#19 Rosh Review

Question: What is the conventional duration of oral antibiotic therapy to achieve maximal pharyngeal GAS eradication rates?

Answer: 10 days.

Question: What is the common ventricular rate seen with atrial flutter?

Answer: 150 bpm, due to the common 2:1 atrioventricular blockade. Rapid Review Atrial Flutter Sawtooth pattern Atrial rate: 250-300/minute Ventricular rate: 150- +/-30 AV node conducts every 2 or 3 atrial impulses

Question: What is the score range of the Glasgow Coma Scale?

Answer: 3 (worst) to 15 (best).

Question: How long is the recommended course of oseltamivir?

Answer: 7-10 days.

Question: What is the blood pressure goal for patients with diabetes mellitus type 2?

Answer: < 140/90.

Question: What is necessary if a patient's screening form is positive for depression?

Answer: A full diagnostic interview to determine the presence or absence and severity of mood and other comorbid psychiatric disorders. Rapid Review Depression Screening Adults: screen only when staff-assisted depression care supports are available

Question: A positive Myerson sign, in which repetitive tapping over the bridge of the patient's nose produces a sustained, involuntary blink response, may be seen in which neurologic condition?

Answer: A positive Myerson sign may be seen in patients with Parkinsonism. Rapid Review Parkinson's Disease Lewy bodies, substantia nigra dopaminergic neuron loss TRAP: Tremor (resting, "pill rolling"), Rigidity, Akinesia, Postural instability Carbidopa/levodopa, anticholinergic drugs Avoid antipsychotics

Question: What is Eisenmenger syndrome?

Answer: A septal defect leading to pulmonary arterial hypertension, causing a right-to-left shunt, bypassing the lungs and resulting in cyanosis and clubbing. Rapid Review Atrial Septal Defect PE will show wide, fixed split S2 Most commonly caused by persistent ostium secundum Comments: May lead to Eisenmengers syndrome

Question: What is the EMG finding in Guillain-Barré?

Answer: Acute denervation of the muscle. Rapid Review Gullain-Barre Syndrome: Patient with a history of recent minor respiratory or GI illness Complaining of symmetric, progressive ascending muscle weakness PE will show lack of deep tendon reflexes Lumbar puncture results will demonstrate increased CSF protein but a normal cell count Most commonly caused by Campylobacter jejuni Treatment is supportive, plasmapheresis, or IVIG

Question: What drug commonly used for maintenance therapy of gout is avoided during an acute gout attack?

Answer: Allopurinol. Except in diuretic-induced gout. Rapid Review Gout Patient will be a middle-aged man Complaining of acute onset of pain in the first MTP (Podagra) Labs will show needle-shaped crystal with negative birefringence Most commonly caused by uric acid crystals Treatment is: Acute: NSAID's Chronic: allopurinol or colchicine Comments: can be triggered by loop and thiazide diuretics

Question: What microcytic anemia may also display Heinz bodies?

Answer: Alpha thalassemia. Rapid Review G6PD Deficiency Patient with a history of taking antimalarials, sulfonamides, nitrofurantoin, fava beans Labs will show heinz bodies Comments: X-linked recessive

Question: What side effect can patients with hemophilia B and inhibitors experience if given factor replacement?

Answer: Anaphylaxis. Rapid Review Hemophilias X-linked recessive A: Factor VIII deficiency B: Factor IX deficiency Easy bruising, hemarthroses Increased PTT

Question: Which two anatomic compartments are the most affected in acute compartment syndrome?

Answer: Anterior compartment of the leg and the volar compartment of the forearm. Rapid Review Compartment Syndrome 6 Ps: Paresthesias, Pallor, Pulselessness, Poikilothermia, Paralysis, Pain out of proportion to exam Most common sites: forearm, lower leg Delta pressure ≤ 30 mm Hg: fasciotomy

Question: What nerve is responsible for pincer grip between the thumb and index finger?

Answer: Anterior interosseous branch of the median nerve.

Question: What is a septic abortion?

Answer: Any type of abortion accompanied by a uterine infection. Rapid Review Abortion Threatened abortion: vaginal bleeding with closed internal os Inevitable: vaginal bleeding with open os Incomplete: partial passage of products of conception (POC) Complete: complete passage of POC Missed: fetal death <20 weeks without POC passage Missed abortion complications: infection, coagulopathy Rh-negative women: RhoGAM

Question: Which fungal species is the most common cause of fungal otitis externa?

Answer: Aspergillus. Rapid Review Otitis Externa Patient with a history of swimming or moisture exposure Complaining of malodorous discharge and pruritus PE will show pain with palpation of tragus/pinna Most commonly caused by Pseudomonas aeruginosa Treatment is topical antimicrobials with or without steroids Comments: Necrotizing otitis externa - a complication seen in diabetics/immunocompromised

Question: What is the most common complication of hereditary spherocytosis?

Answer: Bilirubin gallstones.

Question: What is the most common cause of unilateral hearing loss?

Answer: Cerumen impaction. Rapid Review Meniere's Disease Patient will be complaining of episodic low-frequency hearing loss, tinnitus with aural (ear) fullness, and vertigo lasting one to eight hours Diagnosis is made clinically Most commonly caused by too much inner ear endolymph and increased pressure within the inner ear Treatment is low salt diet, diuretics (HCTZ + triamterene)

Question: What is the most common finding on microscopy for bacterial vaginosis?

Answer: Clue cells.

Question: What diagnostic examination should not be performed if acute diverticulitis is suspected due to the high-risk of perforation?

Answer: Colonscopy. Rapid Review Diverticulitis Patient will be complaining of abdominal pain that is localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits PE will show localized guarding, rigidity, and rebound tenderness Diagnosis is made by CT scan Treatment is abx

Question: What is the prognostic indicator of a melanoma lesion?

Answer: Depth of invasion. Rapid Review Melanoma Least common skin malignancy but highest mortality ABCDE: Asymmetry, Border (irregular), Color (different shades, not uniform), Diameter (>6 mm), Evolution

Question: What is the most common symptom of cardiac ischemia in patients older than 85 years?

Answer: Dyspnea. Rapid Review Ischemic Heart Disease #1 cause of death in USA RFs: family hx, smoking, HTN, DM, cholesterol, male, age > 55 Stable angina: activity → chest pain (CP), relieved by rest, NTG Unstable angina: CP at rest CP, dyspnea, diaphoresis, nausea, hiccups, radiation to shoulder/jaw/back Elderly, diabetics, females, hx of stroke or HF: ↑ risk for atypical presentation Earliest ECG sign of MI: hyperacute T waves Up to 50% of ECGs are negative or nonspecific Highest S/S: troponin I

Question: True or false: hypothyroidism is more common in men?

Answer: False.

Question: Which chronic widespread pain syndrome is thought to be associated with hypovitaminosis D?

Answer: Fibromyalgia. Rapid Review Vitamin D Deficiency Rickets (children) Osteomalacia Tetany

Question: Which disease, caused by lymphatic obstruction, commonly results in chronic hydrocele (elephantiasis)?

Answer: Filariasis, a parasitic disease caused by nematodes (commonly Wuchereria and Brugia species) and transmitted by black flies and mosquitoes. Rapid Review Hydrocele Most common cause of scrotal enlargement in children Fluid around the testicle → painless testicular swelling Right > left Transilluminates Indirect inguinal hernia Ultrasound

Question: What is the standard dosing schedule for the MMR vaccine?

Answer: First dose at age 12-15 months and second dose at school entry, 4-6 years.

Question: At what age can a baby start drinking cow's milk?

Answer: From a nutritional point of view, it is best to delay the introduction of whole cow's milk until the infant is one year old.

Question: What are the other causes of tearing in infants?

Answer: Glaucoma, intraocular inflammation, and external irritation. Rapid Review Dacryostenosis Patient will be a newborn Complaining of eye discharge PE will show large tear lake, overflow of tears onto the cheek, and presence of mucoid material in the canthi Most commonly caused by failure of canalization of the epithelial cells that form the nasolacrimal duct Treatment is nasolacrimal massage 2-3 times daily and cleansing with warm water

Question: What is the most common human enzyme defect?

Answer: Glucose-6-phosphate dehydrogenase (G6PD) deficiency. Rapid Review Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency X-linked recessive Asymptomatic until exposed to oxidative stress Infection, drugs, toxins Antimalarial, sulfonamides, nitrofurantoin, methylene blue, fava beans, vitamin K Hemolytic anemia

Question: What organism is associated with pneumonia in patients with COPD?

Answer: Haemophilus influenzae,Pseudomonas aeruginosa. Rapid Review Bacterial Pneumonia S. pneumonia: most common, rusty colored sputum, rigors, gram+ paired lancets Klebsiella: alcoholics, currant jelly sputum, bulging fissures, S. aureus: IVDA, postinfluenza, elderly, gram+ cocci in clusters H. influenzae: COPD, gram negative pleomorphic rods Pseudomonas: cystic fibrosis, nursing home resident and cyanosis Health care associated pneumonia: pseudomonas, MRSA Outpatient, healthy: macrolide or doxycycline Outpatient, comorbidity: respiratory tract fluoroquinolone (RTF) Inpatient: RTF ICU: antipneumococcal ß-lactam (ceftriaxone or cefotaxime) + either azithromycin or an RTF

Question: Forceful contraction of which muscle is responsible for causing the most common type of pelvic avulsion fracture?

Answer: Hamstring muscle. Rapid Review Pelvic Avulsion Fracture Powerful contraction of lower leg muscle on a developing apophysis Most common type ischial tuberosity avulsion Diagnosed with AP and frog leg radiographs Treated with rest, crutch use, and pain control Surgical pinning rarely required

Question: What is the most common cause of lower intestinal obstruction in neonates?

Answer: Hirschsprung Disease. Rapid Review Constipation in Children Newborns should pass meconium stool within 48 hours By age 3, children should have one bowel movement/day Hirschsprung's disease: absent stool in vault Fleet enema contraindicated in infants (due to hypocalcemia)

Question: What is the reason for amenorrhea when using first generation anti-psychotics?

Answer: Hyperprolactinemia.

Question: What is the most common side effect of oral sulfonylureas?

Answer: Hypoglycemia. Rapid Review Diabetic Ketoacidosis Patient will be a diabetic With a history of Infection, Ischemia (cardiac, mesenteric), Infarction, Ignorance (poor control), Intoxication (FIVE I's) Complaining of abdominal pain, vomiting, and fatigue PE will show hyperglycemia and ketonemia Labs will show anion gap metabolic acidosis Treatment is IV fluids & insulin infusion Comments: Corrected sodium add 1.6 mEq/L for each 100mg/dL in serum glucose

Question: Why is airway compromise in epiglottitis less common in adults than in children?

Answer: In adults, there is an increased trachea diameter to epiglottis diameter making airway compromise unusual. Rapid Review Epiglottitis Patient will be complaining of rapid onset of fever and dysphagia PE will show patient leaning forward, drooling, inspiratory stridor Imaging will show "thumbprint" sign Most commonly caused by H. influenzae, Streptococcus Treatment is IV antibiotics and airway management

Question: What is balanoposthitis?

Answer: Inflammation of the glans and foreskin. Rapid Review Balanoposthitis Patient will be an uncircumcised male Complaining of burning and itching of the penis PE will show erythema and inflammation with scant white discharge Most commonly caused by Candida Treatment is topical antifungal Comments: Recurrent balanitis is seen in diabetics

Question: What are the local and systemic side effects of inhaled corticosteroids?

Answer: Local: Cough, dysphonia, oropharyngeal candidiasis. Systemic: Adrenal suppression, osteoporosis, skin thinning, easy bruising and cataracts.

Question: In a hemodynamically stable pregnant patient with an ectopic pregnancy, what medication is recommended for medical management?

Answer: Methotrexate. Rapid Review Ectopic Pregnancy Patient will be a woman With a history of prior ectopic, PID, tubal surgery, IUD Complaining of vaginal bleeding, abdominal pain, amenorrhea PE will show adnexal tenderness or unexplained hypotension Labs will show positive pregnancy test and lower than expected serum ß-hCG levels Diagnosis is made by ultrasound Most commonly located in a fallopian tube Treatment is MTX or surgery

Question: Irritable bowel syndrome is a common example of which subclass of chronic diarrhea?

Answer: Motility disorder, in which the stool osmotic gap is normal, as in the above patient. Rapid Review Chronic Diarrhea ≥ 3 loose stools/day for ≥ 1 month Classification: Secretory Osmotic: ↑ stool anion gap Inflammatory Dysmotility

Question: What is the most common etiology of ventricular fibrillation?

Answer: Myocardial ischemia. Rapid Review Ventricular Fibrillation Most common cause: ischemic heart disease ECG: irregular chaotic pattern without P waves or QRS complexes Immediate defibrillation

Question: Have any vitamins been shown to help reduce the risk of developing prostate cancer?

Answer: No. Randomized trials have shown that vitamins E and C and selenium are not effective at preventing prostate cancer. Rapid Review Prostate Cancer RFs: age (most important), African-Americans, family hx Asymptomatic until advanced Obstructive uropathy Back pain: metasteses to lumbar spine (↑ ALP) PSA > 10 ng/mL Dx: needle core biopsy

Question: What condition are children with H. Influenzae conjunctivitis prone to develop?

Answer: Otitis Media. Rapid Review Acute Angle-Closure Glaucoma Patient will be entering a dark room or movie theater Complaining of acute unilateral painful vision loss, vomiting, and seeing halos around lights PE will show cloudy cornea and fixed mid-dilated pupil Labs will show ↑ IOP ( > 21 mm Hg) Treatment is topical ßBs, carbonic anhydrase inhibitors, steroids, miotics

Question: What is the preferred method of delivery in a woman with placental abruption?

Answer: Oxytocin-induced vaginal delivery. Cesarean delivery is reserved for significant maternal and fetal instability. Rapid Review Placental Abruption Patient will be a pregnant women in her third trimester With a history of hypertension, trauma or cocaine use Complaining of painful vaginal bleeding Labs will show hypofibrinogenemia

Question: The ankle-brachial index is used to evaluate which disease?

