Family Med
35-year-old man presents with complaints of intermittent, severe pain around his right eye for the past 3 weeks. He reports the pain comes on suddenly and lasts for about 30 minutes at the same time each day. He complains of his right eye watering and sweating on the right side of his face when the pain occurs. Which of the following is the most likely diagnosis? A Cluster headache B Paroxysmal hemicrania C Pituitary tumor D Trigeminal neuralgia
A Cluster headache, first line tx is 100% O2 for acute HA, second line is sumatriptan; maintenance for prevention is verapamil
A 70-year-old woman reports to her primary care physician with a 2-day history of severe back pain. She picked up a heavy load of laundry just prior to experiencing the back pain. She has a past medical history of rheumatoid arthritis, which has been treated with long-term prednisone use, and a 25 pack-year smoking history. Physical exam reveals a thin, Caucasian woman with moderate kyphosis. She is tender at the level of L1. Lower extremity strength and sensation are intact bilaterally. Her vertebral X-ray is shown above. Which of the following is the first-line treatment of this condition? (xray shows osteoporotic changes)(got this right) A Alendronate B Estrogen C Raloxifene D Teriparatide
A Alendronate, this is a bisphosphonate which is first line for osteoporosis
A 45-year-old man presents to the office with patchy hair loss that started suddenly about 1 month ago. The patient has not noticed any hair regrowth. Upon physical examination, there are three discrete smooth oval patches throughout the scalp that are flesh colored. The patches are neither tender nor pruritic. He suffered a death in the family about 3 months ago. Which of the following is the most likely diagnosis? A Alopecia areata B Androgenetic alopecia C Telogen effluvium D Tinea capitis
A Alopecia areata, can also see exclamation mark hairs -telogen effluvium would present with thinning of hair rather than patches of complete hair loss
A 32-year-old woman who is pregnant presents complaining of a strange circular rash to her lower extremity. She recently went camping in Connecticut. On physical exam, she is noted to have an annular erythematous rash with central clearing. The patient has no known drug allergies. What is the most appropriate treatment for this patient? A Amoxicillin B Azithromycin C Chloramphenicol D Doxycycline
A Amoxicillin, this patient is pregnant and doxy is contraindicated in pregnancy
A 26-year-old woman presents to her primary care physician with malaise, nausea, mild abdominal pain, and low-grade fever. The patient reports having a one-time encounter with a male sexual partner she met at a bar about 10 weeks ago. Physical exam findings show mild right upper quadrant abdominal tenderness. CMP reveals that the patient has an AST of 1,000 units/L and an ALT of 1,550 units/L. Which of the following would indicate immunity to the suspected infection? A Anti-HBs B HBsAG C HBV DNA D IgM anti-HBc
A Anti-HBs, hepatitis b surface antibody -HBsAG is hep b surface antigen which shows an active infection
A 67-year-old man with diabetes presents to the clinic complaining of an episode of slurred speech and right-sided upper and lower extremity weakness this morning that lasted 30 minutes and then resolved on its own. His current vital signs are blood pressure 150/90 mm Hg, nonfasting blood glucose 200 mg/dL, pulse 80 beats per minute, and respiration rate 16 breaths per minute. Physical exam is normal, and an electrocardiogram shows normal sinus rhythm. A computed tomography of the head and a Doppler ultrasound of the carotid arteries are pending. Which of the following is the most appropriate treatment for secondary prevention of ischemic stroke in this patient? A Aspirin 325 mg and clopidogrel 75 mg daily B Aspirin 325 mg daily C Rivaroxaban 20 mg daily D Warfarin 5 mg daily
A Aspirin 325 mg and clopidogrel 75 mg daily, this patient is in the moderate-high risk of stroke group due to age >60, BP >140/90, and unilateral weakness so he needs dual therapy -patients in the low risk group would be prescribed ASA daily
A 65-year-old man with a history of congestive heart failure and hyperlipidemia presents to the office for management of symptoms related to congestive heart failure. He reports dyspnea on exertion. His vital signs are within normal limits. Electrocardiogram reveals normal sinus rhythm and left ventricular hypertrophy. A recent echocardiogram reveals an ejection fraction of 40%. His current daily medications include atorvastatin, furosemide, and lisinopril. Which of the following medications would be most appropriate to add to his medication regimen at this time? A Carvedilol B Digoxin C Hydralazine D Spironolactone
A Carvedilol, this is a bb which reduces mortality in CHF
A 15-year-old girl presents with concerns for heavy menstrual bleeding. Menarche was at 13 years of age, and her periods have been regular and heavy for the last year. She states that she often soaks through more than one pad per hour on her heaviest day. The length of her cycle is typically 27 days with 8 days of menstrual bleeding. She reports that she has never been sexually active in the past. She reports no pelvic pain besides mild cramping during the first 2 days of her cycle. Which of the following diagnostic studies would be most useful in determining the diagnosis? A Coagulation studies B Hysteroscopy C Serum prolactin D Sonohysterography
A Coagulation studies, since this is an adolescent, the mc cause would be a coagulopathy rather than something structural -Hysteroscopy (B) is indicated for evaluation of leiomyoma, malignancy, or an endometrial cause of menorrhagia -Serum prolactin (C) levels would be helpful in the workup of amenorrhea as elevated levels can cause absent or scant menstruation -Sonohysterography (D) is used to evaluate the uterus for fibroids, endometrial atrophy or scarring, and malignancy. These causes of abnormal bleeding are less common in adolescence than a coagulation disorder.
