#31 Rosh Review

Question: Optic nerve compression may be the result of aneurysmal mass effect at which artery junction?

Answer: At the bifurcation of the middle and anterior cerebral arteries. Rapid Review Subarachnoid Hemorrhage Sudden onset, thunderclap headache Ruptured berry aneurysm Polycystic kidney disease Head CT/LP Xanthochromia Nimodipine

Question: What is the recommended technique to establish a definitive airway in patients with severe epiglottitis?

Answer: Awake fiberoptic intubation in the operating room with the patient sitting up. 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: How can you distinguish between bronchiolitis and chlamydial pneumonia?

Answer: Chlamydial pneumonia is typically associated with a staccato cough without fever at one to three weeks of age, while bronchiolitis will cause fever. Rapid Review Bronchiolitis: Patient will be an infant Complaining of difficulty breathing PE will show respiratory distress, polyphonic wheezing, and rales CXR will show diffuse infiltrates Diagnosis is made by history and physical exam Most commonly caused by respiratory syncytial virus (RSV) Treatment is supportive care

Question: Which behavioral interventions are effective in treating marijuana dependence?

Answer: Cognitive-behavioral therapy and motivational incentives.

Question: What is the treatment for a cholesteatoma?

Answer: Congenital and acquired cholesteatomas can be eradicated from the temporal bone only by surgical resection. Rapid Review Acquired Cholesteatoma Patient will have a history of chronic ear infections or tympanostomy tubes Complaining of painless otorrhea PE will show yellow or white mass behind the tympanic membrane Treatment is tympanomastoid surgery

Question: What is beriberi?

Answer: Deficiency of thiamine (vitamin B1). Rapid Review Hyperthyroidism Patient will be complaining of heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE will show hyperreflexia Labs will show low TSH and high free T4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Treatment is methimazole or PTU Comments: Propylthiouracil (PTU) P for pregnant

Question: What is the most common inherited hypercoagulable state?

Answer: Factor V Leiden mutation. Rapid Review Antiphospholipid Antibody Syndrome Patient with a history of lupus or other rheumatic diseases Complaining of repeated spontaneous abortions Labs will show thrombocytopenia Most commonly caused by autoimmune Treatment is anti-coagulation

Question: True or false: Closed rupture of a ganglion cyst by striking it with an object is an effective treatment modality?

Answer: False. Rapid Review Ganglion Cyst Patient will be complaining of a painful mass in wrist Most commonly caused by repetitive activity causing tear or degeneration in joint capsule or tendon synovial sheath Treatment is observation or needle aspiration Comments: most common soft tissue tumors of the hand

Question: What medication, commonly used in patients with sickle cell disease, is associated with megaloblastic anemia?

Answer: Hydroxyurea Rapid Review Megaloblastic Anemia B12 deficiency: vegan, pernicious anemia neurologic findings Folate deficiency: alcoholic, antifolate therapy MCV > 100 Hypersegmented neutrophils

Question: What is the most common cause of secondary polycythemia?

Answer: Hypoxia. Rapid Review Polycythemia Vera Patient will be complaining of headache, dizziness, pruritus after showering PE will show hypertension, splenomegaly Labs will show increased RBC mass, overproduction of all cell lines, increased Hgb Most commonly caused by mutation of the Janus kinase 2 gene (JAK2) Treatment is phlebotomy, hydroxyurea, aspirin

Question: What is the mainstay treatment for patients with an identified IgE-mediated disease?

Answer: Imunotherapy which is the subcutaneous injection of incremental amounts of allergan extracts at weekly intervals.

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

Answer: Ischemic cardiomyopathy. Rapid Review Low-Output Heart Failure Systolic dysfunction More common than high-output heart failure Causes: ischemic heart disease (most common), hypertension, cardiomyopathy, valvular heart disease Decreased CO, decreased LVEDP and increased systemic oxygen extraction ratio Rx: oxygen, BiPAP, nitrates, furosemide

Question: For which bacterial pneumonia are alcoholics at higher risk?

Answer: Klebsiella. Rapid Review Lung Abscess Patient will be complaining of several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats CXR will show area of dense consolidation with an air-fluid level inside a thick-walled cavitary lesion Most commonly caused by aspiration pneumonia Treatment is clindamycin

Question: What are the classic muscle biopsy results associated with polymyositis?

Answer: Large nuclei, fiber size variation, atrophy and the simultaneous presence of necrotic and normal type I and type II fibers. Rapid Review Dermatomyositis F>M Polymyositis + rash Rash Malar rash Heliotrope rash Gottron's papules Proximal muscle weakness ↑ CK EMG, muscle biopsy Steroids ↑ Malignancy risk

Question: 0.2 seconds on an ECG is one small or one large block?

Answer: Large. Each small block is 0.04 seconds. Therefore, 5 small blocks to every 1 large block (5 x 0.04 = 0.2). Rapid Review Cardiac Electrical Conduction System SA node → AV node → bundle of his → bundle branches → purkinje fibers

Question: The motor fibers of the trigeminal nerve inervate which muscles?

Answer: Muscles of mastication. Rapid Review Trigeminal Neuralgia Sudden unilateral paroxysms of pain in gums, cheek, chin, temporal forehead Pain in V2 and V3 distributions, not V1 Right side > left side Triggers: chewing, brushing teeth, touching face, hot/cold exposure Carbamazepine

Question: What are indications for nonoperative management of fingertip amputations?

Answer: No bone or tendon exposed and less than 2 cm of skin loss. Rapid Review Mallet Finger Patient will be a basketball or volleyball player With a history of forced hyperflexion of the DIP Complaining of inability to extend DIP Treatment is volar splinting DIP in extension Comments: If untreated -> swan neck deformity

Question: Name some medications which are prescribed for venous insufficiency?

Answer: No oral medications have been shown to be beneficial in the treatment of this condition. Rapid Review Deep Vein Thrombosis Unilateral leg swelling Phlegmasia cerulean dolens (painful blue leg) = massive iliofemoral thrombosis with venous insufficiency Phlegmasia alba dolens (painful white leg) = massive iliofemoral thrombosis → arterial spasm Risk stratification: Well's criteria Modality of choice: ultrasound Treatment: ​Proximal DVT: heparin, warfarin Massive DVT: thrombectomy Isolated calf vein thrombosis: aspirin, ultrasound in 2 - 5 days Recurrent DVT on warfarin: heparin, IVC filter Propagation of DVT on warfarin + heparin: IVC filter

Question: Is an NG tube required in acute pancreatitis?

Answer: No, it is recommended for patients with intractable vomiting or ileus. Rapid Review Acute Pancreatitis Patient will be complaining of epigastric pain radiating to the back, nausea, and vomiting PE will show ecchymosis of left flank (GreyTurner sign), umbilical ecchymosis (Cullen sign) Labs will show elevated lipase (best) and amalyse Diagnosis is made by US and Ranson's criteria Most commonly caused by gallstones > alcohol Treatment is IV fluids

Question: Does an alkaline button battery that passes into the stomach need to be emergently removed endoscopically?

Answer: No. If the battery has passed into the stomach, it can be followed radiographically to ensure passage. Rapid Review Esophageal Foreign Body Site of obstruction: C6 > T4 > T11 AP/PA view: flat side of coin appears Esophageal necrosis → perforation Most FBs that pass pylorus pass spontaneously Observe most esophageal FBs for 24 hours Emergent endoscopy indicated if FB is battery, sharp, or signs of obstruction present

Question: Can administration of the HPV vaccine cause cancer?

Answer: No. The vaccine is made from one protein from the virus that cannot cause HPV infection or cancer.

Question: Palivizumab should be administered monthly prior to the onset of the peak RSV season. When is the peak of RSV season typically?

Answer: November through March. Rapid Review Transposition of the Great Vessels Cyanotic within hours of birth Aorta arises from RV, pulmonary artery arises from LV Diabetic mother Requires L → R shunt for survival CXR: "egg on a string" PGE1, surgery

Question: Which populations are G6PD most common in?

Answer: People of African, Asian, and Mediterranean descent. Rapid Review G6PD Deficiency X-linked recessive Asymptomatic until exposed to oxidative stress Antimalarials, sulfonamides, nitrofurantoin, methylene blue, fava beans, vitamin K Heinz bodies Hemolytic anemia

Question: What organism is responsible for chest X-ray findings of bilateral perihilar infiltrates described as a "bat-wing" pattern?

Answer: Pneumocystis jirovecii. Rapid Review Legionella Pneumonia Patient will be complaining of fevers, malaise, myalgias, cough and GI symptoms Labs will show leukocytosis, elevated liver transaminases and hyponatremia CXR will show unilateral patchy alveolar lower lobe infiltrates Most commonly caused by gram-negative bacillus and is found in aquatic environments Treatment is azithromycin

Question: What condition can the combination of nitrates and phosphodiesterase-5 inhibitors lead to?

Answer: Refractory hypotension. Rapid Review PDE-5 Inhibitors Mechanism: inhibits PDE-5 → corpus cavernosum smooth muscle relaxation + ↑ blood flow → erection Headache, dyspepsia ("Hot and heavy, but then headache, heartburn, hypotension") Nitrates + PDE-5 inhibitor use → refractory hypotension

Question: What are the side effects of amphotericin B?

Answer: Renal injury, anaphylaxis, hypotension, fever, and headaches.

Question: What are the classic ECG changes in a patient with cor pulmonale?

Answer: Right axis deviation, R/S ratio >1 in V1 and <1 in V6, P-pulmonale (increased P wave amplitude in leads 2, 3 and aVF). Rapid Review Cor Pulmonale Pulmonary HTN + RVH → right heart failure MC chronic cause: COPD MC acute cause: PE Right heart catheterization

Question: What is the primary evidence-based treatment for youths with conduct disorder?

Answer: Social competence training, parent and family skills training, medications, academic engagement and skills building, and school interventions. Rapid Review Conduct Disorder Pediatric version of antisocial personality disorder Violating human rights of others

Question: What receptor does sumatripan act on?

Answer: Sumatriptan is a selective 5-HT (1B/D) [serotonin] agonist. Rapid Review Migraine Headache Gradual onset, unilateral > bilateral, throbbing, pulsating First episode: < 30 years old F > M Triggers: cheese, OCPs, pregnancy, menstruation Without aura: most common, N/V, photophobia, phonophobia Aura: scotoma, flashing lights, sounds Abortive rx: triptans, DHE, antiemetics, NSAIDs Ppx: ßBs. CCBs, TCAs Triptans, DHE: contraindicated in HTN or CV disease

Question: What grading system is used to determine prostate cancer prognosis?

Answer: The Gleason score.

Question: Which muscle group will show weakness and atrophy as carpal tunnel syndrome progresses?

Answer: The thenar muscle (abductor pollicis brevis) becomes weak and atrophied in carpal tunnel syndrome. Rapid Review Carpal Tunnel Syndrome Patient with a history of extensive wrist usage such as typing Complaining of pain and numbness in the first, second, and third digits, especially at night PE will show Phalen's sign: reproduction of symptoms with wrist hyperflexion, Tinel's sign: reproduction of symptoms with percussion over carpal tunnel Most commonly caused by median nerve compression Treatment is NSAIDs, volar splint in neutral position

Question: Which age group is at greatest risk for burns, drowning, and falling?

Answer: Toddlers.

Question: True or False: Varicella vaccination is contraindicated in pregnancy?

Answer: True.

Question: True or false: chloroquine is safe during pregnancy?

Answer: True.

Question: True or false: pregnant women require more thyroid hormone and may require dosing adjustments to their thyroid replacement during pregnancy?

Answer: True.

Question: How does one safely remove eyelid oil?

Answer: With eyes closed, use a cotton swab dipped in a dilute water and baby shampoo solution to rub the eyelashes and lid margins. Rapid Review Blepharitis Patient will be complaining of eyelid changes and eyelash flaking PE will show crusting, scaling, and red-rimming of eyelid Diagnosis is made by slit-lamp examination Most commonly caused by dysfunctional meibomian gland Treatment is warm compresses, irrigation, lid massage, and topical antibiotics for flare ups Comments: associated with seborrhea and rosacea

What disorder is characterized by emotional or behavioral responses to a stressful event that develops within 3 months after the onset of a stressor, and the patient's reaction must be in excess of what would be expected given the nature of the event (not the loss of a loved one)? Adjustment disorder Bereavement Grief reaction Personality disorder

Correct Answer ( A ) Explanation: Adjustment disorders comprise a category of emotional or behavioral responses to a stressful event that develop within 3 months after the onset of a stressor, and the patient's reaction must be in excess of what would be expected given the nature of the event. The pathophysiology of adjustment disorders is unknown, but investigators have observed neurochemical changes in patients with these disorders. Adjustment disorders are subtyped according to whether the predominant symptoms are depressed mood, anxiety, or a disturbance of conduct. The symptoms are described as acute if they persist for less than 6 months, and as chronic if they last longer than 6 months. By definition, however, the symptoms cannot persist for more than 6 months after the termination of the stressor. Therefore, the designation of chronic adjustment disorder is given when the stressor itself (e.g., living in a dangerous neighborhood) is ongoing. Though the course of an adjustment disorder is usually brief, the symptoms can be severe and may include suicidal ideation. If the stressful event involves the loss of a significant figure in the patient's life, bereavement (B) is diagnosed rather than an adjustment disorder. Grief reaction (C) may be defined as the physical and emotional pain precipitated by a significant loss. The loss may be of a person or pet, but it can also be of a meaningful place, job, or object. This behavior is not out of proportion to the stressor. Personality disorders (D) involve persistently inadequate adaptive capacities and patterns of behaviors leading to significant impairments in social relationships and occupational performance that does not involve a specific stressor.

A patient presents 90 minutes after acute severe headache, nausea, and vomiting. He states it began during sexual intercourse. He has no fever or focal neurologic signs. You would most likely expect to find which of the following abnormalities on a non-contrast CT of the brain? Bright, high-attenuation density within the subarachnoid space Bright, low-attenuation density within the brainstem Dark, high-attenuation density within the epidural space Dark, low-attenuation density within the ventricles

Correct Answer ( A ) Explanation: Aneurysmal rupture is the fourth most common cause of cerebrovascular disease, and if large enough, can be fatal. They arise from a congenital defect of the vessel wall's internal elastic lamina and media. The majority of all aneurysms occur on the internal carotid artery or its branches. Other locations include the basilar or vertebral arteries or their branches. The most common site is the anterior half of the circle of Willis at a bifurcation of a branching distal artery off of the circle. Most brain aneurysms are recognized only when they rupture, commonly between the ages of 35-65 years, resulting in subarachnoid hemorrhage, and presenting as acute onset severe headache, nausea, vomiting, and meningeal signs without fever. Rupture is not necessarily related to chronic hypertension; sometimes rupture follows a Valsalva maneuver, intense physical effort, or sexual intercourse. Diagnosis is confirmed with CT scanning, or the presence of blood on a lumbar puncture in the setting of a normal CT scan. On a non-contrast brain CT, fresh subarachnoid hemorrhage appears as a bright, white, high-attenuating, amorphous substance within the normally dark CSF-filled subarachnoid spaces. (non-contrast CT bright = bone, clotted blood; dark = air, fluid, fat; gray = brain). Complications include mass effect, vasospasm, and cerebral infarction, but also hydrocephalus and SIADH. Definitive treatment is built on early diagnosis, defining the vasculature with angiography and neurosurgical clipping. Aneurysmal rupture much less commonly occurs in the brainstem (B) vessels (basilar artery and its branches). A talking patient typically does not have brainstem pathology. Bright does not go with low-attenuation. Dark does not go with high-attenuation (C). Aneurysms do not bleed into the epidural space. Fresh subarachnoid hemorrhage clots almost immediately. It becomes denser than intravascular or intracellular fluid, and as such, it appears bright (high-attenuation density on non-contrast brain CT) within the normally dark cerebrospinal fluid spaces (in essence, subarachnoid space) and passageways (ventricular system). Although dark goes with low attenuation, and ruptured aneurysms typically produce blood in the ventricles, clotted hemorrhage appears bright, not dark (D).

