#29 Rosh Review

Question: What are the most common causes of indigestion?

Answer: Gastroesophageal reflux and functional dyspepsia.

Question: Which tests are commonly obtained under an order of "cardiac enzymes"?

Answer: Troponin, creatinine kinase and CK-MB, lactate dehydrogenase and myoglobin. Rapid Review Cardiogenic Shock Patient will be complaining of lethargy, confusion, and somnolence PE will show weak peripheral pulses, rapid heart rate and hypotension < 90 systolic Most commonly caused by complications of acute MI Treatment is stabilize with fluids, pressers, O2

A 37-year-old obese woman presents with symptoms of biliary colic for the past 3 months. An ultrasound is negative for any gallstones. Which of the following is the most appropriate management for this patient? Cholecystectomy Cholecystokinin-HIDA scan CT scan Endoscopic Retrograde Cholangiopancreatography (ERCP)

Correct Answer ( B ) Explanation: For patients presenting with symptoms highly suggestive of gallstones but without gallstones on imaging, a cholecystokinin-HIDA scan should be performed. Cholecystokinin-HIDA scan, is a variant of the hepatobiliary iminodiacetic (HIDA) scan and can be used in the elective setting to assess gallbladder contractility and calculate an ejection fraction. In up to 20% of the patients with symptoms typical of biliary colic, no gallstones are seen on imaging, possibly because of small size or stone composition. Cholelithiasis is one of the most common and costly of all the gastrointestinal diseases. The incidence of gallstones increases with age. At-risk populations include a history of diabetes mellitus, obesity, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. Most patients with gallstones are asymptomatic and gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen. Often, the initial presentation of cholelithiasis is biliary colic, caused by the intermittent obstruction of the cystic duct by a stone. The pain is characteristically steady, is usually moderate to severe in intensity, is located in the epigastrium or right upper quadrant of the abdomen, lasts one to five hours, and gradually subsides. If pain persists with the onset of fever or there is an elevated white blood cell count, it should raise suspicion for complications such as acute cholecystitis, gallstone pancreatitis, and ascending cholangitis. Ultrasonography is the best initial imaging study for most patients, although additional imaging studies may be indicated. Laparoscopic cholecystectomy (A) remains the surgical choice for symptomatic and complicated gallstones (acute cholecystitis and biliary dyskeniesia), with a shorter hospital stay and shorter convalescence period than open cholecystectomy. Choledocholithiasis refers to gallstones that migrated from the gallbladder into the common bile duct. Common duct stones can be asymptomatic or can lead to complications such as gallstone pancreatitis or acute cholangitis. Ascending cholangitis is characterized by fever, jaundice, and abdominal pain (Charcot triad); the addition of altered mentation and hypotension is known as Reynold's pentad. Both develop as a result of stasis of bile and bacterial infection in the biliary tract, and should be promptly addressed with intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) (D) to clear the duct. CT scan (C) is inferior to ultrasound and HIDA for the evaluation of gall bladder disease. However, it does have the benefit to be able to diagnose other pathology that was not apparent.

Question: What skin disorder is most commonly associated with celiac disease?

Answer: Dermatitis herpetiformis. Rapid Review Celiac Disease Patient will be complaining of diarrhea, steatorrhea, flatulence, weight loss, weakness and abdominal distension Labs will show IgA anti-endomysial (AGA) and anti-tissue transglutaminase (anti-tTG) antibodies Diagnosis is made by small bowel biopsy Treatment is gluten free diet Comments: associated with dermatitis herpetiformis (chronic, very itchy skin rash made up of bumps and blisters)

Question: With what cardiac dysrhythmia is the use of macrolide antibiotics associated?

Answer: Prolongation of the QT segment. Rapid Review Atypical Pneumonia Patient will be complaining of gradual onset of dry cough, dyspnea, and extra-pulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance PE will show rales with auscultation of lung fields Most commonly caused by Mycoplasma pneumoniae Treatment is azithromycin

Question: Which two arteries comprise the dual blood supply to the hand?

Answer: Radial and ulnar arteries.

Question: What are the two causes of amiodarone induced hyperthyroidism?

Answer: Destructive thyroiditis (majority) and iodine load (400 times daily requirement). Rapid Review Hyperthyroidism Patient will be complaining of heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE will show hyperreflexia Labs will show low TSH and high free T4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Treatment is methimazole or PTU Comments: Propylthiouracil (PTU) P for pregnant

Question: What are the common infectious agents in cholecystitis?

Answer: E.coli, Klebsiella and Enterobacter. Rapid Review Cholecystitis Patient will be complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy's sign, Boas sign Diagnosis is made by: Initial: US, Gold standard: HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy

Question: Which 3 populations of abuse require reporting to authorities?

Answer: Elder abuse, animal abuse and child abuse. Note, reporting of domestic abuse is not mandated by law.

Question: What is the VACTERL condition?

Answer: A constellation of genetic congenital abnormalities: vertebral anomalies, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, renal anomalies and limb defects. Rapid Review Tetralogy of Fallot Patient with a history of episodes of cyanosis (tet spells) and squatting for relief PE will show pulmonic stenosis, right ventricular hypertrophy, overriding aorta, and VSD CXR will show "boot-shaped" heart Comments: Most common cyanotic congenital heart disease Mnemonic: PROVe:: Pulmonic stenosis, Right ventricular hypertrophy, Overriding aorta, VSD

Question: Does the presence of an intrauterine pregnancy rule out PID?

Answer: Although rare, it can take place concurrently with fertilization or throughout the 1st trimester. Rapid Review Pelvic Inflammatory Disease (PID) Patient will be a Female With a history of multiple sexual partners or unprotected sex or both Complaining of lower abdominal pain, cervical motion tenderness, painful sexual intercourse PE will show mucopurulent cervical discharge, "Chandelier sign" Most commonly caused by Chlaymidia Treatment is ceftriaxone + doxycycline Comments: Fitz-Hugh-Curtis syndrome: perihepatitis + PID

Question: What class of medications causes severe angioedema?

Answer: Angiotensin converting enzyme inhibitors. Rapid Review Angioedema Edema: GI and respiratory tracts Tongue, face, neck Idiopathic cause: ACE inhibitors (most common) Hereditary cause: C1 esterase inhibitor deficiency Hereditary rx: C1 esterase inhibitor replacement or FFP Airway management

Question: What is Heyde's syndrome?

Answer: Aortic stenosis and gastrointestinal bleeding from gastrointestinal angiodysplasia. Rapid Review Aortic Stenosis Patient will be older With a history of diabetes, hypertension Complaining of dyspnea, chest pain, syncope PE will show crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop Most commonly caused by degenerative calcification Treatment is aortic valve replacement Comments: murmur decreases with Valsalva

Question: What are complications of orbital cellulitis?

Answer: Blindness, meningitis, septic cavernous thrombosis.

Question: What are the most commonly used second-generation antihistamines?

Answer: Cetirizine, fexofenadine and loratadine.

Question: What is proBNP?

Answer: Cleavage of the prohormone proBNP produces biologically active 32 amino acid BNP (brain natriuretic peptide) as well as the biologically inert 76 amino acid N-terminal proBNP (NT-proBNP). Rapid Review Brain Natriuretic Peptide (BNP) ↑ Ventricular myocyte stretch → release ↓ In obese BNP < 100 pg/mL: heart failure unlikely Level does not correlate with heart failure severity

Question: What is the name of the mass palpable in the right upper quadrant in a patient with pancreatic cancer?

Answer: Courvoisier's sign: an enlarged, painless, palpable gallbladder. Rapid Review Pancreatic Cancer Most common cause: smoking Progressive, painless jaundice Trousseau sign: migratory thrombophlebitis Courvoisier sign: palpable, nontender gallbladder Tumor marker: CA19-9 CT

Question: Which causative organism should be suspected in patients who have bronchiectasis secondary to cystic fibrosis?

Answer: Cystic fibrosis patients are often infected Pseudomonas aeruginosa and can benefit from long-term antipseudomonal antibiotics, such as inhaled aminoglycosides.

Question: What is the most common type of breast cancer among men?

Answer: Infiltrating ductal.

Question: Where is the most common anatomic location of an AAA?

Answer: Infrarenal.

Question: Prescription of which class of asthma inhalers requires patients to rinse the mouth carefully after use to prevent oral candidiasis?

Answer: Inhaled corticosteroids pose an increased risk of oral candidiasis. Rapid Review Oral Candidiasis Risk factors: HIV, oral steroid use Lesions scrape off

Question: What is the treatment of choice for acute angle-closure glaucoma?

Answer: Intravenous acetazolamide followed by laser peripheral iridotomy as this is a medical emergency. Rapid Review Blepharitis Patient will be complaining of eyelid changes and eyelash flaking PE will show crusting, scaling, and red-rimming of eyelid Diagnosis is made by slit-lamp examination Most commonly caused by dysfunctional meibomian gland Treatment is warm compresses, irrigation, lid massage, and topical antibiotics for flare ups Comments: associated with seborrhea and rosacea

Question: Which tick is responsible for the spread of Lyme disease?

Answer: Ixodes tick. Rapid Review Rocky Mountain spotted fever (RMSF) Patient with a history of recently in the woods hiking or camping Complaining of abrupt onset of severe headache, photophobia, vomiting, diarrhea, and myalgia PE will show maculopapular eruption on the palms and soles Diagnosis is made by skin biopsy Most commonly caused by Rickettsia rickettsia Treatment is ALWAYS doxycycline, even in children

Question: What is the mainstay of treatment for hypertrophic cardiomyopathy?

Answer: Long-term beta-blocker therapy. Rapid Review Hypertrophic Cardiomyopathy Asymmetric LV septal wall hypertrophy → outflow obstruction Autosomal dominant (familial form) Young patient Exertional syncope Sudden cardiac death S4 gallop Midsystolic murmur (↑ as preload ↓) Rx: ßBs or CCBs

Question: What is the most common mechanism of injury in radial head subluxation?

Answer: Longitudinal traction of the arm with the elbow extended. Rapid Review Nursemaid's Elbow Hyperextension and pulling → subluxation of radial head under annular ligament Presentation: elbow flexed + arm pronated Normal x-ray Management: flex and supinate elbow or hyperpronate and extend forearm

Question: The presence of an implantable cardioverter-defibrillator is considered a strong relative contraindication for what diagnostic study?

Answer: Magnetic resonance imaging.

Question: What medication is commonly used for maintenance therapy for opiate use disorder?

Answer: Methadone.

Question: Is the rash of pityriasis rosea contagious?

Answer: No, the rash cannot be spread by direct contact. Rapid Review Pityriasis Rosea Patient with a history of a larger lesion 1 week prior, ​"Herald Patch" Complaining of rash on the back PE will show diffuse papulosquamous rash on the trunk, "Christmas tree-like" distribution Treatment is self-limiting disease, itching with antihistamines

Question: Should ACE inhibitors and ARBs be used together to treat hypertension?

Answer: No.

Question: Do antibiotics reduce the incidence of poststreptococcal glomerulonephritis?

Answer: No. Rapid Review Glomerulonephritis Edema, HTN UA: RBC casts, proteinuria, hematuria

Question: Because TTP causes thrombocytopenia, should platelets be administered?

Answer: No. Platelet transfusions have been shown to cause more thromboses. Rapid Review TTP/HUS HUS: E. coli O157:H7 Autoimmune hemolysis, Renal failure, Thrombocytopenia (ART) Bloody diarrhea Avoid ABX TTP: ART + Fever + Neurologic abnormalities (FAT RN) Normal coagulation studies Plasmapheresis

Question: What is the formula for the alveolar-arterial oxygen gradient at sea level?

Answer: P(A-a)O2 = [(0.21 x (760-47)) - PaCO2/0.8] - PaO2.

Question: What is the initial management of symptomatic cholelithiasis in pregnancy?

Answer: Pain control and supportive care. Rapid Review Cholelithiasis Patient will be an obese woman 40 - 50 years old Complaining of slowly resolving right upper quadrant pain that begins suddenly after eating a fatty or large meal Diagnosis is made by ultrasound Most commonly made of cholesterol Treatment is observation or cholecystectomy Comments: Four "F's": Female, Forty, Fat, Fertile

Question: What are the most common side effects of acetazolamide?

Answer: Paresthesias and polyuria. Rapid Review Acute Mountain Sickness Patient will be climbing a mountain Complaining of "Hangover" like symptoms, headache, nausea, vomiting, insomnia Treatment is halt ascent, acetazolamide Comments: Sulfa allergy - avoid acetazolamide

Question: What is Fitz-Hugh-Curtis syndrome?

Answer: Perihepatitis associated with PID. It manifests as right upper quadrant pain and is seen in 10% of patients with PID. Rapid Review Pelvic Inflammatory Disease (PID) Patient will be a Female With a history of multiple sexual partners or unprotected sex or both Complaining of lower abdominal pain, cervical motion tenderness, painful sexual intercourse PE will show mucopurulent cervical discharge, "Chandelier sign" Most commonly caused by Chlaymidia Treatment is ceftriaxone + doxycycline Comments: Fitz-Hugh-Curtis syndrome: perihepatitis + PID

Question: When do Koplik's spots occur in relation to the rash of measles?

