UWorld- Internal Medicine

B. Dilated cardiomyopathy Dilated cardiomyopathy can be due to genetic causes, viral infection or toxins. It can present with progressive SOB & an XR revealing an enlarged cardiac silhouette.

40-year-old man comes to the ED due to increasing SOB. A CXR is obtained & shows an enlarged cardiac silhouette. Which of the following is the most likely diagnosis in this patient? A. Diaphragmatic hernia B. Dilated cardiomyopathy C. Flail chest D. Pleural effusion E. Tension pneumothorax

D. start the patient on oral Valacyclovir

56-year-old woman presents with a low grade fever & rash. 2 days ago patient had stabbing pain in left torso & became itchy& red over the past day. What is the next step in management? A. order a varicella-zoster PCR from a skin lesion B. prescribe topical acyclovir cream C. prescribe topical clobetasol propionate ointment D. start on oral Valacyclovir E. swab a lesion for viral culture

D. Hyporeflexia Guillain-Barre syndrome is characterized by rapidly progressive symmetric weakness (usually beginning in the legs) & diminished or absent DTRs. Patients also frequently have paresthesias, autonomic dysfunction & respiratory muscle weakness.

62-year-old man comes to the ED due to SOB & weakness. Over the past 4 days, he has had progressive difficulty walking due to bilateral leg weakness & has stumbled several times. The patient has also had tingling & numbness of his hands & feet as well as palpitations & light-headedness when he stands suddenly. For the past day, his hands have been weak, & he has had difficulty swallowing. The patient has had no fever, chest or abdominal pain or bowel/bladder dysfunction. Which of the following is most expected on physical exam of this patient? A. Bilateral papilledema B. Cogwheel rigidity C. Extensor plantar response D. Hyporeflexia E. Sensory level

C. mefloquine chemoprophylaxis until 4 weeks after return prophylaxis typically begins > 2 weeks prior to travel, continued during stay & d/c 4 weeks after return. Measures for avoiding mosquito bites also recommended. India is a malaria endemic country with high rates of chloroquine resist therefore atovaquone-proguanil, doxycycline or mefloquine should be given instead.

19-year-old college presents prior to a trip to India with concern for travel-related infections. He has no chronic medical conditions & is up to date with basic immunizations. PE is normal. Patient is advised to consume bottled water & avoid raw foods. Hep A & Typhoid vaccinations & prescriptions for traveler's diarrhea are provided. Which is the most effective measure for preventing malaria? A. chloroquine chemoprophylaxis during the travel period only B. chloroquine followed by primaquine therapy C. mefloquine chemoprophylaxis until 4 weeks after return D. mosquito repellent (DEET) use during the day E. use of insecticide-treated bed nets at night only

B. The rash will spontaneously resolve but may take 2-3 months. Pityriasis rosea typically presents with a solitary herald patch on the neck or trunk, followed by multiple smaller, oval lesions clustered in a Christmas tree pattern. No treatment is required bc the rash resolves spontaneously over weeks to months.

20-year-old woman comes to the office due to a rash. The patient first noticed a pink spot on her chest 2 weeks ago. The lesion was initially the size of a nickel, but it has since doubled in size. It began fading 3 days ago, but then multiple smaller, pruritic lesions erupted over the trunk. The patient has tried treating the rash with several OTC topicals emollients, but it has not improved. Temp is 36.7C (98.1F). On skin exam, the rash is present on the back, in a Christmas tress fashion there are multiple small, oval lesions in clusters. The rash spares the face, palms & soles. Serum rapid plasma reagin test is negative. Which of the following is the most accurate statement about this patient's disease process? A. The rash is highly contagious & the patient will need to be isolated B. The rash will spontaneously resolve but may take 2-3 months C. This disorder may result in joint inflammation & destruction D. This disorder requires ABX to prevent cardiac complications E. Topical corticosteroids will clear the rash, but relapses are likely

B. Miosis, decreased bowel sounds, hypotension This patient developed somnolence & decreased RR after ingesting unknown pills to avoid police arrest, which is suggestive of opioid intoxication. This confirmed by improvement of RR on administration of Naloxone (opioid antagonist). Decreased respiratory rate is the BEST indicator of opioid intoxication & is the m/c cause of opioid related mortality. Other presentations of opioid intoxication include: mitosis, depressed mental status, decreased bowel sounds & hypotension.

26-year-old man with depressed mental status is brought to the ED by police. Due to fear of arrest, he swallowed a handful of pills as the officers approached him. On exam, the patient responds to painful stimuli but is somnolent. RR is 6/min & after Naloxone bolus infusion increases to 14/min. Lungs are CTA. Which of the following findings were most likely present in this patient on initial assessment? A. Miosis, decreased bowel sounds, HTN B. Miosis, decreased bowel sounds, hypotension C. Miosis, increased bowel sounds, HTN D. Mydriasis, decreased bowel sounds, hypotension E. Mydriasis, increased bowel sounds, HTN

B. Eosinophilic esophagitis Eosinophilic esophagitis (EoE) usually presents as intermittent solid food dysphagia & most common affects younger men (20-30) with atopic conditions (asthma, allergies & eczema). Untreated disease can lead to fibrosis leading to esophageal stricture that result in progressive dysphagia & food impaction. Management includes dietary therapy (allergen avoidance, elimination diet), PPIs & topical glucocorticoids (Fluticasone, Budesonide). Other common symptoms include refractory gastroesophageal reflux & chest/upper abdominal pain. Endoscopic appearance includes furrowing; small whites exudates & multiple stacked, ringlike esophageal indentations (trachealization of the esophagus). Dx is confirmed with esophageal biopsy demonstrating > 15 eosinophils per high-power field.

29-year-old man comes to the office due to difficulty swallowing for the past 2 years. Pork, chicken & steak occasionally "get stuck" in his mid-chest seconds after he swallows. These episodes occur intermittently but with increasing frequency. He has no trouble swallowing water to alleviate his symptoms, but the patient occasionally vomits to eject solid foods. The patient takes antihistamines for allergies & Ibuprofen for knee pain. Vital signs & PE are unremarkable. Endoscopy shows circular rings & thickened, linear furrowing of the esophagus. The lower esophageal sphincter opens spontaneously. Which of the following is the most likely diagnosis? A. Achalasia B. Eosinophilic esophagitis C. Esophageal cancer D. Herpes esophagitis E. Pill esophagitis

E. Related donor kidney transplantation Living-donor renal transplantation provides the best survival benefits for patients with end-stage renal disease. Both living-donor & deceased-donor transplantation provide significant survival benefit over any form of chronic dialysis. Further benefits of renal transplantation over dialysis include better quality of life & improvement of associated complications (anemia, impaired bone metabolism).

34-year-old man with renal failure comes to the office for follow-up. The patient has chronic kidney disease caused by diabetic nephropathy. 3 months ago, he had a prolonged hospitalization due to septic shock & required dialysis for oliguric acute kidney injury from acute tubular necrosis. His rental function has not improved, & the patient has been receiving intermittent hemodialysis for end-stage renal disease. Other medical history includes DM1, gastropraesis & diabetic neuropathy. Which of the following is likely to provide the best mortality benefit in this patient? A. Chronic ambulatory peritoneal dialysis B. Deceased donor kidney transplantation C. Maintenance dialysis via arteriovenous fistula D. Maintenance dialysis via tunneled catheter E. Related donor kidney transplantation

B. High CVP, low CO, high SVR This patient has a massive saddle PE, blockage of both pulmonary arteries to the right lung & left lung. This can can lead to shock (life-threatening condition commonly caused by decreased tissue perfusion due to circulatory failure). Massive occlusion of both pulmonary arteries causes obstructive shock due to impedance of R VENTRICLE forward flow. The poor R ventricular output in massive PE causes reduced L ventricular preload & subsequent reduced CO. CVP is typically elevated due to impaired forward blood flow. SVR is increased in an attempt to maintain adequate tissue perfusion pressure. Normal blood flow: systemic veins --> SVC --> R atrium --> R ventricle --> pulmonary arteries --> lungs --> pulmonary veins --> L atrium --> L ventricle --> aorta --> systemic

35-year-old woman comes to the ED after a syncopal episode. She has persistent chest pressure, dyspnea & lightheadedness. The patient has no prior medical issues & her only regular medication is an estrogen-containing OCP. She smokes a pack of cigarettes/day. PE shows AMS, cold, clammy skin & a swollen right lower extremity .CT pulmonary angiogram shows a massive saddle pulmonary embolism occluding the major artery of both pulmonary arteries. Which of the following changes to central venous pressure (CVP), cardiac output (CO) & systemic vascular resistance (SVR) will most likely be observed in this patient? A. High CVP, high CO, low SVR B. High CVP, low CO, high SVR C. Low CVP, high CO, low SVR D. Low CVP, low CO, high SVR E. Low CVP, low CO, low SVR

E. Send stool for microscopy, electrolytes & fat content The eval & management of chronic diarrhea involves a comprehensive Hx (clear description of stool characteristics, duration & timing of symptoms), basic serum analysis & importantly, stool analysis.

36-year-old man comes to the office due to frequent "loose stools" for the past 10 months. The stools are large in volume, liquid to semisolid, occur up to 3-4 times a day, & often foul-smelling. He also reports excessive flatulence, occasional nausea & abdominal cramping & has lost 4.5kg (9.9lbs). He has no prior medical conditions & has had no recent travel. He consumes a balanced diet & notes no specific association of diarrhea to food Vital signs are normal. Weight is 63.5kg (140lb). The abdomen is soft, non distended & nontender with no organomegaly. Bowel sounds are increased. Rectal exam shows no masses or tenderness & an empty rectal vault. Stool occult blood testing is negative. Samples for blood count, ESR, TSH & serum electrolytes are obtained. Which of the following additional interventions is most appropriate in management of this patient diarrhea? A. Advise a trial of lactose-free diet B. Arrange for GI endoscopy C. Obtain CT scan of the abdomen & pelvis D. Recommend symptomatic treatment with an anti motility agent E. Send stool for microscopy, electrolytes & fat content

C. Furosemide This patient's presentation (progressive dyspnea, tachypnea, elevated JVP, bibasilar lung crackles & an audible 3rd heart sound) is consistent with acute decompensated heart failure (ADHF). ADHF is m/c due to left ventricular systolic or diastolic dysfunction with or with out additional cardiac disease (MI, arrhythmias & acute severe mitral or aortic regurgitation). Initial management of ADHF include ensure hemodynamic stability, providing supplemental oxygen (with ventilatory support as needed), optimizing volume status & identifying and correcting precipitating factors. IV Diuretics (Furosemide, Bumetanide) are the preferred initial therapy in patients with evidence of volume overload. Beta blockers, ACEI & Aldosterone antagonists are useful in chronic HF due to systolic dysfunction but may worse HR symptoms or cause hemodynamic deterioration in ADHF.

62-year-old man comes to the ED due to SOB that has bene progressive over the last 2 weeks. Temp is 37.2C (99F), BP is 122/72, HR is 92/min & RR are 22/min. Pulse ox is 89% on room air. JVP is estimated at 14cm H20. Lung exam reveals bibasilar crackles in the lower 1/3 of the chest. Cardiac exam shows an audible S3 over the cardiac apex. Initial lab results are as follows: Sodium: 132 mEq/L (normal: 136-145) Potassium: 3.6 mEq/L (normal: 3.5-5.0) Chloride: 102 mEq/L (normal: 95-105) Bicarbonate: 20 mEq/L (normal: 22-28) BUN: 26 mg/dL (normal: 7-18) Creatinine: 1.2 mg/dL (normal: 0.6-1.2) Calcium: 9.2 mg/dL (normal: 8.4-10.2) Glucose: 162 mg/dL (normal: < 100-fasting) ECG shows normal sinus rhythm at a rate of 94/min & left bundle branch block. Which of the following is the best initial therapy for this patient? A. Carvedilol B. Dobutamine C. Furosemide D. Lisinopril E. Nitroglycerin

C. Increased peripheral conversion of testosterone to estrogen 5-alpha reductase inhibitors (Finasteride, Dutasteride) are used in treatment of BPH. These meds block the conversion of testosterone to dihydrostestosterone; the excess of testosterone is then available for conversion to estrogens by aromatase, which can lead to gynecomastia.

65-year-old man with BPH comes to the office for a follow-up appointment. He has a Hx of obstructive urinary symptoms & was on Tamsulosin. Tamsulosin caused symptomatic hypotension & Finasteride was prescribed 8 months ago. Since the med change, the patient has had improvement in his urinary symptoms, however he has noticed an increase in the size of his breasts. Glandular tissue, approximately 2cm in diameter, is palpated under the nipples & is mildly tender to palpation. There is no nipple d/c, breast asymmetry or rash. This patient's breast findings are most likely due to which of the following effects? A. Decreased testicular production of testosterone B. Displacement of estrogen from sex hormone-binding globulin C. Increased peripheral conversion of testosterone to estrogen D. Increased prolactin production E. Increased testosterone receptor inhibition

B. Hospitalization and Ceftriaxone + Azithromycin Patients with Community-acquired pneumonia (CAP) require risk stratification with the pneumonia severity index or CURB-65 score to determine if hospitalization is needed. Patients hospitalized on the medical floor should be initiated on empiric IV ABX with an anti-pneumococcal beta lactam (Ceftriaxone) & an advance macrolide (Azithromycin). Respiratory Fluoroquinolones (Levofloxacin) are also effective.

70-year-old man is brought to the ED due to 2 days of fever, chills, SOB & productive cough. His daughter reports that the patient appeared lethargic & confused this morning & refused to eat breakfast. The patient has HTN, DM2 & is up to date on all vaccinations. Temp is 39.4C (103F), BP is 104/62, HR is 118/min & RR are 28/min. Pulse ox shows 86% on room air but improves to 93% on 2L of oxygen. Crackles are heard over the right lower chest field. Heart sounds are normal. Neuro exam shows no focal deficits. Leukocyte count is 17,000/mm3 with 80% neutrophils. CXR reveals consolidation in the right lower lobe. Blood cultures are obtained. Which of the following is the best next step in management of this patient? A. Hospitalization & Cefotaxime B. Hospitalization and Ceftriaxone + Azithromycin C. Hospitalization & Piperacillin-Tazobacam + Levofloxacin D. Hospitalization & Vancomycin + Ceftriaxone E. Outpatient oral Levofloxacin & close follow-up

B. Defibrillation Patients with ventricular fibrillation or pulseless ventricular tachycardia should be managed with immediate defibrillation. In contrast, patients with hemodynamic instability due to a narrow or wide QRS complex tachyarrhthymia (atrial fibrillation, atrial flutter, VT with a pulse) should be managed with synchronized cardioverison.

