PANCE exam d part3

Recent influenza infection recent influenza infection, patients may develop a Staph aureus pneumonia. Lung Abscess Patient presents with several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats CXR: dense consolidation with an air-fluid level inside a thick-walled cavitary lesion Most commonly caused by aspiration pneumonia Tx options: ampicillin-sulbactam, carbapenems, clindamycin ------------------------------------------------------------------------------ Exposure to white powder (A) raises suspicion for possible anthrax exposure. Pulmonary anthrax classically causes a widened mediastinum on chest X-ray. Additional findings include lymphadenopathy and pleural effusions. Pulmonary infiltrates are classically absent. A history of smoking (B) increases the chance of developing lung cancer, which is not classically associated with a fever unless an acute infectious process develops. Smokers are at increased risk for pulmonary infections although not specifically one organism. Residence in Connecticut (D) does not increase risk for a particular infectious etiology to pneumonia. Histoplasmosis is more common in the Mississippi and Ohio River valleys and p

A 37-year-old man presents with cough and shortness of breath. Vital signs are T 102°F, BP 110/76, HR 108, RR 20, and oxygen saturation of 92% on room air. His chest X-ray is shown above. Which of the following helps determine the causative organism? AExposure to white powder BHistory of smoking CRecent influenza infection DResidence in Connecticut

Accumulation of fluid in the alveolar spaces dx:Acute respiratory distress syndrome (ARDS) is an acute lung injury due to the accumulation of fluid in the alveolar spaces. This fluid inhibits gas exchange and leads to hypoxia. Sepsis is the most common cause of ARDS, where acute inflammation of the alveolar walls causes the release of cytokines and neutrophils that further destroy the alveolar endothelium.

A 58-year-old man who is admitted to the hospital for an infected diabetic foot ulcer suddenly develops shortness of breath and decreased consciousness. His history includes insulin-dependent diabetes mellitus, hypertension, and dyslipidemia. He is currently receiving intravenous antibiotics for an infected foot wound, insulin, oral antihypertensives, and an oral statin. Last night, he became febrile but had a negative chest X-ray. His blood pressure is 90/60 mm Hg, pulse is 120 bpm, respirations are 22 per minute, temperature is 101.9°F, oxygen saturation is 80% on room air, and blood glucose level is 190 mmol/L. Physical exam reveals a purulent foot wound, an obtunded patient, decreased breath sounds with crackles bilaterally, weak pulses, cool extremities, and perioral cyanosis. A complete blood count is normal except for leukocytosis. A chest X-ray is shown above. Which condition most likely led to this patient's clinical presentation? AAccumulation of fluid in the alveolar spaces BBacterial infiltrate in the interstitium CDiffuse alveolar hemorrhage DEosinophilic proliferation in the interstitium EMalignant cells in the endobronchial tissue

Hypocalcemia

A 68-year-old man with end-stage kidney disease presents with muscle cramps, numbness, and tingling in the hands and feet. He reports no recent vomiting, abdominal pain, or new medications. Vital signs are BP of 138/91 mm Hg, HR of 93 bpm, RR of 20/minute, and T of 98.2°F. On physical exam, his skin is noted to be dry. Neuromuscular irritability is noted on physical exam, manifesting as hyperexcitability of peripheral neurons. The comprehensive metabolic panel reveals albumin 2.9 g/dL, alkaline phosphatase 120 U/L, calcium 6.8 mg/dL, carbon dioxide 26 mEq/L, potassium 4.5 mEq/L, and sodium 140 mEq/L. An ECG is shown above. Which of the following is the most likely diagnosis? AHypocalcemia BHypokalemia CHypomagnesemia DHyponatremia EHypophosphatemia

A 16-year-old boy with a history of asthma presents to the ED with severe shortness of breath and audible wheezing. He uses an inhaled corticosteroid and a long-acting beta-2-agonist at home daily. However, he has had to use his short-acting beta-2-agonist roughly every hour for the past day. In the ED, his vital signs are BP 114/72 mm Hg, HR 106 bpm, RR 28/min, SpO2 94% on room air, and T 99°F (37.2°C). Diffuse wheezing is appreciated, and intercostal retractions are observed. After oxygen is initiated, what is the next step in management? AAdminister albuterol nebulizer BAdminister epinephrine CAdminister systemic corticosteroids DPrepare for intubation

Administer albuterol nebulizer DX:acute asthma exacerbation. Asthma exacerbations clinically present with shortness of breath, wheezing, cough, and chest tightness. The first step in the treatment of an acute asthma exacerbation includes oxygen and beta-2-agonist nebulizers, such as albuterol. Ipratropium is often added to the first three doses of albuterol in those with a severe exacerbation. Response to treatment is monitored by clinical appearance, physical examination, and peak-flow measurements. A mnemonic for the ED treatment of asthma is: BIOMES - Beta-agonists, ipratropium, oxygen, magnesium sulfate, epinephrine, and steroids. -------------------------------------------------------------- VS Systemic corticosteroids (C) are usually initiated in the emergency department to decrease airway inflammation, but this should occur following initiation of an albuterol nebulizer. The onset of action of the albuterol is minutes, while corticosteroids take longer. Epinephrine (B) is given to those with refractory, severe asthma. Those with severe asthma may also require terbutaline, magnesium, or heliox. For some patients experiencing a severe asthma exacerbation, intubation (D) may be warranted, but this patient does not require intubation at this time.

A 62-year-old woman with a medical history of hypertension and atrial fibrillation presents to the clinic. She reports a new onset of hand tremors, palpitations, anxiety, and weight loss of 7 pounds in the past 3 weeks. On exam, she is afebrile and tachycardic to 105 bpm and has blood pressure of 120/80 mm Hg and SpO2 of 98% on room air. She appears restless while seated for her exam. Her skin is warm and diaphoretic. Her thyroid is diffusely enlarged, but no nodules are palpated. She has a bilateral hand tremor. The remainder of her physical exam findings are normal. Laboratory evaluation reveals a thyroid-stimulating hormone of 0.15 µU/mL, free triiodothyronine of 1.2 ng/dL, and free thyroxine of 3.4 ng/dL. Which of the following medications is most likely to be the cause of her symptoms based on the above findings? AAmiodarone BDigoxin CDiltiazem DMetoprolol ENivolumab

Amiodarone The patient in the vignette presents with hyperthyroidism secondary to amiodarone treatment, also known as amiodarone-induced thyrotoxicosis (AIT). All patients with primary hyperthyroidism, including AIT, will have low levels of thyroid-stimulating hormone and high levels of triiodothyronine and thyroxine. Treatment of AIT includes oral glucocorticoids for a course of several months. If steroid treatment is ineffective, a thyroidectomy should be pursued. In some severe cases, amiodarone should be discontinued. What are other serious side effects of amiodarone? Answer: Bradycardia, hypotension, hepatotoxicity (drug-induced phospholipidosis, hepatic cirrhosis), and pulmonary toxicity (acute respiratory distress syndrome, pneumonitis, pulmonary alveolar hemorrhage).

A 29-year-old man presents with progressive back pain and stiffness that started 2 months ago. The pain is worse at night and when he wakes up in the morning and improves with exercise. In the last week he has also noted pain and stiffness in the hips and ankles. Neurological examination is unremarkable. What is the likely diagnosis? AAnkylosing spondylitis BLumbar radiculopathy CRheumatoid arthritis DSpinal stenosis

Ankylosing spondylitis Ankylosing Spondylitis (Radiographic Axial Spondyloarthritis) Risk factors: male sex, age < 40 Sx: low back pain that's most severe at night and morning stiffness that improves with exercise PE: limited spinal mobility, decreased lumbar lordosis X-ray: squared vertebral bodies, multiple vertebral fusions (bamboo spine) Labs: increased ESR, positive HLA-B27 Treatment options include NSAIDs, physical therapy, TNF-alpha blockers Associated with: uveitis, aortitis, IBD, psoriasis, apical pulmonary fibrosis

A 65-year-old woman presents to the emergency department with reports of severe pain and blurred vision occurring in the right eye that began 3 hours ago while watching a movie in the theater with her daughter. She also reports nausea and seeing halos around lights. Previous medical history is significant for COPD, well-controlled with tiotropium bromide daily, and seasonal allergies. Vital signs include a HR of 86 bpm, BP of 130/70 mm Hg, RR of 22/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical exam reveals a hazy cornea with a poorly reactive, mid-dilated pupil in the right eye. Which of the following medications should be avoided when treating this patient? AAcetazolamide BAtropine CLatanoprost DPilocarpine ETimolol

Atropine anticholinergic agent, which allows dilation of the pupil and would worsen acute angle-closure glaucoma. dx:Acute angle-closure glaucoma Sx: acute unilateral pain and vision loss, headache, vomiting, and seeing halos around lights PE: cloudy cornea and fixed mid-dilated pupil Dx: increased IOP Tx: emergent ophthalmology evaluation, topical beta-blockers (timolol), topical alpha-agonists (apraclonidine), carbonic anhydrase inhibitors (acetazolamide), iridotomy Acute-angle closure glaucoma is a medical emergency and referral to an ophthalmologist should take place urgently. Medical treatment of acute angle-closure glaucoma includes agents that cause miosis, or pupillary constriction, thus allowing the blocked drainage angle to open and reducing the intraocular pressure. Topical eye drops such as timololand apraclonidine that lower the intraocular pressure should be administered quickly after presentation. Systemic medications such as acetazolamide and mannitol can be given as part of a combination regimen with pressure lowering eye drops when a patient cannot be seen by an ophthalmologist within 1 hour.

