geriatrics- ROSH
A previously healthy 63-year-old woman presents to your office with a complaint of a painful rash that started two days ago. Physical exam shows a grouping of vesicles on an erythematous base just distal to the right scapula. There are no other skin lesions present. Which of the following is the most appropriate therapy? A Acyclovir B Amitriptyline C Cephalexin D Ganciclovir
A acyclovir
Which of the following findings on X-ray is suggestive of colorectal cancer? A Apple core sign B Bird's beak sign C Egg-on-a-string sign D String sign
A apple core sign
A 70-year-old male is beginning treatment for peripheral vascular disease. He has a 50 pack year smoking history and is currently smoking one pack per day. His ankle-brachial index is 0.76, and his dorsalis pedis pulses are diminished bilaterally. His main complaint is a reduction in his ability to continue morning walks with his brother due to pain in his calves that resolves with rest. Which of the following is the most appropriate therapy? A) Aspirin, cilostazol, rosuvastatin, smoking cessation, and structured exercise B) Aspirin, rosuvastatin, smoking cessation, and surgical referral C) Clopidogrel, endovascular reperfusion, rosuvastatin, and smoking cessation D) Clopidogrel, structured exercise, and smoking cessation
A ) aspirin, Cilostazol, Rosuvastatin, smoking cessation, and structured exercise
Which of the following risk factors are the three biggest predictors of future fractures in a patient with osteoporosis? A Age, low bone mineral density, and history of a previous fracture B Excess alcohol intake, female sex, and rheumatoid arthritis C Low bone mineral density, smoking, and family history of osteoporosis D Use of systemic corticosteroids, age, and smoking
A Age, low bone mineral density, and history of a previous fracture
Which of the following best describes the physiologic process responsible for the fourth heart sound heard in patients with advanced aortic stenosis? A Atrial contraction against a noncompliant left ventricle B Blood striking a dilated left ventricle during diastole C Delayed closure of the aortic valve in relation to the pulmonic valve D Turbulent blood flow across a calcified aortic valve
A Atrial contraction against a noncompliant left ventricle
A 61-year-old man with a history of diabetes mellitus presents to the emergency department with complaints of weakness, fatigue, chest pain and shortness of breath. His pulse is 58/min, respirations are 14/min and blood pressure is 110/78 mm Hg. Physical exam findings include absent deep tendon reflexes. An ECG shows peaked T-waves, shortened QT interval and ST-segment depression. Which of the following is the most appropriate initial therapy? A Calcium B Epinephrine C Potassium D Sodium bicarbonate
A Calcium Hyperkalemia is a common clinical finding that occurs when the serum potassium concentration is above 3.5-5.5 mEq/Lin adults. The most common cause of hyperkalemia is decreased potassium excretion. This can occur in patients with renal impairment, diabetes mellitus and those taking certain medications such as potassium-sparing diuretics, nonsteroidal anti-inflammatory agents and ACE inhibitors. It can also be the result of increased potassium intake or a shift of potassium from the intracellular to the extracellular space. Many patients with hyperkalemia are asymptomatic. When clinical manifestations occur, patients generally present with symptoms related to cardiac and muscular function. The most common patient complaints are fatigue and weakness. Other symptoms may include chest pain, shortness of breath, nausea, vomiting, and paresthesias. Diagnosis is made when elevated serum potassium is determined through blood testing. The blood test should be repeated before any action is taken to reduce the potassium level in a patient without a previous history of hyperkalemia. Rapid acting therapy should be initiated in patients with hyperkalemia and ECG changes, serum potassium greater than 6.5-7 mEq/L, or in which the serum potassium level is rapidly increasing. Initial therapy is with calcium. Calcium helps to stabilize cardiac membranes but does not actually lower serum potassium levels. Therefore, after calcium is administered, other agents such as insulin with dextrose, should be administered to shift potassium intracellular.
Which of the following laboratory results are most consistent with a diagnosis of immune thrombocytopenia? A Isolated thrombocytopenia with platelets of predominantly normal morphology B Isolated thrombocytopenia with platelets that lack granules C Isolated thrombocytopenia with predominantly large platelets D Thrombocytopenia with anemia and leukopenia
A isolated thrombocytopenia with platelets of predominantly normal morphology
A 62-year-old, otherwise healthy, non-smoking woman presents to the clinic with a cough productive of green sputum for seven days. There is low-grade fever and scattered rhonchi on exam, with an oxygen saturation of 97% on room air. Which of the following is the most likely diagnosis? A Acute bronchitis B Acute exacerbation of COPD C Pneumonia D Upper respiratory infection
A. Acute Bronchitis
A 62-year-old man presents to the emergency room complaining of acute onset hematuria and facial edema. Patient reports that he was out of work for several days due to having a sore throat about two weeks ago but he seemed to have recovered until these new symptoms began earlier today. Urine examination reveals hematuria with red blood cell casts and a decreased glomerular filtration rate. What is the most likely diagnosis? A Acute poststreptococcal glomerulonephritis B Idiopathic hematuria C Immunoglobulin A nephropathy D Minimal change disease
A. Acute poststreptoccoal glomerulonephritis
A 72-year-old man presents complaining of a cough, chest pain, and shortness of breath for the past couple of weeks. He was not concerned enough to seek care until he started noticing bright red blood in his sputum the past couple of days. His weight is down from the last visit. Electrocardiogram is normal. As you await the results of his chest X-ray, what is the most likely diagnosis? A Adenocarcinoma B Large cell carcinoma C Small cell carcinoma D Squamous cell carcinoma
A. Adenocarcinoma
