pance practice exam A

A 17-year-old previously healthy boy presents with abdominal cramping, nausea, vomiting, and diarrhea 2 hours after eating at a picnic. Physical examination is unremarkable. What management is indicated? AAnitiemetics and fluids BCiprofloxacin CCT scan of the abdomen and pelvis DStool cultures

Anitiemetics and fluids dx: rapid onset gastroenteritis

What is normal intraocular pressure?

Answer: < 21 mm Hg.

Which vasopressor increases renal perfusion in low doses?

Answer: Dopamine.

What are contraindications to getting the rotavirus vaccine?

Answer: History of intussusception, weakened immune system, or life-threatening reactions to prior doses of the rotavirus vaccine.

A 45-year-old woman with a history of hypothyroidism on levothyroxine presents to the clinic for routine monitoring of her thyroid-stimulating hormone level. The patient reports she is feeling well and has been taking her levothyroxine as prescribed. Vital signs today include a heart rate of 105 bpm, blood pressure of 135/84 mm Hg, respiratory rate of 20/minute, oxygen saturation of 98% on room air, and temperature of 98.6°F. The patient's thyroid-stimulating hormone level is 0.03 mU/L. Which complication is this patient most at risk for on her current dose of levothyroxine? AAcute kidney injury BAtrial fibrillation CExophthalmos DGoiter EHepatotoxicity

Atrial fibrillation and decreased bone mineral density, resulting in osteoporosis and increased risk of fractures.

Which of the following is a risk factor for iron deficiency anemia? ABariatric surgery BDiet rich in animal protein CGluten-free diet DMale sex

Bariatric surgery procedure done to help with weight loss and can include shortening the length of the small intestine, which affects iron absorption and can cause iron deficiency anemia.

A 3-year-old boy presents to your clinic due to his mother's concerns about the patient having intermittent fevers, fatigue, bruising without injury and a pale appearance. Physical exam reveals a palpable liver and spleen, and pale conjunctiva. Initial laboratory testing reveals elevated white blood cell count and lymphoblasts on the peripheral smear. Which of the following is used to confirm the diagnosis? ABone marrow aspiration and biopsy BComputed tomography of the abdomen CLiver biopsy DUltrasound of the testicles

Bone marrow aspiration and biopsy dx: Acute lymphoblastic leukemia (ALL)

A 23-year-old man presents after closing his right hand in a car door. He is complaining of 10/10 sharp pain to his right index finger. On examination, you note the distal phalanx of the right index finger has ulnar deviation. It is edematous and ecchymotic. The fingernail is intact, however, a subungual hematoma occupying approximately 25% of the nail is present. What is the first step in the management of the subungual hematoma? AApplication of ice to the index finger BSplinting of the right index finger CTrephination of the fingernail DX-ray of the right index finger

X-ray of the right index finger dx:Subungual hematomas an X-ray of the right index finger is the first step in the management of this subungual hematoma. ----------------------------------------------------------------- vs Trephination of the fingernail (C) is the treatment of choice after the X-ray is completed.

patients will develop atrophy of the deltoid muscle and Difficulty with shoulder abduction dx: anterior shoulder dislocation. abducted, externally rotated, and extended arm

A 19-year-old man with no significant medical history presents to the emergency department for a shoulder injury. He states that he was playing basketball and experienced a blow to his extended right arm. He is now experiencing significant right shoulder pain. He does not take any medications. On presentation, vitals are temperature 37°C, BP 115/75 mm Hg, pulse 85 bpm, and SpO2 99%. Physical exam reveals a slightly abducted, externally rotated right arm. The acromion process is prominent in appearance. Range of motion is significantly limited in the right shoulder, but the right arm, wrist, and fingers are 5/5 in strength with normal range of motion. Bilateral arm sensation is normal. Distal pulses are intact. The remainder of the physical exam is normal. If left untreated, which of the following is a complication of the injury described above? ADifficulty with shoulder abduction BDifficulty with shoulder adduction CLoss of biceps reflex DScapular winging ESensory loss along the lateral forearm

Streptococcus pneumoniae dx: Bullous myringitis direct inflammation and infection of the tympanic membrane caused by a viral or bacterial agent. Vesicles or bullae filled with blood or serosanguineous fluid on an erythematous tympanic membrane are the hallmarks of bullous myringitis Acute Otitis Media Patient will be an infant or young child Middle ear effusion + signs of infection/inflammation (fever, otorrhea, pus) Ear pain PE: erythema, bulge and decreased mobility of TM, purulent fluid Most common bacteria isolated: H. influenza (nontypable) (previously S. pneumoniae but has decreased post-PCV13 vaccination) Treatment is amoxicillin; consider amoxicillin-clavulanate in otitis-conjunctivitis syndrome or adults due to drug resistance Consider period of observation if ≥ 2 years and immunocompetent with mild symptoms

A 2-year-old boy presents with right-sided ear pain. On otoscopy, you observe the image seen above. What organism is commonly associated with this condition? AMycoplasma pneumoniae BPseudomonas aeruginosa CStaphylococcus aureus DStreptococcus pneumoniae

Defibrillation dx: Ventricular fibrillation (VF) is the most common dysrhythmia in cardiac arrest patients.

A woman with known coronary artery disease presents to the ED with chest pain and ventricular tachycardia. She becomes unresponsive 5 minutes after admission. Her rhythm strip is seen above. Which of the following is the most appropriate intervention? ABeta-blockade BCardioversion CDefibrillation DVasopressin

Which of the following is the most common type of prostate cancer? AAdenocarcinoma BMetastatic carcinoma CSmall cell carcinoma DSquamous cell carcinoma

Adenocarcinoma

A 7-year-old boy is brought by his mother to the clinic because of coughing. For the past week, he has had a nonproductive cough. On physical examination, vital signs are normal, with erythematous posterior pharynx, and clear breath sounds. Complete blood count is normal. Chest radiograph reveals perihilar infiltrates. Polymerase chain reaction from the boy's nasopharyngeal specimen comes back positive for Mycoplasma pneumoniae. Which of the following is the most appropriate therapy? AAmoxicillin BAzithromycin CCiprofloxacin DOseltamivir

Azithromycin dx: Mycoplasma pneumoniae. Atypical Pneumonia Patient presents with the gradual onset of dry cough, dyspnea, and extrapulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance PE: rales with auscultation of lung fields Chest X-ray: interstitial infiltrate, hilar adenopathy Cause: Mycoplasma pneumoniae, Chlamydia pneumoniae Tx: Azithromycin, doxycycline Which antibiotic should be used if macrolide resistance is suspected or documented in a patient with atypical pneumonia? Answer: Doxycycline or a fluoroquinolone.

A 57-year-old woman with a long history of poorly-controlled diabetes mellitus presents with worsening edema in her legs and an occasional "wet-sounding" cough. Physical exam shows 2+ pitting edema extending to mid-calf bilaterally and trace periorbital edema. Blood tests show hypoalbuminemia and hyperlipidemia and urinary protein excretion is 3.5 grams/24 hours. Which of these complications may occur as a direct result of her new condition? ADeep vein thrombosis BGouty arthritis CPeripheral neuropathy DStruvite calculi

Deep vein thrombosis dx: nephrotic syndrome secondary to a hypercoagulable state may occur in patients with nephrotic syndrome due to excessive urinary protein losses. As serum albumin levels drop below 2 grams/dL, patients typically become deficient in antithrombin, protein C, and protein S, which causes an increased propensity to clotting. PE will show pitting edema Labs will show proteinuria > 3.5 g/24 hr, hyperlipidemia, hypercoagulability (renal vein thrombosis), fatty casts Minimal change disease: children, preceded by URI Rx: steroids Focal segmental glomerulosclerosis: HIV or IVDA, end-stage kidney disease Membranous nephropathy: HBV, HCV, SLE, gold, penicillamine, malignancy NAPHROTIC • Na decrease (hyponatremia) • Albumin decrease (hypoalbuminemia) • Proteinuria > 3.5 g/day • Hyperlipidemia • Renal vein thrombosis • Orbital edema • Thromboembolism • Infection (due to loss of immunoglobulins in urine) • Coagulability (due to loss of antithrombin III in urine)

A 23-year-old woman presents with a complaint of weakness that started in her bilateral arms and moved down to her bilateral legs. She ate at a friend's house who cans her own food. A few hours later, she complained of abdominal pain and vomiting before endorsing upper extremity weakness. Which of the following is the most likely diagnosis? ABotulism BChronic inflammatory demyelinating polyneuropathy CGuillain Barre syndrome DSalmonellosis

Infant Botulism Patient will be an infant History of eating honey or residing near construction site Feeble cry, constipation PE will show symmetric descending paralysis (floppy baby) Most commonly caused by Clostridium botulinum Treatment is IV botulism Ig

57-year-old man presents for several weeks of fatigue, night sweats, and episodic chills. His exam is remarkable for splenomegaly. A complete blood count shows leukocytosis at 175,000 and mild thrombocytosis. The peripheral blood smear shows a left-shifted myeloid series; blasts are less than 5%. Which of the following additional findings is most consistent with your suspected diagnosis? AAuer rods BElevated hematocrit CPhiladelphia chromosome DRouleaux formation

Philadelphia chromosome -------------------------------------------------- vs Auer rods (A) are eosinophilic needle-like inclusions that are pathognomonic for acute myeloid leukemia (AML), which would present with a much more rapid course of illness than Chronic myeloid leukemia (CML).

A 42-year-old man presents to the clinic with several months of worsening intermittent chest pain. Additionally, he has been experiencing both dyspnea and fatigue with exercise. His medical history includes primary hypertension, which is controlled well with lisinopril. His vital signs are heart rate of 80 bpm, blood pressure of 118/78 mm Hg, oxygen saturation of 98%, respirations of 14/minute, and temperature of 98.6°F. Upon physical exam, a systolic ejection murmur most notable at the left upper sternal border is heard. A clicking sound during systole, which decreases when the patient inspires, is also noted. His lungs are clear to auscultation, and his abdomen is soft and nontender. Which of the following is the most likely diagnosis? AAortic regurgitation BAortic stenosis CMitral regurgitation DPulmonic regurgitation EPulmonic stenosis

Pulmonic stenosis ------------------------------------------------------------- vs

Which of the following patients with Salmonella enteritis should receive antibiotics? A13-month-old with diarrhea and no signs of volume depletion B13-year-old boy with sickle cell disease C19-year-old man living in a college dorm D8-year-old boy with no medical problems

13-year-old boy with sickle cell disease Salmonellosis History of eating poultry, meat, or eggs Fever, diarrhea (possibly bloody in children), and abdominal cramps Labs will show fecal WBCs Common cause of osteomyelitis in children with sickle cell disease Treatment • Rx: Ciprofloxacin in severe illness

Which of the following is considered an appropriate regimen for the treatment of bacterial vaginosis? A2% clindamycin cream intravaginally for 7 days BAzithromycin 1 g orally once CCeftriaxone 500 mg intramuscularly once DMetronidazole 2 g orally once

2% clindamycin cream intravaginally for 7 days metronidazole 500 mg orally bid for 7 days, 0.75% metronidazole gel 5 g intravaginally daily for 5 days,

Perform immediate closed reduction dx: Colles The patient in the vignette has a distal radius fracture with neurovascular compromise, which requires immediate closed reduction.

45-year-old man presents to the emergency department reporting left wrist pain after falling onto an outstretched arm from a one story roof. The patient reports he did not hit his head and reports no pain anywhere aside from his wrist. Vital signs today include a heart rate of 105 bpm, blood pressure of 150/94 mm Hg, respiratory rate of 20 breaths per minute, pulse oxygenation of 99% on room air, and temperature of 98.6°F. Physical examination reveals left distal forearm tenderness and a dinner fork deformity. The patient has no open wounds and an intact sensation to light touch, but you are not able to palpate his left radial pulse. The patient's left wrist radiograph is shown above. Which of the following is the best next step in the management of this patient's presentation? AAdmit for orthopedic open reduction with internal fixation BEvaluate for anatomic snuffbox tenderness CMeasure compartment pressure DPerform immediate closed reduction EPlace sugar tong splint with urgent outpatient orthopedic follow-up

Sputum acid-fast bacilli smear and sputum culture dx:Tuberculosis (TB)

46-year-old woman with a history of HIV infection presents to the emergency department for 3 weeks of fevers, cough, and fatigue. During the interview, she notes that she has recently returned from travel in India. She is currently taking dolutegravir 50 mg PO once daily for HIV. At today's visit, her heart rate is 78 beats/minute, blood pressure is 128/84 mm Hg, respiratory rate is 16 breaths/minute, oxygen saturation is 98%, and temperature is 100.5°F. On her physical exam, the heart sounds are regular in rate and rhythm, with no murmurs, lungs are clear to auscultation bilaterally, without wheezing, rhonchi, or rales. She is not using accessory muscles of respiration. You obtain a chest X-ray as seen above. Which of the following tests is the most appropriate next step to confirm the suspected diagnosis for this patient? AInterferon-gamma release assay BNasopharyngeal swab reverse transcription polymerase chain reaction testing CSputum acid-fast bacilli smear and sputum culture DTuberculin skin test EUrine antigen test

Admit to a telemetry unit for cardiology consult and automatic implantable cardiac defibrillator placement dx:Brugada Syndrome Associated with sudden cardiac arrest Management • Implantable cardioverter-defibrillator (ICD) Brugada Syndrome Autosomal dominant Cardiac ion channel dysfunction Structurally normal heart Resting ECG: RBBB pattern and STE in V1-V3 Type 1 STE: coved Type 2 or 3 STE: saddleback ECG: J wave elevation Lethal dysrhythmias

A 22-year-old man presents to the emergency department after a syncopal episode. His ECG is shown above. He is currently asymptomatic with normal vital signs. Which of the following is the most appropriate next step in management? AAdmit to a telemetry unit for cardiology consult and automatic implantable cardiac defibrillator placement BDischarge with cardiology follow up as an outpatient COrder emergent echocardiogram DStart amiodarone for treatment of presumed ventricular tachycardia

Topical betamethasone dx: cutaneous lichen planus The 4 Ps • Pruritic • Polygonal • Purple • Papules An association is noted between hepatitis C virus and lichen planus. The first-line treatment is topical corticosteroids, like topical betamethasone. Oral prednisone (B) should be reserved for patients with severe or extensive disease.