Answer: Peripheral arterial disease (normal is 0.9-1.4; < 0.9 = PAD; >1.4 = calcified PAD). Rapid Review Hypertension: Eighth Joint National Committee (JNC 8) Recommendations PreHTN: systolic blood pressure (SBP) 120-139 mmHg or diastolic blood pressure (DBP) 80-89 mmHg Stage I HTN: SBP 140-159 mmHg or DBP 90-99 mmHg Stage II HTN: SBP >160 mmHg or DBP >100 mmHg Treatment goals: >60 years: SBP <150, DBP <90 All others: SBP <140, DBP <90 1st line rx for general population: thiazide, CCB, ACEI, or ARB 1st line rx for African Americans: CCB or thiazide Chronic kidney disease: Rx should include ACEI or ARB

Question: What is the most common sequelae after lumbar puncture?

Answer: Post-LP headache which can be seen in up to 40% of patients. Rapid Review Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Young obese females Vitamin A toxicity, steroids, tetracycline ↓ CSF absorption HA + visual sx Papilledema, CN VI palsy ↑ opening pressure on LP Acetazolamide, serial LPs

Question: What are the common extrapyramidal symptoms of antipsychotic medication?

Answer: Pseudoparkinsonism, akathisia, acute dystonia and tardive dyskinesia. Rapid Review Schizophrenia ≥ 2 symptoms: Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms Brief psychotic disorder: <1 month Schizophreniform disorder: 1-6 months Schizophrenia: >6 months Schizoaffective disorder: psychosis + mania or depression

Question: What is the treatment for persistent complex bereavement disorder?

Answer: Psychotherapy.

Question: By what mechanism do ACE inhibitors cause hyperkalemia?

Answer: Reduction of aldosterone secretion. Rapid Review ACE Inhibitors Use: HTN, DM II MOA: block the conversion of angiotensin I to angiotensin II ADR: cough, angioedema Comments: Names end in "pril"

Question: Why should fluorodinated corticosteroids not be applied to the face?

Answer: Repeated use can produce permanent cutaneous atrophy. Rapid Review Atopic Dermatitis (Eczema) Patient with a history of asthma or hay fever Complaining of itchy, scaly rash on arms, often worse in the winter PE will show thick, leathery, hyperpigmented areas on flexor surfaces Treatment is topical corticosteroids, lubricating ointments

Question: What is the most common organism associated with bacterial tracheitis?

Answer: Staphylococcus aureus. Rapid Review Epiglottitis: Patient will be complaining of rapid onset of fever and dysphagia PE will show patient leaning forward, drooling, inspiratory stridor Imaging will show thumb print sign Most commonly caused by H. influenzae, Streptococcus Treatment is IV antibiotics and airway management

Question: What percentage of body surface area is used to distinguish Stevens-Johnson syndrome from toxic epidermal necrolysis?

Answer: Stevens-Johnson syndrome < 10% of the body surface area. Toxic epidermal necrolysis > 30 % of the body surface area.

Question: What pathogen causes pneumonia that is associated with bullous myringitis?

Answer: Streptococcus pneumoniae. Bullous myringitis was previously linked to Mycoplasma pneumoniae but it appears, based on middle ear aspirate culture results, that typical acute otitis media pathogens are the true cause. Rapid Review Post-viral Pneumonia Patient with a history of influenza Complaining of fever, productive cough with bloody sputum and shortness of breath CXR will show multiple cavitary lesions Most commonly caused by Staphylococcus aureus

Question: What is the typical duration of treatment for acute otitis media?

Answer: Ten days. Rapid Review Acute Otitis Media Patient will be an infant or young child Complaining of ear pain, fever, URI symptoms PE will show TM erythema and decreased mobility of TM Most commonly caused by viral > bacterial (S. pneumoniae most common) Treatment is amoxicillin

Question: Where are the beta cells located in the pancreas?

Answer: The islets of Langerhans.

Question: Which sex is at increased risk of sudden unexpected death of infancy (SUDI) ?

Answer: The male sex has a higher incidence of SUDI. Rapid Review Sudden unexpected death of infancy (SUDI) Peak incidence: 2-4 mos Risk factors: maternal smoking/drug use, prone sleeping position Recommendations: supine sleeping, pacifiers, breastfeeding

Question: Which cranial nerve palsies are associated with strabismus?

Answer: The nerves which control the extraoccular muscles: third (occulomotor), fourth (trochlear) and sixth (abducens). Rapid Review Strabismus Esotropia: in Exotropia: out Cover-uncover exam Light reflex test

Question: Which DM1 autoantibodies are the most common?

Answer: Those directed against beta-cell glutamic acid decarboxylase. Rapid Review Diabetes Mellitus Type 1 Autoimmune destruction of β cells <30 years old Polyuria, polydipsia, weight loss DKA Insulin always necessary

Question: The risk for congenital heart disease is higher if a parent or sibling has a structural congenital heart defect, true or false?

Answer: True.

Question: True or false: Metacarpal fractures are more common in adults than children?

Answer: True.

Question: What is Chvostek's sign?

Answer: Twitching of the ipsilateral facial muscles with tapping of the facial nerve indicating the presence of hypocalcemia. Rapid Review Multiple Myeloma Patient will be elderly Complaining of back pain PE will show CRAB: hyperCalcemia, Renal insufficiency, Anemia, lytic Bone lesions/Back pain Labs will show monoclonal antibody spike X-ray will show lytic lesions Peripheral blood smear: Rouleaux formations Serum protein electrophoresis: M spike Protein electrophoresis urine analysis: Bence-Jones proteins Most commonly caused by single clone plasma cell malignancy

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

Correct Answer ( A ) Explanation: Abruptio placentae, also called placental abruption, is defined as a premature separation of a normally implanted placenta from the uterus. Similar to placenta previa, it too causes third trimester bleeding, however unlike placenta previa, it is associated with significant pain, fetal stress and maternal complications. The amount of bleeding is variable and depends on the extent of placental separation. Significant painful contractions accompany this condition. Risk factors include maternal hypertension, cocaine use, trauma (namely motor vehicle collisions) and sudden uterine cavity decompression, as in rupture of membranes in a patient with excessive amniotic fluid (hydramnios). Abruption is diagnosed clinically, based on the presence of bleeding, frequent painful uterine contractions and fetal distress. Ultrasound plays a limited role in diagnosis, except for excluding placenta previa in the differential. Definitive treatment includes early fetal monitoring, hemodynamic stabilization and delivery. If the fetus is immature, close monitoring of maternal and fetal status may be considered. Preeclampsia (B) refers to a condition of maternal hypertension and proteinuria which typically occurs in the second half of pregnancy. Uterine atony (C) is a common cause of postpartum, not prepartum, bleeding, in which uterine contractions are insufficient, resulting in a flaccid, not tense, uterus. Vasa previa (D) is a condition in which the umbilical cord attaches into the placental membranes instead of the central placental tissue. This abnormal attachment generates an errant vessel which lies between the cervical os and the fetus, leading to the possibility of rupture and fetal demise.

A 16-year-old boy with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist on an as needed basis. He presently needs to use his short acting beta agonist daily. Which of the following is the most appropriate addition to this patient's medication regimen? Inhaled corticosteroid Leukotriene inhibitor Long acting beta agonist inhaler Methylxanthine oxidase inhibitor

Correct Answer ( A ) Explanation: According to the stepwise approach for managing asthma by the National Asthma Education and Prevention Program, inhaled corticosteroids are indicated for mild to moderate persistent asthma. For most patients twice-daily dosing provides adequate control of asthma symptoms. Short acting beta agonists are helpful with controlling acute exacerbations by acting as bronchodilators; however they are not helpful in the long term management in patients with persistent asthma. Using an inhalation chamber, also known as a "spacer," along with rinsing of the month after inhaled corticosteroid use decreases local side effects and systemic absorption. Long acting beta agonist inhalers (C) should not be used in place of anti-inflammatory therapy. Salmeteol and formoterol are the two long acting beta 2 agonists available for asthma. They are indicated for long-term prevention of asthma symptoms, nocturnal symptoms, and for the prevention of exercised induce bronchospasms. Leukotriene inhibitors (B) are less desirable alternatives to inhaled corticosteroids. They are used to control smooth muscle airway contraction, increase vascular permeability and mucous secretion. Methylxanthine oxidase inhibitors (D) preparations may have beneficial effects in some patients, but their value is limited due to a narrow therapeutic window and modest efficacy.

A 57 year-old man presents to the office with a chief complaint left eye pain and seeing halos around lights. His left eye is seen above. Which of the following is the most likely diagnosis? Acute angle closure glaucoma Acute anterior uveitis Bacterial conjunctivitis Hyphema

Correct Answer ( A ) Explanation: Acute angle-closure glaucoma is an ophthalmologic emergency due to a closed anterior chamber angle. This is the only type of glaucoma that is curable. Patients present with acute onset of pain and vision loss that is most commonly unilateral. As intraocular pressure rises, patients may experience headache, nausea, vomiting, and abdominal pain that is sometimes mistaken as an acute abdominal process. The eye exam may reveal a red, tender globe that may be firm to touch. The cornea may be steamy or hazy and the pupil is mid-dilated and nonreactive. An ophthalmologic consult should be obtained immediately. Treatment incudes topical drops such as carbonic anhydrase inhibitors and beta-blockers. Permanent vision loss can occur if treatment is delayed. Acute anterior uveitis (B) presents with a sudden onset of unilateral eye redness, photophobia, pain and lacrimation. It is associated with systemic illnesses including anklosing spondylitis, Crohn's, ulcerative colitis, reactive arthritis and sarcoidosis. Bacterial conjunctivitis (C) is a self-limiting condition that is characterized by acute onset of redness in one or both eyes, a gritty or burning sensation and discharge that begins watery and eventually becomes purulent. Many patients awaken with their eyelids stuck together. Treatment consists of antibiotic eye drops or ointments. A hyphema (D) is usually secondary to globe trauma and is caused by hemorrhage from either the ciliary body or the anterior chamber.

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

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

Which of the following lab tests will be abnormal in patients with severe hemophilia B? Activated partial thromboplastin time Bleeding time D-dimer Prothrombin time

Correct Answer ( A ) Explanation: Hemophilia B (also referred to as Christmas disease, named after the first person diagnosed with the condition) is caused by a deficiency of factor IX, a factor involved in the intrinsic coagulation cascade. In the severe form (< 1% of factor activity), the activated partial thromboplastin time (aPTT), which measures this cascade, will be abnormal. Factor IX has a longer half-life than factor VIII and therefore, patients with hemophilia B do not require transfusions as often as those with hemophilia A. Bleeding time (B) is normal in both hemophilia A and B. Bleeding time is abnormal in processes that cause platelet dysfunction such as thrombocytopenia, von Willebrand disease, and disseminated intravascular coagulation. Hemophilia B will not affect D-dimer levels (C). The inability of hemophiliacs to form thrombi, in fact, makes them less likely to have an abnormal D-dimer. The prothrombin time (D), which measures the extrinsic coagulation cascade, will be normal.

Which of the following is concerning for melanoma? Areas of pigment regression Other similar lesions Pearly border Regular border

Correct Answer ( A ) Explanation: Melanoma is a highly aggressive malignancy of melanocytes in the skin. Although it is the least common skin malignancy, it has the highest mortality. The peak incidence occurs in 20- to 45-year-olds which is much younger than the other two forms of skin cancer (basal cell carcinoma and squamous cell carcinoma). Any new mole after age 35 needs a dermatologic evaluation since people rarely form new moles at this age. The mnemonic ABCDE helps to remember the characteristics of melanoma: Asymmetry, Border (irregular), Color (different shades, not uniform), Diameter (>6 mm), Evolution. Areas of pigment regression describe changes in color and a lack of uniformity of the lesion. Other similar lesions (B) are atypical. Patients may have nevi or skin moles that appear similar, but as a lesion progresses to become melanoma it looks different from other moles on the body. A pearly border (C) is more consistent with a basal cell carcinoma. These lesions often begin as a pearly papule with telangiectasias. Regular borders (D) are uncommon as the malignancy does not grow in a uniform pattern.

A 70-year-old woman with multiple myeloma presents with confusion, lethargy, abdominal cramping, nausea and generalized weakness. Her vital signs are normal. What electrolyte abnormality is likely responsible for this presentation? Hypercalcemia Hyperkalemia Hypocalcemia Hypokalemia

Correct Answer ( A ) Explanation: Patients with multiple myeloma are at an increased risk for hypercalcemia secondary to increased breakdown of bone. In a patient with multiple non-specific symptoms, electrolyte disturbances should be suspected. Hypercalcemia can present with a number of symptoms including altered mental status, abdominal pain, nausea, vomiting, weakness, lethargy, muscle aches and depression. The most common cause of hypercalcemia is primary hyperparathyroidism. Malignancy is also a common cause. About 30% of patients with multiple myeloma will experience hypercalcemia at some point in their clinical course. Severe hypercalcemia (>14 mg/dl) can lead to both high degree AV blocks and ventricular dysrhythmias. Treatment of hypercalcemia focuses first on restoring intravascular volume with intravenous fluids (IVF). Patients at risk for hypercalcemia are often volume depleted secondary to chronic illness and decreased oral intake. Restoring circulating volume allows for increased perfusion to the kidneys and elimination of calcium through urine. Once intravascular volume has been repleted, the clinician can attempt to enhance renal elimination (i.e. forced diuresis) by administering a loop diuretic (i.e. furosemide). Although not typically started in the ED, bisphosphonates can be given to inhibit osteoclast activity thus reducing the amount of calcium entering the blood stream. Hypocalcemia (C) presents with neuromuscular hypersensitivity manifested by muscle twitching and is not associated with multiple myeloma. ECG may reveal a prolonged QTc. Hypokalemia (D) is often seen in patients with vomiting (mostly due to renal losses, not vomiting itself). ECG in these patients may demonstrate U waves (deflection from baseline after T wave). Hyperkalemia (B) usually presents in patients with renal failure, tissue necrosis (crush injury, burns) and hemolysis. The major manifestations of hyperkalemia are cardiac and a number of ECG findings can be seen.