A 31-year-old woman is diagnosed with her sixth spontaneous abortion. Which of the following is the most likely underlying diagnosis? Antiphospholipid antibody syndrome Hemophilia A Thrombotic thrombocytopenic purpura Von Willebrand's disease

Correct Answer ( A ) Explanation: Antiphospholipid antibody syndrome is an autoimmune disorder that is a well-recognized cause of acquired hypercoagulability. Affected patients produce antibodies to a host of various proteins which predispose to thrombosis in a manner that is not well understood, but may involve interference with normal hemostasis pathways. The generally accepted "1 in 5 rule" states that 1 in 5 patients younger than age 45 with stroke, 1 in 5 patients with deep vein thromboses (DVT), and 1 in 5 patients with recurrent pregnancy loss will test positive for antiphospholipid antibodies. Antiphospholipid antibody syndrome should be suspected in patients with recurrent DVTs, recurrent spontaneous abortions, or recurrent cerebrovascular events, particularly in young people. Approximately 1% of patients with antiphospholipid antibody syndrome develop a rapidly progressive form known as catastrophic antiphospholipid antibody syndrome. This life-threatening condition involves widespread simultaneous small vessel occlusions in multiple organs. Despite treatment, the mortality of catastrophic antiphospholpid antibody syndrome is 50%. Hemophilia A (B) is a X-linked recessive bleeding disorder resulting from low or absent factor VIII. Patients develop bleeding after minor trauma and in severe deficiency spontaneous bleeding can occur. Hemarthrosis, retroperitoneal hemorrhage, and hematomas of deep muscles are common. Intracranial bleeding is a major cause of death. The treatment for hemophilia-related bleeding is administration of Factor VIII. Thrombotic thrombocytopenic purpura (TTP) (C) is a rare clotting disorder characterized by thrombosis in small vessels leading to thrombocytopenia. The classic pentad of findings is microangiopathic hemolytic anemia, thrombocytopenic purpura, neurologic dysfunction, renal failure, and fever. Von Willebrand's disease (D) is an autosomal dominant bleeding disorder in which von Willibrand's factor is low or absent, leading to mucosal bleeding as seen in epistaxis, gingival bleeding, menorrhagia, and GI bleeding.

A 17-year-old girl presents to the ED complaining of lower abdominal pain over the past 8 hours associated with a loss of appetite and mild nausea. She states she is sexually active and on oral contraceptives. Her last menstrual period was 3 weeks ago. Her temperature is 37.8°C. On exam, there is tenderness to palpation in the RLQ of the abdomen. Bowel sounds are absent. Pelvic exam reveals scant white discharge from the cervical os. There is no cervical motion tenderness; the adnexa and ovaries appear normal. Which of the following is the most likely diagnosis? Appendicitis Ectopic pregnancy Pelvic inflammatory disease Tubo-ovarian abscess

Correct Answer ( A ) Explanation: Approximately 7% of people will develop acute appendicitis during their lifetime. Most cases occur in adolescents and young adults. The majority of cases of appendicitis are due to an acute obstruction of the appendiceal lumen. The obstruction is often from an appendicolith, but it also can be caused by a calculus, tumor, parasite, or enlarged lymph node. After obstruction occurs, the intraluminal pressures rise resulting in distension that stimulates the visceral pain described by patients in the periumbilical region. Subsequently, ulceration and ischemia develop as the intraluminal pressure exceeds the venous pressure and bacteria and WBCs begin to invade the appendiceal wall. As the appendix becomes more inflamed, it begins to irritate the surrounding structures, including the peritoneal wall. This somatic pain is localized to the right lower quadrant. If the swelling continues, gangrene develops and perforation will occur. This can lead to the development of an abscess or peritonitis. Elderly patients are more prone to perforation due to age-related anatomic changes of their appendix. On physical exam, the most common finding is localized abdominal tenderness in the right lower quadrant (34% of the time over McBurney's point). Rovsing sign is present when tenderness is referred to the RLQ with palpation of the LLQ. The psoas sign is the increase in pain when the psoas muscle is stretched as the hip is extended. The obturator sign is the elicitation of pain as the hip is flexed and internally rotated. Rebound tenderness is a late finding and usually present with significant inflammation or rupture. The diagnosis of acute appendicitis in women of childbearing age can be difficult. Gynecologic disease can masquerade as appendicitis because of the close proximity of the appendix to the right ovary, fallopian tube, and uterus. The patient in the clinical scenario demonstrates anorexia, fever, RLQ pain, and tenderness with a normal pelvic exam. Therefore, she is more likely to have a diagnosis of appendicitis than pelvic inflammatory disease. The patient is using oral contraceptives and her last menstrual period was 3 weeks ago. Ectopic pregnancy (B) is unlikely; however, a ß-hCG should be obtained to rule out the possibility. Pelvic inflammatory disease (PID) (C) typically presents with diffuse lower abdominal pain with cervical and adnexal tenderness on pelvic exam. Symptoms usually develop over a few days, whereas appendicitis usually develops over a few hours. A tubo-ovarian abscess (TOA) (D) usually develops from prior PID. Often the infection has gone untreated for a while. A TOA should be suspected if an adnexal mass is palpated or there is tenderness of the adnexae or cervix.

Which of the following best describes a congenital cholesteatoma? Benign tumor of the ear canal Fat (lipid) deposits deep in the edge of the cornea Localized deposits of fat that collects in the skin of the upper and lower eyelids Plaques that begin in coronary artery walls

Correct Answer ( A ) Explanation: Congenital cholesteatoma usually appears as a white, round, cystlike structure medial to an intact TM. Cysts are seen most commonly in the anterior-superior portion of the middle ear, although they can present in other locations and within the TM or in the skin of the ear canal. Affected children often have no prior history of otitis media (OM). Congenital or acquired cholesteatoma should be suspected when deep retraction pockets, keratin debris, chronic drainage, aural granulation tissue, or a mass behind or involving the TM is present. Besides acting as a benign tumor causing local bone destruction, the keratinaceous debris of a cholesteatoma is a good culture medium and may become a focus of infection for chronic OM. Complications include ossicular erosion with hearing loss, bone erosion into the inner ear with dizziness, or exposure of the dura, with consequent meningitis or a brain abscess. Cholesteatoma should be removed surgically after CT scan and hearing evaluation, and appropriate antibiotic therapy. A second-look procedure 6-9 months after primary surgery is often recommended to prevent further recurrence. Congenital cholesteatoma is an aggressive disease and needs to be taken care of to prevent permanent damage to the middle and inner ear. None of the following describe a cholestetoma and all refer to other conditions commonly associated with hyperlipidemia. Corneal arcus (B) is a greyish-white ring (or part of a ring) opacity occurring in the periphery of the cornea, in middle and old age. It is due to a lipid infiltration of the corneal stroma, with age the condition progresses to form a complete ring. That ring is separated from the limbus by a zone of clear cornea. Xanthelasma are localized deposits of fats that collect in the skin of the upper and lower eyelids (C). They can be skin-colored to yellowish and are associated about half the time with elevated blood lipids (fats), including cholesterol and triglycerides, which may be a sign of diabetes. Removal usually requires electric cautery or surgery. Cholesterol plaques are the culprits of heart disease. Plaques begin in artery walls (D) and grow over years. The growth of cholesterol plaques slowly blocks blood flow in the arteries. Worse, a cholesterol plaque can suddenly rupture. The sudden blood clot that forms over the rupture then causes a heart attack or stroke.

A 20-year-old woman presents to the ED complaining of fever, chills, and migratory polyarthralgias. On physical exam, you note the lesion above. Which of the following is the most likely diagnosis? Disseminated gonorrhea Drug reaction Meningococcemia Syphilis

Correct Answer ( A ) Explanation: Disseminated gonorrhea is characteristically associated with an arthritis-dermatitis syndrome. Hematogenous spread of local gonorrhea infection occurs in 1%-2% of patients, more commonly in women, particularly those who are menstruating or peripartum. The classic skin lesion begins as erythematous or hemorrhagic papules that evolve into pustules and vesicles with an erythematous halo. The lesions are tender and may have a gray necrotic or hemorrhagic center. The lesions are often multiple and have a predilection for periarticular regions of the distal extremities. The current treatment for disseminated gonococcal infection is ceftriaxone for 7 days. Any drug (B) can produce a skin eruption. The most common eruptions are urticarial and morbilliform rashes. Drug reactions tend to appear within a week after the drug is taken. Skin lesions can occur even after a drug is discontinued. Petechiae develop in the majority of patients with meningococcal disease (C) and involve the axillae, flanks, wrists, and ankles, although they can progress to any part of the body. Lesions commonly begin on the trunk and legs in areas where pressure is applied. These lesions may coalesce to form hemorrhagic patches or purpura, often with central necrosis. Patients with advanced meningococcemia may develop rapidly progressing petechiae, ecchymoses, and extensive palpable purpura, accompanied by DIC and vascular collapse. The rash of secondary syphilis (D) is a diffuse mucocutaneous rash that may be macular, pustular, or mixed. These lesions often become necrotic and are distributed widely with frequent involvement of the palms and soles.

You diagnose a 43-year-old patient with alcohol withdrawal. Lab studies reveal a hemoglobin of 8 g/dL and an MCV of 115. Which of the following is the most common cause of these findings? Direct ethanol toxicity Pyridoxine deficiency Thiamine deficiency Vitamin B12 deficiency

Correct Answer ( A ) Explanation: Ethanol affects practically every organ system in the body. This patient is suffering from macrocytic anemia, most likely as a result of chronic alcohol abuse. Chronic ethanol intake directly suppresses bone marrow by impairing protein synthesis, causing anemia or even pancytopenia. Although patients who abuse alcohol often have concomitant nutritional deficiencies that contribute to the development of megaloblastic anemia, the most common cause of macrocytic anemia is due to direct ethanol toxicity. This is typically reversed after several months of abstinence from alcohol. In addition to the harmful effects of ethanol itself, its metabolite, acetaldehyde, is inherently toxic to biologic systems. Patients presenting with acute ethanol intoxication also commonly have decreased serum ionized magnesium concentrations. Total body magnesium may be depleted due to poor dietary intake, decreased GI absorption, and renal wasting. Pyridoxine deficiency (B) (vitamin B6) is a pediatric disease which usually becomes noticeable within the first 12 months of life in infants with lack of pyridoxine, a coenzyme responsible for numerous essential metabolic reactions. The disease presents with several key symptoms including seizures, irritability, cheilits (inflammation of the lips), conjunctivitis, and neurologic symptoms. In patients receiving isoniazid, pyridoxine deficiency can lead to a sideroblastic anemia because it is required as a cofactor in heme synthesis. Pyridoxine deficiency is a cause of microcytic anemia not macrocytic anemia. Thiamine (C) (vitamin B1), is a water-soluble vitamin not stored in the body to any significant extent, and is therefore subject to deficiencies in patients with poor diet, including alcoholics, pregnant women suffering from hyperemesis gravidarum, and patients with anorexia nervosa. Deficiencies in thiamine result in neurologic consequences such as Wernicke's encephalopathy. It is not associated with macrocytic anemia. Vitamin B12 (D), or cyanocobalamin, is a water-soluble vitamin. Dietary deficiencies can cause megaloblastic anemia, pancytopenia, and neuropsychiatric symptoms. Because of the size of the B12 molecule, deficiencies typically result from issues with absorption (such as pernicious anemia), rather than from poor dietary intake.

A 29-year-old woman presents with itchy eyes for the past four days. She reports "always rubbing them" as it feels like "sandpaper in there". Inspection reveals eyelid margin erythema and swelling, but no discrete nodule, mass or cyst. You appreciate crusting at the base of the eyelashes. An everted-lid examination reveals no inflammation. Sclerae are not injected. Which of the following is the most likely diagnosis? Blepharitis Conjunctivitis Molluscum contagiosum Stye (hordeolum)

Correct Answer ( A ) Explanation: Eyelid inflammation is called blepharitis. Several types exist: seborrheic, staphylococcal, mixed and parasitic. There is also an association with dandruff and acne. Onset can be acute and self-limited, resolving in 2-4 weeks, however, most problematic cases are chronic in nature. Symptoms usually include eye burning and grittiness, tearing, irritation, erythema and crusting along eyelash roots. Seborrheic types commonly result in scales. Meibomitis is likely a better term used in a patient with blepharitis who also has an expressible milky, toothpaste-like exudate from the eyelids. Most cases of blepharitis respond well to basic lid hygiene, which includes make-up avoidance and warm wet compresses followed by mechanical removal of oil. If refractory, prescription antibiotic ointment may be necessary. Conjunctivitis (B) is inflammation of the conjunctiva, the coverings of the sclerae and ocular surfaces of the eyelids. This patient has no inflammation in these areas. Molluscum contagiosum (C) is a common viral infection which results in tiny, multiple waxy nodules with central umbilication. These nodules can present on the eyelids. A stye (D), or hordeolum, is a painful cyst or mass on the eyelid margin that may be filled with serous fluid or pus. This patient has no such mass.

A six-year-old boy is in the clinic for a well-child evaluation. He has good grades and has a lot of friends in school. He plays baseball. He eats a healthy and balanced diet with meat, fruits, and vegetables. His father frequently goes hunting with his friends and has several guns at home. Which of the following is the best statement that you would give to the boy's parents regarding firearm safety? Absence of guns from the home is the most effective means of prevention of firearm injuries in children Firearm mortality among children has increased since the early 1990s Gun safety programs alone appear to reduce the likelihood that children will handle firearms Storing ammunition locked with an unloaded gun reduces the risk of unintentional firearm injury

Correct Answer ( A ) Explanation: Firearm-related injuries are an important cause of death among children and adolescents. Approximately 35 percent of households own guns in the USA. Pediatric health professionals can provide leadership for improved gun safety through education of patients and families, advocacy for legislation that protects children from firearm injuries, or becoming informed spokespersons for firearm safety. The most effective means of prevention of firearm injuries in children is the absence of guns. Locking and unloading guns as well as storing ammunition locked in a different location substantially reduces the risk of a suicide or unintentional firearm injury among youth by up to 73 percent. Because up to 50 percent of homes have at least one firearm stored unsafely, one potential approach to reducing these injuries could focus on improving household firearm storage practices where children and youth reside or visit. Firearm mortality among children has increased since the early 1990s (B) is false; in fact, firearm mortality has declined. However, the reasons for the decline are not clear. Possible explanations include prevention efforts, changes in factors that affect the frequency of violence, and changes in factors that affect whether guns are present when violence occurs. Gun safety programs alone appear to reduce the likelihood that children will handle firearms (C) is wrong because gun safety programs are not particularly effective strategies for the prevention of firearm injuries. Storing ammunition locked with an unloaded gun reduces the risk of unintentional firearm injury (D) is wrong because ammunition should be stored separately from an unloaded gun.

