EM EOR

A 34-year-old woman presents to the ED with severe right eye pain. The pain began after she entered a dark movie theatre. On physical exam, you note a mid-dilated pupil (4 mm) and corneal edema. Which of the following is the correct combination of medications in the treatment for this process? A. Acetazolamide IV, topical apraclonidine, topical timolol B. Mannitol IV, topical timolol, prednisolone IV C. Topical prednisolone, mannitol IV, topical timolol D. Topical timolol, topical apraclonidine, topical prednisolone

A. Acetazolamide IV, topical apraclonidine, topical timolol -This patient is exhibiting signs and symptoms of acute angle closure glaucoma -First, you need to reduce the production of aqueous humor using oral or intravenous acetazolamide, a topical beta blocker such as timolol, and a topical alpha agonist such as apraclonidine. -These are typically given one hour after the start of treatment and require two doses 15 minutes apart.

The impetigo rash is associated with which one of the following conditions? A. Acute glomerulonephritis B. Arthritis C. Clostridioides difficile colitis D. Secondary syphilis

A. Acute glomerulonephritis

A 68-year-old man with a history of severe chronic obstructive pulmonary disease presents with altered mental status. His oxygen saturation is 90% on 4 liters of oxygen via nasal cannula. A venous blood gas is obtained with the following results: pH: 7.15 pO2: 45 mm Hg pCO2: 100 mm Hg HCO3: 38 mEq/L The patient has which of the following acid-base disturbances? A. Acute on chronic respiratory acidosis B. Acute respiratory acidosis C. Metabolic acidosis D. Metabolic alkalosis with respiratory compensation

A. Acute on chronic respiratory acidosis

A 45-year-old woman presents to the emergency department with palpitations. She is placed on the monitor which shows a rapid narrow-complex tachycardia. Her heart rate is 160 bpm and blood pressure is 120/70 mm Hg. Vagal maneuvers are attempted and fail. Next, adenosine 6 mg IV is given intravenously without a change in her rhythm. Repeat vitals show a heart rate 165 bpm and blood pressure 120/70 mm Hg. What is the most appropriate next step in management? A. Adenosine 12 mg intravenous B. Adenosine 6 mg intravenous C. Synchronized cardioversion D. Vagal maneuvers

A. Adenosine 12 mg intravenous -Supraventricular tachycardia (SVT) or paroxysmal supraventricular tachycardia (PSVT) is most commonly caused by a re-entrant pathway in the atrioventricular node. Clinically, patients experience an abrupt onset of tachycardia with a ventricular rate of 120 to 200 beats per minute. -In a stable patient, after vagal maneuvers and a single dose of adenosine 6 mg have been attempted and fail, it is most appropriate to give adenosine 12 mg intravenously.

A 22-year-old woman presents with lower abdominal pain that started two days ago. Today, she had three episodes of vomiting but denies any diarrhea or dysuria. On examination, her temperature is 38.8°C, heart rate 105 beats per minute, and blood pressure 128/72 mm Hg. She is ill-appearing with bilateral lower quadrant tenderness. Pelvic examination reveals moderate yellow discharge and uterine tenderness. There are no adnexal masses appreciated. Pregnancy test is negative. What is the next step in the management of this patient? A. Admission for intravenous cefotetan and doxycycline B. Admission for intravenous ciprofloxacin and metronidazole C. Discharge home following intramuscular ceftriaxone with a 14 day course of oral doxycycline and metronidazole D. Order a computed tomography scan of the abdomen and pelvis with intravenous and oral contrast

A. Admission for intravenous cefotetan and doxycycline -Pelvic inflammatory disease comprises a spectrum of disorders involving the female upper genital tract including endometritis, salpingitis, and tubo-ovarian abscess. -The CDC recommends empiric treatment of PID in young, sexually active women with pelvic or lower abdominal pain who experience cervical motion tenderness, adnexal tenderness, or uterine tenderness that cannot be ascribed to another cause. -. This patient is ill-appearing with vomiting and a high fever making her a candidate for inpatient management with intravenous cefotetan and doxycycline.

What is the most common site of compartment syndrome? A. Anterior compartment of the lower leg B. Anterior compartment of the thigh C. Lateral compartment of the lower leg D. Volar compartment of the forearm

A. Anterior compartment of the lower leg -The most frequently involved compartment is the anterior compartment of the lower leg occurring in association with a tibia fracture. -Clinically, patients present with pain out of proportion to the injury, pain with passive stretching of the muscles in the compartment, and paresthesias

A 76-year-old man presents to the emergency department with shortness of breath and lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of the following is the most appropriate diagnostic test? A. Bedside echocardiography B. Chest radiograph C. Computed tomography angiogram of the chest D. Electrocardiogram

A. Bedside echocardiography -This patient presents with a clinical picture consistent with obstructive shock. His distended neck veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent with pericardial tamponade. -This is a dynamic process over the course of the cardiac cycle, therefore bedside echocardiography is the diagnostic test of choice.

What is the most common symptom of hemorrhoids? A. Bleeding with defecation B. Mucoid discharge C. Painful defecation D. Pruritus

A. Bleeding with defecation

Which of the following conditions has a negative Nikolsky sign? A. Bullous pemphigoid B. Pemphigus vulgaris C. Staphylococcal scalded skin syndrome D. Toxic epidermal necrolysis

A. Bullous pemphigoid

A 75-year-old man with a history of renal colic presents with right flank pain radiating to the right groin. During triage, the patient has a syncopal event. Urinalysis shows no red cells. His blood pressure is 110/60 mm Hg. What is the best care for this patient? A. CT abdomen and pelvis with contrast B. CT abdomen and pelvis without contrast C. Discharge home with urology follow-up D. Intravenous antibiotics

A. CT abdomen and pelvis with contrast -The patient presents with signs and symptoms concerning for an abdominal aortic aneurysm (AAA) and should have a CT scan of the abdomen and pelvis with contrast to confirm the diagnosis.

A 61-year-old previously healthy man presents with three days of gross hematuria and clots in his urine. He denies any dysuria, flank pain, fever, or trauma. On examination, his heart rate is 78 beats per minute, blood pressure 142/72 mm Hg, and temperature 37.4°C. He has no abdominal tenderness or fullness on palpation. Genitourinary exam is unremarkable. Urinalysis is negative for leukocyte esterase and nitrites. There are > 100 red blood cells/hpf and 6 white blood cells/hpf. Creatinine is 1.1. What is the next step in the management of this patient? A. Computed tomography of the abdomen and pelvis with intravenous contrast B. Continuous bladder irrigation C. Discharge home with ciprofloxacin for five days D. Discharge home with urology referral

A. Computed tomography of the abdomen and pelvis with intravenous contrast -Workup should include a full history and physical, urinalysis, and assessment of renal function. If findings do not point to a specific cause of hematuria, a CT scan with IV contrast or renal ultrasound should be ordered to rule out underlying structural disease or mass.

A 41-year-old man with a long history of alcohol use disorder presents to the ED with several weeks of worsening shortness of breath and lower extremity edema. An echocardiogram shows biventricular chamber enlargement, increased systolic and diastolic volumes, and an ejection fraction of 35%. What is the most likely diagnosis? A. Dilated cardiomyopathy B. Hypertrophic cardiomyopathy C. Pericardial effusion D. Pulmonary embolism

A. Dilated cardiomyopathy -Dilated cardiomyopathy is the most common cardiomyopathy. Most cases of dilated cardiomyopathy are idiopathic, but they can also occur in a familial pattern and can result from alcohol misuse or due to medications, such as chemotherapeutic agents. -n echocardiogram is needed to confirm the diagnosis, showing decreased ejection fraction, increased systolic and diastolic volumes, and chamber enlargement.

A 32-year-old G0P0 woman presents with dull, crampy pelvic pain that has been intermittent over the last 6 months. She is currently menstruating and notes the pain seems to worsen with menses. She also reports pain with intercourse but does not have any vaginal discharge. On examination, she is in no acute distress and is afebrile. She has scant blood in the vaginal vault and no significant focal tenderness. No masses are felt. Her pregnancy test is negative. What is the most likely diagnosis? A. Endometriosis B. Mittelschmerz C. Pelvic inflammatory disease D. Ruptured ovarian cyst

A. Endometriosis -Dysmenorrhea, pelvic pain, and dyspareunia are the most frequent presenting complaints, but patients may have bowel or bladder symptoms as well. Infertility is found in a quarter of patients. Physical examination is often normal, but depending on the location and size of the implants, patients may have localized tenderness on pelvic examination.

A 59-year-old woman presents with pain and swelling of the face that began yesterday. She states that the symptoms began abruptly with a fever and chills. Physical exam reveals well-demarcated bright red, indurated skin in a malar distribution. The skin has a peau d'orange appearance. What is the most likely diagnosis? A. Erysipelas B. Rosacea C. Scarlet fever D. Systemic lupus erythematosus

A. Erysipelas -Erysipelas is an infection of the skin that is characterized by an abrupt onset of fever, chills, and malaise followed by the development of a bright red, well-demarcated, indurated area of the skin. -The skin can develop a peau d'orange appearance and classically involves the face in a malar distribution. The diagnosis is clinical.

A 32-year-old Nigerian man presents to the emergency department for blurry vision. He immigrated to the United States 6 months ago. He was diagnosed with a lung disease and was prescribed several medications in Nigeria. Which of the following agents is most likely responsible for his symptoms? A. Ethambutol B. Isoniazid C. Pyrazinamide D. Rifampin

A. Ethambutol -Ethambutol is an antitubercular medication whose side effect profile includes optic neuritis and red-green color blindness. -It is a component of the first-line RIPE therapy: rifampin, isoniazid, pyrazinamide, and ethambutol. The four-drug therapy is for active tuberculosis, and the initial treatment lasts for 2 months.

