Internal Medicine Practice Exam

The serum creatine kinase-MB peaks after an acute myocardial infarction in which of the following time frames? A. 16-24 hours B. 48-72 hours C. 4-6 hours D. 8-12 hours

A. 16-24 hours Cardiac Biomarkers Troponin-Highest sensitivity and specificity Time detectable from onset: 3-12 hoursPeak: 24-48 hours Return to baseline: 5-14 days CK-MB Time detectable from onset: 3-12 hours Peak: 24 hours Return to baseline: 48-72 hrs Useful for dx of reinfarction Myoglobin-First to appear, first to peak, first to declineLacks specificity

A 60-year-old man with intermittent claudication returns to the clinic for interpretation of the results of his ankle-brachial index. Which of the following statements is most accurate? A. A falsely high index may indicate severely hardened, non-compressible leg vessels B. A low ankle-brachial index indicates peripheral venous insufficiency C. An ankle-brachial index of 1.2 indicates severe disease D. It is the ratio of ankle to arm diastolic blood pressure

A. A falsely high index may indicate severely hardened, non-compressible leg vessels. The ankle-brachial index is calculated by measuring the systolic blood pressure in the arm and at the ankle. A ratio of ankle systolic blood pressure to brachial systolic blood pressure under 0.90 is indicative of peripheral arterial disease. A falsely high ankle-brachial index can occur when a patient has severely hardened peripheral arteries which are non-compressible.

Which of the following is a classic sign of acute adrenal insufficiency? A. Abdominal pain B. Bluish-black discolorations of the mucous membranes C. Profound bradycardia D. Severe headache

A. Abdominal pain The hallmarks of adrenal crisis are profound weakness, severe abdominal pain, peripheral vascular collapse, electrolyte abnormalities, and shock. In patients with chronic adrenal insufficiency, an acute adrenal crisis can be precipitated by stressors such as infection, trauma, or surgery. Laboratory studies in patients with acute adrenal insufficiency may show hyponatremia, hypoglycemia, hyperkalemia, low serum cortisol, eosinophilia, or sepsis

An otherwise healthy 24-year-old woman presents with a cough. The cough is productive of white to yellow sputum and has been present for the last three weeks. She states that it began with a fever, sinus pressure, and fatigue, but those symptoms have since resolved. She has never had similar symptoms in the past. Her vital signs are all within normal limits. Lung auscultation is clear bilaterally, although deep breaths induce coughing. What is the most likely diagnosis? A. Acute bronchitis B. Asthma C. Chronic bronchitis D. Community-acquired pneumonia

A. Acute bronchitis

A 24-year-old man presents to the emergency department with fever and chills, right upper quadrant pain, and jaundice. Abdominal ultrasound shows dilation of the common bile duct. What is the most likely diagnosis? A. Acute cholangitis B. Acute cholecystitis C. Acute hepatitis D. Cholelithiasis

A. Acute cholangitis Patient will be complaining of right upper quadrant pain, jaundice, fever (Charcot triad) Diagnosis is made by RUQ ultrasound, CT scan, or ERCP (gold standard) Most commonly caused by choledocholithiasis leading to bacterial infection, E. coli Treatment is antibiotics, definitive treatment is ERCP with antibiotics typically an adjunct Comments: Charcot triad + hypotension and AMS = Reynolds pentad, acute obstruction

A 62-year-old man presents to the emergency room complaining of acute onset hematuria and facial edema. Patient reports that he was out of work for several days due to having a sore throat about two weeks ago but he seemed to have recovered until these new symptoms began earlier today. Urine examination reveals hematuria with red blood cell casts and a decreased glomerular filtration rate. What is the most likely diagnosis? A. Acute poststreptococcal glomerulonephritis B. Idiopathic hematuria C. Immunoglobulin A nephropathy D. Minimal change disease

A. Acute poststreptococcal glomerulonephritis

A 32-year-old man is evaluated in the emergency department for complaints of shortness of breath and palpitations that began at rest approximately 30 minutes ago. He recalls experiencing similar symptoms three days ago that self-resolved after 10 minutes. He denies additional medical history and is not taking any prescription or alternative medications. On physical exam, he has clear and equal breath sounds bilaterally. His blood pressure is 134/88 mm Hg, heart rate 180 beats per minute, and respiratory rate is 24. An ECG shows a narrow-complex supraventricular tachycardia. You have him perform vagal maneuvers but do not see a change in his heart rate or rhythm. Which of the following is the next best treatment? A. Adenosine 6 mg IV B. Amiodarone 300 mg IV C. Atropine 0.5 mg IV D. Synchronized cardioversion

A. Adenosine 6 mg IV AV-Nodal Reentrant Tachycardia Most common cause of paroxysmal SVT Reentrant pathway within AV node ECG: narrow QRS complexes, no P waves, retrograde P waves in QRS Unstable: synchronized cardioversion Stable: vagal maneuvers, adenosine, diltiazem, beta-blockers

A 40-year-old woman, diagnosed three months ago with fibromyalgia, returns to the clinic complaining of persistent overall diffuse pain. She followed your previous advice of starting a regular exercise routine, making better dietary choices, and joining a support group. Energy levels have improved but her pain is unchanged. What is the most likely medication you would start her on? A. Amitriptyline B. Carisoprodol C. Celecoxib D. Prednisone

A. Amitriptyline Fibromyalgia Patient will be a woman Complaining of widespread musculoskeletal pain for > 3 months, non-restorative sleep and generalized fatigue PE will show tenderness at > 11 of 18 anatomic sites ("trigger points") Labs will be normal Diagnosis is made clinically Treatment is education, antidepressants, avoid opioids

A 27-year-old man presents with complaints of tearing pain while having a bowel movement. He notes bright red blood on the toilet paper after wiping. Physical examination reveals a superficial tear without a track in the posterior midline of the anus. Which of the following is the most likely diagnosis? A. Anal fissure B. Anorectal fistula C. Anorectal ulcer D. Hemorrhoid

A. Anal fissure Patient will be complaining of rectal pain and bleeding which occurs with or shortly after defecation PE will show fissure located in the posterior midline Diagnosis is made by visual inspection Treatment is stool softeners, protective ointments, sitz baths Comments: If fissures are located laterally, search for pathologic etiologies

A 70-year-old male is beginning treatment for peripheral vascular disease. He has a 50 pack year smoking history and is currently smoking one pack per day. His ankle-brachial index is 0.76, and his dorsalis pedis pulses are diminished bilaterally. His main complaint is a reduction in his ability to continue morning walks with his brother due to pain in his calves that resolves with rest. Which of the following is the most appropriate therapy? A. Aspirin, cilostazol, rosuvastatin, smoking cessation, and structured exercise B. Aspirin, rosuvastatin, smoking cessation, and surgical referral C. Clopidogrel, endovascular reperfusion, rosuvastatin, and smoking cessation D. Clopidogrel, structured exercise, and smoking cessation

A. Aspirin, cilostazol, rosuvastatin, smoking cessation, and structured exercise

A 67-year-old man presents to the clinic for evaluation of cough, wheezing, malaise, and shortness of breath. His social history is positive for daily cigar smoking for 30 years. He reports his symptoms have been present for four months. He had a similar presentation one year ago and was diagnosed with bronchitis. Which of the following is most likely on physical examination? A. Barrel chest B. Diastolic murmur C. Pectus carinatum D. Scaphoid abdomen

A. Barrel chest

A 28-year-old woman presents to the clinic with worsening symptoms related to her recently diagnosed ulcerative colitis. What would you expect her signs or symptoms to include? A. Bloody diarrhea B. Fistula formation C. Mouth sores D. Night sweats

A. Bloody diarrhea Ulcerative Colitis Patient will be 15-30-year-old Complaining of bloody diarrhea, crampy abdominal pain, tenesmus PE will show continuous mucosal inflammation always involving the rectum Treatment is sulfasalazine, surgery is curative Complications: Toxic megacolon, ↑ colon cancer risk

A 25-year-old man presents to the clinic with fever and a sore throat. A throat swab is performed and the culture comes back positive for group A streptococcus bacteria. What system of his body is at highest risk for permanent damage if proper treatment for his infection is not administered? A. Cardiovascular B. Gastrointestinal C. Musculoskeletal D. Pulmonary

A. Cardiovascular Risk of rheumatic fever and pericarditis. Remember the Jones criteria for rheumatic fever: Major: Joints, carditis, nodes, erythema marginatum, sydenham chorea. Minor: fever, arthralgia, elevated ESR, elevated CRP, and prolonged PR interval. Need 2 major, or 1 major and 2 minor, or 3 minor

A 24-year-old woman presents with complaints of excessive thirst over the past several weeks. She also notes waking up in the middle of the night to urinate. She recently underwent transsphenoidal resection of a pituitary adenoma. Which of the following is the most likely diagnosis? A. Central diabetes insipidus B. Nephrogenic diabetes insipidus C. Primary polydipsia D. Type 2 diabetes mellitus

A. Central diabetes insipidus Central diabetes insipidus is the most common type of diabetes insipidus, is associated with deficient secretion of antidiuretic hormone (ADH) by the posterior pituitary.

