has been sexually abused, suggests that the physician may have some personal issues with children's normal sexuality.

The mother of a 5-year-old girl walks into her daughter's bedroom without knocking and discovers the girl stimulating her genitals. The girl's parents are concerned, but seem to be receptive to advice. What is the best response a physician could give? A) "What disturbs you about this behavior?" B) "Do you think that someone's been molesting her?" C) "Don't you think you should knock before going into her room?" D) "She probably has a vaginal infection. Bring her in so I can examine her." E) "This is not normal behavior for a child this age."

A) Anger and irritability Confusion and other cognitive changes (B), mood swings and other mood changes (C), and serotonin dysfunction (D) are all associated with premenstrual syndrome. The presence of prominent anger, irritability and internal tension in combination with premenstrual symptoms differentiates premenstrual dysphoric disorder from premenstrual syndrome. According to the American Psychiatric Association DSM-IV, prominent anger, irritability and internal tension associated with severe premenstrual syndrome symptoms is defined as premenstrual dysphoric disorder.

The presence of which of the following best differentiates premenstrual dysphoric disorder from premenstrual syndrome? A) Anger and irritability B) Confusion and other cognitive changes C) Mood swings and other mood changes D) Serotonin dysfunction

A) Abduction and external rotation The shoulder is most vulnerable when abducted and externally rotated. A fall or tackle with the arm in this position can cause an anterior shoulder dislocation. Posterior shoulder dislocations are less common and are associated with grand mal seizures and electric shock. Abduction and internal rotation (B), adduction and external rotation (C), adduction and internal rotation (D) are not associated with increased risk of anterior shoulder dislocation.

The shoulder is most vulnerable to an anterior glenohumeral dislocation when in which of the following positions? A) Abduction and external rotation B) Abduction and internal rotation C) Adduction and external rotation D) Adduction and internal rotation

D) Radiofrequency ablation of bypass tracts Catheter ablation of bypass tracts is possible in more than 90% of patients and is the treatment of choice in patients with symptomatic arrhythmias. It is safer, more cost-effective, and just as successful as surgery. Hint: Caution should be employed when using digitalis or intravenous verapamil in patients with the WPW syndrome and atrial fibrillation, since these drugs can shorten the refractory period of the accessory pathway and can increase the ventricular rate, thereby placing the patient at increased risk for ventricular fibrillation.

The treatment of choice for a patient with WPW (Wolff-Parkinson-White Syndrome) who has recurrent episodes of supraventricular tachycardia is which of the following? A IV Verapamil (Calan, Isoptin) B Digoxin (Lanoxin) C Surgical ablation of the accessory pathway D Radiofrequency ablation of bypass tracts

D) Radiofrequency ablation of bypass tracts Catheter ablation of bypass tracts is possible in more than 90% of patients and is the treatment of choice in patients with symptomatic arrhythmias. It is safer, more cost-effective, and just as successful as surgery. Although surgical ablation is an effective therapy, surgery has been virtually replaced by the advent of radiofrequency catheter ablation. Surgery should be reserved for patients who do not respond to other therapy

The treatment of choice for a patient with WPW (Wolff-Parkinson-White Syndrome) who has recurrent episodes of supraventricular tachycardia is which of the following? A IV Verapamil (Calan, Isoptin) B Digoxin (Lanoxin) C Surgical ablation of the accessory pathway D Radiofrequency ablation of bypass tracts

1) beta-hCG 2) Alpha fetoprotein (AFP) 3) Lactate dehydrogenase (LDH) Serum concentrations of AFP and/or beta-hCG are elevated in 80 to 85 percent of men with nonseminomatous GCTs. By contrast, serum beta-hCG is elevated in fewer than 25 percent of seminomas, and AFP is not elevated in pure seminomas. Although these markers can provide supportive evidence for the initial diagnosis of a testicular cancer and are useful for prognosis and risk stratification, their main utility is for monitoring response to treatment and detecting recurrence. Alpha fetoprotein (AFP) is normally produced by the fetal yolk sac and other organs and is essentially undetectable in the serum in normal men

Three serum tumor markers have established roles in the management of men with testicular GCTs:

Hemolytic Uremic Syndrome Treatment of HUS is primarily supportive. In HUS associated with diarrhea, many (~40%) children require at least some period of support with dialysis; however, the overall mortality is <5%. In HUS not associated with diarrhea, the mortality is higher, approximately 26%. Plasma infusion or plasma exchange has not been shown to alter the overall course. ADAMTS13 levels are generally reported to be normal in HUS, although occasionally they have been reported to be decreased. In patients with atypical HUS, eculizumab therapy increases the platelet count and preserves renal function.

Thrombocytopenia (bruising, purpura bleeding) microangiopathic hemolytic anemia (anemia, jaundice, fragmented RBC's/schistocytes on peripheral smear), kidney failure (uremia)

Thrombotic Thrombocytopenic Purpura TTP is a devastating disease if not diagnosed and treated promptly. Plasma exchange remains the mainstay of treatment of TTP. Although never evaluated in clinical trials, the use of glucocorticoids seems a reasonable approach, but should only be used as an adjunct to plasma exchange. Additionally, other immunomodulatory therapies have been reported to be successful in refractory or relapsing TTP.

Thrombocytopenia (petechiae, bruising, purpura, mucocutaneous bleeding involving the skin, oral, epistaxis, Gl, GU-menorrhagia), microangiopatic hemolytic anemia (anemia, jaundice, fragmented RBCs/schistocytes on peripheral smear) kidnev failure/uremia (not as common), neurologic symptoms* (headache, CVA, AMS) with fever (rare)

HUS The hemolytic uremic syndrome (HUS) is defined by the simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. It is one of the main causes of acute kidney injury in children. Although all pediatric cases exhibit the classic triad of findings that define HUS, there are a number of various etiologies of HUS that result in differences in presentation, management, and outcome. Shiga toxin-producing E. coli hemolytic uremic syndrome (STEC HUS) is the most common cause of pediatric HUS, accounting for 90 percent of cases. It primarily affects children under the age of five years

Thrombocytopenia, Hemolytic Anemia, Kidney Damage

TTP Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy caused by severely reduced activity of the von Willebrand factor-cleaving protease ADAMTS13. It is characterized by small-vessel platelet-rich thrombi that cause thrombocytopenia, microangiopathic hemolytic anemia, and sometimes organ damage. TTP is a medical emergency that is almost always fatal if appropriate treatment is not initiated promptly. With appropriate treatment, survival rates of up to 90 percent are possible.

Thrombocytopenia, Hemolytic Anemia, Kidney Damage, Neurologic Symptoms, Fever

D) Phosphodiesterase 5 inhibitors Mechanism: inhibits PDE-5 → corpus cavernosum smooth muscle relaxation + ↑ blood flow → erection Erectile dysfunction (ED) refers to the regular and repeated inability to obtain or maintain an erection. It has several causes, both physical and psychological. Some of these causes are aging, tobacco use, neuropathy and vascular disease (multiple sclerosis, diabetes mellitus), renal failure, cavernosal disorders, prior surgery and selective serotonin reuptake inhibitors. During a normal erection, neurologic input to the penis causes a local secretion of nitric oxide, which allows the vessels in the corpora cavernosa to vasodilate, which in turn, results in an influx of blood. A key second messenger in this pathway is cyclic guanosine monophosphate (cGMP). To keep the pathway in check, an enzyme, phosphodiesterase type 5 (PDE5), breaks down cyclic-GMP, reverting the vasodilatory response. In other words, nitric oxide induced, cGMP mediated, penile vasodilation (erection) is inhibited by PDE5. Using the common pharmacologic mantra of "inhibit the inhibitors", the main class of medications used to treat ED works by inhibiting the inhibitor, phosphodiesterase type 5.

To achieve a normal penile erection, several neurochemical processes are required. Men who suffer from erectile dysfunction are commonly treated with medications from which of the following drug classes? A) Angiotensin-converting-enzyme-inhibitors B) Dihydropholate reductase inhibitors C) HMG-CoA reductase inhibitors D) Phosphodiesterase 5 inhibitors

*Parvovirus B19 infections* aka Fifth disease aka erythema infectiosum Transient aplastic crisis — Parvovirus B19 can cause transient aplastic crisis (TAC), in which the temporary suspension of erythropoiesis leads to severe anemia and related complications. This occurs in individuals with hematologic abnormalities, including increased RBC destruction (eg, sickle cell disease, hereditary spherocytosis) or decreased RBC production (eg, iron deficiency anemia). TAC from parvovirus B19 is a relatively common event for patients with sickle cell disease. In a study of 308 patients with homozygous sickle cell disease, acute infection with parvovirus B19 was documented in 114 patients, of whom 91 (80 percent) developed TAC [28]. The remaining 23 patients with parvovirus B19 infection had slight or no hematologic changes. Parvovirus B19 accounted for all of the cases of aplasia seen in that study.

Transient aplastic crisis in Sickle cell patients has been associated with what condition?

- Fluoroquinolones (Ciprofloxacin 500 mg PO bid x 28 days) OR - TMP-SMX (Bactrim) x 6-12 weeks - TURP for refractory cases.

Treatment for chronic prostatitis

*Azithromycin* Treatment of pertussis is azithromycin, 500 milligrams PO on day 1 and 250 milligrams PO on days 2 to 5. - Remember, Azithromycin is anti-inflammatory in the lungs. *Trimethoprim-sulfamethoxazole*, 160 milligrams/800 milligrams twice a day for 14 days (check renal dosing), is an alternative to those allergic to, or unable to tolerate, macrolides. Treatment is best if started early, in the first week. After that, antibiotic treatment does not alter the duration of cough. Chemoprophylaxis is typically given for household contacts, although the evidence base for such treatment is weak.

Treatment for pertussis (whooping cough)

Fluoroquinolones (Ciprofloxacin 1000 mg PO once daily x 7-14 days). Since patients with pyelonephritis have tissue-invasive disease, the treatment regimen chosen should have a very high likelihood of eradicating the causative organism and should reach therapeutic blood levels quickly. High rates of TMP-SMX-resistant E. coli in patients with pyelonephritis have made fluoroquinolones the first-line therapy for acute uncomplicated pyelonephritis.

Treatment for pyelonephritis

*Nitazoxanide* This agent is the only therapy approved by the US Food and Drug Administration for the treatment of cryptosporidiosis. Nitazoxanide is available in tablet form for adults and as an elixir for children. *To date, however, this agent has not been effective for the treatment of HIV-infected patients*, in whom improved immune status due to antiretroviral therapy can lead to amelioration of cryptosporidiosis. Otherwise, treatment includes supportive care with replacement of fluids and electrolytes and administration of antidiarrheal agents.

Treatment of Cryptosporidium

CCB (Verapamil) Beta Blocker (if LV function is preserved) ***Difficult to treat

Treatment of MAT

*Amiodarone* > Procainamide > Lidocaine Intravenous amiodarone is slower in action than procainamide or lidocaine, but it improves the reversion rate of refractory SMVT and decreases its recurrence after reversion. Procainamide has the advantage of slowing VT even when it fails to terminate, usually resulting in greater hemodynamic stability, whereas lidocaine usually does not slow SMVT. Procainamide terminates over 50 percent of episodes of SMVT, while lidocaine usually terminates only 10 to 20 percent.

Treatment of Stable, sustained VT

IV Magnesium Hypokalemia and hypomagnesemia can predispose to TdP. These disorders can occur together since hypomagnesemia directly causes hypokalemia.

Treatment of Torsades De Pointes

Amoxicillin x 10-14 days 2nd line = Augmentin (amoxicillin-clavulanic acid)

Treatment of choice for Acute Otitis Media (AOM)

Respiratory FQ (Moxifloxacin, *Levofloxacin*, Gemifloxicin) OR macrolide (Clarithromcin or *Azithromycin*) PLUS A beta-lactam (high dose amoxicillin or amoxixillin-clavulanate)

Treatment of outpatient CAP in patients at risk for drug resistance (abx therapy within the past 90 days, age > 65, comorbid illness, immunosuppression, exposure to a child in daycare)

TCAs (Amytriptyline) Beta Blockers Psychotherapy

Treatment of severe, recurrent tension headaches after NSAIDs etc fail.

A) Permethrin (Nix) cream Permethrin 1% cream/shampoo is used to kill the louse and remove the eggs from the hair shafts. Hint: Clotrimazole is an antifungal agent and is not used to treat parasitic infestation. Hint: Podofilox 0.5% solution is used to treat Condyloma accuminata. Hint: Selenium sulfide suspension is used to treat Tinea versicolor fungal infection

Treatment of the patient with Pediculosis pubis consists of which of the following? A) Permethrin (Nix) cream B) Clotrimazole (Gyne-Lotrimin) C) Podofilox (Condylox) solution D) Selenium sulfide (Selsun) suspension

True

True or false: All patients with chronic obstructive pulmonary disease should be prescribed a short-acting bronchodilator?

bloody diarrhea Ulcerative colitis typically presents with episodic bloody diarrhea, lower abdominal cramps, and urgency to defecate.

Ulcerative colitis usually presents with which of the following?

NOAC = *N*on-vitamin-K *O*ral *A*nti-*C*oagulation 1) Direct Thrombin Ihibitor (Dabigatran) 2) Xabans similar or lower rates of major bleeding as well as lower risk of ischemic stroke PLUS the convenience of not having to check the INR and less drug interactions

Usually now preferred over warfarin for anticoagulation in most cases

Legionella outbreaks associated with air-conditioning;

Very sick; old men, COPD; GI symptoms; CXR with patchy infiltrates; relative bradycardia (Faget's sign), hyponatremic, non-specific LFT abnormalities; not transmitted person-to-person

Split S2 and a systolic murmur. Best heard at the apex, radiates to the axilla. Ebstein's anomally is associated with WPW, Characterized by a downward displacement of the tricuspid valve into the RV, due to anomalous (deviating from what is standard, normal, or expected) attachment of the tricuspid leaflets, the Ebstein tricuspid valve tissue is dysplastic (showing abnormal development.) and results in tricuspid regurgitation. Often, the RV is hypoplastic. Surgical approaches include prosthetic replacement of the tricuspid valve when the leaflets are tethered or repair of the native valve.

What abnormal heart sounds would be heard with Ebstein's anomaly?

Anticholinergics ***Doesnt improve the bradykinesia though. works by blocking the excitatory cholinergic effects.

What adjunct medication is indicated for <70y with tremor predominance in parkinson disease?

*Ciprofloxaxin/Dexamethasone* The ideal antibiotic regimen should have coverage against the most common pathogens, *S. aureus and P. aeruginosa*. The *fluoroquinolones* ofloxacin and ciprofloxacin provide excellent coverage against both pathogens. In two clinical trials, ofloxacin appeared to be as effective as polymyxin B-neomycin-hydrocortisone (Cortisporin otic suspension). Another trial found that ciprofloxacin-dexamethasone was superior to polymyxin B-neomycin-hydrocortisone in decreasing inflammation, edema, and achieving pain control. Ofloxacin is safe if there is an associated TM perforation. While we prefer topical fluoroquinolones because of their antimicrobial spectrum, antiinflammatory effects, lack of potential ototoxicity, and lower risk of allergic reactions, they are more expensive than other options and may not be reimbursed by all insurers in the United States. Topical glucocorticoids decrease inflammation, resulting in relief of pruritus and decreased pain.

What antibiotic do we use for Otitis Externa?

Amoxicillin-clavulanate (Augmentin)

What antibiotic is first-line therapy for human bite infection prophylaxis?

Amoxicillin-clavulanate.

What antibiotic is first-line therapy for human bite infection prophylaxis?

Ofloxacin Ofloxacin is safe if there is an associated TM perforation.

What antibiotic is preferred for Otitis Externa if there is a TM perforation?

Aminoglycosides Think the "Mice ins" In general, aminoglycosides are active across a broad spectrum of aerobic gram-negative and gram-positive organisms as well as mycobacteria. Of note, anaerobic bacteria are intrinsically resistant to aminoglycosides. Aminoglycoside-induced ototoxicity may result in either vestibular or cochlear damage. Aminoglycosides are associated with cochlear and vestibular toxicity in a substantial proportion of patients receiving the drug for prolonged periods, leading to hearing loss and disequilibrium, respectively. The pathogenesis of aminoglycoside-induced ototoxicity with hearing loss is less understood. To prevent the development of ototoxicity due to aminoglycosides, strategies include once-daily dosing and careful monitoring of serum drug concentrations. N-acetylcysteine (NAC) can also be considered among patients with end-stage renal disease (ESRD) receiving an aminoglycoside.

What antibiotics must we avoid in TM perforation?

palpable osteophytes at PIP = OA

What are Bouchard's nodes?

palpable osteophytes at the DIP = OA

What are Heberden's nodes?

fragmented RBC's resulting from ↑RBC destruction in the spleen, liver, or small blood vessels

What are schistocytes?

"Children who miss school due to strep throat will "FALE" instead of getting an A" *F*ever, *A*bsence of Cough *L*ymphadenopathy (tender, anterior) *E*xudates on the tonsils *A*ge (Modified Centor = 3-14y ~ add 1 point; 15 - 44 no points added; >45 ~ subtract 1 point) ***<3 criteria means strep pharyngitis is unlikely

What are the Centor criteria for streptococcal pharyngitis?

Sulfa drugs.

What are the most common medications that trigger Stevens-Johnson syndrome?

Rear-facing child seats.

What are the recommendations for child safety seats for children under 2 years of age?

Down syndrome, cerebral palsy, craniofacial dystocia, low birth weight and family history.

What are the risk factors for infantile strabismus?

Foodborne botulism, wound botulism, and infant botulism.

What are the three types of botulism infection?

Adenocarcinoma and squamous cell carcinoma.

What are the two most common types of cervical cancer?

There are no specific lab tests to confirm or refute a diagnosis of myofascial pain syndrome.

What are the typical laboratory abnormalities found in patients with myofascial pain syndrome?

scorpion bite

What bite can cause acute pancreatitis?

There is no defining blood pressure; all that is needed is an elevated pressure in the setting of acute end-organ damage.

What blood pressure defines a hypertensive emergency?

B) High-output cardiac failure Elevated thyroid hormone levels produce a hypermetabolic state and increased beta-adrenergic activity. Common cardiac complaints include palpitations, dyspnea on exertion and decreased exercise tolerance. New-onset atrial fibrillation is common especially in the elderly. Through beta-adrenergic stimulation, elevated thyroid hormone levels can produce high-output cardiac failure. Dilated cardiomyopathy can result from prolonged tachycardia (or tachydysrhythmias) along with the high output state.

What cardiac complication is associated with hyperthyroidism? A) Aortic Dissection B) High-output cardiac failure C) Pericarditis D) Ventricular dysrhythmias

decreased drainage of aqueous humor via trabecular meshwork and canal of schlemm in patients with pre-existing narrow angle of large lens

What causes Acute Angle Glaucoma?

↑RBC mass, hyperviscosity or thrombosis

What causes the symptoms of Polycythemia?

*T-cells* T cell, also called T lymphocyte, type of leukocyte (white blood cell) that is an essential part of the immune system. T cells are one of two primary types of lymphocytes—B cells being the second type—that determine the specificity of immune response to antigens (foreign substances) in the body. T cells originate in the bone marrow and mature in the thymus. In the thymus, T cells multiply and differentiate into helper, regulatory, or cytotoxic T cells or become memory T cells. They are then sent to peripheral tissues or circulate in the blood or lymphatic system. Once stimulated by the appropriate antigen, helper T cells secrete chemical messengers called cytokines, which stimulate the differentiation of B cells into plasma cells (antibody-producing cells). Regulatory T cells act to control immune reactions, hence their name. Cytotoxic T cells, which are activated by various cytokines, bind to and kill infected cells and cancer cells.

What cells mediate RA

*Priapism* A common, serious, and often underdiagnosed problem in SCD. The vast majority of cases are ischemic, in which increased pressure compromises the vascular circulation (ie, a type of compartment syndrome). Over time, repeated episodes cause permanent damage and erectile dysfunction. Thus, priapism is considered a medical emergency in which timely diagnosis and appropriate management are vital to preserving normal function. This is a challenging management area because there are few experts dedicated to managing priapism in SCD and few large trials on which to base practice, and management often involves multiple specialties including urology, emergency medicine, pediatrics, and hematology.

What clincal manifestion of SCD is common and often underdiagnosed in sickle cell disease?

Seizures Lindane is a chlorinated hydrocarbon pesticide that is effective against lice, scabies, and fleas as a 1% lotion or shampoo.

What complication can occur secondary to prolonged application of lindane?

Zoster oticus.

What condition is associated with clear, fluid-filled tympanic membrane vesicles and facial nerve paralysis?

*Modified Duke Criteria* DUKE = D**iagnosed *U*nder *K*ultures and *E*cho

What criteria is used to diagnose infective endocarditis?

Colonscopy

What diagnostic examination should not be performed if acute diverticulitis is suspected due to the high-risk of perforation?

Examination of vaginal discharge for fishy odor and pH along with microscopy

What diagnostic studies are used in women with symptoms of vaginitis?

sentinel loop A sentinel loop is a focal area of adynamic ileus close to an intra-abdominal inflammatory process. The sentinel loop sign may aid in localising the source of inflammation. For example, a sentinel loop in the upper abdomen may indicate pancreatitis, while one in the right lower quadrant may be due to appendicitis.

What do you see?

Decreased production of globin chains of hemoglobin follows Plasmodium falciparum and is thought to provide some genetic evolutionary benefit against malaria

What does "thalassemia" mean?

*C*HF *H*TN *A*ge >/= 75 *D*M *S*troke, TIA, thrombus (2 points Used for risk stratification in nonvalvular A fib.

What does CHADS2 stand for?

*C*ervical *I*ntraepithelial *N*eoplasia = a precursor for cervical cancer CIN 1 = mild dysplasia - observe, LEEO, cold knife CIN 2 = moderate dysplasia - excision or ablation CIN 3 = severe dysplasia - excision or ablation

What does CIN stand for on cervical biopsy histology reults

HLA-B27 The presence of HLA-B27 may be useful diagnostically, since it is found in up to one-half of patients with reactive arthritis. It may be important also prognostically, as HLA-B27 positivity is associated with more chronic disease. The exact role of HLA-B27 in the disease pathogenesis remains elusive.

What does genetic marker is associated with Reactive Arthritis?

Misoprostol (Cytotec) = a synthetic prostaglandin E 1

What drug can be administered to reopen a recently closed ductous arteriosus?

Procainamide

What drug is safe to administer to a patient with wide complex irregular tachycardia?

*cholinergics* (Miotics) Think *Pilocarpine* Opthalmic Miotics = constrict the pupil which will thin the iris and open up that angle. This occurs because sympathetic activity from the ciliary ganglion is lost thus parasympathetics are not inhibited. Remember, sympathetic, fight-or-flight opens the pupils to see better.

What drugs do we use to open the angle in *Acute angle closure glaucoma*

The ulnar (medial) collateral ligament.

What elbow ligament is most commonly injured in pitchers?

Hypercalcemia MC with squamous cell carcinoma

What electrolyte abnormality can be seen with lung cancer and what type of lung cancer is it MC with?

Uveitis, arthritis, or liver disease.

What extraintestinal manifestations may be seen with inflammatory bowel disease?

Nugent's score.

What gram stain scoring system provides a more sensitive and specific diagnosis than wet mount?

Alpha Thalassemia Intermedia = 3/4 abnormal alleles

What is "Hemoglobin H disease"?

granulation tissue that erodes into cartilage and bone

What is "Pannus"?

small, round, yellow-white spots on the outer retina (Scattered, diffuse)

What is "drusen"

occasional aberrantly conducted beats (wide QRS) after short R-R cycles in A fib

What is Ashman's Phenomenon?

IgA Nephropathy MC cause of AGN in adults worldwide. Often affects young males within a couple days of URI or GI infection. IgA is the 1st line of defense in respiratory and GI secretions so infections may cause IgA overproduction that then go and junk up the kidney. Dx: IgA mesangial deposits on immunostaining Tx: ACE inhibitors ± corticosteroids

What is Berger's Disease?

Streptococcal pharyngitis? Note: GAS pharyngitis is usually self-limiting. Typically, the fever is gone by the third to fifth day, and other manifestations subside within 1 week. Rarely, more extensive spread occurs, producing meningitis, pneumonia, or bacteremia with metastatic infection in distant organs. In the preantibiotic era, these suppurative complications were responsible for a mortality rate of 1% to 3% after acute streptococcal pharyngitis. Such complications are much less common now, and fatal infections are rare. Tx: Antimicrobial therapy hastens resolution only if begun within a day, but can avert sequelae. Penicillin VK 12.5-25 mg/kg up to 500 mg bid for 10 days.

What is Centor Criteria used for?

fever, jaundice, and right upper quadrant pain present in about 70% of patients with ascending cholangitis and biliary sepsis. These patients are managed initially with fluid resuscitation and intravenous antibiotics. Diagnosis is made by ERCP Most commonly caused by choledocholithiasis leading to bacterial infection, E.coli

What is Charcot's Triad?

Charcot's triad is fever, jaundice and right upper quadrant pain. This triad is suggestive of ascending cholangitis.

What is Charcot's triad and what is its significance?

Perihepatitis associated with PID. It manifests as right upper quadrant pain and is seen in 10% of patients with PID.

What is Fitz-Hugh-Curtis syndrome?

*a protective RBC enzyme against oxidative stress* RBCs rupture under oxidative stress. Oxidative stress reflects an imbalance between the systemic manifestation of reactive oxygen species and a biological system's ability to readily detoxify the reactive intermediates or to repair the resulting damage

What is G6PD?

Gamma tetramers = Hydrops Fetalis = 4/4 abnormal alleles

What is Hgb Barts?

miosis, ptosis, anhydrosis Also called oculosympathetic paresis, a Horner syndrome can be produced by a lesion anywhere along the sympathetic pathway that supplies the head, eye, and neck.

What is Horner Syndrome?

Antibodies against calcium-gated channels at the neuromuscular junction leads to weakness similar to myasthenia gravis but the weakness IMPROVES with continued use (unlike MG where it gets worse with use)

What is Lambert-Eaton Syndrome?

Antibodies againsty presynaptic voltage-gated calcium channels prevents acetylcholine release. It can mimic Myasthenia Gravis but the key to distinguish is that Labert-Eaton *IMPROVES with repeated muscle use* and Myasthenia Gravis is WORSENED with repeated muscle use Approximately half of patients have concurrent *small-cell lung cancer*. The syndrome can precede detection of malignancy by several years. predominantly a disease associated with older men with a history of cigarette smoking and lung cancer.

What is Lambert-Eaton Syndrome?

Prognosis for acute pancreatitis

What is Ranson Criteria used for?

fever, jaundice, and right upper quadrant pain (Charcot's) + CONFUSION + HYPOTENSION signifies acute suppurative (Suppuration is the process of pus forming. ) cholangitis and is an endoscopic emergency.

What is Reynold's Pentad?

The Schilling test is a medical procedure used to determine whether you're absorbing vitamin B-12 properly. Your doctor may choose to order this test if you have vitamin *B-12 deficiency, or pernicious anemia*. (The Schilling test is primarily of historical interest; this test is no longer routinely available. Lack of access to the radiolabeled vitamin B12 used in the test, declining expertise, and increased availability of other testing with equal or better accuracy has made the Schilling test obsolete in many institutions.)

What is Schilling Test used for?

The "Seats on the bus" It binds free iron to reduce the oxidative damage associated with free iron (think rust). Indirectly measured by "TIBC" or total iron binding capacity.

What is Transferrin/TIBC?

Venous thrombosis associated with metastatic cancer

What is Trousseau's Syndrome

bilateral adrenal hemorrhage + meningococcemia

What is Waterhouse-Friedrichson syndrome?

T score = bone density score from a DEXA scan Normal is ≥ 1 * -1 to -1.5 = repeat every 5 years * -1.5 to -2.0 = repeat every 3-5 years * < -2.0 = repeat every 1-2 years

What is a T score and what value is normal?

Metformin

What is a biguanide medication used to treat type 2 diabetes and polycystic ovary syndrome?

Benign intracranial hypertension (idiopathic intracerebral hypertension), marked by headache and vomiting within the first 4 months of replacement therapy.

What is a complication of growth hormone replacement in the pediatric population?

WPW Patients who present with an acute arrhythmia often require initial pharmacologic therapy for ventricular rate control or restoration of sinus rhythm. However, because of the electrophysiologic differences between AV nodal tissue and tissue comprising an accessory pathway, standard therapy for heart rate control may actually worsen symptoms and lead to clinical deterioration in patients with a tachycardia involving an accessory pathway. Knowledge of the presence of an accessory pathway is critical in choosing the correct initial pharmacologic therapy.

What is an important contraindication to to pharmacological management for A fib?

Temporal Lobe Seizure

What is another name for a complex partial seizure?

*Distention* Abdominal distention is the *most common hallmark* of all kinds of intestinal obstructions and has the *greatest PPV*. 4 hallmarks = "CAVO" = *C*ramping, *A*bdominal distention, *V*omiting, *O*bstipation (cant pass stool or gas - usually a late finding) Hint: Tenderness, like rigidity, is not a predominant finding in obstructed bowel until very late in the course of advancing, untreated cases.

What is considered the most common physical examination finding for intestinal obstruction? A Distention B Fluid wave C Rigidity D Tenderness

Gonadotropin-releasing hormone agonists.

What is considered third-line treatment of continued severe premenstrual symptoms in women who do not tolerate or respond to SSRIs or OCPs?

The "passengers in the seats" Iron stores. Most iron that is not used for hemoglobin synthesis is stored in ferritin protein molecule

What is ferritin?

When objects seen by the affected eye look smaller than in the unaffected eye. associated with *macular degeneration*

What is micropsia?

excessive constriction of the pupil of the eye. Pupillary constriction to light and near stimuli is mediated via parasympathetic (cholinergic) nerve fibers that travel along the third cranial nerve. When the sympathetic input is compromised, parasympathetic dominates. miosis is sometimes confused with meiosis (a type of cell division that results in four daughter cells each with half the number of chromosomes of the parent cell)

What is miosis?

A stone in the salivary gland will cause intermittent swelling while parotitis is associated with persistent swelling.

What is one of the main clinical findings that differentiate sialolithiasis from parotitis?

*inspiratory drop in SBP > 10* indicative of severe airflow obstruction. indicative of several conditions, including cardiac tamponade, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD).

What is pulsus paradoxus?

spelnomegaly, marrow fibrosis with marked pancytopenia 15% of patients present in the spent phase

What is the "Spent Phase" of Polycythemia?

A febrile reaction to antigens that are liberated when spirochetal bacteria (classically syphillis) are destroyed by antibiotic therapy.

What is the Jarisch-Herxheimer reaction?

C) Renal artery stenosis Secondary HTN accounts for 5% of HTN and is due to an underlying and often correctable cause. Suspect Secondary HTN if blood pressure is refractory to antihypertensives or is severely elevated

What is the MC cause of secondary hypertension? A) ETOH B) Oral Contraceptives C) Renal artery stenosis D) Sleep Apnea

COPD decompensation

What is the MC cuause of Multifocal Atrial Tachycardia (MAT)?

This can occur in optic neuritis, in which objects moving in a straight line appear to be moving in a curved trajectory.

What is the Pulfrich phenomenon?

*meperidine (Demerol)* Because morphine is associated with ↑ spasm of the sphincter of Oddi. The sphincter of Oddi is a complex muscular structure that surrounds the distal pancreatic duct, bile duct, and ampulla of Vater. This sphincter mechanism lies mostly within the duodenal wall and measures 6-10 mm in length. Functionally, the sphincter of Oddi is independent from the duodenal smooth muscle system. It serves to prevent reflux of duodenal contents into the ductal system and controls the flow of bile and pancreatic juice into the duodenum.

What is the analgesic of choice for supportive management of acute pancreatitis?

Sigmoidoscopy The radiograph demonstrates a markedly dilated single loop of colon consistent with a sigmoid volvulus. Sigmoidoscopy is used to decompress and detorse the bowel.

What is the best management of this patient?

*G6PD Deficiency* Glucose-6-phosphate dehydrogenase enzyme deficiency. The G6PD / NADPH pathway is the only source of reduced glutathione in red blood cells (erythrocytes). The role of red cells as oxygen carriers puts them at substantial risk of damage from oxidizing free radicals except for the protective effect of G6PD/NADPH/glutathione. People with G6PD deficiency are therefore at risk of hemolytic anemia in states of oxidative stress

What is the condition?: - X-linked recessive - Asymptomatic until exposed to oxidative stress - Antimalarials, sulfonamides, nitrofurantoin, methylene blue, fava beans, vitamin K - Heinz bodies - Hemolytic anemia

Hypothyroidism - Most commonly caused by Hashimoto's thyroiditis - Treatment is levothyroxine - Comments: Takes about 6 weeks to see treatment effects. - Monitor TSH - Hashimoto's: Risk factor for non-Hodgkin lymphoma

What is the condition?: Patient will be complaining of generalized weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain. PE will show periorbital edema, dry skin and coarse brittle hair.

Before 37 weeks.

What is the definition of preterm or premature labor?

Scrotal Ultrasound ***Testicular biopsy is not performed as part of the evaluation due to concern that it may result in tumor seeding into the scrotal sac or metastatic spread of tumor into the inguinal nodes.*** In men with testicular masses, scrotal ultrasound has become an extension of the physical examination, but it should never be considered a substitute for the latter. A cystic or fluid-filled mass is unlikely to represent malignancy. By comparison, seminomas appear as well-defined hypoechoic lesions without cystic areas, while nonseminomatous germ cell tumors (NSGCTs) are typically inhomogeneous with calcifications, cystic areas, and indistinct margins

What is the diagnostic test of choice for suspected testicular cancer?

Metronidazole (Flagyl®)

What is the drug of choice for treating amoebic infections?

B) Propylthiouracil (PTU) = blocks T3 and T4 synthesis by inhibiting thyroid peroxidase Hint: Although thyroid function tests are altered in pregnancy true hyperthyroidism can occur and should be treated. Hint: Radioiodine treatment is contraindicated in pregnancy. Hint: Subtotal thyroidectomy is an option for pregnant patients during the second or third trimesters. Surgery is not indicated for first-trimester pregnancies.

What is the initial treatment of choice for hyperthyroidism in a 10-week pregnant patient? A) No treatment is necessary B) Propylthiouracil (PTU) C) Radioiodine treatment D) subtotal thyroidectomy

C) NSAIDs Corticosteroid injection (A) is considered if conservative therapy fails. Pain relief has only been demonstrated at 1 month with no significant difference at 6 months. Extracorpeal shock wave ultrasound (B) is a second-line therapy with mixed results for any positive benefit. Surgical therapy (D) is considered if all other measures fail. There is no proven benefit that surgical therapy is any more beneficial than conservative therapy

What is the most appropriate first line treatment for plantar fasciitis? A) Corticosteroid injection B) Extracorpeal shock wave ultrasound C) NSAIDs D) Surgical therapy

Mycoplasma

What is the most common atypical cause of pneumonia?

"Unknown"

What is the most common cause for syncope in a patient with a non-specific history, normal physical exam and normal EKG?

Neoplasm

What is the most common cause of a large bowel obstruction?

C) Metastases Metastatic disease (primarily from lung cancer) is the most common cause of an intracranial neoplasm. Other cancers that commonly metastasize to the brain include breast and colon carcinoma. The malignant gliomas (A) (anaplastic astrocytomas and glioblastoma multiforme) are the most common glial tumors. These are located in the cerebral hemispheres. Meningiomas (B) are generally benign, slow-growing tumors that originate in the meninges. Pituitary adenomas (D) are tumors originating from the pituitary gland and are often first noted when the patient exhibits visual impairment from compression of the optic chiasm.

What is the most common cause of an intracranial neoplasm? A) Astrocytoma B) Meningioma C) Metastases D) Pituitary adenoma

Tuberculosis

What is the most common cause of chronic retropharyngeal abscesses?

Peptic ulcer disease.

What is the most common cause of nonvariceal upper GI bleeding

C) Pinworms Patients with pruritus ani complain of an uncontrollable urge to scratch the perianal area. In the pediatric population, the pinworm (Enterobius vermicularis) is the most common cause. In adults, the most common case is the presence of feces on the perianal skin. The condition is most often associated with nighttime pruritus. Diagnosis is made by identifying either adult worms migrating in the perineal area or eggs on a clear piece of tape swab of the anus. Treatment for pinworms includes a single dose of mebendazole or pyrantel.

What is the most common cause of pruritus ani in the pediatric patient? A) Candida B) Lichen planus C) Pinworms D) Seborrheic dermatitis

Pregnancy

What is the most common cause of secondary amenorrhea?

A) Pregnancy essential to exclude by a serum or urine pregnancy test.

What is the most common cause of secondary amenorrhea? A) Pregnancy B) Ovarian failure C) Imperforate hymen D) Hypothalamic amenorrhea

*Staphylococcus aureus* is the most common cause of septic arthritis in adults. (OR "There are about 20,000 cases of septic arthritis in the United States annually with gonococcus being the leading cause and S. aureus in second place." - this is most likely for patients under 35) Hematogenous infection in children was the most common route, but H. influenzae type b (Hib) immunization has decreased this significantly. The peak incidence occurs in children under age 3, and boys are affected twice as often as girls. However, with the increasing frequency of prosthetic joints, a new group has emerged that may be the most problematic. Aspiration of the affected joint in the emergency department is often necessary to differentiate septic arthritis from other causes of synovitis such as gout or pseudogout. Hospitalize all patients with suspected or documented septic arthritis.

What is the most common cause of septic arthritis?

Mumps parotitis, which, in contrast to bacterial parotitis, is usually bilateral.

What is the most common cause of viral sialoadenitis?

Hypertension

What is the most common complication of post-streptococcal glomerulonephritis?

Clue cells.

What is the most common finding on microscopy for bacterial vaginosis?

A unilateral or bilateral facial nerve palsy

What is the most common neurological symptom from second-stage Lyme disease?

Iron deficiency.

What is the most common nutritional deficiency in children?

Sexual activity.

What is the most common risk factor for bacterial vaginosis?

SVT

What is the most common significant dysrhythmia in pediatrics?

Infiltrating ductal.

What is the most common type of breast cancer among men?

Anal fissures.

What is the most commonly encountered anorectal disorder in pediatric patients?

Follicular cyst Corpus luteum cysts (A) are less common than follicular cysts, but clinically more important. Clinically, corpora lutea are not termed corpus luteum cysts unless they are a minimum of 3 cm in diameter. Corpus luteum cysts may be associated with either normal endocrine function or prolonged secretion of progesterone. Corpus luteum cysts vary from being asymptomatic masses to those causing catastrophic and massive intraperitoneal bleeding associated with rupture. Dermoid cysts (B) are benign cystic tumors composed of mature cells. Benign teratomas such as dermoid tumors are among the most common ovarian neoplasms, but not the most common type of ovarian cyst. Theca lutein cysts (D) are the least common of the three types of physiologic ovarian cysts. Unlike corpus luteum cysts, theca lutein cysts are almost always bilateral and produce moderate to massive enlargement of the ovaries.

What is the most frequent cystic structure found in the ovary? Corpus luteal cyst Dermoid cyst Follicular cyst Theca lutein cyst

Leiomyoma (uterine fibroid).

What is the most frequently occurring pelvic tumor in women?

Adrenal insufficiency.

What is the most immediate life threatening complication of pituitary apoplexy?

Urinalysis

What is the most valuable laboratory test for diagnosing urinary tract infection?

Phocomelia

What is the name for the fetal limb malformations caused by thalidomide?

Corrigan's pulse.

What is the name of the rapid quick arterial pulse seen in aortic regurgitation?

Lynch syndrome should be suspected in patients with a strong family history of colon or endometrial cancer and may be grounds for more vigilant screening procedures.

What is the name of the syndrome that causes hereditary nonpolyposis colorectal cancer, in addition to increasing patients' risk of endometrial cancer, ovarian cancer, stomach cancer, or kidney cancer?

Absence of ganglion cells in the mucosal and muscular layers of the colon Hirschsprung's disease results from an absence of ganglion cells in the mucosal and muscular layers of the colon.

What is the pathologic mechanism of Hirschsprung's disease?

Cephalosporins or dicloxacillin are the preferred antibiotics.

What is the preferred antibiotic treatment for mastitis infections?

In-laboratory polysomnography.

What is the preferred diagnostic study for obstructive sleep apnea?

Oxytocin-induced vaginal delivery. Cesarean delivery is reserved for significant maternal and fetal instability.

