CAM Final Sample Questions
18yo WM presents to the ED transported by ambulance after a head-on MVA complaining of difficulty breathing and chest pain that is worse when taking deep breaths. Patient is A&Ox3 and is in mild respiratory distress, but otherwise normal. Patient's vital signs are height: 6'4", weight: 180lb, BP: 106/74, PR: 96, RR: 24, O2 sat: 95%, temp: 98.5. Patient is not on any medications, has no relevant medical history, and denies smoking and alcohol use. The physical exam reveals hyperresonace to percussion, decreased tactile fremitus, and decreased breath sounds on the left side. What is the most likely finding upon chest x-ray?
Visceral Pleural Line
A 50yo presents to the ER with a complaint of recent dyspnea and cough, she got worried and came in because her chest started hurting this morning too. PMHx includes CHF, HTN. Pt is a smoker. On PE you find decreased tactile fremitus, decreased breath sounds, and dullness to percussion, and a light pleural friction rub. On CXR you see blunted costophrenic angles. What is the gold standard management for this pt?
Thoracentesis
A 51 YO WF is admitted to the hospital for pneumonia and started on IV Aztreonam and Levofloxacin. Vitals are as follows: Temperature 100.1, HR 87, Respirations 24, BP 126/84, O2 Sat 98% on room air. Labs show a WBC of 11,000/mm3 and a positive test for Haemophilus influenzae. What would be a correct evaluation of the patient?
The patient does not meet SIRS criteria but should be closely monitored
GH is a 60 y/o WM who presents to the clinic c/o unilateral nasal obstruction with intermittent bleeding. He denies hx of nasal trauma or Anterior rhinoscopy reveals a cauliflower-like growth from the lateral nasal wall. What is the recommended course of treatment for GH?
Surgical excision (note: cauliflower is a descriptor for cancer!)
MP is a 30yo WF with moderate persistent asthma. You perform a pulmonary function test. Regarding her lung function, you expect to find which of the following results?
. FEV1>60% but <80% predicted
You are a PA working in the ER and a trauma comes in due to a car crash. You get assigned a patient who has no eye opening, no verbal response, and no motor response. What is their measurement on the Glasgow Coma Scale?
3 (This is the worst possible score)
MK presents to your clinic complaining of severe fatigue with a cough for the last month. He states that the cough was dry at first, but has become progressively more productive. He reports no dyspnea, and you notice that he has lost 10lbs. since his last visit 6 months ago when he first got out of Jail. A chest X-Ray reveals opacities in the apices of the lungs. What test are you going to perform to definitively diagnose MK?
3 consecutive morning sputum cultures (you suspect TB)
13-month-old female brought to ED by her parents for acute onset dyspnea. Parents state that the child was last seen playing on the floor at their home when her symptoms began approximately 15 minutes ago. Parents deny any previous similar episodes, any recent illnesses and state that their daughter is up to date on all immunizations/vaccinations. Physical exam reveals a non-productive cough, increased work of breathing, cool/pale/diaphoretic skin, perioral cyanosis, tachycardia and tachypnea. Following auscultation, you note a faint, right-sided inspiratory/expiratory wheeze along with decreased breath sounds which are also restricted to the right A/P lower lobe. Visual inspection of the anterior oropharynx noted unremarkable. Initial treatment of this patient includes which of the following?
5 Back Blows followed by 5 Chest Thrusts (kid is in respiratory distress!)
A 67-Year-old patient presents to you complaining of cold like symptoms. His history is nonexistent as he just moved to the United States a couple of years ago. His chest X-ray is is showing signs of Tuberculosis. What is the gold standard test for identifying this disease?
Acid Fast Bacilli
An elderly, fair skinned male patient presents to your fmily practice with 1-2cm lesion on his face that you describe as a dry, rough, scaly "sandpaper" lesion that is moderately erythematous. He has a long history of sun exposure. What is your diagnosis?
Actinic Keratosis
53 yo Asian female presents to ER c/o severe left eye pain, blurred vision, and headache since this morning. She describes seeing halos around lights and reports vomiting twice. Upon physical examination, you note mid-dilated pupil, conjunctival erythema, and a steamy cornea. What is the most likely dx and first step in management?
Acute angle-closure glaucoma; refer to ophthalmology
A 70-year-old WF with a history of HTN and giant cell arteritis presents to the ED complaining of sudden, right-sided decrease in vision. The PA finds significant pallid swelling with a cherry-red spot in the fovea. She denies any pain with the vision loss and the acuity is reduced to hand motion in the OD and intact in OS. Which of the following management options is incorrect?
Administer intravitreal injection of bevacizumab Correct Treatments: A. Emergent referral to an ophthalmologist B. Begin high dose oral prednisone C. Lie patient supine and begin orbital massage D. Perform a temporal artery biopsy
Your patient is a 10 y/o WF with a 1-month history of dyspnea. She notices it bothers her most when she is playing soccer, but it only bothers her once per week. A cough has woken her up at night 1 time since she first noticed these symptoms. Her PMH reveals allergies to cats and dogs, eczema, and no current medications other than Benadryl PRN for her allergies. What is the most appropriate treatment for this patient?
Albuterol Inhaler (this girl has intermittent asthma, so nothing more than an inhaler is needed!)
Your 75-year-old patient comes to his routine physical accompanied by his wife. She states that over the past year he has been very forgetful and has had some strange behavior changes. Recently, he got lost driving them home from church; which is something they have done every Sunday since they've been married. You don't notice any chorea, rigidity, bradykinesia, or tremors. His MMSE yields a score of 20. Otherwise, his physical exam is unremarkable. You order a CT, which shows atrophy of the cerebral cortex. What is your diagnosis and what do you prescribe your patient?
Alzheimer Dz Prescribe Donepezil (good for early) If later in dz, give Memantine
21-year old patient presents to your family medicine clinic complaining of nasal congestion and fever for 12 days. Upon questioning, patient states the discharge is purulent and she feels pressure over her maxillary and frontal sinuses. Vital signs in clinic read: BP: 120/80, P: 72, R: 18, T: 102F, O2: 99%. Pt has no hx of allergies. What would be the appropriate treatment at this time?
Amoxicillin-Clavulanate 1000/62.5mg 2 tabs PO BID x 7 days
What antibiotic will give a peticchial rash in mono patients?
Ampicillin
75 y/o WM, with a PMHx of COPD, presents with a two-week history of worsening dyspnea and chronic cough from baseline. Pt states the cough is worse in the mornings with green/purulent sputum. He has a 50-pack year smoking history. On examination pt is tachypneic with diffuse rhonchi and wheezing throughout. Pulse oxygen saturation is currently 90% on room air with a baseline of 92% on room air. What is the most appropriate course of treatment?
Antibiotics
29 y/o WM presents to the emergency department complaining of a painful, swollen left eye. He reports that he was at a White Sox spring training game when he was hit in the face by a foul ball. Your physical exam findings show decreased visual acuity, diplopia with upward gaze, and anesthesia to the anteromedial cheek. You notice that when he blows his nose (from all of his crying), his eyelid swells. The CT scan you ordered shows a teardrop sign. How do you treat this patient?
Antibiotics, corticosteroids, and referral to ophthalmologist. (this is an orbital blowout fx)
A 5 yo WM presents to the ED with raised, well-circumscribed areas of erythema and edema on his arms. The mother claims the child was playing in the woods prior. The child is in NAD but is scratching at his arms and lower legs. What is the best treatment at this time?
Antihistamines
A 68 year old Caucasian male presents to family practice complaining of shortness of breath, a persistent dry cough, and loss of appetite. He reports 10 pounds of unintentional weight loss over the past two months. Smoking history includes 25 pack years, and he performs very little physical exercise since retiring from the construction business 15 years ago. Vital signs are unremarkable aside from a slightly elevated BMI. Chest x-ray reveals pleural plaques and a honeycomb appearance, most notably in the lower lobes. What is the most likely diagnosis?