72-year-old woman comes to the ED due to intermittent chest pain for the last 2 days. She describes the pain as chest pressure associated with SOB. She has never had similar symptoms. Her PMH is significant for HTN & hyperlipidemia. PE reveals no heart murmurs. ECG shows normal sinus rhythm with T wave inversion in leads V4-V6. Initial troponin I level is undetectable. 2 hours after the initial eval, she becomes unresponsive. Her telemetry strip shows poorly formed, irregular waves. Which of the following is the best next step in management of this patient? A. Amiodarone B. Defibrillation C. Epinephrine D. Lidocaine E. Synchronized cardioversion

C. Mycoplasma pneumoniae Mycoplasma pneumoniae causes atypical pneumonia with indolent symptoms of headache, malaise, low-grade fever, incessant cough, & nonexudative pharyngitis. CXR often reveals interstitial infiltrate with or without a small, serous pleural effusion. Empiric oral ABX (Azithromycin) usually resolve the infection completely

19-year-old man presents due to a week of persistent dry cough that disturbs his sleep. He has also had a sore throat, headaches & fatigue. Yesterday, he noticed a rash on his arms & legs. The patient has no chronic medical conditions & takes no meds. He has not had any sick contacts. Temp: 37.8C (100F); BP: 115/78/min; HR: 86/min; RR: 16/min. Mild pharyngeal erythema present. There is no cervical LAD. Cardiopulmonary exam is normal. A faint macular rash is present on the extremities. CXR reveals increased interstitial markings & a small right-sided pleural effusion. Which of the following organisms is most likely causing this patient's condition? A. Epstein-Barr virus B. Influenza virus C. Mycoplasma pneumoniae D. Parvovirus B19 E. Streptococcus pneumoniae

E. Schistocytes Disseminated IV coagulation is a common complication of gram-negative bacterial sepsis due to activation sepsis due to activation of the coagulation cascade by bacterial endotoxins, which leads to the formation of micro thrombi. Peripheral smear shows fragmented erythrocytes (schistocytes) & thrombocytopenia. Lab tests show decreased fibrinogen levels & prolonged PT & PTT.

20-year-old man is brought to the ED due to a day of fever, HA & neck pain. Temp is 38.7C (101.7F), BP is 120/72, HR is 112/min, RR are 26/min. There is neck stiffness & a petechial rash on the trunk. CSF analysis reveals the following: Glucose: 30mg/dL (normal: 40-70) Protein: 180 mg/dL (< 40) Leukocytes: 1,500/mm3 Neutrophils: 70% CSF gram stain shows gram-negative diplococci. In the ED, the patient's hemodynamic status deteriorates rapidly. BP drops to 80/50 & the venous access sites are oozing blood Which of the following findings most likely to be seen on this patient's peripheral smear? A. Eosinophilia B. Howell-Jolly Bodies C. Hypersegmented neutrophils D. Rouleaux formations E. Schistocytes

E. von Willebrand disease prolonged mucocutaneous bleeding, easy bruising & prolonged PTT

22-year-old woman presents to ED due to continuous gum bleeding after a mouth injury a few hours ago. She was playing doubles tennis & was accidentally struck on her bottom lip by a racquet. The patient has a Hx of bruising with minor trauma & of heavy menstruation with cramps pain. Her mother also had a history of "bleeding issues." BP: 120/70, HR: 80/min. Exam shows blood oozing from a gum abrasion. A fading ecchymosis is present on the right calf, but there are no other skin abnormalities. A fading ecchymosis is present on the right calf , but there is no other skin abnormalities. The remainder of the PE is normal. Lab results: CBC- Hemoglobin: 10.2 MCV: 76uM Platelets: 170,000/mm3 Coagulations- PT: 12 secs INR: 1 Activated PPT: 44 sec What is the most likely cause of this patient's bleeding problem? A. disseminated IV coagulation B. hemophilia A C. immune thrombocytopenia D. vitamin K deficiency E. von Willebrand disease

D. psuedomonas aeruginosa in patients w/ cystic fibrosis, pathogenic bacteria colonize the respiratory tract early in the disease course, in adults, the m/c pathogen is Pseudomonas aeruginoasa

22-year-old woman presents with a worsening cough. The patient has been coughing every day for the past several months, but over the past 4 weeks the cough has worsened, with increased amounts of thick sputum & SOB. The patient also has a Hx of sinusitis & repeated hospitalizations for airway infections. She takes pancreatic enzyme supplements for chronic diarrhea. PE reveals nasal polyps, a barrel-shaped chest, bilateral course lug crackles & digital clubbing. CXR shows hyper inflated lungs & dilated, thickened airways. Sputum culture from this patient is most likely to yield which of the following organisms? A. Aspergillus fumigatus B. Moraxella catarrhalis C. Mycobacterium tuberculosis D. pseudomonas aeruginosa E. Streptococcus pneumoniae

D. Normal glucose, increased lymphocyte & erythrocytes counts Viral infections of the CNS are usually characterized by elevated protein, normal glucose, & an elevated WBC count with a lymphocytic predominance. Patients with herpes encephalitis also usually have elevated erythrocytes in the CSF due to hemorrhagic inflammation of the temporal lobes

23-year-old with no prior history of seizure is brought to the ED after experiencing a generalized tonic-clinic seizure. His roommate says that the patient has had a fever & headache for the past 2 days & that today he was talking nonsensically. The patient has no chronic medical conditions but has had a cold sore on his upper lip for the past few days. Temp: 38.6C (101.5F). MRI of the brain shows swelling of the temporal lobes. In addition to an elevated CSF protein content, CSF analysis is most likely to reveal which of the following? A. Low glucose, increased lymphocyte count B. Low glucose, increased neutrophil count C. Normal glucose, increased erythrocytes count D. Normal glucose, increased lymphocyte & erythrocytes counts E. Normal glucose, normal cell counts

B. acute Hep A with prior Hep B infection acute Hep A virus (HAV) infection results in anti-HAV IgM production. Anti-HAV IgG is produced later & persists following resolution of HAV infection, protecting against repeat infection. Anti-HBs indicates either prior immunization against Hep B virus (HBV) or recovery from an earlier HBV infection (distinguished from immunization by a positive anti-Bc IgG).

24-year-old man presents with several days of poor appetite, abdominal discomfort & dark urine. Temp is 37.4C (99.3F). PE is significant for yellow discoloration of the scleras & skin. Lab results: Anti-HBs: postive Anti-HBc IgM: negative Anti-HBc IgG: positive Anti-HAV IgM: positive Anti-HAV IgG: negative Which of the following is the most likely cause of these findings? A. acute Hep A superimposed on chronic Hep B B. acute Hep A with prior Hep B infection C. acute Hep A with prior Hep B vaccination D. acute Hep B with prior Hep A infection E. acute hepatitis caused by Hep A & B

C. Plasmodium falciparum This patient with fever, icterus, splenomegaly & ring-shaped parasites within RBCs has malaria, which is caused by 4 main species of Plasmodium: P falciparum, P viva, P ovale, P knowlesi. The parasite is transmitted by female Anopheles mosquitos during blood feeing & travels to the liver, where it infects hepatocytes & subsequently undergoes asexual reproduction, which generates hepatic schizonts with thousands of daughter cells (merozoites). Rupture of the schizont into the circulatory system leads to erythrocyte infection & cycles of intraerythrocytic reproduction. As the parasite disseminates throughout the circulation, it can cause nonspecific symptoms (fatigue, fever, malaise, HA) & sometimes life-threatening complications (seizure, renal failure, circulatory collapse). Hepatosplenomegaly & & signs of anemia & hyperbilirubinemia (scleral icterus) are often present. The diagnosis is confirmed when the peripheral blood microscopy reveals intraerythrocytic trophozoites with a "diamond ring" appearance.

24-year-old woman comes to the ED due to 2 days of fever. The patient has no chronic medical conditions. She frequently travels for work as a freelance journalist. Temp is 38.3C (101F). PE is notable for mild scleral icterus & splenomegaly. Peripheral blood smear reveals ring-shaped parasites wishing RBCs. Which of the following infectious agents is most likely responsible for this patient's current condition? A. Borrelia burgdorferi B. Leishmania tropica C. Plasmodium falciparum D. Toxoplasma gondii E. Trichinella spiralis

B. avascular necrosis occurs due to impaired blood supply to a segment of bone. The femoral head is the m/c location. Common causes include sickle cell disease, glucocorticoid therapy, vasculitis & alcoholism.

24-year-old woman presents with left hip & pelvic pain. She has a constant, dull, achy pain at rest that is exacerbated by mov't of the hip or weight bearing. Her medical Hx is significant for sickle cell disease, pneumococcal pneumonia & acute chest syndrome. Temp: 26.8C (98.2F). Patient appears mildly uncomfortable. Pedal pulses are full & there is normal capillary refill & sensation in the feet. No redness or warmth is present over the hip joint but she has decreased passive internal rotation, extension, & abduction at the hip. What is the likely cause of this patient's pain? A. acute bursitis B. avascular necrosis C. osteoarthritis D. RA E. septic arthritis

D. MS MS should be suspected in young women with neuro deficits disseminated in space & time. Common presentations include optic neuritis (monocular blindness, painful eye mov't) & transverse myelitis (motor & sensory loss below the level of the lesion, incontinence) Suspect in patients with > 2 distinctive episodes of CNS dysfunction with at least some resolution that cannot be explained by a single lesion

26-year old women presents to ED with leg numbness & weakness. Yesterday she felt like her legs kept "going to sleep" & when she woke up this morning she had difficulty standing up & walking. She has had 2 episodes of involuntary urine leakage. The patient has DM1 for which she uses an insulin infusion pump. 1 year ago she had right eye pain & impair vision that resolved spontaneously in 1 week. On PE, visual acuity & pupillary reflexes are normal. Muscle strength in right & left lower extremities are 3/5 & 4/5. Bilateral patellar reflexes are 3+ & plantar reflexes are upping. Sensation to vibration, light touch & pain is decreased in both legs. Which is the most likely diagnosis? A. anterior cerebral artery occlusion B. diabetic polyneuropathy C. GBS D. MS E. vitamin B12 deficiency

E. post strep glomerulonephritis acute post-strep glomerulonephritis occurs 10-20 days after strep throat or strep skin infections. It presents with hematuria, HTN, red cell casts & mild proteinuria. Most patients have spontaneous remission & management is primarily supportive.

27-year old man presents with a 2-day history of malaise & dark urine. He has no chronic medical conditions but was treated with oral Dicloxacillin for a blistering skin infection 3 weeks ago. Temp: 37.4C(99.4F), BP: 150/90, HR: 80/min, RR: 15/min. Exam shows periorbital swelling. UA shows 8 RBC/hpf with RBC casts & mild proteinuria. Lab show low serum C3 levels; BUN: 40mg/dL & serum creatinine: 2mg/dL. What is the most likely diagnosis? A. acute pyelonephritis B. drug-induced acute interstitial nephritis C. IgA nephropathy D. Membrano- proliferative glomerulonephritis E. post strep glomerulonephritis

E. SLE SLE is an autoimmune disorder affecting multiple organ systems. Renal involvement may present with nephritic syndrome (hematuria, RBC casts). Nephrotic syndrome may also occur

28-year-old woman comes to the ED due to persistent bilateral headaches. The patient was initially seen at an urgent care clinic for the same symptoms 4 weeks ago & had a normal PE. The headache has failed to improve with Ibuprofen & now the patient also feels fatigued. She has had no fever, cough, SOB, chest or abdominal pain or diarrhea. The patient has no chronic medical conditions but says she sunburns easily. BP: 170/110. PE shows 1+ pitting edema of the bilateral lower extremities but is otherwise unremarkable. Lab results: hemoglobin: 10.8g/dL (normal: 12.0-16.0) platelets: 92,000 (normal: 150,000-400,000) leukocytes: 5,500 (normal: 4,500-11,000) BUN: 40mg/dL (normal: 7-18) creatinine: 2.5mg/dL (normal: 0.6-1.2) UA- protein: 3+ RBC: 20-30/hpf casts: erythrocytes casts Which of the following is the most likely diagnosis? A. Hemolytic uremic sydrome B. Hypertensive emergency C. NSAID-induced interstitial nephritis D. Poststreptococcal glomerulonephritis E. SLE

B. Immune thrombocytopenia purpura immune thrombocytopenia purpura is caused by acquired autoantibodies to platelet antigens & is often associated with a preceding viral illness or ongoing medical condition. Manifestations include mucocutaneous bleeding (heavy menstrual bleeding, epistaxis) and petechiae. Thrombocytopenia may be mild or severe, but platelet morphology on peripheral smear is normal. Coagulation studies, leukocytes & erythematous typically are unaffected.

28-year-old woman presents due to several months of intermittent heavy menstrual bleeding & epistaxis. The patient & her family have no major chronic medical conditions. VS are normal. Cardiopulmonary exam is unremarkable. The abdomen has no hepatomegaly or splenomegaly. There are several non palpable erythematous/violaceous lesions on the lower extremities that do not blanche with pressure. Hemoglobin: 11.8mg/dL & platelets: 16,000/mm3. PT & PTT are normal. A peripheral smear shows normal RBCs & a reduced number of morphologically normal platelets. Which of the following is the most likely diagnosis for this patient? A. Eosinophilia granulomatosis with polyangiitis B. Immune thrombocytopenia purpura C. SLE D. Thrombotic thrombocytopenia purpura E. Von Willebrand disease

C. Performance-enhancing substance abuse Growth hormone abuse can produce a temporary increase in lean body mass & sprint performance. Risks include hyperglycemia, sodium retention, hypertension & MSK complications (myopathy, arthralgias, carpal tunnel syndrome)

28-year-oldman presents due to pain & numbness in the right hand. For the past month, the pain has awakened him at night. The patient also had pain occasionally in other joints but no swelling or stiffness. He is a professional body builder & is training for an upcoming championship. The patient is sexually active with multiple partners. BP: 150/92; BMI: 35kg/m2. The patient is muscular & has normal body hair distribution. Tapping the volar surface of the right wrist elicits tingling of the right thumb & index finger. Mild, bilateral pedal edema is present. Fasting labs: Hemoglobin: 14.4g/dL (13.5-17.5g/dL) Platelets: 320,000/mm3 (normal: 150,000-400,000) Leukocytes: 8,200/mm3 (4500-11,000) Glucose: 142mg/dL (normal: 80-100) AST (SGOT): 38U/L (normal: 8-20U/L) Which of the following is the most likely underlying cause of this patient's current condition? A. Cushing syndrome B. Hereditary hemochromatosis C. Performance-enhancing substance use D. Reactive arthritis E. Rheumatoid arthritis

A. Low Na, High K, High Cl Primary adrenal insufficiency (Addison Disease) is most commonly caused by autoimmune adrenalitis. Due to pathology within adrenal glands, ACTH stimulation does not cause an increase in cortisol level. Electrolyte abnormalities include hyponatremia, hyperkalemia, hyperchloremia & nonanion gap metabolic acidosis.