A 38-year-old man presents to the emergency department with low back pain that began this morning when he rolled over in bed. Throughout the day, he tried ibuprofen and acetaminophen without relief, which prompted him to come to the Emergency Department for further evaluation. Which of the following historical findings is an indication for further investigation? A. Fever B. Intentional weight loss with diet and exercise C. Palpable paraspinal muscle spasm D. Prolonged use of oxycodone

A. Fever -The "red flags" of back pain are historical features and physical exam findings that should prompt further investigation. -Among the red flags is a fever, which could indicate an infection. Investigation for infection should include spinal imaging, urinalysis, complete blood count, C-reactive protein, and erythrocyte sedimentation rate.

What is the most likely cause of acute anemia in an African-American patient with an HIV infection who recently began pneumocystis pneumonia prophylaxis? A. Glucose-6-phosphate-dehydrogenase deficiency B. Hereditary spherocytosis C. Paroxysmal nocturnal hemoglobinuria D. Pyruvate kinase deficiency

A. Glucose-6-phosphate-dehydrogenase deficiency -This patient most likely has hemolytic anemia caused by oxidative stress in the setting of G6PD deficiency. - Pneumocystis pneumonia prophylaxis is most commonly initiated with trimethoprim-sulfamethoxazole, an agent known to be associated with hemolysis in patients with G6PD deficiency.

A 65-year-old man presents to the ED with diffuse bone pain, abdominal cramping, and severe constipation. He is currently undergoing dialysis for end-stage kidney disease but has not been to dialysis this week. Physical exam reveals a lethargic man with diffuse abdominal tenderness without rebound or guarding. Which of the following is the most likely etiology for his symptoms? A. Hypercalcemia B. Hyperkalemia C. Hypomagnesemia D. Hypophosphatemia

A. Hypercalcemia -This patient is exhibiting signs and symptoms consistent with hypercalcemia, which in a patient with chronic kidney failure, is classically caused by tertiary hyperparathyroidism -Signs and symptoms of hypercalcemia include bone pain and remodeling, renal stones, abdominal pain, nausea, constipation, and psychiatric disturbances such as depression, lethargy, psychosis, and even coma. This can be remembered by the classic mnemonic of bones, stones, groans, and psychiatric overtones.

Which of the following is more consistent with the diagnosis of encephalitis rather than meningitis? A. Fever B. Headache C. Neck stiffness D. New psychiatric symptom

D. New psychiatric symptom

An 18-year-old presents to the emergency department with severe pain in his penis. He indicates he has had some mild irritation to the glans and foreskin areas recently. After intercourse tonight he was unable to reduce the foreskin and now has severe pain in the tip of his penis. On examination, the penis is flaccid and the foreskin is retracted proximally. There is swelling to the tip of the penis with mild erythema. What is the most likely diagnosis? A. Paraphimosis B. Penile fracture C. Phimosis D. Priapism

A. Paraphimosis -It is the inability to reduce the proximal edematous foreskin distally over the glans penis into its natural position.

A 32-year-old woman presents to the emergency department with dysuria, back pain, and fever for two days. She indicates she has had urinary tract infections in the past but never this severe. She denies other past medical history and does not take any medications. Vital signs show HR 114, BP 132/80, R 16, T 102.2°F. Examination shows a moderately ill-appearing woman with bilateral costovertebral angle tenderness. What test or tests are required in making an appropriate diagnosis in this patient? A. Urinalysis B. Urinalysis and contrast enhanced computed tomography of abdomen/pelvis C. Urinalysis and non-contrast enhanced computed tomography of abdomen/pelvis D. Urinalysis and ultrasonography of renal parenchyma

A. Urinalysis -The patient in this question is presenting with signs and symptoms of acute pyelonephritis. -the clinical syndrome of fever, chills, flank pain, and nausea or vomiting in conjunction with a urinalysis that is consistent with infection.

A 27-year-old woman presents with chest pain. The patient reports that she was about to give a presentation at her job and suddenly had a feeling of impending doom. In addition to chest pain, she had palpitations and sweating. Which of the following is this patient experiencing? A. Acute stress disorder B. Agoraphobia C. Hypomania D. Panic attack

D. Panic attack

Which of the following is the most common cause of status epilepticus in a patient with known epilepsy? A. Hypoglycemia B. Medication noncompliance C. Meningitis D. Trauma

B. Medication noncompliance

A 52-year-old man with a history of diabetes mellitus and hypertension presents to the ED with palpitations and dyspnea that have been present intermittently over the past week. His vital signs include HR 150 bpm, BP 136/87 mm Hg, RR 15/min, and SpO2 of 97% on room air. His ECG is shown above. The patient has atrial fibrillation with rapid ventricular response. Which of the following is the most appropriate initial management? A. Administer intravenous adenosine B. Administer intravenous diltiazem C. Sedate the patient and perform synchronized cardioversion with 100 joules D. Transport the patient to the cardiac catheterization suite

B. Administer intravenous diltiazem -Patients who are hemodynamically stable can be treated with rate control with beta-blockers or calcium channel blockers (diltiazem) and consideration of rhythm control, either with pharmacologic agents or via synchronized cardioversion.

A 27-year-old previously healthy man comes to the ED with chest pain. He had a viral syndrome with a low-grade fever a few days earlier. He describes the chest pain as sharp, retrosternal in location, with radiation to the left trapezius ridge. It improves with sitting forward and worsens when he lays down. Vital signs are normal. ECG shows diffuse ST segment elevation and PR segment depression. His initial cardiac biomarkers are negative. Which of the following treatments is most appropriate? A. Administration of aspirin and emergent cardiac catheterization B. Administration of ibuprofen and colchicine and discharge home C. Hospital admission for cardiac monitoring and serial cardiac enzymes D. Prescription for azithromycin and discharge home

B. Administration of ibuprofen and colchicine and discharge home -The patient has acute pericarditis. Pericarditis refers to inflammation of the pericardial sac. Classic symptoms include precordial or retrosternal sharp and stabbing chest pain, sometimes with radiation to the trapezius ridge or left arm. Patients may report that pain is worsened in the supine position and improved by sitting up and leaning forward -When viral infection is suspected, treatment is supportive with nonsteroidal anti-inflammatory medications. Therefore, administration of ibuprofen and discharge home is appropriate. Colchicine is also recommended to reduce the risk of recurrent pericarditis.

A 56-year-old woman with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents with acute substernal chest pain that is worse with exertion and associated with nausea and shortness of breath. Her sibling and parent both had "heart attacks" before the age of 55 years. Which of the following offers a proven mortality benefit in acute coronary syndrome? A. Amlodipine B. Aspirin C. Morphine D. Nitroglycerin

B. Aspirin -Aspirin is the prototypical antiplatelet agent for acute coronary syndrome and irreversibly inhibits platelet activity for the entire platelet life cycle (approximately 8-10 days). -Aspirin has been proven to reduce mortality in patients with acute myocardial infarction by 25-50%, both independently and with the use of fibrinolytic therapy.

A 6-year-old boy with a past medical history of glucose 6-phosphate dehydrogenase deficiency presents to the emergency department for a cough associated with vomiting. His parents state that he has been coughing every day for the last week. He is unimmunized but otherwise healthy. He appears well on exam with a dry cough and occasional wheezes. His laboratory workup reveals a leukocytosis with lymphocytic predominance and a chest X-ray with peribronchial thickening. Based on the suspected diagnosis, which of the following is the most appropriate therapy at this time? A. Ampicillin-sulbactam B. Azithromycin C. Ertapenem D. Trimethoprim-sulfamethoxazole

B. Azithromycin -Pertussis is a highly contagious acute respiratory infection caused by the gram-negative rod Bordetella pertussis. Infection is spread by respiratory droplets -Treatment is with azithromycin, although trimethoprim-sulfamethoxazole may be used in macrolide-intolerant patients. Treatment is best if started during the first week of the illness and may have limited utility after the catarrhal phase.

A 28-year-old woman is brought to the clinic by her sister, who is concerned about her recent reckless behavior. The patient has been spending money excessively, acting sexually promiscuous, speaking delusionally, and has not slept for three days. The patient is visibly irritated by her sister's comments. The patient reports periods of depression in the past, which were untreated, but now feels "absolutely great." She is extremely talkative, easily distracted in her thought process, and reports several different grand new ideas, which she explains within the space of a ten-minute discussion. What is the most likely diagnosis? A. Acute stress disorder B. Bipolar disorder C. Borderline personality disorder D. Dysthymic disorder

B. Bipolar disorder

A 23-year-old man with a history of insulin-dependent diabetes presents to the ED with vomiting and shortness of breath. He recently became homeless and has not been using his insulin. On physical exam, he has a fruity odor to his breath. After two hours of treatment in the ED, his serum labs include glucose 190 mg/dL, sodium 133 mEq/L, chloride 101 mEq/L, and bicarbonate 12 mmol/L. Which of the following is the most appropriate next step in management? A. Allow the patient to eat a turkey sandwich B. Change to dextrose-containing intravenous fluid C. Discharge home with endocrinology follow-up D. Transition to subcutaneous insulin therapy

B. Change to dextrose-containing intravenous fluid -Therapy should be continued until the anion gap is closed; however, this may take longer to achieve than the normalization of the serum glucose level. -Once the glucose level is < 200 mg/dL, glucose-containing fluids should be initiated to prevent hypoglycemia.

A 32-year-old man presents with severe, acute left knee pain that occurred while wrestling with his brother. He is unable to bear weight. His knee is held in flexion and he is unable to actively extend it. His leg is shown above. Which of the following is the best next step in management? A. Angiogram B. Closed reduction C. Computed tomography scan D. Orthopedic consultation

B. Closed reduction -The patient has a lateral patellar dislocation. -Closed reduction is the management of a patellar dislocation. The hip is flexed and the knee is passively extended while simultaneous medially-directed stress is applied to reduce the laterally displaced patella to its anatomic location.