Asbestosis
A 44-year-old white female with no significant past medical history presents to the family practice complaining of a productive cough with yellow-green sputum and mild left sided chest pain over the past 3-4 days. Upon assessment, she is febrile (temperature 102 degrees F), tachypneic, and tachycardic, with increased tactile fremitus on the left and dullness to percussion in the left lower lung field. CXR shows an infiltrate in the left lower lobe. Patient lives at home with her husband, and she denies any recent hospitalizations or recently taking antibiotics. She reports NKDA. You diagnose her with pneumonia; how will you treat this patient?
Azithromycin (could also do doxy for CAP)
A 21 y/o WF presents to the ED of your rural hospital at 3 AM. Her college roommates brought her in when they discovered her confused and disoriented. Your patient has a MMSE score of 16 so you question her roommates regarding the history of events surrounding her illness. They say she has been complaining of what she assumed is the flu, given her sore throat, extreme headache, chills, myalgia and extreme fatigue beginning 18 hours ago. They deny witnessing any seizures, head trauma or alcohol/drug use. Her vitals are as follows Temp: 38.9 C, Pulse: 99 and regular, BP: 120/90, RR: 22, SPo2: 98%. Upon physical exam, you note a diffuse petechial rash on her trunk and nuchal rigidity as well as a positive Kernig's and Brudzinski's sign. The neurological exam is negative for papilledema and focal neurological signs. You immediately admit her and begin IV fluids and antipyretics. You have an order placed for a CT without contrast and an LP at 7 AM. What is your next step?
Begin empiric IV Antibiotics (DO NOT DELAY ABX WHILE WAITING FOR LP RESULTS)
A 71-year-old WM is brought into your ER with unilateral facial paralysis. The patient describes this condition as weakness only in the face. The patient has no history of HTN, diabetes, and cold sores. Upon PE the patient has drooping of the corner of his mouth, but when he smiles, his forehead is not spared. What condition do you diagnose him with?
Bell's Palsy (if it were a stroke, the forehead would be spared)
A 38 year old Caucasian female presents to the emergency department complaining of fever, fatigue, dry cough, and dyspnea that has progressively worsened over the past 3 days. She also reports "a bunch of painful red spots" on her lower extremities. She denies any changes in vision or ocular discharge, otalgia, otorrhea, rhinorrhea, sinus pressure, or any recent URIs. Vital signs are unremarkable aside from mild tachycardia and tachypnea. A tissue biopsy reveals noncaseating granulomas, and PFT results include decreased lung volume but a normal FEV/FVC ratio. What chest radiograph findings would you expect to see in this patient to confirm your expected diagnosis?
Bilateral Hilar Lymphadenopathy (Sarcoidosis)
17 yo WM presents with complaints of a red, target like lesion on his left ankle. Pt states he was cleaning out the tool shed 6 hours earlier. He reports mild pain at the site of the lesion, as well as weakness and shaking of the extremity. Pt states he has a slight headache which he rates 3/10. His vital signs include: BP: 121/75, RR: 15, O2Sat: 99% on RA, HR: 90, Temp: 98.6F. Examination of the LLE shows mild rigidity and tenderness to palpation in the muscles surrounding the lesion. The wound appears as a blanched, circular area with surrounding erythema. Two small puncture wounds are located centrally within the blanched region of the wound. What is the most likely cause of the lesion?
Black widow spider bite (black widows show more systemic signs, brown recluses will show necrosis around the bite)
A 38-year-old male presents to your clinic with unknown history and you have diagnosed him with oral candidiasis. You are unsure whether to prescribe him clometrizole lozenges or systemic antifungals. What additional lab test is warranted to aid in your decision?
CD4 Count (checking for HIV, b/c if he does NOT have it you can do nystatin mouth wash or clotrimazole troches; if he does have HIV, you must do oral antifungals)
BP is a 25yo WM who presents to the ER after an "episode" of unconsciousness following the sensation of riding on a roller coaster. Associated this aura was also a period of uncontrollable lip smacking and hand patting. Her vitals are as follows, Temp: 98.6F, Pulse:120, BP: 125/85, RR: 18, O2 sat: 98% RA. You inform BP that she was experiencing a focal seizure. What treatment do you start her on?
Carbemazepine
TA is a 65-year-old WF that presents to family practice. She reports a gradual loss of vision over the past year. You notice that her lens appears to be opaque while she is talking. TA has smoked 1 ppd x 25 years. Her PMI indicates DM II and also takes Prednisone 10mg PO every day. You perform a fundoscopic exam and find an absent red reflex in both eyes. What do you diagnose your patient with?
Cataracts
A 56-year-old white male with a longstanding history of smoking (1 ppd x 30 years) presents to the family practice complaining of a persistent cough, hemoptysis, and progressive weight loss over the past 2-3 months. Upon examination, you noticed dilated veins on his heck with prominent veins on his chest. You are very concerned about lung cancer, so you order a CXR/CT; you ultimately get sputum cytology, and the patient is diagnosed with small cell lung cancer. What is the treatment of choice for this patient?
Chemotherapy
A 5-month-old male patient presents with recurrent URI since birth, chronic sinusitis and sputum production and overall failure to thrive. Chest X-Ray shows signs of bronchiectasis. What test would confirm your suspected diagnosis?
Chloride sweat test (or lick the baby, that works too lol)
A mother presents her 5-year-old son to your walk-in clinic with complaints of right ear pain that started yesterday after returning home from spring break vacation at the beach. The patient does not complain of any other symptoms. On physical examination, you note erythema and edema of the right ear canal and cannot see the tympanic membrane. Manipulation of the right auricle elicits pain. The left ear is normal. Vitals are normal. What is the appropriate recommendation for this patient?
Cipro HC Otic drops
60 year old white female was admitted to the hospital 3 days ago for ischemic stroke. He was anticipating to be discharged home today but he has developed some shortness of breath and a productive cough with purulent sputum. You notice he is now running a fever of 102F. Other vital signs are within normal limits. Re-examination of the patient reveals dullness to percussion and increased tactile fremitus over the right lower lung field. You hear some mild crackles upon auscultation. You determine that the patient is at risk for MRSA and pseudomonas. No Legionella is suspected. You decide to empirically start Vancomycin and piperacillin/tazobactam. What other antibiotic would you order?
Ciprofloxacin (b/c pseudomonas)
72yo Male presents to primary care with complaint of "itchy rash & blisters". Upon physical exam you note scattered excoriations on the bilateral lower extremities. Amid the excoriations, you identify a single 1cm tense, fluid-filled bullae still intact. Pt is negative for vesicles, warty growths, furuncles, fever, weight change, Diabetes, hypertension. Vitals within normal limits. You inquire further about the blisters and find that before they appear, the area is pruritic with urticarial like lesions. The patient also complains that the itching is severe and is affecting both his golfing and sleep. To confirm your diagnosis, you inform the patient that you will complete a punch biopsy of the intact blister at today's visit to send for Direct Immunofluorescent studies. What first line treatment is most appropriate for this patient's likely diagnosis?
Clobetasol cream and oral Prednisone (bullous pemphigoid)
A 56-year-old diabetic patient presents to your practice for a regular physical exam. As a well-trained PA, you are performing a thorough physical exam and while doing so, notice creamy-white curd-like patches overlying the erythematous mucosa of the mouth that rub off with a tongue depressor. Upon questioning, you find your patient wears dentures. Vital signs are normal. Pt denies any recent antibiotic use, history of HIV infections, sore throat, cough, N/V, or pain. What would be the appropriate treatment at this time?