A 12-year-old previously healthy adolescent presents to clinic with one week of cough and fatigue. He has also developed intermittent fevers with a Tmax of 101°F. His cough and fatigue have been progressively worsening. Breath sounds are coarse throughout all lung fields. What is the treatment of choice? AAmoxicillin BAzithromycin CCefdinir DOseltamivir

Azithromycin DX:Atypical Pneumonia Patient presents with the gradual onset of dry cough, dyspnea, and extrapulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance PE: rales with auscultation of lung fields Chest X-ray: interstitial infiltrate Most commonly caused by Mycoplasma pneumoniae: young Legionella: smokers, aerosolized water, air travel, GI symptoms, hyponatremia Chlamydophila pneumoniae: close quarters outbreaks, young, follows pharyngitis Coxiella burnetii: livestock exposure, include LFTs Chlamydophila psittaci: bird exposure, hyperpyrexia, severe HA Treatment: either empiric therapy (covering typical and atypical PNA) or directed therapy (azithromycin for C. pneumoniae) The treatment of choice for atypical bacterial pneumonia is five days of azithromycin. Tetracyclines may also be used in rare cases of azithromycin allergy.

A 32-year-old woman presents to family practice with weight loss and fatigue for the past few months. She has lost approximately 15 pounds in 3 months without trying. She also reports heart palpitations, excessive sweating, and oligomenorrhea. She reports no shortness of breath, illicit drug use, or night sweats. Her medical history includes anxiety, and she takes sertraline 50 mg daily. She is on no other medications. Her vitals include a BP of 128/82 mm Hg, HR of 101 bpm, RR of 12/min, T of 98.7°F, and SpO2 of 100% on room air. She has warm, moist skin, and examination of her thyroid reveals a palpable 1 cm nodule on the left lobe that is nontender. Lab values include a thyroid-stimulating hormone level of 0.2 mU/L, and radioactive iodine uptake scan shows a discrete area of increased uptake, corresponding to the left lobe nodule noted on exam. Which complication is most likely to develop if this patient is left untreated? ABone loss BCoronary artery disease CLoss of vision DMegacolon EMyxedema coma

Bone loss dx: Hyperthyroidism Sx: heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE: hyperreflexia, goiter, exophthalmos, pretibial edema Labs: low TSH and high free T4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Tx: methimazole or PTU PTU in the first trimester of pregnancy --------------------------------------------------------------- vs Myxedema coma (E) is a serious and life-threatening complication of hypothyroidism. Older women are at higher risk for a myxedema crisis, and other risk factors include prolonged cold exposure or a history of stroke or infection. The mortality rate with myxedema coma is high, and treatment includes rewarming, intravenous liothyronine, and mechanical ventilation. This patient has a history and physical exam consistent with hyperthyroidism. Certain ocular manifestations can occur in patients with hyperthyroidism, regardless of the underlying etiology. Common eye manifestations include exophthalmos, lid lag, and eyelid retraction, but loss of vision (C) is not a typical complication of hyperthyroidism. Most vision loss in the US can be attributed to age-related disease such as macular degeneration or complications of diabetes mellitus. Megacolon (D) occurs when the colon is abnormally dilated and is a complication of long-standing hypothyroidism, not hyperthyroidism. Patients with hypothyroidism may present with weight gain, cold intolerance, fatigue, and dry skin. Exam findings typical of hypothyroidism include bradycardia, hair thinning, hyporeflexia, and thyroid goiter. In primary hypothyroidism, TSH would be elevated, and thyroid hormone levels would be low. Hashimoto thyroiditis (an autoimmune disease) is the most common cause of hypothyroidism in the US.

A 35-year-old man with a history of ulcerative colitis presents to the emergency department with complaints of fever, mild abdominal pain, vomiting and diarrhea. His temperature is 102F, pulse is 125/min, and blood pressure is 88/52 mm Hg. Abdominal X-ray reveals colonic dilatation. In addition to fluid resuscitation, which of the following is the most appropriate initial step in management? ABowel rest and nasogastric tube BInitiation of total parenteral nutrition CObtain CT scan of abdomen and pelvis with intravenous contrast DPain control with intravenous morphine

Bowel rest and nasogastric tube dx;Toxic Megacolon History of ulcerative colitis or infectious colitis PE will show systemic toxicity Abdominal X-ray will show the colon dilated > 6 cm Most commonly caused by inflammatory bowel disease Treatment is IVF, Abx, IV corticosteroids (only if related to IBD), surgical consultation --------------------------------------------------------_ vs Total parenteral nutrition (B) may be considered if the patient is malnourished, although has been shown to be of limited value and is not an initial step in the management of patients with toxic megacolon. Obtain CT scan of abdomen and pelvis with intravenous contrast (C) is not the most appropriate next step. An X-ray already identifies colonic dilation and the clinical scenario is consistent with toxic megacolon.Medications reducing colonic motility such as morphine (D) must be stopped and not administered to patients as part of initial management.

A 70-year-old man presents to the clinic reporting unsteady gait, frequent falls, left-sided arm and leg weakness, loss of balance, and difficulty walking. He also reports a headache that is severe and causes nausea. He states the headache began about 2 months ago and has progressively worsened. Valsalva maneuver makes the headache worse. The left-sided weakness started at about the same time as the headache and has gradually become more severe. His history is positive for hypertension, and he has a 15 pack-year smoking history. He takes lisinopril 10 mg daily. His vital signs are within normal limits. Physical exam reveals nystagmus, left-sided upper and lower extremity muscle weakness with hyperreflexia, and antalgic gait. Which of the following is the most likely diagnosis? AAmyotrophic lateral sclerosis BBrain tumor CHemorrhagic stroke DNormal pressure hydrocephalus EParkinson disease

Brain tumor Brain Tumors Most common: metastases Chronic headache worse upon awakening Primary brain tumors classified according to the cell type of origin Treat with surgery, chemotherapy, and radiation therapy ----------------------------------------------------------- vs Normal pressure hydrocephalus (D) may cause gait disturbances, urinary incontinence, and cognitive impairment. However, headache, nausea, and visual deficits do not occur in normal pressure hydrocephalus.

A 66-year-old man presents with complaints of gross hematuria intermittently for the past one week. He has occasional dysuria and notes that his urinary stream has been smaller for the past month. Social history reveals tobacco use of one pack per day for the last 40 years. Which of the following is the most likely to confirm your suspected diagnosis? AA CT scan of the pelvis BCystoscopy CTumor markers DUrine cytology

Cystoscopy most definitive diagnostic test Bladder Cancer Patient will be older History of smoking Painless hematuria Diagnosis is made by cystoscopy Most common type is urothelial (transitional cell) carcinoma

A 53-year-old man wants to establish care at a new primary care clinic after moving. He reports a history of low back pain after a motor vehicle collision 5 years ago and takes ibuprofen 800 mg three times per day. He reports no fever, blood in urine, or abdominal pain. He reports no tobacco, alcohol, or drug use but says he consumes five to six cups of coffee per day. Today, his vitals are a T of 99.1°F, BP of 144/84 mm Hg, RR of 13/min, HR of 88 bpm, and oxygen saturation of 99% on room air. On physical examination, he has normal bowel sounds in all four quadrants and is not tender to palpation over the entire abdomen. Lungs are clear to auscultation, and auscultation of his chest reveals a regular rate and rhythm without any murmurs. Laboratory results reveal a creatinine of 2 mg/dL, and urinalysis reveals mild proteinuria and hematuria. CT scan of the abdomen without contrast reveals bilaterally reduced kidney size with irregular renal contours and papillary calcifications. Which of the following is the most likely diagnosis? AChronic interstitial nephritis BFocal segmental glomerulosclerosis CIschemic tubular necrosis DPolycystic kidney disease ERenal cell carcinoma