A 34-year-old woman with a history of hypertension and chronic hepatitis C presents to her primary care provider with pruritic skin discolorations on her lower extremities. Physical exam reveals the lesions above. Which of the following is the most appropriate management of this condition? AOral cephalexin BOral prednisone CTopical betamethasone DTopical clotrimazole ETopical emollients

Furosemide dx: Symptomatic hyperkalemia is a life-threatening electrolyte abnormality typically seen in patients with underlying acute or chronic kidney disease. While immediate administration of calcium gluconate or calcium chloride does not alter potassium levels, calcium helps prevent potentially fatal cardiac conduction abnormalities or dysrhythmias until the excess extracellular potassium can be driven into cells or out of the body. Treatment can then be initiated with agents to drive excess potassium intracellularly, including insulin (with glucose), beta-2 agonists such as albuterol and sodium bicarbonate. These treatments act to quickly decrease the level of extracellular potassium until treatment such as dialysis, loop or thiazide diuretics (e.g., furosemide), or cation-exchange resinscan be initiated to remove excess potassium from the body. ------------------------------------------------------------------- Calcium gluconate (A) stabilizes the cardiac membrane, antagonizing the effects of potassium on the heart. While it does not affect the amount of extracellular or total body potassium, it prevents possibly fatal cardiac dysrhythmias until definitive treatment for hyper

A 35-year-old man presents to the emergency department after a motor vehicle collision with prolonged extrication. He complains of severe pain in his leg, which was trapped under the car for 3 hours. A 12-lead ECG obtained in triage is shown above. Which of the following interventions will decrease total body potassium stores? ACalcium gluconate BFurosemide CInsulin DMagnesium sulfate

Welding without eye protection earlier in the day dx: Ultraviolet keratitis is the result of corneal epithelial damage from exposure to intense UV light. It can be from welding without eye protection, prolonged exposure to sunlight, or using a tanning bed without eye protection. Patient will be a skier or welder Onset of symptoms is typically delayed for several hours. Bilateral decreased visual acuity, pain, and redness photophobia, and tearing Fluorescein staining will show multiple punctate lesions diffuse Treatment consists of topical cycloplegics, broad spectrum antibiotic eye ointment, and ophthalmologic follow-up.

A 35-year-old man presents to the emergency department at 3:00 am complaining of intense bilateral eye pain, redness, and tearing that woke him from sleep fifteen minutes prior to arrival. Eye examination with fluorescein staining of the corneas reveals diffuse punctate corneal lesions as shown above. Further history would likely reveal which of the following? AAllergies to dust mites, tree pollen, pet dander, and cockroaches BContinuous contact lens usage for the past four months CCorrosive chemical exposure DWelding without eye protection earlier in the day

Obstructive uropathy dx: hydronephrosis The patient's history is concerning for symptomatic urolithiasis and his renal ultrasound illustrates severe hydronephrosis Ultrasound: Hydronephrosis Mild: distention of collecting system Moderate: dilation of collecting system, rounding of calyces, and renal papillae obliteration (bear-paw sign) Severe: calyceal dilation with cortical thinning

A 37-year-old man with no significant past medical history presents to the Emergency Department with sudden onset back pain radiating to his left groin. He reports dysuria and hematuria that began this morning. Vital signs are T 98.5 ºF, HR 103 beats/minute, RR 12 breaths/minute, BP 125/85 mm Hg, oxygen saturation 99% on room air. He appears very uncomfortable and cannot sit still. A bedside ultrasound is obtained and is shown above. Which of the following is the most likely diagnosis? ABenign prostatic hyperplasia BObstructive uropathy CPyelonephritis DRuptured abdominal aortic aneurysm

Calcium gluconate Hyperkalemia Confirm no hemolysis in blood sample History of kidney failure, DKA, rhabdomyolysis, tumor lysis Lethargy, weakness, paralysis PE: bradycardia, hypotension, cardiac dysrhythmia ECG: peaked T waves, prolonged PR, wide QRS Treatment is calcium gluconate, insulin, albuterol, bicarbonate (less effective), dialysis, oral potassium binders (new, still undergoing further investigation) Review medication list for possible causes

A 67-year-old man with hypertension and end-stage kidney disease presents after an incomplete dialysis session secondary to shortness of breath. His vital signs are BP 110/95 mm Hg, HR 50 bpm, RR 22/min, T 37.3°C, and SpO299% on 2 L nasal cannula. You obtain the ECG above. Which of the following is the most appropriate next step in management? ACalcium gluconate BCardiology consultation CDefibrillation DTranscutaneous pacing

Lung consolidation

A 68-year-old woman presents to the ED with an acute onset of fever, productive cough, and dyspnea. Her medical history includes a recent breast cancer diagnosis for which she is undergoing chemotherapy. She takes no other medications. Today, her vitals are temperature 101.2°F, BP 128/84 mm Hg, RR 16 breaths/minute, pulse 103 bpm, and O2 saturation 95% on room air. Physical exam reveals inspiratory crackles, increased tactile fremitus, and dullness to percussion at the right mid to lower lung field. She is tachycardic without any murmurs or gallops, and a pleural friction rub is noted. Her chest XR is shown above. Which of the following is the most likely explanation for these findings? AHyperinflation of lung BLung consolidation CPleural effusion DPneumothorax EPulmonary embolism

A 28-year-old South Asian immigrant who is in her second trimester of her first pregnancy presents to the emergency department with worsening dyspnea, orthopnea, and lower extremity edema. She has never experienced anything like this before. She has no past medical history, but she reports frequent sore throats and ear infections as a child. Which of the following is most likely to be heard on auscultatory exam? AA diastolic decrescendo murmur heard at the left lower sternal border BA diastolic low-pitched decrescendo murmur best heard at the cardiac apex CA holosystolic murmur heard best at the cardiac apex DA systolic crescendo-decrescendo murmur best heard at the right upper sternal border

A diastolic low-pitched decrescendo murmur best heard at the cardiac apex dx: mitral stenosis secondary to rheumatic heart disease -------------------------------------------------------------- vs A systolic crescendo-decrescendo murmur best heard at the right upper sternal border (D) is characteristic of aortic stenosis. A diastolic decrescendo murmur heard at the left lower sternal border (A) classically describes aortic regurgitation. A holosystolic murmur heard best at the cardiac apex (C) is associated with mitral regurgitation.

A 35-year-old-man with a long history of occasional bloody diarrhea and abdominal pain presents with acute-onset severe abdominal pain. Vital signs are significant for a temperature of 102.2°F (39°C), heart rate 140 bpm, and blood pressure 82/55 mm Hg. On physical exam, his abdomen is distended and tympanitic. Which of the following diagnostic studies is indicated first at this time? AAbdominal radiograph BBarium enema CCT scan of the abdomen pelvis with IV contrast DSigmoidoscopy

Abdominal radiograph Toxic Megacolon History of ulcerative colitis or infectious colitis PE will show systemic toxicity Abdominal X-ray will show the colon dilated > 6 cm Most commonly caused by inflammatory bowel disease Treatment is IVF, Abx, IV corticosteroids (only if related to IBD), surgical consultation hallmark of toxic megacolon is colonic dilatation in a patient with a known inflammatory condition of the colon who appears systemically toxic. ------------------------------------------------------------ Barium enema (B) is contraindicated if toxic megacolon is suspected; it may precipitate an ileus and perforation. CT scan of the abdomen and pelvis with IV contrast (C) would not be the first imaging modality of choice; the diagnosis can be easily made on plain film. Sigmoidoscopy (D) is the most sensitive method for establishing the diagnosis of ulcerative colitis, but this is not an appropriate study in the setting of an acute surgical abdomen.

A 6-year-old boy is brought to the emergency department by his mother because he has been having severe abdominal pain that started yesterday. He has refused to eat for the past couple of days and has vomited once since arrival to the ED. He has not had a bowel movement for the past 3 days. On physical exam he appears to be in moderate distress. Vital signs are T 101.3°F, HR 119 bpm, BP 100/68 mm Hg, and oxygen saturation 98% on room air. His abdomen is soft but the right lower quadrant is exquisitely tender. Rebound tenderness is absent. Rectal exam reveals stool in the rectal vault. Which of the following is the most appropriate diagnostic study? AAbdominal computed tomography scan with contrast BAbdominal computed tomography scan without contrast CAbdominal radiograph DAbdominal ultrasound

Abdominal ultrasound dx: Appendicitis 👀👀👀look at image👀👀👀👀 . The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in about half of all cases and is therefore very inconsistent. Rovsing, obturator, and psoas signs are also generally inconsistent Appendicitis Patient presents with fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia PE will show psoas sign (RLQ pain on extension of right hip), obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (RLQ pain when the LLQ is palpated) Diagnosis is made by CT (adults), ultrasound (pediatric or pregnant patients), MRI (pregnant patients with nondiagnostic ultrasound) Most commonly caused by fecolith (fecalith) Treatment is surgery, in some case Abx ----------------------------------------------------------- vs Computed tomography (CT) (A and B) scanning with or without oral or IV contrast is generally the initial diagnostic modality for appendicitis in the adult population. However, due to radiation exposure, CT scans are not recommended as first line in the pediatric population. Plain radiographs (C) are not used to diagnose appendicitis, however they are used to evaluate for small-bowel obstruction.

A 55-year old woman presents with feeling "swollen all over." You do not notice any signs of edema, despite her claim that her rings no longer fit and that she has gone from a shoe size of 6 to a 7 1⁄2 over the last 2 years. A review of systems reveals that she is sweating more than usual, feels fatigued, and often has a dull headache and diffuse arthralgias. On examination she has no joint swelling, erythema, tenderness and no skin abnormalities are noted. This presentation is most consistent with which one of the following? AAcromegaly BCushing's disease CPolymyalgia rheumatica DScleroderma

Acromegaly The classic facial findings, which include enlargement of the supraorbital ridges, mandible and a widened nose, Patient presents with increased head, glove, or shoe size PE will show coarse facial features, oily skin, visual field deficits, diabetes Labs will show increased IGF-1 Most commonly caused by a pituitary adenoma Treatment is transsphenoidal resection

An 18-year-old man presents with mouth pain for 2 days. He reports associated fever, malaise, and a foul metallic taste in his mouth. On examination, you note poor dentition and fetid breath. He has pseudomembrane formation with gingival ulcerations and cervical adenopathy. Which of the following is the most likely diagnosis? AAcute necrotizing ulcerative gingivitis BBulimia CDiphtheria DLudwig angina EOral candidiasis

Acute necrotizing ulcerative gingivitis Acute Necrotizing Ulcerative Gingivitis Poor oral hygiene, tobacco use, immunodeficiency Halitosis, metallic taste, fever Oral ulcers with pseudomembrane Oral hygiene, chlorhexidene rinses Amoxicillin-clavulanate or clindamycin Management • Debridement • Antibacterial rinses (e.g., chlorhexidine) • Antibiotics (e.g., metronidazole)

A 35-year-old previously healthy man presents to your office with a complaint of diarrhea 24 hours after returning from a mission trip to Sierra Leone. He endorses hourly bouts of large volumes of stool that now have a white-colored liquid appearance. Physical exam findings include decreased skin turgor, dry buccal mucous membranes and a rapid, thready radial pulse. Which of the following is the most appropriate next step in management? AAdminister intravenous fluids BAdminister vitamin C CChloroquine DTrimethoprim-sulfamethoxazole

Administer intravenous fluids dx:Vibrio cholera "rice water stool", which refers to watery stool with flecks of mucus. Fever is generally not seen in patients with cholera,

A 64-year-old woman with a history of hypertension arrives by EMS with mental status changes. Paramedics orotracheally intubated the patient after she was found to be unresponsive. Her vital signs are T 37.7°C, BP 222/98 mm Hg, HR 130 bpm, and RR 16/min, assisted. Glucose is 100 mg/dL. Her pupils are pinpoint but are sluggishly reactive to a strong light source. The neurologic exam is unobtainable secondary to pharmacologic paralysis. CT scan of her head shows a large hemorrhage in the region of the pons. Which of the following is the most appropriate next step in management? AAdminister mannitol BAdminister nicardipine CAdminister phenytoin DAdminister recombinant factor VIIa EHyperventilate to pCO2 < 30 mm Hg

Administer nicardipine dx: acute intracranial hemorrhage nicardipine quick-acting calcium channel blocker commonly used for hypertension in the setting of acute intracranial hemorrhage. Persistently elevated blood pressure in patients with intracranial hemorrhage contributes to hematoma expansion and is associated with poorer outcomes Intracerebral Hemorrhage Patient will be > 50 years of age History of hypertension and atherosclerotic risk factors Neurological deficits (indistinguishable from ischemic) PE Pontine lesion: pinpoint pupils, coma, decerebrate posturing Cerebellar: vomiting, dizziness, CN VI palsy Most commonly caused by spontaneous bleeding from arterioles Treatment is blood pressure control (nicardipine), ICP control, reverse all coagulopathies When BP reduction is indicated, intravenous medications such as nicardipine (by continuous infusion) or labetalol (by intermittent bolus) are recommended. ------------------------------------------------------------------ vs Mannitol (A) is an osmotic diuretic that shifts water across the blood-brain barrier. It has been used clinically to reduce intracranial pressure with varying success. It is not the initial therapy to administer to this patient.

A 45-year-old patient with newly diagnosed diabetes mellitus type 2 presents to your office for her annual exam. She has had her hepatitis B vaccination, but wants to know if she needs any additional vaccinations because of her new diagnosis. Which of the following is the most appropriate next step in her management? AAdminister annual influenza vaccine only BAdminister pneumococcus and annual influenza vaccines CAdminister pneumonia prophylaxis with trimethoprim-sulfamethoxazole DThe patient does not need any additional vaccines since she is up to date

Administer pneumococcus and annual influenza vaccines

A 68-year-old woman in the intensive care unit is receiving 350 mg of gentamicin intravenously every 24 hours for the treatment of pneumonia. Gentamicin is a hydrophilic (i.e., water-soluble) medication that is primarily eliminated in the urine. Which of the following clinical scenarios would increase the half-life of gentamicin? AAdministering furosemide to diurese the patient BAdministering norepinephrine for blood pressure support CIncrease the dosing interval to every eight hours DIncreasing the dose to 400 mg every 24 hours

Administering norepinephrine for blood pressure support dx: The half-life of a drug is the time it takes for half of a drug in the body to be eliminated and is a factor of the drug's volume of distribution and clearance. Administering a vasopressor such as norepinephrine causes renal vasoconstriction and decreased kidney perfusion. Decreased kidney perfusion leads to less gentamicin being filtered at the glomeruli for elimination and increases the drug's half-life. Which vasopressor increases renal perfusion in low doses? Answer: Dopamine.

A 28-year-old pregnant person presents to the emergency department reporting fever, chills, nausea, vomiting, and constant back pain for 1 day. She reports dysuria for the past 4 days. She has no prior illnesses, two previous uncomplicated pregnancies, and is currently taking acetaminophen and prenatal vitamins. She reports she is 20 weeks pregnant. Physical exam reveals a diaphoretic patient with costovertebral tenderness on the left, suprapubic tenderness, fundal height of 20 cm, and fetal heart tones of 160 bpm. Vital signs reveal a T of 101.2°F, HR of 100 bpm, RR of 20/min, and BP of 128/80 mm Hg. The complete blood count is normal except for a white blood cell count of 20,000/µL and a neutrophil count of 10,200/µL. The urinalysis results are listed below: Leukocytes: 500/µL Nitrites: +++ Urobilinogen: negative Protein: 15 mg/dL pH: 5.0 Blood: ++ Specific gravity: 1.010 Ketones: negative Bilirubin: negative Glucose: negative What is the best next step in management of this patient's illness? AAdmit for intravenous ceftriaxone administration BAdmit for intravenous ciprofloxacin administration CDischarge with intramuscular ceftriaxone and follow-up outpatient next day DDischarge with

Admit for intravenous ceftriaxone administration dx:pyelonephritis Acute Pyelonephritis Sx: fever, dysuria, and flank pain PE: CVA tenderness Labs: UA + leukocyte esterase, nitrites, microscopy +WBCs, Gram stain, urine culture and susceptibility testing Most commonly caused by Escherichia coli Treatment depends on infection severity and community/host risk factors for resistant pathogens Fluoroquinolones TMP-SMX 3rd/4th gen cephalosporins For critical illness or risk for multidrug-resistant organisms: consider coverage for MRSA, VRE

An 80-year-old woman presents to your office because she is concerned about her vision. She has had worsening vision in her right eye over the past year and denies eye pain, redness, and tearing. She describes seeing "distorted and wavy window blinds". She has no significant past medical history. She wears prescription glasses and has not had any changes in her prescription. Which of the following is the most likely cause of her decrease in vision? AAge-related macular degeneration BAngle closure glaucoma CCataracts DCentral retinal artery occlusion

Age-related macular degeneration dx: Macular Degeneration Patient will be older Bilateral, gradual central field vision loss PE Dry (85% of cases): atrophic changes and yellow retinal deposits (drusen spots) Wet: vascular changes Diagnosis is made by characteristic findings on dilated eye examination Most common cause of blindness in the older population Patients typically have distortion or waviness in the central visual field. Problems with night vision and difficulty reading faces are common symptoms of this disorder. On physical exam, funduscopic examination in age-related macular degeneration is significant for drusen, which are yellowish-colored subretinal deposits in the macula, in the early stages of disease. Drusen are thought to be byproducts of retinal pigment epithelium dysfunction.

