Practice Exam v1: Block 1

4 Nephrotic syndrome Though further testing would be helpful, the most likely diagnosis is nephrotic syndrome. He has the high level of proteinuria (>3.5 g/day per 1.73 m2 body surface area), hypoalbuminemia, and edema associated with nephrotic syndrome. Azotemia and hyperlipidemia can be associated with nephrotic syndrome, as well, but it would be unlikely that a lipid panel would be checked at most urgent care settings for this initial patient presentation. Most likely, this boy has an idiopathic focal segmental glomerulosclerosis (FSGS). Sometimes a positive family history is elicited. The complaint of frothy urine stems from the high content of protein in the urine. The spot urine protein-to-creatinine ratio can provide a quantitative estimate of proteinuria when a 24-hour urine collection is unavailable. A protein-to-creatinine ratio of >3.5 mg/mg equates to a 24-hour urine collection of >3.5 g/24 hours per 1.73 m2 body surface area of protein. An acute pyelonephritis would present much differently. Typical patient complaints include fever, flank pain, perhaps urinary changes (dysuria, gross hematuria), and nausea/vomiting. On physical exam, one would expect to find an elevated temperature, no hypertension, no edema, and a moderately ill-appearing patient with tenderness at the costovertebral angle (CVA). Diabetic nephropathy is a nephrotic disorder with chronic damage to the glomerulus. While further testing could reveal this patient to have had diabetes, which caused the nephrotic syndrome, the current history, physical, and laboratory data (including normal serum glucose and absence of glucosuria) do not support this diagnosis. Only a broader diagnosis of nephrotic syndrome may be made at this point. Henoch-Schönlein purpura is a systemic small vessel vasculitis, classified as a nephritic disease with presentation of purpuric rash, arthralgias, and abdominal pain. This boy had mild hematuria on the urinalysis, and hematuria is a hallmark of nephritic disease. The high level of proteinuria, however, is not associated with nephritic diseases. This patient denied pain, and skin examination was unremarkable with no purpuric rashes noted. Post-streptococcal glomerulonephritis (PSGN) is another nephritic disease, characterized by hematuria. Children, especially boys, are more likely to develop PSGN after a streptococcal infection (pharyngitis or skin). The edema and proteinuria can occur in both PSGN and nephrotic syndrome, but the level of proteinuria (typically less than 500 mg/day), as well as the negative history for recent illness, help rule out PSGN. If there was concern of PSGN, an antistreptolysin O titer could be checked. This is often positive for several months after a streptococcal illness.

A 12-year-old African American boy presents with a 1-month history of poor appetite and has complained of overall not feeling well. When questioned, the boy cannot delineate any specific symptoms except that he feels "puffy." He denies pain, eating disorder, rash, depression, drug use, and fevers. The family denies recent travel. His PMH is unremarkable with no recent or chronic illnesses. He has had no surgeries, and he takes no medications. His family history includes grandparents on both sides with hypertension, with one of these grandparents also having died from some type of kidney problem. His ROS is entirely negative except for the above symptoms and some noted change in urine, which he describes as frothy. He denies dysuria, gross hematuria, polyuria, and nocturia in the ROS. On physical exam, his vitals are: Tem: 97.9°F; Resp 14; HR 90; BP 120/74 mm Hg right arm sitting. It is noted weight is up 2 pounds from his charted weight 3 months ago. HEENT, neck/thyroid, lungs, cardiac, abdominal, musculoskeletal, neurological and derm exams are unremarkable. Examination of extremities reveals bilateral 1-2+ edema in the upper and lower extremities, with 2+ pulses. Basic laboratory studies were ordered and results are available at the time of visit. Given the proteinuria, a urine protein-to-creatinine ratio is obtained, showing 3.6 mg/mg. Question At this point, what is the most likely diagnosis? Answer Choices 1 Acute pyelonephritis 2 Diabetic nephropathy 3 Henoch-Schönlein Purpura 4 Nephrotic syndrome 5 Post-streptococcal glomerulonephritis

1 Wilson's disease Wilson disease is an inherited disorder of copper toxicity due to a genetic defect in copper transport. Beginning at birth, copper is not secreted into the bile or incorporated into the copper protein ceruloplasmin, resulting in low serum levels of ceruloplasmin. Symptoms and signs develop ages 5-40 as copper accumulates in the liver, brain, corneas, kidneys, and reproductive organs. 50% of patients present with hepatitis, 40% present with neurological manifestations (e.g., tremor, speech disorders, dysphagia, incoordination), and 5-10% will first present with Kayser-Fleischer rings (a brown-yellow ring in the cornea around the iris), amenorrhea, miscarriages, or hematuria. Kayser-Fleischer rings are the result of accumulation of copper in the cornea and are the most unique sign of Wilson disease. Diagnosis in confirmed by Kayser-Fleischer rings on slit-lamp examination and the presence of a low serum ceruloplasmin. AST and ALT levels are often elevated, serum copper is low, and 24-hour urinary copper excretion is elevated. Treatment is lifelong chelation, or oral zinc and a low copper diet. Menkes syndrome is an inherited disorder of copper deficiency that occurs in male infants; it is ideally detected before age 2 weeks. Copper is deficient in the liver, serum, and copper proteins, including ceruloplasmin. Symptoms can include hypopigmentation, intellectual disability, vomiting, diarrhea, enteropathy, and bone changes; sparse, wiry, or kinky hair is also a symptom. Diagnosis is based on low copper and ceruloplasmin levels in serum, although diagnostic accuracy of these tests is limited. Menkes syndrome can result in death if not diagnosed early. Hemochromatosis is an inherited disorder of iron metabolism resulting in high iron absorption, iron overload, and subsequent iron deposition in the liver, heart, pancreas, and other organs. Patients are asymptomatic, but they may present with non-specific symptoms including weakness, fatigue, and weight loss with abdominal pain or arthralgias. Patients with elevated transferrin saturation and ferritin levels should undergo genetic testing. Treatment includes maintenance phlebotomy. Sideroblastic anemia is the result of inadequate marrow utilization of iron, resulting in a microcytic and hypochromic anemia in the presence of increased serum iron, ferritin, and transferrin saturation. It is not associated with hemolysis, liver disease, or jaundice. Kernicterus (bilirubin encephalopathy) is brain damage caused by unconjugated bilirubin crossing the blood-brain barrier and being deposited in the basal ganglia and brain stem. Hyperbilirubinemia occurs in preterm infants due to a hemolytic anemia.

A 12-year-old boy presents with fatigue and jaundice. His past medical history is not significant for recent illness, fever, infectious exposures, medication, alcohol, or drug use. He denies gastrointestinal (GI) symptoms and a history of GI disease. On physical examination, he appears ill; the liver edge is palpable and slightly tender. Skin and sclera are icteric, and there is corneal discoloration. On further eye examination using a slit-lamp, brown-yellow rings encircling the iris in the rim of the cornea are noted bilaterally. AST and ALT are elevated, and a serum ceruloplasmin level is ordered; it is reported as low and confirms the diagnosis. What is this disease process is known as? Answer Choices 1 Wilson's disease 2 Menke's syndrome 3 Hemochromatosis 4 Sideroblastic anemia 5 Kernicterus

4 Otolaryngologist The X-ray of the lateral neck demonstrates a retropharyngeal abscess. Definitive treatment consists of surgical drainage performed by an otolaryngologist. This is primarily a pediatric illness, rarely occurring in adolescents and adults. Physical examination may demonstrate nuchal rigidity and/or cervical lymphadenopathy. An X-ray of the lateral neck may reveal the diagnosis with findings of a widened prevertebral soft tissue shadow, the presence of air-fluid level, foreign body, and/or loss of the normal curvature of the cervical spine. The width of the prevertebral soft tissue should be less than or equal to the width of the adjacent vertebral body. Radiologically, it may be difficult to distinguish an abscess from cellulitis in the neck. A follow-up CT scan of the neck may help. A chest X-ray should be done to determine if there is mediastinal extension or aspiration pneumonia. Laboratory findings reflect an acute bacterial infection. White blood cells in the cerebrospinal fluid can result from irritation of the meninges by infection in adjoining tissues.

A 13-month-old girl presents in the urgent care center with a history of fever, increasing lethargy, and decreased appetite for 4 days. She has had watery rhinorrhea, an occasional dry cough, and progressive vomiting with 6 episodes in the prior day, but no diarrhea. Also noted are pain and difficulty when swallowing and noisy breathing. She has no active medical problems and her immunizations are up to date. On examination, her temperature is 39.5°C, respiratory rate 48, apical pulse 162, and blood pressure 90/66 mm Hg. Physical examination demonstrates decreased hydration of the oral mucosa, increased capillary refill time, and cool extremities. Tympanic membranes are clear. Pupils are equal, round, and reactive to light. Nasal mucosa appears mildly erythematous with some dried crusted secretions in both nares. Nasal flaring is noted. There are no oral or pharyngeal lesions visible; tonsils appear to be of normal size and without inflammation or exudates. Neck resists flexion. Shotty bilateral anterior cervical nodes are palpated. The chest is clear and without retractions. The remainder of the examination is normal. Initial laboratory studies provided the following results: CBC - WBC 26,500 with differential 24% polymorphonuclear leukocytes, 60% bands, 11% lymphocytes, 1% eosinophils, and 4% atypical lymphocytes. Hemoglobin 10.8 g/dL, platelets 268,000. Blood culture was drawn. Cerebrospinal fluid - 11 white blood cells and 1 red blood cell/mm3, protein 40 mg/dL, glucose 79 mg/dL. Gram stain showed no organisms. Liver function tests were normal. A basic metabolic panel was normal except for a CO2 of 20 and a BUN of 22. Initial treatment consisted of hydration and antibiotics with a presumptive diagnosis of aseptic meningitis. Fever, irritability, and nuchal rigidity persisted. The following radiograph was obtained. Refer to the image. Question After review of the tests, who is the most appropriate consultant to call? 1 Infectious disease specialist 2 Neurosurgeon 3 Ophthalmologist 4 Otolaryngologist 5 Pulmonologist

5 Pericardial tamponade The clinical picture is suggestive of pericardial tamponade. Patients with pericardial tamponade often present with shortness of breath. The most common symptom is dyspnea. The patient can also present with elevated jugular venous pressure, hypotension, and muffled heart sounds. Pericarditis presents with severe chest pain of sharp retrosternal onset with radiation to the back and worsening with a deep breath or cough. Additionally, the pain is position-dependent: worse when lying flat and better when leaning forward. On physical examination, a pericardial friction rub is pathognomonic of pericarditis. It is a high-pitched squeaking sound. These signs and symptoms are not present in this patient. Signs and symptoms of an acute myocardial infarction may include sudden development of prolonged anterior chest discomfort that may produce arrhythmias, hypotension, shock, or cardiac failure. Sometimes they may be painless. ECG changes can be noted, specifically ST-segment elevations or depressions, presence of Q-waves, or symmetric inversions of T-waves. Elevations of cardiac markers (troponins, CK-MB) may be seen. These are not present in this patient. Muffled heart sounds are not heard in pulmonary edema or a tension pneumothorax.

A 19-year-old man is brought into the ED following a motor vehicle crash in which he, the driver, sustained blunt trauma to the anterior trunk from striking the steering wheel and dashboard. The patient is alert, short of breath, hypotensive, and complains of acute chest pain. On auscultation, muffled heart sounds are heard. Question What is your initial diagnosis? 1 Pericarditis 2 Acute myocardial infarction 3 Pulmonary edema 4 Tension pneumothorax 5 Pericardial tamponade

5 Tracheoesophageal fistula The clinical picture is suggestive of tracheoesophageal fistula. Commonly, the newborn presents with choking, cyanosis, copious secretions, and respiratory distress. Polyhydramnios is common. Symptoms worsen during feedings; stomach distention and pneumonia are possible complications. Continuous esophageal suctioning should persist until definitive repair. Diagnosis is made by placing an NG tube to where resistance is met. An X-ray is taken, and the tube should be visible in a blind pouch. Choanal atresia is a disorder where the back of the nasal passage is blocked. It is defined as bilateral or unilateral. Bilateral is a life-threatening condition that results in severe respiratory distress at birth; it requires immediate placement of an oral airway. Unilateral choanal atresia usually presents later and is confused with chronic sinusitis. Hypertrophic pyloric stenosis usually presents itself between the third and sixth week of life. It will classically have intense projectile vomiting shortly after eating. During physical examination, a discrete 2-3 cm firm movable olive-like pyloric mass can be palpated in the right epigastrium. This is 5:1 higher incidence of this in male infants, specifically firstborn male infants. Intussusception is telescoping of one portion of the intestine into the adjacent segment. This usually occurs between 6 months and 3 years of age and has a slight male predominance and even a seasonal variation, as it increases in incidence during viral enteritis season. Symptoms and signs include sudden significant colicky abdominal pain that occurs every 15-20 minutes, often with vomiting. Currant-jelly stool is also a very distinct sign of this pathology. Meconium ileus is lower on the differential since it is more often found in children that have cystic fibrosis. These newborns fail to pass meconium in the first 12-24 hours and have signs of intestinal obstruction: bilious emesis, abdominal distension, peritonitis, ascites, and possible respiratory distress.

A 19-year-old woman gives birth to an apparently healthy 8 lb female neonate. Choking, coughing, and cyanosis occur during her first attempt at feeding. The mother had polyhydramnios during her pregnancy. Question What is the most likely explanation for the newborn's distress? 1 Choanal atresia 2 Hypertrophic pyloric stenosis 3 Intussusception 4 Meconium ileus 5 Tracheoesophageal fistula

1 Increased TIBC, decreased serum ferritin, decreased serum iron The correct answer is increased Total Iron Binding Capacity (TIBC), decreased serum ferritin, and decreased serum iron. In patients with iron deficiency anemia, iron stores are first depleted, indicated by a decreased ferritin, causing the TIBC to rise. This type of anemia is described as hypochromic and microcytic due to the decreased iron stores present. Red blood cell formation continues but in the presence of decreased iron supply. The mean corpuscular volume (MCV) will stay normal early in the disease process but will fall over time. The other answers have results that do not represent iron deficiency anemia. Decreased TIBC, increased serum ferritin, increased serum iron may represent hemochromatosis. The other answers are not likely to occur.

