family medicine/ ER part 3 final

A 40-year-old woman presents to the clinic for her annual wellness visit. Her past medical history is unremarkable. Her mother was diagnosed with colon cancer at 53 years of age. The patient reports no changes in bowel habits, rectal bleeding, or unexplained weight loss. Which of the following is the correct recommendation for colon cancer screening in this patient? AOrder a carcinoembryonic antigen (CEA) level and screening colonoscopy at this visit BOrder a screening colonoscopy at this visit CPlan on a screening colonoscopy at 43 years of age DPlan on a screening colonoscopy at 50 years of age

Order a screening colonoscopy at this visit screening average-risk individuals beginning at 45 years of age Patients with a first-degree relative with advanced adenoma or colorectal cancer diagnosed before the age of 60 years should have a screening colonoscopy at 40 years of age or 10 years younger than the earliest diagnosis in their family (whichever comes first). USPTF (updated 2021): screen all age 45-75, select patients up to age 85 ACG: start screening at age 45 AAFP: start screening at age 50 Test options: colonoscopy every 10 years, fecal immunochemical test yearly, multitarget fecal DNA every 3 years, CT colonography every 5 year Familial adenomatous polyposis is a syndrome with what type of genetic inheritance? Answer: Autosomal dominance.

A 55-year-old man presents to the clinic with a two-day history of fever, chills, dysuria, hesitancy, and urgency. Temperature is 38.8°C. Digital rectal examination reveals an edematous, firm, and exquisitely tender prostate. Urinalysis demonstrates pyuria and bacteriuria. Which of the following is the next best step in management?

Levofloxacin for 28 days dx: Acute bacterial prostatitis tx: typically with trimethoprim-sulfamethoxazole or a fluoroquinolone (levofloxacin or ciprofloxacin) for four to six weeks. What empiric antibiotic regimen is recommended for treatment of acute bacterial prostatitis in sexually active men younger than 35 years of age? Answer: Ceftriaxone and doxycycline to cover Neisseria gonorrhoeae and Chlamydia trachomatis. Acute Bacterial Prostatitis Sx: fever, chills, perineal or pelvic pain, and dysuria PE: firm and exquisitely tender prostate Most common causes < 35 years old: N. gonorrhoeae, C. trachomatis > 35 years old: E. coli Treatment < 35 years old: ceftriaxone IM and doxycycline > 35 years old: fluoroquinolone or TMP-SMX for 4 weeks Avoid vigorous prostatic massage, which can lead to septicemia

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?

Macular degeneration is characterized by central vision loss Risk factors are multifactorial and include advanced age, tobacco abuse, genetic predisposition, race, obesity, and existing cardiovascular disease. ========================================= Diabetic retinopathy (A) can also be largely asymptomatic or can manifest as a slow decrease in visual acuity. Fundoscopic exam may reveal intraretinal hemorrhages, cotton-wool spots, neovascularization, and macular edema. Open-angle glaucoma (C) is characterized by optic neuropathy and can be, but is not always, associated with increased intraocular pressure. Risk factors include family history, advanced age, and diabetes mellitus. Symptoms include a gradual loss of peripheral visual fields, but often patients are asymptomatic. Presbyopia (D) is a normal decrease in near-vision as a part of aging. The fundoscopic exam should be normal.

A 28-year-old woman presents to the office with complaints of generalized fatigue, weight gain, and depression that began a few months ago and has worsened. Upon examination you notice she has some periorbital edema, and upon palpation, a slightly enlarged thyroid. Which test remains the most sensitive screening tool for diagnosing primary hypothyroidism?

Third-generation thyroid-stimulating hormone assay dx:Hypothyroidism Hypothyroidism Patient presents with generalized weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain PE will show periorbital edema, dry skin, and coarse brittle hair Labs will show high TSH and low free T4, antithyroid peroxidase and antithyroglobulin autoantibodies Most commonly caused by Hashimoto thyroiditis Treatment is levothyroxine Takes about 6 weeks to see treatment effects Monitor TSH Hashimoto: risk factor for non-Hodgkin lymphoma

Which of the following treatments is the recommended initial therapy for the condition pictured above?

Topical nifedipine is the recommended initial therapy for typical anal fissures

A 16-year-old girl presents to the clinic with open and closed comedones without surrounding inflammation on her face and chest. She has tried over-the-counter 2.5% benzoyl peroxide cream, but it was ineffective at reducing her symptoms. Which of the following is the most appropriate initial treatment for this patient?

Topical retinoid

A 32-year-old woman presents to the clinic with a two-year history of headaches. She reports having four to six headaches per month, which are characterized by throbbing, unilateral pain associated with nausea, vomiting, and photophobia. Each headache typically lasts between six to 12 hours. She reports missing multiple days of work each month due to the headaches and would like to try a medication to prevent them. Which of the following is the best prophylactic therapy for this patient?

Topiramate dx Migraine headaches Abortive therapy includes NSAIDs, acetaminophen, and triptans. Prophylactic therapy is indicated for those with more than four headaches per month or headaches lasting longer than 12 hours. First-line prophylactic medications include topiramate, amitriptyline, and beta-blockers. What are common adverse effects of topiramate? Answer: Paresthesia, anorexia, weight loss, fatigue, diarrhea, memory difficulty, hypesthesia, difficulty concentrating, language problems, nausea, and taste perversion.

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A 32-year-old man presents to the clinic with a five-day history of right-sided nasal stuffiness, discharge, and pain. He has no fever, and his symptoms have not worsened during the course of illness. Palpation of the right maxillary sinus elicits tenderness. Which of the following is the most appropriate next step?

Acetaminophen, intranasal fluticasone, and saline irrigation dx:Acute rhinosinusitis For symptoms lasting less than seven days in both viral and bacterial cases of acute sinusitis, symptomatic management with analgesics and antipyretics, saline irrigation, and intranasal glucocorticoids is suggested. Therefore, in this patient with symptoms for less than seven days, acetaminophen, intranasal fluticasone, and saline irrigationwould be the most appropriate next step. What is the best antibiotic treatment regimen for acute rhinosinusitis in patients without penicillin allergy who have risk factors for pneumococcal resistance? Answer: High-dose amoxicillin-clavulanate 2,000 mg/125 mg extended-release tablets twice daily. Acute Sinusitis Sx: nasal congestion, pain or pressure over sinuses, ear pain or pressure, headache, fever PE: purulent rhinorrhea Most commonly caused by viral URIIf viral, tx: supportive care Bacterial sinusitis: purulent nasal secretions and severe symptoms for ≥ 10 daysAmoxicillin or Amoxicillin-clavulanate

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?

Acetazolamide IV, topical apraclonidine, topical timolol dx:acute angle closure glaucoma. Acute angle closure glaucoma is defined by increased intraocular pressure caused by obstruction of aqueous humor drainage via the canal of Schlemm Signs and symptoms of acute angle closure glaucoma include ocular pain, nausea and vomiting, unilateral blurring of vision, photopsia or colored halos around lights, elevated intraocular pressure (often 30 mm Hg or higher), conjunctival injection, a cloudy or steamy cornea due to corneal edema, and a mid-dilated nonreactive pupil. Ophthalmology should be consulted as soon as this diagnosis is suspected for definitive laser iridotomy.

A 62-year-old, otherwise healthy, non-smoking woman presents to the clinic with a cough productive of green sputum for seven days. There is low-grade fever and scattered rhonchi on exam, with an oxygen saturation of 97% on room air. Which of the following is the most likely diagnosis?

Acute bronchitis Acute Bronchitis Patient presents with a productive cough for > 5 days Most commonly caused by viruses Treatment is symptomatic management Most common cause of minor hemoptysis Routine Abx therapy not indicated When should an antitussive be given to a patient with acute bronchitis? Answer: Only when the cough is interfering with sleep.

Which of the following diseases is most commonly associated with a previous history of a hematologic disorder, such as myelodysplastic syndrome, aplastic anemia, or polycythemia vera?

