Rosh

Which of the following is the initial laboratory study used for gestational diabetes screening?

1 hour glucose challenge test

Screening for gestational diabetes should be performed during which of the following weeks of gestation?

24-28 wk

72-year-old man presents with a painful rash on the right side of the forehead that began two days ago. Physical exam reveals a papulovesicular eruption on an erythematous base that does not cross the midline of the forehead. Which of the following is the best pharmacologic treatment?

Acyclovir

A 27-year-old pregnant woman at 16 weeks gestation presents with vaginal discomfort and discharge. Nucleic acid amplification is consistent with trichomonas. Gonorrhea and chlamydia testing is negative. What is the best treatment regimen?

Administer oral metronidazole in a single dose

You are working in the ED when the police bring in a 26-year old man who was involved in a bar fight. The patient is well known to staff as he frequently seeks treatment in the ED for injuries related to fights and alcohol abuse. He has been caught smoking cigarettes in the ED bathroom, has urinated on the floor, and been known to steal food trays and other patients' belongings. As you enter his examination room, you overhear him giving the registration clerk a false identity. Which of the following personality disorders best fits with this patient's behavior?

Antisocial d/o

A 24-year-old man presents with right shoulder pain after a fall onto his outstretched hand. A radiographic demonstrates an anterior inferior articular glenoid fracture. What is the name of this radiographic finding?

Bankart lesion secondary to an impaction injury of the posterosuperior aspect of the humeral head into the anteroinferior glenoid rim causing a fracture

55-year-old-man with known alcoholic cirrhosis presents with a fever and abdominal pain. He is mildly confused and has asterixis on exam. His abdomen is distended and tender to palpation. Paracentesis is completed. The ascitic fluid has a neutrophil count of 280/mm3. Which of the following is the most appropriate intravenous antibiotic for treatment of this condition?

Cefotaxime Spontaneous bacterial peritonitis

Which of the following is most characteristic of Prinzmetal angina?

Chest pain in the early morning

A 64-year-old man presents to the emergency department with crushing chest pain, dyspnea, and diaphoresis that began approximately 30 minutes prior to arrival. An ECG is performed and shows ST elevation in leads I and AVL with reciprocal ST changes in leads III and AVF. He is prepped for immediate cardiac catheterization after stabilization. Which coronary vessel is most likely occluded?

Circumflex artery

A 42-year-old woman presents to your office with a suspicious skin lesion on her back that she noticed two months ago. She has always had multiple dark nevi on her back and shoulders, but over time, this particular lesion has become darker, more raised, and larger. She has a family history of "skin cancer" on her maternal side. She spent most of her childhood outside and had many blistering sunburns as a child. On physical exam there is a black lesion with a blue tint that measures about 6 mm in size. Which of the following should be done to evaluate this lesion?

Complete elliptical excision w 1-3mm margins

Which of the following causes secondary osteoporosis in women?

Corticosteroid use

A 60-year-old woman seen in the clinic presents with a palpable breast mass, which is concerning for breast cancer. She had a negative screening mammogram six months ago. Which of the following is the first step in the diagnostic workup?

Diagnostic mammogram and ultrasound

A 46-year-old woman without significant past medical history presents with drooping of the left side of her face which she noticed this morning when she looked into the mirror. She is unable to completely close her left eye and cannot raise her eyebrows on the left side. Her vision is intact. When asked to puff out her cheeks, air leaks out the left side. The rest of her neurologic exam is normal. Which of the following is the most appropriate initial management?

Discharge home w prednisone and eye patch Bell's palsy

A 6-year-old boy presents to your office with a 5-day history of fever and headache. He denies any changes in vision or nuchal rigiditiy. He denies any international travel but he does mention that he went hiking in Tennessee one week ago. Physical exam reveals a nonpruritic, small, maculopapular rash noted on the arms and wrist that began yesterday. Laboratory values are significant for thrombocytopenia and hyponatremia. Which of the following is the first-line treatment?

Doxy

A 9-year-old boy presents with an acute onset of testicular pain that radiates toward his abdomen and is associated with nausea. An emergent testicular ultrasound is performed and shows altered blood flow to the right testicle and a twisting of the spermatic cord. Which of the following is the most appropriate next step in the management of this patient?

Emergent urologic consultation

A 60-year-old postmenopausal woman presents with painless vaginal bleeding. Her last papanicolaou smear, performed two years ago, was normal. Her pelvic exam in the office reveals a small amount of blood at the cervical os. Which of the following is the most appropriate diagnostic test?

Endometrial biopsy is the initial test for a patient with painless postmenopausal bleeding. Although atrophic vaginitis is the most common cause of postmenopausal bleeding, it is important to rule out endometrial cancer. Endometrial biopsy has few complications, is low cost and has a high sensitivity. Alternatively, a transvaginal ultrasound can be done to assess the thickness of the endometrial strip (< 3-4 mm is normal for a post-menopausal woman).Transvaginal ultrasound can be used to determine endometrial thickness as well as assess for any possible structural causes of bleeding (e.g., polyp).Remember, suspect in postmenopausal women who present with abnormal vaginal bleeding. Most common type is adennocarcinoma. Treatment is with total abdominal hysterectomy and bilateral salpingo-oophorectomy(TAH-BSO)

Drooling, anxiety, fever, and stridor in a patient sitting in a tripod position is indicative of what condition?

Epiglottitis

68-year-old man presents with complaints of vague abdominal pain, unintentional weight loss, and early satiety for the past two months. Which of the following diagnostic studies is likely to provide a definitive diagnosis?

Esophagogastroduodenoscopy

A 12-year-old patient presents with acute unilateral left leg pain that has been worsening over the past couple of months. He denies any history of injury or trauma to the site. The pain is constant at rest and activity and occurs throughout the day and night. On physical exam there is a palpable mass on the left anterior thigh that is painful to touch. There is some petechiae on skin examination however there is no warmth or erythema over the site. Which of the following is the most likely diagnosis?

Ewing sarcoma

A 24-year-old man presents to the clinic with complaints of an acute onset of dysuria and thick, whitish-yellow penile discharge. He reports he had unprotected sexual intercourse with a new female partner within the last week. Physical exam reveals mucopurulent urethral discharge. What is the most likely explanation for these findings?

GC urethritis

57-year-old type 2 diabetic man presents to his primary care provider for his annual physical. He was diagnosed with diabetes seven years ago and has a history of alcohol use disorder. His most recent hemoglobin A1C was 7.9 percent and fasting glucose of 156. He is not on any diabetic medications. He states that two years ago he had an episode of intense mid-abdominal pain that radiated to his back. He has had two more similar episodes. Ever since then, he has constant epigastric pain and has noticed loose, foul smelling stools that float in the toilet. Considering his glycemic control and past medical history, what class of anti-hyperglycemic agents is contraindicated for this patient?

Glucagon-like peptide-1 agonists contraindicated in patients with a history of pancreatitis and should be used with caution in patients with pancreatitis risk factors (alcoholism, biliary disease)

Which of the following is demonstrated on a peripheral blood smear of a patient with glucose 6-phosphate dehydrogenase deficiency?