Which class of medications is considered first-line therapy in a hypertensive patient with diabetes and proteinuria? A Angiotensin-converting enzyme inhibitors B Beta blockers C Calcium channel blockers D Thiazide diuretics
A. Angiotensin-converting enzyme
A 67-year-old man presents to the clinic for evaluation of cough, wheezing, malaise, and shortness of breath. His social history is positive for daily cigar smoking for 30 years. He reports his symptoms have been present for four months. He had a similar presentation one year ago and was diagnosed with bronchitis. Which of the following is most likely on physical examination? A. barrel chest B. diastolic murmur C. pectus carinatum D scaphoid abdomen
A. Barrel chest
A previously healthy 62 y/o woman presents to your office with a complaint of dizziness. for the past two weeks, she has been experiencing an occasional spinning sensation that lasts approximately 20-30 seconds. She first noticed it while tilting her head back in the shower and also had symptoms when rolling over in bed. Which of the following is the most likely diagnosis? A. Benign paroxysmal positional vertigo B. Labyrinthitis C. Meniere disease D. orthostatic hypotension
A. Benign paroxysmal positional vertigo
A 54-year-old man presents to the clinic with a complaint of a productive cough and progressive dyspnea on exertion. His cough was initially dry, 12 years ago, but progressed to productive one year ago. He denies any smoking history, and has otherwise been healthy. He is a mason by trade and enjoys stone sculpting with his wife as a hobby. Which of the following is most likely to confirm the suspected diagnosis? A )Chest X-ray B) Complete blood count with differential C) Pulmonary function test D) Tuberculin skin test
A. Chest xray
A 60-year-old man with a history of significant benign prostatic hypertrophy presents to the clinic complaining of high levels of anxiety with frequent episodes of tachycardia, profuse sweating, feelings of impending doom, nausea, and tingling in his hands and feet. These episodes last about ten minutes and are brought on by stressful social situations. The patient admits to self-medicating for years with excessive amounts of alcohol. Which of the following medications would be safest to initiate in this patient? A Citalopram B Diazepam C Imipramine D Lorazepam
A. Citalopram
A 72-year-old-man presents to your clinic with substernal chest pain, shortness of breath and diaphoresis for the last 30 minutes. He states that this started suddenly when he was taking out the trash. He finds minimal relief with rest and worsening pain with even minimal exertion. His past medical history is significant for hypertension, dyslipidemia, and a 40-pack-year smoking history. He denies any history of cardiac disease, recent travel or surgery. Initial chest X-ray shows hyperexpansion of the lungs but is otherwise within normal limits. Electrocardiogram shows normal sinus rhythm without any acute changes. Laboratory analysis shows a troponin 0.03 ng/mL, D-dimer 410 ng/mL and a normal white blood cell count. He feels this is most likely due to heartburn. Given this information, what is the most likely diagnosis? A Acute coronary syndrome B Boerhaave syndrome C Gastroesophageal reflux disease D Pulmonary embolism
A. acute coronary syndrome
A 74-year-old man presents with complaints of sudden onset of painful swelling anterior to his left ear and fever. He was recently hospitalized for a total hip replacement. On exam, the patient has tenderness to palpation of his left parotid gland as well as trismus. Purulence is expressed from the left Stensen's duct. What is the treatment of choice for your suspected diagnosis? A Admission to the hospital for hydration and intravenous antistaphylococcal antibiotics B Conservative therapy including hydration, parotid massage, and sialogogues C Incision and drainage D Outpatient treatment with oral clindamycin
A. admission to the hospital for hydration and intravenous antistaphylococcal antibotics.
A 70-year-old man with long-standing hypertension presents with fatigue and dyspnea. His dyspnea worsens on exertion and when lying supine. Which of the following physical exam findings would be consistent with a diagnosis of congestive heart failure? A Audible fourth heart sound B Diminished apical impulse C Low-grade fever D Pronounced, diffuse wheezing
A. audible fourth heart sound
A 60-year-old man with intermittent claudication returns to the clinic for interpretation of the results of his ankle-brachial index. Which of the following statements is most accurate? A falsely high index may indicate severely hardened, non-compressible leg vessels B A low ankle-brachial index indicates peripheral venous insufficiency C An ankle-brachial index of 1.2 indicates severe disease D It is the ratio of ankle to arm diastolic blood pressure
A. falsely high index may indicate severely hardened, non-compressible leg vessels
You prescribe ramipril to a 65-year-old man with uncontrolled hypertension and severe renovascular disease. At a follow-up visit four weeks later his creatinine is noted to be 2.3. His creatinine before starting the ramipril was 1.0. By what mechanism did the ACE inhibitor cause this change? A Activating the arachidonic acid pathway B Decreasing glomerular blood flow C Increasing angiotensin II activity D Increasing serum kinin levels
B Decreasing glomerular blood flow
Which of the following drugs slows atrioventricular nodal conduction and should be avoided in a patient with Mobitz type 2 second degree heart block? A Atropine B Digoxin C Lisinopril D Nitroglycerin
B Digoxin
The physician assistant is evaluating a patient suspected of having an iron deficiency anemia. When examining the patient's peripheral blood smear, the diagnosis is reinforced by the presence of which of the following findings? A Howell-Jolly bodies B Hypochromic, microcytic red blood cells C Macrocytic red blood cells D Schistocytes
B Hypochromic, microcytic red blood cells
Which of the following patient complaints is most indicative of angina pectoris? A Brief, fleeting left-sided chest pain described as a "flutter" B Occasional substernal chest pain described as a "deep ache" C Persistent epigastric pain described as "gnawing" D Sudden, searing, substernal chest pain described as "ripping"