A 49-year-old woman presents with chest pain and shortness of breath. Her pain is constant, non-exertional and does not radiate into the back. She denies hemoptysis, history of previous venous thromboembolism, trauma or surgery within the last four weeks or unilateral leg swelling. She takes no medications. She smokes a half pack of cigarettes per day. Her vital signs at triage are temperature 98.6°F, blood pressure 120/80 mm Hg, and heart rate 108 bpm. Her heart rate improves to 97 bpm upon reevaluation. Her physician decides to evaluate her for a pulmonary embolism. In addition to an ECG and a chest X-ray, which of the following is the most appropriate next step in the diagnosis of pulmonary embolism? A. CT pulmonary angiogram B. D-dimer followed by a CT pulmonary angiogram if positive C. Use the pulmonary embolism rule-out criteria to exclude pulmonary embolism D. V/Q scan

B. D-dimer followed by a CT pulmonary angiogram if positive -This patient is low risk for pulmonary embolism but had a heart rate greater than 100 bpm at triage, and therefore, should be evaluated by a D-dimer followed by a CT pulmonary angiogram if positive.

A 46-year-old woman without significant past medical history presents with drooping of the left side of her face which she noticed this morning when she looked into the mirror. She is unable to completely close her left eye and cannot raise her eyebrows on the left side. Her vision is intact. When asked to puff out her cheeks, air leaks out the left side. The rest of her neurologic exam is normal. Which of the following is the most appropriate initial management? A. CT head followed by administration of tPA B. Discharge home with prednisone and eye lubricant and patch at night C. Magnetic resonance imaging of the brain D. Stat neurology consult for neurointerventional procedure

B. Discharge home with prednisone and eye lubricant and patch at night -Weakness of the facial muscles is a sign of Bell palsy, which refers to unilateral cranial nerve VII weakness. -Symptoms of Bell palsy may include ipsilateral facial weakness, drooling, loss of taste sensation, ipsilateral tongue numbness, and ear or retroauricular pain -The treatment of Bell palsy includes prednisone and eye care, such as liberal use of a lubricating ointment during the day and an eye patch at night to prevent corneal abrasions.

Which of the following tests is used to diagnose benign paroxysmal positional vertigo? A. Caloric testing B. Dix-Hallpike maneuver C. Head thrust test D. Rinne test

B. Dix-Hallpike maneuver

A 32-year-old woman presents with dysuria and lower abdominal discomfort. She is sexually active with one male partner and uses condoms inconsistently. She denies vaginal bleeding or discharge, and her pelvic examination is unremarkable. Urinalysis shows 10 WBC/hpf with positive nitrites. Which of the following is the most likely causative organism? A. Acinetobacter B. E. coli C. Enterobacter D. Pseudomonas

B. E. coli -Acute cystitis is an isolated bladder infection. Women are more likely than men to have lower urinary tract infections due to shorter urethral length. Urinary tract infections (UTIs) typically result from ascending bacteria from the urethra -Escherichia coli (E. coli) converts nitrates to nitrite, which is a very useful test to confirm the diagnosis of a UTI. The urine nitrate reaction has > 90% specificity

A 51-year-old man with a history of diabetes mellitus and hypertension presents with approximately 60 minutes of left-sided jaw pain that began while he was shoveling snow. Which of the following tests should be ordered? A. Computed tomography scan of the maxillofacial region B. Electrocardiogram C. Erythrocyte sedimentation rate D. Panorex X-rays

B. Electrocardiogram -The patient has jaw pain that began during exertion. This presentation is concerning for acute coronary syndrome (ACS) and the patient should have an immediate electrocardiogram (ECG) performed.

A 22-year-old woman presents with symmetric lower extremity weakness. She recently had a diarrheal illness. Which of the following might you expect on further workup? A. Creatine kinase elevation B. Elevated protein of the cerebrospinal fluid C. Hyperreflexia D. Meningeal enhancement on MRI of the brain

B. Elevated protein of the cerebrospinal fluid -Guillain-Barré syndrome (GBS) is the most commonly encountered peripheral neuropathy in resource-rich countries -Patients develop symmetric weakness usually worse distally. It is often described as an ascending paralysis with progressive weakness and loss of reflexes. The tone of the rectal sphincter is preserved. -Additionally, lumbar puncture is abnormal, showing a markedly elevated CSF protein with a mild pleocytosis.

A 58-year-old man presents with two days of fever and lower back pain. Digital rectal exam reveals a swollen and tender prostate. His urinalysis reveals 100 WBC/hpf, leukocyte esterase, and nitrites. What is the most likely pathogen causing this condition? A. Chlamydia trachomatis B. Escherichia coli C. Klebsiella D. Pseudomonas

B. Escherichia coli -80% of the cases of acute bacterial prostatitis are secondary to infection with Escherichia coli. Acute bacterial prostatitis is characterized by fever, low back, and perineal pain.

A 22-year-old woman who is sexually active with multiple partners presents with dysuria for 2 days. The urine pregnancy test is negative. Her urinalysis reveals 36 WBC/hpf and is nitrite and leukocyte esterase positive. She is diagnosed with cystitis. What is the most likely bacterial pathogen? A. Chlamydia trachomatis B. Escherichia coli C. Klebsiella species D. Proteus species

B. Escherichia coli -Urinary tract infections are a common diagnosis among females. Escherichia coli is by far the most common bacterial cause of a urinary tract infection.

A 65-year-old man with a medical history of hypertension presents to the emergency department with tearing chest and abdominal pain radiating towards his back. His blood pressure is 185/98 mm Hg. Which of the following medications should be administered first? A. Aspirin B. Esmolol C. Heparin D. Nitroprusside

B. Esmolol -Esmolol is the first-line treatment for a hypertensive patient with an aortic dissection. Rate-controlling medication (e.g., esmolol) should be given before vasodilators to prevent reflex tachycardia and subsequent increase in aortic shearing forces.

A 25-year-old woman with a history of hypertension presents to the emergency department after a syncopal event. She is complaining of lower abdominal pain. Her heart rate is 132 beats/minute and her blood pressure is 85/41 mm Hg. Her urine pregnancy test is positive. Which of the following is the most appropriate next step in management? A. Administer rho(D) immune globulin B. Establish intravenous access C. Obtain a 12-lead electrocardiogram D. Order an abdominal ultrasound

B. Establish intravenous access -Establishing intravenous access is the most appropriate next step in this hemodynamically unstable patient. -This patient likely has significant hemorrhage from a ruptured ectopic pregnancy and requires fluid resuscitation and possible blood transfusion.

An 8-year-old girl with a history of sickle cell anemia presents with diffuse pain consistent with an acute sickle cell pain crisis. While in the emergency department, she develops acute onset headache, right-sided facial droop, and right arm weakness. A CT scan confirms the diagnosis. Which of the following is the next best step in management? A. Alteplase B. Exchange transfusion C. MRI brain D. Tranexamic acid

B. Exchange transfusion -Cerebrovascular events are a potential complication of sickle cell disease. This patient developed symptoms concerning for acute ischemic stroke -For pediatric patients with acute ischemic stroke in the setting of sickle cell disease, exchange transfusion is the treatment of choice

A 28-year-old woman presents to the ED following a finger injury while playing flag football. She states that she sustained a direct blow to the pointer finger when the ball struck her fingertip. On physical exam, the patient has swelling and tenderness at the distal interphalangeal joint. The fingertip rests in 45 degrees of flexion. She is unable to demonstrate active extension of the distal interphalangeal joint but has full passive extension. The skin is intact. X-ray of the finger is obtained, which shows soft tissue swelling but no fracture or dislocation. Which of the following is the most appropriate management for this patient? A. Buddy taping B. Extension splinting of the distal interphalangeal joint C. Extensor tendon reconstruction D. Physical therapy for range of motion and strengthening

B. Extension splinting of the distal interphalangeal joint -Mallet finger occurs when the extensor tendon of the distal interphalangeal (DIP) joint is ruptured. This injury commonly occurs with ball sports when a patient sustains a direct blow to the fingertip resulting in forced flexion of the DIP joint. -Mallet finger injuries may occur with or without a dorsal avulsion fracture of the distal phalanx. Treatment consists of extension splinting of the DIP joint as long as the injury is acute (< 12 weeks) and there is no displaced bony injury

A 34-year-old man presents to the emergency department with left arm pain after a fall on an outstretched hand while walking his dog. He has tenderness and swelling of the forearm as well as wrist pain with attempted pronation and supination. An X-ray is obtained as seen above. What eponym is associated with this fracture? A. Colles fracture B. Galeazzi fracture C. Hutchinson fracture D. Monteggia fracture

B. Galeazzi fracture

A 42-year-old man presents to the ED with racing heart rate and difficulty breathing. On physical exam, you note bilateral ocular proptosis and 3+ non-pitting edema of the bilateral lower extremities. His electrocardiogram is shown above. Which of the following complications of this disease is this patient most likely experiencing? A. Cardiac tamponade B. High output heart failure C. Pulmonary embolism D. Tension pneumothorax

B. High output heart failure -This patient is exhibiting signs and symptoms consistent with thyroid storm. Thyroid storm is a rare, life-threatening hypermetabolic state caused by severe thyrotoxicosis. The most common precipitating factor is an infection. A well-recognized and important complication of thyroid storm is high output heart failure

A 28-year-old woman presents with pain and swelling of her left breast, fever, and myalgias. She had a full-term vaginal delivery 1 week ago and is breastfeeding her infant. On examination, she has a temperature of 38.1°C. The superior lateral quadrant of the left breast is erythematous, warm, and tender to palpation. There is no fluctuance appreciated. What is the next step in management? A. Instruct her to continue breastfeeding and start intravenous vancomycin B. Instruct her to continue breastfeeding and start oral cephalexin C. Instruct her to discontinue breastfeeding and start intravenous vancomycin D. Instruct her to discontinue breastfeeding and start oral cephalexin