Answer: Prior to the onset of rash. Rapid Review Rubeola (Measles) Fever 3 c's: cough, conjunctivitis, coryza Koplik's spots: red spots with blue/white center (pathognomonic) Rash spreads head to feet

Question: What diagnostic criteria is used in Light's criteria?

Answer: Serum protein and pleural fluid lactate dehydrogenase are used in Light's criteria, which is used to distinguish between transudative and exudative pleural effusions.

Question: What injury is likely to be present in a child with a raised elbow fat pad?

Answer: Supracondylar fracture.

Question: What is the mainstay treatment for midgut volvulus?

Answer: Surgical treatment which allows for the entire small intestine along with the transverse colon to be delivered out of the abdominal incision where the volvulus can be reduced.

Question: What is the most common cardiac cause for cyanosis of children (of any age)?

Answer: Tetralogy of Fallot. Rapid Review Tetralogy of Fallot Patient with a history of episodes of cyanosis (tet spells) and squatting for relief PE will show pulmonic stenosis, right ventricular hypertrophy, overriding aorta, VSD CXR will show "boot-shaped" heart Comments: Most common cyanotic congenital heart disease Mnemonic: PROVe:: Pulmonic stenosis, Right ventricular hypertrophy, Overriding aorta, VSD

Question: What is a common complication within 24 hours of initiation of antibiotic treatment of Lyme disease?

Answer: The Jarisch-Herxheimer reaction.

Question: What ligament gets displaced during a radial head subluxation?

Answer: The annular ligament.

Question: Why is there a difference in the treatment between a dog bite and a cat bite?

Answer: The force of a domestic cat's bite does not match that of a dog. However, its sharp teeth may cause a puncture wound into which bacterial organisms are inoculated. Rapid Review Cat Bite Most commonly caused by Pasteurella multocida Treatment is irrigate, leave wound open, amoxicillin - clavulanate Complications: Osteomyelitis, Tenosynovitis

Question: What happens to the C3 and C4 complement levels in serum sickness?

Answer: They are markedly decreased. Rapid Review Serum Sickness Type III hypersensitivity Onset 7-21 days after exposure or 12-36 hours after a reexposure Flulike sx, rash

Question: What is the recommended antibiotic regimen to treat klebsiella pneumonia?

Answer: Third-generation cephalosporin and aminoglycoside. Rapid Review Atypical Pneumonia Patient will be complaining of gradual onset of dry cough, dyspnea, and extra-pulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance PE will show rales with auscultation of lung fields Most commonly caused by Mycoplasma pneumoniae Treatment is azithromycin

Question: List some modifiable risk factors for osteoporotic fracture?

Answer: Tobacco and alcohol use, body weight <127 pounds, regular use of corticosteroids or anticonvulsants, poor balance, poor eyesight, recurrent falls and low calcium intake. Rapid Review Osteoporosis Decline in bone mass with aging → ↑ bone fragility + ↑ fracture risk F > M Risk factors: alcohol, steroid use, whites, Asians Height loss Most common fracture: vertebral body compression fractures DEXA scan T-score ≤ -2.5 Prevention: weight-bearing exercises, calcium, vitamin D, smoking cessation Pharmacologic rx: bisphosphonates (1st line)

Question: What is Trousseau's sign of malignancy?

Answer: Trousseau syndrome is an acquired blood clotting disorder that results in migratory thrombophlebitis. Superficial thrombophlebitis is a common inflammatory-thrombotic disorder in which a thrombus develops in a vein located near the surface of the skin. Rapid Review Pancreatic Cancer Patient with a history of smoking Complaining of painless jaundice, depression, and weight loss PE will show palpable nontender gallbladder (Courvoisier sign), migratory thrombophlebitis (Trousseau's syndrome) Labs will show CA 19-9 serum marker Most common type is adenocarcinoma Comments: Other PE signs: Palpable left supraclavicular lymph node (Virchow's node), palpable nodule bulging into the umbilicus (Sister Mary Joseph sign)

Question: True or false: males and females have equal prevalence of diabetes insipidus?

Answer: True.

Question: The presence of coronary disease or infarcted myocardium is more closely associated with supraventricular tachycardia or ventricular tachycardia?

Answer: Ventricular tachycardia. Rapid Review Ventricular Tachycardia >3 consecutive ectopic ventricular beats Monomorphic, polymorphic Bidirectional: digoxin toxicity Wide complexes Pulseless: immediate defibrillation Unstable: synchronized cardioversion Stable: procainamide, amiodarone, synchronized cardioversion (refractory) If unsure, manage all wide complex tachycardias as ventricular tachycardia

Question: Which bacteria is most associated with consumption of raw shellfish?

Answer: Vibrio species. Rapid Review Salmonellosis Patient with a history of eating poultry, meat, or eggs Complaining of fever, bloody diarrhea, and abdominal cramps Labs will show fecal WBCs Comments: common cause of osteomyelitis in children with sickle cell disease

Question: What lifestyle modifications are recommended for patients with gastroesophageal reflux disease?

Answer: Weight loss, elevating the head of the bed, waiting three hours before lying down after a meal, avoiding large meals and trigger foods. Rapid Review Gastroesophageal Reflux Disease (GERD) Patient with a history of nocturnal cough or asthma Complaining of retrosternal burning sensation radiating upward ("heartburn") usually after eating Diagnosis is made clinically Most commonly caused by LES dysfunction Treatment is weight loss, elevation head of bed during sleep, avoidance of certain foods (caffeine, alcohol, acidic foods)

In which of the following clinical scenarios is an implantable cardioverter-defibrillator indicated for the prevention of ventricular dysrhythmias and sudden cardiac death? A patient with a left ventricular ejection fraction < 35% and heart failure NYHA Functional Class II or III A patient with a normal left ventricular ejection fraction and asymptomatic structural heart disease A patient with sustained ventricular tachycardia in the setting of an acute myocardial infarction A patient with sustained ventricular tachycardia in the setting of hyperkalemia

Correct Answer ( A ) Explanation: A patient with a left ventricular ejection fraction ≤ 35% and heart failure NYHA Functional Class II or III is a clinical scenario in which an implantable cardioverter-defibrillator is indicated. An implantable cardioverter-defibrillator is a small device combining a cardioverter and defibrillator into one implantable unit that is surgically placed in the chest or abdomen. It is battery powered and programmed to detect dysrhythmias, mainly sustained ventricular tachycardia and ventricular fibrillation, which can lead to sudden cardiac death. It has a very high success rate in rapidly terminating ventricular dysrhythmias and evidence shows that it improves survival. Implantable cardioverter-defibrillator implantation is generally considered the first-line treatment for the secondary prevention of sudden cardiac death in patients who have survived an event and for primary prevention in certain high risk populations. Published guidelines exclude cases that are considered "reversible causes." Some of the major indications are as follows. A patient with asymptomatic structural heart disease (B) is not an indication for implantable cardioverter-defibrillator. Only when a patient with structural heart disease, such as hypertrophic cardiomyopathy, has symptoms or unexplained syncope with inducible dysrhythmia on electrophysiological studies is it indicated for an implantable cardioverter-defibrillator. Patients with sustained ventricular tachycardia in the setting of hyperkalemia (D) or acute myocardial infarction (C) are not indicated for an implantable cardioverter-defibrillator. Hyperkalemia and acute ischemia are considered "reversible causes" and correction of the metabolic derangement and revascularization are often adequate measures to reduce the risk of sudden cardiac death.

Which of the following is the treatment of choice in preventing acute mountain sickness? Acetazolamide Dexamethasone Ginkgo biloba Nifedipine

Correct Answer ( A ) Explanation: Acute mountain sickness (AMS) is characterized by symptoms similar to those with a mild viral illness or "hangover" including headache, nausea, vomiting, fatigue, dizziness, and difficulty sleeping. Symptoms typically occur within hours of reaching a high altitude (generally > 8,000 feet) and peak in 24-48 hours. Slow ascent to allow time for acclimatization is the best method of prevention. When that is not possible or when there is a previous history of acute mountain sickness with ascent, use of acetazolamide (125-250 mg twice daily from one day prior to ascent and continuing for 48 hours after reaching altitude) has been shown to prevent the majority of symptoms. Acetazolamide is a carbonic anhydrase inhibitor that induces a renal bicarbonate diuresis resulting in a metabolic acidosis which thereby increases ventilation and arterial oxygenation. The bottom graphic demonstrates the decline in partial pressure of inspired oxygen compared to its value at sea level. Dexamethasone (B) has also been shown to be effective although it does not aid in acclimatization and some studies have shown a rapid onset of symptoms of AMS once the dexamethasone is discontinued. Therefore, it is better used in the treatment of AMS, not its prevention. Ginkgo biloba (C) has been proposed as preventive therapy for AMS based on its antioxidant properties, but studies have been mixed regarding its effectiveness. Nifedipine (D) can be used both to prevent and treat high altitude pulmonary edema, not acute mountain sickness.

A previously healthy 25-year-old woman presents to your office with complaints of nasal congestion, sneezing, and itchy eyes. These symptoms occur every spring. Which of the following is the most appropriate monotherapy? Fluticasone nasal spray Oral diphenhydramine Oral montelukast Phenylephrine nasal spray

Correct Answer ( A ) Explanation: Allergic rhinitis is an inflammation of the nasal mucosa caused by extrinsic allergens. Clinical manifestations include nasal congestion, sneezing, red and itchy eyes, rhinorrhea, headache, postnasal drip, and fatigue. The diagnosis is clinical when the specific allergy triggers are known. For patients with new or unknown triggers, allergy skin testing can be used to determine immediate hypersensitivity to specific allergens. Allergic rhinitis is managed through allergen avoidance and pharmacotherapy. First-line treatment is with glucocorticoid nasal sprays including fluticasone, or second-generation antihistamines. Allergen immunotherapy is used in more severe cases. Diphenhydramine (B) is a first-generation antihistamine. Agents from this class play a limited role in the treatment of allergic rhinitis due to the often undesirable side effect of sedation. Montelukast (C), a leukotriene receptor antagonist, when used as a single agent, produces modest improvement in symptoms and is commonly used in patients with comorbid asthma. It is not as effective as second-generation antihistamines or intranasal steroids and is therefore considered to be second or third-line treatment. Phenylephrine nasal spray (D) is a topical vasoconstrictor decongestant. Nasal decongestant sprays are not recommended as monotherapy in the treatment of allergic rhinitis as their continued use can lead to rebound nasal congestion, also referred to as rhinitis medicamentosa.

A 43-year old man presents complaining of a two-week history of gradually worsening dry cough, fatigue and occasional shortness of breath. He has "felt warm" but has not checked his temperature. Review of systems is notable for mild diarrhea and decreased appetite, though he is drinking fluids well. He denies chronic medical problems and takes no medications. He does not smoke. His temperature is 100.6°F; pulse 112; BP 122/78; RR 24; pulse oximetry is 92% on room air. He appears tired, though is not ill-appearing. Lung-fields sound clear on auscultation, though a chest X-ray is obtained which demonstrates an airspace consolidation in the right middle lobe. What is the most appropriate treatment for his condition? Azithromycin Metronidazole Olsetamivir Piperacillin and Tazobactam

Correct Answer ( A ) Explanation: Azithromycin, a macrolide antibiotic, is the most appropriate choice for this patient with community-acquired bacterial pneumonia (CAP). The most common side effects of azithromycin include nausea, vomiting and diarrhea, though other side effects such as headache and fatigue may occur. Other reasonable choices for treatment would include doxycycline or a fluoroquinolone. The most common organism responsible for "atypical" bacterial pneumonia is Mycoplasma pneumoniae, though suspicion for a particular pathogen should be guided by the patient's co-morbidities as well as setting. In contrast to CAP caused by typical pathogens such as S. pneumoniae or H.influenzae, this type of bacterial pneumonia usually presents more gradually with symptoms of dry cough, dyspnea, and extra-pulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance. Other bacterial organisms causing pneumonia in certain hosts and settings may include Legionella, Moraxella, Staphylococcus, Chlamydia, Pseudomonas, Klebsiella, Acinetobacteria, and Mycobacterium sp. Metronidazole (B) is not indicated for the treatment of community-acquired pneumonia. It has excellent coverage of anaerobic gram-positive cocci and gram-negative bacilli, but does not treat infections caused by Mycoplasma pneumoniae, nor those caused by S. pneumoniae or H. influenzae. Olsetamivir (C) is an anti-viral approved for the treatment of patients with Influenza A or Influenza B infections within the first 2 days of the onset of symptoms. Although patients with influenza may have complaints similar to those this patient is experiencing, symptoms of influenza generally start abruptly and include notable fever. Additionally, even if this patient did have influenza, he is well beyond the window of time in which olsetamivir would provide clinical benefit. Piperacillin and Tazobactam (D) is a combination intravenous medication indicated for a variety of moderate to severe infections, such as certain types of appendicitis, skin and soft tissue infections, endometritis and pneumonia. This patient's presentation does not suggest that hospitalization and IV therapy are required at this time.