Chronic interstitial nephritis Analgesic nephropathy is kidney damage due to analgesic medications and is characterized by chronic interstitial nephritis and papillary necrosis. Common medications that can cause analgesic nephropathy include NSAIDs, aspirin, and acetaminophen alone or in combination with aspirin, codeine, or caffeine. Patients who ingest caffeine in addition to these medications are at a higher risk elevated creatinine and blood urea nitrogen, proteinuria, pyuria, and hematuria. CT abdomen without contrast findings include bilateral small kidney size, papillary calcifications, and kidneys with irregular contours. Treatment involves removing the causal agent and providing supportive measures. ---------------------------------------------------------------- vs Focal segmental glomerulosclerosis (B) is often an underlying cause of nephrotic syndrome in adults in the US. It is characterized by the presence of sclerosis in the glomerulus and results from damage to the podocytes. Patients often present with acute symptoms of nephrotic syndrome, including facial swelling and severe proteinuria. Histological findings of sclerosis on kidney biopsy are needed to make the diagnosis, though differentiating between primary and secondary glomerulosclerosis can sometimes be difficult. Impaired renal perfusion and hypovolemia can lead to kidney injury called ischemic tubular necrosis (C). Risk factors include patients who are recently postoperative, those with underlying chronic disease (such as diabetes), or those with severe blood loss. Decreased flow to the kidneys can result in a rise in creatinine, reduced urine output, and granular casts. High-risk patients should be identified early and be carefully monitored during surgery. Volume status should be monitored and optimized in these patients. Autosomal dominant polycystic kidney disease (D) is a genetic defect that eventually results in renal cyst development. Family history is the biggest risk factor. Most patients present with asymptomatic new-onset hypertension, but they may report blood and protein in the urine, flank pain, or history of kidney stones. Palpable kidney on exam and a decrease in glomerular filtration rate may be seen in these pat

A 30-year-old woman presents with fever and abdominal pain. She is three days postpartum after cesarean section. Physical examination reveals lower abdominal tenderness to palpation and foul smelling vaginal discharge. What management is indicated? ACeftriaxone and azithromycin BClindamycin and gentamicin CFluconazole DMetronidazole

Clindamycin and gentamicin dx: endometritis Endometritis Most common postpartum infection Risk factors: C-section, prolonged labor, prolonged ROM, chorioamnionitis, meconium-stained amniotic fluid, maternal DM, GBS colonization Etiology: polymicrobial (usually two to three aerobic and anaerobic species) Early-onset disease (< 48 hours after delivery) or fever > 101.3 °F Suspect Streptococcus pyogenes Sx: fever, abdominal pain, foul-smelling lochia PE: uterine tenderness and purulent drainage from the uterus Labs: leukocytosis Treatment is clindamycin + gentamicinGBS colonized: add ampicillin or use ampicillin-sulbactam

Which of the following describes a grade 3 ankle sprain? AComplete ligamentous rupture with concomitant distal fibular fracture BComplete ligamentous rupture with considerable swelling, pain, and significant laxity CPartial tear with mild laxity and moderate pain, tenderness, and instability DPartial tear without laxity and only mild edema

Complete ligamentous rupture with considerable swelling, pain, and significant laxity ----------------------------------------------------------- vs Grade 2 ankle sprain (C) is a partial tear with mild laxity and moderate pain, tenderness, and instability. Grade 1 (D) is a partial tear without laxity and only mild edema.

A 40-year-old woman with obesity who is not pregnant presents with left-sided pelvic pain that has been increasing for 2 days. She has left adnexal tenderness on pelvic exam. Which of the following would point to diverticulitis rather than a gynecological cause of her pain? AA history of constipation BA history of nausea and vomiting CA history of ovarian cysts DA wet mount with sheets of white blood cells

Constipation is a risk factor for diverticulitis, inflammation, and microperforation of the wall of a diverticulum. Diverticula are thought to be caused by high colonic intraluminal pressure, resulting from low-fiber, high-fat diets. The most common site for diverticulitis is the left lower quadrant.

A 30-year-old woman presents to the ED with agitation and fever. On physical exam, you note lower extremity hyperreflexia and myoclonus. Vital signs are BP 180/110 mm Hg, HR 130 bpm, RR 28/min, and T 101.8°F (38.8°C). Which of the following combinations likely led to this presentation? ACocaine and propranolol BDextromethorphan and citalopram CHaloperidol and methamphetamine DLithium and furosemide

Dextromethorphan and citalopram Signs and symptoms of serotonin syndrome develop within minutes to hours after exposure to the offending agent(s). These include altered mental status, autonomic instability, myoclonus, hyperreflexia that is greater in the lower extremities, and often severe hyperthermia. Treatment of serotonin syndrome is primarily with benzodiazepines, hydration, and cooling. Cyproheptadine is the classic antidote and may be helpful in moderate to severe cases. vs What is the classic antidote for neuroleptic malignant syndrome? Answer: Dantrolene.

A 72-year-old man is being observed by your clinic for benign prostatic hyperplasia. His symptoms of a weak stream, straining, and post-void dribbling are worsening and he would like to begin medical treatment. You initiate tamsulosin and advise him of which of the following most likely side effect? ADecreased libido BDizziness CErectile dysfunction DHypertension

Dizziness Benign Prostatic Hyperplasia (BPH) Risk factors: advancing age Sx: hesitancy, intermittence or incontinence, frequency or fullness, urgency, nocturia (HI FUN) PE: smooth, firm, mobile prostate without any nodules or indurations Dx: digital rectal exam, UA to rule out alternate causes Caused by stromal and epithelial cell growth in the transitional zone of the prostate Tx: alpha-blockers, 5-reductase inhibitors, surgery (TURP)

A 12-year-old boy with no significant medical history presents to his primary care office with his parent. The patient states he has had a difficult time hearing along with a "ringing" and "popping" sensation to his ears for the past 3 days. Last week, he had cold-like symptoms, which have since resolved. His vital signs are a HR of 89 bpm, RR of 19/min, oxygen saturation on room air of 99%, BP of 104/70 mm Hg, T of 97.8°F, and a BMI of 21.6 kg/m2. On physical exam, the tympanic membrane is clear with appropriate light reflexes bilaterally. Which of the following is the most likely diagnosis for this patient? AAcute otitis externa BAcute otitis media CDysfunction of Eustachian tube DOtosclerosis ETympanic membrane perforation

Dysfunction of Eustachian tube What is the most common organism that causes acute otitis media? Answer: Haemophilus influenzae.

A 44-year-old woman presents with involuntary movements of the neck, face, and tongue. She reports that she was seen earlier in the emergency department for vomiting and received metoclopramide. What management is indicated? ABenztropine BLorazepam CMRI of the brain DNoncontrast CT scan of the head

Dystonic Reaction History of taking antipsychotics, antidopaminergic drugs PE will show muscle spasms (e.g., torticollis), stiffness Treatment is diphenhydramine, benztropine

A 14-year-old boy is brought by his grandparents to the Emergency Department due to difficulty breathing. His grandmother notes that the boy was eating his snack of salted peanuts and an apple when he started to have symptoms of generalized itchiness especially around his mouth, face, and extremities, and swelling around his eyes. Physical examination reveals an irritable child in respiratory distress with periorbital edema, tonsillopharyngeal congestion, poor air entry on lung auscultation, and multiple erythematous and raised wheals on the trunk and extremities. Which of the following is the most important medication in treating this child? ACetirizine BDiphenhydramine CEpinephrine DPrednisone

Epinephrine dx: anaphylaxis

A 52-year-old man comes to the clinic complaining of difficulty swallowing, upper abdominal pain, and heartburn. He says he has a difficult time swallowing solid foods and the food frequently gets "stuck" in his throat. He has a history of food allergies, asthma, and atopic dermatitis. Laboratory studies show markedly elevated serum IgE levels. Upper endoscopy shows stacked circular rings. Which of the following is the most likely diagnosis? AAchalasia BEsophageal stricture CEsophagitis DGastroesophageal reflux disease (GERD)

Esophagitis Eosinophilic Esophagitis (EoE) History of asthma, eczema, food allergies Solid food dysphagia and food impactions Diagnosed via endoscopy, esophageal biopsies Treatment: diet modifications, topical (swallowed) steroids (Flovent) EE is strongly associated with allergic diseases (eg, food allergies, asthma, atopic dermatitis). Laboratory studies typically show elevated levels of serum IgE. Endoscopic findings typically show stacked circular rings that can be transient or fixed along with white nodules with granularity.