Which of the following is an absolute contraindication to the measles, mumps and rubella vaccine? Anaphylactic reaction to neomycin Family history of seizure History of autism History of immune thrombocytopenia

Correct Answer ( A ) Explanation: Prevention against measles, mumps and rubella (MMR) is provided by two doses of a live-virus vaccine. The recommended schedule is the first dose at ages 12-15 months and the second dose at school entry, between ages 4-6 years. The MMR vaccine contains trace amounts of neomycin, therefore patients with a history of anaphylaxis to neomycin should not receive it. Other true contraindications include previous severe allergic reaction to any component of the vaccine, individuals who are immunocompromised, pregnancy, hematologic or solid tumors, and HIV infection with immunosuppression. A family or personal history of seizure (B) is a precaution to giving the MMR vaccine, but not an absolute contraindication. While there has been a great deal of discussion about the connection between vaccinations and autism, no scientific evidence has been found linking the two and history of autism (C) is not an absolute contraindication to the MMR vaccine. There is a risk of developing immune thrombocytopenia (D) after MMR vaccination, however this occurs rarely and is not an absolute contraindication to receiving the vaccine.

Which of the following patients would be considered lowest risk in the natural history of prostate cancer? Gleason score of 5 PSA greater than 10 Stage T3 prostate cancer Stage T4 prostate cancer

Correct Answer ( A ) Explanation: Prostate cancer is the most common malignancy among U.S. men and the second most common cause of cancer death. Most cases remain latent, with only 10% progressing to clinically significant disease. The presentation is often asymptomatic, or may lead to urinary obstruction. The prognosis of prostate cancer correlates with histologic grade and extent (stage) of disease. More than 95% of prostate cancers are adenocarcinomas, and multifocality is common. The histologic (Gleason) grade ranges from 1 to 5, although in the modern era, Gleason grades of 1 and 2 are exceedingly rare; the Gleason score, which refers to the sum of the two most common histologic patterns seen on each tissue specimen, ranges from 4 (2+2) to 10 (5+5). In general, tumors are classified as well differentiated (Gleason score 2 to 6), of intermediate differentiation (Gleason score 7), or poorly differentiated (Gleason score 8 to 10). Therefore lower Gleason scores have better prognosis. Clinical stage T3 or higher (C, D), PSA level above 10 ng/mL (B), and biopsy Gleason score of 7 or higher are associated with poor outcomes. 5-year survival without PSA elevation was 85% for patients with none of these adverse features, 65% for patients with one adverse feature, and 35% for patients with two or three adverse features. These patients are at high risk of nodal and micrometastatic disease and are generally treated with aggressive local therapy in combination with androgen deprivation, which is synergistic with radiation therapy. Several randomized controlled trials suggest that patients with high-risk disease who are treated surgically and have capsule penetration, positive margins, or seminal vesicle involvement should receive immediate adjuvant radiation therapy.

Which of the following is recommended by the American Academy of Pediatrics Task Force on sudden unexpected death of infancy to reduce the risk of sudden unexpected death of infancy in the general population? Parents should consider offering a pacifier at nap time and bedtime Parents should place infants in the prone position for sleep Parents should place infants to sleep on soft mattresses Parents should use home monitoring systems

Correct Answer ( A ) Explanation: Sudden unexpected death of infancy (SUDI) is defined as "the sudden death of an infant less than one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of clinical history." It is the third leading cause of death in infants and may occur at any time during the first two years of life, but it is rare in children younger than one month of age and in those older than one year of age. Most cases occur between two and four months of age. The American Academy of Pediatrics Task Force on sudden unexpected death of infancy recently published guidelines to help reduce the risk of SUDI in the general population. Parents should place infants in supine (B), not prone, position. Soft sleeping surfaces (C) should be avoided. Home monitoring systems (D) have not been shown to change the occurrence of SUDI deaths.

A patient asks you to explain the underlying cause of her newly diagnosed type 1 diabetes mellitus. Which of the following correctly describes the underlying pathology of this disease? Autoimmune destruction of pancreatic cells Excessive hepatic glucose production Myocyte insulin resistance Pancreatic glucagon deficiency

Correct Answer ( A ) Explanation: The pathological basis of type 1 diabetes mellitus (DM1) is an autoimmune destruction of the pancreas. It is marked by lymphocytic infiltration and destruction of the islets of Langerhans beta-cells. As these cells die off, insulin secretion decreases. When 80-90% of the beta-cells are lost, hyperglycemia ensues. Genetic predisposition and viral infections play a role in generating the autoimmune response. Nearly 85% of patients with DM1 have detectable levels of autoantibodies. Other autoimmune disorders, such as Grave's and Addison's disease, are more common in those with DM1. Excessive hepatic glucose production (B) is not a mechanism for DM1, but it is associated with DM2. Normally, insulin acts on the liver to suppress endogenous production of glucose. Myocyte, and other peripheral cell, insulin resistance (C) is largely responsible for the pathophysiology of DM2, not DM1. Glucagon is normally secreted by the pancreas in response to hypoglycemia. It raises blood glucose levels by inducing hepatic glycogenolysis and gluconeogenesis. In effect, its actions are opposite those of insulin. Glucagon under secretion or deficiency (D) would result in a hypoglycemic, and not hyperglycemic, state.

A 52-year-old man with a history of chronic alcoholism and hypertension presents to the Emergency Department with weakness of the right wrist that he first noticed when he woke up this morning. On examination, he is unable to extend the wrist against resistance. Which area of his hand is likely to have decreased sensation? Dorsal first web space Thenar eminence Volar tip of the index finger Volar tip of the pinky finger

Correct Answer ( A ) Explanation: The radial nerve, formed from C6-C8 nerve roots, courses down the medial upper arm before it wraps around the mid-humerus and continues more posteriorly. It is this area, the spiral groove, that is prone to compression injury and subsequent neuropraxia. Prolonged external compression can occur during sleep if the patient's head rests on the upper arm or the arm is hung over the edge of the bed or a bench. Sedation or intoxication increases the risk of this type of injury as the patient will not wake up despite paresthesias in the arm. Patients with a radial nerve palsy (also known as Saturday night palsy) will present with a wrist drop and be unable to extend the wrist against resistance. The fingers will be held in flexion at the MCP joint and the thumb is adducted. The radial nerve supplies sensation to the dorsum of the hand from the thumb to approximately the fourth metacarpal. The dorsal first web space is entirely within the radial nerve distribution and is the best location to confirm radial nerve involvement. Treatment includes splinting of the wrist and physical therapy. Prognosis is good for recovery of function in 3-4 months. Sensation of the thenar eminence (B) and the volar tip of the index finger (C) is supplied by the median nerve. The ulnar nerve supplies sensation to the volar tip of the pinky finger (D).

Which one of the following has been shown to render some improvement in individuals with borderline personality disorder? Dialectic behavioral therapy Omega-3 fatty acids Second-generation antipsychotics Selective serotonin reuptake inhibitors

Correct Answer ( A ) Explanation: There are no proven therapies to reduce the severity of borderline personality disorder (BPD). The most promising psychological therapy is dialectic behavioral therapy (DBT). DBT is a multi-faceted program specifically designed to treat BPD. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings and behaviors that lead to the undesired behavior. The few, small studies of DBT found improvement in many symptoms of BPD, but long-term data is lacking. Another promising therapy is psychoanalytic-oriented day hospital therapy. Omega-3 fatty acids (B), second-generation antipsychotics (C) have been shown to be helpful for some symptoms of borderline personality disorder but not for overall severity. Their benefits are based on single-study results and side effects were not addressed in the studies. Selective serotonin reuptake inhibitors (SSRIs) (D) are not recommended for borderline personality disorder unless there is a concomitant mood disorder.

Which of the following supports the diagnosis of hypothyroidism? High serum thyroid stimulating hormone and low free T4 Low serum thyroid stimulating hormone and high free T4 Low serum thyroid stimulating hormone and normal free T4 Normal serum thyroid stimulating hormone and normal free T4

Correct Answer ( A ) Explanation: Thyroid regulation occurs through the balance of hormones secreted by the hypothalamus, anterior pituitary and thyroid gland. Thyrotropin-releasing hormone (TRH) in the hypothalamus stimulates the anterior pituitary to produce thyroid-stimulating hormone (TSH). This in turn stimulates the thyroid to synthesize and secrete thyroid hormones, T3 and T4. Lab testing is critical in the diagnosis of hypothyroidism because clinical symptoms are non-specific. When the thyroid is unable to secrete sufficient thyroid hormone, low serum T4 signals the pituitary that more thyroid hormone is needed and therefore TSH will be elevated. A suspicion of hypothyroidism is indication for testing of TSH. If elevated, T4 should be tested and if found to be low supports the diagnosis of hypothyroidism. Low serum TSH and either high (B) or normal free T4 (C) occurs with hyperthyroidism. Clinical symptoms of hyperthyroidism are more dramatic and include anxiety, heart palpitations, weight loss, and heat intolerance. Normal serum TSH and normal free T4 (D) are seen when a patient is euthyroid.

Which of the following best describes an inevitable abortion? First trimester bleeding and a closed internal cervical os First trimester bleeding with an open internal os Parts of the product of conception have been passed and may be visible in the cervical os or the vaginal canal Retention of a nonviable intrauterine pregnancy within the uterus, no cardiac activity, and a closed cervical os

Correct Answer ( B ) Explanation: Approximately 80% of miscarriages occur during the first trimester; the rest occur before 20 weeks of gestation or when the fetus is <500 g, considered premature birth. Approximately 25% of pregnant patients experience bleeding. Approximately 50% of all women who have bleeding during early pregnancy miscarry. Those with a history of bleeding who do not miscarry have otherwise fairly normal pregnancies, although they have an increased risk of premature birth and low-birth-weight infants. The 2 major causes of miscarriage are uterine malformations and chromosomal abnormalities. There are several stages of miscarriages. An inevitable abortion is defined by 1st trimester bleeding with an open internal os and no passage of placental or fetal parts. First trimester bleeding and a closed internal cervical os (A) is defined as a threatened abortion. The risk of miscarriage in this population is up to 50%. If products of conception (POC) are present at the cervical os or in the vaginal canal, the abortion is termed incomplete (C). A missed abortion (D) is a term rarely used anymore. It refers to the retention of a nonviable intrauterine pregnancy within the uterus. Products of conception are demonstrable, but fetal development has ceased, there is no cardiac activity visible, and the cervical os is closed. It is better referred to as 1st- or 2nd trimester fetal death.

A patient presents with palpitations and dyspnea. She is placed on a cardiac monitor as seen above. Which of the following is the most likely diagnosis? Atrial fibrillation Atrial flutter Ventricular fibrillation Ventricular tachycardia

Correct Answer ( B ) Explanation: Atrial flutter is a dysrhythmia characterized by an atrial rate of 250-300 bpm. The most common site of pathology is a reentrant circuit in the right atrium about the tricuspid valve annulus. Etiologies include hypertensive heart disease, ischemic heart disease, rheumatic heart disease and cardiomyopathy. The resulting tachycardia typically causes decreased cardiac output with symptoms of palpitations, dyspnea, presyncope and fatigue. It is diagnosed electrocardiographically by regularly shaped and spaced P waves which have the appearance of a sawtooth pattern. These P waves will intermittently be followed by narrow QRS complexes. Management includes electrical or pharmaceutical cardioversion and ventricular rate control (calcium channel blockers and beta-blockers). Atrial fibrillation (A) is disorganized electrical activity and defined by an irregular rhythm with the absence of P waves. Ventricular fibrillation (C) produces a 'wavy line' ECG, of which no discernable rate, P wave or QRS complex is seen. This dyshythmia is associated with pulselessness. Ventricular tachycardia (D) is a wide complex tachycardia.

A 69-year-old woman presents to the emergency department with a complaint of three days of left lower quadrant abdominal pain, nausea, vomiting, and a sudden change in bowel habits. What are you most likely to find on an abdominal and pelvic computed tomography scan? Appendiceal wall thickening Colonic diverticula Dilated loops of small bowel Enlarged pericolonic lymph nodes

Correct Answer ( B ) Explanation: Colonic diverticula found on abdominal and pelvic CT scan is indicative of acute diverticulitis. Acute diverticulitis is the inflammation of a diverticulum, or sac-like protrusion of the colonic wall. The area becomes inflamed and may ultimately develop small perforations of the sac. Patients generally present with abdominal pain localized to the left lower quadrant, nausea, vomiting, low-grade fever, and a change in bowel habits. To make the diagnosis of acute diverticulitis, an abdominal/pelvic CT scan, an abdominal ultrasound, or an MRI of the abdomen/pelvis may be performed. CT scan demonstrates colonic bowel wall thickening, fat stranding, and colonic diverticula; giving the diagnosis of acute diverticulitis. Treatment of acute uncomplicated diverticulitis involves a short-course of antibiotics and dietary changes that focus on decreased fiber during the acute period and long term increased intake of fiber. Complications of the disease, if left untreated, include diverticular abscesses, colonic obstruction, and complete perforation of the diverticulum with peritonitis. Appendiceal wall thickening (A) is indicative of acute appendicitis, or inflammation of the appendix. Patients who present with a chief complaint of right lower quadrant abdominal pain with tenderness to palpation, nausea, vomiting, and fever should have a CT scan performed. Imaging reveals appendiceal wall thickening, an enlarged appendiceal diameter, and fat stranding. Dilated loops of small bowel (C) is a finding on an abdominal CT scan or abdominal X-ray that is indicative of a bowel obstruction. Patients suspected of bowel obstruction present with nausea, vomiting, and cramping abdominal pain. Imaging demonstrates dilated loops of bowel proximal to the site of obstruction, along with bowel wall thickening, and air-fluid levels. Enlarged pericolonic lymph nodes (D) may be indicative of colorectal cancer. Patients diagnosed with colorectal cancer can present with a change in bowel habits, hematochezia, or abdominal pain, or they may present asymptomatically. Imaging should initially be performed and findings of enlarged pericolonic lymph nodes and a mass may be indicative of colorectal cancer. If acute diverticulitis is not suspected or a patient is out of the acute inflammatory window, a colonoscopy should be performed as this is the most accurate diagnostic test of choice for colorectal cancer.