A previously healthy 27-year-old man presents to your office with a complaint of cold symptoms. He says that initially he had sinus congestion and a sore throat, which have since resolved, but he has also had a productive cough for approximately 10 days that is keeping him up at night. Physical exam reveals a temperature of 98.6°F and mild, diffuse wheezing on auscultation of the lungs. Which of the following is the most appropriate therapy? AAlbuterol BAzithromycin COseltamivir DPrednisone

Albuterol dx: Bronchitis Patient presents with a mucopurulent cough for more than 5 days PE will show wheezing and rhonchi CXR will show thickening of the bronchial walls in the lower lobes Most commonly caused by viruses Treatment is symptomatic relief --------------------------------------------------------------- vs Azithromycin (B) is used in the treatment of pertussis and acute exacerbation of chronic obstructive pulmonary disease. Oseltamivir (C) is an antiviral used to treat influenza and should be considered when patients present with symptoms of less than 48 hours onset that include fever.

An 88-year-old woman presents reporting substernal chest burning and difficulty swallowing that started earlier today. She was taking her pills when one of them "got stuck in her throat." She has an extensive medical history and is on multiple medications. Which of the following medications is most likely responsible for her symptoms? AAlendronate BLisinopril CMetformin DSimvastatin

Alendronate dx: Pill esophagitis It is associated with many medications, especially alendronate (a bisphosphonate used in the treatment of osteoporosis), tetracyclines, NSAIDs, potassium chloride, and ferrous sulfate. Treatment includes antacids to reduce esophageal inflammation. Patients should be advised to remain in an upright position while taking their medications and to drink at least 4 ounces of liquid with each pill.

A 41-year-old man with a medical history of type 2 diabetes on metformin presents to your office for his annual wellness exam. The patient reports being in his usual state of health and has no current symptoms. He has a family history of hypertension and is concerned about his blood pressure. He recently monitored his blood pressure at home with a reading of 118/62 mm Hg. He reports also checking his blood pressure last month at the pharmacy, and the reading was 110/67 mm Hg. His vital signs are BP 154/92 mm Hg, HR 83 bpm, RR 13 breaths per minute, and T 37.2°C. The physical exam is unremarkable. Which of the following is the most appropriate intervention? AAmbulatory blood pressure monitoring BHospital admission for blood pressure control CNo further interventions warranted DStart low-dose enalapril EStart low-dose hydrochlorothiazide

Ambulatory blood pressure monitoring dx: White coat hypertension occurs when there are discrepancies between blood pressure readings in and out of the office. considered in any patient with isolated elevated BP (systolic blood pressure [SBP] > 130 mm Hg,diastolic blood pressure [DBP] > 80 mm Hg) without evidence of end-organ damage, such as papilledema, encephalopathy, or acute kidney injury. Ambulatory blood pressure monitoring should be the initial approach to managing suspected white coat hypertension. ------------------------------------------------------------ vs No further interventions (C) is not appropriate currently, as this patient has elevated BP without a diagnosis, which warrants further workup.

A 54-year-old woman presents to the office for her annual physical exam. Her only symptom is a mild headache for 4 or 5 days out of each week for the past 6 months. She reports a family history of high blood pressure and cerebrovascular accidents. She takes no medications and has no previous chronic diagnoses. Vital signs include blood pressure 190/100 mm Hg, pulse 82 beats per minute, temperature 98.6°F, and respirations 15 per minute. Her body mass index is 22 kg/m². Her complete metabolic panel and complete blood count are normal, as is her lipid panel and urinalysis. ECG and CXR are normal. Physical exam, including the fundoscopic exam, is within normal limits. Which of the following combination drug therapies would be the best choice for initial therapy for this patient? AAmlodipine plus diltiazem BAmlodipine plus lisinopril CCaptopril plus losartan DHydrochlorothiazide plus spironolactone ESpironolactone plus captopril

Amlodipine plus lisinopril

Attempt manual reduction dx: rectal prolapse Precipitated by defecating, coughing, and sneezing No vascular compromise: manual reduction in ED Vascular compromise: emergency surgery consultation and reduction Consider CF in pediatric patient Types 1 Mucosal prolapse (hemorrhoids and children) 2 All layers prolapse 3 Intussusception -------------------------------------------------------------- vs In some cases, the rectal tissue becomes edematous and at risk for vascular compromise. These cases require urgent surgical consultation (B). Antibiotics (C) are not necessary in adult rectal prolapse. Pediatric rectal prolapse is more worrisome and is associated with malnutrition, parasitic infection, and cystic fibrosis.

An 83-year-old woman with a history of constipation presents to the ED complaining of a rectal mass. On exam, you note the mass seen in the image above. What is the most appropriate next step in management? AAttempt manual reduction BConsultation to a colorectal surgeon CImmediately begin broad-spectrum antibiotics DInject local anesthesia and perform an excisional thrombectomy

A patient presents with weight loss, nervousness, and palpitations. During physical examination, which of the following signs suggests hyperthyroidism? AAnterior neck bruit BCoarse, dry, scaling skin CDistal muscle weakness DPeriorbital erythema

Anterior neck bruit 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 What are other head and neck physical signs of hyperthyroidism? Answer: Fine, thin, moist skin, prominent eyes with lid retraction (proptosis, or exophthalmos), and a startled expression. Hyperthyroidism is associated with proximal, not distal, muscle weakness. This may be appreciated as shoulder or hip girdle weakness in the setting of normal strength of the hands and ankles. ------------------------------------------------------------- Coarse, dry, scaling skin (B) is more commonly seen in hypothyroidism. Distal muscle weakness (C) is common in peripheral neuropathies. Hyperthyroidism is associated with proximal, not distal, muscle weakness. This may be appreciated as shoulder or hip girdle weakness in the setting of normal strength of the hands and ankles. Periorbital erythema (D) is seen with periorbital cellulitis not hyperthyroidism.

Which of the following valvular disorders is characterized by an early high-pitched, blowing diastolic murmur heard best over the left sternal border, and a wide pulse pressure? AAortic regurgitation BAortic stenosis CMitral stenosis DTricuspid stenosis

Aortic regurgitation PE:Widening pulse pressureBounding water-hammer peripheral pulsesHead bobbing with systole (de Musset sign)Prominent nail pulsations (Quincke pulse)Hyperdynamic apical pulse displaced to the leftDiastolic blowing murmur best heard along LSBSystolic or diastolic thrill or murmur heard over the femoral arteries (Duroziez sign)In severe AR, a mid-diastolic murmur (Austin-Flint murmur) Diagnosis is made by echo to determine the severity of regurgitation Most commonly caused by abnormal leaflets or proximal aortic root Tx: valve replacement surgery for symptomatic patients and asymptomatic patients with EF < 55% or enlarged LV, or progressive LV changes ---------------------------------------------------------- vs

A 67-year-old man with a history of hypertension and remote abdominal aortic aneurysm repair presents to the emergency department after four episodes of gross hematemesis. He had an episode of emesis with some blood last week but dismissed it as a "stomach bug." He reports no history of heavy alcohol use or liver disease. His vital signs on arrival are T 38.5°C, HR 111 bpm, BP 100/80 mm Hg, RR 27/min. His stool is guaiac positive. Which of the following is the most likely cause this patient's symptoms? AAortoenteric fistula BEsophageal varices CMallory-Weiss tear DPeptic ulcer disease

Aortoenteric fistula The classic triad of gastrointestinal bleeding, abdominal pain, and a palpable mass is rarely present and a history of aortic aneurysm is rarely known at the time of presentation. Fever and sepsis may be present due to seeding of the blood with gastrointestinal flora. Management of aortoenteric fistulas is emergent surgical repair. Gastrointestinal bleeding, including hematemesis, hematochezia, and melena, is often the presenting symptom Aortoenteric Fistula History of AAA, aortic repair, aortic graft replacement Reports rectal bleeding PE will show signs of shock Management includes blood transfusion or resuscitation and emergent surgical consultation

A 54-year-old man presents complaining of epigastric pain that started several hours ago. The pain is moderate and sharp but does not radiate. He has a history of hypertension and an exploratory laparotomy 20 years ago. His vital signs on presentation include T 37°C, HR 95 bpm, and BP 136/80 mm Hg. His exam reveals a firm, mildly tender protruding mass in the epigastric region with no overlying skin changes. Which of the following is the best next step? AApply gentle steady pressure to the mass BObtain computed tomography scan of the abdomen CPerform bedside abdominal aortic ultrasound DPerform incision and drainage of the mass

Apply gentle steady pressure to the mass dx: ventral hernia through the incision site from his exploratory laparotomy. Inguinal Hernias Bimodal: < 1 and > 40 years old DirectProtrudes directly through Hesselbach triangle and medial to the inferior epigastric artery (IEA)Bulge decreases upon reclining Indirect​​Most common typeProtrudes through internal ring, lateral to IEA Mnemonic: MDs don't lie​Medial to IEA: directLateral to IEA: indirect Strangulation risk: indirect > direct Nonreducible hernia: emergent surgery consultation

A 63-year-old right-handed man presents to the emergency department with a sudden onset of numbness on the right side of his face, arm, and leg, as well as right arm and leg weakness. His symptoms started fifteen minutes prior to presentation. On exam, the patient has mild aphasia, mild dysarthria, a pronator drift of his right arm, diminished strength of his right arm and leg, and diminished sensation on the right side. Computed tomography of the brain and computed tomography angiography of his brain and neck were performed and by the time the scans were finished the patient had complete resolution of his symptoms. The computed tomography angiography of the neck revealed a 90% stenotic atherosclerotic lesion of the left internal carotid artery. Carotid endarterectomy was scheduled. The most appropriate next step is administration of which of the following? AAspirin BClopidogrel CDual antiplatelet therapy DWarfarin sodium

Aspirin dx: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 Treatment is primarily focused on resolving the symptomatic carotid atherosclerotic disease. A) In patients with recently (within the previous four to six months) symptomatic carotid stenosis of 70 to 99 percent who have a life expectancy of at least five years, a carotid endarterectomy (CEA) is recommended. ---> For patients undergoing CEA, low-dose aspirin treatment should be started prior to the procedure and is continued for at least three months after CEA is done. Carotid revascularization is not recommended for patients with chronic total occlusion of the carotid artery.😶‍🌫️😶‍🌫️😶‍🌫️😶‍🌫️ B) For patients with recently symptomatic carotid stenosis of 70 to 99 percent, carotid artery stenting (CAS) is preferred if any of the following conditions are present: carotid lesion that is not suitable for surgical access, radiation-induced stenosis, or clinically significant cardiac, pulmonary, or other disease that increases the risk of anesthesia and surgery. C) For patients with symptomatic carotid stenosis that is less than 50 percent, medical management with antithrombotic medications is recommended. ----------------------------------------------------------------- Dual antiplatelet therapy (C) is used in patients prior to undergoing carotid artery stenting. It includes both aspirin and clopidogrel.

A 35-year-old woman presents for several days of anterior neck pain radiating to her ears, accompanied by dysphagia and "restlessness." She endorses a low-grade fever and fatigue that is "lingering" from her recent flu-like illness. Physical exam shows a tender, symmetrically enlarged thyroid. Laboratory studies show a normal complete blood count, suppressed thyroid stimulating hormone, low antithyroid antibody titers, and a high erythrocyte sedimentation rate. In addition to propranolol, the most appropriate treatment plan includes which of the following medications?🍹 AAmpicillin BAspirin CLevothyroxine DMethimazole

Aspirin dx:subacute thyroiditis which is treated with oral propranolol to manage her symptoms of hyperthyroidism and aspirin to manage pain. Subacute thyroiditis, or deQuervain thyroiditis, is a common, transient condition that usually presents after a recent viral illness, such as an upper respiratory infection. Subacute (de Quervain) thyroiditis Preceded by viral URI Anterior neck pain Suppressed TSH, elevated ESR Low uptake on thyroid scan Tx: high-dose ASA or NSAID

A 7-year-old boy presents to the office with his mother for evaluation of his angry and defiant behavior that has been steadily worsening over the past year. The mother is teary and exasperated, explaining that it is a battle every day to get him to do normal tasks like getting ready for school or eating meals since he is often argumentative and does not do what he is told. He constantly blames her and her husband for making his life miserable. You suspect oppositional defiant disorder. Assessing for the presence of what common co-occurring disorder is key in effective treatment? AAntisocial personality disorder BAttention-deficit/hyperactivity disorder CAutism spectrum disorder DDisruptive mood dysregulation disorder

Attention-deficit/hyperactivity disorder

According to the United States Preventive Services Task Force (USPSTF), which of the following is considered to put a pregnant woman at high risk for developing preeclampsia? AAutoimmune disease BHistory of cesarean section CHyperlipidemia DYoung maternal age

Autoimmune disease What is the only medication proven to decrease risk of developing preeclampsia in high risk women when administered during the second and third trimester? Answer: Low dose aspirin. 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

A 24-year-old woman presents to her primary care provider with complaints of diarrhea and a pruritic rash for the past four months. She reports an unintentional weight loss of five pounds despite increasing her calorie intake. On exam, her abdomen is slightly distended but nontender. Multiple small papulovesicles are noted on the extensor surface of her elbows and knees. A biopsy of these lesions reveals a granular pattern of immunoglobulin A deposition in the upper papillary dermis. Based upon the likely diagnosis, which of the following is the most appropriate management? AAvoidance of oats, rice, and soy BAvoidance of wheat, rye, and barley COral prednisone DReduction of lactose-containing foods

Avoidance of wheat, rye, and barley dx : Celiac disease patient presents with Dermatitis herpetiformis is an extremely pruritic papulovesicular rash that tends to be located on the extensor surfaces of the extremities, back, buttocks, and neck. Serological test should be performed on all patients with suspected celiac disease. Immunoglobulin A (IgA) endomysial antibody and tissue transglutaminase IgA are the most accurate and commonly used serology tests

A 45-year-old G0P0 woman presents to the office for a routine annual examination. Her medical history is significant for diabetes mellitus, controlled well on metformin, and hypertension, controlled well on losartan. She is not sexually active and reports no previous sexually transmitted infections. Vital signs include HR of 69 bpm, BP of 130/85 mm Hg, RR of 15/min, oxygen saturation of 99% on room air, and T of 98.7°F. Physical examination reveals a painless 2 cm round nodule on the right posterior vaginal orifice. What is the most likely diagnosis? ABartholin gland cyst BCondyloma acuminatum CHerpes simplex virus DParaurethral gland abscess EPerianal abscess

Bartholin gland cyst The most common location for a Bartholin gland cyst or abscess is in the posterior introitus near the 4 o'clock or 8 o'clock positions. The incidence of bartholin gland cysts appear to increase with age and peak around menopause. Pain, induration, and fluctuance are usually present with an abscess. Incision and drainage are usually necessary.