B. Instruct her to continue breastfeeding and start oral cephalexin -Mastitis is most frequently a complication of breastfeeding, usually in the first 6 weeks postpartum, although it may occur in non-breastfeeding women as well -Patients present with signs of cellulitis (erythema, warmth, and tenderness) localized to one area of the breast, as well as fever. -Treatment involves cool compresses and analgesics. -In cases of simple mastitis, breastfeeding should continue to ensure complete drainage of the breast. Oral antibiotics (dicloxacillin or cephalexin) should be prescribed

An 80-year-old woman, with a history of type 2 diabetes mellitus, presents with slowly worsening vision. Her vision is worse in low-intensity light and she has blurring in the center of her vision. Physical examination shows intact peripheral visual fields with a positive Amsler grid distortion. Fundoscopic exam reveals drusen located in the macula of the retina. What is the most likely diagnosis? A. Diabetic retinopathy B. Macular degeneration C. Open-angle glaucoma D. Presbyopia

B. Macular degeneration -Macular degeneration is characterized by central vision loss caused by atrophy of the cells in the central macular region of the retinal pigment epithelium. -Symptoms include wavy or distorted central vision and central blind spots. An Amsler grid will be perceived as distorted by the patient on exam. -Fundoscopic examination in early disease shows drusen.

A 46-year-old man with a history of diabetes mellitus and chronic alcohol use presents to the emergency department with lower back pain that has progressively worsened over the last five days. He denies a history of trauma. On examination, he has a temperature 37.9oC (100.2 F), heart rate 87 beats/minute, and blood pressure 146/75 mm Hg. He has tenderness with percussion over the midline lower lumbar spine. Achilles and patellar reflexes are intact. He has mild decreased sensation of both feet, but his strength is intact. What is the next best step in management? A. Complete blood count B. Magnetic resonance imaging of the lumbosacral spine C. Pain control with ibuprofen and discharge home D. Plain radiographs of the lumbosacral spine

B. Magnetic resonance imaging of the lumbosacral spine -This patient has signs and symptoms concerning for a spinal epidural abscess. High-risk patients include intravenous drug users, alcoholics, and immunocompromised patients (history of diabetes mellitus). -Patients present with lower back pain and often have tenderness with percussion over the spinal processes. Fever is present in only 50% of patients. Focal neurologic deficits can also be present but, again, are lacking in nearly half of patients. -Emergent MRI of the lumbosacral spine is the modality of choice for diagnosing

A 25-year-old man presents to the emergency department after a gunshot wound to the chest. He is awake and following commands. His vital signs are T 97.5°F (36.4°C), BP 89/50 mm Hg, HR 120 bpm, RR 35/min, and SpO2 87% on a nonrebreather face mask. Jugular venous distension is present, and he has diminished breath sounds on the left. Which of the following is the best next step in management? A. Focused assessment with sonography for trauma examination B. Needle decompression of the chest C. Pericardiocentesis D. Upright chest X-ray

B. Needle decompression of the chest -Needle decompression of the chest in the second intercostal space in the midclavicular line is recommended for emergent management of a tension pneumothorax. -A tension pneumothorax is a clinical diagnosis, and definitive management should not be delayed to obtain imaging. Clinical findings include diminished or absent breath sounds on the side of the injury, tracheal deviation away from the side of the injury, and evidence of mediastinal mass effect (hypotension, jugular venous distension).

A 6-week-old infant presents with decreased appetite. The child is underweight for her age, and her mother says that she is not eating well. Physical exam reveals a continuous heart murmur in the left infraclavicular space and a thrill in the suprasternal notch. Which of the following findings would be expected on echocardiogram? A. Overriding aorta B. Patent ductus arteriosus C. Right ventricular outflow obstruction D. Ventricular septal defect

B. Patent ductus arteriosus

A 67-year-old man with a history of bronchogenic carcinoma presents with fever and shortness of breath. His vital signs are T 101.5°F (38.6°C), HR 112 bpm, RR 22/min, BP 100/60 mm Hg, and SpO2 92% on room air. He has right basilar crackles on auscultation and dullness to percussion. A chest X-ray demonstrates a right lower lobar consolidation with costophrenic angle blunting. Which of the following values suggests the presence of an exudative pleural effusion? A. Partial pressure of arterial oxygen < 70% B. Pleural fluid lactate dehydrogenase twice that of serum lactate dehydrogenase C. Pleural fluid pH 7.6 D. Pleural fluid:serum protein ratio < 0.5

B. Pleural fluid lactate dehydrogenase twice that of serum lactate dehydrogenase -Light criteria for the diagnosis of pleural exudative effusion include the presence of at least one of the following: pleural fluid lactate dehydrogenase (LDH) to serum LDH ratio > 0.6, pleural fluid to serum protein ratio > 0.5, or pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH.

Which of the following is the most common pulmonary complication of influenza? A. Empyema B. Pneumonia secondary to superimposed bacterial infection C. Primary viral pneumonia D. Spontaneous pneumothorax

B. Pneumonia secondary to superimposed bacterial infection

Which of the following is the most common injury seen in a child with severe blunt chest trauma such as being struck by a motor vehicle? A. Pneumothorax B. Pulmonary contusion C. Rib fracture D. Tracheobronchial laceration

B. Pulmonary contusion

A 25-year-old man is brought to the emergency department by police for bizarre behavior. His family arrives and states that his behavior changed about eight months ago. He does not abuse drugs or alcohol. On examination, he has a flat affect and appears to be responding to internal stimuli. His speech is disorganized and he says, "I've been running from the Russians who are trying to steal my thoughts." His laboratory and urine studies are unremarkable. What is the most likely diagnosis? A. Schizoaffective disorder B. Schizophrenia C. Schizophreniform disorder D. Schizotypal personality disorder

B. Schizophrenia

Which of the following patients presenting to the emergency department with suicidal ideation would be considered highest risk for suicide if released from the department? A. A 25-year-old African American man who reports depression in the setting of a recent break-up with his girlfriend B. A 35-year-old white woman with a history of schizophrenia who has not been compliant with her medications C. A 50-year-old white man who works as a physician and has been diagnosed with severe depressive disorder D. A 60-year-old married, African American woman with cancer who is tired of her chemotherapy and is ready for "it all to end"

C. A 50-year-old white man who works as a physician and has been diagnosed with severe depressive disorder -However, particular groups of people have been identified as higher risk for suicide attempts and include men, especially those who are above age 45 and white, adolescents, veterans, American Indian teenagers, persons with particular occupations (agricultural workers, physicians, attorneys, and veterinarians), youths and adults who identify as gay, lesbian, bisexual, or transgender, and persons with mental illness, disabilities, or chronic pain

A 26-year-old man presents to the ED after briefly losing consciousness when hit in the head by a foul baseball. The patient was initially alert and talking to you. He is now becoming progressively more somnolent. Which of the following would you expect to see on a non-contrast computed tomography scan of the head? A. A collection of blood layering in the basilar cisterns B. A crescent-shaped frontal hematoma crossing suture lines C. A lenticular-shaped hematoma in the temporal region D. An intraparenchymal hemorrhage within the frontal lobe

C. A lenticular-shaped hematoma in the temporal region -This patient's presentation and physical examination are consistent with a traumatic acute epidural hematoma, a collection of blood between the skull and the dura -The diagnosis is made with a non-contrast CT of the head. This characteristically shows a hyperdense lenticular-shaped hematoma in the temporal region that is sharply defined and does not cross suture lines

A 61-year-old man presents with intermittent shock-like spasms of pain in his right cheek. The pain only lasts a few seconds at a time but recurs frequently. He notes that shaving each morning causes intense spasms of pain, as does chewing. What is the first-line treatment for his likely diagnosis? A. Baclofen B. Botulinum injections C. Carbamazepine D. Diazepam

C. Carbamazepine -Trigeminal neuralgia is characterized by unilateral, shock-like paroxysms of pain in distributions of one or more divisions of the trigeminal nerve. It is often the result of vascular compression of the trigeminal nerve root -The first-line treatment of choice for trigeminal neuralgia is carbamazepine. The initial dosage is 100 mg twice daily.

A 5-year-old boy presents to the emergency department reporting right hip pain. He is febrile and refuses to bear weight on the right foot. There is no history of trauma. X-rays are obtained and are unremarkable. Which of the following diagnostic tests would best exclude a diagnosis of osteomyelitis? A. Blood culture B. Complete blood count with differential C. Erythrocyte sedimentation rate D. Serum glucose

C. Erythrocyte sedimentation rate -Pediatric patients with underlying osteomyelitis almost universally have an elevated erythrocyte sedimentation rate (ESR). An elevated ESR and C-reactive protein have a 98% sensitivity for osteomyelitis in children. -The two most common symptoms of osteomyelitis in children are fever and joint pain.

A 42-year-old man with a history of heavy alcohol use presents with severe abdominal pain and vomiting following an alcohol binge. Lab values are as follows: WBC 14,000, Hgb 10, platelets 98,000, lipase 9,000, AST 200, ALT 107, T. bill 1.6, Na 134, K 5.1, Cr. 3.1, and glucose 313. Which of the following lab values is associated with increased mortality according to the Ranson Criteria? A. AST of 200 B. Creatinine of 3.1 C. Glucose of 313 D. Lipase of 9,000

C. Glucose of 313 -Pancreatitis can be caused by gallstones, alcohol, infection, hypertriglyceridemia, hypercalcemia, tumors, pancreatic divisum, medications, and trauma. -Ranson criteria on admission include age > 55, glucose > 200, WBC > 16,000, AST > 250, LDH > 350.