What is the preferred method of delivery in a woman with placental abruption?

D) Incision and drainage incision and drainage is the treatment of choice for a Bartholin duct cyst.

What is the primary treatment for an infected Bartholin's duct cyst? A) Acyclovir B) Azithromycin C) Warm compresses D) Incision and drainage

Intravenous metronidazole and ceftriaxone +/- vancomycin. Empirical antimicrobial therapy for community-acquired SDE should include a combination of a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone), vancomycin, and metronidazole Prognosis is influenced by the level of consciousness of the patient at the time of hospital presentation, the size of the empyema, and the speed with which therapy is instituted. Long-term neurologic sequelae, which include seizures and hemiparesis, occur in up to 50% of cases.

What is the recommended antibiotic regimen for a brain abscess from an oral or sinus source?

B) Pregnancy-associated plasma protein A (PPA), beta-hCG, and ultrasound of nuchal transparency Pregnancy-associated plasma protein A (PPA), beta-hCG, and ultrasound of nuchal transparency are screening tests done at 10-13 weeks of gestation. Hint: Maternal serum alpha feto protein, beta hCG, estriol, and inhibin-A, are included in the quad screen which is a screening test done in the second trimester from 15-20 weeks of gestation. Hint: Amniocentesis is a diagnostic test not a screening test. Hint: Level II ultrasound is done in the second trimester.

What is the recommended initial first trimester screening test for fetal aneuploidy? A Amniocentesis B Pregnancy-associated plasma protein A (PPA), beta-hCG, and ultrasound of nuchal transparency C Maternal serum alpha feto protein, beta-hCG, estriol, and inhibin-A D Level II ultrasound

B) 50 gram glucose load followed by a blood sugar in 1 hour

What is the recommended method for screening pregnant women for gestational diabetes? A) Fasting blood sugar and 2 hour post prandial B) 50 gram glucose load followed by a blood sugar in 1 hour C) 75 gram glucose load followed by a blood sugar in 2 hours D) 100 gram glucose load followed by a blood sugar at 1 hour, 2 hours, and 3 hours

Nasal continuous positive airway pressure.

What is the recommended treatment for moderate to severe obstructive sleep apnea?

C) Prednisone Polymyositis is an inflammatory myopathy that is classified by patient age at onset or by coexisting diseases, such as myositis associated with neoplasia or myositis associated with collagen vascular diseases (e.g., systemic scleroderma, systemic lupus erythematous). The cause of inflammatory myopathies is unknown, but evidence suggests a genetic predisposition (associated with certain HLA markers) combined with an environmental insult, such as viruses, thereby initiating an autoimmune process. Patients usually experience progressive, symmetric, proximal muscle weakness with fatigue, malaise, and morning stiffness. Muscles often affected are those of the shoulder, neck, and pelvic girdle. Pulmonary (interstitial pneumonitis or fibrosis), cardiac (cardiomyopathy, congestive heart failure, arrhythmias), pharyngeal (dysphagia), and musculoskeletal (myalgias, arthralgias) symptoms might occur, although most patients do not experience synovitis. CK as well as aldolase, ALT, AST, and lactate dehydrogenase (LDH) levels might be elevated. ESR is elevated only half the time. Muscle biopsy can also be helpful in diagnosis. Prednisone, 1 mg/kg/day for up to several months, is the drug of choice; the earlier started in the disease process, the more effective it is. If prednisone is not sufficient, methotrexate, azathioprine, or another immunosuppressant is added.

What is the recommended treatment for polymyositis? A) Antibiotics B) NSAIDs C) Prednisone D) Radiation therapy

Storage for free Hgb. Haptoglobin binds free Hgb to reduce its oxidative toxicity and iron availability for microbes. ↑RBC destruction → ↑free Hgb → ↓Haptoglobin as this storage ability gets used up.

What is the role of Haptoglobin?

Beta-adrenergic blockers given within 24 hours of presentation reduce the risk of developing ventricular dysrhythmias.

What is the role of beta-adrenergic blocking agents in acute myocardial infarction?

Corticosteroids should only be given to patients with cerebral edema related to the abscess.

What is the role of corticosteroids in CNS abscess?

Early ambulation recommended for prophylaxis of venous thromboembolism in low-risk, minor procedures when the patient is under 40 years of age and there are no clinical risk factors. *Hint*: Intermittent pneumatic compression is indicated in patients undergoing a major operation plus an increased risk of bleeding. *Hint*: Low molecular weight heparin is indicated in patients undergoing orthopedic surgery, neurosurgery, or trauma with an identifiable risk factor for thromboembolism.

What is the selected method for the prevention of venous thromboembolism in a 38-year-old male undergoing an inguinal hernia repair?

This case establishes the physicians duty to breach patient confidentiality if the patient poses a significant threat to a 3rd party.

What is the significance of the Tarasoff vs. Regents case?

An open or closed partial lateral internal sphincterotomy.

What is the surgical procedure used in the treatment of chronic anal fissures?

Nucleic Acid Amplification Test (NAAT) NAAT methodology consists of amplifying C. trachomatis DNA or RNA sequences using polymerase chain reaction (PCR), transcription-mediated amplification (TMA), or strand displacement amplification (SDA). These sensitive and specific tests have become the "gold standard," and are the preferred diagnostic method, if available

What is the test of choice for chlamydia?

Nucleic Acid Amplification Test (NAAT) NAAT methodology consists of amplifying C. trachomatis DNA or RNA sequences using polymerase chain reaction (PCR), transcription-mediated amplification (TMA), or strand displacement amplification (SDA). These sensitive and specific tests have become the "gold standard," and are the preferred diagnostic method, if available

What is the test of choice for gonorrhea?

C) 3 hours Tissue plasminogen activator (TPA) catalyzes the conversion of plasminogen to plasmin, which promotes fibrinolysis. Ischemic stroke is caused by sudden occlusion of a cerebral artery by thrombus or embolus, producing a focal neurologic deficit. Timely reperfusion of ischemic brain tissue has been shown to limit irreversible neuronal injury in both humans and animals. The benefit of TPA in acute ischemic stroke was demonstrated in a large, multicentered national study. Patients whose symptoms began within 3 hours of treatment with TPA had significantly less disability at the end of 3 months than those given placebo. Although treated patients had higher incidence of secondary brain hemorrhage (6.4% vs. 0.8 %), there was no difference in mortality between the 2 groups. TPA must be given no later than 3 hours of symptom onset in patients with acute ischemic stroke. Prior to treatment, it is essential to exclude cerebral hemorrhage on a head CT scan. The presence of a bleeding diathesis, uncontrolled hypertension, recent prior stroke, and past history of cerebral hemorrhage are important contraindications for using TPA in acute ischemic stroke. TPA given later than 6 hours of stroke onset is associated with unacceptable risk of cerebral hemorrhage; it is not known whether fibrinolytic therapy can be given between 3 and 6 hours of stroke onset.

What is the therapeutic window for using recombinant tissue plasminogen activator in acute ischemic stroke? A) 1 hour B) 2 hours C) 3 hours D) 4 hours E) 6 hours

1) *IVIG* (2g/kg given within first 10 days) 2) Concomitant *aspirin* (80-100 mg/kg/d - divided into 4 doses and not exceeding 4g per day - orally until patient is afrebrile for 48 hrs then 3-5 mg/kg/day until markers of acute inflammation normalize)

What is the treatment for Kawasaki disease?

Single dose azithromycin.

What is the treatment of choice for Chlamydial urethritis?

*Doxycycline*. Regardless of the side effects that doxycycline can cause in the pediatric population, the *benefits far outweigh the risks*.

What is the treatment of choice for Rocky Mountain Spotted Fever in the pediatric population?

D) Calcium gluconate Hint: Potassium carbonate is a treatment for metabolic acidosis, not magnesium sulfate toxicity. Hint: Terbutaline is a beta-blocker that is used to treat pre-term labor. Hint: Nifedipine, a calcium-channel blocker is used to treat both preterm labor and hypertension in pregnancy. It works by inhibiting calcium transport through slow-type channels, causing reduction in systemic and pulmonary vascular resistance and tocolysis.

What is the treatment of magnesium sulfate toxicity? A Nifedipine B Terbutaline C Potassium carbonate D Calcium gluconate

Supportive bra, cold cabbage leaves, and ice packs.

What is the treatment of tender breast engorgement in a non-breast feeding postpartum woman?

Anovulatory bleeding is caused by the failure of the corpus luteal cyst to form leading to absence of progesterone and unopposed estrogen stimulation on the endometrium.

What is the underlying pathophysiology behind anovulatory bleeding?

homonymous hemianopsia Stroke is the most common etiology, occurs with lesions in the retrochiasmal visual pathways. Many patients will recover spontaneously, over half within the first month. Recovery after six months is unlikely. Homonymous = same side; Hemi = half; anopsia = loss of vision

What is the visual deficit called?

Drusen Drusen are made up of lipids, a fatty protein. Drusen likely do not cause age-related macular degeneration (AMD). But having drusen increases a person's risk of developing AMD

What is this finding?

Weight-Bearing joints!! (knees, hips, cervical/lumbar spine)

What joints are most affected by Osteoarthritis (OA)?

MICROcytic

What kind of anemia does Thalassemia cause?

clear cell carcinoma

What kind of cervical cancer was associated with DES?

Gram-negative sepsis

What kind of infection can be associated with sinus bradycardia

ALT 3-fold increase

What lab is highly suggestive of gallstone pancreatitis

Follicle-stimulating hormone (usually > 70 IU/L).

What laboratory test can aid in the diagnosis of menopause in a woman who is status post hysterectomy?

Torsades de pointes.

What life-threatening arrhythmia can QT prolongation progress to?

A pessary, usually of the ring, Smith-Hodge, donut, cube, or inflatable variety.

What medical treatment can be tried in stage I and II uterine prolapse prior to any surgical treatment?

*Hydroxyurea* *inhibits cells with a high division rate*. preferred agent for initial cytoreductive therapy of PV because of its efficacy, ease of administration, lower cost, long-term safety data, and favorable toxicity profile. HU is an inhibitor of ribonucleotide reductase that interferes with DNA repair. It is effective at lowering platelet counts and reducing thrombotic risk in PV. For select patients, interferon-alpha or busulfan are acceptable alternatives to HU as first-line therapy of PV.

What medication can we give for myelosuppression in Polycythemia Vera

Topical Beta-Blockers eye drops ending in -olol

What medication can we use in Acute angle closure glaucoma to reduce IOP *without affecting visual acuity?*

Allopurinol for hyperuricemia, chemo-related

What medication can we use in polycythemia vera if patient is hyperuricemic after chemo therapy?

A) Acetaminophen The first choice for patients with mild to moderate back pain should be acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen or naprosyn. In patients with severe pain, opiate medications may be necessary. However, it is important to note that no studies have demonstrated the superiority of one pain medication (or class of medication) over another in the treatment of back pain. Patients with milder symptoms should initially be treated with acetaminophen or an NSAID. These medications are well tolerated in short courses with minor side effects. NSAIDs have not been shown to be superior to acetaminophen. Continue daily activities as tolerated. Cyclobenzaprine (B) and diazepam (C) are muscle relaxants that promote sleep but have no evidence supporting their effectiveness in the treatment of back pain. Oxycodone (D) is an opiate analgesic with significant side effects and no proven benefit over more conservative treatments

What medication should be first line treatment in moderate musculoskeletal back pain? A) Acetaminophen B) Cyclobenzaprine C) Diazepam D) Oxycodone

Pneumocystis jirovecii.

What organism is responsible for chest X-ray findings of bilateral perihilar infiltrates described as a "bat-wing" pattern?

Trichomonas vaginalis, a flagellated protozoan visualized on the wet mount causing an itchy, malodorous vaginal discharge.

What organism may be identified by a wet mount made from a vaginal swab?

*Chlamydia & Gonorrhea*

What organism s associated with acute prostatitis in man <35 y

*hypokalemia* since hypomagnesemia directly causes hypokalemia.

What other electrolyte disturbance is seen with hypomagnesemia?

*Meperidine* (Demerol) high doses can cause sezires (in any patient)

What pain med should you avoid in sickle cell?

10-15%

What percentage of African-American males have G6PD Deficiency?

15-25%

What percentage of children with Kawasaki disease who are not treated will go on to develop coronary artery aneurysms?

Up to 40% (Esp. men) The majority of affected persons are asymptomatic, and thus provide an ongoing reservoir for infection.

What percentage of patients with chlamydia are asymptomatic?

20%

What percentage of strokes are hemorrhagic?

80%

What percentage of strokes are ischemic?

3%

What percentage of testicular cancers are nongerminal cell tumors?

Approximately 20%.

What percentage of women with preexisting hypertension develops preeclampsia during pregnancy?

Amiodarone

What pharmacological agent should be considered in treatment of WPW with impaired cardiac function?

Procainamide

What pharmacological agent should be considered in treatment of WPW with normal ejection fraction?

C) Ovulation Ovulation occurs within 30-36 hours of the LH surge and at the time of elevated estrogen. Hint: Secretory phase occurs when estrogen is elevated. Hint: The follicular phase begins with the onset of menses (day 1 of the menstrual cycle) and ends on the day of the LH surge. Hint: Progesterone causes differentiation of the endometrial components and converts proliferative endometrium into a secretory endometrium.

What phase of the female menstrual cycle occurs at the time of elevated estrogen and LH/FSH surge? A Follicular phase B Proliferative phase C Ovulation D Secretory phase

Pregnant women during the second and third trimesters.

What population has a high fatality rate if infected with Hepatitis E?

Spherocytosis Spherocytosis most often refers to hereditary spherocytosis. Spherocytosis is an auto-hemolytic anemia (a disease of the blood) characterized by the production of spherocytes (red blood cells or erythrocytes that are sphere-shaped rather than bi-concave disk shaped). Spherocytes are found in all hemolytic anemias to some degree. Hereditary spherocytosis and autoimmune hemolytic anemia are characterized by having only spherocytes. This is caused by a molecular defect in one or more of the proteins of the red blood cell cytoskeleton. Because the cell skeleton has a defect, the blood cell contracts to a sphere, which is its least flexible configuration.

What red blood cell disorder has a characteristic increase in mean corpuscular hemoglobin concentration (MCHC)?

Pyridoxine (vitamin B6) to prevent peripheral neuropathy.

What should be co-administered with isoniazid?

IV regular insulin and rapid-acting insulin analogs are equally effective in treating DKA. The choice of IV insulin is based upon institutional preferences, clinician experience, and cost concerns. We generally prefer regular insulin, rather than rapid-acting insulin analogs, due to its much lower cost.

What type of insulin should you used to treat DKA or HHS, regular or rapid-acting?

Bronchioalveolar A rare low-grade subtype of adenocarcinoma. Classically presents with columinous sputum and an interstitial lung pattern on CXR.

What type of lung cancer has the best prognosis?

Seminomas

What type of testicular cancer can spread to bone?

*Non*germinal Cell Tumors There are 2 main classifications; Germ cell and Nongerm cell with Germ cell being far more common accounting for 90-95% of all cancers of the testis. (Think "you DONT want little kids with cancer" = NON)

What type of testicular cancer is MC in boys ≤ 10y

6, 11, 16, 18 The quadrivalent form of HPV vaccine (Gardasil) is used in both females and males. Another form of HPV vaccine (Cervarix) is used only in females. You may receive this vaccine even if you have already had genital warts, or had a positive HPV test or abnormal pap smear in the past. However, this vaccine will not treat active genital warts or HPV-related cancers, and it will not cure HPV infection.

What types of HPV does Gardasil vaccine cover?

Folic acid Needed for RBC production and DNA synthesis. Increased folate consumption from ongoing hemolytic anemia is often proposed as a rationale for the use of folic acid in these patients. However, there are no data that folic acid supplementation increases the hematocrit in individuals with SCD; a randomized trial of folic acid supplementation in 117 children with SCD showed that compared with controls, those receiving folic acid did not show an improvement in hemoglobin levels or growth characteristics but did have a decrease in mean cell volume and less dactylitis. Despite this, we believe that the potential yet unknown benefit from folic acid supplementation outweighs the potential harms.

What vitamin is given in treatment of sickel cell disease?

ONLY if persistent asthma not controlled with ICS alone Once asthma control maintained >3 months, step down of LABA is recommended. LABA's should NOT be used alone!!

When do we use LABA's for Asthma?

if pulmonary function testing is nondiagnostic

When do we use bronchoprovocation in diagnosing asthma?

younger patients with lone A fib

When do you consider rhythm control in patients with atrial fibrillation

C) Pap smear in 3years Women who have had 3 consecutive negative annual Pap smears results may be screened every 2 or 3 years if they are 30 or older with no history of CIN 2 or 3, immunosuppression, HIV infection, or diethylstilbestrol (DES) exposure in utero.

When is the recommendation for the next Pap smear in a 36 year-old patient with a history of 3 consecutive negative annual Pap smears and no history of cervical dysplasia? A Yearly Pap smears B Pap smear in 4 years C Pap smear in 3years D Patient does not need any further Pap smears

If *CT is negative but you have a high suspicion of SAH* Xanthochromia!!! Especially if >12h and ↑CSF pressure. Occurs due to lysis of red blood cells and takes at least 2 hours to develop.

When should you get a lumbar puncture if you suspect SAH?

200 mg/dL (11.1 mmol/L)

When the serum glucose reaches ________________ in DKA the IV saline solution is switched todextrose in saline

250 to 300 mg/dL (13.9 to 16.7 mmol/L)

When the serum glucose reaches _________________ in HHS the IV saline solution is switched to dextrose in saline

Apical (upper lobe) fibrocavitary disease

Where does reactivation TB show up?

Last part of the small intestine ("Terminal Ileum") Needs to be bound to intrinsic factor

Where is B12 absorbed in the body

Jejunum the part of the small intestine between the duodenum and ileum.

Where is folate (B9) absorbed in the body?

Ovaries

Where is the most common location to find ectopic endometrial tissue in endometriosis?

B) At the xiphoid process The fundus is at the umbilicus (A) at 20 weeks; between the pubic symphysis and umbilicus (C) at 16 weeks; and between the umbilicus and xiphoid process (D) at 28 weeks.

Where is the uterine fundus palpable at 36 weeks gestation? A) At the umbilicus B) At the xiphoid process C) Between the pubic symphysis and umbilicus D) Between the umbilicus and xiphoid process

B) Category B Category A (A) correlates with agents known to be safe. The FDA requires a relatively large amount of high-quality data on a pharmaceutical for it to be defined as Pregnancy Category A. As a result of this, the FDA allocates many drugs that would be considered Pregnancy Category A in other countries to Category B. Category C (C) correlates with agents that have possible adverse effects. Their use should be considered only if the benefits outweigh the risks. Category D (D) correlates with agents that have known fetal risks and should be used only in life-threatening emergencies where there is no alternative agent.

Which U.S. Food and Drug Administration (FDA) category is defined by the following: Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. A) Category A B) Category B C) Category C D) Category D

Category C

Which United States Food and Drug Administration category describes medications in which the safety of use by pregnant woman is unknown and the drug should not be used unless the potential benefit outweighs the potential risk to the fetus? Category A Category B Category C Category D

Abdominal

Which abnormal reflex is most indicative of intraspinal pathology?

Ciprofloxacin (interferes with the growth plate)

Which antibiotic cannot be given to children or pregnant women?

Ceftriaxone (Rocephin®)

Which antibiotic is associated with cholestasis?

Metronidazole (Flagyl®) (disulfiram is Antabuse®)

Which antibiotic, if taken with alcohol, will produce a disulfiram-like reaction?

Metronidazole, clindamycin, cefoxitin, cefotetan, imipenem, ticarcillin-clavulanic acid, Unasyn®, Augmentin®

Which antibiotics are commonly used for anaerobic infections?

Gentamicin and other aminoglycosides, ciprofloxacin, aztreonam, third-generation cephalosporins, sulfamethoxazole- trimethoprim

Which antibiotics are commonly used for gram-negative infections?

Phenytoin

Which antiepileptic medication can cause hirsutism and gingival hyperplasia?

Verapamil

Which calcium channel blocker has the greatest effect on the AV node?

Giant cell arteritis, the most common elderly primary vasculitis, occurs in 10% of patients with PMR. The main symptoms are jaw claudication, temporal artery pain or beading and diplopia in patients >50 years of age.

Which condition commonly coexists with polymyalgia rheumatica?

3-8 weeks

Which embryologic period is associated with increased teratogenicity during organogenesis?

Aspergillus

Which fungal species is the most common cause of fungal otitis externa?

Women are more likely than men to experience all 5 stages.

Which gender is more likely to experience all 5 stages of grief?

BRCA1 and BRCA2

Which genetic mutations are strongly associated with familial ovarian cancer syndrome?

B12

Which is associated with neurologic symptoms when deficient, B12 or folate?

Sumatriptan, because it causes vasoconstriction.

Which medication used for migraine treatment is contraindicated in patients with coronary or peripheral vascular disease? Why?

*A) Metformin (Glucophage)* is a BIGUANIDE that mainly works by decreasing hepatic glucose production. Hint: Pioglitazone (Actos) is a THIAZOLIDINENIONE that works by increasing insulin sensitivity at the peripheral receptor sites (adipose and muscle tissues). No effect on pancreatic beta cells Hint: Glipizide (GLucotrol) is a SULFONYLUREA that works by stimulating pancreatic insulin release from beta cells. Hint: Sitagliptin (Januvia) works through the incretin system by inhibition of degradation of GLP-1 by inhibiting DDP4 which will increase insulin secretion

Which of the following anti-diabetic drug's mechanism of action works by decreasing hepatic glucose production? A) Metformin (Glucophage) B) Pioglitazone (Actos) C) Glipizide (GLucotrol) D) Sitagliptin (Januvia)

*B)* *Liraglutide (Victoza)* = is a GLP-1 agonist that mimic incretin which leads to insulin secretion. It will also decrease glucagon secretion and delay gastric emptying. No weight gain Hint: Glipizide (Glucotrol) is a SULFONYLUREA that works by stimulating pancreatic insulin release from beta cells. Hint: Pioglitazone (Actos) is a THIAZOLIDINENIONE that works by increasing insulin sensitivity at the peripheral receptor sites (adipose and muscle tissues). No effect on pancreatic beta cells. Hint: Repaglinide (Prandin) is a METAGLITINIDE that stimulated beta cell insulin release

Which of the following anti-diabetic drug's mechanism of action works by mimicing the incretin system? A) Glipizide (GLucotrol) B) Liraglutide (Victoza) C) Pioglitazone (Actos) D) Repaglinide (Prandin)

*C) Glipizide (GLucotrol)* = a SULFONYLUREA that works by stimulating pancreatic insulin release from beta cells. Hint: Metformin (Glucophage) is a BIGUANIDE that mainly works by decreasing hepatic glucose production. Hint: Pioglitazone (Actos) is a THIAZOLIDINENIONE that works by increasing insulin sensitivity at the peripheral receptor sites (adipose and muscle tissues). No effect on pancreatic beta cells Hint: Sitagliptin (Januvia) works through the incretin system by inhibition of degradation of GLP-1 by inhibiting DDP4 which will increase insulin secretion

Which of the following anti-diabetic drug's mechanism of action works by stimulating pancreatic insulin release from beta cells? A) Metformin (Glucophage) B) Pioglitazone (Actos) C) Glipizide (GLucotrol) D) Sitagliptin (Januvia)

A) *Sitagliptin (Januvia)* = works through the incretin system by inhibition of degradation of GLP-1 by inhibiting DDP4 Hint: Glipizide (Glucotrol) is a SULFONYLUREA that works by stimulating pancreatic insulin release from beta cells. Hint: Pioglitazone (Actos) is a THIAZOLIDINENIONE that works by increasing insulin sensitivity at the peripheral receptor sites (adipose and muscle tissues). No effect on pancreatic beta cells. Hint: Repaglinide (Prandin) is a METAGLITINIDE that stimulated beta cell insulin release

Which of the following anti-diabetic drug's mechanism of action works through the incretin system? A) Sitagliptin (Januvia) B) Glipizide (GLucotrol) C) Pioglitazone (Actos) D) Repaglinide (Prandin)

Fluoroquinolone drugs, including levofloxacin,

Which of the following antibiotics is associated with spontaneous tendon rupture?

C) Nitrofurantoin Studies have found only seven medications for which there is solid evidence to prohibit their use in G6PD-deficient patients: dapsone, methylthionine chloride (methylene blue), nitrofurantoin, phenazopyridine, primaquine, rasburicase, and tolonium chloride (toluidine blue). Their review found no substantial evidence to absolutely contravene the use of other medications in normal therapeutic doses. G6PD deficiency is the most prevalent human enzyme deficiency in the world, affecting an estimated 350 to 400 million people. he geographic distribution of G6PD deficiency coincides with the geographic distribution of endemic malaria, implicating a survival benefit. Diagnosis typically occurs when an episode of acute hemolysis is triggered by exposure to oxidant drugs, infection, or ingestion of fava beans.

Which of the following antibiotics may precipitate hemolysis in a patient with G6PD deficiency? A) Amoxicillin/Clavulanate B) Cephalexin C) Nitrofurantoin D) Streptomycin

Doxycycline Cephalexin (A) and penicillin (D) are category B and considered safe in pregnancy. Ciprofloxacin (B) is category C, therefore any benefits must be weighed against any potential harms.

Which of the following antimicrobials is considered category D in pregnancy? Cephalexin Ciprofloxacin Doxycycline Penicillin

B) Down's syndrome Hint: Edward's syndrome is due to trisomy 18. Hint: Wolf's syndrome is due to deletion of the short arm chromosome 4. Hint: Cri du chat syndrome is due to deletion of the short arm chromosome 5.

Which of the following autosomal disorders results from the chromosomal abnormality of trisomy 21? A) Edward's syndrome B) Down's syndrome C) Wolf's syndrome D) Cri du chat syndrome

Vaginal bleeding before 20 weeks of gestation with an open internal os Approximately 80% of miscarriages occur during the first trimester; the rest occur before 20 weeks of gestation or when the fetus is <500 g, considered premature birth. Approximately 25% of pregnant patients experience bleeding. Approximately 50% of all women who have bleeding during early pregnancy miscarry. Those with a history of bleeding who do not miscarry have otherwise fairly normal pregnancies, although they have an increased risk of premature birth and low-birth-weight infants. The 2 major causes of miscarriage are uterine malformations and chromosomal abnormalities. There are several stages of miscarriages. An inevitable abortion is defined by vaginal bleeding before 20 weeks of gestation with an open internal os and no passage of placental or fetal parts.

Which of the following best describes an inevitable abortion? Parts of the product of conception have been passed and may be visible in the cervical os or the vaginal canal Retention of a nonviable intrauterine pregnancy within the uterus, no cardiac activity, and a closed cervical os Vaginal bleeding before 20 weeks of gestation with a closed internal cervical os Vaginal bleeding before 20 weeks of gestation with an open internal os

altered structure and function of the right ventricle Cor pulmonale is the result of pulmonary hypertension associated with diseases of the lung, upper airway, pulmonary vasculature or chest wall. Cor pulmonale is the result of pulmonary hypertension and is not due to left-sided heart disease (D).

Which of the following best describes cor pulmonale? A) Altered structure and function of the left ventricle B) Altered structure and function of the right ventricle C) Congenital heart disease D) Right-sided heart disease due to left-sided heart disease

A) Prevention of convulsions Magnesium sulfate is used to prevent and treat eclamptic seizures. Magnesium sulfate is not sufficient to treat hypertension, therefore antihypertensives must be added. Magnesium sulfate is excreted solely from the kidneys and urine output must be preserved to prevent accumulation of the drug. Magnesium sulfate does nothing to prevent HELLP syndrome.

Which of the following best describes the purpose of intravenous magnesium sulfate in patients with preeclampsia? A Prevention of convulsions B Prevention of HELLP syndrome C Lowering of blood pressure D Reversal of proteinuria

C) Metoprolol (Lopressor) Hint: Propranolol and timolol are nonselective beta-adrenergic antagonists. Hint: Pindolol is an antagonist with partial agonist activity.

Which of the following beta-adrenergic blocking agents has cardioselectivity for primarily blocking beta-1 receptors? A Propranolol (Inderal) B Timolol (Blocadren) C Metoprolol (Lopressor) D Pindolol (Visken

Metoprolol is selective for beta-1 antagonists Hint: Propranolol and timolol are nonselective beta-adrenergic antagonists. Hint: Pindolol is an antagonist with partial agonist activity.

Which of the following beta-adrenergic blocking agents has cardioselectivity for primarily blocking beta-1 receptors? A Propranolol (Inderal) B Timolol (Blocadren) C Metoprolol (Lopressor) D Pindolol (Visken)

B) Autoimmune disease Rapid plasma reagin (RPR) is a diagnostic test that looks for non-specific antibodies to Treponema pallidum, the organism that causes syphilis. The RPR test has a high sensitivity but low specificity. False positives are seen in individuals with autoimmune disease, viral infections (EBV, hepatitis, varicella, measles), lymphoma, malaria, connective tissue disease, pregnancy, older age, and IV drug abuse. As a result of the low specificity, a positive RPR should always be followed up by a more specific treponemal test such as Treponema pallidum hemagglutination assay (TPHA) and Fluorescent Treponemal Antibody Absorption (FTA-ABS). The Venereal Disease Research Laboratory (VDRL) test is also sometimes used as a screening test but the RPR test is generally preferred due to its ease of use.

Which of the following can cause a false positive rapid plasma reagin (RPR)? A) Aspirin use B) Autoimmune disease C) Owning a pet cat D) Young age

C) Cardiac transplantation Cardiac transplantation is effective, with survival rates of 80-90% in 1 year, 60-70% over 5 years. It does improve quality of life despite the immunosuppression medications. Hint: Ventricular assist devices can help to provide TEMPORARY circulatory support to those awaiting transplantation.

Which of the following can optimize quality of life and is a definitive treatment for a patient with refractory heart failure? A) Ventricular assist device B) Intra-aortic balloon counterpulsation C) Cardiac transplantation D) Partial resection of the left ventricle

A) Extreme vulvar irritation Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous. Hint: Firm, painless ulcer (B) is seen in syphilis. Hint: Purulent discharge (D) is noted in gonorrhea. Hint: Tender lymphadenopathy (C) is associated with bacterial infections and is not a feature of candidal vulvovaginitis.

Which of the following clinical manifestations is common in candidal vulvovaginitis? A) Extreme vulvar irritation B) Firm, painless ulcer C) Tender lymphadenopathy D) Purulent discharge

B) A 55-year-old man with a blood pressure of 185/90 mm Hg whose creatinine has increased from 1.0 to 2.5 mg/dL within 36 hours Hypertensive emergency is generally defined as a markedly elevated blood pressure in the setting of acute end-organ damage of the cardiovascular, neurologic, or renal organ system. This condition is a true medical emergency and warrants early reduction of blood pressure (preferably within one hour of identification of the condition) with titratable intravenous medications. It is important to understand, however, that an elevated blood pressure in response to an acute condition is often physiologic; aggressive lowering of the pressure in these conditions (e.g., ischemic stroke) may actually increase morbidity and mortality. Renal failure can be seen as both a consequence and cause of hypertension. Uncontrolled hypertension may cause acute kidney injury and can accelerate the progression of injury in patients with chronic renal failure. Acute worsening of kidney function as seen in this patient whose creatinine increased acutely from 1 to 2.5 mg/dL—in the setting of elevated blood pressure—should be considered a hypertensive emergency and warrants immediate treatment.

Which of the following clinical scenarios can be defined as a hypertensive emergency? A) A 25-year-old pregnant woman in her second trimester with a blood pressure of 155/100 mm Hg with a normal urinalysis B) A 55-year-old man with a blood pressure of 185/90 mm Hg whose creatinine has increased from 1.0 to 2.5 mg/dL within 36 hours C) A 59-year-old asymptomatic man requesting a medication refill and is found to have a blood pressure of 210/110 mm Hg and an ECG consistent with left ventricular hypertrophy (LVH) D) A 63-year-old woman with a history of poorly controlled hypertension who presents with a finger laceration and is noted to have a blood pressure of 200/105 mm Hg

A) Cardiac tamponade Cardiac tamponade results from acute compression of the myocardium by rapid fluid (or gas) accumulation in the pericardial sac. Tamponade develops when fluid filling the pericardial sac accumulates faster than the rate of stretch in the parietal pericardium. The resulting extrinsic pressure on the myocardium exceeds right atrial pressure leading to a reduction in right ventricular filling. With a continued rise in pericardial pressure, cardiac compliance decreases. Flow of blood into the right side of the heart ceases, leading to a precipitous decline in cardiac output. Key to remember: the rate of fluid accumulation, not the absolute volume, is the important factor in the development of tamponade. Constrictive pericarditis (B) usually results from fibrous reaction of the pericardium and is characterized by impaired diastolic filling from external cardiac compression caused by a thickened pericardium. It is usually due to a late consequence of viral pericarditis, or even tuberculosis, and presents with a more indolent course than tamponade. A characteristic auscultatory finding is a pericardial knock in early diastole. A friction rub may also be heard. Pericardial effusions (C) are often asymptomatic and are due to a variety of diseases such as malignancy, renal failure, uremia, trauma, and radiation therapy. If the pericardial effusion accumulates rapidly, it can result in pericardial tamponade. Pneumopericardium (D) is a rare disorder that results in air around or within the pericardial space. It is classically associated with Hamman's sign, which is a loud crunching sound—best heard with the patient in a left lateral recumbent position—and is pathognomonic for mediastinal air.

Which of the following conditions is a result of a rapid increase in pericardial pressure and a clinical picture of acute restrictive cardiomyopathy? A) Cardiac tamponade B) Constrictive pericarditis C) Pericardial effusion D) Pneumopericardium

B) Dilated cardiomyopathy Low output cardiac failure is more common than high output cardiac failure. Low output failure is typically associated with a dilated cardiomyopathy, which may occur as a result of poorly controlled chronic hypertension, ischemic heart disease, or valvular heart disease. Low output failure is characterized by a decreased cardiac output (systolic dysfunction), an increase in left ventricular end-diastolic pressure, and an increased systemic oxygen extraction ratio.

Which of the following conditions is associated with low output heart failure? A) Anemia B) Dilated cardiomyopathy C) Pregnancy D) Thyrotoxicosis

D. Sickle cell anemia Children with sickle cell anemia (D) who no longer have a functional spleen should receive the meningococcal vaccine. Autosplenectomy dramatically increases the risk of serious infections from encapsulated organisms including Neisseria meningitides, Streptococcus pneumoniae and Haemophilus influenzae.

Which of the following conditions should prompt administration of the meningococcal vaccine prior to the standard 11 years of age? A. Cystic fibrosisYour Answer B. Diabetes mellitus C. Hypoplastic left heart D. Sickle cell anemia

Conduct Disorder

Which of the following conditions, in which laws and social norms are repetitively violated, is the most common precursor to antisocial personality disorder?

Intrauterine fetal pole and yolk sac The fetal pole is a mass of fetal cells separate from the yolk sac that first becomes apparent on transvaginal ultrasound just after the 6th week of gestation. Beta-hCG levels (A) increase at a predictable rate in the early stages of pregnancy. Levels of beta-hCG double every 2-3 days during the first 7-8 weeks of normal pregnancies. However, there are conditions other than an intrauterine pregnancy that can lead to significant elevations of beta-hCG, such as gestational trophoblastic disease and molar pregnancy. This disorder is characterized by proliferation of chorionic villi. The associated high level of beta-hCG often leads to hyperemesis. Identifying fetal heart activity (B) does not confirm an intrauterine pregnancy because an ectopic pregnancy can progress to have fetal activity. Only when fetal heart activity is detected within the gestational sac can the pregnancy be confirmed as intrauterine. A true gestational sac is identified on ultrasound by the double ring, also known as the double decidual sign, and confirms an intrauterine pregnancy. A single layer gestational sac (D), or pseudosac, is possible, which looks very similar to a true gestational sac. In this setting, there can still be an ectopic fetus. Therefore, most clinicians confirm an intrauterine pregnancy when a gestational sac with a fetal pole or yolk sac is present.

Which of the following confirms an intrauterine pregnancy? Beta-hCG of 200,000 Fetal heart activity Intrauterine fetal pole and yolk sac Single layer intrauterine gestational sac

C) Tetralogy of Fallot Cyanotic heart disease results from either right-to-left shunting of desaturated blood flowing into the systemic circulation or from decreased pulmonary blood flow. Tetralogy of Fallot is the classic CHD but this group also includes truncus arteriosus, dextroposition (or transposition) of the great arteries, tricuspid atresia and total anomalous pulmonary venous return. The majority of these disorders are identified when patients are still in the nursery.The abnormalities seen in Tetralogy of Fallot include 1) right ventricular outflow tract obstruction, 2) over-riding aorta, 3) ventricular septal defect (VSD) and 4) right ventricular hypertrophy (RVH). An easy mnemonic to remember this is "PROVe" (Pulmonary stenosis, RVH, Overriding aorta, and VSD). Patients typically present with cyanosis that is worse during feeding and crying. They often have poor feeding and in older children, they may squat to relieve symptoms. Patients may experience "tet spells" characterized by acute respiratory distress due to increased right outflow tract obstruction. Patients with severe right ventricular outflow obstruction may present early after birth with profound cyanosis requiring reopening of the patent ductous arteriosus. Patients will have a systolic ejection murmur along the left sternal border. Chest radiography typically shows the classic "boot-shaped" heart. Cyanosis can be recreated by any valsalva maneuver as this results in an increase in the right-to-left shunt across the VSD. Definitive treatment is surgical correction.

Which of the following congenital disorders results in a cyanotic child? A) Atrial septal defect B) Coarctation of the aorta C) Tetralogy of Fallot D) Ventricular septal defect

A) Anterior cervical position The Bishop score is the cervical assessment system most commonly used in obstetrical clinical practice in the United States. This system *tabulates a score of the likelihood of vaginal delivery following induction* based upon the station of the presenting part and four characteristics of the cervix: dilatation, effacement, consistency, and position. Greater cervical dilation and effacement, softer cervix, more anterior cervical position, and great fetal station tabulate to a higher Bishop score and are associated with greater likelihood of vaginal delivery. In contrast, a low Bishop score increases the likelihood that induction will fail to result in vaginal delivery. *A Bishop score ≥ 8 suggests the chances of having a vaginal delivery are good*, and the cervix is considered favorable, or ripe, for induction. If the Bishop score is ≤ 6, the chances of having a vaginal delivery are low, and the cervix is considered unfavorable, or unripe, for induction.

Which of the following contributes to a higher Bishop score? A) Anterior cervical position B) Cervical effacement of 0 to 30% C) Fetal station of -3 D) Firm cervical consistency

Blood volume increases Hemoglobin concentration increases (D) in pregnancy is incorrect. Hemoglobin concentration is decreased as pregnancy is associated with a dilutional anemia caused by the increase in plasma volume which is proportionately greater than red cell volume.

Which of the following correctly describes physiologic changes that occur in pregnancy? Blood volume increases Functional residual capacity increases Gastrointestinal motility increases Hemoglobin concentration increases

B) Second-degree deep partial thickness burn First-degree burns (A) involve only the epidermis and are erythematous and painful, without blisters. They are usually described as looking like a sunburn. These are not considered in the calculation of total body surface area when calculating burn size. Second-degree superficial partial-thickness burns (C) are erythematous and have thin-walled fluid-filled blisters. These usually heal in 2 to 3 weeks without scarring. Third-degree burns (D) involve all layers of the dermis. The skin is firm, white, or charred and often described as leathery. This represents complete tissue destruction, and surgery is necessary except in the smallest of third-degree burns. Fourth-degree burns extend to deeper tissues, including subcutaneous fat, muscle, and bone. Significant debridement and reconstruction are required.

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? A) First-degree burn B) Second-degree deep partial thickness burn C) Second-degree superficial partial thickness burn D) Third-degree burn

C) Nicardipine Nicardipine is a dihydropyridine calcium-channel blocking agent used for the treatment of vascular disorders such as chronic stable angina, hypertension, and Raynaud's phenomenon. Nicardipine is more selective for cerebral and coronary blood vessels than other dihydropyridines. Alendronate (A) is a bisphosphonate that acts as an osteoclast inhibitor to inhibit bone resorption. Calcitonin (B) works to lower serum calcium concentration by inhibiting calcium absorption by the intestines, inhibiting osteoclast activity in the bones, and inhibits renal tubular cell reabsorption of calcium allowing it to be excreted in the urine. Olanzapine (D) is an atypical antipsychotic that is used for the treatment of schizophrenia and bipolar disorder. Olanzapine is structurally similar to clozapine and quetiapine, but is classified as a thienobenzodiazepine.