28-year-old married heterosexual man presents to your office for his annual exam. He tested negative for HIV after getting married and has not had any other sexual partners. He wants to know how often he should be screened for HIV. What prevention guidance do you provide? ABased on your clinical judgment, he is at low risk for contracting HIV and therefore does not need repeat screening at this time BHe should be screened annually, regardless of risk CHe should be screened every 10 years, regardless of risk DHe should be screened every 5 years, regardless of risk

Based on your clinical judgment, he is at low risk for contracting HIV and therefore does not need repeat screening at this time According to the Centers for Disease Control and Prevention (CDC), initial HIV screening should be a normal aspect of clinical care. Individuals ages 13-64 should be routinely screened for HIV infection. Providers may use clinical judgment regarding repeat screening of patients who are low-risk How often should sexually active homosexual men be screen for HIV? Answer: At least annually.

A 76-year-old man presents to the emergency department with shortness of breath and lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of the following is the most appropriate diagnostic test? ABedside echocardiography BChest radiograph CComputed tomography angiogram of the chest DElectrocardiogram

Bedside echocardiography dx: Pericardial Tamponade Patient presents with dyspnea and chest pain PE will show muffled heart sounds, JVD, hypotension (Beck triad), pulsus paradoxus ECG will show low-voltage QRS, electrical alternans Echocardiography = bedside echocardiography is the diagnostic test of choice. Diastolic collapse of RV (highly sensitive and specific) Early systolic collapse of RA (less sensitive but very specific)Plethoric IVC Treatment is pericardiocentesis This patient presents with a clinical picture consistent with obstructive shock. His distended neck veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent with pericardial tamponade.

A previously healthy 20-year-old man presents to the emergency department assisted by his roommates. The patient is febrile, disoriented, has difficulty speaking, and is complaining of generalized abdominal pain. He has a rash that does not blanch on palpation. Laboratory findings include hematocrit 21%, platelets 10,000/mcL, MCV 90 fL, INR 1.6, and creatinine 4.75 mg/dL. Which of the following is the most appropriate next step in management? ABegin emergent plasma exchange BHold treatment until labs for ADAMTS13 deficiency are completed CPrescribe cortisone cream and have the patient follow up with their primary care provider DWatchful waiting as the condition is self-limiting

Begin emergent plasma exchange dx:thrombotic thrombocytopenic purpura (TTP) classic pentad of microangiopathic hemolytic anemia, thrombocytopenia, fever, acute renal failure, and severe neurologic findings. Risk factors: female sex, age < 50, pregnancy Sx: fever, confusion, difficulty speaking, headache, seizure, nausea, vomiting, diarrhea Labs: elevated LDH, elevated indirect bilirubin, normal coagulation studies, microangiopathic hemolytic anemia, and thrombocytopenia Caused by autoantibody against ADAMTS13 leading to severe deficiency of the enzyme Treatment is plasma exchange with intravenous corticosteroids

A 12-year-old boy presented to your office one week ago with complaints of sore throat, bilateral knee pain, and chest pain. Treatment with penicillin was initiated and he has now returned for follow-up. Which of the following laboratory tests is most appropriate to monitor progress of his disease?🎍🎍 ABlood cultures BC-reactive protein CComplete blood count DThroat culture

C-reactive protein dx: Acute rheumatic fever (ARF) is an inflammatory, autoimmune response that develops after infection with Group A Streptococci (GAS). PE: Jones criteria: joints, oh no—carditis!, nodules, erythema marginatum, Sydenham chorea Labs: antistreptolysin O, anti-DNase B, positive throat culture, or positive rapid antigen test Treatment is antibiotics, NSAIDs Modified Jones criteria for a first episode of acute rheumatic fever: need two major or one major and two minor plus evidence of recent GAS infection

A 34-year-old man presents to urgent care with diarrhea and abdominal pain for the past 24 hours. He reports cramping abdominal pain, 10-12 bowel movements in that period, and blood in his stool. He also states he was feeling feverish for 1 day before the abdominal pain started, but he reports no nausea or vomiting. 2 days ago, he returned from a week-long trip to Guatemala. While there, he visited a petting zoo where he had contact with chickens, cows, and donkeys. He was careful to drink bottled water. He has no significant medical history and is on no medications. His vitals include a BP of 111/70 mm Hg, HR of 74 bpm, RR of 14/min, T of 99.0°F, and SpO2 of 99% on room air. On physical examination, he has dry mucous membranes and is tender to palpation in the periumbilical area. Stool guaiac is positive. Stool studies are negative for ova and parasites. What is the most likely cause of his symptoms? ABacillus cereus BCampylobacter jejuni CEntamoeba histolytica DGiardia lamblia ENorovirus

Campylobacter jejuni Traveler's diarrhea is a mostly self-limited disease that occurs within 1 week of travel to another country. The diarrhea, which is often bloody, usually develops within 2-10 days of travel. Campylobacter is a common cause of acute traveler's diarrhea and abdominal pain, with Campylobacter jejuni and Campylobacter coli being among the most likely causes of Campylobacter enteritis.

A 67-year old woman is admitted to the hospital with a change in mental status. The initial workup includes a chemistry profile that reveals a plasma potassium level of 6.4 mEq/L. An ECG is performed that reveals peaked T waves. Which of the following is the most appropriate to administer to this patient? AAlbuterol BCalcium gluconate CFurosemide DSodium polystyrene sulfonate

Calcium gluconate Hyperkalemia Confirm no hemolysis in blood sample History of kidney failure, DKA, rhabdomyolysis, tumor lysis Lethargy, weakness, paralysis PE: bradycardia, hypotension, cardiac dysrhythmia ECG: peaked T waves, prolonged PR, wide QRS Treatment is calcium gluconate, insulin, albuterol, bicarbonate (less effective), dialysis, oral potassium binders (new, still undergoing further investigation) Review medication list for possible causes

What is the most common cause of lens opacity? ACataract BGlaucoma CHyphema DOptic neuritis

Cataract

A 23-year-old man presents with rectal pain. He also reports yellow discharge and tenesmus. He is sexually active with men and has receptive anal intercourse. Which of the following is the most appropriate treatment? ACeftriaxone 1 gm IV and azithromycin 1 gm PO BCeftriaxone 500 mg IM and doxycycline 100 mg PO BID for 7 days CCiprofloxacin 500 mg PO BID for 7 days and metronidazole 500 mg PO TID for 7 days DMetronidazole 500 mg PO TID for 7 days

Ceftriaxone 500 mg IM and doxycycline 100 mg PO BID for 7 days dx: proctitis. # in rectum important consideration in men who have sex with men or women who take part in anal intercourse. I Proctitis Sexually transmitted > radiation, autoimmune Most common organism: N. gonorrhoeae Tenesmus Rectal discharge ------------------------------------------------------ vs Ceftriaxone 1 gm IV and azithromycin 1 gm PO (A) is not the first line treatment in gonococcal or chlamydial infection of the rectum.

A 32-year-old man reports a history of developing diffuse urticaria after taking amoxicillin. To which of the following antibiotics is he most likely to have an allergy? ACefepime BCefoxitin CCeftriaxone DCephalexin

Cephalexin look at image '

A 23-year-old woman presents to your office with complaints of pelvic pain and vaginal discharge. She reports having recent unprotected intercourse with a new partner, and her last menstrual period ended three days ago. Which of the following physical exam findings supports the most likely diagnosis? ACervical cyanosis BCervical motion tenderness CGoodell sign DHegar sign

Cervical motion tenderness dx: Pelvic inflammatory disease (PID) Rx (outpatient) • Ceftriaxone 500 mg* IM PLUS • Doxycycline 100 mg PO BID × 14 days AND • Metronidazole 500 mg PO BID × 14 days Rx (inpatient) • Cefotetan 2 gm IV every 12 hrs OR cefoxitin 2 gm IV every 6 hrs PLUS • Doxycycline 100 mg PO/IV every 12 hrs

A 30-year-old woman presents complaining of pelvic pain and fever. She had a Cesarean section 3 days prior to presentation at 36 weeks gestation for failure to progress and premature rupture of membranes. Her incision is clean and dry. She is tender in the lower abdomen and foul-smelling lochia is noted during pelvic examination. Which of the following is the most important risk factor in the development of this condition? ACesarean section BMultiple internal examinations CPremature labor DPremature rupture of membranes

Cesarean section dx:postpartum endometritis

A 27-year-old previously healthy man visiting the United States from Guatemala presents to the ED with acute dyspnea. He reports feeling well until about one week ago. Vital signs are significant for a BP of 110/70 mm Hg, HR 120 bpm, RR 26 breaths per minute, T 38.3°C, and pulse oximetry of 93% on room air. On exam, you note facial and lower extremity edema, hepatosplenomegaly, and lymphadenopathy. What is the most likely diagnosis? AChagas disease BDressler syndrome CKawasaki disease DTakotsubo cardiomyopathy

Chagas disease latine americas --------------look at image -----------------> Trypanosoma cruzi. The parasite is transmitted through the bite of the reduviid (kissing bug) and is endemic in South and Central America. Acute myocarditis is a common complication of Chagas disease and may manifest with acute heart failure (as in this example) or dysrhythmia (often refractory to rate control). Acute infection is characterized by fever, edema, hepatosplenomegaly, lymphadenopathy, malaise, lymphocytosis, and elevated liver transaminases. In 25% of cases, acute infection progresses to chronic disease, typically with cardiac (dilated cardiomyopathy) or gastrointestinal (megaesophagus and megacolon) involvement.

A 55-year-old man with a history of peptic ulcer disease presents to your office with a complaint of right knee pain that started last night. On physical exam his knee is erythematous, warm and exquisitely tender to palpation. Synovial fluid analysis reveals the presence of positively birefringent calcium pyrophosphate dihydrate crystals. Which of the following is the most appropriate therapy? AAllopurinol BColchicine CIndomethacin DVancomycin

Colchicine dx: Pseudogout Mono or oligo-articular arthritis caused by deposition of calcium pyrophosphate crystals Labs: rhomboid-shaped crystals, weakly positive birefringence X-ray: chondrocalcinosis Tx options: intra-articular steroid injection (one or two joints), NSAIDs, colchicine, systemic corticosteroids Notes: can be associated with hemochromatosis, hyperparathyroidism, hypomagnesemia, hypophosphatemia ---------------------------------------------------- Indomethacin (C) is an NSAID that is first-line in the treatment of acute attacks of both gout and pseudogout. NSAIDs are contraindicated in patients with peptic ulcer disease, heart failure, renal insufficiency, and hypersensitivity to NSAIDs.

A 2-day-old infant boy is evaluated for poor feeding and bilious vomiting. He had a vaginal delivery with no complications. He has not passed any meconium since birth. He has a temperature of 98.6°F, a heart rate of 118 bpm, a blood pressure of 82/56 mm Hg, a respiratory rate of 42/minute, and oxygen saturation of 99%. He is irritable on physical exam. He has a distended abdomen with no palpable mass and a tight anal sphincter upon digital rectal examination. An abdominal radiograph reveals dilated loops of bowel without gas or stool present in the rectum. Which of the following is the underlying cause of this condition? AAbnormal narrowing of the duodenum BCongenital absence of ganglion cells in the rectum and colon CIncomplete closure of the vitelline duct DInflammation of the colonic mucosa into the smooth muscle layer EOutward protrusion of intestinal loop bulges through the umbilical ring

Congenital absence of ganglion cells in the rectum and colon Hirschsprung Disease Congenital aganglionic megacolon Male > female, Down Syndrome History of delayed meconium passage Diagnosis is made by rectal biopsy Most commonly caused by an absence of ganglion cells in the submucosal and myenteric plexus

A 19-year-old woman presents to the clinic with heavy and painful periods for the past year. Her cycles are irregular lasting up to three to four weeks at a time. The patient is not on any medications, is sexually active, and a pregnancy test in the office is negative. She has a normal body mass index and Pap smear, and the pelvic ultrasound and pelvic examination are unremarkable. Which of the following is the first-line treatment for this condition? ACombined oral contraceptive pills BDesmopressin CEndometrial ablation DHigh dose intravenous estrogen A 32-year-old woman presents with vaginal bleeding for two weeks. She states she has had to change her pad every 2-3 hours with the bleeding. Vital signs are normal and physical exam only reveals blood coming from the cervical os. The patient's hemoglobin is 12 g/dL and her pregnancy test is negative. What treatment is indicated for this patient? AAdmission for dilation and curettage BCombination oral contraceptives CHysterectomy DIntravenous estrogen therapy

Combined oral contraceptive pills EtiologyStructural causes: polyp, adenomyosis, leiomyoma, malignancy or hyperplasia (PALM)Nonstructual causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified (COEIN) ------------------------------------------------------------ vs Desmopressin (B) is used as a last resort to treat patients with abnormal uterine bleeding who also have coagulation disorders. Endometrial ablation (C) is minimally invasive surgical procedure used to treat heavy or prolonged uterine bleeding when there is no response to medical therapy. High-dose intravenous estrogen (D) is used for women with heavy menstrual bleeding who are hemodynamically unstable.

You are treating a patient with type 2 diabetes mellitus. He is currently on metformin, but his hemoglobin-A1c is not at goal. You decide to add insulin. Which of the following is the best approach when considering this management plan? AContinue oral medications, add long-acting insulin BContinue oral medications, add short-acting insulin CStop oral medications, start long-acting insulin

Continue oral medications, add long-acting insulin ADA diagnostic criteria: Symptomatic= Random plasma glucose ≥ 200 mg/dL 👀👀👀👀👀👀👀 Asymptomatic = Fasting plasma glucose ≥ 126 mg/dL Glycated hemoglobin (A1C) ≥ 6.5% Plasma glucose ≥ 200 mg/dL 2 hours after a 75 g glucose load during an OGTT Tx: lifestyle modifications then medication (first-line Rx: metformin) Screen adults aged 35-70 with BMI ≥ 25 kg/m2 every 3 yearsThose with additional risk factors need annual screening ---------------------------------------------------------------- vs Long-acting insulin is preferred over short-acting insulin (B) in the early stages of insulin therapy. A gradual transition, and not abrupt cessation (C and D), of oral medications to insulin is the recommended approach.

A 28-year-old woman presents to your office after being bitten on her index finger by a child who she works with. Upon examination, you note a 2 x 2 cm area of macerated skin at the medial aspect of the proximal interphalangeal joint. The patient is neurovascularly intact. Which of the following is the most appropriate next step in management to reduce the likelihood of wound infection? ACopious irrigation of the wound BImmediate prophylactic antibiotic therapy CRadiographs of the hand to rule out presence of foreign bodies DSuturing the wound and send patient home with close follow-up

Copious irrigation of the wound dx:Human Bites Polymicrobial (Eikenella corrodens) Hand wounds: leave open Fight bites: boxer's fracture Abx for all (amoxicillin-clavulanate) --------------------------------------------------------- vs Prophylactic antibiotic therapy (B) is warranted in this case, but only after wound irrigation is properly performed Suturing a bite wound (D) should not be performed since bite wounds are usually deep and penetrating. These wounds should be healed by secondary intention to prevent infection.