Which of the following correctly describes electrocardiographic features of second-degree type I atrioventricular block? A. Absence of discernible P waves B. Constant PR interval followed by a dropped beat C. Grouped beats D. Sawtooth P waves

C. Grouped beats

A 23-year-old professional soccer player collapses during a match. He is pulseless, and cardiopulmonary resuscitation is initiated. Which of the following is the most common cause of sudden death in competitive athletes? A. Arrhythmogenic right ventricular dysplasia B. Dilated cardiomyopathy C. Hypertrophic cardiomyopathy D. Long QT syndrome

C. Hypertrophic cardiomyopathy

A 39-year-old man presents to the emergency department with left hand pain. He denies recent trauma, genital or oral lesions, or fever. His medical history is significant for diabetes mellitus and tobacco abuse. He has a felon. Which of the following is the most appropriate initial therapy for this patient? A. Acyclovir PO B. Clindamycin IV C. Incision and drainage D. Trephination

C. Incision and drainage -Incision and drainage is the recommended initial treatment if the finger is swollen and tense with palpable fluctuance.

A 44-year-old woman presents to the emergency department with one week of crampy abdominal pain that is worse after she eats. She denies alcohol consumption or tobacco abuse. On physical examination, she is overweight and has epigastric and right upper quadrant abdominal tenderness to palpation. Which of the following examination findings is most consistent with cholecystitis? A. Epigastric rebound tenderness B. Grey-Turner sign C. Inspiratory arrest with right upper quadrant palpation D. Right scapular tenderness

C. Inspiratory arrest with right upper quadrant palpation -Cholecystitis is an inflammatory process of the gallbladder -Symptoms include epigastric and right upper quadrant abdominal pain that is worse after eating. -On physical examination, a Murphy sign may be elicited and is considered positive if the patient demonstrates inspiratory arrest with palpation of his or her right upper quadrant while having him or her take a deep breath.

A 45-year-old man with a history of alcoholic cirrhosis presents to the emergency department for confusion. His family brought him. They deny recent trauma, infection, bloody emesis, or stool. He is unable to give a coherent history but seems pleasantly confused. He denies pain. Family report that he no longer drinks alcohol and has not used any medications or drugs recently. On exam, he is drowsy and delirious. His hands flap when held up, and his tongue gyrates back and forth when protruded. Guaiac testing is negative. His abdomen is distended, but soft and nontender. A noncontrast computed tomography scan of the head shows no evidence of bleeding. His renal function is normal, sodium levels are within normal ranges, liver function tests are within his normal ranges, and blood counts are normal. His ammonia level is elevated at 114 µmol/L. What therapy should be initiated? A. Albumin B. Cefotaxime C. Lactulose D. Paracentesis

C. Lactulose -Hepatic encephalopathy is a poorly understood complication of hepatic disease. Patients present with symptoms ranging from fatigue to coma. -. Treatment revolves around removing nitrogenous waste from the system, by means of lactulose. Lactulose is a disaccharide that degrades into lactic acid in the colon. The acidified colonic environment traps ammonia and other nitrogenous waste in the colon, allowing for removal.

A 35-year-old woman presents to the ED with facial swelling. On physical exam, you note major swelling of the tongue (angioedema). Which of the following medications is most likely the cause of this process? A. Amiodarone B. Heparin C. Lisinopril D. Metoprolol

C. Lisinopril -This patient is exhibiting signs and symptoms of drug-induced angioedema. -Signs and symptoms of angioedema include painless, nonpruritic, nonpitting edema of the skin. Angioedema usually affects the tongue, lips, and face -Common triggers of drug-induced angioedema include ACE inhibitors like lisinopril which inhibit bradykinin degradation. This can occur at any time during treatment. Aspirin, NSAIDs, and any cyclooxygenase inhibitors can cause angioedema as can iodinated contrast material.

A 44-year-old man with systemic lupus erythematosus presents to the ED with chest pain and dyspnea. Vital signs are notable for tachycardia and hypotension with a narrow pulse pressure. Bedside ultrasound confirms a large pericardial effusion with collapse of the right ventricle during diastole. Which classic electrocardiogram findings are associated with this disease process? A. Delta wave and shortened PR interval B. Diffuse ST elevation C. Low voltage and electrical alternans D. S wave in lead I and a Q wave and inverted T wave in lead III

C. Low voltage and electrical alternans -The patient has cardiac tamponade. -Classic ECG findings of cardiac tamponade include low voltage QRS complexes and electrical alternans, where there is beat-to-beat variation in the amplitude of the R waves. The treatment for cardiac tamponade causing hemodynamic instability is emergent pericardiocentesis.

A 30-year-old man presents to the ED with 3 weeks of diarrhea. He reports colicky abdominal pain associated with frequent episodes of pale, loose, foul-smelling stools. He returned from a camping trip in New Hampshire 1 month prior. His vital signs are temperature 37.1°C, heart rate 85 bpm, and blood pressure 125/80 mm Hg. Which of the following is the most appropriate treatment for this condition? A. Ciprofloxacin 500 mg daily for 7 days B. Clindamycin 300 mg qid for 7 days C. Metronidazole 250 mg tid for 7 days D. Rifaximin 200 mg tid for 7 days

C. Metronidazole 250 mg tid for 7 days -This patient is presenting with signs and symptoms consistent with giardiasis, the most common cause of parasitic diarrheal infection in the United States. -Classic symptoms include explosive diarrhea, colicky abdominal pain, and pale, loose, foul-smelling stools. The incubation period is 1-3 weeks, followed by an abrupt onset. -Treatment is empiric. The appropriate regimen is metronidazole 250 mg three times a day for 7 days.

A 32-year-old woman presents with progressive fatigue, shortness of breath, and chest discomfort that has worsened over the last 2 days. She had a mild upper respiratory infection last week but otherwise reports no significant past medical history. She does not take any medications and reports no illicit drug use. On examination, she has a T 37.9°C, HR 132 bpm, RR 16/min, and oxygen saturation 98% on room air. Lungs are clear to auscultation. Chest radiograph demonstrates mild cardiomegaly without infiltrates. Electrocardiogram shows sinus tachycardia with nonspecific ST segment and T wave changes. Troponin I is 0.25 ng/mL (normal range ≤0.05 ng/mL). What is the likely cause of her symptoms? A. Acute coronary artery thrombosis B. Community-acquired pneumonia C. Myocarditis D. Pulmonary embolism

C. Myocarditis -Presentation is variable depending on the etiology and stage of disease. Fatigue, fever, chest discomfort, dyspnea, and palpitations are common presenting symptoms in adults. Patients with advanced disease may present with dysrhythmias, heart failure, and cardiogenic shock. -On physical exam, there may be tachycardia that is disproportionate to fever or discomfort, an S3 or S4 gallop, and signs of fluid overload. As pericarditis often occurs concomitantly with myocarditis, a friction rub may be heard

A 74-year-old woman with a history of hypothyroidism presents to the ED with confusion, rigors, and lightheadedness. Vital signs are BP 110/64 mm Hg, HR 48 beats per minute, RR 12 breaths per minute, and T 95.2°F. Her electrocardiogram is shown above. Which of the following is the most likely diagnosis? A. Digoxin toxicity B. Hyperosmolar nonketotic coma C. Myxedema coma D. Nephrogenic diabetes insipidus

C. Myxedema coma -Myxedema coma is defined as severe hypothyroidism resulting in a decompensated metabolic state and mental status change. -It is classically characterized by thickened, non-pitting edema of the skin diffusely associated with severe chronic hypothyroidism. Precipitating factors of myxedema coma include infection, cold exposure, stroke, or medications such as amiodarone or lithium. Mortality in myxedema coma is proportional to the severity of the patient's hypothermia. -Other signs and symptoms of myxedema coma include hypoventilation, bradycardia, poor cardiac contractility, decreased cardiac output, pericardial effusion, and altered mental status.

Which of the following is a known complication of chronic lithium toxicity? A. Diabetes mellitus B. Hypoparathyroidism C. Nephrogenic diabetes insipidus D. Syndrome of inappropriate antidiuretic hormone

C. Nephrogenic diabetes insipidus -Lithium toxicity can present in the setting of acute, acute-on-chronic and chronic ingestions. Chronic lithium ingestion may cause nephrogenic diabetes insipidus, a concentrating defect in the kidneys due to a resistance of antidiuretic hormone.

A 31-year-old man presents to the emergency department in police custody after he was found unclothed, confused, and running down a snowy street. His urine drug test is positive for phencyclidine (PCP). Which of the following ocular findings is most likely present on physical examination? A. Pinpoint pupils B. Proptosis C. Ptosis D. Rotary nystagmus

D. Rotary nystagmus

Which of the following causes acute painful loss of vision? A. Central retinal artery occlusion B. Central retinal vein occlusion C. Optic neuritis D. Retinal detachment

C. Optic neuritis

A 55-year-old woman presents with right finger pain. She reports she habitually bites her nails. On examination, the lateral nail fold and cuticle of the right ring finger is erythematous, fluctuant and tender to palpation. Which of the following is the most likely diagnosis? A. Felon B. Flexor tenosynovitis C. Paronychia D. Tinea unguium

C. Paronychia -A paronychia is an infection of the lateral nail fold or paronychium and is the most common hand infection. Most cases are caused by minor trauma such as nail biting, manicures, or hangnails.