A 24-year-old woman presents to her primary care provider with complaints of progressively worsening fatigue, irritability, dizziness, and headaches for the past 4 months. She states she has had a decreased appetite and has lost 15 pounds in the last 2 months. She has also started to crave salt. Vital signs are T 98.6°F, BP 92/68 mm Hg, HR 80 bpm, RR 18 breaths per minute, and oxygen saturation 99% on room air. Physical examination reveals hyperpigmented skin over the knuckles, palmar creases, gingival mucosa, and vermilion border of the lips. Her fasting blood work is significant for hypoglycemia, hyponatremia, hyperkalemia, and hypercalcemia. Which of the following diagnostic studies is most helpful in confirming the suspected diagnosis? A Cosyntropin stimulation test B Dexamethasone suppression test C Serum dehydroepiandrosterone level D Water deprivation test
A Cosyntropin stimulation test, I correctly identified Addisons disease (primary adrenal insufficiency) which is a deficiency in cortisol. Cosyntropin test is performed by injecting ACTH to stimulate cortisol production; a low cortisol level after ACTH means adrenal insufficiency -B Dexamethasone suppression test: used for cushings bc cushings is due to excess cortisol C Serum dehydroepiandrosterone level: this is elevated in all pts with adrenal insufficiency but is also elevated in 15% of normal population so it is not the most helpful test D Water deprivation test: used to differentiate central vs. nephrogenic DI
A 2-year-old boy presents to the pediatric clinic with right ear pulling. On exam, the right tympanic membrane is bulging. Which of the following pathogens is most likely to cause this condition? A Haemophilus influenzae B Moraxella catarrhalis C Pseudomonas aeruginosa D Streptococcus pyogenes
A Haemophilus influenzae, H influenza and strep pneuma are the mc organisms for OM in pediatrics
A 28-year-old woman presents to the gastroenterology clinic for reevaluation of painless rectal bleeding with bowel movements. She has no personal or family history of colorectal cancer or inflammatory bowel disease. On physical exam, she has visible hemorrhoids originating below the dentate line. Her hemoglobin level is 14.0 mg/dL. She has been treating her condition with increased water intake, increased dietary fiber, sitz baths, and docusate for 12 weeks without improvement. Which of the following is the recommended treatment? A Hemorrhoidectomy B Rubber band ligation C Sclerotherapy D Topical hydrocortisone
A Hemorrhoidectomy -can't do a rubber band ligation on external hemorrhoids due to sensitivity to pain
A 54-year-old man presents to the ED with confusion and slurred speech. Physical examination reveals the presence of asterixis and hyperactive deep tendon reflexes. Laboratory results are significant for an ammonia level of 140 mcg/dL. The patient is treated with lactulose, and his symptoms begin to improve. His past medical history is significant for cirrhosis, and this is the third time he has had this complication. Which of the following treatments is most effective for preventing recurrence of the patient's condition? A Long-term rifaximin therapy B Permanent discontinuation of beta-blocker therapy C Prophylactic anticoagulation therapy D Terlipressin therapy with albumin
A Long-term rifaximin therapy, this is cirrhosis/hepatic encephalopathy
A 25-year-old man presents to his primary care provider for sexually transmitted infection testing. He thinks his girlfriend was recently treated for Chlamydia trachomatis but did not tell him. He has no significant past medical history and reports no discharge, dysuria, or pruritus. Which of the following diagnostic studies is indicated at this time? A Nucleic acid amplification test B Urinalysis on a clean catch urine specimen C Urine culture D Wet prep
A Nucleic acid amplification test, this is first line from either a urine sample or urethral swab
A 44-year-old man presents to his primary care provider for a follow-up on his lipid panel results. His lipid panel results are: Total cholesterol: 320 md/dL Low-density cholesterol: 240 mg/dL High-density cholesterol: 30 mg/dL Triglyceride: 250 mg/dL The patient has a history of diabetes mellitus type 2, and his 10-year atherosclerotic cardiovascular disease risk is 10.1% Which of the following medications is indicated at this time? A Atorvastatin 10 mg B Pravastatin 40 mg C Rosuvastatin 20 mg D Simvastatin 20 mg
C Rosuvastatin 20 mg, this is a high intensity stain, the others are all moderate intensity; needs high intensity due to LDL being >190
A 23-year-old man presents to his primary care provider with complaints of left knee pain, dysuria, and hematuria for 10 days. He reports he had a gastrointestinal infection 3 weeks ago that was resolved after treatment with ciprofloxacin. Urinalysis is significant for a positive leukocyte esterase with 10 RBC/hpf and 7 WBC/hpf. Physical examination reveals a swollen, tender left knee. Which of the following additional findings is most consistent with the suspected diagnosis? A Bilateral flank ecchymosis B Bilateral injected conjunctiva C Left-sided supraclavicular lymphadenopathy D Strawberry red tongue
B Bilateral injected conjunctiva, reactive arthritis presents with oligoarthritis, urethritis, bilateral conjunctivitis
A 62-year-old man presents to the office with a 2-month history of fatigue, shortness of breath, and intermittent headaches. His physical examination is pertinent for conjunctival pallor, dried blood in the nares, and ecchymosis on the shins and arms. No lymphadenopathy or organomegaly is appreciated. A complete blood count with differential is obtained and reveals pancytopenia. Peripheral smear shows the above cell. What is the most likely diagnosis? (slide shows our rods)(got this right) A Acute lymphoid leukemia B Acute myeloid leukemia C Chronic lymphoid leukemia D Chronic myeloid leukemia
B Acute myeloid leukemia, associated with air rods and pancytopenia since myeloblasts are affected
A 67-year-old man with a history of heart failure, hypertension, and diabetes mellitus presents to your office with complaints of heart palpitations, dizziness, and fatigue. Physical exam findings include a body mass index of 35.2 kg/m2and an irregularly irregular pulse with a rate of 120 bpm. Electrocardiogram reading shows absent P waves, R-R intervals without a repetitive pattern, and irregular QRS complexes. Which of the following is the most appropriate therapy? A Amiodarone B Apixaban C Furosemide D Lisinopril
B Apixaban, they didn't ask about getting this patient out of afib, they just wanted to know about the anticoagulation due to the afib
A 21-year-old G2P2 woman presents to her primary care provider with complaints of a facial rash, painless oral ulcers, and arthralgia. She has a history of Raynaud phenomenon. She recently moved from Zimbabwe and is unsure of her vaccination status. Physical examination reveals obesity and the facial rash shown above. Laboratory testing is positive for anti-double-stranded DNA and anti-Smith antibodies. Her vitamin D level is low. Which of the following is appropriate health maintenance education for this patient? A Avoid isometric and graded exercises B Avoid pregnancy for 6 months after active disease C Avoid the annual influenza vaccine D Increase exposure to natural sunlight