Acute myeloid leukemia

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?

Acute on chronic respiratory acidosis

A 72-year-old man presents complaining of a cough, chest pain, and shortness of breath for the past couple of weeks. He was not concerned enough to seek care until he started noticing bright red blood in his sputum the past couple of days. His weight is down from the last visit. Electrocardiogram is normal. As you await the results of his chest X-ray, what is the most likely diagnosis?

Adenocarcinoma

A 22-year-old man presents to the urgent care clinic with shortness of breath, facial swelling and rash. His mother states he was stung by a wasp 20 minutes ago and almost immediately began to have difficulties speaking and breathing. He has a heart rate of 110 beats per minute, respiratory rate 36 breaths per minute, oxygen saturation 92% on room air and blood pressure 92/46 mm Hg. An intravenous line has been placed. What is the most appropriate first step in your management?

Administer epinephrine 0.3 mg IM dx:Anaphylaxis

A 54-year-old man presents to the clinic for his annual preventive visit. He requests screening for type 2 diabetes mellitus stating that his brother was recently diagnosed with this. He denies any classic symptoms of hyperglycemia, including polyuria, polydipsia, blurry vision, or weight loss. Which of the following establishes a diagnosis of type 2 diabetes mellitus?

An asymptomatic patient with HgbA1c values > 6.5% measured on two different days Tx: lifestyle modifications then medication (first-line Rx: metformin) Screen adults aged 35-70 with BMI ≥ 25 kg/m2 every 3 years Those with additional risk factors need annual screening According to the American Diabetes Association, when is screening recommended for type 2 diabetes mellitus? Answer: Annually in patients 35 years of age and older, or in patients less than 35 years with major risk factors.

Current guidelines recommend which of the following as long-term follow up of female patients with Hodgkin lymphoma who have been treated to remission?

Annual mammography starting at age 40 or five to eight years after radiation therapy

A 35-year-old woman presents complaining of a recurrent mouth sore. The sore typically last for 5-6 days and then resolves. It usually takes several months before it reoccurs, usually in the same spot on the inside of her left cheek. On exam a whitish ulcer is seen on the oral mucosa, approximately 8 mm in diameter with a reddish halo around it. Rest of exam is normal. What is the most likely diagnosis?

Aphthous ulcer What is the common name for aphthous ulcer? Answer: Canker sore. ===================================================== Coxsackie virus (B) commonly causes hand, foot, and mouth disease. There are blisters typically found in the mouth and the palms of the hands and soles of the feet. This patient has no hand or foot sores. Herpetiform ulcers (C) look similar to aphthous ulcers but are irregularly shaped and generally appear in clusters of up to 100. Varicella zoster virus (D) or shingles, rarely causes mouth sores; but when it does, ulcers are erythematous and on one side of the roof of the mouth.

A 70-year-old man with long-standing hypertension presents with fatigue and dyspnea. His dyspnea worsens on exertion and when lying supine. Which of the following physical exam findings would be consistent with a diagnosis of congestive heart failure?

Audible fourth heart sound dx:Congestive heart failure involves ventricular dysfunction and can affect the right ventricle, Patients who suffer from congestive heart failure can present with dyspnea, fatigue, orthopnea,peripheral edema, distended neck veins, a sustained and laterally displaced apical impulse, audible extra heart sounds, bibasilar crackles or dullness to percussion at the lung bases. An audible fourth heart sound indicates a stiffened, noncompliant left ventricle.

69-year-old man with a past medical history of diabetes mellitus, hypertension, and medication non-compliance presents to the emergency department with a fever and a cough that has been progressively worsening. He has not has any recent travel or hospitalizations. His temperature is 102°F (38.9°C), blood pressure is 117/68 mm Hg, pulse is 120/min, respiratory rate is 30/min, and oxygen saturation is 94% on room air. A chest radiograph is seen above. Which of the following is the most appropriate treatment for this patient's symptoms? AAzithromycin and ceftriaxone BCefepime CPiperacillin-tazobactam and vancomycin DVancomycin, cefepime, and amikacin

Azithromycin and ceftriaxone dx:Community-acquired pneumonia typically presents with a fever, a cough,crackles on pulmonary exam, and chest radiography demonstrating a lobar consolidation. ======================================== Cefepime (B) is an appropriate antibiotic for hospital-acquired pneumonia with no risk factors for multidrug resistant organisms or MRSA. Piperacillin-tazobactam and vancomycin (C) is appropriate management of ventilator-acquired pneumonia in a patient with risk factors for methicillin-resistant Staphylococcus aureus. Vancomycin, cefepime, and amikacin (D) is appropriate initial management for a patient with hospital-acquired pneumonia with risk factors for both multi-drug resistant bacteria and methicillin-resistant Staphylococcus aureus.

A 70-year-old man is brought into the office by his adult children because he has been leaving his house and wandering in the street. For the last six months, he became increasingly forgetful of names of family members and of places he often visited. He lost interest in his usual hobbies and is more restless. Which of the following is considered the first-line therapy for patients with mild-to-moderate Alzheimer's disease?

Cholinesterase inhibitors dx:Alzheimer Disease Patient's family will report short-term memory loss, confusion about the location of familiar places, difficulty completing daily tasks that would normally take less time to do, poor judgment that can lead to bad decision-making, changes in mood or personality (e.g., increased anxiety) Diagnosis is confirmed by microscopy of the brain that shows amyloid plaques and neurofibrillary tangles Mini-Mental State Examination is used to monitor the progression Treatment is cholinesterase inhibitors (e.g., donepezil), NMDA antagonists (e.g., memantine)Does not cure, only aims to slow progression

A 45-year-old woman presents to the emergency department with dysuria and right flank pain. Her symptoms started 6 days ago with urinary urgency and dysuria. She developed the flank pain 2 days ago and has associated chills and nausea. Vital signs are remarkable for a temperature of 37.8°C (100.0°F), HR 80 bpm, RR 13/min, BP 130/60 mm Hg, and SpO₂ 99%. What is the most appropriate management of this patient?

Ciprofloxacin 500 mg twice daily dx:Pyelonephritis

A 60-year-old man with a history of significant benign prostatic hypertrophy presents to the clinic complaining of high levels of anxiety with frequent episodes of tachycardia, profuse sweating, feelings of impending doom, nausea, and tingling in his hands and feet. These episodes last about 10 minutes and are brought on by stressful social situations. The patient reports self-medicating for years with excessive amounts of alcohol. Which of the following medications would be safest to initiate in this patient?

Citalopram panic attack is a brief episode of intense fear accompanied by somatic or cognitive symptom Benzodiazepines ( Lorazepam , Diazepam) are avoided in patients with substance use disorder. Citalopram is a selective serotonin reuptake inhibitor and is considered first-line therapy in patients with panic disorder. Side effects of citalopram include gastrointestinal disturbances, sleep disturbances, and dry mouth. A black box warning is attached to citalopram and other drugs of its class due to increased risk of suicidal thinking and behavior in children, youth, and young adults during the initial two months of treatment.

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? AComputed tomography of the abdomen and pelvis with intravenous contrast BContinuous bladder irrigation CDischarge home with ciprofloxacin for five days DDischarge home with urology referral

Computed tomography of the abdomen and pelvis with intravenous contrast

A 64-year-old man with a history of diabetes mellitus presents with pain in his right calf while walking. The pain is relieved with rest. He has smoked one pack of cigarettes per day for the past 35 years. Exam reveals a cool extremity with diminished pulses. What is the gold-standard diagnostic study for your suspected diagnosis?

Contrast arteriography dx:peripheral artery disease. =========================================== Bedside ankle-brachial index (A) is a simple test that can be performed at the bedside, and should be measured in patients with one or more findings consistent with peripheral artery disease or other findings on physical exam. The ankle-brachial index is the ratio of the ankle systolic blood pressure divided by the brachial systolic pressure detected with a Doppler probe. An ankle-brachial index of <0.90 has a high degree of sensitivity and specificity for peripheral artery disease, though is not the gold-standard.