Heinz

16-year-old boy presents with a marked hemarthrosis of his knee after tripping and striking it against the edge of a step. This has happened in the past. His activated partial thromboplastin time is prolonged and his prothrombin time and thrombin time are normal. What is the most likely diagnosis?

Hemophilia B

A 28-year-old man was exposed to poison ivy. Between 48 and 72 hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms and neck. He was given oral methylprednisolone starting with 24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day 6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and vesiculation, involving extensive areas of his arms, neck, and face. The most appropriate management at this time would be which one of the following?

High-dose oral prednisone and taper over 2 weeks Toxicodendron dermatitis is an allergic contact dermatitis that occurs from exposure to poison ivy and poison

A three-year-old girl refuses to use her left arm after her mother tugged on her arm to help her cross a street. She does not appear distressed but is holding her arm in pronation with the elbow slightly flexed. Which of the following is the most appropriate next step?

Hyperpronate the forearm while applying pressure to the radial head

An otherwise healthy 38-year-old man reports six days of a painful boil on his upper back. Vital signs are BP 128/82, HR 70, RR 16, T 98.6 F. He has been applying warm compresses to the area, but it is increasing in size, and the pain is worsening. On exam, you palpate a 1 x 1 cm erythematous, tender, fluctuant abscess without induration or surrounding cellulitis. What is the most appropriate treatment for your patients abscess?

I&D only

A 19-year-old woman presents with pain in her mouth. She underwent an extraction of an impacted molar 3 days prior to the onset of her pain. The pain began acutely today after the surgical pain subsided the day after the procedure. Which of the following is the recommended treatment?

Iodoform gauze packing moistened with oil of clove

A 34-year-old woman presents with lower abdominal pain and fever. She had a full-term delivery via cesarean section 4 days ago. On examination, she has a temperature 38.6°C and a heart rate of 112 beats/minute. Her lower abdominal incision is intact with no fluctuance, surrounding erythema, or drainage. She has midline lower abdominal tenderness to palpation. On pelvic examination, she has uterine tenderness with foul smelling lochia. What is the most appropriate management of this patient?

Intravenous clindamycin and gentamicin Postpartum endometritis

A 35-year-old woman presents to the emergency department after she collapsed at work. According to her husband, she suffers from a mood disorder that causes her to have "wild mood swings and reckless behavior." She was diagnosed a year ago and since has been treated with several medications. Her symptoms today consist of nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevated BUN and creatinine, low sodium, and elevated drug levels. All other results are normal. Which of the following medications is most likely the cause of her symptoms?

Lithium

45-year-old woman presents with a painful, red, and swollen right leg that has gotten worse over the past couple of days. She denies any trauma, travel or insect bites or any systemic symptoms such as fevers or chills. She has a history of insulin-controlled diabetes mellitus and her average postprandial sugar is 126-136 mmol/L. She also has a history of hyperhomocysteinemia and Factor V Leiden. She had an episode of cellulitis six months ago. On physical exam her vital signs are HR 82, RR 16, BP 142/86, T 99.7°F, and oxygen saturation 98% on room air. On palpation there is a swelling and tenderness of her entire right leg compared to her left. Measurement of her right calf is 3 cm in diameter greater than her left leg. Ultrasound reveals a noncompressible popliteal vein. Which of the following treatment regimens should be initiated in this patient?

Low molecular weight heparin initially and continue anticoagulation therapy for at least twelve months DVT tx

14-year-old girl present with a pruritic rash since yesterday. She began amoxicillin for acute pharyngitis three days ago. She still complains of sore throat, pain with swallowing, fatigue, and cervical lymphadenopathy. Physical exam reveals a diffuse, morbilliform rash. Which of the following is the most appropriate test to order?

Monospot should be considered in this patient because of the history of pharyngitis and the development of a rash with amoxicillin treatment

Which of the following is characteristic of pemphigus vulgaris?

Mucous membrane involvement positive Nikolsky sign

65-year-old man with a body mass index of 35 kg/m2 presents with a complaint of restlessness at night and daytime drowsiness. His wife says that his snoring keeps her up at night and he occasionally will stop breathing. What is his most likely diagnosis?

OSA

66-year-old man presents with nausea, intermittent abdominal cramping, and frequent diarrhea for the past three days. He was recently hospitalized for pneumonia and was discharged one week ago. He was feeling better until yesterday. Physical examination reveals mild lower abdominal tenderness but is otherwise unremarkable. Of the following choices, which is the most appropriate initial treatment?

Oral metronidazole for mild to moderate Clostridium difficile infection

Which of the following signs is a normal finding during early pregnancy?

chadwick

Which of the following is the most appropriate long term treatment for patellofemoral pain syndrome?

PT

5-year-old boy presents with a rash for 3 days that it started initially as a bright red rash on his cheeks as shown above. One day after the onset of facial rash, he developed a rash on his arms and trunk that has a lacy appearance. What is the most likely cause of his rash?

Parvovirus B19

Which of the following is a risk factor associated with the development of pancreatic cancer?

ciggs

Which of the following is the most common cause of esophageal varices in the United States?

cirrhosis

A thin 19-year old woman presents with abnormal vaginal bleeding stating that her menstrual cycle interval has shortened to 18 days. She reports normal flow and that her cycle lasts for 3-4 days. She has been under a lot of stress. What is this pattern of bleeding called?

Polymenorrhea cycles are occurring at intervals less than 21 days

A previously healthy 55-year-old woman presents to your office with a complaint of vertigo that occurs with positional changes of her head. Which of the following structures is most likely to be involved?

Posterior semicircular canal Benign paroxysmal positional vertigo (BPPV)

Which of the following signs is indicative of a retrocecal location of the appendix?

Psoas Sign The psoas sign, which indicates a retrocecal location of the appendix, is elicited by extending the patient's right leg while lying on the left side, causing stretch of the psoas muscle. An increase in pain is a positive test.Obturator sign signifies pelvic location of the appendiz

Which of the following class of medications is used as first-line therapy for post-traumatic stress disorder?

SSRI

17-year-old woman presents to your clinic with a chief complaint of sadness, loss of appetite, and the inability to sleep. She is having a hard time focusing at work and she is tired all of the time. She tells you that for the past month she has been hearing voices telling her to harm herself. She is interested in treatment. What is the most appropriate first-line therapy for this condition?

Sertraline and olanzapine

28-year-old man present with a painless testicular mass that he recently found on self-examination. Physical exam reveals a solid, fixed mass in the right testicle that is non-tender to palpation. Which of the following findings in this patient's past medical history would place him at increased risk for the suspected diagnosis?

cryptorchidism

A 27-year-old man presents with a foreign body sensation in his right eye. The patient turned on the heat in his car this morning and he felt something fly into his eye. His visual acuity is intact. What is the most appropriate next step in managing this patient?

Slit lamp examination with fluorescein

A 12-month-old girl presents with a fever and the rash shown above, which started around her mouth and is now present on her neck, chest, and groin. Her mucous membranes are not involved. The epidermis is noted to slip away from the underlying dermis when gentle lateral pressure is applied. What is the most likely diagnosis?