Which of the following is the most common cause of blepharitis? Dysfunction of the meibomian glands Inflammation of the lacrimal sac Inflammation of the sclera Obstructed drainage of the trabecular meshwork

Correct Answer ( A ) Explanation: Blepharitis is an inflammation of the eyelids that is a common condition in the geriatric population. There are two forms of blepharitis. The first type is caused by dysfunction of the meibomian glands (which are housed within the eyelids) resulting in thickened secretions. The viscosity of the glandular secretions can be reduced by warming them (e.g., warm compresses to the eyelids multiple times per day) or by using pulse doses of medications that result in thinning of the oils (e.g., doxycycline 100 mg orally twice a day for 1 month). The second form of blepharitis is caused by crusting at the base of eyelashes; seborrheic or staphylococcal overgrowth results in tear film debris that can cause chronic irritation. The mainstay of treatment is mechanical cleansing of the eyelids using a cotton swab or cotton ball soaked in warm water with baby shampoo (to avoid stinging) to loosen debris. Dacryocystitis is an acute or chronic inflammatory condition of the lacrimal sac (B), with secondary obstruction of the nasolacrimal duct. In scleritis, inflammation of the sclera (C) causes conjunctival and scleral vessels to engorge in a diffuse or sectoral manner sometimes with discrete nodules. Obstructed drainage through the trabecular meshwork (D) results in increased intraocular pressure and glaucoma.

Which of the following is the most common type of invasive breast cancer in women? Infiltrating ductal Infiltrating lobular Medullary Papillary

Correct Answer ( A ) Explanation: Breast cancer is the leading cause of cancer death in women worldwide and is the most common type of cancer among women in the United States. Screening of women ages 50-75 is recommended every two years with screening mammography. Earlier and more frequent screenings may be individualized based on patient context. Clinical evaluation of breast cancer includes physical exam, diagnostic imaging and biopsy. Breast carcinomas are categorized as in situ or infiltrating. The two types of in situ carcinomas are ductal and lobular. Infiltrating carcinomas have several different histological subtypes with infiltrating ductal carcinoma being the most common. Infiltrating ductal carcinoma accounts for approximately 50-75% of all invasive breast cancer diagnoses. Prognosis depends on the type and extent of the cancer. Treatment includes surgery and adjuvant treatment including radiation and systemic therapy. Infiltrating lobular carcinoma (B) is the second most common type of infiltrating breast carcinoma. This type of carcinoma tends to metastasize later than infiltrating ductal carcinomas and spread to more unusual locations. Medullary carcinoma (C) occurs more in younger women and makes up approximately 5% of all breast cancer cases. Papillary carcinoma (D) is one of the least common types of breast cancer, making up 1% of cases. It is most commonly found in women older than 65 years.

A 17-year-old girl with a history of well-managed cystic fibrosis is being evaluated for a steadily worsening chronic cough with shortness of breath and wheezing. She is producing copious purulent malodorous sputum and occasional hemoptysis. Crackles are heard at her bilateral lung bases. Which of the following findings would be most expected on this patient's chest radiograph? Dilated, thickened bronchi with "tram-track" marks Low lung volumes and ground glass opacities Lung hyperinflation with flattening of the diaphragm Normal chest radiograph

Correct Answer ( A ) Explanation: Dilated, thickened bronchi are classic radiograph findings in patients with bronchiectasis, the most likely disease in this patient. The bronchi are often described as having "tram-track" or ring-like markings. Scattered, irregular opacities, atelectasis, or focal consolidations may also be noted. A suspicion of bronchiectasis based on radiographic findings and patient symptoms warrants a high-resolution CT scan which is a more precise diagnostic study. Bronchiectasis is suspected in patients who have a chronic cough, dyspnea, wheezing, and heavy production of purulent, foul-smelling sputum. Pleuritic chest pain, weight loss, and anemia are commonly associated. An exam usually reveals crackles at the lung bases and nail clubbing in severe disease. In the United States, the greatest percentage of patients with bronchiectasis develop it secondary to cystic fibrosis. Lung infections, tumor presence, and immunodeficiency states are other less common causes. Antibiotics are usually needed with the choice being guided by sputum cultures. Haemophilus influenza, Streptococcus pneumonia, and Staphylococcus aureus are often isolated. In addition to proper antibiotic coverage, bronchiectasis should be treated with daily chest physiotherapy and inhaled bronchodilators. Lung hyperinflation with flattening of the diaphragms (C) is an expected finding in chronic obstructive pulmonary disease (COPD). While COPD manifests with similar symptoms (excessive cough, sputum production, and dyspnea), the sputum produced is usually not purulent or malodorous. Additionally, COPD would be unlikely in this patient, as it typically occur in patients in their 40's with a significant smoking history. Low lung volumes with ground glass opacities (B) are seen in interstitial lung disease. Interstitial lung disease usually causes dyspnea and a nonproductive cough, not one producing purulent sputum. A normal chest radiograph (D) is unlikely in bronchiectasis, as the airway dilation is usually visible on imaging. Normal chest radiographs typically occur with other conditions, such as asthma or bronchiolitis, which have symptom profiles not fitting those of this patient.

A 65-year-old undomiciled man presents to your emergency department with complaints of fever, productive cough, and shortness of breath. He has a 40-pack-year history of smoking and daily alcohol consumption. His chest radiograph demonstrates a right upper lobe lung infiltrate with an air-fluid level. What is the most likely etiology for this finding? Klebsiella pneumoniae Legionella pneumophilia Mycoplasma pneumoniae Streptococcous pneumoniae

Correct Answer ( A ) Explanation: Klebsiella pneumoniae is a gram-negative encapsulated organism. It occurs most commonly in alcoholic or chronically debilitated patients. Patients with klebsiella pneumonia commonly present with shaking chills, cyanosis, pleuritic chest pain, and a productive cough with characteristic currant-jelly sputum. Chest radiography reveals an infiltrate that is often in the upper lobes (most commonly the right) and is associated with a bulging fissure. If untreated, the infiltrate will progress into a necrotizing lesion with air-fluid levels, and can ultimately lead to development of an empyema. Legionella pneumophila (B) is the most common causative organism of Legionnaire's disease. Legionella is a gram-negative bacillus that lives in the water supply. Transmission occurs through inhalation of contaminated aerosolized droplets emanating from equipment such as cooling towers, evaporative condensers, and shower heads. Legionnaire's disease tends to occur in clusters, with common exposure to the same contaminated source. Spread does not occur from person to person. Infection is associated with hyponatremia, elevated liver enzymes, GI symptoms (watery diarrhea, nausea, vomiting, and abdominal pain), and neurologic signs (seizures, altered mental status, and gait disturbances). Approximately half of patients with Legionnaire's disease will have relative bradycardia. Mycoplasma pneumoniae (C) is considered one of the atypical bacterial causes of pneumonia. It is often referred to as "walking pneumonia," where the patient tends to look better than you would expect, given the diffuse interstitial pattern commonly seen on chest X-ray. Mycoplasma pneumonia is associated with extrapulmonary manifestations such as conjunctivitis, pharyngitis, rash, and pericarditis. Staph aureus pneumonia often affects IV drug abusers, nursing home patients, and those recovering from an influenza infection. Spread to the lungs occurs hematogenously. Chest radiograph reveals a patchy infiltrate that is initially multicentric or peripheral and ultimately progresses to lobar consolidation and abscess formation. Overall, Streptococcus pneumonia (D) remains the most common cause of community-acquired pneumonia. Patients often look ill and tend to have abrupt onset of symptoms, including rigors, before progressing to cough with rust-colored sputum. The chest radiograph of these patients tends to have a single lobar infiltrate, often in the lower lobes of the lung.

An 18-year-old woman presents to the ED with dark-colored urine and malaise for the past three days. Her vital signs are BP 155/85 mm Hg, HR 80, RR 16, and T 36.7°C. On exam, you note 1+ pretibial edema. Urinalysis reveals proteinuria, hematuria, and red blood cell casts. Which of the following is the most likely diagnosis? Acute glomerulonephritis Acute tubular necrosis Hypothyroidism Nephrotic syndrome

Correct Answer ( A ) Explanation: Patients with acute glomerulonephritis present with a spectrum of clinical signs and symptoms. The presence of hematuria, proteinuria, and red blood cell casts are highly suggestive of the diagnosis. In fact, the presence of red blood cell casts alone is highly specific for acute glomerulonephritis. Conversely, if hematuria, proteinuria, and red blood cell casts are absent, glomerulonephritis is highly unlikely. In addition to the urinary findings, patients may present with hypertension, edema, or congestive heart failure secondary to volume overload. Acute tubular necrosis (B) is an intrinsic cause of acute kidney injury that is associated with a variety of renal insults, including ischemia and nephrotoxins. Muddy brown casts are often seen on urinalysis. Hypothyroidism (C) is associated with fatigue, weakness, edema, and urinary retention, but there are no specific findings on urinalysis. Nephrotic syndrome (D) causes edema and proteinuria but is not associated with hematuria or red blood cell casts.

A 77-year-old man presents with syncope. He states he was walking to the bus when he felt chest pain, shortness of breath and passed out. The patient has a history of hypertension. Examination reveals dry mucous membranes and a systolic murmur that radiates to the carotids bilaterally. The patient continues to complain of chest pain. Vitals are unremarkable and the ECG reveals left ventricular hypertrophy. What management is indicated? Intravenous fluids and cardiology consultation Morphine sulfate and admit to telemetry Sublingual nitroglycerin and activation of the cardiac catheterization lab Sublingual nitroglycerin and admit to telemetry

Correct Answer ( A ) Explanation: The patient presents with syncope and a systolic murmur radiating to the neck, which suggests the presence of critical aortic stenosis. Management should focus on restoring preload and cardiology consultation. Aortic stenosis is the most common cardiac-valve lesion in the U.S. A normal aortic valve has an area of 3 cm squared. Reduction by 50% causes significant obstruction and critical aortic stenosis occurs with a valve area <0.8 cm squared. As the disease progresses, left ventricular hypertrophy develops to maintain cardiac output. Patients often are asymptomatic until aortic stenosis has progressed to severe or critical levels. At this point, they often develop angina (due to increased demand and decreased supply), exertional syncope (fixed cardiac output), and congestive heart failure (diastolic and systolic dysfunction). The classic physical examination finding is a crescendo-decrescendo, systolic ejection murmur that radiates to the bilateral carotid arteries. Additionally, carotid pulses may be both diminished and delayed. Once patients develop symptoms, survival is markedly reduced unless the valve is replaced. 50% of patients with angina die within 5 years, 50% with syncope die within 3 years and 50% with dyspnea die within 2 years. Immediate medical management should focus on restoring preload with fluids or blood transfusion if significant anemia is present. The only definitive treatment is valve replacement. Patients with symptomatic aortic stenosis exhibit an extreme sensitivity to vasodilators. Sublingual nitroglycerin (C & D) treats typical anginal symptoms by vasodilation leading to decreased preload and decreased cardiac work load. In aortic stenosis patients, this vasodilation can precipitate worsening symptoms. Morphine (B) causes vasodilation through histamine and is also contraindicated.

A 67-year-old woman presents complaining of dark urine. Over several months she has had increased fatigue and weight loss. There has not been any fever or night sweats. On physical examination, she has scleral icterus and mild jaundice. Her abdomen is soft, non-distended with a palpable mass in the right upper quadrant that is non-tender. Her laboratory values are notable for a total bilirubin of 6.4 mg/dl and a direct bilirubin of 5.0 mg/dl. What is your imaging study of choice? Abdominal CT scan Endoscopic retrograde cholangiopancreatography (ERCP) Right upper quadrant ultrasound Upper GI series

Correct Answer ( A ) Explanation: The patient's symptoms are concerning for pancreatic cancer. This patient has developed painless jaundice, the classic presentation of someone with a mass at the head of the pancreas compressing the bile duct. Patients will often also complain of weight loss typically due to loss of appetite. The imaging study of choice in this situation is an abdominal CT scan. An endoscopic retrograde cholangiopancreatography (ERCP) (B) procedure may be used for therapeutic purposes in order to place a stent for the relief of obstruction. This procedure may also be used in other clinical scenarios like choledocholithiasis needing retrieval of the stone. Right upper quadrant ultrasound (C) may have some utility in visualizing the pancreas although more commonly is used for visualization of the gall bladder. It may be used to help facilitate biopsy in order to obtain tissue for diagnosis. An upper GI series (D) is not helpful in the diagnosis of pancreatic cancer. This may sometimes be used in the evaluation of esophageal symptoms to look for irregularities of the mucosa.

A 24-year-old man presents for evaluation of a rash. The patient reports a mildly pruritic rash on his back and trunk that progressively spread over the last week. You examine and note the rash seen above. Which of the following historical elements is most likely to be obtained upon further questioning? A larger 2 to 5 cm erythematous patch preceded the diffuse rash Fever preceded the onset of rash Oral mucosal lesions preceded the onset of rash Travel to the Southeast USA occurred a week before the rash

Correct Answer ( A ) Explanation: This patient has pityriasis rosea. This is a mild skin eruption that is self-limited usually lasting 4 to 7 weeks. There is no clear etiology of the rash although infection with Herpesvirus 7 or a fungus is suspected. Prior to the onset of the diffuse rash, patients may recall a herald patch described as a 2 to 5 cm erythematous oval plaque similar to the smaller more diffuse lesions. The rash is described as following a "Christmas tree" pattern on the trunk, classically following the skin cleavage lines. There is no indicated treatment for pityriasis rosea other than antihistamines for symptomatic relief if the rash is pruritic. Patients are most commonly asymptomatic but occasionally (5% of the time) have a prodrome of malaise, headache and fever (B) preceding the onset of the diffuse rash. Oral mucosal lesions (C) are rare with pityriasis. A history of travel to the Southeast USA (D) before the onset of rash should raise an index of suspicion for an infectious etiology to the rash like Rocky Mountain Spotted fever, a tick-borne illness caused by Rickettsia rickettsii. This illness occurs most commonly in late spring and early summer and is characterized by a rash that starts distally and spreads to the core.