A 58-year-old woman, newly diagnosed with Sjӧgren's syndrome, returns to the clinic complaining of worsening dry mouth. At her last visit, you recommended she take frequent drinks of water throughout the day and try various over-the-counter products as well as artificial saliva, which she did, but her mouth symptoms persist. What is the most likely medication you would start her on? A. Cevimeline B. Cyclosporine drops C. Low dose prednisone D. Sulfasalazine

A. Cevimeline Cevimeline is a cholinergic agonist that is approved for dry mouth caused by Sjӧgren's syndrome. Sjögren's syndrome is an autoimmune disease that attacks the exocrine glands. Cevimeline works by stimulating nerves to increase the amount of saliva production. Typically it is dosed at 30 mg three times daily. Most common side effects are excessive drooling and sweating, in which case the frequency of dosing is often reduced. Pilocarpine, also a cholinergic agonist, is a possible option for this patient. This medication can also be dosed three times a day, but frequently has to be given four times daily for it to be effective. Sjögren Syndrome Patient will be a woman 40 - 60-years-old Complaining of dry eyes (Xerophthalmia) and dry mouth (Xerostomia) Labs will show SSA (anti-Ro) or SSB (anti-La) Diagnosis is made by positive Schirmer test Most commonly caused by an autoimmune disorder

A 37-year-old woman with a two-year history of rheumatoid arthritis presents to the clinic for worsening joint pain. Previously her disease had been well controlled on 10 mg weekly of methotrexate. You decide to advance her dose to 20 mg weekly to help control her synovitis. What changes in her health maintenance might you have to make with this change? A. Check a complete blood count and blood chemistry profile within six weeks B. Decrease how much folic acid she is supplementing C. Have her screened for tuberculosis before increasing her methotrexate D. Referral to eye provider for a baseline visual field test

A. Check a complete blood count and blood chemistry profile within six weeks Methotrexate is known to cause liver toxicity and requires frequent monitoring. Also, reduction in cell counts can occur including white blood cells, red blood cells, and platelets with methotrexate use.

A 54-year-old man presents to the clinic with a complaint of a productive cough and progressive dyspnea on exertion. His cough was initially dry, 12 years ago, but progressed to productive one year ago. He denies any smoking history, and has otherwise been healthy. He is a mason by trade and enjoys stone sculpting with his wife as a hobby. Which of the following is most likely to confirm the suspected diagnosis? A. Chest X-ray B. Complete blood count with differential C. Pulmonary function test D. Tuberculin skin test

A. Chest X-ray A chest X-ray is most likely to confirm the suspected diagnosis of pneumoconiosis, specifically silicosis. Pneumoconioses are a group of restrictive chronic lung diseases caused by inhalation of particulate matter and are usually related to occupational exposure

A previously healthy 30-year-old woman presents to your office with complaints of dysuria, flank pain, chills, and vomiting. Urine dipstick results are positive for nitrites and leukocyte esterase. Which of the following is the most appropriate therapy? A. Ciprofloxacin B. Fosfomycin C. Nitrofurantoin D. Penicilli

A. Ciprofloxacin

Which of the following electrocardiographic findings is the hallmark of acute pericarditis? A. Diffuse ST elevation B. Irregularly irregular R-R intervals with no distinct P waves C. Prolonged QT interval D. Tall peaked T waves

A. Diffuse ST elevation

A 25-year-old woman presents with intermittent flank pain, hypertension, and blood in her urine. Renal ultrasound shows polycystic kidneys bilaterally. Which of the following complications will this patient most likely develop? A. End stage renal disease B. Intracranial aneurysms C. Portal hypertension D. Renal carcinoma

A. End stage renal disease

A 23-year-old African American woman, with no risk factors for heart disease, presents to the clinic with complaints of sternal chest pain, fatigue, nonproductive cough, and shortness of breath. Vitals and physical exam are normal. Chest X-ray reveals bilateral hilar adenopathy and diffuse reticular opacities. Which of the following is most likely to confirm the diagnosis? A. Endobronchial lung biopsy B. Positron emission tomography scan C. Pulmonary function tests D. Surgical biopsy of mediastinum and lung

A. Endobronchial lung biopsy

A 64-year-old man presents to the clinic reporting a progressive tremor affecting his hands. He states the symptom onset was approximately seven years ago. He states his tremor is now affecting his writing but appears to improve in the evenings after a glass of wine. He has no significant medical history. He does report that his mother had a similar problem but never sought medical attention. On exam, he has no tremor at rest but develops an increasing amplitude tremor in both upper extremities when reaching for items. No bradykinesia or rigidity is present. The rest of his examination is unremarkable. Which of the following is the most likely diagnosis? A. Essential tremor B. Huntington disease C. Parkinson disease D. Wilson disease

A. Essential tremor Diagnosis is made clinically on the basis of family history, as an autosomal dominant transmission occurs in many cases, and clinical presentation. Initial treatment may be episodic, with primidone or propranolol, however, long-term treatment is usually with propranolol or topiramate Complaining of hand tremor that is exacerbated by action and improved after alcohol consumption

A 46-year-old man presents with a painful, red first toe on his right foot. His symptoms came on suddenly one day ago. He states that even light touch is almost unbearable. He denies this ever happening in the past. His vital signs are within normal limits. Erythrocyte sedimentation rate and white blood cell count are normal. Synovial fluid analysis reveals negatively birefringent intra- and extracellular crystals. Which of the following is the most likely diagnosis? A. Gout B. Pseudogout C. Rheumatoid arthritis D. Septic arthritis

A. Gout Patient will be a middle-aged man Complaining of acute onset of pain in the first MTP (Podagra) Labs will show needle-shaped crystal with negative birefringence Most commonly caused by uric acid crystals Treatment is: Acute: NSAIDs, steroids, colchicine Chronic: allopurinol or colchicine Comments: Can be triggered by loop and thiazide diuretics

A 23-year-old man presents for evaluation of a painless right-sided scrotal mass that he noted for the first time while showering one week ago. On physical examination, the mass is located on the anterior surface of the testicle. It is soft on palpation and transilluminates. Which of the following is the most likely diagnosis? A. Hydrocele B. Spermatocele C. Testicular cancer D. Varicocele

A. Hydrocele

A 23-year-old man presents to the emergency department after being stabbed in the flank during a bar fight. He received 2 liters of normal saline by EMS. On arrival, his vital signs are T 37.2°C, HR 130, BP 75/50, RR 30. He appears anxious and diaphoretic. On examination, he has a stab wound to the right flank, abdominal distention, no sensation below the level of T10, weakness of bilateral lower extremities, poor peripheral pulses and cool extremities. Which of the following is the most likely cause of this patient's hemodynamic instability? A. Hypovolemic shock B. Neurogenic shock C. Obstructive shock D. Spinal shock

A. Hypovolemic shock

A 30-year-old man presents to the clinic reporting joint pain and pain with urination. He states that symptoms started two weeks ago. He has left knee and right ankle pain with mild limitations in range of motion secondary to stiffness. Additionally, he has significant bilateral conjunctivitis, and edema at the urethral meatus, but no discharge. His vital signs are all within normal limits. Which of the following is the most likely diagnosis? A. Reactive arthritis B. Rheumatoid arthritis C. Septic arthritis D. Systemic lupus erythematosus

A. Reactive arthritis

Which of the following laboratory values is most likely to be elevated in a patient with hypertonic hyponatremia? A. Serum glucose B. Serum potassium C. Serum sodium D. Serum triglycerides

A. Serum glucose In hyponatremia concurrent with hyperglycemia, a corrected serum sodium should be estimated by remembering that the serum sodium concentration decreases by about 2 mEq/L with every 100 mg/dL increase in glucose concentration. To avoid osmotic demyelination syndrome, hyponatremia of any cause should never be corrected by more than 8 mEq/L in a 24 hour period.

A 35-year-old man presents to the office with acute onset right flank pain radiating to the groin with intermittent nausea and vomiting. A urinalysis and computed tomography of the abdomen and pelvis without contrast were ordered. An urgent referral for outpatient urologist evaluation would be most appropriate for which of the following findings? A. A 3 mm stone in the distal ureter B. A 9 mm mid-ureteral stone C. Hydronephrosis with urinary tract infection D. Ureteral obstruction from a stone in a transplanted kidney

B. A 9 mm mid-ureteral stone Stones that are < 4 mm in diameter are likely to pass on their own with minimal medical management. Stones that are > 8 mm in diameter, however, are unlikely to pass spontaneously and may require stent placement, percutaneous nephrostomy, extracorporeal shockwave lithotripsy, ureteroscopy, and nephrostolithotomy. Therefore, an urgent referral for outpatient urologist evaluation is recommended for a patient with a 9 mm mid-ureteral stone who is likely to need further management Treatment is: < 5 mm: likely to pass spontaneously > 8 mm: unlikely to pass, lithotripsy

Which of the following patients meets the criteria for diagnosis of diabetes mellitus? A. A patient with a fasting plasma glucose of 125 mg/dL and a hemoglobin A1C of 6.0 percent B. A patient with polyuria, blurry vision, and a random glucose of 200 mg/dL C. An asymptomatic patient with a fasting glucose of 130 mg/dL (day 1) and 80 mg/dL (day 2) D. An asymptomatic patient with a random glucose of 250 mg/dL

B. A patient with polyuria, blurry vision, and a random glucose of 200 mg/dL Diabetes Mellitus Type 2 Patient will be middle-aged and obese. Can also affect obese children Complaining of polydipsia, polyphagia, and polyuria Diagnosis is made by ADA Diagnostic Criteria: SymptomaticRandom plasma glucose of ≥ 200 mg/dL (or one of the following) AsymptomaticFasting plasma glucose of ≥ 126 mg/dL Glycated hemoglobin (A1C) of ≥ 6.5 %Plasma glucose of ≥ 200 mg/dL two hours after a 75 g glucose load during an oral glucose tolerance test Most commonly caused by insulin resistance Treatment is lifestyle modification then medication. First line rx: metformin Adults with risk factors need yearly screening. Otherwise, can screen every 3 years

