PANCE exam g part 2

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No intervention dx: second-degree, type I atrioventricular (AV) block

A 52-year-old man presents from his primary care clinician's office for evaluation of an abnormal electrocardiogram. His ECG is seen above. He has no symptoms. What is the appropriate management? AMeasurement of cardiac enzymes BNo intervention CTelemetry observation DTranscutaneous pacer pad placement

A 2-week-old, ex-34 week male infant presents with fever and abdominal distension. The patient has decreased bowel sounds and bloody stool in his diaper. What test should be obtained to make the diagnosis? AAbdominal X-ray BCT scan of the abdomen and pelvis CMRI of the abdomen and pelvis DUrinalysis

Abdominal X-ray dx: necrotizing enterocolitis (NEC) and should have an abdominal X-ray performed emergently to make the diagnosis. NEC is the most common neonatal gastrointestinal emergency. The majority of children affected by this disease are premature aggressive feeding is thought to be a risk factor. Infants with NEC present with feeding intolerance and emesis. They are typically ill-appearing and may present in shock. Lab abnormalities include leukocytosis, thrombocytopenia, hyponatremia, and metabolic acidosis. The imaging modality of choice is abdominal x-ray. It may show intramural air (pneumatosis intestinalis), a loss of symmetrical gas pattern, dilation of loops of bowel, or portal vein gas. Ultrasonography and barium enema have also been used but are rarely helpful in the diagnosis or management. Necrotizing Enterocolitis (NEC) Prematurity Feeding intolerance, bilious or nonbilious vomiting, bloody or guaiac-positive stool Abdominal distension AXR: pneumatosis intestinalis (pathognomonic) IVF, Abx, surgery consultation

What is the most common location for spontaneous bleeding in children with hemophilia A? AAnkle BElbow CGastrointestinal tract DKnee

Ankle Hemophilia A Factor VIII deficiency resulting in spontaneous bleeding X-linked recessive, males affected disproportionately Sx: easy bruising, hemarthroses Labs: increased PTT corrected with a mixing study Tx: Factor VIII replacement (recombinant or purified concentrate)

What is the most appropriate treatment for patients older than 3 years old who are symptomatic giardiasis in addition to supportive care?

Answer: Tinidazole.

A 54-year-old man with cirrhosis presents for evaluation of abdominal pain. The pain is diffuse throughout the abdomen and associated with subjective fever at home. He has no vomiting, diarrhea or change in mental status. His vital signs are T 100.6°F, HR 98, BP 140/88, RR 12, and oxygen saturation of 100% on room air. Bedside ultrasound demonstrates ascites. Which of the following is an indication for intravenous antibiotics? AAscitic fluid neutrophil count of 300 cells/mcL BAscitic fluid pH of 7.35 CAST of 340 U/L DPeripheral white blood cell count of 15,000 cells/mcL

Ascitic fluid neutrophil count of 300 cells/mcL spontaneous bacterial peritonitis (SBP), an acute bacterial infection in the ascitic fluid of patients with ascites in the setting of liver disease. Most commonly, gram negative enteric organisms are responsible for the infection and the treatment of choice is an intravenous third generation cephalosporin. Diagnosis is made based on an ascitic neutrophil count > 250 cells. Spontaneous Bacterial Peritonitis History of chronic liver disease or cirrhosis Fever, chills, and abdominal pain PE will show ascites, shifting dullness Labs will show PMNs > 250/µL, WBC > 1,000/µL, pH < 7.34 Diagnosis is made by analysis of the ascitic fluidIf due to peritoneal dialysis - two of the following abdominal pain or cloudy peritoneal fluid ≥ 100 WBCs/mm3 with 50% PMNs positive culture Most commonly caused by gram-negative rods (eg, E.coli, Klebsiella), Streptococcus Treatment is immediate IV antibiotics (third-generation cephalosporin), consider giving albumin If due to peritoneal dialysis vancomycin for gram-positive and MRSA coverage with a third- or fourth-generation cephalosporin(ie, cefepime), intraperitoneal administration preferred

Which of the following is recommended for long-term secondary stroke prevention for noncardioembolic transient ischemic attack and ischemic stroke? AAspirin BAspirin plus clopidogrel CCilostazol DIndomethacin

Aspirin recommended for secondary stroke prevention for noncardioembolic transient ischemic attack (TIA) and ischemic stroke. Transient Ischemic Attack Transient episode of neurological dysfunction without acute infarction 10% of TIA patients will have a stroke within 90 days Low-risk TIA (ABCD2 score < 4) or moderate to major ischemic stroke (National Institutes of Health Stroke Scale (NIHSS) > 3)Treatment with aspirin alone High-risk TIA (ABCD2 score ≥ 4) or minor ischemic stroke (NIHSS score ≤ 3)Begin with dual antiplatelet therapy (DAPT) for 21 days using aspirin plus clopidogrel ABCD2 score: predicts likelihood of subsequent stroke within 2 days ----------------------------------------------------------------- vs The combined long-term use of aspirin and clopidogrel (B) does not offer greater benefit for stroke prevention than either agent alone but does substantially increase the risk of bleeding complications. The antiplatelet agent cilostazol (C) is a phosphodiesterase 3 inhibitor that is mainly used for intermittent claudication in patients with peripheral artery disease. Several controlled trials have found that cilostazol is effective for preventing cerebral infarction, but the lower tolerability and higher cost of cilostazol compared with aspirin may limit its more widespread use for stroke prevention. Indomethacin (D) has no role in secondary ischemic stroke prevention

A 60-year-old man presents to the office with a history of osteoporosis. Which of the following statements is more common as it relates to men with osteoporosis? ABack pain with vertebral compression fracture is the most common presenting complaint BGonadotropin-releasing hormone analogs for prostate cancer lessen the chances of developing osteoporosis CHigh testosterone levels are associated with osteoporosis DSecondary causes includes hyperthyroidism and coronary artery disease

Back pain with vertebral compression fracture is the most common presenting complaint

A 65-year-old man presents to the emergency department with chest pain and ST-segment elevation in leads II, III, and aVF. The patient has hypotension, and the physical exam reveals jugular venous distention, clear lung fields, and tachycardia. No murmur or S3 is appreciated. What is the next step in management? AAdminister a beta blocker BAdminister morphine sulfate CAdminister sublingual nitroglycerin DBegin intravenous hydration

Begin intravenous hydration What coronary artery supplies the atrioventricular node? Answer: The right coronary artery. Right Ventricular Infarction Hypotension, JVD Clear lungs ST elevation in V4R-V6R ST elevation lead III > lead II Preload dependent Impaired filing of left ventricle Reperfusion, IVF Aggressive volume loading with normal saline boluses is used to restore blood flow to the right ventricle and inotropic support is indicated if hypotension persists -------------------------------------------------------- vs Medications that lower preload, such as nitroglycerin (C) and morphine (B), or drugs that slow the heart rate, such as beta-blockers (A), should be avoided in patients with hypotension and right ventricular infarcts.

A 63-year-old man presents to the emergency department with severe suprapubic pain and incontinence developing over 2 days, during which he has had minimal voiding and has not defecated. Apart from this episode, he has no history of urinary dysfunction or kidney removal. Vital signs are a BP of 140/80 mm Hg, HR of 95 bpm, RR of 15/min, oxygen saturation of 98% on room air, and T of 98.6°F. During history-taking, he is observed to urinate 50 mL urgently into a urinal, but his pain is not relieved. The lower abdomen is taut, and the patient shows guarding on palpation. The urine test is negative for infection, blood, and protein. What is the best next step? AAdmission and referral to a neurologist BBladder ultrasonography CComputed tomography of abdomen and pelvis DOutpatient referral to a urologist ESuprapubic catheterizatio

Bladder ultrasonography A diagnosis of overflow incontinence is suggested by suprapubic pain, combined with small-volume incontinence. To confirm suspicions, the quickest and least invasive measure is bedside bladder ultrasonography, which can determine postvoid residual volume The first step in treating incontinence is to identify the type. The five types of chronic incontinence include urge (associated with overactive bladder or leaking on the way to the bathroom), stress (leaking urine upon abdominal compression, such as coughing or laughing), functional (associated with dementia or immobility), overflow, and mixed. History-taking is vital in making the diagnosis Overflow incontinence is in turn caused by urinary retention, which can be chronic or acute, and has obstructive (benign prostatic hyperplasia [BPH], kidney stones, cancerous mass), iatrogenic(anticholinergics, calcium channel blockers), infectious (prostatitis, cystitis), or neurological (multiple sclerosis, spinal cord injury, cerebral disease) causes. Acute urinary retention such as this case can be painful and lead to hydronephrosis or bladder rupture. In patients with severe prostate enlargement, placement of a Foley catheter to allow voiding may be difficult or impossible. In such cases, placement of a suprapubic catheter through the abdominal wall may be necessary.

A 68-year-old man presents with complaints of a progressive, constant headache for the last three weeks. He was involved in a low speed motor vehicle collision a few days before the headaches began, but did not seek medical attention at the time because of a lack of symptoms immediately following the event. He takes aspirin and lisinopril daily. He denies a prior history of headaches. Noncontrast computed tomography of the head reveals a thin, crescent-shaped collection that is hypodense relative to the adjacent parenchyma. The lesion extends from the right frontal lobe to the ipsilateral falx cerebri, without crossing the midline. Which of the following is the most likely diagnosis? AAcute epidural hematoma BAcute subdural hematoma CChronic subdural hematoma DSubarachnoid hemorrhage

Chronic subdural hematoma ----------------------------------------------------- vs An acute subdural hematoma (B) is generally described as occurring within three days of presentation. The initial CT scan is characterized by a crescent-shaped hyperdense fluid collection between the inner table of the skull and the brain.