A 24-year-old man presents to the ED with a rash on his left flank. He is an avid hiker in the upper Midwest. He was bit by a tick two weeks ago. What would you expect to find on physical examination? Annular erythematous patch with central clearing Diffuse erythroderma over the trunk and extremities Maculopapular rash over the trunk following Langer's lines Petechiae involving the palms and soles before spreading centrally

Correct Answer ( A ) Explanation: This patient is exhibiting risk factors for and signs of Lyme disease. Lyme disease is the most common vector-borne disease in the United States. It is endemic to New England, the mid-Atlantic states, and the upper Midwest. It is caused by the spirochete Borrelia burgdorferi and transmitted by the Ixodes dammini tick, more commonly known as the deer tick. The tick must be attached for more than 48 hours for transmission to occur. There are three stages of clinical Lyme disease. Early Lyme disease is characterized by erythema migrans, an annular erythematous patch with central clearing, which classically has a "bull's eye" appearance. Hematogenous spread leads to diffuse erythema migrans, which spares the palms and soles. Acute disseminated Lyme disease occurs approximately 4 weeks after initial infection and can include meningoencephalitis, Bell's palsy (which may be bilateral), or carditis which often manifests with AV block. Late Lyme disease develops greater than 1 year after initial infection and includes chronic arthritis with or without chronic subtle encephalopathy. Only 50% of patients remember a tick bite; thus, diagnosis may be difficult. Erythema migrans is diagnostic; however, not all patients present with this finding. Initial screening involves ELISA testing with Western Blot and PCR to confirm the diagnosis. If the diagnosis is suspected, empiric treatment should be administered. Treatment for early Lyme disease and mild acute disseminated Lyme disease is doxycycline. In pregnant women or children under the age of 8 years, amoxicillin should be substituted. Patients with neurologic or cardiac manifestations should be admitted and treated with IV ceftriaxone. Diffuse erythroderma over the trunk and extremities (B) is the characteristic rash of toxic shock syndrome. Petechiae involving the palms and soles before spreading centrally (C) is the characteristic rash of the tick-borne illness Rocky Mountain spotted fever. The petechial rash begins on the wrists and ankles, spreads to the palms and soles, and then spreads centrally to the trunk. A maculopapular rash over the trunk following Langers' lines (D) is the characteristic rash of pityriasis rosea. It is classically preceded by a herald patch and follows a dermatomal, "Christmas-tree pattern."

A 34-year-old woman presents to the emergency room with a puncture wound over the second metacarpophalangeal joint of her right hand. She was playing with her friend's cat when it bit her. Which of the following is the most appropriate treatment for this patient? Amoxicllin Amoxicllin-clavulanate Cephalexin Clindamycin

Correct Answer ( B ) Explanation: Amoxicillin-clavulanate is the first line antibiotic for patients with a human, cat, or dog bite. This patient has suffered an animal bite injury. Bite wounds can be complicated by osteomyelitis, septic arthritis, and tenosynovitis; therefore, prophylactic antibiotics are appropriate. Amoxicillin-clavulanate provides essential coverage against Pasteurella multocida, commonly found in the mouths of cats and dogs. In patients with a penicillin allergy, choose an antibiotic with coverage against P. multocida (such as TMP-SMX or doxycycline) paired with anaerobic coverage (clindamycin or metronidazole). Appropriate treatment consists of immediate, copious irrigation, assessment for risk of tetanus and rabies, and administration of prophylactic antibiotics as discussed above. Clindamycin (D) alone does not provide sufficient coverage against P. multocida, the most likely cause of bacterial infection following a cat bite. Amoxicillin (A) does not have sufficient bacterial coverage. Cephalexin (C) does not provide sufficient anaerobic coverage.

In which of the following conditions is hypoxemia caused by a right-to-left shunt? Asthma Eisenmenger syndrome Patent foramen ovale Pulmonary embolism

Correct Answer ( B ) Explanation: Hypoxemia is abnormally low oxygen tension, defined as a PaO2 of < 60 mm Hg, and is caused by numerous mechanisms, including hypoventilation, shunting, ventilation-perfusion mismatch, impaired diffusion, and low inspired oxygen. Right-to-left shunt occurs when deoxygenated blood from the right side of the heart enters the systemic circulation. This can occur because of an anatomic shunt (i.e., congenital cyanotic heart disease), in which deoxygenated blood bypasses the lungs and directly enters the systemic circulation or a physiologic shunt, which occurs when blood traverses nonventilated segments of the lung. Physiologic shunt is seen in conditions of alveolar collapse, such as in acute respiratory distress syndrome (ARDS) or alveolar filling, such as in pulmonary consolidation. The hallmark of right-to-left shunt is that supplemental oxygen fails to increase arterial oxygen levels. This is in contrast to other causes of hypoxemia that respond to supplemental oxygen. Causes of right-to-left shunt include congenital cyanotic heart disease (e.g., truncus arteriosus, transposition of the great vessels, tricuspid atresia, tetralogy of Fallot, and total anomalous pulmonary return), ARDS, pulmonary consolidation, or atelectasis. In addition, an uncorrected left-to-right shunt, such as a ventricular septal defect, atrial septal defect, or patent ductus arteriosus, can eventually become a right-to-left shunt, a phenomenon known as Eisenmenger's syndrome. This occurs when increased pulmonary blood flow from a left-to-right shunt leads to pulmonary hypertension and compensatory right ventricular hypertrophy, and, over time, right ventricular pressures surpass left ventricular pressures, resulting in a change in direction of the shunt. The hypoxemia caused by asthma (A) and pulmonary embolism (D) is due to ventilation-perfusion mismatch, in which a lung segment has imbalanced ventilation and perfusion. A patent foramen ovale (C) is a small hole in between the left and right atria at the location of the fossa ovalis that persists beyond embryonic life. A patent foramen ovale can lead to paradoxical emboli but does not typically cause hypoxemia.

What is the most common form of child abuse in the United States? Emotional Neglect Physical Sexual

Correct Answer ( B ) Explanation: Most states recognize four major types of maltreatment: neglect, physical abuse, psychological maltreatment, and sexual abuse. In the United States, medical providers are mandated reporters of child abuse. Neglect is the most common type of child maltreatment in the United States (78.5%) and is caregiver failure to meet basic nutritional, medical, educational, and emotional needs of a child. Neglect is legally reportable. Nutritional neglect is likely the most common form of neglect that is recognized, typically in the form of failure to thrive (FTT). Risk factors for neglect include poverty, poor support systems, parental mental health issues or mental disability, parental substance abuse, poor parenting skills, or complex child needs. The history and physical exam are extremely important when child abuse is suspected. A thorough history from everyone involved using open-ended questions, is the recommended approach. A full physical exam, including a genital exam is warranted. Signs such as bruising in non-mobile children, ligature marks, or burn marks are red flags for child abuse. Imaging should include a full skeletal survey in any child younger than 2 years with suspected physical abuse as well as a non-contrast computed tomography scan of the head in all children aged 6 months or younger with suspicion of abuse or children younger than 24 months with any suspected intracranial trauma. In cases of neglect, particularly when failure to thrive (FTT) is in question, a workup for organic problems may be undertaken. A provider who can follow up the laboratory results, monitor weight gain closely, and work with the family should be involved. Failure to thrive may require admission or close follow up with a specialist. Physical abuse (C) is characterized by physical injury such as bruises, fractures, tissue disruption resulting from hitting, punching, pinching, kicking, biting, burning, shaking, or otherwise harming a child. Child sexual abuse (D) has been defined by the American Academy of Pediatrics as the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and violate the social taboos of society. Emotional abuse (A) is ongoing emotional maltreatment. Emotional abuse can involve deliberately trying to scare or humiliate a child or isolating or ignoring them.

A 34-year-old woman presents with elbow pain and diminished arm movement following a fall on her outstretched hand. Initial history and physical exam are notable for pain, swelling, and tenderness over the lateral elbow, and inability to fully extend the elbow. Which of the following is indicative of a radial head fracture? Displacement of the radiocapitellar line Posterior fat pad sign Pronator sign Wrist drop

Correct Answer ( B ) Explanation: Patients with radial head fractures typically present with localized swelling, tenderness, and decreased motion of the elbow following a fall on an outstretched hand. These fractures account for approximately 50% of elbow fractures in adults. They may be subtle and are easily missed on plain films. Presence of an elbow joint effusion, as indicated by elevation of the anterior or posterior fat pads or both, points to an occult intra-articular fracture. The posterior fat pad is not seen on a normal lateral X-ray of the elbow and thus is a more reliable indicator of joint effusion. The anterior fat pad can be visible as a thin translucent line on a normal elbow radiograph, but may bulge away from the joint in the setting of an effusion creating the anterior 'sail sign'. Tenderness of the lateral elbow combined with a positive fat pad sign indicate the injury should be treated as a radial head fracture. A line drawn along the long axis of the radial neck should bisect the capitellum on all radiographic views of the elbow. Displacement of the radiocapitellar line (A) indicates subluxation or dislocation of the radial head. Bulging of the fat plane overlying the pronator quadratus muscle seen on a wrist X-ray is referred to as the pronator sign (C) and is suggestive of a wrist fracture. Wrist drop (D) results from damage to the radial nerve and may point to a humeral shaft fracture

An 18-year-old woman presents with fever, confusion, weight loss, and palpitations. Her vital signs are T 100.7°F, HR 140, BP 143/93, RR 20, oxygen saturation 95%, and finger stick glucose of 118. Physical examination reveals a thin woman who is alert and oriented x3 with a regular, fast heart rate, and brisk reflexes. Her roommate tells you that the patient has been taking a friend's levothyroxine in an attempt to lose weight. What management should be initiated? Beta-blocker Beta-blocker, dexamethasone Beta-blocker, dexamethasone, propylthiouracil, and potassium iodide Calcium channel blocker, dexamethasone

Correct Answer ( B ) Explanation: This patient presents with thyroid storm secondary to exogenous thyroid hormone abuse (levothyroxine). Excess thyroid hormone leads to a hypermetabolic state and increased beta-adrenergic activity. In thyroid storm, patients present with fever, marked tachycardia, gastrointestinal symptoms and central nervous system dysfunction. Cardiac complications include atrial tachydysrhythmias and high-output heart failure. An increase in catecholamine-binding sites leads to a heightened response to adrenergic stimuli. In endogenous thyroid storm, the thyroid gland produces excess T4 and T3. Peripherally, T4 is converted into the more active T3. Patients with a history of hyperthyroidism can decompensate to thyroid storm due to a number of precipitants including sepsis, myocardial infarction, trauma, surgery and pregnancy. Treatment of thyroid storm from endogenous thyroid hormone focuses on four targets: 1) blocking peripheral effects of hormone with beta-blockade, 2) blocking peripheral conversion of T4 to T3 with steroids (specifically dexamethasone), 3) blocking hormone synthesis with propylthiouracil (PTU) or methimazole and blocking hormone release from the thyroid gland with potassium iodide. Propranolol is the beta-blocker of choice as it also acts to reduce peripheral conversion of T4 to T3. In addition to reducing peripheral conversion of T4 to T3, steroids also treat any relative adrenal insufficiency. PTU should be given 1 hour prior to administration of potassium iodide as giving potassium iodide before blocking hormone release can lead to increased thyroid hormone production and release. However, since this patient is hyperthyroid from taking too much levothyroxine (exogenous), treatment includes administration of beta-blockers and corticosteroids (dexamethasone). In exogenous overdose, PTU and potassium iodide are not indicated (C) as there is no thyroid gland overproduction or release of hormone. Beta-blockers, not calcium channel blockers (D), are the treatment of choice for the peripheral effects of thyroid hormone. In patients where beta-blockers are contraindicated, reserpine can be used instead. Dexamethasone (A) is still necessary with exogenous thyroid hormone abuse if the ingestion is a T4 formulation in order to prevent conversion to the more active T3 form. Beta-blocker alone is not adequate treatment.