B Avoid pregnancy for 6 months after active disease -Active SLE disease is associated with significant impairment of fetal organ development
A 50-year-old man presents to his primary care provider with complaints of shortness of breath and a dry cough that has progressed over the last 3 years. He has worked as a field engineer on nuclear power plants for 29 years. Physical examination reveals the presence of multiple cutaneous nodules on the fingers and forearms. His chest X-ray reveals hilar lymphadenopathy and diffuse parenchymal infiltrates. Which of the following occupational lung diseases is the most likely diagnosis? (got this right) A Asbestosis B Berylliosis C Byssinosis D Silicosis
B Berylliosis, associated with nuclear power, nuclear reactor, dental, metal machine shops, and aerospace industries -Asbestosis: associated with insulation, demolition, shipbuilding, and textile industries -Byssinosis: associated with textile industries that process cotton, hemp, or flax -Silicosis: associated with exposure to silica and is most often seen in the mining, glass manufacturing, sandblasting, and quarry industries
A 22-year-old woman with no significant past medical history presents to the gastroenterology clinic with chronic abdominal pain and intermittent constipation and diarrhea for the past 6 months. She reports no fever, weight loss, or blood in her stool. On exam, she has diffuse abdominal discomfort with palpation but no focal tenderness. Laboratory studies reveal a white blood cell count of 7,000/µL, hemoglobin of 15 mg/dL, and a C-reactive protein of 0.4 mg/dL. Testing for antitissue transglutaminase antibodies is negative. Which of the following pharmacologic interventions is most beneficial for abdominal pain associated with the most likely diagnosis? A Cholestyramine B Dicyclomine C Loperamide D Lubiprostone
B Dicyclomine, this is a GI antispasmodic which can treat IBS
A 62-year-old man presents to the ophthalmology clinic with a gradual onset of decreased visual acuity bilaterally. He describes it as difficulty reading the text on his computer screen and difficulty driving. Dilated eye examination with a slit lamp reveals drusen deposits around the macula. Which of the following is the most likely diagnosis? A Cataract B Dry age-related macular degeneration C Glaucoma D Wet age-related macular degeneration
B Dry age-related macular degeneration -dry vs. wet -dry: slit lamp exam shows druse, more common, gradual loss of vision, due to macular thinning, not total blindness -wet: neovascularization on slit lamp, less common, sudden loss of vision, due to bleeding or leakage of fluid, more severe central vision loss
A 61-year-old woman with a history of alcohol use disorder and Crohn disease presents to the office for her well-woman visit with concerns of fatigue and feeling mentally foggy. On physical examination, she appears mildly pale, and loss of papillae is noted on the tongue. Baseline blood work is obtained. Her hemoglobin and hematocrit are mildly decreased at 11 g/dL and 32%, respectively. Her mean corpuscular volume is 117 fL. Vitamin B12 and folate levels are borderline low, but methylmalonic acid and homocysteine are elevated. What physical exam finding would be expected on examination given the patient's history and laboratory results? (got this right) A Chlorosis B Gait ataxia C Koilonychia D Oral ulcers
B Gait ataxia, seen in vit B12 def -koilonychia and chlorosis (green skin) is seen in iron def -oral ulcers are seen in folate def
A 20-year-old man who is unvaccinated and currently residing in a college dormitory presents with fever, stiff neck, and altered mental status. His physical examination is concerning for the rash noted in the image above. His diagnostic workup includes CT scan of the head, which is normal, and a lumbar puncture with cerebrospinal fluid analysis and culture and sensitivity, which reveals pleocytosis with predominant neutrophils, decreased glucose concentration, and elevated protein concentration. An opening pressure is elevated. Which of the following Gram stain results would you expect to find in this patient? A Gram-negative bacilli B Gram-negative diplococci C Gram-positive lancet-shaped diplococci D Gram-positive motile coccobacilli
B Gram-negative diplococci, Neisseria meningitidis is this
A 65-year-old man presents to the emergency department with decreased visual acuity. He describes the vision change as moving spots and flashing lights in the visual field of his right eye. Which of the following additional findings is most suggestive of the suspected diagnosis? A Corneal opacity with fluorescein uptake on Wood lamp B Gray curtain moving across the visual field C Loss of central vision D Protrusion of uveal content
B Gray curtain moving across the visual field, correctly identified retinal detachment Retinal detachment is defined by the retina detaching from its underlying supportive layers, such as the choroid. The classic presentation of a retinal detachment is a progressive peripheral visual field defect, such as a curtain moving across the visual field. Most patients have a retinal detachment in the setting of a posterior vitreous detachment, which manifests with an increase in floaters and flashing lights in one eye. Patients who experience a new peripheral visual field defect should be evaluated urgently by an ophthalmologist. Patients with retinal detachment typically require surgical repair using one of the following procedures: laser or cryoretinopexy, pneumatic retinopexy, scleral buckle, or vitrectomy. Retinal detachment that is not treated leads to surgery
A 42-year-old woman presents to her primary care provider with complaints of worsening left hip pain and difficulty ambulating over the past 4 weeks. She reports no history of falls or trauma. She does have a history of bilateral osteoarthritis of the knees, plantar fasciitis, and low back pain. Physical examination reveals morbid obesity and tenderness to palpation over the left lateral hip. No erythema or swelling is appreciated. Passive and active abduction of the left hip reproduces the pain over the lateral hip without causing inguinal pain. Her standing anteroposterior pelvic radiograph is shown in the image above. Which of the following is the most likely diagnosis? (xray was normal) A Femoroacetabular impingement B Greater trochanteric pain syndrome C Microbial trochanteric bursitis D Osteoarthritis of the hip
B Greater trochanteric pain syndrome, I identified that this was trochanteric bursitis which is apparently the old name for greater trochanteric pain syndrome
A 22-year-old man presents to his primary care provider with a nonpruritic, nontender rash on his hands and the soles of his feet that appeared yesterday. He reports hiking in the northeastern United States 2 weeks ago. His past sexual history is significant for unprotected intercourse with multiple male and female partners. His physical examination is unremarkable except for the rash on his palms and soles, which is shown in the image above. Which of the following infections in the patient's history is associated with the most likely diagnosis? (picture shows erythema multiforme) A Borrelia burgdorferi B Herpes simplex virus C Rickettsia rickettsii D Treponema pallidum