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1)An acutely hot, swollen, and tender joint(s) with restriction of movement is considered to be septic arthritis until proven 2) sinus Bradycardia :Initial pharmacologic treatment for an unstable patient is atropine. Since this patient presents with both a syncopal episode and diaphoresis, she is unstable and atropine is the appropriate therapy. After an initial dose of atropine, infusions of epinephrine or dopamine may also be considered, and for more emergent casestranscutaneous pacing may be necessary. 3)Which of the following examination findings is most consistent with cholecystitis? nspiratory arrest with right upper quadrant palpation 4) The posterior cerebral artery (B) supplies the occipital lobe. Symptoms of a posterior cerebral artery stroke are subtle and may include ataxia, vertigo, contralateral motor weakness, and visual field cuts. The middle cerebral artery (D) is the artery most commonly involved in ischemic stroke. Symptoms depend on what area of the artery is involved as well as which lobe is dominant in the patient. Typical symptoms include contralateral hemiparesis (involving both the arm and leg, in contrast to an ACA stroke), facial droop, and sensory loss. Involvement of the dominant lobe will result in aphasia, which may be expressive, receptive, or both. 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? Right anterior cerebral artery 5) SEARCH UP GI DISEASE IMAGES ON XRAY 6)Which of the following types of traumatic events has the highest probability of resulting in post-traumatic stress disorder? Rape 7)LAAWG >55 age > 55, glucose > 200, WBC > 16,000, AST > 250, LDH > 350. At 48 hours, findings associated with increased mortality include failure of a decrease in hematocrit > 10%, an increase in BUN > 5 mg/dL, Ca < 8 mg/dL, PaO2 < 60 mm Hg, base deficit > 4 mEq/L, rapid fluid sequestration > 6 L. Patients with 0-3 positive findings have a mortality rate of 1%, while those with 3-4, 5-6, > 7 findings have mortality rates of 15%, 40%, 100%, respectively. In this case, glucose of 313 is a predictor of increased mortality. 8)What is the most likely cause of acute anemia in an African-American patient with an HIV infection who recently began pneumocystis pneumonia prophylaxis? Glucose-6-phosphate-dehydrogenase deficiency 9)Which of the following causes acute painful loss of vision?Optic neuritis 30% of patients will develop multiple sclerosis (MS) within five years. Vision loss, most commonly a loss of central vision, and loss of color perception, develop over a period of hours and peaks in about one week. Eye pain, typically worse with eye movements, occurs in about 90% of patients. On examination, an afferent pupillary defec symptoms will gradually improve. Intravenous corticosteroids h 10)Which muscle is most commonly involved with rotator cuff injuries? Supraspinatus 11) Injury to which of the following structures characterizes a strain? Connective tissue between muscle and bone A sprain, on the other hand, is an injury to the ligaments which are the connective tissue between separate bones of a joint (D) What type of injury is a rotator cuff tear? Answer: A strain. 12)Which of the following is the most common pulmonary complication of influenza? Pneumonia secondary to superimposed bacterial infection 13)A 45-year-old man with a history of Marfan Syndrome is noted to have a high-pitched blowing diastolic murmur at the left sternal border. What valvular disorder is most likely present? Aortic regurgitatio 14)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? Pulmonary contusion 15)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? Paraphimosis . Phimosis (C) is the inability to retract the foreskin proximally. Infection, poor hygiene, and previous preputial injuries with scarring are common causes of pathologic phimosis. Scarring at the tip of the foreskin can occlude the preputial meatus, infrequently causing urinary retention. Priapism (D) is a urologic emergency that is characterized by a persistent, painful, pathologic erection in which both corpora cavernosa are engorged with stagnant blood. Many cases of priapism are related to oral antihypertensive agents, neuroleptic medications, or oral agents related to erectile dysfunction. 16)Which of the following is one of the most helpful signs to rule out testicular torsion? Presence of the cremasteric reflex 17)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?Suprapatellar bursa 18)felon, which is a pyogenic infection of the digital subcutaneous tissue and pulp. Staphylococcus aureus i 19)Which of the following offers a proven mortality benefit in acute coronary syndrome? Aspirin 20)

Place patient on 100% oxygen and repeat chest radiograph in six hours dx:spontaneous simple pneumothorax

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?

Perforated gastric ulcer

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?

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.

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?

Chronic obstructive pulmonary disease dx: multifocal atrial tachycardia (MAT). MAT occurs when at least three different atrial ectopic focidepolarize to pace the heart.

A 79-year-old man presents to the ED complaining of dyspnea. His rhythm strip is shown above. What is the most likely underlying process?

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?

Admission for intravenous cefotetan and doxycycline dx: Pelvic inflammatory disease

A 74-year-old man presents with complaints of sudden onset of painful swelling anterior to his left ear and fever. He was recently hospitalized for a total hip replacement. On exam, the patient has tenderness to palpation of his left parotid gland as well as trismus. Purulence is expressed from the left Stensen's duct. What is the treatment of choice for your suspected diagnosis?

Admission to the hospital for hydration and intravenous antistaphylococcal antibiotics dx: suppurative parotitis

A two-year-old boy presents to the urgent care with persistent coughing, choking and wheezing that began about an hour ago. His mother states that he was found playing with some of her older son's small plastic toys before the symptoms began. You suspect foreign body aspiration. What test is the most definitive for diagnosis and treatment of this condition?

Bronchoscopy dx: Foreign body aspiration What is cafe coronary syndrome? Answer: Sudden collapse that results from choking on a large object (often poorly chewed meat) causing nearly complete airway obstruction.

A 29-year-old woman presents to your clinic for fatigue and darkening skin. She reports she went on vacation one month ago and thought that her skin changes were from tanning. She is specifically concerned about darkening on her hands and around her lips. She doesn't report any illness, fevers, or chest pain. Which of the following tests should be completed initially to help diagnose this patient's condition?

Basic metabolic panel and morning serum cortisol level dx:addison Corticoadrenal Insufficiency 1°: Addison disease Weakness, fatigue, anorexia, weight loss Hyperpigmentation (1° disease) Hyponatremia and hyperkalemia (1° disease) ↑ ACTH = 1° disease ↓ ACTH = 2° disease Hydrocortisone Fludrocortisone (1° disease)

A 74-year-old man with family history of macular degeneration presents with worsening day and night vision and difficulty reading even with his bifocal glasses on. Which of the following fundoscopic findings is more suggestive of exudative advanced macular degeneration?

Presence of choroidal neovascularization with subretinal fluid and vessel hemorrhages Why is frequent follow-up and screening for conversion from nonexudative to exudative AMD so important? Answer: If exudative AMD is left untreated, patient can become legally blind in a matter of months.

A 67-year-old woman with hyperlipidemia is diagnosed with hypertension. She has no history of diabetes mellitus or chronic kidney disease. According to the Eighth Joint National Committee panel, which of the following is an appropriate systolic blood pressure goal for this patient?

systolic pressure is 150 mm Hg or higher or when the diastolic pressure is 90 mm Hg or higher {look at image } What age group responds best to angiotensin-II receptor blockers as a first-line treatment for hypertension? Answer: Patients under age 50 years, as they tend to have a more responsive renin-angiotensin system than older patients.

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? ABaclofen BBotulinum injections CCarbamazepine DDiazepam

Carbamazepin dx: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.

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?

Change to dextrose-containing intravenous fluid ----------------------------------------------------- Guidelines typically recommend not allowing patients to eat (A) until after the anion gap is closed. While the patient's blood sugar is improved, he should not be discharged (C) as the anion gap is likely not closed and his DKA has not resolved despite serum glucose normalization. The patient should not be transitioned to subcutaneous insulin (D)until the anion gap is closed, at which point the subcutaneous insulin should be initiated 30 minutes prior to discontinuation of the insulin drip

A 17-year-old girl with a history of sickle cell disease and asthma presents with four days of fever, cough, and left chest pain. Temperature is 39°C (102.2°F), pulse rate is 98/min, respirations are 24/min, blood pressure is 135/90 mm Hg, and SaO₂ is 92% on room air. Physical exam reveals an uncomfortable-appearing girl with intercostal retractions. Which of the following is most likely to confirm the diagnosis?