B Occasional substernal chest pain described as a "deep ache"
A previously healthy 65-year-old woman presents to your office with a complaint of thickened and discolored toenails. Previous potassium hydroxide examination of her toenail scrapings shows the presence of dermatophytes. Which of the following is the most appropriate therapy? A Oral fluconazole B Oral terbinafine C Topical medicated chest rub D Topical terbinafine
B Oral terbinafine
A 47-year-old man presents to the emergency department due to acute, sharp chest pain that is relieved by leaning forward. A pericardial friction rub is auscultated on cardiac examination and an ECG shows diffuse ST elevations. Echocardiography reveals a small pericardial effusion. Which of the following is the most appropriate initial treatment? A Atenolol B Ibuprofen C Nitroglycerin D Prednisone
B ibuprofen
When prescribing levothyroxine for an elderly patient with hypothyroidism, how does the dosing differ? A) Levothyroxine dose is greater than the dose required for younger adults B) Levothyroxine dose is lower than the dose required for younger adults C) Levothyroxine dose is the same as the dose required for younger adult D) Older adults should be not be treated with levothyroxine due to safety concerns
B) Levothyroxine dose is lower than the dose required for younger adults
A 67-year-old woman presents to the emergency department for evaluation of a productive cough for five days. She is alert and oriented. Physical exam reveals crackles at the left lung base. Blood pressure is 102/68, temperature is 100.9oF, respirations are 33 per minute, heart rate is 105 beats per minute, and oxygen saturation is 93% on room air. Labs reveal a BUN of 18 mg/dL and creatinine of 1.0 mg/dL Her chest X-ray shows an infiltrate in the left lower lobe. What is the most appropriate course of action? A Admission to the ICU and start treatment with levofloxacin B Admission to the medical ward and start treatment with ceftriaxone and azithromycin C Discharge the patient home with a five-day course of azithromycin and instructions to follow up with primary care in 48-hours D Discharge the patient home with a seven-day course of doxycycline and instructions to follow up with primary care within three days
B. Admission to the medical ward and start treatment with ceftriaxone and azithromycin
A 67 y/o woman is admitted to the hospital with a change in mental status. The initial workup includes a chemistry profile that reveals a plasma potassium level of .4 mEq/L (N 3.7-5.2) An EKG is performed that revealed peaked T waves. Which of the following is the most appropriate to administer to this patient? A. Albuterol B. Calcium Gluconate C. Furosemide D. Sodium Polysyrene sulfonate
B. Calcium Gluconate
A 57-year-old woman presents to the clinic to establish care and reports seven months duration of sudden, abrupt onset of diarrhea. She also reports occasionally experiencing a "fluttery feeling" in her chest accompanied with facial flushing. Her medical history includes hypertension and a significant cough that has been present for two years. She has a 25 pack year tobacco use history. Chest X-ray reveals left lower lobe atelectasis. Which of the following is the most likely diagnosis? A. Angioedema B Carcinoid tumor C Cardiac dysrhythmia D Irritable bowel syndrome
B. Carcinoid Tumor Carcinoid Syndrome Patient will be complaining of skin flushing, wheezing, and diarrhea Diagnosis is made by 24-hour excretion of 5-hydroxyindoleacetic acid (5-HIAA) in the patient's urine Most commonly caused by carcinoid tumors (neuroendocrine tumors that secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides)
A 64-year-old man with a history of diabetes mellitus presents with pain in his right calf while walking. The pain is relieved with rest. He has smoked one pack of cigarettes per day for the past 35 years. Exam reveals a cool extremity with diminished pulses. What is the gold-standard diagnostic study for your suspected diagnosis? A Bedside ankle-brachial index B Contrast arteriography C Duplex ultrasound D Plain radiograph
B. Contrast Arteriography
Sildenafil is prescribed for an otherwise healthy 54-year-old man who is diagnosed with erectile dysfunction. Which of the following is a potential adverse effect of this medication? A. Constipation B. Cyanopsia C. Prostate specific antigen elevatin D. Urinary Retention
B. Cyanopsia Cyanopsia, or blue discoloration of vision, is a potential side effect of sildenafil. The effect may be more likely with higher dosages of medication and is usually temporary. Sildenafil inhibits phosphodiesterase type five (PDE-5), thereby increasing nitric oxide levels and cyclic guanosine monophosphate, which results in smooth muscle relaxation. Sildenafil is used most commonly for erectile dysfunction, however, it may also be used to treat pulmonary hypertension. Cyanopsia is hypothesized to be related to the vascular effects of the inhibition of phosphodiesterase type five, the effects of phosphodiesterase type six on the retina, and potentially to retinal exposure to elevated levels of cyclic guanosine monophosphate. Cyanopsia is uncommon but is a potential adverse effect from any phosphodiesterase type five medication. Additional common side effects include hypotension, flushing, headache, dyspepsia, hearing loss, and nasal congestion. If phosphodiesterase medication is contraindicated or not tolerated, prostaglandin or papaverine cavernosa injections may be a treatment option, but they carry a risk of penile plaque formation. Additionally, vacuum devices may be useful, but require significant planning and teaching on how to operate
A 72-year-old woman presents with left knee pain for the past several months that has been worse over the last seven days. It is worse with walking and better with rest. She takes acetaminophen to alleviate the pain. She denies any injury or previous surgery on the knee. An X-ray is ordered and shows chondrocalcinosis, narrowed joint spaces, and subarticular reactive sclerosis. Bone spur formation is also noted. What is the most likely diagnosis? A Calcium pyrophosphate deposition disease B Degenerative arthritis C Neuropathic osteoarthropathy D Rheumatoid arthritis
B. Degenerative arthritis