Clotrimazole troches 10mg 5x/day x 14 days (also educate on cleaning the dentures better)
4 yo WF presents to the ER with mother around midnight with shortness of breath. Mother reports that symptoms started a few days ago but are only getting worse. On physical exam, you notice that the patient has a cough that sounds like "barking" and inspiratory/expiratory stridor. You also see mild retractions with breathing. Your first line of treatment is Dexamethasone and nebulized epinephrine which improves patient's shortness of breath. What is the most likely diagnosis?
Croup (barking cough is buzzword here)
Brady Edge, A 65yof, presents to the ER with a headache with abrupt onset, nausea, vomiting, and an altered mental status. The patient is hypertensive. You correctly suspect nontraumatic intracerebral hemorrhage. Which of the following is true regarding this patient?
HTN is the likely cause of the condition, and for this reason administer IV mannitol DO NOT DO LP
A 5-year-old boy presenting to the ER with dysphagia, fever, inspiratory stridor, drooling, and leaning forward with his hands on his knees. He most likely has epiglottitis. What is the most common cause of epiglottitis?
Haemophilus influenza type B
76 y/o WM presents to your ED with complaints of left sided weakness along with sensory loss on the same side. Upon examination of his visual fields, you notice that the Pt. has bilateral symmetric loss of vision in half of the visual fields, and his eyes are deviated to the right. His daughter states that the Pt. started having symptoms around 0930 while having breakfast. It is now 1045. You rightfully order a non-contrast CT scan to rule out hemorrhage. What is the gold standard for identifying ischemic stroke?
Diffusion weighted MRI
A 78-year-old man on dialysis for renal failure presents with a 2-day history of erythema, tenderness, and warmth to his right leg. When you ask about MRSA, he states "No, I never did have the Measles." This makes you want to cover MRSA. His medical record notes an anaphylactic reaction to Bactrim. What should be prescribed?
Doxycycline
JK is a 75-year-old WF that presents to family practice. She states she has bilateral blurred central vision loss. Her ability to see details and differentiate color has diminished. She refers to her vision as "donut like". You do a test to check her peripheral fields and her peripheral vision is still intact. You also a perform a fundoscopic exam and see small, round, yellow-white spots on the outer retina. What do you diagnose your patient with?
Dry Macular Degeneration
Patient is a 17-year-old female presenting to the ED by ambulance. The patient is confused, fatigued, and has no recall of that morning, so history is mostly obtained from the mother. The mother states the patient, "woke up and started shaking for a few minutes" and was "out of it" afterwards. The mother states this has never happened before. Which of the following test(s) would be helpful in diagnosing this patient?
EEG MRI Drug Test CMP (need to know the cause of the seizure, so run everything)
A 59 y/o WM presents to family practice with a 1-week history of lower back pain with left leg numbness and weakness. He is also concerned about his prostate because he is having difficulty completing micturition and controlling his bowels for 1 week. Upon physical exam you note loss of sensation on the left posterior leg, plantar foot, and perianal region. You note decreased anal sphincter tone and weakened plantar flexion of the left foot. Based on this presentation, what is the next appropriate step?
Emergency consult with surgeon
A 70 y/o WM comes to your primary care clinic complaining of dyspnea whenever he goes to check the mail each day. His PMH shows a 40 pack year history of smoking and hypertension. Your physical exam reveals increased chest AP diameter, decreased breath sounds in all lung fields, and decreased tactile fremitus. What is the likely diagnosis?
Emphysema
A 45-year-old male patient presents to the Emergency Room with his wife complaining of headache and temperature of 101.3 Fahrenheit. He Is slow to answer your question and has a low MMSE score of 17. During the physical exam, you find that he has nuchal rigidity but Kernig's and Bruzdzinski's are absent. A CT of the head shows no underlying hemorrhage. You perform a PCR and find a positive Herpes Simplex Virus. What is your diagnosis?
Encephalitis
A 7 yo WM presents to your clinic with his mother. The mother claims that her son has "staring spells" throughout the day that are interrupting his school work. She tells you she is worried that he might be developing ADD and that he needs to get his head out of the clouds. She asks you if there is any medication she can give him to keep him from "spacing out." She is also extremely concerned about side-effects and wants her son on a drug with very few side-effects. What is the best prescription choice?
Ethosuxamide
A 25-year-old WF reports with redness of the right eye for 2 days. She explains that her friends have similar symptoms, and they think it's pink eye. The reason for her coming in is to contain her condition so that it doesn't spread. She elaborates on how she has had no pain but complains of morning crusting and yellow purulent discharge in which she has trouble opening her eye. No other abnormalities are present on physical examination. What would you advise her in order to contain the situation?
Explain that it is bacterial conjunctivitis, so prescribe her with ciprofloxacin and advise her to wash her hands often.
Which of the following presentations is MOST concerning for Stevens-Johnson Syndrome/TEN?
Facial blistering and erythematous macules on the oral mucosa and conjunctiva of a 21-year-old female who recently started TMP-SMX (Bactrim) for UTI. Bactrim is one of the MC drugs that cause this!
A patient rushes to his local urgent care with eye pain. Pain was relieved with analgesic eyedrops and fluorescein staining revealed linear abrasions. What is the best first line treatment?
Fluoroquinolone eyedrops (cipro) Must use fluoroquinolones if it's a contact wearer!
JB is a 5yo BM whose mother brought him into your clinic. He has had a couple of nose bleeds in the last two days and his mother says that he's been mouth breathing. Upon examination, you notice a mucopurulent discharge draining from his left nostril and a foul-smelling odor coming from his nose. What is the most likely cause of JB's symptoms?
Foreign body
Your patient presents to your office complaining of acute right ear pain. You find out she went to a Red-Hot Chili Peppers concert two nights ago. She reports that she had experienced some mild hearing loss and felt a popping sensation, but now she is experiencing discharge from her right ear. On physical exam, you see a perforated TM with mild erythema and purulent discharge. You advise the patient to avoid water and moisture in the affected ear and prescribe her some otic drops. What antibiotic drops should you avoid in this patient?
Gentamicin (aminoglycosides are ototoxic y'all!)
38-year-old male patient presents to primary care office. Patient says he has noticed patches on his tongue. Upon closer inspection you see that the patches are on the dorsal and lateral borders of the tongue and surrounded by a well-demarcated white border. Touching the patches, you see that they are smooth, glossy and absent of filiform papilla. What is this condition?
Geographic tongue
A 37yo WF shows up at your primary care clinic for slowly worsening hearing loss in her right ear and a feeling of "ear fullness". Upon physical examination, you notice a buildup of cerumen blocking the tympanic membrane. You apply a few drops of Debrox, have her wait for 5 minutes, and then attempt to flush the cerumen out. Unfortunately, it isn't working. What is the most appropriate next step in treating this patient?
Have the patient use OTC Debrox for a day or two at home and then return to the clinic to try flushing it out again (you could also fish it out with a curette)
58 yo BM comes into your primary care office complaining of a painful cut on his right foot that will not go away. During physical exam, you notice decreased motor function in his toes and a decreased touch and vibrational sense on DIP of right foot. Pt denies injury to the foot. Pt's T: 98.2, HR: 88bpm, BP: 127/86, 02: 98%, Ht: 5'10, Wt: 285lbs. What will you test next to determine the MAIN cause of motor and sensory loss in his right foot?
Hemoglobin A1C (diabetic neuropathy)
A 25 y/o WF comes to your clinic complaining of recent upper respiratory infection to include fever, malaise, and rhinorrhea x 5 days. Patient states the symptoms resolved with OTC Nyquil at night and Tylenol during the day. Today the patient is complaining of pain in her left eye with reduced vision and sensitivity to light for the last 24 hrs. Patient denies wearing contacts, exposure to ocular debris, injury to the eye or excessive rubbing. VS within normal limits, afebrile. After visual inspection of the sclera, conjunctiva, and fundoscopic you rule out global cause. Next, you complete fluorescein instillation bilaterally to her eyes. The right eye is without concern. The left eye presents with a dendritic branching brightly lit area midline involving the cornea. What is your diagnosis and what is your next step in treatment?