Which of the following is the most common type of prostate cancer? Adenocarcinoma Metastatic carcinoma Small cell carcinoma Squamous cell carcinoma

Correct Answer ( A ) Explanation: In the United States, prostate cancer is the most frequently diagnosed type of cancer in men after skin cancer. Prostate cancer is seen more commonly in African-American men and the likelihood of developing this type of cancer increases with age. Risk factors include a family history of prostate cancer, cigarette smoking and a diet high in animal fat. The most common type of prostate cancer is adenocarcinoma, with approximately 95% of cases having this pathology. Most patients diagnosed with prostate cancer are asymptomatic and the cancer is found on digital rectal exam (DRE) or because of an elevated serum prostate specific antigen (PSA). Diagnosis is made with biopsy. Treatment decisions are determined after discussion with the patient about the severity of disease and quality of life related to treatment side effects. Options include active surveillance, prostatectomy, radiation therapy and hormonal therapy. The majority of men with prostate cancer are diagnosed and treated while the cancer is localized to the prostate. Metastatic cancer (B) occurs less commonly. When prostate cancer is advanced, it often presents with skeletal manifestations as it has a high likelihood of metastasizing to the bone. Other types of cancer including small cell carcinoma (C) and squamous cell carcinoma (D) make up the remaining 5% of cases of prostate cancer.

Which of the following antibiotics is most appropriate to use in a 64-year-old man with a history of benign prostatic hyperplasia and glucose-6-phosphate deficiency and a recently diagnosed urinary tract infection? Cephalexin Nitrofurantoin Phenazopyridine Trimethoprim-sulfamethoxazole

Correct Answer ( A ) Explanation: In this patient with benign prostatic hypertrophy (BPH), glucose-6-phosphate (G6PD) deficiency, and cystitis, care must be taken not to precipitate a hemolytic crisis. Oxidant drugs such as nitrofurantoin, phenazopyridine, dapsone, and sulfonamides can cause hemoglobin precipitation within the RBC, which leads to removal of the cell from circulation via the spleen. Patients with severe G6PD enzyme deficiency who ingest oxidant drugs can experience severe hemolysis and cardiovascular collapse. For those with more minor forms of the hereditary disease, the lengthy course of antibiotics required for this complex cystitis may be sufficient to cause symptomatic hemolytic anemia, jaundice, and splenomegaly. Cephalexin, a first-generation cephalosporin, is not associated with causing oxidative stress and is, therefore, an acceptable choice for this patient. The other choices here— nitrofurantoin (B), phenazopyridine (C), and trimethoprim-sulfamethoxazole (D)—are all medications used in the treatment of some forms of cystitis. Unfortunately, they are also among the most common causes of hemolytic crisis in patients with G6PD. They would not be a good choice in this patient.

A 10-year-old boy presents to your office with elbow pain. The pain is located along the medial aspect of the elbow and is exacerbated while pitching during his Little League games. Your examination reveals mild swelling along the medial aspect of the right elbow. Radiographs show mild hypertrophy of the medial epicondyle. What is the initial treatment of choice for this condition? Complete rest from throwing for four to six weeks Eccentric exercise regimen for four weeks Orthopedic referral Physical therapy for four weeks

Correct Answer ( A ) Explanation: Little Leaguer's elbow is an inflammation of the apophysis of the medial epicondyle. It usually occurs in athletes between the ages of nine and 12 years old. There is pain along the medial aspect of the throwing arm. Examination often reveals tenderness to palpation, swelling and decreased range of motion along the medial aspect of the elbow. The treatment of choice involves cessation of all throwing activities for four to six weeks, then a gradual and progressive throwing program after the initial period of inactivity. Most players are able to return to throwing full-time after 12 weeks. Strengthening, stretching, and conditioning programs provided by physical therapy (D) should be encouraged, but this is not the initial therapy or the treatment of choice. Orthopedic consultation (C) is indicated if loose bodies, avulsion fractures, or osteochondritis dissecans are noted on X-ray. Referral would also be indicated for failure of conservative treatment. An eccentric exercise regimen (B) would not be part of the treatment regimen.

Which of the following congenital heart diseases would benefit from palivizumab administration? Cyanotic congential heart disease Patent ductus arteriosus Pulmonic stenosis Secundum atrial septal defect

Correct Answer ( A ) Explanation: Palivizumab is a humanized monoclonal antibody administered intramuscularly to prevent respiratory syncytial virus (RSV) infections. RSV is the most common cause of lower respiratory tract infections in infants and children worldwide. Children with congenital heart disease (CHD) who develop RSV infections tend to have a higher rate of ICU admissions and require mechanical ventilation more frequently than do children without CHD. Therefore, it is important to prevent RSV infection in this special group. However, not every type of CHD will require palivizumab. CHD conditions that would benefit from palivizumab include cyanotic or complex CHD, congenital heart failure requiring medications, and moderate to severe pulmonary hypertension. Patent ductus arteriosus (B), pulmonic stenosis (C), secundum atrial septal defect (D), small ventricular septal defect, uncomplicated aortic stenosis, and mild coarctation of the aorta are considered to be hemodynamically insignificant CHD that do not require palivizumab administration.

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

Correct Answer ( A ) Explanation: Polyarteritis nodosa is a systemic vasculitis of small to medium vessels. It represents an autoimmune inflammatory disorder of unknown origin. It results in transmural fibrinoid necrosis. It typically affects younger males. Symptoms include proximal myalgia and weakness (similar to polymyalgia rheumatica, and commonly expressed as difficulty climbing stairs), arthralgias, tender subcutaneous palpable nodules, abdominal pain with diarrhea or GI bleeding and glomerular ischemia with hypertension, renal failure, and hematuria. Compared to other vasculitides, polyarteritis nodosa does not affect the pulmonary vasculature, however it is accompanied by systemic inflammatory signs such as low grade fever, malaise, unintentional weight loss, and night sweats. Treatment includes prednisone and cyclophosphamide. Polymyalgia rheumatica (B) is characterized by shoulder and pelvic girdle pain and stiffness, a lack of skin findings, age >50 years, an elevated ESR (typically over 50 mm/h) and a normal creatine kinase. Polymyositis (C) is also characterized by proximal muscle weakness and elevated creatinine kinase, but it more commonly occurs in females over the age of 50 years, less commonly occurs with arthralgias or arthritis, doesn't occur with tender subcutaneous nodules and is typically associated with a high ANA titer. Pseudogout (D) is a crystal-induced, acute onset, monoarthritis.

A 60-year-old woman presents with neck and chest rash. Review of systems is significant for proximal arthralgias and myalgias of 3 months duration. Examination of the skin reveals a violet-hue on both eyelids, reddened macules on the neck, shoulders and chest and thick, scaly skin on the dorsal surfaces of the metacarpophalangeal and proximal interphalangeal joints. However, there are no tender subcutaneous nodules. You send the patient for electromyography and nerve conduction testing. You would expect findings most consistent with which of the following pathologies? Myopathy Neuropathy Retinopathy Vasculopathy

Correct Answer ( A ) Explanation: Polymyositis is an idiopathic inflammatory myopathy. It causes proximal myalgias and weakness, similar to polyarteritis nodosa and polymyalgia rheumatica, which can present as pelvic and shoulder girdle functional impairments. It most often presents in females over age 50 years. In addition, pharyngolaryngeal weakness occurs, and manifests as dyspnea, dysphagia and dysphonia. Three classic skin findings commonly coexist with polymyositis. A heliotrope rash (symmetric violet-erythema, located periorbitally, especially about the eyelids), a cloak-like or cape rash (erythematous confluent macules on the neck, shoulders and chest), and Gottron's papules (scaly, violaceous thickened knuckle skin, sometimes confused with psoriasis). When these are present, the syndrome can be designated polymyositis-dermatomyositis (dermatomyositis). Lab testing usually reveals a positive ANA and high creatinine kinase. The classic EMG findings are those of myopathy: positive sharp waves, fibrillations, complex repetitive discharges and small amplitude, short duration, polyphasic motor units with an early recruitment pattern. Treatment options include prednisone, methotrexate and cyclophosphamide. Neuropathy (B) and myopathy are the two main disease conditions that electrodiagnostics are used to evaluate. This patient has no sensory symptom complaints, just rash plus myalgia plus arthralgia, which should be thought of as "skin + rheum". Furthermore, this is such a common presentation of polymyositis-dermatomyositis. Therefore, neuropathy is not expected. EMG/NCS (electrodiagnostics) do not evaluate retinal (C) or peripheral vessel (D) disease.

A 27-year-old pregnant woman presents to your office with questions about travel preparation. She is planning a six-month mission trip to Ghana and wants to know if she needs any medical care prior to leaving. Which of the following is the most appropriate next step in management? Advise patient to delay trip until after delivery Advise patient to use mosquito bite prevention Prescribe malaria prophylaxis with chloroquine Prescribe malaria prophylaxis with doxycycline

Correct Answer ( A ) Explanation: Risk factor assessment is an important aspect of counseling patients who plan to travel abroad. Geographic location and the type of traveler are both factors to be considered, especially with regards to advising about malaria prophylaxis. The Centers for Disease Control provides a helpful website with country and risk for malaria that may be referenced when counseling patients about the need for malaria prophylaxis. High-risk groups include pregnant women, military personnel and individuals born in regions endemic to malaria who relocate to another region then return to visit their native country. Because malaria is a life-threatening illness for both mother and fetus, pregnant patients should be advised to delay their trip until after delivery. Mosquito bite prevention (B) is an important part of malaria prevention and should be advised for all patients traveling to malaria endemic areas. Techniques to prevent mosquito bites should be used together with malaria prophylaxis for non-pregnant patients traveling to these countries. Chloroquine-resistant malaria (C) is common in both Africa and Asia. The most recent advisories should be consulted prior to determining an appropriate course of prophylaxis. Doxycycline (D) is a daily medication used for malaria prophylaxis in areas with chloroquine-resistant malaria. Patients begin taking it 1-2 days prior to exposure, then continue daily during exposure and for 4 weeks post-exposure. Doxycycline should not be administered during pregnancy due to potential adverse affects to the fetus.

Which of the following is an important predisposing factor for the development of the condition seen in this radiograph? Atherosclerosis Hernia Hyperparathyroidism Ulcer disease

Correct Answer ( A ) Explanation: The calcified wall of an abdominal aortic aneurysm (AAA) is visualized in this radiograph. The most common plain-film findings of an AAA is a curvilinear calcification of the aortic wall or a paravertebral soft tissue mass. Rarely with longstanding aneurysms, is the erosion of one or more vertebral bodies seen. Atherosclerosis, age >60 years, smoking, and family history are all important predisposing factors for the development of AAA. An AAA is a disease of aging and is rare before age 50 years. It is found in 5%-10% of elderly men screened with ultrasound. AAAs progressively enlarge, weakening the vessel wall, and ultimately rupture resulting in fatal hemorrhage. The most important factor in determining the risk of rupture is the size of the aneurysm. The rupture risk increases dramatically with increased aneurysmal size, and most ruptured AAAs have diameters >5 cm. Rupture usually occurs in the retroperitoneum; even those who make it to the OR still have a mortality close to 50%. The classic triad of a ruptured AAA is pain, hypotension, and a pulsatile abdominal mass, although many patients have only 1 or 2 of these components. Pain usually localizes to the abdomen, back, or flank, and is sometimes tragically misdiagnosed as renal colic. Treatment involves hemodynamic support and definitive repair by a vascular surgeon. Hernias (B) are the second most common cause of bowel obstruction, preceded by adhesions. Air fluid levels and dilated loops of bowel are radiographic findings associated with bowel obstruction. Primary hyperparathyroidism (C) is associated with some patients with recurring renal calculi. Secondary hyperparathyroidism can lead to abnormal bone resorption and manifests as bone syndromes such as rickets, osteomalacia, and renal osteodystrophy. Duodenal and gastric ulcers (D) are complicated by perforations that can lead to the detection of free air in the abdominal cavity. Free air is generally seen under the diaphragm in an erect patient.

A 30-year-old woman presents to the ED complaining of pain in the right side of her face for the last two days. The pain is sharp, severe, and lasts several seconds. The pain is associated with an involuntary movement of the side of her mouth. In between episodes, there is no pain. She has no past medical history. Her vitals include a temperature of 36.6°C, BP 122/78, HR 80, RR 20. Her exam is normal. Which of the following medications has been shown to relieve this condition and is the first line treatment? Carbamazepine 100 mg twice daily Gabapentin 100 mg three times daily Phenytoin 100 mg three times daily Prednisone 60 mg once daily

Correct Answer ( A ) Explanation: This patient has trigeminal neuralgia (tic douloureux), a disorder of the trigeminal nerve (cranial nerve V). The treatment is carbamazepine 100 mg twice daily. Carbamazepine is thought to work by reducing postsynaptic tetanic contractions. It is used to treat trigeminal neuralgia and is used as an antiepileptic. It is the only antiepileptic used for this condition. Trigeminal neuralgia is characterized by paroxysms of severe unilateral pain in the trigeminal nerve distribution, sometimes described as recurrent bursts of an electric shock. The pain lasts only a few seconds and most commonly occurs on the right side of the face. On exam, you may be able to elicit pain by tapping trigger zones along the distribution of the trigeminal nerve. Otherwise, there should be no demonstrable physical findings. Gabapentin (B) is an analog of the neurotransmitter gamma-aminobutyric acid (GABA) and is used to treat seizures, postherpetic neuralgia, and restless leg syndrome. It is sometimes used as a second-line agent for trigeminal neuralgia. Phenytoin (C) is used to treat seizures. It is sometimes used as a second-line agent for trigeminal neuralgia. Prednisone (D) is an oral steroid. It is often used in the treatment of cranial nerve VII palsy, or Bell's palsy, but has no specific indication for trigeminal nerve disorders.

A 22-year-old woman presents to the emergency department after developing a widespread rash following a bee sting. The patient reports she has been stung once previously but never had a reaction. She denies difficulty breathing but states she feels somewhat light-headed. She is otherwise healthy, and has no significant past medical history. Vital signs are T 37, BP 85/60, HR 100, RR 18, oxygen saturation is 98%. A diffuse urticarial rash is present on the patient's extremities. Which of the following is the next best step in management? Intramuscular epinephrine Nebulized albuterol Observation Oral diphenhydramine

Correct Answer ( A ) Explanation: This woman's presentation is concerning for anaphylaxis. Anaphylaxis is characterized by upper airway obstruction, rash, bronchospasm, and hypotension or cardiovascular collapse. Although she does not yet have trouble breathing, epinephrine is indicated. Anaphylaxis occurs as a result of IgE-mediated hypersensitivity that causes mast cell degranulation and histamine release. Patients typically present with a combination of hives, facial edema, pruritus, respiratory difficulty, and hypotension in the setting of an inciting factor such as bee sting, peanuts, shellfish and other foods. Anaphylaxis generally does not occur during the patient's first exposure to the allergen, instead presenting following the subsequent exposures. Intramuscular epinephrine and the close monitoring of vital signs are the foundation of anaphylaxis treatment. Patients with a history of reactive airway disease may benefit from albuterol nebulizers as a supplement. Intramuscular epinephrine should be administered every 5-15 minutes until the symptoms resolve. Observation (C) is an inappropriate answer, as the history and physical exam indicated this patient is having an anaphylaxis episode. Antihistamines such as diphenhydramine (D) can be useful to treat the urticarial symptoms, but does not address respiratory symptoms that may develop. Although it should be administered, it is critical that epinephrine administration is not delayed. Albuterol (B) is helpful in patients with reactive airway disease and may be minimally useful in anaphylaxis to stimulate beta-2-receptors for bronchodilation, but the patient does not have a history of asthma.