Which of the following drugs is classified as a calcium channel blocker? A) Alendronate B) Calcitonin C) Nicardipine D) Olanzapine

D) Metronidazole Treatment for BV is with metronidazole 500 mg PO BID or clindamycin 300 mg PO BID for 7 days. Alternatively, metronidazole and clindamycin can be prescribed as a vaginal suppository. Unlike with other sexually transmitted infections, treatment of the partner does not reduce the response rate or rate of recurrence. Azithromycin (A) is often used to treat Chlamydia trachomatis infections in cervicitis or urethritis. Ceftriaxone (B) is a 3rd generation cephalosporin that is active against Neisseria gonorrhoea. Doxycycline (C) treats C. trachomatis infections

Which of the following drugs must be prescribed in a patient with cervicitis in whom bacterial vaginosis is also suspected? A) Azithromycin B) Ceftriaxone C) Doxycycline D) Metronidazole

D) small cell Small cell lung cancer is the most common type of lung cancer that is metastatic at the time of discovery, and therefore has the poorest prognosis. (Small Cell = Small Chance of survival - Small Cell = Central ("S" Sound))

Which of the following forms of lung cancer is associated with the poorest prognosis? A squamous cell B adenocarcinoma C large cell D small cell

B) Hyperreflexia

Which of the following historical or physical exam findings is most consistent with a diagnosis of hypomagnesemia? A) Bradycardia B) Hyperreflexia C) Hypotonia D) Perioral paresthesias

C A patient over age 65 with Grave's disease. Radioactive iodine is the recommended treatment for overactive thyroid tissue in patients without risk for subsequent thyroid cancer, leukemia, or other malignancies. Hint: Patients with toxic solitary nodules may be treated with surgery or radioactive iodine. Surgery isrecommended for patients under 40 years of age. Hint: Subacute thyroiditis is usually self-limited. Thyroid iodine uptake is low in this condition, thus rendering radioactive iodine ineffective

Which of the following hyperthyroid patients would be the best candidate for radioiodine therapy? A A 30-year-old patient with toxic adenoma. B A 50-year-old man with subacute thyroiditis. C A patient over age 65 with Grave's disease. D A pregnant woman with Hashimoto's thyroiditis

*Red blood cell distribution width (RDW)* The RDW is usually increased in iron deficiency and normal in thalassemia.

Which of the following indices reported in a standard complete blood count panel is most helpful to differentiate between iron deficiency anemia and thalassemia?

D) history of smoking in a patient older than age 35 A history of smoking in a patient older than age 35 is considered one of the absolute contraindications to prescribing oral hormonal contraceptives due to the increased risk of thromboembolic events. Hint: Oral hormonal contraceptives have been proven to reduce the risk of ovarian and endometrial cancer. Current recommendations include use in patients with a high risk of ovarian cancer due to family history or BRCA gene status Hint: Oral hormonal contraceptives are one of the acceptable treatments for primary dysmenorrhea as periods are less painful due to suppression of ovulation.

Which of the following is a contraindication to prescribing oral hormonal contraceptives? A) history of iron deficiency anemia B) history of dysmenorrhea since age 15 C) positive family history of ovarian cancer D) history of smoking in a patient older than age 35

C) history of salpingitis Hint: While high levels of estrogen and progesterone are thought possibly to increase the risk of ectopic pregnancy because these hormones slow the movement of the fertilized egg through the fallopian tube, no proven association has been established. Hint: Alcohol intake has not been associated with an increased risk of ectopic pregnancy. Hint: Advanced maternal age, not younger maternal age, is an established risk factor for ectopic pregnancy.

Which of the following is a major risk factor for an ectopic pregnancy? A alcohol intake B young maternal age C history of salpingitis D low dose oral contraceptive use

A) CD4 count of 125 Pneumocystis jirovecii pneumonia (PCP), previously called Pneumocystis carinii pneumonia, is the most common cause of death in individuals with AIDS-related complications. Primary prophylaxis is indicated when CD4 counts fall below 200. Risk factors for the development of this opportunistic infection include a history of PCP, decreased CD4 count, as well as undiagnosed weight loss, oropharyngeal candidiasis, night sweats and fever in individuals with CD4 counts above 200 cells. Definitive diagnosis is by cytopathologic or histopathologic evidence of the organism in induced sputum samples, bronchoalveolar lavage fluid, or tissue. Trimethoprim-sulfamethoxazole is the recommended medication for prophylaxis and is also used for treatment of the disease.

Which of the following is an indication for prophylaxis against Pneumocystis jirovecii pneumonia in individuals infected with HIV? A) CD4 count of 125 B) CD4 count of 1500 C) Individuals taking anti-retroviral therapy D) Pregnant women with HIV regardless of CD4 count

D) Undescended testis Torsion is bimodal (A) with most cases occurring during the first year of life or during puberty. Epididymitis (B) may mimic the symptoms of torsion but is more gradual in onset. It does not predispose to torsion. Nearly 50% of cases arise in men between the ages 20 and 29 years. If untreated, it can lead to orchitis, testicular abscess, and sepsis. Although fixed testes (C) can still torse, it is not associated with an increased likelihood of torsion. Testicular torsion can occur at any age, but it has bimodal peaks: the first year of life and at puberty (ages 12 to 18). Torsion results from maldevelopment of fixation between the enveloping tunica vaginalis and the posterior scrotal wall, as seen with an undescended testicle (cryptorchidism). Characteristically, the involved testis is aligned along a horizontal rather than a vertical axis. Frequently there is a history of an athletic event, strenuous physical activity, or trauma just before the onset of scrotal pain. The pain usually occurs suddenly, is severe, and is usually felt in the lower abdominal quadrant, the inguinal canal, or the testis. On physical exam, there is loss of the cremasteric reflex. This is observed in nearly 100% of patients with torsion. The testicle is usually tender and firm and the scrotum is swollen and tender. In cases with a high suspicion of torsion, the patient should be taken to the OR immediately by a urologist. If the diagnosis is equivocal, color Doppler and ultrasound is the best diagnostic modality.

Which of the following is associated with an increased likelihood of testicular torsion? A) Age greater than 50 years B) Epididymitis C) Fixed testis D) Undescended testis

D) fetal distress Passage of meconium is associated with fetal distress usually due to asphyxia Hint: Meconium passage occurs most commonly in post-term deliveries, not pre-term deliveries. Passage of meconium is related to mature development of the gastrointestinal tract and is rarely seen before 36 weeks gestation Hint: Prolonged labor, not fast labor, is associated with potential passage of meconium into the amniotic fluid.

Which of the following is associated with meconium-stained amniotic fluid during labor? A) transition B) prematurity C) fast labor D) fetal distress

B) Methylmalonic acid is increased Vitamin B12 is found in animal products and binds to intrinsic factor (IF) secreted by gastric parietal cells. This complex is absorbed in the terminal ileum. Pernicious anemia is an autoimmune disorder in which antibodies act against intrinsic factor and gastric parietal cells leading to chronic atrophic gastritis and decreased production and function of intrinsic factor. This subsequently leads to vitamin B12 deficiency. In vitamin B12 deficiency, serum methylmalonic acid is increased. In elderly patients, this form of megaloblastic anemia is one of the leading causes of vitamin B12 deficiency. Pernicious anemia is associated with other immunologic diseases such as Sjögren's syndrome, Hashimoto's disease, type 1 diabetes mellitus, and celiac disease. It is also associated with an increased risk for gastric cancer and carcinoid tumors. Vitamin B12 deficiency caused by dietary deficiency or malabsorption is rare. Dietary causes of deficiency are limited to elderly people who are already malnourished. Since the 1980s, the malabsorption of vitamin B12 has become rare, due to the decreasing frequency of gastrectomy and surgical resection of the terminal small intestine Other disorders associated with vitamin B12 malabsorption include deficiency in the exocrine function of the pancreas after chronic pancreatitis (usually alcoholic), lymphomas or tuberculosis of the intestine, Crohn's disease, Whipple's disease, and celiac disease. Uncommon etiology also includes nitrous oxide anesthesia and abuse.

Which of the following is associated with pernicious anemia? A) Homocysteine levels are decreased B) Methylmalonic acid is increased C) Normocytic erythrocytes D) Vitamin B12 elevation

D) Left atrial appendage TEE allows 2-D and Doppler imaging of the heart through the esophagus. Given the close proximity of the esophagus to the heart, high-resolution images can be obtained, especially of the left atrium, mitral valve apparatus, and aorta

Which of the following is better visualized with transesophageal echocardiogram (TEE) than transthoracic echocardiogram? A) Ventricular wall motion B) Pulmonary arteries C) Right ventricle D) Left atrial appendage

B) Multiple sclerosis (MS) is most common in people of Northern European descent. = Becomes more prevalent the further you live from the equator Hint: Multiple sclerosis occurs 2- to 2.5-fold more frequently in women than in men Hint: FIrst-line treatment is high-dose IV corticosteroids. Plasmapharesis is used if not responsive to corticosteroids Hint: More common in young adults 20-40y

Which of the following is correct regarding multiple sclerosis? A) MS is more common in men than in women B) MS is more common in Norther Europeans than in African-Americans C) First-line treatment is plasmapharesis because steroids will make this condition worse. D) More common in patients over over 40 yrs old

A number of screening measures are used to determine the likelihood of scoliosis, but radiography is needed for the diagnosis of scoliosis as determined by the Cobb angle.

Which of the following is necessary to confirm the diagnosis of scoliosis?

D) Cesarean section prior to onset of labor and rupture of membrane Cesarean section performed prior to the onset of labor and rupture of membranes significantly reduces the risk of perinatal HIV transmission. Planned cesarean section delivery at 38 weeks of gestation to prevent perinatal transmission of HIV is recommended in women with a viral load of >1000 copies/mL.

Which of the following is recommended to reduce the risk for perinatal transmission of HIV in a patient with a viral load of >1000 copies/mL? A Vaginal delivery with female condom B Episiotomy to shorten second stage of labor C Use of forceps or vacuum extractor to shorten second stage of labor D Cesarean section prior to onset of labor and rupture of membrane

A) Alpha-methyldopa (Aldomet®) The use of ACE inhibitors (B) and angiotensin II receptor antagonists (C and D) in late pregnancy has been associated with renal dysfunction, oligohydramnios, neonatal anuria, and other congenital anomalies such as skull ossification defects. However, data have also suggested an increased risk of congenital anomaly after exposure limited to the first trimester of pregnancy. Alpha-methyldopa is a centrally acting alpha-adrenergic medication used as a first line antihypertensive agent for pregnant women. If adequate control cannot be obtained, a second drug, most often nifedipine or hydralazine, can be added. Labetalol is gaining popularity for use as first-line single-agent therapy, but may be associated with fetal growth restriction.

Which of the following is recommended to use as an anti-hypertensive in a pregnant woman? A) Alpha-methyldopa (Aldomet®) B) Lisinopril (Zestril®) C) Losartan (Cozaar®) D) Valsartan (Diovan®)

B) elevation of blood pressure Hint: Headache and visual disturbances indicate severe pre-eclampsia and are late findings that indicate a need to deliver the fetus. Hint: Since weight gain and edema are common occurrences during pregnancy, they are less reliable indicators of pre-eclampsia. Most current sources no longer list them as diagnostic criterion for pre-eclampsia. Hint: While proteinuria is a defining diagnostic criterion of pre-eclampsia, it is a late finding and may not be present even with eclampsia.

Which of the following is the earliest and most reliable clinical manifestation of pre-eclampsia? A onset of proteinuria B elevation of blood pressure C excessive weight gain and edema D headache and visual disturbances

D) Weight loss and continuous positive airway pressure Albuterol (A) use has not been shown to help in the management of sleep apnea. Tracheostomy (C), which bypasses the entire upper airway, is an effective treatment for obstructive sleep apnea, but it is invasive and should be reserved for patients with life-threatening arrhythmias or those who have failed conservative treatment. Oral appliances (B), or mandibular advancement devices, are used to increase upper airway caliber and are modestly effective for patients with mild to moderate obstructive sleep apnea. Weight loss and continue positive airway pressure remains the most proven and effective therapy for obstructive sleep apnea. The continuous positive airway pressure acts as a pneumatic splint, holding the airway open. In addition, even a small reduction in body weight is associated with clinically significant improvements, and weight loss alone may be curative in some patients. Other lifestyle or conservative measures may include curbing alcohol intake before bedtime and avoiding a supine posture if obstructive sleep apnea is position dependent. Comments: can lead to pulmonary hypertension and cor pulmonale (right ventricular hypertrophy)

Which of the following is the initial treatment of choice in an overweight patient with moderate obstructive sleep apnea? A) Albuterol nebulizer 30 minutes prior to sleep B) Oral appliances C) Tracheostomy D) Weight loss and continuous positive airway pressure

*Inguinal orchiectomy followed by retroperitoneal radiation* therapy cures about 98% of patients with stage I seminoma. Hint: Surveillance is an option in stage I disease of a non-seminoma testicular tumor. (u) B. Patients with stage IIC and stage III are treated with chemotherapy.

Which of the following is the most appropriate intervention for a stage I testicular seminoma?

C) Orchiectomy and radiation Inguinal orchiectomy followed by retroperitoneal radiation therapy cures about 98% of patients with stage I seminoma. Hint: Chemotherapy is used for later stage tumors (II/III) and followed by surgery in stage III tumors Hint: Surveillance is an option in stage I disease of a nonseminoma testicular tumor. (u) B. Patients with stage IIC and stage III are treated with chemotherapy. Hint: Patients with stage IIC and stage III are treated with chemotherapy

Which of the following is the most appropriate intervention for a stage I testicular seminoma? A Watchful waiting B Chemotherapy initially C Orchiectomy and radiation D Orchiectomy and chemotherapy

Rectal biopsy A rectal biopsy showing the absence of ganglion cells in both the submucosal and muscular layers of the involved bowel is the most appropriate diagnostic study for Hirschsprung disease.

Which of the following is the most appropriate study for diagnosing Hirschsprung disease?

D) Vaginal hysterctomy Vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy (A). Operative management of an enterocele with an anterior colporrhaphy (B), or a rectocele with a posterior colporrhaphy (C) is often performed at the time of operation for uterine prolapse after the patient has undergone a hysterectomy, but is not the surgical treatment for uterine prolapse.

Which of the following is the most appropriate treatment for stage IV uterine prolapse in a 50-year-old woman with no medical problems and no previous surgical history? A) Abdominal hysterectomy B) Anterior colporrhaphy C) Posterior colporrhaphy D) Vaginal hysterctomy

Vaginal hysterectomy Vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy (A). Operative management of an enterocele with an anterior colporrhaphy (B), or a rectocele with a posterior colporrhaphy (C) is often performed at the time of operation for uterine prolapse after the patient has undergone a hysterectomy, but is not the surgical treatment for uterine prolapse

Which of the following is the most appropriate treatment for stage IV uterine prolapse in a 50-year-old woman with no medical problems and no previous surgical history? Abdominal hysterectomy Anterior colporrhaphy Posterior colporrhaphy Vaginal hysterectomy

B) Salmonella nontyphoidal Salmonellosis is the most common cause of foodborne disease. It is associated with consumption of milk products, poultry and eggs. Transmission can also occur from pets, specifically reptiles.

Which of the following is the most common cause of bacterial foodborne disease in the United States? A) Campylobacter B) Salmonella C) Shigella D) Vibrio cholerae

C) Uterine atony Postpartum hemorrhage is defined as a loss of > 500 mL of blood after delivery. An enlarged and "boggy" uterus is seen with uterine atony. If this is palpated, then vigorous uterine massage should be performed to help prevent atony. Cervical laceration (A) occurs in greater than half of all vaginal deliveries. Most of these are under 0.5 cm. Small lacerations, up to 2 cm, heal on their own without complication. A larger or deeper cervical laceration should be suspected if there is bleeding with a firm uterus. The cervix should be visualized completely after delivery to check for lacerations and if bleeding profusely should be surgically repaired. A retained placenta (B) is a rare cause of post-partum hemorrhage. The placenta should be thoroughly examined after delivery and if a piece is missing, the uterus should be explored and portions of the placenta that are retained should be removed. Uterine rupture (D) has a multitude of causes including previous uterine scarring from C-section or other uterine surgery, including surgeries involving the cervix. This is the most common cause of uterine rupture. The uterus can also rupture if overstimulated which can occur with the use of oxytocin induction or augmentation. The treatment is surgical and hysterectomy may be required if the rupture is life-threatening.

Which of the following is the most common cause of post-partum hemorrhage? A) Laceration to the cervix B) Retained placenta C) Uterine atony D) Uterine rupture

Epithelial The most common primary type of ovarian cancer is of epithelial cell origin (90%), followed by germ cell origin (<5%, but the most common type in women younger than 20 years of age), then stromal cell origin (<2%). The most common malignant epithelial cell ovarian tumor is a serous cystadenocarcinoma.

Which of the following is the most common cell type of ovarian cancer? Epithelial Germ cell Granulosa cell Stromal

D) Sinus tachycardia

Which of the following is the most common dysrhythmia associated with the diagnosis of pulmonary embolism? A) Atrial fibrillation B) AV-nodal reentrant tachycardia C) Multifocal atrial tachycardia D) Sinus tachycardia

D) Pseudomonas aeruginosa The most common cause of otitis externa is infection due to Pseudomonas aeruginosa and Staphylococcus aureus. The pain from otitis externa is caused by inflammation and edema of the ear canal skin, which is normally adherent to the bone and cartilage of the auditory canal. The inflammatory reaction can be caused by bacteria, fungi, or contact dermatitis. Cerumen protects the canal by forming an acidic coat that helps prevent infection. Factors that predispose to otitis externa include absence of cerumen, often from excessive cleaning by the patient, water that macerates the skin of the auditory canal and raises the pH, and trauma to the skin of the auditory canal from foreign bodies or use of cotton swabs. Treatment includes suction and gentle warm irrigation of the canal. 2% acetic acid solution or an alternative drying medication can be administered. A topical antibiotic drop with steroid is first-line therapy (neomycin/polymyxin/hydrocortisone). Use the suspension rather than the solution if the tympanic membrane is ruptured.

Which of the following is the most common etiology of external otitis? A) Aspergillus niger B) Candida C) Moraxella catarrhalis D) Pseudomonas aeruginosa

Intractable pain Hint: While the possible presence of pancreatic cancer is an indication for surgery, there is no indication for prophylactic surgery to decrease the risk of cancer

Which of the following is the most common indication for operative intervention in patients with *chronic pancreatitis*?

B) Intractable pain Hint: While the possible presence of pancreatic cancer is an indication for surgery, there is no indication for prophylactic surgery to decrease the risk of cancer Hint: While the majority of patients go on to develop diabetes mellitus 25 years after the clinical onset of chronic pancreatitis, this is not an indication for surgical intervention as it would lead to more severe exocrine deficiency.

Which of the following is the most common indication for operative intervention in patients with chronic pancreatitis? A Weight loss B Intractable pain C Exocrine deficiency D To decrease risk of cancer

D) Herpes simplex virus Although numerous infections have been reported in association with erythema multiforme (EM), herpes simplex virus (HSV) is the most common and best documented. The pathogenesis of EM is incompletely understood, but evidence increasingly implicates a host-specific, cell-mediated immune response to an antigenic stimulus that targets keratinocytes at the dermal-epidermal junction. EM has variable cutaneous manifestations. EM is characterized by the acute onset of a symmetric, fixed cutaneous eruption of erythematous macules, papules, vesicles, or bullae most commonly distributed on the palms, dorsal surfaces of the hands and feet, and extensor surfaces of the arms and legs with relative sparing of the face, trunk and mucous membranes. Lesions can expand and evolve over several days to assume the classic annular "target" appearance with a dusky, necrotic center surrounded by a ring of edema and pallor and an erythematous border. Borrelia burgdorferi (A) is associated with Lyme's disease and skin condition called erythema migrans.

Which of the following is the most common infection associated with erythema multiforme? A) Borrelia burgdorferi B) Haemophilus influenzae Type b C) Hepatitis C virus D) Herpes simplex virus

B) Hirsutism The patient with polycystic ovarian syndrome typically presents with *hirsutism or infertility* Hint: Desquamation is noted in toxic shock syndrome. Hint: Galactorrhea is noted in hyperprolactinemia.

Which of the following is the most common manifestation of polycystic ovarian syndrome? A) Desquamation B) Hirsutism C) Galactorrhea D) Rebound tenderness

Asymptomatic Patients with primary hyperparathyroidism are most commonly found to have this disease by an incidental finding of hypercalcemia on routine laboratory testing as a result of screening. Up to 0.1% of the adult population has this condition which is most commonly seen in females over age 50.

Which of the following is the most common presentation for an elderly female patient with primary hyperparathyroidism? A Abdominal pain B Renal lithiasis C Acute pancreatitis D Asymptomatic

D) breast mass

Which of the following is the most common presenting clinical manifestation of breast cancer? A breast tenderness B nipple discharge C nipple retraction D breast mass

D) Squamous cell carcinoma Cervical cancer is the third most common gynecologic cancer in the United States with a lower rate of incidence and mortality than ovarian or uterine cancer. Rates are lower because of the use of Papanicoloau (Pap) screening which allows for detection of pre-cancerous and early-stage disease. Countries worldwide without access to cervical cancer screening have rates of cervical cancer that are much higher than the United States, with cervical cancer remaining the second most common type of cancer in women worldwide. Human papillomavirus is found in more than 99% of all cervical cancers and causes the development of cervical neoplasia. Risk factors for cervical cancer include activities that lead to infection with the human papillomavirus (HPV), oral contraceptive use and cigarette smoking. The most common type of cervical cancer is squamous cell carcinoma, which is found in 69% of cases of cervical cancer in the United States.

Which of the following is the most common type of cervical cancer? A) Adenocarcinoma B) Cervical sarcoma C) Small cell carcinoma D) Squamous cell carcinoma

D) Squamous cell carcinoma Human papillomavirus is found in more than 99% of all cervical cancers and causes the development of cervical neoplasia. Risk factors for cervical cancer include activities that lead to infection with the human papillomavirus (HPV), oral contraceptive use and cigarette smoking. The most common type of cervical cancer is squamous cell carcinoma, which is found in 69% of cases of cervical cancer in the United States. Adenocarcinoma (A) is the second most common type of cervical cancer. It is found in 25% of cases of cervical cancer in the United States. Other histologies make up 6% of cases of cervical cancer including cervical sarcoma (B) and small cell carcinoma (C).

Which of the following is the most common type of cervical cancer? A) Adenocarcinoma B) Cervical sarcoma C) Small cell carcinoma D) Squamous cell carcinoma

A) Infiltrating ductal Infiltrating lobular carcinoma (B) is the second most common type of infiltrating breast carcinoma. This type of carcinoma tends to metastasize later than infiltrating ductal carcinomas and spread to more unusual locations. Medullary carcinoma (C) occurs more in younger women and makes up approximately 5% of all breast cancer cases. Papillary carcinoma (D) is one of the least common types of breast cancer, making up 1% of cases. It is most commonly found in women older than 65 years.

Which of the following is the most common type of invasive breast cancer in women? A) Infiltrating ductal B) Infiltrating lobular C) Medullary D) Papillary

A) uterine atony Uterine atony is the most common cause of postpartum hemorrhage. Predisposing factors include any conditions that cause excessive uterine enlargement, abnormal labor or conditions that interfere with uterine contraction. Hint: Retained placental tissue only acccounts for 5-10% of postpartum hemorrhage and usually occurs later. Hint: Genital tract trauma may lead to lacerations of the lower genital tract that cause postpartum hemorrhage, however this is much less common than uterine atony.

Which of the following is the most common underlying cause of early postpartum hemorrhage? A) uterine atony B) genital tract trauma C) coagulation disorders D) retained placental tissue

C) Nontender scrotal mass that transilluminates A hydrocele is a fluid-filled mass that is nontender to palpation. Diagnosis is readily made by transillumination, however evaluation is still warranted as 10% of testicular tumors may have an associated hydrocele.

Which of the following is the most consistent physical examination finding associated with a hydrocele? A) Tender and swollen testicle B) Palpable painless mass on the testicle C) Nontender scrotal mass that transilluminates D) Inability to get exam finger above scrotal mass

Epigastric tenderness Epigastric tenderness is a key feature of duodenal ulcer. Hint: Flank tenderness is caused by urologic disorders such as pyelonephritis and renal lithiasis. Hint: Right upper quadrant tenderness on palpation is a typical feature for cholecystitis.

Which of the following is the most consistent physical examination finding in a patient with duodenal ulcer?

A) decrease in estrogen Hint: While there is a slight decrease in testosterone levels during menopause, this has not be shown to be responsible for the majority of menopausal symptoms Hint: Progesterone and androstenedione levels both decrease, not increase, in the menopausal female patient and therfore can not account for any menopausal symptoms.

Which of the following is the most significant factor in the production of menopausal symptoms? A) decrease in estrogen B) decrease in testosterone C) increase in progesterone D) increase in androstenedione

A) increased fluid production due to increased hydrostatic pressure A transudative pleural effusion occurs in the setting of normal capillary integrity and suggests the absence of local pleural disease. Chronic heart failure accounts for 90% of transudates. Hypoalbuminemia, cirrhosis, and acute atelectasis are also causes of a transudate.

Which of the following is the pathophysiologic process of a transudative pleural effusion? A) increased fluid production due to increased hydrostatic pressure B) decreased lymphatic clearance of fluid from the pleural space C) infection in the pleural space D) bleeding into the pleural space

D) Surgical resection Surgical resection is the treatment of choice for pituitary adenomas >1 cm in diameter or those with compression of the optic chiasm, erosion of bone, or extension into the walls of the sella. The transsphenoidal approach (Hardy procedure), preferable to the transcranial route (most often right perioral craniotomy), achieves gross total resection in one-third of patients. Improvement in microsurgical technique and imaging has reduced mortality to below 2%. Dopamine agonists such as bromocriptine (A), cabergoline, quinagolide, and pergolide (B) are effective in micro- as well as macroprolactinomas and lead to reduction in tumor size, improvement of symptoms, and normalization of prolactin levels. Radiation therapy (C) is provided as primary treatment to older adult patients, those who are not surgical candidates, and following partial resection. Tumor shrinkage is seen only years after treatment. Adverse effects are infrequent and include necrosis of the adjacent portions of the temporal lobe, hearing loss, optic neuropathy, and radiation-induced sarcomas.

Which of the following is the recommended treatment for a pituitary adenoma >1 cm in size? A) Bromocriptine (Parlodel®) B) Pergolide (Permax®) C) Radiation D) Surgical resection

D) remove blood A large volume hemothorax is treated by *immediate insertion of a large bore thoracostomy tube* to (1) drain existing blood and clot, (2) quantify the amount of bleeding, (3) reduce the risk of fibrothorax, and (4) permit apposition of the pleural surfaces in an attempt to reduce hemorrhage. Hint: Pleurodesis is a procedure by which an irritant is placed into the pleural space following chest tube drainage and lung re-expansion.

Which of the following is the recommended treatment of a large volume hemothorax? A perform pleurodesis B drain the empyema C administer antibiotics D remove blood

A) early ambulation Early ambulation is recommended for prophylaxis of venous thromboembolism in low-risk, minor procedures when the patient is under 40 years of age and there are no clinical risk factors. Hint: Elastic stockings are indicated for patients at moderate risk of venous thromboembolism in ages 40-60 with minor procedures with additional thrombosis risk factor, or major operations for patients under age 40 without additional clinical risk factors. Hint: Intermittent pneumatic compression is indicated in patients undergoing a major operation plus an increased risk of bleeding

Which of the following is the selected method for the prevention of venous thromboembolism in a 38-year-old male undergoing an inguinal hernia repair? A early ambulation B elastic stockings C intermittent pneumatic compression D low-molecular weight heparin

A) early ambulation Early ambulation is recommended for prophylaxis of venous thromboembolism in low-risk, minor procedures when the patient is under 40 years of age and there are no clinical risk factors. Hint: Low molecular weight heparin is indicated in patients undergoing orthopedic surgery, neurosurgery, or trauma with an identifiable risk factor for thromboembolism. Intermittent pneumatic compression is indicated in patients undergoing a major operation plus an increased risk of bleeding.

Which of the following is the selected method for the prevention of venous thromboembolism in a 38-year-old male undergoing an inguinal hernia repair? A) early ambulation B) elastic stockings C) intermittent pneumatic compression D) low-molecular weight heparin

B) Sclerotherapy Sclerotherapy is effective in decreasing the risk for rebleeding in a patient with esophageal varices. Hint: All the other options are for acute management of active bleeding. With the advent of modern endoscopic techniques which can rapidly and definitively control variceal bleeding, Sengstaken-Blakemore tubes (basically a type of NG tube) are rarely used at present

Which of the following is the therapy of choice for long-term management of esophageal varices in a patient who cannot tolerate beta blocker therapy? A) Octreotide (Sandostatin) B) Sclerotherapy C) Transjugular intrahepatic portosystemic shunt (TIPS) D) Sengstaken-Blakemore tube

C) Surgical removal is associated with a 25% to 30% rate of recurrence Uterine fibroids decrease in size during menopause (A) and enlarge early in pregnancy. Uterine fibroids are 2x more common in African American women (B) than in White women. Uterine fibroids are usually multiple in nature (D) rather than single

Which of the following is true regarding uterine fibroids? A) Increase in size during menopause B) More common in White women than African American women C) Surgical removal is associated with a 25% to 30% rate of recurrence D) Typically occur as a single fib

Hemophilia B (also referred to as Christmas disease, named after the first person diagnosed with the condition) is caused by a deficiency of factor IX, a factor involved in the intrinsic coagulation cascade. In the severe form (< 1% of factor activity), the activated partial thromboplastin time (aPTT), which measures this cascade, will be abnormal. Factor IX has a longer half-life than factor VIII and therefore, patients with hemophilia B do not require transfusions as often as those with hemophilia A

Which of the following lab tests will be abnormal in patients with severe hemophilia B? A) Activated partial thromboplastin time B) Bleeding time C) D-dimer D) Prothrombin time

A) Ca-125 Ca-125 is one of the best tumor markers in epithelial ovarian cancer. Hint: Only in young girls and adolescents should an LDH and AFP be ordered as there is a greater likelihood of a malignant germ cell tumor.

Which of the following laboratory markers are helpful in establishing the diagnosis of ovarian cancer in a 55 year-old post-menopausal women? A) Ca-125 B) CEA C) LDH D) AFP

D) Urine culture Hepatitis C antibodies (A) screening is not recommended in all pregnant patients. Hepatitis C infection should be screened for in high risk patients, such as patients with a history of illicit drug use, patients with HIV, incarcerated patients, and patients whose current sexual partner is infected with hepatitis C. Thyroid stimulating hormone (B) is not recommended in all pregnant patients. The American College of Gynecology and Obstetrics recommend testing patients for thyroid dysfunction if they have any of the following: symptoms of thyroid disease, personal or family history of thyroid disease, type 1 diabetes, goiter, history of neck or head radiation, and amiodarone or lithium use. Tuberculin skin testing (C) for latent tuberculosis is not indicated in all pregnant women. Tuberculosis screening is recommended in patients who are immunosuppressed and in patients who are in close contact with individuals with active tuberculosis.

Which of the following laboratory studies should be performed on all pregnant women during the initial prenatal visit? A) Hepatitis C antibodies B) Thyroid stimulating hormone C) Tuberculin skin testing D) Urine culture

A) Metoclopramide (Reglan) It is a centrally acting dopaminergic antagonist that is used in the treatment of nausea and vomiting. Prochlorperazine (B), promethazine (C), and trimethobenzamide (D) are all Category C agents. Prochlorperazine and promethazine are also dopamine antagonists. The mechanism of action for trimethobenzamide is not well understood. Ondansetron (trade name Zofran) another commonly prescribed antiemetic is also Category B.

Which of the following medications is commonly used to treat hyperemesis gravidarum is considered Category B? A) Metoclopramide (Reglan) B) Prochlorperazine (Compazine) C) Promethazine (Phenergan) D) Trimethobenzamide (Tigan)

D) Methyldopa Hydrochlorothiazide (A), and diuretics in general, are considered second-line agents. Angiotensin-converting enzyme inhibitors, such as lisinopril (B) and angiotensin receptor blockers, such as losartan (C) are contraindicated in pregnancy because of toxic effects on the fetus.

Which of the following medications is the preferred outpatient treatment of hypertension in pregnancy? A) Hydrochlorothiazide B) Lisinopril C) Losartan D) Methyldopa

A) A confused 65-year-old man brought from a house fire who exhibits good long-term recall, no recall of immediate events, normal vital signs, carboxyhemoglobin level of seven Dementia results from a gradual loss of mental capacity with preservation of motor and speech. Dementia generally occurs in the elderly. Remote memories are often preserved. The most common types of dementia are Alzheimer's disease and vascular dementia, both insidious in onset. Symptoms may worsen acutely because of a concurrent medical condition. Physical exam and laboratory workup are generally unrevealing. ) This patient has acute delirium (B) caused by carbon monoxide poisoning (CO). CO poisoning can lead to confusion, headache, vomiting, and syncope (C, D, E). A febrile illness can lead to delirium in elderly patients. In the evaluation of all such patients, it is critical to differentiate acute delirium, which is a confusional state where functions of cognition and attention are impacted due to an underlying medical cause from chronic dementia.

Which of the following patients is most likely suffering from dementia? A) A confused 65-year-old man brought from a house fire who exhibits good long-term recall, no recall of immediate events, normal vital signs, carboxyhemoglobin level of seven B) A confused 65-year-old man brought from a house fire who exhibits poor long-term recall, no recall of immediate events, normal vital signs, carboxyhemoglobin level of 25 C) A confused 80-year-old man brought from home with fever, back pain, and urinary retention D) A confused 80-year-old man brought from home with fever, cough, and hypoxia E) A confused 80-year-old man brought from home with increased thirst, increased urination, and blood sugar monitor that reads "high"

A) Chadwick's sign Chadwick's sign is a bluish discoloration of the vagina early in pregnancy; it usually appears by 12 weeks of gestation.

Which of the following physical examination findings is present in a 12 week singleton pregnancy? A Chadwick's sign B Uterus palpable at the level of the umbilicus C Blood pressure lower than non-pregnant state D Hyperreflexia

D) Folic acid (B9) Folic acid given daily has been shown to effectively reduce the risk of neural tube defects. It should be started 1-3 months prior to pregnancy.

Which of the following prenatal vitamins has been shown to decrease the risk of neural tube defects? A) Riboflavin (B2) B) Niacin (B3) C) Thiamine (B1) D) Folic acid (B9)

B) Hepatitis B surface antigen negative, Hepatitis B surface antibody positive In individuals that are vaccinated and immune due to previous vaccination hepatitis B surface antigen will be negative and hepatitis B surface antibody will be positive. This suggests that antibodies have been formed because of vaccination and not exposure to virus. Hepatitis B vaccine is part of routine immunizations in the United States, and as a result, the incidence of HBV has significantly declined. The diagnosis of HBV infection requires the evaluation of the patient's blood for hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), and hepatitis B core antibody (HBcAb). Although the presence of HBsAg indicates that the person is infectious, the presence of HBsAb indicates recovery and immunity from HBV infection or successful immunization against HBV. HBcAb appears at the onset of acute HBV infection, but may also indicate chronic HBV infection.

Which of the following profiles is consistent with immunity to hepatitis B virus secondary to vaccination? A) Hepatitis B core antibody positive, Hepatitis B surface antibody positive B) Hepatitis B surface antigen negative, Hepatitis B surface antibody positive C) Hepatitis B surface antigen positive, Hepatitis B e antigen positive D) Hepatitis B surface antigen positive, Hepatitis B surface antibody negative

C) Denial, Anger, Bargaining, Depression, Acceptance Although the stages of grief can be experienced in different orders, the classic teaching is that Denial precedes anger (A), bargaining (B) and depression (D).

Which of the following represents the classic order of the stages of grief? A) Anger, Denial, Bargaining, Depression, Acceptance B) Bargaining, Anger, Denial, Depression, Acceptance C) Denial, Anger, Bargaining, Depression, Acceptance D) Depression, Denial, Anger, Bargaining, Acceptance

B. Fluoride drops and tablets

Which of the following sources of fluoride has the highest risk of causing dental fluorosis? A. Community water fluoridation with 0.7 ppm fluoride B. Fluoride drops and tablets C. Fluoride gel and varnish D. Tooth brushing with 1000 ppm fluoride toothpaste

B) Leukocytosis is seen in the majority of cases An appendicolith (A) is identified radiographically (most commonly on CT) but only in 10% of patients. The perforation rate (C) in patients under 2 years of age approaches 90% and often occurs as the initial presentation. The presence of an appetite (D) does not rule out appendicitis. A retrocecal appendicitis with limited peritoneal irritation may be associated with minimal gastrointestinal symptoms. Up to 33% of patients diagnosed with appendicitis do not report anorexia on initial presentation.

Which of the following statements is *true* regarding appendicitis? A) An appendicolith is identified in the majority of cases of appendicitis B) Leukocytosis is seen in the majority of cases C) Perforation is rare in patients younger than 2 years D) The presence of an appetite makes the diagnosis unlikely

C) Preliminary screening is a blood glucose >130 one hour after a 50 gram glucose load In about 50% of women, GDM is reversible after pregnancy and does not inevitably evolve into type 2 diabetes (A). Asymptomatic type 1 and type 2 diabetes, or latent autoimmune diabetes of adults existing before pregnancy may become clinical and irreversible. Glitazones (B) might be effective in overcoming the insulin resistance of pregnancy but are contraindicated. Their mechanism of action as transcription factors is a theoretic risk for teratogenesis. Screening for gestational diabetes is performed at 24-28 weeks' gestation not at 32-36 weeks (D).

Which of the following statements is true regarding gestational diabetes? A) Gestational diabetes eventually evolves into Type 2 diabetes B) Glitazones are the first line treatment C) Preliminary screening is a blood glucose >130 one hour after a 50 gram glucose load D) Screening is performed between 32 and 36 weeks

D) The onset of serum sickness generally occurs within one to two weeks Serum sickness (D) is an immune-complex mediated reaction characterized by malaise, joint pain, urticaria, fever, adenopathy, and hepatosplenomegaly. Symptoms usually begin one to two weeks after drug exposure and may take several weeks to resolve. Treatment is generally supportive with corticosteroids administered for more severe cases. Celecoxib contains a sulfonamide moiety (A), but recent data shows that the cross-reactivity between antibiotic sulfonamides and non-antibiotics sulfonamides may not occur at all or at the very least this potential is extremely low. Specifically, the mechanisms of cross-reactivity causing anaphylaxis are very unlikely to occur when using a non-antibiotic sulfonamide. The true cross-reactivity rate is unclear. The rate of cross-reactivity of penicillins and first generation cephalosporins is approximately 1%-7%, not 50% (B). Third and fourth generation cephalosporins have a much lower cross reactivity than first generation, closer to 1%. Many patients with a penicillin allergy can tolerate second- and third-generation cephalosporins without issue. However, patients with life-threatening reactions to penicillin should not receive cephalosporins in the ED unless absolutely necessary. Patients with a history of penicillin anaphylaxis should not be given penicillin or cephalosporins, however, there are a few selected indications where desensitization (C) should be performed. An example is the pregnant patient with syphilis and a penicillin allergy. Careful desensitization should occur in the ICU with increasing doses of the medication.

Which of the following statements regarding allergic drug reactions is true? A) Celecoxib often causes a reaction in patients with a sulfonamide allergy B) Cross-reactivity between penicillins and first generation cephalosporins is 50% C) Patients with a history of anaphylaxis to penicillin can never be given penicillin D) The onset of serum sickness generally occurs within one to two weeks

A) High serum thyroid stimulating hormone and low free T4 Low serum TSH and either high (B) or normal free T4 (C) occurs with hyperthyroidism. Clinical symptoms of hyperthyroidism are more dramatic and include anxiety, heart palpitations, weight loss, and heat intolerance. Normal serum TSH and normal free T4 (D) are seen when a patient is euthyroid. Thyroid regulation occurs through the balance of hormones secreted by the hypothalamus, anterior pituitary and thyroid gland. Thyrotropin-releasing hormone (TRH) in the hypothalamus stimulates the anterior pituitary to produce thyroid-stimulating hormone (TSH). This in turn stimulates the thyroid to synthesize and secrete thyroid hormones, T3 and T4. Lab testing is critical in the diagnosis of hypothyroidism because clinical symptoms are non-specific. A suspicion of hypothyroidism is indication for testing of TSH. If elevated, T4 should be tested and if found to be low supports the diagnosis of hypothyroidism.