A 4-week-old girl is brought to urgent care with eye discharge. Her father reports four days of yellow discharge from both eyes. Her eyes have not appeared red. Her physical exam is notable for tearing of both eyes, scant yellow discharge, and non-injected conjunctiva. Which of the following is the best next step? Artificial tears four times per day Nasolacrimal duct massage three times per day Surgical probing Systemic antibiotics

Correct Answer ( B ) Explanation: Congenital nasolacrimal duct obstruction, or dacryostenosis is a common condition in newborns. The condition may be present at birth or may present at several weeks of life. It is caused by failure of canalization of the epithelial cells that form the nasolacrimal duct. Clinical findings include a large tear lake, overflow of tears onto the cheek, and presence of mucoid material in the canthi that has refluxed from the lacrimal sac. The presence of tears triggers rubbing and irritation of the eyes, which may lead to erythema or maceration of the skin. Infection and inflammation of the nasolacrimal sac may occur in infants with dacryostenosis, including dacryocystitis, pericystitis, and rarely periorbital cellulitis. These patients will have swelling, redness, and tenderness of the lacrimal sac, and may also exhibit fever and irritability. Treatment of uncomplicated dacryostenosis consists of nasolacrimal massage 2-3 times daily and cleansing with warm water. Topical antibiotics may be added if there is mucopurulent drainage. Most cases resolve spontaneously. Artificial tears (A) can be used with supportive care in cases of neonatal chemical conjunctivitis but this is not the best therapy for patients with dacryostenosis. Surgical probing (C) is the therapy of choice for cases of dacryostenosis that do not resolve by one year of age, with a cure rate of 80%. Systemic antibiotics (D) should be initiated in cases of acute dacryocystitis or periorbital cellulitis. Surgical intervention is typically required in these cases.

A four-year-old from Guatemala presents to the emergency room with a fever, drooling, and inspiratory stridor. Dad states that the child appeared well the day prior to presentation. The child is sitting with his neck extended. Which of the following is the most likely diagnosis? Croup Epiglottitis Laryngomalacia Tracheitis

Correct Answer ( B ) Explanation: Epiglottitis presents with rapid onset of respiratory distress, high fever, muffled voice, and drooling. Physical exam is significant for an anxious child with stridor. They are typically sitting in a tripod position, leaning forward with their neck extended. Epiglottitis is a clinical diagnosis; however, a lateral neck X-ray may aid in the diagnosis. The classic thumb print sign can be seen where the enlarged rounded epiglottis extends into the hypopharyngeal airway. Thickening of the aryepiglottic folds are also suggestive of epiglottitis. Patients should be observed closely for airway compromise. Some patients require advanced airway management, which should be performed in the operating room by an anesthesiologist. Parenteral antibiotics should be administered to cover Haemophilus influenzae B, Streptococcus pneumoniae, β-hemolytic Streptococci, and Staphylococcus aureus. Antibiotics can be narrowed based on culture and sensitivities. The rate of epiglottitis has decreased since the introduction of the HiB vaccine. However, this patient is from another country and may not have received the HiB vaccine. Children with croup (A) usually present with a barking cough due to inflammation of the glottis and subglottis. These patients do not look as sick as those with epiglottitis and are not at the same risk for airway compromise. Laryngomalacia (C) is a congenital disorder leading to collapse of the supraglottic structures inwards during inspiration. It is associated with stridor, but patients are not in distress and not febrile. The condition typically spontaneously resolves by 18 months of age. Tracheitis (D) is a bacterial infection of the subglottic airway. It is associated with a URI prodrome similar to croup that intensifies to include high fever, inspiratory, and expiratory stridor.

A factory worker sustains a crush injury to his lower left leg. He has 9/10 sharp pain, distal pallor and paresthesias. The skin is intact but swollen. Minimal passive plantar flexion reproduces significant pain. Which of the following measurements are necessary to confirm a diagnosis? Ankle-brachial index and wedge pressure Diastolic blood pressure and intracompartmental pressure Mean arterial pressure and jugular venous distension Stroke volume and heart rate

Correct Answer ( B ) Explanation: Extremity compartments are bound by fascial planes and contain muscles, nerves and arteries. Acute compartment syndrome occurs when the vascular supply is unable to properly perfuse these structures. Cases are typically acute and traumatic, especially when long bones, such as the femur and tibia, fracture, or when there is a crush injury. Pathologically, injury causes intracompartmental pressure to build, which decreases venous outflow, which backs-up arterial inflow, which ultimately leads to ischemic necrosis in as little as 4 hours. Pain out of proportion to injury, distal paresthesias, distal paresis or paralysis and distal pallor are common presenting symptoms. A key physical finding is intolerable passive stretching of muscles about an injury site. Since necrosis is imminent if left untreated, suspected compartment syndrome needs immediate diagnosis and treatment. Compartment syndrome is confirmed when the diastolic blood pressure minus the intracompartmental pressure is ≤ 30 mm Hg or absolute compartment pressure > 30-40 mm Hg. Once confirmed, surgical fasciotomy of the compartment is essential for favorable prognosis. The wound is left open. Delayed closure or skin grafting is performed after edema has resolved. Ankle-brachial Index (A) is used to evaluate peripheral arterial disease. Wedge pressure (A) is used to evaluate intrapulmonary capillary pressure. Mean arterial pressure (C) is based on cardiac output and peripheral vascular resistance. It is considered the perfusion pressure of end organs. It is important to consider this in patients with arterial or cardiac disease, however, it is not used in diagnosing compartment syndrome. Jugular venous distension (C) is used to evaluate cardiac function, not distal extremity perfusion. Stroke volume and heart rate (D) are used to determine cardiac output when evaluating a patient with cardiac disease, not traumatic orthopedic disease.

Which of the following is characterized by macrocytic anemia with increased reticulocytes and Heinz bodies? Alpha thalassemia Glucose-6-phosphate dehydrogenase deficiency Sickle cell anemia Vitamin B12 deficiency

Correct Answer ( B ) Explanation: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked enzymatic defect common in that can result in hemolysis after acute illnesses or intake of oxidant drugs. G6PD deficiency is the most common enzymatic deficiency in humans. G6PD catalyzes the initial step of a pathway that is key in protecting red blood cells from oxidative injury. Diagnosis is based on assays for G6PD, although tests are often falsely negative during acute hemolysis because reticulocytes carry higher amounts of G6PD. The hemolysis of G6PD deficiency leads the body to respond with increased reticulocyte (immature red blood cells) production. Heinz bodies are also formed due to damaged hemoglobin components. Heinz bodies are small round inclusions inside of the cell. Heinz bodies may be visible early during the hemolytic episode but do not persist in patients with an intact spleen because they are removed by the spleen. Heinz bodies may also be seen in chronic liver disease, Nicotinamide Adenine Dinucleotide Phosphate (NADPH) deficiency, and Alpha-Thalassemia. A peripheral smear during workup for G6PD deficiency may also reveal "bite cells." These are red blood cells with semi-circular portions of the cell membrane ("bites") removed by macrophages in the spleen attempting to remove damaged red blood cells. Alpha thalassemia (A) can have Heinz bodies, but causes microcytic anemia rather than macrocytic. The abnormal hemoglobin formation of thalassemia causes both a decreased production rate and the smaller size of the red blood cells. Sickle cell anemia (C) may cause macrocytic anemia and increased reticulocytes due to hemolysis but is not associated with Heinz bodies. Vitamin B12 deficiency (D) also causes macrocytic anemia but does not have an increase reticulocyte count or Heinz bodies. In vitamin B12 deficiency, there is a shortage of resources to create the red blood cells, rather than an increase in the destruction of red blood cells; hence reticulocyte levels do not rise.

You prescribe ramipril to a 65-year-old man with uncontrolled hypertension and severe renovascular disease. At a follow-up visit four weeks later his creatinine is noted to be 2.3. His creatinine before starting the ramipril was 1.0. By what mechanism did the ACE inhibitor cause this change? Activating the arachidonic acid pathway Decreasing glomerular blood flow Increasing angiotensin II activity Increasing serum kinin levels

Correct Answer ( B ) Explanation: One of the actions of angiotensin II is to vasoconstrict efferent arterioles as they leave the glomerulus. This vasoconstriction stabilizes renal perfusion pressure and helps maintain normal creatinine levels. ACE Inhibitors block the conversion of angiotensin I to angiotensin II which causes a modest reduction in renal blood flow. This reduction may be severe in patients with bilateral renal artery stenosis, hypertensive nephrosclerosis, congestive heart failure, polycystic kidney disease or chronic kidney disease. In all of these cases renal perfusion is already compromised. By blocking angiotensin II with an ACE inhibitor, glomerular blood flow is decreased even further thus worsening the patient's creatinine. Activation of the arachidonic acid pathway (A) and increased serum kinin levels (D) are thought to be involved in the classic ACE inhibitor cough. Increased angiotensin II (C) activity would increase renal perfusion pressure and stabilize the creatinine, not worsen it.

A 45-year-old patient with newly diagnosed diabetes mellitus type 2 presents to your office for her annual exam. She has had her hepatitis B vaccination, but wants to know if she needs any additional vaccinations because of her new diagnosis. Which of the following is the most appropriate next step in her management? Administer annual influenza vaccine only Administer pneumococcus and annual influenza vaccines Administer pneumonia prophylaxis with trimethoprim-sulfamethoxazole The patient does not need any additional vaccines since she is up to date

Correct Answer ( B ) Explanation: Patients with diabetes mellitus require regular monitoring and health maintenance to prevent diabetes-related complications. Health maintenance for these patients includes three vaccinations: annual influenza, pneumococcus ​(repeated at age 65 if given prior to that age) and the hepatitis B three dose series. Patients with diabetes mellitus require annual foot, dental and dilated eye examinations, blood pressure monitoring, and smoking cessation counseling. Upon diagnosis, a serum creatinine should be drawn. Annual fasting serum lipids and urinary albumin-to-creatinine ratios should be monitored. Hemoglobin A1C should be obtained every 3-6 months with a goal of <7%. Annual influenza vaccine should be administered along with pneumococcus vaccine (B) and the hepatitis B series. Pneumonia prophylaxis with trimethoprim-sulfamethoxazole (C) is indicated in the prevention of Pneumocystis jirovecii pneumonia in patients with HIV infection and a CD4 count less than 200 cells/microL. The patient reports being up to date with her vaccinations (D), but now that she has the diagnosis of diabetes mellitus type 2, the provider needs to make sure that she is following the additional health maintenance recommendations to prevent diabetes-related complications.

A 14-year-old girl presents for evaluation. Two weeks ago, she collided with an opponent while playing soccer. She was assessed on the field and complained of a headache and dizziness. She was instructed to sit out for the remainder of the game. She continues to complain of headache, dizziness, and difficulty concentrating. Which of the following is the most likely diagnosis? Concussion Post-concussion syndrome Second impact syndrome Tension headache

Correct Answer ( B ) Explanation: Post-concussion syndrome is the sequelae of a mild traumatic brain injury or concussion that is defined by the continuation of symptoms of headache, dizziness, and cognitive impairment. A mild traumatic brain injury is a mild injury to the brain caused by a blunt force or shaking of the brain inside of the skull. It is defined as a Glasgow Coma Scale of 13-15 and generally patients do not lose consciousness. A concussion is a subset of a traumatic brain injury and can also be defined as mild, moderate, or severe. Symptoms of a concussion include headache, dizziness, nausea, vomiting, blurred vision, amnesia, disorientation, and loss of consciousness. Post-concussion syndrome is the continuation of these mild traumatic brain injury symptoms. While the specific timeline that separates a concussion from post-concussion syndrome is still not well established, symptoms that continue seven to 10 days after the initial injury are considered to be caused by post-concussion syndrome. Patients typically begin to feel relief within one month and treatment is aimed toward symptom relief and education. A concussion (A) is a subset of a mild traumatic brain injury caused by a direct blow to the head or neck or shaking of the brain against the skull. Acute, but temporary neurologic impairment ensues, and patients present with a variety of complaints such as headache, dizziness, difficulty concentrating, difficulty sleeping, disorientation, amnesia, or even temporary loss of consciousness. Diagnosis includes neurologic and cognitive testing, as well as a brain CT scan to rule out intracranial hemorrhage or other processes. Treatment includes brain rest, and if not treated adequately, complications such as post-concussion syndrome, second impact syndrome, or post-traumatic epilepsy can occur. Second impact syndrome (C) is defined as diffuse cerebral swelling caused by a second impact to the brain before the first concussion has resolved. Second impact syndrome is a rare, but catastrophic process in which the brain can no longer regulate the increased intracranial pressure induced by a second injury. This can lead to severe brain injury and even death. Tension headache (D) is the most common type of acute or chronic headache and may be caused by increased pain receptor sensitivity in the central nervous system and muscular tightness but is typically not originated from a traumatic impact to the brain. Symptoms of a tension headache include bilateral non-descriptive head pain with pericranial muscular tenderness. While symptoms of a tension headache may be similar to that of a concussion or post-concussion syndrome, the cause of the headaches differs.

A 49-year-old woman with a history of osteoarthritis presents stating that she feels like the room around her is spinning. She reports a similar episode three weeks ago, and since then, has had an intermittent ringing sound in her ears. Her husband adds that over the same time frame she also has developed some difficulty hearing from the left ear. During your exam, the patient has an episode of non-bilious vomiting and states that the room is spinning again. Vital signs are normal. Which of the following is the most likely diagnosis? Benign paroxysmal positional vertigo (BPPV) Ménière's disease Salicylate toxicity Vestibular neuronitis

Correct Answer ( B ) Explanation: This patient has Ménière's disease. This disorder is associated with increased endolymph within the cochlea and labyrinth. The common triad is tinnitus, vertigo, and unilateral hearing loss (sensorineural). A key finding in Ménière's disease is fluctuating hearing loss. Episodes are abrupt in onset and associated with nausea and vomiting. There are often long, symptom-free intervals between attacks. Benign paroxysmal positional vertigo (A) is sudden in onset, short-lived, and positional in nature. It is not associated with tinnitus or hearing loss. Salicylate (aspirin) toxicity (C) is associated with tinnitus and reversible hearing loss. The patient has a history of osteoarthritis and may be using aspirin for her pain; however, salicylate toxicity is usually associated with bilateral hearing loss. Symptoms of vertigo are also uncommon in such patients. Vestibular neuronitis (D) manifests with severe vertigo positional in nature but not associated with hearing loss. It is usually preceded by a viral upper respiratory infection.