Which of the following structures of the ear contains auditory sensory receptors? ACochlea BSemicircular canals CTensor tympani DVestibule

Cochlea Vibratory impulses from the auditory ossicles of the middle ear are transmitted into the fluid-filled cochlea. The cochlea contains tiny hair-like auditory receptors which detect vibratory input and convert them into electrical impulses which are transmitted to the brain via the auditory nerve. What is the membrane called that connects the middle ear to the cochlea? Answer: The oval window. ---------------------------------------------------------------- vs The semicircular canals (B) contain cristae and macule which detect angular and linear acceleration, respectively. The tensor tympani (C) is a small muscle within the ear which arises from the auditory canal and connects to the malleus. The vestibule (D) contains the otolithic organs which process balance and orientation

A 56-year-old man presents with intermittent headaches, dizziness, and pruritus, especially after showering, over the past 2 weeks. On examination, his heart rate is 87 bpm, blood pressure is 152/82 mm Hg, and oxygen saturation is 97% on room air. He has splenomegaly without associated abdominal tenderness. His neurologic exam is normal. Which of the following studies is required to diagnose his most likely condition? ABone marrow biopsy BComplete blood count CCoombs test DPeripheral smear

Complete blood count dx:Polycythemia Vera Patient presents with headache, dizziness, pruritus after showering PE will show hypertension, splenomegaly Labs will show increased RBC mass, overproduction of all cell lines, increased Hgb Most commonly caused by mutation of the Janus kinase 2 gene (JAK2) Treatment is phlebotomy, hydroxyurea, aspirin

A 58-year-old man presents to the emergency department with complaints of a moderate headache and blurry vision over the past few hours. On exam, his blood pressure is 210/110 mm Hg. Which finding are you most likely to observe during the funduscopic exam? ACells and flare BCherry red spot CCotton wool spots DHollenhorst plaques ERoth spots

Cotton wool spots dx:hypertensive emergency Retinal disease can be observed during the funduscopic exam, which will reveal retinal or "flame" hemorrhages, soft exudates (cotton wool spots), or papilledema. What is hypertensive encephalopathy? Answer: A symptom complex including severe hypertension, headache, vomiting, visual disturbance, mental status changes, seizures, and retinopathy with papilledema. ----------------------------------------------------------------- vs

A 76-year-old man presents complaining of generalized weakness for the past two weeks. His wife states that he has almost no appetite and he spends all day lying in bed. Physical exam reveals a mildly emaciated male who responds slowly to questions. He has hyperpigmented palmar creases. Laboratory workup reveals a serum sodium level of 130 mmol/L and a serum potassium level of 5.8 mmol/L. Which of the following laboratory values is consistent with this patient's presentation? ADecreased antidiuretic hormone level BDecreased cortisol level CDecreased thyroid-stimulating hormone level DDecreased thyroxine level

Decreased cortisol level dx: Primary adrenal insufficiency, also known as Addison disease Most common signs and symptoms of Addison disease include anorexia, generalized weakness, skin hyperpigmentation, and hypotension. Hyponatremia and hyperkalemia result from a decrease in aldosterone production, which decreases the number of sodium-potassium antiporters present in the renal tubules. This leads to increased excretion of sodium and retention of potassium. Further workup would reveal a decreased cortisol level. Treatment consists of glucocorticoid and mineralocorticoid replacemen Primary Adrenal Insufficiency (Addison Disease) Sx: abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE: hyperpigmentation of skin and mucus membranes and hypotension Labs: hyponatremia and hyperkalemia Most commonly caused by autoimmune destruction of the adrenal cortex Tx: hydrocortisone or other glucocorticoidMost patients also require mineralocorticoid (fludrocortisone) ----------------------------------------------------------------- vs A decreased antidiuretic hormone (ADH) level (A) is seen in central diabetes insipidus. It is characterized by polydipsia, polyuria, and an increased serum sodium level. A decreased thyroid-stimulating hormone (TSH) level (C)is seen in hyperthyroidism, and is the result of negative feedback from overproduction of thyroxine, or thyroid hormone. Symptoms of hyperthyroidism include heat intolerance, weight loss, anxiety, tachycardia, and hair loss. Electrolyte abnormalities are not consistent with hyperthyroidism. A decreased thyroxine (T4) level (D) is characteristic of hypothyroidism. Symptoms of hypothyroidism include cold intolerance, weight gain, generalized weakness, and edema. Hypothyroidism does not cause electrolyte abnormalities.

Which of the following is appropriate education for a man with newly diagnosed hypertension? AAlcohol consumption should be limited to 2 ounces of ethanol or less per day BBrisk walking 20 minutes per day, three days per week will decrease blood pressure CDietary intake of potassium (90 meq - 120 meq) may lower both systolic and diastolic blood pressure DRecommended sodium intake is 2800 mg or less per day

Dietary intake of potassium (90 meq - 120 meq) may lower both systolic and diastolic blood pressure ACC/AHA 2017 Hypertension Normal: < 120/80 mm Hg Elevated BP: systolic 120-129 mm Hg, diastolic < 80 mm Hg Stage 1 HTN: systolic 130-139 mm Hg, diastolic 80-89 mm Hg Stage 2 HTN: systolic ≥ 140 mm Hg OR diastolic ≥ 90 mm Hg First-line treatment is ALWAYS lifestyle modifications Medications recommended for systolic ≥ 130 mm Hg or diastolic ≥ 80 mm Hg AND clinical CVD or 10-year CVD risk ≥ 10% First-line Rx: thiazide First-line Rx for Black patients: CCB or thiazide First-line Rx for CKD patients with albuminuria: ACE inhibitor or ARB ------------------------------------------------------------- vs Alcohol consumption (A) has an inverse effect upon blood pressure and should be limited to one ounce of ethanol (2 drinks) or less per day for men and half an ounce of ethanol (1 drink) or less daily for women (one drink is approximately 0.6 ounces). Patients with hypertension should also be encouraged to reduce stress where possible and to consume more fruits, vegetables, and low-fat dairy products. Tobacco cessation is essential, as well. Brisk walking 20 minutes per day, three days per week (B) is not long enough nor frequent enough to produce consistent blood pressure lowering results, as it is considered a moderate intensity aerobic exercise. Patients may engage in high-intensity exercise 20 minutes per day, three days per week and see blood pressure reductions. Total daily intake of 2800 mg of sodium (D) is not likely to produce a reduction in blood pressure and should be more stringent (under 2500 mg).

A 20-year-old man presents to the emergency department in police custody after his roommate called the police because the patient came home extremely agitated with altered mentation. His roommate reports he was at a rave party earlier tonight. Vital signs include HR of 125 bpm, BP of 180/120 mm Hg, RR of 22/minute, oxygen saturation of 98% on room air, and T of 100.2°F. Physical examination reveals an agitated and hyperactive patient who is oriented to person but not place, time, or situation. He has no focal neurologic deficits. His skin is diaphoretic, and his pupils are dilated. He has no nystagmus and exhibits no signs of delusions or hallucinations. Which of the following substances would most likely cause this presentation? AAnticholinergics BBenzodiazepines CEcstasy DKetamine EPhencyclidine

Ecstasy dx: MDMA (3,4-methylenedioxymethamphetamine) is a popular illicit drug in adolescents and young adults. Ecstasy is a common street name for MDMA. he desired effects of MDMA include increased alertness, reduced fatigue, euphoria, increased sexual arousal, disinhibition, and feelings of increased physical and mental powers. These effects begin about 1 hour after oral ingestion. However, MDMA can also result in minor adverse effects or serious adverse effects. Minor adverse reactions include agitation, anxiety, disorientation, nausea, bruxism (grinding teeth), diaphoresis, blurry vision, tachycardia, and hypertension, all of which usually resolve spontaneously within a few hours. The serious adverse effects are less common but include severe hypertension, severe tachycardia, hyperthermia, delirium, and psychomotor agitation. Life-threatening complications can occur, including intracranial hemorrhage, myocardial infarction, aortic dissection, dysrhythmias, disseminated intravascular coagulation, rhabdomyolysis, seizure, and serotonin syndrome. The routine laboratory evaluation of the poisoned patient should include at least a point-of-care glucose, acetaminophen levels, salicylate levels, electrocardiogram, and pregnancy test if applicable. Patients with significant toxicity suspected to be due to MDMA should have a complete metabolic panel, coagulation studies, and creatine kinase. Patients who have severe hypertension or psychomotor agitation from MDMA should be treated with benzodiazepines. Refractory hypertension can be treated with nitroprusside or phentolamine. Beta-blockers should be avoided because they may lead to unopposed alpha-adrenergic stimulation, which can cause a paradoxical rise in blood pressure. Gastrointestinal decontamination with activated charcoal is recommended for patients with MDMA intoxication who present within 1 hour of ingestion and can protect their airway. Butyrophenones, such as haloperidol and droperidol, should not be used to sedate patients with MDMA intoxication because they can interfere with heat dissipation, prolong the QTc interval, and reduce the seizure threshold. Patients with seizures, hyperthermia, or serotonin syndrome from MDMA intoxication should be

An 11-year-old girl is seen in the clinic for a well-child visit and is found to have a BMI in the 96th percentile for age and sex. What additional studies should be ordered, according to the American Academy of Pediatrics? AAbdominal ultrasound to look for fatty liver disease BFasting lipid panel, fasting glucose, alanine aminotransferase CHemoglobin A1C and complete metabolic panel DNo additional studies are recommended until age 12 years

Fasting lipid panel, fasting glucose, alanine aminotransferase dx: pediatric obesity Evaluate weight for height/length in children < 2 years oldOverweight: ≥ 95th% Evaluate BMI percentile in children ≥ 2 years oldOverweight: BMI 85-94th%Obese: BMI ≥ 95th% Structured weight management (≥ 6 years old):Offer healthy eating guidelinesEncourage exercise ≥ 1 hour/dayMonitor sleeping patternsLimit screen time Interventions (≥ 6 years old):Low-intensity guided self-help interventionConsider pharmacotherapy (FDA-approved drugs for adolescents)Consider bariatric surgery ------------------------------------------------------------- vs An abdominal ultrasound (A) is indicated in children with elevated liver function tests, which would be concerning for NAFLD. According to the new guidelines, hemoglobin A1C alone can be measured instead of a fasting glucose to rule out abnormal glucose metabolism but a full comprehensive metabolic panel (C) is not necessary. As detailed above, the AAP recommends basic lab screening for children with a BMI above the 95th percentile starting at 10 years old (D).

A 43-year-old man with a history of alcohol use disorder presents with generalized weakness. Physical examination reveals pale conjunctiva. The patient's hematocrit is 25%, and his mean corpuscular volume is 110 fL. Which of the following treatments is most likely indicated? AFolic acid supplementation BLead chelation therapy CSplenectomy DThiamine supplementation

Folic acid supplementation ----------------------------------------------------------- vs Thiamine (D) (vitamin B1) is often deficient in those with chronic alcohol use disorder, as well, but does not cause anemia. Thiamine is required in glucose metabolism and can result in beriberi or Wernicke-Korsakoff syndrome.

Which of the following laboratory abnormalities would most likely be present in patients receiving mannitol for increased intracranial pressure? AHyperglycemia BHypernatremia CIncreased osmolar gap DNonanion gap acidosis

Increased osmolar gap Osmolar gap is calculated by determining an estimated serum osmolality and subtracting that from the patient's measured osmolality. An osmolar gap of greater than 10 indicates that other osmotically active molecules are present in the serum (e.g., ethanol, methanol, ethylene glycol). Complications of the use of mannitol include volume depletion, hyponatremia, and acute kidney injury. ------------------------------------------------------------------ vs Mannitol is a sugar alcohol but does not cross-react with glucose assays, so mannitol does not cause hyperglycemia (A). Hypernatremia (B) is a complication of the use of hypertonic saline (i.e., any solution greater than 0.9% sodium chloride) which is also used in the management of increased intracranial pressure. Hypertonic saline lowers the intracranial pressure through the same hyperosmotic mechanism as mannitol. Nonanion gap acidosis (D) is a complication of the carbonic anhydrase inhibitor acetazolamide. Acetazolamide is used in patients with hydrocephalus to decrease cerebrospinal fluid production. Nonanion gap acidosis is caused by acetazolamide increasing renal excretion of bicarbonate. The anion gap does not increase due to an increase in chloride levels. The anion gap can be measured by subtracting the sum of the patient's serum bicarbonate and chloride from their serum sodium. Values less than 16 are considered normal.