Which of the following supports the diagnosis of hypothyroidism? A) High serum thyroid stimulating hormone and low free T4 B) Low serum thyroid stimulating hormone and high free T4 C) Low serum thyroid stimulating hormone and normal free T4 D) Normal serum thyroid stimulating hormone and normal free T4

D) Fluorescent treponemal antibody absorption (FTA-ABS) The FTA-ABS and the MTA-TP are specific treponemal tests used for the confirmation of syphilis. Hint: The RPR is a non-specific test. False positives are common. Hint: The VDRL if positive must by confirmed with an additional testing because of a large number of false positives including bacterial and viral infections, pregnancy, chronic liver disease, connective tissue disorders. Hint: The Weil-Felix agglutination test is used for rickettsial infections not syphilis.

Which of the following tests is the most specific for the diagnosis of syphilis? A) Rapid plasma reagin (RPR) B) Weil-Felix agglutination test C) Venereal Disease Research Laboratory (VDRL) D) Fluorescent treponemal antibody absorption (FTA-ABS)

D) Verapamil Due to poor calcium reserves in the sarcoplasmic reticulum in infants, verapamil (calcium channel blocker) use in infants can cause profound hypotension and cardiovascular collapse. Therefore, it should be avoided in patients younger than 12-months-old.

Which of the following treatments is contraindicated in the treatment of a 5-month-old with supraventricular tachycardia? A) Adenosine B) Ice bag to face C) Propranolol D) Verapamil

CABG CABG is the treatment of choice in a diabetic with two or three vessel disease.

Which of the following treatments will most benefit the diabetic patient with two vessel coronary disease?

D) Intermittent longitudinal mucosal ulcers and fissures Ulcerations tend to be linear with transverse fissures in Crohn's disease. These skip (intermittent) lesions are common with Crohn's disease. Hint: Rectal pseudopolyps and diffuse ulceration and bleeding are associated with ulcerative colitis rather than Crohn's. Hint: Sheets of WBCs or "pseudomembranes" can be detected in patients with pseudomembranous colitis.

Which of the following typical findings would be revealed during a sigmoidoscopy on a patient with Crohn's disease of the intestine? A) Rectal pseudopolyps B) Diffuse ulceration and bleeding C) Sheets of WBCs with inflamed mucosa D) Intermittent longitudinal mucosal ulcers and fissures

A) Facial laceration from a dog bite Although dog bite wounds are high risk for infectious complications, those that are cosmetically deforming are often closed primarily, especially on the face. Dog bites are high risk for infection from organisms commonly found in the dog's mouth, which include S. aureus, P. multocida, and S. viridans. Although controversy exists over management of animal bite wounds, generally it is agreed that wounds that are cosmetically deforming (including those on the face) should be repaired primarily. All bite wounds must be thoroughly irrigated and cleansed. Wounds on the extremities and that are not as cosmetically concerning are generally left open or loosely approximated. Certain lacerations are best managed when left open or closed in a delayed fashion. These include lacerations that are heavily contaminated or have extensive associated tissue damage, human bites, animal bites that are not cosmetically significant, and contaminated lacerations on the bottom of the feet. A laceration on the plantar aspect of the foot sustained on an unknown object while walking in a stream (B) would be considered contaminated. Lacerations over the MCP joints (C) that occur during a fistfight are considered to be human bites and should not be closed primarily. Puncture wounds on the leg (D) from a dog bite are considered high risk for infection and are not cosmetically significant, therefore should not be closed primarily.

Which of the following wounds is a potential candidate for primary closure? A) Facial laceration from a dog bite B) Laceration on sole of the foot after stepping on an unknown object in a stream C) Laceration over the metacarpal-phalangeal joint sustained during a fistfight D) Puncture wounds on the leg as a result of a dog bite

*Borderline and histrionic personality disorders*. Borderline = unstable moods, behavior, and relationships. Histrionic = excessive attention-seeking emotions, usually beginning in early adulthood, including inappropriately seductive behavior and an excessive need for approval.

Which of the personality disorders are associated with an increased risk of suicide attempts?

Infection is often polymicrobial and can include E. Coli, aerobic streptococci, and Bacteroides.

Which organisms are commonly found in tubo-ovarian abscesses?

Left side.

Which side are varicoceles more common?

Cavus feet (Pes cavus). Cavus foot consists of an unusually high longitudinal arch of the foot

Which type of foot anomaly is plantar fasciitis common in?

Non-Small Cell Carcinoma

Which type of lung cancer is most common of the two broad categories?

Choriocarcinomas

Which type of testicular cancer has the worst prognosis

Infants ,2y (esp, <2mo)

Who is most often affected by acute bronchiolitis?

Isoniazid (INH) for children <4y with exposure to contacts with active disease

Who needs ppx treatment for TB and what do you give?

It is believed that the sigmoid colon stabilizes the left ovary so that it is less likely to torse.

Why is ovarian torsion more common on the right side?

C) Hepatitis B panel Uremia/chronic renal impairment (A), diabetes mellitus (B), hyperthyroidism (D) are associated predominantly with axonal neuropathy. Categorized as axonal or demyelinating based on neurophysiologic findings. Diffuse polyneuropathies lead to a symmetric sensory, motor, or mixed deficit, often most marked distally. They include the hereditary, metabolic, and toxic disorders; idiopathic inflammatory polyneuropathy (Guillain-Barré syndrome); and the peripheral neuropathies that may occur as a nonmetastatic complication of malignant diseases. Involvement of motor fibers leads to flaccid weakness that is most marked distally; dysfunction of sensory fibers causes impaired sensory perception. Tendon reflexes are depressed or absent. Paresthesias, pain, and muscle tenderness may also occur. Electrodiagnostic testing is initially used in the evaluation of polyneuropathy, with the goal of defining a predominant injury process, either axonal nerve damage or demyelinating nerve damage. Specific lab tests should be reserved until after this determination, as a certain disease tends to cause a certain nerve injury pattern: Laboratory workup includes a complete blood cell count, serum protein electrophoresis with reflex to immunofixation or immunotyping, determination of plasma urea and electrolytes, liver biochemical tests, thyroid function tests, vitamin B12 level, tests for rheumatoid factor and antinuclear antibody, HBsAg determination, a serologic test for syphilis, fasting blood glucose level and hemoglobin A1c, urinary heavy metal levels, cerebrospinal fluid examination, and chest radiography. Cutaneous nerve biopsy may help establish a precise diagnosis (eg, polyarteritis, amyloidosis). In about half of cases, no specific cause can be established; of these, slightly less than half are subsequently found to be familial.

You are evaluating a patient with polyneuropathy. His nerve conduction study reveals a predominantly demyelinating injury process. Which of the following laboratory serum tests would best delineate this patient's diagnosis? A) Creatinine B) Hemoglobin A1C C) Hepatitis B panel D) Thyroid function studies

A) Prostate gland Benign prostatic hyperplasia (BPH) is also known as benign enlargement of the prostate. It is incorrectly referred to by many as benign prostatic hypertrophy, as the process is based on increased number, and not increased size, of prostatic cells. It involves stromal and epithelial cell hyperplasia which results in adenofibromatous nodules. As the nodules enlarge, and prostate specific antigen levels rise, the urethra compresses and leads to urinary tract obstruction and infections, urinary hesitancy, frequency and retention. Detection and monitoring are accomplished with a digital rectal examination. Physical examination begins with positioning the patient in a fetal position, or bent forward over a table or desk. Continue with inspection of the perineum looking for mass, erythema, edema and rashes. Palpation follows with a generally lubricated digit inserted into the anus. Rotation of the examiner's digit in the distal anorectal canal allows for assessment of mass, nodules, induration or irregularities. Palpation of the posterior, usually superior (if patient is bent over a table), surface mainly evaluates the rectal wall. Anterior (or inferior, if patient is bent over a table) rectal wall palpation not only evaluates the rectum but also the prostate, which sits anterior to the anterior rectal wall. End the examination by placing some stool on a hemoccult card to look for blood.

You are examining an elderly man who complains of urinary frequency and hesitancy. During a digital rectal examination, palpation of the anterior rectal wall offers the best approach in evaluating which of the following structures? A) Prostate gland B) Testicle C) Ureter D) Urethral meatus

A) Change maternal position Variable decelerations occur from umbilical cord compression and oligohydramnios. They are treated by changing maternal positioning to relieve pressure on the umbilical cord. Additionally, amnioinfusion may be used to relieve umbilical cord compression in cases of oligohydramnios Hint: Delivery of the baby by c-section is not indicated in variable FHR decelerations and may be harmful to the baby.

You are following a patient in labor at term. You evaluate the fetal monitoring tracing and note the presence of variable, repetitive decelerations in the heart rates. The contractions have a sharp deceleration slope. What is the recommended treatment for these decelerations? A Change maternal position B Administer tocolytic therapy C Apply vibroacustic stimulation D Perform cesarean section

B) Decrease in concentration of Lactobacillus sp. The patient has vaginal discharge due to bacterial vaginosis. It represents a complex change in the vaginal flora brought about by the reduction in concentration of the dominant lactobacilli. These lactobacilli produce hydrogen peroxide that is important in preventing overgrowth of anaerobes that are normally present in the vaginal flora. The loss of lactobacilli results in the increase of vaginal pH and massive overgrowth of anaerobes. These anaerobes produce large amounts of proteolytic carboxylase enzymes that break down vaginal peptides into amines. Common anaerobes include Gardnerella vaginalis, Ureaplasma sp., and Mycoplasma sp. Clinical features include off-white, thin, and homogeneous vaginal discharge with "fishy" odor. Diagnosis is based on the presence of at least three of Amsel criteria: characteristic vaginal discharge, pH ˃ 4.5, positive whiff test, and clue cells on wet mount. Treatment is indicated for relief of symptoms using metronidazole or clindamycin administered either orally or intravaginally.

You are in the clinic with a medical student who saw a 17-year-old girl for vaginal discharge. The medical student informs you that the patient complains of yellow discharge that is accompanied by pruritus. The patient has been sexually active for the past six months with one partner. The patient also has an intrauterine device placed six months ago. On examination, there is white vaginal discharge with strong odor. The vaginal pH is 5 with clue cells on wet mount. You diagnose bacterial vaginosis. The medical student asks you what causes it. Which of the following statements would best describe the cause of bacterial vaginosis? A) Acquisition of Trichomonas vaginalis B) Decrease in concentration of Lactobacillus sp. C) Increase in concentration of Gardnerella vaginalis D) Overgrowth of Candida albicans

B) Uterine fibroids Patients with uterine fibroids often have menorrhagia and/ or metrorrhagia. On examination, the uterus will be larger, and irregularly-shaped. If a mass is present and it moves with the uterus, it is suggestive of a fibroid. Hint: It is important to consider an ovarian neoplasm in a patient with a palpable adnexal mass, however, most adnexal masses are asymptomatic and not associated with menstrual changes.

You are performing a routine gynecological examination on a 49 year-old female. She states that for the last six months her periods have been getting heavier and lasting for seven days duration. She also tells you that she has been experiencing urinary frequency and constipation. Her abdominal exam is unremarkable. On pelvic examination you feel a slightly enlarged uterus and a left adnexal mass that moves with the uterine fundus. Which of the following is the most likely diagnosis? A Adenomyosis B Uterine fibroids C Ovarian neoplasm D Diverticular disease in the colon

D) Polycystic ovary syndrome The girl has signs and symptoms of polycystic ovary syndrome (PCOS) that consists of ovulatory dysfunction or menstrual irregularity and hyperandrogenism such as hirsutism and acne. The evaluation for PCOS begins with a focused clinical evaluation for the presence of hirsutism and menstrual irregularity. Then, it is followed by laboratory testing for androgen excess by measuring total or free testosterone. Demonstration of hyperandrogenism in a patient with an abnormal degree of menstrual irregularity fulfills the diagnostic criteria for PCOS. Patients may further be evaluated with ovarian ultrasonography to rule out other causes of hyperandrogenism. PCOS would demonstrate polycystic ovaries either excessive size or follicle number (or both), in the absence of a dominant-size follicle (> 1.0 cc) or a corpus luteum. Management of PCOS involves treatment of individual components of the syndrome (hirsutism, oligomenorrhea, infertility, and obesity), depending upon the patient's goals.

You are seeing a 16-year-old girl in clinic because of menstrual irregularity. She had menarche at 12 years of age and since then has had irregular menses that occur every 80 to 90 days. Her periods last for five to seven days with moderate amount of bleeding. She denies sexual activity. She does not report pain with menses and does not take any medication. She admits to shaving excess hair on her upper lip and chest. On examination, you note BMI of 30, severe acne on face, and Tanner 5 breasts and pubic hair. Her vital signs are normal. Which of the following is the most likely diagnosis? A) Abnormal uterine bleeding B) Anorexia nervosa C) Cushing syndrome D) Polycystic ovary syndrome

A) Cyclobenzaprine Pregabalin (D) is cleared for use in fibromyalgia, not myofascial pain syndrome. Oxycontin (C) and other opioid medications are not recommended for myofascial pain syndrome. It has been described as "hyperirritable spots, usually within a taut band of skeletal muscle or in the muscle's fascia that is painful on compression and can give rise to characteristic referred pain, tenderness, and autonomic phenomena" - Myofascial pain can essentially be defined as the presence of trigger points, focal distinct painful spots located in *palpable taut bands of muscles*. It is a *common musculoskeletal cause of pain*, and can be associated with local and distal sensory abnormalities as well as autonomic, sleep and mood disorders. Treatment begins with aggressive physical therapy, which includes specific treatments of myofascial release, ultrasound, spray-and-stretch techniques, posture rebalancing and specific muscle stretch-strengthen exercises. Further treatment options include cognitive-behavior therapy and trigger point injection therapy. Medications also play a role. Muscle relaxants, such as cyclobenzaprine, provide pain relief. NSAIDs, only when used in conjunction with other active treatment, are also beneficial for pain relief.

You diagnose a patient with myofascial pain syndrome. In an effort to decrease her overall pain levels, which of the following medications is most appropriate to prescribe? A) Cyclobenzaprine (Flexeril) B) Haloperidol (Haldol) C) Oxycodone (OxyContin) D) Pregabalin (Lyrica)

A) Extraoccular muscle lengthening Strabismus is a condition of globe misalignment that results in the inability of both eyes to fixate on the same point in space, diplopia, poor depth perception and decreased binocular vision. Goals of treatment include obtaining near normal acuity, obtaining or improving fusion, eliminating any associated sensorimotor adaptations (as in adaptive compensatory head-positioning) and obtaining a favorable functional appearance of normal eye alignment. Interpersonal eye contact and positive self-image rely heavily on the normal position of the eyes, as such, treating strabismus is important for acuity and psychological matters. Treatment options include refractive correction, use of prisms, vision therapy, chemodenervation, pharmacologics and extraoccular muscle surgery. Strabismus surgery is based on lengthening or shortening the extraoccular muscles, repositioning them on the globe so as to achieve normal alignment.

You diagnose strabismus in a 6-month-old girl. During your discussion with the parents, you educate them on the typical surgical procedure. Which of the following would most likely be included in your discussion? A) Extraoccular muscle lengthening B) Laser correction of corneal defects C) Laser-incision and drainage through the iris D) Ultrasound vibration of the lens

Estrogen plus progestin Androstenedione (A & B) is a precursor hormone in the biosynthesis of estrogen. Its transformation requires an ovary to be receptive to luteinizing hormone, a process which does not occur in menopause. Estrogen alone (C) is the treatment in women who have had a hysterectomy. In women who have not had a hysterectomy, estrogen plus progestin is recommended to prevent endometrial hyperplasia.

You have been monitoring a 52-year-old perimenopausal woman's hot flashes. She has not had a hysterectomy. Her symptoms have been so mild that she does not require medication. However, for the past two months, her hot flashes have increased in frequency, duration and intensity. She is now asking for a medication. Which of the following is the most appropriate for medical management of her moderate to severe symptoms? Androstenedione alone Androstenedione plus estrogen Estrogen alone Estrogen plus progestin

Mean corpuscular volume (MCV)

a measure of RBC size. It is expected to decrease in both thalassemia and iron deficiency anemia.

Mean corpuscular hemoglobin concentration (MCHC)

a measure of the concentration of hemoglobin within the RBC. It is calculated by dividing the hemoglobin concentration by the hematocrit. It is expected to decrease in both iron deficiency and thalassemia anemia.

*Red blood cell distribution width (RDW)*

a measure of the deviation in volume of the RBCs. It is calculated by dividing the standard deviation of the MCV by the mean MCV and multiplying by 100.

Mean corpuscular hemoglobin (MCH)

a measure of the hemoglobin content within a RBC and is calculated by dividing the hemoglobin concentration by the red blood cell count. It is usually low in both iron deficiency and thalassemia anemia.

Coxiella burnetti (Q fever)

animal exposure (ex. cattle)

Central retinal artery occlusion (CRAO)

edematous, pale retina with a cherry-red spot.

1) Simple Partial = consciousness fully maintained 2) Complex Partial = consciousness impaired

Name the two types of partial (focal) seizures

High-resolution ultrasound.

Which imaging modality is preferred to localize a parathyroid adenoma?

A) Kyphosis Kyphosis is a posterior convex angulation of the thoracic spine as evaluated on a side view. Excessive and exaggerated angulation results in cosmetic problems, back pain, and cardio-respiratory problems. Kyphosis may be post-traumatic or non-traumatic type. Scheuermann's kyphosis, postural, congenital, and metabolic bone disease are a few of the non-traumatic causes of kyphosis.

13-year-old girl presents for her school physical. On examination, you notice the posterior curvature of her thoracic spine to be very prominent and bulging backward. What type of deformity of the spine does she have? A) Kyphosis B) Scoliokyphosis C) Scoliosis D) Lordosis E) Gibbus

Ethosuximide ***only works for absence

1st line management of Absence Seizures

IM B12

1st line management of B12 Deficiency anemia

MRSA, Pseudomonas, Candida

3 Orgnisms to consider in endocarditis in IV drug users

Francisella tularensis

31 yo woman who skins rabbits presents with high fever, SOB, hemoptysis

Bypass surgery indicated in the presence of rest pain and provides relief of symptoms in 80 to 90% of patients. Hint: While an exercise program is appropriate with claudication, rest pain is a surgical indication.

A 54 year-old female who has diabetes presents with rubor, absence of hair, and brittle nails of her left foot. She complains of leg pain that awakens her at night. Examination reveals a femoral bruit with diminished popliteal and pedal pulses on the left side. The most appropriate therapy would be

B Diabetes mellitus Hint: Recent URI, heart murmur and swelling of the ankle would not put her at risk for an infection post surgery.

A 60 year-old female presents for pre-op evaluation for surgical treatment of a tri-malleolar fracture of the left ankle. Which of the following puts her at an increased risk for infection post-surgery? A Recent URI B Diabetes mellitus C Heart murmur D Swelling of the ankle

colorectal carcinoma. UC = weight loss, blood and mucus in stools, change in bowel habits, as well... but it *would also have tenesmus/urgency*

A 60-year-old male presents with a recent history of change of bowel habits, weight loss, and blood and mucus in his stools. The most likely diagnosis is

Cabergoline, whose dopamine agonism antagonizes the release of prolactin.

Which medication can be considered to halt lactation in women with poorly controlled infection, severe symptoms, instability or wide spread nipple excoriation?

C) *Progesterone* Ovulation can best be confirmed by measuring serum progesterone levels in the mid-luteal phase Hint: LH, FSH, and prolactin are used to confirm ovulation in patients with *irregular menstrual cycles*. Hint: TSH is used only if signs of thyroid disease are present.

A couple presents having not been able to conceive over the past 12 months. Evaluation of the male has been normal. The female has had regular menses. Ovulation can be confirmed with mid-luteal phase measurement of which of the following? A) Thyroid stimulating hormone B) Luteinizing hormone C) Progesterone D) Prolactin

Axillary = sensory from the shoulder joint and skin covering the inferior deltoid

Which nerve is most often injured with shoulder dislocations?

Thrombotic Thrombocytopenic Purpura

ADAMTS13 should make you think of

Staph aureus

gradual onset, productive cough, fever/dyspnea; after a viral illness; gram-positive cocci in clusters; CXR with multi-lobar infiltrate/abscess/pleural effusion; IVDA

Inhibition of beta-1 receptors decreases aqueous fluid production

How do Beta-Blockers help treat Glaucoma?

Prostaglandin F-2 analog increases aqueous fluid flow -prost

How do Prostaglandin Analogs treat Glaucoma?

PO Vancomycin

C-diff: nonpregnant: severe disease 1st line treatment

PO Vancomycin

C-diff: pregnant: 1st line treatment

PT

How do we check Warfarin effect?

Sync Cardioversion

Treatmet of Unstable VT with a pulse

5-7 days must bridge with heparin

Warfarin (Coumadin) Full therapeutic effect

Sputum fungal and mycobacterial cultures

What should you check in patient with cavitary opacities on CXR?

Fever may persist up to 1 week after initiation of appropriate antibiotic therapy

What should you tell a patient who still has a fever 5 days after initiation of appropriate antibiotic therapy?

A abdominal mass Hint: Syncope is not common in abdominal aortic aneurysm, unless it ruptures.

Which of the following conditions is most suggestive of an asymptomatic abdominal aortic aneurysm? A abdominal mass B hypertension C chest pain D syncope

A Permanent pacemaker

Which of the following is first-line treatment for a symptomatic bradyarrhythmia due to sick sinus syndrome? A Permanent pacemaker B Radiofrequency ablation C Antiarrhythmic therapy D Anticoagulation therapy

A) alpha-adrenergic blocker Alpha-adrenergic blockers are used preoperatively to control hypertension in a patient with pheochromocytoma that occurs from unopposed alpha stimulation when the tumor is manipulated. Hint: Beta-adrenergic blockers are used to control tachycardia and arrhythmias, if present, after the hypertension has been controlled.

While awaiting operative removal of pheochromocytoma, which of the following classes of medications are used for control of hypertension? A alpha-adrenergic blocker B beta-adrenergic blocker C ACE inhibitor D diuretic

young and middle-aged males

Who is mostly affected by cluster headaches?

Neurotoxicity

Why don't we like lindane for pediculosis capitis?

Dicloxacillin Aztreonam (A) and Penicillin V (D) are antibiotics that do not properly cover staphylococcal infections. Although metronidazole (C) is a common treatment of many gynecologic conditions, its cidal properties are ineffective against Staphylococcus aureus. However, it should be administered if mastitis is associated with subareolar abscess and nipple retraction.

You diagnose lactation mastitis in a postpartum 17-year-old woman. She is currently breast feeding her healthy newborn. She has no allergies. In addition to local ice packs and ibuprofen, which of the following is the most appropriate treatment? Aztreonam Dicloxacillin Metronidazole Penicillin V

Prematurity

a major risk factor for severe disease in with RSV

lead poinsonning anemia

abdominal pain with constipation, neruologic symptoms (ataxia, fatigue, etc), anemia symtpoms, metabolic acidosis

Klebsiella pneumonia

alcoholic who presents with fever, chills, and productive cough. CXR shows lobar pneumonia

Anaerobic

alcoholics, high risk aspiration; CXR with abscess formation, pleural effusions, air-fluid level

Subclinical hyperthyroidism

an abnormally low serum thyroid-stimulating hormone level (TSH) and normal levels of free thyroxine (T4) and triiodothyronine (T3).

lead poinsonning anemia

basophilic stippling and ringed sideroblasts in bone marrow

Granuloma inguinale, also called donovanosis The disease is rare in the United States but is endemic in India, southern Africa, and central Australia.

begins as subcutaneous nodules on the penis or labial-vulvar area. The nodules then progress to the more classic painless, ulcerative lesions. These lesions are highly vascular, which explains both their appearance (*beefy red*) and their tendency to bleed easily on contact. Lymphadenopathy is not usually present, but subcutaneous granulomas may occur and mimic lymphadenopathy.

CK (A) is a protein that is found in large quantities in cardiac and skeletal muscle and is thus nonspecific. Myoglobin (B) is found in all muscle tissue and rises earlier in myocardial infarction than troponin. However, a single normal level does not rule out a myocardial infarction. While CK levels return to normal within 48-72 hours, troponin levels take up to 5-14 days (D) to return to baseline.

cardiac markers in regards to myocardial infarction?

*Kawasaki Disease* Kawasaki disease (KD, previously called mucocutaneous lymph node syndrome) is one of the most common vasculitides of childhood. The cause(s) of KD remain(s) unknown despite clinical and epidemiologic data suggesting a relationship to infections. Treatment is IVIG + aspirin, #1 cause of pediatric acquired heart disease, risk for coronary artery aneurysm, Mnemonic: *CRASH and burn*: Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet edema, and Fever

child < 4 years old, With a history of high fever for 5 days, Complaining of conjunctivitis, rash, adenopathy, strawberry tongue, hand/feet edema, fever

Allogenic bone marrow transplant

definitive management of alpha-thalassemia major

Plummer-Vinson Syndrome Patients with Plummer-Vinson syndrome are typically white women in their fourth to seventh decade. raises the risk of oral squamous cell cancer and esophageal cancer.

dysphagia + esophageal webs + atrophic glossitis + iron deficiency

Roseola Most infections occur before the age of three. Symptoms vary from absent to the classic presentation of a fever of rapid onset followed by a rash. The fever generally lasts for three to five days. The rash is generally pink and lasts for less than three days. Complications may include febrile seizures, with serious complications being rare.

fever of rapid onset followed by a rash in children usually under 3 yrs of age.

Acute Otitis Media (AOM)

fever, ear pain, conductive hearing loss, stuffiness, ear tugging in infants

NSAIDs If there is a specific etiology of the pericarditis, then therapy should be directed at that etiology. Otherwise, nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy for acute pericarditis Ibuprofen has the best side effect profile, but other NSAIDs should be equally effective. Ketorolac (C) is an NSAID with an excellent analgesic profile, but it has poor anti-inflammatory effects. Therefore, it is not recommended for the treatment of acute pericarditis.

first line treatment for acute pericarditis?

Yersinia pestis (plague) buboes

fleas from rodents; hematogenous spread, biologic terrorism; person-to-person transmission; doxycycline

Chlamydia psittaci (psittacosis)

infected birds

Chicken Pox also known as varicella, is a highly contagious disease caused by the initial infection with varicella zoster virus (VZV). The disease results in a characteristic skin rash that forms small, itchy blisters, which eventually scab over. It usually starts on the chest, back, and face then spreads to the rest of the body. Other symptoms may include fever, tiredness, and headaches. Symptoms usually last five to seven days.

small, itchy blisters, which eventually scab over, usually starts on the chest, back, and face then spreads to the rest of the body.

H flu

63yo man with h/o COPD, DM and debilitation presents with SOB, fever, and CXR showing patchy infiltrates

B) Pituitary adenoma

A 54-year-old woman presents with nervousness, a tremor, and irritability. She indicates that she has lost some weight over the last few weeks even though her appetite has increased. She also says that she is feeling feverish. You suspect that she may have a thyroid condition and order the appropriate labs. The lab results are as follows: What is the most likely diagnosis? A) Thyroid storm B) Pituitary adenoma C) Graves' Disease D) Hashimoto's thyroiditis E) Iodine deficiency

C) Volar forearm The volar forearm splint is best for temporary immobilization of forearm, wrist and hand fractures and is the *splint of choice for Colles' fracture*. Hint: A volar splint with *thumb spica* is used to immobilize the first metacarpophalangeal joint and is useful for *scaphoid fractures*

A 60 year-old female injured her right wrist when she slipped and fell onto her outstretched hand. Radiographs show a fracture through the metaphysis of the distal radius with dorsal displacement and angulation. Which of the following splints is the best method of temporary immobilization? A Dorsal forearm B Ulnar gutter C Volar forearm D Volar with thumb spica

21

At what age should we initiate cervical cancer screening (pap with cytology)?

Labetalol Labetalol is drug of choice in situations characterized by markedly elevated intracranial pressure. 20 mg intravenously every 10 minutes according to response, maximum 300 mg total dose; or 0.5 to 2 mg/minute intravenous infusion

Hypertensive emergencies: increased intracranial pressure or renal disease - 1st line treatment

Iron deficiency anemia workup and get a CT scan

In children with recurrent otitis media what should you check?

Osteoporosis A hypoestrogenic patient can develop severe osteoporosis, leading to increased mortality due to femoral neck fractures. Hormone replacement therapy, with estrogen-progesterone combinations, helps to maintain normal bone density. Overall, the prognosis for patients with amenorrhea is good, provided that neoplastic sources have been excluded and hormone replacement therapy is considered.

You are treating a patient for primary amenorrhea. Her diagnostic evaluation has determined that the etiology is primary ovarian failure. Which of the following disorders is this patient at risk for? Cluster headaches Gastrointestinal bleeding Menorrhagia Osteoporosis

A CT scan with IV contrast (An ultrasound (D) in experienced hands can be very useful in identifying an RPA, but is not yet accepted as first line overall.)

______________ is currently the imaging modality of choice for a retropharyngeal abscess (RPA),

Acute chest syndrome

__________________ is the leading cause of death in SCD (Sickle Cell Disease)

60 - 100

Accelerated junctional rhythm rate

Ceftazidime (Ceftaz®)

Third-generation cephalosporin; strong activity against Pseudomonas

Adenosine

1st line medication for PSVT if stable and narrow complex

Legionella pneumophila

Pneumonia: Intracelular gram negative rods

Football, followed by wrestling.

Which school team sport has the highest injury rate in the United States?

*blood culture* Typhoid fever is best diagnosed by blood culture, which is positive in the first week of illness in 80% of patients who have not taken antimicrobials.

Best way to diagnose Typhoid fever

Chorioamnionitis, an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection.

What infectious condition should all PROM patients be evaluated for?

Lyme disease.

What infectious etiology is associated with complete heart block?

Alpha Thalassemia Minor = 2/4 abnormal alleles

What is "alpha trait" (thalassemia)?

Fluconazole (Diflucan®)

Antifungal agent (IV or PO) not associated with renal toxicity

Multiple Sclerosis

Bilateral internuclear ophthalmoplegia (eyes can't look at nose) is pathognomonic

B12 deficiency Macrocytic Anemia (almost exclusively)

Anemia: MCV >115

In 20-40% of all cases.

How often does slipped capital femoral epiphysis (SCFE) present bilaterally?

Albuterol, Xopenex, Terbutaline

Name 3 SABA's for Asthma treatment

Bundle of Kent

Name of accessory pathway in WPW

Anaerobes (aspiration)

Pneumonia: MC in R lower lobe

Triple therapy with *c*larithromycin, *a*moxicillin (or metronidazole) and a *P*PI for 10-14 days. *CAP* it

What medications are recommended for treatment of H. pylori associated peptic ulcer disease?

Treated like migraines 1st line = NSAIDs, ASA, Acetaminphen

Treatment of tension headaches

Placenta accreta, increta and percreta; three different forms of abnormal placenta-uterus separation.

What are some common causes of retained placenta?

74

At what age should breast cancer screening for women without risk factors stop?

40.

At what age should patients be referred to a gynecologist to rule out Bartholin gland cancer?

leaning forward or fetal position

What position relieves the pain of pancreatitis?

B12 deficiency Macrocytic Anemia

Anemia: neurologic symptoms, paresthesias, gait abnormalities, memory loss, dementia

DEXA Scan (dual-energy x-ray absorptiometry) Bone density T score ≤ -2.5 The original National Osteoporosis Foundation guidelines recommend bone mass measurements in postmenopausal women, assuming they have one or more risk factors for osteoporosis in addition to age, sex, and estrogen deficiency. The guidelines further recommend that bone mass measurement be considered in all women by age 65, a position ratified by the U.S. Preventive Health Services Task Force.

Best test for Osteoporosis

Cooley's Anemia

Beta Thalassemia aka

*>/= 12% increase in FEV1* The currently recommended criteria in adults for a significant response to a bronchodilator are that FEV1 and/or FVC should increase by 12 percent or more and by at least 200 mL, although there is not complete consensus on these criteria

Bronchidilator challenge test criteria for diagnosing asthma

Chvostek Sign = hypocalcemia

Facial muscle spasm when facial nerve is tapped

*imipenem/cilastatin (Primaxin)* 500-1000 mg intravenously every 6 hours more Secondary Options: (CS) ceftriaxone : 1-2 g intravenously every 12 hours (PCN) ampicillin : 500 mg intravenously every 6 hours (FQ) ciprofloxacin : 400 mg intravenously every 12 hours The use of antibiotics in noninfected pancreatitis has fluctuated over the last decade, but is not currently routine practice as there is no clear evidence of benefit. A meta-analysis demonstrated no difference in the mortality rate between patients receiving antibiotics and those receiving a placebo for the treatment of severe acute pancreatitis.

If you HAVE to use antibiotics for acute pancreatitis, what is your first line option?

prerenal azotemia Patients who have prerenal azotemia with otherwise normal kidneys will have severe sodium retention in order to help to save fluid. The amount of sodium in the urine is therefore very low.

Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (less than 1%). Which of the following is the most likely diagnosis?

Gallstones (40%)

MC cause of acute pancreatitis

Iron/Folic acid supplementation Possibly blood transfusions if sever

Management for severe anemia related to G6PD deficiency

Leukotriene Modifiers/Receptor Antagonists (LTRAs) useful in asthmatics with allergic rhinitis/aspirin induced asthma. ppx only.

Montelukast (Singulair), Zafirlukast (Accolate), Zileuton (Zyflo)

Anti-cyclic citrullinated peptide antibody

Most specific lab for RA

Chlamydia pneumoniae Mycoplasma pneumoniae Legionella pneumophilia

Name 3 common causes of ATYPICAL pneumonia

Osteoarthritis

Narrowed joint space, sclerosis, and osteophyte formation

*Legionella pneumophila* Gram negative aerobic bacilli that hangs out around warm stagnant water. More severe disease than other Atypical Pneumonia. Antibiotic course for 21 days = start with Azithromycin (macrolide) or a respiratory tract quinolone.

Pneumonia: GI symptoms, anorexia, n/v/d, increased LFTs and hyponatremia

Staphylococcus aureus

Pneumonia: Hematogenous spread in IVDU, increased in immunocompromised and elderly,

Mycoplasma pneumoniae

Pneumonia: Increased in school-aged, college students, military recruits

Staphylococcus aureus

Pneumonia: Often seen after viral illness, ex: Flu

100 cells/mcl = Fluconazole first, Ampho B second

Primary prophylaxis of Cryptococcus is recommended at what CD4 count?

150 cells /mcl = Itraconazole first, Ampho B second

Primary prophylaxis of Histoplasmosis in HIV is recommended at what CD4 cell count?

50 cells/mcl = Azithromycin or Clarithromcin first, Rifabutin second

Primary prophylaxis of MAC is recommended at what CD4 count?

100 cells/mcl = TMP/SMX first, Dapsone + Pyrimethamine + Folinic acid second

Primary prophylaxis of Toxoplasmosis is recommended at what CD4 count?

*Post Infectious Acute Glomerulonephritis (AGN)* Labs: ↑ antistreptolysin (ASO) titers and low serum compliment (C3) Dx: biopsy revealing hypercellularity, ↑monocytes/lymphocytes, immune humps of IgG, IgM, and C3 Tx: supportive

Pt will be a 2-14 y boy with facial edema up to 3 weeks after strep with scanty cola-colored/dark urine

1) only lower BP if ≥185/110 for thrombolytics 2) only lower BP if ≥220/120 if no thrombolytics or if MAP >130

Rules for lowering BP in stroke

Alpha Thalassemia

SE Asian with microcytic anemia and no response to iron treatment

Jaw osteonecrosis, pill esophagitis, pathological femur fx (esp IV)

SE of bisphosphonate (-dronates) use for OP

Carbamazepine

Seizure med associated with hyponatremia (SIADH) and blood dyscrasias (rare)

Pulse ox <96% = admit to hospital

Single best predictor of acute bronchiolitis disease in children

*Dopamine Blockers* Ex: Metoclopramide, given with diphenhydramine to prevent EPS, dystonic reactions, and parkinsonism symptoms d/t decreased dopamine

Symptomatic (abortive) management of migraine if not triptans or ergotamines.

*Chemotherapy* SCLC usually presents with disseminated disease, and treatment strategies have focused on systemic therapy. Although SCLC is highly responsive to both chemotherapy and radiotherapy (RT), it commonly relapses within months despite treatment.

Treatment of choice for Small Cell lung cancer

Corticosteroids + Cyclophosphamide Cyclophosphamide is an alkylating agent that prevents cell division by cross-linking DNA strands and decreasing DNA synthesis. The safety and efficacy for the treatment of nephrotic syndrome in adults or in other renal diseases has not been established.

Tx of Rapidly Progressive Glomerulonephritis (RPGN)

>250

Typical blood glucose level in DKA

>600

Typical blood glucose level in HHS

*Acute angle closure glaucoma*

Unilateral ocularl pain

Horseshoe kidney, duplicate collecting system, hypospadia and cryptorchidism.

What are congenital abnormalities commonly associated with Wilms tumor?

Gastrointestinal side effects such a diarrhea and abdominal cramps. Less commonly, metformin causes lactic acidosis.

What are potential common side effects of metformin?

dextrose in saline

When the serum glucose reaches 200 mg/dL (11.1 mmol/L) in DKA or 250 to 300 mg/dL (13.9 to 16.7 mmol/L) in HHS, the IV saline solution is switched to.....

Ovarian cancer.

Which type of malignancy is often associated with dermatomysoitis in women?

Orthodromic (95%)

impulse goes down the normal AV node pathway first and returns via the accessory pathway in circles perpetuating the rhythm = NARROW COMPLEX TACHYCARDIA

Bacillus anthracis (anthrax)

inhaled spores; biologic terrorism; CXR with wide mediastinum; eschar or GI or respiratory; gram positive rod; not person-to-person transmission; doxycycline

Hamman's sign = Pneumopericardium = a rare disorder that results in air around or within the pericardial space

loud crunching sound—best heard with the patient in a left lateral recumbent position

Hodgkin lymphoma

mainly presents as asymptomatic lymphadenopathy located above, not below, the diaphragm, usually in the chest or neck, with constitutional "B" symptoms (unexplained weight loss, unexplained fever, night sweats) and intermittent high fever.

Rubella (German Measles) Symptoms often appear two to three weeks after exposure, and also include mild fever and headache. The rash is sometimes itchy and is not as bright as that of measles. Swollen lymph nodes are common and may last a few weeks. A fever, sore throat, and fatigue may also occur. In adults joint pain is common.

mild fever and headache.

transformation zone = squamocolumnar junction

What part of the cervix is highest risk for malignancy

Mucosal human papilloma virus (HPV)

most common sexually transmitted infection (STIs) seen by the dermatologist.

Lorazepam (Ativan) Intravenous lorazepam is the most commonly used initial therapy.

1st line management of status epilepticus

A) Luteinizing hormone (LH) Luteinizing hormone is responsible for ovulation and, therefore, peaks at that time Hint: The majority of progesterone is secreted by the corpus luteum and, therefore, peaks after ovulation has occurred. *A mid-luteal phase serum progesterone above 3 ng/mL establishes ovulation.* Hint: Prolactin is an anterior pituitary hormone, and although important in reproduction and pregnancy, it is not present in high levels at the time of ovulation. Hint: Prostaglandin is likely associated with the production of vasospasm, vascular necrosis, and menstrual flow, not ovulation

*At the time of ovulation* in a normal menstrual cycle, there is a peak in the serum concentration of which of the following? A) Luteinizing hormone B) Prostaglandin C) Progesterone D) Prolactin

C) Procainamide

A 65-year-old man is brought to the ED complaining of nausea for the last two hours. On arrival to the emergency department, EKG shows a wide complex tachycardia. His blood pressure is 110/70 mm Hg. He denies any headache, chest pain, or difficulty breathing. Which of the following is the most appropriate next step in management? A) Defibrillation B) Magnesium sulfate C) Procainamide D) Synchronized cardioversion

Gabapentin

If estrogen is contraindicated in a postmenopausal woman, which alternative medication can be used to treat significant hot flashes, especially if there is concurrent sleep disturbance?