A 67-year-old woman presents to the emergency department for evaluation of a productive cough for five days. She is alert and oriented. Physical exam reveals crackles at the left lung base. Blood pressure is 102/68, temperature is 100.9oF, respirations are 33 per minute, heart rate is 105 beats per minute, and oxygen saturation is 93% on room air. Labs reveal a BUN of 18 mg/dL and creatinine of 1.0 mg/dL Her chest X-ray shows an infiltrate in the left lower lobe. What is the most appropriate course of action? A. Admission to the ICU and start treatment with levofloxacin B. Admission to the medical ward and start treatment with ceftriaxone and azithromycin C. Discharge the patient home with a five-day course of azithromycin and instructions to follow up with primary care in 48-hours D. Discharge the patient home with a seven-day course of doxycycline and instructions to follow up with primary care within three days

B. Admission to the medical ward and start treatment with ceftriaxone and azithromycin The CURB-65 algorithm can be used along with clinical judgement in determining the appropriate site of care for a patient with community acquired pneumonia. Community-acquired Pneumonia (CAP) Patient will be complaining of sudden onset of cough, fatigue, and fever PE will show focal rales with auscultation of lung fields Most commonly caused by Streptococcus pneumoniae

A 40-year-old woman is found to have a malar rash . Which laboratory test has the highest sensitivity for this medical condition? A. Anti-double-stranded DNA B. Anti-nuclear antibody C. Cyclic citrullinated peptide antibody D. Erythrocyte sedimentation rate

B. Anti-nuclear antibody

A 75-year-old man presents with complaints of difficulty breathing when exercising. He notes he was able to walk two miles a day but recently has been experiencing increased shortness of breath and dizziness during daily walks. On physical examination, the patient is found to have a harsh midsystolic ejection murmur, best heard in the second right intercostal space, radiating to the neck. Which of the following is the most likely diagnosis? A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis

B. Aortic stenosis

A 20-year-old woman with a history of cystic fibrosis presents for evaluation of a two year history of multiple episodes of what she describes as "bronchitis". She complains of chronic cough productive of foul-smelling sputum. Auscultation reveals crackles at the lung bases. Chest X-ray is notable for airway dilatation and thickening. Which of the following is the most likely diagnosis? A. Asthma B. Bronchiectasis C. Chronic bronchitis D. Emphysema

B. Bronchiectasis

A 55-year-old man involved in a motor vehicle collision reports shortness of breath during morning rounds. He incurred a left open tibial fracture as a result of the collision and underwent intramedullary rod placement 48 hours ago. Physical examination reveals a diaphoretic patient in mild distress, rales in the right lower lobe, tachycardia without murmurs, and a swollen left lower extremity. His vital signs are remarkable for a pulse of 110 beats per minute and respiratory rate of 26 breaths per minute. His medical history is remarkable for a recent diagnosis of lung cancer. Which of the following is most likely to confirm the diagnosis? A. Chest X-ray B. CT pulmonary angiography C. D-dimer D. Lupus anticoagulant

B. CT pulmonary angiography

A 57-year-old woman presents to the clinic to establish care and reports seven months duration of sudden, abrupt onset of diarrhea. She also reports occasionally experiencing a "fluttery feeling" in her chest accompanied with facial flushing. Her medical history includes hypertension and a significant cough that has been present for two years. She has a 25 pack year tobacco use history. Chest X-ray reveals left lower lobe atelectasis. Which of the following is the most likely diagnosis? A. Angioedema B. Carcinoid tumor C. Cardiac dysrhythmia D. Irritable bowel syndrome

B. Carcinoid tumor Carcinoid tumor is a type of neuroendocrine tumor involving a spectrum of neoplasms. Patient will be complaining of skin flushing, wheezing, and diarrhea Diagnosis is made by 24-hour excretion of 5-hydroxyindoleacetic acid (5-HIAA) in the patient's urine Most commonly caused by carcinoid tumors (neuroendocrine tumors that secrete vasoactive material such as serotonin, histamine, catecholamine, prostaglandins, and peptides)

Sildenafil is prescribed for an otherwise healthy 54-year-old man who is diagnosed with erectile dysfunction. Which of the following is a potential adverse effect of this medication? A. Constipation B. Cyanopsia C. Prostate specific antigen elevation D. Urinary retention

B. Cyanopsia Cyanopsia, or blue discoloration of vision, is a potential side effect of sildenafil. The effect may be more likely with higher dosages of medication and is usually temporary. Sildenafil inhibits phosphodiesterase type five (PDE-5), thereby increasing nitric oxide levels and cyclic guanosine monophosphate, which results in smooth muscle relaxation.

A 28-year-old male presents to the clinic with a four-year history of abdominal bloating, flatulence, diarrhea, and a pruritic rash on his buttocks and knees. He states his symptoms are worse with the consumption of pasta. Which of the following is most likely to confirm the diagnosis? A. 25-hydroxyvitamin D B. Duodenal biopsy C. HLA-DQ genotyping D. Tissue transglutaminase IgA antibody

B. Duodenal biopsy Duodenal biopsy is the confirmatory test for celiac disease (gluten-sensitive enteropathy). Celiac Disease Patient will be complaining of diarrhea, steatorrhea,flatulence, weight loss, weakness and abdominal distension Labs will show IgA anti-endomysial (EMA) and anti-tissue transglutaminase (anti-tTG) antibodies Diagnosis is made by small bowel biopsy Treatment is gluten free diet Comments: Associated with dermatitis herpetiformis (chronic, very itchy skin rash made up of bumps and blisters)

A 60-year-old man with a history of hypertension and heavy tobacco use has been compliant with his 80 mg dose of atorvastatin for the past twelve months. His current total cholesterol measurement is 220 mg/dL. You decide to add another lipid lowering agent. Which of the following drugs has proven beneficial for the prevention of adverse cardiovascular disease events when added to statin therapy? A. Cholestyramine B. Ezetimibe C. Fenofibrate D. Niacin

B. Ezetimibe The only non-statin lipid-lowering agent that has proven to have additive effects on the prevention of cardiovascular adverse events is ezetimibe, which inhibits intestinal absorption of cholesterol. Ezetimibe is administered in an oral daily dose of 10 mg. Common side effects include diarrhea and cough.

A 44-year-old woman with a history of chronic pancreatitis secondary to alcohol abuse presents to the clinic for routine care. She reports her symptoms are well-controlled. She was last seen a year ago. Which of the following tests is indicated for this patient? A. Abdominal ultrasound B. Fasting glucose level C. Magnetic resonance cholangiopancreatography D. Serum amylase and lipase

B. Fasting glucose level A fasting glucose level is indicated for this patient as she has a history of chronic pancreatitis, which greatly elevates her risk for the development of diabetes, specifically diabetes type 3c.

A 64-year-old man presents to the clinic with generalized pain in his neck, shoulders, and hips. He states the pain is worse in the mornings and is sometimes associated with one-sided headaches. His erythrocyte sedimentation rate and C-reactive protein are both elevated. You diagnose him with polymyalgia rheumatica. What other condition would you suspect in this patient? A. Fibromyalgia B. Giant cell arteritis C. Systemic lupus erythematosus D. Trigeminal neuralgia

B. Giant cell arteritis

Which laboratory study is required to confirm the diagnosis of thalassemia? A. Bone marrow biopsy B. Hemoglobin electrophoresis C. Iron studies D. Peripheral smea

B. Hemoglobin electrophoresis

You are treating a 62-year-old man who is seven days status-post coronary angiogram and stent placement, following an acute myocardial infarction. He has been on a heparin drip for five days. Lab calls to notify you that his previously normal platelet count is now 48,000/mcL. Which of the following is the most likely diagnosis? A. Disseminated intravascular coagulation B. Heparin-induced thrombocytopenia C. Immune thrombocytopenia D. Thrombotic thrombocytopenic purpura

B. Heparin-induced thrombocytopenia

Which of the following best describes the etiology of the jaundice seen in patients with thyroid storm? A. Direct constricting effects of thyroid hormone on the biliary duct B. Hepatic tissue hypoxia due to increased peripheral consumption of oxygen C. Hypotension leading to decreased gut motility D. Impaired reabsorption of thyroid hormone in the enterohepatic circulation

B. Hepatic tissue hypoxia due to increased peripheral consumption of oxygen. Signs and symptoms of thyroid storm include hyperpyrexia, nausea, vomiting, diarrhea, mental status changes, jaundice, high-output congestive heart failure, cardiac tachyarrhythmias, hypertension, and diaphoresis. PE will show goiter, lid lag, hand tremor, and warm, moist skin Labs will show low TSH and high free T4 or T3 Most commonly caused by an acute event Treatment is: 1) beta blocker (propranolol) 2) thionamide (propylthiouracil or methimazole) 3) iodine solution 4) glucocorticoids

A 31-year-old woman, newly diagnosed with rheumatoid arthritis, presents to the clinic to start treatment for her disease. Other than her joint pain and fatigue, she is otherwise healthy and denies any other complaints. She has two children and, although not currently trying to conceive, she is considering having one more child in the near future. What is the most likely medication you would start her on? A. Etanercept B. Hydroxychloroquine C. Leflunomide D. Methotrexate