A 7-year-old boy accompanied by his mother presents to your office, complaining of a rash and bilateral knee and ankle pain. He also notes some mild crampy abdominal pain associated with nausea but denies vomiting, diarrhea, and fever. On exam you note the rash seen above. He has swelling around his patellar joints bilaterally, and the area is very painful. There are no palpable abdominal masses. His lungs are clear and the remainder of the physical examination is unremarkable. What complication is this patient at greatest risk for? AIntussusception BJoint damage CPneumonia DThrombocytopenia

Intussusception Palpable purpura Lower extremities and buttocks Normal platelet count The rash will not blanch with pressure. Gastrointestinal involvement is typically seen during the acute phase of illness and may precede the rash. It is thought to be due to small vessel involvement and usually presents as gastrointestinal colic but may lead to ischemia (heme positive stools) and intussusception. When intussusception occurs, it is usually ileoileal, unlike the more common ileocolic, and is more difficult to diagnose and reduce by barium or air contrast enema. 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)

Which of the following is the most common cause of sudden cardiac arrest and sudden cardiac death? AAnomalous coronary artery BCardiomyopathy CIschemic heart disease DLeft ventricular hypertrophy

Ischemic heart disease

A 65-year-old man presents to the ED after a fall. He says he has had trouble walking for a while. His examination is significant for normal cranial nerve function, normal strength, a resting tremor, and difficulty stopping when he is walking. What is the cellular pathology associated with this condition? ADemyelination BLewy bodies CLoss of anterior horn cells DNeurofibrillary tangles

Lewy bodies The symptoms can be remembered with the mnemonic TRAP:resting Tremor, cogwheel Rigidity, Akinesia, and impairment of Posture or equilibrium Parkinson Disease Patient presents with rigidity, bradykinesia, postural instability, micrographia PE will show a resting pill-rolling tremor, mask-like facies, cog-wheeling of extremities, shuffling gait Most commonly caused by dopamine depletion in basal ganglia Treatment is levodopa-carbidopa -------------------------------------------------------------- vs Demyelination (A) is associated with multiple sclerosis and Guillain-Barré syndrome. Loss of anterior horn cells (C)is associated with amyotrophic lateral sclerosis, a progressive degenerative upper and lower motor neuron disease. Neurofibrillary tangles (D) and amyloid plaques are thought to be responsible for Alzheimer disease, which is a progressive cognitive disorder.

A 65-year-old man presents to his primary care clinic for a 3-month follow-up. He was diagnosed with stage 2 chronic kidney disease 3 months ago. He reports no headache, fatigue, or any other symptoms. He has a medical history of diabetes mellitus and hypertension and takes metformin 1,000 mg twice daily, exenatide 10 mcg subcutaneously twice daily, and hydrochlorothiazide 25 mg daily. He reports no smoking, drinks two beers per week, and does not use drugs. Today, his vital signs include a T of 97.8°F, BP of 122/78 mm Hg, RR of 12/min, HR of 87 bpm, oxygen saturation of 99% on room air, and BMI of 38 kg/m2. His lungs are clear to auscultation bilaterally, there is no swelling in his lower extremities, and his heart rate is regular without murmurs, gallops, or rubs. His laboratory results reveal a fingerstick glucose of 122 mg/dL, his urine is without any proteinuria or glucosuria, and his GFR today is 55 mL/min/1.73 m2. He asks if he should follow any specific diet, given his new diagnosis. Which of the following is a recommended dietary intake for patients with this new diagnosis? AIncrease dietary fat to > 60% of total energy intake BIncrease protein intake to > 2.5 g/kg/day CLimit p

Limit potassium intake to 40 and 70 mEq/day Diabetes and chronic hypertension are two major risk factors, Diuretics are often prescribed to help control high blood pressure, and angiotensin-converting enzyme (ACE) inhibitors can be renal protective in patients with proteinuria. Patients with CKD are at increased risk of disorders of fluid and electrolyte balance, such as hyperkalemia. A potassium intake between 40 and 70 mEq/day and a low-salt diet (< 2 g/day) are recommended. ------------------------------------------------------------------ vs Patients with CKD are at high risk for cardiac complications, such as coronary artery disease. When treating patients with CKD, it is important to assess their risk of complications, including heart disease. Hyperlipidemia and a high-fat diet are linked to coronary artery disease, and patients should keep their percent of dietary intake of fats around 30-40% of total intake. A diet of over 60% fats (A) puts patients at high risk for hyperlipidemia and other complications. A high-protein diet, such as protein intake > 2.5 g/kg/day (B), can contribute to an increase in intraglomerular pressure and worsen CKD. Reduced intake of protein in patients with CKD may slow the progression of the disease in otherwise healthy individuals. A protein intake of 0.8-1.0 g/kg/day is recommended for patients with CKD, and those with nephrotic syndrome should restrict their protein intake even more. Disturbances in phosphorus and calcium metabolism are common in patients with CKD, resulting in hyperphosphatemia, hypokalemia, and eventually elevated parathyroid hormone. There is also evidence that links high phosphorus levels to an increased risk of cardiovascular mortality in patients with CKD. Dietary phosphorus should be restricted to around 600-800 mg/day (D). Phosphorus-rich foods, such as eggs, nuts, meats, and processed food, need to be limited. Hypertension is common in patients with CKD, and a low-salt diet (< 2 mg/day) is recommended to help control blood pressure and decrease the risk of heart failure. A sodium intake between 2,500 and 5,000 mg/day (E) is not considered a low-salt diet and would not be appropriate for this patient. Fluid restriction may also be ne

A 38-year-old woman presents with fatigue, anorexia, muscle aches and hyperpigmentation. Laboratory tests are significant for a sodium level of 128 and a potassium level of 5.6. Which of the following is the most appropriate to obtain next in the work up of this patient's condition? AACTH (Cosyntropin) stimulation test BAdrenocorticotropic hormone (ACTH) level CCT scan DMorning serum cortisol level

Morning serum cortisol level Primary Adrenal Insufficiency (Addison Disease) Sx: abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE: hyperpigmentation of skin and mucus membranes and hypotension Labs: hyponatremia and hyperkalemia Most commonly caused by autoimmune destruction of the adrenal cortex Tx: hydrocortisone or other glucocorticoidMost patients also require mineralocorticoid (fludrocortisone) --------------------------------------------------------- vs If low serum cortisol levels are present then the patient should undergo an ACTH (Cosyntropin) stimulation test (A) to confirm the diagnosis. ACTH levels (B) are measured in order to differentiate between primary and secondary adrenal insufficiency. ACTH levels are increased in primary adrenal insufficiency and decreased in secondary adrenal insufficiency. Radiographic imaging is also helpful in determining the cause of Addison disease, but it is relatively nonspecific in patients with autoimmune destruction. It is important to make a biochemical diagnosis of adrenal insufficiency before radiographic imaging.

A 32-year-old previously healthy man presents to the ED with a 4-hour history of palpitations. He denies chest pain, shortness of breath, or history of similar palpitations. He does admit to heavy alcohol use in the past week, drinking 1 pint of vodka and a 24-pack of beer each day. In the ED, his vital signs are BP 135/75, HR 115, RR 14, and oxygen saturation 98% on room air. An irregularly irregular rhythm is heard on auscultation and an ECG shows irregularly irregular QRS complexes without P waves. What is the next step in management? AChemical cardioversion BObservation CRate control DSynchronized cardioversion

Observation Patients generally present with palpitations. The rhythm tends to spontaneously convert back to a sinus rhythm within 24-48 hours; thus, the best step in management at this time is to observe the patient with cardiac monitoring. Atrial Fibrillation Rate will be irregular Rhythm will be irregular Notable feature: No defined P waves Labs: CBC, BMP, TSH & free T4 (especially for first Afib) Treatment: Unstable: cardioversion Stable: rate control is mainstay (diltiazem, metoprolol) > 48 hours: anticoagulate for 21 days prior to cardioversion Determine the need for anticoagulation by using CHA2DS2-VASc score Most common sustained dysrhythmia in adults ---------------------------------------------------------------- vs If the patient stays tachycardic beyond 24-48 hours, rate control (C) can be employed, using medications such as calcium channel blockers or beta-blockers. Chemical cardioversion (A) and synchronized cardioversion (D) are both unnecessary now, as the patient is likely to revert to a sinus rhythm on his own. However, if symptoms persist, cardioversion may be used to reduce the risk of thrombus formation in addition to the need for either anticoagulation or a transesophageal echocardiogram. In addition, if the patient becomes unstable at any time, synchronized cardioversion would be used.

A 3-year-old presents to your emergency department with fever, new onset torticollis, and difficulty swallowing. Concerned about a retropharyngeal abscess, you obtain X-rays of the neck to evaluate the soft tissues anterior to the spine. Which of the following is the appropriate method to tell the X-ray technologist to obtain the films? AOn expiration with neck extension BOn expiration with neck flexion COn inspiration with neck extension DOn inspiration with neck flexion

On inspiration with neck extension

A 25-year-old G1P0 woman at 34 weeks gestation presents to the clinic for a regular prenatal visit. She has noticed swelling in her feet but denies any associated pain as well as any other new symptoms. Temperature is 98.0°F, blood pressure is 155/92 mm Hg, and body mass index is 38.0 kg/m². Serum creatinine is 1.8 mg/dL. Which of the following is the most likely diagnosis? ADeep vein thrombosis BEclampsia CLymphedema DPreeclampsia

Preeclampsia Preeclampsia Pregnancy > 20 weeks gestation or postpartum Visual disturbances, severe headaches, or asymptomatic Evaluation will show new-onset hypertension (≥ 140/90 mm Hg) with either proteinuria (≥ 300 mg/24 hr or urine protein: creatinine ratio ≥ 0.3) OR significant end-organ dysfunction Treatment: delivery at 37 weeks (without severe features) and 34 weeks (with severe features) AND prevention of seizures with magnesium sulfate and prevention of permanent maternal organ damage New-onset hypertension < 20 weeks gestation: suspect molar pregnancy

Which of the following is true regarding primary hyperthyroidism? ALithium is a common cause BPropranolol is the drug of choice for adrenergic symptoms CTSH is elevated DWeight gain is common

Propranolol is the drug of choice for adrenergic symptoms 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 Lithium (A) is a cause of hypothyroidism. In primary hyperthyroidism, TSH is depressed (C). TSH may be elevated in cases of TSH-secreting pituitary adenomas, although this is a rare cause of hyperthyroidism. Weight gain (D) is common in hypothyroidism.