Chest X-ray with left-sided lobar infiltrate dx: acute chest syndrome requires radiographic evidence of a consolidation plus fever or respiratory findings (such as hypoxemia, cough, and respiratory distress). . In adults, the proportion of acute chest syndrome due to fat or bone marrow emboli is greater than in children, where the most common etiology is infection. Patients with SCD are at risk for vaso-occlusive crises and infectious complications with significant morbidity and mortality. Mainstays of management in children and adolescents with acute chest syndrome include antimicrobial therapy, pain control, exchange transfusion, and volume repletion. --------------------------------------------------------- an acute drop in hemoglobin and reticulocytosis (A) is most pronounced during splenic sequestration and hemolytic crisis, and splenomegaly is a prominent exam finding. However, most SCD patients will be functionally (or surgically) asplenic by 17 years of age, making these complications less likely in this patient

A 28-year-old man presents to clinic who was recently diagnosed with gout and started on allopurinol therapy. Which of the following lab values must be closely monitored when treating a patient with allopurinol over time?

Creatinine

A previously healthy 21-year-old woman presents to your office with complaints of abdominal pain and diarrhea for the past year. She describes the abdominal pain as located in the lower abdomen and relieved by defecation. Her diarrhea symptoms include a small volume of loose stool, typically after meals. She has tried over the counter antidiarrheal medication without relief. Which of the following is the most appropriate next step in management? AColonoscopy BDietary modification CFood allergy testing DTesting for ova and parasites

Dietary modification dx:rritable bowel syndrome (IBS) Initial management is by establishing a therapeutic relationship with the patient, providing education, and with dietary modification, including a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) and in certain cases avoiding gluten and lactose. Pharmacologic agents are added to treatment if initial conservative management fails.

A 58-year-old man with a 20 pack-year smoking history complains of a chronic, productive cough. Diffuse wheezing is noted on physical exam. Which of the following additional physical exam findings would be expected? ADecreased anteroposterior chest diameter BDecreased heart sounds CProlonged inspiratory phase of breathing DSplitting of the first heart sound

Decreased heart sounds due to lung hyperinflation. dx:(COPD) Treatment involves smoking cessation, inhaled bronchodilators, inhaled corticosteroids, and supportive care as necessary (oxygen, pulmonary rehabilitation).

A 30-year-old man with a 10-year history of alcohol overuse presents with a symmetrical erythematous facial rash in areas that are exposed to the sun. He reports being a little confused and forgetful lately. A urine test shows a deficiency in N-methylnicotinamide. What additional symptom might be seen due to this deficiency? ADiarrhea BFlushing CGingivitis DParesthesias

Diarrhea dx:Niacin (vitamin B3) deficiency, or pellagra 4D's dermatitis, dementia, and diarrhea and death. can also be seen with carcinoid syndrome or prolonged use of isoniazid. Niacin status can be determined by measuring urinary N-methylnicotinamide or the erythrocyte NAD/NADP(ratio).

A 32-year-old man presents by emergency medical services after being the unhelmeted operator of a motorcycle involved in a collision with a truck. He was found approximately 15 feet from where his motorcycle was found and is intubated at the scene for depressed mental status. His vital signs on arrival are HR 38/min, BP 62/40 mm Hg, T 36.2°C, and RR 14/min on mechanical ventilation. His extremities are warm, well perfused, and without obvious deformity. His exam is otherwise significant only for widespread road rash. Which of the following is the most likely cause of the patient's hypotension?

Distributive shocK ============================================= cariogenic = symptoms of poor circulatory flow, such as cool, pale extremities and slowed capillary refill. What are the traumatic causes of obstructive shock? Answer: Cardiac tamponade and tension pneumothorax. Patients with hemorrhagic shock present with signs of poor peripheral perfusion, such as weak peripheral pulses, paleness, poor capillary refill, and cool extremities. Cerebral hypoperfusion may lead to subtle mental status changes including anxiety and confusio Obstructive shock (D) results from a decrease in venous return or cardiac compliance due to a left ventricular outflow obstruction or a significant decrease in preload, as seen in cardiac tamponade or a massive pulmonary embolism.

A 19-year-old woman with obesity presents to your office with a chief complaint of irregular menstrual cycles for the past 2 years. She also reports abnormal hair growth along her chin and acne. Which one of the following tests, if elevated, would support a diagnosis of polycystic ovarian syndrome?

Elevated total free testosterone Polycystic ovary syndrome is the most common endocrinopathy in reproductive-aged women and is characterized byovulatory dysfunction, polycystic ovaries, and hyperandrogenism. What medications are recommended to help induce ovulation in patients with polycystic ovary syndrome? Answer: Clomiphene, letrozole, and metformin.

A 46-year-old woman presents to the clinic with redness and decreased vision in her left eye. She states she was playing frisbee with her kids when it hit her directly in the left eye. Her past medical history is significant for unprovoked pulmonary embolism on life-long apixaban therapy. Physical exam reveals bright red blood occupying 50-60% of the anterior chamber. Visual acuity is significantly decreased on the affected side. You also note mild periorbital ecchymosis, but intact and painless extra-ocular movements. What is the most appropriate next step in management?

Emergent ophthalmology referral dx: Hyphema History of blunt or penetrating trauma Blurry vision PE will show unequal pupils, injected conjunctiva or sclera, and blood in anterior chamber Treatment is with eye protection, limitation of activity, and head elevation of 30-45 degrees General treatment measures include an eye shield, bed rest, elevation of the head of the bed, pain control, and cycloplegia. Permanent vision loss can result from a hyphema and emergent ophthalmology referral is almost always indicated. What is ghost cell glaucoma? Answer: An increase in intraocular pressure as a result of old blood cells that travel into the anterior chamber and block off the trabecular meshwork ----------------------------------------------------------- Eyepatch, cycloplegics, and follow-up with ophthalmology in one week (B) may be indicated in very small hyphemas; however, an ophthalmologist should be involved early in the case if possible. Hospitalization and bed rest (C) would be indicated in this patient; however, it should only be done after ophthalmology has been consulted and is involved in the case to avoid delays in critical treatment. Magnetic resonance imaging of the orbit (D) may be indicated in some cases to evaluate deep structures; however, it is not indicated as first-line treatment.

A 32-year-old man presents with persistent ringing in his ears that occurs daily and lasts throughout the day. This has been going on for several months, but recently has been getting gradually worse. He is a construction worker by trade. Health history is unremarkable except for lower back pain for which he pops some ibuprofen throughout the day. He denies any other medications. He does not smoke but usually has five to six beers on the weekend. His examination is unremarkable. What is the most likely cause of his tinnitus?

Excessive ibuprofen use Excessive ibuprofen use, or use of any nonsteroidal anti-inflammatory drugs (NSAID), including aspirin, has been commonly known to cause tinnitus. This used to be a very common complaint among patients with inflammatory arthritis when NSAIDs were the main form of treatment. Younger men, in particular, are notorious for underestimating how many over-the-counter medications they are taking and the possible consequences they could have. Providers should try to elicit a clear history of medication use and patients should also be educated on the risk of taking excessive medications.

A 40-year-old man with ulcerative colitis presents to the ED with severe abdominal pain. His temperature is 99.9°F, pulse 120 beats/minute, respirations 20 breaths/minute, blood pressure 80/50 mm Hg, and oxygen saturation 98% on room air. His abdomen is markedly distended, diffusely tender with guarding, and tympanitic to percussion. Abdominal radiograph shows a markedly distended colon with loss of haustra and pneumoperitoneum, but no air-fluid levels. His serum lactate level is 8 mmol/L. In addition to intravenous fluids and antibiotics, which of the following is the best management at this time?