A 77-year-old man comes to your clinic having difficulty with daily activities. He finds it hard to rise from chairs, and has slowness to start movements. His wife is present and adds that his voice even seems softer. On exam, you note a pill-rolling tremor in his right hand. Which of the following additional findings is consistent with this patient's suspected disease? Chorea Masked face Ptosis Short-term memory impairment

Correct Answer ( B ) Explanation: This patient is exhibiting signs and symptoms of Parkinsonism, a movement disorder characterized by tremor, rigidity, bradykinesia, postural instability, and "masked" or emotionless facial features. Other findings may include a mild decline in intellectual function, a decreased blink rate, a softened voice, impairment of fine motor skills, anosmia, and a shuffling gait. Parkinsonism is relatively common, affecting all ethnic groups and genders equally. The most common etiology of Parkinsonism is idiopathic Parkinson's disease, which usually presents between ages 45-65 with a steady progression of symptoms. This disease is due to a degeneration of the dopaminergic nigrostriatal system responsible for maintaining a balance of dopamine and acetylcholine, neurotransmitters necessary for normal movement. Diagnosis relies on ruling out other similar neurodegenerative conditions. There is no current cure for Parkinson disease or treatment to slow progression, though therapies to improve functionality are available as necessary. Levodopa is commonly used, as this medication is converted to dopamine in the body and can temporarily relieve all symptoms when used in combination with carbidopa to allow for appropriate conversion of the medication. Dopamine agonists such as bromocriptine have similar efficacy and can be given with levodopa or before this medication is initiated. Selective monoamine oxidase inhibitors may also be used with levodopa for patients becoming unresponsive to levodopa alone. Other options include amantadine for relief of mild disease symptoms, anticholinergic medications to control patients' tremor and rigidity, and atypical antipsychotics to manage the confusion and psychosis that may occur with dopaminergic therapies. Physical and speech therapy are usually appropriate adjuncts. Finally, deep brain stimulation remains a surgical option to improve functionality in appropriate candidates. Chorea (A), along with dementia, is considered a hallmark symptom of Huntington disease, a movement disorder that usually presents in middle-aged patients and is inherited in an autosomal dominant pattern. Patients are unable to prevent these involuntary, writhing bodily movements. This is generally the opposite concern of Parkinsonism, where patients are unable to initiate movement. Ptosis (C) is a common finding in myasthenia gravis, though not a common symptom in patients with Parkinsonism. Short-term memory impairment (D) would likely not be present in a patient with early to moderate Parkinsonism with no other comorbidities. Rather, Parkinsonism may cause a general cognitive decline noted in executing daily activities and interests. Short-term memory impairment is more typical of patients with other forms of dementia, such as Alzheimer's disease.

A 21-year-old woman presents with progressive headaches for 1 month. She also complains of intermittent blurred vision bilaterally and increased headache with coughing. Fundoscopic examination reveals the above. What abnormality is typically found on lumbar puncture in patients with this presentation? Decreased glucose Elevated opening pressure Elevated red blood cell count Elevated white blood cell count

Correct Answer ( B ) Explanation: This patient presents with signs and symptoms consistent with a diagnosis of idiopathic intracranial hypertension (IIH), which can be diagnosed by an increased opening pressure on lumbar puncture. IIH, previously called pseudotumor cerebri and benign intracranial hypertension is a relatively common disease. It is typically seen in obese women. The exact pathophysiology of the disease is not fully understood but it seems to result from a decreased outflow of cerebrospinal fluid (CSF) and increased brain water content. The headache is typically gradual in onset and generalized. It may be worsened by eye movement or valsalva maneuver (or other maneuvers that increase intracranial pressure). Visual complaints are common and can range from transient blurring of vision to vision loss. The headache may also be accompanied by nausea, vomiting and dizziness. Physical examination reveals papilledema and patients may also have visual field defects. Diagnosis is made by an increased opening pressure on lumbar puncture. Opening pressure will be elevated (>20 cm H2O in nonobese patients and >25 cm H2O in obese patients). Decreased glucose (A) and elevated white blood cell count (D) are typically seen in meningitis. An elevated red blood cell count (C) is found in subarachnoid hemorrhage.

A 19-year-old man presents with a sore throat and difficulty swallowing. He has had 4 days of worsening sore throat and fever but today he was unable to swallow any liquids. Physical examination reveals a muffled voice, difficulty tolerating saliva, and minimal pharyngeal erythema with a midline uvula. He also has tenderness over the hyoid bone. Which of the following managements is most likely indicated? Inhaled racemic epinephrine and discharge home Intravenous antibiotics and admission Intravenous corticosteroids and discharge home Needle aspiration of peritonsilar area

Correct Answer ( B ) Explanation: This patient presents with symptoms and signs concerning for epiglottitis and should have antibiotics started and admission for further monitoring. Epiglottitis is a localized cellulitis of the supraglottic structures including the aryepiglottic folds, arytenoids, lingual tonsils, epiglottis and base of the tongue. It may be caused by viral or bacterial agents (Haemophilus influenzae type b is the most common). Although incidence in pediatric populations has decreased with the H. influenzae vaccine, it is becoming more common in adults and can lead to rapid airway obstruction. Patients usually present with dysphagia, odynophagia and sore throat. Pain may be severe in relation to physical exam findings. Additionally, patients frequently complain of a muffled voice. Fever is present in half of cases. Physical examination typically reveals mild inflammation in the oropharynx and may reveal tenderness to the neck over the hyoid bone. Epiglottitis is a clinical diagnosis but may be aided by plain radiographs of the neck, which shows edema of the epiglottis (thumb sign). An epiglottic width greater than 8 mm or an aryepiglottic fold greater than 7 mm suggests epiglottitis. Definitive diagnosis can be made with indirect laryngoscopy. Management in patients focuses on protecting the airway when necessary starting IV antibiotics (ceftriaxone and ampicillin-sulbactam are first-line) and admission for monitoring. Supportive care with hydration is important as well. Inhaled racemic epinephrine (A) is a temporizing measure that should be instituted prior to controlling the airway. Patients that improve after inhaled epinephrine should be monitored as a rebound phenomena has been described. Intravenous corticosteroids (C) have not been shown to be efficacious. Needle aspiration of the peritonsillar area (D) is the treatment of choice in pertonsillar abscess.

An eight-year-old girl presents to your office with complaints of increased thirst, increased volume of urine and weight loss. Physical exam is normal except for the patient appearing slightly ill and with a weight loss of seven pounds since her last well child exam. Hemoglobin A1C is 9.2%. Which of the following is the most appropriate therapy? Glipizide Insulin Metformin Repaglinide

Correct Answer ( B ) Explanation: Type 1 diabetes mellitus (DM) occurs when autoimmune destruction of the beta cells of the pancreas make the body unable to produce insulin. Onset of the condition occurs most commonly in children, but it can also develop in adults. Family history of type 1 DM is a risk factor for developing the disorder. The classic symptoms include polyuria, polydipsia, polyphagia, and weight loss. Onset can occur suddenly, and individuals often present with diabetic ketoacidosis as the initial presentation. Diagnosis can be confirmed with a random plasma glucose concentration of 200 mg/dL or higher in a patient with symptoms of hyperglycemia, a fasting plasma glucose concentration of 126 mg/dL or higher on more than one occasion, a positive oral glucose tolerance test or a glycated hemoglobin (A1C) of 6.5 percent or greater. Treatment is with exogenous insulin since the body is unable to produce insulin on its own. Glipizide (A) is an oral sulfonylurea used in the treatment of type 2 DM. Metformin (C) is an oral biguanide used as first-line treatment for type 2 DM. Repaglinide (D) is an oral meglitinide used with type 2 DM. Oral medications are not used in the treatment of type 1 DM.

A three-year-old girl presents to the clinic with fever for two days. Her father describes increased fussiness, decreased oral intake to solids, and recent nasal congestion. She does not take medications but developed a rash to amoxicillin in the past. On examination, her temperature is 39.2°C, heart rate 110, blood pressure 90/65, respiratory rate 22, and oxygen saturation 98 percent. Physical examination of the right tympanic membrane shows bulging and erythema with purulence behind the membrane. The rest of her examination is unremarkable. Which of the following is the best initial therapy? Amoxicillin Azithromycin Cefdinir Trimethoprim-sulfamethoxazole

Correct Answer ( C ) Explanation: Cefdinir is an appropriate first-line antibiotic choice for a child with acute otitis media (AOM) and non-type 1 hypersensitivity reaction to penicillin. Allergies to penicillin should be categorized into type 1 hypersensitivity reactions, such as anaphylaxis or urticarial, and non-type 1 hypersensitivity reactions, such as rash. Cross-reactivity reactions with cephalosporins are possible, but less likely with non-type 1 hypersensitivity reactions. Therefore, first line therapy with cefdinir would be a good option. Cefdinir has a broad efficacy, and it is a well-tolerated medication. Also, it can be given once daily. Other cephalosporins that might be considered include oral cefuroxime suspension or intramuscular ceftriaxone. However, cefuroxime is not palatable, making adherence poor. Ceftriaxone is more expensive, and also has the side effect of pain due to the injection. However, it is useful in cases when patients have failed oral second-line therapy or if patients are found to have highly resistant S. pneumoniae. Amoxicillin (A) is the first-line therapy for AOM, due to its high efficacy against S. pneumoniae, its safety profile, palatability, and low cost. The drug may be inactivated by some beta-lactamase-producing strains of nontypable H. influenzae and M. catarrhalis. However, it should not be given to patients with prior allergic reactions. Azithromycin (B) should be used for children with type 1 hypersensitivity reactions secondary to penicillin. However, this would not be first-line therapy for a non-type 1 hypersensitivity reaction, as cephalosporins have better activity than macrolides against the usual bacterial pathogens. In general, azithromycin has poor activity against S. pneumoniae as well as the beta-lactamase-producing strains of H. influenzae. Additionally, use of macrolides is linked to increased resistance to group A streptococcus and S. pneumoniae. Trimethoprim-sulfamethoxazole (D) has resistance patterns that include H. influenzae and S. pneumoniae. There is a high clinical failure rate when using this medication to treat acute otitis media, so it is not considered an adequate first-line agent.

A young woman suffers from chronic diarrhea. A detailed history provides no evidence of provocative medications as the cause. You send a stool sample to the laboratory and obtain the following results: Color: Yellow-brown Water: High Fat: Negative Blood: Negative WBCs: Negative Osmotic gap: Normal These results suggest which of the following as the most likely causative of this patient's diarrhea? Infectious Malabsorption Motility Osmotic

Correct Answer ( C ) Explanation: Chronic diarrhea is diagnosed when a person has 3 or more watery or loose stools per day for greater than 1 month. The difficulty in determining an etiology is due to the extensive differential that accompanies this diagnosis. There are several etiologic classes of chronic diarrhea: medications like SSRIs and PPIs, motility disorders like scleroderma and diabetic autonomic neuropathy, secretory disorders such as that which occurs in laxative abuse, osmotic abnormalities such as lactose intolerance, infectious etiologies like parasitic infections, inflammatory bowel disease and malabsorption abnormalities such as celiac disease and pancreatic insufficiency. Evaluation starts with ruling-out medication causes. Then, a stool sample should be sent for fecal fat, and if present, consider the malabsorptive disorders as causative. If the stool sample contains occult blood or WBCs, consider infectious and inflammatory conditions, then order a stool culture and obtain a colonoscopy. The stool sample should also be tested for an osmotic gap using the osmality, sodium level and potassium level of the stool. High gap values point toward the osmotic and malabsorption etiologies, while a normal gap suggests the secretory and motility disorders. When considering an osmotic cause, a patient should be further tested with a H+ breath test, laxative screen and empiric lactose-free diet. If considering the secretory or motility causes, further testing includes a CT scan, hormone levels (serotonin, gastrin, thyroxine and calcitonin) and a colonoscopy. An infectious cause (A) of chronic diarrhea would usually produce a stool that contains WBCs. The malabsorptive disorders (B) which lead to chronic diarrhea typically produce a fatty stool with an elevated osmotic gap. Osmotic disorders (D) result in an increased, not normal, stool osmotic gap.

A 73-year-old woman with a past medical history of hypertension, hyperlipidemia, coronary artery disease, and chronic systolic heart failure presents to the clinic complaining of acute onset of pain in her first metatarsophalangeal joint. She denies recent trauma. Her medications include metoprolol succinate, atorvastatin, aspirin, lisinopril, furosemide and potassium. Which of the following medications is most likely contributing to her acute joint pain? Aspirin Atorvastatin Furosemide Metoprolol succinate

Correct Answer ( C ) Explanation: Furosemide is the most likely medication to be contributing to this patient's acute attack of gouty arthritis. Hyperuricemia is a relatively common finding in patients treated with a loop or thiazide diuretic and may, over a period of time, lead to gouty arthritis. Diuretics may increase the relative risk of gout by nearly 80%. Loop and thiazide diuretics decrease urate excretion by increasing net urate reabsorption; this can occur either by enhanced reabsorption or by reduced secretion. A diagnosis of gout is not necessarily an indication for discontinuation of the diuretic. Most patients with diuretic-induced gout are treated with a urate-lowering drug such as allopurinol. Treatment of diuretic-induced asymptomatic hyperuricemia is usually not necessary as the diuretic agent should be held. Some clinicians use allopurinol specifically in diuretic-induced gout to lower urate. Aspirin (A), atorvastatin (B) and metoprolol succinate (D) are not associated with hyperuricemia or gouty arthritis.