Which of the following hormones is involved in diabetes insipidus? Adrenocorticotropic hormone Antidiuretic hormone Glucagon Insulin

Correct Answer ( B ) Explanation: There are two types of diabetes insipidus (DI), central and nephrogenic. The primary symptom of both types is the passage of large amounts of dilute urine. The posterior pituitary gland secretes antidiuretic hormone (ADH), which is the hormone involved in DI. Decreased secretion of ADH is characteristic of central DI. The majority of cases of central DI are idiopathic, although it may be caused by malignancy, neurosurgery or trauma. Patients with nephrogenic DI are unable to concentrate their urine because of resistance to ADH in the kidney. Nephrogenic DI can occur with lithium toxicity, renal disease, hypokalemia, hyperglycemia, pregnancy, and as a side effect of a number of other medications including amphotericin B, cidofovir, foscarnet and ofloxacin. Diagnosis of DI is confirmed through laboratory testing. Patients with suspected DI should have a 24-hour urine collection to assess urine volume, as well as serum electrolytes and glucose, urinary specific gravity, plasma and urine osmolality, and plasma ADH level. Treatment for central DI is fluid replacement and desmopressin. Patients may need hospitalization for monitoring and determination of fluid needs. Initial treatment for nephrogenic DI is a low-salt, low-protein diet, frequent voiding, and a thiazide diuretic. Patients taking lithium may have individualized treatment considerations. Adrenocorticotropic hormone (A) is secreted from the anterior pituitary gland and stimulates the release of steroid hormones from the suprarenal gland. Glucagon (C) and insulin (D) are hormones secreted by the pancreas. Glucagon is produced by alpha cells and increases glycogen breakdown and glucose release in the liver. This process raises blood glucose levels. Insulin is produced by beta cells and lowers blood glucose levels. It is secreted in response to high blood glucose levels in the body and is the hormone involved in diabetes mellitus types 1 and 2.

A 56-year-old overweight woman presents with a painful mouth for the past week. She says this is her third flare of these "mouth sores" in 6 months. Her only daily medication is losartan for hypertension. An exam reveals an erythematous oral cavity with clumpy, adherent, white patches that bleed when removed with a tongue depressor. Which of the following laboratory tests is appropriate at this time? Anti-Epstein-Barr virus titer Fasting blood glucose Thyroid stimulating hormone Vitamin B12 assay

Correct Answer ( B ) Explanation: This patient has recurrent oral candidiasis, for which uncontrolled diabetes mellitus is a common risk factor. A fasting blood glucose is the most appropriate test at this time to screen for diabetes. Oral candidiasis, or thrush, usually presents as painful, curd-like, creamy-white patches overlying an erythematous oral mucosa or pharynx. Though these patches can easily be removed with a tongue depressor, removal may reveal bleeding mucosa. Oral candidiasis is usually diagnosed clinically, though a wet preparation using potassium hydroxide might show spores or non-septate mycelia. In addition to underlying diabetes mellitus, risk factors for oral candidiasis include poor overall health or oral hygiene, use of dentures, prior head or neck radiation, and current use of chemotherapy or systemic or inhaled corticosteroids. Further work-up may be necessary to rule out an underlying anemia or HIV infection. Oral candidiasis usually responds well to antifungal therapy in the form of Nystatin mouth rinse or oral fluconazole. However, newer anti-fungal agents like voriconazole might be needed for patients with underlying HIV or otherwise fluconazole-refractory candidiasis. Oral candidiasis should resolve rapidly once an appropriate treatment is initiated. An anti-Epstein-Barr virus titer (A) would be appropriate if Epstein-Barr virus (EBV) were suspected as the cause of this patient's pain. However, oropharyngeal discomfort due to EBV typically presents with a shaggy white-purple tonsillar exudate as opposed to the white, curd-like patches of candidiasis. Other symptoms will usually include lymphadenopathy, fatigue, and fever, which were not present in this patient. A thyroid stimulating hormone (C) will not be beneficial in addressing an underlying cause of recurrent oral candidiasis. Though prior thyroid radiation is a risk factor, oral candidiasis has not been shown to be related to an under or overactive thyroid. A vitamin B12 assay (D) is not necessary because this patient's symptoms are not consistent with the beefy red glossitis with glossodynia seen in vitamin B12 deficiency.

A 23-year-old, sexually active woman, presents with abdominal pain. Vital signs are normal. Pelvic examination reveals cervical motion tenderness and adnexal tenderness. Which of the following treatments is most likely indicated? Ceftriaxone 250 mg IM once + azithromycin 1000 mg PO once Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 14 days Clindamycin 300 mg PO BID for 7 days Metronidazole 500 mg PO BID for 7 days

Correct Answer ( B ) Explanation: This patient presents with signs and symptoms consistent with pelvic inflammatory disease (PID) and should be treated with ceftriaxone 250 mg IM and 2 weeks of doxycycline. PID is an ascending infection beginning in the cervix and vagina and ascending to the upper genital tract. Neisseria gonorrhoeae and Chlamydia trachomatis are most commonly implicated. It can present with a myriad of symptoms although lower abdominal pain is the most common. Other symptoms include fever, cervical or vaginal discharge and dyspareunia. Pelvic examination reveals cervical motion tenderness (CMT), adnexal tenderness and vaginal or cervical discharge. Inadequately treated PID can lead to tubo-ovarian abscess, chronic dyspareunia and infertility. Due to the variable presentation and serious sequelae, the CDC recommends empiric treatment of all sexually active women who present with pelvic or abdominal pain and have any one of the following: 1) CMT, 2) adnexal tenderness or 3) uterine tenderness. Treatment should cover the most common organisms and typically consists of a third generation cephalosporin (ceftriaxone) and a prolonged course of doxycycline. Patients with systemic manifestations or difficulty tolerating PO should be admitted for management. Ceftriaxone and azithromycin (A) are used in the treatment of cervicitis or urethritis. Clindamycin (C) and metronidazole (D) are used in the treatment of bacterial vaginosis.

A 57-year-old man with HIV complains of gradually increasing pain and difficulty with swallowing despite use of omeprazole that was prescribed for suspected gastroesophageal reflux. An endoscopy reveals yellow-whitish nodular plaques adherent to an erythematous mucosa. What is the next most appropriate step in management of this patient? Esophageal dilation Fluconazole Pantoprazole Prednisone

Correct Answer ( B ) Explanation: This patient's symptoms and endoscopic examination suggest candida esophagitis. Diagnosis is made when yeast or hyphae forms are present in stained samples obtained at the time of endoscopy. Candida species are found in the throats of normal, healthy patients, though infections may occur in the immunocompromised host such as this patient with HIV. Patients may be asymptomatic though common symptoms include pain or difficulty with swallowing. First-line therapy of candida esophagitis is oral fluconazole. Fluconazole is an inhibitor of the cytochrome P450 system so drug-drug interactions may occur. Itraconazole is prescribed for those with persistent symptoms despite treatment and IV anti-fungal therapy may be required for those who cannot tolerate oral therapy. Complications of candida esophagitis include esophageal bleeding, stricture, perforation or systemic invasion. Esophageal dilatation (A) is a procedure performed by endoscopy to help widen the lumen of an esophagus which has developed a stricture as the result of chronic inflammation, mechanical or chemical injury, or other cause. Symptoms of esophageal stricture include progressive dysphagia and episodes of obstruction caused by food that cannot pass through the area of narrowing. Diagnosis of stricture is helped by use of a barium swallowing study. This patient's symptoms are not specific for stricture, nor is one seen at the time of endoscopy. Though untreated esophagitis may lead to stricture, dilatation is not yet indicated for this patient. Pantoprazole (C) is a proton-pump inhibitor most commonly used to treat gastroesophageal reflux disease, and is used in many types of esophagitis. This patient has ongoing symptoms of esophagitis despite already taking another type of proton-pump-inhibitor (omeprazole). Changing to a different PPI is not expected to resolve the candida infection without treatment first with fluconazole. Prednisone (D) is an oral steroid used in the treatment of inflammatory conditions. Administration of steroids in this patient may worsen his condition since prednisone is an immunosuppressant.

Which of the following would you most expect to find in a patient who presents to the emergency department in cardiogenic shock? Dehydration High pulse pressure Low cardiac index Warm, hyperemic extremities

Correct Answer ( C ) Explanation: Cardiogenic shock is the leading cause of death in acute myocardial infarction. It is characterized by decreased cardiac output and tissue hypoxia in the presence of sufficient intravascular volume. Patients present with hypotension, tachycardia, altered mentation, cool cyanotic extremities, faint peripheral pulses, and oliguria. A low pulse pressure is also typically encountered. Coronary angiography is indicated if myocardial ischemia or infarct is present. Invasive hemodynamic monitoring may be used, the results of which show a high pulmonary capillary wedge pressure (> 15 mm Hg) and a low cardiac index (stroke volume x heart rate / body surface area; < 2.2 L/min/m2). The cardiac index is a hemodynamic parameter that relates the cardiac output from the left ventricle in one minute to body surface area. Thus, relating cardiac performance to the size of the individual. Treatment mainstay includes prompt inotropic medications such as dopamine, dobutamine and phosphodiesterase inhibitors, and norepinephrine. Other measures include the placement of central and peripheral arterial lines, possible fluid resuscitation, ICU care, electrolyte and acid-base correction, intra-aortic balloon pump, percutaneous coronary intervention or coronary artery bypass grafting. Dehydration (A), as evidenced by orthostatic hypotension and dry mucous membranes, are not expected in cardiogenic shock, as the definition of this type of shock excludes the possibility of hypovolemia. A low, not high, pulse pressure (B) is expected in cardiogenic shock. Pulse pressure is the systolic BP minus the diastolic BP, normally considered around 40 mm Hg (120-80). Low pulse pressure is considered when the pulse pressure is < 25% of the systolic BP. Cool, cyanotic extremities (D) are expected in cardiogenic shock.

A 40-year-old woman presents with acute onset right upper quadrant pain, nausea and vomiting. It began 18 hours ago after a Mexican meal, and has progressively worsened. She is febrile and has tenderness in the right upper quadrant. She is not jaundiced. Blood tests are significant for a leukocytosis but only mildly elevated liver enzymes, bilirubin and amylase. Ultrasound examination reveals gallbladder wall thickening and pericholecystic fluid. The common bile duct is patent. Which of the following is the most likely diagnosis? Biliary colic Cholangitis Cholecystitis Choledocholithiasis

Correct Answer ( C ) Explanation: Cholelithiasis, or gallstones, may obstruct the cystic duct (CyD), leading to inflammation, swelling and infection of the gallbladder. This is called cholecystitis, and usually presents with acute right upper quadrant pain that may radiate to the shoulder or back, nausea, vomiting and fever. Examination usually reveals right upper quadrant tenderness, a positive Murphy's sign (worsening right upper quadrant pain and inspiratory arrest during palpation of the right subcostal region) and a palpable gallbladder. Laboratory tests may show a leukocytosis with mildly increased bilirubin, liver enzymes and amylase. Diagnosis is made clinically and confirmed with right upper quadrant ultrasound, showing gallbladder wall thickening and pericholecystic fluid. If the ultrasound is equivocal, a HIDA scan can be used to make the diagnosis, which shows passage of contrast into the common bile duct but not into the gallbladder. Treatment includes NPO status, intravenous fluids, antibiotics and cholecystectomy usually within 3 days after onset of symptoms. Complications include gallbladder gangrene, bile duct leaks, retained stones, sphincter of Oddi dysfunction and gas-forming organism infection of the gallbladder wall. Biliary colic (A) is episodic right upper quadrant or epigastric pain and nausea that begins abruptly and lasts for many hours. However, biliary colic does not lead to a thickened gall bladder wall or pericholecystic fluid. Cholangitis (B) is due to infection of the common bile duct (CBD). It may present similarly to cholecystitis, but is also associated with increased bilirubin leading to jaundice. Ascending cholangitis is characterized by Charcot's triad (right upper quadrant pain + jaundice + fever) and Reynold's pentad (Charcot's triad + shock + mental status changes). Choledocholithiasis (D) is a stone in the common bile duct and can lead to cholangitis.

A 32-year-old man presents after a syncopal episode. He was running on the track when he developed shortness of breath followed by witnessed syncope. He was not post-ictal and had no seizure activity. He reports that his father's brother died while playing basketball. Physical examination is notable for a midsystolic crescendo-decrescendo murmur. Which of the following is the most likely diagnosis? Aortic stenosis Arrhythmogenic right ventricular dysplasia Hypertrophic cardiomyopathy Wolff-Parkinson-White syndrome

Correct Answer ( C ) Explanation: Hypertrophic cardiomyopathy is an autosomal dominant disease causing mutations in the cardiac sarcomere protein. This leads to abnormal muscle protein development and compensatory hypertrophy of the left ventricle. Most commonly, there is asymmetric hypertrophy with significant enlargement of the anterior interventricular septum. During exertion, patients may experience syncope associated with shortness of breath, chest pain or palpitations. In a large percentage of patients, the presenting symptom is sudden death. The ECG is abnormal in 90% of cases and abnormalities include left ventricular hypertrophy, "dagger-like" Q waves in the inferior and lateral leads, and nonspecific ST segment changes. The diagnosis is made by echocardiogram. Treatment and prevention of symptoms is aimed at maintaining adequate left ventricular filling and increasing diastolic time for filling. Aortic stenosis (A) can also be associated with exertional syncope and causes a crescendo-decrescendo murmur. However, these patients are typically older and often have other symptoms such as progressive dyspnea with exertion and angina. Arrhythmogenic right ventricular dysplasia (B) is another leading cause of sudden death in young athletes. Cardiomyopathy develops as the right ventricle is replaced by fat tissue. The ECG may demonstrate epsilon waves in 50% of people. This is a small positive deflection at the end of the QRS complex. The S wave upstroke may also be prolonged in leads V1-V3. The physical examination will not reveal a cardiac murmur. Wolff-Parkinson-White syndrome (D) is one of several pre-excitation syndromes that predispose patients to dysrhythmia. In Wolff-Parkinson-White an abnormal accessory pathway exists between the atria and ventricles. Sudden cardiac death is rare in patients with this syndrome. Classic ECG findings include a short PR interval with associated delta wave (upsloping of the QRS complex).