A 19-year-old woman presents with weakness and increased fatigue over the past several months. Laboratory studies reveal a hemoglobin of 9.7 g/dL with a hematocrit of 32%. Question Which of the following results would indicate an iron deficiency anemia? Answer Choices 1 Increased TIBC, decreased serum ferritin, decreased serum iron 2 Decreased TIBC, decreased serum ferritin, decreased serum iron 3 Increased TIBC, increased serum ferritin, increased serum iron 4 Increased TIBC, increased serum ferritin, decreased serum iron 5 Decreased TIBC, increased serum ferritin, decreased serum iron

5 Topiramate This patient is suffering from migraine headaches, common headaches classically described as throbbing in nature and accompanied by nausea (and possibly vomiting), photophobia (sensitivity to light), phonophobia (sensitivity to sounds), and possibly visual changes and aura. Migraines are more common in women than men, but can occur in men. They are usually a chronic condition, beginning in adolescence or early adult years. Often a family history is present. Stress, sleep deprivation, and various foods can be among many triggers for migraines. With a classic history and no alarm features of a more serious condition, no testing would be necessary. Treatment approach includes offering treatment for acute headache and, with frequent migraine such as this patient's, prophylactic treatments, such as topiramate, propranolol, amitriptyline, valproic acid, and botulinum toxin type A. Topiramate augments GABA activity and has primarily been used for seizure disorders. It is approved and effective for prevention of migraine headaches. Cetirizine, an antihistamine, is useful for allergic rhinitis and urticarial. If this patient's headaches were attributed to allergic symptoms, cetirizine may be useful. However, cetirizine does not prevent migraines. Clopidogrel reduces platelet activation and aggregation and is used in acute coronary syndromes and prevention of thromboembolism. Although migraine headaches can be attributed to intracranial vascular changes, there is no role for clopidogrel in reducing migraine frequency. Hydrocodone, a semi-synthetic opioid, is often marketed in combination with other analgesics (such as acetaminophen) and is mostly used for acute pain. Especially with the frequency of this patient's headaches and risk for addiction/abuse, opioid use should be discouraged for this patient. Opiates are not especially effective for the acute migraine pain and are not at all effective for migraine prophylaxis. Sumatriptan works on 5-HT1 serotonin receptors to cause vasoconstriction. It is primarily used for acute migraine treatment, but is it also useful in acute treatment of cluster headaches. It has an oral, nasal, and subcutaneous route of delivery. Sumatriptan is not recommended for prophylaxis of any type of headache.

A 19-year-old woman presents with worsening headaches. She reports a multi-year history of episodic, throbbing headaches. They have intensified, and she now misses classes and work periodically due to her headaches. Recently, the headaches occur about 4-6 times per month, up from 1-2 per month when she first started experiencing headaches. Her headaches last 2-3 days duration and are accompanied by nausea, vomiting, and light sensitivity. After the headache resolves, she denies any residual symptoms. She denies neurologic symptoms, such as vision or taste changes, gait disturbances, and memory loss. She has tried multiple over-the-counter pain medications without relief. Her mother and maternal aunt experienced similar headaches. She reports some increased stressors and less sleep since starting college. Her past medical history is unremarkable, with no known medical conditions (except for the headaches), no surgeries, no chronic medications, and no drug allergies. She has never been sexually active and reports regular menses. She denies the use of tobacco, alcohol and drugs. On physical exam, the patient appears comfortable and reports no headache at this time. Her entire exam, including neurological, is normal. Question In addition to treatment options for acute headache, this patient should be educated about which of the following daily medications to prevent headache episodes? 1 Cetirizine 2 Clopidogrel 3 Hydrocodone 4 Sumatriptan 5 Topiramate

5 Retinoblastoma Retinoblastoma is the most common primary malignant intraocular tumor of childhood. It usually appears quite early in the first 5 years. Leukocoria, a white or Cat's eye reflex in the pupil is the most frequent finding. There may also be strabismus due to vision impairment. Ocular inflammation, intraocular hemorrhage, glaucoma, or heterochromia iridis may be seen. On fundoscopic exam, the tumor may appear as a small to large white mass depending on its stage. Primary treatment includes enucleation, though smaller tumors diagnosed at an earlier stage may be amenable to newer alternative treatments such as cryotherapy and photocoagulation. Though leukocoria may be seen in retrolental fibroplasia or advanced stage of retinopathy of prematurity, it is predominantly a disorder in preterm, low birth weight infants who received supplemental oxygen in the newborn period. These infants are susceptible due to the immaturity and subsequent damage of developing retinal vasculature. If the retina goes through various stages to ischemia and neovascularization, leukocoria may be seen representing retinal detachment and a subsequent membrane formation. Phakomata are retinal findings hallmarking hamartomatous disorders such as tuberous sclerosis. The distinctive ocular lesion is a yellowish multinodular cystic lesion arising from the retina or disc. Similar lesions can occur in neurofibromatosis. Retinitis pigmentosa is a progressive degeneration of the retina characterized by pigmentary changes, arteriolar attenuation, some degree of optic atrophy and progressively deteriorating visual impairment. Granularity or mottling of the retinal pigment pattern or distinctive focal pigment aggregates can be seen via fundoscopy. Retinoschisis is a congenital disorder involving splitting of the retina into an inner and outer layer. Usually, good vision is maintained. An elevation of the inner layer of the retina can be seen.

A 2 week old female infant is seen for her newborn well baby exam after a normal birth and delivery. She has been nursing well, has regained her birthweight and her development appears normal for her age so far. Physical examination is normal with the exception that ophthalmoscopic evaluation reveals a faint white reflex in her right eye. What is the most likely diagnosis? Answer Choices 1 Retrolental fibroplasia 2 Phakomata 3 Retinitis Pigmentosa 4 Retinoschisis 5 Retinoblastoma

4 Gastroesophageal mucosal tear The presentation is consistent with a gastroesophageal mucosal tear, also called Mallory-Weiss syndrome. Vomiting and retching may cause a tear that involves only the mucosa and is not transmural. The tear usually involves the gastric mucosa near the squamous to columnar mucosal junction, but it may also involve the esophageal mucosa. A wide variety of causes have been cited, such as gastroenteritis, alcohol binging, ulcers, and hiatus hernia. In fact, any condition that causes retching and vomiting can cause the tear. Patients present with upper gastrointestinal bleeding that may be severe. Most patients recover with only conservative management, but those with severe arterial bleeding require surgery. Acute gastritis or acute esophagitis is unlikely to cause profuse bleeding or vomiting, although a small amount of bleeding may occur. Carcinoma of the stomach would be a rare cause of vomiting and would be an unlikely diagnosis in a 21-year-old. Angioectasias are small vascular anomalies that may be present anywhere in the gastrointestinal tract. They may cause intermittent episodes of bleeding but are unlikely to cause massive hemorrhage.

A 21-year-old man is brought to the emergency room by his friends. One hour earlier he started retching excessively and vomited violently several times. Prior to becoming ill, he had been at a party and was consuming a lot of liquor. The vomitus was mainly bright red blood (about 2 quarts) and dizziness followed. What is the likely cause of this clinical picture? 1 Acute gastritis 2 Carcinoma of stomach 3 Acute esophagitis 4 Gastroesophageal mucosal tear 5 Gastric angioectasia

3 Hypertension This patient likely is suffering from Cushing syndrome, also known as hypercortisolism. Consequences of excessive levels of circulating cortisol, no matter the etiology, will lead to signs and symptoms such as central obesity but thin extremities, a moon face, a buffalo hump, supraclavicular fat pads, protuberant abdomen, and hirsutism; there may also be oligomenorrhea, amenorrhea, or in men, possible erectile dysfunction. Backaches, headaches, acne, purple striae, and impaired wound healing may also be found in these patients. Although secondary hypertension only accounts for 5-10% of all hypertension cases, Cushing syndrome has been found to be a potential cause for these cases. Its main cause is the mineralocorticoid effects of excess glucocorticoids. Hypotension is an incorrect response. Hypokalemia secondary to aldosteronism is what would potentially lead to secondary hypertension. Exophthalmos is a physical exam sign that is evident in patients with hyperthyroidism. If carotid bruits are auscultated, this is usually a sign of carotid stenosis.

A 22-year-old woman presents with an 8-month history of amenorrhea. Further questioning elicits additional pertinent positives of backaches, headaches, hirsutism, and acne. Physical examination reveals a female patient with a moon-shaped facies, multiple purple striae, and significant central obesity (body mass index of 36). Question Considering the likely diagnosis, what other abnormality would be expected? 1 Hyperkalemia 2 Hypotension 3 Hypertension 4 Exophthalmos 5 Carotid bruit

4 Cotton-wool patches The correct response is cotton-wool patches. The patient has the diagnosis of primary essential hypertension. Essential hypertension accounts for 95% of all hypertension diagnoses, with secondary, malignant, and other causes making up the remaining 5%. It is widely known how detrimental hypertension is to cardiovascular health in the United States; 35% of myocardial infarctions and strokes, 49% of episodes of heart failure, and 24% of all premature deaths have some link to hypertension, making this a widespread health concern. It is strongly recommended by the US Preventive Services Task Forces that all people 18 years or older be screened for high blood pressure. Every patient has risk factors that make them more susceptible to hypertension, even with lifestyle modifications. This patient has both modifiable as well as non-modifiable risk factors that are most likely contributing to his diagnosis. His ethnicity, sex, family history, obesity, increased BMI, and increased waist circumference are all factors. Other well-known risk factors for developing essential hypertension include a lack of physical activity, smoking, high cholesterol levels, and the diagnosis of diabetes. Fundoscopic examination of any patients diagnosed with essential hypertension is an invaluable component; it can reveal how severe the high blood pressure has been anatomically and physiologically on the body up to that point. Cotton-wool patches usually appear as gray or white ovoid lesions that have soft borders. These occur secondary to infarction of the nerve fibers within the fundus area; hypertension is a common etiology that can lead to the presence of this pathology. Drusen bodies are fundoscopic findings that are yellowish round spots; they vary in size, but they are generally small. Edges of these areas may appear soft or hard. Although Drusen bodies may be seen in normal aging patients, it is very commonly related to the diagnosis of age-related macular degeneration. Microaneurysms are considered a hallmark finding of diabetic retinopathy. Deep retinal hemorrhages are also commonly seen in patients with diabetes. A macular star results from punctate exudates that radiate from the fovea in a star pattern; this is seen in patients who are experiencing malignant hypertension.

A 25-year-old African American man presents with blood pressure issues. He states that he attended a work-sponsored health fair and had his blood pressure taken. The health fair representative strongly urged him to make an appointment to be seen by his primary care provider. The fair occurred 3 months ago. He has randomly checked his blood pressure at different times since the health fair in local grocery stores, and although he does not remember the numbers, he knows that "they were above normal." The patient also believes that both his mother and father are taking blood pressure medication, but he is not 100% sure. Vitals at this time reveal a BMI of 30 kg/m2 and a waist circumference of 41 inches; blood pressure is 175/95 mm Hg in the left arm and 172/99 mm Hg in the right arm. Question Based upon the diagnosis at this time, what would most likely be seen during the fundoscopic examination of this patient? 1 Drusen bodies 2 Microaneurysms 3 Deep retinal hemorrhages 4 Cotton-wool patches 5 Macular star

1 Vitamin A deficiency In cases of vitamin A deficiency, patients can present with inability to see well in dim light or night blindness. There may also be conjunctival and corneal xerosis, pericorneal and corneal opacities, and Bitot's spots. Bitot's spots are a collection of keratin appearing as triangular foamy spots on the conjunctiva. The patient may also have xeroderma, hyperkeratotic skin lesions, and increased susceptibility to infections. Causes include inadequate dietary intake and malabsorption. Dietary sources of vitamin A include fish, liver, egg yolk, butter, cream, dark green leafy vegetables, yellow fruits, and vegetables. In cases of pyridoxine (or vitamin B6 deficiency), patients can present with peripheral neuropathy, seborrheic dermatosis, glossitis, and cheilosis. Laboratory investigations reveal anemia with lymphopenia. Causes include malabsorption as well as medications such as isoniazid and penicillamine. Dietary sources of vitamin B6 include liver, legumes, whole grain cereals, and meats. In cases of vitamin C (or ascorbic acid) deficiency, patients can present with bleeding tendencies (as a result of weakened capillaries) and impaired wound healing due to impaired formation of connective tissue. On examination, the gums may be swollen and friable; the teeth may be loose. There may also be multiple splinter hemorrhages on the nails and ecchymoses, especially over the lower limbs. Causes include inadequate dietary intake and certain conditions such as pregnancy and lactation that increase vitamin C requirements. Dietary sources of vitamin C include citrus fruits, such as oranges, lemons, and tangerines, as well as tomatoes and potatoes. Niacin deficiency causes pellagra, which is characterized by symmetrical dermatitis, usually on parts of the body exposed to sunlight scarlet glossitis and stomatitis, diarrhea, mental aberrations, such as memory impairment, depression, and dementia Causes include inadequate dietary intake, especially in patients with corn-based diets and alcoholism. Dietary sources include legumes, yeast, meat, and enriched cereal products. Vitamin E deficiency may cause a hemolytic anemia in premature infants. Laboratory investigations reveal low plasma tocopherol levels, a low hemoglobin level, reticulocytosis, hyperbilirubinemia, and creatinuria. Causes of vitamin E deficiency in premature infants include limited placental transfer of vitamin E and the resultant low levels at birth combined with its relative deficiency in the infant diet. Dietary sources for older children and adults include wheat germ, vegetable oils, egg yolk, and leafy vegetables.

A 25-year-old man from China presents with a 1-month history of an inability to see well while walking home from work at night. He also reports that he has been getting sore throats more frequently. He is a recent immigrant from his home country; he lives alone and eats mainly a rice-based diet. On examination, you note pericorneal and corneal opacities. Question What is the most likely diagnosis? Answer Choices 1 Vitamin A deficiency 2 Pyridoxine deficiency 3 Vitamin C deficiency 4 Niacin deficiency 5 Vitamin E deficiency

4 Cervical motion tenderness Cervical motion tenderness along with a history suspicious for pelvic inflammatory disease (PID) is a red flag for the diagnosis. While testing for sexually transmitted infections (especially Chlamydia trachomatis and Neisseria gonorrhea) is indicated, the diagnosis is typically based on history and physical exam. The Centers for Disease Control Sexually Transmitted Treatment Guidelines recommend empiric treatment for PID if one or more of the following minimum criteria are present on exam: cervical motion tenderness, uterine tenderness, adnexal tenderness A high index of suspicion is needed, and treatment should be initiated while awaiting laboratory results. The examiner should further elicit this patient's sexual partner history and potential vaginal/cervical discharge. Other conditions, such as endometritis and endometriosis, could cause cervical motion tenderness. The CDC guidelines are helpful in selecting antibiotic therapy and whether to treat as inpatient or outpatient. Most women will find that pelvic exam is uncomfortable, but tenderness with movement of the cervix is not a normal finding and indicates inflammation in the uterus. The remaining physical exam findings listed are less helpful than a finding of cervical motion tenderness. Abdominal guarding is a common physical exam finding with many gastrointestinal, urinary, and pelvic disorders. Guarding refers to voluntary or involuntary contraction of the abdominal musculature in response to pain felt during palpation. It is not a specific finding for pelvic inflammatory disease, and it would not help narrow a diagnosis as much as cervical motion tenderness. A physical exam finding of an adnexa approximately 2.5 cm in size is a normal physical exam finding. When the patient is thin enough for a good estimate of ovarian size, an examiner may notice enlargement in the case of ovarian cysts, ectopic pregnancy, tumors, and other ovarian disorders. A finding of normal ovarian size does not narrow the differential for this patient. An anteverted uterus on physical exam simply indicates the angle of the fundus points toward the ventral side of the patient. This is also a normal finding, and it does not assist in arriving at a definitive diagnosis. Discomfort with speculum insertion can be related to many factors, including examiner skill, patient anxiety, vaginal inflammation, and many gynecologic disorders. This finding is non-specific and also does not help with diagnosis.