An 18-year-old woman presents after having a syncopal episode. She reports a 2-day history of lower abdominal pain and vaginal spotting. Her BP is 86/42 mm Hg, HR is 128 bpm, RR is 18/min, and oxygen saturation is 99% on room air. She is drowsy but answers questions appropriately. What is the most appropriate next step in management? AEstablish large-bore IV access and administer an IV fluid bolus BInitiate rapid sequence induction and orotracheal intubation CPerform a bedside urine pregnancy testing DPerform an ultrasound of the abdomen to assess for free fluid

Establish large-bore IV access and administer an IV fluid bolus

A six-month-old boy presents with five days of nasal congestion and discharge that has now progressed to fever, coughing, and wheezing. You suspect acute bronchiolitis. What are you likely to find on physical examination? ACervical lymphadenopathy BExpiratory wheezing CInspiratory stridor DPharyngeal exudate

Expiratory wheezing dx: Bronchiolitis 1-3 day prodromal URI symptoms PE: tachypnea, retractions, polyphonic wheezing, and rales Diagnosis is made by history and physical exam Most commonly cause: respiratory syncytial virus (RSV) Treatment is supportive care

You receive the laboratory report of a pericardial effusion sample sent yesterday from an inpatient with metastatic lung cancer. Which of the following results would you most expect? AExudate with Gram-positive bacilli BExudate with low-protein and high glucose levels CExudate with positive cytology DTransudate with elevated carcinoembryonic antigen levels

Exudate with positive cytology Pericardial Effusion Pericarditis, autoimmune disorders, cardiac surgery, uremia, medications, cancer If heart function is affected by effusion → cardiac tamponade Dullness to percussion at the point of maximal impulse Cardiomegaly without pulmonary congestion on chest X-ray Diagnosed with echocardiography (anechoic fluid between two echogenic pericardial layers) Tx: Acute pericardial effusion affecting hemodynamics - pericardiocentesis Chronic effusion and/or hemodynamically stable - treat underlying etiology, repeat pericardiocentesis or pericardiectomy may be indicated

A 26-year-old woman presents with a monochorionic, diamniotic twin pregnancy at 20 weeks of gestation in which polyhydramnios is visualized on ultrasound in twin one, and oligohydramnios in twin two. Doppler flow from placenta to both fetuses is good. The bladder of twin two is not visualized. Which of the following clinical interventions would be the best choice for this patient? AAmnioreduction BExpectant management with weekly Doppler blood flow studies CFetoscopic laser ablation of placental anastomoses DSelective reduction

Fetoscopic laser ablation of placental anastomoses dx: Twin-twin transfusion syndrome Stage one refers to polyhydramnios/oligohydramnios, visualized bladders in both fetuses, and evidence of normal umbilical Doppler flow. Stage two is entered when the bladder of the donor fetus is not visualized on ultrasound. Further, if Doppler flow is abnormal in either fetus, ---->Stage one twin-twin transfusion syndrome may be managed expectantly, but stages two through five require clinical intervention. The intervention of choice in Quintero stage two is fetoscopic laser ablation of placental anastomoses. the procedure is recommended for Quintero stage two to four in pregnancies from 16 to 26 weeks of gestation due to evidence of a two-fold increase in perinatal survival as compared to expectant management alone. stage three has begun. Stage fouris when one or both of the fetuses show signs of hydrops, and stage five refers to the death of one or both fetuses

A 26-year-old woman is found to have a blood pressure of 160/90 mm Hg. Similar values are obtained on two subsequent visits. She denies episodic headaches, palpitations, and diaphoresis. She is not obese. On abdominal exam, she is found to have a renal bruit. No abdominal masses are palpated. Her serum creatinine is 1.5 mg/dL. What is the most likely diagnosis? AAutosomal dominant polycystic kidney disease BFibromuscular dysplasia CMinimal change disease DPheochromocytoma

Fibromuscular dysplasia suspected in women younger than 35 years with unexplained hypertension Causes: atherosclerosis, fibromuscular dysplasia, kidney transplantFibromuscular dysplasia: young women In kidney transplant: surgical vascular damage, native vascular disease, immunologic factors, CMV Refractory HTN Dx: MRA, doppler US, CTA, renal angiography Tx: Angioplasty vs surgical revascularizationUnilateral renal artery stenosis: ACEIs, ARBs ----------------------------------------------------------------- vs Autosomal dominant polycystic kidney disease (A) usually presents with abdominal or flank pain, abdominal mass, and hematuria. A history of recurrent urinary tract infections is common. Pheochromocytoma (C) is characterized by episodic headaches, palpitations, diaphoresis, and severe hypertension. These symptoms are caused by a catecholamine-secreting tumor.

Which of the following antiarrhythmic medications is contraindicated in the setting of coronary artery or structural heart disease? AAmiodarone BDofetilide CDronedarone DFlecainide

Flecainide

Which of the following laboratory abnormalities would most likely be seen in a patient with severe anorexia nervosa? AIncreased creatinine BIncreased follicle-stimulating hormone CIncreased glomerular filtration rate DIncreased total cholesterol

Increased total cholesterol may be increased due to increased production of cardioprotective high-density lipoprotein

A 5-day-old female infant is brought to clinic by her concerned mother for jaundice extending from her face down to her chest. The infant was born at 39 weeks' gestation by cesarean section for prior maternal cesarean section. Her postnatal course has been uncomplicated, and she was discharged with her mother on the third day of life. She did not require phototherapy. The mother was told that she and the baby had the same blood type. She is exclusively breastfeeding on demand and the mother feels that it is going well. The infant is having yellow-green stools after each feed and has a wet diaper approximately every four hours. She has lost 4% of her birth weight. What is the most appropriate next step in management? AFurther assessment of breastfeeding BObtain total serum bilirubin, hematocrit, and direct antibody testing CPhototherapy DTransition to formula feeding

Further assessment of breastfeeding dx; Suboptimal Intake Jaundice Aka breastfeeding failure jaundice Mother has decreased milk production Child may have weight loss, dehydration, hypernatremia Child should be seen shortly after hospital discharge by clinician Support mother with resources (lactation consultation) Use of donated breast milk or formula in the interim -------------------------------------------------- Phototherapy (C) is unlikely to be necessary in this infant with no signs of dehydration on examination and low concern for underlying hemolytic, hepatic, or gastrointestinal disease. If the physician has concern for hyperbilirubinemia approaching phototherapy levels, a total serum bilirubin could be obtained. Transition to formula feeding (D) is unnecessary in this infant who is obtaining adequate hydration through breast milk alone. Exclusive breastfeeding is recommended for the first 6 months of life due to its multiple health benefits for the infant, as well as infant and maternal bonding. Formula supplementation is suggested only in the setting of severe dehydration or inadequate lactation. Even in the setting of inadequate lactation, interventions to improve positioning, latch, and milk production should be attempted prior to discontinuation of breastfeeding.

A 19-year-old man presents with multiple painful ulcers on his penis. Genital examination reveals multiple purulent-based, sharply defined, circular ulcers on the shaft of the penis. He also has tender, enlarged, inguinal lymph nodes. Which of the following organisms is the most likely cause of his symptoms? ABorrelia burgdorferi BHaemophilus ducreyi CPlasmodium falciparum DTreponema pallidum

Haemophilus ducreyi Chancroid Risk factors: sexually active Sx: painful genital ulcers PE: papule evolves to a pustule which ulcerates, ulcers on an erythematous base covered by a gray or yellow purulent exudate and painful lymphadenopathy (bubo) Caused by Haemophilus ducreyi Tx: ceftriaxone 250 mg IM or azithromycin 1 g oral

What is the most common sexually transmitted infection in the United States? AChlamydia BGonorrhea CHuman papillomavirus DSyphilis

Human papillomavirus

A 70-year-old woman presents to clinic complaining of a dull, aching pain in her right knee that has been gradually worsening over the past two years. This pain was previously controlled with ibuprofen, but now her pain has started to limit her daily activities. What is the next best step in her treatment? AAcetaminophen BGlucosamine and chondroitin CIntra-articular injection of cortisone with lidocaine DTotal knee arthroplasty

Intra-articular injection of cortisone with lidocaine

A 21-year-old woman with a history of celiac disease presents with an erythematous sharply-defined plaque that is covered in a thin scale on her lower back. It has been slowly worsening over the last few months. It is slightly itchy but otherwise does not bother her. She has a similar rash on her elbows. A skin biopsy is completed. Which of the following pathology results would be most consistent with the diagnosis? AGranular deposits of IgA within the dermal papillae BHomogenized superficial dermis with a flattened dermoepidermal junction CHyperkeratosis, degeneration of the basal cell layer and colloid bodies DHyperkeratosis, parakeratosis, and acanthotic epidermis ELeukocytoclasia, nuclear dust, and endothelial cell swelling