An 18-month-old boy is brought in by his parents for shortness of breath. The parents woke to him coughing a low-pitched cough. They also noted other noises when he was breathing in that resolved upon walking outside. The patient is frequently coughing but has no abnormal sounds on auscultation of the neck or lungs. What is the most appropriate treatment? AAlbuterol BDexamethasone CRacemic epinephrine DRibavirin

Dexamethasone dx: Croup [Laryngotracheitis] The administration of dexamethasone is the mainstay of therapy and has been shown to decrease the duration of symptoms, decrease return visits to the ED, decrease the length of stay in the ED, and decrease the need for epinephrine. In patients with stridor, the administration of racemic epinephrine leads to rapid improvement of symptoms in most cases. Patients who have received racemic epinephrine need a period of observation after treatment to ensure that stridor and retractions do not recur. On X-ray, the steeple sign is present due to a narrowing of the upper trachea from the infection.

A 19-year-old man presents to the clinic after losing his job a month ago. During your interview, the patient reports he drinks daily. You suspect the patient has alcohol use disorder. Which of the following is a criterion for the diagnosis of alcohol use disorder? ACraving or strong urge to use alcohol BDrinking at least six alcoholic beverages per day CHaving legal problems related to alcohol use DSymptoms lasting at least 6 months

Craving or strong urge to use alcohol Alcohol Use Disorder Mild: Two to three symptoms Moderate: Four to five symptoms Severe: Six or more symptoms Symptoms 1) Recurrent drinking leading to inability to fulfill major role obligations 2)Recurrent drinking in hazardous situations 3)Continued drinking despite alcohol-related social or interpersonal problems 4)Evidence of tolerance or alcohol withdrawal 5)Use of alcohol for relief or avoidance of withdrawal 6)Drinking in larger amounts or over longer periods than intended 7)Persistent desire or unsuccessful attempts to stop or reduce drinking 8)Great deal of time spent obtaining, using, or recovering from alcohol 9)Important activities given up or reduced because of drinking 10)Continued drinking despite knowledge of physical or psychological problems caused by alcohol 11)Craving or having a persistent urge to drink alcohol ------------------------------------------------------------- Drinking at least six alcoholic beverages per day (B) is not required for a diagnosis of alcohol use disorder. There is no minimum amount of alcohol consumption needed for diagnosis. Having legal problems related to alcohol use (C) was previously part of the DSM-IV criteria for alcohol abuse but was removed from the DSM-5 criteria. Patients need to have symptoms of alcohol use disorder in the last 12 months, they do not have to have symptoms for 6 months (D), to meet the criteria for diagnosis.

A 74-year-old man with hyperlipidemia, diabetes mellitus, hypertension, and a 25 pack-year history of tobacco use presents to the clinic with a recent onset of severe epigastric abdominal pain that radiates to his back. His current medications include metformin, exenatide, lisinopril, propranolol, simvastatin, aspirin, and niacin. Vital signs include HR 97 bpm, RR 16 breaths/min, BP 138/87 mm Hg, T 98.8°F, SpO2 98% on room air, and an unintentional weight loss of 12 lbs in 1 month. Physical examination reveals scleral icterus, hepatomegaly, and an enlarged, nontender gallbladder. Laboratory studies include serum lipase 115 U/L, bilirubin 2.8 mg/dL, alkaline phosphatase 200 U/L, alanine aminotransferase 32 U/L, and aspartate aminotransferase 28 U/L. Which of the following findings is most likely to be seen on diagnostic imaging given the most likely diagnosis? ABile duct wall thickening and focal bile duct dilation BDilation of the pancreatic and common bile ducts CObstruction of the common bile duct by cholelithiasis DPancreatic atrophy EPeripancreatic fluid collection

Dilation of the pancreatic and common bile ducts dx: Pancreatic Cancer Risk factors: history of smoking GREATEST RISK Sx: abdominal or epigastric pain, painless jaundice, weight loss, anorexia Labs: CA 19-9 serum marker useful in monitoring Dx: U/S, ERCP or MRCP, CT, endoscopic ultrasound Management:Resectable disease: Whipple procedure (pancreaticodudenectomy) + adjuvant chemoUnresectable disease: FOLFIRINOX or gemcitabine-based chemo Most common type is adenocarcinoma Poor prognosis Trousseau syndrome,Tender migratory thrombophlebitis palpable nontender gallbladder (Courvoisier sign) another sign of pancreatic cancer Initial testing for patients with jaundice is transabdominal ultrasonography, Ultrasound findings consistent with pancreatic cancer include a focal, hypoechoic hypovascular solid mass with irregular margins and dilation of the pancreatic and common bile ducts, also called the double duct sign. Findings on ERCP suggesting a malignant tumor of the pancreas include the double duct sign, a pancreatic duct stricture > 1 cm in length, pancreatic duct obstruction, and absence of changes suggestive of chronic pancreatitis. Patients with weight loss and abdominal pain without jaundice should have abdominal computed tomography (CT) ordered initially. Suspected pancreatic cancer is best assessed using dual-phase contrast-enhanced spiral CT with arterial phase enhancement and portal venous phase enhancement. Results from this test indicating exocrine pancreatic cancer include an ill-defined hypoattenuating mass within the pancreas with secondary signs, including pancreatic duct cutoff, dilation of the pancreatic or common bile duct, parenchymal atrophy, and contour abnormalities. --------------------------------------------------------------- vs Obstruction of the common bile duct by cholelithiasis (C) is not commonly found in patients with pancreatic cancer. Cholelithiasis often presents with laboratory evidence of obstruction, including hyperbilirubinemia, elevated aminotransferase levels, and potentially elevated lipase levels. Patients with obstruction secondary to cholelithiasis do not report unintentional weight loss and report symptoms of biliary colic and nausea and vomiting that can b

An elderly man presents with 6 months of progressive positional dyspnea. Nine months ago, he had a mild heart attack and was properly treated. Today, you appreciate a new loud, blowing holosystolic murmur heard at the apex. Which of the following color Doppler echocardiography findings would you most expect to find based on these signs and symptoms? ADuring diastole, blood flows from the right ventricle into the right atrium BDuring diastole, blood is seen flowing from the aorta into the coronary arteries CDuring systole, blood flows from the left ventricle into the aorta DDuring systole, blood is seen flowing from the left ventricle into the left atrium

During systole, blood is seen flowing from the left ventricle into the left atrium

A 60-year-old postmenopausal woman presents with painless vaginal bleeding. Her last papanicolaou smear, performed two years ago, was normal. Her pelvic exam in the office reveals a small amount of blood at the cervical os. Which of the following is the most appropriate diagnostic test? AColposcopy with endocervical curettage BEndometrial biopsy CHysteroscopy DTransabdominal ultrasonography

Endometrial biopsy

A 24-year-old woman presents to the office for a fertility consult. She and her partner have been trying to conceive for 18 months without success. Her menstrual cycles are anywhere between 21 and 45 days in length, and each period lasts between 7 and 10 days with heavy bleeding, requiring at least one tampon change per hour during her heaviest days. Her temperature is 98.7°F, blood pressure is 136/82 mm Hg, heart rate is 98 bpm, and respiratory rate is 22/minute. Her body mass index is 36 kg/m2. A physical exam reveals scattered comedones and papulopustules to the forehead, cheeks, and nose and some visible hair to the upper lip and chin. Which of the following is this patient at greatest risk for developing malignancy of? AAdrenal gland BBreast CCervix DEndometrium EThyroid gland

Endometrium dx: Polycystic ovary syndrome (PCOS . Body mass index (BMI) ≥ 30 kg/m2, amenorrhea, acne, hirsutism, acanthosis nigricans, insulin resistance, and infertility are hallmark features of PCOS. Ovulatory dysfunction, hyperandrogenism, and polycystic ovaries Common PE findings: bilateral ovarian enlargement, acanthosis nigricans, high BMI Laboratory evaluation: Oligomenorrhea: hCG, FSH, TSH, prolactin Hyperandrogenism: total testosterone and sex hormone-binding globulin or bioavailable and free testosterone, morning 17-hydroxyprogesteroneMetabolic disease screening: 2-hour oral glucose tolerance test, fasting lipid panel Commonly associated with insulin resistance, which may be the central etiology Treatment is combination low-dose oral contraceptive pills, lifestyle changes, metformin Most common cause of infertility. Letrozole is first-line therapy for ovulation induction

A 58-year-old man presents with bilateral buttock and shoulder pain. Other than hypertension, he has no significant medical history. He states that he has felt "stiff" and "tired" for the past few weeks. He denies any specific injury, but does report being more active in the garage working on his classic automobile. He also denies back pain. Examination reveals no skin or digit abnormalities. Ophthalmologic examination is within normal limits. The gluteal and periscapular muscles are tender to palpation, but there is no discernable trigger point, warmth or induration. Which of the following laboratory abnormalities is most likely present in this patient? AAntinuclear antibody positivity BErythrocyte sedimentation rate > 50 mm/h CHLA-B27 positivity DSideroblastic microcytic anemia

Erythrocyte sedimentation rate > 50 mm/h dx: Polymyalgia rheumatica (PMR) is an acute vasculitic condition marked by acute proximal muscle pain and stiffness. Age of onset is > 50 years.

A 64-year-old woman with morbid obesity presents with skin changes of the bilateral lower extremities that have been present for the past several months. She reports darkened patches of skin in the ankle areas with associated mild itching. On examination, there are erythematous, hyperpigmented, and eczematous patches with skin breakdown and weeping at the medial ankle areas. Pitting edema is present. Which of the following describes the pathophysiology for the most likely diagnosis? AArterial insufficiency caused by atherosclerosis BAutoimmune disease targeting the basement membrane CDelayed-type hypersensitivity reaction to an antigen DExtravasation of plasma proteins and red blood cells into the subcutaneous tissue EOvergrowth of commensal yeast and Malassezia globosa

Extravasation of plasma proteins and red blood cells into the subcutaneous tissue dx: Stasis dermatitis occurs in patients who have chronic venous insufficiency (CVI). ----look at image -----

A 35-year-old man presents to the clinic describing severe nausea, vomiting, and diarrhea for the past 1 day after eating at a new restaurant. He states he has been unable to keep very much food or liquids down over the past several days. He describes associated symptoms of abdominal pain and fatigue. He reports no previous medical history and does not take any medication regularly. Vital signs include a HR of 112 bpm, BP of 88/56 mm Hg, RR of 16/min, oxygen saturation of 98% on room air, and T of 99.6°F. Serum creatinine is 1.9 mg/dL. On physical examination, he appears pale with decreased skin turgor and dry mucous membranes. Which of the following laboratory findings will be associated with the patient's most likely diagnosis? ABlood urea nitrogen/creatinine ratio < 20 BFractional excretion of sodium < 1% CMuddy brown casts DPresence of nitrites EUrine osmolality < 350 mOsm/kg

Fractional excretion of sodium < 1% dx: pre renal acute kidney injury

A 64-year-old man presents to the clinic for a routine complete physical examination. His history is significant for type 2 diabetes mellitus, hypertension, and obesity. His current medications include amlodipine, aspirin, furosemide, metformin, and saxagliptin. His blood glucose logs show poorly controlled diabetes, and a recent hemoglobin A1C is 8.9%. If empagliflozin is added to his medication regimen to increase glycemic control, which of the following medications will need to be adjusted? AAmlodipine BAspirin CFurosemide DMetformin ESaxagliptin

Furosemide Sodium-glucose cotransporter 2 (SGLT-2) inhibitor & Loop diuretics such as furosemide The combination of loop diuretics and SGLT-2 medications can cause hypotension. Both medications can cause increased volume of urination and number of voids, leading to dehydration and volume depletion. Care should be taken when prescribing these medications, and adjusting the dosage of the loop diuretic must be considered to decrease the risk of hypotension.

A 3-year-old boy is referred to the Emergency Department due to concern for Kawasaki Disease. He has persistent high fevers for five days. He also has a generalized scarlatiniform rash, red and cracked lips, and three days of watery diarrhea. Today he developed bilateral conjunctival injection without exudate. In addition to the features described, generalized lymphadenopathy is also noted. Which of this patient's clinical features is inconsistent with a diagnosis of Kawasaki Disease? ADiarrhea BGeneralized lymphadenopathy CNon-exudative conjunctivitis DScarlatiniform rash

Generalized lymphadenopathy dx:Kawasaki Disease Children < 5 years old History of high fever × 5 days bilateral non-exudative Conjunctivitis, rash, adenopathy, strawberry tongue, hand or foot edema, fever #1 cause of pediatric acquired heart disease, risk for coronary artery aneurysm CRASH and burn: conjunctivitis, rash, adenopathy, strawberry tongue, hand or foot edema, uncontrolled high fever Tx: IVIG + aspirin Diarrhea (A), along with other gastrointestinal symptoms such as abdominal pain and vomiting, is common in Kawasaki Disease, but it is non-specific and non-diagnostic.

An 18-year-old sexually active man presents with painful swelling in his groin. He developed painful lesions on his penis 1 week ago and now has right-sided groin swelling. His examination demonstrates multiple penile ulcerations and a large, painful, fluctuant lymph node in the right groin. Which organism is responsible for this infection? AChlamydia trachomatis BHaemophilus ducreyi CHerpes simplex virus DKlebsiella granulomatis

Haemophilus ducreyi Chancroid: Haemophilus ducreyi, painful chancres, inguinal bubo multiple painful genital ulcers and the characteristic inguinal bubo. The ulcerations are sharply demarcated with purulent bases. Half of the patients have lymph node involvement with a unilateral, large, painful, and fluctuant node (bubo) Management (any from below) • Azithromycin 1 g PO • Ceftriaxone 250 mg IM • Consider empiric treatment for syphilis ----------------------------------------------------------- vs Lymphogranuloma venereum: Chlamydia trachomatis serovars L1-L3, painless ulcer, inguinal lymphadenopathy transient painless genital ulcer followed by painful inguinal adenopathy. The lymph nodes enlarge above and below Poupart ligament, causing the LGV "groove sign." Treatment is with doxycycline or erythromycin. Granuloma inguinale: Klebsiella granulomatis, beefy red ulcer Klebsiella granulomatis (D) causes granuloma inguinale characterized by painless genital ulcers. The lesions are highly vascular, resulting in a beefy red appearance and bleeding on contact. There is no associated regional adenopathy. Treatment is with doxycycline.

An 81-year-old man is admitted to the hospital for agitation and combative behavior. He has a history of Alzheimer disease and hyperlipidemia, for which he takes donepezil and simvastatin. His family, who cares for him, reports that this combative behavior is atypical. The agitation started suddenly this afternoon and worsened over a period of 5 hours. There has been no recent change to his medications, and his family reports no recent falls or known head injury. He is afebrile. His blood pressure is 108/74 mm Hg, heart rate is 102 bpm, and the rest of his vital signs are within normal range. He appears anxious and is trying to pull out his intravenous lines. There is no localization of neurologic findings on examination. Baseline labs are drawn and a urine sample is obtained, which is positive for nitrites. The patient is started on empiric antibiotics for a presumptive urinary tract infection. What would be the most appropriate initial management for the patient's agitation at this time? AAdminister intramuscular olanzapine BApply soft restraints CHave a sitter or family member at the bedside DIncrease dose of donepezil EStart patient on a low-dose benzodiazepine

Have a sitter or family member at the bedside dx:Delirium ---------------------------------------------------------- the above management is more appropriate initially. Benzodiazepines can cause paradoxical confusion. This could be an appropriate selection if the patient were presenting in benzodiazepine or alcohol withdrawal.