30-year-old woman is evaluated for 3 months of progressive fatigue, decreased appetite & 10-lb weight loss. The patient has DM1 & has noticed decreased insulin requirements over this time. She has no other medical conditions. Physical exam shows a generalized increase in pigmentation of the skin, especially involving the palmar creases. Measurement of serum cortisol before & after administration of exogenous adrenocorticotropic hormone (ACTH) shows no difference in levels. Which of the following changes in serum lab values is most likely present in this patient? A. Low Na, High K, High Cl B. Low Na, Low K, Low Cl C. Normal Na, High K, normal Cl D. Normal Na, Low K, High Cl E. Normal Na, Low K, Low Cl

B. Graves Disease Graves Disease is caused by antibodies to the TSH receptor. It typically presents with hyperthyroidism & a diffuse goiter. Opthalmopathy is present at the time of diagnosis in about 25% of cases. Radioiodine uptake is increased with a diffuse pattern. Treatment options include antithyroid drugs, radio iodine ablation & surgical thyroidectomy

32-year-old woman is evaluated for heat intolerance & palpitations for the past few weeks. 2 years ago, she delivered a healthy baby boy via an uncomplicated vaginal delivery. 1 month ago, she was treated symptomatically for an URI. BP is 144/70, HR is 110/min. Exam shows no proptosis. The thyroid gland is diffusely enlarged without nodules or tenderness. Lab results: TSH: 0.005 uU/mL Free T4: 3.2 ng/dL (normal: 0.9-2.4) Serum T3: 410 ng/dL (normal: 70-195) Radioactive iodine uptake at 24 hours is 32% (normal: 10-20%) with a diffuse pattern. Which of the following is the most likely diagnosis in this patient? A. Euthyroid sick syndrome B. Graves disease C. Postpartum thyroiditis D. Silent (painless) thyroiditis E. Subacute thyroiditis

D. PET/CT scan Classic Hodgkin lymphoma typically presents with enlarged lymph nodes or a mediastinal mass on CXR. Tissue Bx confirms the diagnosis. PET/CT scan of the chest abdomen & pelvis is advised for stating & determining treatment options.

32-year-old, HIV-negative man comes to the office for eval of a neck mass that he first discovered 2 weeks ago. The patient has no other associated symptoms. PE shows enlarged, firm, nontender, mobile & left-sided anterior cervical lymph nodes. The remainder of the exam is unremarkable. CBC, CMP, & CXR are within normal limits. Cervical lymph node Bx is consistent with classic Hodgkin lymphoma. Which of the following is the best next step in management of this patient? A. Bone marrow Bx B. Lapartomy with splenectomy C. Local radiation therapy D. PET/CT scan E. Serum protein electrophoresis

E. Treponema pallidum

34-year-old male presents due to painless penile ulcer, which he first noticed 3 days ago. He had unprotected sex with a new partner a few weeks ago. Temp is 37.1C (98.8F). Exam reveals a 2-cm nontender ulcer close to the glans penis with raised indurated margin & a clean base. There are no surrounding lesions or vesicles. There are several bilateral enlarged inguinal lymph nodes which are firm, nontender & rubbery. PE is otherwise unremarkable. Rapid plasma reagin & HIV testing are negative. Infection with which of the following is most likely the cause of patient's symptoms? A. Chlamydia B. haemophilus ducreyi C. HSV D. Neisseria gonorrhoeae E. Treponema pallidum

A. Advise him to stop alcohol & tobacco use Tobacco & alcohol are reversible risk factors for PACs. Beta blockers are often helpful in symptomatic patients.

34-year-old man presents for eval of premature atrial complexes found on a routine ECG. He has had no chest pain, SOB or lightheadedness. He has smoked 1-2 packs of cigarettes daily & consumed 1-2 beers a day for the past 10 years. The patient's family history is significant for a MI in his mother at the age of 65 & a stroke in his father at age 72. He has no personal history of HTN or DM. PE, including vital signs, is normal. Which of the following is the best next step in management of this patient? A. Advise him to stop alcohol & tobacco use B. Order 24-hour Holter monitor C. Perform trans thoracic echo D. Provide reassurance & follow-up if symptoms develop E. Start beta blocker therapy

E. Transmural bowel inflammation Crohn's disease can involve any component of the GI tract from the mouth to the anus, such as aphthous ulcers & perianal skin tags & fistulas. Biopsy typically reveals focal ulceration with transmural inflammation

34-year-old man presents with foul-smelling anal discharge & perianal discomfort for the past several weeks. The patient has recurrent anal fissures & uses stool softeners & a topical analgesic. He also has occasional caked sores & recurrent abdominal pain & diarrhea. The patient has not traveled since a trip to South America 1 year ago. Temp: 38C (100.4F). Tenderness is present in the RLQ on deep palpation. Perianal exam shows a large posterior skin tag. A fistula anterolateral to the anus is draining whitish material. Further evaluation of this patient is most likely to reveal which of the following? A. Colonic ulcers containing protozoal cysts B. Diffuse colitis with no skip areas C. Lymph nodes with caseating granulomas D. Segmental inflammation of the mesenteric arteries E. Transmural bowel inflammation

E. HPV HPV types 16 & 18 are strongly associated with anal & cervical squamous cell carcinoma. HIV infection increases prevalence of HPV infection & the risk of anal carcinoma; this risk is further augmented in men who have sex with men

34-year-old man who is HIV positive presents due to several months of pain & itching in the perirectal area. He also has intermittent rectal bleeding. The patient was diagnosed with HIV 3 years ago but has been noncompliant with appointments. On exam, a single hard mass with superficial ulceration measuring approx. 2x2 cm is noted in the anal canal. No hemorrhoid present. No palpable LAD present. CD4+ T lymphocyte count is 280/mm3. What is the most likely cause of this patient's anal pathology? A. candida albicans B. cytomegalovirus C. EPV D. HSV-2 E. human papillomavirus

A. catheter ablation the patient's ECG shows a Wolff-Parkinson-White (WPW) pattern, a type of preexcitation caused by an accessory pathway. Normal electrical impulses pass from the atria to the ventricles via the AV node/His-Purkinje system; however in patients with WPW, an extra conduction pathway (accessory pathway) directly connects the atria to the ventricles & bypasses the AV junction. The accessory pathway conducts faster than the AV node & excites the ventricles prematurely, manifesting on the ECG as a "short PR interval with a characteristic delta wave & widened QRS complex. Patients with WPW syndrome are at risk of sudden cardiac death & require treatment with catheter ablation.

36-year old man is brought to the ED due to loss of consciousness. He was standing when he felt light-headed, had a pounding sensation in his chest & passed out. On awakening, the patient felt "completely fine." He denies prior episodes like this. BP: 124/68, HR: 80/min. Cardiac exam reveals normal heart sounds with regular rhythm. ECG is shows a "short PR interval, delta wave, & wide QRS complex." Echo is normal. After hospital admission, telemetry shows a brief episode of supra ventricular tachycardia that resolves spontaneously. What is the next best step in management of this patient? A. catheter ablation B. coronary angiography C. loop event recording D. nuclear stress test E. tilt-table test

B. Diltiazem Vasospastic angina results from hyperactivity of intimal smooth muscle leading to intermittent coronary artery vasospasm. CCB (Diltiazem, Amlodipine) cause coronary after vasodilation & are the preferred pharmalogic treatment.

37-year-old woman presents due to occasional episodes of nocturnal substernal chest pain that wake her during sleep. The pain is occasionally associated with sweating, palpitations & nausea but no dyspnea. The pain episodes resolves spontaneously after 10-15 mins. She leads a sedentary lifestyle but can clime 2 flights of stairs without any discomfort. The patient has no Hx of HTN or DM. She smokes 1/2 pack of cigarettes daily. BP: 134/70, HR: 75/min & regular, RR: 14/min. Heart sounds are normal without murmurs. Extended ambulatory ECG monitoring shows transient ST-segment elevation in leads I, aVL, V4-V6 during an episode of pain. Coronary angiogram shows no significant coronary obstruction. Which is the best treatment for this patient? A. aspirin & Rosuvastatin B. Diltiazem C. Omeprazole D. Propranolol E. Ranolazine

D. Hidradenitis suppurativa Hidradenitis suppurativa is a chronic, relapsing condition characterized by inflammatory occlusion of hair follicles. It presents as painful nodules in the axillae & groin that can progress to abscesses, sinus tracts & acneiform scarring.

38-year-old man presents with painful nodular lesions under the arms. They appeared a year ago, but symptoms have worsened over the past 3 months & the patients notices a foul odor. He had DM2 & hyperlipidemia & is taking oral meds. Vitals are normal. Skin exam shows tender, fluctuant nodules with SQ fibrosis at the axillae bilaterally. Which of the following is the most likely diagnosis in this patient? A. Acanthosis nigricans B. Acne vulgaris C. Furunculosis D. Hidradenitis suppurativa E. Intertrigo

E. Proton pump inhibitor (PPI) Chronic cough is a common presenting symptom of GERD & in some cases may be the only presenting symptom. Initial management of suspected cough-predominate GERD involves lifestyle modifications & PPI therapy. Choice D- ACE inhibitors (Lisinopril) are a common cause of chronic cough & should be considered in patients taking these meds. The patient's hoarseness & throat irritation & increased symptoms after wine (acidic) or a large meal make GERD a more likely cause of the cough.

38-year-old woman comes to the office due to several months of persistent cough. The patient first only occasionally awakened at night or in the early morning by severe bouts of coughing, but this now occurs every few days. The cough is often accompanied by wheezing; she has no daytime cough but has had occasional hoarseness, throat irritation & chest pain. She has noticed that her symptoms are worse when she drinks wine with dinner or eats a large meal. The patient has not had any symptom exacerbation or dyspnea with exercise. The patient has HTN, which is controlled with Lisinopril & seasonal allergies. Temp is 36.8 (98.2F) & BP is 120/70. BMI is 30kg/m2. Nasal & pharyngeal mucosal appear normal. The lungs are CTA & heart sounds are normal. The abdomen is soft & nontender. Which of the following is the most likely to improve this patient's cough? A. Inhaled beta-2-agonist B. Intranasal glucocorticoid C. Leukotriene inhibitor D. Lisinopril d/c E. Proton pump inhibitor (PPI)

C. left ventricular hypertrophy acromegaly is caused by excessive production of growth hormone, usually due to a pituitary adenoma. MSK manifestations include bony hypertrophy (frontal bossing, enlarged jaw, hands & feet) & osteoarthritis. Left ventricular hypertrophy is often common in acromegaly & may progress to heart failure.

45-year-old man presents due to slowly progressive joint pain. His knee & ankle joints are stiff & painful when he walks. Over the past year, the patient he has also experienced excessive sweating & his ring & shoe sizes have increased. He has no prior medical issues & takes no medications. PE shows coarse facial features with a prominent forehead, protruding jaw & widely separated maxillary teeth. There is mild swelling & crepitus of the knees & ankles bilaterally. Which is associated with this patient's condition? A. aortic root dilation B. bicuspid aortic valve C. left ventricular hypertrophy D. mitral valve prolapse E. pericardial effusion

A. Cushing syndrome Cushing Syndrome presents w/ central obesity, proximal muscle weakness, HTN & easy bruising. Besides exogenous glucocorticoid administration, the m/c etiologies include increased pituitary secretion of ACTH (Cushing disease), an adrenal tumor & ectopic ACTH production

39-year old woman presents with a 4-month Hx of progressive muscle weakness. The patient has had difficulty combing her hair bc her arms feel weak when she holds them above her head. In addition she has had a 9-kg (20lb) weight gain as well as irregular menses with vaginal dryness & low libido. Medical Hx is significant for HTN & hyperlipidemia. BP: 150/100, HR: 90/min. BMI: 37kg/m2. PE shows oily facial skin with prominent acne & scattered bruises on her arms & lower legs. The abdomen in obese, soft & nontender. DTRs are normal. Lab results: Sodium: 142mEq/L Potassium: 3.6mEq/L Chloride: 104 mEq/L HCO3: 29 mEq/L Glucose: 166mg/dL Creatinine kinase: 68U/L What is the most likely cause of patient's symptoms? A. Cushing syndrome B. Hypothyroidism C. Lambert-Eaton myasthenic syndrome D. PCOS E. Primary hyperaldosteronism

E. Viral infection Viral infection is thought to be the most common cause of acute pericarditis. Pericarditis is often characterized by pleuritic chest pain, a friction rub on cardiac auscultation, diffuse ST elevation on ECG & mild to moderate-sized pericardial effusion

39-year-old man comes to the ED with anterior chest pain. He had felt well until the pain developed 4 days ago. The patient says the pain is sharp & makes it difficult to take a deep breath. Since yesterday, he has also felt out of breath. The patient has had no other symptoms & has no chronic medical conditions. His father died of a heart attack at age 52 & his mother has rheumatoid arthritis. He does not use alcohol or tobacco. Temp: 37.4C (99.3F); BP: 112/65; HR: 103/min & regular. Bedside US exam demonstrates a moderate pericardial effusion. Which of the following is the most likely cause of this patient's condition? A. Autoimmune disease B. Coronary artery disease C. Gram-positive cocci D. Malignancy E. Viral infection

D. Proteus mirabilis This is a urease-producing bacterium that commonly causes UTIs (including pyelonephritis). Urease generates ammonium, resulting in urinary alkalization (pH> 8). This decreases the solubility of phosphate, dramatically increasing the risk of urinary calculi with struvite stones (magnesium ammonium phosphate).