Hyperkeratosis, parakeratosis, and acanthotic epidermis dx; ------------------------------------------------------------- vs Granular deposits of IgA within the dermal papillae (A) is a characteristic dermatopathology finding of dermatitis herpetiformis on direct immunofluorescence microscopy, which is the gold standard for diagnosis. Homogenized superficial dermis with a flattened dermoepidermal junction (B) is histologically characteristic of lichen sclerosus et atrophicus and is not typical for psoriasis. Hyperkeratosis, degeneration of the basal cell layer, and colloid bodies (C) (non-nucleated eosinophilic deposits) are typical histologic findings associated with lichen planus. Leukocytoclasia, nuclear dust, and endothelial cell swelling (E) are seen with red cell extravasation in vasculitis

You are called to examine a one-week-old boy in the ED for seizures. At home, the mother noticed jittery bilateral leg movements that cannot be stopped when the legs are held. The neonate was born full-term to a 25-year-old G2, P2 mother with limited prenatal care. There were no complications at delivery. At the ED, the vital signs are normal with a normal neurologic examination. You note abnormal facie consisting of a small mouth, cleft palate, low set ears, and a widened distance between the inner canthi with short palpebral fissures. Which of laboratory finding is most consistent with the diagnosis? AAnemia BHyperkalemia CHypocalcemia DHypoglycemia

Hypocalcemia " my thought prolonged QT" dx: abnormal face that presents with seizures, which is suspicious for DiGeorge syndrome. This disorder arises from a failure of migration of neural crest cells into the third and fourth pharyngeal pouches. About 80 to 90 percent of patients with DiGeorge syndrome have microdeletions involving chromosome 22q11. Patients typically present in the first week after birth with signs of hypocalcemia such as tetany or seizures that is secondary to hypoplastic or absent parathyroid glands. CATCH-22 Cardiac abnormalities Abnormal facies Thymic absence/abnormality, T cell abnormality Cleft palate Hypocalcemia Chromosome 22 In hypocalcemia, what do you give to stabilize the heart? Answer: Calcium gluconate.

A 16-year-old girl with a history of severe asthma is admitted to the ICU due to a recent, acute exacerbation of her respiratory symptoms. The patient has been receiving bronchodilator therapy and corticosteroids, but she has shown limited improvement in her breathing despite aggressive treatments. Since arrival, her vital signs have changed from BP of 130/84 to 90/60 mm Hg, HR of 121 to 101 bpm, RR of 30 to 9/min, SpO2 of 91% to 89%, and T of 99.1°F. On exam, she is confused, agitated, and lethargic. Chest auscultation reveals no wheezing and there are retractions visible during inhalation. An arterial blood gas shows a pH of 7.32, PaCO2 of 50 mm Hg, and bicarbonate of 24 mmol/L. Which of the following is the most likely cause of this acid-base disorder? ADiuretic treatment BHypoventilation CIncreased intracranial pressure DRecent packed red blood cell transfusion ESevere infection

Hypoventilation Hypoventilation is the most likely cause out of the above choices for primary respiratory acidosis. Hypoventilation, with resultant hypercapnia, can be secondary to brain stem injury, neuromuscular disease, opiates, ventilator dysfunction, or as in this case, severe asthma. Other causes include chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary embolism, or aspirated foreign body. An arterial blood gas (ABG) will demonstrate a decreased pH and an increased PaCO2 level.

A 23-year-old man presents with testicular pain for 3 hours. He does not report any trauma. The pain is constant, sharp, and severe and is accompanied by nausea and vomiting. His vital signs are normal, except for a heart rate of 110 bpm. On examination, there is no swelling, but the left testicle is extremely tender to palpation. The cremasteric reflex is absent. What management is indicated? ACeftriaxone 500 mg IM once and doxycycline 100 mg PO BID for 7 days BCT scan of the abdomen and pelvis without contrast CImmediate scrotal ultrasound followed by urology consultation DImmediate urology consultation followed by scrotal ultrasound

Immediate urology consultation followed by scrotal ultrasound dx:testicular torsion, Bimodal distribution: infants and young men Sx: intense scrotal pain PE: exquisite tenderness of the testicle, hard testes, high-riding testes, absent cremasteric reflex Diagnosis is confirmed by ultrasound with Doppler Treatment: urgent surgery, manual detorsion if surgery delayed; pain control

A 55-year-old woman with a history of hypertension and diabetes mellitus presents to the emergency department after becoming incoherent during a work meeting 45 minutes prior to arrival. On examination, a right facial droop and right upper extremity weakness is appreciated. Vital signs are within normal limits. Her serum blood glucose is within normal limits. A non-contrast head computed tomography scan is normal. Electrocardiogram reveals normal sinus rhythm. Which of the following is the next appropriate step in management? AIntravenous heparin bolus and infusion BIntravenous recombinant tissue-type plasminogen activator bolus and infusion CMagnetic resonance imaging of the brain DWatchful waiting

Intravenous recombinant tissue-type plasminogen activator bolus and infusion dox: ischemic stroke

A five-year-old boy presents with a progressive rash on his legs and buttocks over the past two days along with intermittent abdominal pain and anorexia. His mother states he has not been as active lately because of pain in his knees and ankles. He was otherwise healthy up until a week ago when he started complaining of intermittent headache and fever which she treated with acetaminophen. Which of the following is a known complication of the patient's diagnosis? AAppendicitis BHypertrophic pyloric stenosis CIntussusception DNecrotizing enterocolitis

Intussusception dx:Immunoglobulin A Vasculitis (formerly Henoch-Schönlein Purpura) IgA-mediated small vessel vasculitis most common in children ages 3-15, 10% of cases occur in adults Risk factors: history of recent URI Sx: rash that begins on buttocks and lower extremities, abdominal pain, arthralgia, hematuria, proteinuria PE: pink papules → raised purpura → ecchymosis that is not painful Treatment is supportive care Complications include nephropathy (ESKD more common in adults), intussusception (more common in children) What is the most common manifestation of renal disease in patients diagnosed with Henoch-Schönlein Purpura? Answer: Hematuria.

Which of the following findings seen on rectal examination is most consistent with a concomitant systemic process? AAnal fissure with bleeding BAnal fissure with deep ulcer CAnterior midline anal fissure DLateral anal fissure

Lateral anal fissure like Crohn disease, HIV, leukemia, tuberculosis, or syphilis. Anal Fissure Patient presents with rectal pain and bleeding that 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, topical nitroglycerin or nifedipine If fissures are located laterally, search for pathologic etiologies

A 62-year-old man with a medical history of hypertension and hyperlipidemia presents to the emergency department by ambulance with sudden-onset neurological deficit. His current medications include losartan, amlodipine, hydrochlorothiazide, and atorvastatin. A stat MRI reveals acute right lacunar infarct. Which of the following is the most likely physical exam finding? AExpressive aphasia BLeft hemineglect CLeft hemiparesis DRight gaze deviation ERight hemiparesis

Left hemiparesis Lacunar infarcts affect the contralateral side A stroke to what area of the brain causes Wernicke aphasia? Answer: The posterior section of the superior temporal gyrus. ========================================================= vs Expressive aphasia (A) is a classic finding in damage to the Broca area, which is located in the frontal lobe. Patients with expressive aphasia can understand what others are saying but have difficulty forming sentences. Left hemineglect (B) is seen in right middle cerebral artery strokes. Lacunar strokes do not present with cortical symptoms such as neglect, aphasia, or hemianopia. Right gaze deviation (D) is commonly seen in right cerebral hemisphere strokes. This is not seen in lacunar strokes. Lacunar infarcts affect the contralateral side. Right hemiparesis (E) is seen in left lacunar infarcts rather than right lacunar infarcts.