A four-year-old boy presents to the emergency department for inability to walk. He has had two days of leg pain and has been irritable for the past day. The morning of presentation, he refused to get out of bed or bear weight. On his initial examination, he has 1/5 strength in his lower extremities, and 4/5 strength in his upper extremities. Patellar reflexes cannot be elicited. Which of the following is the most likely CSF finding? WBC 120, Glucose 20, Protein 80 WBC 120, Glucose 65, Protein 80 WBC 2, Glucose 65, Protein 135 WBC 2, Glucose 65, Protein 40

Correct Answer ( C ) Explanation: Guillain-Barré syndrome is a postinfectious polyneuropathy that can affect patients of all ages. It typically follows a viral illness (e.g., Epstein Barr virus and cytomegalovirus) but has also been associated with some immunizations. Typically, the weakness begins in the lower extremities, then ascends along the trunk. Bulbar muscles may be involved, and respiratory failure can occur. Young children may present with refusal to bear weight, irritability, and flaccid tetraplegia. Tendon reflexes may be lost early or later in the course. Analysis of the CSF is helpful in making the diagnosis of Guillain-Barré. CSF studies will show an elevated protein level, typically twice the upper limit of normal. The white blood cell count in the CSF is normal. This dissociation between high CSF protein and normal cell counts (albuminocytologic dissociation) is diagnostic for Guillain-Barré syndrome. In addition, the CSF glucose level falls within the normal range. Bacterial and viral CSF cultures will be negative. Imaging studies may support the diagnosis. MRI findings might include contrast enhancement of the intrathecal nerve roots and the cauda equina on postgadolinium T1-weighted images. Normal CSF (D) has a low white blood cell count, a glucose level that is > 60 percent of the serum glucose level, and a protein level < 45 mg/dL. The fluid should appear clear, and the opening pressure should not be elevated. Bacterial meningitis (A) may have CSF that appears cloudy or purulent; however, it could still be clear. The opening pressure is usually elevated (> 25 cm H2O). The white blood cell count is elevated, usually about 100 cells/µL. The glucose will be low (< 40 percent of the serum glucose) and the protein will be high (> 50 mg/dL). Aseptic or viral meningitis (B) may have an elevated opening pressure, with clear CSF. The glucose level is normal, but the protein will be elevated (> 50 mg/dL). The white blood cell count ranges from 10-1,000 cells/µL.

A mother brings in her 2-week-old infant for a well child check. She reports that she is primarily breastfeeding him, with occasional formula supplementation. Which one of the following should you advise her regarding vitamin D intake for her baby? Breastfed infants do not need supplemental vitamin D Intake of vitamin D in excess of 200 IU/day is potentially toxic The baby should be given 400 IU of supplemental vitamin D daily Vitamin D supplementation should not be started until he is at least 6 months old

Correct Answer ( C ) Explanation: In 2008, the American Academy of Pediatrics increased its recommended daily intake of vitamin D in infants, children, and adolescents to 400 IU/day. This recommendation follows in the wake of widespread vitamin D deficiency in the United States and other countries in all age groups. The reason that breastfed infants are deficient in vitamin D is not because human milk is deficient in vitamin D per se but because mothers who are deficient in vitamin D have vitamin D-deficient milk, which leads to vitamin D deficiency in the infant. Studies are underway to determine if higher maternal vitamin D supplementation doses will safely and effectively increase milk vitamin D levels that will lead, in turn, to optimal vitamin D status in the breastfeeding infant. In this way, both mother and infant could be replete. Until such studies are completed and published, a safe alternative is for infants to receive a vitamin D-only supplement to provide 400 IU vitamin D. Breastfeeding does not provide adequate levels of vitamin D (A). Exclusive formula feeding probably provides adequate levels of vitamin D, but infants who consume less than 1 liter of formula per day need supplementation with 400 IU of vitamin D daily. Vitamin D supplementation should be started within the first 2 months of birth (D). 200 IU (B) of daily vitamin D is not an adequate amount in exclusively breastfed infants.

Which of the following medications is most likely to cause gingival hyperplasia? Doxycycline Lamotrigine Phenytoin Vancomycin

Correct Answer ( C ) Explanation: Phenytoin is an antiepileptic medication and is known to cause gingival hyperplasia. The etiology of this side effect is not entirely understood. Phenytoin has many other side effects such as rashes, nystagmus and ataxia and carries a black box warning for increased risk of severe hypotension and cardiac arrhythmias. Doxycycline (A) is a tetracycline antibiotic that often causes photo-sensitivity, which typically presents as an exaggerated sunburn and often blisters. It can also cause discoloration of teeth and inhibition of bone growth in children. Doxycycline has many indications including, but not limited to, anthrax, Lyme disease, rosacea and many sexually transmitted infections. Lamotrigine (B) is a medication used to treat seizures as well as bipolar disorder. It can also cause gingival hyperplasia, but much more rarely than phenytoin. Lamotrigine is more well known to cause Stevens-Johnson syndrome. This is a severe mucocutaneous reaction characterized by extensive necrosis and detachment of the epidermis. This is a rare but serious side effect and requires hospitalization. Vancomycin (D) is an antibiotic that treats many gram positive, multidrug-resistant organisms, including S. aureus, enterococci and C. difficile. The most common adverse reaction to vancomycin is "red man syndrome" when given intravenously. This is an idiopathic infusion reaction characterized by flushing, erythema and pruritus that usually affects the upper body, neck and face.

A 7-year-old boy presents complaining of occasional intermittent lower abdominal pain over the last several weeks associated with a decline in the frequency of bowel movements to one every third day. When he does defecate, stools are hard to pass and sometimes painful. There is no blood in the stools. He has no chronic medical problems, has never had surgery, and takes no medications. Review of systems are negative and physical exam is normal. What is the most appropriate initial intervention for this child? Bisacodyl Phosphate enema Polyethylene glycol Referral to gastroenterologist Soap suds enema

Correct Answer ( C ) Explanation: Polyethylene glycol is an osmotic laxative, and reasonable first line oral medication to use for maintenance therapy of constipation, defined as a two week history or more of delay or difficulty in defecation. Other options include magnesium hydroxide, lactulose and sorbitol. The most common cause of constipation in children is functional constipation, meaning constipation without objective evidence of a pathological condition. Behavioral modification including unhurried time on the toilet after meals to discourage withholding of stool, as well as feeding children a diet of whole grains, fruits and vegetables is recommended as part of the treatment of constipation, though studies suggest that medication is often necessary to achieve regular bowel movements. Fever, abdominal distension, anorexia, nausea, vomiting, weight loss, or poor weight gain suggest a more serious etiology and should prompt further work-up with imaging and laboratory studies. Bisacodyl (A) is a stimulant laxative and is not recommended as initial maintenance therapy for children with constipation. It may be used as rescue therapy for help with relieving stool impaction, though this patient's physical exam does not suggest that impaction is present. One could obtain an abdominal X-ray but it is not needed in this scenario. Side effects of bisacodyl may include diarrhea, abdominal pain and proctitis. Phosphate soda enemas (B) may be used if stool impaction is diagnosed, and the patient and parents prefer this treatment for disimpaction over oral agents. Other types of enemas that may be considered include those with mineral oil and saline. Enemas are not recommended for the long-term maintenance therapy of constipation in most patients. Soap suds enemas (E), tap water and magnesium enemas are not recommended for use in children due to the risk of toxicity. Referral to a gastroenterologist (D) should be considered for patients who do not respond to therapy as expected, for those with symptoms, exam findings or other evidence to suggest organic disease, or for those whose management is complex due to other medical or social factors.

A 76-year-old woman with a history of chronic obstructive pulmonary disease presents to your office in December with complaints of fever, muscle aches, headache and malaise that started yesterday. Which of the following is the most appropriate next step in management? Advise supportive care measures including acetaminophen Begin a course of azithromycin Begin a course of oseltamivir Begin a course of prednisone

Correct Answer ( C ) Explanation: Seasonal influenza is caused by influenza A or B viruses and results in acute respiratory illness. Clinical presentation includes fever, myalgia, headache and malaise and high-risk patients can experience serious complications including death. Antiviral therapy can shorten the duration of illness and viral shedding and decrease the severity of symptoms. Patients with symptoms that began 24-48 hours prior to presentation should be evaluated for being at high risk of complications and those at high risk should start a course of oseltamivir. Groups considered to be at high risk include adults 65 years and older, children 2 years and younger, immunocompromised patients, pregnant women, residents of nursing homes or chronic care facilities, and individuals with certain chronic illnesses including chronic pulmonary disease. Supportive care measures (A) should be advised for all patients with cold or flu symptoms, regardless of high-risk status or additional treatment. Azithromycin (B) is used for chronic obstructive pulmonary disease (COPD) exacerbations, along with prednisone (D). Viral respiratory infections in patients with COPD can lead to COPD exacerbation, which is why starting a course of oseltamivir early is so important.

You provide care to a middle-aged man with hypertension and diabetes. He recently lost his job, and you are concerned that he may be exhibiting mild symptoms of depression. According to the US Preventive Services Task Force, screening for depression is recommended if which of the following exists? A local suicide prevention hotline routinely handles calls from your surrounding area The patient has a strong social support of friends, family and coworkers There is a cognitive-behavior therapist that works in your clinic You have developed a detailed depression screening form

Correct Answer ( C ) Explanation: The US Preventive Services Task Force recommends that adults should only be screened for depression when there is staff-assisted care and support available to make an accurate diagnosis, offer effective treatment and provide follow-up care. There is evidence that this model improves clinical outcomes. Staff-assisted care support refers to ancillary staff that can assist the primary care physician in many areas, such as behavior treatment, medication adherence and follow-up care. The USPSTF recommends against routine screening of adults for depression if there is no staff-assisted care support currently established. A suicide prevention hotline (A) may not be beneficial in the treatment of adult depression. Family and non-family support alone (B) does not warrant routine screening of depression. Screening (D) and feedback alone does not improve clinical outcomes.

A four-year-old boy is in the clinic for evaluation of jaundice. He had a runny nose and a fever three days ago, and last night, the parents noticed he had decreased appetite and yellowing of the eyes. He has a history of requiring phototherapy during his neonatal period. The boy and his mother both have O positive blood type. On physical exam, the boy appears ill with icteric sclerae and splenomegaly. Laboratory testing shows anemia, reticulocytosis, elevated mean corpuscular hemoglobin concentration (MCHC), elevated indirect bilirubin, negative Coombs test as well as numerous spherocytes found on peripheral blood smear. Which of the following is the most likely diagnosis? Autoimmune hemolytic anemia Glucose-6-phosphate dehydrogenase deficiency Hereditary spherocytosis Neonatal alloimmune hemolytic anemia

Correct Answer ( C ) Explanation: The boy has signs, symptoms and laboratory findings that are consistent with hereditary spherocytosis (HS). It is the most common hemolytic anemia due to a red cell membrane defect. It is a result of heterogeneous alterations in one of six genes that encode for proteins involved in vertical associations that tie the membrane skeleton to the lipid bilayer. It is commonly accompanied by jaundice that requires treatment with phototherapy or exchange transfusion in the newborn period. Beyond the neonatal period, jaundice is rarely intense. Exacerbations may be hemolytic, aplastic or megaloblastic in origin. Increased hemolysis may accompany viral illnesses, probably due to splenomegaly and hypersplenism associated with the illness as in the case of the boy in the vignette. The diagnosis of HS is suspected at any age because of the presence of hemolysis (elevated serum lactate dehydrogenase, elevated indirect bilirubin, reduced haptoglobin). The critical findings suggesting the diagnosis of HS include a positive family history of HS, an elevated MCHC (usually >36 g/dL), and the presence of spherocytes on the peripheral blood smear. Autoimmune hemolytic anemia (A) and neonatal alloimmune hemolytic anemia (D) closely resemble HS because of a high percentage of spherocytes on peripheral blood smear. What differentiates autoimmune hemolytic anemia is that it presents with a positive direct antiglobulin (Coombs) test. Neonatal alloimmune hemolytic anemia is most often due to ABO or Rh incompatibility between the mother and newborn. This is excluded because the boy and his mother have the same blood type. Glucose-6-phosphate dehydrogenase deficiency (B) results in hemolysis after exposure to drugs with oxidant properties that result in oxidative damage to hemoglobin in circulating red cells.

In the clinic, you are evaluating a 15-year-old girl who is complaining of increased vaginal discharge. She had her menarche at 12 years of age and since then has had irregular periods. She uses tampons during her menses. She notes thick yellowish vaginal discharge in between her periods. She denies burning, pain, or pruritus. She started to be sexually active for the past month with one partner. She uses condoms for contraception. On examination, you note Tanner 5 pubic hair and white discharge. You examine the discharge and obtain pH of 4, with negative whiff test and absence of clue cells on microscopy. You perform a pregnancy test, which is negative. Which of the following is the next best step? Advise her to stop using tampons Encourage her to douche after her period Provide her with reassurance Send culture for Gardnerella vaginalis

Correct Answer ( C ) Explanation: The girl's vaginal discharge is physiologic leukorrhea and therefore she should be reassured that this is normal. Normal vaginal discharge is composed of 1 to 4 ml fluid per day that is white or transparent, thick or thin, and usually odorless. The pH of normal vaginal secretions is 4.0 to 4.5. This is formed by mucoid endocervical secretions in combination with sloughing of epithelial cells and normal vaginal flora. The discharge may become more noticeable during the middle of menstrual cycle, during pregnancy, or with the use of estrogen-progestin contraceptives. The normal discharge may be yellowish, slightly malodorous, accompanied by mild irritative symptoms, but it is not accompanied by pruritus, pain, burning, erythema, or local erosion. The absence of these signs and symptoms distinguishes it from pathologic discharge like vaginitis or cervicitis. Advising her to stop using tampons (A) is not needed since tampon use would not affect her vaginal discharge. Encouraging her to douche after her period (B) is not recommended. Douching is when a woman puts a liquid inside the vagina to rinse it out. This is not advised and does not prevent vaginal discharge. Sending culture for Gardnerella vaginalis (D) is not correct because this organism is the etiologic agent in bacterial vaginosis, which the patient does not have. Bacterial vaginosis presents with off-white, thin, homogenous discharge, fishy odor, pH greater than 4.5, positive whiff test, and clue cells on wet mount.