A 72 y/o man is being observed by your clinic for benign prostatic hyperplasia. his symptoms of a weak stream, straining, and post-void dribbling are worsening and he would like to begin medical treatment. you initiate tamsulosin and advise him of which of the following most likely side effects? A. Decreased libido B. Dizziness C. Erectile Dysfunctin D. Hypertension
B. Dizziness
A 64-year-old man presents to the clinic with generalized pain in his neck, shoulders, and hips. He states the pain is worse in the mornings and is sometimes associated with one-sided headaches. His erythrocyte sedimentation rate and C-reactive protein are both elevated. You diagnose him with polymyalgia rheumatica. What other condition would you suspect in this patient? A. Fibromyalgia B. Giant cell arteritis C. Systemic lupus erythematosus D. Trigeminal neuralgia
B. Giant cell arteritis
You are treating a 62-year-old man who is seven days status-post coronary angiogram and stent placement, following an acute myocardial infarction. He has been on a heparin drip for five days. Lab calls to notify you that his previously normal platelet count is now 48,000/mcL. Which of the following is the most likely diagnosis? A. Disseminated intravascular coagulation B. Heparin-induced thrombocytopenia C. Immune thrombocytopenia D. Thrombotic thrombocytopenic purpura
B. Heparin-induced thrombocytopenia
A 55-year-old man presents to the clinic, reporting progressive pain in his lower back, pelvis, and right hip that started eight months ago. He reports pain while walking and it feels worse at night. Ibuprofen provides some relief. On physical exam, he has tenderness and warmth at the lumbar spine, right iliac wing, and right greater trochanter. A mild varus deformity of the right thigh is noted. Lab analysis reveals high serum alkaline phosphatase and radiographs show lytic lesions. Which of the following is the most likely cause of these findings? A. Chronic soft tissue degeneration B Hypervascular bone C Osteolytic infectious process D Soft tissue mass effect
B. Hypervascular bone
A 59-year-old woman presents to the clinic reporting numbness in her hands and around her mouth, as well as muscle cramps, fatigue, and intermittent hoarseness. Her medical history includes hypertension, hyperlipidemia, diabetes, and a thyroid malignancy which was recently treated by surgical excision. On physical examination, she is noted to have an ataxic gait, hyperresponsive deep tendon reflexes, and appears to be anxious. Additionally, carpal spasms are noted when her blood pressure is taken. Her vital signs are within normal limits for her age. Results of a complete blood count and complete metabolic profile are notable for a low total calcium. Which of the following is the most likely diagnosis? A. Hyperparathyroidism B Hypoparathyroidism C Hypophosphatemia D Hypothyroidism
B. Hypoparathyroidism
A 67-year-old man presents to your office six months after prostatectomy for follow up on his previously diagnosed prostate cancer. Labwork reveals an elevated serum prostate specific antigen. After discussing options with the patient, a decision is made to use pharmacologic treatment. Which of the following is the most appropriate initial agent? A Doxazosin B Leuprolide C Tadalafil D Terazosin
B. Leuprolide
Which of the following medications is first-line therapy to treat parkinson's disease ? A. Amantadine B. Levodopa C. Propranolol D. Selegiline
B. Levodopa
1 65 y/o man presents to the ED after a fall. He says he has had trouble walking "for a while." His examination is significant for normal cranial nerve function, normal strength, a resting tremor, and difficulty stopping when he is walking. what is the cellular pathology associated with this condition? A. demyelination B. Lewy Bodies C. Loss of anterior horn cells D. Neurofibrillary tangles
B. Lewy Bodies
A 70-year-old woman presents to your office with a complaint of difficulty having bowel movements. She tells you that she has a bowel movement every 2-3 days, the stool is hard and she has to strain. Which of the following is the most appropriate initial therapy? A Docusate sodium B Methylcellulose C Polyethylene glycol D Senna
B. Methylcellulose
A 50-year-old man with a body mass index of 52 kg/m² presents to the clinic complaining of daytime sleepiness and dyspnea on exertion. His peripheral oxygen saturation on room air is 93%. Further testing reveals obesity hypoventilation syndrome with concurrent obstructive sleep apnea. The patient is put on a weight loss regimen which includes diet and exercise. In addition, which of the following is the best choice for initial therapy in this patient? A. Nocturnal bilevel positive airway pressure B. Nocturnal continuous positive airway pressure C. Oral theophylline dosed every twelve hours D. Twenty-four hour supplemental oxygen
B. Nocturnal continuous positive airway pressure
Which of the following patients meets the criteria for diagnosis of diabetes mellitus? A A patient with a fasting plasma glucose of 125 mg/dL and a hemoglobin A1C of 6.0 percent B A patient with polyuria, blurry vision, and a random glucose of 200 mg/dL C An asymptomatic patient with a fasting glucose of 130 mg/dL (day 1 and 80 mg/dL (day 2) D An asymptomatic patient with a random glucose of 250 mg/dL
B. a patient wiht polyuria, blurry vision, and a random glucose of 200 mg/dL
A 58-year-old man with a 20 pack-year smoking history complains of a chronic, productive cough. Diffuse wheezing is noted on physical exam. Which of the following additional physical exam findings would be expected? A Decreased anteroposterior chest diameter B Decreased heart sounds C Prolonged inspiratory phase of breathing D Splitting of the first heart sound
B. decreased heart sounds
A 67-year-old obese man with a past medical history of heart failure presents with complaints of daytime sleepiness and morning headaches. He notes that he frequently will doze off in church. His wife complains of his snoring. What is the gold-standard diagnostic study for your suspected diagnosis? A Home sleep apnea testing B In-lab polysomnography C Nocturnal electrocardiogram D Nocturnal pulse oximetry
B. in-lab polysomnography