A 35-year-old woman presents to your office with a complaint of wrist pain. Physical exam findings include a flesh-colored, smooth, firm, rounded swelling on the dorsal aspect of her wrist that transilluminates. Which of the following is the most likely diagnosis? Epidermoid cyst Ganglion cyst Lipoma Tophus

Correct Answer ( B ) Explanation: Ganglion cysts are benign lesions and are one of the most common soft tissue swellings of the wrist and hand. They occur most commonly in the second to fourth decade of life with a slight predominance in women. Patients may present with an obvious swelling or may have joint pain as the primary complaint without an obvious etiology. Diagnosis is generally by physical exam with the lesion being palpable and able to transilluminate. Ultrasound and magnetic resonance imaging may also help with diagnosis. Initial treatment is with nonsurgical measures including observation or needle aspiration. Surgical intervention may be indicated if conservative measures are not effective and patients continue to experience pain or limited range of motion. Epidermoid cysts (A) are small, hard, freely mobile cysts, often with a central punctum commonly found on the digits or interdigital webs. They are generally less than 1 cm in diameter and do not transilluminate. Lipomas (C) are soft, painless, freely mobile nodules of the hand and wrist that are slow growing and do not transilluminate. Tophi (D) are firm, subcutaneous nodules caused by uric acid deposition in patients with gout. They may be yellow with overlying erythema and typically originate at the joint margin.

Which of the following conditions is associated with low output heart failure? Anemia Dilated cardiomyopathy Pregnancy Thyrotoxicosis

Correct Answer ( B ) Explanation: Low output cardiac failure is more common than high output cardiac failure. Low output failure is typically associated with a dilated cardiomyopathy, which may occur as a result of poorly controlled chronic hypertension, ischemic heart disease, or valvular heart disease. Low output failure is characterized by a decreased cardiac output (systolic dysfunction), a decrease in left ventricular end-diastolic pressure, and an increased systemic oxygen extraction ratio. Anemia (A), pregnancy (C), and thyrotoxicosis (D) are associated with high output cardiac failure, which is caused by excessive demand for tissue perfusion resulting in hyperdynamic cardiac dysfunction with a supranormal cardiac output and decreased oxygen extraction ratio. Pulmonary congestion and peripheral edema occur as a result of elevated diastolic pressures. Over time, systolic myocardial dysfunction occurs, and patients develop classic heart failure indistinguishable from other end-stage cardiomyopathies.

A 56-year-old man presents with intermittent headaches, dizziness, and pruritus over the past two weeks. On examination, heart rate is 87 beats/minute, blood pressure 152/82 mm Hg, and oxygen saturation 97% on room air. He has splenomegaly without associated abdominal tenderness. His neurologic exam is normal. Which of the following studies is most likely to lead to his diagnosis? Bone marrow biopsy Complete blood count Coombs test Peripheral smear

Correct Answer ( B ) Explanation: Primary polycythemia vera is a myeloproliferative disorder that affects all cell lines. It occurs primarily in middle-aged or older patients. Symptoms may be mild and nonspecific, such as headache, weakness, dizziness, and pruritus or may be acute and severe manifesting in the thrombotic complications of stroke, myocardial infarction, and deep venous thrombosis. On examination, plethora, engorgement, and splenomegaly are commonly noted. Diagnostic criteria include an increased red cell mass (hemoglobin > 18.5 g/dL in men and > 16.5 g/dL in women), normal oxygen saturation, and splenomegaly on examination. Many patients will also have platelet counts > 400,000/mm3 and white blood cell counts > 12.0 x 109/L. Treatment consists of therapeutic phlebotomy to keep the hematocrit < 55%. A bone marrow biopsy (A) is not required for a diagnosis of primary polycythemia vera. A Coombs test (C) detects antibody or complement on human red blood cell membranes and is used in the diagnosis of hemolytic anemias. A peripheral smear (D) looks for the presence of abnormal or immature cells in the blood. It is also used in the diagnosis of hemolytic anemias and will show schizocytes or spherocytes.

An 8-year-old boy presents for a well-child check. He wants to join his school's basketball team that involves weightlifting. His mother has concerns regarding whether this is appropriate for a child his age. Which of the following is the most accurate statement regarding resistance training? Most injuries related to resistance training are the result of weightlifting movements such as modified cleans, pulls, and presses Resistance training can begin as early as age 6 with appropriate supervision Resistance training is appropriate for children who are at least 10 years of age or are at least 4 feet 5 inches in stature The mechanical stress from heavy resistance training can negatively impact linear growth during childhood and early adolescence

Correct Answer ( B ) Explanation: Strength or resistance training refers to a type of physical conditioning which involves the progressive use of resistive loads and a variety of modalities including weights, weight machines, elastic bands, and medicine balls. This is distinguished from power lifting programs which focuses on lifting maximal amounts of weight and from bodybuilding which focuses on increasing muscle size and definition. Substantial concern exists within the general public that any type of strength training is an unsafe practice for the developing child, and specifically that it may stunt growth. There is no evidence to suggest that appropriate strength-training programs negatively impact linear growth. Rather, the mechanical stress of resistance training may actually support childhood bone formation as well as have a beneficial effect on overall cardiovascular fitness, lipid profiles, bone mineral density, and mental health. Proper weight training involves many reps with low resistance. It is essential that proper techniques and safety precautions are followed and that strict supervision by a qualified instructor is provided in order for strength training to be safe and effective. Also, prior to beginning such programs, a physician should perform a thorough medical evaluation. Therefore, resistance training can begin as early as age 6 with appropriate supervision. Referral to a sports medicine specialist may be indicated for patients with a history of chemotherapy and childhood cancer or with uncontrolled hypertension. Likewise, children with a history of congenital heart disease should be referred to a pediatric cardiologist prior to starting resistance training. Finally, the pediatrician should remind the patient that a complete fitness program also includes aerobic exercise and that the use of anabolic steroids and other performance enhancing substances is strongly discouraged. Most injuries related to resistance training (A) are secondary to improper lifting technique or inadequate supervision. Incorporating weightlifting movements into resistance training has been shown to significantly increase strength without report of injury. Resistance training may begin as early as ages 6 to 8 (C) with proper technique and appropriate supervision by a qualified instructor. The mechanical stress from heavy resistance training (D) in the context of proper technique has not been shown to have an impact on linear growth in any prospective youth resistance training study.

A 55-year-old man presents to the office interested in obtaining medication for his erectile dysfunction. He states he has trouble maintaining and keeping erections 75% of the time and has no other medical problems. His main concern is that he is single and sometimes not sure when the opportunity will present to have sex, so he wants the medication with the longest duration. Which of the following medications should you recommend? Sildenafil (Viagra®) Tadalafil (Cialis®) Vardenafil (Levitra®) Yocon (Yohimbine®)

Correct Answer ( B ) Explanation: Tadalafil has a duration of 24-72 hours. Phosphodiesterase-5 inhibitors are first-line therapy for erectile dysfunction (ED) and are effective in most cases, including antidepressant-induced ED and diabetes related. In 1998, sildenafil was the first PDE-5 inhibitor to become FDA approved, followed by vardenafil and tadalafil in 2003. The medications differ in absorption, potential effective time interval, and side effects. Sildenafil (A) and vardenafil (C) have a short duration of action (approximately 3-hours). Yohimbine (D) antagonizes alpha-2-adrenergic receptors. In one systematic review, yohimbine improved self-reported sexual function and penile rigidity compared with placebo. It has not been clinically researched for ED in the last decade. Yohimbine has significant adverse effects, including elevation of blood pressure and heart rate, increased motor activity, nervousness, irritability, and tremor. It has a half-life of 36 minutes.

An 18-year-old man with schizophrenia presents after ingesting a razor blade. The patient indicates that he feels a foreign body sensation at his lower chest. The patient is tolerating secretions and appears to be in no acute distress. X-ray shows a metal foreign body in the distal esophagus. What management is indicated at this point? CT scan of the chest to further evaluate the location of the foreign body Emergent endoscopy Glucagon 1 mg Observation

Correct Answer ( B ) Explanation: The patient presents with a non-obstructing, sharp foreign body in the lower esophagus that will require immediate removal by endoscopy to prevent further damage. The esophagus is a muscular distensible tube that allows objects up to 20 mm to pass without difficulty. It does, however, have four areas of natural narrowing that may be sites for impaction: Most impactions occur in the mid to distal 1/3 of the esophagus. Foreign bodies, especially metal ones, can be localized using plain radiographs. It is important to get radiographs of the neck, chest and abdomen as the esophagus is large and spans all of these areas. Patients with soft or dull-edged objects (i.e. pieces of food) who are tolerating their own secretions can be managed conservatively with medications or observation. Those with sharp-edged foreign bodies will usually require emergent removal to prevent perforation of the esophagus, stomach or intestines. Esophageal perforation can be diagnosed with plain radiographs enhanced by water-soluble contrast agents (i.e. diatirzoate meglumine) instead of barium, which is toxic to tissue if it leaks from the esophagus. The false-negative rate of contrast enhanced plain radiographs is <1%. However, these studies should not delay endoscopy if the patient ingested a sharp foreign body. CT scan (A) is helpful in identifying non-radioopaque foreign bodies like small animal bones, food bolus and nonorganic objects. CT scan is also helpful in visualizing the surrounding tissues and in diagnosing perforation. However, endoscopy should not be delayed by CT scan when a sharp foreign body is present as the longer the delay, the more likely a perforation occurs. Glucagon (C) causes relaxation of esophageal smooth muscle leading to relief of obstruction. It is only effective in lower esophageal obstructions and can cause nausea, vomiting, flushing and diaphoresis. It should not be used when the suspected foreign body is sharp. Observation (D) is a reasonable plan in a patient with a soft foreign body obstruction where the patient is tolerating their secretions. These foreign bodies may pass on their own within 24 hours, have a low risk for perforation and may be difficult to remove on endoscopy because of their soft texture. If the obstruction is present for >24 hours, however, the patient should undergo endoscopy regardless of the type of foreign body.

A 3-week-old boy presents with non-bilious, forceful emesis for 2 days. On examination, the infant appears active and feeds vigorously followed immediately by vomiting. Which of the following is the most appropriate diagnostic study? Abdominal radiograph Abdominal ultrasound CT scan of the abdomen and pelvis Urine dip

Correct Answer ( B ) Explanation: The patient presents with symptoms consistent with hypertrophic pyloric stenosis, which is most accurately diagnosed by ultrasound of the abdomen. Hypertrophy or hyperplasia of the pyloric sphincter is not present at birth but develops progressively over time. It typically presents in infants between the age of 2 weeks and 2 months. Pyloric stenosis is characterized by projectile, non-bilious vomiting that occurs immediately after feeding due to gastric outlet obstruction. Infants will appear very hungry in between feedings. On examination, peristaltic waves may be seen moving from left to right and the clinician may palpate an "olive" shaped mass in the right upper abdomen. Labs may reveal a hypochloremic metabolic alkalosis in patients with delayed presentations. The cornerstones of diagnosis are either ultrasound or upper GI series. Both have an accuracy of 95%. CT scan of the abdomen and pelvis (C) has never been studied in the diagnosis of pyloric stenosis. It should not be the modality used when there are other options with lower (or no) radiation exposure. In advanced stages of complete pyloric obstruction, plain abdominal radiographs (A) may reveal an enlargement of the stomach and pylorus but sensitivity is low. Urine dip (D) is the first step in the diagnosis of a wide range of diseases most commonly a cystitis (Urinary tract infection). The analysis includes testing for the presence of proteins, glucose, blood, ketones, nitrites, leukocytes, and PH, but it will not diagnose a pyloric stenosis.

A 21-year-old man presents to the ED with a sore throat. He was seen two days ago for the same complaint, but now the pain is worse. On examination, there is no pharyngeal erythema or tonsillar exudate. You obtain the soft tissue neck radiograph as seen above. Which of the following is the most likely diagnosis? Bacterial tracheitis Epiglottitis Peritonsillar abscess Retropharyngeal abscess

Correct Answer ( B ) Explanation: This patient has epiglottitis, a disease that is now more common in adults than in children since the development of the conjugate H. influenzae type B vaccine. Patients typically present complaining of a severe sore throat but have a normal oropharyngeal exam. They may position themselves sitting up, leaning forward, mouth open, head extended, and panting. Often there will be pain with movement of the thyroid cartilage. The clinical triad associated with epiglottitis is drooling, dysphagia, and distress (referred to as the 3 Ds). A lateral soft tissue neck radiograph may demonstrate an enlarged epiglottis that is thumb-shaped. This is referred to as the thumbprint sign. Bacterial tracheitis (A) is a rare, life-threatening disease that most commonly occurs in children under three years of age. It can mimic croup, but patients are more toxic appearing. Clinically, this can present similar to epiglottitis. A peritonsillar abscess (C) is the most common deep facial infection in adults. Patients present with fever, sore throat, trismus, and a peritonsillar mass that displaces the soft palate and uvula. A retropharyngeal abscess (D) is mostly a condition of infants and children, although it has been described in adults. Patients present with fever, neck pain, difficulty talking (termed cri du canard or a duck-like voice), swallowing, and breathing. Oropharyngeal exam shows anterior displacement of the posterior pharyngeal wall. The neck radiograph may show prevertebral soft tissue swelling.

A 28-year-old woman with no past medical history presents to the emergency department with acute dyspnea. Physical exam reveals tachycardia, warm extremities, wide-pulse pressure, bounding pulses, a systolic flow murmur, exophthalmos and a neck mass. Which of the following is the most likely diagnosis? Aortic regurgitation High output heart failure Low output heart failure Methamphetamine intoxication

Correct Answer ( B ) Explanation: This patient most likely has high-output heart failure secondary to thyrotoxicosis. High output heart failure occurs when cardiac output is elevated in patients with reduced systemic vascular resistance. Examples include thyrotoxicosis, anemia, pregnancy, beriberi and Paget's disease. Patients with high output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands. In high output heart failure the heart rate is typically elevated, the pulse is usually bounding and the pulse pressure wide. Pistol-shot sounds may be auscultated over the femoral arteries, which is referred to as Traube's sign. Subungual capillary pulsations, often referred to as Quincke's pulse, may also be present. Although these findings may be seen in other cardiac conditions, such as aortic regurgitation or patent ductus arteriosus, in the absence of those conditions, these signs are highly suggestive of elevated left ventricular stroke volume due to a hyperdynamic state. Patients with chronic high output also may develop signs and symptoms classically associated with the more common low-output heart failure; specifically, they may develop pulmonary or systemic venous congestion or both, while maintaining the above normal cardiac output. Low output heart failure (C) is often secondary to ischemic heart disease, hypertension, dilated cardiomyopathy, valvular and pericardial disease or arrhythmia. It can cause dyspnea but is not associated with symptoms of a hyperdyanimic state. Aortic regurgitation (A) is classically associated with bounding pulses, a wide pulse pressure and subungual capillary pulsations; however, aortic regurgitation is less likely in a young woman with no past cardiac history. Additionally, this woman has exophthalmos and a goiter on exam, which support the diagnosis of thyrotoxicosis. Methamphetamine intoxication (D) usually presents with agitation, tachycardia, and psychosis; however, it is not associated with a hyperdynamic state, exophthalmos or a goiter.