An 18-year-old man presents complaining of fever, right-sided abdominal pain, anorexia, and vomiting. When you palpate his left lower quadrant, he complains of pain in his right lower quadrant. Based on this information, which of the following signs is considered positive? A. McBurney sign B. Obturator sign C. Psoas sign D. Rovsing sign

D. Rovsing sign

A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his fingers after returning home from 4-week summer camp one week ago. He reports several other campers had similar symptoms. On exam, you note excoriations in the inguinal region and axillae, surrounding scattered erythematous papules. Which of the following is the most appropriate treatment? A. Ketoconazole B. Lindane C. Permethrin D. Prednisone

C. Permethrin -This patient has scabies, a pruritic dermatitis caused by cutaneous infection with the mite Sarcoptes scabiei var. hominis. Scabies is spread by skin-to-skin contact and should be considered in patients with generalized pruritus -The treatment of choice is permethrin 5% lotion. Individuals affected by scabies should avoid skin-to-skin contact with others

A 32-year-old woman, who is at 20 weeks gestational age, presents to the ED after a seizure. Her vital signs are BP 115/70 mm Hg, HR 105 bpm, RR 16/min, T 38.5°C, and pulse oximetry 98% on room air. On exam, you note some confusion, but otherwise there are no focal deficits. Lab results reveal a hemoglobin of 7 g/dL and platelets of 12,000/µL. A peripheral blood smear reveals schistocytes. Which of the following is the most appropriate treatment for her condition? A. Delivery of fetus B. Magnesium sulfate C. Plasmapheresis D. Platelet transfusion

C. Plasmapheresis -The patient has thrombotic thrombocytopenic purpura (TTP). The classic pentad of TTP includes CNS abnormalities, renal pathology, fever, microangiopathic hemolytic anemia, and thrombocytopenia. -The mainstay of treatment for TTP is plasmapheresis (plasma exchange)

A 38-year-old man with a past medical history of hypertension and stage III chronic kidney disease presents with severe left foot pain that began in the middle of the night. He appears comfortable but has exquisite tenderness to palpation of the left, first metatarsophalangeal joint. The joint is erythematous and warm. His vital signs include a temperature of 99.1°F, BP 132/85 mm Hg, RR 16 breaths/minute, and oxygen saturation 99% on room air. Arthrocentesis of the involved joint is performed and synovial fluid analysis reveals negatively birefringent crystals. Which of the following is the most appropriate therapy at this time? A. Allopurinol B. Naproxen C. Prednisone D. Probenecid

C. Prednisone -The patient has acute gouty arthritis. -First-line treatment for acute gout is with colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin or naproxen unless contraindications exist. -Advanced kidney disease is a contraindication to NSAID use and should be avoided in this patient. Patients intolerant to NSAIDs may be treated with steroids such as prednisone.

Which of the following is one of the most helpful signs to rule out testicular torsion? A. Presence of a bell-clapper deformity B. Presence of Prehn sign (relief of scrotal pain upon elevation of scrotum) C. Presence of the cremasteric reflex D. Vertical lie of testicle

C. Presence of the cremasteric reflex -The cremasteric reflex is a superficial reflex elicited by lightly stroking the superior and medial (inner) thigh of a man. The normal response is an immediate contraction of the cremaster muscle that pulls up the testis (> 0.5 cm) on the side stroked. -The presence of a cremasteric reflex appears to be one of the most helpful signs in ruling out testicular torsion.

A 22-year-old man presents with upper extremity weakness. He notes that he was drinking heavily last night and when he woke up this morning he was unable to move his hand. On examination, he has normal strength in the biceps and triceps but weakness of the wrist extensors, finger extensors, and brachioradialis. Injury to what nerve accounts for his symptoms? A. Median nerve B. Musculocutaneous nerve C. Radial nerve D. Ulnar nerve

C. Radial nerve -This patient presents with findings consistent with a radial nerve palsy. The radial nerve is formed from nerve roots C5 through T1. It runs adjacent to the humerus in the spiral groove of the upper arm. -There will be weakness of the wrist extensors, resulting in a wrist drop, as well as weakness of the finger extensors and brachioradialis muscle

A 67-year-old man with a history of hypertension and diabetes mellitus presents to the emergency department with sudden onset of left leg weakness. His examination is notable for 3/5 strength in his left lower extremity as well as diminished sensation over his left toes, foot, and leg. He has a flat affect and appears slow in his speech. Which of the following vascular territories is most likely affected in this patient? A. Left lenticulostriate arteries B. Left posterior cerebral artery C. Right anterior cerebral artery D. Right middle cerebral artery

C. Right anterior cerebral artery -Symptoms of an ACA infarction include contralateral lower extremity weakness and sensory loss with sparing of the upper extremity and face.

A 39-year-old woman presents to the emergency department with right leg pain and mild swelling. She denies any previous medical history or trauma. She does not take any medication. Examination is remarkable for tenderness along the right calf venous distribution and minimal swelling of the right lower leg. What is the most appropriate diagnostic workup of this patient? A. Duplex ultrasonography to evaluate for deep venous thrombosis. If negative, send a D-dimer. If D-dimer is positive, treat for deep venous thrombosis. B. Duplex ultrasonography to evaluate for deep venous thrombosis. If negative, the patient may be discharged C. Send a D-dimer. If negative, the patient may be discharged. D. Send a D-dimer. If positive, treat for deep venous thrombosis.

C. Send a D-dimer. If negative, the patient may be discharged. -In a patient with low-to-moderate risk for DVT, the appropriate workup includes at least a negative high-sensitivity D-dimer test in order to complete the workup without imaging. If duplex ultrasonography is performed first in this moderate risk patient and is negative, either a high-sensitivity D-dimer test should be sent and should be negative or the patient should seek serial duplex ultrasonography.

A 32-year-old man presents to the emergency department with a report of fever and shortness of breath. On physical exam, he is noted to have coarse breath sounds bilaterally and a systolic murmur. A chest radiograph is obtained and shown above. Which of the following abnormalities is likely to be noted on an echocardiogram? A. Diffuse myocardial hypokinesis B. Mitral valve vegetations C. Pericardial effusion D. Tricuspid valve vegetations

D. Tricuspid valve vegetations -Tricuspid valve vegetations are the most likely abnormalities seen on an echocardiogram. This patient has endocarditis affecting his tricuspid valve.

An 18-month-old boy presents with his father for a cough and difficulty breathing. The father states that the child has had nasal congestion and coryza for the last two days. On exam, he has a barking cough, inspiratory stridor, and a prolonged inspiratory phase. Which of the following would you expect to see on radiographic evaluation? A. Edema of the epiglottis B. Intraluminal membranes of the tracheal wall C. Subglottic narrowing

C. Subglottic narrowing -Subglottic narrowing and distention of the hypopharynx may be seen on chest radiograph or a soft tissue neck radiograph, respectively, in a child with croup. Subglottic narrowing is often called the "steeple sign"

Which muscle is most commonly involved with rotator cuff injuries? A. Infraspinatus B. Subscapularis C. Supraspinatus D. Teres minor

C. Supraspinatus

A 7-year-old girl presents to the ED with noisy breathing, fever, and drooling. On physical exam, she is in obvious respiratory distress with audible stridor at rest. Vital signs are BP 90/60 mm Hg, HR 150 beats/minute, RR 40 breaths/minute, and T 103.8°F. Which of the following are you likely to see on a lateral radiograph of the soft tissues of the neck? A. Steeple sign B. Subcutaneous emphysema C. Thumbprint sign D. Widening of the prevertebral soft tissues

C. Thumbprint sign -This child is exhibiting signs and symptoms of epiglottitis. Diagnosis of epiglottitis is clinical. If the diagnosis is not clear, a lateral soft tissue X-ray of the neck could be obtained and would reveal a "thumbprint" sign.

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

C. Topical ciprofloxacin -Topical ciprofloxacin is first-line treatment for a corneal ulceration. This is because of the necessary coverage against Pseudomonas aeruginosa. -Risk factors for developing a corneal ulcer include incomplete lid closure (e.g. secondary to Bell's palsy) and soft contact lenses use. Symptoms include redness, swelling of the lids, foreign body sensation, and photophobia.

A 25-year-old G1P0 woman at 38 weeks gestation presents to the ED after feeling a gush of fluid. On tocometry you note variable decelerations of the fetal heart rate. You perform a sterile vaginal exam and feel a pulsating mass protruding from the cervical os. Which of the following appropriately matches the diagnosis with the next step in management? A. Breech positioning, attempt external version B. Shoulder dystocia, knee-to-chest positioning C. Umbilical cord prolapse, elevate presenting part D. Uterine inversion, administer tocolytics

C. Umbilical cord prolapse, elevate presenting part -This patient has evidence of umbilical cord prolapse, which is defined by delivery of the umbilical cord prior to the delivery of the fetus -Management of umbilical cord prolapse is by immediate elevation of the presenting part and emergent cesarean section.

A 24-year-old woman presents to the emergency department with a headache and receives a lumbar puncture. She is eventually discharged home in improved condition, but returns 24 hours later with a worsened headache, now throbbing in nature, which is worse in the standing position and relieved in the supine position. Which of the following reduces the risk of post-lumbar puncture headache? A. Inserting the needle bevel perpendicular to the spine B. Lying supine for one hour after the lumbar puncture is completed C. Using a higher gauge needle

C. Using a higher gauge needle -Post-lumbar puncture headache is the most common complication of a lumbar puncture (LP). -Modern evidence-based strategies for prevention include the use of a higher gauge spinal needle (which corresponds to a smaller caliber needle),

A 55-year-old man presents with fever and right upper quadrant pain. On examination, you note that the patient is jaundiced and slightly altered. Clinically you make the diagnosis of cholangitis. Which of the following is the final component of Reynold's pentad? A. Acute kidney injury B. Dilated common bile duct C. Elevated lipase D. Hypotension

D. Hypotension -Cholangitis is caused by obstruction of the common bile duct and subsequent ascending infection. -Charcot in 1877 with the clinical triad of fever, right upper quadrant pain, and jaundice. -The presence of Charcot's triad and sepsis - defined as hypotension and altered mental status - is called Reynold's pentad.