Herpes Simplex Infection, Ophthalmology consultation aka Keratitis
74yo BM presents to ED complaining that he is unable to catch his breath since this morning. Patient's vital signs are height: 5'11", weight: 265lb, BP: 144/86, PR: 114, RR: 28, O2 sat: 94%, temp: 98.9. Upon obtaining a thorough history the patient reveals he had a right knee replacement 10 days ago and is walking around very much. Current medications include acetaminophen, tramadol, and atorvastatin. Patient has been a 0.5ppd smoker for 35 years and denies alcohol use. Being an awesome PA, you order a helical CT scan and doppler ultrasound which are both positive. What sign during the physical exam is most likely to be positive?
Homan's Sign
JS comes in to your clinic c/o this painful bump on her eye. On physical examination you notice a swollen, red lump on her upper eyelid. She states she woke up with it and hasn't taken any medications yet. What is the likely diagnosis?
Hordeolum (b/c its painful duh)
A 65-year-old WM with a history of HTN and DM II woke up one morning with sudden dizziness and mild nausea. It resolved within a couple minutes, but he noticed that it returned when he lay down. The symptoms persisted throughout the week and he went to his primary care physician for an evaluation. His PCP performed the Dix-Hallpike Test and diagnosed him with benign paroxysmal positional vertigo. Which of the following were findings noted on the physical exam?
Horizontal fatigable nystagmus (BPPV can also be rotatory/torsional nystagmus)
Beyoncé brought her 48-year-old husband Jay-Z in to the ER. She reports that he tried to cheat on her, which is not something any sane individual would do to her. He has had personality changes, chorea, and dementia. In your PE you realize that Queen B is correct in her assumptions and diagnose Jay-Z with a disease that has no cure and is usually fatal within 15-20 years. What did you diagnose Jay-Z with?
Huntington's Dz
An 84-year-old WM presents to the primary care clinic with a c/o unilateral hearing loss. Upon PE, the PA observes that the pt has some d/c from the ears, conductive hearing loss, and some mild peripheral vertigo. The otoscopic exam reveals a white mass behind the TM. What would be the most pertinent PMH to obtain from the pt from this dx?
Hx of chronic Eustachian tube dysfunction
A preterm 36-week infant of uncomplicated vaginal birth is in the NICU with respirations of 86 breaths per minute. She is cyanotic on room air and you notice accessory muscle use, nasal flaring, and grunting on expiration. Chest x-ray reveals low lung volume and diffuse reticulogranular ground glass appearance with air bronchograms. What is the most likely diagnosis?
Hyaline Membrane disease
EL comes into your ED c/o of being poked in the eye really bad. On physical examination you see blood sitting in the bottom of his eye, teardrop pupil and severely diminished visual acuity. He states he has double vision and eye pain. You perform the seidel test and it's positive for blood in the anterior chamber. You are worried they are going to lose their vision, so you refer him to see an ophthalmologist emergently. What do you suspect the diagnosis is?
Hyphema (hypopion would be pus in the anterior chamber)
34 YO WF presents with right ear pain and swelling for 2 weeks. Pt reports she was treated for an ear infection and lost her ear drops a while ago. She complains of slight hearing loss to her right ear along with purulent discharge. She has been taking Acetaminophen for pain without relief. Pt has a known history of DM, HTN, HLD. She has a PCN allergy. Upon examination, you find her right ear TTP, otorrhea, as well as granulation tissue on the floor of the EAC. What is proper treatment for this patient?
IV Ciprofloxacin (IV b/c this is MALIGNANT OE, plus she's diabetic so that was the big clue)
33-year-old WF presents to the emergency room with unilateral vision loss. She reports she has been losing her vision gradually for the past few days. Upon exam, you observe pain with ocular movement, afferent pupillary defect, and some optic disc swelling. What is your best next course of action?
IV methylpredisolone (side note: optic neuritis, probably from MS!)
47yo WM presents to family practice with complaint of a worsening cough and some dyspnea. Pt says that it has been getting worse over the past few months and is getting worried. He has no significant medical hx, but is a smoker, 1ppd x 20 years. On PE you find inspiratory bilat crackles and clubbing of the fingers. You decide to order a CXR and find a honeycombing pattern. What is your dx?
Idiopathic Pulmonary Fibrosis
A young female patient comes into your clinic complaining of R eye pain and vision loss. She has no pertinent PMHx, no pertinent family hx and her vitals are all within normal range. Upon visual examination, you find a Marcus-Gunn pupil in her R eye, decreased visual acuity, pain with EOMs and loss of color vision. You note her R optic nerve to be inflamed upon fundoscopic exam. She also expresses she has been very fatigued lately and her fingers have been going numb. She has a +Lhermitte's sign and a +Babinski sign. You correctly order an MRI with gadolinium and an LP to confirm your suspected diagnosis. What do you expect to find in her LP that will best support your diagnosis?
Increased IgG (oligoclonal bands) (MS)
A 30 year old white male presents to the ED by ambulance after an MVA. He complains of shortness of breath and right sided chest pain that began suddenly after the accident. He does not have any other injuries or complaints. O2sat is at 89% on room air. Your pulmonary physical exam reveals absent breath sounds and hyperressonance over the right the over the right lung field. You notice the trachea looks slightly deviated to the left. What other findings would you expect to find in this patient?
Increased JVP (tension pneumothorax b/c trachea is deviated, need to do needle aspiration asap)
A 43yo WF presents with smooth, discrete, circular patches of hair loss that have developed over the last few weeks. Asid from treating possible underlying causes, what is the management of this condition?
Intralesional corticosteroids (alopecia)
A 15 y/o WF presents to your clinic with a runny nose. She moved to Knoxville from Chicago 3 months ago. She reports itchy eyes, and nose, as well as frequent sneezing. The nasal discharge is clear, and her nasal mucosa is pale and boggy. You diagnose her with allergic rhinitis. What is your first line treatment for this disorder?
Intranasal corticosteroids
65 yo WM with a PMHx of HIV, DM, and HLD presents with complaints of a lesion on his back that he reports was first noticed by his husband 1 week ago. Patient states that the lesion does not hurt, but will bleed if it is scratched or picked. On exam, the lesion is a reddish-purple nodule that is approximately 3 mm in size. What is the most likely diagnosis and what is the next step of treatment?
Kaposi sarcoma- biopsy
A 64 yo WF presents to your clinic c/o "itchy spots" on her knees onset 3 days ago. She is concerned that she may have gotten rug burn, as she states that the rash appeared a few hours after playing on the ground with her grandson but become more irritable over the last few days. As you inspect her knees you see a raised, dark red plaque with thick silver scales. While inspecting the rest of her skin you notice some slight pitting in her fingernails. You decide to prescribe her topical steroids and ask her to come back in a month to assess her progress and consider further treatment. What clinical manifestation is associated with this patient's symptoms?
Koebner's phenomenon Psoriatic arthritis Auspitz sign Lichenification (all are right answer)
A patient comes in to the Emergency Room where you work as a PA. They present with nausea, vomiting, and a continuous spinning sensation. On your physical exam you find decreased hearing in the left ear and a Weber test that lateralizes to the right ear. They have a negative Dix-Hallpike test and are not helped by the Epley Maneuver. You deduce that they are having a problem with their CN VIII. What do you diagnose this patient with?
Labyrinthitis (Ddx is vestibular neuritis, but labyrinthitis will show sensorineural hearing loss and neuritis will not!)