A 25-year-old woman presents with pelvic pain for the last 3-4 menstrual cycles, the most recent episode with increasing symptoms for approximately 2 weeks. She has tried over-the-counter pain relievers without relief. She admits deep dyspareunia, and she has been with her current sexual partner for about 6 months. She admits that she does not use barrier contraception every time with her current and previous partner, although she is on an oral contraceptive pill. She has no chronic medical conditions. There are no allergies to any medications. She denies urinary issues. She admits to nausea, but no vomiting or diarrhea. She reports a negative home pregnancy test this morning. Her last pelvic exam was over 1 year ago. LMP was 1 week ago. Question Which of the following physical exam findings would best narrow your diagnosis? Answer Choices 1 Abdominal guarding 2 Adnexa approximately 2.5 cm in size 3 Anteverted uterus 4 Cervical motion tenderness 5 Discomfort with speculum insertion

5 C8 The most likely nerve affected in this case is the C8 nerve root. Impingement of C8 may cause numbness and tingling, primarily on the medial surface of the arm and into the ulnar side of the hand into the fourth and fifth digits. Impingement may also cause dysfunction of the hand, as it innervates the small hand muscles. Impingement of the C4 nerve root may cause neck and upper shoulder numbness and pain. Impingement of C5 nerve root may cause deltoid and shoulder numbness and pain, and biceps and brachioradialis tendon reflexes may be diminished. Numbness, if it occurs, is in the lateral arm. Impingement of the C6 nerve root can cause numbness and tingling down the arm into the thumb, with weakness in the bicep muscle and diminished brachioradialis tendon reflex in the affected extremity. Impingement of C7 also causes numbness and pain down the affected arm but into the middle finger, and the triceps reflex may be diminished on exam.

A 28-year-old man presents following a motor vehicle accident 20 minutes prior. He states that it was just a fender bender, but he feels he might have whiplash. His neck is stiff and sore, and he has developed numbness and tingling on the medial surface of his right arm and into his right fourth and fifth digits. On physical examination, his bicep strength is +5/5 on the left and +5/5 on the right. His biceps tendon reflex is 2+ on the left and 2+ on the right. In addition, his triceps tendon reflex is 2+ on the left and 2+ on the right. His finger extension, wrist extension (ulnar), and grip strength on the right is diminished compared to the left. The remainder of the physical exam is normal. Question Based on the above presentation, what is the cervical nerve root most likely affected? Answer Choices 1 C4 2 C5 3 C6 4 C7 5 C8

4 Hyperresonance to percussion Hyperresonance to percussion over the affected area is the most consistent finding on physical exam for a pneumothorax. Based on history, physical exam, and radiographic findings, spontaneous pneumothorax is the most likely diagnosis. Whisper pectoriloquy is absent over the affected area. Egophony is heard when consolidation is present, not with a pneumothorax. Tactile fremitus is decreased over the affected area on physical exam. A pleural rub is not typically heard with a pneumothorax, but it is heard in conditions such as pleuritis, pleural effusion, and possibly pneumonia.

A 28-year-old man presents with acute onset of dyspnea and left-sided chest pain. He denies any trauma or previous similar complaints in the past. Chest X-ray demonstrates a visceral pleural line just under the left hilum. Question What left-sided findings would you expect on physical exam? Answer Choices 1 Positive whisper pectoriloquy 2 Egophony 3 Increased tactile fremitus 4 Hyperresonance to percussion 5 Pleural rub

3 Thyroid function studies The correct answer is thyroid function studies, including a TSH and Free T4 to confirm gestational thyrotoxicosis, which is commonly due to Graves' disease. Gravid patients frequently have fatigue during the first trimester, but if the symptoms were solely due to the pregnancy, they would have most likely subsided by the second trimester. Patients with thyrotoxicosis have hyperactivity that results in insomnia; they are easily fatigued, especially with physical exertion. Typically, thyrotoxicosis presents with weight loss, but in the case of a gravid woman, a weight gain of <0.9 kg/month is inadequate at this point in the pregnancy. Sinus tachycardia is the most common arrhythmia associated with hyperthyroidism. Periorbital edema is frequently seen in Graves' ophthalmopathy with or without proptosis, and hyperreflexia is a common neurological manifestation. Urinalysis would confirm the presence of proteinuria as seen in preeclampsia. Preeclampsia may be asymptomatic or present with weight gain or edema, wherein facial edema is more specific than ankle edema. Other signs include hyperreflexia due to neurologic involvement that can progress to seizures and dyspnea; pulmonary edema can be seen in cases of severe preeclampsia. Preeclampsia is diagnosed when a gravid woman presents with a new onset of hypertension (140/90 mm Hg) in the presence of proteinuria. This diagnosis would be less likely than thyrotoxicosis because the patient's blood pressure is not elevated to this level; it would not explain the patient's sinus tachycardia. A CBC with iron studies would identify an iron deficiency anemia, which could present with fatigue, dyspnea, tachycardia, and lack of weight gain if she had poor oral intake, but it would not explain the insomnia or hyperreflexia. Palpitations, shortness of breath, rapid heart rate, and shakiness could be seen if the patient was experiencing panic attacks. A psychiatric evaluation could establish this diagnosis, but it would not explain the patient's resting tachycardia, lack of weight gain in pregnancy, periorbital edema, or hyperreflexia. A cardiac stress test would identify a cardiac abnormality, such as coronary artery disease or an arrhythmia. These could explain the dyspnea on exertion and palpitations, but would not likely be associated with periorbital edema or resting tachycardia; they would not explain the lack of weight gain in pregnancy or hyperreflexia.

A 28-year-old woman at 24 weeks gestation presents with insomnia and fatigue. Her symptoms have worsened as the pregnancy has progressed. She has noticed dyspnea on exertion that is associated with palpitations when grocery shopping or going to the laundromat. Vital signs are blood pressure of 128/88 mm Hg, pulse is 102/minute, respirations are 16/minute, and temperature is afebrile. Weight is 138 lb, which is stable from her last visit 4 weeks ago. On physical exam, the patient is a gravid woman in no acute distress. Clinical findings include mild periorbital edema without ankle edema and brisk ankle reflexes. Examination is otherwise unremarkable. Question Which of the following will confirm the most likely diagnosis? Answer Choices 1 Cardiac stress test 2 Psychiatric evaluation 3 Thyroid function studies 4 CBC with iron studies 5 Urinalysis

3 Erythema nodosum This patient presents with classical findings of sarcoidosis. Erythema nodosum (EN) may occur in up to 39% of sarcoidosis cases, characterized by tender erythematous nodules most commonly located on the anterior tibial areas. EN is usually related to the acute presentation of systemic sarcoidosis (fever, malaise, polyarthralgia, and bilateral hilar lymphadenopathy) and has a self-limited course of about 1 month. EN is a non-specific skin lesion that is also observed in rheumatic fever, inflammatory bowel disease, infections (coccidioidomycosis, histoplasmosis, α-hemolytic streptococci, tuberculosis, and syphilis), patients with hypersensitivity reactions to drugs (oral contraceptives, NSAIDs), and pregnancy. Despite all these associations, EN is typically idiopathic in approximately 55% of the cases. An EN biopsy should be avoided, as histopathology shows non-specific subcutaneous inflammation and vasculitis. While lupus pernio is a skin manifestation of sarcoidosis, it is unusual on the legs; it is a specific cutaneous manifestation of chronic systemic sarcoidosis. Lupus pernio is characterized by red-to-purple indurated papules, plaques, or nodules; they are most commonly seen on the mid-face, particularly the alar rim of the nose and the hands. Biopsy shows granulomas and is diagnostic of sarcoidosis. Erythematous patches and plaques can be seen in multiple situations, including systemic lupus erythematosus (SLE) and dermatomyositis (DM). The classical SLE rash has a butterfly shape and is localized on the cheeks and the nose ridge. In DM, the rash is localized on the face, neck, back, and shoulders (shawl sign). Like erythema nodosum, pretibial myxedema is usually located on the anterior tibial areas. Pretibial myxedema is characterized by areas of a waxy, discolored induration resultant of glycosaminoglycans accumulation in Grave's disease. Erythema multiforme presents with multiple types of lesions, including macules, papules, and vesicles; however, the classic description is the "target lesion," which is characterized by multiple erythematous rings around a dusky blue center (commonly located on the trunk or extremities). It is usually seen in drug reactions (penicillin, sulfa drugs, phenytoin, and aspirin), but it can also be associated with infections (Mycoplasma pneumoniae, HSV), cancers (lymphoma, leukemia), and autoimmune conditions (collagen diseases, vasculitis). It is part of a spectrum that includes Steven-Johnson syndrome and toxic epidermal necrolysis. Sarcoidosis most commonly affects people of African and Northern European ancestry.

A 28-year-old woman of Norwegian descent presents with cough, dyspnea, joint pain, fever, fatigue, and weakness. Her history is negative for occupational and environmental exposure. A previous tuberculin skin test was negative. Chest X-ray shows interstitial infiltrate and bilateral hilar lymphadenopathy. Ophthalmological investigation (slit lamp) reveals a clinically silent uveitis. Blood tests show hypercalcemia, and transbronchial biopsy shows non-caseating granulomas. Therapy with systemic corticosteroids is initiated. Question What skin lesions would be most likely revealed in this patient's legs upon physical examination? 1 Lupus pernio 2 Erythematous patches and plaques 3 Erythema nodosum 4 Pretibial myxedema 5 Erythema multiforme

4 Patent ductus arteriosus Patent ductus arteriosus (PDA) is a continuous murmur heard throughout S1 and S2 with a crescendo-decrescendo sound. Patients often experience exercise intolerance, palpitations, tachycardia, dyspnea, and fatigue at an older age. As an infant, they can present with early congestive heart failure symptoms, tachycardia, poor feeding, slow growth, tachypnea, and recurrent lower respiratory tract infections. The murmur is best heard over the left subclavicular region. With a large sized PDA, chest X-ray findings show enlargement of the left ventricle and left atria. There is also an increase in pulmonary vasculature. This is due to the left-to-right shunting, which causes volume overload and enlargement of these areas. Atrial septal defect (ASD) is incorrect because the murmur is a widened, fixed splitting pattern during S2. The systolic murmur is heard at the upper left sternal border. On chest X-ray, there is enlargement of the right atrial and right ventricle because of the left-to-right shunting that occurs. Congenital pulmonic valve stenosis is incorrect because this tends to be asymptomatic. If symptoms do occur, they present with right-sided heart failure, abdominal fullness, and pedal edema in advanced disease. On exam, a prominent a wave is present, and a right ventricular heave is palpated. The murmur is a loud, late-peaking crescendo-decrescendo systolic ejection murmur heart at the upper left sternal border. Ventricular septal defect is incorrect because this is a harsh, holosystolic murmur heard best at the left sternal border. Most people remain asymptomatic. A systolic thrill is often palpated on exam. Congenital aortic valve stenosis is incorrect because this is a harsh, crescendo-decrescendo systolic murmur. It is loudest at the base of the heart and radiates to the neck. This is present from birth, unlike the murmurs in ASD, VSD, and PDA.

A 3-month-old term infant presents for a wellness exam, and the parents report worsening in the infant's feeding habits and rapid breathing. On exam, there is a grade III/VI harsh heart murmur heard over the left subclavicular region that starts in early systole, peaks at S2, and decrescendos until the next S1. The infant is tachypneic and has bounding pulses of the upper and lower extremities. All other findings are within normal limits. A chest X-ray shows an enlarged left ventricle and atrium and increased pulmonary vasculature markings. Question What is the most likely diagnosis? 1 Atrial septal defect 2 Congenital pulmonic valve stenosis 3 Ventricular septal defect 4 Patent ductus arteriosus 5 Congenital aortic valve stenosis

3 Erythema multiforme The patient had sudden onset of target lesions as seen above. Target lesions are classic for erythema multiforme. The diagnosis is further suggested by her recent cold sore, which is consistent with herpes simplex, one of the triggers for erythema multiforme. Impetigo presents with honey-colored crusted lesions. Patients with erysipelas present with a sharply demarcated erythematous plaque. Erythema infectiosum presents with red cheeks with circumoral pallor and macropapules on the extremities. Patients with varicella develop a progression of macules to papules, vesicles, and crusts.

A 3-year-old girl is brought to the emergency department by her parents. They noticed the abrupt onset of a rash that began on her trunk and extended to her extremities symmetrically. The rash has been accompanied by fever, and her parents note that she napped longer than usual today. She has no chronic medical conditions, but her mother states that she did have a cold sore recently. On examination, the following is seen. Refer to the image. Question What is the most likely diagnosis? 1 Impetigo 2 Erysipelas 3 Erythema multiforme 4 Erythema infectiosum 5 Varicella

4 Bartholin gland cyst This patient most likely has a Bartholin gland cyst. The Bartholin glands are located at approximately the 4 o'clock and 8 o'clock positions at the introitus. Secretions help with vaginal lubrication. A cyst may form when the gland outlet is obstructed; infection occasionally develops, leading to an abscess. Both Bartholin cysts and abscesses can be painful. Initial conservative treatment consists of warm compresses to encourage drainage. If this is unsuccessful, incision and drainage are necessary. If Neisseria gonorrhea is implicated as a causative organism, appropriate antibiotic treatment should be prescribed. Vaginal candidiasis (also known as a yeast infection) would be characterized by symptoms of vaginal pruritus and discharge. Vulvar pain is common, and patients may note pain upon sitting, but a physical exam would reveal vaginal and vulvar erythema, thick white discharge, and hyphae on the wet mount. The fungal hyphae are especially noticeable when potassium hydroxide (KOH) is applied to the microscope slide to lyse the other cells. Vaginal candidiasis is not associated with a solitary vulvar mass. Herpes simplex, type 2 is typically the strain associated with genital herpes. A symptomatic patient with herpes may describe vulvar lesions causing pain with sitting. When lesions are visible, herpes is characterized by multiple painful vesicles and/or ulcerated lesions. Herpes lesions are typically much smaller than the described single mass. Lichen sclerosis is a chronic, progressive dermatological problem, often involving the vulvar and perineal epithelium. It is characterized by pruritus, dyspareunia, and fissuring of the skin. Lichen sclerosis is more common in post-menopausal women, and physical exam reveals thin, white-appearing tissue. Masses are not associated with lichen sclerosis. Vaginal intraepithelial neoplasia (VAIN) is typically located at the upper third of the vagina. Its presence is usually detected by an abnormality on the Pap pathology from asymptomatic patients. This patient's 2 cm mass at the introitus could potentially be a malignant tumor, but VAIN is an unlikely diagnosis. Bartholin gland carcinoma is a possibility, but it is very rare.