39-year-old woman comes to the ED due to 3 days of fever, dysuria & left flank pain. The patient has a Hx of UTIs & had a ureteropelvic junction calculus removed 2 years ago. Temp is 38.3C (100.9F), BP is 120/70, HR is 110/min. Left CVA tenderness is present. UA shows: pH: 8.5 (normal: 4.6-8.0) Blood: positive Leukocyte esterase: positive Bacteria: many WBC: 100+/mm3 Imaging reveals an enlarged left kidney with perinephritic fat stranding & a non obstructive renal calculus. Which of the following organisms is most likely to be seen in this patient's urine culture? A. Candida albicans B. Citrobacter freundii C. Enterococcus faecalis D. Proteus mirabilis E. Staphy aureus

A. acute pancreatitis characterized by epigastric abdominal pain associated with nausea & vomiting. Alcohol abuse & gallstone disease are the m/c causes. Potential complications include pleural effusion, acute respiratory distress syndrome, ileum & renal failure

45-year-old man presents to ED with upper abdominal pain. He describes it as "nagging" & constant & rates at 6/10. The pain started 6 hours ago & was not relieved by OTC antacids. It gets somewhat better when he sits up & leans forward. Patient has had 2 episodes of vomiting since pain started. He smokes a pack of cigarettes daily. He drinks 4-6 cans of beer a day & several more on the weekends. Temp: 37.8C (100F), BP: 100/70, HR: 110/min, RR: 20/min. Abdominal exam shows mild epigastric tenderness without guarding or rebound. CXR shows a small left-sided pleural effusion. Which is the most likely diagnosis in this patient? A. acute pancreatitis B. intra-abdominal abscess C. mesenteric ischemia D. MI E. peptic ulcer perforation

D. Lateral neck XR Epiglottits should be suspected in patients with sore throat, hoarseness, stridor, pooled oral secretions & drooling. Risk factors include DM, obesity & preceding URIs. The diagnosis can be confirmed (in those with stable status) using lateral neck XR showing "thumb-print sign"

40-year-old man comes to the clinic due to runny nose, cough & sore throat. He began having rhinorrhea 5 days ago & subsequently developed a cough that is worse at night. The patient has been taking OTC cough medication, but it has not improved his symptoms. 3 days ago, he developed a sore throat, which he attributes to frequent coughing. Today, his throat is more painful & he has been having difficulty swallowing liquids. The patient has DM2, for which he takes several meds for glycemic control. Temp is 37.9C (100.2F); BP is 148/90; HR is 110/min, RR are 22/min. BMI is 35kg/m2. Pulse ox shows 99% on room air. The patient winces when swallowing. Exam shows pooling of oral secretions & several dental carries. The posterior oropharynx appears mildly erythematous due to postnasal drip. The anterior neck is soft but tender to palpation. Lung exam reveals faint stridor with no crackles or rhonchi. Which of the following is the best next step for establishing a diagnosis in this patient? A. Chest XR B. Diptheria PCR C. Group A Strep Rapid Antigen D. Lateral neck XR E. Sputum gram stain & culture

A. achalasia achalasia commonly presents with chronic dysphagia to both solids & liquids, regurgitation, difficulty belching & weight loss. Achalasia is caused by impaired peristalsis of the distal esophagus & failure of the LES to relax when food boluses reach it.

40-year-old man presents for eval of dysphagia. For the past 3 years, the patient has had difficulty swallowing solid foods & liquids, with symptoms worsening recently. He reports that it is easier to swallow standing upright. He has occasional regurgitation of undigested food & has lost 5kg (11lbs) over past 6 months. The patient has no other medical conditions & does not use tobacco, alcohol or drugs. VS are normal. The neck is supple without masses. Cardiopulmonary exam shows no abnormalities. Barium esphagogram shows dilation of the esophagus & narrowing of the esophagogastric junction. What is the most likely diagnosis? A. achalasia B. esophageal cancer C. esophageal web D. GERD E. Zener diverticulum

B. Measure serum TSH & FSH Vasomotor symptoms, insomnia & irregular menses could be due to hyperthyroidism or menopause in middle-age women. Serum TSH & FSH levels should be measured in patients < 45 with these symptoms. Menopause is defined as absent menses for 12 months. In women >45 with menopausal symptoms, no lab eval is indicated but in women <45 with menopausal symptoms (like this patient) require a serum FSH level to evaluate for other causes of amenorrhea (primary ovarian insufficiency) & a serum TSH to evaluate for thyroid disease. Vaginal rugae = structures of the vagina that are transverse ridged formed out of the supporting tissues & vaginal epithelium - minimal rugation indicates vaginal atrophy which is a symptom of menopause

41-year-old woman comes to the office due to night sweats & insomnia. For the past month, she has awakened completely soaked with perspiration almost every night. She has also had difficulty concentrating at work. The patient has had irregular menstrual periods for the past 6 months. Temp is 36.7C (98F); BP is 140/90; HR is 80/min; RR are 14/min. Skin is normal & there is no periorbital edema. The thyroid is nonenlarged & nontender & there are no masses. The uterus is small & anteverted & the vagina has minimal rugation (ridges). There are no adnexal masses. Urine pregnancy test is negative. Which of the following is the best next step in management of this patient? A. Measure 24-hour urinary catecholamines B. Measure serum TSH & FSH C. Order urine toxicology screen D. Prescribe oral hormone replacement E. Provide reassurance & education about menopause

C. Clinical diagnosis only Tetanus is a clinical diagnosis that should be suspect in patients who have characteristic symptoms (lockjaw, muscle pain/spasms, difficulty swallowing), particularly if they are unlikely to be adequately vaccinated or have an antecedent cutaneous injury.

42-year-old man comes to the ED due to worsening jaw pain & stiffness. His symptoms began 2 days ago & have limited his ability to eat. Today the patient has developed stiffness in his neck. He has had no fever, chills, headache, focal weakness or numbness. The patient is a farmer & sustained a wooden splinter injury in his forearm while working in a barn a week ago. He has not had medical care in over 10 years. On exam, the patient tis not able to open his mouth. The muscles of his neck are tense, and his neck ROM is impaired. Which of the following is the best approach to establishing diagnosis in this patient? A. Anaerobic blood culture B. CSF analysis C. Clinical diagnosis only D. Serum toxin assay E. Several sets of antibody titers

E. Syphilis Secondary syphilis is characterized by systemic symptoms (fever, malaise), widespread LAD (particularly epitrochlear) & a diffuse maculopapular rash that begins on the trunk & extends to the extremities, including the palms & soles (+/- oral lesions & condyloma latum) Diagnosis is made with serology (using both a treponemal & nontreponemal test). 1 IM dose of PCN G Benzathine is standard treatment.

42-year-old man comes to the office due to a week of subjective fear, sore throat, malaise, HA & skin rash. The rash began on his trunk 1 week ago & has no spread to his entire body. He has had no chest pain, SOB, diarrhea, or urethral d/c. He has had 3 new female sex partners over the last year. Temp is 37.2C (99F). Exam shows a full-body maculopapular rash, including the palms & soles, with no excoriations. Several raised, grey mucosal patches are seen in the mouth. Cervical, axillary, inguinal & epitrochlear LAD is present. HIV testing is negative. Which of the following is the most likely cause of this patient's symptoms? A. Bacterial endocarditis B. Disseminated gonococcal infection C. EPV infection D. Rocky Mountain spotted fever E. Syphilis

E. Zinc supplement Risk factors for trace mineral deficiency include malabsorption, bowel resection, poor nutritional intake & dependence on parenteral nutrition. Clinical manifestations of zinc deficiency include hypogonadism, impaired taste, impaired wound healing, alopecia & skin rash with perioral involvement

42-year-old man with a history of Crohn disease comes to the office for follow-up. He had a partial ileal resection due to a stricture & also had multiple surgeries to treat an enterocutaneous fistula. The patient has received parenteral nutrition for the past several weeks & recently restarted oral feeding. He reports no bloody diarrhea but no fever or abdominal pain. The patient says that food does not taste the same as before. On exam, he has patchy alopecia & a pustular, crusting skin rash with scaling & erythema around the mouth & on the extremities. No abdominal tenderness is present & bowel sounds are normal. The jugular venous pulse is normal & there is no lower extremity edema. Which of the following is most likely to improve this patient's current condition? A. Elemental copper B. Gluten avoidance C. Niacin therapy D. Selenium supplement E. Zinc supplement

D. Toxoplasma gondii Toxoplasma Gondi is an intracellular parasite that is typically transmitted to humans after accidental ingestion of contaminated cat feces (cat handling, litter box). Patients with severe immunocompromise, particularly advanced AIDS, can develop encephalitis with multiple ring-enhancing lesions

42-year-old woman is brought to the office due to personality changes. Her family reports that she has become withdrawn & does not talk as much as before. She has also had difficulty picking things up with her right hand. The patient has HIV infection & does not take her antiretroviral therapy consistently. VS is normal. Motor strength is decreased in her right upper extremity. CD4 count is 78 cells/mm2, & plasma HIV RNA (viral load) is 400,000 copies/mL. CT scan of the head shows a small hypodense area in the left frontal lobe with ring enhancement. 2 similar lesions are present in the basal ganglia & cerebellum. Which of the following pathogens is the most likely cause of this patient's current condition? A. Bartonella henselae B. Crypto coccus neoformans C. HSV D. Toxoplasma gondii E. Treponema pallidum

A. ADE of meds Aspirin & beta blockers are common meds that can trigger bronchoconstriction in patients with asthma. Short-term use of cardioselective beta blockers is usually safe in patients with mild-to-moderate asthma, but all beta blockers should be used with caution. Choice B- acute bronchitis is usually caused by viral URI & is characterized by persistent cough +/- sputum production. Timing of symptom onset in this patient being 1-2 days (after new medication) & lacks other symptoms suggestive of URI (rhinorrhea) making this option less likely. Choice C- Acute pericarditis is characterized by sharp, pleuritic CP that is often relieved by leaning forward. A pericardial friction rub may be present on auscultation. Dyspnea is less common. Choice D- Patients with pleural effusion have dullness to percussion of the chest wall, decreased breath sounds & decreased movement of the ipsilateral chest wall. Choice E- Patients with pulmonary embolism can have CP, dyspnea &/or tachypnea. Wheezing & prolonged expiration are possible but not typical.

43-year-old man comes to the hospital for chest pain. The patient has never had CP before but has had occasional episodes of dyspnea & coughing. His medical Hx is significant for allergic rhinitis & childhood eczema. Initial ECG shows ST depression in lateral leads, but no cardiac marker evidence of acute MI. The patient is admitted for further eval & is treated wit Aspirin, Clopidogrel, LMW-Heparin, Metoprolol & Lisinopril. The next morning he has SOB & a dry cough but no CP. Temp is 37.2C (99F), BP is 122/70, HR is 63/min, RR are 22/min. O2 sat is 95% on room air. Pulmonary exam shows prolonged expiration with bilateral wheezes. Cardiac exam is normal. Which of the following is most likely responsible for this patient's current respiratory symptoms? A. ADE of meds B. Bronchial infection C. Pericarditis D. Pleural effusion E. Pulmonary embolism

E. uncompensated respiratory acidosis respiratory acidosis can be uncompensated or compensated. Increased PaCO2 leads to an increased hydrogen ion concentration in the body. The kidneys attempt to compensate for this by increasing reabsorption of HCO3 to help buffer access acid. However renal compensation takes time (hours to days). Acutely (<8 hours)-- the level of HCO3 is only mildly increased due to renal compensation & rises by 1mEq/L for every rise of 10mmHg in PaCO2. Chronically (>24hours)-- the level of HCO3 becomes significantly elevated due to renal compensation & rises by 3-4mE/L for every rise of 10mmHg in PaCO2

43-year-old man is brought to the ED after being found unresponsive by his wife. She says he was in his usual state of health when she left home a few hours ago. The patient has a Hx of depression & DM2. He was recently laid off from work. BP: 100/60, HR: 64/min. PE reveals patient is unresponsive to deep sternal rub & has mildly dry mucous membranes. ABG results: pH: 7.22 PaCO2: 60mmHg HCO3:24 mEq/L What is the most likely current acid-base status in this patient? A. metabolic acidosis with respiratory compensation B. respiratory acidosis with renal compensation C. respiratory alkalosis with renal compensation D. uncompensated metabolic acidosis E. uncompensated respiratory acidosis

E. Mid-diastolic murmur at the cardiac apex Cardiac auscultation in patients with mitral stenosis indicates a loud first heart sound, an early diastolic sound after second heart sound (opening snap), and a low-pitched diastolic murmur heard best at the cardiac apex

44-year-old woman presents with progressive SOB & cough. She can hardly walk a block without having to stop due to dyspnea. The patient has recently immigrates to the US from the Middle East. She has a history of a "heart murmur" & joint pains as an adolescent. She is a lifetime nonsmoker. BP: 110/70; HR: 110/min & irregularly irregular. ECG shows atrial fibrillation. An echocardiogram shows thickening of the mitral valve leaflets with commissural fusion & restricted mitral valve opening. Which of the following is the most likely finding on PE? A. Early diastolic murmur at the left upper sternal border B. 4th heart sound at the cardiac apex C. Holosystolic murmur at the left mid sternal border D. Late systolic murmur at the cardiac apex E. Mid-diastolic murmur at the cardiac apex

A. Candida albicans Intertrigo is most commonly due to Candida infection and causes erythematous plaques & erosions in intertriginous regions (inguinal perineal, genital intergluteal). Factors that increase the risk of intertrigo include: disruption of skin barrier function due to friction (obesity) excessive moisture (occlusive clothing, high heat/humidity) impaired immune function (HIV, glucocorticoid therapy) local environment conductive to microbial growth (DM with hyperglycemia) Intertrigo presents with erythematous plaques in a symmetric "kissing" or "mirror image" pattern across the skin fold. Candida intertrigo typically also forms satellite lesions (vesicles, papules, pustules) near the primary infection. Diagnosis is primarily clinical but KOH of skin scrapings can help confirm by visualization of pseudohyphae with budding yeast.

45-year-old woman presents to the office for eval of a rash. The rash started 3 weeks ago under her breasts & has gradually spread to her chest. There is no associated pruritus. The patient has DM2, HTN & GERD. Her meds include HCTZ, Metformin & Omeprazole. She does not use tobacco, EtOH or illicit drugs. VS are WNL. BMI is 38kg/m2. Skin exam shows erythematous, symmetric plaques across the breast skin fold with a papular satellite lesion in the left breast skin fold. There is no warmth or tenderness around the lesions. Which of the following is the most likely organism causing this patient's rash? A. Candida albicans B. Corynebacterium minutissimum C. Staph aureus D. Trichophyton rubrum E. Varicella zoster virus

E. Reinforce education about HTN & treatment goals Uncontrolled HTN more commonly represents pseudo resistant HTN rather than true resistant HTN. Medication non adherence is a common cause of pseudo resistant HTN & should be suspected & adequately addressed prior to changes in treatment or workup for secondary causes of HTN.