A 68-year-old man presents to the clinic with concerns for a skin lesion that he noticed 2 months ago. Physical exam reveals a round, well demarcated, dark brown, elevated lesion with a waxy surface on his back. An excisional biopsy is performed and shows keratin-filled pseudocysts. What is the most likely diagnosis? AAcrochordon BActinic keratosis CDermatofibroma DSeborrheic keratosis ESquamous cell carcinoma

Seborrheic Keratosis Risk factors: advancing age PE: velvety, waxy lesions with stuck-on appearance on the face, shoulders, chest, and back Caused by a benign, epidermal neoplasm Treatment is not necessary Leser-Trelat sign: rapid appearance of multiple SK lesions associated with GI malignancy

A 17-year-old girl presents to your clinic with a chief complaint of sadness, loss of appetite, and the inability to sleep. She is having a hard time focusing at work and she is tired all of the time. She tells you that for the past month she has been hearing voices telling her to harm herself. She is interested in treatment. What is the most appropriate first-line therapy for this condition? ALithium BPsychotherapy CSertraline DSertraline and olanzapine

Sertraline and olanzapine Depression Symptoms SIG E CAPS Sleep: insomnia or hypersomnia Interest: anhedonia Guilt: worthlessness Energy: fatigue, lack of concentration Cognition or concentration: reduced cognition, difficulty concentrating Appetite (weight loss): usually declined, occasionally increased Psychomotor retardation or agitation: restlessness or slowness Suicidality: thoughts of death --------------------------------------------------------------- vs Sertraline (C) is an antidepressant that if used alone in cases of major depressive disorder with psychotic features would be an under-treatment. Lithium (A), a mood stabilizer, can be added to the medication regimen if after four to eight weeks, there is no improvement of symptoms while on an antidepressant plus antipsychotic. While psychotherapy (B) should be a part of the treatment course for major depressive disorder with psychotic features, it is not first-line therapy. Psychotherapy can be initiated after starting an antidepressant plus antipsychotic medication, especially if the patient is resistant to these medications.

An 8-year-old boy presents to the emergency department via EMS after having a seizure. His parents are both at the bedside and report that the patient has had diarrhea with dark red mucus for 2 days. The diarrhea started watery and then progressed to dark red with mucus, and it also hurts when he has bowel movements. His vital signs are a HR of 90 bpm, RR of 19/min, oxygen saturation on room air of 99%, BP of 98/60 mm Hg, and T of 102.8°F. On physical exam, the patient has diffuse abdominal tenderness without guarding or rebound. Which of the following is the most common cause of this patient's suspected diagnosis? AIntussusception BRotavirus CSalmonella DShigella sonnei EVibrio cholerae

Shigella sonnei --------------------------------------------------------------- vs Intussusception (A) occurs when a segment of the intestine telescopes into an adjoining intestinal lumen. Patients present with vomiting, colicky abdominal pain, and passage of blood per rectum, which is often described as a jelly-like stool. Fever is not a common symptom of intussusception, which helps differentiate it from shigella. Salmonella (B) is an infection caused by eating undercooked poultry. Incubation period is between 6-48 hours. It presents about 5-14 days after infection. Symptoms include abdominal pain and bloody mucoid diarrhea. Symptoms present gradually which helps differentiate salmonella from shigella where the symptoms are sudden in onset.

A 17-year-old boy presents to his pediatrician complaining of persistent drainage from his ear. He has a history of chronic ear infections and, one month prior, was started on amoxicillin secondary to symptoms of hearing loss and drainage along with physical exam findings of an inflamed, bulging tympanic membrane. When his symptoms failed to resolve, his medication was changed to amoxicillin-clavulanate; however, the patient is still experiencing symptoms. Given his history and the persistence of symptoms despite antibiotic therapy, what diagnosis should be considered? ABenign necrotizing otitis externa BCholesteatoma CChronic cerumen impaction DForeign body EMastoiditis

The development of an acquired cholesteatoma should be considered in a patient with a history of frequent ear infections and persistent ear drainage despite appropriate antibiotic therapy

A 10-year-old boy presents to your office with elbow pain. The pain is located along the medial aspect of the elbow and is exacerbated while pitching during his Little League games. Your examination reveals mild swelling along the medial aspect of the right elbow. Radiographs show mild hypertrophy of the medial epicondyle. What is the initial treatment of choice for this condition? AComplete rest from throwing for four to six weeks BEccentric exercise regimen for four weeks COrthopedic referral DPhysical therapy for four weeks

The treatment of choice involves cessation of all throwing activities for four to six weeks, then a gradual and progressive throwing program after the initial period of inactivity. Most players are able to return to throwing full-time after 12 weeks. ----------------------------------------------------------------- vs Strengthening, stretching, and conditioning programs provided by physical therapy (D) should be encouraged, but this is not the initial therapy or the treatment of choice. Orthopedic consultation (C) is indicated if loose bodies, avulsion fractures, or osteochondritis dissecans are noted on X-ray. Referral would also be indicated for failure of conservative treatment. An eccentric exercise regimen (B) would not be part of the acute treatment regimen. It may be used long term in the overall reconditioning of the muscle and tendon

Which of the following represents appropriate management of a thrombosed external hemorrhoid in the acute 48-hour setting? AExcision BReduction CSitz baths DSurgery referral

Thrombosed external hemorrhoids presenting within 48 - 72 hours of symptom onset should be excised Hemorrhoids Sx: discomfort and itching in the anal region, if thrombosed may also report pain PE: Internal: proximal to the dentate line External: distal to the dentate line Tx: lifestyle modifications, sitz baths, analgesic creams, rubber band ligation, sclerotherapy, surgical excision ----------------------------------------------------------- vs Reduction (B) should be performed on nonthrombosed external hemorrhoids if possible. Sitz baths (C) are helpful for nonthrombosed external hemorrhoids. Surgical referral (D) should not replace excision.

A 16-year-old girl with a history of asthma and allergic rhinitis presents to the clinic for a pruritic rash that has been ongoing for the past 3 months. She has had no new exposures or changes to her environment. On physical exam, there is a pruritic dry scaly erythematous rash that is predominately located in the flexural surfaces. She experiences dry flakey skin on a weekly basis. What is the initial treatment of choice? AClobetasol ointment BCrisaborole ointment CHydrocortisone lotion DTacrolimus ointment ETopical emollients

Topical emollients dx:Atopic dermatitis, better known as eczema, is an intensely pruritic skin condition that is characterized by dry skin that develops into a red rash and is known as the "itch that rashes." It is commonly found on the flexural surfaces, and chronic scratching usually results in thickened skin with accentuation of skin lines, known as lichenification.

A 63-year-old man presents to your office complaining of episodic diarrhea and wheezing. His wife also mentions that his skin will occasionally look flushed. You suspect carcinoid syndrome. What initial diagnostic study is most appropriate to confirm this condition? AAbdominal computed tomography scan BAbdominal magnetic resonance imaging CErythrocyte sedimentation rate DTwenty four hour urine excretion of 5-hydroxyindoleacetic acid

Twenty four hour urine excretion of 5-hydroxyindoleacetic acid dx; Carcinoid Syndrome Patient presents with skin flushing, wheezing, and diarrhea Diagnosis is made by 24-hour excretion of 5-hydroxyindoleacetic acid 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)

Which of the following is the most appropriate treatment for stage IV uterine prolapse in a 50-year-old woman with no medical problems and no previous surgical history? AAbdominal hysterectomy BAnterior colporrhaphy CPosterior colporrhaphy DVaginal hysterectomy

Vaginal hysterectomy dx: uterine prolapse Uterine Prolapse Risk factors: multiparity, age, decreasing estrogen levels, trauma Rx: Kegel exercises, pessary, surgery --------------------------------------------------------------- vs Vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy (A). Operative management of an enterocele with anterior colporrhaphy (B), or a rectocele with posterior colporrhaphy (C) is often performed at the time of the operation for uterine prolapse after the patient has undergone a hysterectomy, but is not the surgical treatment for uterine prolapse.

Which of the following medical conditions excludes a child from participation in a sports event this weekend? ACurrent fever BHistory of HIV infection CHistory of persistent asthma DKnown seizure disorder

fever should be excluded from sports participation.

A 5-month-old girl presents to the ED with her parents who are concerned about brief episodes of whole body muscle contraction. On physical exam, the child has poor head control and absent palmar grasp. Her electroencephalogram shows hypsarrhythmia. Which of the following is the most likely diagnosis? ACerebral palsy BInfantile spasms CKernicterus DTay-Sachs disease

infantile spasms or West syndrome. Infantile spasms are defined by the triad of the following findings: clusters of myoclonic seizures on awakening,hypsarrhythmia pattern on electroencephalogram, and developmental delay. Signs and symptoms of infantile spasms usually begin at 4-8 months of age. Hypsarrhythmia is also nearly pathognomonic for the diagnosis of infantile spasms. A lumbar puncture should also be considered and performed to rule out meningitis or encephalitis. Management of infantile spasms is primarily with adrenocorticotropic hormone (ACTH), prednisone, and antiepileptic medications. -------------------------------------------------------------------- vs Cerebral palsy (A) may present with seizures and developmental delay. However, the child will also typically have other findings including muscular spasticity. Hypsarrhythmia is also nearly pathognomonic for the diagnosis of infantile spasms. Kernicterus (C) will usually present with jaundice and hypotonia. Tay-Sachs disease (D) presents with muscle atrophy beginning at age 6 months and an abnormal funduscopic exam with blindness. What population has the highest risk for Tay-Sachs disease? Answer: The Ashkenazi Jewish population.