B. Hydroxychloroquine Hydroxychloroquine is generally considered to be safe until the patient knows they are pregnant. Rheumatoid Arthritis Patient will be a woman 40 - 50-years-old Complaining of morning stiffness lasting > 30 minutes PE will show symmetrical soft, red, tender, swelling in joints -MCP, PIP. Bilateral ulnar deviation at MCP, boutonniere deformity, and swan-neck deformity Labs will show positive RF, anti-cyclic citrullinated peptide antibodies Most commonly caused by autoimmune destruction of synovial joints Treatment is DMARDs

An otherwise healthy 20-year-old man suddenly collapses and dies while playing intramural basketball. The patient's brother died two years ago while playing soccer. Which of the following is the most likely diagnosis? A. Dilated cardiomyopathy B. Hypertrophic cardiomyopathy C. Restrictive cardiomyopathy D. Takotsubo cardiomyopathy

B. Hypertrophic cardiomyopathy Patient will be a young athlete Complaining of dyspnea on exertion (most common presenting symptom) PE will show harsh crescendo-decrescendo systolic murmur which increases in intensity with Valsalva maneuver and decreases with squatting Diagnosis is made by echocardiography Most commonly caused by an autosomal dominant genetic defect Treatment is refraining from vigorous physical activity, beta-blockers or calcium channel blockers Comments: Most common cause of sudden death in young athletes

A 55-year-old man presents to the clinic, reporting progressive pain in his lower back, pelvis, and right hip that started eight months ago. He reports pain while walking and it feels worse at night. Ibuprofen provides some relief. On physical exam, he has tenderness and warmth at the lumbar spine, right iliac wing, and right greater trochanter. A mild varus deformity of the right thigh is noted. Lab analysis reveals high serum alkaline phosphatase and radiographs show lytic lesions. Which of the following is the most likely cause of these findings? A. Chronic soft tissue degeneration B. Hypervascular bone C. Osteolytic infectious process D. Soft tissue mass effect

B. Hypervascular bone Hypervascular bone, due to the presence of Paget disease of the bone, initially causes osteolysis with subsequent overactive osteoblastic activity leading to bone deposition and resulting in high bone turnover.

A 59-year-old woman presents to the clinic reporting numbness in her hands and around her mouth, as well as muscle cramps, fatigue, and intermittent hoarseness. Her medical history includes hypertension, hyperlipidemia, diabetes, and a thyroid malignancy which was recently treated by surgical excision. On physical examination, she is noted to have an ataxic gait, hyperresponsive deep tendon reflexes, and appears to be anxious. Additionally, carpal spasms are noted when her blood pressure is taken. Her vital signs are within normal limits for her age. Results of a complete blood count and complete metabolic profile are notable for a low total calcium. Which of the following is the most likely diagnosis? A. Hyperparathyroidism B. Hypoparathyroidism C. Hypophosphatemia D. Hypothyroidism

B. Hypoparathyroidism Two classic exam findings are Chvostek sign, facial twitching caused by tapping around the facial nerve, and Trousseau sign, which is carpal spasming induced with obliteration of the brachial artery. Patient with a history of recent thyroid surgery Complaining of extremity and perioral paresthesias, tetany, and lethargy Labs will show low PTH, low calcium, high phosphorus

A 73-year-old man with a history of atrial fibrillation and hypertension presented to the emergency department with a severe headache and change in mental status beginning suddenly two hours prior to arrival. Given patients acute presentation and history of known dysrhythmia, stroke protocol was initiated and an ischemic stroke was confirmed on a non-contrast CT scan of the head. If the patient had an embolic event in his left anterior cerebral artery, which of the following findings would be expected on physical examination? A. Broca aphasia B. Incontinence C. Left-sided upper extremity weakness D. Macular-sparing homonymous hemianopsia

B. Incontinence Ischemic Stroke Anterior cerebral artery: frontal lobe dysfct, apraxia, contralat paralysis (lower > upper) Middle cerebral artery: contralat paralysis (upper > lower), aphasia Posterior cerebral artery and VBI: LOC, nausea/vomiting, CN dysfct, ataxia, visual agnosia Rule out hypoglycemia CT reveals loss of grey-white interface, acute hypodensity Thrombolytics

When evaluating a patient with chest pain, you note ST-segment elevation in leads II, III and aVF. Which of the following is the most likely diagnosis? A. Anterior wall myocardial ischemia B. Inferior wall myocardial ischemia C. Lateral wall myocardial ischemia D. Posterior wall myocardial ischemia

B. Inferior wall myocardial ischemia

A 28-year-old woman with no known drug allergies presents to the clinic after discharge from the hospital for acute rheumatic fever with carditis. Echocardiographic records reveal subsequent mitral valve disease. Which of the following is the most appropriate choice for secondary prophylaxis of rheumatic fever in this patient? A. Intramuscular injection of penicillin G benzathine every 21-28 days for 10 years B. Intramuscular injection of penicillin G benzathine every 21-28 days until age 40 C. Oral azithromycin 250 mg once daily for 10 years D. Oral penicillin V 250 mg twice daily for 10 years

B. Intramuscular injection of penicillin G benzathine every 21-28 days until age 40

A 26-year-old man presents with an acute severe asthma exacerbation. You decide to perform rapid sequence endotracheal intubation due to impending respiratory failure. The patient has no known medication allergies. Which of the following agents is most appropriate for induction in this case? A. Etomidate B. Ketamine C. Midazolam D. Propofol

B. Ketamine RSI: Induction Agents EtomidateHemodynamically neutralMyoclonusAdrenal suppression KetamineChronotrope/inotropeBronchodilator (useful in obstructive lung disease)↑ ICP (controversial) MidazolamAnticonvulsant effects PropofolShort onset/durationHypotensionApnea

A 65-year-old man with a 30 pack-year smoking history presents for an annual physical exam. He is a current smoker. He asks about lung cancer screening. Which of the following screening methods would you recommend? A. Chest radiography B. Low-dose chest computed tomography C. Positron emission tomography D. Sputum cytology

B. Low-dose chest computed tomography The United States Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years.

n the treatment of Alzheimer disease, which of the following pharmacologic treatment options is found to be neuroprotective? A. Donepezil B. Memantine C. Selegiline D. Vitamin E

B. Memantine

A 60-year-old man presents to the clinic with a high-pitched, blowing systolic murmur heard best at the apex and radiating to his left axilla. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Mitral regurgitation C. Pulmonic stenosis D. Tricuspid regurgitation

B. Mitral regurgitation

A 50-year-old man with a body mass index of 52 kg/m² presents to the clinic complaining of daytime sleepiness and dyspnea on exertion. His peripheral oxygen saturation on room air is 93%. Further testing reveals obesity hypoventilation syndrome with concurrent obstructive sleep apnea. The patient is put on a weight loss regimen which includes diet and exercise. In addition, which of the following is the best choice for initial therapy in this patient? A. Nocturnal bilevel positive airway pressure B. Nocturnal continuous positive airway pressure C. Oral theophylline dosed every twelve hours D. Twenty-four hour supplemental oxygen

B. Nocturnal continuous positive airway pressure

A patient was recently diagnosed with histoplasmosis. Where would you suspect this patient recently traveled? A. Northeastern United States B. Ohio River Valley C. Pacific Northwest D. Southwestern United States

B. Ohio River Valley Patient with a history of travel to Ohio/Mississippi river valleys and exposure to bird/bat droppings X-ray will show solitary pulmonary calcification, hilar and mediastinal adenopathy Diagnosis is made by culture Treatment is itraconazole or amphotericin B

What is the most common presenting symptom of bladder carcinoma? A. Nocturia B. Painless hematuria C. Unintentional weight loss D. Urinary frequency

B. Painless hematuria The primary modality to diagnose bladder cancer is with cystoscopy, which allows for direct visualization of tissues and biopsy of any abnormalities. Smoking is the most important risk factor of bladder cancer.

A 35-year-old woman presents to the clinic complaining of worsening symptoms related to her recently diagnosed scleroderma (systemic sclerosis). Which of the following symptoms is most consistent with the diagnosis of scleroderma? A. Dry mouth and dry eye complaints B. Skin tightening around the fingers with pitting at the fingertips C. Tenderness at the temporal areas D. Weakness of proximal muscles without pain

B. Skin tightening around the fingers with pitting at the fingertips Classically, limited cutaneous scleroderma causes CREST syndrome; Calcinosis of the skin, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Laboratory studies may reveal elevated antinuclear antibody (present in all patients but has low specificity), anti-topoisomerase I (anti-Scl-70) antibody (specific for diffuse disease), anti-centromere antibody (specific for limited disease).