B Herpes simplex virus, common cause of erythema multiforme
A 30-year-old woman presents to her primary care provider with complaints of widespread, achy musculoskeletal pain, fatigue, and chronic headache for the past 9 months that have severely interfered with her activities of daily living. She states her pain is worse in the morning and aggravated by minor activities. She reports no known sick contacts but states she feels like she has had the flu for 9 months. Her past medical history is significant for anxiety and depression. Physical examination is significant for muscle tenderness over the neck, shoulders, bilateral arms and legs, and upper and lower back. Which of the following is most likely to be found in the patient's history? A Distal to proximal progression of muscle weakness B Insomnia C Proximal extremity muscle weakness that improves throughout the day D Recent infection with Campylobacter jejuni
B Insomnia, this is fibromyalgia which does not have reproducible weakness on exam (Not mentioned in the vignette but was not significant on exam) A Distal to proximal progression of muscle weakness and D Recent infection with Campylobacter jejuni are both associated with Guillain barre
A 34-year-old woman presents to her primary care physician for a 48-72-hour recheck of her tuberculin skin test that was placed for preemployment screening. On evaluation, she has a 10 mm area of induration surrounded by a 30 mm area of erythema where the skin test was placed. She otherwise appears well, with no concerning symptoms, fevers, respiratory symptoms, gastrointestinal or neurologic complaints, or other rash. She was born in Guatemala and moved to the United States 2 years ago but otherwise can identify no other risk factors for tuberculosis. She does not recall receiving the bacillus Calmette-Guérin vaccine and does not have scarification on her arms. What is the best next test to confirm her tuberculosis status? A Chest X-ray B Interferon-gamma release assay blood test C Sputum samples for acid-fast bacilli smear D Sputum samples for mycobacteria culture
B Interferon-gamma release assay blood test -1st positive PPD--> confirm with interferon gold test -interferon gold test can determine between active and past infection -can also tell if positive PPD was from prior vaccination
A 25-year-old man is referred to a urologist for a testicular mass. He has no significant past medical history and has never been sexually active. Which of the following physical examination findings is most concerning for metastatic disease? A Localized tenderness with swelling of the posterior right testis B Lower extremity edema C Nontender, diffuse enlargement of the right testis D Nontender, discrete mass of the right testis
B Lower extremity edema, this is just a general sign of metastasis along with back pain and cough -Nontender, diffuse enlargement of the right testis and Nontender, discrete mass of the right testis are both common findings of primary testicular cancer
A 68-year-old man with a history of coronary artery disease and acute myocardial infarction 2 months ago presents to the clinic complaining of nonpainful, complete vision loss in his left eye with acute onset 8 hours ago. He reports no headache or fever. Physical exam reveals an afferent pupillary defect on the left with no ability to count fingers. Funduscopic exam reveals a pale retina with a cherry-red spot in the macula. Current medications include metoprolol tartrate 50 mg twice daily, lisinopril 10 mg daily, atorvastatin 20 mg daily, sildenafil 50 mg as needed, and aspirin 81 mg daily. Erythrocyte sedimentation rate is within normal limits. Which of the following is the best next step for this patient? (got this right) A Intra-arterial recombinant tissue plasminogen activator B Ophthalmology consult and ocular massage C Oral high-dose prednisone D Oral nitroglycerin
B Ophthalmology consult and ocular massage, this is acute retinal artery occlusion, Symptoms of retinal artery occlusion include acute-onset, painless, unilateral vision loss that may involve most or all visual fields. On exam, there will be an afferent pupillary defect (dilation of the affected pupil when a swinging flashlight moves toward it) and retinal pallor on funduscopic exam. A cherry-red spot may appear in the macula. Patients with carotid artery disease may have an audible bruit on auscultation
A 4-year-old girl presents to the office for severe diarrhea that began yesterday. She attends daycare. The patient's caregiver reports her symptoms started with a flu-like illness of fever and malaise before she developed frequent bloody, watery stools occurring eight times yesterday and four times today. She reports lower abdominal pain and tenesmus. Physical examination reveals a temperature of 100.5°F. Stool microscopy is performed and reveals fecal leukocytes and red blood cells. The sample is sent for culture. What intervention, in addition to oral rehydration therapy, should be considered in this patient, given the most likely diagnosis? A Fecal microbiota transplantation B Oral azithromycin C Oral loperamide D Oral metronidazole
B Oral azithromycin, this is shigella
A 54-year-old man presents to his primary care provider with complaints of intermittent epigastric pain, postprandial fullness, nausea, and vomiting for the past 3 weeks. He reports no heartburn, regurgitation, or dysphagia. An upright chest X-ray is ordered and shows a retrocardiac air-fluid level. Which of the following in the patient's history is associated with the suspected diagnosis? A Congenital malformation B Partial gastrectomy C Recent ingestion of undercooked chicken D Trauma
B Partial gastrectomy, this question is getting at a hernia rather than a congenital abnormality
31-year-old woman presents to the office with right-sided back pain, nausea, and chills. Symptoms were preceded by several days of dysuria. Physical examination is significant for a temperature of 38.1°C and right-sided costovertebral angle tenderness. Urinalysis reveals pyuria and the presence of leukocyte esterase and nitrates. Culture is pending. The patient reports she has experienced numerous struvite stones in the past after urinary tract infections. What type of bacteria would you expect to see in her culture? A Escherichia coli B Proteus mirabilis C Pseudomonas aeruginosa D Staphylococcus saprophyticus
B Proteus mirabilis, these are associated with struvite stones -e coli is by far the mc organism normally
A 64-year-old man is establishing care in the family medicine office as a new patient. No prior medical records are available. His review of systems is pertinent for intermittent headaches and aquagenic pruritus. Upon further questioning, the patient reports he was previously diagnosed with a hematologic condition, but he cannot remember the name. On physical examination he is noted to have a ruddy facial plethora and palpable splenomegaly. Laboratory studies reveal a hemoglobin of 17.8 g/dL. What follow-up question would be pertinent to ask the patient, given this information? A "Do you get regular blood transfusions?" B "Do you have the HLA-B27 mutation?" C "Have you ever had a blood clot before?" D "Have you previously been exposed to Agent Orange?"