Staphylococcal scalded skin syndrome

74-year-old woman presents with complaints of fever, productive cough with bloody sputum, shortness of breath, and headache. These symptoms developed and worsened drastically over the past 3 days. She recently recovered from an influenza infection 1 week ago. Her medical history otherwise includes only well-controlled hypertension. Vital signs on presentation are as follows: T 39°C, HR 106, BP 110/75, RR 30, oxygen sat 95% RA. A chest radiograph is obtained and a subsequent CT scan of the chest demonstrates multiple cavitary lung lesions. Which of the following organisms is most likely responsible for this patient's presentation?

Staphylococcus aureus post-viral secondary necrotizing pneumonia.

A 10-year-old boy presents with a two day history of sore throat, fever and headache. He denies cough, significant rhinorrhea or head congestion. Physical exam is remarkable for enlarged, erythematous tonsils with a pharyngeal whitish exudate. He has marked lymphadenopathy over his anterior and posterior cervical lymphoid chain. What is the most likely diagnosis?

Strep pharyngitis

Which of the following bacteria most commonly causes acute mastoiditis?

Strep pneumo Tx: dicloxillin

65-year-old obese woman presents to her primary care provider with a complaint of accidentally wetting herself when she laughs too hard or sneezes. She states that she wears liners on her underwear in case of an accident. What is the most likely diagnosis?

Stress incontinenance

A 35-year-old man presents to the emergency department with pain and swelling under the tongue for the last 3 days. The pain worsens when eating. Physical exam reveals normal range of motion of the jaw and tongue. The oropharynx is normal. At the base of the tongue, there is a tender, firm, mobile mass without purulent discharge. There is no erythema or swelling of the external, submandibular region. Which of the following is the most appropriate next step in management?

Suck on hard candies, massage sialogogue in wharton duct

Which of the following conditions requires droplet precautions?

TB

78-year-old man with a history of hypertension and diabetes presents to the emergency department after an episode of left arm weakness and numbness that began two hours ago and lasted about 30 minutes before it resolved completely. This has never happened to him in the past. Physical exam is unremarkable. Which of the following is the most likely diagnosis?

TIA

A 21-year-old woman presents with pain, tearing, photophobia, and left eye redness. She has been wearing her contact lenses continuously for the last two weeks. A slit lamp examination reveals a white, hazy opacity on the cornea at the 3 o'clock position of the cornea with associated limbal flush. Which of the following is the most appropriate pharmacotherapy?

Topical cyclopentolate

A 55-year-old woman complains of itchy patches on her wrists for the past week. She denies new exposures, medication changes, or other areas of involvement. Physical exam reveals purple, polygonal, papular lesions on the volar aspect of the wrists. Close inspection reveals tiny, white lines on the surface of the lesions. What is the best initial treatment for this skin disorder?

Topical fluocinonide

A six-month-old girl is brought to the clinic for routine health supervision visit. She interacts well with her parents. She can babble and roll over. She has also started eating solid food. The family is going on a vacation to Philippines for two weeks. The parents express concern that there is currently a measles outbreak in Manila. Which of the following is the best statement regarding measles transmission?

Transmission occurs via person-to-person contact as well as airborne spread

A 28-year-old woman presents with a concern about "lumpy, tender breasts." She states that the upper, outer quadrants of both breasts develop multiple small masses off and on throughout the month. The physical exam does not show a discrete lump, skin changes of the breasts, or nipple discharge. Which of the following is the initial best test to investigate her condition?

US

32-year-old man presents with severe bilateral eye pain that started in the late evening while watching television. He works as a welder during the day. He has associated tearing, photophobia, and foreign body sensation. He does not use contact lenses. Visual acuity in 20/40 OD and 20/40 OS. His eye examination after fluorescein staining is seen above. What is the most likely diagnosis?

UV keratitis

24-year-old previously healthy woman presents to the ED complaining that she cannot move her legs. The symptoms occurred suddenly after she was told that her fiancé died in a motorcycle accident. She denies any associated symptoms, including pain. The sensation and deep tendon reflexes in her lower extremities are normal. She has normal muscle tone. What is the most likely diagnosis?

conversion d/o

A 63-year-old woman was recently diagnosed with herpes zoster. Which of the following signs could indicate the impending development of herpes zoster ophthalmicus?

hutchinson sign

32-year-old woman is brought to the ED by her husband because she "has been acting strangely." She has a past medical history of depression that is well controlled with fluoxetine. He also reports she has been suffering from a cold and took over-the-counter cough medication a few hours prior to the onset of her symptoms. She is agitated and confused. Her blood pressure is 160/80 mm Hg, pulse is 140 beats per minute, and temperature is 39°C. She is flushed and her pupils are dilated. She has clonus and hyperreflexia in her lower extremities, as well as a tremor in her hands. What is the most likely diagnosis?

32-year-old woman is brought to the ED by her husband because she "has been acting strangely." She has a past medical history of depression that is well controlled with fluoxetine. He also reports she has been suffering from a cold and took over-the-counter cough medication a few hours prior to the onset of her symptoms. She is agitated and confused. Her blood pressure is 160/80 mm Hg, pulse is 140 beats per minute, and temperature is 39°C. She is flushed and her pupils are dilated. She has clonus and hyperreflexia in her lower extremities, as well as a tremor in her hands. What is the most likely diagnosis?

Which of the following groups of people should receive the pneumococcal polysaccharide vaccine?

65+

A 55-year-old man presents to the ED with left knee pain after a fall from standing 2 days prior. He has a history of diabetes mellitus. He states he has been progressively less able to walk because of the pain. On physical examination, the left knee is warm, erythematous, diffusely tender, and swollen with a large effusion. There are no rashes or deformities. He has significant pain on passive range of motion. His vital signs are BP 150/85 mm Hg, HR 105 beats per minute, RR 16 breaths per minute, and T 102.7°F. Which of the following synovial fluid analysis results is most indicative of a diagnosis of septic arthritis?

80,000 WBC per high power field with 90% neutrophils and glucose 40 mg/dL

2-week-old, ex-34 week male infant presents with fever and abdominal distension. The patient has decreased bowel sounds and bloody stool in his diaper. What test should be obtained to make the diagnosis?

Abdominal Xray It may show intramural air (pneumatosis intestinalis), a loss of symmetrical gas pattern, dilation of loops of bowel or portal vein gas. concerned for necrotizing enterocolitis (NEC)

A 7-year-old otherwise healthy boy presents with his mother complaining of brief "staring spells" for the past 2 months. These episodes are described as 15-second lapses of blank stares with impairment of consciousness. After these attacks, he resumes his previous activity. Which of the following is the most likely diagnosis?

Absence seizure

3-year-old girl was walking on the sidewalk with her mom when she fell onto the street. In a panicked state, her mom picked up the little girl by her arm. Immediately after, the little girl refused to move her right arm complaining that it hurt. In the emergency room, the girl is holding her right arm in a flexed, pronated, and adducted position. There is no crepitus, swelling, or point tenderness along the entire right arm or clavicle. Which of the following is the next step in management of this patient?