*TZD's* (thiazolidinediones) = antihyperglycemics MOA: *increases insulin sensitivity* in adipose tissue, skeletal muscle, and liver NOTE: may cause edema, weight gain, new heart failure, or exacerbate sexisting heart failure, especially in combo with insulin AE common: edema, weight gain, URI, headache, myalgia AE serious: hepatotoxicity, heart failure exacerbation, resumption of ovulation, macular edema, fracture, bladder tumor ***according to lecture, these had bad press but they are actually fine.***

-glitazone (diabetes)

orchiectomy → radiation

Management of low-grade seminoma

B) Permethrin topical The patient has Scabies. Red, itchy, prupritic papules or nodules on the scrotum, glans, or penile shaft, body fold is PATHOGNOMONIC for scabies.

14 year old boy presents with red, itchy, papules and nodules on his scrotum. What is the treatment? A) Lindane B) Permethrin topical C) Griseoflilvin D) topical Clindamycin

PJP (Formerly PCP)

19 yo patient with AIDS and cell count <200 cells/mm3 presents with high fever, nonproductive cough, and dyspnea

*Azithromycin 1 gram orally for 1 dose* Advantages of azithromycin — Azithromycin has excellent intracellular and tissue penetration. Due to its half-life of five to seven days, azithromycin can be administered as single-dose therapy (1 gram orally) under direct observation. AND It can be used in pregnant women. In general, C. trachomatis is highly susceptible to tetracyclines and macrolides. Within these two classes, first-line agents include doxycycline and azithromycin, respectively. The CDC recommends either agent as first-line therapy for the treatment of chlamydial infection. We prefer the use of azithromycin (1 gram single-dose therapy) with observed therapy when possible. If it is not available, then we use doxycycline (100 mg twice daily) for seven days with patient counseling on the need for adherence for optimal outcome. Re-test in 3 weeks to ensure clearance of the organism.

1st line treatment for Chlamydia

Sotalol (Beta Blockers) Of course beta blockers may have already been initiated to slow the ventricular rate in AF.

Atrial Fib: modestly effective in maintaining sinus rhythm and can be tried first in selected patients, such as those without structural heart disease who are concerned about proarrhythmia

C) Ultrasound In a 25 year-old an ultrasound is the best choice because of the density of the breast tissue in young women. Hint: Mammographies are not recommended in women prior to the age of 35 without family history of breast cancer or BRCA positive. Hint: MRI's of the breast are done in patients with prior breast cancer or who have BRCA 1 or 2 positivity. Hint: Excisional biopsy is not indicated without differentiation of lesion by ultrasound.

25 year-old female presents for a routine gynecological examination. You palpate a 2 cm breast mass in her right breast. Her menstrual period was last week. She has no family history of breast cancer. What is the modality of choice to further evaluate her breast mass? A Magnetic resonance imaging (MRI) B Excisional biopsy C Ultrasound D Mammography

D) Salmonella spp. This patient has osteomyelitis of the distal femur. Patients with sickle cell have an increased risk of osteomyelitis overall, especially from Salmonella spp. Additionally, Salmonella spp. are the most common pathogen identified in sickle cell patients with osteomyelitis.

5-year-old boy with sickle cell disease presents with a limp, which his mother noticed 2 days ago. On exam, the patient is well appearing. Vital signs are significant for fever with temperature of 38.1°C. Heart rate and blood pressure are normal. The patient demonstrates an antalgic gait, and there is warmth and tenderness to palpation of the soft tissues in the distal thigh. Lab tests show a normal WBC count and elevated CRP and ESR. Plain radiographs of the femur show soft tissue swelling in the distal thigh as well as a periosteal reaction in the distal femur. Knee radiographs are normal. What is the most likely infecting organism? A) Haemophilus spp. B) Klebsiella spp C) Pseudomonas spp. D) Salmonella spp.

Percutaneous coronary intervention (PCI) Immediate coronary angiography and primary percutaneous coronary intervention have been shown to be superior to thrombolysis.

52 year-old male with history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient?

C) cefotaxime (3rd gen cephalosporin) Cefotaxime provides coverage for osteomyelitis caused by staphylococcus or salmonella. Hint: Norfloxacin is contraindicated in children because Fluoroquinolones may cause growth plate arrest, tendon rupture and damage to articular cartilage. (CI in < 18y and pregnant women) Codeine might relieve pain, but will not treat the cause of osteomyelitis. Aspirin is not indicated for the treatment of osteomyelitis.

6-year-old child with sickle cell anemia presents with fever and pain over the right tibia. There is tenderness along the anterior tibia, but no pain with motion of the knee or ankle. Which of the following is the most appropriate initial treatment? A aspirin B codeine C cefotaxime D norfloxacin

Mesenteric infarction *Acute onset of severe diffuse abdominal pain in a person with atrial fibrillation* warrants the suspicion of mesenteric infarction. Vomiting and constipation may be seen, along with occult blood in the stool. Bowel sounds may be normal. Hint: Abdominal and chest x-rays would reveal free air under the diaphragm in a ruptured duodenal ulcer and a small bowel obstruction would reveal air-fluid levels with distended bowel loops.

70 year old man complains of abdominal pain of four hours duration. He states that he has *vomited* twice since the onset of pain. He also complains of three days of *constipation*. He is *afebrile* and the physical examination is noteworthy for a distended, diffusely tender abdomen with normoactive bowel sounds. His rectal exam reveals hemoccult positive brown stool. Medications include omeprazole (Prilosec) for GERD, digoxin and warfarin (Coumadin) for *atrial fibrillation*, OTC multivitamins and stool softeners. The abdominal and chest x-rays show no abnormalities. Which of the following is the most likely diagnosis?

*Varicella, or chickenpox* Inclusion bodies = nuclear or cytoplasmic aggregates of stable substances, usually proteins. They typically represent sites of viral multiplication and usually consist of viral capsid proteins (the protein shell of a virus).

A Tzanck smear of the vesicle contents may demonstrate giant cells with inclusion bodies

D) Basal Cell Carcinoma Basal cell carcinoma usually begins as a small indented nodule localized around hair follicles, typically in sun exposed regions of the skin. It typically begins to form an ulcerated center as it enlarges. This type of tumor rarely metastasizes but is locally invasive. It can be quite disfiguring. Excision is necessary to prevent its spread.

A patient comes to see you for a growth on his forearm. He has had it for 7 years and is concerned that it may be enlarging. You observe a well circumscribed, pink, slightly pigmented, raised nodule about 1 centimeter in diameter. The center appears slightly ulcerated. What is the most likely diagnosis? A) Melanoma B) Molluscum Contagiosum C) Squamous Cell Carcinoma D) Basal Cell Carcinoma E) Lipoma

ANA (antinuclear antibody)

A positive ______________ suggests a mixed-connective tissue disease, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, polymyositis or Sjogren's syndrome, all of which typically display skin and/or digit abnormalities.

AV Nodal Reentry Tachycardia 2 pathways, BOTH WITHIN the AV node (Slow and fast)

AVNRT

TMP-SMX (Bactrim)

Add this drug if PCP suspected in HAP

C) Systolic blood pressure Witnessed out-of-hospital cardiac arrest patients can be stratified by using the 3-criteria Cardiac Arrest Score developed by Thompson and McCullough. The criteria are: (1) Systolic blood pressure in the emergency department; (2) time from loss of consciousness to return of spontaneous circulation; (3) neurologic responsiveness.

After return of spontaneous circulation from a ventricular fibrillation arrest, mortality can be determined by calculating a Cardiac Arrest Score, which takes into account which of the following factors? A) Left ventricular ejection fraction B) Pre-hospital pharmacologic treatment C) Systolic blood pressure D) Time to presentation to the emergency department

1) Assessment of risk of embolization 2) Determination of benefits vs risks of anticoagulation

All patients with nonvalvular A fib should undergo ______________.

*Rheumatoid Arthritis* - Usually insidious onset with morning stiffness and joint pain. - Symmetric polyarthritis with predilection for small joints of the hands and feet; deformities common with progressive disease. - Radiographic findings: juxta-articular osteoporosis, joint erosions, and joint space narrowing. - Rheumatoid factor and antibodies to cyclic citrullinated peptides (anti-CCP) are present in 70-80%. - Extra-articular manifestations: subcutaneous nodules, interstitial lung disease, pleural effusion, pericarditis, splenomegaly with leukopenia, and vasculitis.

Arthritis 3 or more joints, morning stiffness, for more than 6 weeks, with anemia of chronic disease

Rheumatoid Factor (Sensative, not specific)

Best initial test for RA

Pulmonic Regurgitation (PR) Severe pulmonary HTN increases the velocity of the regurgitation.

Brief decrescendo early diastolic murmur @ LUSB {2nd left intercostal space) with full inspiration. increased venous return increases murmur, decreased venous return decreases murmur. A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

PO Vancomycin

C-diff: nonpregnant: mild to moderate disease: 2nd line treatment

Up to 24 hours

CT can be normal during stroke for how long?

Stage IIb to IVa

Cervical cancer: Locally advanced covers what stages?

Stage 0

Cervical cancer: carcinoma in situ is what stage?

Entacapone Tolocapone (Think the "Capone's")

Name the 2 COMT Inh used in adjunctive management of Parkinson Disease.

Squamous = 90% Adenocarcinoma = 10%

Name the 2 types of cercvical cancer and their percentages

painless erythematous macules in the palms and soles

Janeway Lesions

Wernike "sensory" aphasia MCA Dominant (usually L-side) defect

Defect in understanding speech or writing

> 10^5 (100,000) on clean catch urine

Definitive diagnosis of cystitis in women

- leukocytosis - anemia - ↑ESR/Rheumatoid factor

Labs seen in Infective Endocarditis

Angiography

Gold standard in diagnosing hemorrhagic stroke

trophozoites/cysts in stool

How do we diagnose giardia

AREDS and Amsler Grid with a special combination of vitamins and minerals, called the "AREDS formula." This formula seems to protect the eye from the damage caused by AMD. There are no treatments for dry AMD besides the AREDS formula. Zinc, Vitamins A, C, and E. Amsler Grid to monitor stability at home

How do we manage dry macular degeneration?

nitroglycerine + furosemide nitroglycerine causes a decrease in preload and cardiac output and increases coronary blood flow.

Hypertensive emergencies: left ventricular failure and/or pulmonary edema - 1st line treatment

Parkinson Disease

Idiopathic dopamine depletion → failure to inhibit acetylcholine in the basal ganglia (Ach is an excitatory CNS neurotransmitter, dopamine is inhibitoty). Onset of symptoms 45-65y MC. Cytoplasmic inclusions (Lewy bodies), loss of pigment cells seen in the substantia niara.

Tricuspid

MC valve involved in infective endocarditis in IV drug users

*serum potassium is below 3.3 mEq/L* since insulin will worsen the hypokalemia by driving potassium into the cells. Patients with an initial serum potassium below 3.3 mEq/L should receive aggressive fluid and potassium replacement prior to treatment with insulin. Insulin therapy should be delayed until the serum potassium is above 3.3 mEq/L to avoid complications such as cardiac arrhythmias, cardiac arrest, and respiratory muscle weakness

In DKA or HHS the only indication for delaying the initiation of insulin therapy is...

Ach = excitatory Dopamine = inhibitory

In the CNS which is excitatory and which is inhibitory: Ach = __________ Dopamine = __________

- acid peptic ulcer disease - renal insufficiency - diabetes - CHF

In which patients should NSAIDs be avoided?

*Acute angle closure glaucoma*

Intermittent blurring vision, halos around lights, and tunnel vision

No, but breathing problems, urticaria, and edema in response to penicillins are contraindications to the cephalosporins

Is rash (only) in response to penicillins a contraindication to cephalosporins?

Otitis media with S. peumoniae

MC acute compication of acute bronchiolitis

Bundle of James connects to the bundle of HIS, so the QRS is NARROW (unlike the wide ARS seen in WPW)

Name of accessory pathway in LGL

ampicillin-sulbactam (Unasyn), ceftriaxone (Rocephin), cefotaxime,

Name the anti-pneumococcal (anti Strep pneumoniae) beta-lactams

Resting tremor Worse at rest and with emotional stress. Lessened with voluntary activity, intentional movement and sleep. Usually confined to one limb or one side for years before it becomes generalized.

Often the 1st sign of parkinson disease

Chancroid

Patient presents with multiple painful papules to penis which subsequently ulcerate over days. Gram stain of an aspirate from the inguinal bubo reveals short gram-negative bacilli in a linear or parallel formation—often described as a "school of fish."

Pneumocystis jirovecii Pneumonia (PCP) Tx: is TMP-SMX

Patient with a history of HIV, Complaining of gradual onset of non-productive cough, Labs will show CD4 < 200, increased LDH; CXR will show bilateral infiltrates (bat wing pattern)

B) Regular insulin Regular insulin is the drug of choice as this will maintain the mother's blood sugar but not cross the placenta. The oral anti-hyperglycemic agents Glyburide and Metformin are safe alternatives and are a reasonable alternative for women who fail nutritional therapy and refuse to take, or are unable to comply with, insulin therapy. Hint: Actos is a pregnancy category class C medicine and is not recommended for the treatment of gestational diabetes. Hint: Corticosteroids will cause the blood glucose to increase. Hint: Glucagon is given to patients when their blood glucose is abnormally low. Glucagon stimulates gluconeogenesis.

Pharmacologic treatment of a patient with gestational diabetes should consist of which of the following? A) Pioglitazone (Actos) B) Regular insulin C) Oral corticosteroids D) Glucagon

Ciprofloxacin

Please note that this FQ is NOT a respiratory FQ

Haemophilus Influenza

Pneumonia: 2nd MC cause of community acquired pneumonia

Chlamydophilia pneumoniae

Pneumonia: Atypical, hoarseness, URI symptoms, sinusitis

Atypical pneumonia

Pneumonia: CXR shows diffuse patchy interstitial or reticulonodular infiltrates

Typical pneumonia

Pneumonia: CXR shows lobar pneumonia

*Klebsiella* Klebsiella (gram negative, facultative anaerobic bacilli) is normal flora of the human intestinal tract. If no evidence of in vitro resistance, go with Ceftriaxone. The 3rd gen Cephalosporins are good for meningitis, gonorrhea, and CAP. If evidence of ESBL or extremely ill, go with a carbapenem which is the broadest of all antibiotics. ("Dont be *Jelly* cuz Im in the *club*")

Pneumonia: Currant jelly sputum

Staphylococcus aureus

Pneumonia: Gram positive cocci in clusters

Haemophilus Influenza

Pneumonia: Increased with underlying pulmonary disease; COPD, bronchiectasis

Klebsiella Pneumonia

Pneumonia: Severe illness in alcoholics

Staphylococcus aureus

Pneumonia: Usually bilateral with multilobar infiltrates or abscesses

Simple Partial

Seizure: consciousness is fully maintained, EEG shows focal discharge at the onset of the seizure

Cefoxitin (Mefoxin®)

Second-generation cephalosporin; used for mixed aerobic/anaerobic infections; effective against Bacteroides fragilis and anaerobic bacteria

Atonic

Seizures: "Drop Attacks" - suddent loss of postural tone

*Beta Thalassemia* due to extramedullary hematopoiesis

Skull X-ray shows bossing with "hair on end appearance"

Polycythemia Excessive Red Blood Cell production due to chronic myeloproliferative neoplasm

Splenomegaly + Facial plethora (flused face)

Rheumatoid Arthritis Tx: Prompt initiation of DMARDs (Methotrexate); NSAIDs for pain control (Corticosteroids if NSAIDs fail)

Swollen, tender, erythematous, "Boggy" joints

1) Anthihistamine antiemetics (Ex: Meclizine) 2) Benzodiazepines (Ex: Diazepam) 3) Lasix (diuretics may slow endolymphatic pressure) 4) Low salt diet (may decrease swelling in endolymph) 5) Steroids

Symptomatic Management for Meniere's Disease

Ghon complex

TB: calcified primary focus + lymph node

Sertoli Cell Tumors Sertoli cell tumors are less common than Leydig cell tumors, accounting for 0.1 percent of testicular tumors in a National Cancer Database analysis. Gynecomastia and other signs of hyperestrogenism are present in 20 to 30 percent of cases. In contrast to Leydig cell tumors, virilization is only rarely seen.

Testicular Cancer: often benign. May secrete hormones (ex: androgens, estrogens) but hyperestrogenism is more common; virilization is only rarely seen.

Caucasions and Kleinfelter's syndrome

Testicular cancer is most common in what populations?

Beta-hCG

Testicular cancer: Often elevated in nonseminomatous (NSGCTs) (esp choriocarcinoma)

A) Losartan All the other options will cause hyperuricemia. Losartan is the only ARB that doesn't cause hyperuricemia (so it can be safely used)

Which could you use for hypertension in your patient with Gout? A) Losartan (Cozaar) B) Enalapril (Vasotec) C) Furosemide (Lasix) D) HCTZ (Microzide)

Chagas disease.

Which disease is transmitted by the reduviid bug?

Levofloxacin and Moxifloxacin

These are the two respiratory FQs bolded in PPP

Defib

Treatment of VT with no pulse

seminoma

Under microscopic visualization has a "fried-egg" appearance and are routinely negative for AFP and hCG.

Metronidazole (Flagyl®)

Used for serious anaerobic infections (e.g., diverticulitis); also used to treat amebiasis; patient must abstain from alcohol use during therapy

Rate Control

Usually preferred as initial management of symptomatic atrial fibrillation

*ceftriaxone* HACEK organisms are considered ampicillin resistant; unless growth is adequate in vitro to obtain susceptibility testing results, penicillin and ampicillin should not be used for treatment of IE due to these organisms. However, virtually all HACEK organisms, even strains that produce beta-lactamase, are highly susceptible to third-generation cephalosporins such as ceftriaxone.

What antibiotic should you use with the *HACEK* organisms

Upper endoscopy.

What is the management for acid or base ingestions?

iron-containing nucleated red cells

What are "Sideroblasts"

Hirschsprung Disease.

What is the most common cause of lower intestinal obstruction in neonates?

Azithromycin

What is the treatment of choice for pertussis?

Chlamydia

What organism is Reactive Arthritis most commonly associated with?

D) Flecainide Flecainide is contraindicated in the setting of coronary artery or structural heart disease because of the increased risk of polymorphic ventricular tachycardia. Flecainide is a class IC antiarrhythmic and is an effective agent against both ventricular and supraventricular dysrhythmias.

Which of the following antiarrhythmic medications is contraindicated in the setting of coronary artery or structural heart disease? A) Amiodarone B) Dofetilide C) Dronedarone D) Flecainide

Splenic autoinfarction

_____________________ occurs early in life in Sickle Cell patients and makes patients more susceptible to encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitides

Lhermitte phenomenon suggests cervical radiculopathy, spondylosis, myelopathy, or multiple sclerosis.

a sensation of electricity traveling down the spine triggered by flexion of the neck muscles

Subacute thyroiditis

an abrupt onset of thyrotoxic symptoms as hormone leaks from an inflamed, painful gland. It often follows a viral illness. Symptoms usually resolve within eight months. This condition can be recurrent in some patients. A transient hypothyroidism often occurs before resolution.

Legg-Calvé-Perthes

an idiopathic avascular necrosis of the femoral head in school-aged children.

Pernicious Anemia

autoimmune destruction of gastric parietal cells that secrete intrinsic factor → B12 deficiency

Waterhouse-Friedrichson syndrome Tx: Ceftriaxone and vancomycin

bilateral adrenal hemorrhage + meningococcemia

Haemophilus influenza

elderly, COPD, smokers; gradual onset fever, dyspnea, chest pain; CXR with patchy infiltrates/pleural effusion; gram-negative encapsulated coccobacillus

Klebsiella

elderly, alcoholic, COPD, diabetes; fevers, rigors, chest pain; herpes lesion, currant jelly sputum; CXR with "bulging minor fissure" (right upper lobe opacity bows into minor fissure)

Shigella

frequent, small volume, bloody stools, abdominal cramps, and tenesmus, particularly if accompanied by fever, what should you expect?

Coccidioides immitis (coccidioidomycosis)

fungal; regional, San Joaquin Valley/ California; erythema nodosum; think about fungal in dirt exposure/construction

Blastomyces dermatitidis (blastomycosis)

fungal; regional, Southeast US

RSV

globally the most common cause of acute lower respiratory infection and also a common cause of acute and recurrent otitis media.

Pseudomonas

gram-negative aerobic bacilli causes severe hospital-acquired infections associated with a high mortality rate, especially in immunocompromised hosts.

Procainamide

intravenous drug of choice for acute termination of suspected antidromic (WIDE, down normal, up accessory) AVRT (1 within AV node, 1 outside the AV node).

UA, CBC, ESR, ASO titers (ASO titers increased in Streptococcal infections, RA, and other collagen diseases)

labs to draw for suspected glomerulonephritis

Granuloma inguinale Caused by the Gram-negative bacteria Klebsiella granulomatis. Affects mostly people of lower socioeconomic status living in the tropical and subtropical areas.

lesions evolve and, depending on the stage, can be a painless papule, vesicle, or nodule on the genitalia or a beefy-red, velvety ulcer with a rolled border. Diagnosis is made by demonstrating intracellular Donovan bodies on histology.

*Lead poisoning* Lead (Pb), a stable metallic element with an atomic number of 82 and atomic weight of 207, was first smelted around 4000 BC as a by-product of silver processing. he consequences of lead toxicity have been recognized for millennia. Despite this knowledge, lead was included as an ingredient of gasoline in the 1920s and continued to be used in paint in some developed countries until the 1970s. In many low-income countries, lead in gasoline and industrialized uses of lead (eg, smelters, mines, or refineries) remain major sources of exposure. Children younger than six years of age (and particularly those younger than 36 months) are more susceptible to the toxic effects of lead than are adults because they have an incomplete blood-brain barrier that permits the entry of lead into the developing nervous system and because they have a greater prevalence of iron deficiency, which can result from and cause lead poisoning through increased absorption of lead from the gastrointestinal tract.

linear hyperdensities at metaphyseal plates

G6PD Deficiency

most common enzymatic disorder of RBCs.

moxifloxacin, gemifloxicin, levofloxicin

name the respiratory FQs

"basophilic stippling" They are most often seen in the thalassemias, alcohol abuse, lead and heavy metal poisoning, and the rare condition hereditary pyrimidine 5'-nucleotidase deficiency

presence of blue granules of various sizes dispersed throughout the cytoplasm of the red cell, which represent ribosomal precipitates.

Goodpasture's syndrome There is short-lived production of circulating autoantibodies, which are directed against an antigen intrinsic to the glomerular basement membrane (GBM), in response to an unknown inciting stimulus. The prognosis of untreated acute glomerulonephritis due to anti-GBM antibody disease is extremely poor. In a previously described case series of 67 patients, death or dialysis ensued in over 90 percent of patients. In another review of 32 patients with Goodpasture's syndrome, 29 progressed to renal failure, most of them in less than six months.

syndrome of glomerulonephritis and pulmonary hemorrhage.

The first step in management is instillation of lidocaine solution in the ear canal to drown the insect.

A 16-year-old boy presents to the ED with a foreign body sensation and buzzing in his right ear that began early this morning and woke him up. Physical exam reveals a moving insect in the external auditory canal. Which of the following is the most appropriate next step in management of this condition?

Infantile hypertrophic pyloric stenosis.

In infants, erythromycin use is a risk factor for development of what gastrointestinal condition?

Bacterial infection of the skin lesions.

What is the most common complication associated with chicken pox?

Hemorrhoids are the most common cause of rectal bleeding in adults.

What is the most common cause of rectal bleeding in an adult?

Dermatitis herpetiformis an intensely pruritic papulovesicular rash, is pathognomonic for Celiac disease. As with the gastrointestinal manifestations of Celiac disease, dermatitis herpetiformis typically resolves with full elimination of gluten from the diet.

A 33-year-old woman with a history of Celiac disease presents with a chronic, pruritic papulovesicular lesions occurring symmetrically over the extensor surfaces of her elbows and knees. Several vesicles have a crusted appearance. Which of the following is the most likely diagnosis?

Quadricep weakness and patellar arthrosis.

What are two common complications of untreated recurrent patellar instability?

Up to 75% of new cases of Celiac disease are diagnosed in women.

Which gender predominates in newly diagnosed cases of Celiac disease?

Vital Capacity This patient has Guillain-Barré syndrome (GBS); The most serious complication of GBS is respiratory failure from diaphragmatic weakness. Measuring the vital capacity or negative inspiratory force (NIF) is critical to assessing respiratory effort.

A 16-year-old girl presents to the ED complaining that she cannot walk up the steps. She has been well recently except for an episode of gastroenteritis two weeks ago. On exam, she has decreased strength in her bilateral lower extremities with absent patellar and ankle jerk reflexes. What is the most important next test to perform?

*Chlamydia trachomatis* Women who present with symptoms of acute dysuria, frequency, and pyuria do not always have bacterial cystitis. In fact, up to 30% will show either no growth or insignificant bacterial growth on a midstream urine culture. Most commonly these patients represent cases of *sexually transmitted urethritis* caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or Herpes simplex virus.

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

Dilation of the pampiniform venous plexus along the spermatic cord is referred to as varicocele. This condition is suspected in any swelling of the spermatic cord, especially when palpation reveals a nontender "bag of worms" consistency. Secondary varicocele can occur due to abdominal mass compression of the renal veins (more common with right sided varicocele), or superior mesenteric artery compression of the left renal vein (aka "Nutcracker Syndrome"; most commonly due to renal cell carcinoma and retroperitoneal fibrosis/adhesions).

A 28-year-old man presents with scrotal swelling and pain. Examination reveals a left, nontender, swollen spermatic cord that feels like a "bag of worms." The swelling reduces when the patient moves to a supine position. There are no skin lesions, hernia or testicular abnormalities. In addition to scrotal ultrasonography, you may consider ordering further imaging with attention to which of the following organs?

- This patient is presenting with *GASTRIC ulcer* disease secondary to Helicobacter pylori infection. - Triple therapy with clarithromycin 500 mg BID, amoxicillin 1 g BID (metronidazole 500 mg BID if allergic to penicillin), and a proton pump inhibitor (such as lansoprazole 30 mg BID) for 10-14 days is currently recommended for all patients with confirmed H. pylori infection.

A 43-year-old woman presents to the ED with abdominal pain. She reports that the pain is *epigastric and worse with food*. She denies any fevers, chills, vomiting, or diarrhea. She recently visited a gastroenterologist who told her she had a bacterial infection in her stomach, however, she did not follow up or receive treatment. On exam, her abdomen is soft and nontender. Which of the following is the most appropriate treatment regimen for this patient's condition?

Dysphagia to solids, upper abdominal pain, GERD-like symptoms (eg, heartburn), food impaction, and a history of allergies suggests eosinophilic esophagitis (EE).

A 52-year-old man comes to the clinic complaining of difficulty swallowing, upper abdominal pain, and heartburn. He says he has a difficult time swallowing solid foods and the food frequently gets "stuck" in his throat. He has a history of food allergies, asthma, and atopic dermatitis. Laboratory studies show markedly elevated serum IgE levels. Upper endoscopy shows stacked circular rings. Which of the following is the most likely diagnosis?

Dizziness (Dizziness is commonly caused by tamsulosin, an alpha-blocker that offers relatively quick improvement of symptoms in benign prostatic hyperplasia (BPH).)

A 72-year-old man is being observed by your clinic for benign prostatic hyperplasia. His symptoms of a weak stream, straining, and post-void dribbling are worsening and he would like to begin medical treatment. You initiate tamsulosin and advise him of which of the following most likely side effect?

In 2016, the US Food and Drug Administration (FDA) stated that the serious adverse effects associated with fluoroquinolones generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections who have other treatment options. For patients with these infections, fluoroquinolones should be reserved for those who have no alternative treatment options. In most cases of acute sinusitis and acute bronchitis, viral rather than bacterial infections are common, and antimicrobials may not be needed. This announcement was based on an FDA safety review showing that systemic fluoroquinolone use is associated with side effects, which although uncommon can be disabling and potentially permanent, including those involving the tendons, muscles, joints, nerves, and central nervous system.

Fluoroquinolones

Metronidazole (Flagyl) (Flushing, fast heartbeats, nausea, thirst, chest pain, vertigo, and low blood pressure may occur when alcohol is ingested)

What antibiotic can cause a disulfiram effect?

Because 45% to 55% of testicular cancer patients have azoospermia or oligospermia at or beyond 2 years after therapy, those patients who wish to preserve fertility should be offered semen cryopreservation before the start of therapy.

What are the clinical recommendations for preserving sperm count in patients with testicular carcinoma?

Smoking cessation, alcohol abstinence, and avoidance of NSAIDS (including aspirin).

What are three lifestyle changes that should be recommended to patients with peptic ulcer disease?

Lidocaine ointment for topical anesthesia, nifedipine gel for reduction of anal canal pressure, and injection of botulinum toxin for relaxation of the anal sphincter.

What are three treatment options for anal fissures in addition to warm soaks and debulking agents?

Anything that causes inflammation such as infection, malignancy, recent trauma/surgery, and lupus. Unfortunately many of these predispose patients to pulmonary emboli.

What can cause a positive D-dimer?

Disseminated intravascular coagulation (DIC). In disseminated intravascular coagulation, abnormal clumps of thickened blood (clots) form inside blood vessels. These abnormal clots use up the blood's clotting factors, which can lead to massive bleeding in other places. Symptoms include blood clots and bleeding, possibly from many sites in the body. The goal is to treat the underlying cause and provide supportive care through IV fluids and blood transfusions. Causes include inflammation, infection, and cancer.

What complication should be suspected in a patient with HELLP syndrome with clinically significant bleeding and elevated prothrombin time (PT), partial thromboplastin time (PTT), and decreased fibrinogen?

SJS involves less than 10 % BSA epidermal detachment whereas TEN has epidermal detachment in greater than 30% BSA.

What distinguishes Stevens-Johnson Syndrome from toxic epidermal necrolysis?

The crops of smallpox all develop with the same timing whereas in chickenpox they present in various stages.

What distinguishes chickenpox from smallpox?

Severe hypothermia on presentation.

What finding in myxedema coma is most predictive of mortality?

Stasis dermatitis occurs with venous insufficiency and valvular incompetency. The proximal skin appears thin and brown, and may occur with distal macules, papules, red irritation, skin thickening and edema.

What is stasis dermatitis?

It is a scoring scale for cerebral aneurysms and subarachnoid hemorrhage. The scale ranges from 0 (unruptured aneurysm) to 5 (deep coma, decerebrate posturing).

What is the Hunt and Hess Clinical Grading Scale?

ASCA is present in 60-70% of patients with Crohn's disease.

What is the antibody associated with Crohn's disease?

A granuloma in the choroid of the retina that is specific for disseminated TB.

What is the choroidal tubercle?

10 days.

What is the conventional duration of oral antibiotic therapy to achieve maximal pharyngeal GAS eradication rates?

Polycystic ovary syndrome. - Unknown etiology but most commonly associated with insulin resistance and dyslipidemia - Labs will show high LH:FSH (high LH compared to FSH) and androgen excess - Treatment is combination OCP's, lifestyle changes, metformin

What is the most common cause of infertility in women?

Amyloidosis Prognosis is poor if due to amyloidosis. Cardiac transplantation can be used if there is no systemic involvement

What is the most common cause of restrictive cardiomyopathy?

Most commonly, treat the underlying cause which will often improve the dysrhythmia. Nodal agents are not as effective as in other dysrhythmias.

What is the treatment for multifocal atrial tachycardia?

Infiltration of the esophageal squamous epithelium with eosinophils. Additionally, basal cell hyperplasia and lamina propria fibrosis can also seen.

What is typically seen on histopathology in patients with eosinophilic esophagitis?

Lidocaine (spray, gel, and solution), oil (olive and mineral), and alcohol.

What liquids have been shown to be effective in drowning otic live insect foreign bodies?

Erythema multiforme, drug eruption, secondary syphilis, Rocky mountain spotted fever, hand-foot-and-mouth disease, scabies.

What rashes commonly appear on the palms?

Streptococcus mutans.

Which bacteria are most closely associated with dental caries?

Alpha blockers are associated with intraoperative Floppy Iris Syndrome in patients undergoing cataract surgery.

Which class of BPH medications poses an increased risk of complications in patients undergoing cataract surgery?

Native Americans.

Which ethnicity is known for having the greatest risk for developing gallstones and acute cholecystitis?

Non-Hodgkin lymphoma (NHL) is the leading cause of non-solid organ cancer-related death. It has a significantly worse prognosis than that of Hodgkin lymphoma. Signs and symptoms of NHL include persistent, painless, peripheral lymphadenopathy. Any lymph node that is > 1 cm in size and persistent for > four weeks without association with a documented infection should be considered for biopsy. NHL may mimic infectious mononucleosis. Acute myeloid leukemia (A), Hodgkin lymphoma (B), and multiple myeloma (C) are all much less common causes of cancer-related death than Non-Hodgkin lymphoma.

Which of the following is the leading cause of non-solid organ cancer-related death?

Bupropion

Which smoking cessation medication is recommended for patients who are concerned about post-cessation weight gain?

Dressler syndrome It consists of fever, pleuritic pain, pericarditis and/or a pericardial effusion. also known as postmyocardial infarction syndrome. The disease consists of a persistent low-grade fever, chest pain (usually pleuritic in nature), pericarditis (usually evidenced by a pericardial friction rub), and/or a pericardial effusion. The symptoms tend to occur 2-3 weeks after myocardial infarction, but can also be delayed for a few months. It tends to subside in a few days, and very rarely leads to pericardial tamponade.[8] An elevated ESR is an objective, yet nonspecific, laboratory finding.

an autoimmune mediated acute febrile illness associated with a pericarditis that occurs two weeks to several months after an acute myocardial infarction.

Radiofrequency ablation

Definitive management of atrial flutter

*Acute angle closure glaucoma*

Mid-dilated, fixed, nonreactive pupil with eye that feels hard to palpation

Klebsiella Pneumonia

Pneumonia: associated with cavitary lesions

Penicillin G.

What is the treatment of choice for primary syphilis infection?

80-years-old.

What is the upper age limit for tPA administration up to 4.5 hours?

Iron deficiency anemia

Ice cravings (pagophagia)

Mycoplasma pneumonia, Haemophilus influenzae, Streptococcus pneumoniae and Chlamydia pneumoniae **Routine blood cultures (B) are not recommended in the treatment of uncomplicated CAP.

CAP: most common pathogens

Perforated duodenal ulcer Perforation of a duodenal ulcer causes sudden, severe pain, with rebound tenderness and rigid abdomen on physical examination. It is *often associated with coffee ground emesis*. Hint: A patient with AAA may present with pain radiating to the back, however would not have coffee ground emesis or an acute abdomen.

50 year-old male with history of alcohol abuse presents with acute, severe epigastric pain radiating to the back. The patient admits to an episode of coffee ground emesis. On examination he is ill-appearing with a rigid, quiet abdomen and rebound tenderness. Which of the following is the most likely diagnosis?

Carcinoma of head of pancreas Seventy-five percent of pancreatic cancers are in the head. Risk factors include age, tobacco use, obesity, chronic pancreatitis, family history and previous abdominal radiation.

A 65 year-old homeless male with a history of pancreatitis is seen in the emergency department for vomiting, upper abdominal pain, back pain and weakness. He is cachetic, pale and jaundiced. A 4-5 cm mass is palpable in the mid to right hypochondrium. What is the most likely diagnosis?

D) placental insufficiency Hint: Pelvic dystocia, particularly that due to small bony architecture, is the most common cause of passage abnormalities and is not directly associated with FHR deceleration Hint: The drop in FHR is caused by an interference with uterine blood flow to the intervillous space causing an early, not late, deceleration.

A decrease in the fetal heart rate (FHR) occurring late during contractions is noted. The FHR returns to the baseline slowly after the uterine contraction. The physician assistant should be alerted to the possibility of A) pelvic dystocia B) precipitous labor. C) fetal head compression. D) placental insufficiency

Jarisch-Herxheimer reaction

A febrile reaction to antigens that are liberated when spirochetal bacteria (classically syphillis) are destroyed by antibiotic therapy.

CHA2DS2-VASc or CHADS2 CHA2DS2-VASc is no preferred by most, takes more risk factors into consideration.

A fib: assessment of the risk of embolization

C) Diphenhydramine The girl has clinical findings of anticholinergic poisoning that consists of hyperthermia, tachycardia, mydriasis, and dry skin.

A four-year-old girl is seen at the ED because of possible ingestion. She was unattended for several minutes when she went through her grandmother's bag containing bottles of bethanecol, clonidine, diphenhydramine, and fluoxetine. Upon arrival at the ED, her examination reveals temperature of 38°C, heart rate of 120, respiratory rate of 16, blood pressure 85/56, pupils 5 mm equal and reactive and dry skin. Which of the following is the most likely medication that caused the girl's findings? A) Bethanecol B) Clonidine C) Diphenhydramine D) Fluoxetine

Addison's disease Patients with Addison's disease have primary adrenal failure from an autoimmune problem in the adrenal gland or due to hemorrhage into the adrenal gland. These patients are not able to make glucocorticoids, mineralocorticoids, or sex hormones which result in hypotension, hyperpigmentation (from an increase in the ACTH and MSH hormones) and are hyponatremic.

A patient presents to the office with worsening fatigue, weight loss, and weakness. She notes that she is having recurrent bouts of abdominal pain and has been losing her pubic hair. Patient is found to have orthostatic hypotension. Which of the following conditions is most likely? A Cushing's syndrome B Pheochromocytoma C Primary hyperparathyroidism D Addison's disease

Dx: Patellofemoral instability Image: The axial view, also commonly called the sunrise view, allows the clinician a direct visualization of how the patella sits in the femoral trochlear groove.

A runner presents with recurrent anterior knee pain. She reports a "popping" sensation followed by severe pain. These episodes are brief because the pain resolves once she moves her "kneecap back into position". In the initial evaluation of this patient, a radiologic order would most likely include which of the following views?

A) Get acetaminophen level four hours after ingestion Performing immediate gastric lavage (C) involves placing a tube into the stomach to aspirate contents, followed by flushing with aliquots of fluid. Although it was used routinely in the past, objective data do not document or support clinically relevant efficacy. Thus in most cases, its use is no longer recommended. Obtaining transaminases, synthetic and renal function (B) can be done for baseline, and these laboratory values followed serially in cases of acetaminophen ingestion. However, it is more important to obtain an acetaminophen level to direct management. Any child with a history of acute ingestion of greater than 200 mg/kg should be referred to a healthcare facility. If a toxic ingestion is suspected, a serum acetaminophen level should be calculated four hours after the reported time of ingestion. For patients who present to medical care more than four hours after ingestion, a stat acetaminophen level should be obtained. Acetaminophen levels obtained fewer than four hours after ingestion are difficult to interpret and cannot be used to estimate the potential for toxicity. The serum acetaminophen level is then plotted on the Rumack-Matthew nomogram and any level that is in the possible or probable hepatotoxicity range should then be treated with N-acetylcysteine.

A three-year-old boy is brought to the emergency department due to acetaminophen ingestion. About two hours prior, he was found by his mother with an open bottle of acetaminophen and several tablets scattered on the floor. The mother was not sure how many tablets were missing. The boy had one episode of vomiting at home. He is asymptomatic upon arrival at the emergency room. On examination, the boy is active with normal vital signs and physical examination. Which of the following is the most appropriate next step in management? A) Get acetaminophen level four hours after ingestion B) Obtain transaminases, synthetic and renal function C) Perform immediate gastric lavage D) Treat with syrup of ipecac urgently

ruxolitinib Subclass: Kinase Inhibitors Mechanism of Action: inhibits janus-associated kinases (JAK) 1 and 2, leading to disruption of cytokine and growth factor signaling pathways. PV is associated with JAK2 mutation.

Among cytoreductive agents, the most effective for Polycythemia Vera-associated pruritus may be _______________________.

C) Ataxic (Biot's) It is generally a poor prognostic sign. Biot's respiration is caused by the medullary lesion due to strokes or trauma or by pressure on the medulla due to uncal or tentorial herniation.

An abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. What is the breathing pattern? A) Cheyne-Stokes B) Apneusis C) Ataxic D) Cluster E) Kussmaul

Testicular cancer

Any hematoma or hydrocele secondary to minor scrotal trauma should raise suspicion for what condition?

slows AV nodal conduction These can be remembered by the mnemonic "ABCD"-- adenosine, beta-blockers, calcium channel blockers, and digoxin.