36 y/o male presents to ED with c/c of dyspnea x 4 days. Pt also admits to fever, chills, myalgia, malaise, HA and nausea accompanied by several episodes of vomiting and diarrhea. Pt states that all of his symptoms began simultaneously and have progressively worsened since their onset. Pt states that he works in construction and just recently switched projects to an indoor site to get out of the summer heat. Pt denies any known provocative or palliative factors but states that many of his coworkers are having similar symptoms. Physical exam reveals equal/symmetrical chest rise and decreased bronchial breath sounds. Dullness to percussion, increased tactile fremitus and rales are noted in both R/L lower lobes. Pt denies any previous similar symptoms in the past along with any recent illness, surgery, trauma. You diagnose this pt with a type of CAP pneumonia. What is the most likely causative agent?
Legionella (remember it comes from water or AC)
CC presents to the ED complaining of unilateral hearing loss x 4 days. She also notes a slight ringing in her right ear as well as slight unsteadiness while walking. You suspect a vestibular schwannoma. How do you confirm this diagnosis?
MRI
A mother presents to your ED with her 2 year old son. She is in a panic because she believes her child has swallowed a small object that is now lodged in his throat because she can hear inspiratory stridor and her son is drooling. When you look at the child, you see that he is tripoding in order to breathe and appears in extreme distress. When looking in the boy's mouth, you notice no trauma nor can you visualize a foreign object. You decide to order a lateral cervical X ray, and it shows a thumb sign on the throat. What is your first step for treatment?
Maintain and support his airway (2nd would be IV abx)
A patient with no history of trauma reports to the ED complaining of tenderness behind his left ear. He tells you that he was diagnosed with otitis media 2 weeks ago but did not want to take the antibiotics prescribed to him. At this time, you observe left ear proptosis, a large erythematous bump on his mastoid process, with an elevated temperature. What disorder of the ear does this patient most likely have?
Mastoiditis (order a CT scan to confirm, consult ENT, probs gonna need surgery and definitely IV Abx)
SK is a 31 yo female who presents to her PCP office with a CC of "Right hand going numb and pins and needles." She said that she wakes up in the middle of the night with increased numbness, tingling and pain in the right hand. She states that she also notices that it bothers her at the end of the work day; she is a receptionist and spends most of her day at a desk typing. The patient is 30 weeks pregnant and has no significant past medical history. BP: 120/80, HR: 78, RR: 14, Temp: 98.6. Upon evaluation, you gather that the numbness and tingling is isolated to the palmar aspect of the thumb, index and middle fingers. What nerve is entrapped in this neuropathy and what test would you expect to be positive?
Median Nerve Phalen Sign (carpal tunnel syndrome)
A 67-year-old male presents to family practice for his yearly physical. He is a lawn care specialist, married, a social drinker and a 1 pack/day smoker for 25 years. During the skin exam you notice an irregular asymmetrical black/blue elevated patch on the back of his right leg that measures 8 mm across. When asked about it, he says he has never noticed it before. Your diagnosis this as...
Melanoma (Know ABCDE for exam)
GW is a 60 year old WM presenting to Urgent Care with pain in his chest and difficulty breathing. He claims that he thinks that he may be having a heart attack. When asked more about the history of his symptoms, he also notes recent night sweats and is currently is living in a home that was built in 1970. What do you suspect upon hearing this information?
Mesothelioma
CB, a 18 WF, is a freshman in college and comes home for Fall Break. She complains to her mother that she doesn't feel well, her throat hurts and is extremely lethargic. She has missed her collegiate soccer practice for the last week and her coach is unhappy. Her mother takes her temperature and notes she has a fever of 102. CB tells her mother that she started feeling sick about 2-3 weeks ago. She went to a walk-in clinic 5 days ago and the NP did a rapid strep test but it came back negative. However, the NP prescribed her some antibiotics anyway. She has been taking the antibiotics for 4 days and hasn't felt any better. In fact, she feels worse and now she notices a petechial body rash. CB's mother takes her into your clinic. On physical exam you note she has a fever, exudative tonsils, tender posterior cervical lymphadenopathy and a petechial body rash. CB has NKDA. What is the first test you order for CB?
Monospot test
A mother brings her 4-year old son into your clinic to address the lesions on the child's face. She states that they arose several days ago and initially just "looked like little bumps", but now appear to have "gotten worse." Upon examination, the child's vitals are all within normal limits. You visualize multiple sores surrounding the child's lips and nose that appear to have recently ruptured resulting in a scaly, honey-colored crust. Upon further questioning, you discover that the child attends a community daycare while his parents are at work. You correctly identify this outbreak as impetigo and caution the mother on the incredible contagiousness of the disease. What first line therapy would you enact on this child?
Mupirocin topical ointment
John Travolta is a 35-year-old male presenting to your family practice complaining of intermittent sharp ear pain with fluctuating conductive hearing loss. He states that he came back from vacation in Hawaii 2 weeks ago and started experiencing this pain about 7 days ago. He went to an urgent care last week and was diagnosed with having a viral upper respiratory infection and was told to rest and hydrate. You rule out other causes of his ear pain and diagnose him with Eustachian tube dysfunction. What do you prescribe him?
Nasal decongestant
A 12-month-old patient with diagnosed RSV appears to have nasal flaring and chest retraction, has an oxygen saturation of 96% on room air, a respiratory rate of 80 breaths per minute, a temperature of 102.1 degrees F, and a persistent, non-productive cough. What indications suggest moderate to severe respiratory distress and hospital admission?
Nasal flaring and chest retractions
A 7 yo WF arrives in the ED after rapidly developing widespread blisters on her trunk and face over the past 12 hours. You determine the patient is having a hypersensitivity reaction to Bactrim, which was prescribed for acute otitis media. What test would be positive if the epidermis separates after you gently rub lateral to a lesion?
Nikolsky Sign
The dude with basal cell carcinoma and erysipelas got a culture which comes back positive for Streptococcus pyogenes. What do you do?
Nothing, keep him on the IV Penicillin
A 25 y/o WF presents to your clinic complaining of "nasty, cracked toenails". She reports that a few months ago, after an especially rough week of grad school, she treated herself to a pedicure. She notes that the salon she chose wasn't the cleanest, but she got a killer deal (she's ballin' on a budget after all!). Now that the weather is getting warmer, she wants to rock sandals, but is embarrassed by the way her toenails look. Upon physical exam, you note thickened, discolored, cracked toenails on both feet. A KOH smear confirms your suspicions, and you diagnose her with onychomycosis. How do you treat her fungal infection?
Oral terbinafine x 12 weeks (use oral for nails and scalp!)
A 30-year-old female presents to the emergency department complaining of persistent right ear pain and fever onset 3 weeks ago. The patient has finished a course of antibiotics for acute otitis media without relief. On examination the patient has a red, bulging right tympanic membrane and tenderness to the right mastoid bone. The left ear is normal. Other than a temperature of 102 degrees, vitals are normal. The patient has a history of smoking, hypertension, and diabetes mellitus. What is your next course of action?
Order a CT Scan (check for mastoiditis people)
72 yo WM presents to family practice with his daughter complaining of his hand shaking when he is watching television for the past several months. The PA-C observes a shuffling, festinating gait as the patient is walking to the exam room. The patient's daughter reports that her father "is slower moving than he used to be, and he has had some falls recently, but luckily he wasn't injured." Patient reports a medical history of HTN, Hyperlipidemia, and has a BMI of 33. Vitals Signs: BP= 94/70, HR= 75, RR= 21, SaO2= 95%, T= 98.6 F. Physical Exam reveals resting tremor in the right had that looks like the patient is rolling a pill around in his fingers and disappears when the patient uses his hand. Increased resistance to passive movement is also noted but the rest of the exam is normal. What is your diagnosis?