A 32-year-old woman presents with a 2-day history of having a vaginal "bump"; the bump is painful to sit on. She has never had this problem before, and she has been monogamous with the same sex partner for 7 years. On physical exam, you notice a solitary 2 cm smooth, slightly tender mass at the introitus. A KOH/wet mount demonstrates squamous cells with no white blood cells (WBCs), hyphae, or motile organisms. Whiff test is negative. Refer to the image. Question What is the most likely diagnosis? Answer Choices 1 Vaginal candidiasis 2 Herpes simplex, type 2 3 Lichen sclerosis 4 Bartholin gland cyst 5 Vaginal intraepithelial neoplasia (VAIN)

5 Elevated urinary free cortisol (UFC) levels This patient is presenting with signs and symptoms consistent with Cushing syndrome; in this case, it is most likely from an adrenal adenoma source. Expected laboratory findings associated with the syndrome may include an elevated leukocyte count, hyperglycemia, and a hypokalemic metabolic alkalosis, which may occur in patients with markedly elevated cortisol due to cortisol activation of the renal mineralocorticoid receptor. The diagnosis of Cushing syndrome due to endogenous overproduction of cortisol requires the demonstration of inappropriately high serum cortisol or urine cortisol levels. Urinary free cortisol (UFC) determination has been widely used as an initial screening tool for Cushing syndrome because it measures cortisol over a 24-hour period. Menstrual irregularities, amenorrhea, infertility, and decreased libido may occur in women due to inhibition of pulsatile secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which is likely due to interruption of luteinizing hormone-releasing hormone (LHRH) pulse generation.

A 33-year-old woman presents due to a 15-pound weight gain over 2 months; there is also muscle weakness, menstrual irregularities, amenorrhea, infertility, skin bruising, memory loss, and periods of depression. She denies any medication use or dietary changes; she has tried to lose weight unsuccessfully through increased exercise. She denies any headache, vision changes, hearing changes, chest pain, abdominal symptoms, polyuria, polydipsia, or breast discharge. Her physical exam reveals a blood pressure of 145/94 mm Hg. Her skin physical exam is remarkable for the findings in the image. Refer to the image Question What is an expected diagnostic finding in this patient? 1 Hyperkalemia 2 Metabolic acidosis 3 Elevated FSH and LH levels 4 Hypoglycemia 5 Elevated urinary free cortisol (UFC) levels

4 Transilluminating the mass A prominent ganglion cyst of the dorsal wrist will transilluminate, while a solid tumor will not. The active range of motion is usually not affected with a ganglion cyst except for tenderness that may limit the motion. Although ganglions are usually smooth on the surface, tumors can be too. Radiographs are taken to rule out any bony pathology, but they won't reveal the ganglion. MRI is used for locating the mass and its origin. Most ganglions and tumors are tender to firm palpation or pressure.

A 34-year-old woman presents to your clinic with a 3-month history of a mildly tender mass on the dorsocentral aspect of her dominant right wrist. She says the lump "comes and goes," but this time it has stayed and become tender. She denies any known trauma of the wrist or hand. What examination technique would help to show that this mass is a ganglion cyst? Answer Choices 1 Checking the active range of motion of the wrist 2 Palpating the mass for size & shape 3 Obtaining radiographs of the wrist 4 Transilluminating the mass 5 Palpating the mass for tenderness

3 Pneumocystis pneumonia Whenever a young patient presents with fever, progressive exertional dyspnea, hypoxia, and loss of weight, the possibility of Pneumocystis jiroveci pneumonia complicating acquired immunodeficiency syndrome (AIDS) should be considered, especially when diffuse interstitial infiltration (or patchy shadows) are found on chest radiological study. The history of a homosexual encounter favors this diagnosis. This should be followed by tests to confirm HIV. The increased alveolar-arterial O2 gradient indicates severe respiratory dysfunction. Bronchoalveolar lavage with lung biopsy is an appropriate early step in his evaluation. Finding pneumocystic cysts in the alveolar lavage is a confirmatory diagnosis for Pneumocystis jiroveci pneumonia. Treatment is based on the alveolar-arterial O2 gradient, which is considered mild when the value is less than 35 mm Hg, moderate when it is 35-45 mm Hg, and severe disease when more than 45 mm Hg. The mainstay of treatment is given intravenously or orally. Combined therapy of trimethoprim-sulfamethoxazole and corticosteroids is necessary in the treatment of a severe case of pneumocystis in AIDS. Administration of corticosteroids helps to prevent respiratory failure and death in AIDS patients. When Pneumocystis jiroveci Pneumonia is found in the absence of underlying immunosuppression from malignancy or drug, the patient fulfills the definition of AIDS. The laboratory findings are not suggestive of tuberculosis, legionella pneumonia, lung cancer, or syphilis.

A 35-year-old man is admitted to the hospital with progressive shortness of breath, fever, and worsening cough. The patient had been in good health until 2 months ago, when he began losing weight. This was associated with anorexia, intermittent diarrhea, night sweats, and then a nonproductive cough. He had lost more than 20 pounds by the time he was admitted to the hospital. His past medical history is unremarkable. He has been divorced for 5 years, and he has 1 child. He is employed as a medical equipment salesman, traveling extensively in the midwest. He admits to drinking alcohol in large amounts on weekends, but he denies tobacco and intravenous drug use. He gives history of a previous homosexual encounter. Physical examination shows that the chest was normal to percussion and clear by auscultation, except for a few scattered rhonchi. The heart is normal except for tachycardia. The abdomen is soft with normal bowel sounds. Genitalia are normal; however, there is a painful 2 cm ulceration at the anal verge. The neurologic exam is unremarkable. Chest radiological findings show diffuse bilateral interstitial infiltrates. Arterial blood gases on room air show pO2 57 mm Hg, pCO2 31 mm Hg, and pH 7.45. His alveolar-arterial O2 gradient is 55 mm Hg. Bronchoalveolar lavage fluid with lung biopsy shows the presence of cysts. Sputum cytology is negative for acid-fast bacilli. Question What is the most likely diagnosis? Answer Choices 1 AIDS-related tuberculosis 2 Secondary syphilis 3 Pneumocystis pneumonia 4 Lung cancer 5 Legionella pneumonia

2 Modification of activities, use of NSAIDs, and physical therapy The first-choice treatment is modification of activities that produce pain, use of nonsteroidal anti-inflammatory drugs (medications may help relieve symptoms), and physical therapy. The goal is pain control and inflammation reduction. Movement is needed to maintain flexibility and range of motion. Rest arm in a sling is incorrect because movement needs to occur in order to prevent frozen shoulder (adhesive capsulitis). Movement is needed to maintain flexibility and range of motion. Subacromial corticosteroid injections are considered to be the third line of treatment, not the first. Surgical treatment is considered for refractory shoulder cuff pain or tears if conservative management failed for more than 6 to 12 months (therefore, not the first-line choice for treatment). Surgical treatment also depends on the patient's age, loss of function, weakness, and pain. Opioid analgesics might be used if the NSAIDs do not alleviate the pain; however, NSAIDs should be tried first.

A 35-year-old man presents with right shoulder pain that is becoming progressively worse. He expresses concern that, although he visits the gym 3 times a week, over the past month he has not been able to increase the amount of weight he lifts secondary to the shoulder pain. He has not tried anything to alleviate the pain. The pain is at its worst at night while he is trying to sleep. He also reports pain while in the shower washing his hair or using the shoulder press machine at the gym. He denies any history of recent trauma or sports-related injury; however, upon questioning, he reports that about 1 month ago he and his wife painted their entire house in a weekend. Upon physical exam of the shoulders, no swelling, atrophy, redness, or bruising is noted. Point tenderness is noted over the right lateral deltoid muscle. Active ROM of the right shoulder at 80 degrees of abduction elicits pain. Patient has a negative drop arm test, negative apprehensive test, and a positive Neer impingement test of the right shoulder. Question What is the suggested first-line of treatment? Answer Choices 1 Rest with arm in sling 2 Modification of activities, use of NSAIDs, and physical therapy 3 Corticosteroid injections 4 Surgical treatment and corticosteroid injections 5 Opioid analgesics

1 Control hypertension on something other than lisinopril. This patient should be advised to change her antihypertensive from lisinopril, which is an angiotensin-converting enzyme inhibitor (ACEI). Lisinopril is considered a category D drug during the second and third trimesters of pregnancy, showing "positive evidence for human fetal risk." The class of ACEIs is "associated with fetal and neonatal injury, including hypotension, neonatal skull hypoplasia, anuria, reversible or irreversible renal failure, and death." If the hypertension is mild and this patient becomes pregnant, the healthcare provider may utilize close monitoring or initiate treatment with preferred agents, such as alpha-methyldopa, labetalol, or nifedipine. Decreasing caloric intake, especially below 1200 kcal per day, would not be recommended for this patient. It is estimated that normal pregnancy increases the daily caloric intake by 300 kcal. She should aim for a weight gain of approximately 0.66 pounds per week, with an overall weight gain of 15-25 pounds during a pregnancy, which is less than the 25- to 35-pound recommended gain for a woman of normal BMI. This patient's obesity is a risk factor for birth defects, but she should be advised to focus weight loss efforts prior to a pregnancy, not during one. The patient should not be advised to start oral medications for insulin resistance with the specific intent of decreasing birth defects. Though fetal malformations are strongly associated with maternal hyperglycemia, especially in the first trimester, there is no such association shown with the use of oral medications for insulin resistance for reducing the risk. This patient should be screened appropriately for development of gestational diabetes if she becomes pregnant. Oral drug therapy should be discontinued because there is insufficient data to establish the safety of these products. This patient does not need to discontinue her oral contraceptive for a several months' time prior to conception. The return to fertility takes roughly 2 weeks for most patients who have been using oral contraceptives, but birth defects are not associated with recent use of oral contraceptives. If the patient desires another pregnancy at age 36 and has an uncomplicated obstetric history, she should be advised to seek genetic counseling to fully explain her risks, given her advanced maternal age status (>35 years old). Allowing the patient to make an informed decision is preferable to advising the patient to avoid pregnancy entirely.

A 36-year-old P2 obese woman desires another pregnancy, and she seeks your advice for anything she should do prior to becoming pregnant. Her previous pregnancies and deliveries were uncomplicated, but the most recent one was 8 years ago. Her PMH is significant for insulin resistance and mild hypertension, which is currently controlled with lisinopril. Her current method of contraception is an oral combination contraceptive. Her body mass index is 31. Question What statement is the best advice in regard to reducing her birth defect risk in a subsequent pregnancy? Answer Choices 1 Control hypertension on something other than lisinopril. 2 She needs to cut caloric intake to <1200kcal daily as soon as she becomes pregnant to minimize obesity-related birth defect risk. 3 She needs to start oral medication for the insulin resistance to decrease risk of birth defects. 4 She should discontinue her oral contraceptive 3 months prior to attempting conception to minimize birth defect risk. 5 She should not consider pregnancy at all, given her advanced maternal age status.

2 Bell's Palsy The correct answer is Bell's palsy, a condition with a typically sudden onset that affects the facial nerve, causing unilateral facial paralysis. Typical symptoms of CN VII dysfunctions include the inability to raise the affected eyebrow or close affected eyelid, drooping of affected corner of the mouth, loss of nasolabial folds, inability to taste in anterior two-thirds of tongue, loss of ability to tear, and hyperacusis. This can occur due to infections such as HSV, herpes zoster, or influenza, as well as complications of diabetes or fluid retention in pregnancy. It is important to distinguish between peripheral and central etiologies. If the patient can raise their eyebrow of the affected side, further investigation of central etiology should be sought. Trigeminal neuralgia presents with sharp pain on one side of the mouth that radiates to the ipsilateral ear, eye, or nostril. This is caused by irritation of CN V, leading to intense shooting electric bolt pain with spasms. TN typically does not cause paralysis but can cause increased lacrimation, conjunctival injection, and rhinorrhea. Multiple sclerosis is a demyelinating disorder; it causes a multitude of symptoms, typically including diplopia or unilateral visual loss, weakness, numbness, and/or tingling in the extremities or face, Lhermitte's sign, gait disturbance or balance problems, bladder problems, and pain. The course is usually remitting-relapsing. Myasthenia gravis is an autoimmune neuromuscular disorder that commonly presents with weakness in ocular, limb, bulbar, and respiratory muscles. Ptosis and diplopia, as well as difficulty swallowing, fatigue, and muscle weakness can occur. Primary lateral sclerosis is an upper motor neuron disease that causes muscle nerve cells to slowly break down, causing limb weakness, stiffness, and fasciculations. It can also cause imbalance, hoarseness, slurred speech, facial muscle weakness, and later difficulty swallowing and breathing.