Which of the following is the most predictive risk factor for cardiac ischemia? Diabetes mellitus Family history of coronary artery disease Past medical history of coronary artery disease Tobacco use

Correct Answer ( C ) Explanation: The most predictive risk factor for cardiac ischemia is a past medical history of coronary artery disease. The classical coronary risk factors have been repeatedly shown to increase the risk of ischemic heart disease in patients followed over many years. But in the acute setting, a history of coronary artery disease is most predictive. Diabetes mellitus (A), a family history of coronary artery disease (B), tobacco use (D), hypertension, and hyperlipidemia are traditional risk factors for coronary artery disease based on population studies and are predictive for the lifetime development of coronary artery disease, but only weakly predictive of the likelihood of acute ischemia. They can, however, help to predict poor outcomes in patients already diagnosed with acute coronary syndrome.

A 12-year-old girl presents with right hip pain after kicking a ball to score at her soccer game. She describes hearing a "pop" followed by immediate pain. The patient can limp and localizes pain to the anterior right hip. An X-ray is obtained as seen above. Which of the following is the most appropriate management? Immobilization with a spica cast Muscle relaxant and heat Non-weight-bearing and pain control Surgical pinning

Correct Answer ( C ) Explanation: The patient has a pelvic avulsion fracture of the anterior inferior iliac spine (AIIS). This is the result of forced muscle contraction, causing a fracture at the muscular origin. The commonly fractured pelvic apophysis locations in descending order of incidence include ischial, anterior inferior iliac spine, anterior superior iliac spine, superior pubic ramus, and iliac crest. Risk factors include sports such as gymnastics, soccer, and hurdles. Prevention is through stretching of the commonly involved muscles including the sartorius, rectus femoris, hamstring, iliopsosas, and leg adductor muscles prior to participating in sports. Diagnosis is with plain radiographs of the pelvis in anterior posterior and frog leg views. Pelvic avulsions rarely require pinning and most often successfully heal with crutch use and pain control. Occasionally, this type of injury heals with excessive callus formation. Sport activity should be limited for fpur to six weeks. Spica casting of the pelvis (A) is the treatment for femoral shaft fractures in children. It is not indicated in pelvic avulsion fractures. Muscles relaxants and heat (B) would be indicated if your suspected diagnosis is muscle strain or spasm rather than avulsion. Surgical pinning (D) is a treatment for pelvic avulsion fractures. However, pinning is rarely required since these injuries most commonly heal without surgical intervention but rather with rest and non-weight-bearing.

A 19-year-old man with diabetes presents with penile pain and dysuria. Physical examination of the penis reveals the image above. The patient states he has had similar episodes in the past. What management is indicated? Azithromycin and ceftriaxone Ciprofloxacin Clotrimazole cream Hydrocortisone cream

Correct Answer ( C ) Explanation: The patient presents with balanitis, which results from inflammation of the glans penis or the glans and foreskin (balanoposthitis). The primary cause is infection, most commonly Candida. Treatment consists of topical antifungal. Balanitis can also be caused by bacterial agents such as group A beta-hemolytic streptococci. Additionally, it may be secondary to irritation, trauma or contact dermatitis. Recurrent balanitis is seen in diabetics from C. albicans. Patients typically complain of pain, discharge, and itching. The glans may appear erythematous and tender to palpation. Systemic symptoms may be present but are unusual. Management of fungal balanitis includes topical antifungal agents such as clotrimazole, adequate hygiene and glycemic control. In patients with no history of diabetes who present with fungal balanitis, diabetes should be considered and a finger stick should be obtained. Azithromycin and ceftriaxone (A) are indicated for the treatment of gonorrhea or Chlamydia infections. Ciprofloxacin (B) does not have activity against fungal agents and would not be adequate in the treatment of bacterial balanitis. Hydrocortisone cream (D) can reduce inflammation in patients with severe balanitis but will not result in cure of fungal balanitis.

Which of the following is the most commonly fractured carpal bone seen in hand fractures Capitate Hamate Scaphoid Triquetrum

Correct Answer ( C ) Explanation: The scaphoid is located in the proximal carpal row along with the lunate, triquetrum and pisiform bones. It is the most commonly fractured carpal bone. Mechanism of injury is generally a fall on an outstretched hand with the wrist in extension and radial deviation. Patients present with pain and swelling on the radial side of the wrist, limited range of motion and tenderness to palpation of the anatomic snuffbox. Initial management includes accurate diagnosis of the fracture, pain control, reduction and splinting (thumb spica splint) of the injury and referral to a hand surgeon for follow up. The capitate (A) and hamate (B) bones are both located in the distal carpal row. Fractures to bones in this row are less common than to those in the proximal row. The triquetrum (D) is located in the proximal carpal row and is the second most common carpal bone fracture.

A 17-year-old man with asthma presents with an itchy, scaly rash on his arms and legs. He states that he has had the rash on and off for years. He states that the itching is severe and keeps him up at night. Physical examination reveals hyperpigmented areas to the antecubital and popliteal fossae which are thick and leathery. What management is indicated? Antibiotic ointment Cephalexin Corticosteroid ointment Oral steroids

Correct Answer ( C ) Explanation: This patient presents with an exacerbation of atopic dermatitis (AD) requiring topical corticosteroid treatment. AD is a common dermatologic condition. It is often referred to as eczema or chronic dermatitis. Patients with AD have abnormal humoral and cell-mediated immunity but the exact mechanism of the disease is unknown. AD has no pathognomonic skin lesions but does have a set of diagnostic criteria. These criteria include a history of involvement of flexor surfaces, generalized dry skin, history of asthma or hay fever, onset of rash before 2 years of age and flexor surface dermatitis. The presence of three or more of these is 85% sensitive and 96% specific for AD. AD is a chronic disease that waxes and wanes and is often worse in the winter. In general, treatment for AD is directed at controlling inflammation, dryness and itching. When patients present with acute symptoms, topical corticosteroid ointments can provide symptomatic relief. Antihistamines may be necessary as well. in addition, avoid scented products, wear light weight clothing, avoid hot baths, wash clothing in dye-free, unscented detergent. Antibiotic ointments (A) are not useful as bacteria are not the causative agent. The same is applicable to using cephalexin (B), a first generation cephalosporin. Oral steroids (D) are rarely used in the treatment of AD as topical agents are adequate.

A nine-year-old girl is brought by her father to the clinic because of a sore throat. For the past two days, she has complained of a sore throat and fever. She denies any rhinorrhea or coughing. On physical examination, vital signs are normal, with erythematous posterior pharyngeal wall, exudates on tonsils, and palatal petechiae. A rapid antigen detection test for group A streptococcus (GAS) comes back positive. Which of the following is the most appropriate therapy? Ciprofloxacin Oseltamivir Penicillin VK Trimethoprim-sulfamethoxazole

Correct Answer ( C ) Explanation: Tonsillopharyngitis due to Streptococcus pyogenes, also known as group A Streptococcus (GAS), presents with abrupt onset of sore throat, tonsillar exudate, tender cervical adenopathy, and fever, followed by spontaneous resolution within two to five days. The goals of antimicrobial therapy for eradication of group A Streptococcus (GAS) from the pharynx in the setting of acute streptococcal pharyngitis include: (1) reducing duration and severity of clinical signs and symptoms, including suppurative complications; (2) reducing incidence of nonsuppurative complications; and (3) reducing transmission to close contacts by reducing infectivity. Antimicrobial therapy is warranted for patients with symptomatic pharyngitis if the presence of group A streptococci (GAS) in the pharynx is confirmed by culture or rapid antigen detection testing (RADT). Antibiotic options for treatment of GAS pharyngitis include penicillin (and other related agents, including ampicillin and amoxicillin), cephalosporins, macrolides, and clindamycin. Ciprofloxacin (A) and trimethoprim-sulfamethoxazole (D) should not be used for treatment of GAS pharyngitis because of high rates of resistance to these agents and their frequent failure to eradicate even susceptible organisms from the pharynx. Oseltamivir (B) is used in the treatment of influenza.

A woman with known coronary artery disease presents to the ED with chest pain and ventricular tachycardia. Five minutes after admission she becomes unresponsive. Her rhythm strip is seen above. Which of the following is the most appropriate intervention? Beta-blockade Cardioversion Defibrillation Vasopressin

Correct Answer ( C ) Explanation: Ventricular fibrillation is the most common dysrhythmia in cardiac arrest patients. Instead of coordinated ventricular depolarization and contraction, ventricular fibrillation (VF) is characterized by rapid disorganized excitation potentials that amount to ineffective contraction. VF occurs with acute infarct or ischemia as well as old infarct or ischemia. Common triggers include electrocution, myocardial ischemia, and hypoxia. Electrocardiographically, VF appears as a chaotic, disorganized waveform that has no discernible typical morphology. Ventricular fibrillation is incompatible with life. Treatment is with immediate defibrillation. Vasopressin (D) was previously part of the ACLS protocol for pulseless ventricular tachycardia (pVT) and ventricular fibrillation (VF). However, the new 2015 AHA guidelines, have removed vasopressin all together. Beta-blockers (A) are not indicated for VF. Cardioversion (B) is only used in patients with organized electrical activity and who have a pulse.

A 23-year old woman presents to the emergency room with lethargy, nausea, and vomiting. She is tachypneic on physical exam and has a fruity odor to her breath. Her urine shows 4+ ketones and glucose and her fingerstick glucose reveals a blood glucose level of 650 mg/dL. What should be the initial therapy in this patient? Bicarbonate infusion Half-normal saline with dextrose infusion Intravenous insulin Normal saline infusion

Correct Answer ( D ) Explanation: According to the physical presentation and lab values, this patient is in diabetic ketoacidosis (DKA) and requires immediate treatment with normal saline infusion. The initial goal is to correct intravascular volume because glucose induces an osmotic diuresis that causes a fluid loss of approximately 3-6 liters. Infusion of isotonic solution of 0.9% sodium chloride at a rate of 1 to 1.5 liters/hour should be used until signs of severe volume depletion are resolved. Diabetic ketoacidosis is characterized as serum glucose level > 250 mg/dL, a pH < 7.3, a serum bicarbonate level < 18 mEq/ L, an elevated serum ketone level, and dehydration. Insulin deficiency is the main precipitating factor. The main goals of treatment are to restore volume deficits, resolve elevated blood glucose levels, correct electrolyte abnormalities and treat the precipitating cause. Bicarbonate infusion (A) is not usually indicated unless there is severe acidosis defined as arterial blood pH < 7 mEq/L. A continuous infusion of intravenous insulin (C) should be initiated after fluid resuscitation has been started. After exclusion of hypokalemia, a continuous infusion of regular insulin at a dose of 0.1 units/kg/hour is recommended. Transition from intravenous insulin to subcutaneous insulin is initiated when the blood glucose level is less than 250mg/dL and the anion gap is normalized. Half normal saline (0.45%) with dextrose infusion (B) should be initiated when the glucose level is less than 250 mg/dL.

A patient presents with scrotal swelling suspicious of hydrocele. Which of the following is the most appropriate intervention at this time? Complete metabolic panel and urinalysis Computed tomography scan Surgical consultation Ultrasonography «

Correct Answer ( D ) Explanation: As the testicle descends during fetal development, an out-pocketing of the peritoneum follows. This is known as the processus vaginalis testis, which normally pinches off after complete descent to form the tunica vaginalis testis. Any fluid accumulation in the tunic vaginalis testis, or in a persistent processus vaginalis testis, is called hydrocele. Hydroceles, although commonly self-limited in newborns, can occur at any age, and almost always present as painless, unilateral scrotal swelling of acute or insidious onset. Typical examination findings include a fluctuant, ovoid, nontender mass about the testicle, making direct palpation of the testicle difficult. A hydrocele transilluminates on exam. What widens the differential in hydrocele is the possibility of having swelling about the testicle or swelling about the spermatic cord. If the swelling extends proximally to the inguinal ring, one must consider an indirect inguinal hernia. In any case of scrotal swelling, color Doppler ultrasonography is the first diagnostic test recommended. Serum and urine studies (A) are not warranted in hydrocele, but may be helpful in any urinary tract infectious condition. CT scan (B) is the not the initial diagnostic test in evaluating scrotal swelling. Immediate surgical consultation (C) is not necessary for hydrocele, although it is required if testicular torsion is suspected.

An African American man is sent home with a prescription for an antibiotic after being diagnosed with a urinary tract infection. Two days later he returns because his "eyes are yellow." Which of the following antibiotics was most likely initially prescribed? Amoxicillin Cephalexin Doxycycline Trimethoprim-sulfamethoxazole

Correct Answer ( D ) Explanation: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive hereditary disease that results in characteristically low levels of G6PD. This is present in 11% of African American men. Individuals with this deficiency may exhibit nonimmune hemolytic anemia in response to a variety of oxidant stressors such as exposure to particular medications or (more commonly) infection. Trimethoprim-sulfamethoxazole can cause an oxidative stress that leads to hemolytic anemia. Other medications associated with hemolysis in G6PD deficiency include the following: Amoxicillin (A), cephalexin (B), and doxycycline (C) are not associated with hemolytic anemia due to G6PD deficiency.

You see a one-year-old girl in your office. The girl was brought by her parents to the clinic for a well child examination. The girl has been doing well and has gained weight appropriately. The parents deny respiratory difficulties or diaphoresis. On physical exam, you note a murmur. Which of the following features is associated with an innocent murmur? Blowing quality Grade 3 intensity Increased intensity with upright position Short systolic duration

Correct Answer ( D ) Explanation: Heart murmurs are common in infants and children. While the prevalence of congenital heart disease is approximately 1 percent, a majority of children have innocent murmurs at some time. Being able to distinguish a murmur associated with heart disease from a benign etiology is important for diagnosis and management. When evaluating an infant or child with a cardiac murmur, it is important to assess whether there are any symptoms concerning for heart disease. Concerning symptoms at any age include respiratory difficulties, diaphoresis (especially with exertion), and poor growth. In infants, symptoms may include poor feeding or excessive irritability. In older children, chest pain and syncope are important symptoms. The physical examination should include careful review of the vital signs, assessment of heart rate and rhythm, assessment of pulses, and a detailed cardiovascular exam. Features associated with innocent murmurs include the following: grade ≤ 2 intensity (flow murmurs and innocent Still's murmur are usually grade I or grade II in intensity), softer intensity when the patient is sitting compared with when the patient is supine, short systolic duration, minimal radiation, musical or vibratory quality. Blowing quality (A) is a feature of a pathologic murmur that is associated with regurgitant valves. Grade 3 intensity (B) is associated with a pathologic murmur. This is because lesions associated with increased turbulence are associated with a louder murmur. Increased intensity with upright position (C) is a usual feature of a pathologic murmur. Most innocent murmurs (with the exception of cervical venous hum) typically become softer in the upright position.