Parkinson's Dz (tx with levodopa/carbidopa)
A 9 y/o male presents to family practice. His mother states he came home from school today complaining of an itchy head which he did not have when he left for school this morning. She explains she looked through his hair and found small white balls throughout and tried washing it with no relief. You prescribe him Permethrin shampoo and counsel her to wash all fabrics in the house with hot water and detergent upon returning home. What is the diagnosis of this patient?
Pediculosis
A 9-year old girl is brought in to your clinic by her mother. Her mother reports that her daughter had been sick for the past 5 days with what she described as a "sore throat," and that she hadn't brought her to seek treatment because of their lack of insurance. Recently, the young girl's sore throat has worsened and she has begun to develop a rash which pushed her mother to bring her in to see you. The girl's face appears flushed with circumoral pallor, and her vitals reveal a fever of 102.4 degrees Fahrenheit. When performing an oral exam, you note that her tongue appears to be swollen and bumpy and that there are paired, white tonsillar exudates visible. When examining her skin, you note a sandpaper-like rash along the axillary, antecubital, and inguinal creases. Being a knowledgeable PA, you order a Rapid Strep Antigen Test which comes back positive and then correctly diagnose Scarlet Fever. She has NKDA. What is the most appropriate first line treatment?
Penicillin G
KP is a 73 yo M who presents to the ER complaining of chest pain, dyspnea, syncope on exertion, and a nonproductive cough that has been worsening over the past 2 days. He has a known history of COPD x 10 years. On physical exam, you hear a narrow splitting of S2 with a loud P2, and notice measurable JVD. What is going to be your first step in managing KP?
Perform a right heart catheterization
A woman brings her 5yo daughter to your clinic. She states that her daughter will not stop itching. She has already tried applying calamine lotion. On further questioning, she states that her daughter seems to scratch more at night and does not have allergies. On examination of the child, you find that the child has sores from where she has been scratching on the flexor aspects of both wrists and the interdigital web spaces of her hands. You also notice small papules and vessels. The mother states that the girl's little brother has also started scratching and she is afraid that it has spread to the rest of the family. What is your tx?
Permethrin 5% cream (scabies)
A patient reports to the ED complaining of pain with swallowing. Upon examination of his oropharynx, you see bilateral inflamed tonsils, no exudates, and a unilateral swelling of the left tonsil which protrudes past midline, slightly deviating the uvula. He informs you that he has had to stay home from work as his muffled voice prevents him from communicating with colleagues. Which of the following is the correct treatment of this man's disease?
Piperacillin-Tazobactam Abx therapy with I&D
29 yo WF comes into ER in NAD complaining of tingling in her feet that has progressed to her shins. Results from her LP showed increased protein and a normal WBC count. You admit the patient to the hospital. What treatment do you start her on?
Plasmapheresis (Guillain Barre)
36yo Female presents to primary care with complaint of "itchy hands". Her past medical history is positive for chickenpox at 2yo, appendectomy at 14yo, & occasional flares ups of atopic dermatitis. She primarily works as a server but has started to help with cleaning dishes. She reports that she keeps having tiny blisters pop up on the sides of her fingers that dry up and are severely itchy. Physical exam reveals some scaling & fissuring with clear, small 1-2mm tapioca studded vesicles on the palms, lateral & medial aspects of fingers. KOH prep is negative under the microscope. What is the most likely diagnosis?
Pompholyx
A mother brings her 2yo son in with right ear pain for 3 days. The mother states that her son has been fussy and tugging at their right ear often. The child also has a fever of 100.2 degrees F but all other vital signs are WNL. Upon examination, you notice erythema and bulging of the tympanic membrane in the right ear. The left ear appears normal and unaffected upon examination. The patient's mother denies any allergies. The patient's mother also states that he has not received any antibiotic treatment in the past month and denies ever having anything like this before. You prescribe the patient amoxicillin, but the patient's mother brings him back in 3 days stating that her son does not seem to be improving. What is the next treatment option?
Prescribe amoxicillin-clavulanate
Patient with trauma to the head is brought to the ER after suffering from a car wreck. She reports her pain levels as a 9/10 for her eye and cheek but reports of no loss of consciousness or a headache. When viewing her left eye, you notice signs of swelling and possible enophthalmos. Upon further investigation, decreased visual acuity and decreased EOMs are noted. For proper diagnosis, you decide to perform a CT of her head, and when images return you visualize a fracture of the orbital floor, in which more than half of the maxillary sinus is filled with fluid. Discovering this, what would be your plan?
Prompt ophthalmic referral
TW is 35 yo WF presenting to prompt care complaining of increased shaking in her right hand that is getting worse. TW states that the shaking gets worse when she's trying to drink a cup of coffee and trying to knit. She also works in a high stress job as a lawyer. Upon physical exam you notice that the finger-nose-finger test is positive for movement with intention. You diagnose her with an essential tremor. What can you prescribe to her?
Propranolol
A patient of yours who has cystic fibrosis presents to your office with complaints of increased sputum production that is very thick with a foul smell. Reports having hemoptysis yesterday as well. You order a high-resolution CT which shows "tram tracks." What is the most likely associated pathogen with this presentation?
Pseudomonas
A surfer comes into your clinic with an eye complaint. He can see normally out of both eyes but has a fibrovascular mass extending laterally across his sclera from his right inner eye. You would most likely diagnose him with a:
Pterygium Tx with artificial tears (surgical excision if it encroaches on vision) Pinguecula is similar but never enchroaches on vision, just a little yellow triangle)
A 12-month-old female patient presents to the ED with dyspnea, wheezing and a cough for 10 days that worsened over the last 2 days. Her mother also noted a fever that seems to be worsening. This patient was born premature at 36 weeks without any further complications and lives in has 5 other siblings under the age of 6 living in the same household. A nasal washing for a rapid diagnostic assay was performed. What is the most common infection causing these symptoms in infants older than 2 months and children under the age of 2?
RSV supportive tx (esp hydration!)
TD a 59 yo male who presented to the ER with L sided facial paralysis and ringing in his L ear and is concerned he has a stroke. He reports excruciating shooting pain on the L side of his face over the past two days and states that he noticed that the left-sided facial droop 3 hours ago. Patient's only medical condition is HTN, that is well controlled with Lisinopril 10 mg Q day. NKDA. BP: 128/78 HR: 89 RR: 14 Temp: 98.6 degrees. While doing your neuro exam you notice the patient's hearing is diminished in the L ear and that there are dark crusted lesions over the external L ear. The pt is unable to activate his left-sided facial muscles. You correctly place the patient on high dose acyclovir. What most accurately describes the patient's primary diagnoses?
Ramsay Hunt Syndrome
28-year-old male presents to emergency room. He is experiencing facial droop, otalgia in his R ear and vertigo. When testing his hearing you find ipsilateral hearing loss and you notice a vesicular rash on the pinna of his ear. You suspect what condition?
Ramsay Hunt Syndrome (this is caused by herpes y'all)
A 48-year-old female presents to family practice with a concern of "I think I have skin cancer". You take a look at the nodule she is referring to on her left shoulder and it is small, well circumscribed, waxy, and looks "stuck on". What is you first line of treatment?
Reassure (seborrheic keratosis heck yeah)
A 5 y/o BM presents to your clinic with his mother for a well-child visit. Upon a full body skin examination, you notice two small dome-shaped, pearly flesh-colored papules with central umbilication. They are non-pruritic and nontender. His history is notable for daycare and a PCN allergy. Which of the following is the MOST appropriate next step?
Reassure the patient and his mother that these will most likely clear within 3-6 months without intervention This is mulluscum contagiosum-->you can also freeze off the lesions if its jsut a few!