Actively supinate and flex the elbow while applying pressure over the radial head Nursemaid elbow

23-year-old man with a history of type 1 diabetes presents to the Emergency Department with abdominal pain, vomiting, and fatigue. He has not been taking his insulin. He is found to have diabetic ketoacidosis. His vital signs and mental status are normal except for RR of 26 bpm and HR of 112 bpm. He has a normal electrocardiogram. Treatment is initiated with intravenous normal saline and insulin. After one hour of insulin therapy, his pH is 7.21, glucose is 190 mg/dL, anion gap is 22, bicarbonate is 13 mmol/L, and potassium is 5.5 mEq/L. Which of the following is the most appropriate next step?

Add dextrose to IV fluids

12-month-old girl is brought in for evaluation of abdominal pain. She has been intermittently lying on the floor and "doubling up" with abdominal pain. The episodes last about one minute and then resolve. She had one episode of emesis. Physical exam reveals a palpable mass in the right lower quadrant of the abdomen. Which of the following is the most appropriate diagnostic test?

Air/contrast enema An air/contrast enema is indicated when intussusception is suspected. Intussusception is a telescoping of the bowel into an adjacent segment and is the most common cause of intestinal obstruction in young children. This typically affects children between the ages of six months to three years of age and is characterized by bouts of intermittent, severe abdominal pain. It can be accompanied by vomiting and "currant jelly" stool that is the result of blood from venous infarction of the bowel along with mucous production. The most common area for this to occur is at the terminal ileum into the right colon. A barium enema can be both diagnostic and therapeutic, reducing the intussusception. Several attempts at reduction can be made through using this modality before surgery is indicated. Surgical resection is indicated if the bowel is gangrenous or cannot be reduced.

22-year-old man with a recent diagnosis of schizophrenia is brought by his parents for evaluation of abnormal behavior. His mother notes that he has been very restless and has been pacing around the house constantly. On examination, his vital signs are unremarkable. He is noted to be mildly agitated and rocking back and forth on the examining table. What is the likely diagnosis?

Akathisia subjective sensation of motor restlessness. It occurs most frequently with high-potency dopamine-2 receptor antagonists (e.g. haloperidol, fluphenazine, and thiothixene), but can also be seen with any antipsychotic medication

A 65-year-old farmer presents with a non-healing ulcer on the right side of his nose as seen above. The lesion bleeds when he scratches it. He denies any pain or systemic symptoms. What is the treatment for this lesion?

Mohs micrographic surgery squamous cell carcinoma,

42-year-old man with a history of hypertension presents to the emergency department by ambulance after his wife called 911 out of concern for a possible overdose. The patient is confused and unable to answer questions upon arrival. His blood pressure is 80/50 mm Hg, heart rate is 45 beats/minute, and respiratory rate is 12 breaths/minute. Electrocardiogram findings include a prolonged PR interval. His glucose is 60 mg/dL. Which of the following is the most likely explanation?

B-blocker OD

A 77-year-old man presents for evaluation of a painless skin lesion on his forehead that has been progressively getting larger over the last few months. Physical exam reveals a raised, smooth-surfaced lesion with pearly borders, small telangiectasias as shown above. What is the most likely diagnosis?

basal cell carcinoma

5-year-old girl presents to clinic with a gradual onset of generalized malaise and severe vigorous coughing fits but without a fever. Which of the following bacteria are you likely to find on a posterior nasopharynx culture?

Bordetella pertussis

A 27-year-old woman presents with symptoms of excessive eating followed by vomiting. Her BMI is 29 kg/m2 and her teeth are eroded. Which of the following is the most likely diagnosis?

Bulimia nervosa Bulimia nervosa is a psychological disorder characterized by excessive eating followed by a compensatory behavior in an attempt to lose weight (e.g., vomiting or using laxatives). It is most commonly seen in womenapproximately 20 years of age and often accompanies other psychological disorders (e.g., anxiety, depression, and suicidality). Patients with bulimia nervosa have a range of body mass indexes from normal to obese, and they often restrict their caloric intake between their binge episodes in order to maintain or lose body weight. Patients present with tachycardia, hypotension, dry skin, and eroded tooth enamel. They are often anxious or suicidal. Assessment should include both a general examination as well as a psychiatric examination. Complications of bulimia nervosa include gastrointestinal disorders, dehydration, and type 2 diabetes mellitus. Treatment includes nutritional counseling, medical management, cognitive behavioral therapy, and pharmacologic therapy. Anorexia nervosa (A) is an eating disorder defined as low body mass index, fear of gaining weight, and a distorted perception of body weight. Patients with this disorder do not intake an adequate amount of calories and lose weight by purging or excessive exercise. Co-morbidities often include a history of other psychiatric disorders and suicidality, and patients are typically thin with dry skin and hair loss, and women have amenorrhea. Binge eating disorder (B) is the overly excessive intake of food due to patients feeling they do not have control over what they are eating. Patients typically eat until they are excessively full, they eat large amounts of food when not hungry, and they are embarrassed afterwards. In binge eating disorder, there is no act of purging after eating. Co-morbidities include psychiatric disorders and type 2 diabetes. Purging disorder (D) is characterized by compensatory actions to control weight, such as self-induced vomiting or laxatives in the absence of excessive binge eating. Patients typically present with a normal body mass index, swollen gums, and eroded teeth enamel.

When evaluating for stress urinary incontinence, which of the following tests should be performed to confirm the diagnosis?

bladder stress test

A 30-year old woman presents complaining of pelvic pain and fever. She had a Cesarean section 3 days prior to presentation at 36 weeks gestation for failure to progress and premature rupture of membranes. Her incision is clean and dry. She is tender in the lower abdomen and foul-smelling lochia is noted during pelvic examination. Which of the following is the most important risk factor in the development of this condition?

C-section

A mother brings in her 8-year-old son in for evaluation after stepping on a nail with his bare right foot in their unfinished basement this morning.He was able to pull the nail out of his foot and the nail measured one inch. Examination of his foot reveals a nontender 2 mm puncture wound with no surrounding erythema. He completed his DTaP (Pediatric-Diphtheria-Tetanus-acellular Pertussis) vaccination series three years ago. What is the most appropriate next step?

Clean wound and discharge home

28-year-old woman presents to your office with a complaint of mood swings. She tells you that she constantly fights with her boyfriend and gets angry easily. She often uses cocaine and binge eats when under stress. Last month, she held a knife to her wrist during an argument with her boyfriend but did not follow through with the suicide attempt. Which of the following is the most appropriate next step in management?

CBT

A six-year-old boy is brought to clinic because of a sore throat. For the past two days, he has had low-grade fever, decreased activity, and sore throat. Review of his medical records show that his parents declined routine vaccinations. On physical examination, his vital signs are normal. Findings include enlarged cervical lymph nodes and gray and white exudates on the pharynx. Upon scraping of the exudate, bleeding is noted. Complete blood count is normal. Throat culture is pending. Which of the following is the most likely etiologic agent?

Corynebacterium diphtheria

49-year old woman presents to a rural emergency department with acute onset monocular vision loss in her right eye. She denies pain or any other deficits but states she has been feeling nervous and has lost weight over the past three weeks. On physical exam, she has complete visual field loss in the right eye. Fundoscopic exam reveals a pale retina and a single bright red spot just off of center. After she is treated appropriately for her emergent problem, what additional testing is most appropriate?