Exploratory surgery dx:Toxic megacolon,

A 50-year-old man presents to your clinic to discuss his most recent lab results. He has a history of hyperlipidemia for which he takes rosuvastatin 20 mg daily, and diabetes for which he takes metformin 500 mg twice daily. The lab results for his fasting-lipid profile are LDL 126 mg/dL, HDL 40 mg/dL, and triglycerides 900 mg/dL. His HbA1C is 6%. Which of the following medications should be added? Which of the following laboratory studies should be ordered in a patient being evaluated for hypertriglyceridemia?

Fenofibrate Thyroid-stimulating hormone dx:Hypertriglyceridemia hypertriglyceridemia Involves nonpharmacologic interventions such as weight loss, aerobic exercise, avoidance of sugars, alcohol, medications that raise serum triglyceride levels, and glycemic control. For patients with triglyceride levels persistently above 886 mg/dL, drug therapy is recommended to lower the risk of pancreatitis. Fenofibrate is the recommended first-line therapy and can reduce triglyceride levels by a half or more. Hypertriglyceridemia PE: Skin xanthomas, tendinous xanthomas, corneal arcus Mild to moderately elevated triglycerides > 150 mg/dL increase risk of cardiovascular disease Severely elevated triglycerides > 1000 mg/dL increase risk of pancreatitis Treatment Mild to moderate elevationReduction in weight and carbohydrate intake, aerobic exerciseStatins +/- icosapent ethyl when indicated to reduce ASCVD risk Severe elevation: fibrates, omega-3 fatty acids, niacin, avoidance of alcohol

A 22-year-old woman presents with a mass in her right breast that she noticed while showering. She has noticed pain in the area just prior to her menstrual cycles each month. An ultrasound is ordered and shows multiple cystic lesions in the right breast. Which of the following historical factors may be contributing to this condition?

Frequent alcohol consumption

A 22-year-old woman presents with a mass in her right breast that she noticed while showering. She has noticed pain in the area just prior to her menstrual cycles each month. An ultrasound is ordered and shows multiple cystic lesions in the right breast. Which of the following historical factors may be contributing to this condition? What is the only treatment of fibrocystic breast conditions approved by the US Food and Drug Administration (FDA)?

Frequent alcohol consumption dx: fibrocystic breast changes Treatment is well-fitting supportive bras, applying heat to the breasts, or over-the-counter pain relievers Most common lesion of the breast Fibrocystic changes are generally benign and do not increase risk for breast cancer What is the only treatment of fibrocystic breast conditions approved by the US Food and Drug Administration (FDA)? Answer: Danazol.

A 67-year-old man presents to the emergency department with shortness of breath. His symptoms have gradually been worsening over the past month, however, after a recent upper respiratory infection, he noticed his symptoms markedly worsened. The patient has a past medical history of diabetes, hypertension, chronic kidney disease, and heart failure. The patient's oxygen saturation is 90% on room air. Physical exam is notable for bilateral lower extremity pitting edema and pulmonary crackles. Initial laboratory values are notable for a potassium of 5.6 mEq/L, a blood urea nitrogen of 45 mg/dL, and a creatinine of 2.2 mg/dL. An initial ECG is within normal limits, and a chest radiograph shows trace bilateral pleural effusions with increased interstitial markings. Which of the following is the best next treatment for this patient?

Furosemide may produce better outcomes and reduce mortality. dx:hF

A 45-year-old man presents to clinic for follow up after recently being diagnosed with hepatitis B. Which of the following serologic markers is the best marker of current viral replication and increased infectivity?

Hepatitis B envelope antigen ============================================ Hepatitis B core antibody (A) detects if the body has been exposed to the hepatitis B virus in the past. It does not indicate if the patient is currently infected with the virus. It will be negative in those who are immune to hepatitis B due to vaccination. Hepatitis B envelope antibody (B) indicates either chronic hepatitis B with low viral replication or recovery from the disease. Hepatitis B surface antibody (D) indicates a patient has immunity to hepatitis B. It is present if the patient developed immunity secondary to vaccination or if the patient is immune secondary to cleared virus.

An otherwise healthy 24-year-old man presents with complaints of diarrhea, nausea, vomiting, and crampy abdominal pain. The patient reports ingesting undercooked chicken 24 hours prior. His temperature on presentation is 37.9°C. Vital signs are otherwise unremarkable. Which of the following is the most appropriate treatment for the suspected diagnosis?

Hydration dx:Salmonella gastroenteritis commonly associated with ingestion of contaminated poultry, eggs, or milk products. occur within 12 to 72 hours following exposure and include diarrhea, nausea, vomiting, fever, and abdominal cramping. The diarrhea may be bloody or described as "pea soup", though these descriptors do not reliably distinguish it from other types of gastroenteritis. Salmonellosis with bacteremia localizing in joints or bones commonly occurs in patients with what coexisting medical condition? Answer: Sickle cell disease. Salmonellosis History of eating poultry, meat, or eggs Fever, diarrhea (possibly bloody in children), and abdominal cramps Labs will show fecal WBCs Common cause of osteomyelitis in children with sickle cell disease

A 58-year-old woman presents to the clinic with right facial weakness since this morning. Which additional finding would suggest a diagnosis of cerebrovascular accident rather than Bell's palsy?

Inability of the right eye to abduct

A 55-year-old man with diabetes presents to the emergency department for acute-onset atraumatic right knee pain associated with redness and an effusion. He has no history of similar episodes and reports no fever. Arthrocentesis yields cloudy yellow fluid with 10,000 white blood cells/µL, blue needle-shaped crystals on microscopy, and a negative Gram stain. Which of the following is the most appropriate treatment of this patient's condition?

Indomethacin orally and discharge dx: gouty arthritis needle-shaped negatively birefringent (blue color when perpendicular to the polarized light) ================================================== Allopurinol (A) is a xanthine oxidase inhibitor used in the prevention of gout to lower systemic uric acid levels. It is not used in the acute phase, as these patients often have normal blood uric acid levels

A 56-year-old woman with hypothyroidism and diabetes presents with right shoulder pain and stiffness for the past three months. She has trouble reaching overhead and putting on her coat. Examination reveals reduced active and passive range of motion of the right shoulder. Which of the following is an appropriate treatment strategy?

Intra-articular corticosteroid injection dx;Adhesive capsulitis or frozen shoulder. It is an idiopathic condition, though it is associated with preexisting conditions such as diabetes and hypothyroidism and can occur following shoulder trauma. With moderate to severe symptoms, an intra-articular injection of corticosteroids is useful. What finding on magnetic resonance imaging is highly specific for adhesive capsulitis? Answer: Coracohumeral ligament thickening.

Which of the following is considered a minor diagnostic criterion for diagnosis of infective endocarditis, according to the Duke criteria?

Intravenous drug abuse

Which of the following laboratory results are most consistent with a diagnosis of immune thrombocytopenia?

Isolated thrombocytopenia with platelets of predominantly normal morphology Primary Immune Thrombocytopenia Patient will be a child 2-6 years old History of recent viral infection Red spots on skin or easy bleeding PE will show petechiae, purpura, and gingival bleeding Labs will show platelets < 100,000/µL Most commonly caused by antiplatelet antibodies Treatment is observation, steroids, IVIG ===================================================== True or false: Thrombocytopenia is associated with HIV infection and acquired immune deficiency syndrome? Answer: True.

A previously healthy 35-year-old woman presents to your office with concerns about an upcoming blood test. She is supposed to have her cholesterol levels checked next week and is very anxious about the procedure. She has avoided blood tests in the past out of fear and even gets anxious when she sees someone on television getting an injection or having blood drawn. Which of the following is the most appropriate therapy?