Farmer John presents to your primary care clinic Monday evening c/o an erythematous, itchy rash on the anterior surface of both forearms. Upon visual examination, you note that Farmer John is scratching erythematous lesions that stop at his sleeve line. While doing a thorough history, you discover that early in the am, several of Farmer John's goats got out of a fenced-in field. He found them eating weeds near the woods. Refusing to be herded back into the field, the goats had to be picked up and carried back. He spent the day outside fixing the fence. He first noticed the rash when he came in for dinner hours later. Being the insightful PA that you are, you ask him what the patch of weeds that the goats were in looked like. He describes the weeds as having three clusters of leaves each. With this additional information, what do you want to do to help Farmer John?
Recommend calamine lotion Counsel not to scratch Can do a topical steroid (or systemic if it's all over)
4 YO WM presents to your clinic in tears accompanied with an unhappy mother. Mom reports the patient was eating jelly beans and stuck one up his nose. Pt is crying, with foul smelling, mucopurulent nasal discharge out one nare and a visual obstruction on the right. Mom googled self help blogs and attempted to blow in the patient's nose to remove the jelly bean with no luck. What should you do next?
Removal with forceps and counsel the patient against sticking objects into his nose
2-year-old Hispanic male is brought to your clinic by his mother. The child has been irritable for the past 3 days and has been clutching at his ears. Other than a temperature (rectal) of 102, vital signs are within normal limits. Pt has no medical history and no reported allergies. Upon exam, neither tympanic membranes are visible due to cerumen impaction. What is the next step in managing this patient
Remove the cerumen in order to see the TM
A 60 y/o BM comes to your Emergency Department. He has a history of cataract extraction last year (no complications), nearsightedness, and use of glasses for 40 years. Patient denies history of Diabetes, hypertension, atherosclerosis, hyperlipidemia, or cardiac disease. His chief complaint is visual changes with sudden onset. His visual field loss is described as starting low and expanding upward. Upon reviewing his history, he does admit to seeing new "floaters" over the past week. Upon physical exam, central vision is intact at this time, fundoscopic exam reveals a retinal gray cloud with visual identification of tears in the lower retina. What is your diagnosis and what position should the patient be placed in immediately?
Retinal Detachment, head elevated back with nose to the ceiling
PA is a 75yo WM presenting to the ER with concerns of weakness in his lower extremities, and recent dysphagia. Upon physical exam, you notice drooping of the palate, pooling of saliva, and that PA has a depressed gag reflex. 4+ reflexes accompany his symptoms. Based on this presentation, what do you treat PA with?
Riluzole (ALS)
PM is a 18yo WM who comes to your office complaining of shortness of breath that comes and goes a few times a week and causes him to wake up 3 to 4 times per month. You have correctly diagnosed him with asthma. Choose an appropriate treatment for his condition.
SABA rescue inhaler for exasperations and a daily lose-dose ICS
A 30 yo WF presents to primary care complaining of her skin appearing "dirty" and itching. She states that no matter how much she scrubs it does not go away. On examination, you find velvety, hyperpigmented plaques on the axillae. She has normal VS and a BMI of 30. She has no PMH. What is your next best step?
Screen for Diabetes Mellitus (Acanthosis Nigrans)
An 18yo WM presents with severe left eye pain. The patient states that it has been hurting for a couple of days following a sinus infection. The patient has a fever of 101.0°F. Upon examination you notice proptosis, restriction of extraocular movements, decreased visual acuity and swelling with redness of the lids in the patient's left eye. Which of the following is NOT something you would do for this patient?
Send the patient home with oral antibiotics
A 35-year-old WF presents to your office with a complaint of "severe episodes of dizziness" lasting 1-2 hours. Episodes started 6 months ago and pt states she has nausea and vomiting accompanying the episodes. She also thinks water is stuck in her ear because it feels full and she can hear the ocean through her right ear even though she lives in TN. What clinical finding do you expect to find on your PE?
Sensorineural hearing loss
HB comes into your clinic complaining of weakness and paresthesias in her lower extremities. She states that she first noticed it in her feet while walking and now it has spread to her knees and thighs. While obtaining her HPI, you discover that she went camping 2 weeks ago where she consumed chicken and unpasteurized milk from her farm for dinner. She also complains of recent nausea, vomiting, and diarrhea. Her physical exam reveals tachycardia, dyspnea, and decreased DTRs. Based on your most likely diagnosis for HB, what is your first line treatment?
Tell her 60% have full recovery and admit her for Plasmapheresis
3. A 39-year-old white male presents to the ER c/o a "burning on my face" x 2 days. PMH positive for hypertension. He has NKDA/NKEA and no recent antibiotic tx. The patient is a farmer in East TN who denies any recent trauma, but states he's had a "sore throat" and headache for a few days. Upon examination of his face, you note superficial, intensely erythematous, shiny plaques with sharp edges on his right cheek and nose with preauricular lymphadenopathy. While observing the right side of his face, you also note a small, pearly papule with raised borders and telangiectasia on the lateral portion of his right eyebrow. When asked about this spot, he responds that it's been there for a few months and bleeds occasionally, but he hasn't thought much of it. Given your pending culture and CBC, what are your next steps in treating this man?
Shave biopsy of the basal cell carcinoma and IV Penicillin for erysipelas
IJ is a 45 y/o WF who presents to the clinic c/o nasal obstruction and a whistling sound when breathing through her nose. Upon physical examination you observe a saddle nose deformity to the external nose and a large anterior septal perforation. What can you provide your patient in the office that may help to relieve her symptoms?
Silicone button prosthesis
BM is a 55-year-old WM presenting for his yearly physical. He claims that recently, he has been getting out of breath when he exerts himself. Upon looking at his chest x-day you find egg shell calcifications of both the hilar and mediastinal nodes. What can you confidently diagnose BM with?
Silicosis
MJ presents to your office bleeding out of the left nostril after playing one-on-one basketball with LB. Pt states bleeding started 5 min ago when LB elbowed him going up for a rebound. Pt has no hx of recurrent epistaxis, neoplasms, or hereditary hemorrhagic telangiectasia. What is the best choice of treatment for MJ regarding the bleeding?
Sit down, lean forward, and apply direct pressure of the nares for 15 minutes
Ahab, a 48 yo WM, presents to the derm clinic c/o rough spots on his skin. You find out that he is a sailor and he is only in port for a short while before he has to go back out to sea (gotta kill a whale or something). You examine his skin to find erythematous, cutaneous horns on his shoulders and the back of his neck. You diagnose him with actinic keratosis. After performing a biopsy for confirmation, you return to tell the patient that he needs to wear sunscreen and a hat if he is going to continue being a sailor and that you need to see him every 6 months. Since he had actinic keratosis, what are you concerned about for the future?
Squamous Cell Carcinoma
MD is a 47 yo WM who presents to your family practice with unilateral tearing, redness, and edema to the medial canthal of his right lower lid. Upon physical examination, you diagnose MD with acute dacryocystitis. You order a gram stain to figure out what empiric therapy to use and find what pathogen, which is also the most common etiology of dacryocystitis?
Staphylococcus aureus
A 54 yo WF presents to the ED complaining of a severe throbbing, unilateral headache for 24 hours. Reports pain as an 8 out of 10, nausea and one episode of vomiting last night. Pt reports worsening symptoms with movement and bright lights. Denies any recent head trauma. Reports previous similar symptoms twice in the last two years. States she took 2 Tylenol yesterday morning with no relief. Reports she was diagnosed with PAD last year and she takes simvastatin every day. Photophobia is noted. The rest of the Physical Exam is normal. Vitals Signs: BP= 133/83, HR= 81, RR= 18, SaO2= 98%, T= 99.4 F. What medication is contraindicated for the treatment of her complaint?