A 42-year-old woman presents to the clinic with a history of stage I differentiated papillary thyroid carcinoma that was treated five years ago with thyroidectomy and had an excellent clinical response. The patient requests monitoring for recurrent thyroid disease. A serum thyroid-stimulating hormone (TSH) level is ordered. Which of the following is the recommended range to maintain in this patient? A. < 0.1 mU/L B. 0.1-0.5 mU/L C. 0.1-2.0 mU/L D. 0.5-5.0 mU/L

C. 0.1-2.0 mU/L Papillary - most common, least aggressive Anaplastic - least common, most aggressive

A 26-year-old pregnant woman presents to the office to discuss her concerns regarding genetic conditions that may affect her child. She states that her father was diagnosed with Huntington disease twelve years ago. Patient reports the only other individual in her family known to have Huntington disease was her paternal grandmother. The patient has not personally been tested. Which of the following values indicates the likelihood that the patient received the abnormal gene from her father if it was passed down in an autosomal dominant disorder? A. 100% B. 25% C. 50% D. The patient cannot receive the abnormal gene from her father

C. 50%

A 22-year-old man presents to the office for his one week follow up after his third concussion in four years. The patient plays rugby on his college intramural team. His most recent concussion was complicated by a period of loss of consciousness at the time of injury. He admits to having headaches and intermittent dizziness for the past couple of days. His headache appears to be tension-type in nature. He is eager to return to rugby and is requesting clearance to play. Which of the following is the most appropriate education to give your patient? A. Can return as headaches after a concussion are expected B. Can return as subsequent concussions increase resilience to future ones C. Cannot return as patient is currently symptomatic D. Cannot return as patient meets criteria for chronic traumatic encephalopathy

C. Cannot return as patient is currently symptomatic

A 64-year-old man presents to the clinic for management of chronic symptomatic hypercalcemia of malignancy. Despite the continued use of bisphosphonates, his total calcium level remains elevated. Which of the following is the most appropriate medication this patient should receive next? A. Calcitonin B. Cinacalcet C. Denosumab D. Zoledronic acid

C. Denosumab In the case of a patient with chronic symptomatic hypercalcemia of malignancy that is refractory to bisphosphonate therapy, denosumab, a monoclonal antibody which inhibits bone resorption via inhibition of receptor activator of nuclear factor kappa-B ligand (RANKL) can be used. In addition, denosumab is an option for patients in whom bisphosphonates are contraindicated due to severe renal impairment, as it is not renally excreted.

A 21-year-old man presents with a complaint of a painless "lump" near his anus. He reports occasional blood on the toilet paper when he wipes after straining to have a bowel movement. He also complains of intermittent peri-anal itching. On inspection, you note a pink, circular lesion visualized on the anus that is not pedunculated. It is firm and non-tender. What is the most likely diagnosis? A. Anal abscess B. Anal skin tag C. External hemorrhoid D. Internal hemorrhoid

C. External hemorrhoid Hemorrhoids Patient will be complaining of pain and itching in the anal region PE will show: Internal - proximal to the dentate line External - distal to the dentate line Treatment is lifestyle modifications, sitz baths, analgesic creams, or surgical excision

A 77-year-old woman presents to the clinic complaining of recent onset of headaches. She denies any visual changes and vitals are normal. On exam, she is tender over the right temporal area. She follows with cardiology for a history of a heart valve replacement and with rheumatology for a disease that "has a long name" which she can't remember. Which of the following is the most likely diagnosis? A. Cluster headache B. Fibromyalgia C. Giant cell arteritis D. Trigeminal neuralgia

C. Giant cell arteritis

A 65-year-old woman presents to the ED with sudden onset of right eye pain and blurred vision. Physical examination reveals circumcorneal injection, a 7 mm right pupil that is unresponsive to light and an intraocular pressure of 35 mm Hg. Which of the following is the gold standard test to confirm the diagnosis? A. Dark room provocation B. Dilated fundus examination C. Gonioscopy D. Slit lamp grading

C. Gonioscopy Gonioscopy is considered the gold standard in the diagnosis of acute angle closure glaucoma, an ocular emergency that this patient is experiencing. This method allows the examiner to examine the angle that is formed between the cornea's posterior surface and the iris' anterior surface. An experienced provider, such as an ophthalmologist, should perform this test. Care must be taken to not shine light directly onto the pupil as the angle could widen and create an error in measurement. Acute Angle-Closure Glaucoma Patient will be entering a dark room or movie theater Complaining of acute unilateral painful vision loss, vomiting, and seeing halos around lights PE will show cloudy cornea and fixed mid-dilated pupil Testing will show IOP ( > 21 mm Hg) Treatment is topical beta-blockers, carbonic anhydrase inhibitors, mioticsIridotomy is definitive treatment, but not used for initial management

A woman presents to the clinic complaining of pedal edema. Which of the following would be most suggestive of congestive heart failure as the likely etiology? A. History of bulimia nervosa B. History of chronic renal insufficiency C. History of diabetes mellitus D. History of inflammatory bowel disease

C. History of diabetes mellitus

A 50-year-old man with a history of asthma and hypertension presents to the emergency department with shortness of breath, wheezing, and cough. He reports poor compliance with his medications due to lack of access to a primary care provider. He denies chest pain. His vital signs in triage are 36.9°C, HR 87, BP 240/140, RR 22. His physical examination reveals mild wheezing, bibasilar rales, and an S3. His ECG shows normal sinus rhythm. His laboratory workup is significant for a BNP of 360 ng/L and a troponin of 0.3 ng/mL. Which of the following is the most likely cause of the patient's symptoms? A. Acute thrombotic myocardial ischemia B. Asthma exacerbation C. Hypertensive emergency D. Pulmonary embolism

C. Hypertensive emergency

An 80-year-old woman with a 36-pack-year history of smoking tobacco presents with a chief complaint of increasing dyspnea on exertion over the past six months. Physical exam reveals clubbed digits and bilateral lower lung crackles. Computed tomography shows honeycombing of the lung parenchyma. What is the most likely diagnosis? A. Bronchiectasis B. Chronic obstructive pulmonary disease C. Idiopathic pulmonary fibrosis D. Sarcoidosis

C. Idiopathic pulmonary fibrosis

A 24-year-old woman is admitted to the intensive care unit after developing thyroid storm status post appendectomy and is being treated with propylthiouracil. What is the mechanism of action of this drug? A. Decreases adrenergic tone B. Decreases vasomotor instability C. Inhibits conversion of thyroxine to triiodothyronine D. Inhibits release of thyroid hormone

C. Inhibits conversion of thyroxine to triiodothyronine

Which of the following best represents an appropriate lipid screening protocol for an adult man with no other cardiovascular risk factors? A. Lipid profile beginning at age 20 B. Lipid profile beginning at age 30 C. Lipid profile beginning at age 35 D. Lipid profile beginning at age 40

C. Lipid profile beginning at age 35

A 17-year-old woman with a history of severe menorrhagia was admitted for a blood transfusion after fainting at school. Her history is positive for fatigue, exertional dyspnea, and increased cravings for ice over the past several weeks. Laboratory findings show hemoglobin 6 g/dL, hematocrit 22%, mean corpuscular volume 72 fL, total serum iron 23 mcg/dL, and total iron binding capacity 92 micromol/L. The patient was found to have conjunctival pallor and koilonychia on physical examination. What additional physical exam finding would you expect to find? A. Facial plethora B. Jaundice C. Loss of tongue papillae D. Petechiae

C. Loss of tongue papillae Loss of tongue papillae or atrophic glossitis is seen in patients with iron deficiency anemia. Iron deficiency anemia is common in women of reproductive age and children.

A 21-year-old woman presents to the clinic with several large, anterior and posterior cervical lymph nodes. She complains of weight loss and night sweats for the past four months. Which of the following is the most effective next step in the diagnosis of Hodgkin lymphoma? A. CT scan of neck, chest and abdomen B. Fluorescence immunophenotyping C. Lymph node excisional biopsy D. Lymph node fine needle aspiration

C. Lymph node excisional biopsy Hodgkin Lymphoma Patient will be complaining of lymphadenopathy (often cervical and painless), pruritus, fever, night sweats, unintentional weight loss, and frequent infections Diagnosis is made by lymph node biopsy showing Reed-Sternberg cells

A 70-year-old man with a history of HIV infection presents to the office for routine testing of his CD4 count. His last CD4 count was 90 cells/mcL and the results from this visit show a CD4 count of 45 cells/mcL. Which of the following opportunistic infections are patients prone to developing when their CD4 count drops below 50 cells/mcL? A. Histoplasmosis B. Kaposi sarcoma C. Mycobacterium avium complex D. Toxoplasmosis

C. Mycobacterium avium complex Those with CD4 counts below 200 cells/mcL are considered to have developed acquired immunodeficiency syndrome (AIDS) and require prophylactic treatment for a variety of opportunistic infections. Many infections can be prevented by taking antibiotics or antifungal medications. Patients with CD4 counts less than 50 cells/mcL are at risk for infection with mycobacterium avian complex and cytomegalovirus retinitis. < 250: Esophageal candidiasis < 200: PCP pneumonia < 100: Cerebral toxoplasmosis, Cryptococcosis < 50: Mycobacterium avian complex

A 38-year-old, previously healthy woman presents with pedal edema, dyspnea, fever and fatigue. Electrocardiogram reveals non-specific ST-T wave changes. Cardiac troponin and CK-MB are elevated. Echocardiogram shows segmental wall motion defects. Cardiac catheterization is negative for perfusion defects and the chest radiograph shows bilateral pleural effusions. Which of the following is the most likely diagnosis? A. Endocarditis B. Myocardial infarction C. Myocarditis D. Pneumonia

C. Myocarditis Question: Name three drugs known to cause myocarditis. Answer: Clozapine, thiazide diuretics, and penicillins. Myocarditis Patient will be complaining of fatigue, fever, chest discomfort, dyspnea, and palpitations PE will show tachycardia that is disproportionate to fever or discomfort Echocardiogram will show decreased ventricular ejection fraction with hypokinesis and wall motion abnormalities Gold standard for diagnosis is an endomyocardial biopsy

What is the treatment of choice for an otherwise healthy patient with a confirmed diagnosis of acute idiopathic pericarditis? A. Antiviral therapy B. Glucocorticoids C. NSAIDs D. Pericardiocentesis