A transudative pleural effusion is identified after thoracentesis. Which of the following clinical scenarios is most consistent with this type of effusion? A27-year-old female with a lupus flare B47-year-old female with alcohol use disorder with an elevated lipase C65-year-old male with an ejection fraction of 15% and pulmonary edema D72-year-old male recently diagnosed with lung cancer

65-year-old male with an ejection fraction of 15% and pulmonary edema

A 72-year-old-man presents to your clinic with substernal chest pain, shortness of breath and diaphoresis for the last 30 minutes. He states that this started suddenly when he was taking out the trash. He finds minimal relief with rest and worsening pain with even minimal exertion. His past medical history is significant for hypertension, dyslipidemia, and a 40-pack-year smoking history. He denies any history of cardiac disease, recent travel or surgery. Initial chest X-ray shows hyperexpansion of the lungs but is otherwise within normal limits. Electrocardiogram shows normal sinus rhythm without any acute changes. Laboratory analysis shows a troponin 0.03 ng/mL, D-dimer 410 ng/mL and a normal white blood cell count. He feels this is most likely due to heartburn. Given this information, what is the most likely diagnosis? AAcute coronary syndrome BBoerhaave syndrome CGastroesophageal reflux disease DPulmonary embolism

Acute coronary syndrome ----------------------------------------------------------- vs Pulmonary embolism (D) classically presents with acute onset pleuritic chest pain and shortness of breath and is associated with recent surgery or immobilization. While it is a common diagnosis in patients with chest pain, a negative D-dimer and lack of risk factors are highly suggestive against pulmonary embolism in this case. Gastroesophageal reflux disease (C) generally presents with a postprandial retrosternal burning sensation. It is not typically associated with shortness of breath and should be a diagnosis of exclusion in patients with acute chest pain.

A 68-year-old man presents to the clinic reporting depressed mood every day of the week, for the majority of each day, for more than 3 months. He has a loss of interest in activities that used to give him pleasure and has feelings of worthlessness but reports no suicidal thoughts or intentions. His medical history includes Parkinson disease and urinary incontinence, for which he receives levodopa-carbidopa daily and mirabegron daily. He reports fair control of muscle rigidity and tremor and urinary symptoms on his current drug regimen. Which of the following is the best clinical intervention for this patient? AAdd amantadine BAdd quetiapine CAdd sertraline DDiscontinue levodopa-carbidopa ESwitch from levodopa-carbidopa to selegiline

Add sertraline First-line therapy for patients with Parkinson disease and concomitant depression is with selective serotonin reuptake inhibitors, such as sertraline. Other classes of antidepressants that may also be beneficial include tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors. ----------------------------------------------------------------- vs To add amantadine (A) would not benefit this patient because amantadine can have severe side effects and should be limited for use in patients younger than 65 years with dyskinesias that are associated with levodopa-carbidopa treatment. The side effects of amantadine include psychosis, dizziness, livedo reticularis, confusion, depression, suicidal ideation, orthostasis, and peripheral edema. To add quetiapine (B) would be appropriate if the patient in the above vignette was demonstrating psychosis, but he is not. He does not report paranoia or hallucinations. When quetiapine is added to the regimen for a patient with Parkinson disease and psychosis, the dose must be low at the start and increase very gradually. To discontinue levodopa-carbidopa (D) would not be advised because the patient is responding well to the treatment and has improved muscle control. To switch from levodopa-carbidopa to selegiline (E) would be a step-down in treatment efficacy for Parkinson disease. While selegiline is a monoamine-oxidase inhibitor and may improve this patient's depression, his Parkinson-related motor symptoms would likely worsen. An alternative to adding sertraline would be to add selegiline to the levodopa-carbidopa. Selegiline and sertraline should not be used in combination due to risk of serotonin syndrome.

A 35-year-old woman with a prior history of suicidal ideations is brought to the ED approximately 10 hours after ingesting an unknown quantity of acetaminophen and ibuprofen. She is reporting nausea and abdominal pain. Her blood pressure is 150/80 mm Hg, heart rate is 90 bpm, respiratory rate is 18/min, and temperature is 36.8°C. Physical examination reveals diffuse abdominal pain. What is the most appropriate next step in management? AAdminister glutathione BAdminister N-acetylcysteine CArrange for hemodialysis DDetermine acetaminophen level

Administer N-acetylcysteine Risk of severe hepatotoxicity increases if the patient is not treated with N-acetylcysteine (NAC)within the first 8 hours after ingestion. Severe hepatotoxicity may develop and lead to multiorgan failure and death if the poisoning is not treated appropriately. If patient presents within the first 4 hours after ingestion, acetaminophen and transaminases must be obtained at 4 hours after the ingestion and Rumack-Matthew nomogram can then be used to determine if treatment is needed. If the patient presents after 8 hours from the time of the ingestion, a loading dose of NAC at the initial dose of 140 mg/kg should be administered without delay. Acetaminophen level as well as transaminases must be determined, but therapy should not be delayed while awaiting the results of the laboratory studies. NAC is available in IV and PO formulations, with compatible bioavailability. Intravenous NAC must be administered in cases of fulminant liver failure and pregnancy. All intentional ingestions require a psychiatric consultation once the patient is medically stable. Acetaminophen Toxicity Sx: abdominal pain, nausea, vomiting, and jaundice PE: RUQ tenderness Labs: elevated AST and ALT Treatment is N-acetylcysteine (restores glutathione) Above Rumack-Matthew nomogram line: treat Below Rumack-Matthew nomogram line: no treatment necessary Determine if overdose was accidental or intentional --------------------------------------------------------- vs Glutathione (A) binds to NAPQI, toxic metabolite of acetaminophen, thus allowing its excretion. However, there is no available formulation of glutathione. Acetaminophen cannot be removed sufficiently by hemodialysis (C). However, renal failure develops in 25% of cases of severe hepatotoxicity and dialysis may be necessary in those cases. Acetaminophen level (D) should be determined, but NAC must be administered as soon as possible and obtaining laboratory should not delay the process.

What test is helpful in ruling out the diagnosis of systemic lupus erythematosus? AAnti-Smith antibody BAntinuclear antibody CC-reactive protein DErythrocyte sedimentation rate

Antinuclear antibody it is present in nearly all patients with systemic lupus erythematosus (SLE). --------------------------------------------------------------- vs Anti-Smith antibody (B) is a more specific antibody for SLE, but it is not present in all patients with the disease.

HIV

Clinical course: exposure → acute HIV syndrome → seroconversion → asymptomatic period → symptomatic period Dx: 4th generation HIV-1/2 combination antigen and antibody immunoassay followed by HIV-1/HIV-2 differentiation immunoassay Dx tests become positive during seroconversion (3-12 weeks after exposure) Chronic watery diarrhea: Cryptosporidium White cottage-cheese lesions: Candida Irremovable white lesions on lateral tongue: hairy leukoplakia (EBV) Pneumonia, CD4 < 200/mm3: PCP TB: CD4 < 200/mm3, may have negative CXR or PPD Ring-enhancing intracranial lesions + focal neurologic deficits: Toxoplasma gondii Ring-enhancing intracranial lesions + AMS: primary CNS lymphoma Meningitis, CD4 < 100/mm3: Cryptococcus Focal neurologic deficits, nonenhancing white matter lesions, CD4 < 200/mm3: PML (JC virus) Retinitis, cotton-wool spots: CMV Dark purple skin or mouth nodules: Kaposi sarcoma Cutaneous: HSV, zoster reactivation

A 3-year-old boy was running full speed and tripped over his toy, falling on his right leg. An X-ray shows an isolated nondisplaced distal spiral fracture of the tibia. Which of the following is the next best step in the treatment? AConsult orthopedics for casting and further treatment BObservation as this fracture heals spontaneously in toddlers CObtain a skeletal survey DObtain a workup for bone cancer

Consult orthopedics for casting and further treatment dx:n isolated spiral fracture of the tibia after a rotational fall is known as a "toddler's fracture" or childhood accidental spiral tibial (CAST) fracture. The fracture is found in the distal two thirds of the tibia in 95% of cases, is undisplaced, and has a spiral pattern. There should not be an associated fibular fracture. The child often will walk with a limp and is in acute pain. The initial radiographic images may be inconspicuous (a faint oblique line) and often even completely normal. Treatment consists of a short leg orthopedic cast or CAM walking boot for several weeks, therefore consulting orthopedics for casting is the appropriate next step in treatment. --------------------------------------------------------------- vs] This child should not be observed (B) because this fracture does not heal spontaneously and it in fact needs intervention. A skeletal survey (C) should be obtained in all cases of suspected child abuse to assess for fractures in multiple stages of healing. Pediatric bone cancer (D) usually presents as a swelling or localized pain in a bony area and if metastasis occurs then systemic symptoms may be present.

Of the following, which is the most common infectious etiology of diarrhea in patients with AIDS? ACandida BCryptosporidium CCytomegalovirus DMycobacterium avium complex

Cryptosporidium is a common cause of diarrhea when the CD4 count falls below 100 cells/mm3. ----------------------------------------------------------------- vs Candida (A) is not considered a significant risk factor. Cytomegalovirus (C) is a viral infection that may lead to colitis and is of particular concern in AIDS patients with rectal bleeding and tenesmus. Mycobacterium avium complex (D) is a rare cause of diarrhea and typically only occurs once the CD4 count has fallen below 50 cells/mm3.

A 55-year-old man with a medical history of hypertension presents to the emergency department with 2 days of left lower quadrant pain and a fever of 38.2°C at home. He denies nausea or vomiting and has been able to tolerate oral intake at home. He reports some intermittent painless hematochezia over the last year but states that he has never had a colonoscopy. His vitals are HR 89 beats per minute, RR 16 breaths/min, and BP 142/90 mm Hg. His abdominal exam shows moderate tenderness to palpation of the left lower quadrant without rebound or rigidity. A CT scan confirms diverticulitis without perforation or abscess formation. Which of the following is the most appropriate next step in the management of this patient's diverticulitis? AAdmit for inpatient intravenous antibiotics BDischarge home with follow-up in 48 hours CSurgery consult for colon resection DUrgent colonoscopy to rule out colon cancer

Discharge home with follow-up in 48 hours uncomplicated acute diverticulitis may be discharged home without oral antibiotics with close follow-up in the next 48 hours. If antibiotics are indicated, ciprofloxacin and metronidazole or trimethoprim-sulfamethoxazole and metronidazole are two commonly used regimens. These patients should be given clear return precautions for worsening fever or abdominal pain as this could indicate treatment failure or the development of complications. Diverticulitis Sx: abdominal pain that is localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits PE: localized guarding, rigidity, and rebound tenderness Diagnosis is made by CT with IV contrast: thickened bowel wall, "fat stranding," may show complications - bowel perforation, abscess, fistula, obstruction Consider treatment with supportive care and/or antibiotics based on risk factors and presentation Antibiotics to cover gram-negative and anaerobic bacteria, bowel rest, and surgery (in severe cases) High-fiber diet can help in prevention ---------------------------------------------------------------- vs Patients with complicated diverticulitis or with other criteria for hospitalization require hospital admission for fluids, pain control, and intravenous antibiotics (A). Features of complicated diverticulitis include abscess formation, bowel obstruction, fistula formation, and bowel perforation. Other criteria for hospital admission include sepsis, advanced age (> 70 years), significant comorbidities, immunocompromised status, inability to tolerate oral intake, and failure of outpatient therapy. Intravenous antibiotics should generally cover anaerobic organisms and gram-negative rods. Elective colon resection (C) is an option for patients with recurrent diverticulitis or those with high risk of complications from recurrent diverticulitis, such as those with a complicated first episode or with immunosuppression. This patient, however, does not have an indication for elective colon resection. Colonoscopy (D) to assess the extent of diverticular disease and exclude colon cancer is indicated in all patients with diverticulitis who have not had a colonoscopy in the last year. This should oc