A 58-year-old woman presents to the clinic with right facial weakness since this morning. Which additional finding would suggest a diagnosis of cerebrovascular accident rather than Bell's palsy? A Drooping of the right side of the mouth when smiling B Inability of the right eye to abduct C Inability to fully close the right eyelid D No wrinkling of the right side of the forehead with eyebrow elevation
B. inability of hte right eye to abduct
A 73-year-old man with a history of atrial fibrillation and hypertension presented to the emergency department with a severe headache and change in mental status beginning suddenly two hours prior to arrival. Given patients acute presentation and history of known dysrhythmia, stroke protocol was initiated and an ischemic stroke was confirmed on a non-contrast CT scan of the head. If the patient had an embolic event in his left anterior cerebral artery, which of the following findings would be expected on physical examination? A Broca aphasia B Incontinence C Left-sided upper extremity weakness D Macular-sparing homonymous hemianopsia
B. incontinence
A 50-year-old man presents to clinic with worsening right shoulder pain that began four months ago. There was no trauma or inciting event. Over the past month, he has also been experiencing worsening stiffness in the right shoulder that is interfering with his activities of daily living. Clinical exam shows decreased passive and active range of motion of the shoulder in all planes compared to the contralateral shoulder. X-rays of the shoulder are obtained and are normal. Which of the following is the most appropriate initial treatment for this patient? A Immobilization with a shoulder sling B Physical therapy with gentle range of motion exercises C Shoulder arthroscopy with lysis of adhesions D Shoulder arthroscopy with rotator cuff repair
B. physical therapy with gentle range of motion exercises
Which of the following is appropriate education for a man with newly diagnosed hypertension? A Alcohol consumption should be limited to 2 ounces of ethanol or less per day B Brisk walking 20 minutes per day, three days per week will decrease blood pressure C Dietary intake of potassium (90 meq - 120 meq) may lower both systolic and diastolic blood pressure D Recommended sodium intake is 2800 mg or less per day
C Dietary intake of potassium (90 meq - 120 meq) may lower both systolic and diastolic blood pressure
Which of the following is a late complication of acute myocardial infarction? A Cardiogenic shock B Complete heart block C Dressler syndrome D Pulmonary edema
C Dressler syndrome
An 80-year-old woman with a 36-pack-year history of smoking tobacco presents with a chief complaint of increasing dyspnea on exertion over the past six months. Physical exam reveals clubbed digits and bilateral lower lung crackles. Computed tomography shows honeycombing of the lung parenchyma. What is the most likely diagnosis? A Bronchiectasis B Chronic obstructive pulmonary disease C Idiopathic pulmonary fibrosis D Sarcoidosis
C Idiopathic pulmonary fibrosis
An 83-year-old woman with a history of hypothyroidism, diabetes mellitus and hypertension is brought to the emergency department with altered mental status. She is found to be hypothermic, hypotensive and bradycardic. Puffiness in the hands and face, a thickened nose and swollen lips are noted on physical exam. Pupils are normal size, equal and reactive to light. Which of the following is the most likely diagnosis? A adrenal insufficiency B Diabetic ketoacidosis C Myxedema coma D Opiate overdose
C Myxedema coma
A previously healthy 71-year-old woman presents to your office with complaints of white spots in her mouth and a sore tongue. Physical exam reveals dentures, white plaques on the buccal mucosa and tongue, and erythematous lesions on the hard palate. Which of the following is the most appropriate therapy? A Oral acyclovir B Oral ibuprofen C Oral nystatin suspension D Oral viscous lidocaine solution
C Oral nystatin suspension
A 70-year-old man is brought into the office by his adult children because he has been leaving his house and wandering in the street. For the last six months, he became increasingly forgetful of names of family members and of places he often visited. He lost interest in his usual hobbies and is more restless. Which of the following is considered the first-line therapy for patients with mild-to-moderate Alzheimer's disease? A Antidepressants B Antiparkinsonian agents C Cholinesterase inhibitors D NMDA antagonists
C. Cholinesterase inhibitors
A 56-year-old man presents with epigastric abdominal pain that is radiating toward his mid-back that started yesterday. He has associated symptoms of nausea, vomiting, and anorexia. On physical exam, he has marked tenderness in the epigastrium. Labs reveal an elevated lipase. What is the most common etiology of this patient's condition? A Alcohol use B Autoimmune disease C Gallstone-related disease D Metabolic derangement
C. Gallstone-related disease
A 77-year-old woman presents to the clinic complaining of recent onset of headaches. She denies any visual changes and vitals are normal. On exam, she is tender over the right temporal area. She follows with cardiology for a history of a heart valve replacement and with rheumatology for a disease that "has a long name" which she can't remember. Which of the following is the most likely diagnosis? A . Cluster headache B. Fibromyalgia C. Giant cell arteritis D. Trigeminal neuralgia
C. Giant cell arteritis
A 45-year-old man presents to clinic for follow up after recently being diagnosed with hepatitis B. Which of the following serologic markers is the best marker of current viral replication and increased infectivity? A Hepatitis B core antibody B Hepatitis B envelope antibody C Hepatitis B envelope antigen D Hepatitis B surface antibody
C. Hepatitis B envelope antigen
An 84 y/o woman is recovering in the hospital from an acute anterior ST elevation myocardial infarction four days ago without complication. The patient suddenly develops chest pain, tachypnea and dyspnea. Her pulse is 115 BPM, RR 26, BP 85/50 in both arms. She has elevated juglar venous pulsations and distant heart sounds. Her lungs are clear to auscultation bilaterally and no new murmur is appreciated. What is the most likely etiology of her acute decompensation? A. Acute aortic dissection B. Acute mitral regurgitation C. Left ventricular free wall rupture D. Post infarction ventricular septal defect