C "Have you ever had a blood clot before?" -polycythemia vera (chronic myeloproliferative neoplasm from jak2 mutation): Thrombosis is the leading cause of morbidity and mortality in patients with polycythemia vera. Polycythemia vera is a myeloproliferative disorder that results in an increase in red blood cell mass. Present with vasomotor symptoms, such as erythromelalgia and aquagenic pruritus. Headache, dizziness, and early satiety may also be reported. Physical examination may reveal facial plethora (ruddy cyanosis) and splenomegaly. Findings of elevated hemoglobin and hematocrit on a complete blood count (CBC). In addition to elevations in hemoglobin and hematocrit, a CBC may also reveal increases in total white blood cell count and thrombocytosis. Most patients will also have a JAK2 gene mutation. Bone marrow biopsy reveals hypercellularity and prominent proliferation of erythroid, granulocytic, and megakaryocytic cells. Thrombosis in patients with polycythemia vera may include myocardial infarction, deep vein thrombosis, cerebral infarction, and pulmonary embolism. The goal of treatment is to improve symptoms and reduce or prevent complications. Low-risk patients are treated with therapeutic phlebotomy to maintain a hematocrit below 45%, low-dose aspirin to treat vasomotor symptoms and prevent thrombosis, and cardiovascular risk factor management. High-risk patients are also treated with therapeutic phlebotomy and low-dose aspirin, but they additionally receive cytoreductive therapies. Cytoreductive therapies may include hydroxyurea (first line), interferon, or busulfan.
A 19-year-old woman presents with severe pelvic pain, nausea, vomiting, and fever. She also reports purulent vaginal discharge. A pelvic exam reveals bilateral adnexal tenderness and a positive chandelier sign. A urine pregnancy test is negative. After evaluation in the emergency department, she is admitted, treated with cefoxitin intravenously every 6 hours, and improves over the next 24 hours. What medication regimen should be prescribed for her upon discharge home? A Azithromycin for 3 days B Ceftriaxone and azithromycin for 7 days C Doxycycline for 14 days D Metronidazole for 10 days
C Doxycycline for 14 days, this is most appropriate b/c she received a cephalosporin inpatient so she should receive coverage for chlamydia outpatient which would be doxy
A 55-year-old man presents to his primary care provider with complaints of increasing peripheral vision loss for the past 3 months. His past medical history is significant for diabetes mellitus. Physical examination reveals optic disk cupping and a cup to disc ratio of 0.7. Tonometry reveals an intraocular pressure of 40 mm Hg. Visual field testing confirms significant peripheral field defects. Which of the following medications is most appropriate at this time? A Acetazolamide B Brimonidine C Latanoprost D Pilocarpine
C Latanoprost, this is chronic glaucoma which is treated with a topical prostaglandin analog like latanoprost to decrease IOP by increasing outflow of aqueous humor -pilocarpine is used for acute angle-closure glaucoma
A 66-year-old man with a history of coronary heart disease presents to the emergency department after collapsing in the parking lot. His monitor shows the rhythm above. There is no palpable pulse. Cardiopulmonary resuscitation is initiated, and intravenous access is established. A defibrillator is attached, and 200 joules of biphasic energy are delivered. After 2 minutes of cardiopulmonary resuscitation, epinephrine 1 mg IV is given. Return of spontaneous circulation is achieved, but the patient is not following commands. Blood glucose is 170 mg/dL. Temperature is 38.0°C. Mean arterial pressure is 90 mm Hg. Which of the following clinical interventions is most appropriate at this time? A Administer hypotonic fluids to reduce cerebral edema B Lower blood glucose to < 100 mg/dL C Lower core body temperature to 32-36°C D Lower mean arterial pressure to < 65 mm Hg
C Lower core body temperature to 32-36°C, apparently this is associated with better outcomes if the patient is not responding to commands after initial resuscitation
A 24-year-old woman with human immunodeficiency virus infection presents to the clinic for a checkup and annual vaccines. She has no current complaints and needs refills on her raltegravir and tenofovir-emtricitabine. Her current CD4 cell count is 180/microL. Which of the following vaccines is indicated for this patient's health maintenance? A Inactivated zoster vaccine B Measles-mumps-rubella vaccine C Meningococcal vaccine D Varicella vaccine
C Meningococcal vaccine, should be given every 5 years for HIV patients -inactivated zoster vaccine should be done if pt over 50 with CD4 under 200
A 37-year-old man presents to his primary care provider with intermittent chest discomfort, palpitations, and worsening dyspnea on exertion over the past 5 months. The patient states he has also noticed decreased excursion tolerance and occasional lightheadedness while exercising. Physical examination is significant for a midsystolic click. When the patient is asked to squat, the click is heard later in systole. Which of the following valvular disorders is most likely to be seen on echocardiography? A Aortic regurgitation B Hypertrophic cardiomyopathy C Mitral valve prolapse D Pulmonary stenosis
C Mitral valve prolapse, mid systolic click which increases with valsalva/standing and decreases/is heard later with squatting
A 16-year-old girl presents to urgent care with her father after injuring herself when she was bounced off of a trampoline. The father states the patient fell onto her outstretched left arm with her elbow extended and her forearm hyperpronated from a height of about 8 feet. Her X-ray is shown above. What is the most likely diagnosis? (xray shows proximal ulnar shaft fracture and proximal radial head dislocation) A Galeazzi fracture B Maisonneuve fracture C Monteggia fracture D Smith fracture
C Monteggia fracture -galeazzi fracture: distal radius fracture with radioulnar joint dislocation
A 45-year-old man presents with complaints of bilateral shaking in his hands for over 5 years. The patient is concerned because it is becoming obvious when he points at the board during his lectures. Which of the following additional findings is most consistent with the suspected diagnosis? A Bradykinesia B Pill-rolling tremor C Relief of symptoms with alcohol D Resolution of tremor during stressful situations