A 29-year-old man with no significant medical history or chronic medication presents to the emergency department for recurrent rhinorrhea with associated sneezing and an irritative cough. He has an itchy nose and throat and reports chronic sniffing and nose-wiping secondary to the rhinorrhea. He typically takes over-the-counter cetirizine with adequate relief of his symptoms but describes persistent symptoms at this time. Vital signs include a HR of 89 bpm, RR of 18/min, BP of 106/70 mm Hg, T of 98.1°F, and SpO2 of 99% on room air. The patient is prescribed the most effective treatment for his condition. What is the most likely complication of this therapy? AAcute glaucoma BDry eyes CEpistaxis DHypertension EStunted growth

Epistaxis Intranasal glucocorticoids (fluticasone, mometasone) are the first-line initial agents used to treat this condition as they are the single most effective maintenance therapy for allergic rhinitis. The most likely adverse effect of this medication class is epistaxis; scant blood seen in the nasal mucus is often due to mucosal irritation and can be treated effectively with cessation of treatment on the affected side for a few days before resuming bilateral administration. Allergic Rhinitis History of asthma, atopic dermatitis, and sinusitis Sx: sneezing, rhinorrhea, and nasal congestion PE: infraorbital edema and darkening, transverse nasal crease, pale edematous nasal turbinates, cobblestoning of the posterior pharynx Dx: based on clinical history, may be confirmed with skin testing or allergen-specific IgE Management includes glucocorticoid nasal spray, removal of the allergen source (if known) Nasal polyps, asthma, and aspirin-sensitivity (Samter triad) While first-generation oral antihistamines (e.g., diphenhydramine) may be used, second-generation agents (e.g., cetirizine, fexofenadine) are preferred due to reduced sedation, paradoxical agitation, and impairment of cognitive function. Antihistamine nasal sprays (azelastine, olopatadine) or intranasal cromolyn may be administered for patients with mild symptoms who desire alternative therapy. Oral montelukast is another agent that may be added to treatment regimens. Patients with severe or refractory allergic rhinitis should be referred to an allergy specialist for further evaluation and treatment. -------------------------------------------------------------- vs Acute glaucoma (A) is not an adverse effect of intranasal glucocorticoids, but decongestants can acutely worsen this condition and should be avoided, if possible, in patients with closed angle glaucoma. Decongestants are often administered to patients who achieve incomplete relief with oral antihistamine use alone. Dry eyes (B) are a common class-wide side effect of oral antihistamines, including second-generation agents. This anticholinergic effect is not associated with intranasal glucocorticoid administration. Hypertension (D) can be exacerbated with the use of decongestants, bu

A 68-year-old man was admitted to the hospital for an acute exacerbation of his chronic systolic congestive heart failure. What education should be given to this patient upon discharge to help prevent readmission? AAvoid physical activity BElevate lower extremities CMonitor daily weights DRestrict fluid intake

Monitor daily weights

A woman presents with significant family and work related stress. She has been drinking alcohol more frequently than usual. For the past two weeks, she has noticed upper central abdominal pain, nausea, and loss of appetite. Initial laboratory testing reveals a mild anemia. You decide to order an esophagogastroduodenoscopy, which only reveals gastric epithelial inflammation. Which of the following is the most likely diagnosis? AEsophagitis BGastritis CPancreatitis DPeptic ulcer disease

Gastritis inflammation of the stomach epithelium secondary to an inflammatory response. The most common cause of acute gastritis is due to H. pylori infection. Gastritis Diagnosis is confirmed histologically Most common acute cause: NSAIDs > alcohol Atrophic gastritis Type A chronic: pernicious anemia Type B chronic : H. pylori Management includes treating the underlying cause or stopping offending agents Infection with H. pylori is a strong risk factor for malignancy

A 43-year-old woman presents to the emergency department via EMS following a motor vehicle collision. She has multiple lacerations that are still actively bleeding. She reports no significant medical history, and her only medication is oral birth control. Vitals are a T of 98.4°F, BP of 90/60 mm Hg, RR of 13/min, HR of 101 bpm, and oxygen saturation of 99% on room air. On physical examination, her mucous membranes and skin are dry. She has multiple contusions and lacerations over her torso and extremities, decreased lung sound on the right, and regular heart rhythm without murmurs. Laboratory results reveal a hemoglobin of 7.8 g/dL. CXR in the trauma bay reveals a right-sided hemothorax, and a chest tube is placed. She is at high risk for acute kidney injury due to poor perfusion. Which of the following is a diagnostic criterion for acute kidney injury, according to Kidney Disease: Improving Global Outcomes guidelines? ABlood urea nitrogen to creatinine ratio > 20:1 BFractional excretion of sodium < 1% CIncrease in serum creatinine by ≥ 0.3 mg/dL within 48 hours DIncrease in serum creatinine to ≥ 2 times baseline within the 3 days EUrine volume < 2 mL/kg/hour for 24 hours

Increase in serum creatinine by ≥ 0.3 mg/dL within 48 hours dx/; Criteria for Acute Kidney Injury Diagnostic criteria for AKI include an increase in serum creatinine by ≥ 0.3 mg/dL (≥ 26.5 micromol/L) within 48 hours, an increase in serum creatinine to ≥ 1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume < 0.5 mL/kg/hour for 6 hours. Management involves finding the underlying cause, removing any potential insults, and hydration. Potential insults include hypotension, NSAIDs, contrast dyes, and nephrotoxic medications.

A 45-year-old woman who receives chronic dialysis missed her last two scheduled sessions of dialysis. Which of the following compensatory mechanisms would be expected in this patient? ADecreased respiratory rate to increase CO2 and decrease the serum pH BDecreased respiratory rate to increase CO2 and increase the serum pH CIncreased respiratory rate to decrease CO2 and decrease the serum pH DIncreased respiratory rate to decrease CO2 and increase the serum pH

Increased respiratory rate to decrease CO2 and increase the serum pH A patient who misses scheduled dialysis sessions begins to build up acid in the serum which results in a decrease in serum pH (acidemia). The physiologic response is to increase respiratory rate to exhale more CO2 (decrease CO2) in an attempt to raise and bring the serum pH closer to the normal range. Chronic Kidney Disease Definition: permanent loss of kidney function > 3 months Most commonly caused by DM, HTN PE: uremic frost, HTN, pulmonary edema, pericardial rub, encephalopathy Complications: Volume overload Electrolyte imbalance (hyperkalemia, hyperphosphatemia, hypocalcemia) Normocytic anemia: ↓ EPO + anemia of chronic disease Secondary hyperparathyroidism, mineral bone disorder Acidosis Platelet dysfunction, bleeding Cardiovascular disease and dyslipidemia CKD stages Stage 1: normal kidney function (eGFR ≥ 90) and ≥ 3 months of proteinuria Stage 2: mild reduction in kidney function (eGFR 60-89) and ≥ 3 months proteinuria Stage 3: moderate reduction in kidney function (eGFR 30-59) Stage 4: severe reduction in kidney function (eGFR 15-29) Stage 5: kidney failure (eGFR < 15) - requires dialysis or transplant for survival (ESRD)

A 27-year-old woman is on an estrogen-progestin oral contraceptive. Which of the following mechanisms of action is the most important for providing contraception? AAlteration in cervical mucus BImpairment of normal tubal motility and peristalsis CInhibition of the midcycle luteinizing hormone surge DRendering the endometrium less suitable for implantation

Inhibition of the midcycle luteinizing hormone surge so that ovulation does not occur. Combination estrogen-progestin oral contraceptives are potent in this regard, but progestin-only pills are not. There are many other indications for the use of oral contraception including hyperandrogenism, dysmenorrhea, menorrhagia, and other menstrual cycle disorders such as premenstrual syndrome as well as hormone replacement in women with primary hypogonadism. ------------------------------------------------------------------- vs Alteration in cervical mucus (A) is a progestin-related mechanism of contraception. Alterations in cervical mucus make it less permeable to penetration by sperm. Impairment of normal tubal motility and peristalsis (B) is a progestin-related mechanism of contraception. It prevents normal transportation of sperm. Rendering the endometrium less suitable for implantation (D) is due to daily progestin exposure leading to endometrial decidualization and eventual atrophy.

A 23-year-old man diagnosed with human immunodeficiency virus infection is taking a highly active antiretroviral regimen containing indinavir dosed at 800 mg three times daily. At a recent visit, he was prescribed ritonavir 100 mg by mouth twice daily, and his indinavir dose was changed to 800 mg twice daily. What pharmacokinetic principle has ritonavir altered that allows indinavir to be dosed less frequently? AAbsorption BDistribution CElimination DMetabolism

Metabolism Clearance is an important factor in determining the proper dosing regimen for a drug in terms of both achieving suitable levels for efficacy and avoiding supratherapeutic levels that cause toxicity. Ritonavir is being used in this case as a potent cytochrome P450 3A4 inhibitor that decreases the metabolism of indinavir. This reduces the clearance of indinavir and increases its half-life (i.e., the time it takes for half of the drug to be eliminated from the body). A longer half-life means that the drug has to be dosed less frequently to achieve the same level of inhibiting the reproduction of the human immunodeficiency virus. Less frequent dosing increases patient compliance and provides effective viral suppression. -------------------------------------------------------------- vs Absorption (A) is not a determinant of the clearance of a medication but is still an important factor to consider for a number of drug interactions. Interactions decreasing absorption (e.g., calcium-containing products binding to fluoroquinolone antibiotics in the intestine) lead to therapeutic failures while other interactions increase absorption and improve therapeutic efficacy (e.g., increased absorption of the antifungal itraconazole when consuming acidic beverages). Distribution (B) is an important determinant of drug clearance. When drugs distribute extensively into the tissues (e.g., muscle, adipose tissue), they are not present in the blood to be transported to the kidneys or liver for elimination. Drug interactions that increase the volume of distribution of a drug typically increase the half-life of a drug (e.g., the hydrophilic antibiotic tobramycin partitioning into the interstitial fluid of a patient with peripheral edema). Elimination (C) is an extremely important factor for drug clearance and most commonly involves renal elimination. Any drug that is eliminated in the kidneys will have decreased clearance if kidney function is reduced (e.g., vancomycin being dosed every 24 hours instead of every 8 hours in a patient with renal dysfunction). Occasionally, interactions that decrease renal clearance are used for therapeutic benefit. Probenecid was previously used to inhibit renal secretion of penicillin in

You are caring for a patient who presents with acute decompensated heart failure. For the past two years, he has been maintained on beta-blockade. His current blood pressure is 136/83 mmHg and heart rate is 67 bpm. Which of the following infusions is the most appropriate choice to support cardiac contractility? ADobutamine BDopamine CFurosemide DMilrinone

Milrinone Acute decompensated heart failure is commonly treated with three classes of inotropes: 1. beta-adrenergic agonists, 2.phosphodiesterase III inhibitors, and 3. calcium-sensitizers. Inotropes are medications that enhance the contractility of the heart. Milrinone is a phosphodiesterase inhibitor which enhances intracellular cyclic adenosine monophosphate (cAMP) and calcium. Milrinone vasodilates the coronary arteries without additional myocardial oxygen consumption. Since its mechanism of action is not achieved primarily through beta-receptors, it is a favorable choice for patients receiving concurrent beta blockade therapy. ----------------------------------------------------------------- vs Dobutamine (A) is a positive inotrope that may be used in the treatment of acute decompensated heart failure. However, since it is primarily a beta-1 agonist, it is not the most appropriate choice for a patient receiving beta blockade. Dopamine (B) works primarily on beta-1, beta-2, and alpha-1 receptors and is not the best answer since beta receptor down regulation occurs in heart failure. Furosemide (C) is a diuretic. Although this medication is often used to reduce hypervolemia, it does not support cardiac contractility and is incorrect.