46-year-old woman presents for a follow-up of HTN. The patient was diagnosed with HTN 2 years ago. Nonpharmacological management was initially advised, but she was started on Valsartan & Amlodipine 1 year ago due to persistent HTN. A month after treatment initiation, BP was 130/80 and she reported no adverse effects from the meds. Since then, the patient has missed several follow-up appts, which she attributes to being busy at work. She currently has no concerns & overall feels "great." The patient has no other medical conditions. She works as a salesperson & eats fast food several times a week. Today, BP is 152/88 and a repeat measurement several mins later is unchanged; HR is 76/min and regular. BMI is 28kg/m2. PE & labs are unremarkable. ECG shows normal sinus rhythm with nonspecific T-wave changes. Which of the following is the best next step in management of this patient? A. Add Chlorthalidone to her medical regimen & follow up B. Encourage low-salt diet & follow up in 6-8 weeks C. Initiate workup for secondary HTN D. Obtain 24-hour ambulatory BP monitoring E. Reinforce education about HTN and treatment goals

D. provide reassurance that no further TB treatment or eval is needed at this time patients with latent TB infection who receive treatment require no further testing or monitoring unless they develop symptoms of active TB (weight loss, fever, cough)

48-year old woman who has immigrated to the US 1 year ago from SE Asia presents as a new patient. Her previous health care provided performed tuberculin skin test, which showed a 12-mm induration. CXR at that time revealed a single calcified hilar lymph node with no other abnormalities. She then completed 9 months of Isoniazid therapy earlier this year. She denies fever, chills, weight loss, anorexia, cough or night sweats. Temp is 36.5C (97.7F). PE is normal. With regard to the patient's risk of TB, what is the next best step in management? A. obtain induced sputum samples for mycobacterial culture B. obtain induced sputum samples for NAAT C. perform an interferon-gamma release assay D. provide reassurance that no further TB treatment or eval is needed at this time E. repeat TB skin test

C. Labetalol This patient's presentation & CT findings are consistent with aortic dissection. IV beta blockers (Labetalol, Esmolol) are the treatment of choice for the initial medical management of patients with acute aortic dissection, as they lower HR and BP and reduce left ventricular contractility.

48-year-old man comes to the ED due to severe chest pain that started 2 hours ago. He has difficulty localizing the pain, saying that it "hurts all over my chest." He has had no SOB, lightheadedness, syncope or palpitations. The patient has no know medical conditions. He is a lifetime nonsmoker and does not use illicit drugs. His father died suddenly at age 52 from a presumed heart attack. Temp is 36.7C (98.1F), BP is 178/102, HR is 105/min and regular and RR are 16/min. On physical exam, the lungs are CTA and heart sounds are normal. ECG reveals sinus tachycardia, left ventricular hypertrophy & T-wave inversion in leads V5 and V6. A CT image of the chest shows intimal tears separating the true & false lumens of the ascending and descending aorta. In addition to pain control, which of the following is the most appropriate, immediate pharmacotherapy for this patient? A. Furosemide B. Hydralazine C. Labetalol D. Nitroprusside E. Unfractionated Heparin

D. substance use history alcoholic hepatitis is m/c seen in patients with a Hx of chronic, heavy alcohol use. It is characterized by fever, jaundice, anorexia & tender hepatomegaly with lab results showing an aspartate aminotransferase/alanine aminotransferase ration of > 2:1

50-year old man is admitted to hospital due to worsening jaundice, anorexia, general malaise & upper quadrant abdominal pain over the past 3 days. Temp> 38.3C (100.9F) BP: 130/86, HR: 86/min. Cardiopulmonary exam is unremarkable. Scleral icterus & tender hepatomegaly present. Lab results: CBC- hemoglobin: 12g/dL MCV: 102um3 platelets: 120,000 leukocytes: 13,000 LFTs- albumin 3.4g/dL alkaline phosphatase: 105U/L aspartate aminotransferase (SGOT) 212U/L alanine aminotransferase (SGPT) 99U/L Which of the following is the most helpful in establishing a diagnosis in this patient? A. FHx B. Med Hx C. serum acetaminophen level D. substance use Hx E. travel Hx to a developing country

E. Lisinopril ACE inhibitors & angiotensin receptor blockers (ARBs) are effective agents agents that can lower BP & slow progression of proteinuric chronic kidney disease, even in patients with serum creatinine concentrations up to 3mg/dL. With careful dietary instruction & monitoring, ACE inhibitor therapy is appropriate for many of these patients

50-year-old woman presents for a follow-up for chronic kidney disease diagnosed during routine lab work up. Her history, PE & screening lab findings did not indicate a course for her chronic kidney disease. A 24-hour urine showed 1.5g/day of proteinuria. A renal US revealed echogenic kidneys measuring about 9cm bilaterally without evidence of obstructive uropathy. She takes no medications. Her BP is 152/92 and previously recorded BP was 156/92. The PE is within normal limits. The patient's most recent lab results are as follows: Sodium: 140mEq/L Potassium: 4.4mEq/L Chloride: 104mEq/L Bicarb: 22mEq/L Creatinine: 1.7mEq/L Glucose: 100mg/dL Which of the following would be the best therapeutic agent for this patient? A. Amlodipine B. Carvedilol C. Clonidine D. Hydrocholothiazide E. Lisinopril

A. Advanced HIV infection Patients with HIV have much higher rates of lymphoma than the general population. Many cases are due to underlying EPV.

52-year-old man comes to the office due to progressively enlarging neck mass, fatigue & weight loss over the past 2 months. PE shows enlarged, firm & nontender cervical lymph nodes. The patient also has enlarged tonsils, bilateral axillary LAD & splenomegaly. Excisions lymph node Bx is performed & reveals non-Hodgkin lymphoma that is positive for EPV. Which of the following is a risk factor for this patient's condition? A. Advanced HIV infection B. Aspirin & NSAID use C. Cigarette smoking D. Radiation exposure E. Socioeconomic status

A. Ankle-brachial index Peripheral artery disease should be suspected in patients with risk factors for atherosclerosis who have an extremity with shiny, hairless skin, particularly if a non healing ulcer is present. The ankle-brachial index is a helpful noninvasive assessment for peripheral artery disease.

53-year-old obese man comes to the office due to frequent discomfort in his R foot that limits his daily activities. His PMH is significant for DM2, HTN & gout. He has been poorly compliant with is prescribed med regimen. The patient has a 20 pack-year smoking Hx & drinks 2-3 alcoholic beverages per week. BP is 128/76 & HR is 82/min. On PE, the skin of the right foot is thin, shiny & devoid of hair. There is a small shallow ulcer on the outer aspect of the R great toe. Which of the following is most likely to diagnose the cause of this patient's foot discomfort? A. Ankle-brachial index B. Electromyography C. Serum uric acid level D. Skin Bx E. Ulcer swab for Gram stain & culture

D. Pulmonary embolism Patients with massive pulmonary embolism usually present with signs of hypo perfusion (hypotension, syncope), dyspnea, pleuritic chest pain & tachycardia. The thrombus can cause right ventricular dysfunction. The patient's malignancy (prothrombin state) & acute presentation of dyspnea, chest pain, tachycardia, hypoxia & clear lungs are suggestive of a PE.

53-year-old woman is brought to the ED after she collapsed suddenly while standing & lost consciousness for approx. 3 mins. She recovered spontaneously but was very weak & dyspneic. She also has left-sided chest pain The patient was recently diagnosed with colon cancer on a routine colonoscopy & is scheduled to undergo surgical resection. Her only other medical condition is HTN, and she is not compliant with her meds. BP is 86/50 and HR is 120/min and regular. Pulse Ox shows 80% on room air. She is diaphoretic & tachypneic. Jugular venous pressure is elevated at 13cm H20. Lungs are CTA. Further workup in this patient would most likely show which of the following? A. Acute mitral regurgitation B. Left bundle branch block C. Mediastinal widening D. Pulmonary embolism E. Tension pneumothorax

E. CML is caused by translocation of chromosomes 9 & 22 that produces the BCRIABL gene (Philadelphia chromosome), resulting in unregulated tyrosine kinase activity. Tyrosine kinase inhibitors such as imantinib are the initial treatment of choice in almost all patients

54-year old man has experienced fatigue for the last 6 months. He has no significant med Hx. Exam shows mild splenomegaly. Cytogenic testing reveals a BRCIABL translocation consistent with chronic myeloid leukemia. Which of the following is the best initial treatment option for this patient? A. alkylating agent B. bone marrow transplantation C. leukapheresis D. therapeutic phlebotomy E. tyrosine kinase inhibitor

D. psychological distress psychogenic causes of ED include performance anxiety, depression, sexual trauma, relationship probs & stress. Important clouds include sudden-onset & normal nocturnal erections

54-year-old man presents due to difficulty maintaining an erection for the last several weeks. He says, "one night I was having sex with my wife & couldn't maintain an erection. Since then, it has continued to be a problem." The patient still has morning erections. The patient has HTN, CAD & depression. His current meds included amlodipine, lisinopril & bupropion. He has been married for 20 years but reports he & his wife have been arguing since he began spending more time at work following a promotion 2 months ago. PE is unremarkable. Which is the most likely cause of this patient's erectile dysfunction? A. advancing age B. antidepressant-induced ADE C. antihypertensive-induced adverse effect D. psychological distress E. vascular insufficiency

B. Canagliflozin Metformin is the recommended first-line medication for most patients with DM2. Options for add-on therapy in patients with established CV disease include glucagon-like peptide-1 agonists & sodium-glucose cotransporter 2 (SGLT2) inhibitors. SGLT2 inhibitors are associated with decreased BP, decreased risk of heart failure & CV events & minor weight loss

54-year-old presents for a diabetes follow-up. The patient has a 5-year history of DM2, which is treated with Metformin. He also has HTN & had coronary stunting for a MI 1 month ago. BP: 130/74; HR: 68/min; BMI: 30kg/mm2. PE is normal. A serum creatinine level is 0.8mg/dL & hemoglobin A1c is 7.8%. Which of the following meds has an added protective effect on this patient's cardiac & weight-related comorbidities? A. Basal insulin B. Canagliflozin C. Glipizide D. Pioglitazone E. Repaglinide

D. Medication adverse effect patients with malnutrition, pregnancy or certain comorbid diseases (diabetes mellitus) should be started on pyridoxine supplementation when treated for latent or active TB with Isoniazid (INH). This helps prevent INH-mediated pryridoxine deficiency

54-year-old woman comes to the office as a new patient. She immigrates to the US 3 weeks ago & has a Hx of DM2. She was also diagnosed with active pulmonary TB 4 months ago. She completed 2 months of intensive anti tuberculosis therapy with 4 drugs & now is on Isoniazid & Rifampin alone. Repeat sputum testing for acid-fast bacillus is negative. The patient feels well overall but does have tingling & numbness of the bilateral hands & feet that started a fe weeks ago. VS are normal. Neuro exam shows normal motor strength but decreased touch & pain sensation in the bilateral upper & lower extremities. Romberg sign is positive. Hemoglobin A1C is 7%. Which of the following is the most likely cause of this patient's current symptoms? A. Degeneration of the dorsal & lateral spinal columns B. Inflammatory demyelination of axons C. Loss of motor neurons D. Medication adverse effect E. Micro vascular nerve injury

B. high preload, low cardiac output, high afterload acute MI can lead to profound impairment in left ventricular contractility, decreased stroke volume & decreased cardiogenic shock. Low cardiac output leads to high left ventricular end-diastolic volume (preload) & a compensatory increase in systemic vascular resistance (afterload)

55-year-old man is brought to the ED with SOB & generalized weakness since yesterday. He has also had several episodes of midline chest pain but currently no chest pain. Medical Hx includes HTN, DM2 & peripheral vascular disease. The patient is a smoker with a 20-pack-year history. Temp: 37.5C (99.5F). BP: 80/50, HR: 120/min, RR: 30/min. He appears to be in respiratory distress & extremities are cold & clammy. There is visible jugular venous distention with the patient in a sitting position. Chest auscultation reveals bilateral crackles. Abdomen is soft & nontender. ECG shows sinus tachycardia with a left bundle branch block. Serum lactate level is 3.5mg/dL (normal <2). The patient is suspected to have had an acute MI. Which is most likely to be seen in this patient? A. high preload, high cardiac output, low after load B. high preload, low cardiac output, high afterload C. low preload, high cardiac output, high afterload D. low preload, high cardiac output, low afterload E. low preload, low cardiac output, high afterload

C. S3 Patients with severe mitral regurgitation develop left ventricular volume overload & an S3 gallop due to the large volume of regurgitant flow reentering the ventricle during diastole.

55-year-old woman comes to the office due to persistent SOB. Over the last year, she has had difficulty climbing the stairs to her bedroom & performing household chores. The patient also feels fatigued at the end of the day. She has o chest pain, cough, syncope, or lower extremity swelling. The patient is a lifetime nonsmoker. BP is 133/75 & HR is 85/min and regular. The apical impulse is displaced to the left & there is palpable systolic thrill. A 4/6 blowing & high-pitched holosystolic murmur is heard at the apex. Which of the following additional findings is most likely present in this patient? A. Opening snap B. Pulsus paradoxus C. S3 D. S4 E. Wide & fixed splitting of S2

A. fluid accumulation in the alveolar spaces ARDS is caused by injury of the pulmonary epithelium &/or endothelium & occurs most often due sepsis or pneumonia. ARDS causes capillary damage & leakage of protein-rich fluid into the alveoli.

56-year old woman is brought to the ED due to 3 days of dysuria & back pain. Temp is 39.2C (102.6F), BP: 70/40, HR: 130/min, RR: 28/min. The patient is confused and has suprapubic & costovertebral angle tenderness. The skin is diffusely warm but there are no rashes or edema. CBC demonstrates leukocytosis with increased neutrophils. UA is positive for leukocyte esterase & nitrites & microscope shows numerous bacteria. Several hours later, the patient becomes increasingly hypoxic & requires mechanical ventilation. This patient's respiratory Sx are most likely due to which of the following pathologic conditions? A. fluid accumulation in the alveolar spaces B. necrotizing inflammation with pulmonary hemorrhage C. scattered noncaseating granulomas D. thick mucus plugs in the bronchi & bronchioles E. wedge-shaped areas of hemorrhagic necrosis

C. Obtain exercise stress test Clinically stable patients with unstable angina or non-ST elevation MI undergo early risk stratification. Low-risk patients should have noninvasive stress testing prior to hospital d/c; intermediate- or high-risk patients should be referred for early coronary angiography.

56-year-old man presents to the ED due to chest pain. He was watching TV when he developed dull, pressure-like chest pain. The pain progressively worsened and radiated to the throat but spontaneously resolved within 20 mins. He denies palpations, syncope, dyspnea or diaphoresis. The patient is otherwise health & is a lifetime nonsmoker. He currently has no chest pain. BP is 150/80 and HR is 78/min. ECG shows sinus rhythm with T-wave inversion in leads V5 and V6. CXR is normal. Troponin level is normal (<0.012 ng/dL). Aspirin, Metoprolol, Atorvastatin, Clopidogrel & SQ Enoxaparin are initiated. 8 hours later, he is still without chest pain. ECG is unchanged & repeat Troponin level is normal. Which of the following is the best next step in management of this patient? A. D/c home with Aspirin, Metoprolol & Atorvastatin B. Obtain coronary calcium score C. Obtain exercise stress test D. Perform coronary angiography within 24 hours E. Provide reassurance & d/c home with no new meds

C. HCTZ SGLT2-inhibitors lower blood glucose by decreasing the reabsorption of glucose in the kidney. The m/c side effects are genital candidiasis, UTIs & osmotic diuresis leading to hypotension. The patient is on a diuretic & already hypotensive & should have her HCTZ dose decreased or d/c prior to initiating canagliflozin.