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

Correct Answer ( B ) Explanation: Vaginal bleeding after menopause is an abnormal finding. The most common cause of vaginal bleeding after menopause is atrophy of the vaginal mucosa or endometrium, however 5-10% of postmenopausal women with vaginal bleeding have endometrial cancer. Endometrial cancer is potentially lethal, therefore any postmenopausal woman who presents with vaginal bleeding needs to be evaluated to rule out this etiology. After a careful history and physical exam, initial diagnostic testing to rule out endometrial cancer involves either endometrial biopsy or transvaginal ultrasound. Advantages of an endometrial biopsy include its high sensitivity, low cost and low incidence of complications. Women who need evaluation of the adnexa or myometrium, or who can't tolerate endometrial biopsy should be referred for transvaginal ultrasound. If either test is inconclusive, further testing is warranted. Cervical cancer screening should also be a part of the workup for postmenopausal vaginal bleeding. Abdominal ultrasound (A) is not recommended for women with postmenopausal vaginal bleeding. If ultrasound needs to be used, transvaginal ultrasound is the appropriate diagnostic test to order. Postmenopausal women with an endometrial thickness < 3-4 mm on transvaginal ultrasound are unlikely to have endometrial carcinoma. Hysterectomy (C) may be indicated based on the results of the diagnostic imaging, but is not an initial step in management of postmenopausal vaginal bleeding. All women who present with postmenopausal vaginal bleeding should be evaluated with either endometrial biopsy or transvaginal ultrasound, there is no role for watchful waiting (D).

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

Correct Answer ( C ) Explanation: Cavitary lesions of the lung have multiple causes, including both infectious and non-infectious etiologies. These include bacterial pneumonia, fungal disease, tuberculosis, malignancies and some pulmonary vascular disease. The bacteria most commonly associated with cavitations are anaerobes, aerobic gram-negative bacilli and Staph aureus. After a recent influenza infection, patients may develop a Staph aureus pneumonia. Of particular concern is community-associated methicillin-resistant Staph aureus (CA-MRSA) after influenza especially in a rapidly progressive pneumonia in younger, healthy patients. Staph pneumonias often have necrotizing features creating the cavitation and may also lead to the development of pneumatoceles. Exposure to white powder (A) raises suspicion for possible anthrax exposure. Pulmonary anthrax classically causes a widened mediastinum on chest X-ray. Additional findings include lymphadenopathy and pleural effusions. Pulmonary infiltrates are classically absent. A history of smoking (B) increases the chance of developing lung cancer, which is not classically associated with a fever unless an acute infectious process develops. Smokers are at increased risk for pulmonary infections although not specifically one organism. Residence in Connecticut (D) does not increase risk for a particular infectious etiology to pneumonia. Histoplasmosis is more common in the Mississippi and Ohio River valleys and persons taking part in activities that disturb the soil are at increased risk.

A 15-year-old girl presents to clinic for a well child check. During her Home and Environment, Education and Employment, Activities, Drugs, Sexuality, Suicide and Depression (HEADSS) exam, she admits to using marijuana on a weekly basis for the past six months. She also drinks alcohol to excess once every few weeks. She denies smoking tobacco or using any other illicit substances. Which of the following is the most accurate information to give this patient? Chronic marijuana use improves focus and performance In human studies, marijuana has shown teratogenicity Marijuana can cause dependence and withdrawal Tetrahydrocannabinol concentrations are lower in today's marijuana compared to prior decades

Correct Answer ( C ) Explanation: Marijuana is the most commonly abused illicit drug, and is used by over 1/3 of US high school students. The active component, tetrahydrocannabinol (THC), leads to the effects of euphoria, elation, and hallucination. Side effects of the drug include impaired short-term memory, poor attention, loss of judgment, distorted time perception, and occasionally visual hallucinations and distorted body image. In the acute setting, serious adverse effects might include anxiety, panic, psychotic symptoms at high doses, and motor vehicle accidents. Marijuana is used in many medical conditions due to its antiemetic properties and appetite stimulation. Dependence occurs in about 10% of users. Withdrawal usually occurs within 24 to 48 hours of stopping the drug, and symptoms include malaise, irritability, insomnia, diaphoresis, night sweats, GI disturbance, and drug craving. The withdrawal symptoms usually peak by day 4 and are resolved by day 10-14. Chronic marijuana use (A) is associated with anxiety and depression, as well as learning difficulties, poor job performance, and respiratory complications such as sinusitis, bronchitis, and asthma. Animal studies have shown possible teratogenicity (B), but no human studies have ever shown this adverse effect. THC concentrations (D) are 5 to 15-fold higher in today's marijuana compared to the marijuana used in the 1970s.

A 73-year-old man with a history of hypertension and COPD presents with the ECG seen above. Which of the following is the correct diagnosis? Atrial fibrillation Atrial flutter Multifocal atrial tachycardia Wandering pacemaker

Correct Answer ( C ) Explanation: Multifocal atrial tachycardia (MAT) is a subset of atrial tachycardia, with more than 2 foci of impulse formation. On the ECG, at least 3 distinctively different P waves with varying P'-R, R-R, and P'-P' intervals are seen. MAT is often associated with pulmonary disease (e.g., COPD) and hypoxemia, either directly from these conditions or as a result of beta-adrenergic agonist or chronic methylxanthine treatment. MAT often resolves when the underlying condition is treated. MAT is easily confused for atrial fibrillation because both rhythms may be irregular and tachycardic, but P waves exist in MAT, not atrial fibrillation. Atrial fibrillation (A) is characterized as an irregularly irregular rhythm where there are multiple atrial foci firing rapidly and continuously, creating a fibrillating baseline. The QRS complexes are occurring irregularly but are usually of normal duration and configuration. The ECG above has P waves, which are not present in atrial fibrillation. Atrial flutter (B) is a fast atrial tachycardia (with an atrial rate upwards of 250-300 b/min) that can be due to a re-entry problem and is characterized by a sawtooth pattern (created by the rapidly firing atrial foci); the QRS complexes are typically regular. An irregular rhythm can occur with variable blocks. Wandering pacemaker (D) is similar to MAT in that there are 3 different P wave morphologies However, the rate in wandering pacemaker is 60-100 beats per minute, slower than MAT.

A 47-year-old woman presents to your office for follow up on her newly diagnosed hypothyroidism. Six weeks ago you prescribed levothyroxine after her thyroid-stimulating hormone was found to be elevated. She has been taking her medication as instructed and her symptoms improved, but retesting of her thyroid-stimulating hormone shows that it is still elevated. Which of the following is the next best step in management? Change medication to a thyroid hormone preparation containing T3 Decrease dose of levothyroxine and repeat TSH testing in 6 weeks Increase dose of levothyroxine and repeat TSH testing in 6 weeks Maintain current dose of levothyroxine and repeat TSH testing in 6 weeks

Correct Answer ( C ) Explanation: Patients with newly diagnosed hypothyroidism started on thyroid hormone replacement will often feel better and have a decrease in symptoms after 2-3 weeks of treatment. It takes approximately six weeks to achieve a steady-state thyroid-stimulating hormone (TSH) concentration. Once thyroid hormone replacement is initiated, TSH should be re-checked in six weeks. An elevated TSH after six weeks indicates that there is not enough thyroid hormone, because the lack of thyroid hormone stimulates the anterior pituitary to produce more TSH. The dose of levothyroxine can be increased by 12 to 25 mcg/day and TSH should be tested again in six weeks. This process continues until TSH is in the normal reference range, at which point TSH may be monitored yearly. Any time a dosage change is made, repeat TSH testing must occur six weeks later. Thyroid hormone replacement with T3 (A) is not recommended for the majority of patients. First-line treatment is synthetic T4. A decrease in the dose of levothyroxine (B) is made when TSH is low. A high TSH means that the patient does not have sufficient thyroid hormone. Maintaining the current dose (D) will not provide the patient with enough thyroid hormone and is not recommended with a high TSH.

Which of the following statements is true regarding prosthetic heart valves? Anticoagulation is optional with mechanical valves Mechanical valves are associated with less hemolysis and are less thrombogenic than bioprosthetic are Mechanical valves are more prone to paravalvular leaks than bioprosthetic valves are Mechanical valves make opening and closing sounds similar to, but louder than, those of native valves

Correct Answer ( C ) Explanation: Prosthetic heart valves are classified as either mechanical (constructed of entirely synthetic material) or biologic (human, porcine, bovine). All prosthetic valves are associated with complications ranging from structural failure and thrombosis to systemic embolization, hemolysis, and endocarditis. A paravalvular leak occurs when a portion of the prosthetic valve becomes unseated from the valve annulus. It is more common with mechanical valves. When it occurs immediately after surgery, it is usually due to suture disruption, whereas delayed leaks are generally due to endocarditis. Clinically, patients typically present with sudden onset of pulmonary edema or severe hemolytic anemia. It is often associated with a regurgitant murmur. Bioprosthetic valves have a lifespan of 8-10 years; this is less than the > 20-year lifespan of mechanical valves. Mechanical valves are associated with greater hemolysis (B) and are more thrombogenic than bioprosthetic valves are and therefore require lifelong anticoagulation (A). Prosthetic valve thrombosis has an incidence of approximately 2% per year, with both bioprosthetic and appropriately anticoagulated mechanical valves. Mechanical valves typically make a loud metallic closure sound and a softer opening click (D). Mechanical aortic valves are also associated with a systolic ejection murmur. Bioprosthetic valves make opening and closing sounds that are similar to, but louder than, native valves.

A 34-year old resident physician from Iowa presents for a health examination prior to hospital employment. His examination is unremarkable, but a chest radiograph shows bilateral lung fields with BB-sized calcifications and hilar adenopathy. A PPD skin test is negative. The findings in this patient are most likely a result of which of the following? Coccidioidomycosis Cryptococcosis Histoplasmosis Tuberculosis

Correct Answer ( C ) Explanation: The majority of people with normal immunity who develop histoplasmosis manifest an asymptomatic or clinically insignificant infection. The most common abnormality on chest radiograph is a solitary pulmonary calcification. Cavitation is rare, but hilar and mediastinal adenopathy is seen frequently. It is highly prevalent in the Midwestern United States and exposure to bird or bat excrement is a common cause. The spectrum of this illness ranges from asymptomatic infection to severe disseminated disease. Culture remains the gold standard for diagnosis but requires a lengthy incubation period. Fungal staining produces quicker results than culture but is less sensitive. Therapy is indicated in chronic or disseminated disease and severe, acute infection. Amphotericin B is the agent of choice in severe cases and itraconazole is effective in moderate disease. The chest radiographic findings in coccidiomycoses (A) can be normal or may progress from single or multiple areas of airspace consolidation to the formation of nodules or cavities. Clinical symptoms are similar to those found in histoplasmosis however, coccidiomycoses is generally seen in inhabitants of the southwestern United States. A patient with pulmonary cryptococcosis (B) may present with mild-to-moderate symptoms, including fever, malaise, cough with scant sputum, pleuritic pain, and hemoptysis. On chest radiography, cavitation and hilar lymphadenopathy are uncommon. Calcification and pulmonary fibrosis or stranding are usually absent. Patients with tuberculosis (D) will have a positive protein purified derivative (PPD) skin test unless they are severely immunocompromised. Chest radiographs may show a patchy or nodular infiltrate. Tuberculosis may be found in any part of the lung, but upper lobe involvement is most common. Cavity formation, noncalcified round infiltrates, homogenously calcified nodules and military patterns are alternative findings on chest radiograph.

Which of the following medications should be used as prophylactic therapy for patients with recurrent migraine headaches? Dihydroergotamine (DHE) Ketorolac Propranolol Sumatriptan

Correct Answer ( C ) Explanation: The pharmacologic treatment of migraine headaches is divided into abortive and prophylactic therapies. Prophylactic therapies are intended to decrease the frequency and intensity of attacks and is indicated for patients who have frequent attacks (>2 episodes per month), prolonged attacks lasting more than 48 hours, or attacks that are severe and debilitating. Beta-adrenergic blocking agents such as propranolol reduce both the frequency and severity of migraine headache and are most widely used for prophylaxis. Other medications used for migraine headache prophylaxis include calcium channel blockers, tricyclic antidepressants, anticonvulsants, and monoamine oxidase inhibitors. Dihydroergotamine (DHE) (A) and sumatriptan (D) are abortive therapies used for moderate to severe attacks. Ketorolac (B) and other NSAIDS and acetaminophen are used as abortive therapies used for mild to moderate attacks.

A 62-year-old man with a history of chronic obstructive pulmonary disease presents with cough, headache, dyspnea, and watery diarrhea that started 6 days ago. He was seen at a local urgent care 4 days ago and prescribed amoxicillin-clavulanate without improvement. He is ill appearing with a fever of 38.7°C and inspiratory rales on auscultation. Which of the following results would be most consistent with his diagnosis? Right upper lobe infiltrate with bulging fissure on chest X-ray Serum potassium 6 mEq/L Serum sodium 128 mEq/L Sputum gram stain with gram positive cocci in pairs

Correct Answer ( C ) Explanation: This patient is presenting with Legionella pneumonia. It was first identified in 1976 after an outbreak at the American Legion Convention in Philadelphia. Legionella is a gram-negative facultative intracellular bacillus and is found in aquatic environments. Transmission is from inhalation of contaminated aerosols. It is a more common cause of pneumonia in the summer months when other pathogens are less frequently seen. Patients at risk include smokers, those with underlying respiratory disease (e.g. COPD) or immunosuppression, and men > 50 years of age. Patients present with fevers, malaise, and myalgias. The cough is initially dry, but becomes productive of purulent sputum as the illness progresses. Gastrointestinal symptoms are frequently seen, including diarrhea in about 50% of patients. Hyponatremia is also commonly seen. Typical chest X-ray findings include unilateral patchy alveolar lower lobe infiltrates occasionally accompanied by pleural effusions. Laboratory studies include leukocytosis, elevated liver transaminases, and hyponatremia. Diagnosis is made based on clinical findings and urinary antigen assay. The antibiotic of choice is azithromycin. Alternative agents include trimethoprim-sulfamethoxazole and fluoroquinolones. Upper lobe infiltrates with a bulging fissure (A) are seen in Klebsiella pneumoniae. The gram stain in Legionella typically shows numerous polymorphonuclear lymphocytes (PMNs), but no predominant organism. Sputum gram stain with gram positive cocci in pairs (D) is consistent with pneumococcal pneumonia. Diarrhea typically leads to hypokalemia, not hyperkalemia (B). Patients with Legionella may have hyponatremia, but not hypernatremia.

A 45-year-old left-handed man presents to the Emergency Department with an injury to his left hand. He was playing basketball with his son and developed sudden onset of pain in the distal aspect of his long finger when trying to catch the ball. Exam findings at rest are shown above. The patient is unable to actively extend his distal interphalangeal joint. Which of the following is the most likely diagnosis? Boutonniere finger Jersey finger Mallet finger Trigger finger

Correct Answer ( C ) Explanation: This patient presents with a mallet finger injury, caused by disruption of the terminal extensor tendon distal to the distal interphalangeal (DIP) joint. This injury typically occurs due to an impaction blow to the tip of the extended finger, forcing the DIP joint into flexion. It is common sports related injury and typically affects middle-aged men. The long finger of the dominant-hand is most commonly affected. Physical exam reveals a swollen and painful DIP with the fingertip at rest in 45 degrees of flexion, and patients are unable to actively extend the DIP joint. On X-rays, a bony avulsion can be present. Most mallet injuries are treated with volar splinting of the DIP joint in extension for at least six weeks. Patients should be referred to a hand surgeon for follow-up and to ensure that no surgical intervention is needed. A Boutonniere finger (A) or deformity is caused by rupture of the central slip causing a characteristic DIP joint extension and proximal interphalangeal joint flexion. Jersey finger (B) refers to rupture of the flexor digitorum profundus tendon at the insertion at the distal phalanx and leads to inability to actively flex the DIP joint. Trigger finger (D) describes painless locking and snapping of a finger during flexion due to mismatch in the size of the flexor tendons and the surrounding pulley system.