Lorazepam 30 minutes prior to the procedure dx:Phobic disorders First-line treatment is cognitive behavioral therapy (CBT) with exposure treatment, however medications are often used when CBT is not available or there is a time constraint. In this case, benzodiazepines, such as lorazepam, are the most commonly used agents and are administered 30 minutes before exposure to the stimulus. How long does the fear or anxiety of a specific stimulus need to occur before it can be diagnosed as a specific phobia? Answer: Six months.

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?

Magnetic resonance imaging of the lumbosacral spine dx:a spinal epidural abscess. High-risk patients include intravenous drug users, alcoholics, and immunocompromised patients (e.g. history of diabetes mellitus).

A 42-year-old man presents to the clinic with low back pain. It started 2 days ago after he helped his son move into a new apartment. He does not remember any specific injury. He has no numbness or tingling in his legs, no problems walking, and no issues going to the bathroom. Which of the following diagnostic imaging studies is indicated to assess this patient's condition?

No imaging study is required for the diagnosis of nonspecific mechanical low back pain, especially when there are no red flags present.

A 25-year-old man presents to the emergency department with complaints of palpitations, shortness of breath, vomiting, and diarrhea. His past medical history is significant for Graves disease and asthma. He is in acute distress and diaphoretic. His blood pressure is 170/110 mm Hg, heart rate is 165 beats/minute, respirations are 53 breaths per minute, and his oral temperature is 39.3°C. Which of the following is the correct sequence of agents used to treat this condition?

Metoprolol, methimazole, hydrocortisone, ipodate, cholestyramine dx:Thyroid storm[look at image] Iodine-containing agents (Lugol solution, supersaturated potassium iodide, iopanoic acid, ipodate) prevent the release of preformed thyroid hormone and must be given at least 1 hour after thionamide administration. Failure to do so results in iodine being used as substrate for de novo thyroid hormone synthesis.

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, BP 89/50 mm Hg, HR 120 bpm, RR 35/min, and oxygen saturation 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 next best step in management?

Needle decompression of the ches dx: tension pneumothorax

A 52-year-old man presents with two episodes of bright red blood per rectum. He denies any abdominal pain. Vital signs are stable. Physical examination reveals no abdominal tenderness and no source of bleeding on anoscopy, but bright red blood is visualized inside the anus. A review of old records shows a colonoscopy report from three years ago with diverticulosis. Which of the following is the most appropriate management plan?

Observation with serial blood counts and GI consultation

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?

Patent ductus arteriosus ================================================ One of the most common congenital heart disorders is tetralogy of Fallot, which is made up of four anatomical findings. These patients are found to have an overriding aorta (A), right ventricular outflow obstruction (C), a large ventricular septal defect (D) and right ventricular hypertrophy. They have difficulty feeding, episodes of turning blue while crying or feeding ("Tet spells") and failure to thrive. Treatment is surgical.

A 47-year-old woman presents with complaints of hot flashes and sleep disturbance for the past 18 months. For the past nine months, she has had irregular bleeding lasting up to eight days every six to eight weeks. She complains of dyspareunia. Based on history alone, what is the most appropriate diagnosis?

Perimenopause ===================================================== premenopause (D) typically do not have irregular bleeding or vasomotor symptoms unless an underlying endocrine disorder is present.

A 45-year-old man presents with complaints of persistent worsening bilateral heel pain for the past month. He reports that the pain is the worst when he first steps down out of bed in the morning and then it gradually improves but never goes away. On exam, he is the most tender over the sole of the foot near the calcaneus and has a high arch in both feet. The remainder of the exam is unremarkable, except for the fact that he is overweight. What is the most likely diagnosis?

Plantar fasciitis A classic history of plantar fasciitis is described as pain when first stepping out of bed as the leg and calf muscles have become tight overnight, which adds additional strain to the affected area. Pain improves with walking or stretching the calf but then worsens again after periods of inactivity. Being overweight, having high arches, wearing ill-fitting shoes, excessive pronation with ambulation, and prolonged periods of standing (especially on hard surfaces) are common causes.

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?

Plasmapheresi dx:thrombotic thrombocytopenic purpura (TTP). The classic pentad of TTP includes CNS abnormalities, renal pathology, fever, microangiopathic hemolytic anemia, and thrombocytopenia. If plasmapheresis cannot be immediately performed, fresh frozen plasma (FFP) should be administered until plasmapheresis can be performed.

A 65-year-old woman with no known illness presents with dyspnea and a grade 3/6 systolic murmur. Which of the following would suggest the diagnosis of aortic stenosis rather than mitral valve regurgitation?

Prominent fourth heart sound

A 45-year-old man presents to the clinic with a burning sensation in his chest and sour taste in his mouth three to four times per week for the past several weeks. He reports no weight loss, vomiting, dark stools, or dysphagia. BMI is 29 kg/m2. CBC is normal. Which of the following is the best next step for this patient?

Proton pump inhibitor dx: Gastroesophageal reflux disease What medications for treating acid reflux should be avoided in pregnancy? Answer: Antacids containing sodium bicarbonate or magnesium trisilicate. Gastroesophageal Reflux Disease (GERD) History of nocturnal cough or asthma Retrosternal burning sensation radiating upward (heartburn) usually after eating Most commonly caused by LES dysfunction Lifestyle modifications: weight loss, elevate head of bed during sleep, avoid certain foods (caffeine, alcohol, acidic foods) H2 receptor antagonists for mild or intermittent symptoms, PPIs (most effective) for frequent (two or more times weekly) or debilitating symptoms Consider surgery for refractory cases

Where is the coronary artery blockage most likely to be found in this patient?[ stemi in inferior leads]

Right coronary artery ST Segment Elevation Myocardial Infarction (STEMI) Patient presents with substernal chest pain that radiates to the neck and arm Labs will show elevated troponin I or troponin T and CK, ST segment elevations > 1 mm in more than two contiguous leads TreatmentPCI (percutaneous coronary intervention): gold standardThrombolytic therapy Aspirin P2Y12 receptor blocker Beta blocker Anticoagulation Anterior wall ST elevation in leads V1 through V4 Inferior wall ST elevation in leads II, III, and AVF Lateral wall ST elevation in leads I, AVL, V5, and V6 Posterior wall ST depressions in leads V1 through V3 and elevations in leads V8 and V9

A 34-year-old man presents to your office. He notes easy fatigability and dyspnea. On auscultation there is a widened S2 split, and a harsh, non-radiating systolic crescendo-decrescendo murmur located at the second intercostal space which is decreased after the patient performs a Valsalva maneuver. The patient also has a right ventricular precordial lift. Which of the following valvular conditions does this patient have?

Pulmonic stenosis What is the most common valvular disorder associated with tetralogy of Fallot? Answer: Pulmonary stenosis. ------------------------------------------------------- Aortic stenosis (A) produces a systolic crescendo-decrescendo murmur that radiates to the carotid arteries and right clavicle. Patients may report exertional syncope and chest pain. Mitral stenosis (B) is often the result of rheumatic fever. Symptoms include orthopnea, paroxysmal nocturnal dyspnea, fatigue. The murmur is diastolic in nature and is associated with an opening snap. The murmur produces a decrescendo-crescendo rumble best heard at the apex. Tricuspid stenosis (D) produces a fluttering sensation in the neck, fatigue, and cold extremities. Patients may also have right upper quadrant pain secondary to hepatic enlargement. Auscultation may reveal a soft opening snap and a mid-diastolic rumble, if heard at all.