C. Left ventricular free wall rupture.
A 60 y/o woman presents to clinic with complaints of right hand tremor that began 4 months ago. The patient reports the tremor improves with purposeful movements of the hand. She also reports difficulty double clicking a computer mouse and loss of sense of smell. On PE, a resting tremor of the right hand is observed. the patient demonstrates a shuffling gait. the patient shows increased resistance with passive range of motion of the right upper extremity compared to the left. which of the following is the patient's most likely diagnosis? A. essential tremor B. huntington disease C. Parkinson disease D. Wilson Disease
C. Parkinson disease
A 74-year-old man with family history of macular degeneration presents with worsening day and night vision and difficulty reading even with his bifocal glasses on. Which of the following fundoscopic findings is more suggestive of exudative advanced macular degeneration? A A cup-to-disc ratio of 0.3 with arteries narrower than veins B Accumulation of small yellow deposits on the macula C Presence of choroidal neovascularization with subretinal fluid and vessel hemorrhages D Presence of cotton wool spots and flame hemorrhages
C. Presence of choroidal neovascularization with subretinal fluid and vessel hemorrhages
A 77-year-old woman presents with dizziness and being light headed. She denies any new medications or other recent changes. Vitals are temperature 98.0ºF, blood pressure 93/56 mm Hg, and pulse 72 bpm. Physical exam is unremarkable. Her medications include metoprolol 50 mg daily, atorvastatin 10 mg daily, vitamin D 1,000 IU daily, and acetaminophen 500 mg as needed. Which of the following is the most likely cause of her dizziness? A Acetaminophen use B Atorvastatin use C Metoprolol use D Vitamin D supplementation
C. metroprolol use
A 65-year-old woman with no known illness presents with dyspnea and a grade 3/6 systolic murmur. Which of the following would suggest the diagnosis of aortic stenosis rather than mitral valve regurgitation? A Hyperdynamic left ventricle B Murmur best heard at apex C Prominent fourth heart sound D Wide splitting of S2
C. prominent fourth heart sound
A 54-year-old man presents with urinary frequency and urgency over the past several days. He notes painful urination as well as chills. His temperature on presentation is 38.6°C. Digital rectal exam reveals a warm, edematous, tender prostate. His urine is cloudy. What is the most likely diagnosis? A Cystitis B Epididymitis C Prostatitis D Urethritis
C. prostatitis
A 65-year-old woman presents to the ED with sudden onset of right eye pain and blurred vision. Physical examination reveals circumcorneal injection, a 7 mm right pupil that is unresponsive to light and an intraocular pressure of 35 mm Hg. Which of the following is the gold standard test to confirm the diagnosis? A. Dark room provocation B. Dilated fundus examination C. Gonioscopy D. Slit lamp grading
C.Gonioscopy Gonioscopy is considered the gold standard in the diagnosis of acute angle closure glaucoma, an ocular emergency that this patient is experiencing. This method allows the examiner to examine the angle that is formed between the cornea's posterior surface and the iris' anterior surface. An experienced provider, such as an ophthalmologist, should perform this test. Care must be taken to not shine light directly onto the pupil as the angle could widen and create an error in measurement.
Which of the following guidelines for breast cancer screening is consistent with those of the United States Preventive Services Task Force (USPSTF)? A Begin annual screening mammography at age 40Your Answer B Begin annual screening mammography at age 55 C Continue screening mammography as long as the patient is in good health D Discontinue screening mammography at age 75
D Discontinue screening mammography at age 75
A 56-year-old woman presents to the office with complaints of double vision, drooping eyelids, and speech that becomes slurred late in the day. Patient reports symptoms have been ongoing for weeks. Physical exam reveals ptosis and speech that is "nasal" in quality. The patient underwent a positive tensilon test. Blood work was positive for acetylcholine receptor binding antibodies. Which of the following is first line in the treatment of this patient's neuromuscular disease? A Carbidopa/levodopa B Edrophonium C Plasmapheresis D Pyridostigmine
D Pyridostigmine
A 50-year-old man currently on a regimen of penicillin develops a diffuse rash and facial swelling. On physical exam there are diffuse dark reddish purple papular lesions on his trunk, face, and extremities with extensive blister formation. Prior to the onset of the rash the man complained of a nonproductive cough, fever, and chills. Based on his history and physical exam, what is the most likely diagnosis? A Herpes zoster B Impetigo C Scabies D Stevens-Johnson syndrome
D Stevens-Johnson syndrome
A 58-year-old man presents to your office with complaints of chronic cough and difficulty breathing. He has smoked approximately 2 packs of cigarettes per day since he was 14 years old and has not seen a doctor in many years. You order spirometry testing, which shows airflow limitation (predicted FEV1 45%). Which of the following is the most appropriate therapy? A Azithromycin B Guaifenesin C Prednisone D Tiotropium
D Tiotropium
n what part of the prostate does benign prostatic hyperplasia most commonly develop? A Central zone B Fibromuscular stroma C Peripheral zoneYour Answer D Transitional zone
D Transitional zone
A 78-year-old man with a history of hypertension and diabetes presents to the emergency department after an episode of left arm weakness and numbness that began two hours ago and lasted about 30 minutes before it resolved completely. This has never happened to him in the past. Physical exam is unremarkable. Which of the following is the most likely diagnosis? A Cerebrovascular accident B Global cerebral ischemia C Intracerebral hemorrhage D Transient ischemic attack
D transient ischemic attack
Which of the following patients with congestive heart failure is most in need of hospitalization? A) A 65-year-old man with stable angina and two pounds of recent weight gain B) A 68-year-old woman whose internal cardiac defibrillator went off five days ago C) A 70-year-old man with 2+ pedal edema and dyspnea on exertion D) A 75-year-old woman with blood pressure of 80/60 mmHg and confusion