A 45-year-old man presents with severe rectal pain and bleeding for three hours. He is known to have chronic stage IV internal hemorrhoids that bleed severely from time to time. Vital signs are temperature 98.6°F, respiratory rate 22 breaths/minute, blood pressure 100/55 mm Hg, heart rate 105 bpm, and oxygen saturation 98% on room air. Physical exam shows purple, necrotic nodules covered by mucosa that is protruding through the anal canal. Complete blood count shows white blood cell count 5.8/L, hemoglobin 10 mg/dL, hematocrit 30%, and platelet count 265,000/microL. Which of the following is the most effective management? ABipolar cautery BHemorrhoidectomy CInjection sclerotherapy DRubber band ligation ETopical hydrocortisone

Hemorrhoidectomy stage I (hemorrhoid is confined to the anal canal), stage II (hemorrhoid protrudes through the anal canal but reduces spontaneously), stage III (hemorrhoid requires manual reduction after bowel movements), and stage IV (hemorrhoid chronically protrudes and is at risk of strangulation). Thrombosed external hemorrhoids are typically blue or purple in color and are very tender. Clot evacuation provides immediate pain relief for patients with thrombosed external hemorrhoids Hemorrhoidectomy is reserved for patients with chronic severe bleedingdue to stage III or IV hemorrhoids or those with acutely thrombosed stage IV hemorrhoid with necrosis. Complications include postoperative pain and impaired continence. . Treatment of hemorrhoids includes lifestyle modification, sitz baths, analgesic creams, and surgical excision. Lifestyle modifications include a high fiber diet and increased hydration. Sitz baths may provide temporary pain relief. For patients with stage I, II, or III internal hemorrhoids who are unresponsive to conservative treatment, more invasive treatments (injection sclerotherapy, rubber band ligation, and bipolar cautery) are indicated. Rubber band ligation is the preferred treatment due to its ease of use and high rate of efficacy. What are some complications of rubber band ligation? Answer: Pelvic sepsis, pelvic abscess, urinary retention, and bleeding.

A 23-year-old G1P0 woman with an estimated gestational age of 8 weeks presents to the emergency department with persistent nausea and vomiting for the past week. She has lost 5 pounds in 7 days. She is lightheaded and has been unable to tolerate any liquid or food. She reports no diarrhea, dysuria, fever, or vaginal bleeding or discharge. Her T is 98.1°F, BP is 95/65 mm Hg, HR is 110 bpm, RR is 18/min, and oxygen saturation level is 98% on room air. She has decreased urine output with dark colored urine. Urinalysis is positive for ketones. Her serum blood urea nitrogen is 28 mg/dL, creatinine is 1.1 mg/dL, aspartate aminotransferase is 35 U/L, alanine transaminase is 39 U/L, serum bilirubin is 0.5 mg/dL, platelet count is 180,000 cells/microL, magnesium is 2.0 mg/dL, and potassium is 2.7 mmol/L. On physical examination, she has dry mucous membranes. Her abdomen is soft and nontender, and the psoas sign is negative. What is the most likely diagnosis? AAcute fatty liver of pregnancy BAppendicitis CHemolysis, elevated liver enzymes, and low platelet count syndrome DHyperemesis gravidarum EUTI

Hyperemesis gravidarum Patients may present with signs of dehydration with ketonuria, hypokalemia, and contraction alkalosis. Treatment typically consists of IV fluids, antiemetics, and vitamins. What are the most serious complications of hyperemesis gravidarum? Answer: Mallory-Weiss tear of the esophagus, diaphragmatic tear, hypokalemia, and metabolic alkalosis. Hyperemesis Gravidarum Peak incidence: weeks 8-12 Weight loss Hypokalemia Ketonemia Rx: IVF with 5% dextrose, antiemetics (doxylamine plus pyridoxine is first line)

A woman in her third trimester of pregnancy is involved in a motor vehicle collision. She presents to the ED with new-onset vaginal bleeding and pelvic pain. Which of the following laboratory abnormalities is consistent with the most likely diagnosis? ADecreased prothrombin time BHypofibrinogenemia CProteinuria DThrombocytosis

Hypofibrinogenemia and thrombocytopenia dx: Abruptio placentae Risk factors: hypertension, trauma, or cocaine use Painful vaginal bleedingMost often during the third trimester Labs will show hypofibrinogenemia Tx: fetal monitoring, hemodynamic stabilization, delivery What other blood product is commonly transfused in a woman with abruptio placentae? Answer: Packed red blood cells, to treat the volume-depleting and oxygen-carrying insult which stems from abruption.

A 55-year-old man with a medical history of hypertension presents to the emergency department with worsening diffuse muscle cramps and weakness for the past 2 days. The weakness started bilaterally in his legs but now involves his arms. He reports that exercising is more difficult because of the weakness. The patient takes hydrochlorothiazide, which he started 2 weeks earlier for hypertension. Vital signs include HR of 103 bpm, BP of 142/80 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a distressed man with 3 out of 5 strength in each extremity. The patient has no ptosis, intact cranial nerves, or intact sensation with light touch. Which of the following is the most likely cause of the patient's symptoms? AHypermagnesemia BHyperuricemia CHypocalcemia DHypokalemia EHyponatremia

Hypokalemia dx: History of diuretics use, diarrhea, vomiting Weakness, hyporeflexia, cramping, paresthesias ECG will show U waves, T wave flattening, ST depression, QT prolongation Treatment is potassium replacement along with magnesium In addition to potassium supplementation, what medication can be used to reverse hypokalemic thyrotoxic periodic paralysis? Answer: Propranolol (nonselective beta-blocker). hydrochlorothiazide electrolytes imbalance : hypokalemia, hyponatremia, hypercalcemia, and/or hypomagnesemia. --------------------------------------------------------------- Hypermagnesemia (A) can cause neuromuscular toxicity that results in decreased or absent deep tendon reflexes, somnolence, or muscle paralysis. Hypokalemia is the more likely cause of the patient's muscle weakness since the patient just started taking hydrochlorothiazide, which can cause hypokalemia and hypomagnesemia. Hyperuricemia (B) refers to elevated levels of uric acid in the blood. It is a possible adverse effect of thiazide diuretics, such as hydrochlorothiazide.Patients with hyperuricemia may be asymptomatic or may have bouts of gouty arthritis (painful and swollen joints) or uric acid nephrolithiasis. Hypocalcemia (C) can manifest with a variety of symptoms, including perioral numbness, paresthesias of the hands and feet, muscle cramps, carpopedal spasm, laryngospasm, and seizures. However, hypokalemia is more likely since the patient had muscle weakness and because thiazide diuretics cause hypercalcemia rather than hypocalcemia. Hyponatremia (E) can manifest with nausea, malaise, headaches, and lethargy. In severe cases (typically levels below 115-120 mEq), the patient may have seizures and coma. Although hyponatremia can also be seen in patients who recently started a thiazide diuretic, the symptoms of muscle weakness and muscle cramps are more consistent with hypokalemia.

Which of the following is associated with myxedema coma? AHyperglycemia BHypernatremia CHypotension DTachycardia

Hypotension dx:Myxedema coma is a life-threatening condition of hypothyroidism with a classic presentation of bradycardia, hypothermia, hypotension, and altered mental status. Hypothyroidism exacerbation → ↓ metabolic state + AMS PE: stupor, hypoventilation, hypotension, bradycardia Rx: IV thyroid hormone replacement, glucocorticoids High mortality Why is intravenous triiodothyronine (T3) rarely administered? Answer: It can precipitate dysrhythmias and sudden death.

A 14-year-old girl with onset of menarche 6 months prior reports irregular menstrual cycles, with variations between cycle lengths of as much as 12 days. Most of her periods consist of painless, heavy bleeding. She is currently experiencing such a period, with blood loss that requires frequent changing of menstrual pads with use of 10 or more pads per day. She has no history of epistaxis or easy bruising and takes no medications. Bimanual and speculum exam reveals copious blood in the vaginal vault with no identifiable nonuterine source. The uterus is of normal size and contour without tenderness. Adnexa are nontender to palpation without identifiable masses or abnormalities. She has been sexually active with one partner and her urine pregnancy test result is negative. What is the most likely cause for this patient's menstrual irregularities? AAdenomyosis BChlamydial endometritis CHypothalamic-pituitary-ovarian axis immaturity DUterine fibroids EVon Willebrand disease

Hypothalamic-pituitary-ovarian axis immaturity dx: Abnormal uterine bleeding (AUB) ----------------------------------------------------------- Uterine fibroids (D) can often be identified on pelvic examination as an enlarged, mobile uterus with an irregular contour and are confirmed via pelvic ultrasound. In adolescents, these structural lesions are not as common as AUB-O Adenomyosis (A) is defined as endometrial-type glands and stroma present within the myometrium of the uterus, frequently with surrounding myometrial hypertrophy or hyperplasia. This etiology, termed AUB-A, has a questionable impact on AUB and is less likely than ovarian dysfunction to be the cause of this condition in an adolescent with heavy menstrual bleeding and recent onset of menarche.

A 27-year-old previously healthy man presents to your office with a complaint of low back pain. He tells you that one week ago he was moving heavy furniture when he suddenly felt his back "give out". Since that time, he has been having constant pain and decreased range of motion. Which of the following is the most appropriate therapy? AGabapentin BIbuprofen COxycodone DPrednisone

Ibuprofen Acute low back pain Red flags of low back pain include interruption in bladder or bowel function, significant trauma, fever, history of intravenous drug use or cancer, unexplained weight loss, and pain that is increased or unrelieved by rest. Back Pain Night pain, weight loss: malignancy Back pain + fever + neurological deficits: epidural abscess Acute bony tenderness: fracture Young, morning stiffness: seronegative spondyloarthropathy Urinary retention: cauda equina syndrome Pain with extension, relief with flexion: spinal stenosis Image if red flags present

A 15-year-old boy presents to his primary care clinic with left ear pain and swelling since being kicked in the left ear yesterday. The incident happened during wrestling practice when he was warming up. He was not wearing his headgear at the time. He reports no other injury, fever, or drainage of this area. He has no significant medical history and takes no medication. Today, his vitals are T of 98.7°F, BP of 108/74 mm Hg, RR of 13/min, HR of 78 bpm, and oxygen saturation of 99% on room air. On physical examination, his left ear has 3 cm of erythematous tender fluctuant swelling over the scaphoid fossa. This area is tender to palpation. What is the best next step in management? AApply pressure dressing BIncision and drainage COral antibiotics DReassurance and observation ETopical anti-inflammatories

Incision and drainage dx: auricular hematoma 🍹 Management • Acute (<48 hr) and small (<2 cm): needle aspiration • Large (> 2 cm) or 48 hrs- -7 days: incision and drainage • Pressure dressing to prevent recurrence of hematoma • > 7 days: referral to ENT/plastic surgeon

Which of the following is the most common cause of bladder calculi? AChronic indwelling catheter BHyperparathyroidism CInfection of residual bladder urine with urea-splitting organisms DProstatitis

Infection of residual bladder urine with urea-splitting organisms What are some urea-splitting bacteria? Answer: Proteus, Pseudomonas, Klebsiella, Staphylococcus, and Mycoplasma. Nephrolithiasis Sx: flank pain radiating to groin PE: patient won't lie still, hematuria Diagnosis: noncontrast helical CT, most common location is the ureterovesical junction (UVJ) Most commonly caused by calcium oxalate Struvite: staghorn calculi, urease-producing bacteria Uric acid: radiolucent on X-ray, gout Cystine: children with metabolic diseases Treatment < 5 mm: likely to pass spontaneously > 5 mm: medical expulsive therapy (tamsulosin), urology consultation in certain cases > 10 mm: urology consultation, shock wave lithotripsy, ureteroscopy

An 82-year-old man presents with acute symptoms of ischemic colitis. He subsequently undergoes emergent bowel resection surgery. The surgical report details an infarction of the descending colon and recto-sigmoid junction. Pathology in which of the following arteries is the most likely cause of this condition? ACeliac trunk BInferior mesenteric artery CPortal vein DSuperior mesenteric artery

Inferior mesenteric artery dx: Ischemic colitis frequently occurs in the elderly population, typically on the left side of the abdomen. Symptoms range from transient colitis and reversible colopathy to chronic ulcerating colitis, stricture, gangrene and fulminant colitis. Clinical manifestations include crampy left lower quadrant pain, frank or occult fecal blood, fever and peritoneal signs. History of atherosclerotic disease, aortoiliac surgery, cardiopulmonary bypass Acute onset of crampy abdominal pain CT imaging will show bowel wall edema Most commonly caused by inadequate blood flow through the mesenteric vessels Treatment: most cases resolve with supportive care ----------------------------------------------------------------- vs The superior mesenteric artery (D) supplies the lower duodenum, proximal two-thirds of the transverse colon, and pancreas.

A 7-year-old boy is diagnosed with type I diabetes mellitus. He is prescribed insulin detemir 10 units subcutaneously every morning and insulin lispro 3 units subcutaneously three times daily with meals. Which of the following is an appropriate patient education point to make to the patient and his family? AInsulin detemir and lispro can be mixed together in the same syringe BInsulin detemir can be injected into the same site every day CInsulin detemir can be stored at room temperature while the vial is in use DInsulin detemir can be used if the solution appears cloudy

Insulin detemir can be stored at room temperature while the vial is in use What insulin should be drawn up last when mixing insulin aspart and insulin neutral protamine hagedorn? Answer: Insulin neutral protamine hagedorn (i.e. clear before cloudy).

A 67-year-old woman with New York Heart Association class III congestive heart failure presents to clinic for a routine examination. Her chief complaint is worsening peripheral edema. Which of the following abnormalities would you most expect to find during a physical examination? AFinger-nail clubbing BJugular venous distension CKussmaul breathing DPulsus paradoxus

Jugular venous distension and increased jugular venous pulsation. Congestive failure is also associated with an S3 heart sound. Heart Failure Staging and Classification American Heart Association/American College of Cardiology staging Stage A: high risk without symptoms or disease Stage B: structural disease without Sx Stage C: structural disease with Sx Stage D: refractory heart failure New York Heart Association classification I: asymptomatic II: Sx with ordinary activity III: asymptomatic only at rest IV: Sx at rest ------------------------------------------------------------ Finger-nail clubbing (A) is more indicative of pulmonary, instead of cardiac, pathology. Kussmaul breathing (C) is associated with severe metabolic acidosis such as diabetic ketoacidosis. Cheyne-Stokes respiration may be seen with chronic heart failure. Pulsus paradoxus (D) is a systolic blood pressure drop of ≥ 10 mm Hg during inspiration. It is commonly seen in pericardial tamponade, but not congestive heart failure.