C Relief of symptoms with alcohol, correctly identified essential tremor which improves with alcohol use -bradykinesia and pill-rolling tremor are both associated with Parkinson's not essential tremor -essential tremor is activated by voluntary movement and accentuated by goal-directed movements
A 45-year-old woman presents to her primary care provider for hypertension management. An office blood pressure measurement 2 weeks ago was 136/92 mm Hg. Her home blood pressure measurements for the past 2 weeks show an average systolic pressure of 136 mm Hg and an average diastolic pressure of 92 mm Hg. Her blood pressure measurement in the office today is 138/92 mm Hg. Which of the following best categorizes the patient's condition based on these findings according to the American College of Cardiology? A Elevated blood pressure B Isolated diastolic hypertension C Stage 1 hypertension D Stage 2 hypertension
D Stage 2 hypertension Normal: <120, <80 Elevated BP: 120-129, <80 Stage 1: 130-139, 80-89 Stage 2: >/=140, >/=90 HTN emergency: >/=180, >/=120
A 32-year-old man presents to his primary care provider with complaints of chest burning for the past 2 months. He reports he has a burning sensation in his chest that seems to occur within 1 hour of eating a fatty or spicy meal. The symptoms occur once or twice each week and are worse when he lies down. He has been taking famotidine twice daily for the past 3 weeks but is still having symptoms. Which of the following is the best next step in the pharmacologic management of this patient? A Continue famotidine and begin omeprazole twice daily B Continue famotidine for 3 more weeks C Discontinue famotidine and begin cimetidine twice daily D Discontinue famotidine and begin omeprazole once daily
D Discontinue famotidine and begin omeprazole once daily, this pt is unresponsive to H2 blocker which should be d/c, also PPI therapy is taken QD
A 35-year-old man presents to the clinic complaining of a progressive chest pain that he has had for about 1 week. He describes the pain as a severe, sharp pain to the center of his chest. He states the pain worsens when he takes a deep breath and when lying down. He has been leaning forward because he says this is the only position in which the chest pain gets better. On physical exam, there is a pericardial friction rub. The patient has not tried any medications to help with his pain. Which of the following is the most appropriate therapy for this patient? A Acetaminophen and colchicine B Corticosteroids C Ibuprofen D Ibuprofen and colchicine
D Ibuprofen and colchicine, this is apparently first line treatment for pericarditis (not NSAIDs alone)
A 65-year-old man with a history of type 2 diabetes mellitus presents to the clinic reporting intermittent chest pain for the past 2 weeks. The patient states symptoms occur with walking long distances and are resolved with rest. The pain is described as chest pressure, with occasional radiation to the lower jaw, that lasts approximately 2 minutes. Physical exam is unremarkable. A stress test reveals ST depression and reproduced angina symptoms. Coronary angiography reveals single-vessel disease. Which of the following treatments is indicated? A Alteplase B Coronary artery bypass graft C Heparin D Percutaneous transluminal coronary angioplasty
D Percutaneous transluminal coronary angioplasty, indicated due to involvement of only 1 vessel and not the left coronary -CABG indicated for > 50% stenosis involving the left main coronary artery, > 70% stenosis multi-vessel disease, or a decreased left ventricular ejection fraction < 40%
A 25-year-old woman presents with complaints of intermittent headache. The patient describes the headache as a band tightening around her head. Headaches are relieved with ibuprofen. Which of the following additional physical exam findings would be present given the most likely diagnosis? A Headache aggravated by routine physical activity B Nasal congestion C Nausea and vomiting D Pericranial muscle tenderness
D Pericranial muscle tenderness, this is a tension headache
A 46-year-old man presents to his primary care provider for a follow-up on his laboratory results. His fasting glucose level is 232 mg/dL, and his hemoglobin A1C is 9.2%. His past medical history is significant for a treated hepatitis B infection and diabetes mellitus type 2. Which of the following should be recommended to the patient at this time? A Hepatitis B vaccination B Monthly measurement of A1C level C Ophthalmology follow-up in 5 years D Pneumococcal polysaccharide vaccine
D Pneumococcal polysaccharide vaccine -this pt had hep B so no need for vaccine
A 32-year-old woman is hospitalized for bilateral pulmonary embolisms following a period of immobilization after suffering a femur fracture. She has a family history of blood clots. Her medical team makes the decision to start her on warfarin while first bridging her with heparin. Several days into her admission, the heparin is discontinued. The patient develops large, demarcated violet areas of necrotic skin tissue on her breasts. What hypercoagulable disorder should be considered given the course of the patient's illness? A Antiphospholipid syndrome B Antithrombin III deficiency C Factor V Leiden D Protein C deficiency
D Protein C deficiency Warfarin-induced skin necrosis is a complication of warfarin therapy that can be observed in patients with protein C deficiency. Protein C deficiency is a hypercoagulable disorder that can be inherited or acquired. Patients with protein C deficiency have an increased risk of venous thromboembolism (VTE), particularly deep vein thrombosis in the leg, pulmonary embolism, and thrombosis within the mesenteric veins. In addition to VTE, adverse pregnancy outcomes, such as fetal loss and miscarriage, can be observed. Patients with protein C deficiency can also develop warfarin-induced skin necrosis due to the transient hypercoagulable state secondary to depletion of protein C that occurs when first starting warfarin. For patients with warfarin-induced skin necrosis, warfarin should be discontinued immediately. The warfarin antagonist, vitamin K, should be administered, and unfractionated heparin can be given to continue anticoagulation. Additionally, protein C should be administered to the patient either via protein C concentrate or through fresh frozen plasma.