A 37-year-old woman presents with a history of right-sided facial paralysis and periauricular discomfort since she awoke this morning. She is afebrile. She had a "cold sore" 1 week prior to her symptoms, but this resolved without complications. During her neurologic exam, she was discovered to have an inability to raise her right eyebrow and close her right eye completely. She also has drooping of the right corner of her mouth. The rest of her neurologic exam is normal. There are no masses or rashes evident. She denies history of prior CVA or neurologic illnesses. She does not take any medications. Question What is the most likely diagnosis? Answer Choices 1 Trigeminal neuralgia 2 Bell's Palsy 3 Multiple sclerosis 4 Myasthenia gravis 5 Primary lateral sclerosis

2 Type II This is the classic age and mechanism of injury for a supracondylar humerus fracture. Pain is worse with flexion or extension, especially in displaced fractures (as indicated by the deformity in this child's case). This injury typically has a large effusion or edema and ecchymosis; it is often deformed (if fracture is displaced) and has crepitus. Patients will not usually allow you to passively move the elbow. The axillary nerve would not be injured in this case; it is proximal to the elbow and rarely involved. The classification involved is classically describing a Type II supracondylar humerus fracture, according to the Gartland Classification System. Type I: Non-displaced, with anterior periosteum detachment from anterior humerus by up to 3 cm, but not torn. Type III: Displaced often in 2 or even 3 planes. Type IV: Completed periosteal disruption and instability in flexion and extension (typically diagnosed intraoperatively). Type V is not part of the Gartland Classification System

A 4-year-old girl presents 30 minutes after falling from a 4-foot-tall slide on her outstretched right dominant arm with her elbow fully extended. There was no loss of consciousness, but there was immediate extreme pain; there is an obvious deformity at the elbow. On presentation, the girl is holding her right elbow and she will not allow passive movement. Radiographs demonstrate displacement with a major deformity in the sagittal plane. Posterior cortex and posterior periosteal hinge still intact. Question What classification of the most likely diagnosis is this case describing? 1 Type I 2 Type II 3 Type III 4 Type IV 5 Type V

5 Referral to an otolaryngologist for surgical intervention The treatment for cholesteatoma is surgical removal or marsupialization of the sac. This should be performed by a specialist. Antibiotics and/or steroids can be tried as nonsurgical measures, but the question asks for the definitive treatment. Observation and follow-up or earplugs are not recommended since the cholesteatoma may cause destruction of the middle ear ossicles and spread to the mastoid process, worsening the condition.

A 41-year-old man presents for evaluation of hearing loss. He states that he is having more difficulty in his right ear than his left. He began to notice this about 6 months ago, when while talking on his cell phone, he had to routinely switch to his left ear because of difficulty understanding the words while listening with his right ear. He states that he has had ear drainage for approximately 6 months. He also states that he was in the Navy for a few years and as a recreation activity took up scuba diving. He recalls multiple ear infections during his time in the Navy. Question During the otoscope examination, you note deep retraction pockets, a white mass behind the tympanic membrane, and focal granulation at the peripheral of the tympanic membrane. What is the most appropriate treatment for this patient? Answer Choices 1 10 days of therapy with 2nd generation cephalosporin 2 14 days of therapy with an otic solution of antimicrobials and corticosteroids 3 Close observation and follow-up in 2 weeks 4 Close observation and referral to an otologist for custom made ear plugs 5 Referral to an otolaryngologist for surgical intervention

5 Alcohol abstinence This patient has alcoholic cirrhosis of the liver. The four signs of decompensation are jaundice, encephalopathy, ascites, and variceal hemorrhage, of which he has three. He is therefore gravely ill and needs intense management by a team of doctors. The most important prognostic consideration is alcohol abstinence. Continued drinking is very likely to hasten his demise from liver failure and its complications. On the contrary, abstinence can halt or in some cases reverse liver injury. Compliance with medical management, including diuretics and steroids, is also a key issue in management of the condition, but abstinence is more important. Patients treated in a hospital tend to go back to drinking alcohol once they get better and go home. Smoking cessation is advisable in the long-term prevention of several types of cancer, but it is less relevant to the progression of liver injury caused by alcohol. Nutritional support is essential in these patients since they tend to be malnourished; it improves survival. Carbohydrates and calories should be given in adequate amounts to reduce protein catabolism, promote gluconeogenesis, and prevent hypoglycemia. Folic acid and thiamine must also be replenished. Nutritional support will fail if the patient continues to drink. Liver transplant is offered to patients only if they have a 6-month period of abstinence from alcohol, and it is contraindicated if the patient is unable to abstain from drinking.

A 43-year-old man presents with jaundice, weight gain, enlarged abdomen, and peripheral edema in his legs for the last several weeks. He reports fatigue, malaise, and insomnia. His wife and adult son are with him. They tell the ER physician assistant that his oral intake has been limited to excessive alcohol ingestion and very little food in the last few weeks. He has a history of hypertension being treated with amlodipine 5 mg. Family history is significant for his father having hypertension and having an older brother with alcoholism. He has smoked 1 pack of cigarettes daily since he was 18 years old. He has been drinking 12-24 cans of beer daily for the last 15 years. On examination, his temperature is 99.2°F, BP 140/86 mm of Hg, pulse 86/minute, respiratory rate 18/minute. His sclerae are icteric. Lungs have decreased air entry at the bases. Heart sounds are normal. Abdominal exam shows ascites and caput medusae without hepatomegaly. He has pitting pedal edema bilaterally and a fine tremor in his hands. He is alert and fully oriented. Labs are ordered and are pending. Question In the management of this patient, what is the most important factor in regards to his survival? Answer Choices 1 Compliance with medical management 2 Stage of liver disease progression 3 Nutritional support with carbohydrates and vitamins 4 Time lapse in arranging liver transplant 5 Alcohol abstinence

4 Order a mammogram. A mammogram should be ordered. The patient is a 45-year-old woman with spontaneous serous discharge. Nipple discharge is a common breast complaint and is usually associated with benign etiology. Because most nipple discharge is a result of benign processes, less invasive, non-surgical diagnostic modalities have been explored to alleviate the need for surgical intervention. Most of the patients with nipple discharge have benign disease, such as intraductal papilloma, papillomatosis, duct ectasia, or fibrocystic condition. Studies have shown that approximately 11% of patients will have an underlying carcinoma. To be significant, nipple discharge should be spontaneous, persistent, and non-lactational. Persistent clear or bloody nipple discharge merits, at the very least, diagnostic breast imaging. All nipple discharges associated with a breast lump must be surgically evaluated. The incidence of associated cancer is much higher when the discharge is serosanguineous or sanguineous. Mammography has been utilized for evaluation of obvious abnormality to guide surgical intervention. The sensitivity of mammography for detecting malignant ductal pathology is 57% and the positive predictive value is 16.7%. It should be the initial test in patients with clinically significant nipple discharge and in women over 40. Cytological analysis of the discharge fluid has traditionally shown high false-negative rates, and it is not revealing in localizing the lesion. Hemoccult testing has been shown to be useful for determining the presence of blood, but its use in predicting histology is questionable. For the patient in this case, all the tests noted could be indicated. An FSH can be used to check for menopausal status, and a prolactin level could be done to check for abnormal levels. A TSH to check for hypothyroidism could also be done; decreased thyroid hormones are associated with galactorrhea. Hypothyroidism would also explain the menstrual irregularity. Mammography should be conducted initially; later, hormonal assay and a cytological examination can be carried out. In summary, given that this patient presented with spontaneous persistent discharge, the most appropriate initial approach would be to perform a mammography.

A 45-year-old woman presents with a 3-day history of persistent nipple discharge. She is essentially healthy with an insignificant past medical history. She quit her job to stay home with her young children in the past year; she has noted a weight gain of 15 lb, which she attributes to being at home more, leading to increased snacking as well as less activity. She also says her periods have spaced out, occurring anytime from 28-53 days. They still last about 2-3 days, as they previously had. She denies hot flashes and the possibility of pregnancy; her husband had a vasectomy. Her review of systems is otherwise negative. She takes vitamin E every day, but she takes no other medications or herbs; she denies the use of illicit drugs. On physical exam, you note a healthy-looking woman. Her breast exam is negative for lumps, dimpling, and nipple retraction. You are able to express some clear fluid from the left nipple. It seems serous. Her axillary exam is negative for any enlarged lymph nodes; the rest of her exam is normal. Question What is the next step in the management of this patient? 1 Check an FSH. 2 Do microscopy of the fluid. 3 Check a prolactin level. 4 Order a mammogram. 5 Check a TSH

4 Adrenal cortex This patient has signs and symptoms consistent with Addison's disease. Addison's disease is primary adrenal insufficiency. The symptoms include weight loss, lethargy, nausea, vomiting, and salt craving. Due to the lack of mineralocorticoids, there will be hyponatremia and hyperkalemia. Addison's disease is primary adrenal insufficiency, so the pathology is located in the adrenal cortex. The primary problem is not in the pituitary. There would be an ACTH deficiency if the primary pathology were located in the pituitary, rather than an elevated ACTH. In this scenario, the pituitary is responding appropriately by increasing ACTH secretion. Addison's disease is also not due to pathology in the adrenal medulla, pancreas, or sympathetic ganglia.

A 45-year-old woman presents with recent, unexplained weight loss, and lethargy. She has had several episodes of nausea and vomiting. She admits to craving salty foods. On physical examination, there is a hyperpigmentation to her skin and mucus membranes. Her blood pressure is 85/60 mmHg. Her laboratory results show hyponatremia and hyperkalemia. Her serum ACTH level is elevated. Question What is the most likely site of the pathology? Answer Choices 1 Pituitary 2 Adrenal medulla 3 Pancreas 4 Adrenal cortex 5 Sympathetic ganglia

2 Continue metronidazole. The patient has an uncomplicated case of Clostridium difficile colitis. Current guidelines call for her to continue metronidazole for a course of 10-14 days. C. difficile is a gram-positive, spore-forming rod; it accounts for 15-20% of antibiotic-related cases of diarrhea and almost all cases of pseudomembranous colitis. Disruption of the normal colonic microflora is usually the precipitating event for C. difficile colitis. This disruption is generally caused by the use of broad-spectrum antibiotics, such as clindamycin, broad-spectrum penicillin, and cephalosporins. Colonization of C. difficile occurs after the microfloral disruption, during which the heat-resistant spores are converted into vegetative spores. Asymptomatic carrier state or clinical manifestations of C. difficile colitis develop depending on the host immune factor. Manifestations range from mild diarrhea to life-threatening C. difficile pseudomembranous colitis. The use of clindamycin prior to the occurrence of diarrhea strongly suggests pseudomembranous colitis as the cause of the diarrhea. Pseudomembranous colitis is an inflammatory bowel disorder associated with antibiotic use. It is due to toxins of Clostridium difficile. The toxins bind to intestinal mucosal epithelial cells and cause watery, secretory diarrhea, abdominal pain, fever, and dehydration. The mucosa shows yellow plaques, focal ulceration, and exudates, which form the characteristic pseudomembrane. Stool samples are positive for fecal leukocytes, and the toxin and the organism may be cultured. Metronidazole is a first-line therapeutic agent in the treatment of C. difficile colitis given in the dose of 500 mg orally 3 times a day for 10-14 days. It is inexpensive and has an efficacy >90%. The response to treatment with metronidazole is usually rapid, with fever resolution occurring within 24 hours and diarrhea resolution within 4-5 days. Vancomycin is approximately as effective as metronidazole in the treatment of C. difficile colitis. Vancomycin should be initiated in patients with severe symptoms (e.g., leukocytosis >15,000 cells/uL or serum Cr 1.5 x normal). It is administered orally in the dose of 125 mg 3 times a day for 10-14 days. Initial treatment of severe cases of pseudomembranous colitis must be aggressive, with intravenous metronidazole and oral vancomycin given in combination. In cases where medical therapy fails, surgical intervention, such as colectomy and ileostomy, may be necessary. Ampicillin and clindamycin, being the agents that most commonly cause C. difficile colitis, should not be administered; they may cause the condition to worsen. Ciprofloxacin is not the drug of choice for treating unresolved cases of pseudomembranous colitis following metronidazole treatment.

A 48-year-old woman presents with a 1-week history of diarrhea and fever. Stool is watery and associated with abdominal pain. She has no other medical conditions other than osteomyelitis, for which she was treated with clindamycin 3 weeks ago. The patient was started on oral metronidazole after a diagnosis of diarrhea secondary to Clostridium difficile was made 1 week ago. The patient's condition has not resolved after 7 days of metronidazole treatment. Question What is the next best step in her management? 1 Switch to vancomycin. 2 Continue metronidazole. 3 Switch to ampicillin. 4 Switch to ciprofloxacin. 5 Switch to clindamycin.

2 Oral hairy leukoplakia on tongue The correct answer is oral hairy leukoplakia on the tongue. Oral hairy leukoplakia (OHL) presents as unilateral or bilateral non-painful white lesions that can be seen on the margins, dorsal, or ventral surfaces of the tongue or on the buccal mucosa. The OHL lesions may range from appearing smooth and flat to raised, irregular, and feathery. OHL is associated with HIV infection and immunosuppression and rarely develops in patients who are immunocompetent. Rales, vitiligo, alopecia areata, and clubbing may be seen in patients with HIV infection, but none of these findings are considered specific for HIV infection.

A 55-year-old African American woman presents to you with fatigue, non-productive cough, and hair loss, as well as admitting to a 40 pack-year smoking history. You take a thorough history and perform an appropriate physical examination, and you suspect Human Immunodeficiency Virus (HIV) infection. Question Which of her physical exam findings is most specific for HIV infection? 1 Basilar rales on lung auscultation 2 Oral hairy leukoplakia on tongue 3 Vitiligo 4 Alopecia areata 5 Clubbing

1 Refer the patient for a transrectal ultrasound of the prostate and order a PSA level The correct response is to refer the patient for a transrectal ultrasound of the prostate and order a PSA level. The clinical picture is suggestive of prostate cancer. Signs and symptoms include those similar to benign prostatic hyperplasia (BPH) (e.g., urinary frequency, urinary hesitancy, nocturia, hematuria, difficulty achieving erections). Most patients are asymptomatic. Prostate cancer may manifest as focal nodules or areas of induration within the prostate. Modern transrectal ultrasound provides high definition images of the prostate and guides biopsy. Measurement of the PSA is useful in detecting and staging prostate cancer. Serum acid phosphatase would not be useful since it is found in many organs. A prostatic acid phosphatase would be more specific in diagnosing prostate cancer. Since a nodule was found in this patient, it needs to be investigated further; reassuring the patient would be considered an insufficient medical practice. Prazosin is an alpha-blocker used in the treatment of BPH. BPH usually results in a smooth firm elastic enlargement of the prostate, which is not seen in this patient. Norfloxacin is an antibiotic used in the treatment of urinary tract infections. Signs and symptoms of a UTI include painful urination, increased frequency, and an odd smell to the urine. Urinalysis may show positive leukocyte esterase, nitrates, and blood, with WBCs and bacteria on microscopic examination.