ECG microembolism caused by A-fib associated with hyperthyroidism

A 12-year-old boy presents with a sore throat and fever that began two days ago. The throat pain is primarily located on the right side. On examination, his right tonsil is 3+ and erythematous. A bulge is located in his right soft palate. The uvula is deviated to the left. What is the next best step in management?

FNA

A six-year-old girl is brought to the clinic because of a rash. She was in school when she developed the rash about 2 hours ago. She denies difficulty of breathing, throat tightness, vomiting, or abdominal pain. On physical examination, there are multiple raised, erythematous plaques, with central pallor that are less than one centimeter to several centimeters in diameter on her arms and appear to be consistent with acute urticaria. Which of the following is the most appropriate therapy?

Fexofenadine Acute urticaria 2nd gen H1 antihistomaines are 1st line therapy

You examine a two-day-old boy in the neonatal intensive care unit. He was born to a 26-year-old G2, P2 mother via normal spontaneous vaginal delivery. The mother had limited prenatal care. The nurse notes that the infant has a poor suck. On examination, you note that the neonate is small for gestational age, with microcephaly, enlarged liver, and petechiae. On complete blood count, you note thrombocytopenia. You suspect congenital cytomegalovirus infection. Which of the following is the most appropriate therapy?

Ganciclovir Intravenous (IV) ganciclovir and its orally available prodrug, valganciclovir, are the first-line antiviral agents of choice for treatment of congenital CMV disease.

A 73-year-old woman presents with right knee pain for the past several months that has been worse over the last three days. It is worse with walking and better with rest. She has not tried anything to alleviate the pain. Physical examination reveals bony enlargement of the knee and joint line tenderness. An X-ray is ordered and shows narrowed joint spaces, and subarticular reactive sclerosis. She denies any injury or previous surgery on the knee. Which of the following is the best initial pharmacologic treatment?

Ibuprofen

The finding seen in the image above is most commonly associated with which of the following viral infections?

Herpes simplex virus Herpes simplex virus (HSV) is the most common viral infection associated with erythema multiforme (EM)

44-year-old previously healthy woman presents with unilateral facial pain that began several hours ago. She now has swelling in the left side of her face and tenderness in this area. Physical exam reveals left-sided parotid gland swelling, trismus, and purulent ductal discharge. Which of the following is the best pharmacologic treatment?

IV naficillin Intravenous nafcillin is the first-line treatment recommended for acute suppurative sialadenitis. Patients usually present with acute parotid swelling, skin erythema and warmth, tenderness, trismus, purulent ductal discharge, fever, and malaise. The most common cause is salivary stasis from an underlying stricture or obstruction of the duct. The most common pathogens are Staph aureus, S. pneumoniae, E. coli, and H. influenzae. Complications from untreated infections include cellulitis and abscess formation. In addition to intravenous antibiotics, treatment includes warm compresses and analgesics, massage of the gland, sialogogues, improved oral hygiene, and rehydration. Most patients recover completely; however, higher mortality rates are seen in immunocompromised and debilitated patients.

65-year-old man with carcinoma of the cecum has a decreased hemoglobin, mean corpuscular hemoglobin concentration and mean corpuscular volume. What is the most likely diagnosis?

IDA

A 13-year-old boy presents with the acute onset of right testicular pain and swelling. An emergent testicular ultrasound is performed and shows altered blood flow to the right testicle and a twisting of the spermatic cord. Which of the following findings is consistent with the diagnosis?

relief of pain w elevation of scrotum

Which of the following is considered the gold standard in the treatment of chronic anal fissures?

Lateral internal sphincterotomy

A 6-year-old boy presents with left hip pain that started four weeks ago. He denies any history of trauma. He describes the pain as a dull, aching pain that is worse with activity. The pain has gradually worsened, and the mother notes that he now walks with a limp. On examination, his temperature is 37.6°C. He denies pain with palpation of the left leg, but has pain and limited range of motion with internal rotation at the hip. What is the most likely diagnosis?

Legg Calve Perthes

A 5-year-old African American boy is seen in clinic because he has been complaining of pain in his hip that is worse with ambulation. He denies any systemic symptoms, injury or recent illness. An MRI reveals osteonecrosis of the femoral head. Which of the following is the most likely diagnosis?

Legg-Calve-Perthes Legg-Calve-Perthes disease is an idiopathic osteonecrosis of the proximal femoral head resulting from compromise of the blood supply due to the rapid competing growth of the secondary ossification centers. It usually occurs in children 4-10 years of age and is more common in boys than girls. Patients most commonly present with an intermittent limp associated with mild pain in the anterior thigh or hip, which results from the necrosis of the involved bone. In approximately 90% of instances, the disorder is unilateral. Early radiographic changes may reveal only a nonspecific effusion of the joint associated with slight widening of the joint space. This is known as the acute phase, and it may last 1-2 weeks. Eventually, the disease may progress to collapse of the femoral head, which is the active phase, and it can last 12-40 months. A bone scan can be used to evaluate the site for avascular necrosis. Initial therapy is supportive. If the condition progresses, the orthopedist may recommend minimal weightbearing and protection of the joint, which is accomplished by maintaining the femur abducted and internally rotated so that the femoral head is held inside the acetabulum. This is accomplished by means of either the use of orthotic devices or surgery, however surgery proves to be more beneficial at containing the femoral head inside of the acetabulum.

A patient diagnosed with sarcoidosis presents with erythema nodosum, hilar adenopathy and migratory polyarthralgia. This presentation is characteristic of which of the following syndromes?

Lofgren syndrome

A four-year-old girl is brought to the clinic because of a rash. Five days prior, she developed fever, decreased appetite, eye redness, and coughing. Yesterday, the mother noted the appearance of a rash that started on the face and today has spread to the neck and trunk. The girl has not had any vaccines since the mother was opposed to it. On physical examination, temperature is 38.5ºC with erythematous, maculopapular, blanching rash on the neck, upper trunk, lower trunk, and extremities. Which of the following is the most likely diagnosis?

Measles

A 14-year-old girl presents to the emergency department with a complaint of vaginal discharge. She admits to being sexually active with one male partner. Pregnancy testing is negative. Clue cells are noted on microscopic wet mount examination of the vaginal discharge. What is the most appropriate treatment for this patient?

Metronidazole 500mg BID for 7d

3-year-old girl presents with increasing redness and swelling involving her right eye for the past four days. Her mother states that the child has become increasingly irritable, less active, and is febrile. The child recently had nasal congestion and rhinorrhea prior to onset of these symptoms. Examination reveals an ill-appearing 3-year-old girl lying quietly on the exam table. Her temperature is 102°F. Visual acuity is 20/40 in the right eye and 20/30 in the left eye. The right eye reveals mild proptosis, severe erythema, increased warmth and swelling involving the eye and surrounding tissues. Which of the following is the most appropriate diagnostic evaluation?

Orbital and sinus CT scan

A G1P0 woman who is 38 weeks pregnant presents to the clinic reporting a sudden gush of clear fluid from her vagina. The leakage was so significant that it soaked her clothes and bed sheets. She denies contractions. Which of the following would be expected finding in this patient?