A 3-week-old male is brought to your office because of a sudden onset of bilious vomiting of several hours duration. He is irritable and refuses to breastfeed, but stools have been normal. He was delivered at term after a normal pregnancy, and has no health problems to date. A physical examination shows a fussy child with a distended abdomen. Radiography of the abdomen shows a "double bubble" sign. Which one of the following is the most likely diagnosis? Infantile colic Intussusception Midgut volvulus Necrotizing enterocolitis

Correct Answer ( C ) Explanation: Midgut volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of "feeding problems" with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the "double bubble" sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus. Infantile colic (A) usually begins during the second week of life and typically occurs in the evening. It is characterized by screaming episodes and a distended or tight abdomen. Its etiology has yet to be determined. There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age. Necrotizing enterocolitis (D) is typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life. The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools. Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition. Intussusception (B) is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age. The disorder occurs predominantly in males. The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases. At least two of these findings will be present in approximately 60% of patients. The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants. Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as "currant jelly." An air enema using fluoroscopic guidance is useful for both diagnosis and treatment.

Which medication should be included in the antihypertensive regimen of patients with chronic kidney disease? Amlodipine Hydrochlorothiazide Lisinopril Metoprolol

Correct Answer ( C ) Explanation: Multiple studies have shown that utilizing angiotensin-converting-enzyme (ACE) inhibitors or angiotensin II receptor (ARB) blockers in patients with hypertension slows the progression of kidney disease in patients with chronic kidney disease such as diabetes. Lisinopril is an ACE inhibitor. Calcium channel blockers such as amlodipine (A) are less effective in decreasing renal disease according to several studies. Diuretics including hydrochlorothiazide (B) are used as first line antihypertensives in the general population. Beta-Blockers including metoprolol (D) have shown great benefit in patients with heart failure, including patients with hypertension and diabetes. A renal protective effect has not been identified.

During a well-child visit, a 9-year-old boy and his father ask about health safety and sports activity. The boy wants to play baseball. His medical history is significant for tetralogy of Fallot, which was surgically corrected when he was 3-years-old. His last echocardiogram shows a right ventricular pressure to be < 50 mm Hg. Which of the following recommendations do you make? A functional capacity evaluation is needed first He may only play leisure sports, like golf or cycling It is safe for him to play any sport, including baseball The boy should abstain from all sports and physical education class

Correct Answer ( C ) Explanation: Physical activity limitations may be recommended for children with a past history of congenital heart disease. There are no restrictions on any sport activity, including competition and contact sports, in patients who have had surgical correction of tetralogy of Fallot and whose right ventricular pressure is < 50 mm Hg. Functional capacity evaluations (A) are used to determine work restrictions, not sports eligibility. Those with surgically repaired tetralogy of Fallot, with right ventricular pressure > 50 mm Hg (B) or cardiomegaly, should not participate in rigorous or contact sports. However, they may play leisure sports such as jogging, golf or cycling. Significant sports limitations, even abstinence from physical education class (D), are recommended for any child with severe pulmonic or aortic stenosis, or atrial or ventricular septal defect with moderate to severe pulmonary vascular obstructive disease. This vignette above makes no mention of these findings.

A 3-year-old girl presents because she is not using her left arm. Her father was playfully swinging her around by her forearms earlier in the day. What is the most likely diagnosis? Posterior elbow dislocation Radial head fracture Radial head subluxation Shoulder dislocation

Correct Answer ( C ) Explanation: Radial head subluxation, also known as nursemaid's elbow, is the most common elbow injury in children. It typically occurs in children ages one to four years and is caused by traction of a pronated forearm while the elbow is extended. This occurs when a parent is swinging a child around while holding onto their hands or forearms, or when pulling a child's arm to prevent the child from falling. Patients with a radial head subluxation present with little distress and hold their arm close to their body with the elbow either fully extended or slightly flexed with a pronated forearm. Edema and ecchymosis at the site are uncommon. Supination of the forearm elicits increased pain. Diagnosis is made clinically, but radiographs may be useful to rule out fracture. Treatment includes reduction of the radial head by supinating and flexing the forearm. Posterior elbow dislocation (A) is a dislocation of the ulnar bone from the humerus. It is a common dislocation in children that occurs after a fall on an outstretched arm or twisting the elbow. Patients present with a prominent olecranon process, swelling, and limited elbow range of motion. Associated fractures are common and treatment includes reduction by elbow supination and flexion. Radial head fracture (B) is a fracture of the radius bone in the forearm that most commonly occurs after a fall onto an outstretched arm. Patients typically present with pain, swelling, and tenderness to palpation over the lateral elbow and range of motion may be limited. Radiographic imaging is important to detect a fracture and a "sail sign" seen on X-ray is indicative of an occult, nondisplaced radial head fracture. Shoulder dislocation (D) is the dislocation of the humeral head on the glenoid cavity. An anterior shoulder dislocation is more common than a posterior dislocation, and it is typically caused by a force to an abducted, externally rotated, and extended arm. Patients present with their arm by their side in the dislocated position and resist all movements from this position. Treatment includes relocation with or without procedural sedation.

A 14-year-old boy presents to the Emergency Department for a rash. He reports the abrupt onset of fever, headache, and myalgias three days ago. This morning, he developed a blanching, red, macular rash on his wrists and palms that now involves his extremities and trunk. What is the most likely cause of his symptoms? Measles virus Neisseria meningitidis Rickettsia rickettsii Staphylococcus aureus

Correct Answer ( C ) Explanation: Rocky Mountain spotted fever (RMSF) is a febrile, tick-borne illness caused by Rickettsia rickettsii. Patients present with abrupt onset of fever, headache, myalgias, and nausea followed three to five days later with a blanching, macular rash that initially is found on the wrists and ankles before spreading centripetally. The rash later becomes petechial. Despite its name, RMSF is relatively rare in the Rocky Mountain states and is found primarily in the southeastern United States. Carried mostly by the American dog tick (Dermacentor variabilis) and the Mountain wood tick (Dermacentor andersoni), R. rickettsii is an obligate intracellular bacteria that damages endothelial cells. This in turn starts a cascade of reactions that result in widespread vascular lesions that manifest as the clinical features of the disease. Without treatment, mortality is near 25%. Management includes supportive care and doxycycline. The measles virus (A) causes symptoms of cough, coryza, conjunctivitis, fever, and rash. The rash typically starts on the head and spreads down to involve the trunk. Neisseria meningitidis (B) can also cause a fever, headache, and rash. However, the rash associated with N. meningitidis typically spares the palms and soles. Staphylococcus aureus (D) can cause toxic shock syndrome which is characterized by fever, hypotension, and a diffuse erythematous macular rash that later desquamates.

A 3-year-old boy presents to the ED with three days of fever, cough, and runny nose. On exam, you note conjunctival injection and an erythematous, nonblanching, nonvesicular, maculopapular rash behind his ears and on his hairline, with a few spots on his chest. Which of the following is the most likely diagnosis? Roseola Rubella Rubeola Varicella

Correct Answer ( C ) Explanation: Rubeola, or measles, is associated with fever and rash with cough, conjunctivitis, coryza, and Koplik spots. The characteristic rash is erythematous, nonblanching, and maculopapular. It begins on the head, usually behind the ears and around the hairline, with subsequent spreading down the face, to the trunk, and extremities (centrifugal spread). The rash may coalesce into salmon-colored patches and typically disappears within one week. Koplik's spots or pinpoint-sized white lesions on a red background that appear on the buccal mucosa opposite the molars are pathognomonic. Roseola (A) is a viral infection with the onset of a rash that occurs upon resolution of a high fever. It is common in ages 6-18 months. Rubella (B) is often referred to as "three-day measles." It is a mild illness, except for congenital infection, which can cause major birth defects. It is associated with fever, rash, and prominent lymphadenopathy with tender posterior auricular, cervical, and occipital nodes. Varicella (D) (chicken pox) is associated with a flu-like illness and the formation of macules that progress to fluid-filled vesicles in an erythematous base ("dew drops on a rose petal"). Crops of lesions typically appear at the same time with vesicles in various stages of healing.

A patient presents to the Emergency Department with wrist and hand weakness. He is holding his wrist in flexion and his hand is hanging limply. He is unable to extend his wrist against resistance. Which of the following nerves is most likely injured? Axillary nerve Median nerve Radial nerve Ulnar nerve

Correct Answer ( C ) Explanation: The patient has wrist drop, which is caused by injury to the radial nerve. The radial nerve innervates the dorsal extrinsic muscles in the forearm, which function in wrist and metacarpophalangeal (MCP) joint extension, as well as abduction and extension of the thumb. Radial nerve motor function can be assessed by having the patient extend the wrist against resistance. Patients with an intact radial nerve should be able to make the "thumbs up" sign. Sensation is tested in the first dorsal web space. Radial nerve injury has many causes, including trauma to the brachial plexus or the humerus (the radial nerve runs along the lateral border of the humerus). Additionally, prolonged use of crutches, which applies pressure along the nerve, can result in a radial nerve palsy. Similarly, "Saturday night palsy" refers to an intoxicated individual falling asleep with their arm slung over a chair, compressing the radial nerve. The axillary nerve (A) innervates the deltoid, teres minor, and the long head of the triceps. Injury to the axillary nerve leads to shoulder and elbow motor deficits. The median nerve (B) innervates the flexor muscles of the wrist, the thenar muscles, and the lumbricals to the 2nd and 3rd digits. Median nerve motor function can be assessed by testing thumb opposition and pincer grasp. Patients with an intact median nerve should be able to make the "A-OK" sign. The ulnar nerve (D) innervates the hypothenar muscles, most of the intrinsic muscles of the hand, and the adductor pollicis. Ulnar nerve motor function can be tested with thumb opposition and pincer grasp. Damage to the distal ulnar nerve can result in claw hand, in which the little and ring fingers are held in flexion at the interphalangeal joint.

A 22-year-old woman presents with lower abdominal pain and abnormal vaginal discharge for 4 days. She is sexually active with multiple partners and does not consistently use barrier contraception. She has bilateral adnexal tenderness and yellow discharge on pelvic exam. Her urine pregnancy test is negative. In addition to a 1-time dose of ceftriaxone, what is the most appropriate outpatient course of antibiotics for the patient? Azithromycin 1 gram PO x 1 Ciprofloxacin 500 mg PO BID x 14 days Doxycycline 100 mg PO BID x 14 days Metronidazole 500 mg PO BID x 14 days

Correct Answer ( C ) Explanation: The patient's presentation is consistent with pelvic inflammatory disease (PID), which represents a spectrum of disorders usually secondary to 1 or more sexually transmitted diseases involving the upper genital tract of women. PID can include any of the following: mucopurulent cervicitis, endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis. Patients typically present with complaints of lower abdominal pain, with or without dyspareunia; abnormal bleeding; or abnormal vaginal discharge. On exam, patients usually have lower abdominal tenderness, cervical motion tenderness, and bilateral adnexal tenderness. Outpatient management is appropriate for mild cases of PID and includes ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg PO BID for 14 days. A single 1-gram dose of azithromycin (A) is part of the regimen to treat cervicitis and urethritis in men. It can also be used for PID but should be administered once weekly for 2 weeks. The CDC no longer recommends fluoroquinolones (B) for the treatment of gonococcal infections and associated conditions such as PID due to high resistance. Metronidazole (D) is not required as part of the PID treatment regimen, but it is added sometimes to also treat trichomoniasis or vaginitis or if there is a concern for anaerobic infection.

A 4-year-old girl presents complaining of left knee pain. The patient was started on antibiotics one week ago for a simple ear infection. She now has a widespread morbilliform rash, urticaria, several swollen joints, and temperature of 39.3°C. Which of the following is the most likely diagnosis? Henoch-Schönlein purpura Postviral arthritis Serum sickness Still's disease Systemic lupus erythematosis

Correct Answer ( C ) Explanation: This patient has acute serum sickness. Her presentation is classic with the development of a rash, joint pain, and fever a week after beginning antibiotics. Serum sickness is an immune-complex deposition disease (type III hypersensitivity) that occurs after exposure either to animal proteins or serum or to a variety of drugs. Serum sickness has distinctive cutaneous findings. Erythema first occurs on the sides of the fingers, toes, and hands before a more widespread morbilliform appears, sometimes with urticaria. Rash, fever, constitutional symptoms, and arthralgia are the most frequent clinical findings. Symptoms usually start 12 to 36 hours after ingestion if there has been previous immune system priming; absent this, onset may be delayed 7 to 21 days after antigen exposure. Treatment is supportive with antihistamines and antipyretics. Henoch-Schönlein purpura (HSP) (A) is an acute, systemic vasculitis, primarily affecting venules and arterioles. It is associated with a palpable purpuric rash that usually begins on the lower extremities and progresses toward the torso. Patients often have associated abdominal pain, arthritis, and hematuria. Postviral arthritis (B) is a fairly common condition of toddlers. It is characterized by a recent viral syndrome with manifestation of monoarticular arthritis once the patient defervesces. Still's disease (D) is an autoimmune condition that heralds the onset of juvenile rheumatoid arthritis. It is characterized by high fever, arthritis, and a faint salmon-colored fleeting rash. This is similar to this patient's presentation, but with the recent exposure to antibiotics and an urticarial rash, serum sickness is the most likely diagnosis. This patient's rash is not consistent with HSP. Lupus (E) is associated with fever and arthritis but is more indolent in nature.