C. NSAIDs Pericarditis Patient will be complaining of pleuritic chest pain radiating to the back that is worse when lying back and improved when leaning forward PE will show tachycardia and pericardial friction rub ECG will show PR depression, PR elevation (aVR), diffuse ST-segment elevation (concave) Most commonly caused by idiopathic then viral (Coxsackie) Treatment is NSAIDs, colchicine

A 44-year-old man presents for a follow-up visit for his known gastroesophageal reflux disease. He has been taking a histamine-2-receptor antagonist twice a day. He continues to have symptoms at least three times per week. Which of the following is the next best therapy? A. Calcium carbonate B. Famotidine C. Omeprazole D. Sucralfate

C. Omeprazole Proton pump inhibitors (PPIs), such as omeprazole, should be used in patients who fail twice-daily histamine-2-receptor antagonist therapy, in patients with erosive esophagitis, or patients with severe and frequent symptoms of gastroesophageal reflux disease (GERD). PPIs inhibit gastric acid secretions by irreversibly binding and inhibiting the hydrogen-potassium ATPase pump. They should be taken 30 minutes before the first meal of the day. Treatment is weight loss, elevation head of bed during sleep, avoidance of certain foods (caffeine, alcohol, acidic foods)

A 37-year-old man was found to have a pituitary adenoma on MRI after presenting to the hospital complaining of headaches and visual impairment. Based on the location of the benign tumor, compression of which cranial nerve is most likely causing the patient's visual symptom? A. Abducens nerve B. Oculomotor nerve C. Optic nerve D. Trochlear nerve

C. Optic nerve The optic nerve is the most commonly affected cranial nerve in pituitary adenomas. The pituitary sits in the sella turcica of the skull. Due to the location of the tumor, the pituitary adenoma most commonly grows in the suprasellar direction applying pressure to the optic chiasm of the optic nerve (cranial nerve II). The result of the optic chiasm compression results in bitemporal hemianopsia.

A 40-year-old man presents to the clinic with burning abdominal pain that extends from his navel to his chest for the past couple of days. Loss of appetite is his only other complaint. Physical exam is normal. He smokes one pack of cigarettes per day and drinks two to three beers daily. An ulceration in the gastric lining is seen on upper endoscopy. What is the most likely diagnosis? A. Barrett esophagus B. Gastric cancer C. Peptic ulcer disease D. Ulcerative colitis

C. Peptic ulcer disease Results from an increase in digestive acid production or loss of protection of the stomach or proximal small intestine lining, leading to either gastric or duodenal ulcers depending upon location. It is associated with two major factors, Helicobacter pylori infection and nonsteroidal anti-inflammatory use. Burning epigastric pain is by far the most common symptom and may be the only symptom, however, the majority of cases are asymptomatic. Other common symptoms are early satiety, fatty food intolerance, heartburn, nausea, and sometimes hematemesis. Definitive diagnosis is made by endoscopy. Duodenal ulcer: pain is alleviated by ingesting food (mnemonic: DUDe give me food) Gastric ulcer: pain is exacerbated by ingesting food

Which of the following scenarios is most likely to result in a metabolic acidosis? A. Bacterial pneumonia with underlying chronic obstructive lung disease B. Hyperventilation due to anxiety C. Persistent diarrhea D. Vomiting

C. Persistent diarrhea Persistent diarrhea causes loss of bicarbonate in the stool and a resulting metabolic acidosis. Metabolic acidosis is usually confirmed with arterial blood gas (ABG) test, which would show a low pH and low bicarbonate level.

A 32-year-old woman presents to the clinic for evaluation of palpitations and is diagnosed with Graves' disease. Which of the following is the most appropriate therapy for acute management of her symptoms? A. Dexamethasone B. Methimazole C. Propranolol D. Propylthiouracil

C. Propranolol

A 44-year-old woman presents to the clinic for evaluation of a syncopal episode that occurred while walking her dog two days ago. She denies amnesia or head trauma. She has had increasing dyspnea on exertion and pedal edema. Physical examination reveals clubbing of her fingers and central cyanosis. Auscultation of the heart reveals tricuspid insufficiency, widely split second heart sound with a palpable P2. Echocardiogram reveals a large ostium secundum atrial septal defect with bidirectional flow. Which of the following is the most likely diagnosis? A. Acute pericarditis B. Atrial myxoma C. Pulmonary hypertension D. Takotsubo cardiomyopathy

C. Pulmonary hypertension What mean pulmonary arterial pressure defines pulmonary hypertension? Answer: Greater than 25 mm Hg at rest or greater than 30 mm Hg during exercise.

A 42-year-old woman presents with right upper quadrant abdominal pain that began four hours prior to arrival in the emergency department. She has associated nausea and has had one episode of emesis. An ultrasound is ordered of the right upper quadrant which shows pericholecystic fluid and thickening of the gallbladder wall. Which of the following signs or symptoms would be consistent with this patient's diagnosis? A. Abdominal distention B. Jaundice C. Right scapular pain D. Shaking chills

C. Right scapular pain Cholecystitis Patient will be an overweight (Fat),Fertile,Female in her Forties (4Fs) Complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula) Diagnosis is made by:Initial - US Gold standard - HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy

A 65-year-old man presents to the clinic reporting fever, nausea, diffuse joint pains, and a rash. He states his symptoms began four days ago after a camping trip in Tennessee. He denies any sore throat, cough, vomiting, diarrhea, or itching. Physical examination reveals a painless maculopapular rash on his wrists and palms, diffuse joint tenderness, and mild upper abdominal tenderness. His temperature is 100.5°F, but the rest of his vital signs are within normal limits for his age. Which of the following is the most likely diagnosis? A. Cellulitis B. Lyme disease C. Rocky Mountain spotted fever D. Syphilis

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

A 47-year-old woman presents to the clinic reporting bilateral swelling of her cheeks, as well as dry mouth and eyes. She reports insidious progression of the symptoms, with no distinct date of onset. Physical exam reveals dry mucous membranes and bilateral parotid gland swelling. Lab results indicate elevated rheumatoid factor, elevated antinuclear antibody with a speckled staining pattern, and a positive anti-Ro antibody test. Which of the following is the most likely diagnosis? A. Lymphoma B. Rheumatoid arthritis C. Sjögren syndrome D. Systemic lupus erythematosus

C. Sjögren syndrome

Which of the following physical exam findings is most indicative of angina pectoris? A. Left-sided chest pain associated with a dermatomal vesicular rash B. Reproducible chest pain on chest wall palpation C. Substernal chest pain associated with a new third heart sound D. Substernal chest pain associated with decreased heart sounds and jugular venous distention

C. Substernal chest pain associated with a new third heart sound

Which of the following is associated with aortic stenosis? A. de Musset sign B. Holodiastolic decrescendo murmur C. Syncope D. Wide pulse pressure

C. Syncope Patient will be older With a history of diabetes, hypertension Complaining of dyspnea, chest pain, syncope PE will show crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop Most commonly caused by degenerative calcification Treatment is aortic valve replacement Comments: murmur decreases with Valsalva

Which of the following statements is most correct regarding total parenteral nutrition in a patient with Crohn disease? A. Patients tolerate enteral feedings well after total parenteral nutrition is discontinued B. Total parenteral nutrition carries the risk of deep vein thrombosis and cardiomyopathy C. Total parenteral nutrition is an alternative to chronic low dose steroids D. Total parenteral nutrition is not recommended in those with short bowel syndrome

C. Total parenteral nutrition is an alternative to chronic low dose steroids Crohns Disease Patient will be complaining of chronic nonbloody diarrhea, crampy abdominal pain, and weight loss PE will show aphthous ulcers, anal fissures, perirectal abscesses, anorectal fistulas Labs will show ASCA positive, p-ANCA negative Diagnosis is made by colonoscopy Colonoscopy will show skip lesions, cobblestone mucosa, transmural inflammation Surgery will not be curative Comments: Can occur anywhere on GI tract from mouth to anus

A 35-year-old man presents to the emergency department with low-grade fever, flu-like symptoms, petechiae, and a new onset murmur. Which of the following diagnostic tests is most sensitive to diagnose this condition? A. Chest computed tomography B. Electrocardiogram C. Transesophageal echocardiogram D. Transthoracic echocardiogram

C. Transesophageal echocardiogram Bacterial Endocarditis Patient will be complaining of fever, rash, cough, and myalgias Physical exam will show Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE) Diagnosis is made by echocardiography and Duke criteria Most commonly caused by:IVDA: S. aureus, tricuspidNative valve: Staphylococcus aureus, Streptococcus viridans (m/c in previously diseased), mitral Treatment is antibiotics Comments: GI malignancy: S. bovis Dental prophylaxis in some cases

Which of the following patients with congestive heart failure is most in need of hospitalization? A. A 65-year-old man with stable angina and two pounds of recent weight gain B. A 68-year-old woman whose internal cardiac defibrillator went off five days ago C. A 70-year-old man with 2+ pedal edema and dyspnea on exertion D. A 75-year-old woman with blood pressure of 80/60 mmHg and confusion

D. A 75-year-old woman with blood pressure of 80/60 mmHg and confusion

Which of the following represents the most common type of gallstone disease in the United States? A. Black pigment B. Brown pigment C. Calcium carbonate D. Cholesterol

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

Which of the following occurs with multiple sclerosis? A. Abnormality in the genetic code for specific muscle proteins B. Axonal degeneration in the peripheral nervous system C. Blocking of receptors at the neuromuscular junction of skeletal muscles D. Destruction of myelinated axons in the central nervous system

D. Destruction of myelinated axons in the central nervous system Patient will be a Caucasian female Complaining of pain with eye movement, monocular vision loss, sensory abnormalities PE will show spinal electric shock sensation with neck flexion (Lhermitte phenomenon) CSF will show ↑ IgG protein, WBC pleocytosis Diagnosis is made by T2-weighted MRI Most commonly caused by a demyelinating disorder Treatment is symptomatic, methylprednisolone, interferon beta-1a Comments: Bilateral internuclear ophthalmoplegia is pathognomonicVitamin D deficiency may be a risk factor for MS

A 26-year-old man presents to the clinic four hours after receiving benzathine penicillin G for primary syphilis. He states he has sweating after resolution of a brief fever two hours after his injection. Physical examination reveals diaphoresis, a significantly more pronounced chancre, tender lymphadenopathy, and mild tachycardia. His vital signs are as follows: temperature of 100.2°F, heart rate of 108 beats per minute, blood pressure 104/60 mm Hg, and respiratory rate of 24 breaths per minute. Which of the following is the best treatment option? A. Ceftriaxone B. Diphenhydramine C. Dobutamine D. Ibuprofen

D. Ibuprofen Ibuprofen is a treatment option for the Jarisch Herxheimer reaction, a phenomenon that classically occurs within the first 24 hours after beginning treatment for any spirochetal infection, including syphilis.