1)At what age should the quadrivalent meningococcal vaccine be offered to immunocompetent children? Eleven years of age 2)In what part of the prostate does benign prostatic hyperplasia most commonly develop? Transitional zone 3)What is the most common histologic type of prostate cancer? Answer: Adenocarcinoma. 4)What are Janeway lesions? Answer: Small, non-tender, erythematous macules or nodules on the palms and soles of patients with infective endocarditis. 5)Which of the following is most suggestive of delirium? Rapid decline in mental status over two days 6)What is an acceptable first-line medication in treating agitated delirium? Answer: Haloperidol. 7)What are the most common secondary malignancies in patients who have received chemotherapy or radiation treatment for Hodgkin lymphoma? Answer: Lung, breast and gastrointestinal cancers. 8)According to the American Diabetes Association, when is screening recommended for type 2 diabetes mellitus? Answer: Annually in patients 35 years of age and older, or in patients less than 35 years with major risk factors. 9)Familial adenomatous polyposis is a syndrome with what type of genetic inheritance? Answer: Autosomal dominance. 10)Salmonellosis with bacteremia localizing in joints or bones commonly occurs in patients with what coexisting medical condition? Answer: Sickle cell disease. 11)Why is frequent follow-up and screening for conversion from nonexudative to exudative AMD so important? Answer: If exudative AMD is left untreated, patient can become legally blind in a matter of months. 12)What is cafe coronary syndrome? Answer: Sudden collapse that results from choking on a large object (often poorly chewed meat) causing nearly complete airway obstruction. 13)Which of the following treatments for chronic obstructive pulmonary disease-related chronic bronchitis is associated with decreased mortality? Oxygen therapy 14)What class of drugs may be used for palliative care of dyspnea associated with severe COPD? Answer: Opioids. 15)Which of the following treatments is the recommended initial therapy for the condition typical anal fissures?Topical nifedipine is the recommended initial therapy 16)What age group responds best to angiotensin-II receptor blockers as a first-line treatment for hypertension? Answer: Patients under age 50 years, as they tend to have a more responsive renin-angiotensin system than older patients. 17)Is a myocardial infarction within the past three months a contraindication to fibrinolytic therapy for acute ischemic stroke? Answer: Yes. 18)What finding on magnetic resonance imaging is highly specific for adhesive capsulitis? Answer: Coracohumeral ligament thickening. 19)What are the two most common organs or systems of the body affected by systemic lupus erythematosus? Musculoskeletal system and skin 20)What is the most common way that lupus can affect your lungs? Answer: Pleuritis or inflammation of the pleura, the lining that covers the outside of the lungs.

Q/A 1

1)Which of the cardiac biomarkers is released earliest in the setting of an MI? Answer: Myoglobin. 2)What is the only treatment of fibrocystic breast conditions approved by the US Food and Drug Administration (FDA)? Answer: Danazol. 3)What is the most common valvular disorder associated with tetralogy of Fallot? Answer: Pulmonary stenosis. 4)Medications with what effects are a common cause of sialadenitis? Answer: Anticholinergic. 5)Which of the following laboratory results are most consistent with a diagnosis of immune thrombocytopenia? Isolated thrombocytopenia with platelets of predominantly normal morphology 6)What complication of untreated hypothyroidism is considered life-threatening? Answer: Myxedema coma. 7)What is the common name for aphthous ulcer? Answer: Canker sore. 8)What empiric antibiotic regimen is recommended for treatment of acute bacterial prostatitis in sexually active men younger than 35 years of age? Answer: Ceftriaxone and doxycycline to cover Neisseria gonorrhoeae and Chlamydia trachomatis. 9)What is adrenal crisis? Answer: In patients with adrenal insufficiency, a significant stressor or illness can lead to a life-threatening condition of shock, hypotension, and volume depletion 10)In women with an intact uterus, unopposed estrogen therapy increases a patient's risk of developing what? Answer: Endometrial cancer. 11)What is ghost cell glaucoma? Answer: An increase in intraocular pressure as a result of old blood cells that travel into the anterior chamber and block off the trabecular meshwork 12)What is the best antibiotic treatment regimen for acute rhinosinusitis in patients without penicillin allergy who have risk factors for pneumococcal resistance? Answer: High-dose amoxicillin-clavulanate 2,000 mg/125 mg extended-release tablets twice daily. 13)What are the red flag symptoms of back pain? Answer: Significant trauma related to age, major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer, or suspected spinal infection. 14)Is atrioventricular block always pathological? Answer: No. First degree atrioventricular block may be present in healthy individuals with high vagal tone. 15)

Q/A2

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?

Radial nerve ========================================== The median nerve (A) is responsible for the motor function of the flexor muscles of the anterior forearm compartment (except for the flexor carpi ulnaris and part of the flexor digitorum profundus), the thenar muscles, and the lateral two lumbricals. Compression of the median nerve as it passes through the carpal tunnel of the wrist will result in pain and paresthesias in the distribution of the median nerve. The musculocutaneous nerve (B) innervates the coracobrachialis, the biceps brachii, and the brachialis. Injury to this nerve will result in weakness of elbow flexion with associated sensory loss over the lateral forearm. Ulnar (D) neuropathy at the elbow is the second most common compression neuropathy and results in sensory loss and paresthesias over the fourth and fifth digits as well as weakness with finger and wrist flexion.

Which of the following is most suggestive of delirium?

Rapid decline in mental status over two days What is an acceptable first-line medication in treating agitated delirium? Answer: Haloperidol. acuteness of presentation. Delirium generally presents as a rapid decline in mental status over hours to days. This is in contrast to a prolonged, consistent onset of dementia and other chronic brain diseases. Symptoms may be vague and mild at first, but a change in mental status may be the only sign of underlying illness in older patients.

A 30-year-old semi-professional tennis player returns to your clinic for persistent right elbow pain that is burning in nature and sometimes radiates down his forearm to his wrist. There is no swelling to the area and the pain is increased with wrist extension. Radiographs are negative for fracture. When he was initially seen a few weeks ago you prescribed conservative therapy with rest, ice, a compression band, physical therapy, and over-the-counter nonsteroidal anti-inflammatories as needed, but he has seen no improvement and his grip strength seems to be decreased. What is your next most likely treatment option?

Reimaging of the arm ==================================================== Continuing conservative therapy for another month (B) is too long, especially for a professional player. If some improvement had been seen, continuing conservative therapy for another couple of weeks would be appropriate. Referral for surgery (D) is not indicated yet. A corticosteroid injection may be tried before proceeding to a surgical procedure.

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?

Relocation of free floating otoconia

A 29-year-old woman presents to your clinic complaining of back pain for four days. She was playing volleyball with her friends, and noticed the pain after the match. She reports no falling, trauma, numbness or tingling in her legs, or difficulty going to the bathroom. On exam, you note lumbar tenderness off of midline. In addition to pain management, which of the following is the most appropriate plan for this patient?

Remain active and limit bed rest What are the red flag symptoms of back pain? Answer: Significant trauma related to age, major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer, or suspected spinal infection.

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?

Respiratory syncytial virus bronchiolitis, which is the most common lower respiratory tract infection in patients less than two years of age

A 37-year-old woman presents with a history of episodic vertigo, right-sided aural fullness, and right-sided tinnitus for the past several months. The episodes typically last 12 hours. Physical exam reveals her ears to be normal. Audiometric evaluation shows a low-frequency sensorineural hearing loss in the right ear. Dix-Hallpike testing is negative. MRI of the brain and internal auditory canals was normal. Which of the following is the most appropriate treatment for the suspected diagnosis?

Restricting sodium intake to 2 to 3 g daily dx:Ménière disease is a triad of symptoms including episodic vertigo, sensorineural hearing loss, and tinnitus Initial management includes recommending a salt-restricted diet as well as limiting caffeine, nicotine, and alcohol. Patients who do not respond to conservative management may be candidates for diuretics or betahistine which reduce the degree of endolymphatic hydrops. Intractable cases may benefit from invasive treatments including intratympanic gentamicin or labyrinthectomy/vestibular nerve section.