Which of the following best describes the underlying pathophysiology of ventricular tachycardia? Calcified mitral valve leaflets Electrical blockade in the atrioventricular node Irritable ventricular foci Reentrant pathway exists between atria and ventricles

Correct Answer ( C ) Explanation: Ventricular tachycardia (VT) is usually initiated by irritable ventricular automaticity foci. These foci may become irritable by several factors, three of which are hypokalemia, hypoxia and ischemia. Hypoxia may result from airway obstruction, lack of air (as in suffocation or drowning) and pulmonary compromise (as in pulmonary embolus or pneumothorax). Myocardial ischemia or infarction occurs in disease states such as chronic ischemic heart and coronary disease, or in emergent states, as in hypovolemic shock or cardiogenic shock. The more common causes of irritation are coronary insufficiency (vasospasm as with cocaine, atherosclerosis or thrombosis and embolus) and myocardial infarction. Once a ventricular foci is irritated enough, it will take over as the dominant pacemaker, suppressing the sinoatrial node, and resulting in a tachycardia usually between 150-250 bpm. Electrical blockade thru the atrioventricular node (B) is the basis of AV block, not ventricular tachycardia. Mitral stenosis is caused by rheumatic fever and leaflet calcification (A). A diseased mitral valve is associated with atrial fibrillation. A reentrant pathway between atria and ventricles (D) explains the basis of supraventricular tachycardia (SVT).

You are caring for a patient who is diagnosed with pancreatic adenocarcinoma. The oncologist makes a note of a positive Trousseau's syndrome in the documentation. Which of the following is she referring to? Nontender palpable gallbladder Palpable left supraclavicular lymph node Popliteal pain with abrupt ankle dorsiflexion Tender migratory thrombophlebitis

Correct Answer ( D ) Explanation: Cancer of the pancreas is divided into two main categories. The most common type is adenocarcinoma (85%). The remaining 15% consists of cystic neoplasms, acinar cell carcinomas, endocrine cell cancers and metastases. Pancreatic adenocarcinoma is the fourth leading cause of cancer deaths in the United States. Risk factors include familial gene mutations, tobacco use, obesity and chronic pancreatitis. Jaundice with or without pain, as well as unexplained new onset diabetes, pancreatitis or malabsorption, are common presenting symptoms. The classic presentation is painless jaundice. Examination may reveal an epigastric mass, a palpable nontender gallbladder (Courvoisier sign), hepatomegaly and ascites. Trousseau's syndrome may also be present. This represents the hypercoagulability that accompanies many cancers, and is found on examination as tender migratory thrombophlebitis which can occur in crops of veins at different times. Diagnosis is confirmed with a pancreatic protocol computed tomography scan. CA 19-9 is a serum marker that is often elevated in pancreatic cancer but has poor sensitivity for early detection. Its specificity is approximately 85%. Lesions limited to the head, periampullary zone, and duodenum are amenable to resection by a Whipple procedure (pancreaticduodenectomy). Adjunct chemotherapy with fluorouracil or gemcitabine is beneficial. The gallbladder may be painlessly palpable (A) in biliary tract and pancreatic cancers. This is referred to as Courvoisier's sign. Virchow's sign, or Virchow's node, is a palpable left supraclavicular lymph node (B) common in gastric and pancreatic cancers. Homan's sign is popliteal pain after abrupt ankle dorsiflexion (C). It is associated with lower extremity deep vein thrombosis, which may occur in any cancer-related hypercoagulable state.

Twenty-four hours after eating a salad containing bean sprouts, a 25-year-old man became ill with fever, abdominal pain and bloody diarrhea. Which of the following organisms is most likely cause of his symptoms? Clostridium perfringens Cryptosporidium parvum Enterotoxigenic Escherichia coli Salmonella enterica

Correct Answer ( D ) Explanation: Foodborne illness should always be on the differential when a patient presents with gastrointestinal symptoms such as nausea, vomiting, diarrhea, abdominal pain and fever. A thorough history provides important information in diagnosing foodborne illness and should include description of clinical symptoms, exposure to high-risk types of food and the duration of time between consumption of the infected food and onset of symptoms. Salmonella enterica is a gram-negative bacterium that causes inflammatory diarrhea. Signs and symptoms of inflammatory diarrhea include the presence of blood or mucus in the stool, severe abdominal pain and fever. Salmonellosis is typically associated with consumption of raw meat or poultry, but can also be associated with fresh produce such as bean sprouts, tomatoes, lettuce, and melons. The illness is self-limited and treatment generally is with fluid replacement, although antibiotics are used in certain cases (i.e. immunocompromised patients and children). A consult should be done with the local health department to report the illness and help determine next steps. Clostridium perfringens (A) is transmitted through previously cooked or reheated meats and poultry. Symptoms are caused by a preformed enterotoxin. It is characterized by abdominal cramps, nausea, minimal vomiting, and watery diarrhea. Cryptosporidium parvum (B) has an incubation period of 7-28 days and is transmitted through consumption of unpasteurized milk, fresh produce, contaminated water or through person-to-person spread. This foodborne pathogen causes symptoms including watery diarrhea. Enterotoxigenic Escherichia coli (C) is often the cause of traveler's diarrhea and in the United States has been associated with outbreaks on cruise ships. Transmission is through the fecal-oral route and symptoms include watery diarrhea.

A 52-year-old obese man presents to your office with complaints of burning chest pain, food regurgitation and cough approximately once every week. He tells you that he likes to eat spicy foods and often eats a large meal shortly before bedtime to help him sleep. Which of the following is the most appropriate initial therapy? Bismuth subsalicylate Metoclopramide Omeprazole Ranitidine

Correct Answer ( D ) Explanation: Gastroesophageal reflux disease (GERD) occurs when excessive amounts of gastric juice reflux into the esophagus causing uncomfortable symptoms or complications. Patients with GERD present with esophageal symptoms including heartburn, dysphagia and regurgitation. Extraesophageal symptoms such as cough, sore throat, hoarseness, noncardiac chest pain, and erosion of the teeth enamel may also be seen. Patients who are morbidly obese or who have an elevated body mass index have a greater risk of developing GERD. The diagnosis of GERD may be made clinically and the role of endoscopy is controversial. Upper endoscopy is recommended when the diagnosis is unclear and in patients with alarm features including recurrent vomiting, gastrointestinal bleeding, anemia, weight loss and dysphagia. Other indications for endoscopy include GERD that is refractory to initial treatment, men older than 50 years with risk factors for Barrett's esophagus and esophageal carcinoma, and patients with severe erosive esophagitis. Treatment strategies involve using either a step-up or step-down approach to therapy and all include lifestyle modifications as an initial recommendation. Step-up therapy is recommended for patients with mild GERD, which is defined as episodes occurring less than twice every week. Initial treatment is with a histamine 2 receptor antagonists, such as ranitidine. Bismuth subsalicylate (A) is an antidiarrheal agent available over the counter that is used to treat diarrhea and as part of the treatment for Helicobactor pylori infection. Metoclopramide (B) is an antiemetic that is not recommended as monotherapy or adjunctive therapy in patients with GERD. Omeprazole (C) is a proton-pump inhibitor that is used in the step-down approach to treatment of GERD.

A 49-year-old man presents with mental status changes and fever. Brain CT scan is normal. His urine toxicology screen is negative. Laboratory findings show a serum sodium of 137 mEq/L, serum potassium of 5.1 mEq/L, serum creatinine of 1.9 mg/dL, WBC of 9 000/L, hemoglobin of 9.3 g/dL, and platelets of 19 000/L. Which of the following would you expect to see on skin examination? Acanthosis nigricans Erythromelalgia No abnormalities Purpura

Correct Answer ( D ) Explanation: Hemolytic-uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are microvascular thrombotic disorders associated with platelet aggregation, thrombocytopenia, erythrocyte injury, and elevated serum lactate dehydrogenase levels. They both present with microangiopathic hemolytic anemia, thrombocytopenia, and renal failure, but TTP may have concurrent neurologic abnormalities and fever. Both diseases are associated with thrombocytopenia that often leads to purpura, petechiae, and bleeding. HUS usually occurs in children 5-10 days after an episode of E. coli-induced bloody diarrhea, in which the shiga toxin activates platelets and renovascular cells leading to thrombosis. TTP usually occurs in adults and can be idiopathic or secondary to drugs, autoimmune disease, pregnancy, or HIV. In TTP, the pathophysiology is based on an inhibition of the enzyme ADAMTS13, which leads to large multimers of von Willebrand factor. The exact distinction between HUS and TTP can be difficult; they share common symptoms. As in any hemolytic state, the peripheral blood smear will have schistocytes (fragmented erythrocytes, also called helmet cells). If either condition is suspected, urgent plasmapheresis (remove plasma and replace with fresh frozen plasma) is performed daily for 1-8 weeks until the lactate dehydrogenase or hemoglobin normalizes. Consider administering corticosteroids for inadequate response to plasmapheresis and splenectomy for recurrent cases. Prompt recognition of TTP is important because the disease responds well to plasma-exchange treatment but is associated with a high mortality rate when untreated. Acanthosis nigricans (A) is a brown-black, velvety hyperpigmentation, typically found in the body folds of patient's with obesity, insulin-resistant diabetes, hypothyroidism, acromegaly, and Cushing's disease. Erythromelalgia (B) is a microvascular, thrombi-induced hyperemia associated with polycythemia vera. It occurs intermittently in the distal extremities and can be quite painful. Abnormalities (C) are expected, as discussed in the explanation.

A 70-year-old woman with a history of hypertension presents to the Emergency Department with a complaint of abdominal pain. On physical examination, there is a pulsatile mass in the midline of her abdomen. Which of the following is the most common risk factor for the development of this condition? Diabetes mellitus Female sex Hypertension Smoking history

Correct Answer ( D ) Explanation: Smoking is the most common preventable risk factor associated with the development of an abdominal aortic aneurysm (AAA). AAA occurs when there is localized dilation of the abdominal aorta. The risk of rupture increases as the aneurysm grows in size. A ruptured AAA has a nearly 90% mortality rate. Risk factors include smoking history, male sex, history of peripheral vascular disease, Caucasian race, and a family history of AAA. The U.S. Preventive Services Task Force recommends that men between the age of 65-75 with a history of smoking at least 100 cigarettes should be screened once for an AAA. Hypertension (C) is a less common risk factor, and the evidence for its role is still questionable. Female gender (B) is not a risk factor. Diabetes mellitus (A) is associated with a lower incidence of AAA and is protective, however, the mechanism is not well understood.

A 32-year-old man presents to your office with a new diagnosis of celiac disease. He wants to make sure that he is adhering to a gluten-free diet and is confused about what he can eat. Which of the following foods can he safely include on his diet? Fried chicken with gravy Spaghetti with marinara sauce Tuna fish sandwich on whole wheat bread Vegetables with brown rice

Correct Answer ( D ) Explanation: Management of celiac disease involves lifelong adherence to a gluten-free diet. Patients with a new diagnosis of celiac disease may be confused about what they can and cannot eat. Consultation with a dietician is important in the initial treatment of celiac disease. Clarification of which foods contain gluten is important in order for the patient to avoid clinical symptoms related to malabsorption. Rice, corn, potatoes, and soybeans are all gluten-free foods that patients with celiac disease can eat. Foods with wheat, barley and rye should be avoided. Patients should be counseled to read all food labels before eating to check for either a gluten-free indication or ingredients that are known to be gluten-free. Fried chicken with gravy (A) contains flour in both the breading and gravy. Flour is derived from wheat and contains gluten. Traditional pastas such as spaghetti (B) are made from wheat flour. Gluten-free pastas made from rice and other gluten-free flours are available. Whole wheat bread (C) is made from flour containing gluten and should be avoided in patients with celiac disease.

Which of the following can decrease levels of brain natriuretic peptide? Elderly age Female sex Kidney failure Obesity

Correct Answer ( D ) Explanation: Obesity can falsely decrease levels of brain natriuretic peptide. Brain natriuretic peptide is a natriuretic hormone that was initially identified in the brain but is also released from the heart, particularly the ventricles. It is released in response to volume expansion and increased wall stress in the cardiac ventricles. Increased plasma concentrations are found in heart failure in response to increased ventricular filling pressures from volume overload. An elevated serum brain natriuretic peptide is a nonspecific finding that does not establish the diagnosis of heart failure. However, levels > 500 pg/mL is consistent with heart failure, and a level < 100 pg/mL effectively eliminates heart failure as an acute cause of dyspnea. It is most useful in differentiating dyspnea due to heart failure verses that due to pulmonary disease. Brain natriuretic peptide is less helpful in the setting of increased body mass index as obese patients tend to have lower plasma levels of brain natriuretic peptide concentrations than nonobese patients. The etiology of this phenomena is not entirely understood. Elderly age (A), female sex (B) and kidney failure (C) can falsely elevate levels of brain natriuretic peptide, not decrease them. Plasma concentrations can vary with age, sex and renal function. Levels increase with renal failure secondary to reduced excretion and concentrations are inversely related to glomerular filtration rate.