An elderly woman presents with intermittent leg pain. She states it is a burning heaviness that is not necessarily associated with activity. Inspection reveals several dilated and tortuous veins about the lower legs. The skin is edematous and speckled with dark brown areas of capillary dilation but no specific pallor. Distal motor and sensory examinations are intact. Which of the following is the most appropriate initial tests in the evaluation of these symptoms? Angiography Coagulation panel Duplex ultrasonography Electrodiagnostics

Correct Answer ( C ) Explanation: Venous insufficiency, mainly due to incompetent or absent venous valves, can lead to retrograde blood flow in the superficial or deep venous systems. Ultimately, this leads to the syndrome of chronic venous insufficiency, which is marked by poor cosmesis, pain, lipodermatosclerosis, ulceration and life-threatening infections. The pain is usually described as burning, cramping or heaviness that occurs constantly in almost 20%, and episodically in almost 50% of sufferers. Chronic venous stasis or hypertension causes the characteristic skin changes of capillary proliferation, red or brown coloring, fat necrosis and fibrosis. These may be associated with edema, cellulitis, ulceration and cutaneous infarction. Although typical, these physical findings are only suggestive of the condition. Any suspicion is best evaluated initially with duplex ultrasonography. Angiography (A) is the test of choice for patients with suspected arterial insufficiency and peripheral arterial occlusion disorder. These conditions are more commonly associated with pain with activity and skin pallor, atrophy and shiny appearance. A coagulation panel (B) is usually performed as a baseline test before initiating anticoagulation in a patient with documented deep venous thrombosis. The above symptoms do not confirm, but merely suggest, venous insufficiency, which may be due to superficial or deep venous thrombosis. A diagnosis needs to be made before preparing for treatment. Electromyography and nerve conduction studies (D) are recommended for those with complaints and findings of distal neuropathy or myopathy, not venous insufficiency.

A 56-year-old woman presents with burning pain and tingling on the palmar surfaces of digits 1-3 of her right hand. The pain has been present for several months and awakens her at night. There is no atrophy or weakness of her hand. However, volar wrist percussion causes a shock-like pain extending to the palmar surfaces of digits 1-3. Which of the following tests proved positive in this examination? Finkelstein Phalen Spurling Tinel

Correct Answer ( D ) Explanation: A Tinel test is considered positive when percussion of the volar wrist in the region of the median nerve produces tingling or a shock-like pain in the palmar surfaces of digits 1-3. This test is generally sensitive for clinically diagnosing carpal tunnel syndrome, an entrapment neuropathy due to some form of compression or narrowing of the carpal tunnel that impinges the median nerve. Other physical exam findings may include a positive Phalen sign in which flexion of both wrists to 90 degrees for one minute causes pain or tingling in the median nerve distribution. The carpal compression test, in which the clinician applies steady, direct pressure over the carpal tunnel to elicit tingling, may be even more sensitive for the condition. Carpal tunnel syndrome generally presents with pain and tingling in the median nerve distribution and may initially bother the patient only during sleep. A history of performing repetitive activities may be noted. Diabetes mellitus and fluid retention during pregnancy can also contribute to carpal tunnel compression. A work-up for carpal tunnel syndrome may include an ultrasound to observe flattening of the median nerve, or electromyography and nerve conduction studies to differentiate it from a more proximal neuropathy. A trial of wrist extension splinting, as well as NSAIDs and corticosteroids, may help. Surgical carpal tunnel release can be considered for symptoms beyond 12 months of conservative treatment. A Finkelstein test (A) requires sharp, ulnar deviation of the thumb while the fingers are flexed around the thumb into a fist. Pain at the wrist is suggestive of deQuervain tenosynovitis. A Phalen test (B) is positive when flexion of both wrists to 90 degrees for one minute causes pain or tingling in the median nerve distribution. Like A Tinel test, a positive Phalen test suggests carpal tunnel syndrome. A Spurling test (C) requires the patient to rotate and extend the neck to one side while the clinician gently applies an axial load to the neck. Nerve root compression is likely when this test produces cervical radiculopathy.

A 16-year-old African American boy presents with a scalp rash. On examination, it is a 5 x 5 cm boggy and thickened area of the right parietal cap with an overlying scaly and crusty plaque and hair loss. The lesion appears yellowish-green under a Wood's lamp. What is the treatment of choice for this lesion? Clotrimazole ointment Ketoconazole shampoo Oral amphotericin B Oral griseofulvin

Correct Answer ( D ) Explanation: A kerion is best treated with oral griseofulvin. A kerion is an abscess caused by a fungal infection most commonly on the scalp but may also present on the upper limbs and the face. It appears as a boggy, pus-filled lesion with significant inflammation. The overlying skin often has an eczematous, itchy rash as well as hair loss. The patient may also have nearby lymphadenopathy, fevers, and malaise. The fungal infections that can cause a kerion include Microsporum canis and the Trichophyton genus. Exam with a Wood's lamp reveals yellow-green fluorescence. Scrapings and hair samples can be sent for microscopy and fungal culture to confirm the diagnosis. A course of six to eight weeks of an oral anti-fungal agent such as griseofulvin, itraconazole, or terbinafine is recommended. Antibiotics may also be indicated if a bacterial infection is also present. Clotrimazole ointment (A) is an anti-fungal most useful in yeast infections, athlete's foot, and ringworm. Anti-fungal shampoos with ketoconazole (B) may be useful to prevent transmission to others. Amphotericin B (C) is an anti-fungal medication that can be used intravenously to treat systemic fungal infections.

Which of the following states a correct order of electrical current through the heart during one cycle of normal cardiac depolarization? Atrioventricular node -> sinoatrial node Bundle of His -> atrioventricular node Left bundle branch -> right bundle branch Right bundle branch -> purkinje fibers

Correct Answer ( D ) Explanation: A normal cycle of cardiac depolarization begins in the right atrium's sinoatrial node and passes through the right atrium's internodal tracts to activate the atrioventricular node. The AV node then sends the electrical impulse to the Bundle of His, which then passes current through the left and right bundle branches to the ventricular Purkinje fibers. Atrioventricular (AV) block is characterized as a delay in processing the electrical impulse within the atrioventricular node. This ultimately results in a delay in ventricular depolarization and contraction. There are three main types: first, second and third degree AV block. First-degree AV block is characterized as a prolonged PR interval > 0.2 sec, beginning at the start of the P wave and ending at the start of the QRS complex. Common causes of this type of block include electrolyte abnormalities, enhanced vagal tone (as in athletes), myocarditis or infarction and medications. Common medications which slow cardiac conduction through the AV node and produce a prolonged PR interval include beta and calcium-channel blockers, anticholinesterases and digitalis. Current passes normally from the SA to the AV node (A). Normal conduction is from the AV node to the Bundle of His (B), not the reverse. The left bundle does not normally propagate current to the right bundle (C).

Which of the following is the most common physical exam finding in an abdominal aortic aneurysm? Abdominal bruit Diminished femoral pulses Duodenal obstruction Pulsatile abdominal mass

Correct Answer ( D ) Explanation: A pulsatile abdominal mass is the most common physical examination finding in a patient with an abdominal aortic aneurysm (AAA). Patients with unruptured AAA rarely have any symptoms. If pain is present, it is usually gradual in onset and dull. Patients occasionally describe colicky pain that can be in the back or stomach making it easy to confuse this diagnosis with renal colic. The presence of acute severe pain typically heralds rupture. The most prominent physical examination feature is a pulsatile abdominal mass. Typically, the mass is palpated at the level of the umbilicus. The ability to palpate an AAA depends on the size of the AAA and the patients body habitus. An abdominal bruit (A) is an uncommon finding. Generally, patients have good distal perfusion and so femoral pulses will not be diminished (B). Duodenal obstruction (C) may occur but is very rare.

A 11-month-old previously healthy boy presents in January with a two-day history of rhinorrhea, cough, and wheezing. Physical exam is significant for bilateral wheezing and crackles heard at the lung bases. The patient's pulse oximetry is 96 percent on room air. Which of the following is the most appropriate next step in management? Administer racemic epinephrine Albuterol nebulizer treatment every four hours Chest X-ray Observation and supportive care

Correct Answer ( D ) Explanation: Bronchiolitis is a lower respiratory tract viral infection that is caused by damage of the epithelial cells lining the small airways, which leads to acute inflammation, increased mucous production, and bronchospasm. Bronchiolitis peaks between December and March. The clinical presentation includes rhinorrhea, cough, wheezing, low-grade fever, and shortness of breath. Bilateral wheezing and crackles are heard on pulmonary exam. Poor feeding and respiratory distress (tachypnea, nasal flaring, and hypoxemia) are indicators of increased severity. Oxygen saturation less than 95 percent, PO2 less than 65, PCO2 greater than 40, atelectasis on chest X-ray, and respiratory rate greater than 70 are also all indicators of severe disease. Bronchiolitis most commonly occurs between two and seven months of age, but can occur in those up to two years old. The most common virus associated with bronchiolitis is respiratory syncytial virus (RSV). Other causes include parainfluenza virus, metapneumovirus, and adenovirus. Symptoms can last up to five days and generally worsen by day three before subsiding. Most patients can undergo observation and supportive care. Treatment is symptomatic and includes cool mist. Hospitalization is determined by the patient's comorbidities, reliability of parents, duration of symptoms, and condition on presentation (hypoxia, tachypnea, dehydration, age). Racemic epinephrine (A) is the treatment for laryngotracheobronchitis (croup) caused by parainfluenza virus and is characterized by a barking cough and inspiratory stridor. Bronchodilators (B), such as albuterol, are not routinely given when managing bronchiolitis. Bronchiolitis is usually a clinical diagnosis, and a chest X-ray (C) is not required to make the diagnosis. Chest X-ray findings typically include hyperinflation and patchy infiltrates. Focal findings are not consistent with bronchiolitis.

Which of the following distinguishes conduct disorder from oppositional defiant disorder? Angry and resentful Argues with adults Deliberately trying to annoy someone Physical aggression towards others

Correct Answer ( D ) Explanation: Conduct disorder can be distinguished from oppositional defiant disorder by the presence of physical aggression and other severe forms of antisocial behavior. Conduct disorder is characterized by a persistent pattern of serious rule-violating behavior, including behaviors that harm (or have the potential to harm) others. The patient with conduct disorder typically shows little concern for the rights or needs of others. The symptoms of conduct disorder are divided into 4 major categories: (1) Physical aggression to people and animals including bullying, fighting, weapon carrying, cruelty to animals, and sexual aggression; (2) Destruction of property, including fire setting and breaking and entering; (3) Deceitfulness and theft; and (4) Serious rule violations, including running away from home, staying out late at night without permission, and truancy. To meet the diagnosis, >3 of these symptoms must be present at least 1 year (1 or more in the past 6 months) and must impair the youth's function at home, at school, or with peers. The onset of conduct disorder may occur in early childhood but usually occurs in late childhood or adolescence. In a majority of patients, the disorder remits by adulthood. A substantial fraction of patients develop antisocial personality disorder as adults. Early onset of conduct disorder, along with high frequency of diverse antisocial acts across multiple settings, predicts a worse prognosis and increased risk for antisocial personality disorder. Patients with conduct disorder also are at risk for the development of mood, anxiety, somatoform, and substance-use disorders in adulthood. Being angry and resentful (A), arguing with adults (B), deliberately trying to annoy someone (C) are some of the criteria for oppositional defiant disorder. Oppositional defiant disorder is characterized by a persistent pattern of angry outbursts, arguing, vindictiveness, and disobedience, generally directed at authority figures (such as parents and teachers). To meet the diagnosis, >4 of these types of behavior must be more frequent and more severe than children of a given developmental stage normally exhibit (especially when tired, hungry, or under stress), must be present at least 6 months, and must impair the youth's function at home, at school, or with peers.

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

Correct Answer ( D ) Explanation: Routine screening for cervical cancer with the Papanicolaou test (Pap smear) is recommended for all women aged 21 years or older, at least every 3 years. Women with a previous history of an abnormal pap smear may require closer follow up depending on the abnormal results. Women 30 years or older with no previous history of abnormal pap smears can undergo screening every 5 years. Routine screening is not recommended for women greater than 65 years of age with a history of adequate screening with negative results. The Human Papillomavirus vaccine (HPV) is recommended to all females between 9-26 years of age and males between 9 and 21 years of age. This patient should also undergo counseling on prevention of sexually transmitted diseases, birth control and smoking cessation. Routine screening for ovarian cancer by ultrasound (C), measurement of tumor markers, or pelvic exam is not recommended. The positive predictive value is low because of the low prevalence of ovarian cancer in the general population. The meningococcal vaccine (B) is only recommended for adults with asplenia, first-year college students living in dormitories or military personnel. Woman 50-74 years of age should receive a mammography (A) every two years for breast cancer screening. However, some women may require earlier screening based on patient context (family history, genetic make-up) and the benefits and harms should be discussed with the patient. Do not routinely screen women >75 years of age with mammography.

Which of the following vaccines does the Centers for Disease Control and Prevention consider safe for administration during pregnancy? HPV (human papillomavirus) LAIV (live, attenuated influenza vaccine) MMR (measles, mumps, rubella) Tdap (tetanus, diphtheria, pertussis)

Correct Answer ( D ) Explanation: The Centers for Disease Control and Prevention (CDC) recommends routine Tdap (tetanus, diphtheria, pertussis) vaccination during each pregnancy between the 27-36 weeks gestation and the vaccine is considered safe at any point in pregnancy. At this time, the CDC does not recommend vaccinating pregnant women with the HPV vaccine (A). Live attenuated vaccines such as the LAIV (live, attenuated influenza vaccine) (B) should not be given during pregnancy, however the inactive influenza vaccine is currently recommended for routine administration during influenza season at any stage of pregnancy. MMR (C) is a live virus vaccine and should not be given during pregnancy.

Which of the following is an appropriate therapy for a patient with severe acute pancreatitis? Antibiotics Anticholinergic agents Calcium chloride Crystalloid infusion

Correct Answer ( D ) Explanation: The management of pancreatitis is primarily supportive. All patients with pancreatitis require fluid resuscitation, as volume depletion is common secondary to inadequate oral intake, vomiting and third space losses. Fluids should be replaced with lactated Ringer's solution or normal saline; several liters may be required. There is emerging evidence that resuscitation with lactated Ringer's results may reduce the incidence of SIRS as compared to normal saline. Vitals signs and urine output should be used to judge the adequacy of volume replacement. Anticholinergics (B) have not been demonstrated to be effective for pancreatitis and can make assessment of ongoing treatment difficult. Antibiotics (A) are not indicated for acute pancreatitis unless there is objective evidence of infection, such as fever or increasing WBC. Calcium chloride (C) has no role in the treatment of pancreatitis.