A 25-year-old woman presents after experiencing a depressed mood, loss of pleasure in almost all activities, weight loss, poor concentration, and insomnia for the last 2 weeks. Prior to this, she had a period of euphoric mood for 10 days with associated inflated sense of self, decreased need for sleep, and racing thoughts. She was unable to work because of the severity of these symptoms. She reports no substance use, and her medical history is benign. Which of the following would be the most appropriate FDA-approved treatment for this patient at this time? A Carbamazepine B Lamotrigine C Lithium D Quetiapine
D Quetiapine, this is bipolar 1 which is characterized by severe swings from manic episodes to depressive episodes; bipolar 2 is characterized by hypomanic episodes with episodes of severe depression -lithium is for acute episodes of mania or for maintenance in combination with a first line therapy
A 45-year-old woman presents to her primary care provider with complaints of worsening right shoulder pain and stiffness for 2 months. She describes the pain as diffuse, dull, and achy. Her pain is worse at night and with overhead movements. She has been taking ibuprofen, which only alleviates the pain occasionally. Her past surgical history is significant for a rotator cuff repair 3 months ago. Physical examination reveals a well-developed, well-nourished woman with her right arm in a sling. Passive range of motion of the right shoulder is decreased in all planes and causes the patient significant pain. Grip strength and neurovascular testing are normal bilaterally. Which of the following is the most appropriate clinical intervention at this time? A Arthroscopic surgical release B Manipulation under anesthesia C Prescribe night splints D Refer to physical therapy
D Refer to physical therapy, correctly identified adhesive capsulitis; PT is first step therapy for adhesive capsulitis, manipulation under anesthesia is for >10 months of symptoms or if more conservative management doesn't work
A 50-year-old man presents to the office for evaluation of progressive dyspnea on exertion and a persistent nonproductive cough. Symptoms began about 6 months ago. He has no significant medical history other than atrial fibrillation, which has been well-controlled on amiodarone for the past 12 months. He does not take any other medications. He reports no history of tobacco or illicit drug use or exposure to occupational agents. On physical examination, his heart rate and rhythm are regular, and no murmur or gallop is heard. Inspiratory crackles are noted diffusely in both lungs. His jugular venous pressure is normal, and he has no peripheral edema. Which of the following findings is most likely to be seen on chest radiography? A Bilateral hilar adenopathy B Kerley B-lines C Pleural plaques D Reticular opacities
D Reticular opacities, this is interstitial lung disease A Bilateral hilar adenopathy: seen in sarcoidosis B Kerley B-lines: seen in CHF C Pleural plaques: seen in mesothelioma
A 29-year-old woman presents to the office with a complaint of progressive fatigue over the past 3 months. She reports intermittent low-grade fevers and night sweats on rare occasions. Chart review from her last visit indicates an unintentional 16-pound weight loss over the past 3 months. On physical examination, the left deep cervical and supraclavicular lymph nodes are enlarged, firm, and nontender to palpation. What finding on lymph node biopsy is most consistent with the patient's most likely diagnosis? A Gallium uptake in a pattern resembling lambda B Granulomatous inflammation with caseation necrosis C Monomorphic medium-sized cells with basophilic cytoplasm D Rounded bilobed cells with two nucle
D Rounded bilobed cells with two nucle, AKA Reed-sternberg cells which is classic for Hodgkin lymphoma -B Granulomatous inflammation with caseation necrosis: this is TB but this is unlikely with no cough/travel history
A 19-year-old man presents to his primary care provider after an episode of dyspnea, chest pain, and postexertional syncope. He reports his father and brother have had similar symptoms in the past. Echocardiography is significant for left ventricular hypertrophy with a thickened septum, left ventricular hypercontractility and hypertrophy, left atrial enlargement, and diastolic dysfunction. Physical examination findings reveal a bisferiens carotid pulse, triple apical impulse, and prominent a wave. Which of the following cardiac auscultation findings is most consistent with the patient's condition? A Murmur decreases with Valsalva B Murmur increases with squatting C S3 gallop D S4 gallop
D S4 gallop, correctly identified hypertrophic cardiomyopathy which has an S4 gallop due to stiff LV -hypertrophic cardiomyopathy decreases with squatting and increases with valsalva -S3 is heard in CHF
A 4-year-old boy presents to the office with his parents, out of concern for sudden bruising, spots all over his body, and blood in his stool that developed suddenly today. There is no report of recent trauma or abuse. The patient's mother reports no fever but does report he was ill in the past month with an upper respiratory infection. On physical examination, the boy is noted to be afebrile, pale, and nontoxic-appearing. Ecchymosis is noted on the patient's legs and left arm along with the finding in the image above. No lymphadenopathy or splenomegaly is appreciated. Complete blood count reveals a platelet count of 12,000/microL. Hemoglobin and hematocrit are within normal range. Coagulation studies reveal no prolongation. What intervention would be appropriate for this patient? A Prescribe prednisone taper and follow up in 2 weeks B Refer to gastroenterology for sigmoidoscopy C Refer to hematology for outpatient workup of malignancy D Send to emergency department for further evaluation
D Send to emergency department for further evaluation, this is idiopathic thrombocytopenia purpura/immune thrombocytopenia and due to the GI bleed and low platelets, emergency evaluation should be done -tx would be IVIG + platelet transfusion; glucocorticoids used for less severe cases
A 58-year-old man with a history of heart failure presents to the ED with worsening shortness of breath and pitting edema of the bilateral lower extremities. Vital signs are T 98.6°F, BP 202/112 mm Hg, HR 105 bpm, RR 24 breaths per minute, and oxygen saturation 94% on room air. A chest X-ray and echocardiogram show pulmonary edema and acute left ventricular dysfunction. His ECG shows sinus tachycardia with no ST segment or T wave changes. The patient is given furosemide for pulmonary edema. Which of the following blood pressure medications is most appropriate at this time? A Hydralazine B Labetalol C Metoprolol D Sodium nitroprusside
D Sodium nitroprusside, this is a vasodilator that reduces after load in patients with acute HF -metoprolol and labetalol are contraindicated in acute HF due to reduction of cardiac contractility