56-year-old woman presents for follow-up on her DM2. Despite optimal lifestyle & compliance with meds, her a1c remains elevated at 8.2%. The patient also has HTN, her current meds include Metformin, Sitagliptin, Amlodipine, HCTZ & Aspirin. BP: 102/7-. IF canagliflozin is added to the patient's diabetes management. Which of the following meds will need a dose adjustment? A. amlodipine B. aspirin C. HCTZ D. Metformin E. Sitagliptin

B. Gastric adenocarcinoma Acanthosis nigricans is characterized by pigmented thickened plaques that arise in flexural regions such as the axillae or back of the neck. It is usually associated with benign conditions such as insulin resistance or obesity. However, sudden appearance or rapid spread can signal the presence of malignancy within the GI tract or lungs

57-year-old man present with complaint of poor appetite & weight loss. His symptoms have been present for 6 weeks & are progressively worsening. He has no associated blurry vision, polydypsia or polyuria. The patient has smoked 2-packs of cigarettes daily for 30 years & drinks 3-5 alcoholic drinks daily. VS are normal. On PE, the patient is thin & has pale conjunctivae & a shiny tongue. Velvety, hyperpigmented plaques on the skin are noted in the axillae & neck. There is mid tenderness to palpation in the epigastric region. The remainder of the abdomen is nontender. Lab studies show a moderate, hypochromic microcytic anemia & glucose level of 98mg/dL. Which of the following is the most likely diagnosis in this patient? A. Adrenal insufficiency B. Gastric adenocarcinoma C. Diabetes mellitus D. Tuberculosis E. Vitamin B12 deficiency

A. Foot imaging for osteomyelitis Osteomyelitis can arise in those with diabetic neuropathy and peripheral vascular disease without evidence of infection therefore foot imaging (XR, MRI) is generally recommended for all diabetic foot ulcers that are at least 1 of the following: - deep (exposed bone, positive probe-to-bone testing) - long-standing (present >7-14 days) - large (>2cm) - associated with elevated ESR/CRP - associated with adjacent soft tissue infection

58-year-old man presents due to an ulcer on the sole of the right foot fo 4 weeks. The ulcer has failed to heal despite wound care with moisture-retentive dressings & pressure offloading orthotic devices. The patient has had no right foot pain, redness, swelling, fever or chills. He has a 10-year history of DM complicated by diabetic neuropathy. PE shows a 3-cm ulcer under the 1st metatarsal head of the right foot; the wound has a clean base & no significant discharge. There is no surrounding erythema or areas of fluctuant or tenderness. Which of the following is the best next step in management of this patient' foot ulcer? A. Foot imaging for osteomyelitis B. Hyperbaric oxygen therapy C. Lower extremity angiography D. VItamin C & zinc supplementation E. Wound dressing with a topical ABX

C. Pramipexole patient has Idiopathic Parkinson Disease Deep brain stimulation is considered in patients who have medically refractory resting tremor, Levodopa-induced dyskinesia or significant motor fluctuations Donepezil is used to increase AcetylCoA levels in the frontal lobes of patients with dementia. This patient scored a 29/30 on the MMS, making dementia unlikely Propranolol is used to treat an essential tremor (worse with action) Trihexyphenidyl is used to treat idiopathic Parkinson disease induced resting tremor but does not that symptoms of bradykinesia and rigidity

58-year-old man presents due to tremor of his right hand. The patient first noticed the tremor 1 year ago & it has progressively worsened to the point that he has difficulty writing. Mini-Mental-State Exam score is 29/30. A low-frequency resting tremor is noted in the right hand. The tremor is exacerbated by mental distraction & becomes less prominent when the patient reaches for a pen. When the patient writes, his words become progressively smaller & illegible. Mild rigidity of the bilateral upper extremities & decreased arm swing during ambulation are present. Lab tests & MRI of brain are normal. What is the next best step in management of this patient? A. deep brain stimulation B. Donepezil C. Pramipexole D. Propranolol E. Trihexyphenidyl

A. Acyclovir Esophagitis is usually the result of a noninfectious process such as GERD. However, patients with impaired cell-mediated immunity (chemotherapy, post-transplantation, AIDS) are also at risk for esophageal infections. The leading causes are Candida, Cytomegalovirus & HSV. The classic HSV finding on a biopsy is multinucleated giant cells.

58-year-old woman comes to the office due to a week of pain with swallowing. Her symptoms have progressively worsened, & now she cannot eat comfortably. The patient has primary biliary cholangitis progressing to cirrhosis. She underwent a liver transplant 2 years ago & is on immunosuppressive therapy. Vital signs are normal. The patient has epigastric tenderness with no abdominal distention or guarding. Upper endoscopy shows several small esophageal ulcerations with distinct borders located in the middle & lower portions of the esophagus. A biopsy taken at the edge of an ulcer shows multinucleated giant cells. Which of the following is the most appropriate treatment for this patient? A. Acyclovir B. Azithromycin C. Fluconazole D. Omeprazole E. Tenofovir

B. Ciprofloxacin Acute bacterial prostatitis is characterized by fever, dysuria & a swollen, tender prostate. Most cases are caused by coliform organisms (E. coli). Urine culture is required to define the underlying pathogen, but 6 weeks of therapy with Trimethoprim-Sulfamethoxazole (Bactrim) or a Fluoroquinolone is generally required to ensure eradication.

59-year-old man comes to the ED due to lower abdominal pain. The patient has had 2 days of fever, chills, dysuria & pelvic pain; this morning, he was unable to pass any urine. He has never had similar symptoms before. Temp is 39C (102.2F). Suprapubic fullness & tenderness present. DRE shows an edematous & exquisitely tender prostate. The external genitalia are normal. A suprapubic catheter is placed, which drains 800mL of urine. Lab exam shows: CBC- leukocytes: 17,800/mm3 (normal: Serum Chemistry- creatinine: 1.7 mg/dL (normal: 0.6-1.2) UA- leukocyte esterase: positive nitrites: positive WBC: 10-20/hpf Which of the following is the most appropriate med for this patient? A. Azithromycin B. Ciprofloxacin C. Clindamycin D. Doxycycline E. Nitrofurantoin

A. Bladder cancer This patient's smoking history, subacute voiding symptoms (dysuria, urgency, frequency), suprapubic pain & hematuria likely indicated bladder cancer. Most cases arise in adults > 40y/o who have chronic exposure to chemical carcinogens such as cigarette smoke or industrial chemicals (dyes, paints, rubber). Common manifestations include: Hematuria: tumors are fed by new, friable blood vessels that often bleed into the urinary tract. Hematuria is commonly painless & tends to occur throughout micturition & may be gross (visible) or microscopic. Voiding Symptoms: tumors often protrude into the bladder & reduce bladder volume or cause detrusor overactivity, leading to subacute/chronic voiding symptoms such as dysuria, frequency & urgency. Although bladder cancer is often associated with painless hematuria, some patients with bladder cancer have dysuria as part of their voiding symptoms. Suprapubic pain: this usually indicates a more advanced tumor that has penetrated the muscle & invaded the surrounding soft tissue or nerves.

59-year-old man comes to the office due to a month of dysuria, urinary urgency & frequency. Over the past few days, he has also had dull, non radiating suprapubic pain. The patient has smoked a pack of cigarettes daily for 40 years. Vital signs are normal. Mild suprapubic tenderness is present. Rectal exam reveals a smooth, firm enlargement of the prostate with no tenderness, induration or asymmetry. Lab results are as follows: UA- Specific gravity: 1.016 Protein: none Blood: moderate Leukocyte esterase: negative Nitrites: negative Bacteria: none WBC: 1-2/hpf RBC: 20-30/hpf Casts: none Which of the following is the most likely explanation for this patient's symptoms? A. Bladder cancer B. Bladder infection C. Chronic bacterial prostatitis D. Prostate cancer E. Urethral stricture

C. Stool assay for ova & parasites hookworm infections are encountered worldwide, particularly in tropical areas & present with abdominal symptoms & failure to thrive. Common labs include microcytic anemia & eosinophilia. Exam of the stool for hookworm eggs is diagnostic

6-year-old girl is brought to a walk-in clinic for eval of growth. The patient & her family immigrated to the US from Haiti 2 months ago. For the past 3 months, decreased appetite has led to weight loss. The patient has had occasional abdominal discomfort & diarrhea. There is no gross blood or mucus in the stool. A mild cough early in the course of symptoms has resolved. VS are normal. Weight is at the < 5th percentile. The abdomen is soft, slightly distended & has hyperactive bowel sounds. There is generalized mild tenderness to deep palpation. Fecal occult test is positive. Lab results as follows: CBC- hemoglobin: 9.4g/dL (normal: 12.0-16.0) MCV: 65uUM3 (80-100) platelets: 380,000/mm3 (150,000-400,000) leukocytes: 7,400/mm3 (4,500-11,000) neutrophils: 65% (54-62%) eosinophils: 15% (1-3%) lymphocytes: 20% (25-33%) LFTs- albumin: 2.5g/dL (normal: 3.5-5.5g/dL) AST SGOT: 37U/L (normal: 8-20) ALT SGPT: 24U/L (normal: 8-20) Which of the following diagnostic studies is most likely to be abnormal in this patient? A. Serum folate level B. Serum IgA anti-tissue trans glutamine seems antibody C. Stool assay for ova & parasites D. Stool culture E. Toxin enzyme immunoassay for C. Difficile

A. impaired afferent arteriolar vasodilation patients with intravascular volume depletion (CHF, diarrhea, excessive diuresis) & CKD depend on renal prostaglandin production to dilate the afferent glomerular arteriole & maintain the GFR. NSAIDs inhibit prostaglandin synthesis, which can cause prerenal azotemia in at-risk patients

60-year old woman is being evaluated for abnormal renal function. She has a serum creatinine of 2.2mg/dL on routine lab monitoring; her creatinine level a year ago was 1.2mg/dL. The patient has a Hx of nonischemic cardiomyopathy & systolic HF & has been on a stable medical regimen for the past 2 years. She has no dyspnea, fever, rash or lower extremity swelling but has been taking Ibuprofen for 2 weeks due to L knee osteoarthritic pain. UA results: protein: none WBC: none RBC: none Sediment: none Ibuprofen is d/c & her kidney function returns to normal in a week. Which explains this patient's transient deterioration in renal function? A. impaired afferent arteriolar vasodialtion B. impair efferent arteriolar vasodilation C. interstitial inflammation D. toxic injury to the proximal tubules E. vasculitis of the glomerular capillaries

D. HCTZ Thiazide diuretics can cause hyponatremia (more commonly than loop diuretics), especially in older individuals with a low BMI or frailty. Treatment consist of stopping the diuretics as well as administering fluid repletion for patients who have associated hypovolemia.

80 year-old woman comes to the office due to nausea, fatigue & dizzy spells. She has been followed for several years for osteoporosis, DM2, depression, lower extremity swelling & mild cognitive impairment. The patient was recently started on treatment for HTN. BP is 144/90, HR is 78/min. Serum sodium: 122 mEq/L (normal: 136-145) Creatinine: 0.9 mg/dL (normal: 0.6-1.2) Which of the following meds is the most likely cause of this patient's symptoms? A. Atenolol B. Eplerenone C. Furosemide D. HTCZ E. Lisinopril

A. Detailed occupational history To establish a diagnosis of pleuropulmonary asbestosis patients should have clear evidence of exposure to asbestos, evidence of pulmonary fibrosis & no signs of other similar causes of lung disease. The most common source of asbestos exposure is occupational.

61-year-old man comes to the office due to dyspnea on exertion. He has recently developed SOB when performing yard work or household chores. The patient's symptoms have progressed over the past 2 years. He occasionally has chest pain that is worse with deep breathing & exertion. The patient has no cough, wheezing or sputum production. Temp is 36.1C (97F), BP is 134/80, HR is 88/min & RR are 18/min. Pulse ox on room air shows 91%. Pulmonary exam reveals fine end-inspiratory crackles at the bases. Extremities demonstrate clubbing but no peripheral edema. CXR reveals increased reticular marking predominantly at the bases consistent with interstitial fibrosis. The pleura are diffusely thickened with calcifications & there are small bilateral effusions. Which of the following would be most helpful in establishing this patient's diagnosis? A. Detailed occupational history B. FHx of malignancy C. Hx of exposure to pets D. Hx of prior TB exposure E. Recent travel to fungal-endemic area

B. accompanying tongue biting epileptic seizure can present similarly to a number of other conditions & can be especially difficult to differentiate from syncope. Tongue biting, especially of the lateral tongue, is highly specific for epileptic seizure & can be helpful in confirming in the diagnosis.

62-year-old man brought to ED after losing consciousness at church 30 mins prior. The patient was attending a service with his wife when he suddenly became unresponsive. He was noted to have brief jerking mov't of arms. Patient was helped to the floor & became responsive about 2 mins later. In the ED patient is alert & awake & has mild tongue pain. Patient had a similar episode 3 weeks ago, while sitting on the commode, he became disoriented & then found himself lying on the bathroom floor. He had no lightheadedness or chest pain prior to these events. VS are WNL and without orthostatic changes. A small non bleeding laceration is present on the lateral border of the tongue. The remainder of exam is normal. What finding is the most indicative of epileptic seizure compared to syncope. A. abnormal extremity mov'ts B. accompanying tongue biting C. episodic nature of the sx D. patient position at onset E. transition time to return to baseline

D. Statin This patient with CV risk factors (HTN, smoking) & a carotid bruit developed right upper extremity weakness & aphasia that resolved without intervention; this is characteristic of a TIA, which in this case, likely occurred following atheroembolization or low flow from the patient's carotid artery lesion. Those with TIA are at increased risk of stroke. Secondary prevention includes anti-platelet agents (aspirin), statins & lifestyle modifications (tobacco cessation).

62-year-old man comes to the ED due to right upper extremity weakness. 30 mins ago, the patient was at his office when he developed difficulty holding a pen. His grip in the right hand was weak & he could not lift his right arm. He could not speak. The patient has never had similar symptoms before. He had no LOC, weakness of other extremities, vision abnormality or HA. The symptoms resolved spontaneously. Medical Hx is significant for HTN & a 30-pack-year smoking history. BP is 140/84; HR is 82/min & regular. PE shows no extremity weakness or sensory loss. There is a left carotid bruit; the remainder of the exam shows no abnormalities. Noncontrast CT scan of the head is normal. Which of the following pharmacotherapies is most appropriate in management of this patient? A. Benzos B. Glucocorticoids C. SSRI D. Statin E. Tissue plasminogen activator

B. Atropine Acute angle-closure glaucoma results from an acute rise in IOP due to impaired aqueous humor drainage in the anterior chamber, necessitating an emergency ophthalmology referral. Meds that may precipitate an attack include asthma meds, decongestants & mydriatics. Mydriatics such as Atropine are contraindicated during an acute attack.