A 45-year-old hypertensive man presents with a persistent, dry cough. He is currently taking clonidine 0.1 mg three times daily, amlodipine 10 mg daily, lisinopril 40 mg daily, and aspirin 81 mg daily. Which of his medications is most likely contributing to his symptoms? A. Amlodipine B. Aspirin C. Clonidine D. Lisinopril

D. Lisinopril

A 68-year-old man presents to the clinic with a past medical history of hepatitis B infection and hepatic cirrhosis. Which of the following is the best choice for surveillance of development of hepatocellular carcinoma in this patient? A. Abdominal CT scan every 12 months B. Abdominal CT scan every two years C. Liver ultrasound every 12 months D. Liver ultrasound every six months

D. Liver ultrasound every six months

A 35-year-old Caucasian man presents to the emergency department with slurred speech and right facial drooping. He had a similar episode a few months ago and did not suffer any residual effects. He also has a history of deep venous thrombosis in the left leg but has no history of surgeries, hypertension, or diabetes. Which of the following should be included in the evaluation to determine the cause of this condition? A. Bone marrow biopsy B. D-dimer C. Hemoglobin electrophoresis D. Lupus anticoagulant

D. Lupus anticoagulant Antiphospholipid syndrome is an acquired autoimmune disorder that causes a hypercoagulable state. Individuals with this disorder are known to have recurrent venous or arterial thrombosis at an early age, although not all patients are symptomatic.

Which of the following statements is most accurate regarding health maintenance for a patient with chronic pancreatitis? A. Abstinence from alcohol will improve symptoms but will not decrease mortality B. Enteric coated pancreatic enzymes require coadministration with an H2 antagonist C. Long chain triglycerides can provide extra calories in patients with weight loss D. Malabsorption of fat soluble vitamins may occur but is rarely clinically symptomatic

D. Malabsorption of fat soluble vitamins may occur but is rarely clinically symptomatic

A 60-year-old man with insulin-dependent diabetes mellitus, gastroparesis, hypertension, and congestive heart failure has just received a new diagnosis of pheochromocytoma. Which of the following medications should be discontinued? A. Furosemide B. Insulin lispro C. Lisinopril D. Metoclopramide

D. Metoclopramide To prepare for surgical excision, medications which cause stimulation of pheochromocytoma activity must be discontinued. These medications include beta-blockers (in the absence of alpha-blocking agents), glucagon, metoclopramide, and histamine.

A 48-year-old man with a history of hypertension presents to the emergency department with a headache and blurring of vision. He reports poor compliance with his blood pressure medications due to lack of access to a primary care provider. On presentation, his vital signs are 36.9°C, HR 87, BP 190/120, RR 16. He denies chest pain or shortness of breath. Physical examination is unremarkable. His laboratory studies are notable for a creatinine of 2.5 U/L. Which of the following is contraindicated in the control of this patient's blood pressure? A. Esmolol B. Labetalol C. Nicardipine D. Nitroprusside

D. Nitroprusside Hypertensive emergency is an acute elevation of blood pressure associated with end-organ damage, typically of the kidneys, brain, heart, aorta, or eyes. Nitroprusside should be avoided in the setting of renal failure due to the risk of cyanate and thiocyanate toxicity.

Which of the following diagnostic studies is the most appropriate for a 33-year-old healthy man with a history of episodic tension-type headache in the setting of a normal neurological examination? A. CT scan B. MRI with contrast C. MRI without contrast D. No diagnostic study is necessary

D. No diagnostic study is necessary

A 32-year-old woman with Marfan syndrome is brought to the emergency department by her husband after she experienced a syncopal episode. She complains of acute onset of sharp substernal chest pain with radiation to her back. On arrival, her vital signs are T 37.3C, HR 130, BP 90/40, RR 27. The blood pressure is similar in bilateral arms. Physical examination reveals no jugular venous distention and heart sounds are auscultated clearly without murmurs, rubs, or gallops. Which of the following is the most appropriate next step in the management of this patients condition? A. Labetalol B. Nitroprusside C. Norepinephrine D. Normal saline

D. Normal saline The cause of the hypotension should be determined and first-line treatment of hypotension in the setting of aortic dissection with aortic rupture or tamponade is fluid resuscitation CT angiogram is the gold standard for diagnosis of dissection.

A 52-year-old man with a history of hepatitis B presents with complaints of fever, weakness, and pain in his right thigh and knee. He reports a 25-pound weight loss over the past three months. Physical examination reveals patchy, well demarcated reticular rash and palpable tender lumps over the lower extremities. Foot drop is noted as well. Immunofluorescence testing for antineutrophil cytoplasmic antibodies is negative. Renal biopsy reveals inflammation of the medium-sized arteries as well as polymorphonuclear cells. Which of the following is the most likely diagnosis? A. Eosinophilic granulomatosis with polyangiitis B. Granulomatosis with polyangiitis C. Henoch-Schönlein purpura D. Polyarteritis nodosa

D. Polyarteritis nodosa

A 56-year-old woman presents to the office with complaints of double vision, drooping eyelids, and speech that becomes slurred late in the day. Patient reports symptoms have been ongoing for weeks. Physical exam reveals ptosis and speech that is "nasal" in quality. The patient underwent a positive tensilon test. Blood work was positive for acetylcholine receptor binding antibodies. Which of the following is first line in the treatment of this patient's neuromuscular disease? A. Carbidopa/levodopa B. Edrophonium C. Plasmapheresis D. Pyridostigmine

D. Pyridostigmine Myasthenia Gravis Patient will be complaining of proximal muscle weakness, ptosis, and diplopia that is worse at the end of the day PE will show ice test improves sx Diagnosis with serologic testing for autoantibodies, electrophysiologic studies Most commonly caused by autoimmune destruction of acetylcholine receptors Treatment is acetylcholinesterase inhibitors, such as pyridostigmine Comments: associated with thymoma

A 75-year-old woman presents with complaints of weakness. She has difficulty getting up from a seated position, going up or down stairs, and lifting heavier objects that she could before without difficulty. You decide to order a muscle biopsy to rule out or confirm your suspicion of polymyositis. What muscle do you most likely want biopsied? A. Brachioradialis B. Gastrocnemius C. Latissimus dorsi D. Quadriceps femoris

D. Quadriceps femoris Quadriceps femoris, or possibly anyone of the four large muscles of the thigh, are most commonly used for biopsy in confirming the diagnosis of polymyositis

A 72-year-old man presents to the clinic for his annual health check. He has a 12-year history of benign prostatic hyperplasia. He denies recent worsening of his voiding symptoms. Vitals are within normal limits. Previous digital prostate exams revealed a smooth, enlarged prostate, but now a small hard nodule is felt on the right lobe. On labs, prostate-specific antigen is 9.2 ng/mL. Records show his prostate-specific antigen was 3.4 ng/mL 12 years ago. Which of the following is the most appropriate next step? A. Increase his tamsulosin dose B. Obtain a baseline computed tomography of his prostate and recheck in six months C. Referral to oncology for radiation therapy D. Referral to urology for prostate biopsy

D. Referral to urology for prostate biopsy Referral to urology for prostate biopsy is the best course of action at this point. Based on a suspicious nodule felt on exam and elevated prostate-specific antigen (PSA), this patient likely has prostate cancer. Biopsy will confirm the diagnosis and help with staging Question: What is the recommended age for an average-risk man to discuss prostate-specific antigen blood test? Answer: Age 50, but 40-45 for African-Americans and those with a positive family history, particularly with relatives younger than 65 with a history of prostate cancer. Prostate Cancer Patient will be an older man Complaining of obstructive uropathy and lower back pain Labs will show PSA > 10 ng/mL Diagnosis is made by needle core biopsy Comments: Age is the most important risk factor, Gleason score used to grade prognosis

A 62-year-old man presents reporting urinary hesitancy, dribbling, and feeling of incomplete voiding. He states his symptoms have been progressively worsening for the last six months. He denies hematuria, pain with urination, or scrotal swelling. Which of the following physical exam findings is most consistent with the diagnosis of benign prostatic hypertrophy? A. Asymmetry of the prostate B. Boggy consistency of the prostate C. Decreased anal sphincter tone D. Rubbery consistency of the prostate