Any medication that _______________________ is contraindicated in WPW.

Any age.

At what age does immune thrombocytopenia present?

Betalactam + Macrolide OR Betalactam + broad spectrum FQ

Basic treatment of CAP in ICU

Metronidazole

C-diff: nonpregnant: mild to moderate disease: 1st line treatment

*Increased murmur intensity with inspiration* = due to increased right sided blood flow during inspiration = Helps to distinguish TR from MR

Carvallo's sign

Multiple Sclerosis Path: Most commonly caused by a demyelinating disorder Dx: is made by T2-weighted MRI Tx: is symptomatic, methylprednisolone Comments: Bilateral internuclear ophthalmoplegia (eyes can't look at nose) is pathognomonic

Caucasian female, Complaining of pain with eye movement, monocular vision loss, sensory abnormalities; PE will show spinal electric shock sensation with neck flexion (Lhermitte phenomenon); CSF will show ↑ IgG protein, WBC pleocytosis

Radiofrequency ablation

Definitive management of WPW

periumbilical ecchymosis sign of pancreatitis

Cullen's sign

*Granuloma inguinale* (also known as "donovanosis") Caused by the Gram-negative bacteria Klebsiella granulomatis. Affects mostly people of lower socioeconomic status living in the tropical and subtropical areas.

Diagnosis is made by demonstrating intracellular Donovan bodies on histology (rod-shaped organisms seen in cytoplasm of mononuclear phagocytes).

- UA and Urine Culture (often negative in CHRONIC) - Avoid prostatic massage in ACUTE, it may cause bacteremia - Transrectal ultrasound: may be helpful for suspected abscess or calculi

Diagnosis of Acute Prostatitis

1) Delta wave = surred QRS upstroke 2) Wide QRS 3) Short PRI

ECG diagnostic criteria of WPW

Short PR-interval with NORMAL QRS

EKG appearance of Lown-Ganong-Levine (LGL)

*Hypokalemia* Endogenous catecholamines, acting via beta-2 adrenergic receptors, can *promote potassium entry into cells* by increasing the activities of the Na-K-ATPase pump and the Na-K-2Cl cotransporter and possibly by increasing the release of insulin. A proposed physiologic role for this effect of increased beta-2 adrenergic activity is to moderate the acute hyperkalemia of exercise.

Electrolyte disturbance of SABA

*G6PD Deficiency* Heinz Bodies = inclusions within red blood cells composed of denatured hemoglobin.

Episodic hemolytic anemia + Heinz Bodies

*Shigella* It is transmitted by direct person-to-person spread and, less commonly, through contaminated food and water. Shigella species are a common cause of bacterial diarrhea worldwide, especially in developing countries. Shigella organisms can survive transit through the stomach since they are less susceptible to acid than other bacteria; for this reason as few as 10 to 100 organisms can cause disease

Explosive watery diarrhea → mucoid, bloody

NSAIDs Corticosteroids are 2nd line if no symptom relief with NSAIDs

First line for pain control in RA

Nitazoxanide

For treatment of patients 12 to 36 months what medicaion is preferred for Giardia?

Tinidazole Because it has a longer half-life than nitazoxanide and may be administered as a single dose with high efficacy (>90 percent). Metronidazole, a related drug, was carcinogenic in animal studies.

For treatment of patients ≥3 years of age what medicaion is preferred for Giardia?

African-American males

G6PD deficiency MC affects what population?

*HACEK* organisms Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella, HACEK organisms are considered ampicillin resistant; unless growth is adequate in vitro to obtain susceptibility testing results, penicillin and ampicillin should not be used for treatment of IE due to these organisms. However, virtually all HACEK organisms, even strains that produce beta-lactamase, are highly susceptible to third-generation cephalosporins such as ceftriaxone.

Gram negative organisms that are associated with the development of large vegetations and are often hard to culture in infective endocarditis

adenocarcinoma (think breast tissue filled with glands)

Gynecomastia associated with what type of lung cancer

Gram negative organisms that are associated with the development of large vegetations and are often hard to culture Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella,

HACEK organisms

Hig grade Squamous Intraepithelial Lesion Includes: CIN 2, 3, and carcinoma in situ

HSIL

Hypertrophic Cardiomyopathy (HCM)

Harsh systolic crescendo-decrescendo murmur. Decreases with increased venous return, increases with decreased venous return A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

A) Cervical carcinoma Human papilloma virus (types 16, 18, and 31) has been linked to the development of cervical carcinoma.

Human papilloma virus has been strongly associated with the development of which of the following? A) Cervical carcinoma B) Ovarian carcinoma C) Pelvic inflammatory disease D) Vaginitis

3-4 weeks of anticoagulation and TEE showing no atrial thrombi (Another option is to start IV Heparin, cardiovert within 24 hrs, and anticoagulation for 4 weeks)

If atrial fib has been present for unknown / long time, what must we do to cardiovert?

-gliptins = DPP4 Inhibitors

Inhibits inactivation of incretin hormones (GLP-1) resulting in glucose-stimulated increased insulin secretion and decreased glucagon secretion

Biphosphonates

Inhibts Calcium release from bone

D) After delivery of the infant The patient should not receive the rubella vaccine during the course of her pregnancy as the possibility of transmission of the rubella virus does exist. During the time that the patient is without protective titer she should avoid anyone with active rubella infection. The proper time to receive the vaccine is after delivery of the infant.

It is determined that a woman has a nonexistent rubella titer level during her first trimester of pregnancy. When should she receive the rubella vaccine? A) During the first trimester of pregnancy B) During the second trimester of pregnancy C) During the third trimester of pregnancy D) After delivery of the infant

Polycythemia Vera

JAK2 mutation is associated with what condition?

Low grade Squamous Intraepithelial Lesion Includes: CIN 1 Usually results of transient HPV infections (esp in young women). May progress to cancer in 7 years. Can observe (75% resolve by immune system w/in 1 year) or Excise.

LSIL

Calcitonin (injection or nasal spray)

Last line therapy for osteoporosis

Shigella Shigella organisms can survive transit through the stomach since they are less susceptible to acid than other bacteria; for this reason as few as 10 to 100 organisms can cause disease

Lower abdominal pain, high fever, tenesmus, explosive watery diarrhea leading to mucoid, bloody diarrhea

Adenocarcinoma ("Travels all the way from the gardern of Eden [Aden-])

Lung cancer: This type tends to metastasize to distant areas

Adenocarcinoma Adenocarcinoma is the most common type of lung cancer in contemporary series, accounting for approximately one-half of lung cancer cases. The increased incidence of adenocarcinoma is thought to be due to the introduction of low-tar filter cigarettes in the 1960s, although such causality is unproven.

Lung cancer: Typically presents in the periphery

Ischemic heart disease

MC cause of VT

Strep Viridans Oral flora source of infection. Tx with Penicillin or Ampicillin + Gentamicin. Vancomycin in IVDA

MC organism in SUBACUTE bacterial endocarditis

Enterococci (also consider fungi, yeast, GNRs)

MC organism in infective endocarditis in men 50y with history of GI/GU procedures

Noncontrast CT to rule out hemorrhage (may be normal during the first 6-24 hrs)

Method of choice for ischemic stroke diagnosis

PORT/PSI (Pneumonia Severity Index) and the CURB 65.

Name 2 clinical prediction rules that may be used to help determine whether a patient with CAP requires inpatient or outpatient management?

Ipratropium (Atrovent) Blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscle causing bronchodilation; local application to nasal mucosa inhibits serous and seromucous gland secretions. Most useful in the 1st hour.

Name an anticholinergic used to treat acute asthma exacerbation

C) HCTZ Thiazides and CCB's.

Optimum therapy for hypertension in an African-American patient. A) Spironolactone B) Atenolol C) HCTZ D) Captopril

Mallet Finger Tx: is volar splinting DIP in extension Comments: If untreated -> swan neck deformity

Patient will be a basketball or volleyball player, With a history of forced hyperflexion of the DIP, Complaining of inability to extend DIP

Chlamydophilia pneumoniae

Pneumonia: Intracellular parasite

D) *ESR > 50 mm/h* (normal is <25 in females, <17 in males) *Clinical*: Pain/stiffness in PROXIMAL joints in patients >50y. Closely related to giant cell arteritis *Dx*: clinical, High ESR, w/ or w/o elevated platelets (acute phase reactant), normochromic/normocytic anemia *Tx*: Low-dose corticosteroids (10-20 mg/day). NSAIDs. Methotrexate. *Hints*: Positive Schirmer (A) is decreased tear production and is associated with Sjogren's Syndrome. Positive Anti-centromere Antibodies (B) is associated with limited scleroderma/CREST. It is more specific and has a bette prognosis. Anticardiolipin antibodies (C) is associated with AntiPhospholipid Antibody Syndrome (APLS) in SLE and is associated with fale-positive VDRL/RPR d/t cardiolipin present in reagent.

Polymyalgia rheumatica (PMR): Which of the following laboratory abnormalities is most likely present in this patient? A) Positive Schirmer Test B) Positive Anti-centromere Antibodies C) Anticardiolipin antibodies D) Elevated ESR

Tamoxifen is the adjuvant therapy of choice in post-menopausal estrogen receptor positive axillary node negative breast cancer.

Postmenopausal patient is diagnosed with grade I breast cancer. The tumor is 0.7 cm in size, estrogen-receptor positive, and axillary nodes are negative. After undergoing a lumpectomy, which of the following adjuvant therapy is indicated for this patient?

Hyponatremia

SIADH causes what electrolyte abnormality

toward the side of the lesion

Stroke: Gaze preference is usually in what direction?

A basilar artery stroke this artery feeds the entire vertebrobasilar system or posterior circulation. This structure feeds the reticular activating system leading to the impaired levels of consciousness or even loss of consciousness. Basilar artery occlusion can also rarely cause locked-in syndrome, which occurs with bilateral pyramidal tract lesions in the ventral pons and is characterized by complete muscle paralysis except for upward gaze and blinking. Basilar artery occlusions have a high risk of death and poor outcomes.

Stroke: impaired levels of consciousness or even loss of consciousness.

anosognosia MCA nondominant side (usually R-side)

Stroke: inability or refusal to recognize a defect or disorder that is clinically evident.

correction of the potassium deficit. Potassium replacement is initiated immediately if the serum potassium is <5.3 mEq/L. Almost all patients with DKA or HHS have a substantial potassium deficit, usually due to urinary losses generated by the glucose osmotic diuresis and secondary hyperaldosteronism. Despite the total body potassium deficit, the serum potassium concentration is usually normal or, in approximately one-third of cases, elevated at presentation. This is largely due to insulin deficiency and hyperosmolality, each of which cause potassium movement out of the cells.

The second step in the treatment of DKA, after infusion of isotonic saline, is.....

*KASH* *K*lebsiella Staph *A*ureus *S*trep pneumoniae *H* flu

Typical pneumonia organisms

Surgical resection especially if localized to the chest. Treatment regimens vary depending on the stage of cancer. Stage I to IIIA lung cancer is potentially curable; hence, curing the patient is the main goal. For patients with stage IIIB or IV disease, the goal of treatment is to reverse, delay, or prevent symptoms due to the local or metastatic tumor, hoping for an unusual but marked response that is seen in a minority of people.

Treatment of choice for Non Small Cell lung cancer

All are manifestations of left-sided endocarditis. Roth spots are retinal hemorrhages and Osler nodes are painful nodes on the digits both caused by immunologic vasculitis.

What are Roth spots and Osler nodes?

Vancomycin

Used to treat methicillin-resistant Staphylococcus aureus (MRSA); used orally to treat C. difficile pseudomembra- nous colitis (poorly absorbed from the gut); with IV administration, peak/trough levels should be monitored

red cells stacked like coins Bone pain is the most common symptom in myeloma, reflects abnormal serum protein levels.

What are Rouleaux formations?

tertiary syphilis - (VDRL stands for Venereal Disease Research Laboratory) that detects an antibody that is present in the bloodstream when a patient has syphilis.

VDRL is seen in patients with...

*Anti-angiogenics* (ex: Bevacizumab) Use: Immunotherapy; Antiangiogenic Agents; Macular Diseases - binds and inhibits vascular endothelial growth factor, decreasing microvascular growth and metastatic progression

VEGF inhibitors

Idiopathic in nature Account for 90% of all headaches. Includes migraine, tension, and cluster or rebound. Tensiona and migraine MC in women.

What are "primary" headahces?

Tubo-ovarian abscess, infertility, ectopic pregnancy.

What are 3 consequences of PID?

- Preeclampsia/eclampsia, - pulmonary embolism of trophoblastic cells - hyperemesis gravidarum

What are the most common complications of a molar pregnancy?

Alpha-adrenergic receptor blockers.

What drug class is considered first-line for the treatment of BPH?

Inherited/Genetic

What is meant by "Intrinsic" Hemolytic Anemia

Urinary frequency, dysuria and recurrent infections.

What urinary symptoms typically accompany the vaginal symptoms of atrophic vaginitis?

If reticulocyte count is high

When do we give folate supplementation in treatng thalassemia?

Tdap Live vaccinations pose a theoretical risk to the fetus and are contraindicated in pregnant women. While live attenuated influenza vaccine (A) administered intranasally is contraindicated, inactivated influenza vaccine is recommended to any woman who is or will be pregnant (any trimester) during influenza season. Measles, mumps, rubella (MMR) vaccine (B) and varicella vaccine (D) are also live vaccines and should not be administered to pregnant patients.

Which of the following vaccinations is considered safe in pregnancy? Live attenuated influenza Measles, mumps, rubella Tdap Varicella

Fluoroquinolones, OR trimethoprim-sulfamethoxazole.

__________________ such as ciprofloxacin or levofloxacin are commonly used to treat *outpatient pyelonephritis*. Another option is ____________________.

Smoking Higher doses are needed in smokers

___________________ decreases Theophylline levels

Carbamazepine

_______________________ is not indicated for the treatment of absence seizures (petit mal); it has been associated with increased frequency of generalized convulsions in these patients.

Beta-hCG, alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH)

____________________________are tumor markers seen in patients with testicular cancer and should be ordered if the ultrasound reveals an intra-testicular mass.

SGLT2 Inhibitors = "-gliflozins"

blocks the reabsorption of glucose from the kidneys and increases glucose loss in the urine

SARS (Severe Acute Respiratory Syndrome)

coronavirus; highly contagious and lethal; travelers

Tumor lysis syndrome (TLS) Patho: caused by the destruction of a large number of rapidly proliferating neoplastic cells. Acidosis may also develop. Acute renal failure occurs frequently. TLS is most often associated with the treatment of Burkitt's lymphoma, acute lymphoblastic leukemia, and other rapidly proliferating lymphomas, but it also may be seen with chronic leukemias and, rarely, with solid tumors. Tx: Recognition of risk and prevention are the most important steps in the management of this syndrome. The standard preventive approach consists of allopurinol, urinary alkalinization, and aggressive hydration.

hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia

Parkinson Disease Bradykinesia: slowness of voluntary movements and decreased automatic movements.

lack of swinging arms while walking and a shuffling gait

Thalassemia

microcytic anemia patient with normal to ↑serum iron and/or no response to iron treatment

*Autoimmune Hemolytic Anemia* Autoimmune hemolytic anemia (AIHA) due to the presence of warm agglutinins is almost always due to the presence of IgG antibodies that react with protein antigens on the red blood cell (RBC) surface at body temperature. For this reason, they are called "warm agglutinins" even though they seldom directly agglutinate the RBCs. Positive antiglobulin (Coombs) test — The diagnosis of warm agglutinin AIHA is based upon detection of antibody and/or complement components on the surface of the RBC (ie, a positive direct antiglobulin [Coombs] test), or, less commonly, in the circulation (ie, a positive indirect antiglobulin [Coombs] test).

microspherocytes , Coombs POSITIVE

Tinea corporis

presents with annular or circular plaques that expand centrifugally. As the lesions expand, they develop slightly raised leading edges with whitening of the center. Single or multiple lesions may be present

nonseminomatous germ cell tumors (NSGCTs)

serum AFP concentrations greater than 10,000 micrograms/L are found almost exclusively in patients with ___________________ or hepatocellular carcinoma.

Moraxella catarrhalis

similar to haemophilus influenza pneumonia

neuropathic pain

spontaneous, burning, dysesthetic (an unpleasant, abnormal sense of touch), diffuse pain

Erythropoietin-alpha

treatment of anemia of chronic disease if due to renal disease.

Due to chronic disease or meds Ex: hypogonadism, high cortisol states (prolonged high-dose corticosteroid use, cushings), thyrotoxicosis, low estrogen, malignancy, immobile, heparin therapy, anticonvulsant therapy,DM, liver disease

what is "secondary" osteoporosis?

Urologic and rectal, as it is difficult for some women to localize bleeding from the vagina, urethra or anus.

Which nongynecologic sources must be initially considered in any woman with abnormal uterine bleeding?

Infective Endocarditis

splinter hemorrhages of proximal nail bed, clubbing, hepatosplenomegaly, septic emboli

*Ramsay-Hunt Syndrome* = Herpes Zoster Oticus ***Note the vesicular eruptions on the neck*** *Patho*: reactivation of latent varicella zoster virus (HHV-3) in the facial nerve and geniculate ganglion..The second most common cause of facial paralysis. *Clinical*: Consists of a severe facial palsy associated with a vesicular eruption in the external auditory canal and sometimes in the pharynx and other parts of the cranial integument; often the eighth cranial nerve is affected as well. *Tx*: Oral Acyclovir and Corticosteroids. It is important to protect the involved eye from corneal abrasions and ulcerations by using lubricating drops.

Otalgia and facial palsy with lesion picutred.

LDH Serum lactate dehydrogenase (LDH) concentrations are elevated in 40 to 60 percent of men with testicular germ cell tumors (GCTs). LDH is a less sensitive and less specific tumor marker than beta human chorionic gonadotropin (beta-hCG) or alpha fetoprotein (AFP) for men with nonseminomatous GCTs, but it may be the only marker that is elevated in some seminomas. Serum LDH can be elevated due to a variety of processes that result in tissue injury, and thus, serum LDH is neither a sensitive nor specific indicator of disease recurrence in men with GCTs

Other than Beta-hCG and AFP, what marker may be elevated in testicular cancer?

asthma

PE: prolonged with wheezing, hyperresonance to percussion, decreased breath sounds, tachycardia, tachypnea, accessory muscle use

Testicular cancer In any man with a solid, firm mass within the testis, testicular cancer must be the considered diagnosis until proven otherwise. Prompt diagnosis and treatment of testicular cancer provides the best opportunity for cure. Nevertheless, both patient and clinician factors often contribute to a delay in diagnosis. Painless scrotal masses are sometimes ignored, while testicular cancers presenting with scrotal pain are often treated as epididymitis. The diagnostic evaluation of men with suspected testicular cancer includes scrotal ultrasound followed by radiographic testing, measurement of serum tumor markers, radical inguinal orchiectomy, and in some cases, retroperitoneal lymph node dissection (RPLND). The results are used to determine the histologic type and extent of disease, and to guide therapy. Testicular biopsy is not performed as part of the evaluation due to concern that it may result in tumor seeding into the scrotal sac or metastatic spread of tumor into the inguinal nodes.

Painless testicular mass, solid or enlargement, unable to separate from testicle, may have dull pain or testicular heaviness

Typhoid (enteric) fever Salmonella typhii

"Pea soup" stools

*Posterior Cerebral Artery* The most frequent finding in patients with PCA territory infarction is a hemianopia (blindness over half the field of vision.). The PCA mainly supplies the bottom and back parts of the brain. Everything from the left field goes to the right side of the brain and vice-versa and they both converge after the optic chiasm which explains the Contralateral homonymous hemianopsia

*Stroke*: Visual Hallucinations, Contralateral homonymous hemianopsia (loss of half of the field of view on the same side in both eyes.)

*alpha-2 agonists* drops: decrease aqueous fluid production, decrese IOP PO: treats HTN

-onidine

Rubella, "German measles," or "Third disease" was once a common childhood disease that had its highest incidence during the spring. Dx: The clinical diagnosis in an individual case is often difficult, but the epidemic nature of the illness, along with the seasonal variation and high expression rate of the exanthem, help in establishing the diagnosis. A history of inadequate immunizations may assist in the diagnosis. Tx: There is no specific therapy.

1- to 5-day prodrome of fever, malaise, headache, and sore throat. The exanthem began as irregular pink macules and papules on the face, spreading to the neck, trunk, and arms in a centrifugal distribution. Suboccipital and posterior auricular Lymphadenopathy is noted.

Otitis Externa

1-2 days of ear pain, pruritis in the ear canal, discharge, pressure, fullness, but hearing is usually preserved

Amiodarone

1st line medication for stable wide complex tachycardia

Atropine ***Because excess vagal stimulation is the most common cause, the anticholinergic (thin "anti-vagal") Atropine is 1st line*** (Epi or TCP are options if no respone to Atropine)

1st line treatment of sinus bradycardia

Atropine (Then Epi or a pacemaker)

1st line treatment of symptomatic Mobitz-I second degree AV block

*IV hydration and Oxygen* Reverses/prevents sickling. Then narcotics for adequate pain control

1st step in management of pain crisis in sickle cell

Coxiella burnetti Q fever is a zoonotic infection caused by the pathogen Coxiella burnetii. C. burnetii, is a potential agent of bioterrorism.

21 yo male farmer presents with sudden onset high fever, myalgias, hacking cough. He mentions he often cleans at one of the slaughter houses.

*Sheehan's Syndrome* Path:partial or complete pituitary insufficiency due to postpartum necrosis of the anterior pituitary gland in women with severe blood loss and hypotension during delivery. Dx: MRI of the pituitary and hypothalamus is necessary to exclude a tumor or other pathology. Tx: All deficient hormones must be replaced.

24 y/o female recently delivered. Delivery was complicated by a large amount of blood loss. No is presenting with fatigue, weight loss, sudden loss of lactation. and postural hypotension. Labs reveal hyponatremia, anemia, low T4, TSH, cortisol, ACTH, prolactin, gonadotropin, FSH, LH, and estrogen.

A) Antibiotic therapy Antibiotic therapy should be started immediately along with tetanus if needed Hint: Reducing the fracture in the absence of neurological symptoms could cause nerve injury and is not indicated immediately.

25 year-old female presents to the ED with an open fracture of the left fibula sustained from an auto accident. The patient has no neurological findings. In addition to stabilization of the patient which of the following should be immediately initiated? A) Antibiotic therapy B) Apply a bi-valve cast C) Reduce the fracture D) Surgical debridement

IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis

25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and vomiting. He admits to "partying with cocaine all night". He describes his urine as a dark brown color. Serum creatinine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which of the following is the initial mainstay of therapy for this condition?

A) Tetanus prophylaxis Tetanus prophylaxis should be initially considered in all burn patients. Hint: Debridement of blisters is controversial, however *blisters on the palms and soles should remain intact*. Hint: IV fluids are indicated for severe partial thickness burns covering *more than 10%* TBSA or in burns with complications.

28 year-old male presents with burns sustained from hot grease splashed on his left hand earlier this afternoon. The burn extends from his palm to the volar aspect of his wrist and has an erythematous base, covered by an intact blister. There are a few small scattered blisters over the dorsum of the left hand. Which of the following is the initial intervention of choice? A) Tetanus prophylaxis B) Admission to a burn unit C) Intravenous fluid administration D) Debridement of blisters

EtOH (35%)

2nd MC cause of acute pancreatitis

*Valproic Acid* In patients who have inadequate control of TAS or intolerable side effects on ethosuximide, we suggest switching to valproate monotherapy, although *lamotrigine* may be a better alternative in females of childbearing age based on the increasingly well characterized fetal risks of valproate.

2nd line management of absence seizure if patients who fail or do not tolerate first-line therapy (ethosuxamide)

AV nodal blockers = beta blockers or CCBs

2nd line medications for PSVT if stable and narrow complex if Adenosine didnt work

Chlamydia psittaci

35 yo woman bird breeder presents with 3 day h/o high fever, hacking cough, severe headache which she feels is like the flu

Legionella pneumophila

40 yo man presents with SOB adn productive cough, recalls onset of symptoms after returning from a spa

Cholangitis characterized by a history of biliary pain, fever, chills, and jaundice associated with episodes of abdominal pain.

45 year-old type 2 diabetic female with history of cholelithiasis presents to the clinic with 2-3 episodes of sudden, severe epigastric pain that radiates to her shoulder. She has associated nausea and vomiting. Temperature is 101 degrees F and she is experiencing chills. Today her eyes appear yellow in color. Which of the following is the most likely diagnosis for this patient?

C) Blood test to look for the presence of diabetes and HIV infection Recurrent vulvovaginal candidiasis is defined as four or more yeast infections in 1 year. The possibility of uncontrolled diabetes mellitus or immunodeficiency should be considered in women with recurrent vulvovaginal candidiasis. When it has been determined that no reversible causes are present (e.g., antibiotic therapy, uncontrolled diabetes, OCP use) and initial therapy has been completed, maintenance therapy may be appropriate. Selected long-term regimens include the use of clotrimazole and fluconazole. The role of boric acid and lactobacillus therapy remains in question.

45-year-old woman is noted to have four yeast infections in 1 year. Appropriate management of this patient should be A Continued observation and treatment only if symptomatic B Further evaluation for hypothyroidism C Blood test to look for the presence of diabetes and HIV infection D Prophylactic therapy with weekly metronidazole E Examination for endometrial structural abnormalities

C) Continue her yearly women's health examinations The patient is advised to have regular pelvic exams. The limited prevalence of ovarian cancer and the lack of sensitivity and specificity of current available tests have so far prevented the implementation of routine ovarian cancer screening of the general population. Hint: BRCA 1-2 has been found to be associated with ovarian cancers in approximately 5% of cases. However the expression of this gene in BRACA 1-2 carriers are unpredictable. Therefore, routine testing for this gene has limited value at this time Hint: The CA-125 recognizes the antigen CA-125 which is present in serous ovarian tumors but not in mucinous or nonepithelial ovarian tumors however the test is not considered a cost effective screening test. Hint: Refined imaging techniques offer promise for the future however much work remains before these tests are considered accurate or cost effective screening tests.

56 year-old female presents to the clinic wanting testing for ovarian cancer. Her best friend was just diagnosed with Stage 4 primary cancer of the ovary. She denies family history of breast or ovarian cancer. According to screening guidelines, which of the following do you recommend? A BRCA 1-2 gene testing B A pelvic ultrasound yearly C Continue her yearly women's health examinations D CA-125testing

B) Inferior wall myocardial infarction

63 year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis? A Aortic dissection B Inferior wall myocardial infarction C Acute pericarditis D Pulmonary embolus

B) Demineralization Osteoporosis presents with varying degrees of back pain and loss of height is common. The serum calcium, parathyroid hormone, phosphorus, and alkaline phosphatase are normal. Xray findings demonstrate demineralization in the spine and pelvis. *Hint: Chondrocalcinosis* is the presence of calcium-containing salts in articular cartilage and is commonly seen in hyperparathyroidism, diabetes, hypothyroidism, and gout. *Hint: Paget's* disease of bone presents with bone pain, kyphosis, bowed tibias, large head, and deafness. The initial lesions are destructive and radiolucent. Paget's disease has a normal serum calcium and phosphate, but the serum alkaline phosphatase is elevated. *Hint: Hyperparathyroidism* is frequently asymptomatic. Serum parathyroid hormone and serum calcium are elevated. X-ray findings include demineralization, subperiosteal resorption of bone especially in the radial aspects of the fingers.

65 year-old female presents to the office with a six-month history of back pain. The patient states that she is shrinking and thinks she is about an inch shorter than she was a year ago. Serum parathyroid hormone, calcium, phosphorus, and alkaline phosphatase are all normal. Which of the following would you most likely see on the x-ray of her spine? A) Radiolucent lesions B) Demineralization C) Chondrocalcinosis D) Subperiosteal resorption

Non-Small Cell Carcinoma

85% of lung cancers are of this type

B) Fluoxetine (Prozac) SSRI's provide symptom improvement for patients with premenstrual syndrome (PMS) Hint: Anxiolytics have shown to be effective however its potential for dependency makes it not the best choice.

A 32 year-old female complains of severe irritability and emotional lability accompanied by weight gain, breast tenderness, and headache starting mid-cycle each month and abating with the onset of menses. She has tried relaxation therapy, exercise, dietary changes and over the counter pharmacologic interventions with minimal relief of her symptoms. Which of the following prescription medications is the best choice to relieve her symptoms? A Alprazolam (Xanax) B Fluoxetine (Prozac) C Oral contraceptive pill (Ortho-novum 1/35) D Spironolactone (Aldactone)

B) Excisional biopsy Excisional biopsy is the next step in cases of bloody fluid, residual mass or thickening. Hint: Monthly follow-up is indicated in cases where the mass disappears with aspiration or the fluid is clear. Hint: Hormone therapy is indicated in cases of breast cancer that express hormone receptors. Hint: Repeat fine needle aspiration is indicated in solid masses which are benign or in which cytologic findings are inconclusive.

A 35 year-old female presents with a solitary breast mass. Fine needle aspiration reveals bloody fluid with no malignant cells. What is the next best step in the care of this patient? A) Monthly follow-up B) Excisional biopsy C) Hormone therapy D) Repeat fine needle aspiration

This patient presents with a paronychia or a localized abscess of the nail fold that should be incised and drained. (Oral antibiotics and warm soaks (C) are helpful if only cellulitis is present without abscess.)

A 44-year-old woman presents with pain to her second digit for 2 days. Physical examination reveals a small fluctuant area at the eponychium. What management is indicated?

D) Observation only for pseudocyst A pseudocyst is formed when pancreatic fluid leaks and is confined by organs adjacent to the pancreas. Eventually, a fibrous wall forms around the collection. Most cysts regress spontaneously over a period of several weeks, but in some cases complications such as bleeding, abscess formation, and intractable pain may occur. Several interventional approaches — surgical, radiologic and endoscopic — have been tried. Endoscopic ultrasound has gained popularity in the management of pseudocysts, as it can identify complex cyst wall structures, in particular pseudoaneurysms, do fine-needle aspiration to rule out a neoplasm, and find a favorable spot for drainage. Ruling out a cystic pancreas neoplasm before endoscopic drainage is essential, as attempts at transgastric emptying of a neoplasm can have disastrous effects and compromise further surgical management of the neoplasia. Indications for intervention are intractable pain, expanding lesions, and infection. A frequently quoted study found that complications such as bleeding, abscess formation, or perforation rose sharply after 6 weeks of observation, and that intervention is warranted if a pseudocyst does not resolve in this period. However, more recent studies have challenged this assumption and proposed that observing asymptomatic pseudocysts for longer periods is safe. Pseudoaneurysms are found in 10% of pseudocysts. Signs suggesting a pseudoaneurysm include overt bleeding, sudden pseudocyst enlargement, and an abrupt fall in hematocrit. Their presence is a concern when drainage is considered and does not lead to a higher overall bleeding rate or constitute indication for intervention. Angiography has higher sensitivity and can perform therapeutics, but an angio-CT scan has adequate sensitivity for ruling out a pseudoaneurysm before proceeding with therapeutics. When intervention is warranted, angiographic coil embolization and operative resection can be performed.

A 48-year-old Caucasian man presents with severe epigastric pain radiating to the back after a bout of drinking. Two weeks later, a repeat ultrasound showed a round, thin-walled hypoechoic lesion near the pancreas tail measuring 4 cm in its largest diameter and with some calcifications in its walls. MRCP visualized a communication between this cavity and the pancreatic duct. Endoscopic ultrasound detected an area of high-speed flow close to the gastric wall. Which of the following is the most appropriate next step in management? A) Perform angio-CT scan B) Perform angiography with coil embolization C) Refer for a Puestow procedure D) Observation only

B) CEA Hint: AFP is used to monitor recurrence of hepatocellular carcinoma. Hint: CA 19-9 is used to monitor recurrence of pancreatic carcinoma. Hint: CA-125 is used to monitor recurrence of ovarian carcinoma

A 65 year-old patient with adenocarcinoma of the colon in remission presents for follow-up. Which of the following tumor markers should be monitored? A) AFP B) CEA C) CA 19-9 D) CA-125

Adenocarcinoma The most serious complication of Barrett's esophagus is esophageal adenocarcinoma

A patient diagnosed with Barrett's esophagus is at an increased risk for the development of what type of cancer?

D) Small bowel Pain from the small intestine, appendix, or proximal colon causes *periumbilical pain* Hint: Pain from the stomach, duodenum, or pancreas causes *epigastric pain*. Hint: Pain from the bladder, uterus, or colon causes *hypogastric pain*

A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated with? A) Bladder B) Stomach C) Pancreas D) Small bowel

3%

A standard one unit phlebotomy (500 mL) should reduce the hematocrit by _____ percentage points in a normal-sized adult

*Salmanellosis* fever (often with chills), nausea and vomiting, cramping abdominal pain, and diarrhea, which may be grossly bloody, lasting 3-5 days. Differentiation must be made from viral gastroenteritis, food poisoning, shigellosis, amebic dysentery, and acute ulcerative colitis. The diagnosis is made by culturing the organism from the stool. In most cases, treatment of uncomplicated enterocolitis is symptomatic only. However, patients who are malnourished or severely ill, patients with sickle cell disease, and patients who are immunocompromised (including those who are HIV-positive) should be treated with ciprofloxacin,

Abdominal pain, fever, cramping, vomiting, mucus + bloody diarrhea lasting 3-5 days.

JNC-8 recommends treating hypertensive adults > 60 years old to a goal of < 150/90 mm Hg,

According to JNC-8, patients older than 60 years with hypertension and no other medical history, should be treated to which of the following blood pressure goals?

C) Vertebral spine Hint: Long bones are most commonly affected with osteomyelitis in children. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection

Adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis? A) Femur B) Humerus C) Vertebral spine D) Tibia

- Vitamin D = slows progression (consider adding calcium citrate of carbonate) - SERMS (Raloxifene) = used in postmenopausal women. Will decrease progression; is protective vs breast cancer; NOT associated with risk of endometrial cancer. - Estrogen = used in postmenopausal women. Also helps with the symptoms of menopause BUT increases risk for endometrial and breast cancer, CAD, stroke, VTE

After bisphosphonates how should we treat osteoporosis

B) Diphenhydramine The patient has pityriasis rosea. It most commonly occurs in the spring and fall seasons and is seen in older children and young adults. The rash initially presents with a single red lesion on the trunk, known as a herald patch. In about one to two weeks, the rash progresses to pink maculopapular oval patches covering the trunk in a characteristic "Christmas tree" pattern. Patients with pityriasis rosea require symptomatic treatment, including diphenhydramine to relieve itching. The rash resolves within 3-8 weeks and is not contagious.

An 11-year-old girl presents with a rash for the past 2 weeks. Her mother states that the rash began as a single red spot on the patient's upper back and then spread to the rest of her body. On physical exam, you note pink maculopapular oval patches on the patient's trunk. What treatment is indicated? A) Acyclovir B) Diphenhydramine C) Topical ketoconazole cream D) Trimethoprim-sulfamethoxazole

A) nulliparity.

An increased incidence of breast cancer is associated with A nulliparity. B late menarche. C trauma to the breast. D early natural menopause.

*Goodpasture's Disease* a disorder in which circulating antibodies are directed against an antigen intrinsic to the glomerular basement membrane (GBM), thereby resulting in acute or rapidly progressive glomerulonephritis that is typically associated with crescent formation. Goodpasture's syndrome and Goodpasture's disease are often used synonymously to refer to anti-GBM antibody-mediated disease, which typically presents with the syndrome of glomerulonephritis and pulmonary hemorrhage. There is short-lived production of circulating autoantibodies, which are directed against an antigen intrinsic to the glomerular basement membrane (GBM), in response to an unknown inciting stimulus

Anti-GBM antibody disease

Pip/Tazo (Zosyn) Cefepime

Anti-pseudomonal beta-lactams for pneumonia

Lambert-Eaton Syndrome

Antibodies against calcium-gated channels at the neuromuscular junction leads to weakness *similar to myasthenia gravis*

Do not lower unless >/= 185/110 in candidate for thrombolytic >/= 220/120 in patient NOT candidate for thrombolytic

BP reduction strategy for acute phase of ischemic stroke

Rapid reduction to SBP 100-120 within 20 minutes

BP reduction strategy in Acute Aortic Dissection

Anti-pseudomonal betalactams AND anti-pseudomonal Aminoglycoside or FQ

Basic treatment of hospital acquired pneumonia

Beta Thalassemia

Become syptomatic at 6 months, frontal bossing and maxillary overgrowth, hepatosplenomegaly, severe hemolytic anemia (jaundice, dyspnea, pallor), osteopenia, iron overload, pigmented gallstones

light chain immunoglobulins in the urine The presence of light chain immunoglobulins in the urine causing renal toxicity. Bence Jones protein causes direct renal tubular toxicity and results in tubular obstruction by precipitating in the tubules.

Bence-Jones proteins

*Peak Expiratory Flow Rate (PEFR)* Best to obtain baseline. PEFR >15% from initial attempt = no response to treatment. Normal 400-600. Best used for monitoring patients. the maximal rate that a person can exhale during a short maximal expiratory effort after a full inspiration. In patients with asthma, the PEFR percent predicted correlates reasonably well with the percent predicted value for the forced expiratory volume in one second (FEV1)

Best and most objective way to assess asthma exacerbation severity & patient response in the ED

Lyme disease

Bilateral facial nerve palsy is virtually pathognomonic for _____________________.

Mitral Regurgitation (MR)

Blowing, holosystolic (pansystolic) murmur at apex with radiation to axilla (high-pitched). increased venous return increases murmur, decreased venous return decreases murmur A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

*Usually not helpful* may help rule out other etiologies. Usually normal but may or may not show hyperinflation.

CXR in asthma

No, Cesarean delivery is indicated for all patients with sonographic evidence of complete placenta previa.

Can a woman with complete placenta previa undergo a vaginal delievery?

No. The vaccine is made from one protein from the virus that cannot cause HPV infection or cancer.

Can administration of the HPV vaccine cause cancer?

Yes. The concerning change in muscle receptors that occurs from burns takes place over 7-10 days after the burn.

Can succinylcholine be used for rapid sequence intubation in an acute burn patient?

Use of Adenosine in patients with asthma/COPD may cause bronchospasm

Caution with Adenosine in treatment of PSVT

Alpha Thalassemia Intermedia = Hemoglobin H disease = 3/4 abnormal alleles Presentation is similar to beta-thalassemia major

Chronic anemia, pallor, hepatosplenomegaly, frontal and maxilla bony overgrowth, pathologic fractures, pigmented gallstones, iron overload

B) Perform a conization of the cervix A conization of the cervix is recommended in this case because there is a substantial discrepancy between the screening Pap test and the histologic data from biopsy and ECC. Additionally the ECC is positive for disease in this case.

Colposcopic examination of the cervix of a 38 year-old woman with a high-grade lesion on Papanicolaou (Pap) smear yields a positive endocervical canal curettage (ECC) as its only abnormality. Which of the following is the most appropriate next step in this patient? A) Repeat the Pap smear in 3 months B) Perform a conization of the cervix C) Repeat the colposcopic examination in 3months D) No follow-up is required

Hirschsprung's disease also termed congenital aganglionic megacolon, results from a lack of ganglion cells in the bowel wall.

Congenital absence of ganglionic nerve cells innervating the bowel wall is seen in which of the following conditions?

Intracranial Abscess Tx: 3rd gen cephalosporin + metronidazole if no source known, neurosurgery consultation

Contiguous infection of middle ear, sinus, or teeth, surgery, trauma, hematogenous spread, HA, fever, focal neurological deficit, Ring enhancing lesions

*Avoid the AV nodal blockers!!! (ABCD)* ABCD = Adenosine, Beta-blockers, CCBs, Digoxin May cause preferential conduction through the fast pathway worsening the tachyarrhythmia

Contraindicated in treatment of WPW

drop it

Correction of DKA will invariably do what to the patients serum potassium?

NOT indicated unless history of underlying reactive airway disease

Corticosteriods for acute bronchiolitis

Mast Cell Modifiers - Asthma Inhibit acute phase response to cold air, exercise, and sulfites. Used as prophylaxis only; effective ppx may take several weeks. Minimal side effects (throat irritation)

Cromolyn (Intal) Nedocromil (Tilade)

*Small Cell Carcinoma* (SCLC) SCLC = *S*ome *C*ushings with *L*ung *C*ancer

Cushng syndrome (ectopic ACTH production) MC with what type of lung cancer?