Pooling of amniotic fluid in the vaginal fornix on physical exam

21-year-old woman presents to the emergency department with facial swelling, malaise and blisters in her mouth since yesterday. Associated symptoms include a low-grade fever and fatigue for the past four days. Physical exam reveals a rash scattered across the chest and upper extremities that appears like "targets," as well as desquamating blistering lesions of the tongue and buccal mucosa. Her past medical history is significant only for recent treatment of atypical community-acquired pneumonia. Which of the following is the most likely diagnosis?

SJS Stevens-Johnson syndrome (SJS) is most commonly triggered by medications. It is a severe mucocutaneous reaction and is on a continuum with toxic epidermal necrolysis. Steven Johnson syndrome is characterized by less than 10% of body surface area skin detachment while toxic epidermal necrolysis is characterized by greater than 30% of the body surface area being detached. It affects women more than men and has a higher prevalence in human immunodeficiency virus and active malignancy. Medications such as sulfanamides, allopurinol, and nonsteroidal noninflammatory agents are a few of the most common causes. Another common trigger is Mycoplasma pneumoniae infection. It often presents with a prodromal phase including fever, conjunctiva irritation and arthralgias followed by a cutaneous eruption that begins on the face and thorax and progresses downward symmetrically. These lesions then become vesicles and eventually erupt and the skin sloughs off. Mucous membrane involvement includes blistering lesions of the oral mucosa, lips, conjunctivae, and genitals. Treatment is supportive and aimed at decreasing fluid losses, infection, and pain control. Referral to a burn center is recommended.

7-year-old boy presents with right ankle pain after jumping off his bunk bed. On examination, he has tenderness and swelling over the medial malleolus. His ankle X-ray is shown above. What is the diagnosis?

Salter-Harris type III fracture a fracture that extends through the epiphysis intra-articularly through the physis

An otherwise healthy 42-year-old woman presents with three days of dysuria, urinary frequency, and urinary urgency. Her urine dipstick reveals moderate nitrites, leukocyte esterase and blood. On physical exam she has no costovertebral angle tenderness. She denies nausea, vomiting, fevers, and chills. Which of the following is the most appropriate next step?

Treat with five days of 100 mg nitrofurantoin twice daily and check culture and sensitivity

A 6-year-old boy is brought to the emergency room by his mother because he has been complaining of severe abdominal pain that started yesterday. He has refused to eat for the past couple of days and has vomited once since arrival to the emergency room. He has not had a bowel movement for the past 3 days. On physical exam he appears to be in moderate distress. His abdomen is soft but is exquisitely tender in the right lower quadrant on palpation. Rebound tenderness is absent. Rectal exam reveals stool in the rectal vault. Vital signs are T 101.3°F, HR 119, BP 100/68, and oxygen sat 98% on room air. Which of the following is the most appropriate diagnostic study?

US

38-year-old pregnant woman at 35 weeks gestation with a history of tobacco use presents to the emergency department with sudden onset painful vaginal bleeding and contractions. On bimanual examination, her uterus feels firm and rigid. Which of the following is the most likely diagnosis?

abruptio placenta

A previously healthy 27-year-old man presents to your office with a complaint of cold symptoms. He says that initially he had sinus congestion and a sore throat, which have since resolved, but he has also had a productive cough for approximately 10 days that is keeping him up at night. Physical exam reveals a temperature of 98.6°F and mild, diffuse wheezing on auscultation of the lungs. Which of the following is the most appropriate therapy?

albuterol

Which of the following is the most common cause of cirrhosis in the United States?

alcoholic liver

71-year-old woman presents for "pink eye." She is rubbing her eyes, and complains of itching. Both eyes appear irritated and red-rimmed with clear scales adherent to her lashes. The meibomian glands appear inflamed. There are no changes in vision, and she denies any exposure to allergens or chemicals. She states this happened in the past. Which of the following is the most likely diagnosis?

blepharitis

A 46-year-old woman presents with muscle weakness that has progressively worsened over the last several months. She has particularly noticed it when trying to stand up from a seated position, and she now has to use the armrests. Physical examination reveals weakness of the deltoids and hip flexors. Testing positive for which of the following autoantibodies is most consistent with the diagnosis?

anti-Jo-1 autoantibodies. polymyositis

43-year-old woman with a past medical history of poorly controlled diabetes mellitus and obesity presents for an itchy rash underneath her breasts for the past month. Physical exam reveals a macular rash that is bright red with small satellite lesions in the bilateral inframammary areas. A potassium hydroxide preparation reveals pseudohyphae. What is the most likely diagnosis?

candidiasis

54-year-old woman presents with intermittent numbness and tingling in the first three digits of her right hand for the last week. The symptoms are exacerbated by knitting or typing. Physical exam reveals positive Phalen and Tinel signs. What is the most likely diagnosis?

carpal tunnel

Which antibiotic is the most appropriate for treatment of acute otitis media in a child with a rash from amoxicillin?

cefdinir

21-year-old woman presents with pelvic pain that has been worsening over the last two days. She reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin, copious vaginal discharge, cervical motion tenderness, and a mass in the left adnexa. Pregnancy test is negative. A pelvic ultrasound reveals a complex multiloculated left adnexal mass. Which of the following intravenous antibiotic regimens represents the most appropriate pharmacotherapy?

cefoxitan and doxy (TOA)

A 24-year-old woman presents for follow-up after an abnormal Pap smear. Colposcopy is performed and reveals a white, sharply demarcated area on the cervix after application of acetic acid. What is the most likely diagnosis?

cervical dysplasia

A 66-year-old man presents with complaints of gross hematuria intermittently for the past one week. He has occasional dysuria and notes that his urinary stream has been smaller for the past month. Social history reveals tobacco use of one pack per day for the last 40 years. Which of the following is the most likely to confirm your suspected diagnosis?

cystoscopy

27-year-old tall, thin male presents to the emergency room with moderate right-sided chest pain and dyspnea. He says it started quickly while he was watching television 30 minutes ago. He is tachypneic and tachycardic, however his heart rate and blood pressure are stable at this point. Lung exam reveals decreased breath sounds at his right lung field. Which of the following other physical exam findings would be expected in this patient?

decr right sided tactile frem

70-year-old man, with a past medical history of type 2 diabetes, presents for a routine eye exam. He has noticed a gradual loss of peripheral vision since his eye exam last year. On examination, he has diminished visual fields, elevated intraocular pressure, and symmetrically enlarged cup-to-disk ratio bilaterally. What is the most likely diagnosis?

diabetic retinopathy

A 55-year-old woman presents with a complaint of left lower quadrant abdominal pain, constipation, and fever. On palpation, she is tender in the left lower quadrant with guarding and rebound tenderness. Which of the following is the most likely diagnosis?

diverticulitis

An 18-year-old woman comes to the emergency department with sudden onset of right lower abdominal pain. She describes the pain as crampy and intermittent. Her last menstrual period was 7 weeks ago. She has noticed vaginal spotting during the past few days. Physical examination shows a tender lower abdomen with guarding. Pelvic examination shows a slightly enlarged uterus, cervical motion tenderness, and a palpable adnexal mass. Which of the following is the most likely diagnosis?

ectopic pregnancy

A 72-year-old man with a history of chronic tobacco use presents to clinic with a complaint of increasing dyspnea while walking to his mailbox. Physical examination reveals decreased breath sounds, hyperresonance to percussion, and a barrel chest. A chest X-ray is obtained that demonstrates hyperinflation with flattened diaphragms. What is the most likely diagnosis?