A 55-year-old man with a history of alcohol use disorder and cirrhosis presents to the emergency department reporting abdominal distension and weight gain. He states that his symptoms have been slowly progressing over the past 3 weeks. He is not taking any medications and reports no orthopnea, abdominal pain, lethargy, or confusion. Vitals are temperature 37°C, blood pressure 120/80 mm Hg, pulse 89 bpm, and SpO2 98% on room air. Physical exam reveals a man with jaundice in no acute distress. His abdomen is markedly distended and nontender to palpation in all four quadrants with bulging flanks. There is dullness to percussion in the flank region. The remainder of the physical exam is unremarkable. Which of the following is the best next step in management? AObtain abdominal ultrasound BPerform diagnostic paracentesis CPrescribe oral diuretic with outpatient follow-up in 2 weeks DPrescribe oral lactulose with outpatient follow-up in 2 weeks ERecommend sodium restricted diet

Obtain abdominal ultrasound dx: ascites If there are indications of ascites based on history and physical exam, the first step in diagnosis should be abdominal ultrasound to confirm its presence and to look for evidence of cirrhosis or malignancy. Diagnostic paracentesis is most useful for determining the cause of ascites. Ascites fluid should be evaluated for appearance (e.g., clear, bloody, cloudy), serum-to-ascites albumin gradient, cell count and differential, and total protein concentration. Most occurrences of small amounts of cirrhosis-related ascites can be managed with dietary sodium restriction alone. For patients with moderate to large ascites, diuretic therapy, therapeutic paracentesis, or both may be necessary. Diuretic treatment is usually with spironolactone alone or in combination with furosemide. The prognosis for patients with ascites due to cirrhosis is poor, with a < 50% 2-year survival rate after the onset. Thus, liver transplantation should be considered for these patients.

A man who is pale and ill-appearing presents to the emergency department with reports of two episodes of bright red vomitus. A medical history review reveals alcohol use disorder, chronic hepatitis, and cirrhotic liver disease. Vitals include a HR of 105 bpm, RR of 18/min, BP of 96/55 mm Hg, T of 97.7°F, and SpO2 of 95% on room air. Laboratory testing reveals hemoglobin 10.1 g/dL, hematocrit 38.7%, INR 1.7, and platelet count 82,000/μL. Two large-bore intravenous access lines are placed with aggressive fluid repletion and prophylactic antibiotic administration initiated. What is the next step in treatment? AFresh frozen plasma transfusion BOctreotide infusion CPlatelet transfusion DPropranolol administration ETransvenous intrahepatic portosystemic shunt

Octreotide infusion dx; esophageal varices Any patient with bleeding esophageal varices requires stabilization with intravenous fluid replacement. Antibiotic prophylaxis with intravenous agents such as ceftriaxone reduces in-hospital mortality and the risk of serious infection in patients with esophageal varices. Vasoactive substances (octreotide, somatostatin, terlipressin) reduce splanchnic and hepatic blood flow and portal venous pressures and should be administered after patients are initially stabilized. Additionally,l band ligation via endoscopy can improve survival. Vitamin K should be administered to patients with cirrhosis and an abnormal prothrombin time and patients with hepatic encephalopathy and increased ammonia should additionally be treated with lactulose. Endoscopy is performed within 12-24 hours of hemodynamic stabilization to exclude other or associated causes of upper gastrointestinal bleeding. Balloon tamponade can also be used to control acute bleeding while more definitive treatment measures are being prepared. Portal pressure can be reduced long-term with the administration of nonselective beta-blockers (e.g., propranolol, nadolol), with a target heart rate of 55-60 bpm. A transvenous intrahepatic portosystemic shunt (TIPS) procedure is appropriate for patients who have had recurrent bleeding from gastric varices, who have portal hypertensive gastropathy, who have not responded to endoscopy or pharmacologic therapies, who are unwilling or unable to undergo other therapies, or who live in remote locations. Esophageal Varices Caused by portal hypertension, history of chronic liver disease or alcohol use Associated with massive UGIB Diagnosis is made by upper endoscopy: dilated submucosal esophageal or gastric veins Treatment: hemodynamic support, endoscopy with banding, octreotide, prophylactic ceftriaxone, balloon tamponade for temporary hemostasis Prophylaxis: nonselective beta-blockers (nadolol, propranolol), endoscopic ligation, TIPS for select patients; liver transplant is definitive treatment ---------------------------------------------------------------- vs Fresh frozen plasma transfusion (A) is not appropriate in patients with cirrhosis and an elevated INR once stab

A 36-year-old woman with a history of an opioid use disorder presents to your family practice. She explains that it was easier to purchase drugs on the street than obtain prescription for opioids to get relief from her whiplash injury. In the past 6 months, she has lost her job and her house, and last week, her daughter was placed in a foster home. She appears agitated but highly motivated to reverse her losses. She has no other substance use, and her last opioid use was this morning. You have received medications for opioid use disorder certification, and your clinic has a dedicated behavior health counselor. What is the best medication for her treatment? ALong-acting opioid agonist BLong-acting opioid antagonist COpioid partial agonist DShort-acting opioid agonist EShort-acting opioid antagonist

Opioid partial agonist Buprenorphine, PAs can prescribe buprenorphine once they have undergone medications for opioid use disorder training overseen by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). This training necessarily involves counseling as well as administration and supervised prescription of buprenorphine. Buprenorphine is administered in various routes, including sublingual, transdermal patch, and injection. It is also combined with naloxone (an opioid antagonist) in products that help to prevent drug diversion. It should be given 12-24 hours after the last use of opioid. ------------------------------------------------------------------ vs long-acting opioid agonist (A) (i.e., methadone) is also used for opioid use disorder but can only be administered by a dedicated clinic. It is a full agonist with some euphoric effects, but its long half-life reduces drug dependence. It requires twice- or thrice-weekly clinic visits. A long-acting opioid antagonist (B), namely naltrexone, blocks the euphoria effect of opioids but does not address pain, the patient's primary concern. Also, naltrexone cannot be started unless the patient has inactive use of opioids. A short-acting opioid agonist (D) describes drugs such as heroin, as well as short-term painkilling drugs such as morphine and fentanyl. These drugs are highly addictive because of their quick onset and immediate withdrawal. A short-acting opioid antagonist (E), or naloxone, is used to reverse opioid overdose and also blocks the euphoria effect. It is used in combination with morphine for pain in hospitalized patients and in combination with buprenorphine to treat drug addiction more safely.

A 35-year-old obese woman who just delivered a 10 lb baby after 48 hours of labor starts hemorrhaging from the vaginal area and has a sudden drop in blood pressure. She was in her 41st week of gestation when she was admitted to have labor induced. Which of the following is the best initial step in diagnosing the underlying cause of bleeding? ADo manual exploration of the uterine cavity BOrder a complete blood count COrder a pelvic and abdominal ultrasound to identify the source of bleeding DPalpate to determine the size and firmness of the uterus

Palpate to determine the size and firmness of the uterus Uterine atony, the failure of the uterus to contract and retract after the baby is delivered, is the most common cause of postpartum hemorrhage and can lead to rapid and severe hemorrhage and hypovolemic shock. What is the most common cause of traumatic postpartum hemorrhage? Answer: Cervical tears. -------------------------------------------------------------- vs Manual exploration of the uterine cavity (A) is used to evaluate if portions of the placenta still remain in the uterine cavity and is a good next step after uterine atony is ruled out. A complete blood count (B) gives baseline information about the hemoglobin and hematocrit status but will not reflect the hemodynamic status of the patient right away. It can be used to rule out thrombocytopenia, which would have been diagnosed during her prenatal visits. A pelvic and abdominal ultrasound (C) can confirm uterine size and shape and be used to evaluate for any remaining placental portions or blood clots, but this method can be time-consuming and unnecessarily delay treatment.

A 25-year-old woman is admitted to the labor and delivery unit. Fetal heart rate monitor has been placed. Which of the following findings would necessitate the planning for emergent intervention and possible cesarean section or instrumented vaginal delivery? AAbsence of variable decelerations BBaseline fetal heart rate of 110 to 160 bpm CModerate fetal heart rate variability (6 to 25 bpm) DRecurrent late decelerations

Recurrent late decelerations Late Deceleration Onset, nadir, and recovery of deceleration follow onset, peak, and end of contraction Due to uteroplacental insufficiency Category one represents normal pattern with minimal possibility of fetal injury. It can progress to another stage. Category two represents an atypical tracing that should be monitored. Category three tracings are abnormal and are at increased risk of fetal injury, either hypoxemia or metabolic acidemia. Any one of the following would classify the heart rate as category three: absent variability with recurrent late decelerations, absent variability with recurrent variable decelerations, absent variability with bradycardia, or a sinusoidal pattern. Emergent intervention should be planned for with category three classifications.