A 50-year-old man presents to the emergency department with sudden onset of shortness of breath. He has a history of heart failure with an ejection fraction of 25%. Vital signs include temperature 100°F (37.7°C), blood pressure 220/110 mm Hg, heart rate 125 bpm, and respiratory rate 30/min. On examination, he appears anxious and tachypneic. Chest X-ray demonstrates diffuse bilateral interstitial opacification. Which of the following is the most appropriate initial treatment? A. Albuterol B. Dobutamine C. Furosemide D. Nitroglycerin

D. Nitroglycerin -Acute hypertensive heart failure can result in pulmonary edema that must be managed with aggressive preload and afterload reduction -Nitroglycerin can be administered sublingually and intravenously to achieve rapid and titratable improvement in hypertension via vasodilation with a reduction in preload and afterload

A 58-year-old man presents with chest pain. His electrocardiogram is shown above. A right-sided electrocardiogram is also performed and shows elevated ST segments in V4R and V5R. Which of the following medications is contraindicated? A. Aspirin B. Bivalirudin C. Heparin D. Nitroglycerin

D. Nitroglycerin -The patient has evidence of a right ventricular infarction. In the majority of people, the right ventricle receives its blood supply from the right coronary artery. -Nitroglycerin, which is commonly used in acute myocardial for its preload and afterload reducing effects, should not be used in right ventricular infarction because it can precipitate critical hypotension and cardiovascular collapse. -Treatment of right ventricular infarction, in addition to early reperfusion, includes using fluids to maintain adequate preload, reducing right ventricular afterload, and using inotropes like dobutamine, if needed, to support the failing right ventricle.

A 60-year-old man with a history of chronic obstructive pulmonary disease presents by EMS in respiratory distress. He is diaphoretic and is sitting up in bed leaning forward. His vital signs are T 100.1°F (37.8°C), HR 95 bpm, RR 30/min, BP 150/90 mm Hg, and SpO2 79% on room air. There is poor air movement with prolonged expiratory wheezes. A nonrebreather face mask is placed, but his work of breathing and oxygen saturation are not improving. In addition to intravenous glucocorticoid and nebulized beta-agonist medications, which of the following is the most appropriate next step in management? A. Ceftriaxone and azithromycin B. Endotracheal intubation C. Intravenous magnesium sulfate D. Noninvasive positive pressure ventilation

D. Noninvasive positive pressure ventilation -This patient is having an acute exacerbation of his chronic obstructive pulmonary disease (COPD). Acute exacerbations are characterized by worsening pulmonary symptoms that are brought on by pulmonary irritants or infection. -Noninvasive positive pressure ventilation (NIPPV) is beneficial for patients with severe acute exacerbations who are acidemic (pH < 7.36), hypercapnic (PaCO2 > 50 mm Hg), hypoxemic (PaO2 < 60 mm Hg or SaO2 < 90 mm Hg), or who have severe dyspnea, respiratory fatigue or increased work of breathing.

A 54-year-old woman with a history of hyperthyroidism presents to the ED with fever, vomiting, palpitations, and tremors. Which of the following would you expect to find on physical exam? A. Dry, scaling skin B. Loss of eyebrow hair C. Maculopapular rash D. Ocular proptosis

D. Ocular proptosis -This patient is exhibiting signs and symptoms consistent with thyroid storm. Thyroid storm is a rare, life-threatening hypermetabolic state caused by severe thyrotoxicosis. -he most common precipitating factor is infection. Signs and symptoms of thyroid storm include bilateral ocular proptosis, anxiety, tremulousness, psychosis, obtundation, seizure, coma, fever, tachycardia (out of proportion to fever), high-output heart failure, circulatory collapse, diarrhea, and vomiting

A 5-year-old boy with a history of sickle cell anemia presents with dyspnea and fatigue. His mother notes that 1 week prior, he had a fever, headache, and bright red rash on his cheeks, which has since resolved. Laboratory studies show a decrease in his baseline hemoglobin by 30%. Infection with which virus likely precipitated his current symptoms? A. Coxsackievirus B. Human herpesvirus 6 C. Measles virus D. Parvovirus B19

D. Parvovirus B19 -Erythema infectiosum is a generally benign, self-limiting disease that affects young children ages 4 to 10 years. It is caused by parvovirus B19. -After a brief, mild prodrome of malaise and low-grade (if any) fever, patients develop a characteristic facial rash with a slapped cheek appearance. One to four days later, the rash spreads to the trunk and extremities and takes on a lacy appearance -certain children with a history of hematologic abnormalities, such as sickle cell anemia, may develop transient aplastic crisis due to a marked reduction of erythroid cell precursors. These patients may present with onset of pallor, fatigue, lethargy, and shortness of breath due to anemia.

A 45-year-old woman, who works as a day laborer, presents with epigastric abdominal pain that began one hour prior to arrival. She has been having abdominal discomfort after meals for the past several weeks. Today, she developed sudden onset, severe abdominal pain far worse than what she has been experiencing. She denies back pain, nausea, and vomiting. On exam, she is tachycardic but has otherwise normal vital signs. Her abdomen is significantly tender in the epigastric region with rebound and guarding. Chest X-ray is as above. What is the most likely diagnosis? A. Cholecystitis B. Gallstone pancreatitis C. Gastritis D. Perforated gastric ulcer

D. Perforated gastric ulcer -Peptic ulcer disease is marked by ulcerations of the gastric mucosa, often due to nonsteroidal anti-inflammatory drug use or H. pylori infection. -When the ulcer erodes through the entire bowel, the result is a perforated gastric ulcer -TThe patient often experiences an abrupt onset of severe epigastric pain as gastrointestinal contents leak into the peritoneal cavity.

A 22-year-old healthy man presents with acute onset pleuritic, left-sided chest pain and mild dyspnea. Social history includes smoking a pack of cigarettes a week. Vital signs include blood pressure 142/74 mm Hg, heart rate 82 beats/minute, and oxygen saturation 97% on room air. He is in no acute distress. His chest radiograph is shown above. Which of the following is the best next step in management? A. Discharge home with ibuprofen for pain relief B. Order a computed tomography scan of the chest C. Perform a chest tube thoracostomy D. Place patient on 100% oxygen and repeat chest radiograph in six hours

D. Place patient on 100% oxygen and repeat chest radiograph in six hours -This patient has a spontaneous simple pneumothorax. -A small spontaneous pneumothorax in a healthy, minimally symptomatic patient can be treated with 100% oxygen, observation, and repeat radiography in six hours. If there is no progression on repeat chest X-ray, the patient can be discharged home with close follow up. Spontaneous pneumothoraces have a 20-50% chance of recurrence.

A 61-year-old woman with no medical or family history of heart disease presents with a trimalleolar ankle fracture after a fall. As part of her preoperative workup, an ECG is obtained. The patient has a 1st degree AV block. Which of the following is the most appropriate next step? A. Administer intravenous calcium chloride, insulin, glucose, and sodium bicarbonate B. Order serial cardiac biomarkers and admit to cardiology C. Place transcutaneous pacer pads and make arrangements for a transvenous pacemaker D. Reassure the patient and the orthopedic surgeon that no treatment is necessary

D. Reassure the patient and the orthopedic surgeon that no treatment is necessary -These patients should be monitored closely on telemetry to make sure they do not develop a complete heart block. Since this patient is asymptomatic, it is appropriate to reassure the patient and the orthopedic surgeon that no treatment is necessary.

A 65-year-old woman presents to the emergency department with acute onset vertigo. She denies associated decreased hearing or tinnitus. Vital signs are normal. Horizontal head impulse test shows a corrective saccade when the head is turned to the left. Dix-Hallpike maneuver elicits a leftward rotary nystagmus that is fatigable. Which of the following mechanisms will provide the most definitive treatment of this condition? A. Dopamine receptor antagonism B. Inhibition of the reabsorption of sodium from the distal convoluted tubules C. Positive allosteric modulators of GABA type A receptors D. Relocation of free floating otoconia

D. Relocation of free floating otoconia -The Dix-Hallpike test can aid in the diagnosis of BPPV -Rotatory nystagmus following a latency of < 30 seconds is considered a positive test; the nystagmus exhibits rapid eye torsions toward the affected ear and fatigues after 10-40 seconds. The side exhibiting the positive test is the side of the lesion. -The most definitive treatment for BPPV is the Epley maneuver which uses gravity to relocate free floating otoconia along the semicircular canals and into the utricle, where they are unlikely to cause vertigo.

An 18-month-old boy presents to the emergency department with worsening shortness of breath. The parents report he has had a cough, runny nose, and fussiness for the past five days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is given an albuterol nebulizer treatment without any improvement of his wheezing. Chest X-ray does not show any abnormality. Which of the following organisms is the most likely cause of his symptoms? A. Bordetella pertussis B. Haemophilus influenzae C. Parainfluenza virus D. Respiratory syncytial virus

D. Respiratory syncytial virus -The patient has bronchiolitis, which is the most common lower respiratory tract infection in patients less than two years of age. It remains the leading cause of hospitalization in infants under one year of age. Bronchiolitis is most commonly caused by respiratory syncytial virus (RSV),

A 56-year-old woman with a history of lung cancer presents to the emergency department with confusion, nausea, and vomiting. She is unable to provide much history due to her confusion. She is dehydrated and is oriented only to self. She is afebrile. Her renal function is normal. Her serum calcium level is 14 mg/dL. What is the most likely mechanism for her hypercalcemia? A. Abnormal calcium clearance in the kidneys B. Bony erosion due to metastases C. Production of vitamin D analogues by the tumor D. Secretion of parathyroid hormone related protein from the tumor

D. Secretion of parathyroid hormone related protein from the tumor -Solid tumors are most likely to result in hypercalcemia due to secretion of parathyroid hormone related proteins (PTHrp) from the tumor.