A 33-year-old man arrives at the urgent care with a fever and dysuria for several days. An abdominal exam reveals suprapubic tenderness. A gentle digital rectal exams reveals a warm, exquisitely tender prostate. Which of the following interventions is contraindicated in the diagnosis and treatment of his most likely condition? Aminoglycoside antibiotics Percutaneous suprapubic tube Quinolone antibiotics Urethral catheterization

Correct Answer ( D ) Explanation: Urethral catheterization is contraindicated in the management of acute bacterial prostatitis, the most likely diagnosis in this patient. Acute bacterial prostatitis usually results from the ascent of gram-negative organisms up the urethra as urine refluxes into the prostatic ducts. Symptoms will include fever, dysuria, urinary urgency or frequency, and suprapubic, perineal, or sacral pain. Urinary obstruction may result as the infection progresses. A digital rectal exam typically shows a warm, boggy prostate. However, great care should be used to perform a gentle rectal exam, as vigorous prostatic massage in a patient with acute bacterial prostatitis can lead to septicemia. Non-specific laboratory findings may include leukocytosis with a left shift. A urinalysis will show bacteria and pyuria. Urine should be cultured to distinguish the offending organism. Septic or extremely ill patients may require hospitalization with intravenous aminoglycoside antibiotics until the fever and symptoms resolve. Urinary obstruction should be managed by placement of a percutaneous suprapubic tube in lieu of a urinary catheter. Acute bacterial prostatitis should be treated for 4-6 weeks with a quinolone antibiotic with a follow-up culture on urine and prostatic secretions to ensure resolution of the infection. Appropriate treatment usually prevents the development of chronic bacterial prostatitis. Aminoglycoside antibiotics (A) and quinolone antibiotics (C) are both appropriate for management of acute bacterial prostatitis. The selection of antibiotic for bacterial prostatitis is largely dependent on the severity of symptoms and patient allergies. A percutaneous suprapubic tube (B) is a safe alternative to urethral catheterization in patients with acute bacterial prostatitis in the event that they develop urinary obstruction during treatment.

Question: What is the time course for treatment of group A streptococcal pharyngitis?

Answer: 10 days.

Question: What percent of aortic aneurysms >5 cm can be palpated?

Answer: 75%, but only 5-10% of patients with an AAA have an abdominal bruit. Rapid Review Abdominal Aortic Aneurysm (AAA) Advanced age, male, smoking hx, HTN Acute abdominal pain + hypotension + pulsatile abdominal mass US: 100% sensitive CT: 100% sensitive, detects rupture/leak AAA > 5 cm: ↑ risk of rupture Renal colic in elderly: r/o AAA

Question: To prevent Little Leaguer's elbow, the American Academy of Pediatrics recommends limiting players to how many pitches per game?

Answer: 90 pitches.

Question: What is the most common cause of hemolytic disease of the newborn?

Answer: ABO incompatibility.

Question: What is the classic triad of AAA?

Answer: Abdominal/back pain, hypotension and a pulsatile abdominal mass. Rapid Review Abdominal Aortic Aneurysm (AAA) Advanced age, male, smoking hx, HTN Acute abdominal pain + hypotension + pulsatile abdominal mass US: 100% sensitive CT: 100% sensitive, detects rupture/leak AAA > 5 cm: ↑ risk of rupture Renal colic in elderly: r/o AAA

Question: Which two types of organisms are most commonly implemented in acute prostatitis?

Answer: Acute prostatitis is usually caused by E. coli or Pseudomonas species. Rapid Review Prostatitis Patient will be complaining of fever, chills, perineal/back pain and dysuria PE will show a warm, exquisitely tender prostate Most commonly caused by: < 35 y/o: N. gonorrhoeae, C. trachomatis > 35 y/o: E. Coli Treatment is: < 35 y/o: Ceftriaxone or ofloxacin and doxycycline > 35 y/o: Ciprofloxacin or TMP/SMX Comments: Avoid vigorous prostatic massage can lead to septicemia

Question: What is a saddle pulmonary embolism?

Answer: An embolus that lodges in the bifurcation formed by the main pulmonary artery and right and left pulmonary arteries. Rapid Review Pulmonary Embolism 95% arise from deep leg veins Sudden onset of symptoms in 50% SOB, CP, tachypnea ECG: sinus tachycardia, nonspecific ST-T changes, right heart strain, S1Q3T3 (classic finding) CXR: nonspecific abnormalities, Hampton's hump (pleural-based wedge infarct), Westermark's sign (vascular cut-off sign) V/Q scan: usually nondiagnostic Low clinical suspicion: negative D-dimer excludes PE Dx of choice: CTPA Treatment: Anticoagulation Thrombolytics (if massive and HD unstable or submassive with shock, respiratory failure or evidence of moderate to severe RV strain) Embolectomy (last resort)

Question: What is the main objective in management of women with postmenopausal vaginal bleeding?

Answer: Exclusion of cancer. Rapid Review Endometrial Cancer Patient will be a postmenopausal woman Complaining of abnormal vaginal bleeding Diagnosis is made by transvaginal ultrasound or endometrial biopsy Most common type is adenocarcinoma Treatment is total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO)

Question: Which school team sport has the highest injury rate in the United States?

Answer: Football, followed by wrestling.

Question: What is the most common cause of septic arthritis in patients under 35 years of age?

Answer: Gonococcal arthritis. Rapid Review Disseminated Gonococcal Infection Fever, migratory arthritis, rash Erythematous or hemorrhagic papules → pustules/vesicles with erythematous halos Tenosynovitis

Question: Spelunkers are at an increased risk for which fungal infection?

Answer: Histoplasmosis. Rapid Review Histoplasmosis Patient with a history of travel to Ohio/Mississippi river valleys and exposure to bird/bat droppings X-ray will show solitary pulmonary calcification, hilar and mediastinal adenopathy Diagnosis is made by culture Treatment is itraconazole or amphotericin B

Question: Other than magnesium sulfate and cardioversion/defibrillation, what is another treatment for torsades de pointes?

Answer: Increase the heart rate to shorten ventricular repolarization, also known as overdrive pacing. Rapid Review Torsades de Pointes (TdP) ECG will show rhythm > 100 beats per minute and frequent variation in the QRS axis and morphology Most commonly caused by acquired or congenital long QT interval syndrome Treatment is Unstable: defibrillation Stable: intravenous magnesium sulfate and stopping the offending drug

Question: What important pathology classically presents with bilious emesis in infants?

Answer: Malrotation with volvulus must be suspected with bilious vomiting in infants. Rapid Review Pyloric Stenosis Patient will be 2 - 6 weeks old Complaining of non-bilious projectile vomiting after feeding and early satiety PE will show RUQ olive-like mass (hypertrophied pylorus) Labs will show hypochloremic hypokalemic metabolic alkalosis Diagnosis is made by ultrasound or UGI series (string sign) Treatment is surgical

Question: Which neurologic entity is commonly associated with rheumatologic diseases like polyarteritis nodosa?

Answer: Mononeuritis multiplex, a painful, asymmetrical sensorimotor peripheral neuropathy with numbness and weakness. Rapid Review Polyarteritis Nodosa Patient will be a man 40 - 50 years old Complaining of malaise, fever, sore throat, joint and muscle aches and pains PE will show tender lumps under the skin, especially on the thighs and lower legs Labs will show ↑ ESR, ANCA negative Diagnosis is confirmed by biopsy showing necrotizing arteritis or by arteriography Treatment is steroids Comments: "starburst" livedo (painful violaceous plaques that are surrounded by livedo reticularis) is pathognomonic

Question: What are 3 rare complications of hand-foot-and-mouth disease?

Answer: Myocarditis, pneumonia, meningoencephalitis. Rapid Review Hand, Foot, Mouth Disease (HFMD) Patient will be a child younger than 5 years of age Complaining of decreased appetite and fever PE will show an oral exanthem plus a macular, maculopapular, or vesicular rash on the hands and feet Most commonly caused by Coxsackievirus A Treatment is supportive

Question: What is a medical treatment of choice for acromegaly?

Answer: Octreotide - a somatostatin analog, 100 mcg subcutaneously. Rapid Review Acromegaly Patient will be complaining of increased head, glove, or shoe size PE will show coarse facial features, oily skin, visual field deficits, diabetes Labs will show increased IGF-1 Most commonly caused by pituitary adenoma Treatment is transphenoid resection

Question: What is the classic clinical presentation of placental abruption?

Answer: Painful third-trimester vaginal bleeding. Rapid Review Placenta Previa Patient will be a pregnant women in her third trimester Complaining of painless vaginal bleeding Diagnosis is made by ultrasound Comments: Do not do a digital vaginal exam

Question: What is the best treatment for adjustment disorders?

Answer: Psychotherapy is the treatment that is most frequently recommended. Rapid Review Adjustment disorder Behavioral response Develops ≤3 months after onset of stressor Reaction is excessive Symptoms resolve by 6 months

Question: What is the most frequent site of arterial embolism?

Answer: The bifurcation of the common femoral artery. Rapid Review Arterial Thromboembolism Risk factors: recent MI, atrial fibrillation Sudden onset 5 Ps: pain, pallor, paresthesias, pulselessness, paralysis Most common source: left heart Most common site: femoral artery bifurcation

Question: What is the inherent pacemaker rate of the AV node?

Answer: The rate is 40-60 beats/min. Rapid Review Multifocal Atrial Tachycardia Irregularly irregular ≥ 3 different P waves Rate: 100-180 Nonconducted P waves are present Pulmonary disease/COPD Treat underlying condition Unstable: CCBs

Question: Where is a common location for pregnant patients to experience pain due to appendicitis?

Answer: The right upper quadrant due to displacement of the appendix by the gravid uterus. Rapid Review Appendicitis Patient will be complaining of fever, pain that began periumbilical then moved to RLQ, nausea and anorexia PE will show Psoas sign (RLQ pain on extension of right hip), Obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (right lower quadrant pain when the left lower quadrant is palpated) Diagnosis is made by ultrasound, CT Most commonly caused by fecalith Treatment is surgery

Question: What is the recommended INR for a mechanical mitral valve?

Answer: The target INR for a mechanical mitral valve is 3-3.5, whereas a mechanical aortic valve is 2.5-3. Rapid Review Prosthetic Heart Valve Complications Lifespan: mechanical > biologic Anticoagulation: mechanical only Click: mechanical only Paravalvular leak Endocarditis

Question: True or false: Benzodiazepines should be avoided in the treatment of panic disorder for patients with a history of substance abuse?

Answer: True.

Question: What is the most common cause of pleuritic chest pain?

Answer: Viral infection. Rapid Review Viral Pleuritis URI Chest pain Supportive care

Which of the following is true regarding the condition seen in the images above? The causative organism is spread via the fecal-oral route The illness occurs most frequently in the winter months Treatment is with antiviral medications Vaccination prevents the disease

Correct Answer ( A ) Explanation: The lesions are manifestations of hand-foot-and-mouth disease, a viral infection caused by coxsackievirus. Toddlers and school-age children are most commonly affected. Transmission is by the fecal-oral route and usually occurs in the summer and fall months in crowded places where children congregate such as a swimming pool. It is characterized by a prodrome of fever, malaise, sore throat, and anorexia over a couple of days, followed by the appearance of the characteristic rash. The location of the lesions involve the following: (1) hands and palms (dorsal and palmar surface, sides of fingers); (2) sides of feet and toes, soles (plantar surface); (3) usually the anterior portion of the mouth, most frequently the tongue and buccal mucosa, hard palate, gingivae, and lips. The most frequent site of the lesions is the mouth and the hands are more frequently involved than the feet. The mouth lesions begin as small red macules or papules that turn into vesicles then ulcerate and crust. The extremity lesions are vesicular and pink to red in appearance.They are typically distributed bilaterally and symmetrically on the hands and feet. The skin lesions may be asymptomatic or painful, while the mouth lesions are almost always painful. Treatment is supportive with oral fluids and antipyretics. In most cases, the course is self-limited, resolving in 7-10 days. Herpangina is a characteristic exanthem produced by several eneterovisues, with coxsackie A, B, and echovirus being the most common. This condition is characterized by oral lesions that usually appear in the posterior aspect of the mouth, specifically on the anterior tonsillar pillars (most common), posterior pharyngeal wall, soft palate, tonsils, uvula, and occasionally the posterior buccal mucosa. Herpangitis is rarely associated with aseptic meningitis or other severe enteroviral illnesses. Coxsackie occurs more commonly in the summer and fall months (B) rather than in the winter months, as with many other viral exanthems. Treatment is supportive. Antiviral medications (C) have no benefit. Unlike for varicella, there is no vaccine (D) for coxsackievirus.

Acromegaly is the disease state characterized by a pituitary adenoma that secretes which hormone? Adrenocorticotropic hormone (ACTH) Growth hormone (GH) Prolactin (PRL) Thyroid-stimulating hormone (TSH)

Correct Answer ( B ) Explanation: Acromegaly is the disease state characterized by a pituitary adenoma that secretes growth hormone (GH). Features of acromegaly include: coarse facial features, oily skin, visual field deficits, diabetes, and increased head, glove, or shoe size. In the work up of acromegaly, the first screening tests are the measurement of the serum insulin-like growth factor I level, postprandial serum GH, and TRH stimulation test. These are followed by an oral glucose tolerance test, which is considered conclusive if there is failure to suppress serum GH to <2 ng/ml after an oral load of 100 g glucose. GH-releasing hormone level >300 ng/ml is indicative of an ectopic source of GH. Pituitary adenoma is a benign neoplasm of the anterior lobe of the pituitary that causes symptoms, either by excess secretion of hormones or by a local mass effect as the tumor impinges on other, nearby structures (e.g., optic chiasm, hypothalamus, pituitary stalk). Pituitary adenomas are classified by their size, function, and features that characterize their appearance. Microadenomas are <10 mm in size, and macroadenomas are >10 mm in size. Cushing's disease is a disease state where the pituitary adenoma is secreting adrenocorticotropic hormone (ACTH) (A). Thyrotropin-secreting pituitary adenomas secrete primarily thyroid-stimulating hormone (TSH) (D). A prolactinoma secretes prolactin (PRL) (C).

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

Correct Answer ( B ) Explanation: Arterial embolism can be divided into thromboembolic and atheroembolic causes. Most arterial thromboemboli originate in the left side of the heart and are frequently associated with a recent myocardial infarction, atrial fibrillation, or valvular abnormalities. Acute arterial thromboembolism results in the sudden loss of a previously present pulse. In general, patients with arterial thromboembolism have few physical findings suggestive of long-standing peripheral vascular disease and will have normal proximal and contralateral limb pulses. These patients typically do not have well-developed collateral circulation and are at high risk for limb ischemia. Arterial atheroemboli (A) refers to microemboli consisting of cholesterol, calcium, and platelet aggregates dislodged from proximal complicated atherosclerotic plaques. In the peripheral vascular system, atheroemboli characteristically present with cool, painful, and cyanotic toes ("blue-toe" syndrome). Arterial thrombosis (C) is a chronic condition associated with progressive development of complicated atherosclerotic plaques. Peripheral arterial thrombi are usually firmly attached to the damaged arterial wall and rarely embolize. Patients will exhibit signs of longstanding atherosclerosis in their lower extremities (atrophy, loss of hair growth, thickened toe nails) and often have a history of claudication. These patients have well-developed collateral circulation, which helps protect them from limb-threatening ischemia. Arterial vasospasm (D), such as Raynaud's disease, causes a sharp border between ischemic and normal tissue. This condition is characterized by intermittent attacks of triphasic color changes (pallor, cyanosis, rubor).