A 55-year-old man presents with increased urinary frequency, nocturia, and the inability to achieve an erection for the past few months; he is also experiencing difficulty starting and maintaining a steady stream. Rectal examination reveals a non-tender, non-enlarged prostate with an isolated left posterior lobe nodule. Answer Choices 1 Refer the patient for a transrectal ultrasound of the prostate and order a PSA level 2 Order a serum acid phosphatase 3 Reassure the patient and schedule a follow-up appointment in 6 months 4 Initiate prazosin and schedule a follow-up appointment in 4 weeks 5 Initiate norfloxacin therapy for 7 days and schedule a follow-up in 2 weeks

5 Low sodium diet The clinical picture is suggestive of Meniere's disease. The classic syndrome consists of episodic vertigo lasting 20 minutes to several hours associated with fluctuating low-frequency sensorineural hearing loss, tinnitus, and a sensation of aural pressure. The Dix-Hallpike maneuver is a diagnostic maneuver for benign paroxysmal positional vertigo. Treatment involves a low sodium diet and diuretics. Restricting water intake will lead to dehydration and an increase in sodium levels, worsening the symptoms of Meniere's disease. Diazepam can be used for Meniere's disease but is usually used for severe vertigo. The question is indicating initial treatment. Diazepam is used in the treatment of vestibular neuronitis. In vestibular neuronitis, a paroxysmal, usually single attack of vertigo occurs without accompanying impairment of auditory functions and will persist for several days to weeks before clearing. Examination reveals nystagmus. These symptoms are not present in this patient. Antibiotics are not indicated for Meniere's disease. Fluticasone propionate is an anti-inflammatory nasal spray used to treat the nasal symptoms of indoor and outdoor nasal allergies and year-round non-allergic nasal symptoms. Fluticasone helps reduce the inflammation that leads to nasal symptoms that include congestion, sneezing, and itchy, runny nose, which are not demonstrated in this patient.

A 55-year-old woman presents with episodic vertigo, tinnitus, hearing loss, and ear fullness. Her ear and eye physical examination are unremarkable. You perform a Dix-Hallpike maneuver, which is negative. There are no carotid bruits noted on auscultation. What is the best initial recommendation to make? Answer Choices 1 Restrict water intake 2 Diazepam10 mg BID 3 Antibiotics 4 Fluticasone propionate 5 Low sodium diet

4 Laryngeal cancer The correct answer is laryngeal cancer. Tobacco abuse is a common predisposing factor in laryngeal cancer and affects men more often than women. Persistent hoarseness in this population should cause suspicion of cancer. Many patients with laryngeal cancer present with palpable anterior cervical lymphadenopathy. Acute laryngitis lasts for about 1 week and typically follows a viral infection. Chronic laryngitis—often due to irritants, vocal abuse, or gastroesophageal reflux—does not typically have accompanying non-tender lymphadenopathy. Thyroid cancer may present with anterior cervical lymphadenopathy but is rarely seen with progressive hoarseness. Vocal cord nodules are typically found in patients who overuse their voices and is not related to tobacco abuse. Strep pharyngitis typically causes tender cervical lymphadenopathy unrelated to tobacco abuse and does not cause progressive laryngitis.

A 56-year-old man presents with a history of persistent and progressive unrelenting hoarseness for the last few months. He is a 50 pack-year smoker but quit 1 year ago. Physical examination demonstrated a 2-cm firm non-tender right anterior cervical lymph node. Question Which of the following is the most likely diagnosis? Answer Choices 1 Laryngitis 2 Thyroid cancer 3 Vocal cord nodule 4 Laryngeal cancer 5 Strep pharyngitis

2 Graves' disease The correct answer is Graves disease, which is identified with radioactive iodine uptake (RAIU) with an increased amount of iodine uptake consistent with hyperthyroidism. Ultrasound of the thyroid reveals a diffuse uniform pattern throughout the gland. This is due to the autoimmune process of Graves disease in which circulating thyroid-stimulating immunoglobulins affect the entire gland. On physical exam, the gland will be firm and diffusely enlarged, which explains the diffuse uptake of iodine throughout the gland in the typical uniform pattern on RAIU and ultrasound. Silent thyroiditis may occur spontaneously or may be drug-induced (e.g. chemotherapeutic agents, amiodarone, lithium). This is more common in women and approximately 50% of those affected have antithyroid antibodies (indicating an autoimmune process). A toxic multinodular goiter, an etiology of thyrotoxicosis, can present with signs, symptoms, and laboratory values consistent with hyperthyroidism. On thyroid exam, a multinodular goiter will present with multiple fibrotic areas in an enlarged gland. A multinodular goiter will reveal a heterogeneous pattern of radioactive iodine uptake localized to multiple hyperfunctioning nodules of various sizes throughout the gland. Patients with thyroid cancer most often present asymptomatically, with or without a palpable thyroid nodule and normal thyroid function studies. There is typically a normal RAIU uptake, but the scan reveals an area of decreased iodine uptake localized to the site of the thyroid cancer, which is often referred to as a "cold nodule." Subacute thyroiditis usually occurs during or after a respiratory illness and presents acutely with symptomatic pain in the gland that is often associated with fever, elevated WBCs, and an elevated sedimentation rate. Changes in serum thyroid hormone levels will depend upon the phase of the disease. Early in the disease, thyroid function is normal; then, hyperthyroidism develops as thyroid hormone is released from the gland after the initial insult. The pituitary gland responds to the excess circulating thyroid hormone by decreasing TSH production. Subsequently, the patient will progress from hyperthyroidism to euthyroidism to hypothyroidism. As thyroid hormone levels drop, the pituitary will respond by increasing TSH production, and the patient will enter the recovery phase, resuming normal thyroid function. RAIU will reveal a normal or low iodine uptake because there is no increased thyroid tissue activity and there is often no pattern visible on scan due to the limited uptake.

A 56-year-old man presents with signs and symptoms of hyperthyroidism in the presence of a palpable goiter. Laboratory studies are borderline suggestive, but they do not confirm thyrotoxicosis. Further testing includes a radioactive iodine uptake and ultrasound of the thyroid, which reveals a high uptake in a diffuse uniform pattern throughout the gland. Question What is the most likely diagnosis? Answer Choices 1 Thyroiditis 2 Graves' disease 3 Toxic multinodular goiter (TMNG) 4 Toxic Thyroid Adenoma 5 Thyroid cancer

2 Adhesive capsulitis The most likely diagnosis is adhesive capsulitis. It is often associated with diabetes, ischemic heart disease, and thyroid disorders. It can also result from immobility following a traumatic shoulder injury. Patients complain of a slow, gradual onset of shoulder pain that can be severe, even at night. The pain is generalized and referred to the superolateral aspect of the shoulder and upper arm. Examination reveals no swelling at the glenohumeral joint. Passive and active ROM are greatly limited in all movements. Acromioclavicular sprain is common in younger people and athletes. The classic cause is the direct blow to the acromion with the humerus in the adducted position. This drives the acromion medially and inferiorly. Falling on an outstretched hand or elbow can also cause an acromioclavicular sprain. Fracture of the clavicle is one of the most common injuries. It is usually caused by a fall on the lateral aspect of the shoulder. Less commonly, it is caused by a direct blow or falling on the outstretched hand. Although complications are uncommon, they can occur. With this type of injury lung and neurovascular compromise can occur. AP X-ray is the best way to ascertain a clavicle fracture. Glenohumeral dislocations in younger people are most commonly caused by direct trauma and sports injuries. Patients with this type of injury are usually unwilling to move the affected arm, and they tend to cradle it with the unaffected arm. About 80-90% of shoulder dislocations are anterior shoulder dislocations. An excessive external rotation or abduction force usually causes this type of injury. A bulge may be noticeable where the humeral head rests, with an emptiness beneath the acromion. Posterior shoulder dislocation usually happens when the humeral head is driven posteriorly with force. Rotator cuff tendonitis (tendinopathy) is associated with pain and difficulty actively abducting or rotating the arm. Overuse injuries often cause irritation of the tendon sheath, causing tendonitis. Symptoms are usually pain and weakness made worse by overhead activities and abduction and external rotation. The degree of trauma depends on the type of tear. With full thickness tears, the degree of trauma is significant, as with a major fall, MVA, or shoulder dislocation. Partial thickness tears can be caused by a lesser degree of trauma; overuse injuries can cause tears as well. MRI is the imaging of choice.

A 58-year-old woman with diabetes presents with a 1-month history of left shoulder pain. She rates the pain an 8/10 and describes it as a constant ache. The pain is worse at night, and it is gradually becoming more severe. Her ROM is becoming compromised. It is becoming more difficult for her to put on her coat and take care of her yard. She denies any redness, bruising, or swelling. She cannot recall any direct injury to her shoulder, and she denies any previous trauma or surgery. On physical exam, both active and passive ROM are compromised. er, and she denies any previous trauma or surgery. On physical exam, both active and passive ROM is compromised. Question What is the most likely diagnosis? Answer Choices 1 Acromioclavicular sprain 2 Adhesive capsulitis 3 Fracture of the clavicle 4 Glenohumeral dislocation 5 Rotator cuff tendonitis (tendinopathy)

3 46% The correct answer is 46%. This estimation is based on the Rule of Nines. Body surface area is estimated at 9% for the following areas: -head and neck -anterior surface of upper torso -anterior surface of lower torso -posterior surface of upper torso -posterior surface of lower torso -anterior surfaces of each leg -posterior surfaces of each leg -and an additional 1% for the groin area for a total of 100%. In this case, 9% for her head and neck, 9% for the anterior surface of both arms, 9% for the anterior surface of her right leg, 9% for her anterior upper torso, 9% for her anterior lower torso, and 1% for the genital area for a total of 46%.

A 59-year-old woman presents for second- and third-degree burns on her head and neck, the anterior surfaces of her upper extremities, anterior right leg, and anterior trunk, including her genital area. What is the estimate of the extent of the patient's burns, according to the Rule of Nines? Answer Choices 1 36% 2 37% 3 46% 4 45% 5 55%

2 Aortic regurgitation The correct answer is aortic regurgitation, as it presents as a soft, early diastolic, high-pitched murmur heard best when sitting and leaning forward. It is often a result of rheumatic heart disease, which may be inferred from the patient's history. Tricuspid stenosis presents as a diastolic rumbling murmur typically accompanied by a thrill heard louder on inspiration. Mitral stenosis is similar in presentation to tricuspid stenosis but is not affected by inspiration. Mitral valve prolapse and pulmonic stenosis are examples of systolic murmurs, in contrast to diastolic murmurs heard in this patient.

A 61-year-old man presents with a recent history of increased fatigue with mildly increased exertional dyspnea. The patient denies any significant past medical history but states that he had some heart problems as a child, though he was never clear as to what was the problem. On cardiac examination, you hear an early diastolic, soft decrescendo murmur with a high-pitched quality, especially when the patient is sitting and leaning forward. No thrill is felt. Question Based on this patient's presentation, what do you expect as the patient's diagnosis? 1 Tricuspid stenosis 2 Aortic regurgitation 3 Mitral stenosis 4 Mitral valve prolapse 5 Pulmonic stenosis

1 Serum protein electrophoresis The correct answer is serum protein electrophoresis, as your index of suspicion is high for Multiple Myeloma (MM) based on the case history and physical exam. Prostate and colon cancers are unlikely, as the rectal exam and colonoscopy did not yield any significant findings. Typical presenting signs and symptoms include fatigue, pallor, back pain, and occasionally infection, and the median range for this disease is 65 years. Anemia is almost always present and serum protein electrophoresis will almost always include a paraprotein, usually IgG, occasionally IgA and light chains. Bone marrow biopsies are also performed to aid in the diagnosis of MM. A complete blood count is an important first step to look for anemia and other blood cell dyscrasias, but it is not specific for MM. Serum calcium levels are often found to be elevated at the time of diagnosis but also not specific for MM. Elevated total serum protein and albumin levels are often found in patients with MM but are not specific findings.

A 64-year-old man presents to his PCP for the first time in 4 years with a recent history of fatigue with pallor and worsening back pain in the lumbar region for the past 3-4 months. He denies any injury to his back or similar pain in the past. He had a colonoscopy 3 months prior, and 2 benign polyps were removed without other abnormalities. At that time, he also had a PSA level of 3.1 ng/mL. On examination, BP: 143/92 mm Hg, P: 75 bpm and regular, Resp: 16/minute, Temp: 97.6°F. Skin exam reveals marked pallor without lesions or bruising. Musculoskeletal exam reveals bony tenderness along lumbar vertebrae without paraspinal muscle tenderness on palpation. Decreased range of motion of the spine is noted due to pain elicited during the examination. The remainder of the examination including digital rectal exam, focal neurological, pulmonary, and cardiac exams are within normal limits. Question Which of the following tests will be most helpful in making your diagnosis? Answer Choices 1 Serum protein electrophoresis 2 Complete blood count with differential and platelets 3 Serum calcium level adjusted for serum protein 4 Total serum protein 5 Urine albumin

1 EKG Because he has some minor (age >45) and intermediate clinical predictors of increased cardiac risk (some of his creatinines), under the most recent American College of Cardiology guidelines, he may proceed to surgery without testing, given that his exercise tolerance is good and his anticipated type of surgery (orthopedic) represents moderate cardiac risk. At a minimum, an EKG would be indicated, with the results potentially guiding further cardiac evaluation, if necessary. Prior to surgery, an assessment of the cardiac risks associated with the surgery, the patient's functional capacity (METS tolerated), and the patient's overall cardiac risk should be assessed. Low-risk procedures include ambulatory and endoscopic procedures, breast and cataract procedures, and superficial procedures. Moderate-risk procedures include prostate surgery, orthopedic procedures, intra-abdominal and intrathoracic procedures, head and neck surgery, and carotid endarterectomies. High-risk procedures include aortic and major peripheral artery surgeries. This patient is due to have knee surgery, a procedure with moderate cardiac risk. His exercise capacity is moderate to good; being able to swim and have intercourse without getting winded is the equivalent of being able to tolerate >4 METS. See references for assessments of functional capacity of stress. Regarding personal risk factors for cardiac disease, he has no major clinical predictors, such as unstable angina or congestive heart failure. He does have hypertension, but it is controlled and no left ventricular hypertrophy was detected on the last EKG. A new EKG may help assess this risk and serve as a more recent baseline marker to help assess postoperative changes, should they occur. Additionally, he is over 45, his BMI is >25, and some of his serum creatinines have been elevated, presenting additional cardiac risks. In their 2014 guidelines, the ACC/AHA note that 12 lead electrocardiogram testing "is not useful for asymptomatic patients undergoing low-risk procedures," "is reasonable in patients with known cardiovascular and cerebrovascular disease and/or arrhythmias," and "may be considered for asymptomatic patients without coronary disease, except for those undergoing low-risk surgery." Additionally, he has an elevated serum creatinine, which may be suggestive of kidney disease, an intermediate predictor of postoperative heart disease. His creatinine has varied around the 1.5 mg/dL level considered an intermediate clinical predictor of postoperative heart disease (see American Heart Association Guidelines below). The etiology of his serum creatinine is unknown and should be evaluated to see if ibuprofen, lisinopril, and hydration are implicated and if decreasing or discontinuing meds results in lower serum creatinines. High-risk procedures (e.g., aortic aneurysm repair) in patients with poor exercise tolerance would warrant stress echocardiography (to look for areas of ischemia) followed by cardiac catheterization (to look for occluded coronary vessels) if the stress echo was abnormal. Echocardiography may be indicated in patients with known valvular disease or low ejection fractions, and evaluation for arrhythmias with Holter monitoring may be indicated in patients with significant arrhythmias. Severe valvular disease, decompensated congestive heart failure, and significant arrhythmias are all major clinical predictors of postoperative cardiac risk; none of these problems are apparent in this patient.