An 84-year-old woman is recovering in the hospital from an acute anterior ST elevation myocardial infarction four days ago without complication. The patient suddenly develops chest pain, tachypnea and dyspnea. Her pulse is 115 beats per minute, respiratory rate is 26 breaths per minute, blood pressure is 85/50 mm Hg in both arms. She has elevated jugular venous pulsations and distant heart sounds. Her lungs are clear to auscultation bilaterally and no new murmur is appreciated. What is the most likely etiology of her acute decompensation? AAcute aortic dissection BAcute mitral regurgitation CLeft ventricular free wall rupture DPost infarction ventricular septal defect

Left ventricular free wall rupture

A 23-year-old man presents to the emergency room with intermittent severe left-sided flank pain that radiates to his groin. He reports being healthy otherwise and is training for a marathon. He also consumes very little water on a daily basis. Which of the following is the preferred imaging modality to diagnose the suspected condition? ALow-dose computed tomography of the abdomen and pelvis without contrast BMagnetic resonance of the abdomen and pelvis CUltrasound of the abdomen and kidneys DX-ray of kidneys, ureters and bladder

Low-dose computed tomography of the abdomen and pelvis without contrast dx: nephrolithiasis

A 66-year-old man with a history of chronic alcohol use and poor dentition presents with 1 week of fever, dyspnea, and cough productive of purulent sputum. Chest radiographs reveal infiltrates in the posterior segments of the upper lobes. If untreated, what is the most likely complication of this disease? AHypertrophic cardiomyopathy BInfective endocarditis CLung abscess DLung cancer

Lung abscess Lung Abscess Patient presents with several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats CXR: dense consolidation with an air-fluid level inside a thick-walled cavitary lesion Most commonly caused by aspiration pneumonia Tx options: ampicillin-sulbactam, carbapenems, clindamycin recent influenza infection, patients may develop a Staph aureus pneumonia.

A 65-year-old man presents to the emergency room with a crushing substernal chest pain. He states the pain started 30 minutes before and he has never had an episode like this before. He is a smoker and has a history of diabetes. His mother had a myocardial infarction at 60 years of age. He takes insulin for his diabetes but no other medications including over-the-counter medications. He has no known allergies. His initial cardiac troponin was negative and his ECG reveals ST depression that measures 0.8 mm in the anterior leads. According to his TIMI score, which of the following is the most appropriate management? AAdminister 300 mg of clopidogrel BDischarge the patient home with close follow up CMeasure serial cardiac troponin levels DPerform an immediate percutaneous intervention

Measure serial cardiac troponin levels TIMI risk score is used to estimate mortality in patients with unstable angina and non-ST elevation MI's the total score is out of 7. The management of patients with intermediate scores (2, 3, and 4) includes anti-platelet therapy and serial troponin measurement. Anti-platelet therapy in this patient includes aspirin and clopidogrel combined. Clopidogrel alone is only used in patients who cannot tolerate aspirin therapy. A loading dose of aspirin should be administered to any chest pain patient and in those with a non-STEMI or unstable angina, the addition of clopidogrel is needed. This patients TIMI score is 3. He gets one point for his age, one point for having three cardiac risk factors and one point for having ST changes that are greater than 0.5 mm. -------------------------------------------------------------- vs If the TIMI score is considered low risk (0 or 1) then the patient may potentially be safely discharged to home (B) after measurement of an early cardiac marker such as a 3 to 6 hour troponin, combined with a period of observation or management in a chest pain unit. Clopidogrel alone (A) is not used for antiplatelet therapy in NSTEMI patients unless the patient is allergic to aspirin. Patients with TIMI scores of 5 have a 26% event rate and these patients should undergo immediate early aggressive therapy with antithrombotic medications and percutaneous intervention (D).

Which of the following is a known common side effect of using etomidate for rapid sequence induction?👀😎😶‍🌫️👀👀 ABronchorrhea BHypotension CMyoclonic jerks DTachycardia

Myoclonic jerks RSI: Induction Agents Etomidate Hemodynamically neutral Myoclonus Adrenal suppression Ketamine Chronotrope, inotrope Bronchodilator (useful in obstructive lung disease) ↑ ICP (controversial) Midazolam: Anticonvulsant effects Propofol: Short onset and duration Hypotension Apnea

Your patient presents for an evaluation of foot pain and numbness. After taking a history and performing a physical exam, you suspect polyneuropathy. Which of the following is the most appropriate initial diagnostic test? ALumbar puncture BNerve biopsy CNerve conduction study DSkin biopsy

Nerve conduction study

A 23-year-old woman presents to the clinic for her annual physical. On her physical exam, she is well nourished and sitting comfortably. Cardiac and pulmonary exams are unremarkable. Vascular exam reveals 2+ amplitude of dorsalis pedis and posterior tibial pulses bilaterally. Mild swelling of her right foot is noted. She reports no injury or pain. No significant past medical history. She reports returning to California from a trip to Italy last week. Medications include oral contraceptive pills and a multivitamin. Heart rate is 88 beats per minute, BP is 119/81 mm Hg, respirations are 16 breaths per minute, O2 saturation is 100% on room air, and temperature is 97.6°F. D-dimer is 450 ng/mL. Ultrasound shows a 2 cm thrombosis of the right posterior tibial vein. Which of the following treatment options would be most appropriate for this patient? ACompression therapy and leg elevation BIbuprofen therapy and warm compresses CInferior vena cava filter placement DObservation with ultrasound every week for 2-4 weeks ERivaroxaban for 3 months

Observation with ultrasound every week for 2-4 weeks dx: DVT -------------------------------------------------- vs Inferior vena cava filter (C) is indicated for patients with DVT who are at high risk for bleeding. Bleeding risk factors include thrombocytopenia, CrCl < 30 mL/min, hepatic failure, gastric ulcer, active cancer, bleeding in the prior 3 months, and advanced age. Rivaroxaban (E) treatment and other direct oral anticoagulants are preferred for patients with symptomatic DVT who are at low risk of bleeding, asymptomatic patients with DVT who have clot extension into or toward the proximal veins, or those at risk for proximal extension. The preferred duration of treatment is 3 months.

A 7-year-old boy with no significant medical history presents to the clinic with new-onset bed-wetting. According to his parent, the child suddenly started wetting the bed about a week ago. He is not experiencing increased frequency, daytime wetting, urgency, hesitancy, dysuria, or abdominal pain. There have been no changes in diet, sleeping habits, or psychological stressors. He is not currently on any medication. Vitals include a temperature of 98.6°F, heart rate of 85 bpm, blood pressure of 95/65 mm Hg, respiratory rate of 20/min, and SpO2 of 98% on room air. The child's BMI is 18 kg/m2. He is interactive and answers questions appropriately. The remainder of the physical exam is normal. What is the best next step in management? ADesmopressin BObtain a urinalysis CProvide reassurance that this will resolve within a few weeks DRenal and bladder ultrasound ESuggest a bed enuresis alarm

Obtain a urinalysis Clinical • Initial workup for new onset includes history, physical, and urinalysis Evaluation of a child with monosymptomatic nocturnal enuresis includes a history, physical, and urinalysis. The primary goal should be to rule out any underlying etiologies of enuresis, such as urinary tract infection. Other important diagnoses to consider include obstructive sleep apnea, diabetes mellitus, diabetes insipidus, chronic kidney disease, and psychiatric disorders. Primary nocturnal enuresis is diagnosed if there are no findings suggestive of an underlying medical or behavioral condition. Desmopressin (A) is indicated for patients with primary nocturnal enuresis who are refractory to behavioral interventions. Prior to treatment, an evaluation for any underlying etiology must be performed. Reassurance (C) is appropriate for patients with primary nocturnal enuresis. This patient has secondary enuresis, warranting further evaluation and treatment of the underlying cause. Renal and bladder ultrasound (D) is not indicated in the evaluation of monosymptomatic nocturnal enuresis. Urologic imaging should be considered in patients with signs and symptoms of structural urologic abnormalities. A bed enuresis alarm (E) is appropriate for patients with primary nocturnal enuresis.