62-year-old woman is brought to the hospital due to severe, right-sided HA, nausea & eye pain. The patient was fixing a light bulb when she saddening felt pain in her right eye. Over the next few minutes, she developed loss of vision, photophobia & redness in the same eye. The patient has not experienced any trauma. On PE, she appears to be in intense pain. The right eye is red, has conjunctival flushing & feels hard on palpation. The right pupil is mid-dilated & nonreactive to light. Visual activity of the eye is 20/200. Which of the following meds should be avoided in this patient? A. Acetazolamide B. Atropine C. Mannitol D. Pilocarpine E. Timolol

C. protamine sulfate protamine sulfate is used as a reversal agent for heparin. Vitamin K & fresh frozen plasma can be used to reverse warfarin effects.

63-year-old man is brought to hospital due to sudden-onset chest pain & dyspnea. The patient has glioblastoma multiforme for which he has been undergoing radiation treatment. Temp 36.1C (97F), BP: 110/80, HR: 118/min & RR: 26/min. Pulse ox shows 90% on room air. CT pulmonary angiogram reveals a left-sided pulmonary embolism & he started on continuous unfractionated heparin infusion. Several hours later, the patient begins to experience severe HA & quickly becomes unconscious. CT scan of the head reveals bleeding into the tumor. After stopping the heparin infusion, administration of which of the following is indicated for immediate anticoagulant reversal? A. fresh frozen plasma B. platelets C. protamine sulfate D. prothrombin complex concentrate E. Vitamin K

C. Legionella pneumophilia Legionella pneumophilia has a propensity to affect older adults with chronic lung disease who smoke. It causes Legionnaires' disease which is characterized by high fever, diarrhea, headache & confusion. L pneumonphilia is a gram-negative rod that is typically not detected on a Gram stain.

63-year-old man is brought to the ED after recent onset of high fever, confusion, headache, watery diarrhea & cough. The patient has been smoking 2 packs of cigarettes daily for more than 30 years & has been diagnosed with chronic bronchitis. He lives in a nursing home & several other residents have similar symptoms. Temp: 40.1C (104F); BP: 100/70; HR: 91/min; RR: 28/min. Sputum gram staining reveals numerous neutrophils but no bacteria. Which of the following is the most likely cause of this patient's clinical presentation? A. Coccidioides immitis B. Klebsiella pneumoniae C. Legionella pneumophilia D. Mycobacterium avium E. Mycoplasma pneumoniae

B. E. coli this patient with unilateral testicular pain & palpable swelling of the epididymis likely has an acute epididymitis acute epididymitis typically manifests with unilateral testicular pain & epididymal swelling. Those age > 35 usually develop epididymitis due to bacteriuria from bladder outlet obstruction; ascending coliform organisms such as E. coli are the most likely pathogens. Patients < 35 are more likely to have epididymitis due to sexually transmitted infections with Chlamydia trachoma's or Neisseria gonorrhoeae.

63-year-old man presents due to 2 days of increasing scrotal pain. Pain is worse with touch or mov't & is not relieved by Ibuprofen. He also complains of mild burning on urination & increased urinary frequency. His medical Hx includes BPH. The patient is married & sexually active with his wife. Temp is 38.1C (100.8F). PE shows scrotal mass in the left scrotum this is mildly erythematous. Cremasteric reflex intact. No urethral discharge present. Which is the most likely cause of the patient's current condition? A. Chlamydia trochomatis B. E. coli C. mumps virus D. Neisseria gonorrhoeae E. Staph. aureus

E. supraclavicular this patient has progressive epigastric pain (only partially relieved with antacids), weightless, GI bleeding most likely has gastric cancer. intraabdominal malignancies can metastasize via lymphatic Chanels which travel along side organ's respective blood supply. The thoracic duct receives all lymphatic drainage from the abdominal viscera & lymph from this duct is sampled by the left supraclavicular lymph node. Enlargement of this node (Virchow's node) may signify an occult abdominal malignancy.

64-year old man presents with 6 months of progressive epigastric pain that is worsened by food ingestion. The patient also reports a 10kg (22lb) weight loss within this & several episodes of vomiting in the last 2 weeks. He has been taking OTC omeprazole without any relief. PE shows epigastric fullness. Fecal occult blood test is positive. Gastric outlet obstruction due to malignancy is suspected. Bx of which of the following lymph node structures is most likely to show deposits of malignant cells? A. axillary B. deep cervical C. epitrochlear D. inguinal E. supraclavicular

E. Prescribe oral antihypertensive med & arrange outpatient follow-up Patients with severe asymptomatic HTN S: >180 &/or D: >120 (HTN emergency) warrant initiation of oral meds to lower BP over hours to days but usually do not require in patient care. If desired, short-acting oral agents can be given initially & BP rechecked. The patient can then be prescribed a long-acting agent to continue at home. Close outpatient follow-up is recommended.

64-year-old man comes to the ED due to a right forearm laceration from a fall in his garden. He has some bleeding from the wound but no other symptoms. The patient was diagnosed with HTN several years ago but has not followed up & takes no meds. BP is 210/118 and HR is 78/min and regular. Cardiopulmonary & fundoycopic exams are unremarkable. ECG shows normal sinus rhythm with voltage criteria for left ventricular hypertrophy. Lab results show Potassium of 3.9 mEq/L and Creatinine of 0.8 mg/dL. The laceration is sutured and tetanus vaccine is given. Repeat BP is 196/114. Which of the following is the best next step in management of this patient? A. Admit to hospital for IV antihypertensive therapy B. Advise lifestyle modifications & home BP monitoring C. Obtain serial cardiac biomarkers & echocardiography D. Order diagnostic tests for secondary causes of HTN E. Prescribe oral antihypertensive med & arrange outpatient follow-up

B. CT of the abdomen This patient has some features of major depression (low mood, weight loss) & anxiety. However, given his age, smoking history, jaundice & recent diagnosis of DM (despite lack of obesity), this presentation is concerning for pancreatic cancer. Depression, weight loss & new-onset DM may occur as early manifestations of pancreatic cancer. CT of the abdomen is indicated as part of the initial diagnostic eval.

64-year-old man comes to the office for eval of low mood began 2 months ago. The patient has been feeling sad & anxious for no reason, but feels like something bad is going to happen. The patient has been skipping lunch due to a decreased appetite & has lost 9kg (20lbs) in the last few months. He continues to enjoy reading & has no difficulty falling or remaining asleep. The patient formerly smoked tobacco, with a 20-pack-year history. Medical history includes recently diagnosed diabetes mellitus. Vital signs are normal. BMI is 19kg/m2. The patient is thin, appears anxious & is slightly jaundice. He reports not suicidal ideation, hallucinations or delusions. TSH level is 4.0 uU/mL (normal: 0.5-5.0). Which of the following is the best next step in management of this patient? A. Brain MRI B. CT of the abdomen C. Electroconvulsive therapy D. Mirtazapine E. Paroxetine

C. degenerative joint disease patient has slowly progressive pain relieved by rest indicating osteoarthritis (degenerative joint disease) of the hip

64-year-old man presents due to increasing pain in his right groin for the past several months. The pain increases with activity, is relieved with rest and sometimes radiates to upper thigh. The patient denies trauma or falls. VS are nml. Exam shows pain on passive internal rotation of the right hip but no focal tenderness on palpation of the groin & hip region. Reflexes are 2+ in lower extremities & no sensory deficits noted. Muscle bulk, tone & strength normal. Posterior tibial pulses 2+ bilaterally. What is the cause of this patient's hip pain? A. aortoilliac vascular occlusion B. cutaneous nerve compression C. degenerative joint disease D. inflammation of the trochanteric bursa E. referred pain from lumbosacral spine

D. Reduced alcohol intake Patients with hypertriglyceridemia should be evaluated for secondary causes & initially managed with exercise, weight loss, a low-fat/low-carb diet & reduction or cessation of alcohol intake. In patients with mild hypertriglyceridemia (150-500 mg/dL) who have or are at high risk for arthersclerotic CV disease, statins are 1st-line therapy.

64-year-old man was admitted 2 days ago for non-ST segment elevation MI. He underwent percutaneous coronary intervention to the right coronary artery on the day of admission & has since been symptom free. The patient has HTN for which he takes Lisinopril & drinks a 6-pack of beer most nights. BP is 142/90. BMI is 28kg/m2. A faint bruit is heard over the right carotid artery. Fasting lipid panel results- Total cholesterol: 306 mg/dL (normal: <200) HDL: 40 mg/dL (normal: >60) LDL: not calculated Triglycerides: 465 mg/dL Thyroid function tests are normal. In addition to high-intensity statin therapy, which of the following is the best recommendation for management of this patient's lipid disorder? A. Carb-free diet B. Extended-release Niacin C. Gemfibrozil D. Reduced alcohol intake E. Vitamin E supplementation

A. chronic interstitial nephritis OTC analgesics such as NSAIDs can cause renal failure (analgesic nephropathy) if taken in large amounts over extended periods of time. Affected patients typically have a modest elevation in serum creatinine, proteinuria & evidence of tubular dysfunction (polyuria, nocturne). Microscopic hematuria & sterile pyuria (WBC without bacteria) also may be seen on UA. NSAIDs concentrate in the renal medulla particularly in the papillae & increase oxidative stress, resulting in damage to tubular & vascular endothelial cells. Chronic interstitial nephritis results with prolonged use of NSAIDs. Visualized patchy interstitial inflammation w. subsequent tubular atrophy & fibrosis, papillary necrosis & scarring.

64-year-old man who recently moved to the area comes to the office for a new patient eval. He has chronic low back pain, resulting from an injury 8 years ago, for which he uses several OTC analgesics. Most recently, the patient has been taking Naproxen daily. He has no other joint pain, fever, rash, urinary Sx or other medical conditions. BP: 135/70, HR: 78. Exam shows trace lower extremity edema. Lab results show blood counts WNL, BUN: 12mg/dL & serum creatinine of 2.0mg/dL. UA reveals 1+ protein & 3-4 WBC/hpf. Renal US demonstrates bilateral shrunken & irregular kidneys w/ a few papillary calcifications. What is the diagnosis of this patient? A. chronic interstitial nephritis B. chronic pyelonephritis C. focal segmental glomerular sclerosis D. ischemic tubular necrosis E. renal artery stenosis

A. Being hospitalized & taking ABX for pneumonia ABX disrupt the normal intestinal flora, which can allow overgrowth of Clostridioides (Clostridium) difficile, an anaerobic, spore-forming bacillus. C. diff produces toxins that penetrate colonic epithelial cells, leading to watery diarrhea, abdominal cramping & colitis. The present of pseudomembranes (white-yellow plaques on colonic mucosa) is tightly suggestive of C. diff infection.

65-year-old man comes to the ED due to abdominal pain & diarrhea. 3 weeks ago, he drove from Texas to Mexico for a family vacation. Temp is 38.3C (100.9F), BP is 115/70 and HR is 98/min. Abdominal exam shows mild, generalized tenderness with no rebound tenderness or guarding. Leukocyte count is 14,000/mm3. Sigmoidoscopy demonstrates white-yellow plaques on the colonic mucous, findings consistent with pseudomembranes. Further questioning regarding this patient's trip to Mexico is most likely to reveal what? A. Being hospitalized & taking ABX for pneumonia B. Consuming shellfish from the hotel buffet C. Drinking unpurified tap water on several occasions D. Eating undercooked pork at a resort BBQ E. Preparing home-canned foods to consume during the trip

C. Diabetic nephropathy Patients with diabetes for > 10 years can develop diabetic nephropathy. Risk factors include poor glycemic control, elevated blood pressure, smoking & increasing age. Clinical findings include mild-to-moderate proteinuria & chronic kidney disease with elevated creatinine.

65-year-old man presents due to straining during urination & a weak urinary stream for the past 6 months. He wakes up on average twice a night to urinate. The patient was diagnosed with DM2 14 years ago & takes Metformin & Insulin. His other medical conditions include hypertension, gout & moderately decreased visual acuity. BP: 160/100; HR: 70/min. BMI: 30kg/m2. Exam shows trae bilateral edema. Post-void bladder residual volume is normal. UA shows 3+ protein (900mg/dL) & no blood. Serum clearance level is 2.1mg/dL. Which of the following is most likely cause of this patient's chronic kidney disease? A. Ascending infection B. Cystic kidney disease C. Diabetic nephropathy D. Membranous nephropathy E. Obstructive uropathy

B. excessive calcium carbonate intake

65-year-old woman present for a followup. 2 months ago patient was found to have a low bone mineral density on screening DXA. Her serum calcium & vitamin D levels were WNL & weekly Alendronate therapy was prescribed. After starting the bisphosphonates, patient had burning epigastric discomfort for which she takes chlorthalidone. BP: 110/66, HR: 88/min. PE is normal. Serum creatinine was 0.8mg/dL 2 months ago & 1.7mg/dL today. Serum calcium is 12.8mg/dL today. What is the most likely cause of this patient's hypercalcemia? A. bisphosphonate-induced osteonecrosis B. excessive calcium carbonate intake C. increased release of PTH D. increased renal activation of vitamin D E. renal tubular effect of thiazide diuretic

C. monitoring while treating COPD exacerbation multifocal atrial tachycardia is a supra ventricular tacharrhythmia characterized with > 3 different morphologies, atrial rate >100/min & an irregular rhythm. It is usually precipitated by an acute respiratory illness in patients with underlying lung disease. Treatment should be directed at correcting underlying inciting disturbance (in this patient, COPD)

66-year old man is admitted to the hospital for an acute exacerbation of COPD. He has had worsening SOB, wheezing & a productive cough with mucoid sputum for the past several days. Temp: 37.1C (98.8F), BP: 130/80, HR: 114/min & irregular. Pulse ox: 86% on room air. PE reveals moderate respiratory distress, bilateral expiratory wheezing & distant heart sounds. ECG shows an irregular narrow complex tachycardia with 3 different P-wave morphologies & a variable PR interval. Serum electrolytes are normal. What is the next best step in management of this patient? A. anti arrhythmic meds to convert to normal sinus rhythm B. anticoagulation & CCB C. monitoring while treating COPD exacerbation D. rate control with a nonselective BB E. trans esophageal echo & cardioversion

E. Spironolactone Aldosterone antagonists (Spironolactone, Eplerenone) are recommended for patients with left ventricular systolic dysfunction who continue to have symptoms despite appropriate therapy with a diuretic, beta blocker & ACE-I/ARB.