emphysema

A 58-year-old woman with a history of previous cerebrovascular accident presents to the emergency department by ambulance due to concern for possible overdose. According to her husband, at home she was vomiting and complaining of nausea and ringing in her ears. The patient is confused and unable to answer questions upon arrival. Her blood pressure is 90/57 mm Hg, heart rate is 112 beats/minute, respiratory rate is 28 breaths/minute, and temperature is 103.1°F. Which of the following interventions should be avoided if possible?

endotracheal intubation

A 34-year old woman is diagnosed with rheumatoid arthritis and started on hydroxychloroquine. Which of the following should be monitored while she is taking this medication?

eye exam With long-term use, hydroxychloroquine can cause irreversible damage to the retina

A 34-year-old woman presents to your office with complaints of mood swings, difficulty sleeping, headache, and fatigue that seem to be related to her menstrual cycle. She has tried lifestyle modifications, including regular exercise and healthy diet, without relief. Which of the following is the most appropriate therapy?

fluoxetine

44-year-old man with a history of hypertension presents with purple, polygonal, papular lesions on the wrists. The lesions are pruritic and have been present for the last several weeks. A skin biopsy is ordered. Which of the following histology results would be most consistent with the suspected diagnosis?

hyperkeratosis, degeneration of basal cell layer, colloid bodies

16-year-old female competitive runner complains of pain and tenderness over her shins when she runs. On physical exam you notice point tenderness over her left tibia. X-rays are normal but MRI reveals a hairline fracture in the tibia. She has suffered multiple stress fractures of this bone before. A prompt workup should be initiated for which of the following disorders?

hypopara

A 22-year-old woman presents complaining of vaginal bleeding and cramping for the last 4 hours. She is known to be 14-weeks pregnant. Her cervical os is dilated to 4 cm and she is actively bleeding. Pelvic ultrasound shows the gestational sac in the lower uterine segment near the cervix. Which of the following is the most likely diagnosis?

inevitable abortion he patient is experiencing an inevitable abortion, which is characterized by an open cervical os and a gestational sac at the opening of the uterus on ultrasound. The case should be discussed with the patient's obstetrician as the patient may ultimately require dilatation and curettage if all the products of conception (POC) do not pass spontaneously or the bleeding is not controlled.

39-year-old man presents with a worsening sore throat and difficulty swallowing for the past day. He is dyspneic. Palpation of the neck reveals bilateral cervical adenopathy and pain with gentle palpation of the anterior neck. A soft tissue lateral neck radiograph demonstrates a "thumbprint" sign. Which of the following is the most appropriate pharmacotherapy?

inhaled recemic epi

Which of the following fetal heart tracings patterns is indicative of uteroplacental insufficiency?

late decels

A patient presents with right-sided homonymous hemianopia. Which of the following is the location of the suspected lesion?

left optic tract

23-year-old woman presents with a dry cough, malaise, sore throat, and subjective fever for the last two weeks. She was seen at an urgent care four days ago and was prescribed a cough syrup. Physical examination reveals diffuse crackles. Vital signs are within normal limits. Which of the following is the most appropriate empiric treatment?

levofloxacin

Koebner's phenomenon is most likely to be observed in which disease process?

lichen planus when lesions appear at the site of mechanical or thermal trauma

A 35-year-old woman presents with concerns of a mass on her back that has been present for the last few years. Physical exam reveals a soft, rubbery, round, well-circumscribed, mobile mass, approximately 3 cm in diameter in the subcutaneous tissue. There are no overlying skin changes noted. What is the most likely diagnosis?

lipoma

45-year-old man with a history of obesity and diabetes mellitus presents to the emergency department complaining of abdominal pain that radiates to his back, and nausea and vomiting. Physical examination reveals tenderness in his epigastrium and yellow deposits are noted on the extensor surfaces of his forearms. Which of the following will most likely be seen on his lipid panel?

markedly elevated TG

47-year-old man presents as a trauma activation after a head-on motor vehicle crash at 20 mph. He was a restrained driver and the airbags did deploy. There were no drugs or alcohol involved. He is uncertain if he lost consciousness. EMS extricated him, put him in spinal immobilization, and splinted an obviously fractured femur. On primary survey, his airway is protected, he is breathing easily, and is normotensive. Vital signs are within normal limits. Secondary survey is notable for a GCS score of 15, a mildly tender right trapezius muscle, and an ecchymotic and deformed left femur with normal distal neurovascular function. The presence of which historical or physical finding necessitates cervical spinal imaging?

mech of injury

58-year-old previously healthy woman presents with complaints of dyspnea on exertion and fatigue for the past one month. She denies unexplained weight loss or weight gain, chest pain, or cough. Physical exam reveals a low pitched, diastolic murmur, heard best at the apex. There is an associated opening snap. Which of the following is the most likely diagnosis?

mitral stenosis

A nine-year-old girl is in the clinic for a follow-up. She was diagnosed with asthma a few days ago after an emergency room visit. She would have night awakenings about twice a week. She would also use her inhaled short-acting beta agonists about every day for relief of shortness of breath. On physical examination, you notice occasional wheezing on right and left lung fields. Which of the following is the best classification of her asthma severity?

moderate persistent

Which of the following causes acute painful loss of vision?

optic neuritis

A 22-year-old previously healthy woman presents with pain and swelling of her right third digit for the past 2 days. Physical exam reveals swelling and erythema of the entire distal digit with fluctuance of the lateral nail fold as shown above. An incision and drainage is performed and the decision is made to begin antibiotics out of concern for an associated cellulitis. Which of the following is the most appropriate pharmacologic therapy?

oral cephalexin

A 19-year-old woman presents with pelvic pain that has been worsening over the last four days. She reports associated nausea and several episodes of emesis today. Vital signs include blood pressure of 113/68 mm Hg, pulse of 112 beats per minute, and oral temperature of 38.2°C. Physical exam reveals cervical motion tenderness and fullness in the left adnexa. Urine pregnancy test is negative. Which of the following would be the most appropriate next step in managing this patient?

order pelvic ultrasound This patient has symptoms consistent with a tubo-ovarian abscess (TOA)

What is the most common physical exam finding during the primary stage of syphilis infection?

painless chancre

42-year-old man presents via emergency medical services after an injury that occurred while he was working. There was an explosion at the chemical plant where he was employed. An initial survey of the patient shows deep-partial thickness burns of his neck and face along with burns of varying degrees on his torso and hands. There is soot in his nose and mouth. Which of the following is the most appropriate next step in managing this patient?

prepare for emergent intubation

55-year-old man presents to his pulmonologist with progressive shortness of breath over the past year. He was previously healthy and now can barely make it up the stairs in his home. A chest radiograph shows enlargement of the pulmonary arteries with a normal sized cardiac shadow and normal-appearing lung fields. An echocardiogram is performed showing a normal-shaped left ventricle and thickened myocardium in the right ventricle. Which diagnosis is most likely in this patient?

pulm arterial HTN

A 71-year-old man presents to the Emergency Department complaining of left eye pain that has been increasing over the last few hours. The pain is associated with blurred vision and nausea. Physical examination of the left eye is shown. Which aspect of the comprehensive eye examination is contraindicated in this patient?