Sumatriptan
A mother brings her one year old into your clinic for his one-year checkup and scheduled vaccines. Mother reports no concerns for the patient at this time. Labs are drawn, and you have concern due to abnormal values, specifically electrolyte imbalances that show pancreatic insufficiency. You also notice that the patient is also behind on the growth chart in height and weight and falls in a low percentile. You have concern for many things but the first you want to rule out is cystic fibrosis. What is the primary testing needed to be done to rule this out?
Sweat Chloride Test
An 18 yo female patient is brought into your clinic this afternoon by her mother. Her mom complains that the patient has been very tired and fatigued lately, especially in the evening. She is worried the patient is coming down with the flu. Upon questioning the patient, you learn that she feels fine in the morning, but as they day goes on, she feels very fatigued, weak and can barely keep her eyes open. She states that when she lies down, the weakness generally fades. While speaking with her, you ask her to look up at the ceiling and notice increased ptosis as she continues to gaze upward. Continuing with your exam, you find: normal DTRs, normal pupillary response and normal sensation on all extremities. You have a strong suspicion of Myasthenia Gravis. You order a chest CT, looking for a common abnormality found in these patients. What are you looking for?
Thymoma
Gandalf the White, a 2003 yo WM, presents to the derm clinic. You state that you would've guessed he was 60! Unamused, he proceeds to tell you a long story about a bal-rog, some towers, and a ring. Anyway, he lost his cloak along the way and got a bit of a tan but there are a few spots that are still very light colored. You perform a KOH test and see "spaghetti and meatballs" under the microscope. What is the most likely diagnosis?
Tinea Versicolor
A 23 yo WF presents to your clinic c/o an itchy rash that has been bothering her for about two weeks. She states that the rash is located on her neck. You assess her skin and find a diffuse, ill-defined erythematous patch on the posterior neck at the hairline. She denies using any new laundry detergents, soaps or lotions. PMHx includes asthma as a child and seasonal allergies. Her medications include a daily multivitamin and oral contraceptive. She states that she has tried Benadryl to help with the itching at night but it makes her too drowsy the next day. What could you recommend to this patient that will best help treat her rash?
Topical corticosteroids (this is atopic dermatitis peeps)
Brady Edge, A 38yom, is transported to the ER via ambulance following a Tonic-Clonic seizure that started 30 minutes ago and has not ceased. As the physician assistant, you are called upon to treat this patient's generalized convulsive status epilepticus (GCSE). Airway, breathing, and circulation are under control, and an IV has been placed for this patient. Patient has NKDA. Which of the following IV treatments is not appropriate for the patient at this immediate time?
Topiramate Appropriate include Lorazepam (1st line), Dextrose, Thiamine
Patient is a 24-year-old female presenting to an urgent care complaining of a headache and neck stiffness for 4 days. Patient states she often gets these headaches, but this one is only mildly improved by the usual 800mg dose of Ibuprofen that she takes. Patient complains of photophobia but denies phonophobia. Patient also complains of moderate intensity pain banding from her forehead to the back of her head and down her neck. Which medication should you administer this patient?
Toradol (tension HA)
A 54 y/o WF presents to your family practice for routine annual physical. During your ROS, you discover that she had an episode of weakness and numbness of her left arm, along with what her husband called a "droopy face," and some slurring of her speech. She states that she did not seek medical care at the time because her symptoms went away in less than an hour. During your physical assessment, you hear carotid bruits on auscultation. Being the excellent PA that you are, you send your Pt. for Duplex ultrasonography and a CTA. Based on your findings and the imaging modalities of choice, what did your Pt. likely have?
Transient Ischemic Attack
A 20 y/o WM presents to your clinic with a painful oral lesion. He reports getting these during test weeks and suspects they could be related to stress. Upon inspection of his buccal mucosa, you notice a white, round ulcer with surrounding erythema. You diagnose him with aphthous ulcers. He requests something for the pain. What do you prescribe?
Triamcinolone in orabase
A 20 y/o BF presents to family practice. She explains she is beginning to have white patches on her chest and back which she noticed about two weeks ago. She explains she has tried to use OTC moisturizers with no relief. The patient denies any itchiness or flakes associated with the patches. Upon examination you find areas of maculopapular depigmentation with distinct borders. You counsel the patient on sunscreen protection and refer her to a dermatologist for UV light therapy. What is the diagnosis of this patient?
Vitiligo
A 17 y.o. female comes in to the walk-in clinic where you work as a PA. She presents with a sore throat and a hoarse voice for 3 days. She reports that she is in a musical on Friday and needs to get better quickly to return to rehearsal. Vitals are BP 118/78, HR 88, Temp. 98.6, RR 16, and O2 99% on room air. On physical exam you see redness at the back of her pharynx, but no exudates or cobble-stoning. She reports no fever, chills, or body aches. What treatment do you choose?
Vocal Rest (you can do oral steroids if she wants to get back to singing asap)
27-year-old woman comes in to your clinic with a chief complaint of itchiness around the eye for two days. You notice that there is some crusting and redness of the eyelid. She has never had this previously, but you note in her medical history that she has eczema. What is your most likely treatment based on her symptoms?
Warm compresses, baby shampoo, eyelid scrubbing
A 47 y/o WF presents to your primary care clinic c/o "painful fingertips x 3 months." Upon examination, you see that digits 2-4 are involved on her left hand and digits 2, 4, and 5 on her right hand. The fingertips involved have erythema and edema around the nails. There is a buildup of pus underneath the skin along the lateral side of several of the affected nails. The affected nails also appear discolored. During the history, she tells you that she has been hand-washing her dishes and her elderly neighbor's dishes daily for the past few months. Given the physical presentation and history, you suspect that she has chronic paronychia. Of the following, what would be the best treatment plan to initiate for this patient?
Wear gloves when washing dishes Oral antifungals
You receive a referral to your dermatology clinic for a 33 y/o BM with acne. Upon physical examination, you note erythema, facial flushing, telangiectasia, and coarsening of the skin to his bilateral cheeks and nasal bridge. He notes slight burning and stinging around these areas. You are careful to note the absence of comedones. The patient's medical history is significant only "social" drinking, which he admits to five nights a week. Which of the following is an appropriate treatment for him?
avoid alcohol topical metronidazole (rosacea)
56 yo WM presents to primary care with a white, homogenous plaque on the side of his tongue. It is non-tender and cannot be scraped off. He has a 30-year ppd smoking hx. Based on your most likely diagnosis, what is your next step?
biopsy lesion
A 45 yo WM presents to the ER with hemoptysis, focal wheezing, and cough. PMH includes recurrent pneumonia, hyperlipidemia, and asthma. Your attending decides to order a fiberoptic bronchoscopy which reveals a pink to purple well vascularized tumor in the central airway. You accurately diagnose him with a bronchial carcinoid tumor. While counseling the patient on his diagnosis you educate him on carcinoid syndrome. What does this include?
flushing, diarrhea, wheezing, hypotension
A mother brings her 16-month child into your clinic. She complains that for the past two weeks her child has had a lack of appetite, fatigue, and cough. Over the last couple of days, the cough has worsened and is followed by a deep, high pitched inspiration. The mother denies vaccinations for the child. You suspect a Bordetella Pertussis infection. Which test will best confirm this?
nasopharyngeal culture
What should you counsel someone with mono about?
reassurance that the virus will go away rest and absolutely NO contact sports
Mark is a 42 yo man who presents to family practice with SOB and nonproductive cough x 2 weeks. His history is unremarkable other than smoking x 20 years and his career as a coal miner. Upon physical exam, you notice clubbing of the fingers and hear inspiratory crackles when auscultating. You order a chest CT and view diffuse reticular opacities, otherwise known as honeycombing. You explain to Mark that he has a restrictive pulmonary disease that is due to chronic progressive interstitial scarring from persistent inflammation. What do you tell Mark is causing this disease?
the cause is unknown (idiopathic pulmonary fibrosis)