A 27-year-old woman presents with visual changes. She notes progressive worsening vision in her right eye over the last two days. She reports pain with movement of her eye. On examination, she has an afferent pupillary defect in that eye and a swollen optic disk on fundoscopy. What is the most likely diagnosis? AMacular degeneration BOptic neuritis CPapilledema DRetinal detachment

Optic neuritis Optic Neuritis Patient presents with acute monocular vision loss, pain worse with eye movements, loss of color (red) vision, and transient worsening of vision with increased body temperature (Uhthoff phenomenon) Diagnosis is made clinically. MRI will confirm demyelination Most commonly caused by multiple sclerosis Treatment is IV methylprednisolone

A 19-year-old woman presents to the emergency department with pelvic pain that has been worsening over the last four days. She reports associated nausea and several episodes of emesis today. Vital signs include blood pressure of 113/68 mm Hg, pulse of 112 beats per minute, and oral temperature of 38.2°C. Physical exam reveals cervical motion tenderness and fullness in the left adnexa. Urine pregnancy test is negative. Which of the following would be the most appropriate next step in managing this patient? ABegin oral metronidazole and azithromycin BEmergent gynecology consult COrder a complete blood count and urinalysis DOrder a pelvic ultrasound

Order a pelvic ultrasound dx: Tubo-Ovarian Abscess Most commonly caused by a complication of pelvic inflammatory disease Sx: lower abdominal pain, fever, vaginal discharge PE: unilateral adnexal tenderness Dx: pelvic ultrasound Tx: intravenous antibiotics, surgical drainage, or both

A 19-year-old woman presents to your clinic with concerns about increased, thicker vaginal discharge over the past 2 days. Her last menstrual period began 12 days ago. Her concern relates to her recent decision to begin having intercourse with her boyfriend. He is using condoms, but the condom broke 3 days ago. Vital signs are BP of 118/85 mm Hg, HR of 75 bpm, RR of 15/min, T of 98.7°F, and BMI of 22 kg/m2. No erythema is seen at the vulva, and the cervix appears pale pink with clear mucus at the cervical os. Upon bimanual exam, the uterus is normal in size, and the adnexa are somewhat tender. What is the best explanation for her discharge? ABacterial vaginosis BCandidiasis COvulation DPelvic inflammatory disease ETrichomoniasis

Ovulation Physiologic Leukorrhea

A 22-year-old woman presents with tooth pain 3 days after a dental extraction. The pain is localized to the site where the tooth had been removed. There is a small amount of exposed bone, but no erythema or swelling. The patient has foul breath. Which of the following is the best management strategy? AAdmission for emergent surgical intervention BAdmission for intravenous antibiotics CDischarge with recommendation for NSAIDs DPacking with iodoform gauze

Packing with iodoform gauze Alveolar osteitis occurs 3-4 days after dental extraction. It is caused by the premature loss of the healing blood clot from the socket leading to localized inflammation and infection. Pain is usually accompanied by a foul odor. Treatment consists of irrigation and packing with iodoform gauze, medicated dental paste or eugenol (oil of cloves). This confers almost immediate relief of pain. Alveolar Osteitis (Dry Socket) Patient will be 3-5 days postextraction PE will show inflammation and local osteitis with a clean extraction site Most commonly caused by loss of healing clot Treatment is pack socket with iodoform gauze and eugenol oil

A 72-year-old man presents with concerns of "looking yellow." He is asymptomatic but reports an unintentional 15-pound weight loss over the last two months. Physical examination reveals jaundice, mild epigastric tenderness, and palpable periumbilical nodules. Which of the following is the most likely diagnosis? AColon cancer BEsophageal cancer CGastric cancer DPancreatic cancer

Pancreatic cancer jaundice, cachexia, supraclavicular lymphadenopathy (Virchow nodes),periumbilical lymphadenopathy (Sister Mary Joseph nodes), weight loss, mild epigastric discomfort, andlethargy Pancreatic Cancer Risk factors: history of smoking Sx: abdominal or epigastric pain, painless jaundice, weight loss, anorexia Labs: CA 19-9 serum marker useful in monitoring Dx: U/S, ERCP or MRCP, CT, endoscopic ultrasound Management: Resectable disease: Whipple procedure (pancreaticodudenectomy) + adjuvant chemo Unresectable disease: FOLFIRINOX or gemcitabine-based chemo Most common type is adenocarcinoma Poor prognosis

54-year-old man is found unconscious in a drug store with an empty bottle of minoxidil at his side. He is brought to the emergency room where he is found to be in profound vasodilatory shock with a heart rate of 135 bpm and blood pressure of 57/45 mm Hg. Which of the following vasopressors has the ability to cause a reflex decrease in heart rate and cardiac output?😶‍🌫️😶‍🌫️😩😶‍🌫️😩😎😩😎😩😎😩🍹 ADopamine BEpinephrine CNorepinephrine DPhenylephrine

Phenylephrine is a sympathomimetic drug that works by selectively activating alpha-1 adrenergic receptors, causing vasoconstriction. Due to this potent vasoconstriction and increase in systemic vascular resistance (i.e. increase in afterload), there is a compensatory decrease in heart rate and cardiac output. What urologic emergency can be managed with the use of phenylephrine? Answer: Priapism.

A 2-month-old boy is sent to the emergency department by his pediatrician for a cough and an abnormal CBC with lymphocytosis. He is up-to-date with immunizations. His older sibling, who is 4 years old, is not up-to-date since the pediatrician suspended his immunizations due to a developing neurologic condition. The sibling has also had a febrile illness and has been coughing for more than 3 weeks. You observe the 2-month-old coughing and see a period of perioral cyanosis. What method of confirmatory testing has the best combined sensitivity and specificity for the diagnosis? ABlood cultures BDirect fluorescent antibody on nasal swabs CPolymerase chain reaction of nasopharyngeal secretions DSputum cultures

Polymerase chain reaction of nasopharyngeal secretions dx:pertussis. Pertussis is a highly contagious respiratory infection caused by Bordetella pertussis.Pertussis is commonly called whooping cough most sensitive and specific testing is via polymerase chain reaction (PCR) of nasopharyngeal secretions.

t her annual checkup, a 33-year-old patient mentions difficulty conceiving after 7 months of unprotected and appropriately timed intercourse. She and her husband each have a child from their previous marriages. She experienced menarche at age 12 and reports a 30-day menstrual cycle with premenstrual symptoms of breast tenderness and bloating. Vital signs are BP of 110/70 mm Hg, HR of 70 bpm, RR of 12/min, T of 97.0°F, and BMI of 24 kg/m2. Findings on her Pap test 3 years ago were normal. Her facial skin is without blemishes or noticeable hirsutism. The pelvic exam reveals a cervical os with a transverse slit. The bimanual exam reveals a normal-sized uterus and no pain at the adnexa. What is the best next step for the couple's difficulty conceiving? AClomiphene citrate BFollicle-stimulating hormone levels CHysterosalpingogram DReassurance and no further workup ETransvaginal ultrasound

Reassurance and no further workup

A 50-year-old woman with a medical history of hypertension on amlodipine and diabetes mellitus on metformin presents to the emergency department with right flank pain, nausea, and sweats for the past 7 days. The patient has been nauseous and has lost weight. She was treated for a urinary tract infection with antibiotics 3 weeks ago. Vital signs include a HR of 120 bpm, BP of 120/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 101.5°F. Physical examination reveals a mildly distressed and diaphoretic woman with right costovertebral angle tenderness. The patient's laboratory studies are below: White blood cell count: 18,000/µL Creatinine: 1.5 mg/dL BUN: 35 mg/dL Urinalysis: 1,000 WBC/hpf, 200 RBC/hpf, and many bacteria Which of the following is the most likely diagnosis? AAcute cystitis BAcute interstitial nephritis CBladder cancer DRenal abscess ERenal cell carcinoma

Renal abscess Renal Abscess Systemic symptoms (fever, chills, anorexia) + Unilateral flank pain Secondary to UTI/pyelonephritis or hematogenous spread (bacteremia) Risk factors: uncontrolled diabetes, nephrolithiasis Organisms: E. Coli, Klebsiella, Proteus Diagnosis: CT or ultrasound (fluid-filled cavity within kidney) Tx: Antibiotics +/- drainage ------------------------------------------------------ vs Acute cystitis (A) does not cause systemic symptoms, such as fever, or flank pain. Therefore, renal abscess is more likely.

A four-year-old boy is new to your practice and comes into the clinic with his mother for a health supervision visit. The family recently migrated to the United States. The mother does not have any concerns. On exam, you note height at 5th percentile, enlargement of the costochondral junction, widening of the wrist and varus deformities of the legs. X-ray shows osteopenic epiphyseal centers. Laboratory tests reveal elevated alkaline phosphatase and low serum phosphorus and calcium. Which of the following is the most likely diagnosis? ABlount disease BHypophosphatasia CRickets DSkeletal dysplasia

Rickets Vitamin D deficiency Disorder of children Genetic causes Bony deformity Breastfed babies may need supplements Lack of sun exposure What do you call the impaired mineralization of bone that usually occurs together with rickets? Answer: Osteomalacia. ------------------------------------------------- vs Blount disease (A) is pathologic varus deformity that results from disruption of normal cartilage growth at the medial aspect of the proximal tibial physis. Typical radiographic finding is that of a varus deformity of the proximal tibia with medial beaking and downward slope of the proximal tibial metaphysis. Hypophosphatasia (B) is a rare genetic disorder characterized by bone demineralization that is similar to rickets. It is due to a mutation in the tissue-nonspecific alkaline phosphatase gene that then leads to low serum alkaline phosphatase activity in contrast to rickets. In skeletal dysplasia (D) there is the presence of bilateral and symmetric bowed legs. The radiographic features can be similar to those of rickets. However, serum phosphorus is usually normal.