pupillary dilation

32-year-old woman with history of migraine headaches presents for evaluation of increased frequency of headaches. She takes abortive medication for migraines 2-4 times weekly and misses several days of work a month. You decide to start topiramate daily for migraine prophylaxis. Of the following, which one is the most common side effect of this medication?

paresthesia Topiramate is an anticonvulsant used for migraine prevention and treatment of epilepsy. Central nervous system side effects are the most common and include paresthesias, nervousness, fatigue, ataxia, drowsiness, lack of concentration, dizziness and confusion. Topiramate should be initiated at a low dose and gradually titrated to the recommended dose to reduce the risk of these side effects. Also, topiramate should not be discontinued abruptly, but instead decreased gradually over weeks, as sudden cessation may increase the risk for seizure. In addition to anticonvulsants, antihypertensive agents and antidepressants are sometimes used for migraine prophylaxis. Beta-blockers and tricyclic antidepressants are commonly used. Patients with a history of bronchospastic disease should avoid nonselective beta-blockers, such as propranolol, due to the possible side effect of bronchospasm (B). Tricyclic antidepressants antagonize muscarinic receptors leading to dry mouth (A), constipation, urinary retention, and sometimes blurred vision. Topiramate is used in the prevention of seizures (D) as well as migraines, and seizure is also a potential side effect of abrupt discontinuation of topiramate

A 31-year-old previously healthy woman presents to your office with a complaint of low back pain. One week ago she was lifting heavy boxes at work when she felt her back "give out". Since then she has had constant pain and decreased range of motion. She has had to take time off work. Which of the following is the most appropriate next step in management?

patient ed

Which of the following antibiotics is first line in the treatment of acute Group A streptococcal pharyngitis?

pen VK

A 26-year-old woman presents with tooth pain. Physical examination of her mouth reveals the above findings. Which of the following is the most likely diagnosis?

periapical abscess

A 20-year-old man presents with a sore throat that has been worsening over the last two days. Physical exam reveals trismus and a muffled voice. Exam of the posterior oropharynx reveals a swollen uvula that is displaced toward the left. There is inferior and medial displacement of the right tonsil. His temperature is 102.8°F. A needle aspiration is performed. Which of the following is the most likely causative pathogen?

peritonsillar abscess caused by Group A Streptococcus happens as a complication of Group A Strep throat It is most common in young adults in the spring and winter months and symptoms include trismus, muffled voice, sore throat, and dysphagia. Patients sometimes complain of pain radiating toward the ear on the affected side. Physical exam reveals displacement of the tonsil and uvula, lymphadenopathy, and drooling. The diagnosis can be confirmed with a needle aspiration of the purulent material. If the diagnosis is uncertain, a CT scan of the neck will demonstrate a fluid collection. Treatment depends on clinical symptoms, but typically includes needle aspiration or incision and drainage. Appropriate antibiotic treatment includes ten days of amoxicillin/clavulanic acid or clindamycin.

A patient presents to the clinic complaining of a tearing pain with bowel movements and reports small streaks of blood on the toilet paper. A physical examination of the patient's anus reveals a lesion most likely in which of the following anatomic locations?

post midline

Examination of a 75-year-old woman reveals a tender, dilated, right temporal artery. She also complains of right-sided jaw pain when chewing. Her temperature is 38.1°C (100.5°F). Which of the following is the most appropriate initial treatment for this patient?

prednisone

68-year-old Caucasian man presents to the clinic with concerns for a skin lesion that he noticed 2 months ago. Physical exam reveals a well demarcated, tan, elevated lesion that appears "pasted-on" his neck. An excisional biopsy is performed and shows intraepidermal proliferation of squamous cells. What is the most likely diagnosis?

seborrheic keratosis

A 33-year-old man presents with pain and swelling in his left knee since yesterday. He has also had a fever with a maximum temperature of 102.3°F. Physical exam reveals swelling of the left knee with erythema and warmth noted. There is pain with passive range of motion. What is the most likely diagnosis?

sept

Which of the following tumor markers is elevated in testicular cancer?

serum AFP

A 31-year-old woman presents with thinning of her hair over the past month. She says she thinks she's pulling out more hair than normal when she grooms. Her history is significant for an uncomplicated labor and delivery three months ago. During an exam, a pull-test extracts 25-30 hairs with white bulbs at the ends. Which of the following tests would most likely reveal an underlying cause?

serum ferritin

A 32-year-old man is admitted to the intensive care unit with a high fever, severe headache, vomiting, and rash for three days. Physical exam reveals a petechial rash involving the palms and soles that began on his wrists and ankles. Labs reveal dehydration and acute renal failure. Which of the following diagnostic tests would be most useful in securing a diagnosis?

skin biopsy - RMSF

72-year-old man presents with worsening low back pain for the past one month. The pain is worse with extension of his back and after walking for several minutes. The pain is relieved with sitting. Physical exam shows that extension of the spine produces pain radiating down his bilateral legs. Which of the following is the most likely diagnosis?

spinal stenosis

A three-year-old girl is brought to the clinic by her mother due to complaints of a sore throat and decreased oral intake. She has had elevated temperatures with a Tmax of 99.9°F. She has also had nasal congestion, occasional cough, and general malaise. On examination, the child appears tired but non-toxic and well-hydrated. Her conjunctiva are mildly injected bilaterally. Clear-to-white nasal discharge is present in the bilateral nares. Her oropharynx is erythematous with 2+ tonsils and cobblestoning of the posterior pharynx. She has shotty, non-tender bilateral cervical adenopathy. Her lungs are clear to auscultation. Her heart rate is regular with no murmurs, rubs, or gallops. Her abdomen is soft, non-tender, and non-distended. Her extremities are warm and well-perfused. What intervention is indicated?

supportive care viral pharyngitis

A 35-year-old man with a history of gastroesophageal reflux disease presents to the Emergency Department with chest pain and fever. An outpatient esophagogastroduodenoscopy was performed three days ago and revealed no gastric ulcers. On exam, he is ill-appearing and tachycardic. Which of the following is the next best step in management of this patient?

surgery consult

A 32-year-old man presents after falling off a porch onto the driveway an hour ago. His family reports that he did not lose consciousness, but has become progressively more drowsy since the accident. He has vomited twice. His non-contrast head computed tomography scan is shown above. What is the most likely etiology of this condition?

tear of middle meningeal artery epidural hematoma

Which oral antifungal agent has the highest cure rate for toenail onychomycosis?

terbifine

What is the most common cause of acute compartment syndrome?

tibia fx

Perioral dermatitis characteristically spares which of the following facial regions?

vermillion border

9-year-old child is being evaluated for frequent epistaxis and easy bruising tendencies. Bleeding time is prolonged. PT, PTT, and INR are within normal limits. What is the most likely diagnosis?

von Willebrand

14-year-old Caucasian girl presents to your office with complaints of developing "patches of pale skin" on her knees. You examine the areas and find macular lesions with depigmentation and convex borders on the skin overlying the bilateral anterior patella. Which of the following is the best initial diagnostic test?

wood's lamp vitiligo