D. A 75 y/o women with BP 80/60 and confusion
A 62-year-old man with a history of atrial fibrillation on warfarin presents with epistaxis. Examination reveals continuous oozing of blood from the right naris with no obvious source of bleeding. There is no blood in the posterior pharynx or left naris. The bleeding is controlled with oxymetazoline spray and chemical cautery with silver nitrate. Vital signs include an irregular heart rate of 82 beats per minute, blood pressure 142/76 mm Hg and temperature 37.2ºC. Laboratory studies show a hemoglobin of 12.6 g/dL and INR 5.2. The patient is observed for one hour and has no further bleeding. What is the next step in managing this patient's coagulopathy? A. Administer fresh frozen plasma B. Administer idarucizumab C. Administer vitamin K 10 mg IV and hold the next dose of warfarin until the INR is within therapeutic range D. Administer vitamin K 2.5 mg PO and instruct the patient to hold his next dose of warfarin
D. Administer vitamin K 2.5 mg po and instruct the patient to hold his next. dose of warfarin
A 64-year-old man presents to the clinic for management of chronic symptomatic hypercalcemia of malignancy. Despite the continued use of bisphosphonates, his total calcium level remains elevated. Which of the following is the most appropriate medication this patient should receive next? - Calcitonin - Cinacalcet - Denosumab - Zoledronic acid
Denosumab
A 68-year-old man presents to the clinic with a past medical history of hepatitis B infection and hepatic cirrhosis. Which of the following is the best choice for surveillance of development of hepatocellular carcinoma in this patient? A. Abdominal CT scan every 12 months B. Abdominal CT scan every two years C. Liver ultrasound every 12 months D. Liver ultrasound every six months
D. Liver ultrasound every six months
A 62-year-old previously healthy, nonsmoking man presents to your office with questions about his cholesterol. His recent lab results include total cholesterol 253 mg/dL, high- density lipoprotein 38 mg/dL, low-density lipoprotein 165 mg/dL and triglycerides 250 mg/dL. He has an ASCVD score of 9%. Which of the following is the most appropriate initial therapy? A Fenofibrate B Fish oil C Gemfibrozil D Lovastatin
D. Lovastatin
A 60-year-old man with insulin-dependent diabetes mellitus, gastroparesis, hypertension, and congestive heart failure has just received a new diagnosis of pheochromocytoma. Which of the following medications should be discontinued? A Furosemide B Insulin lispro C Lisinopril D Metoclopramide
D. Metoclopramide
A woman presents to the clinic complaining of pedal edema. Which of the following would be most suggestive of congestive heart failure as the likely etiology?
Diabetes Mellitus
A 72-year-old man presents with concerns of "looking yellow." He is asymptomatic but admits to an unintentional 15 pound weight loss over the last two months. Physical examination reveals jaundice, mild epigastric tenderness, and palpable periumbilical nodules. Which of the following is the most likely diagnosis? A Colon cancer B Esophageal cancer C Gastric cancer D Pancreatic cancer
D. Pancreatic cancer
A 52-year-old man with a history of hepatitis B presents with complaints of fever, weakness, and pain in his right thigh and knee. He reports a 25-pound weight loss over the past three months. Physical examination reveals patchy, well demarcated reticular rash and palpable tender lumps over the lower extremities. Foot drop is noted as well. Immunofluorescence testing for antineutrophil cytoplasmic antibodies is negative. Renal biopsy reveals inflammation of the medium-sized arteries as well as polymorphonuclear cells. Which of the following is the most likely diagnosis? A Eosinophilic granulomatosis with polyangiitis B Granulomatosis with polyangiitis C Henoch-Schönlein purpura D Polyarteritis nodosa
D. Polyarteritis nodosa
A 60-year-old man presents for annual physical examination. He notes recent onset of daily headache as well as pruritus after showering. He has splenomegaly on physical exam. Complete blood count is notable for a hemoglobin of 18.7 g/dL and hematocrit of 55%. Further testing reveals JAK2 mutation. What is the most likely diagnosis? A Chronic myelogenous leukemia B Folic acid deficiency C G6PD deficiency D Polycythemia vera
D. Polycythemia vera
A 56-year-old, overweight man presents for bronchitis. He tells you that every winter he gets bronchitis that makes him short of breath and productive of "tons" of mucus for two to three months. Further questioning reveals that he has smoked heavily for 35 years but is trying to cut back. A physical exam is normal except for a BMI of 31, and a lung exam that shows rhonchi bilaterally. Which of the following tests would be most useful in initially guiding diagnosis and management of his condition? A Arterial blood gas analysis B Chest CT scan C Chest radiograph D Pulmonary function testing
D. Pulmonary function testing
A 75-year-old woman presents with complaints of weakness. She has difficulty getting up from a seated position, going up or down stairs, and lifting heavier objects that she could before without difficulty. You decide to order a muscle biopsy to rule out or confirm your suspicion of polymyositis. What muscle do you most likely want biopsied? A Brachioradialis B Gastrocnemius C Latissimus dorsi D Quadriceps femoris
D. Quadriceps femoris
A 72-year-old man presents to the clinic for his annual health check. He has a 12-year history of benign prostatic hyperplasia. He denies recent worsening of his voiding symptoms. Vitals are within normal limits. Previous digital prostate exams revealed a smooth, enlarged prostate, but now a small hard nodule is felt on the right lobe. On labs, prostate-specific antigen is 9.2 ng/mL. Records show his prostate-specific antigen was 3.4 ng/mL 12 years ago. Which of the following is the most appropriate next step? A Increase his tamsulosin dose B Obtain a baseline computed tomography of his prostate and recheck in six months C Referral to oncology for radiation therapy D Referral to urology for prostate biopsy
D. Referral to urology for prostate biopsy
A 76-year-old man with a history of hypertension presents to your office with complaints of heart palpitations and fatigue over the past month. Vital signs include an irregular pulse ranging from 80-90 bpm. Cardiac exam reveals an irregular heartbeat and a displaced point of maximal impulse.ECG reveals an irregularly irregular rhythm with a narrow QRS complexes and a rate of 82 and no ST segment or T wave changes. Which of the following is the most appropriate therapy to initiate? A Aspirin B Digoxin C Lisinopril D Rivaroxaban