72-year-old man with ischemic cardiomyopathy comes to the office following a hospitalization for decompensated CHF. He says that he becomes SOB after walking a few blocks on a level surface. His meds include Aspirin 81mg/day, Carvedilol 25mg/BID, Quinapril 40mg/day, Atorvastatin 40mg/day & Furosemide 40mg/day. His BP is 128/76, HR is 76/min, RR are 16/min. Lung exam is CTA. Cardiac exam shows a 3rd heart sound. There is no peripheral edema. A recent echocardiogram showed left ventricular ejection fraction of 30%. Lab results shows- Potassium: 3.9 mEq/L (normal: 3.5-5.0) Creatinine: 1.0 mg/dL (normal: 0.6-1.2) Which of the following additional treatments would most benefit this patient? A. Amlodipine B. Digoxin C. Hydralazine D. Metolazone E. Spironolactone

E. Squamous cell carcinoma A tonsil uler in a smoker is likely due to squamous cell carcinoma. Choice A- tonsil malignancy is unlikely to be adenocarcinoma. Lung adenocarcinoma shows some risk factors (smoking, age) & possible presenting symptoms (cough, hemoptysis) with oropharyngeal SCC, but it does not metastasize to the tonsil Choice B- Aphthous ulcers are common, painful ulcers that typically present with an erythematous border & a white membrane covering the ulcer. However, they typically resolve in 1-2 weeks & are usually seen in the oral cavity (tongue, buccal mucosa) rather than the oropharynx (tonsil) Choice C- Non-Hodgkin rarely presents on the tonsil & much less common than head & neck SCC. It would also cause tonsillar enlargement rather than ulceration & is usually seen in patients with immunosuppression or autoimmune diseases. Choice D- Small cell carcinoma is cancer of the lungs & does not appear on the tonsil.

66-year-old man comes to the office due to a worsening sore throat over the last 3 months. The patient has smoked 2 packs of cigarettes for the past 50 years. VS are normal. Ear exam is normal. The nasal mucosa is dry & exam of the oral cavity shows poor dentition with no lesions Oropharyngeal exam shows an enlarged, firm right tonsil with a 1-cm ulceration with surrounding fibrinous debris. There is no cervical adenopathy. Bx of this lesion would most likely reveal which of the following? A. Adenocarcinoma B. Aphthous ulcer C. Non-Hodgkin lymphoma D. Small cell carcinoma E. Squamous cell carcinoma

C. Ischemic optic neuropathy giant cell arteritis (GCA) is characterized by granulomatous inflammation of the media, with fragmentation of the internal elastic laminate of medium & small branches of the carotid artery. Anterior ischemic optic neuropathy is a severe complication of GCA resulting in irreversible blindness, & patients with suspected GCA require immediate glucocorticoid therapy

67-year-old man comes to the office with a persistent headache & pain in the jaw when chewing food. For the past 2 months, he has been unable to eat "tough foods like steak b/c the pain makes it take too long to chew them." The patient has hypertension, DM2 & hyperlipidemia. BP: 130/70; HR: 76/min & regular. PE is unremarkable. The patient is immediately started on appropriate therapy & an arterial biopsy is performed. Histopathy shows multinuclear giant cells & internal elastic membranous fragmentation. Prompt institution of therapy in this patient most likely reduces the risk of which of the following complications? A. Glomerulonephritis B. Hepatic necrosis C. Ischemic optic neuropathy D. MI E. Pulmonary hemorrhage

C. vancomycin, ampicillin, ceftriaxone, dexamethasone patients with suspected acute bacterial meningitis require urgent empiric treatment with ceftriaxone & vancomycin. Ampicillin should be added for those > 50 to empirically cover for Listeria. All patients should also receive Dexamethasone to reduce risk of neurologic sequelae & death from potential pneumococcal meningitis

68-year old man brought to ED due to fever, HA & lethargy. The patient was previously healthy. Temp: 39.4C (103F), BP: 80/50, HR: 98/min, RR: 20/min. The patient is lethargic & oriented only to person. He moves all 4 extremities on command. Moderate neck pain & stiffness are present. Lab workup obtained & head CT scan & LP are planned. Which is the next best step in management of this patient? A. IV acyclovir alone B. vancomycin, ampicillin, meropenem C. vancomycin, ampicillin, cefrtiaxone, dexamethasone D. vancomycin, cefepime E. vancomycin, ceftriaxone

B. Chronic hyperglycemia-induced microvascular injury Chronic hyperglycemia in patients with DM can leaded to increased permeability & arteriolar obstruction in retinal vessels. The resulting ischemia stimulates production of vascular endothelial growth factor & other angiogenic factors, leading to neovascularization (proliferative diabetic retinopathy). Complications include retinal hemorrhage, retinal detachment & vision loss.

68-year-old woman is evaluated for vision impairment. The patient has a decrease in both distant & near vision & has had occasional floaters. She has had no pain or redness in her eyes, HA, focal weakness or sensory loss. Medical Hx is notable for DM2, HTN & CKD. BP is 138/84, HR is 76/min. The pupils are equal & reactive to light bilaterally. Anterior chambers are clear & there are no opacities of the cornea or lens. Funduscopic exam reveals scattered retinal micro aneurysms, dot-and-blot hemorrhages & cotton-wool spots as well as new blood vessel formation. Which of the following contributed most to the pathogenesis of this patient's current ocular condition? A. Age-related degeneration of retinal pigment epithelium B. Chronic hyperglycemia-induced microvascular injury C. Ganglion cells death due to to high IOP D. Retinal artery occlusion from atherosclerotic disease E. Vascular injury from increased intraluminal pressure

E. lactated ringer soln the initial management of septic shock requires rapid fluid resuscitation to replace intravascular volume & restore adequate end-organ perfusion. The is best accomplished with IV bolus of isotonic crystalloid in the form of 0.9% (normal) saline or lactated ringer soln

68-year-old woman with COPD is brought to ED due to worsening fever, cough, & confusion. The patient has had a "cold & congestion" since last week, which initially improved but she began feeling worse again 3 days ago & is now eating poorly. Temp is 39.4C (102.9F), BP: 74/46, HR: 128/min, RR: 30/min. O2 sat is 94% on 2L/min. On PE the patient is lethargic with dry mucous membranes. Lung exam reveals dullness to percussion & crackles at the right base. CXR shows a right lower lobe consolidation. IV access is established. IV of which of the following is the best next step in management? A. 0.45% saline B. 3% saline C. 5% dextrose in 0.45% saline D. albumin soln E. Lactated Ringer soln

D. Vitamin B12 level The initial workup of suspected dementia should include neuropsychological testing (Montreal Cognitive Assessment), selected lab tests (CBC, CMP, TSH, B12) & neuroimaging (MRI). Patients in specific risk groups may warrant additional targeted testing.

69-year-old woman is brought to the office by her husband due to forgetfulness. The patient is a retired law professor who taught classes until 2 years ago when she began to have difficulty remembering lessons plans. Since then, her memory has worsened, and she has gotten lost during her normal neighborhood walk on more than 1 occasion. Her husband has taken over all cooking & cleaning; moreover, the patient is unable to drive or use public transportation on her own. Vital signs are normal. She scores a 22/30 on Montreal Cognitive Assessment (normal: >26). There are no focal neurologic deficits. Which of the following is the best next step in evaluation of this patient? A. Cerebrospinal fluid testing B. Electroencephalogram C. No additional testing indicated D. Vitamin B12 level E. Vitamin D level

C. IV magnesium sulfate IV magnesium sulfate is the 1st-line therapy for the initial treatment & prevention of recurrent episodes of tornado de pointes, regardless of the patient's serum magnesium levels. Temporary transvenous pacing is performed in patients who do not respond to IV magnesium sulfate. This patient has developed acquired long QT syndrome as a result of interactions between 2 QT interval-prolonging medications (Sotalol) which he was taking for atrial fibrillation & azithromycin, which was prescribed for pneumonia

70-year-old man is hospitalized due to community-acquired pneumonia. He has hypertension, paroxysmal atrial fibrillation & peripheral vascular disease for which he takes Warfarin, Sotalol, & Lisinopril. He is started on Azithromycin, Ceftriaxone & oxygen therapy. 2 days later, the patient has 2 episodes of loss of consciousness associated with seizure like activity. Telemetry during 1 of these episodes shows 3 sinus beats with a prolonged QT interval, followed by a deterioration into a rapid ventricular rhythm consistent with polymorphic ventricular tachycardia (Torsade de pointes) On exam, the patient is now awake & alert but oriented only to person. BP: 120/70; HR: 65/min; RR: 14/min. A basic metabolic panel drawn 30 mins prior to the first event is unremarkable. Which of the following is the best next step in management of this patient? A. IV amiodarone B. IV lidocaine C. IV magnesium sulfate D. Oral Metoprolol E. Temporary transvenous pacing

D. Parkinson disease dementia Characterized by executive & visuospatial dysfunction with relatively mild memory impairment at first. PDD may be distringuished from dementia with Lewy bodies by the timing of symptom onset; if Parkinsonism predates cognitive impairment by > 1 year, PDD should be diagnosed.

74-year-old man is brought to the office by his wife due to a change in behavior. Over the last year, the patient has had difficulty recognizing his grandchildren & has gotten lost in his local grocery store more than once. He enjoys playing Sudoku but has had increasing difficulty completing the puzzles. He sometimes sees animals in the house despite the couple not owning any. The patient has not seen a doctor in > 20 years & takes no meds. His wife says that he started "slowing down" and developed stiffness & a hand tremor that started approximately 4 years ago, preceding his current behavioral symptoms. Exam shows intact cranial nerves & pinprick & light touch sensations. There is rigidity in the bilateral upper & lower extremities that is worse on the left. Tremor is present in both hands at rest & is worse in the left hand. Movements & speech are slowed. Gait is unsteady & marked by a shortened stride. Which of the following is the most likely diagnosis? A. Alzheimer disease B. Dementia with Lewy bodies C. Normal pressure hydrocephalus D. Parkinson disease dementia E. Vascular dementia

C. Metoprolol anticoagulation in addition to rate &/or rhythm control are the accepted treatments for atrial fibrillation. In the presence of tachycardia, beta-adrenergic antagonists or non-dihydropyridine calcium channel blockers can be used to rapidly control the heart rate.

76-year-old man presents to office due to increased fatigue over the last 2 months. His exercise tolerance has also decreased. He has not had any chest pain, N/V, dizziness or syncope. The patient's other medical conditions include HTN & hyperlipidemia. BP: 124/79. On exam his lungs are CTA & a short mid systolic murmur is heard over the right upper sternal border. His ECG shows atrial fibrillation. Which is the best initial medical treatment for this patient? A. Quinidine B. Clonidine C. Metoprolol D. HCTZ E. Amlodipine

E. Thrombocytopenia Disseminated intravascular coagulation (DIC) typically presents with signs of bleeding (oozing from venipuncture sites) in the setting of sepsis, malignancy or severe trauma. Widespread activation of the coagulation cascade leads to the formation of IV microthrombi, which consumes coagulation factors (prolonged PT/PTT), platelets (thrombocytopenia) & fibrinogen. Subsequent fibrinolysis increases D-dimer

78-year-old resident of an extended care facility is brought to the ED due to lethargy, fevers & poor oral intake for the last day. Temp: 39C (102F); BP: 70/40; HR: 120/min & regular. On exam, the patient is lethargic but arousable. His extremities are warm. A Foley catheter is inserted into the bladder & drains 500mL of cloudy urine consistent with UTI. 5 hours after admission, the patient begins to bleed from the nose & venipuncture sites & the Foley catheter begins to drain blood-tinged urine. Which of the following lab findings would most likely to be seen in this patient? A. Increased fibrinogen B. Normal D-dimer C. Normal PTT D. Normal PT E. Thrombocytopenia

B. Diltiazem Common side effects of nondihydropyridine CCB (diltazem, verapamil) include constipation, bradycardia, AV conduction block (negative chonotropic effects) and worsening of heart failure in patients with reduced left ventricular function (negative inotropic effect).

82-year-old man is brought to the ED after a syncopal episode. He has had no chest pain or dyspnea but has severe constipation of recent onset. He was hospitalized 2 weeks ago for atrial fibrillation with rapid ventricular response & was discharged home with oral meds. Medical history is also significant for severe COPD requiring oxygen therapy. BP is 105/60 and HR is 50/min. ECG show new-onset second-degree AV block. Which of the following meds is the most likely cause of this patient's current condition? A. Amlodipine B. Diltiazem C. Lidocaine D. Propanolol E. Terazosin

B. Chronic mesenteric ischemia This patient with a Hx of vascular disease most likely has chronic mesenteric ischemia, which commonly presents with cramps, postprandial epigastric pain, food aversion & weight loss. PE may show signs of malnutrition, as well as an abdominal bruit in approximately 50% of patients, but otherwise is unremarkable. Diagnosis is with CT angiography. Treatment involves risk reduction (tobacco cessation), nutritional support & revascularization.

83-year-old woman comes to the office due to a yearlong Hx of progressively severe, cramps abdominal pain that occurs immediately after she eats. The pain is diffuse but more pronounced in the epigastric area & is associated with frequent bloating & occasional diarrhea. The patient has had a 15-kg (33lb) weight loss over the past year. She has lost her appetite since the pain began. The patient has HTN, DM2, hypercholesterolemia, peripheral vascular disease & coronary artery disease. 3 years ago, she had an inferior wall myocardial infarction. BP is 140/92. BMI is 24kg/mm2. The abdomen is soft, nontender & non distended. Bowel sounds are present. Abdominal XR is normal. Which of the following is the most likely cause of this patient's presentation? A. Biliary colic B. Chronic mesenteric ischemia C. Chronic pancreatitis D. Crohn disease E. Irritable bowel syndrome

B. impaired cough reflex patient with impaired consciousness, advanced dementia & other neuro disorders are predisposed to aspiration pneumonia due to impaired swallowing & cough reflex

87-year-old woman with advanced dementia is brought to the ED due to 3 days of fever & occasional foul-smelling sputum. The patient is bed bound & requires assistance with all activities of daily living. Med Hx is signifiant for a hemorrhagic stroke that occurred 8 months ago. Temp is 38.3C (100.9F), BP: 100/70, HR: 105/min & RR: 20/min. O2 sat is 90% on room air. The patient is not oriented to name, time or place. PE shows dry mucus membranes & decreased skin turgor. Breath sounds are decreased in the right lung field. Heart sounds are normal. CXR reveals an infiltrate in the lower lower of the right lung. Which is the most important important predisposing factor for this patient's condition? A. depressed immunity B. impaired cough reflex C. impaired mucociliary clearance D. increased gastric residual volume E. severe gastroesophageal reflux