A 45-year-old woman presents to the clinic with infrequent bowel movements. She says that for most of her adult life she has had one or two bowel movements per week and has had to strain during bowel movements. She reports no rectal bleeding, weight loss, or family history of colorectal cancer. Physical examination reveals her abdomen is soft and nontender. She has tried increasing her water and fiber intake with minimal improvement. Which of the following pharmacologic treatments would improve her condition by increasing the flow of water into the intestines? A Bisacodyl B Docusate C Loperamide D Sorbitol
D Sorbitol -docusate decreases surface tension of stool and makes it easier for water to get into stool to soften it -bisacodyl is a laxative
An 18-year-old woman presents with her parents who are concerned about her dietary habits. She has been binge eating and then either vomiting or using laxatives as a compensatory behavior for the past several months. Which of the following historical findings would be consistent with the most likely diagnosis? A Attention-deficit disorder B Narcissistic personality disorder C Schizoid personality disorder D Specific phobia disorder
D Specific phobia disorder, fear of gaining weight
A 30-year-old man presents to the clinic complaining of fatigue, night sweats, and a 20-pound unintentional weight loss in the past 4 months. He takes no daily medications and does not smoke. Physical exam reveals diffuse nontender lymphadenopathy and a temperature of 100.8°F. Which of the following additional physical exam findings is most consistent with the presumed diagnosis? (got this right) A Cardiac friction rub B Decreased sensation in bilateral feet and hands C Enlarged thyroid gland D Splenomegaly
D Splenomegaly this is Hodgkins lymphoma: presents with diffuse lymphadenopathy, fever consistently ≥ 100.4°F, unintentional weight loss of over 10% of body weight in the past 6 months, drenching night sweats, may have splenomegaly or hepatomegaly, A mediastinal mass may be noticeable on chest X-ray. Laboratory analyses of patients with Hodgkin lymphoma will show increased lymphocytes and may show anemia. Definitive diagnosis is through biopsy of a lymph node. The lymph node will demonstrate Reed-Sternberg cells in a polymorphous inflammatory infiltrate on microscopic examination. Treatment of Hodgkin lymphoma is with chemotherapeutic agents such as doxorubicin.
A 23-year-old woman presents to the office with increasing fatigue and inability to concentrate. She has been gaining a lot of weight in her face and abdomen and has had multiple yeast infections over the past year. The patient reports no history of exogenous steroid use. A physical exam reveals some purple striae around her abdomen and thighs. She also has very thin extremities. Initial testing reveals elevated cortisol levels and no suppression with low-dose dexamethasone suppression test. Which of the following further tests will confirm the diagnosis of Cushing disease? A Low serum adrenocorticotropic hormone levels B No change after corticotropin-releasing hormone stimulation test C No suppression with high-dose dexamethasone suppression test D Suppression with high-dose dexamethasone suppression test
D Suppression with high-dose dexamethasone suppression test -cushing caused by acth secreting pituitary adenoma will show high acth levels and suppression with high dose dexa suppression test since the tumor is responsive to high doses and not low doses; cortisol levels are measured after introduction of dexamethasone
A 65-year-old man with a history of hypertension, hypercholesterolemia, and a 40 pack-year smoking history presents to his primary care provider 1 week after stent placement during a percutaneous transluminal coronary angioplasty. He states he has been feeling well since the procedure. He also reports he lost his postvisit summary and is unsure of any medication changes he should be aware of. What medication should be initiated in this patient? (got this right) A Dabigatran B Dipyridamole C Heparin D Ticagrelor
D Ticagrelor, in CAD after a cardiac event, pts should be placed on dual anti platelet therapy with ASA and either ticagrelor or clopidogrel
A 70-year-old man presents to his primary care provider to discuss his chronic obstructive pulmonary disease. His last pulmonary function test revealed FEV1 of 60%. He has not had any exacerbations in the past year, however, he reports an increase in symptoms in the past 2 months. He is coughing more, has noticed an increase in sputum production, and is becoming breathless with minimal exertion. He currently only uses ipratropium as needed. What medication should be initiated next for this patient? A Albuterol B Budesonide C Theophylline D Tiotropium
D Tiotropium, since he has had no exacerbation in the past year, he should switch to a long acting anti-muscarinic like tiotropium rather than the short acting ipratropium
A 21-year-old woman presents to an obstetrician after a positive home pregnancy test. She states she has a history of irregular menses and her last menstrual period was 6 weeks ago. Her beta-human chorionic gonadotropin is 46,000 mIU/mL. A transvaginal ultrasound is shown above and estimates a 7 week gestational age. Which of the following tests should always be ordered at this time? A Alpha-fetoprotein B Estradiol C Inhibin A D Urinalysis
D Urinalysis, this is a normal pregnancy and a UA should be ordered
A 21-year-old man presents to the emergency department via ambulance after his mother found him seizing early this morning. The patient's mother reports she heard a choking sound coming from her son's room around 4:00 AM. She reports his arms and legs were jerking for at least 1 minute, and he was not responsive. He urinated on himself. In the emergency department, he appears to be postictal, and the oropharynx examination reveals a tongue laceration. Toxicology screen is negative, and finger stick blood glucose is within normal range. Upon further questioning, the patient's mother reports he had a similar episode 2 years ago, but it was determined he did not need any further intervention at that time. Which of the following is the preferred pharmacologic intervention, given the most likely diagnosis? A Carbamazepine B Phenytoin C Topiramate D Valproate
D Valproate, this is a generalized epileptic seizure with first line management of valproate -topiramate is second line management -carbamazepine and phenytoin can worsen generalized epileptic seizures
A 30-year-old man presents with right eye pain and swelling. The patient reports that his symptoms have been worsening over the past 3 days. Physical exam reveals lid erythema, pain with extraocular movements, sluggish right pupil response, and visual acuity of 20/40. He reports a history of an upper respiratory infection 2 weeks ago. The patient has no known drug allergies and no medications. CT scan of the head shows inflammation of the extraocular muscles with fat stranding. No abscess or intracranial involvement is noted. What is the most appropriate intervention for this patient? A Metronidazole B Trimethoprim-sulfamethoxazole C Vancomycin D Vancomycin and ceftriaxone
D Vancomycin and ceftriaxone, correctly identified orbital cellulitis which needs aggressive abx tx with vanco (masa coverage) and ceftriaxone for broad coverage