A 65-year-old man with a 10-year history of hypertension controlled with lisinopril comes for preoperative evaluation before his arthroscopic knee surgery. He has never smoked and has never had a heart attack, congestive failure, arrhythmia, valvular problems, or abnormal lipids. His activity level is limited by knee pain; he does light to moderate housework and occasional swimming without dyspnea or chest pain. He is sexually active. His medications include ibuprofen for knee pain. His BMI is 26.5, blood pressure is 120/80 mm Hg, and the remainder of his exam is normal. His last electrocardiogram (EKG), taken 5 years ago shortly after a panic attack, showed normal sinus rhythm. His most recent (fasting) serum creatinine was 2.1 mg/dL with a blood urea nitrogen of 20 mg/dL. Past serum creatinines were in the 1.8-2.1 mg/dL range. He has no proteinuria. Question What further pre-operative cardiac evaluation, if any, is indicated? Answer Choices 1 EKG 2 Cardiac catheterization is indicated 3 Holter monitoring is indicated 4 Echocardiography is indicated 5 Stress-echocardiography is indicated

2 Magnetic resonance imaging MRI has been identified as the most sensitive imaging modality for the diagnosis of osteomyelitis, and it is particularly helpful in identifying soft tissue involvement. Plain radiographs are readily available, but they can be associated with a false negative result early in the course of the disease. CT and nuclear medicine bone scanning are both less sensitive than MRI. Nuclear medicine images are most helpful in identifying a location or multiple sites of infection. Venous ultrasound is not indicated for the diagnosis of osteomyelitis; it is used in the diagnosis of deep vein thrombosis.

A 65-year-old man with uncontrolled diabetes presents for evaluation of a foot injury. He ran into his dresser 3 days ago, and an ulceration has developed at the site of the injury. He admits to minimal localized pain, and he denies any associated fever or chills. On examination, the ulceration measures 2.5 cm in diameter, and a sterile probe can be easily advanced to the underlying bone. Question Based on your suspected diagnosis, what diagnostic test should be ordered because it has the highest level of sensitivity? 1 Plain radiograph 2 Magnetic resonance imaging 3 Computer tomography 4 Venous ultrasound 5 Nuclear medicine bone scan

1 Fluid collection in the scrotum that transilluminates A hydrocele is a collection of fluid between layers of the tunica vaginalis that surrounds the testicle. The typical presentation of a hydrocele is a painless scrotal swelling that can worsen throughout the day. When a flashlight or penlight is held behind the scrotum in a dark room, the light will transmit through the fluid; this is known as transillumination. A hydrocele is not usually bothersome; patients will usually only take issue if it is large enough to get in the way. Hydroceles can be treated surgically, but this is usually reserved for the most bothersome cases. A solid lesion in the scrotum that does not transilluminate describes how a testicular mass may present on physical examination. A hydrocele is not solid and does transilluminate. While a hydrocele is a fluid collection in the scrotum, it usually does transilluminate. There are no genitourinary findings that would involve a fluid collection in the scrotum that would not transilluminate. Dilated veins in the scrotum that transilluminate typically represent a varicocele rather than a hydrocele. The dilated veins are often described as feeling like a "sack of worms" on physical examination. A cystic mass in the scrotum that transilluminates typically represents a spermatocele. A spermatocele is usually freely movable and located both superior and posterior to the testicle.

A 68-year-old man presents with scrotal swelling; he has had the swelling for the past few months. It is not bothering him, but his wife wants him examined. His history is not significant for any other GU history or symptoms. A genitourinary examination reveals a right hydrocele. Question What would the examination findings describe? 1 Fluid collection in the scrotum that transilluminates 2 Solid lesion in the scrotum that does not transilluminate 3 Fluid collection in the scrotum that does not transilluminate 4 Dilated veins in the scrotum that transilluminate 5 Cystic mass in the scrotum that transilluminates

1 Congestive heart failure Congestive heart failure is the most common cause of transudative pleural effusion. In transudative pleural effusion, pleural fluid function is increased, but the patient has normal capillaries, causing increased hydrostatic pressure and/or decreased oncotic pressure. Thoracentesis will reveal protein less than 3 g/dL, glucose levels equivalent to serum glucose, and a total nucleated cell count level less than 500/mm with predominantly lymphocytes. Pulmonary embolism, pneumonia, pancreatitis, and malignancy are all causes of exudative pleural effusion.

A 69-year-old man presents with shortness of breath associated with a nonproductive cough. He notes stabbing chest pain that increases with inspiration. On exam, there is dullness to percussion over the left side. EKG and cardiac enzymes are normal. Chest X-ray confirms presence of pleural effusion. Thoracentesis is performed. Pleural fluid is straw-colored on exam with protein 2 g/dL, glucose is equivalent to serum level, and total nucleated cell count is 300/mm with predominantly lymphocytes. Question What factor is most likely contributing to the patient's pleural effusion? 1 Congestive heart failure 2 Pulmonary embolism 3 Pneumonia 4 Pancreatitis 5 Malignancy

3 Pericardial tamponade This patient presents with Beck's triad: distended neck veins, muffled heart sounds, and hypotension, seen in pericardial tamponade. Pericardial effusions are common after CABG and have been reported to occur in 22-85% of patients. Cardiac tamponade after cardiac surgery has been reported in 0.8-6% of patients. When this develops within the first 24 hours, it is termed early cardiac tamponade and requires surgical intervention to control the bleeding. If it occurs at least 5-7 days postoperatively, it is called late cardiac tamponade and is related to excessive mediastinal drainage. Pericardial tamponade can be seen in penetrating and (sometimes) blunt chest trauma. In this case, the patient has developed a pericardial tamponade secondary to obstruction of the chest tubes draining the pericardial sac postoperatively. Characteristically, a fluid bolus will temporarily elevate the blood pressure in these patients. Although patients who are hypovolemic will demonstrate hypotension with tachycardia, they would not experience distended neck veins or rapid fluctuations in blood pressure in response to IV fluids. The patient's presentation, along with the fact that the chest tube drainage has decreased, is indicative of cardiac tamponade; it is not indicative of cardiomyopathy, sepsis, or myocardial infarction.

A 70-year-old man is in the ICU post-coronary artery bypass grafts. He is post-op day 9 and becomes both hypotensive and tachycardic. His blood pressure improves with 1 bolus of IV fluid, but he becomes hypotensive again 30 minutes later. His heart sounds are muffled, neck veins are distended, and the chest tubes draining the pleural space have decreased output over the past 3 hours. The patient is afebrile. Question What is the most likely etiology for this patient's hypotension? 1 Hypovolemia 2 Cardiomyopathy 3 Pericardial tamponade 4 Sepsis 5 Myocardial infarction

4 Ventriculoperitoneal shunt Clinical triad of slowly progressive gait disorder, followed by impairment of mental function and then sphincteric incontinence strongly suggests the presence of normal-pressure hydrocephalus. Ventricular expansion is the cause of symptoms, and surgical CSF shunting is the main treatment modality. The potential benefit from surgery is usually evaluated by testing gait, cognition, and micturition before and after CSF drainage. Antimuscarinic Tolterodine is an antispasmodic that is used for symptomatic treatment of urinary incontinence in patients with an overactive bladder (urge incontinence). Antimuscarinic drugs are contraindicated in patients with glaucoma. A urinary tract infection will probably manifest with a strong, persistent urge to urinate, burning sensation when urinating, passing frequent, small amounts of urine that has unusual smell and the appearance. Your patient has no such signs and symptoms; therefore, in this case, antibiotics are not indicated. Donepezil is used to treat dementia, but in the case of normal-pressure hydrocephalus, the problem is anatomic (the distortion of the periventricular limbic system and frontal lobes), and the best treatment is probably surgical. Kegel exercises can prevent or control urinary incontinence and other pelvic floor problems in cases of pelvic sphincter weakness. However, pelvic sphincter weakness will probably manifest as stress incontinence.

A 70-year-old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have became "dull". Over the past month, she has started having urinary urgency and involuntary leaking of urine. Besides multivitamins and local application of the Timolol for glaucoma, she takes no other medications; there are no other symptoms. Question What is most likely the best method of treating the patient's urinary problems? 1 Antimuscarinic drug (Tolterodine) 2 Antibiotic (Sulfamethoxazole/trimethoprim) 3 Acetylcholinesterase inhibitor (Donepezil) 4 Ventriculoperitoneal shunt 5 Kegel exercises

1 Expand volume with IV fluids prior Explanation Mild volume expansion prior to the CT with IV contrast is recommended to prevent contrast nephropathy in higher-risk patients. Hydration should begin an hour or more before the procedure and should continue several hours after the CT. There is evidence showing better results with NaHCO3 over regular saline (NaCl). This patient had several indicators of volume depletion: she was taking a diuretic and had decreased oral intake, along with potentially some fluid/blood loss with the diverticulitis, and her BP was hypotensive. A change to metformin is not recommended for this patient. Metformin, while not directly nephrotoxic, can increase the likelihood of lactic acidosis. She likely has some pre-existing renal disease (diabetic nephropathy) and metformin is relatively contraindicated in this patient. Some experts recommend cessation of metformin when patients undergo contrast studies in order to decrease the likelihood of contrast nephropathy. Loop diuretics are also not recommended. These drugs can increase risk of contrast nephropathy and should be discontinued, preferably a few days prior to any contrast studies. Though mannitol has a role in treatment and prevention of oliguria, it is an osmotic diuretic and can increase risk of renal damage after exposure to contrast. Traditional high-osmolar iodinated contrast material carries a higher risk of contrast nephropathy than the newer low osmolar contrast materials. Risk is also dose-dependent, so a single study with a shorter exposure to a lower dose has less chance of inducing contrast nephropathy compared to repeat/multiple studies with longer administration of high-dose.

A 78-year-old Caucasian woman is admitted with a provisional diagnosis of diverticulitis with reports of acute abdominal pain and anorexia with minimal oral hydration for several days. Past medical history is significant for diabetes mellitus diagnosed 12 years ago and hypertension (though she was hypotensive at admission). Both conditions were reported to have been under good control. Her medications include regular and long-acting insulin and hydrochlorothiazide/lisinopril 25/20 mg QD. Her son had recently been giving her 800 mg ibuprofen BID-TID for her abdominal pain during the last week. She has no known allergies. While in the hospital, the patient's laboratory results are followed daily. 2 days after the CT with contrast, it is noted that her serum creatinine has risen to a level of 3.5 mg/dL. Records from 1 month ago at her family physician showed her labs to include a hemoglobin A1C of 6.8%, creatinine of 1.8 mg/dL, and her blood pressure was 107/68 mm Hg. Question Which of the following measures would have been the best prevention for this patient's sudden decline in renal function? Answer Choices 1 Expand volume with IV fluids prior 2 Change her insulin to metformin prior to the contrast study 3 Initiate a loop diuretic prior to the contrast study 4 Start IV mannitol immediately after the contrast study and continue for 72 hours 5 Use high-osmolar iodinated radiocontrast material during the contrast study

2 Chlamydia urethritis Chlamydia is one of the most common sexually transmitted diseases; it would be the most appropriate response in this case. Male patients may be asymptomatic or they may have a white penile discharge, as seen in this patient. Gonococcus is also a sexually transmitted disease. It most often causes a yellowish-greenish discharge rather than a white discharge. Candida is a yeast infection. It is usually associated with vaginitis or bladder infection, although a urethritis may occur. Itching is a common symptom, as is thick white discharge. Although it may be transmitted sexually, this is not the most common route of transmission. Glans-Balanitis is an acute or chronic inflammatory condition affecting the glans penis. It may occur as a complication of an infection. This diagnosis would not explain the patient's penile discharge. Human papillomavirus infection does not typically cause a white urethral discharge. It is most commonly associated with genital warts.

A 9-year-old boy presents with burning during urination and a creamy white penile discharge. The grandmother is concerned about sexual abuse by a female caregiver. Question What is the most likely diagnosis? 1 Candidal urethritis 2 Chlamydia urethritis 3 Glans-Balanitis 4 Gonococcal urethritis 5 Human papillomavirus

5 Carboxyhemoglobin level The family has CO poisoning. Carboxyhemoglobin is formed when inhaled CO binds to hemoglobin after being absorbed into the bloodstream. CO has an affinity for hemoglobin that is 250 times that of oxygen. Both oxygen transport and delivery to tissues are reduced as carboxyhemoglobin interferes with the dissociation of oxygen that should be provided until symptoms resolve and carboxyhemoglobin levels decrease to 5% or less. Delivery of 100% oxygen reduces the elimination half-life of CO to 1 hour from 4-5 hours. Hemoglobin level gives no indication of how much is bound to oxygen versus how much may be bound to CO. Thus, a hemoglobin level may be normal, and yet most of it may be bound to CO as carboxyhemoglobin. Pulse oximetry that measures oxygen saturation is falsely normal because oxyhemoglobin and carboxyhemoglobin cannot be differentiated. Pulse oximeters use 2 light-emitting diodes (a red one and an infrared light). Oxygenated hemoglobin absorbs infrared light and nonoxygenated hemoglobin absorbs red light. The pulse oximeter determines the relative absorption of each and gives the percentage of oxygenated versus nonoxygenated hemoglobin present. With significant carboxyhemoglobinemia, the oximeter will reflect only the oxygen saturation of normal hemoglobin and not the percentage of hemoglobin bound to carbon monoxide. Blood gas analysis may show metabolic acidosis with a normal arterial oxygen tension (PaO2) as a measurement of dissolved oxygen, and it can overestimate the true oxygen saturation of hemoglobin. Urinalysis may show myoglobinuria due to eventual muscle necrosis as CO binds to myoglobin, decreasing its oxygen-carrying capacity.