D. Rubbery consistency of the prostate

A patient with a history of radiation therapy for a neck neoplasm presents for evaluation of difficulty swallowing solid foods, but not liquids. Upper gastrointestinal radiography reveals a proximal esophageal stricture. Which of the following is the most appropriate therapy? A. Initiate H-2 antagonist therapy B. Initiate proton pump inhibitor therapy C. Refer for surgical resection D. Schedule mechanical dilation

D. Schedule mechanical dilation Mechanical dilation is the primary treatment for esophageal strictures.

A 23-year-old woman, with no risk factors for heart disease, presents to the clinic with complaints of sternal chest pain, fatigue, and shortness of breath. She was recently diagnosed with sarcoidosis. In your review of systems check, other than pulmonary, what area do you want to focus on the most? A. Gastrointestinal B. Musculoskeletal C. Renal D. Skin

D. Skin Skin and lymph nodes are the two most commonly affected areas, after the lungs, by sarcoidosis. History and physical exam should include a thorough review of skin changes. Sarcoidosis is an inflammatory condition characterized by the presence of noncaseating granulomas in organs and tissues, such as the lungs, skin, lymph nodes, eyes, kidneys, joints, and various others. Lupus pernio (chronic, violaceous, raised plaques and nodules commonly found on the cheeks, nose, and around the eyes) is pathognomonic for sarcoidosis and is the most specific physical exam finding in this disease

A 65-year-old man with significant tobacco use presents with general malaise, unexplained weight loss, and occasional flank pain. Computed tomography of the abdomen shows a localized renal mass in the left kidney. What is the only curative treatment for this condition? A. Chemotherapy B. Radiofrequency ablation C. Stem cell transplantation D. Surgical resection

D. Surgical resection Renal cell carcinoma is the most common type of kidney cancer in adults. Cigarette smoking doubles the risk of developing renal cell carcinoma. Other risk factors include obesity, occupational exposure to certain chemicals and hypertension. Diagnosis is commonly delayed as symptoms are nonspecific and insidious in development. Few patients present with the classic triad of flank pain, hematuria, and flank mass.

Which of the following conditions is most commonly associated with malar or "butterfly" rash? A. Parvovirus B19 infection B. Pregnancy C. Rosacea D. Systemic lupus erythematosus

D. Systemic lupus erythematosus Systemic lupus erythematosus is most commonly seen in African-American patients of childbearing age. Antinuclear antibodies (ANA) is the best initial screening test (most sensitive but not specific). The presence of either anti-double-stranded DNA (dsDNA) and anti-smith (anti-SM) antibodies is diagnostic of SLE (very specific but not sensitive). Treatment is NSAIDs, steroids, immunosuppressants, hydroxychloroquine Drug-induced: Hydralazine, INH, Procainamide, Phenytoin, Sulfonamides (HIPPS). False-positive test for syphilis

A 67-year-old man presents to the emergency department with an acute exacerbation of chronic bronchitis and is hospitalized. His home medications include inhaled albuterol and ipratropium. Administration of which of the following is contraindicated? A. Albuterol 2.5 mg per nebulizer B. Levofloxacin 500 mg IV C. Methylprednisolone 125 mg IV D. Theophylline 200 mg per oral route

D. Theophylline 200 mg per oral rout Historically, theophylline was used quite often in COPD and asthma treatment, but it has a narrow therapeutic range, and can easily become toxic. The effects of toxicity are primarily due to sympathomimetic response, such as tachycardia, hypotension, altered cognition, hyperglycemia, and seizure. With the advent of newer treatments, such as inhaled beta agonist and anticholinergics, theophylline has been relegated to use in refractory cases, as the risk of toxicity is too high to justify the possible benefit.

A 24-year-old woman presents to the Emergency Department with fever and shortness-of-breath for the last 48 hours. Her past medical history is significant for recent IV drug abuse. On physical exam, you auscultate a pansystolic ejection murmur best heard at the left lower sternal border. You also note nontender macular lesions on the palms of her hands and soles of her feet. Laboratory analysis is significant for a white blood cell count of 20,000/mcL, erythrocyte sedimentation rate of 67 mm/hour, and C-reactive protein of 6.5 mg/L. Which imaging modality would be most appropriate to confirm your diagnosis? A. Cardiac catheterization B. Chest X-ray C. CT angiogram of the chest D. Transthoracic echocardiogram

D. Transthoracic echocardiogram Bacterial Endocarditis Patient will be complaining of fever, rash, cough, and myalgias Physical exam will show Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nailbed hemorrhages, Emboli (FROM JANE) Diagnosis is made by echocardiography and Duke criteria Most commonly caused by:IVDA: S. aureus, tricuspidNative valve: Staphylococcus aureus, Streptococcus viridans (m/c in previously diseased), mitral Treatment is antibiotics Comments: GI malignancy: S. bovis Dental prophylaxis in some cases

A 55-year-old woman with a history of HIV presents to the clinic complaining of a productive cough and dyspnea for two weeks. Her oxygen saturation is 92%, temperature is 101.5°F, pulse is 95/minute, respirations are 17/minute, and blood pressure is 130/85. She has a 10-year history of rheumatoid arthritis and is currently being treated with infliximab. Chest X-ray shows diffuse, bilateral, interstitial infiltrates. The diagnosis is confirmed by examination of respiratory secretions. Which of the following is the most appropriate therapy? A. Azithromycin B. Levofloxacin C. Prednisone D. Trimethoprim-sulfamethoxazole

D. Trimethoprim-sulfamethoxazole Pneumocystis jirovecii. HIV-infected patients with a CD4 count < 200 are at the highest risk of PCP.

A 32-year-old man with a history of inherited hemolytic anemia and methicillin-resistant Staphylococcus aureus (MRSA) presents to the office complaining of an abscess. Physical exam reveals a 4 cm fluctuating abscess in the left axilla with extensive surrounding cellulitis. Foul smelling purulent material is expressed during incision and drainage. Patient reports a history of a hemolytic episode last year after being given an antibiotic by another provider for a similar abscess. What antibiotic was likely given for the patient's previous abscess? A. Cephalexin B. Doxycycline C. Nitrofurantoin D. Trimethoprim-sulfamethoxazole

D. Trimethoprim-sulfamethoxazole Trimethoprim-sulfamethoxazole and other medications in the sulfonamide drug class are known to be oxidative drugs. Oxidative drugs can lead to hemolytic episodes in patients with G6PD (glucose-6-phosphate dehydrogenase) deficiency due to the resultant decrease in glutathione allowing oxidative injury of the red blood cells. G6PD Deficiency Patient with a history of taking antimalarials, sulfonamides, nitrofurantoin, fava beans.Infection is also a cause for the hemolysis Labs will show heinz bodies, presence of bite cells on the smear Consider testing patients prior to starting potential agents in at risk patients Comments: X-linked recessive

A patient presents with a grade II/VI late systolic murmur heard best in the fifth intercostal space in the midclavicular line. Which of the following cardiac processes best correlates with this finding? A. Left-to-right blood flow across a small, muscular ventricular septal defect B. Regurgitant blood flow from the left ventricle to the left atrium C. Regurgitant blood flow from the right ventricle to the right atrium D. Turbulent blood flow across redundant mitral valve tissue

D. Turbulent blood flow across redundant mitral valve tissue This describes mitral valve prolapse, which is the most common cause of a late systolic murmur and is typically preceded by a click.

Which of the following represents the best treatment plan for correction of systemic acidosis in status epilepticus? A. Fomepizole 15 mg/kg IV infusion over 30 minutes B. Intravenous insulin infusion at 0.1 units/kg/hour C. Sodium bicarbonate 2-5 mEq/kg IV infusion over four to eight hours D. Watchful waiting for auto-correction of the acidosis once seizure activity is controlled

D. Watchful waiting for auto-correction of the acidosis once seizure activity is controlled Status epilepticus refers to a prolonged epileptic crisis (> or equal to 5 minutes of continuous seizure activity) or more than one seizure without recovery from the postictal state in between episodes.

A 57-year-old woman presents to the clinic complaining of difficulty getting out of bed in the morning and difficulty climbing the stairs into the house. She also reports a weight loss of 20 pounds over the past six months. You suspect a diagnosis of polymyositis. Which of the following physical exam findings is most consistent with the diagnosis of polymyositis? A. Painful proximal muscles without weakness B. Positive Homan's sign C. Several positive tender points D. Weakness of the proximal muscles without pain

D. Weakness of the proximal muscles without pain Polymyositis Patient will be complaining of progressive weakness of three months duration PE will show diffuse tenderness of proximal muscles in the shoulder girdle and pelvic girdle without rash or joint swelling and neurologic examination yields normal results Labs will show (+) Anti-Jo, (+) Anti-SRP Treatment is corticosteroids

Which of the following is the mode of genetic transmission for hemophilia B? A. Autosomal dominant B. Autosomal recessive C. X-linked dominant D. X-linked recessive

D. X-linked recessive

A 35-year-old man with no history of tobacco use, diabetes or hypertension presents with substernal chest discomfort during physical exertion for the past six months. The pain is relieved by rest. His body mass index is 23. Which of the following physical exam findings would suggest a diagnosis of familial hypercholesterolemia? A. Bony nodules on the interphalangeal joints B. Hepatosplenomegaly C. Widespread flat hyperpigmented macules D. Yellow papules on the eyelids

D. Yellow papules on the eyelids Such signs include cutaneous xanthoma, which are visible subcutaneous deposits of cholesterol. They are typically found over tendons, and when found on the eyelids are called xanthelasma.