A 42-year-old woman with no significant past medical history presents to the family practice office for evaluation of new onset thrombocytopenia. She denies any recent illness and does not take any medications or supplements. She denies the development of skin lesions, neurologic or constitutional symptoms. CBC with differential, peripheral smear, BMP, PT/INR and aPTT are otherwise within normal limits. What is the most likely diagnosis? ADisseminated intravascular coagulation BHemolytic uremic syndrome CPrimary immune thrombocytopenia DThrombotic thrombocytopenic purpura

Primary immune thrombocytopenia Primary Immune Thrombocytopenia - Pediatric 2-6 years old Antiplatelet autoantibodies H/o recent viral infection Non-blanching petechiae/purpura, gingival bleeding Labs: platelets < 100,000/µL, normal WBC, normal hematocrit Tx: activity restriction, observation, glucocorticoids and IVIG or IV anti-D if severe

A 56-year-old man presents to the emergency department with mouth pain and difficulty swallowing, worsening over the past day. He reports that he does not have a primary care physician and has not seen a dentist in more than 12 years. He has smoked one pack of cigarettes per day for the past 35 years. His blood pressure is 152/94 mm Hg, heart rate is 122 bpm, temperature is 101.2°F, oxygen saturation is 95%, and respiratory rate is 26/min. On physical examination, the patient is noted to be drooling and has unintelligible speech secondary to trismus. The submandibular area of the neck is swollen, tender, and indurated but without palpable lymphadenopathy. Visualization of the oropharynx is attempted, which reveals a tender and elevated floor of the mouth. There is no tonsillar enlargement or asymmetry, no uvular deviation, and no posterior pharynx enlargement or bulge. Based on the suspected diagnosis, what is the most likely source for the patient's infection? AEpiglottis BMastoid air cells CMaxillary sinus DParotid gland ERoots of the teeth

Roots of the teeth Ludwig Angina Aggressive, rapidly spreading cellulitis of bilateral submandibular, sublingual, and submental spaces Dental infections (molars) or immunodeficiency PE: tongue elevation, brawny edema, dysphagia, dysphonia, drooling Dx: clinical, CTw/contrast Tx: fiberoptic or awake intubation, antibiotics, ENT consultation Treatment should include prompt airway management via fiberoptic nasotracheal intubation or tracheostomy. Empiric broad-spectrum intravenous antibiotics, such as ampicillin-sulbactam, should be initiated. Otolaryngology should be consulted. Surgery is generally not indicated unless an abscess is identified or if the patient's condition is not improving on antibiotics. \-------------------------------------------------------------

Which of the following electrocardiogram findings indicate left main coronary artery subocclusion or occlusion? ABiphasic T waves in leads V2-3 BCoved ST segment elevation > 2 mm followed by a negative T wave in leads V1-3 CHorizontal ST depression with tall, broad R waves and upright T waves in leads V1-3 DST elevation in aVR > V1 with horizontal ST depression in I, II and V4-6

ST elevation in aVR > V1 with horizontal ST depression in I, II and V4-6 ST segment elevation in lead aVR > 1 mm, especially when the elevation is greater than that seen in the ST segment of V1 should prompt concern for occlusion of the left main coronary artery extent of ST segment elevation in aVR correlated with increased mortality. Other ECG findings consistent with left main occlusion include horizontal ST depression in leads I, II, and V4-6. ------------------------------------------------------------------- vs biphasic T waves in leads V2-3 (A) are seen in Wellens syndrome and are highly specific for critical stenosis of the left anterior descending artery. The ECG pattern is seen when the patient is pain-free, but they often present after an episode of angina. Urgent catheterization is indicated as these patients are at high risk for extensive anterior wall myocardial infarction. Coved ST segment elevation > 2 mm followed by a negative T wave in leads V1-3 (B) is referred to as the Brugada sign. Taken in conjunction with a family history of early sudden cardiac death, documented ventricular fibrillation or ventricular tachycardia, or a history of syncope, this ECG finding identifies patients with a high incidence of sudden cardiac death. Definitive treatment is with the placement of an automated implantable cardiac defibrillator. A posterior myocardial infarction is characterized by horizontal ST depression with tall, broad R waves and upright T waves in leads V1-3 (C). Posterior myocardial infarctions are often seen in conjunction with inferior or inferolateral infarctions.

A 16-year-old boy comes to the clinic complaining of a change in mental status. He had a 2 cm painless genital ulcer that resolved on its own about one year ago. Screening tests reveal a positive rapid plasma reagin. Which of the following represents the appropriate treatment regimen? ASend a cerebrospinal fluid VDRL and start penicillin G 4 million units IV every 4 hours BSend a cerebrospinal fluid VDRL and start penicillin G benzathine 2.4 million units IM once weekly CSend an FTA-ABS and start ceftriaxone 2 g IV daily DSend an FTA-ABS and start penicillin G 4 million units IV every 4 hours

Send a cerebrospinal fluid VDRL and start penicillin G 4 million units IV every 4 hours The patient in this scenario is suspected of having late-stage neurosyphilis (based on his history of primary syphilis), given his positive RPR and altered mental status. Other symptoms of neurosyphilis include personality changes, bladder incontinence, headache, hearing loss, and blurred vision. ----------------------------------------------------------------- vs Penicillin G benzathine (B) could be used as a treatment for neurosyphilis, however, it should be dosed daily rather than weekly. Ceftriaxone (C) is an alternative treatment for those patients with a penicillin allergy. FTA-ABS (D) can be used to confirm a positive RPR. Although it is more sensitive than CSF VDRL in neurosyphilis, it is less specific. Therefore, CSF VDRL is the preferred diagnostic test for neurosyphilis.

A 65-year-old man with a medical history of type 2 diabetes, hypertension, and chronic kidney disease stage 2 presents to the emergency department. His current medications include insulin, metformin, lisinopril, and amlodipine. The man is accompanied by his partner who states he has been confused for the last several hours. The man also reports increased sweating, headache, dizziness, and hand tremors. His vital signs are temperature of 37°C, HR of 110 bpm, BP of 120/80 mm Hg, RR of 14 bpm, and SpO2 of 98% on room air. Physical exam reveals a well-appearing man with a BMI of 35 kg/m2 in no acute distress. He is somnolent but answers questions appropriately. He is oriented to person, place, and date. He has a mild resting tremor in both hands. The remainder of his physical exam is unremarkable. Laboratory testing reveals WBC of 4,500/µL, hemoglobin of 15 g/dL, platelets of 200,000/µL, sodium of 137 mEq/L, potassium of 4.0 mEq/L, chloride of 100 mEq/L, bicarbonate of 25 mEq/L, blood urea nitrogen of 30 mg/dL, creatinine of 2.3 mg/dL, and glucose of 40 mg/dL. His thyroid-stimulating hormone level is 3.0 µU/mL. His kidney function compared to labs from his last clinic visit 6 months ago

The patient in the vignette presents with insulin-induced hypoglycemia. Hypoglycemia is defined as plasma glucose concentration ≤ 70 mg/dL. Risk factors for hypoglycemia include increased age, chronic kidney disease, increased duration of diabetes, malnutrition, exercise, and alcohol consumption. Hypoglycemia is most commonly related to type 1 diabetes, but it also can occur in the treatment of type 2 diabetes with glucose-lowering agents such as insulin, sulfonylureas, and meglitinides. Other causes of hypoglycemia include hormone deficiencies, liver and kidney failure, insulinoma, and critical illness (sepsis).

A 31-year-old woman at 35 weeks gestation presents with brief painless, bright red vaginal bleeding. In addition to fetal monitoring, which of the following is the most important initial management? AAdministration of betamethasone to hasten fetal lung maturity BEstablishing IV access and beginning magnesium infusion CSterile speculum examination DTransvaginal ultrasound

Transvaginal ultrasound Placenta Previa Painless vaginal bleedingMost often during the third trimester Diagnosis is made by ultrasound (transvaginal > transabdominal) Do not do a digital vaginal exam Delivery: cesarean section at 36 0/7-37 6/7 gestation ------------------------------------------------------------- vs Administration of betamethasone to hasten fetal lung maturity (A) may be indicated for patients with preterm labor (contractions resulting in cervical dilatation) prior to 37 weeks gestation. Establishing IV access and beginning a magnesium infusion (B) is appropriate initial therapy to prevent seizures in a patient with severe preeclampsia. In a patient with preeclampsia, progression to severe disease is defined as systolic blood pressure ≥ 160 mm Hg, diastolic blood pressure ≥ 110 mm Hg, new-onset cerebral or visual disturbances, impaired liver function, or serum creatinine > 1.1 mg/dL. Vaginal bleeding is not a typical clinical finding associated with preeclampsia. A sterile speculum cervical exam (C) is contraindicated until placenta previa is ruled out, as this can lead to significant hemorrhage.

A 3-year-old boy presents to the Emergency Department after four episodes of emesis and three episodes of diarrhea starting this evening. He has had a few sips of water at home. His vital signs are reassuring except for mild tachycardia and he appears mildly dehydrated on examination. He is given a dose of ondansetron for nausea in the waiting room. What is the next best step in management? AAdminister a bolus of 0.9% sodium chloride BAdmit for maintenance intravenous fluids CDischarge home with lactobacillus DTrial of oral rehydration solution

Trial of oral rehydration solution In cases of mild to moderate dehydration, oral rehydration therapy is preferred to intravenous hydration. ----------------------------------------------------------------- vs

A 46-year-old woman presents to the emergency department with fever, cough, and hemoptysis. She has a history of intravenous opioid use. Vital signs are BP 110/65 mm Hg, HR 120 beats per minute, RR 20 breaths per minute, and T 103.4°F. On auscultation of the chest, you hear a faint systolic ejection murmur. Which of the following is the most appropriate initial therapy? AAmpicillin and gentamicin BCeftriaxone COxacillin and rifampin DVancomycin and ceftriaxone

Vancomycin and ceftriaxone IVDA: Staphylococcus aureus, tricuspid Native valve: Staphylococcus aureus, viridans streptococci (most common in previously diseased), mitral ------------------------------------------------------------ vs Ampicillin and gentamicin (A) would be an appropriate antibiotic regimen for resistant viridans group streptococci and nonresistant enterococci. It does not adequately cover MRSA, which should be covered. Ceftriaxone (B) does not cover the typical infecting organisms. Oxacillin and rifampin (C) would be partially appropriate for a patient with prosthetic valve endocarditis as it covers Staphylococcus aureus and adds rifampin to penetrate the biofilm on prosthetic valves; however, this would also not be an adequate regimen for MRSA as oxacillin would need to be substituted with vancomycin.

A 5-week-old infant presents with dyspnea and fluid overload but not cyanosis. Auscultation reveals a loud, holosystolic murmur at the lower left sternal border. Echocardiography would most likely show which of the following abnormalities? AAorta is connected to the right ventricle BPulmonary artery is connected to the left ventricle CVentricular septal defect in the membranous portion DVentricular septal defect in the muscular portion A 3-day-old baby girl has a holosystolic murmur along the left lower sternal border. What is the most likely diagnosis? AAortic stenosis BAtrial septal defect CPatent ductus arteriosus DVentricular septal defect

Ventricular septal defect in the membranous portion dx:Ventricular Septal Defect PE will show a loud, harsh, holosystolic murmur at the lower left sternal border Diagnosis is made by echo Treatment: most close spontaneously by adulthood Most common pathologic murmur in childhood