A family presents in the middle of winter. They live in a low-income housing development. Due to their gas furnace being broken, they have been using a kerosene heater at night for the past week. For the last 3 days, both parents and the two siblings have been experiencing varying degrees of headache, dizziness, nausea, vomiting, and fatigue; symptoms are particularly severe at night and have been increasing in intensity each night they occur. The 4-year-old daughter has been very lethargic; occasionally, she seems to black out or fall asleep very soundly. She and her 9-year-old brother have also had a cough, runny nose, and sore throat for the past week. On exam, other than seeming tired, findings are nonspecific. Both children have a runny nose but their lungs and ears are clear. What is the best test to confirm exposure of the most likely diagnosis in this case? Answer Choices 1 Hemoglobin level 2 Pulse oximetry 3 Blood gas analysis 4 Urinalysis 5 Carboxyhemoglobin level

4 Initiation of a diuretic Diuretics are the most effective means of providing symptomatic relief to patients with exacerbations of signs and symptoms relating to their significant heart failure. Many of the signs and symptoms being relayed in the original stem point to significant pulmonary edema and/or congestion. This is a key characteristic in the overall pathology of dilated cardiomyopathy, along with other related consequences of ventricular dilation/dysfunction. Dilated cardiomyopathy is the cause in about 25% of all patients suffering from congestive heart failure. Calcium channel blockers are avoided unless it is absolutely necessary for rate control (as in atrial fibrillation). There is no indication that the patient is in atrial fibrillation at this time. There is little evidence that the initiation of angiotensin II receptor blockers will improve the morbidity and mortality in patients such as this one. Aldosterone antagonists are used primarily in patients with a history of hypertrophic or fibrotic cardiomyopathy; this patient is specifically suffering from dilated cardiomyopathy. Statin therapy's main goal is to lower lipid levels and is seen as part of secondary treatment and prevention of cardiovascular disease. This factor is most likely not relating to signs and symptoms presenting in the patient currently.

A long-standing patient of yours is experiencing acutely worsening symptoms and signs of dilated cardiomyopathy. Symptoms include fatigue, dyspnea with mild exertion, paroxysmal nocturnal dyspnea, severe lower extremity edema, and clubbing. Physical exam is significant for an S3 gallop and jugular venous distention. Daily medications include a β-blocker, adult dose aspirin, and an ACE inhibitor. Question What clinical intervention would be the most logical next step in helping resolve their current symptoms? 1 Initiation of a calcium channel blocker 2 Initiation of an aldosterone antagonist 3 Initiation of a statin 4 Initiation of a diuretic 5 Initiation of an angiotensin II antagonist

1 Lice The gold standard for diagnosing lice is finding a live louse on the head. Lice feed by biting the skin and sucking the blood of the individual on which they are living. The bites cause itching, so the infected person tends to scratch. Non-prescription medications can be used to treat the infestation. Scabies are tiny mites that burrow under the skin and lay eggs. Itching is the most common symptom of scabies. The itch of scabies is insidious and relentless. Treatment can include Elimite, which is considered the drug of choice. Thrush is a yeast infection that occurs in the mouth. Oral thrush causes creamy white lesions on the tongue or inner cheeks. Amphotericin B may be used to treat thrush. Ringworm is a fungal infection that grows on the outer layer of skin, hair, or nails. On the skin, ringworm appears as patches with clear centers and blister-like bumps. The treatment is an over-the-counter lotion. Dandruff occurs when the skin cells of the scalp flake off. The flake mixes with oil and dust to form dandruff. One can treat flaking and dryness with over-the-counter dandruff or medicated shampoos.

A young woman presents with her daughter, who appears to be about 6 years old. You note that the child's eyes are downcast and she is scratching her scalp. On closer inspection, you note a tiny white wingless insect and tiny eggs attached to the hair shafts. The child's mother also notes that the same insects are present in the girl's eyelashes. Question What is your working diagnosis? Answer Choices 1 Lice 2 Scabies 3 Thrush 4 Ringworm 5 Dandruff

4 Montgomery Asberg Depression Rating Scale (MADRS) The psychiatric evaluation of this patient would most likely include a measure of the severity of this patient's depressive symptoms as well as an assessment of current antidepressant drug therapy. The most appropriate tool for these purposes is the Montgomery Asberg Depression Rating Scale (MADRS). The MADRS is designed to be used in patients with major depressive disorder to measure the change in symptom severity during the treatment of depression. It is also a sensitive measure of the degree of severity of depressive symptoms. The Abnormal Involuntary Movement Scale (AIMS) is used to assess the occurrence of dyskinesias in patients receiving neuroleptic treatment. The Weinberg Screening Affective Scale (WSAS) is a self-reported questionnaire used to evaluate the presence of depressive symptoms in children and adolescents. The Disruptive Behavior Disorders Rating Scale (DBDRS) is a tool used to screen for attention deficit hyperactivity and conduct disorders. The Brief Psychiatric Rating Scale (BPRS) is designed to assess psychopathology, which includes positive, negative, and affective symptoms in patients with diagnosed or suspected schizophrenia or other psychotic illnesses.

An 87-year-old man who resides in an assisted living facility has been on a regimen of sertraline 50 mg daily for the treatment of depression. Recently, the staff has noted a change in his behavior. The change is marked by agitation and irritability. Friends have observed him to be withdrawn; he refuses to participate in recreational activities and rarely appears for meals. There are concerns about his symptoms, and the medical director at the facility requests a psychiatry consultation. Question What test would you most likely want to use in the evaluation of this patient? 1 Abnormal Involuntary Movement Scale (AIMS) 2 Weinberg Screening Affective Scale (WSAS) 3 Disruptive Behavior Disorders Rating Scale (DBDRS) 4 Montgomery Asberg Depression Rating Scale (MADRS) 5 Brief Psychiatric Rating Scale (BPRS)

2 To treat alcohol abuse Alcohol abuse is a risk factor for developing avascular necrosis of the hip. Treating the alcohol abuse decreases the risk. Avascular necrosis is death of the bone in the femoral head. Physical therapy will not prevent this from occurring in a patient with a risk factor (e.g., alcohol abuse). Treating the hip strain will help the patient now, but treatment will not decrease the patient's risk of getting avascular necrosis. Although weight loss is beneficial for patient's overall health, it would not reduce the risk of developing avascular necrosis. Since the problem is the patient's current alcohol abuse putting him at an increased risk for avascular necrosis, starting NSAIDs would not be preventative.

An obese 45-year-old man presents with right hip pain that extends to the groin; the pain started after helping a neighbor move the week prior to presentation. Any attempts at physical activity cause symptoms to worsen. The patient's medical history is significant for diabetes, depression, and alcohol abuse. After physical examination and diagnostic testing, he is diagnosed with a hip strain. Due to concern over the possibility of the patient developing avascular necrosis of the hip, what recommendation should you make to the patient? 1 To get physical therapy 2 To treat alcohol abuse 3 To treat hip strain only 4 To lose weight 5 To start NSAIDs

1 Serum calcitonin levels Serum calcitonin levels is the correct answer. The vignette and the histopathology slide shown are characteristic of medullary carcinoma of the thyroid. Typically, the pathology involves large amounts of amyloid stroma with vesicular nuclei. Being a tumor of the parafollicular C cells, calcitonin is produced in large quantities, and it is detectable in the serum. An elevated calcitonin level in a patient with a suspicious thyroid nodule is suggestive of medullary carcinoma. BRCA mutation analysis is incorrect. While associated with a host of cancers, it does not help make an early diagnosis of medullary cancer (or any cancer). It merely helps to identify those at risk of developing further malignancies and plays a role in the approach to management. Wermer's syndrome genetic testing is incorrect. Genetic testing makes a diagnosis of Wermer's syndrome, which predisposes to Medullary cancer, but not of Medullary cancer itself. RET proto-oncogene testing is incorrect. It is diagnostic for MEN2a syndrome, not medullary cancer. Radioiodine uptake scanning is incorrect. In today's setting, its utility is mainly in the evaluation of hyperthyroidism and in identifying cold nodules.

As part of a routine checkup, a 40-year-old man is evaluated by his family practitioner. He smokes 1/2 a pack of cigarettes a day, and he has an occasional drink of wine. For the past 5 years, he has been on SSRIs for mild depression. On general physical examination, his BP is 110/70, and his BMI is 25. The physician notes slight enlargement of his thyroid gland with a solitary left upper lobe nodule. Careful examination reveals cervical lymphadenopathy. An FNAC of the nodule shows the picture below, with large amounts of amyloid stroma as well as disorganized spindle-shaped cells with large vesicular nuclei. Refer to the image. Question What laboratory test would have helped identify the tumor at an early stage? 1 Serum calcitonin levels 2 BRCA mutation analysis 3 Werner's syndrome genetic testing 4 RET proto-oncogene testing 5 Radioiodine uptake scanning

2 Cranial CT scan

Case A 16-year-old boy sustained a head injury during wrestling practice. During a practice match, the boy's head struck the concrete floor and he then received a secondary blow to the head by nearby wrestler. He briefly lost consciousness and then was dazed, confused, and slow to respond to questions for a few minutes. His vision became briefly blurry and double. His balance was initially unstable but improved with time; however, he developed lethargy and a headache. He did not have any nausea or vomiting. His mother was instructed to have him checked for a head injury. On exam about an hour later, he appears tired but is alert and oriented and able to recount the events leading to his injury, though he is a somewhat unsure about what happened right after. His vitals are stable, and visual acuity is 20/40 in both eyes; head and neurologic exam are normal, including equal and reactive pupils and cranial nerves. His very anxious mother says he suffered a concussion 2 seasons ago while playing football and had to sit out practice for 2 weeks. Question What management options would be best for this patient? Answer Choices 1 Observation only 2 Cranial CT scan 3 MRI 4 Skull radiographs 5 Ultrasonography

2 Mitral stenosis Mitral stenosis is a rumbling diastolic murmur heard best at the apex in the left lateral position. It may be a result of underlying rheumatic heart disease. Tricuspid stenosis presents as a diastolic rumbling murmur that is typically accompanied by a thrill heard along the left sternal border rather than at the apex; it is louder on inspiration. Mitral valve prolapse and pulmonic stenosis are examples of systolic murmurs; a diastolic murmur is heard in this patient. Aortic regurgitation presents as a soft early diastolic high-pitched murmur heard best when sitting and leaning forward.

Case A 49-year-old woman presents with a history of gradual onset of reduced exercise tolerance while working out at the gym. She is afebrile and otherwise feels well. Cardiac exam reveals a III/VI diastolic rumbling murmur located at the apex; it is heard best in the left lateral position. Question Cross Highlights What is the most likely diagnosis? Answer Choices 1 Tricuspid stenosis 2 Mitral stenosis 3 Mitral valve prolapse 4 Pulmonic stenosis 5 Aortic regurgitation

4 Cocaine intoxication The clinical picture is suggestive of cocaine intoxication. Presenting symptoms of cocaine intoxication can include hypertension, tachycardia, diaphoresis, anxiety, dilated pupils, agitation, nasal congestion, and psychosis. A narcotic overdose may present with symptoms of miotic pupils and decreased pulse and blood pressure. Acute anxiety, a schizophrenia, and bipolar disorder are all psychiatric disorders. They would not cause changes such as pupillary dilatations or nasal congestion.

The sister of a 20-year-old man is concerned because her brother has not been himself lately; his mood has been alternating from happy and euphoric to irritable and depressed. The man states that he is adjusting to his new life at college, which has so far been stressful. He states that he does not smoke, does not do recreational drugs, and only drinks socially at parties. Physical examination reveals marked nasal congestion, dilated pupils, heart rate of 120 beats/min, and a blood pressure of 155/92 mm Hg. What is the best diagnosis? Answer Choices 1 Narcotic overdose 2 Acute anxiety 3 Panic attack 4 Cocaine intoxication 5 Bipolar disorder

4 Complete blood count This patient is presenting with altered mental status, fatigue, weight loss, and fever, which are concerning for the presence of an underlying infection. The correct response is complete blood count. Many conditions, including infections and myocardial infarction, have subtle and atypical presentations in the elderly. The first signs are often nonspecific, such as a change in mental status and fatigue. Physicians taking care of older patients must be especially vigilant for this reason. Fever is an important warning sign, but the febrile response may be attenuated in older patients. It is often advised that any temperature over 99°F be considered elevated, warranting further workup. In addition to physical examination, the standard fever workup includes complete blood count, urinalysis and culture, and chest X-ray. Erythrocyte sedimentation rate may be included if there is concern for osteomyelitis, endocarditis, temporal arteritis, or other specific disease entity. Other specific imaging may be warranted if there is suspicion of an intra-abdominal process or because of findings on physical exam.

You are evaluating a 78-year-old man who lives in a nursing home due to moderate Parkinsonism. The patient does not have any specific complaints, but nursing home staff have noticed that he does not seem as alert as usual and is spending more time in his room sleeping. He is also eating less and has dropped 2 lb in the last 2 weeks. The patient's temp is 100.8°F; pulse 100 bpm; respiration 25/min; and bp 120/70 mm Hg. On exam, he is aware of the place, but not the exact time or date. His HEENT exam is unremarkable. His cardiac exam reveals tachycardia, but no murmurs or rubs. His lung sounds are decreased at the bases. Question Based on this presentation, what should be included as part of the initial workup? 1 Psychiatric evaluation 2 CT of the head 3 Nutritional evaluation 4 Complete blood count 5 Erythrocyte sedimentation rate (ESR)

5 Maternal smoking during pregnancy Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant under the age of 1 that is unexplained by thorough case investigation, autopsy, and review of case history. The occurrence peaks between 2-3 months of age. Since 1994, when the Back to Sleep campaign began recommending placing infants in a supine position, there has been a consistent decrease in SIDS rate. SIDS is still responsible, however, for more infant deaths in the United States than any other cause of death during infancy beyond the neonatal period. The predominant hypothesis concerning the etiology remains that certain infants may have a maldevelopment or delay in maturation of the brainstem neural network responsible for arousal, which affects the physiologic response to life-threatening challenges during sleep. Independent risk factors for SIDS that have been consistently identified across studies are prone sleep position, lower socioeconomic class, overheating, late or no prenatal care, young maternal age, preterm birth and/or low birth weight, male sex, and maternal smoking during pregnancy. Breastfeeding is considered a protective factor against SIDS.

You receive notice that one of your patients, a 2-month-old boy, was found dead in his crib. He was just seen for his 2-month well-baby check and seemed healthy and thriving, although he was recovering from a mild upper respiratory infection. His mother recently returned to work and the infant was being cared for by a nanny during the day. You remember counseling about "back to sleep" care and other risks for this condition. Although she is a smoker, she had cut back during her pregnancy and said she now only smokes outside. An investigation and autopsy find no evidence of foul play or underlying medical condition that might have been responsible for the infant's death. What is a risk factor for this condition that most likely caused this baby's death? Answer Choices 1 Bedsharing 2 Care by secondary caregivers 3 Presence of soft objects in crib 4 Pacifier use 5 Maternal smoking during pregnancy