A 24-year-old woman presents to your office with a complaint of severe anxiety. Approximately three times per week she has episodes of sweating, chest pain, heart palpitations, shaking and fear of losing control or dying. The episodes seem to occur and resolve spontaneously. Which of the following is the most appropriate therapy? Carbamazepine Citalopram Imipramine Risperidone «

Correct Answer ( B ) Explanation: Panic disorder is a psychiatric illness characterized by recurrent episodes of panic attacks. Panic attacks are periods of intense fear with specific symptoms that develop quickly and peak less than 10 minutes from the onset of the attack. Symptoms include sweating, chest pain, heart palpitations, shaking, fear of losing control, fear of dying, perceived shortness of breath, nausea, dizziness, chills or hot flashes. Panic disorder often occurs co-morbidly with other psychiatric disorders, such as major depressive disorder, schizophrenia, obsessive-compulsive disorder, agoraphobia, and social phobia. Women experience panic disorder two to three times more frequently than men. Development of panic disorder generally occurs between ages 18-45 years, with the average age being 24 years. Diagnosis is determined using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Initial treatment for panic disorder is with an antidepressant, cognitive behavioral therapy, or a combination of the two. When a decision is made to treat with medication, first-line treatment is with a selective serotonin reuptake inhibitor (SSRI), such as citalopram. There is no evidence to support the use of anticonvulsants, such as carbamazepine (A) in the treatment of panic disorder. Tricyclic antidepressants, such as imipramine (C) are sometimes used, but because of their substantial side effect burden and poor tolerance they are not first-line agents. Second-generation antipsychotics, such as risperidone (D) are not recommended in the treatment of panic disorder due to concern about side effects.

You are seeing an elderly man with new onset of peripheral edema, head fullness and neck venous engorgement. Initial testing shows normal left heart function. You suspect cor pulmonale. Which of the following tests is the most accurate in confirming this diagnosis? Cardiac magnetic resonance imaging Electrocardiography Right heart catheterization Ultrafast ECG-gated computed tomography

Correct Answer ( C ) Explanation: Cor pulmonale is defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. Although the most common cause of right heart failure is left-sided heart disease, cor pulmonale is right heart dysfunction due to a lung, and not heart, problem. Just like systemic hypertension causes changes in left ventricular function, pulmonary hypertension causes changes in right ventricular function. This major underlying pathology is largely due to some kind of pulmonary vascular bed compromise, which can be primary pulmonary hypertension or thromboembolic disease, but more commonly anatomic compromise (COPD, interstitial lung disease and rheumatologic or connective tissue/collagen vascular disorders) or vasoconstrictive compromise (chronic hypoxic states and acidemia). When evaluating a patient with right heart failure, cor pulmonale is considered if pulmonary pathology is causative. However, if the etiologic evaluation is void of a pulmonary source, then the diagnosis of cor pulmonale cannot be made. In this situation, the clinician then tries to pinpoint a cardiac or blood disorder. Even when a pulmonary source is found to be a cause of right side heart failure, it is equally important to determine if there is such a coexisting non-pulmonary cause, such as increased blood viscosity, atrial and ventricular defects, congenital heart disease, cardiomyopathies and constrictive pericarditis. The general approach to evaluating a patient with suspected cor pulmonale begins with routine lab testing, chest radiography and electrocardiography (ECG). Further investigation of underlying pulmonary pathology is then accomplished via pulmonary function testing, ventilation/perfusion (V/Q) scanning and chest computed tomography. Right heart catheterization is the most accurate but invasive test to confirm the diagnosis of cor pulmonale. Cardiac magnetic resonance imaging (A) may provide valuable information about right ventricular size, shape, structure and function. This information, however, does not identify the lung as the site of pathology. ECG (B) changes of right ventricular hypertrophy and strain may suggest cor pulmonale. Again, these do not isolate the location of the underlying pathology. Ultrafast ECG-gated computed tomography (D) is used to study right ventricular function, mainly ejection fraction and wall mass. Its use is still experimental, but in the future, it may be used in following the progression of, not diagnosing the presence of, cor pulmonale.

Which one of the following children should undergo testing for streptococcal pharyngitis? A 16-year-old with pharyngitis, rhinorrhea, and voice hoarseness A 2-year-old with fever and cough A 5-year-old with fever, cough, and tender anterior cervical lymphadenopathy A 9-year-old asymptomatic household contact whose brother was recently diagnosed with acute streptococcal pharyngitis

Correct Answer ( C ) Explanation: Pharyngitis has many etiologies including infectious (bacterial, viral, fungal), GERD, trauma, toxins, and malignancy. Bacterial pharyngitis is most commonly caused by group A strep (GAS). Testing and treatment for group A strep are based on the Centor criteria (1) Temperature >38°C; (2) Tender anterior cervical lymphadenopathy; (3) Absence of cough; (4) Presence of pharyngotonsillar exudates; (5) Age <15 years; (6) Age >45 years subtracts a point. Rapid antigen testing should be obtained in patients suspected of having bacterial pharyngitis who have 2-3 positive features of the Centor criteria. When an appropriate sample is obtained, the rapid antigen test has a sensitivity around 70% to 90%. However, a negative rapid strep test still requires a throat culture given the high false negatives. In patients who have 4 out of 4 elements of the Centor criteria, the positive predictive value for strep pharyngitis is 60% and the patient should be treated empirically and no rapid strep test obtained. For 2-3 Centor criteria, a rapid strep test should be sent and treatment initiated if positive. If negative, a confirmatory throat culture should be sent and treatment held until culture results are available. Centor criteria of 0-1 has a negative predictive value of 70%+ and no testing or treatment should be initiated. Treatment of strep pharyngitis remains to be penicillin. The patient in the above scenario has three Centor criteria (age < 15, fever, and tender anterior cervical lymphadenopathy) and should undergo rapid antigen testing for group A streptococcal pharyngitis. A 16-year-old with pharyngitis, rhinorrhea, and voice hoarseness (A) most likely has a viral cause of pharyngitis and rapid strep testing and treatment is not recommended. Children younger than 3 years of age (B) should not routinely be tested as streptococcal pharyngitis is uncommon and acute rheumatic fever is rare in this age group. Despite exposure to GAS at home or school asymptomatic patients (D) should not be tested or treated.

A 54-year-old man with a history of schizophrenia presents to the ED after a syncopal episode. During your evaluation, he becomes diaphoretic and complains of dizziness. You are able to feel a radial pulse, and he is alert and talking with you. His rhythm strip is seen above. Which of the following represents the first-line treatment of this disorder? Amiodarone Labetalol Magnesium sulfate Synchronized cardioversion

Correct Answer ( C ) Explanation: This ECG shows a rapid, irregular, wide-complex rhythm with multiple QRS morphologies or polymorphic ventricular tachycardia. This most commonly appears as a cyclical progressive change in cardiac axis—otherwise known as torsades de pointes. Torsades often occurs in the setting of a prolonged QT interval during sinus rhythm and is due to abnormal ventricular repolarization. The patient above has a history of schizophrenia. This condition is managed with antipsychotics (risperidone, olanzapine), which are associated with prolonging the QT interval. A QT interval of 500 msec (congenital or acquired) is a risk factor for development of torsades. In adults, however, most causes of QT prolongation are acquired and multifactorial involving drug interactions, myocardial ischemia, and electrolyte disturbances. The immediate management for a patient with torsades is IV magnesium sulfate given as a bolus. If this patient decompensates and loses his pulse, then he'll require defibrillation. Amiodarone (A) is an antidysrhythmic often used in patients with ventricular tachycardia and ventricular fibrillation. However, amiodarone itself causes QT prolongation and can be deleterious in patients with torsades. Labetalol (B) is a combination beta- and alpha-blocking agent that is contraindicated in ventricular dysrhythmias due to its AV-nodal effects. Administration during torsades will likely worsen the dysrhythmia. Although electrical cardioversion (D) is the standard treatment for many wide-complex tachycardias, torsades is less responsive to electricity. It is also difficult to synchronize due to the undulating axis of torsades. If the patient decompensates and loses his pulse, then defibrillation should be performed.

A G2P0010 woman presents with painful bleeding at 37 weeks by last menstrual period. She reports no prenatal care during the pregnancy. She is induced and delivers a male infant who is cyanotic, tachycardic, tachypneic, and noted to have generalized edema. The infant requires multiple interventions for stabilization including intubation. Which of the following is the most likely etiology of his presentation? Erythema marginatum Erythema multiforme Erythema toxicum neonatorum Erythroblastosis fetalis

Correct Answer ( D ) Explanation: Erythroblastosis fetalis is caused by the transplacental passage of maternal antibody active against paternal RBC antigens of the infant and is characterized by an increased rate of RBC destruction that leads to anemia and jaundice in newborn infants. Isoimmune hemolytic anemia occurs in Rh-positive infants born to Rh-negative mothers. This rarely occurs during a first pregnancy, as the mother must form antibodies against the fetal D antigen. Once the mother is sensitized to Rh antibodies, even a small amount of antigen can stimulate antibody production. Maternal IgG antibodies cross the placenta resulting in fetal hemolytic disease. The severity of symptoms can range from mild anemia to hydrops fetalis and death. When the hematopoietic system is exceeded, profound anemia occurs and results in pallor, cardiac decompensation, respiratory distress, and anasarca, and circulatory collapse. Treatment includes supportive care, blood transfusion, exchange transfusion, and IVIG. In order to prevent sensitization, Rh negative should receive anti-D globulin in the following situations: after giving birth to a Rh positive infant, ectopic pregnancy, abdominal trauma in pregnancy, amniocentesis, chorionic villus biopsy, or abortion. The patient in the above scenario had an abortion and likely never received human anti-D antibody, which led to sensitization and erythroblastosis fetalis. Erythema marginatum (B) is associated with rheumatic fever and is one of the major Jones criteria. It is an erythematous macule on the trunk that clears centrally. Erythema multiforme (C) is a hypersensitivity reaction on the early part of the spectrum leading to toxic epidermal necrolysis. Erythema toxicum neonatorum (A), often referred to as E-tox, is a common rash seen in newborns. It is benign and only requires supportive care.

An obese 34-year-old woman is brought to the Emergency Department with respiratory distress. Two months ago she was in the hospital for knee surgery. Paramedics report an acute onset of dyspnea and pleuritic chest pain. She also complains of a tender thigh on the same side of her knee surgery. She is tachycardic and tachypneic, and mildly hypotensive. Examination reveals decreased breath sounds but no hyperresonance. An emergent chest radiograph is relatively normal except for some mild atelectasis. Which of the following is the most likely diagnosis? Acute bronchitis Pleural effusion Pneumothorax Pulmonary embolism

Correct Answer ( D ) Explanation: Pulmonary embolism refers to the obstruction of a pulmonary artery by thrombus, tumor, air or fat that originated elsewhere in the body, mostly from the deep veins of the lower extremities. It is classified as acute or chronic, and massive or submassive. It is often a fatal disease, leading to a mortality rate of 30% without treatment. Risk factors include immobilization, surgery or central venous instrumentation within the last three months, stroke/paresis/paralysis, cancer, chronic cardiac disease, autoimmune disease, obesity, >1 pack per day tobacco use, hypertension and a history of deep vein thrombosis. Most patients experience dyspnea with or without wheezing, cough, pleuritic chest pain, orthopnea, lower extremity pain or swelling, tachypnea, tachycardia, jugular venous distension, decreased breath sounds and an accentuated pulmonic component of S2. These signs and symptoms are variable and nonspecific. Furthermore, up to 32% of patients present asymptomatically. As such, the diagnosis can be difficult. The mainstay of treatment is anticoagulation. Acute bronchitis (A) presents as the "common cold", with rhinorrhea, nasal congestion and cough lasting longer than 5 days. Cardiopulmonary distress is usually not common with bronchitis. Pleural effusion (B) is diagnosed clinically and confirmed with radiography. The usual findings in pleural effusion are dependent bibasilar white opacities on chest radiography. A relatively normal radiograph is not common with pleural effusion. Pneumothorax (C) usually presents with sudden onset dyspnea, pleuritic chest pain, hyperresonant percussion and an abnormal chest radiograph showing air in the pleural space. A normal radiograph in a patient with recent post-surgical immobilization is not the typical scenario for pneumothorax.

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

Correct Answer ( D ) Explanation: The differential diagnosis for third-trimester vaginal bleeding includes placental abruption, placenta previa, cervical or rectal lesions, or bloody show (expulsion of a blood-tinged mucus plug). The clinical scenario of painless, bright red vaginal bleeding is most suggestive of placenta previa. In placenta previa, the placenta abnormally overlies the cervical os. Most cases of placenta previa diagnosed on 20-week ultrasound resolve in the months prior to delivery as the lower uterine segment elongates and the placenta no longer overlies the cervical os. However, in up to 20% of cases the placenta remains positioned over the cervix, which can cause significant and life-threatening hemorrhage at the time of delivery. A patient presenting to the ED with vaginal bleeding should undergo ultrasound to evaluate for placenta previa. Transvaginal ultrasound is safe and more accurate than transabdominal ultrasound for diagnosis of placenta previa​, although transabdominal ultrasound can be utilized as an initial screening study. Patients with suspected placenta previa should not undergo speculum exams or digital cervical exams due to the risk of precipitating significant hemorrhage. The vagina may be visually inspected to confirm and quantify vaginal bleeding but more invasive exams should not performed unless an obstetrician is present. Patients with confirmed placenta previa are managed by elective cesarean section. Administration of betamethasone to hasten fetal lung maturity (A) is indicated for women with preterm labor (contractions resulting in cervical dilatation) prior to 37 weeks gestation. Sterile speculum examination (C) and sterile digital cervical exam (B) are contraindicated until placenta previa is ruled out as this can lead to significant hemorrhage.

A 29-year-old woman presents to the ED complaining of pain on inspiration. Over the previous 3 days, she has experienced a low-grade fever, sore throat, and body aches. Auscultation of her lungs reveals normal breath sounds. Her chest radiograph is seen above. Which of the following is the most appropriate next step in management? D-dimer Doxycycline Inspiratory and expiratory radiographic views Supportive care

Correct Answer ( D ) Explanation: This patient has pleuritic chest pain in the setting of a recent upper respiratory infection (URI). Viral pleuritis and pulmonary infarction are commonly associated with pleuritic chest pain. The patient's history often helps to establish the diagnosis of pleural inflammation. The pain of viral pleuritis usually is preceded by several days of a typical viral prodrome, with low-grade fever, sore throat, and other upper respiratory or constitutional symptoms. Management of viral pleuritis includes supportive care with NSAIDs. In the absence of these prodromal symptoms, an alternative etiology for pleuritis should be sought. A patient history of congestive heart failure, liver disease, uremia, or malignancy should direct further evaluation. A D-dimer (A) helps to risk stratify patients with suspected pulmonary embolism. It is usually reserved for those patients of low to moderate risk of having a pulmonary embolism. The Wells criteria for pulmonary embolism is commonly used as a tool to risk stratify such patients. The patient in the clinical scenario does not meet criteria for suspected pulmonary embolism. Doxycycline (B) is used in the outpatient treatment of pneumonia. This patient demonstrates signs of infection (low-grade fever); however, her chest radiograph is normal, and her infection is consistent with a viral etiology. It is also important to confirm that women of childbearing years are not pregnant prior to administration of doxycycline, which is contraindicated in pregnancy. Inspiratory and expiratory (C) radiographic views are sometimes used to help diagnose a small pneumothorax. Pleuritic chest pain is sometimes experienced in patients with a pneumothorax. The radiograph above is normal, and the patient has other signs and symptoms consistent with a URI rather than pneumothorax.