Broca "expressive" aphasia MCA Dominant (usually L-side) defect

Defect in expressing speech, writing or signs

Urine Culture

Definitive diagnosis for pyelopnephritis

1) ↑Hgb/Hct; Hypercellular bone marrow; JAK2 mutation 2) ↑Hgb/Hct; Hypercellular bone marrow; ↓serum erythropoietin levels

Diagnostic criteria for Polycythemia Vera

Nucleic Acid Amplification Test (NAAT) NAAT of the first-catch urine is the diagnostic test of choice. In general, nucleic acid amplification testing (NAAT) is the test of choice for the initial microbiologic diagnosis of N. gonorrhoeae infection, although culture remains an important diagnostic tool when antibiotic resistance is suspected.

Diagnostic test of choice for Gonorrhea

Abdominal CT

Diagnostic test of choice for acute pancreatitis

No

Does neonatal ophthalmic erythromycin prevent infection with Chlamydia trachomatis?

Although rare, it can take place concurrently with fertilization or throughout the 1st trimester.

Does the presence of an intrauterine pregnancy rule out PID?

EBSTEIN'S ANOMALY

Downward displacement of the tricuspid valve into the RV, due to anomalous attachment of the tricuspid leaflets, the valve tissue is dysplastic and results in tricuspid regurgitation. The abnormally situated tricuspid orifice produces an "atrialized" portion of the RV lying between the atrioventricular ring and the origin of the valve, which is continuous with the RA chamber. Often, the RV is hypoplastic. What is the condition?

Inhaled Corticosteroids Effective long-term control with very low incidence of systemic side effects

Drug of choice for long term, persistent (chronic maintenance) of asthma

same as for outpatient Most experts recommend administering *a minimum of 5 days of therapy and continuing antibiotic use until the patient is afebrile for 48-72 hrs.*

Duration of treatment of CAP in hospitalized patients

B) Menorrhagia Amenorrhea (A) is the absence of bleeding for > 3 cycles. Metrorrhagia (C) is light uterine bleeding at irregular intervals. Menometrorrhagia is heavy uterine bleeding at irregular intervals. Oligomenorrhea is regular bleeding which cycles at intervals > 35 days. Polymenorrhea (D) is regular bleeding which cycles at intervals < 21 days. Dysfunctional uterine bleeding is a diagnosis of exclusion; refers to excessive, noncyclic bleeding which is mainly due to anovulation. Menorrhagia is excessive bleeding (> 80 mL per cycle) or menstruation > 7 days, which is mainly due to an anatomic or hemostatic abnormality.

During the menstruation section of a gynecologic history, you determine that your 36-year-old patient's menstrual periods are increasing in length from four days to eight days, even though she still cycles every 28 days. She also reports more blood flow than typical during the first three days of these new eight day periods. Which of the following terms correctly defines this abnormal uterine bleeding? A) Amenorrhea B) Menorrhagia C) Metrorrhagia D) Polymenorrhea

G6PD Deficiency

EPISODIC hemolytic anemia associated with sulfa drugs, fava beans, infections

Mitral Stenosis (MS)

Early-mid diastolic rumble @ apex (low-pitched) esp in LLD position* (± preceded by OS), increased venous return increases murmur, decreased venous return decreases murmur A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

Acute pancreatitis Lipase is more specific, Hct will be decreased if its hemorrhagic, ALT is ↑ 3x highly suggestive of gallstone pancreatitis, and the hypocalcemia is due to necrotic fat binding the calcium and lowering level in the blood.

Elevated amylase, lipase, and ALT with HYPOcalcemia

Meniere's Disease

Episodic peripheral vertigo lasting 1-8 hrs, horizontal nystagmus, nausea, vomiting

Meniere's Disease

Episodic vertigo lasting minutes to hours, tinnitus, ear fullness, fluctuating hearing loss (primarily low-tone hearing loss)

OA

Evening stiffness, decreases with rest, worsens throughout the day and with changes in weather, Hard bony Joints

↓serum iron as a consequence of ↑hepcidin produced by the liver in inflammatory states (which inhibits macrophage iron release), ↑ferritin (as an acute phase reactant) which sequesters iron into storage.

Explain the pathophysiology of anemia of chronic disease.

Metoprolol (Beta Blocker) or Diltiazem (CCB)

First line medication for rate control in atrial fibrillation

*TMP-SMX* (Bactrim) Patients with Shigella gastroenteritis typically present with high fever, abdominal cramps, and bloody, mucoid diarrhea In response to increasing minimum inhibitory concentrations (MICs) to fluoroquinolones among Shigella isolates in the United States the Centers for Disease Control and Prevention has recommended reserving antibiotic treatment for individuals with more severe symptoms, abnormal hosts, and special circumstances. Results of antimicrobial susceptibility testing should guide antibiotic regimen selection. *Treatment options generally include a fluoroquinolone, azithromycin, and a third generation cephalosporin (cefixime or ceftriaxone). Trimethoprim-sulfamethoxazole and ampicillin are also options if susceptibility is documented*.

First line treatment of severe shigellosis

Giardia Giardia duodenalis (also known as G. lamblia or G. intestinalis) is a protozoan parasite capable of causing sporadic or epidemic diarrheal illness. Giardiasis is an important cause of waterborne and foodborne disease, daycare center outbreaks, and illness in international travelers. Beavers are reservoirs for the protozoa.

Frothy, greasy, fould diarrhea, no blood or pus. Malabsorption with cramping and bloating.

Amebiasis Entamoeba histolytica infection occurs throughout the world, but the highest prevalence rates are found in developing countries in Asia, Africa, and Central and South America, where sanitation is suboptimal. E histolytica cysts are ingested by consuming contaminated food or water or via fecal-oral contact, often during sexual activity; hence, there is a higher prevalence among homosexuals. Clinically, colonic colonization by E histolytica produces a wide spectrum of symptoms ranging from no symptoms in the majority of patients to devastating pancolitis with toxic megacolon, requiring emergency colectomy and carrying a mortality rate as high as 50%. In most symptomatic individuals, mild initial diarrhea progresses to dysentery with blood and mucus in the stool and crampy abdominal pain, often with tenesmus.

GI Colitis, dysentery, liver abscess

Decrease BP (MAP) by no more than 25% within the first hour Decrease an additional 5-15% over the next 23 hours using IV agens

General management strategy in Hypertensive Emergency

Typhoid fever (Salmonella)

Gradual onset of malaise, headache, nausea, vomiting, abdominal pain. Relative bradycardia, splenomegaly, and abdominal distention and tenderness. Slow (stepladder) rise of fever to maximum and then slow return to normal. "Rose spots".

Hyperthyroidism, goiter, eye disease (orbitopathy), and occasionally a dermopathy referred to as pretibial or localized myxedema. caused by autoantibodies to the thyrotropin receptor (TRAb) that activate the receptor, thereby stimulating thyroid hormone synthesis and secretion and thyroid growth (causing a diffuse goiter). *The presence of TRAb in the serum and orbitopathy on clinical examination distinguishes the disorder from other causes of hyperthyroidism*. The terms Graves' disease and hyperthyroidism are not synonymous, because some patients may have orbitopathy but no hyperthyroidism, and there are many other causes of hyperthyroidism in addition to Graves' disease.

Graves disease

hepatitis B immunity due to administration of the hepatitis B vaccination. - *HBsAg* is a marker for the hepatitis B surface antigen, a protein on the surface of the hepatitis B virus. Presence of this protein in the body conveys that the person is currently infected and that they have either acute or chronic hepatitis B. - *Anti-HBc* is the total hepatitis B core antibody that appears at the onset of symptoms and remains for life. This marker indicates a previous or ongoing infection with hepatitis B. - *Anti-HBs* is the hepatitis B surface antibody, which is positive when a patient has recovered from the disease or when a patient has been immunized against the disease either by vaccination or prior infection.

HBsAg negative, anti-HBc negative, anti-HBs positive is the serologic marker combination indicative of...

Pulmonic Stenosis (PS)

Harsh mid-systolic ejection crescendo-decrescendo murmur (maximal & LUSB) radiates to neck. Murmur increases with inspiration. A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

Cluster Headaches Postulated Mechanisms: Vascular dilation, Trigeminal Nerve stimulation, Circadian rhythm association First line agents = Triptan Agents Oxygen Inhalation = Apply 100% via nonrebreather face mask at 12-15 Liters per minute for 15-20 minutes (Complete relief in 78% of patients)

Headache is unilateral, periorbital/temporal, sharp, lancinating, and comes in bouts lasting <2 hrs, worse at night and/or with EtOH

In the morning when intracranial pressure is highest after a night of recumbent positioning.

Headaches associated with a brain tumor are classically worse during what time of day?

Meniere's Disease Meniere disease is a condition that is thought to arise from abnormal fluid and ion homeostasis in the inner ear. The disease is named for Prosper Menière, a French physician who first reported that the inner ear could be the source of a syndrome manifesting episodic vertigo, tinnitus, and hearing loss. The classic pathologic lesion of Meniere disease is termed endolymphatic hydrops. This lesion can be definitively diagnosed only by postmortem histopathologic analysis of the temporal bone. However, hydrops has also been identified in postmortem examination of temporal bones where there was no history of Meniere symptoms. It is unclear why excess fluid builds up in the endolymphatic spaces of the inner ear. Several theories have been proposed, but all remain unproven. Periods of remission but *BOTTOM LINE, IT IS CHRONIC*

Hearing loss, tinnitus, aural (relating to the ear) fullness, with nausea/vomiting

Tricuspid Regurgitation (TR) Carvallo's sign = increased murmur intensity with inspiration (due to increased right sided blood flow during inspiration). Helps to distinguish TR from MR.

Holosystolic blowing high-pithced murmur at sub-xyphoid area (left mid-sternal border). Little to no murmur radiation. Increased murmur intensity with inspiration. A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

Stops RBC destruction

How can splenectomy help in certain cases of thalassemia?

Similar to B12 but NOT ASSOCIATED WITH NEUROLOGIC ABNORMALITIES Replacing folate if its B12 deficiency will correct the anemia but NEUROLOGIC SX WILL WORSEN!!

How can you differentiate between B12 and folate deficiency anemias? Why is this important?

T wave usually in opposite direction of the QRS Compensatory pause

How can you tell if a wide rhythm is a PVC?

Inhibition of that enzyme decreases aqueous fluid production

How do Carbonic Anhydrase Inhibitors treat Glaucoma?

fluorescein angiography The capabilities of fundus photographic imaging are enhanced by fluorescein, a dye whose molecules emit green light when stimulated by blue light. The dye highlights vascular and anatomic details of the fundus, making fluorescein angiography invaluable in the diagnosis and evaluation of many retinal conditions. Because it can so precisely delineate areas of abnormality, it is an essential guide for planning laser treatment of retinal vascular disease.

How do w diagnose wet macular degeneration?

Peripheral smear will show normocytic hemolytic anemia with heinz bodies

How do we diagnose G6PD Deficiency

Colposcopy and biopsy Pap and cytology is only used for screening. Colposcopy and biopsy Indicated for dysplasia or malignancy on Pap smear or symptoms suggesting more advanced disease. In the US, guidelines recommend that young women (21-29 years) should have a Pap test every 3 years.

How do we diagnose cervical cancer?

1) *Medicines called VEGF inhibitors* - These medicines come in shots that go right into the eye. They help keep new blood vessels from forming. 2) *Photodynamic therapy* - For this treatment, you get a shot of a medicine that "sticks to" abnormal blood vessels. This medicine becomes toxic when it is exposed to light. After you get the shot, a doctor or nurse shines a special light into your eye. When the light hits the medicine in the blood vessels in the back the eye, the medicine destroys the blood vessels. 3) *Laser surgery* - For this treatment, doctors shine lasers into the eye and use them to destroy abnormal blood vessels in the retina.

How do we manage wet macular degeneration

Metronidazole + fluid/electrolyte replacement The approach to treatment of symptomatic individuals with giardiasis includes antimicrobial therapy and supportive care (eg, correction of fluid and electrolyte abnormalities resulting from the diarrhea).

How do we treat Giardia?

By reducing both lipolysis and glucagon secretion (and it may augment ketone utilization.) Inhibition of lipolysis requires a much lower level of insulin than that required to reduce the serum glucose concentration. Therefore, if the administered dose of insulin is reducing the glucose concentration, it should be more than enough to stop ketone generation

How does insulin diminish ketone production?

decreases Ca++ mediated smooth muscle contraction

How does magnesium help treat severe asthma?

*Metronidazole* Invasive colitis is generally managed with metronidazole (alternative therapies include tinidazole, ornidazole, and nitazoxanide), followed by a luminal agent (such as paromomycin, diiodohydroxyquin, or diloxanide furoate) to eliminate intraluminal cysts. A 10-day course of metronidazole eliminates intraluminal infection in many cases, but a second agent is still warranted. Asymptomatic patients with E. histolytica (and not E. dispar or E. moshkovskii) should be treated with an intraluminal agent alone.

How is Amebic colitis (Amebiasis) treated

≈4 months

How long do folate stores last in the body?

4-6 weeks (aminoglycosides used only for first 2 weeks)

How long do we treat infectious endocarditis?

squamous cell carcinoma Squamous cell carcinoma was the most frequent histologic type of lung tumor in nearly all studies done prior to the mid-1980s. Now, adenocarcinoma is more common than squamous cell carcinoma, particularly in women. Most squamous cell carcinomas (60 to 80 percent) arise in the proximal portions of the tracheobronchial tree. The diagnosis of squamous cell carcinoma is predicated upon the presence of keratin production by tumor cells and/or intercellular desmosomes (referred to as "intercellular bridges")

Hypercalcemia MC with what type of lung cancer?

Fenoldopam Fenoldopam is useful in renal insufficiency because it causes an increase in blood flow to the kidneys. It acts as a selective peripheral dopamine-1-receptor agonist with arterial vasodilator effects. Its hemodynamic effects are a decrease in afterload and an increase in renal perfusion.

Hypertensive emergencies: acute renal failure - 1st line treatment

Ketamine

IV anesthetic that may be used as adjunct to asthma treatent due to bronchodilator effects

B) Secretory luteal phase under the influence of estrogen and progesterone. The endometrial changes seen in the latter half of the cycle are under the influence of both estrogen and progesterone from the corpus luteum. During this phase, the endometrium becomes more vascularized and slightly edematous.

If a woman has a normal 28-day menstrual cycle what tissue and hormonal phase occurs during the last 14 days? A) Proliferative follicular phase under the influence of estrogen. B) Secretory luteal phase under the influence of estrogen and progesterone. C) Proliferative follicular phase under the influence of estrogen and progesterone. D) Secretory luteal phase under the influence of estrogen

48 hours

If atrial fib has been present for < __________ we can go right to sync cardioversion

*phenobarbital* If SE persists, phenobarbital may be given. However, if duration of SE is prolonged, this step is sometimes skipped and general anesthesia started.

If fosphenytoin/phenytoin don't abort the seizure what do you try next?

Calcitonin

Inhibits bone resporption

C) Scabies Usually spares the neck & face. - commonly found in the intertriginous zones including web spaces between fingers/toes, scalp.

Intensely pruritic lesions:* papules, vesicles & linear burrows* Intense pruritus with minimal skin findings increased intensity at night* A) Lice B) Molluscum contagiosum C) Scabies D) Tinea infections

D) Cluster It is generally seen in lesions in the low pons or upper medulla. It differs from Cheyne-Stokes pattern because there is no increasing and decreasing depth of respirations.

Irregular breathing with periods of apnea that occurs at irregular intervals. What is the breathing pattern? A) Cheyne-Stokes B) Apneusis C) Ataxic D) Cluster E) Kussmaul

Alzheimer's, vascular dementia, Creutzfeldt-Jakob disease

Irreversible Causes of Dementia

40 - 60

Junctional rhythm rate

Small Cell Lung Cancer

Lambert-Eaton is often associated with what other condition?

A) Extensor carpi radialis brevis Lateral epicondylitis, commonly referred to as tennis elbow, is an inflammatory condition involving the lateral epicondyle of the humerus. The lateral epicondyle is the site of origin for the wrist and digit extensors and the forearm supinators. Muscles that originate at the lateral epicondyle include the extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris. Lateral epicondylitis is often the result of repetitive supination of the forearm. Patients present with focal tenderness over the lateral epicondyle as well as proximal wrist extensor muscle mass pain with resisted wrist extension with the elbow in full extension, and pain with passive wrist flexion with the elbow in full extension. Treatment includes nonsteroidal anti-inflammatory medications and activity modification. A counterforce brace placed distal to the elbow and physical therapy is recommended as well.

Lateral epicondylitis involves inflammation at the attachment of which of the following muscles? A) Extensor carpi radialis brevis B) Flexor carpi radialis C) Pronator teres D) Triceps

Prolactin Helps to differentiated it from pseudoseizures. Serum prolactin assessment has limited utility as a diagnostic test for epileptic seizures and is not recommended as part of the routine evaluation. In selected cases, an elevated serum prolactin may be useful in differentiating generalized tonic-clonic and focal seizures from psychogenic nonepileptic seizures in adults and older children. A low serum prolactin does not exclude epileptic seizure, although it lowers the likelihood of an epileptic seizure if the event appeared to be a generalized tonic-clonic seizure.

Levels of this hormone are increased in seizures

a sensation of electricity traveling down the spine triggered by flexion of the neck muscles

Lhermitte phenomenon

Severe COPD

MAT classically associated with....

Mycoplasma pneumoniae Lacks cell wall = doesn't respond to beta-lactams The mainstays of therapy for possible M. pneumoniae infection are macrolides such as erythromycin and azithromycin, doxycycline, or a fluoroquinolone such as levofloxacin or moxifloxacin.

MC cause of ATYPICAL (walking) pneumonia

*Hypomagnesemia / hypokalemia* Hypokalemia and hypomagnesemia can predispose to TdP. These disorders can occur together since hypomagnesemia directly causes hypokalemia.

MC cause of Torsades De Pointes

GABHS (± occur after any infection)

MC cause of post Infectious Acute Glomerulonephritis (AGN)

unknown (37%) followed by vasovagal (reflex mediated, 21%), cardiac (10%), orthostatic (9%), medication related (7%)

MC cause of syncope

A fib

MC chronic arrhythmia

Asthma

MC complication of bronchiolitis later in life

Sulfa drugs

MC medical trigger for G6PD deficiency acute hemolytic anemia episode

Theophylline SE

MC nervousness, nausea, vomiting, anorexia, headache, diuresis, tachycardia, CNS/Respiratory stimulant. Many drug interactions. Narrow therapeutic index.

orchiectomy with retroperitoneal lymph node disection

Management for low-grade (stage 1) nonseminoma (limited to testes)

Phlebotomy Therapeutic phlebotomy is the mainstay of controlling RBC mass. We recommend that the hematocrit be maintained at <45 percent in all patients with PV; some experts suggest hematocrit targets of <45 percent in men and <42 percent in women. A standard one unit phlebotomy (500 mL) should reduce the hematocrit by 3 percentage points in a normal-sized adult (eg, from 46 to 43 percent). Since phlebotomy controls polycythemia by producing a state of absolute iron deficiency, iron supplementation should not be given. May also give low-dose aspirin

Management of choice for Polycythemia Vera

Vagal, beta-blocker, or CCB

Management of stable atrial flutter

*Hereditary Spherocytosis* Hereditary spherocytosis (HS) is the most common hemolytic anemia due to a red cell membrane defect. It is a result of heterogeneous alterations in one of six genes (most often the ankyrin gene) that encode for proteins involved in vertical associations that tie the membrane skeleton to the lipid bilayer. The diagnosis of hereditary spherocytosis (HS) is suspected in the presence of anemia, jaundice, and splenomegaly in a subject with a positive family history of hemolytic anemia. Routine blood counts reveal anemia and reticulocytosis, a low mean corpuscular volume (MCV), increased mean corpuscular hemoglobin concentration (MCHC), and an increased red cell distribution width (RDW). Spherocytes are prominent on the peripheral blood smear. Direct and indirect antiglobulin tests are negative.

Microspherocytes, Coombs NEGATIVE

Tricuspid Stenosis (TS)

Mid-diastolic murmur at left lower sternal border (xyphoid border) (4th ICS). Low frequency. increased venous return increases murmur, increased on inspiration, decreased venous return decreases murmur. A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

Mitral Valve Prolaps (MVP) Any maneuver which makes the LV smaller (Valsalva, standing) results in earlier click & longer murmur duration (2ry to increased prolapse). Squatting decreases & delays click onset.

Mid-late systolic ejection click best heard at the apex ± mid-late systolic murmur. A) Aortic Stenosis (AS) B) Aortic Regurgitation (AR) C) Mitral Stenosis (MS) D) Mitral Regurgitation (MR) E) Mitral Valve Prolaps (MVP) F) Hypertrophic Cardiomyopathy (HCM) G) Pulmonic Stenosis (PS) H) Pulmonary Regurgitation (PR) I) Tricuspid Stenosis (TS) J) Tricuspid Regurgitation (TR)

↓serum erythropoietin levels Erythropoietin (EPO) is essential for the terminal maturation of erythroid cells. EPO is a glycoprotein cytokine secreted by the kidney in response to cellular hypoxia; it stimulates red blood cell production in the bone marrow.

Minor diagnostic criteria for Polycythemia

Levodopa/Carbidopa (Sinemet) By far the single most effective agent. carbidopa reduces the amount of levodopa needed → less SE of levodopa. This agent should be the first line and main agent used for Parkinsonism. All other agents are adjuncts only. Treatment is symptomatic as no curative or disease-modifying agents are available. Treatment is designed to supplement depleted dopamine stores in the substantia nigra, thus minimizing or eliminating symptoms and improving quality of life. Early in the disease, dopaminergic supplementation is often sufficient to markedly reduce, and even eliminate, symptoms. However, as the disease progresses, complications develop. Adjunctive medication regimens are moderately effective in managing these complications. However, ultimately the disease progresses, and in most patients medications will become less effective and complications will make treatment challenging.

Most effective treatment for the management of parkinson disease.

Teratoma

Most testicular cancers are uniform and smooth except for which irregular-border subtype?

Patho: Malignant proliferation of plasma cells derived from a single clone. The cause of myeloma is not known. Presentation: Bone pain is the most common symptom in myeloma, affecting nearly 70% of patients. Unlike the pain of metastatic carcinoma, which often is worse at night, the pain of myeloma is precipitated by movement. Plasma cell = a fully differentiated B cell that produces a single type of antibody.

Multiple myeloma

*tapping the bridge of nose repetitively causes a sustained blink.* Myerson's sign or glabellar tap sign is a medical condition where a patient is unable to resist blinking when tapped on the glabella, the area above the nose and between the eyebrows. It is often referred to as the glabellar reflex. It is often *an early symptom of Parkinson's disease*, but can also be seen in early dementia as well as other progressive neurologic illness.

Myerson's sign

Prednisone, Solumedrol (methylprednisolone), Prenisolone

Name 3 corticosteroids used to treat acute asthma exacerbations

1) *Ceftriaxone* (Rocephin), 2) Cefotaxime 3) Amp/sulbactam (Unasyn) 3) Ertapenem Beta-lactam antibiotics inhibit the growth of sensitive bacteria by inactivating enzymes located in the bacterial cell membrane, known as penicillin binding proteins, which are involved in cell wall synthesis. These antibiotics are generally bactericidal against susceptible organisms.

Name 4 Betalactams for treatment of pneumonia

Diabetic autonomic neuropathy, gastroparesis, hyperthyroidism, scleroderma, amyloidosis.

Name some organic causes of altered intestinal motility?

1) Brimonidine ($$) 2) Apraclonidine ($$$$) *** think the "-onidines" like clonidine, will probably go with Brimonidine because it is cheaper.

Name the 2 Alpha-2 agonists used for Acute angle closure glaucoma in PPP

*Selegeline*, Rasagiline

Name the 2 MAO-B inhibitors in PPP to treat Parkinson Disease

1) Pilicarpine ($) 2) Carbachol ($$)

Name the 2 miotics/cholinergics for Acute angle closure glaucoma in PPP

1) Gingival hyperplasia 2) Steven Johnson Syndrome 3) Hirsutism

Name the 3 SE of phenytoin mentioned in PPP

D) Chadwick's sign Hint: McDonald's sign is when the uterus becomes flexible at the uterocervical junction at 7-8 weeks. Hint: Hegar's sign is the softening of the cervix that often occurs with pregnancy.

On examination of a pregnant patient the physician assistant notes a bluish or purplish discoloration of the vagina and cervix. This is called A Hegar's sign. B McDonald's sign C Cullen's sign D Chadwick's sign

A) Increased second heart sound split with inspiration due to the increased blood flow across the aortic and pulmonic valves. Hint: Diastolic murmurs in pregnancy should be considered pathological and evaluated further Hint: Facial edema in uncommon in pregnancy and if it occurs, the medical provider should consider preeclampsia. Hint: Hyperreflexia occurs with preeclampsia and does not occur in a normal pregnancy

On physical examination of a pregnant patient, which can be considered a normal finding? A Increased second heart sound split with inspiration B Diastolic murmur C Facial edema D Hyperreflexia

C) Endotracheal intubation and mechanical ventilation Indications for early endotracheal intubation and mechanical ventilation in treatment of flail chest include patients that are over the age of 65, have comorbid lung disease and associated severe head trauma. Other indications include shock, three or more associated injuries and fracture of eight or more ribs. *Hint: While application of elastic binders and adhesive tape was historically utilized to stabile the chest, this intervention has been found to decrease chest expansion and worsen lung atelectasis.*

On physical examination there is evidence of head trauma. The left side of the chest wall appears to move inward with inspiration and outward with expiration. A chest x-ray reveals multiple rib fractures on the left. Which of the following is the most appropriate intervention? A) Surgical fixation of the fractured ribs B) Application of elastic binders and adhesive tape C) Endotracheal intubation and mechanical ventilation D) Chest physiotherapy that encourages frequent coughing

B) Verapamil Beta blockers or Non-Dihydropyridine Calcium Channel blockers are first line to also provide rate control.

Optimum therapy for Hypertension in patient with atrial fibrillation. A) Lisinopri B) Verapamil C) Furosemide D) Losartan

D) Amlodipine (Norvasc) Use a CCB. Note: Losartan is the only ARB that doesn't cause hyperuricemia (so it can be safely used)

Optimum therapy for hypertension in a patient with Gout A) Spironolactone (Aldactone) B) HCTZ (Microzide) C) Atenolol (Tenormin) D) Amlodipine (Norvasc)

B) HCTZ (Microzide) Thiazides lower urinary calcium excretion.

Optimum therapy for hypertension in a patient with Osteoporosis and no other comorbidities A) Spironolactone (Aldactone) B) HCTZ (Microzide) C) Atenolol (Tenormin) D) Amlodipine (Norvasc)

A) Terazosin alpha-1 blockers. May cause 1st dose syncope, dizziness, headache, and/or weakness. Not used as 1st line.

Optimum therapy for hypertension in patient with BPH A) Terazosin (Hytrin) B) Furosemide (Lasix) C) Amlodipine (Norvasc) D) Losartan (Cozaar)

IV verapamil OR IV diltiazem (nondihydropyridines)

Orthodromic (narrow) Wolff-Parkinson-White syndrome: Acute termination, third line (after Vagal Maneuvers and IV adenosine)

Acetaminophen Toxicity Tx: is N-acetylcysteine Comments: Rumack-Matthew nomogram - stratifies the risk of liver failure

Patient will present after OD and be complaining of ​abdominal pain, nausea, vomiting, and diaphoresis, PE will show RUQ tenderness, Labs will show elevated AST and ALT

Rapidly Progressive Glomerulonephritis (RPGN) Rapidly progressive glomerulonephritis (RPGN) is a clinical syndrome manifested by features of glomerular disease in the urine and by progressive loss of renal function over a comparatively short period of time (days, weeks or months). It is most commonly characterized morphologically by extensive crescent formation Tx: Corticosteroids + Cyclophosphamide

Patients may present with hypertension, azotemia, oliguria, proteinuria, and edema. Renal insufficiency is present at diagnosis in almost all cases, with the plasma creatinine concentration often exceeding 3 mg/dL

Chlamydophila send IgM, IgG titers

Pneumonia: hoarseness, fever leads to respiratory symptoms after a few days,

Legionella pneumophila

Pneumonia: increased incidence in elderly, smokers, immunodeficient patients

Mydriasis (dilation of the pupil) Ex: dim lights, sympathoMIMETICS and ANTIcholinergics

Precipitating factor in acute angle glaucoma

Acetaminophen (Acetaminophen had decreased bleed risk, But NSAIDs are more effective)

Preferred initial treatment for OA in elderly with bleed risk and mild-mod disease?

Ciprofloxacin (Cipro®)

Quinoline antibiotic with broad-spectrum activity, especially against gram-negative bacteria, including Pseudomonas

3 doses over a MINIMUM of 6 months classically administered at day 0, at 2 months, and at 6 months. Minimum interval between first 2 doses is 4 weeks, minimum interval between 2nd and 3rd is 12 weeks.

Recommendation for HPV vaccine if >15y

None OR aspirin

Recommended therapy for CHADS2 score of 0

Warfarin OR aspirin

Recommended therapy for CHADS2 score of 1 (moderate risk)

*reactive arthritis* formerly known as Reiter syndrome, is the classic triad of peripheral arthritis, conjunctivitis, and urethritis or cervicitis ("can't see, can't pee, can't climb a tree).

Reiter Syndrome

Parkinson Disease

Relatively immobile face (fixed facial expression), widened palpebral fissures, Myerson's sign (tapping the bridge of the nose repetitively causes sustained blink). Decreased blinking. Seborrhea of the skin

Cryptogenic Organizing Pneumonia (COP) Formerly known as Bronchiolitis Obliterans with Organizing Pneumonia (BOOP) = Persistent alveolar exudates lead to inflammation and scarring of the bronchioles AND alveoli. Often idiopathic or occurs after pneumonia. Tx = Corticosteroids

Resembles pneumonia on CXR but does not respond to antibiotics

Macula

Responsible for central vision as well as detail and color vision

They can spread hematogenously and can cause pulmonary symptoms

Risk of nongerminal cell tumors in testicular cancer.

Often seen in CXR but not used for screening

Role of CXR in diagnosis lung cancer

Useful for central lesions

Role of bronchoscopy in diagnosis of lung cancer

May be useful for central lesions (Ex squamous and small cell)

Role of sputum cytology in diagnosis of lung cancer

Useful for peripheral lesions; CT or fluoroscopy guided

Role of transthoracic needle biopsy in diagnosis of lung cancer

*hepatitis, pancreatitis* Uses: Migraine/Headache; Bipolar Disorder; Seizure Disorders

SE of valproic acid

Small Cell Carcinoma

SIADH/HYPOnatremia associated with what type of lung cancer?

Phenobarbital

Seizure med associated with depression, osteoporosis, irritability and permanent neurologic deficit if injected into or near peripheral nerves.

Valproic Acid

Seizure med associated with pancreatitis and hepatotoxicity

Complex Partial (Temporal Lobe)

Seizure: Consciousness impaired, aura leads to impaired consciousness

Absence (Petit Mal) Seizure

Seizures: Brief lapse of consciousness, patient usually unaware of attack, brief staring episodes, eyelid twitching, NO post-ictal phase

*Acute angle closure glaucoma* True Optho Emergency!!! This is an unusual but frequently misdiagnosed cause of a red, painful eye. Asian populations have a particularly high risk of angle-closure glaucoma. When the pupil becomes mid-dilated, the peripheral iris blocks aqueous outflow via the anterior chamber angle and the intraocular pressure rises abruptly, producing pain, injection, corneal edema, obscurations, and blurred vision. In some patients, ocular symptoms are overshadowed by nausea, vomiting, or headache, prompting a fruitless workup for abdominal or neurologic disease. The diagnosis is made by measuring the intraocular pressure during an acute attack or by performing gonioscopy, a procedure that allows one to observe a narrow chamber angle with a mirrored contact lens.

Severe, sudden, unilateral ocular pain, red eye, blurred vision, nausea, vomiting, and/or headache

Pancoast Syndrome = tumors at the superior sulcus of the lung The growing tumor can cause compression of a brachiocephalic vein, subclavian artery, phrenic nerve, recurrent laryngeal nerve, vagus nerve, or, characteristically, compression of a sympathetic ganglion (the superior cervical ganglion), resulting in a range of symptoms known as Horner's syndrome.

Shoulder pain, miosis, ptosis, anhydrosis, atrophy of hand/arm muscles

*SHIN*s *S*. pneumo *H*. flu *I*nfluenza *N*. meningococcus

Sickel cell patients should be immunized for which pathogens?

Procainamide class Ia; thus it is a Na+ channel blocker and K+ channel blocking effect of cardiomyocytes . Ia lengthens the action potential (right shift)

Stable, wide complex tachycardia that you suspect is WPW, what should you give?

Lacunar Infarct Lacunar infarcts are small (0.2 to 15 mm in diameter) noncortical infarcts caused by occlusion of a single penetrating branch of a large cerebral artery. These branches arise at acute angles from the large arteries of the circle of Willis, stem of the middle cerebral artery (MCA), or the basilar artery.

Stroke: Ataxic hemiparesis and clumsiness leg > arm

Lacunar Infarct Lacunar infarcts are small (0.2 to 15 mm in diameter) noncortical infarcts caused by occlusion of a single penetrating branch of a large cerebral artery. These branches arise at acute angles from the large arteries of the circle of Willis, stem of the middle cerebral artery (MCA), or the basilar artery.

Stroke: Dysarthria (clumsy hand syndrome)

ACA

Stroke: Greater in leg/foot > upper extremity, face is spared

middle cerebral artery (on the opposite side of the lesion.) The middle cerebral artery is the vessel most commonly involved in stroke, and clinical findings can be quite variable, depending on exactly where the lesion is located and which brain hemisphere is dominant. If the patient's dominant hemisphere with the language center is involved (most commonly left side of the brain), aphasia is present. If the nondominant hemisphere is involved, inattention, neglect, extinction on double-simultaneous stimulation, dysarthria without aphasia, and constructional apraxia (difficulty in drawing complex two-dimensional or three-dimensional figures) may occur.

Stroke: significant motor and sensory loss The upper extremities are affected more than the lower extremities and aphasia.

posterior cerebral artery stroke the posterior cerebral artery supplies the occipital lobe and cerebellum. The classic symptoms and signs of posterior circulation strokes include ataxia, nystagmus, altered mental status, and vertigo. Motor dysfunction, although common, is typically minimal, which can keep some patients from realizing they have had a stroke.

Stroke: visual changes, nystagmus, difficulty with coordination, ataxia, nausea and vomiting.

Clindamycin

Strong activity against gram-negative anaerobes such as B. fragilis; adequate gram-positive activity

Ethambutol (EMB)

TB this medication is associated with peripheral neuropathy and optic neuritis

Ranke's complex

TB: healed fibrocalcific complex on CXR

Pyrazinamide

TB: this medication can be given after 1st trimester

Rifampin

TB: what medication associated with thrombocytopenia?

Isoniazid Esp. if over 35 yrs of age

TB: what medication is associated with hepatitis?

Rifampin

TB: what medication is associated with orange colored urine?

Isoniazid Prevened by giving pyridoxine (B6)

TB: what medication is associated with peripheral neuropathy?

Pyrazinamide (PZA)

TB: what medication is associated with photosensitive dermatologic rash?

Linezolid May be preferred to Vancomycin

This antibiotic may be preferred in treatment of CA-MRSA CAP.

*Hydroxyurea* An antimetabolite. In sickle cell anemia, hydroxyurea increases red blood cell (RBC) hemoglobin F levels, RBC water content, deformability of sickled cells, and alters adhesion of RBCs to endothelium. exact mechanism of action unknown; inhibits ribonucleotide reductase, immediately inhibiting DNA synthesis

This medication is used to reduce the frequency of pain crisis in sickle cell disease

ASO titers

This titer is increased in Streptococcal infections, RA, and other collagen diseases

*Large Cell* (Anaplastic) Large Cell = Large Mortality Rate

This type of lung cancer has the worst prognosis.

Small Cell (Oat Cell) Carcinoma METs usually found on presentation, typically central, aggressive and because there are METs, surgery is usually NOT the treatment of choice.

This type of lung cancer typically metastasizes early

B) Elevate the legs. Dependent edema is a common and rarely serious complication of pregnancy due to impedance of venous return. Leg elevation improves circulation. Hint: Limitation of fluid is not indicated and may be harmful Hint: Thiazide diuretics are contraindicated and could be harmful.

To relieve dependent edema in a pregnant patient, which of the following should be instituted as treatment? A) Limit fluid intake. B) Elevate the legs. C) Prescribe thiazide diuretics. D) Strict avoidance of sodium.

Amoxicillin or Nitrofurantoin (Macrobid)

Treatment for cystitis in pregnant women

ACE inhibitors ± corticosteroids

Treatment of IgA nephropathy

A macrolide (Clarithromcin or Azithromycin) OR Doxycycline

Treatment of outpatient CAP in previously healthy patients with no recent (90 days) use of antibiotics.

worsening of MS symptoms with heat (ex: exercise, fever, hot tubs)

Uhthoff's phenomenon

Legionella

Very sick, old men, COPD, GI symptoms, CXR with patchy infiltrates...

COWS: Cold Opposite, Warm Same

Vestibulo-ocular reflex

Obesity, diabetes mellitus and HIV.

What are 3 predisposing factors for intertrigo?

*Blind spots, shaddows* associated with *macular degeneration*

What are scotomas?

Applying local heat and taking oral vitamin E or thiamine have been shown to give some improvement in managing primary dysmenorrhea.

What are some holistic therapies and supplements that have been shown to improve the pain of primary dysmenorrhea?

When straight lines appear bent associated with macular degeneration`

What is metamorphopsia?

Prophylactic colectomy.

What is the treatment for familial adenomatous polypsosis (FAP)?

Propranolol

What medication is recommended for the treatment of atrial dysrhythmias associated with hyperthyroidism?

Transillumination

What test is used to diagnose a hydrocele?

Impaired mobility of the tympanic membrane

Which of the following signs has the greatest likelihood ratio for acute otitis media?

Replacement leads to reticulocytosis with new cells taking up large amounts of potassium.

Why can B12 replacement cause HYPOkalemia?

Type II diabtetics make enough insulin to prevent ketogenesis usually Inhibition of lipolysis requires a much lower level of insulin than that required to reduce the serum glucose concentration.

Why do type 2 diabetics typically not get DKA even with higher blood sugars?

rule out gallstones, bile duct dilation, ascites, or pseudocysts

Why do we do abdominal US for suspected pacreatitis?

Patients are naturally iron overloaded These patients may look like iron deficiency anemia - hypochromic, microcytic - but their serum iron levels are normal to high.

Why do we want to avoid iron supplementation in thalassemia patients?

No, intramuscular B12 should be administered. Oral will not be absorbed.

Will administering oral vitamin B12 help to treat B12 deficiency in pernicious anemia?

iron deficiency anemia The major causes of iron deficiency are decreased dietary intake, reduced absorption, and blood loss. In adults in resource-rich countries, dietary intake is almost always adequate, and it is usually reasonable to assume that the cause is blood loss until proven otherwise, with the implied need to search for and identify the cause.

angular chelitis, nail spooning (koilonychia), pica

macrolides Antibiotic treatment does not significantly reduce the severity or duration of illness but does decrease infectivity. Childhood vaccination and clinical disease do not provide lifelong immunity (A).

antibiotic class of choice for pertussis

Prolonted QT interval

common predisposing condition for VT

hyperpathia

continued sensation after a stimulus is removed, such as continuing to feel vibration after a tuning fork is removed

patent ductus arterosus

continuous machine-like murmur.