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? ASchizoaffective disorder BSchizophrenia CSchizophreniform disorder DSchizotypal personality disorder

Schizophrenia schizophrenia include symptoms lasting at least six months and include delusions or disorganized speech and one of the following: hallucinations, negative symptoms, or grossly negative or catatonic behavior. Negative symptoms include a flat affect, decreased motivation, anhedonia, decreased emotional expression, decreased social interaction, and decreased speech. ====================================== Schizoaffective disorder (A) is a condition in which symptoms of schizophrenia exist concurrently with a mood disorder (mania or major depression). Schizophreniform disorder (C) is characterized by symptoms of schizophrenia lasting longer than one month but less than six months. Schizotypal personality disorder (D) is a cluster A personality disorder and part of the schizophrenia spectrum of disorders. It is characterized by odd beliefs and eccentric behaviors, thoughts, dress, and style. Patients often do not engage in interpersonal relationships and display a pattern of social deficits. Which antipsychotic is known to cause agranulocytosis? Answer: Clozapine.

A 17-year-old girl presents for routine evaluation of her asthma. She notes daily symptoms requiring the use of her rescue inhaler as well as nocturnal awakenings two times per week. What is the most appropriate treatment regimen for controlling this patient's asthma symptoms?

Short-acting inhaled beta-2 agonist as needed plus low-dose inhaled corticosteroid and long-acting inhaled beta-2 agonist moderate persistent asthma

An 87-year-old woman presents from the nursing home with swelling of her neck after eating breakfast. She complains of dry mouth. On exam, there is erythema, swelling, and tenderness to her neck in the submandibular region. Pus is expressed through the left Wharton's duct. What is the most likely diagnosis?

Sialadenitis =inflammation of a salivary gland due to salivary stasis. It predominantly affects either the parotid or submandibular glands. Predisposing factors include dehydration or chronic illness. Medications with what effects are a common cause of sialadenitis? Answer: Anticholinergic. Pus is typically expressed from Stensen's duct when the parotid gland is involved and Wharton's duct when the submandibular gland is involved. If the gland gets infected, the causative organism is usually Staphylococcus aureus. Treatment includes measures to increase salivary flow, including hydration, warm compresses, massage of the affected gland, and sialogogues. Antistaphylococcal antibiotics such as dicloxacillin 500 mg four times a day for seven to ten days may be needed. =================================================== dental abscess (A) presents as painful swelling of the buccal or lingual mucosa. Neck swelling may occur. Teeth in the affected region may be tender on percussion and with mastication. Diagnosis is made radiographically and treatment involves incision and drainage and antibiotics. Tooth extraction is sometimes needed. Ludwig's angina (B) is the most commonly encountered neck space infection. It is a cellulitis of the sublingual and submandibular spaces, often arising from infection of the mandibular dentition. Patients have edema and erythema of the upper neck under the chin and it often involves the floor of the mouth. The tongue may be displaced upward. Treatment involves securing the airway and intravenous antibiotics. Plunging ranula (C) is a mucocele or retention cyst arising from an obstruction in the sublingual glands in the floor of the mouth and extending through the mylohyoid muscle into the neck. Ranulas are often painless and slow growing. Treatment is surgical resection.

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?

Subarachnoid hemorrhage (look at ct image ) A history of polycystic kidney disease is a risk factor for developing berry aneurysms, which may spontaneously rupture and cause a subarachnoid hemorrhage. 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. Management includes supportive care, including airway management as needed, nimodipine, and neurosurgical consultation.

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?

Subglottic narrowing "steeple sign" dx:Croup is typically caused by parainfluenza virus characteristic "barking" cough and inspiratory stridor. Treatment should initially begin with dexamethasone and possibly nebulized epinephrine depending on severity. ================================================= Edema of the epiglottis (A) is seen in epiglottitis and can be noted on a lateral soft tissue radiograph of the neck as the "thumb print" sign. Epiglottitis can quickly cause airway compromise and if this finding is present, steps should be taken to protect the airway.

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?

Supportive care ================================================= Liver transplantation (B) is indicated for fulminant liver failure. Most patients with alcoholic hepatitis recover with supportive care and alcohol cessation. N-acetyl-cysteine (C) is the antidote for acetaminophen toxicity, which is a major cause of liver failure.

A 27-year-old woman presents to the clinic with a chief complaint of right eye redness. She reports mild pruritus. On physical examination, there is erythema of the bulbar conjunctiva with mild serous discharge. Which of the following is the most appropriate next step in the management of this patient?

Supportive care with cold compresses dx:viral conjunctivitis

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?

Swelling over the lateral malleoli= ankle sprain . The Ottawa Ankle Rules are frequently used by physicians and nurses to determine the likelihood of a fracture versus a sprain and the need for imaging. ================================================== Patients with bony tenderness over the malleolar zone (A), bony tenderness over the midfoot zone (B), or an inability to walk four steps in the emergency department (C) should be considered to have a more serious injury and potentially a fracture. These patients require further diagnostic imaging with radiography.

Which of the following statements is true concerning patients with cholestatic jaundice?

They have decreased total bile salt pool size Cholestasis is the accumulation of bile in the liver as a result of decreased secretion of bile by hepatocytes or obstruction of the bile ducts. cholestatic jaundice can result from hepatocellular causes such as drug-induced cholestasis, viral hepatitis, and progressive familial syndromes. Obstructive cholestasis in older children and adults can result from cholelithiasis, various types of cholangitis, and tumors. As bile salts are retained in the parenchyma of the liver during cholestasis, down-regulation occurs and less bile salts are produced, resulting in a decrease in the total bile salt pool size as well as a decrease in the enterohepatic recirculation of the bile salts. What is Charcot's triad? Answer: Fever, abdominal pain and jaundice seen in patients with cholangitis.

1)What causes the parotid swelling seen in some patients diagnosed with bulimia nervosa? Noninflammatory stimulation of the salivary glands 2)A 41-year-old woman presents to the clinic with symmetrically distributed, coalescent, hyperpigmented macules in sun-exposed areas of the face. Which of the following is the most likely diagnosis?Melasma 3)Which of the following sets of results is most consistent with a diagnosis of emphysema?Low diffusion capacity of the lung for carbon monoxide with low forced expiratory volume in one second/forced vital capacity ratio 4)Which of the following cholesterol-lowering agents has demonstrated regression in coronary atherosclerosis and is indicated as first-line therapy for patients with coronary artery disease? Rosuvastatin 5)A previously healthy 20-year-old woman presents to your office with a complaint of hair loss. Physical exam reveals one smooth, circular patch of hair loss about the size of a quarter. The few remaining hairs in the affected area are noted to have tapering at the proximal end of the hair shaft. A pull test of hair at the edge of the patch is positive. Which of the following is the most likely diagnosis?Alopecia areata 6)Which of the following medications, when used as monotherapy, is most likely to induce mania in patients with bipolar I or bipolar II disorder? Citalopram 7) What are common adverse effects of topiramate? Answer: Paresthesia, anorexia, weight loss, fatigue, diarrhea, memory difficulty, hypesthesia, difficulty concentrating, language problems, nausea, and taste perversion. 8)A 27-year-old man presents with a diagnosis of stage I seminoma. What is the initial treatment of choice? Orchiectomy 9)Which of the following antiepileptic drugs has a black box warning concerning teratogenicity? Valproic acid 10)What is the treatment of choice for severe pelvic inflammatory disease in a patient with no known drug allergies? Cefoxitin 2 g IV every six hours plus doxycycline 100 mg orally every twelve hours 11)When should an antitussive be given to a patient with acute bronchitis? Answer: Only when the cough is interfering with sleep. 12)What medications are recommended to help induce ovulation in patients with polycystic ovary syndrome? Answer: Clomiphene, letrozole, and metformin. 13)Which of the following diagnostic studies would be most helpful to obtain in a patient complaining of syncopal episodes? Fasting glucose Laboratory studies that may be obtained in patients with a history of syncope include a CBC, serum electrolytes, fasting glucose, total creatine kinase, cardiac enzymes, and urinalysis. 14)What is the initial treatment of choice for patients presenting with acute uncomplicated inflammation of a Meibomian gland? Warm compresses 15)Which of the following from the patient's presentation, history, and findings is a factor indicating the need for medical management of atherosclerotic cardiovascular disease according to the American Heart Association? Total cholesterol is 218 mg/dL

q/a 3 correct