A 2-year-old boy presents from a rural Native American reservation with an episode of a 3 minute generalized seizure. On further questioning, he has had 3 days of diarrhea, tenesmus, and fever. He has no prior history of seizures. Which of the following is most likely causing his symptoms? ACampylobacter BSalmonella CShigella DYersinia

Shigella Shigellosis Patient presents with fever, bloody and mucoid diarrhea, and seizures (more common in children) Labs will show fecal RBCs and WBCs Treatment is based on resistance patterns but commonly azithromycin, ciprofloxacin, third-generation cephalosporin Consider Zinc or Vitamin A if malnourishment is present Complications: HUS, reactive arthritis

Which of the following factors predicts the highest risk of suicide completion?👀👀👀👀😨 AFemale gender BMarried relationship status CPoor financial status DSubstance use

Substance use SADPERSONS Scale for Suicide Risk Assessment Sex (male) Age (teenager or ≥ 45 years) Depression Previous attempt Ethanol or drug use Rational thinking loss Social supports lacking Organized plan No spouse Sickness (psychiatric or general medical illness) Most suicides involve firearms --------------------------------------------------------- VS Females (A) attempt suicide more often than men but are less likely to die from the attempt. Pregnant women and mothers are at lower risk than others. Being married (B) is protective against suicide. Those at the highest risk are single persons or those who are separated, widowed, or divorced. Poor financial status (C) is also a risk factor for suicide, along with recent legal problems and homelessness, but these factors do not raise the risk of completed suicide as much as problematic substance use.

A 55-year-old man presents to the office interested in obtaining medication for his erectile dysfunction. He states he has trouble maintaining and keeping erections 75% of the time and has no other medical problems. His main concern is that he is single and sometimes not sure when the opportunity will present to have sex, so he wants the medication with the longest duration. Which of the following medications should you recommend? ASildenafil BTadalafil CVardenafil DYohimbine

Tadalafil Sildenafil (A) and vardenafil (C) have a short duration of action (approximately 3 hours). Yohimbine (D) antagonizes alpha-2 adrenergic receptors. In one systematic review, yohimbine improved self-reported sexual function and penile rigidity compared with placebo. It has not been clinically researched for ED in the last decade. Yohimbine has significant adverse effects, including elevation of blood pressure and heart rate, increased motor activity, nervousness, irritability, and tremor. It has a half-life of 36 minutes.

A 21-year-old woman is brought in by ambulance from a soccer game where she was kicked by a teammate as her left leg was planted. Per the ambulance report, the patient was found with the knee bent completely under her, crying in severe pain. She was unable to bear weight on the extremity at the scene. On examination, there is no gross bony deformity of the left leg, knee, or thigh. Peri-patellar ecchymosis and a significant effusion are noted. The knee hyperextends when the leg is lifted by the heel and the knee joint is extremely unstable on valgus and varus stress. Femoral, popliteal, posterior tibial, and dorsalis pedis pulses are present. Which of the following is the most likely diagnosis in this patient? AAnterior cruciate ligament tear BMedial meniscus tear CPatellar dislocation DTibiofemoral dislocation

Tibiofemoral dislocation Knee Dislocation History of violent trauma PE will show dimple sign with posterolateral dislocation Most common causes Anterior dislocation: hyperextension of the knee Posterior dislocation: a direct blow to the anterior tibia with the knee flexed Treatment is reduction and knee splint with 15-20 degrees of flexion Complications can involve popliteal artery and peroneal nerve Refer if: knee cannot be reduced, signs of vascular compromise, signs of infection, extreme pain or instability

A 5-year-old child is brought to the clinic by a parent due to continuously scratching their scalp for the past 24 hours. The child has a history of asthma and uses an albuterol inhaler as needed. The child attends school, but the parent is unaware of any sick contacts. Vital signs include HR of 95 bpm, BP of 103/60 mm Hg, RR of 18/minute, and T of 98.7°F. On examination, adherent white flecks are attached to hair proximal to the scalp and cannot be dislodged. What is the treatment of choice? AKetoconazole shampoo BOral ivermectin CTopical 1% permethrin DTopical 5% permethrin ETopical lindane

Topical 1% permethrin

A 26-year-old woman with a known history of AIDS presents to the ED for strange behavior, according to her boyfriend. Reportedly, she complained of a headache for a few days prior and then began acting bizarrely. In the ED, she has a temperature of 38.5°C (101.3°F). Neurological examination is remarkable for word-finding difficulties accompanied by episodes of clanging and echolalia, along with decreased attention span, recall, and consolidation. A contrast CT scan of the brain reveals multiple ring-enhancing lesions without evidence of midline shift. Which of the following is the most appropriate next step in management? AConsult neurosurgery for a brain biopsy BObtain an MRI CTreat with dexamethasone DTreat with pyrimethamine and sulfadiazine ETreat with trimethoprim-sulfamethoxazole

Treat with pyrimethamine and sulfadiazine Toxoplasmosis Caused by the protozoan parasite Toxoplasma gondii In immunocompetent adults typically asymptomatic and self-limited In patients with HIV infection: reactivation, especially when CD4 < 100 cells/microL Encephalitis: fever, headache, focal neurologic deficits Toxoplasma IgG + CT: multiple ring-enhancing lesions Pneumonitis: dyspnea, nonproductive coughChorioretinitis: eye pain, decreased vision Tx: pyrimethamine, sulfadiazine

31-year-old woman presents with acute onset eye pain, followed by unilateral blurred vision. Which of the following tests may confirm a diagnosis of optic neuritis? AOrbital computed tomography BSnellen chart testing CVisual evoked potential testing DVisual field testing

Visual evoked potential testing -------------------------------------------------------------- vs CT scanning (A) has a very limited role in the setting of optic neuritis. Evoked potentials and MRI are the preferred modalities. The Snellen chart (B) is used to test visual acuity. Although a patient with optic neuritis likely will have acuity defects, the presence of such does not confirm the diagnosis. Visual field (D) abnormalities occur in several different eye conditions. Field defects do not confirm a diagnosis of optic neuritis.

A 63-year-old man with a history of hepatitis C presents to the ED with concerns of generalized abdominal pain and distension. Vital signs are HR 110 bpm, RR 22/min, BP 130/67 mm Hg, T 103.64°F (39.8°C), and SpO2 97% on room air. On exam, his abdomen is tender and moderately distended. Diagnostic paracentesis is performed. Which of the following results should prompt treatment with antibiotics? AAscitic fluid pH of 7.35 BWBC of 275 cells/mm3 with 20% lymphocytes CWBC of 370 cells/mm3 with 90% neutrophils DWBC of 500 cells/mm3 with 40% neutrophils

WBC of 370 cells/mm3 with 90% neutrophils Spontaneous bacterial peritonitis (SBP) ascitic fluid granulocyte count > 500 cells/mm3 correlates with positive cultures in more than 90% of cases, however, ED treatment for SBP should be initiated if the neutrophil count is greater than 250 cells/mm3. Therefore, fluid with a WBC 370 cells/mm3 with 90% neutrophils meets criteria for treatment. • PMN > 250/uL • Positive Gram stain/culture Management • Third-gen cephalosporin (e.g., cefotaxime)

hich of the following neonatal reflexes is present at birth and remains for life? AMoro BPalmar/plantar grasp CSucking DWithdrawal

Withdrawal

A 32-year-old man with a past medical history of depression and schizophrenia presents to your clinic for a routine follow-up appointment. Six months ago, he was prescribed olanzapine for management of his schizophrenia and has since had a 10 kg increase in weight. He states that he is concerned about the weight gain as his father was "overweight and died of a heart attack in his 40s." Which medication would be most appropriate for this patient? AChlorpromazine BClozapine CQuetiapine DZiprasidone

aripiprazole and ziprasidone are associated with the lowest amount of weight gain (less than 1 kg) image dictates the QT prolongation LOOK AT ALL THESE MEDS SIDEEFFECTS

Tourette Disorder Multiple motor and one or more vocal tics Onset before 18 years old Waxing and waning nature complicate assessment of interventions Psychoeducation of patient, family, school may be sufficient for nonimpairing tics Habit reversal therapy is first-line intervention for impairing tics If meds required, alpha-2 agonists preferred due to better safety profile than antipsychotics

coprolalia, the involuntary, compulsive use of obscenities. Echolalia (B) is involuntary repetition of words or phrases spoken by others. Glossolalia (C) is speaking elaborate but meaningless speech, or speaking an unknown language. Palilalia (D) is involuntary repetition or echoing of one's own words.