Which of the following is the most reliable indication of an achilles tendon rupture? AInability to ambulate BInability to plantar flex the foot CPain along the posterior ankle DPositive calf squeeze test

Positive calf squeeze test

A 22-year-old woman presents with pain and swelling of the plantar surface of her foot. She reports that 2 days prior to arrival, she was walking in sneakers and stepped on a nail that punctured her foot. Physical examination demonstrates 3 cm of warm and blanching erythema without induration or fluctuance. Her tetanus vaccination is up-to-date. An X-ray shows no foreign body. Which antibiotic is an appropriate choice to cover the organism at risk from her shoe? ADicloxacillin BLevofloxacin CLinezolid DTrimethoprim-sulfamethoxazole

Levofloxacin dx Pseudomonas aeruginosa , Pseudomonas rarely causes skin and soft tissue infections.Levofloxacin is an oral fluoroquinolone with adequate Pseudomonas aeruginosa coverage and is the drug of choice for puncture wounds. Staphylococcus aureus and Streptococcus species are still the most common causative organisms, especially when the injury occurs in a patient not wearing sneakers, but the particular clinical scenario above mandates coverage for Pseudomonas. In a patient presenting without concern for possible pseudomonal infection, coverage with dicloxacillin or cephalexin would be appropriate. ------------------------------------------------------------ vs Trimethoprim-sulfamethoxazole (D) is a sulfa-based antibiotic, which in the setting of skin infections has widespread activity against community-associated MRSA. It does not have any activity against Pseudomonas and would not be indicated in this clinical scenario.

A patient with rheumatoid arthritis presents with new onset generalized weakness, fatigue, facial swelling and weight gain. Examination is significant for periorbital edema, dry skin and coarse brittle hair. Laboratory testing reveals a high titer of antithyroid antibodies. Which of the following will most likely be prescribed? ALevothyroxine BMethimazole CMetoprolol DRadioactive iodine

Levothyroxine dx: Hypothyroidism is most commonly caused by Hashimoto's thyroiditis. Sx: generalized weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain PE: periorbital edema, dry skin, and coarse brittle hair Labs: high TSH and low free T4 Most commonly caused by Hashimoto thyroiditis Dx: antithyroid peroxidase and antithyroglobulin autoantibodies Tx: levothyroxine = Takes about 6 weeks to see treatment effects Monitor TSH 😨Hashimoto: risk factor for non-Hodgkin lymphoma😨 ------------------------------------------------------------- Methimazole (B), metoprolol (C) and radioactive iodine (D) are all used for the treatment of hyperthyroidism

You have made a new diagnosis of polycystic kidney disease in one of your primary care patients. Proper maintenance of normal blood pressure should be obtained with which of the following medications? AFurosemide BLosartan CMetoprolol DVerapamil

Losartan . Angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) are the preferred therapeutics. Associated with increased risk for liver involvement, berry aneurysm, and intracerebral hemorrhage Polycystic Kidney Disease Sx: asymptomatic, flank pain or hematuria PE: hypertension Dx: ultrasound (most common), CT, MRI; may be incidentally discovered on imaging Most commonly caused by autosomal dominant disorder Treatment is BP control: ACEIs, ARBs

A 9-year-old boy presents with penile pain. On genitourinary exam the patient is unable to tolerate reduction of the distal prepuce over the glans penis. The glans is noted to be very swollen. What is the next best step in management? ADorsal penile slit procedure BEmergency circumcision CManual reduction after topical lidocaine DTopical corticosteroids

Manual reduction after topical lidocaine dx: paraphimosis, which describes the inability to reduce the foreskin over the glans penis ----An attempt at manual reduction is indicated for paraphimosis------------------------------ What medical procedure puts uncircumcised boys at risk for developing paraphimosis? Answer: Catheterization of the urethra during for which the foreskin has to be retracted.

A 65-year-old woman reports acute pain in the left eye and vomiting after walking into a movie theater. On examination, her cornea is cloudy. She has photophobia and a fixed pupil. She reports an allergy to sulfa. What is the most appropriate action? AAdministration of acetazolamide BMeasurement of intraocular pressure CTopical mydriatic agent DUltrasound of the eye

Measurement of intraocular pressure dx: Acute angle-closure glaucoma occurs classically when patients move into a situation with lower light causing dilation of the pupil leading to obstruction of the aqueous humor outflow tract. Patients experience the abrupt onset of symptoms including eye pain, headache, vomiting, and blurred vision. Patients may also describe seeing a halo around lights. On examination, the conjunctiva is injected with a cloudy appearance to the cornea. The pupil is typically mid-sized or dilated and either fixed or sluggishly reactive. One must suspect the diagnosis clinically and measure and document the intraocular pressure. Goals of treatment include rapid reduction of intraocular pressure through both topical and intravenous agents. Topical agents include beta-blockers (timolol), alpha agonists (apraclonidine), and topical steroids. In addition, acetazolamide (carbonic anhydrase inhibitor) is commonly used to decrease aqueous humor production. Mannitol (osmotic diuretic) can be used as an intravenous agent for severe cases. Definitive correction requires surgery. Tx: emergent ophthalmology evaluation, topical beta-blockers (timolol), topical alpha-agonists (apraclonidine), carbonic anhydrase inhibitors (acetazolamide), iridotomy

A 65-year-old man who works in a standing position at a machinist shop presents to the clinic reporting swelling in his lower legs. The swelling comes and goes but seems to be worse at the end of the day. He has a history of hypertension, hypercholesterolemia, and superficial thrombophlebitis. His daily medications are hydrochlorothiazide 25 mg, losartan 50 mg, and atorvastatin 40 mg. His temperature is 97.9°F, blood pressure is 122/70 mm Hg, heart rate is 66 bpm, respiratory rate is 14/minute, and oxygen saturation is 98% on room air. On examination, his heart has a regular rate and rhythm, and his lungs are clear to auscultation bilaterally. He has leathery-appearing skin circumferentially around his upper ankles, which is flaky and itchy. There is also venous engorgement throughout his lower legs bilaterally. Which of the following would also be expected on a physical exam? ADecreased hair growth BDorsal pedal ulceration CLateral malleolus ulceration DMedial malleolus ulceration EPlantar pedal ulceration

Medial malleolus ulceration

A 32-year-old woman presents six hours after ingesting 40 tablets of regular-strength (325 mg) aspirin in a suicide attempt. She is lethargic with a heart rate of 106 beats/minute, blood pressure of 142/84 mm Hg, respiratory rate of 30 breaths/minute, and a temperature 38.5°C. What abnormality would be expected on her arterial blood gas? AMixed respiratory acidosis with a metabolic alkalosis BMixed respiratory alkalosis with a metabolic acidosis CPure metabolic acidosis DPure respiratory alkalosis

Mixed respiratory alkalosis with a metabolic acidosis dx:Aspirin toxicity results in a complex acid-base disturbance. Salicylates stimulate the respiratory center resulting in tachypnea, with a subsequent decrease in pCO2 and respiratory alkalosis. Cell metabolism is also interrupted, leading to the production of lactic acid and ketoacids and an elevated anion gap metabolic acidosis. The mixed respiratory alkalosis with the elevated anion gap metabolic acidosis can result in a near-normal pH. In the late stages of toxicity, as the patient becomes progressively more fatigued with associated electrolyte abnormalities and dehydration, a respiratory acidosis can occur which signals impending cardiovascular collapse.

Which of the following medications helps prevent cerebral vasospasm in patients with spontaneous subarachnoid hemorrhage? ALisinopril BMetoprolol CNimodipine DVerapamil

Nimodipine Subarachnoid Hemorrhage Patient presents with abrupt onset of "worst headache of life" or thunderclap headache Diagnosis is made by noncontrast CT scan, blood will appear white on the CT If CT negative and performed within 6 hours of symptom onset, subarachnoid hemorrhage effectively ruled out If CT negative and suspicion high, lumbar puncture or CT angiography Most commonly caused by a ruptured aneurysm Hunt & Hess classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm)

A 50-year-old man presents to the emergency department with sudden onset of shortness of breath. He has a history of heart failure with an ejection fraction of 25%. Vital signs include temperature 100°F (37.7°C), blood pressure 220/110 mm Hg, heart rate 125 bpm, and respiratory rate 30/min. On examination, he appears anxious and tachypneic. Chest X-ray demonstrates diffuse bilateral interstitial opacification. Which of the following is the most appropriate initial treatment? AAlbuterol BDobutamine CFurosemide DNitroglycerin

Nitroglycerin dx: pulmonary edema that must be managed with aggressive preload and afterload reduction. . In addition to addressing hypertension, acute heart failure exacerbations are managed with supplemental oxygen, non-invasive positive pressure ventilation, loop diuretics (e.g., furosemide) in cases of severe volume overload, and assessment of an underlying cause (e.g., acute myocardial infarction, pericardial tamponade). Acute Pulmonary Edema Crackles, jugular venous distension CXR: cephalization, Kerley B lines, effusions Initial Rx BPAP: ↑ oxygenation, ↓ work of breathing, ↓ preload, ↓ afterload Nitroglycerin: ↓ preload, ↓ afterload Furosemide: diuresis Second-line Rx: Hypotension without signs of shock: dobutamine (may worsen hypotension) Severe hypotension with signs of shock: norepinephrine (↑ systemic vascular resistance, ↑ HR, ↑ BP, ↑ myocardial O2 demand) --------------------------------------------------------------- vs Furosemide (C) may be given after vasodilators in patients with acute heart failure and severe volume overload. Prior to diuretic use, it is imperative to manage hypertension and cardiac contractility to optimize pulmonary function.

A young woman reports 3 months of worsening vision, noting blurred and diplopic abnormalities. She also complains of left leg and right arm weakness. Examination reveals extraocular palsies, poor visual acuity, nystagmus, left leg and right arm strength deficits and a positive Romberg sign. You suspect a central inflammatory demyelinating process. Which of the following imaging and results would help to confirm a diagnosis? ANoncontrast head CT scan with cervical spine central stenosis BNoncontrast head CT scan with ventricular enlargement CNoncontrast T1-weighted brain MRI with corpus callosal hyperintensities DNoncontrast T2-weighted brain MRI with periventricular hyperintensities

Noncontrast T2-weighted brain MRI with periventricular hyperintensities Multiple Sclerosis Demyelinating CNS lesions separated in space and time Risk factors: female sex, age < 30, birth at northern latitude (possibly linked to vitamin D deficiency) Sx: pain with eye movement, monocular vision loss, diplopia with lateral gaze, sensory abnormalities PE: afferent pupillary defect (Marcus Gunn pupil), spinal electric shock sensation with neck flexion (Lhermitte sign), impaired bilateral adduction (bilateral internuclear ophthalmoplegia) Dx: MRI: periventricular white matter lesions CSF: oligoclonal IgG bands, WBC pleocytosis Tx:Acute exacerbation: methylprednisoloneDisease modifying: natalizumab, ocrelizumab, glatiramer acetate*, interferon beta-1a*Note: Natalizumab associated with PML, test for JC virus antibodies Question: What is the most common acquired neurologic disability in young adults?

A 25-year-old man presents to the clinic for a painless testicular mass that has slowly grown over the past 5 months. Vital signs include HR of 90 bpm, BP of 120/80 mm Hg, RR of 20/minute, oxygen saturation of 98% on room air, and T of 98.6°F. Physical examination reveals a nontender ovoid-shaped mass in the right testicle. Ultrasound of the bilateral scrotum reveals an inhomogeneous right testicular mass with calcifications, cystic areas, and indistinct margins. Laboratory studies include an alpha-fetoprotein of 1,000 ng/mL, lactate dehydrogenase of 1,200 IU/L, and beta-human chorionic gonadotropin of 10,000 mIU/mL. Which of the following is the suspected histological diagnosis? ALeydig cell tumor BNonseminoma germ cell tumor CSeminoma germ cell tumor DSertoli cell tumor ETransitional cell tumor

Nonseminoma germ cell tumor Nonseminoma testicular germ cell tumors typically cause elevation in beta-human chorionic gonadotropin and alpha-fetoprotein, while seminoma germ cell tumors only cause elevation in beta-human chorionic gonadotropin in 20% of patients.

Which of the following agents is considered the vasopressor of choice for treatment of septic shock? ADopamine BEpinephrine CNorepinephrine DPhenylephrine

Norepinephrine Norepinephrine acts primarily as an α-adrenergic agonist, causing vasoconstriction that results in an increase in blood pressure. It also has β-adrenergic properties, which causes an increase in cardiac output and heart rate. The combination of α-adrenergic and β-adrenergic properties benefits patients who have septic shock. Norepinephrine also has a short duration of action, which allows for rapid adjustment of dosing in response to changes in a patient's hemodynamic status. ------------------------------------------------------------------ vs Epinephrine (B) has both α-adrenergic and β-adrenergic properties and has a greater affinity for alpha- and beta-receptors than norepinephrine. Its use is associated with a higher rate of cardiac dysrhythmias and a decrease in splanchnic blood flow. Phenylephrine (D) is a pure α-adrenergic agent that causes vasoconstriction and impairment of tissue blood flow throughout the body, most notably in the splanchnic circulation. Dopamine (A) was once widely used in the treatment of septic shock, but studies have shown that it has no advantage over norepinephrine and its use is associated with a higher death rate.

A 26-year-old woman presents to the emergency department with reports of sudden-onset severe right lower abdominal pain, beginning 2 hours ago after leaving the gym. She describes the pain as sharp and localized to her right lower abdomen. She states the pain is aggravated when sitting and reports no alleviating factors. She reports no significant medical history and takes no medications or supplements. Vital signs include a HR of 96 bpm, BP of 125/82 mm Hg, RR of 20/min, oxygen saturation of 98% on room air, and T of 98.6°F. On physical examination, she is tender to palpation in the right lower abdomen. Beta-human chorionic gonadotropin is negative, hemoglobin is 14.1 g/dL, WBC is 9,000/µL, and a transvaginal ultrasound reveals a right ovarian cyst with Doppler flow and a small amount of free fluid. What is the best next step for management of this condition? ACT scan of abdomen and pelvis BDiagnostic laparoscopy CEmpiric antibiotics DObservation and reassurance EOral contraceptive pills

Observation and reassurance dx: A ruptured ovarian cyst is a common occurrence in patients of reproductive age. Physiologic rupture of follicular cysts occurs with each ovulation cycle and is generally asymptomatic or associated with mild midcycle pain. Rupture of a hemorrhagic cyst may be associated with sudden-onset unilateral lower abdominal pain due to blood stretching the ovarian cortex or irritating the abdomen. The pain is typically sharp and focal. Patients may also have increased pain while sitting due to irritation of the psoas muscle. Cyst ruptures often occur following activity, such as sexual intercourse or strenuous exercise. Most patients with an ovarian cyst rupture are candidates for: observation and reassurance. Patients with an uncomplicated cyst rupture do not require emergency surgery, but if they are hemodynamically unstable, laparoscopy is the preferred surgical approach. In reproductive-aged women, most ovarian cysts spontaneously regress.