A 28-year-old man presents to the emergency department by ambulance. His family called for help after finding him unresponsive at home with a syringe on the floor beside him. His blood pressure is 120/78 mm Hg, pulse 95/min, and respirations are 6/min and shallow. On physical exam he is non-responsive to questions, his skin is cool with cyanosis, and his pupils are minimally reactive to light and constricted. Which of the following is the most appropriate next step in management? Administer naloxone Administer sodium bicarbonate Place a nasogastric tube and administer activated charcoal Support airway and breathing

Correct Answer ( D ) Explanation: Opioid abuse and overdose is a problem in the United States and worldwide. Deaths due to overdose are common and increasing in number. Clinical features of opioid intoxication include altered mental status, hypoventilation, decreased bowel sounds, low to normal blood pressure and heart rate, and miotic pupils. Medical providers should attempt to obtain as much historical information as possible, however an accurate history is not essential in initial management of these patients. Hypoventilation is the most common vital sign abnormality. The first step in management of an overdose is supporting the patient's airway by providing assisted ventilation with supplemental oxygen through the use of a bag-valve-mask. Naloxone (A) is an opioid antagonist and should be administered to all patients with opioid overdose, preferably by intravenous route. Naloxone may be given by subcutaneous or intramuscular route if obtaining intravenous access will cause a delay in administration. However, the treatment for opioid overdose is oxygen. Meaning, these patients first require management of airway and breathing. Sodium bicarbonate (B) is administered in various other overdoses such as salicylate (aspirin) and tricyclic antidepressants, but is not useful in opioid overdose. Use of activated charcoal (C) is contraindicated in this patient since he is obtunded. Moreover, the patient requires immediate attention to his airway and breathing and any delay can result in death.

A 9-year-old presents complaining of a swollen red eye. The nurse notes that the patient is febrile to 103ºF. On exam you note the findings seen above. The patient has pain with eye movement and you note an afferent pupillary defect. Which of the following treatment regiments should be immediately instituted? Amoxicillin-Clavulanate Bacitracin ophthalmic ointment Cefazolin and erythromycin Cefuroxime and vancomycin

Correct Answer ( D ) Explanation: Orbital cellulitis is a life-threatening infection of the tissues posterior to the orbital septum. It occurs most commonly in children. The causative organisms include S. aureus, S. pneumoniae, H. Influenzae, and S. pyogenes. The infection is either spread locally from a dental infection, sinus infection, dacryocystitis, trauma, or hemaogenously. Patients present with very painful erythematous swelling of the eyelid, conjunctivitis, proptosis, opthalmoplegia, and fever. There may be blurry vision and pain with eye movements. An afferent pupillary defect is often present. Patients should be started on broad-spectrum intravenous antibiotics that are antistaphylococcal and antistreptococcal such as ceftriaxone. Vancomycin is added to cover MRSA. A CT scan can be obtained to evaluate for postseptal extension or abscess. If there is concern for associated cavernous sinus thrombosis, an MRI with venous phase is indicated. Ophthalmology and ENT consultation should also be obtained. Amoxicillian-Clauvnate (A) is the treatment of choice for preseptal cellulitis. Preseptal cellulitis is an infection of the subcutaneous tissues anterior to the orbital septum. It can progress to orbital cellulitis. Bacitracin ophthalmic ointment (B) is used to treat simple conjunctivitis, not orobital cellulitis. Although cefazolin (first generation cephalosporin) and erythromycin (C) are antistaphylococcal and antistreptococcal, they are not broad-spectrum enough and do not cover for MRSA.

A 72-year-old woman with osteoporosis sees you for health maintenance care. She currently takes vitamin D 200 IU/day and calcium 1500 mg/day. Her most recent bone mineral density is 2.5 standard deviations below the norm. Which of the following is the most appropriate treatment regimen? Continue calcium, continue vitamin D and add estrogen Continue calcium, increase vitamin D and add colchicine Increase calcium, continue vitamin D and add calcitriol Increase vitamin D, continue calcium and add alendronate

Correct Answer ( D ) Explanation: Osteoporosis, a decrease in bone mass, can be classified as primary and secondary. Primary osteoporosis is the most common type of osteoporosis. It is more common in women than men. A person reaches peak bone density at about age 30. After that, the rate of bone loss slowly increases, while the rate of bone building decreases. Whether a person develops osteoporosis depends on the density of the bones in early life as well as health, diet, and physical activity at all ages. In women, accelerated bone loss usually begins after monthly menstrual periods stop. This happens when a woman's production of estrogen slows down (usually between the ages of 45 and 55). In men, gradual bone thinning typically starts at about 45 to 50 years of age, when a man's production of testosterone slows down. Osteoporosis usually does not have an effect on people until they are 60 or older. Women are usually affected at an earlier age than men, because they start out with lower bone mass. Secondary osteoporosis has the same symptoms as primary osteoporosis. But it occurs as a result of having certain medical conditions, such as hyperparathyroidism, hyperthyroidism, or leukemia. It may also occur as a result of taking medicines known to cause bone breakdown, such as oral or high-dose inhaled corticosteroids (if used for more than 6 months), too high a dose of thyroid replacement, or aromatase inhibitors (used to treat breast cancer). Secondary osteoporosis can occur at any age. Dual-energy X-ray absorptiometry (DEXA) scan measures loss of bone mineral density (BMD) and is the most accurate and precise method to diagnose osteoporosis. Treatment begins with prevention, and includes early adulthood adequate calcium and vitamin D intake, regular weight-bearing exercise and tobacco and alcohol avoidance. The recommended calcium intake for those aged 19-50 years is 1000 mg/day, and those aged 51 years and older, 1200mg/day. Recommendations for vitamin D intake are 400 IU/day for young adults, and 800-1200 IU/day for the elderly. Pharmaceuticals are recommended when bone mineral density scores are below 1.5 to 2 standard deviations below the young-adult-norm, based on the presence (≤1.5) or absence (≤2) of fracture risk factors. Prescription options include estrogen replacement therapy, alendronate (or other bisphosphonate), calcitonin and raloxifene (a selective estrogen receptor modulator). This patient is only taking 200 IU/day, but should be taking 800-1200 IU/day. Osteoporosis pharmaceuticals are recommended for bone mineral density scores less than 2 standard deviations below the norm. Colchicine (B) is used in the treatment of acute gouty arthritis, not osteoporosis. A woman over age 70 years should have 800-1200 mg/day of vitamin D (A), the patient in the above scenario is only taking 200 IU/day. Additionally, estrogen is no longer a first-line approach for the treatment of osteoporosis in postmenopausal women because of increased risk of breast cancer, stroke, and venous thrombosis. 1500 mg/day of calcium (C) is sufficient for a 72-year-old woman with osteoporosis. Furthermore, this patient's vitamin D supplementation needs to be increased.

A 2-year-old girl presents to the ED reluctant to move her left arm. The patient's father states that he grabbed his daughter by her wrist to pull her up from the floor. On exam, there is no swelling or deformity. Which of the following maneuvers should be attempted to correct the injury? Full elbow flexion followed by pronation Hypersupination of the forearm Pronation followed by elbow flexion Supination followed by elbow flexion

Correct Answer ( D ) Explanation: Radial head subluxation (aka nursemaid's elbow) most commonly occurs in children 2 to 3 years of age with a predilection toward females. The injury is due to displacement of the radial annular ligament into the radiocapitellar articulation. Clinically, the child will not move the affected arm but otherwise is in no distress. There are two maneuvers for reduction: supination technique and the hyperpronation technique. For the supination technique, hold the elbow at 90 degrees, firmly supinate the child's wrist, and then flex the child's elbow directing the wrist toward the ipsilateral shoulder. The hyperpronation technique is performed by holding the child's elbow at 90 degrees and then firmly pronating at the wrist. After successful reduction, relief is immediate, and the child typically begins to move the affected extremity within 5 to 10 minutes. Full elbow flexion followed by pronation (A), hypersupination of the forearm (B), pronation followed by elbow flexion (C) are not recommended techniques for reduction of radial head subluxation.

Which of the following can cause an exudative pleural effusion? Cirrhosis Congestive heart failure Nephrotic syndrome Systemic lupus erythematosus

Correct Answer ( D ) Explanation: Systemic lupus erythematosus can cause an exudative pleural effusion. A pleural effusion is an accumulation of fluid in the pleural space and can either be exudative or transudative. Exudates result primarily from pleural and lung inflammation which result in increased capillary and pleural membrane permeability. It can also be caused by impaired lymphatic drainage of the pleural space. Disease in virtually any organ can cause exudative pleural effusions by a variety of mechanisms, including infection, malignancy, immunologic responses, lymphatic abnormalities, noninfectious inflammation, iatrogenic causes, and movement of fluid from below the diaphragm. Some examples include pneumonia, tuberculosis, pancreatitis, connective tissue disorders such as lupus or rheumatoid arthritis, and malignancy, more commonly breast, lung, lymphoma or leukemia. Transudative pleural effusions result from imbalances in hydrostatic and oncotic pressures in the chest. Congestive heart failure (B) accounts for up to 90% of all transudative pleural effusions. Nephrotic syndrome (C) and cirrhosis (A) are also causes of transudative pleural effusions.

A 14-day old boy is brought to clinic for a well-child check. The boy was born full-term via normal spontaneous vaginal delivery to a G2, P2 mother who had limited prenatal care. There were no complications at delivery. The boy has not yet regained birth weight and has been breastfeeding poorly. On physical examination, you note bluish discoloration of the lips and oral mucosa, clear breath sounds and a harsh left upper sternal border murmur. Which of the following chest X-ray findings is consistent with Tetralogy of Fallot? Egg-shaped heart Heart shaped like a snowman Increased pulmonary blood flow Lack of vascular congestion

Correct Answer ( D ) Explanation: The boy has central cyanosis with a harsh murmur characteristic of pulmonary stenosis. These findings are suspicious for tetralogy of Fallot (TOF). TOF is composed of four anatomic defects consisting of an overriding aorta, right ventricular hypertrophy, pulmonary stenosis, and ventricular septal defect (VSD). The clinical presentation depends upon the degree of pulmonary stenosis. The more severe the stenosis, the greater is the reduction of pulmonary blood flow and increased cyanosis. On examination, the patients are usually comfortable and in no distress. During hypercyanotic (tet) spells, patients usually become hyperpneic or agitated. The murmur of TOF is usually due to pulmonary stenosis and not the VSD. The murmur is due to the degree of obstruction and to the amount of flow across the obstruction. The diagnosis of TOF is generally made by echocardiography. Other tests that are often performed during the evaluation of TOF include chest radiography and electrocardiogram. The classic chest X-ray in TOF demonstrates a "boot-shaped" heart with an upturned apex and a concave main pulmonary artery segment. The heart size is often normal, and pulmonary flow will appear normal or decreased. Treatment of TOF involves surgical closure of the VSD as well as repair of the pulmonary stenosis. The timing of this procedure depends upon the degree of obstruction to pulmonary blood flow. The following are possible chest radiography findings in cyanotic heart diseases: egg-shaped heart (A) is found in transposition of the great arteries, heart shaped like a snowman (B) is described in total anomalous pulmonary venous return, and increased pulmonary blood flow (C) can be found in truncus arteriosus, transposition of the great arteries, and total anomalous pulmonary venous return.

A 21-year-old man presents with severe swelling of the left side of his tongue and his left upper lip. He tells you his brother had the same problem 2 years ago. Which of the following is the most effective treatment? Cryoprecipitate Diphenhydramine Epinephrine Fresh frozen plasma

Correct Answer ( D ) Explanation: This patient has non-allergic angioedema, likely hereditary angioedema with his brother's history of the same reaction. Patients have a deficiency of the C1 esterase inhibitor causing an increased production of bradykinin due to activation of the kallikrein-kinin system. The hereditary form is autosomal dominant. With angioedema, vasodilation and edema occur in the deeper dermal layers causing swelling but often no superficial skin changes in color. Signs include edema of the airway, face, genitals and extremities. Abdominal pain associated with nausea, vomiting and diarrhea may also occur. Immediate attention to the airway is necessary with a low threshold for controlled intubation. Fresh frozen plasma contains the C1 inhibitor and its administration may help stop the angioedema. C1 inhibitor replacement protein, derived from pooled human plasma is available in two forms for treatment of hereditary angioedema. Cryoprecipitate (A) has no role in the treatment of angioedema. Cryoprecipitate is rich in fibrinogen and may be indicated in cases of severe disseminated intravascular coagulation. Diphenhydramine (B) is an antihistamine blocking the H1 receptor. The pathway of hereditary angioedema does not involve mast cells and histamine release and therefore the medication will have no effect. An allergic form of angioedema exists often in combination with urticaria in which case diphenhydramine may offer benefit. Epinephrine (C) is indicated for anaphylaxis. Unless there is an allergy component to angioedema, epinephrine will not decrease symptoms. The administration of nebulized racemic epinephrine, however, may help stabilize airway edema.