Atopic dermatitis

erythematous, pruritic plaques, which are often located over flexor surfaces

Pyelonephritis ESSENTIALS OF DIAGNOSIS = Fever, Chills, Flank pain., More than 100,000 CFUs on urine culture. Pyelonephritis is an infection of the kidney parenchyma. Pyelonephritis usually results from upward spread of cystitis but can also result from hematogenous seeding of the kidney from another infectious source. The most common bacteria involved are the same organisms that cause uncomplicated cystitis: E. coli, S. saprophyticus, Klebsiella species, and occasionally Enterobacter. *Fever* is the main feature distinguishing cystitis and pyelonephritis. First-line outpatient treatment is usually a *fluoroquinolone* (Ciprofloxacin 1000 mg PO once daily x 7-14 days). Patients experiencing severe nausea and vomiting who are unable to tolerate oral agents may need to be hospitalized for parenteral therapy. Patients with severe illness, suspected bacteremia, or sepsis should also be admitted. Patients who do not respond to 48 hours of appropriate antibiotics should be worked up for occult complicating factors or other diagnoses.

fever, tachycardia, back/flank pain, CVA tenderness, nausea/vomiting

Histoplasma capsulatum (histoplasmosis)

fungal; regional, Mississippi River valley

Goodpasture's Disease There is short-lived production of circulating autoantibodies, which are directed against an antigen intrinsic to the glomerular basement membrane (GBM), in response to an unknown inciting stimulus. The prognosis of untreated acute glomerulonephritis due to anti-GBM antibody disease is extremely poor. In a previously described case series of 67 patients, death or dialysis ensued in over 90 percent of patients. In another review of 32 patients with Goodpasture's syndrome, 29 progressed to renal failure, most of them in less than six months. Tx: High dose corticosteroids + Cyclophosphamide + plasmapharesis (to remove the antibodies)

glomerulonephritis, pulmonary hemorrhage, and anti-GBM antibodies

Chlamydophila

gradual onset; dry cough, fever, wheezing; CXR with patchy infiltrates; non-toxic neonate with staccato cough, but affects all ages

aortic stenosis

harsh crescendo-decrescendo systolic murmur, heard loudest at the base of the heart and radiating to the neck.

Tinea versicolor

hyper-pigmented or hypo-pigmented papules, patches, and plaques. Scaling may also be present. A herald patch and Christmas-tree distribution are not present

PLASMA CELL MYELOMA (FORMERLY MULTIPLE MYELOMA) *CRAB*: hyper*C*alcemia, *R*enal insufficiency, *A*nemia, lytic *B*one lesions/*B*ack pain

hypercalcemia, renal, insufficiency, anemia, lytic bone lesions/back pain

D) pleural effusion Hint: Consolidation from pneumonia would have an increased tactile fremitus. Hint: pneumothorax is HYPERresonant to percussion Hint: Asthma is HYPERresonant to percussion because it is an obstructive disease (traps air)

lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause? A asthma B consolidation C pneumothorax D pleural effusion

Atypical pneumonia

low-grade fever, dry nonproductive cough, myalgia, malaise, sore throat, headache, n/v/d

Cardiac Syncope They include arrhythmia, ischemia, structural/valvular abnormalities (eg, aortic stenosis), cardiac tamponade, and pacemaker malfunction.

most common life-threatening conditions associated with syncope and thus the most important to diagnose or predict.

Ventricular Septal Defect Clinical: loud, harsh, holosystolic murmur at the lower left sternal border Dx: echo Tx: most close spontaneously

most common pathologic murmur in childhood

Anterior dislocations are most common and make up 95-97% of all shoulder dislocations.

most common type of shoulder dislocation?

Myofascial pain syndrome

multiple areas of localized musculoskeletal pain and tenderness in association with tender points. The pain is deep and aching and may be accompanied by a burning sensation, most often involves the posterior neck, low back, shoulders, and chest.

Reactive arthritis

peripheral arthritis, axial arthritis, constitutional symptoms, enthesitis (is inflammation of the entheses, the sites where tendons or ligaments insert into the bone.), mucous membrane involvement, skin rash, circinate balanitis, ocular manifestations, cardiac manifestations

*Stool culture* Shigella should be suspected in the setting of frequent, small volume, bloody stools, abdominal cramps, and tenesmus, particularly if accompanied by fever. Nausea and vomiting are notably absent in most patients. Stool culture is the preferred method for the diagnosis of Shigella, as it *provides an isolate for subsequent susceptibility testing*. A *leukemoid reaction* (defined as a white blood count of 50,000/mm3 or more) has been observed in Bangladesh among approximately 4 percent of patients, most commonly in children between 2 and 10 years of age (and not at all in children younger than one year of age). In this study, the mortality rate also was increased among patients with a leukemoid reaction (21 versus 7 percent). In contrast, *a study conducted in the United States found no association between disease severity and a high white blood cell count*

preferred method for the diagnosis of Shigella (high fever, abdominal cramps, and bloody, mucoid diarrhea)

Drusen Drusen are made up of lipids, a fatty protein. Drusen likely do not cause age-related macular degeneration (AMD). But having drusen increases a person's risk of developing AMD

small, round, yellow-white spots on the outer retina

*Myerson's sign* Think Parkinson Disease. Myerson's sign or glabellar tap sign is a medical condition where a patient is unable to resist blinking when tapped on the glabella, the area above the nose and between the eyebrows. It is often referred to as the glabellar reflex. It is often an early symptom of Parkinson's disease, but can also be seen in early dementia as well as other progressive neurologic illness.

tapping the bridge of nose repetitively causes a sustained blink.

atrial septal defect

the first heart sound may be normal or split, there may be a midsystolic pulmonary ejection murmur at the upper left sternal border, and in older children, the second hart sound may have fixed splitting

Lymphogranuloma vernereum

unilateral tender inguinal and femoral lymphadenopathy. The genital lesion is a small, shallow, painless vesicle or ulcer.

Lambert-Eaton Syndrome (Compared to myasthenia gravis which gets worse) Antibodies against calcium-gated channels at the neuromuscular junction leads to weakness similar to myasthenia gravis

weakness IMPROVES with continued use

<3y and >30y

what age group tends to get the nonallergic form of asthma?

JAK2 mutation Janus Kinase 2 gene (JAK2) resulting in unregulated hematopoiesis. JAK2 V617F mutation (96% of polycythemia cases) JAK2 exon 12 mutations (3% of polycythemia patients)

what causes Polycythemia?

Abnormal synthesis of DNA, nucleic acid and metabolism of erythroid precursors.

what does Vit B12 deficiency cause?

*osteomyelitis* (especially *salmonella*)

what infection is notable in sickle cell patients?

Postmenopausal and senile (old peopleO

what is "primary" osteoporosis?

Nonbacterial warty vegetations on both sides of the leaflets that can be a sourcr of embolization. Seen especially with SLE Tx: manage the SLE, may need anitcoagulation

what is Libman-Sacks Endocarditis

ice cravings Should make you suspect iron deficiency anemia

what is pagophagia?

Uhthoff's phenomenon = Multiple Sclerosis

worsening of symptoms with heat (ex: exercise, fever, hot tubs)

Polycythemia

↑RBC's, ↑WBCs, ↑platelets

- B12 deiciency - Folate (B9) Deficiency

Name the bolded Macrocytic Anemias in PPP (2)

1) Dyspnea 2) Wheezing 3) Cough (esp at night)

Name the classic triad of asthma

*BALS* *B*ronchoalveolar *A*denocarcinoma *L*arge cell *S*quamous vell

Name the types of non-small cell lung cancer

acetazolamide, beta-blockers, mannitol

What drugs do we use to lower IOP in *Acute angle closure glaucoma*

Intravenous ceftriaxone and Intravenous metronidazole.

What is an alternative regimen to treat endometritis?

Decreased milk volume production

What is the effect of cigarette smoking on breastfeeding?

Triptans

What is the first-line abortive therapy for moderate to severe migraine headaches?

High dose progestin preparations.

What is the first-line therapy for recurrent endometrial carcinoma?

Endometriosis abnormal growth of endometrium outside the uterus, particularly in the pelvis and ovaries. Retrograde menstruation is the most widely accepted cause; however its pathogenesis is not clearly understood. Ultimately, a definitive diagnosis of endometriosis is made only by histology of lesions removed at surgery.

"3 Ds," dysmenorrhea, dyspareunia, and dyschezia, as well as abnormal uterine bleeding are among the well-recognized manifestations

Reactive arthritis Patho: Inflammatory arthritis triggered by antecedent gastrointestinal or genitourinary infections. Clinical: enthesitis (inflammation of sites where tendons attach to bone), Dactylitis, Mucocutaneous Lesions (Circinate balanitis is an inflammatory lesion on the glans or shaft of the penis; keratoderma blennorrhagicum, a papular, waxy rash that affects primarily the palms and soles), Aphthous ulcers; Ocular Inflammation, Dx: The presence of HLA-B27 may be useful diagnostically, since it is found in up to one-half of patients with reactive arthritis. Tx: NSAIDs remain the treatment of first choice for the articular manifestations of reactive arthritis. DMARDs (sulfasalazine) may be considered in patients with reactive arthritis refractory to NSAIDs and glucocorticoids.

"Cant see, Cant pee, Cant climb a tree"

GLP-1 agonists = anti hyperglycemic MOA: incretin analog that increases glucose-stimulated insulin secretion and decreases glucagon secretion. Slows gastric emptying and reduces appetite. Only available as subQ injections. CI: don't mix with DPP4 Inhibitors (-gliptines) AE common: hypoglycemia, N/V, diarrhea, constipation, flatulence, dizziness, headache AE serious: angioedema, anaphylaxis, pancreatitis, renal dysfunction, injection site necrosis/cellulitis/etc

-tide

Mononucleosis

-year-old girl presents to the emergency department with a one-day history of rash. The rash is erythematous, macular, blanching, and covers her trunk and extremities. It is not painful or pruritic, and there are no vesicles, bullae or mucosal lesions noted. She has bilateral lymphadenopathy in the posterior cervical chains with splenomegaly on palpation of her abdomen. The rest of her physical exam is normal. Her pediatrician started an antibiotic last week for pharyngitis but she has not improved. What is the most likely etiology of her rash?

Polyarteritis Nodosa It is a multisystem, necrotizing vasculitis of small and medium-sized muscular arteries in which involvement of the renal and visceral arteries is characteristic. Polyarteritis nodosa does not involve pulmonary arteries, although bronchial vessels may be involved; granulomas, significant eosinophilia, and an allergic diathesis are not observed.

"starburst" livedo (painful violaceous plaques that are surrounded by livedo reticularis) is pathognomonic for what condition?

Sulfonylurea 2nd gen = antihyperglycemic Ex: Glipizide, Glyburide MOA: stimulates pancreatic beta cell insulin release. NOTE: can lead to hemolytic anemia in patient with G6PD deficiency; use caution or consider other agents AE common: weight gain, fatigue, diarrhea, nausea, dyspepsia, rash AE serious: leukopenia, thrombocytopenia, liver problems, blood problems.

-zide or -ride

*Carbonic Anhydrase Inhibitors* Note: Sulfonamide derivatives; verify absence of *sulfa allergy* before prescribing. *Used mainly to treat* *glaucoma*. Inhibition of that enzyme decreases aqueous fluid production

-zolamide

100% Oxygen (6-10L) For patients with acute cluster headache, we recommend initial treatment with either 100 percent oxygen or a triptan, in agreement with national guidelines and expert consensus. Oxygen should be tried first if available (eg, in a hospital or emergency clinic setting) since it is without side effects. Otherwise, subcutaneous sumatriptan 6 mg can be used as initial therapy.

1st line management of cluster headaches

*Lamotrigine*, *Topiramate*, Valproic Acid, etc. Lamotrigine & Topiramate: newer agents carry the benefits of improved side-effect profiles and fewer drug-drug interactions. Valproic acid: contraindicated during pregnancy, therefore, not a good option in most women of childbearing years. Most seizures remit spontaneously within two minutes and rapid administration of a benzodiazepine or antiseizure drug is not required. No single antiseizure drug is optimal for every patient or even most patients.

1st line management of grand mal seizures

*Azithromycin* 1 gram orally once as single dose

1st line treatment for Chlamydia in Pregnancy

Beta Agonist (SABA)

1st line treatment for acute asthma exacerbation

Nitro and Lasix Avoid Hydralazine and Beta Blockers in CHF

1st line treatment for hypertensive emergencies with Acute Heart Failure

A) IV rehydration IV rehydration with crystalloids for 24 to 72 hours is the mainstay of therapy for rhabdomyolysis. Hint: NSAIDS, such as Toradol (Ketorolac), should not be used due to the vasoconstrictive effects on the kidneys. Hint: Fasciotomy is indicated for compartment syndrome

25 year-old male presents to the ED with left calf pain and cramping, as well as nausea and vomiting. He admits to "partying with cocaine all night". He describes his urine as a dark brown color. Serum creatinine kinase (CK) is 1325 IU/L (Normal Range 32-267 IU/L). Which of the following is the initial mainstay of therapy for this condition? A IV rehydration B Fasciotomy C Toradol (Ketorlac) D Hydrotherapy

< 35 y/o = ceftriaxone/doxycycline,

26-year old sexually active man presents with a 3-day history of unilateral, painful testicular swelling. He reports subjective fevers and dysuria and denies nausea and vomiting. Urinalysis shows leukocyte esterase and greater than 10 white blood cells. What is the next step in management for this patient?

A Tetanus prophylaxis Tetanus prophylaxis should be initially considered in all burn patients. Hint: IV fluids are indicated for severe partial thickness burns covering more than 10% TBSA or in burns with complications. Hint: Debridement of blisters is controversial, however blisters on the palms and soles should remain intact.

28 year-old male presents with burns sustained from hot grease splashed on his left hand earlier this afternoon. The burn extends from his palm to the volar aspect of his wrist and has an erythematous base, covered by an intact blister. There are a few small scattered blisters over the dorsum of the left hand. Which of the following is the initial intervention of choice? A Tetanus prophylaxis B Admission to a burn unit C Intravenous fluid administration D Debridement of blisters

A) Apnea The patient in this vignette has a ductal-dependent cardiac lesion that requires a patent ductus arteriosus (PDA) to preserve blood flow from the aorta to the pulmonary artery. At approximately 1 week of age, the PDA may close and cause sudden cardiovascular collapse. PGE1 infusion is potentially life-saving, but it is important to be aware of its adverse reactions. For example, apnea is a known adverse reaction of PGE1 infusion; therefore, it is important to secure the airway with endotracheal intubation prior to its infusion.

A 1-week-old boy born at full term to a 16-year-old primigravida mother with no complications presents to the ED for lethargy. In the ED, his vital signs are T 37°C, HR 166, RR 82, and pulse oximetry of 80%. On exam, he is lethargic with diffuse pulmonary rales and rhonchi, cold extremity, and decreased peripheral pulses. Given concern for ductal-dependent cardiac lesion, you administer prostaglandin E1 (PGE1) infusion. Which of the following is a known adverse reaction of a PGE1 infusion? A) Apnea B) Hypertension C) Hypothermia D) Thrombocytosis

A) A single dose of 150 mg fluconazole Boric acid (B) and topical nystatin (D) are used in women who have complicated vulvovaginal candidiasis and who are allergic to fluconazole. Complicated infections are defined as having severe signs or symptoms, the presence of a candida species other than Candida albicans, or in women with a history of recurrent vulvovaginal candidiasis infections, poorly controlled diabetes mellitus, pregnancy, or immunosuppression. Metronidazole (C) is used in the treatment of bacterial vaginosis.

A 25-year-old woman with a recent history of antibiotic use presents to your office with a complaint of vaginal discomfort. For the past week she has been experiencing intense vaginal pruritus and has noticed a white discharge. Which of the following is the most appropriate next step in her management? A) A single dose of 150 mg fluconazole B) Boric acid intravagina for seven days C) Metronidazole 500 mg twice/day for seven days D) Topical nystatin 100,000 units daily for seven days

Ceftriaxone or Vancomycin + Gentamicin (replace the PCN with ceftriaxone)

Suggested empiric therapy for SUBACUTE native valve infective endocarditis, 2nd line

C) Placenta previa presents with sudden, painless, profuse bleeding in the third trimester Hint: Disseminated intravascular coagulation presents with systemic signs of bleeding and thrombosis and typically presents at the time of delivery.

A 30-week pregnant patient presents with sudden onset of profuse, painless vaginal bleeding. Which of the following is the most likely diagnosis? A Abruptio placentae B Uterine rupture C Placenta previa D Disseminated intravascular coagulation

drooping eyelids (ptosis) Severe, advanced cases of MG may show muscle weakness, however, it is usually proximal, not distal. The hypothenar muscles (D) would not likely be affected in MG. Very few cases display distal weakness.

A 35-year-old woman makes an appointment to establish primary care. Three months ago she was diagnosed with myasthenia gravis which is now only mildly symptomatic and is properly treated by a neurologist. Which of the following would you most expect to find during her intake physical examination?

D) Compartment pressure Compartmental pressures should be obtained as soon as possible. If they are elevated this is a surgical emergency. Hint: Doppler studies will confirm the presence of a decreased pulse. Hint: A. X-rays of the lower leg and ankle will only determine bone placement.

A 38 year-old male sustained a fracture of the left distal tibia following a 25-foot fall and is taken to the operating room for an open reduction internal fixation of the distal tibia. Sixteen hours post-op, the patient develops sustained pain, which is not relieved with narcotics. On passive range of motion of the toes the patient "yells" in agony. The patient also states that the top of his foot has decreased sensation. On physical examination the physician assistant notes that the leg is swollen and the foot is cool to touch. Based upon this information what diagnostic testing should be done? A X-ray of the lower leg and ankle. B Doppler studies. C Bone scan. D Compartment pressure

Graves' disease

An undetectable TSH, Antithyroid antibodies and thyroxine are elevated

B12 or folate deficiency Macrocytic Anemia

Anemia: Hypersegmented Neutrophils

Mesenteric thrombosis This patient is at risk for mesenteric ischemia due to advanced age, atherosclerosis and atrial fibrillation. This is the classic presentation for this condition with pain out of proportion to physical examination findings. Hint: Toxic megacolon is a complication seen with ulcerative colitis or electrolyte abnormalities in which the bowel loses its tone.

A 76 year-old female presents to the ED with the worst abdominal pain in her life. The pain began following a large meal and is located periumbilically. Although she is writhing in pain, she does not have an exacerbation of the pain on palpation of the abdomen. She has a history of coronary artery disease, asthma, and atrial fibrillation. Which of the following is the most likely diagnosis?

A) Anterior cerebral artery The patient has a stroke syndrome characteristic of the anterior cerebral artery. Patients with ischemic insults to the anterior cerebral artery will often affect frontal lobe function causing patients to lack insight and have impaired judgment. Motor function and sensation is decreased on the opposite site of the body with the lower extremities affected more than the upper extremities.

A 77-year-old man presents with left sided weakness. The patient woke this morning with difficulty moving his left side. On examination, his leg is weaker than his arm. Which vascular structure is likely responsible for this stroke? A) Anterior cerebral artery B) Basilar artery C) Middle cerebral artery D) Posterior cerebral artery

A) Cesarean section Internal fetal monitoring (B), multiple gestation (C), and premature rupture of membranes (D) also increase the risk for endometritis but are less common than cesarean delivery. Other risk factors include young maternal age, maternal HIV infection, and lower socioeconomic class. Postpartum endometritis is the most common puerperal infection, usually developing on the 2nd or 3rd day postpartum. Typically, the lochia has a foul odor, and the patient develops a leukocytosis. The infection begins in the endometrium and can extend to the myometrium or parametrium. It is a serious infection that can lead to complications such as peritonitis, septic thrombophlebitis, and necrotizing fasciitis. The pathogens involved are typically the flora of the bowel, perineum, vagina, and cervix. The strongest risk factor for endometritis is a cesarean section.

A woman presents with fever and foul-smelling vaginal discharge 3 days after delivery of a full-term fetus. She is febrile, with uterine tenderness on pelvic exam. Which of the following is the strongest risk factor for postpartum endometritis? A) Cesarean section B) Internal fetal monitoring C) Multiple gestation D) Premature rupture of membranes

Mediterranean (Ex: Greek, Italian)

Beta Thalassemia MC in what population

Underlying left ventricular dysfunction (LV EF < 30-35%).

What is the greatest risk factor for sudden death from ventricular fibrillation?

Mast Cell Modifiers Cromolyn (Intal) Nedocromil (Tilade)

Asthma: Inhibit acute phase response to cold air, exercise, and sulfites. Used as prophylaxis only; effective ppx may take several weeks.

LABA's Salmeterol (Serevent), Symbicort, Advair

Asthma: Prevents symptoms, especially nocturnal asthma

flecainide or propafenone BOTH = Class Ic antiarrhythmic; The class I antiarrhythmic agents interfere with the sodium channel. Ic does not significantly affect the action potential (no shift). stabilizes membranes; prolongs action potential phase 0.

Atrial Fib: generally select ________________ as the first antiarrhythmic drug for AF without structural heart disease, to include those with hypertension who do not have left ventricular hypertrophy.

Rhythm Control - DCC (syncronized cardioversion) - Pharm - Radiofrequency ablation

Atrial Fibrillation management in younger patients with lone A fib

B) CT scan of the orbit CT scan of the orbit is the study of choice to evaluate a suspected blowout fracture

An 18 year-old male who was struck in the left eye with a baseball presents with ocular pain, periorbital ecchymosis, and restricted upward gaze. Which of the following is the diagnostic study of choice in this patient? A Zygomatic arch x-ray B CT scan of the orbit C Ultrasonography D Fluorescein staining

AV Reciprocating Tachycardia one pathway within the AV node and a second pathway OUTSIDE the AV node (ex: WPW)

AVRT

1. fever, 2. chest pain, 3. the presence of new pulmonary infiltrates

Acute chest syndrome

Levofloxacin or Azithromycin

Add this drug if Legionella suspected in HAP

Vancomycin

Add this drug if MRSA suspected in HAP

IV Magnesium decreases Ca++ mediated smooth muscle contraction

Adjunct treatment for asthma, indicated in severe asthma

Kiesselbach's plexus Tx: direct pressure, packing, cautery,

Anterior nose bleeds:

*fluoroquinolones* (ie: ciprofloxacin) Because of increasing antimicrobial resistance, *fluoroquinolones* are the agents of choice for treatment of salmonella infections. *Trimethoprim-sulfamethoxazole* had been effective treatments but resistance has spread globally.

Antibiotic therapy for Typhoid fever

Primary TTP

Antibodies vs. ADAMTS13 leads to decreased ADAMTS13

IV procainamide Adenosine, verapamil, diltiazem, beta blockers, digoxin should all be avoided if NOT certain of diagnosis. Procainamide is the intravenous drug of choice for acute termination of suspected antidromic AVRT.

Antidromic (Wide) Wolff-Parkinson-White syndrome: Acute termination, Stable patients (if NOT certain of the WPW)

Nafcillin (Nafcil®)

Antistaphylococcal penicillin commonly used for cellulitis

A Urine Sodium <20 mEq/L and a Fraction of Excreted Na (FENa) <1%

Aside from BUN/Creatinine ratio, what other lab findings are consistent with prerenal acute renal failure?

Theophylline Not often used due to narrow therapeutic index. it is a methylxanthine (similar to caffeine). Theophylline has two distinct actions; smooth muscle relaxation (ie, bronchodilation) and suppression of the response of the airways to stimuli (ie, non-bronchodilator prophylactic effects). Bronchodilation is mediated by inhibition of two isoenzymes, phosphodiesterase (PDE III and, to a lesser extent, PDE IV) while non-bronchodilation effects are mediated through other molecular mechanisms.

Asthma: Bronchodilator that improves respiratory muscle indurance

HUS

Autoimmune hemolysis, Renal failure, Thrombocytopenia (ART) + Bloody diarrhea

"Cola-colored" / dark urine ***The presence of gross hematuria in nephritic is what distinguishes nephritic from nephrotic

What is the hallmark of acute glomerulonephritis (AGN)

Dopamine agonists (Bromocriptine) MOA: Directly stimulates dopamine receptors.

What medication is sometimes used in young patients to delay the use of levodopa

Borderline Personality Disorder (BPD)

Cluster B personality disorder, F > M, Splitting, Unstable mood and relationships, Self-mutilation, ↑suicide risk

Aspirin

What medication other than high-dose prednisone should be given to patients with giant cell arteritis?

2 weeks after initiation of therapy

When is TB patient no longer considered infectious?

D) Timolol : nonselective beta-2-adrenergic antagonist Brimonidine (A) is a selective alpha-2-agonist that decreases aqueous humour production and increases its drainage through the trabecular meshwork. Dorzolamide (B) is a carbonic anhydrase inhibitor that decreases production of aqueous humour. Lantanoprost (C) is a prostaglandin analog that increases drainage of aqueous humour.

During a round-table discussion with your ophthalmology team, you are asked to describe the mechanism of action of certain glaucoma medications. Which of the following correctly matches the drug to its action? A) Brimonidine : carbonic anhydrase inhibitor B) Dorzolamide : prostaglandin analog C) Lantanoprost : selective alpha-2-agonist D) Timolol : nonselective beta-2-adrenergic antagonist

B) 16 to 18. Hint: At 12 weeks, fundal height is palpable just above the pubic symphysis.

During a routine prenatal visit, the fundal height is found to be midway between the pubic symphysis and umbilicus. The number of weeks gestation is estimated to be A 10 to 12. B 16 to 18. C 20 to 22. D 26 to 28

IgA mesangial deposits on immunostaining the mesangium is a structure associated with the capillaries. It is continuous with the smooth muscles of the arterioles. It is outside the capillary lumen, but surrounded by capillaries. The diagnosis can be confirmed only by kidney biopsy with immunofluorescence or immunoperoxidase studies for IgA deposits. Given the generally benign course of patients with IgA nephropathy who have isolated hematuria, a renal biopsy is usually performed only if there are signs suggestive of more severe or progressive disease, such as persistent urine protein excretion of at least 500 mg/day (which may increase over time) or an elevated serum creatinine concentration. New-onset hypertension or a significant elevation in blood pressure above a previous stable baseline that does not exceed 140/90 mmHg (eg, from 100/60 to 130/80 mmHg) is also associated with a greater likelihood of progressive disease but is primarily seen in patients who also have one or both of the other adverse predictors. A number of other tests have been proposed for the evaluation of possible IgA nephropathy, but none are recommended

Dx of IgA Nephropathy

acute pancreatitis

Epigastric tenderness, decreased bowel sounds, tachycardia, dehydration, shock of severe

Low iron and stores are used up (↓ferritin [passengers] and ↑TIBC [available seats])

Explain iron deficiency anemia findings (Iron, ferritin, TIBC)

TTP The introduction of treatment with plasma exchange markedly improved the prognosis in patients, with a decrease in mortality from 85-100% to 10-30%.

Fever + Autoimmune hemolysis, Renal failure, Thrombocytopenia (ART) + Neurologic abnormalities (FAT RN), Normal coagulation studies

Azithromycin OR Respiratory FQ (moxifloxacin, gemifloxicin, levofloxicin) PLUS antipneumococcal beta-lactam (ampicillin-sulbactam (Unasyn), ceftriaxone (Rocephin), cefotaxime)

First-line therapy in ICU patients with CAP

Respiratory FQ (moxifloxacin, gemifloxicin, levofloxicin) OR Macrolide (azithromycin, clarithromycin) PLUS beta-lactam (cefotaxme, ceftriaxone, ampicillin)

First-line therapy in hospitalized patient with CAP

1) is volume repletion with normal saline. 2) bisphosphonates 3) osteonecrosis of the jaw

Immediate treatment for severe symptomatic hypercalcemia _______1__________. Long-term therapy of hypercalcemia of malignancy involves treatment with ______2________, which may cause _____3__________.

SubArachnoid Hemorrahge

Impaired consciousness without focal symptoms

hypokalemia Despite the total body potassium deficit, the serum potassium concentration is usually normal or, in approximately one-third of cases, elevated at presentation. This is largely due to insulin deficiency and hyperosmolality, each of which cause potassium movement out of the cells. The altered potassium distribution is rapidly reversed with the administration of insulin and can result in an often dramatic fall in the serum potassium concentration, despite potassium replacement

In DKA, correction of DKA invariably will cause what to happen to the potassium?

Deficient Usually due to urinary losses generated by the glucose osmotic diuresis and secondary hyperaldosteronism (retains Na+ and dumps K+ and H+). Correction of DKA invariably will cause hypokalemia. K+ repletion recommended if potassium is low/normal (ex. 20-40mEq/L if K+ <5.5). If potassium is high, hold repletion & then replete K+ when serum K+ falls into the normal range. Potassium replacement is initiated immediately if the serum potassium is <5.3 mEq/L.

In DKA, patient is always total body potassium

BPH Glaucoma

In what conditions are anticholinergics contraindicated in treatment of PD according to PPP?

patient with cavitary opacities on CXR

In what patients should you check Sputum fungal and mycobacterial cultures?

D) AB negative mother, spontaneous abortion Rho-GAM is indicated for an unsensitized Rh-negative patient who has had a spontaneous or induced abortion, ectopic pregnancy, or at the time of amniocentesis. It is also indicated at 28 weeks gestation and within 72 hours of delivery of an Rh-positive infant.

In which of the following maternal-fetal blood type pairings should the mother receive Rho-GAM? A A positive mother, O negative infant B A negative mother, O negative infant C AB positive mother, spontaneous abortion D AB negative mother, spontaneous abortion

serum Calcium, Phosphate, PTH, and ALP are usually NORMAL!!! Slight elevations of Alk Phos may occur following acute fractures. LOW vitamin D

Labs in osteoporosis

Parkinson Disease

Lewy bodies and loss of pigment cells seen in the substantia nigra

HPV DES (DiEthylStilbestrol, a synthetic estrogen used in OCPs back in the day)

List the two bolded risk factors for cervical carcinoma in PPP

IgA Nephropathy (Berger's Disease)

MC cause of acute glomerulonephritis worldwide

Streptococcus pneumoniae Gram Positive cocci in pairs. Of the approximately four million cases of pneumonia each year in the United States, pneumococcus (Streptococcus pneumoniae) is the most common agent leading to hospitalization in all age groups

MC cause of community acquired pneumonia

Hypertension two of the three described mechanisms for lacunar stroke are related to a chronic vasculopathy associated with systemic hypertension.

MC cause of lacunar infarcts

Anemia of chronic dz (ACD)

MC cause of normocytic anemia

Junctional dysrhythmias

MC rhythm seen with digitalis toxicity

Blood Cultures before antibiotic initiation - 3 sets at least 1 hour apart Echocardiogram - vegetations, abscess, valve perforation, prosthetic dehiscence

Major diagnostic criteria for infective endocarditis

Debulking chemo → orchiectomy and radiation

Management of high-grade seminoma

C) Staphylococcus aureus The most common pathogen associated with postpartum mastitis is Staphylococcus aureus which arises from the nursing infant's throat and nose

Mastitis associated with breastfeeding is most commonly caused by what bacteria? A Listeria monocytogenes B Escherichia coli C Staphylococcus aureus D Streptococcus pyogenes

Pneumonia Severity Index (PSI) AND CURB-65

Name the 2 widely used clinical prediction rules available to guide admission and triage decisions for CAP

1) iron deficiency 2) alpha/beta thalessemia 3) EARLY anemia of chronic dz (Lead poisoning is also in the differential)

Name the 3 MC causes of MICROcytic anemia

Mycoplasma pneumoniae, Chlamydia pneumoniae, and Strep pneumoniae

Name the 3 MC organisms in adult pneumonia (18- 40 yrs)

1) *↑Hgb*/Hct 2) Hypercellular bone marrow *biopsy* 3) *JAK2* mutation

Name the 3 Major diagnostic criteria for Polycythemia

- Methotrexate - Bactrim - Phenytoin

Name the 3 drugs that can cause folate deficiency anemias in PPP

1) Airway Hyperreactivity 2) Bronchoconstriction 3) Inflammation

Name the 3 main components of Asthma

1) Adenocarcinoma = 35% 2) Squamous Cell = 20% 3) Large Cell = 10%

Name the 3 types of non-small cell carcinoma

1) Absence (Petit mal) 2) Tonic-Clonic 3) Myoclonic 4) Atonic

Name the 4 types of Generalized Seizures

Strep pneumo, H flu, anaerobes, gram-negatives

Name the MC organisms in pneumonia in adults 45 yrs and older

Rheumatoid nodules Twenty percent of patients have subcutaneous rheumatoid nodules, most commonly situated over bony prominences but also observed in the bursae and tendon sheaths. Nodules are occasionally seen in the lungs, the sclerae, and other tissues. Nodules correlate with the presence of rheumatoid factor in serum ("seropositivity"), as do most other extra-articular manifestations.

Name this finding

Rubella and cytomegalovirus.

Name two common viral causes of prenatal hearing loss?

B) decreased serum phosphate Parathyroid hormone stimulates the osteoclasts to increase bone resorption, leading to elevated calcium levels. *PTH works in the kidney to increase calcium reabsorption and increase renal excretion of phosphorous*. Hematocrit is not affected by parathyroid hormone.

Primary hyperparathyroidism is characterized by which of the following? A) decreased serum magnesium B) decreased serum phosphate C) increased hematocrit D) increased bone density

The most important treatment is frequent instillation of saline into the nares followed by suctioning. Counsel parents that symptoms may persist for up to 3 weeks to help avoid unnecessary ED returns for persistent mild symptoms.

Primary treatment for bronchiolitis

B) growth of the lobules and alveoli. Prior to menses, the breast swelling that women notice is a result of the progesterone which is secreted from the corpus luteum. During menses, the swelling subsides. Hint: Proliferation of the mammary ducts is under the influence of estrogen.

Progesterone influence on the breast tissue prior to menstruation causes A) proliferation of the mammary ducts. B) growth of the lobules and alveoli. C) proliferation of Cooper's ligaments. D) increase in the number of glands of Montgomery.

prophylactic PCN from 4 months t 6 years Sepsis is seen with encapsulated organisms, often fatal, especially in children. Because The spleen is the dominant site for the production of IgM antibodies required for opsonizing encapsulated pathogens. Thus, whenever elective splenectomy is considered, patients should undergo appropriately timed preoperative immunization against Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), and Haemophilus influenzae type b

Prophylactic for sickle cell patients

Warfarin (Maintain INR between 2-3)

Recommended therapy for CHADS2 score 2 or above (high risk)?

partial or complete pituitary insufficiency due to *postpartum necrosis of the anterior pituitary* gland in women with severe blood loss and hypotension during delivery. (With destruction of 90% or more, symptoms of acute adrenal insufficiency predominate (see Adrenal Insufficiency). Women may present with persistent hypotension, tachycardia, hypoglycemia, and failure to lactate. If the condition is not treated promptly, serious complications and even death may occur)

Sheehan's syndrome

Thrombotic Thrombocytopenic Purpura

The classic picture is a pentad of microangiopathic hemolytic anemia, thrombocytopenia, fever, renal failure, and fluctuating neurologic symptoms. In clinical practice, the complete pentad is only present in about 5% of patients. Some patients will present with only minor, nonspecific complaints including weakness, gastrointestinal upset, and fluctuating neurologic complaints.

beta-hydroxybutyrate In humans, beta-hydroxybutyrate is synthesized in the liver via the metabolism of fatty acids.

The disappearance of ketoacid anions in the serum and correction of the ketoacidosis can be monitored by measuring ___________________ directly

*Survival advantage* Limiting some microbes' access to iron can reduce their virulence, thereby potentially reducing the severity of infection. Blood transfusion to patients with anemia of chronic disease is associated with a higher mortality, supporting the concept.

Theory behind anemia of chronic disease

kerion = Leads to scarring alopecia

This condition begins as Tinea capitis (scalp ringworm) that undergoes a delayed-type hypersensitivity reaction to the causative fungus. This inflammation causes the initial erythematous, scaly plaque of Tinea capitis to become boggy with inflamed purulent nodules and plaques.

underlying pulmonary disease, most commonly COPD.

This electrocardiogram demonstrates multifocal atrial tachycardia, a form of atrial tachycardia diagnosed on the electrocardiogram by three distinct p-wave morphologies. In approximately 60% of cases, patients have____________________________.

carotid artery dissection. Risk factors include minor neck trauma (cervical manipulation in this patient), family history of arterial disease, and connective tissue disorders.

This is the most frequent cause of stroke in patients < 45 years old.

Methimazole Pregnancy Category D (FDA) - There is positive evidence of human fetal risk. Methimazole crosses the placenta to a greater degree than propylthiouracil and has been associated with fetal aplasia cutis. However, propylthiouracil can be associated with liver failure. Some experts recommend propylthiouracil in the first trimester and methimazole thereafter. Radioiodine should not be used during pregnancy, either for scanning or for treatment, because of effects on the fetal thyroid. In emergent circumstances, additional treatment with beta blockers may be necessary. Hyperthyroidism is most difficult to control in the first trimester of pregnancy and easiest to control in the third trimester.

What medication should be avoided in the first trimester of pregnancy when treating hyperthyroidism?

Ectopic pregnancies.

What obstetrical complication occurs most often during the 6th and 8th week of pregnancy?

*E. coli* Gram negatives: Think pseudomonas and gram negative facultative anaerobic bacilli

What organism is associated with acute prostatitis in man >35 y

D) Basal body temperature measurements Hint: Endometrial biopsy (A) will identify changes associated with infertility, however it is *invasive and often done later* in the evaluation. Hint: Hysterosalpingogram (B) provides information about the internal female genital tract. This is *usually done later* in the work-up. Hint: Serum progesterone levels (C) drawn at mid-luteal phase *will help determine normal from abnormal cycles*. Levels above 15 ng/mL will indicate a normal cycle

What should be the initial evaluation of the etiology of infertility in a 25 year-old female who has been trying to conceive for 1 year? A) Endometrial biopsy B) Hysterosalpingogram C) Serum progesterone levels D) Basal body temperature measurements

Signs of HYPOkalemia Replacement leads to reticulocytosis with new cells taking up large amounts of potassium.

What signs must you watch out for with B12 replacement?

Fitz-Hugh-Curtis syndrome.

What syndrome can be seen when pelvic inflammatory disease spreads to the abdomen?

Serum and urine protein electrophoresis.

What tests may be ordered to confirm the diagnosis of multiple myeloma?

Valproic Acid, Clonazepam

What two medications does PP recommend for treatment of myoclonus?

1) Headache 2) vomiting

What two symptoms should make you think hemorrhagic stroke over ischemic stroke

16 & 18 (70%)

What two types of HPV are most common causes of cervical cancer

Wernike Defect in understanding speech or writing MCA Dominant (usually L-side) defect

What type of aphasia is "sensory"

Squamous Cell *C*entrally located *C*avitary lesions (central necrosis) hyper*C*alcemia *P*ancoast syndrome

What type of lungs cancer is "CCCP"

Middle/lower lobe

Where does primary TB show up on CXR?

Aminoglycosides and vancomycin Prevention of nephrotoxicity and ototoxicity. The practice of routine therapeutic drug monitoring originated when the guidelines for monitoring peak and trough concentrations of aminoglycosides were applied to vancomycin therapy, based on similarities in pharmacokinetic and toxicity profiles (e.g., nephrotoxicity and ototoxicity). Vancomycin is restricted use by CDC.

With which common anti- biotics must serum levels be determined?

*Shigella* Shigella species are a common cause of bacterial diarrhea worldwide, especially in developing countries. Shigella organisms can survive transit through the stomach since they are less susceptible to acid than other bacteria; for this reason as few as 10 to 100 organisms can cause disease. Given its relatively low infectious dose, Shigella transmission can occur via contaminated food and water and via direct person-to-person spread.

Young child with explosive watery diarrhea leading to febrile seizures

cystic fibrosis.

Young children with nasal polyp formation should be screened for which hereditary disorder?

B) Second degree Hint: A first degree tear involves the vaginal mucosa or perineal skin, but does not involve the underlying tissue. They are often so small that few or no stitches are required. Hint: Second-degree lacerations go deeper, into the underlying tissue and muscles but not into the rectal sphincter. These tears need to be stitched closed, layer by layer. Hint: A third degree tear extends through to the rectal sphincter, but not into the rectal mucosa. Hint: A fourth degree tear extends all the way into the rectal mucosa. goes through the anal sphincter and the tissue underneath it.

Your patient has just delivered her baby vaginally without difficulty. The patient has a laceration of the vaginal mucosa including the perineal body. You repair it without difficulty. On the chart you document this as what type of tear? A) First degree B) Second degree C) Third degree D) Fourth degree

Beta-hCG

______________________ is the most commonly elevated tumor marker in testicular cancer.

Ewing sarcoma

a cancer of bone and nearby soft tissues. It can occur at any age, but most commonly during the early teenage years. It most commonly occurs in the pelvic bones, chest wall and the middle of long bones.

von Hippel-Lindau syndrome

a rare, autosomal dominant genetic disorder characterized by several tumors: retinal and central nervous system hemangioblastomas, renal cell carcinoma, pheochromocytoma, pancreatic islet cell tumors and epididymal cystadenomas. Presenting symptoms include headache, balance problems, dizziness, weakness and vision problems.