An 8-month-old boy fails to obtain age-appropriate milestones. His mother feels that he is too fatigued to properly feed. An echocardiogram reveals a large atrial septal defect. Which of the following physical examination abnormalities would you most expect to find in this infant? Bradycardia Cyanosis Prominent left ventricular impulse Widely split and fixed S2

Correct Answer ( D ) Explanation: In the vast majority of cases, an atrial septal defect results in an intracardiac left-to-right shunt, which typically manifests as right ventricular overload and increased stroke volume. ASDs are associated with some physical examination abnormalities, depending on the degree of shunting and the compliance of the ventricles, systemic vasculature and peripheral vasculature. A hyperdynamic right ventricular impulse may be appreciated. Pulmonary artery dilation may produce an ejection click. Splitting of S1 and S2 is also common. In fact, a widely split and fixed S2 is very common in large left-to-right shunts. Large shunts can also produce a left sternal murmur, heard higher as a systolic crescendo-decrescendo murmur, and lower as a middiastolic rumble. Bradycardia (A) is not a common finding in symptomatic ASDs. The majority of ASDs result in left-to-right shunting. As such, there typically is no pulmonary bypass, and therefore, no resulting cyanosis (B). Prominent right, not left (C), ventricular impulse is commonly associated with the left-to-right shunting of an ASD.

A 56-year-old widow comes to the physician at the request of her daughter. The patient's husband passed away unexpectedly 14 months ago from a heart attack. She tells you that she has been having a very difficult time since her husband's death. She hasn't been sleeping well because she can't get used to sleeping alone. She no longer enjoys going over to her daughter's house and finds interacting with her grandchildren too tiresome. She says she keeps thinking about the day her husband died and feels guilty about not being able to get him to the hospital sooner. She denies any plans to hurt herself, but does say she wonders if she'd be better off if she could join her husband. Which of the following diagnoses is most appropriate? Acute stress disorder Major depressive disorder Normal grief Persistent complex bereavement disorder

Correct Answer ( D ) Explanation: Intense symptoms of depression and guilt that persist beyond 12 months following the death of a loved one is indicative of persistent complex bereavement disorder. Not only do symptoms persist beyond 12 months, but they are generally severe in nature and interfere with daily functioning. According to the DSM V, persistent complex bereavement disorder, also called complicated grief disorder, has overlapping symptoms with major depressive disorder and posttraumatic stress disorder (PTSD), but is currently considered an independent condition. Normal grief (B) is limited to 12 months following the loss of a loved one. Feelings of pervasive hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are present in patients with depression or complicated grief, but are not components of normal grief. Major depressive disorder (C) can overlap with persistent complex bereavement, but the latter is considered an independent condition. Acute stress disorder (A) is similar in symptomatology to post traumatic stress disorder, but is restricted to within 1 months following exposure to a traumatic event.

Which of the following is considered a negative symptom of schizophrenia? Delusions Disorganized speech Hallucinations Poverty of speech

Correct Answer ( D ) Explanation: Negative symptoms in schizophrenia include alogia or poverty of speech, avolition or lack of purposeful action and affective flattening or decreased emotional reactivity. Schizophrenia is a complex illness or group of disorders characterized by hallucinations, delusions, behavioral disturbances, and disrupted social functioning in what is usually an otherwise clear sensorium. Schizophrenia involves at least a 6-month period of continuous signs of the illness. The lifetime incidence of schizophrenia is approximately 1%. This figure is remarkably stable across racial, cultural, and national lines. Age of onset is usually during adolescence or early adulthood. The course is highly variable, but generally involves significant functional impairment. Schizophrenia involves at least a 6-month period of continuous signs of the illness. Positive symptoms may include: delusions (A), disorganized speech (B), hallucinations (C), catatonic or bizarre behaviors along with the negative symptoms discussed above.

A mother has noticed a "cross-eye" in her 3-month-old boy. Examination reveals no gross external deformities. Pupillary light reflexes are intact. The eyelids, sclerae and pupils are normal appearing. A cover-uncover test reveals a left eye esotropia. Which of the following is the most likely diagnosis? Amblyopia Ectropion Leukocoria Strabismus

Correct Answer ( D ) Explanation: Strabismus, also known as "cross-eye" or "wall-eye", is a condition of eyeball misalignment that results in the inability of both eyes to fixate on the same point in space. This results in poor depth perception and diplopia. It occurs in 5 of every 100 US citizens, and is one of the most common eye disorders of infants and children. It is mostly due to extraoccular muscle imbalance or central nervous system abnormalities, such as cranial nerve palsies, Brown's syndrome and Kearns-Sayre syndrome, although the exact mechanism of disease is largely unknown. The eyes, or one eye, may point in (esotropia), out (exotropia), up (hypertropia) or down (hypotropia). A cover-uncover test is required in making the diagnosis. The current recommendation is to screen for strabismus at every well child check. Early diagnosis and treatment offer the best chance at normal binocular vision. Left untreated, strabismus can lead to amblyopia (A), also known as "lazy eye". In this condition, decreased acuity is not due to any structural anomaly or visual pathway abnormality, but is a result of the brain ignoring the visual input from the strabismic eye in an attempt to limit diplopia and poor depth perception. Half of the cases of ambylopia are caused by strabismus. Ectropion (B), the outward turning of the lower eyelid, is mainly due to aging degeneration of the supporting connective tissues. A combination of an abnormal pupillary light reflex and a whitish-appearing pupil is called leukocoria (C), and can be caused by retinoblastoma, cataract, vitreous opacity or corneal opacity.

What is the most common causative organism in community acquired pneumonia? Klebsiella pneumoniae Mycoplasma pneumoniae Staphylococcus aureus Streptococcus pneumoniae

Correct Answer ( D ) Explanation: Streptococcus pneumoniae is a gram positive cocci and is the most common organism causing community acquired pneumonia. Symptoms of community-acquired pneumonia include fever, tachycardia, chills, shortness of breath, cough, myalgias, and pleuritic chest pain. Some patients may also present with GI symptoms such as nausea, vomiting or diarrhea. Physical exam findings may include increased respiratory rate, crackles, increased tactile fremitus and dullness on percussion. Klebsiella pneumoniae (A) is more commonly seen in alcoholics with pneumonia and may present with currant jelly sputum. Mycoplasma pneumoniae (B) is an atypical organism that causes community-acquire pneumonia. It is considered atypical because it cannot be cultured on standard medium nor seen on a gram stain. Mycoplasma is often associated with "walking pneumonia." Staphylococcus aureus (C) pneumonia often follows recent influenza.

A detailed history and examination does not aid in the evaluation of new-onset hypertension in a 47-year-old man. In an attempt to search for an underlying cause, you order a basic metabolic panel, complete blood count, lipid panel and ECG. Which of the following tests should also be added to this standard diagnostic screen of secondary hypertension? Aortic ultrasound Echocardiogram Renal angiogram Urinalysis

Correct Answer ( D ) Explanation: The evaluation of hypertension involves specific history questions, exam findings and laboratory testing. A standard history should include questions about the presence of comorbidities (coronary artery disease, atherosclerosis, congestive heart failure, previous myocardial infarction, peripheral arterial disease, hypercholesterolemia, transient ischemic attacks and strokes, diabetes, renal insufficiency, endocrinopathies, retinal disease, connective tissue disease and obstructive sleep apnea), medications (oral contraceptives, corticosteroids, NSAIDs and cyclosporine), social history (salt intake, tobacco use, alcohol use, cocaine and methamphetamine use, dietary intake, and exercise trends) and family history of hypertension. The physical examination must include serial bilateral arm BP measurements, cardiac exam (murmurs, evidence of left ventricular hypertrophy), peripheral vascular and skin exam (edema, bruits, capillary refill, striae, moon fascies), thyroid exam, abdominal exam (masses, bruits), fundoscopic exam and neurologic exam. Baseline laboratory-diagnostic testing should include a basic metabolic panel, complete blood count, urinalysis, lipid panel and ECG. Aortic coarctation or aneurysm are rare causes of secondary hypertension. They are associated with abdominal, cardiac and peripheral vascular findings, which are missing in the above patient. Ultrasound (A) is the diagnostic test of choice when evaluating such abnormalities. Echocardiography (B) may be warranted if the clinician suspects left ventricular hypertrophy, valvulopathy, coronary artery disease or prior myocardial infarction as a cause of secondary hypertension, all of which would be suggested by abnormalities found during history and physical examination. Renal angiogram (C) offers great sensitivity and specificity in determining renovascular disease as a cause of secondary hypertension. However, it is not considered part of an initial evaluation, and should be considered if the initial tests above are noncontributory.

A previously healthy 37-year-old man presents with right ear pain which has been present for the past 3 days. On examination, the external canal is erythematous and edematous. A crusted exudate is present. The external canal is so swollen that it will not allow passage of an otoscope to visualize the tympanic membrane. Which of the following is the most appropriate treatment? Oral amoxicillin/clavulanate Oral fluconazole Topical acetic acid 2% solution Topical ciprofloxacin 0.3% - dexamethasone 0.1% drops

Correct Answer ( D ) Explanation: The patient has otitis externa, which refers to infection and inflammation of the external auditory canal. Factors which predispose to otitis externa include local trauma (often from scratching or attempted cerumen removal) and elevation of the local pH (frequent contact with water from swimming in pools or freshwater lakes). The clinical presentation of otitis externa includes erythema and edema of the external canal. Clear or purulent otorrhea and crusting exudate may be present. The inflammation may spread to the tragus and auricle, and in severe cases, to the periauricular soft tissues. The treatment for bacterial otitis externa should be aimed at treating the most common organisms causing otitis externa: Pseudomonas aeruginosa, Staphylococcus aureus, Enterobacteriaceae, and Proteus species. Topical treatment is standard, with oral medications reserved for febrile patients or those with involvement of the periauricular soft tissues. If the tympanic membrane is ruptured or external canal inflammation precludes visualization of the tympanic membrane such that perforation cannot be ruled out, non-ototoxic topical medications should be used in order to avoid causing damage to the inner ear. In this case, the best choice is topical ciprofloxacin 0.3% - dexamethasone 0.1% drops. Topical acetic acid 2% solution (C) is an accepted treatment for otitis externa, but is not safe with tympanic membrane perforations. Since the tympanic membrane cannot be visualized to rule out a perforation, acetic acid should be avoided. Oral amoxicillin/clavulanate (A) is reserved for febrile patients or those with extensive periauricular soft tissue involvement. Oral fluconazole (B) is used for fungal otitis externa. Fungal otitis externa is most commonly seen in immunocompromised patients, those with recent long-term antibiotic therapy, or in hot humid climates.

67-year-old woman presents with shortness of breath and a cough for 3 days. The patient admits to recently having a fever, chills, rhinorrhea, and myalgias for 10 days. She had one episode of diarrhea and has been nauseated. Her past medical history is positive for COPD. She does not smoke but she drinks two cans of beer daily. In the ED, her vital signs are BP 120/76, HR 108, RR 20, oxygen saturation 97% on room air, and temperature 101.2°F. A chest X-ray shows a left lower lobe consolidation. It is suspected that this patient has pneumonia caused by Staphylococcus aureus. Which aspect of this patient's history supports this suspicion? Alcohol consumption Gastrointestinal symptoms History of COPD Recent viral symptoms

Correct Answer ( D ) Explanation: The patient's recent history of fever, chills, rhinorrhea, and myalgias raises suspicion for influenza. Staphylococcus aureus is a common pathogen causing pneumonia in those currently or recently infected with influenza virus. Patients with pneumonia often present with tachypnea, tachycardia, dyspnea, chest pain, cough, fevers, and rales. S. aureus, a common nosocomial pathogen in adults, can lead to a necrotizing pneumonia. In those with gastrointestinal (B) or neurologic symptoms, Legionella pneumophilia should be considered. In those with excessive alcohol consumption (A), a common pathogen is Klebsiella pneumoniae. A history of COPD (C) raises suspicion for Haemophilius influenzae and Pseudomonas aeruginosa.

A thin woman of Afghan descent presents for a new patient evaluation. She always wears a burqa, an enveloping outer garment worn by many Islamic women. Baseline laboratory testing is unremarkable, but a bone densiometry test reveals osteomalacia. Further specific laboratory testing would most likely reveal which of the following disorders? Hypervitaminosis E Hypervitaminosis K Hypovitaminosis A Hypovitaminosis D

Correct Answer ( D ) Explanation: Vitamin D deficiency is found in individuals with insufficient sun exposure. Under ultraviolet light from the sun, cholesterol in the skin converts to a vitamin D precursor, which then becomes activated after liver and renal hydroxylation. Without the UV light from the sun, this vitamin D pathway is dysfunctional. Active vitamin D is necessary for cell differentiation, intestinal villi and connective tissue function, immune regulation and bone mineralization. Vitamin D deficiency in children is called rickets, and is characterized by bowed legs, knock-knees, protuberant abdomen and "knobby" ribs. Adult vitamin D deficiency leads to osteomalacia, osteoporosis, proximal myalgias, proximal weakness and myofasciculations. Although rare, vitamin E toxicity, or hypervitaminosis E (A), causes abdominal discomfort and hypercoagulation. Also rare, hypervitaminosis K (B) causes hemolytic anemia, brain damage and hypercoagulation. Hypovitaminosis A (C) is more common outside of the US. It causes night blindness, xeropthalmia, xerosis, keratomalacia, dry scaly skin, tooth cracking, periodontal disease and arthralgias.