A 33-year-old man presents with pain and swelling in his left knee since yesterday. He has also had a fever with a maximum temperature of 100.9°F. Physical exam reveals swelling of the left knee with erythema and warmth noted. There is pain with passive range of motion. What is the most likely diagnosis? A. Bursitis B. Gout C. Osteoarthritis D. Septic arthritis

D. Septic arthritis -Septic arthritis is an infection of the joint that is typically characterized by joint pain, joint swelling, and a fever. The involved joint can present with an effusion and be painful with both active and passive range of motion.

A 75-year-old man with a long-standing history of constipation presents complaining of abdominal pain for the last two days. He is now experiencing abdominal distention, constipation, and inability to pass gas for the last 12 hours. On examination, his abdomen is distended and tympanitic to percussion. You obtain an upright abdominal X-ray as seen above. What is the most likely diagnosis? A. Cecal volvulus B. Intussusception C. Irritable bowel syndrome D. Sigmoid volvulus

D. Sigmoid volvulus -The patient is suffering from a sigmoid volvulus, an intestinal obstruction that resulted when a non-fixed, redundant loop of the sigmoid colon twisted and obstructed the lumen. Sigmoid volvulus is more common in elderly, debilitated patients with a history of chronic constipation. -the hallmark symptoms include abdominal pain, distention, and constipation. If the twist involves the vascular supply, the patient can develop gangrenous bowel.

A 93-year-old man on aspirin presents to the ED with epistaxis. On physical exam, you note bleeding from bilateral nares and down the posterior pharynx. You are unable to visualize the source of bleeding. Which of the following vessels is most likely the source of bleeding in this patient? A. Facial artery B. Kiesselbach plexus C. Labial artery D. Sphenopalatine artery

D. Sphenopalatine artery -This patient is exhibiting signs and symptoms of posterior epistaxis. Posterior epistaxis is less common than anterior epistaxis and is most commonly due to bleeding from the sphenopalatine artery, located at the posterior aspect of the middle nasal turbinate. Patients with posterior epistaxis typically complain of bleeding from both nostrils.

A 35-year-old woman with a history of migraines and polycystic kidney disease presents to the emergency department with a severe, diffuse headache. The onset was abrupt, approximately 1 hour prior to arrival. Her vital signs are within normal limits. She has photophobia and phonophobia, as well as pain with extraocular movements. Which of the following is the most likely diagnosis? A. Classic migraine B. Idiopathic intracranial hypertension C. Meningitis D. Subarachnoid hemorrhage

D. Subarachnoid hemorrhage -Subarachnoid hemorrhage (SAH) accounts for approximately one-third of all hemorrhagic strokes. Atraumatic SAH is due to ruptured aneurysms. A history of polycystic kidney disease is a risk factor for developing berry aneurysms -Classic symptoms include an abrupt "thunderclap" headache that is maximal in severity at onset. Patients often have signs of meningeal irritation secondary to blood in the subarachnoid space. These include nuchal rigidity, painful extraocular movements, photophobia, and a positive Brudzinski or Kernig sign.

An 81-year-old man with a history of atrial fibrillation presents with abdominal pain. He fell two weeks ago and was advised to stop his anticoagulation medication after the fall. He reports diffuse, severe abdominal pain but is minimally tender on examination. He has symmetric pulses in his extremities. What is the most likely anatomic location of his pathology? A. Aortic bifurcation B. Celiac trunk C. Inferior mesenteric artery D. Superior mesenteric artery

D. Superior mesenteric artery -Impairment of blood flow to the mesentery is a life-threatening emergency that leads to mesenteric ischemia. -Arterial emboli cause most cases of acute mesenteric ischemia. Patients classically describe diffuse abdominal pain that is out of proportion to their tenderness on physical examination. -Patients with atrial fibrillation (particularly those not adequately anticoagulated) are at high risk. The most common location for embolization is the superior mesenteric artery.

A 51-year-old man with a history of alcohol use presents with three days of anorexia, nausea, vomiting, and right upper quadrant abdominal pain. Vital signs are HR 115, BP 114/83, RR 20, and oxygen saturation 96% on room air. On physical examination, he appears jaundiced and tender hepatomegaly is noted. Liver function tests are notable for AST 433 IU/L, ALT 206 IU/L, and total bilirubin 8.0 mg/dL. INR is prolonged at 1.6. Which of the following is the appropriate treatment for this condition? A. Cholecystectomy B. Liver transplantation C. N-acetyl-cysteine D. Supportive care

D. Supportive care -Alcoholic hepatitis is an acute inflammatory condition of the liver triggered by alcohol use or abuse -Key findings on physical examination include jaundice and tender hepatomegaly. In severe cases with hepatic decompensation, ascites and encephalopathy may be present. Laboratory findings in alcoholic hepatitis include moderate AST and ALT elevations (up to seven times normal) with a classic AST to ALT ratio of 2:1 or greater. -Treatment for alcoholic hepatitis is supportive

A 54-year-old woman presents with a swollen knee. On examination, a large joint effusion is present. With which of the following spaces does the knee joint communicate? A. Anserine bursa B. Infrapatellar bursa C. Prepatellar bursa D. Suprapatellar bursa

D. Suprapatellar bursa

A 54-year-old man presents with abdominal pain, vomiting, and fever. Physical examination reveals an ill-appearing man with a mass in the right groin as seen above. Which of the following is the most immediate next step required? A. Abdominal X-ray B. CT scan of the abdomen and pelvis C. Scrotal ultrasound D. Surgical consultation

D. Surgical consultation -This patient presents with signs and symptoms concerning for a strangulated hernia and should have an emergent surgical consultation for possible operative management. -a strangulated hernia occurs after incarceration and involves impairment of blood flow (arterial, venous or both) to the viscus. Patients with strangulated hernias typically present with bowel obstruction and are toxic appearing.

A 30-year-old man presents to the emergency department with an ankle injury after he twisted his ankle when stepping off of the curb. The patient mainly complains of pain near the right lateral malleolus. Which of the following examination findings would be more indicative of an ankle sprain that would not require further diagnostic imaging? A. Bony tenderness in the malleolar zone B. Bony tenderness in the midfoot zone C. Inability to bear weight on the ankle D. Swelling over the lateral malleoli

D. Swelling over the lateral malleoli -Swelling over the lateral malleoli is a common finding in ankle sprains. This finding, particularly without other bony tenderness in a patient who is able to bear weight, is more indicative of an ankle sprain and would not make a physician more suspicious for an ankle fracture.

Which of the following is correct when estimating an adult burn patient's percent of total body surface area affected? A. Each arm is approximately 18% B. The area covered by the patient's palm is approximately 5% C. The entire head is approximately 18% D. The perineum is approximately 1%

D. The perineum is approximately 1%

A 24-year-old woman presents with right thumb pain. She recently fell while skiing. On examination, she has swelling and tenderness over the base of the thumb on the ulnar side. She has weakness when pinching an object between her thumb and index finger. Which of the following structures is most likely to be injured? A. Extensor pollicis brevis B. Extensor pollicis longus C. Radial collateral ligament D. Ulnar collateral ligament

D. Ulnar collateral ligament -The patient has an injury to the ulnar collateral ligament, also known as "gamekeeper's thumb" named after Scottish gamekeepers who developed this injury pattern from repeatedly twisting the necks of hares. -The mechanism of injury is a forceful radial abduction of the thumb with a subsequent partial or complete tear in the ulnar collateral ligament at the insertion into the proximal phalanx of the thumb. Patients present with pain, swelling, and tenderness on the ulnar side of the metacarpophalangeal joint of the thumb

Which of the following is the most sensitive finding in cauda equina syndrome? A. Back pain B. Saddle anesthesia C. Urinary incontinence D. Urinary retention

D. Urinary retention

A 30-year-old woman presents complaining of vaginal itching and irritation. She also complains of vaginal discharge. Which of the following supports a diagnosis of uncomplicated candidal vaginitis? A. Cervical motion tenderness on bimanual examination B. Positive amine odor with KOH preparation C. Trichomonads on microscopic examination D. Vaginal pH < 4.5

D. Vaginal pH < 4.5 -A vaginal pH < 4.5 is suggestive of candidal vaginitis which occurs when the normal vaginal flora is overtaken with growth of Candida species, most commonly C. albicans

A 57-year-old man presents to the ED with headache, blurred vision, and fatigue. His wife notes he has a "blood problem" that his doctor is monitoring. Which of the following underlying conditions is most frequently complicated by hyperviscosity syndrome? A. Acute myeloid leukemia B. Multiple myeloma C. Polycythemia vera D. Waldenstrom macroglobulinemia

D. Waldenstrom macroglobulinemia -This patient is exhibiting signs and symptoms associated with hyperviscosity syndrome. Hyperviscosity syndrome is defined as elevated serum viscosity that causes sludging, decreased microvascular perfusion, and vascular stasis -Signs and symptoms of hyperviscosity syndrome are primarily secondary to end-organ ischemia creating mimics of disease processes such as myocardial ischemia, stroke, pulmonary infarction, congestive heart failure, renal failure, mucosal hemorrhages, or visual disturbances secondary to retinal ischemia

Which of the following types of traumatic events has the highest probability of resulting in post-traumatic stress disorder? A. Combat exposure B. Death of a loved one C. Kidnapping D. Rape

D. rape

A 50-year-old woman presents to the emergency department following a syncopal episode. On physical exam she is diaphoretic. She is alert and oriented. Her blood pressure is 90/50 mm Hg and respirations are 12 per minute. Patient has sinus bradycardia. What is the most appropriate pharmacologic treatment for this patient's condition?

atropine

Pregnant women with head lice should be treated with____

permethrin