D. Rivaroxaban
A 62-year-old man presents reporting urinary hesitancy, dribbling, and feeling of incomplete voiding. He states his symptoms have been progressively worsening for the last six months. He denies hematuria, pain with urination, or scrotal swelling. Which of the following physical exam findings is most consistent with the diagnosis of benign prostatic hypertrophy? A. Asymmetry of the prostate B. Boggy consistency of the prostate C. Decreased anal sphincter tone D. Rubbery consistency of the prostate
D. Rubbery consistency of the prostate
A 65-year-old man with significant tobacco use presents with general malaise, unexplained weight loss, and occasional flank pain. Computed tomography of the abdomen shows a localized renal mass in the left kidney. What is the only curative treatment for this condition? A. Chemotherapy B. Radiofrequency ablation C. Stem cell transplantation D. Surgical resection
D. Surgical resection
A 68-year-old woman presents with worsening right knee pain. She has had pain there for years, but it has gradually increased in the past couple of months. Acetaminophen is no longer effective. Plain films show joint space narrowing bilaterally with osteophytes on the right. Medical history is unremarkable, except for the presence of pyrosis, peptic ulcer disease ten years ago, and lifelong obesity. What treatment would you likely prescribe next? A Celecoxib 200 mg twice a day B Hydrocodone 5/325 mg twice a day C Ibuprofen 800 mg up to four times a day as needed D Tramadol 50-100 mg up to four times a day as needed
D. Tramadol 50-100 mg up to four times a day as needed
A 50-year-old woman presents to the Emergency Department with a two-day history of right upper quadrant pain. She has a history of hypercholesterolemia and her examination is significant for a positive Murphy's sign. What is the preferred imaging modality? A Abdominal barium meal B Abdominal computed tomography scan C Abdominal plain film D Abdominal ultrasound
D. abdominal ultrasound
A 57-year-old woman presents to the clinic complaining of difficulty getting out of bed in the morning and difficulty climbing the stairs into the house. She also reports a weight loss of 20 pounds over the past six months. You suspect a diagnosis of polymyositis. Which of the following physical exam findings is most consistent with the diagnosis of polymyositis? A Painful proximal muscles without weakness B Positive Homan's sign C Several positive tender points D Weakness of the proximal muscles without pain
D. weakness of the proximal muscles without pain
A 65-year-old man with a 30 pack-year smoking history presents for an annual physical exam. He is a current smoker. He asks about lung cancer screening. Which of the following screening methods would you recommend? A )Chest radiography B)Low-dose chest computed tomography C) Positron emission tomography D) Sputum cytology
Low dose chest CT
A 60-year-old man presents to the clinic with a high-pitched, blowing systolic murmur heard best at the apex and radiating to his left axilla. Which of the following is the most likely diagnosis? A Aortic stenosis B Mitral regurgitation C Pulmonic stenosis D Tricuspid regurgitation
Mitral regurgitation
A 65-year-old man presents to the clinic reporting fever, nausea, diffuse joint pains, and a rash. He states his symptoms began four days ago after a camping trip in Tennessee. He denies any sore throat, cough, vomiting, diarrhea, or itching. Physical examination reveals a painless maculopapular rash on his wrists and palms, diffuse joint tenderness, and mild upper abdominal tenderness. His temperature is 100.5°F, but the rest of his vital signs are within normal limits for his age. Which of the following is the most likely diagnosis? - Cellulitis - Lyme disease - Rocky Mountain spotted fever - Syphilis
Rocky mountain spotted fever
How would a hernia of the anterior vaginal wall resulting in the bladder descending to a lower anatomical position be documented in a medical chart? A Cystocele B Enterocele C Rectocele D Uterine procidentia
a Cystocele
55-year-old man presents to the emergency department with substernal chest pain. He has had three episodes of chest pain with exertion in the past 24 hours. Each has lasted 20 to 30 minutes and resolved with rest. His past medical history is significant for hypertension, hyperlipidemia, asthma, and chronic obstructive pulmonary disease. He currently smokes one pack/day of cigarettes. His family history is remarkable for early coronary artery disease in a sibling. Home medications include chlorthalidone, simvastatin, aspirin, albuterol, and home oxygen. In the emergency department, he is chest pain free after receiving three sublingual nitroglycerin tablets. ECG shows 0.8 mm ST-segment depression in V5, V6, lead I and aVL. Cardiac biomarkers are negative. Which aspects of this patient's history add to the likelihood that he might have death, myocardial infarction (MI), or urgent revascularization in the next 14 days? A Age B Aspirin usage C Beta-agonist usage D Diuretic usage
aspirin use
A 67-year-old man presents after being in a motor vehicle collision 20 minutes ago. His wife reports that there was a brief period of unconsciousness followed by a lucid interval. Past medical history is significant for cardiac stents to the left anterior descending coronary artery, and the patient has been on warfarin ever since stent placement. Vital signs include temperature 98.6°F, respiratory rate 18 breaths/minute, blood pressure 120/65 mm Hg, heart rate 90 beats/minute, and oxygen saturation 98% on room air. Physical examination shows no neurological deficits. Glasgow Coma Scale score is 12. Complete blood count shows white blood cell count 5.8/L, hemoglobin 15 mg/dL, hematocrit 45%, and platelet count 265,000. The comprehensive metabolic panel reveals no abnormalities. Prothrombin time is 16 seconds, and international normalized ratio is 4.0. Computed tomography shows a 15 cm3 lens-shaped pattern with clot thickness of 8 mm and no midline shift. Which of the following is the most appropriate next step in management? A. Craniotomy B. Mannitol C. Protamine D. Prothrombin complex concentrate
prothrombin complex concentrate