A 50-year-old man with a medical history of alcohol use disorder and chronic obstructive pulmonary disease on prednisone presents to the orthopedic clinic with progressive left hip pain for the past 3 months. Vital signs today include a heart rate of 80 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 20 breaths per minute, pulse oxygenation of 99% on room air, and temperature of 98.6°F. Physical examination reveals a regular rate and rhythm and lungs are clear to auscultation. The left hip pain is exacerbated with left hip internal rotation and abduction. Hip radiographs are unremarkable. What is the best next step in the management of this patient's condition? AIncrease the dose of prednisone BObtain MRI of the left hip CPerform arthrocentesis DProvide reassurance and acetaminophen EProvide reassurance and ibuprofen

Obtain MRI of the left hip dx: Avascular necrosis Common causes include traumatic injuries that damage blood vessels supplying the bone, heavy alcohol use, prolonged corticosteroid use, and systemic lupus erythematosus. At which location are bisphosphonates known to increase the risk of osteonecrosis? Answer: Jaw.

What is the most appropriate therapy for carcinoid syndrome? AOctreotide BOlanzapine COmeprazole DOxaliplatin

Octreotide 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)

A 53-year-old man works as a metal fabricator in a local tool and die shop. While he was grinding a piece of iron, he felt something hit his eye. He presented to the ED, was diagnosed with a corneal abrasion, and was discharged home with the correct treatment. He presents now to clinic with continued pain and irritation, as well as new onset discharge. Examination reveals an oval ulcer with ragged edges, severe conjunctival inflammation, eyelid edema and mucopurulent discharge. Which of the following is the most appropriate intervention? AHyperbaric oxygen therapy BObtain a rheumatology panel COphthalmologic consultation DTopical fluconazole

Ophthalmologic consultation dx:Corneal Ulcer Patient will have a history of trauma, incomplete closure, or extended contact lens use PE will show oval ulcer with ragged edges, severe conjunctival inflammation Most commonly caused by Staphylococcus, Pseudomonas( contact lens wearers), Streptococcus pneumoniae Treatment is emergent ophthalmology consult

A 34-year-old previously healthy patient presents to the emergency department with a painful, swollen abscess on the thigh. On examination, the 0.8 cm abscess is shallow, fluctuant, and accompanied by surrounding erythema and warmth. There is no lymphatic streaking. Vital signs include a temperature of 101.5°F, heart rate of 93 bpm, blood pressure of 121/76 mm Hg, and respiratory rate of 13 breaths/min. CBC indicates WBC 7,000 cell/µL. Which of the following is the most appropriate therapy for this patient? AOral amoxicillin BOral doxycycline COral vancomycin DTopical clindamycin ETopical mupirocin

Oral doxycycline --------------oral Clindamycin or a sulfa drug (such as trimethoprim-sulfamethoxazole) is another acceptable alternative.------------------------ dx: Methicillin-resistant Staphylococcus aureus (MRSA) is a strain of Staphylococcus that has developed resistance to beta-lactam antibiotics. This resistant strain is often health care-associated but is also found in the community. MRSA Oxacillin minimum inhibitory concentration ≥ 4 mcg/mL Risk factors include recent hospitalization or surgery, residence in a long-term care facility or prison, HD, HIV, IVDA, sharing needles, razors, sports equipment, or towels Confirm via culture Oral options (based on local resistance patterns): clindamycin, doxycycline, linezolid, TMP-SMX IV options: daptomycin, linezolid, vancomycin Patients may be chronic carriers, consider decolonization Use good hygiene, keep equipment clean

A 12-year-old girl presents with a patch of hair loss with fine scaling. Occipital adenopathy is present on examination. What treatment is indicated? AKetoconazole shampoo BOral griseofulvin CTopical corticosteroids DTopical nystatin

Oral griseofulvin dx:tinea capitis. he most common presentation of tinea capitis is an irregularly defined patch of scaly skin that enlarges and later causes alopecia. The infection is often not noticed until alopecia occurs. Affected hair may also be broken, resulting in curved, "comma," hairs or corkscrew-shaped hairs. Occipital lymphadenopathy is often present.

A parent brings in her 16-month-old boy because she is concerned that he appears pale. Vital signs are within normal limits for age except for mild tachycardia. He appears pale on physical exam, is irritable but consoles appropriately, and appears tired. You hear a systolic flow murmur and tachycardia on the cardiac exam. Otherwise, the physical exam is normal. Laboratory testing reveals the following: hemoglobin 6.5 g/dL, hematocrit 19.2%, mean corpuscular volume 60 fL, mean corpuscular hemoglobin 19.3 pg, mean corpuscular hemoglobin concentration 27.1 g/dL, serum iron 10.5 µmol/L, serum total iron-binding capacity 148 µmol/L, serum ferritin 14 ng/mL, reticulocytes 1.5%. What is the best treatment for this child? AOral ferritin supplementation BOral iron supplementation CPacked red blood cell transfusion DParenteral iron transfusion

Oral iron supplementation Labs: microcytic, hypochromic red blood cells, decreased serum iron level, an increase in the total iron binding capacity (TIBC), and decreased serum ferritin levels High RDW Most common cause of microcytic anemia Iron Deficiency Anemia ------------------------------------------------------------ vs Parenteral iron transfusion (D) carries with it a danger of anaphylaxis, and the hematologic response to iron supplementation is the same whether the treatment is administered orally or intravenously.

A 35-year-old woman presents to your office to establish care as a new patient. She has a history of ulcerative colitis with multiple flare-ups. Which of the following is the most appropriate maintenance therapy? AHydrocortisone suppositories BOral mesalamine COral metronidazole DOral prednisone

Oral mesalamine dx: Ulcerative colitis --------------------------------------------------------------- Hydrocortisone suppositories (A) are used in an acute flare-up of ulcerative colitis, but not as maintenance therapy. Oral prednisone (D) is used in an acute flare-up of ulcerative colitis, but not as maintenance therapy. Oral metronidazole (C) is used in the treatment of Crohn's disease, but not for treatment of ulcerative colitis.

A 68-year-old woman presents with abrupt onset of fever, malaise, body aches, headache, and sore throat. Rapid strep test is negative and nasal swab is positive for influenza B. Which of the following is the most appropriate therapy?

Oseltamivir Symptoms generally include rapid onset of fever and myalgias, often accompanied by cough, sore throat, chills, and headache. Influenza Patient presents with sudden onset of fever, headache, cough, myalgia, sore throat, fatigue Diagnosis is made clinically, can be confirmed with reverse transcription polymerase chain reaction (RT-PCR) or viral culture Treatment is mainly supportive or oseltamivir for patients at increased risk for severe diseaseStart oseltamivir as early as possible, after 48 hours it may not confer any benefit Most common cause of viral pneumonia in adults New vaccine needed yearly Monitor patients for postinfluenza pneumonia

A previously healthy 35-year-old woman presents to the emergency department with pleuritic chest pain and malaise. She has been feeling unwell for the past few days with intermittent fever. Her pulse is 87 beats/minute, respiratory rate is 19 breaths/minute, blood pressure is 122/82 mm Hg, and temperature is 37.0°C. On exam, a pericardial friction rub is appreciated. Echocardiography is negative for pericardial effusion. Which of the following is the most appropriate management? AAdmission and intravenous acyclovir BAdmission and intravenous gentamicin COutpatient follow-up and oral naproxen DOutpatient follow-up and oral prednisone

Outpatient follow-up and oral naproxen dx: Pericarditis Sx: pleuritic chest pain radiating to the back that is worse when lying back and improved when leaning forward PE: tachycardia and pericardial friction rub, distant heart sounds ECG: PR depression, PR elevation (aVR), diffuse ST segment elevation (concave) Causes: idiopathic, viral Tx: NSAIDs, colchicine

What is the treatment of choice for the bradycardic component of sick sinus syndrome? AAblation of accessory pathways BChronotropic medications CNo treatment is necessary DPacemaker

Pacemaker Sinus Node Dysfunction (formerly Sick Sinus Syndrome) Patient presents with syncope and palpitations ECG will show tachycardia-bradycardia syndrome Most commonly caused by SA node dysfunction Treatment is pacemaker placement and rate control medication

A 43-year-old woman is diagnosed with thyroid cancer. The oncologist tells the patient that she has the most common form of thyroid cancer and also the least aggressive form, quoting a 10-year survival rate of 97%. What type of thyroid cancer does the patient have? AAnaplastic carcinoma BFollicular carcinoma CMedullary carcinoma DPapillary carcinoma

Papillary carcinoma Thyroid Carcinoma PE: solitary hard nodule Labs/Studies: normal thyroid function, cold nodule DiagnosisInitial: US Confirmation: Fine-needle biopsy Papillary: most common, least aggressive Anaplastic: least common, most aggressive Medullary: associated with MEN2, calcitonin can be used as a tumor marker

A 16-year-old girl presents to clinic with 3 weeks of worsening right knee pain. She attends dance class since age 5 and now dances 20 hours a week. She denies any inciting injury and continues to dance on the injured leg. On exam, she has pain at the inferior and medial pole of the right patella with no swelling or erythema of the knee. Which of the following is the most likely diagnosis? AAnterior cruciate ligament rupture BMedial meniscus tear CPatella dislocation DPatellofemoral pain syndrome

Patellofemoral pain syndrome Patellofemoral Pain Syndrome Overuse disorder Aching anterior knee pain that is worse with loaded flexion (stair climbing, jumping, prolonged sitting) Pain with squatting is the most sensitive sign Tx: activity modification, physical therapy, NSAIDs ---------------------------------------------------------- vs Patella dislocation (C) is usually caused by sudden twisting of the leg or a direct blow that causes the patella to dislocate lateral of its normal placement in the patellofemoral groove. The patient experiences intense pain and typically has effusion on exam.

Which of the following tests for function of the median nerve? AAbduction of the index finger against resistance BExtension of the wrist against resistance CPincer function of the thumb and index finger DSensation of the dorsum of the first webspace

Pincer function of the thumb and index finger MedianMotor: OK signSensory: two-point discrimination of tip of index finger UlnarMotor: abduct index finger (scissors motion)Sensory: two-point discrimination over tip of fifth finger RadialMotor: wrist and finger extensionSensory: dorsal thumb-index finger web space

You have recently diagnosed a reduced ejection fraction in a 50-year-old man with congestive heart failure. He is currently stable and adherent to his medications. Which of the following vaccinations is indicated for this patient at this time to prevent further exacerbations? AHepatitis A BMeningococcal CPneumococcal DTdap EVaricella

Pneumococcal Pneumococcal Vaccination Recommendations for Adults Aged ≥ 65 Years Prior to January 2022 Adult Pneumococcal Vaccines Indicated in adults ≥ 65 years or < 65 years with risk factors For those who have not previously received PCV (or vaccine status unknown): One dose of PCV20 or PCV15 should be given If PCV 15 is given, administer PPSV23 at least 1 year later (except in patients with certain risk factors where an interval ≥ 8 weeks can be considered) For those who previously received PCV13 but not PPSV23: Administer PPSV23 at least 1 year after PCV13 Vaccines are inactivated

A 30-year-old man presents with asymmetric myalgias and arthralgias. He also complains of difficulty climbing stairs. You note fever, hip and shoulder muscle weakness and tender palpable purpura, without associated atrophy on examination. However, there is no facial or truncal rash. Laboratory testing reveals a low hematocrit, a high creatine kinase, a negative antinuclear antibody titer, and an elevated erythrocyte sedimentation rate. Which of the following is the most likely diagnosis? APolyarteritis nodosa BPolymyalgia rheumatica CPolymyositis DPseudogout

Polyarteritis nodosa Risk factors: male sex, age 40-60, hepatitis B infection Sx: malaise, fever, sore throat, joint and muscle aches and pains PE: tender lumps under the skin, especially on the thighs and lower legs Labs: ↑ ESR, ANCA negative Dx: confirmed by biopsy that shows necrotizing arteritis or by arteriography Tx: steroids Starburst livedo (painful violaceous plaques that are surrounded by livedo reticularis) is pathognomonic ------------------------------------------------------- vs Polymyalgia rheumatica (B) is characterized by shoulder and pelvic girdle pain and stiffness, a lack of skin findings, age >50 years, an elevated ESR (typically over 50 mm/h) and a normal creatine kinase. Polymyositis (C) is also characterized by proximal muscle weakness and elevated creatine kinase, but it more commonly occurs in females over the age of 50 years, less commonly occurs with arthralgias or arthritis, doesn't occur with tender subcutaneous nodules and is typically associated with a high ANA titer.

A previously healthy 16-year old boy presents to your office after having a syncopal episode at the start of track practice. An ECG reveals a QTc of 520 ms. This is confirmed on a subsequent ECG. This finding is associated with which one of the following rhythm abnormalities? AParoxysmal supraventricular tachycardia BPolymorphic ventricular tachycardia CSinus arrest DThird degree atrioventricular block

Polymorphic ventricular tachycardia (torsades de pointes) Prolonged QT Syndrome Patient presents with syncope, seizure, palpitations ECGMen: QT interval > 440 msecWomen: QT interval > 460 msec More commonly caused by medications > familial prolongation, low Mg, K, Ca Treatment Congenital: beta-blocker, cardiology consult, consider genetic testing and counseling Acquired: stop offending medications, correct electrolyte disturbances, IV magnesium or pacing for torsades de pointes ----------------------------------------------------------- vs Third-degree atrioventricular block (D) results from various pathologic states causing infiltration, fibrosis, or loss of connection in portions of the healthy conduction system. Third-degree atrioventricular block can be either congenital or acquired

A 5-year-old boy has acute onset of hematuria, periorbital edema, and hypertension. He has no other complaints and review of systems is unremarkable. Recent medical history is significant for a "cold" last week. What is the most likely etiology of his hematuria? ACoagulopathy BIgA nephropathy CPost-streptococcal glomerulonephritis DUrinary tract infection

Post-streptococcal glomerulonephritis Strep pharyngitis=1-2 weeks Strep skin infection=3-6 weeks PE: hypertension, hematuria, and periorbital edema Labs: proteinuria and red blood cell casts in the urine, low C3 and CH50 Most commonly caused by group A beta-hemolytic Streptococcus Management includes mainly supportive measures, e.g., salt and water restriction If edema and hypertension present, concurrent furosemide can help Most common infectious cause of acute glomerulonephritis What is the most common complication of post-streptococcal glomerulonephritis? Answer: Hypertension. ----------------------------------------------------------- vs IgA nephropathy (B) may also cause gross hematuria. However, hematuria caused by IgA nephropathy begins within 1-2 days of the onset of upper respiratory or gastrointestinal infection.

A 57-year-old man presents to the emergency room after awakening with severe pain in his left big toe. He ate at steakhouse and had several bottles of beer the night before. He has a past medical history of chronic kidney disease. His latest creatinine clearance was 25 mL/min. Joint aspiration reveals negatively birefringent crystals. Which of the following is the most appropriate treatment? AAllopurinol BColchicine CIndomethacin DPrednisone

Prednisone dx: gout Colchicine should be used with caution in renal failure. Corticosteroids, either orally, intravenously, intramuscularly, or intra-articularly, are the treatment of choice when colchicine and NSAIDs cannot be used. Oral steroids should be tapered to avoid a rebound flare. Sx: podagra (acute onset of pain in the first MTP) PE: hot, red, tender joint, tophi Labs: needle-shaped crystal with negative birefringence, uric acid can be low, normal or elevated Treatment Acute: NSAIDs, steroids, colchicine Chronic: allopurinol (first line), febuxostat, probenecid Can be triggered by loop and thiazide diuretics

A 15-year-old girl complains of vaginal discharge over the past two weeks. She reports recently becoming sexually active but uses condoms consistently during intercourse. Which of the following favors a diagnosis of bacterial vaginosis over trichmoniasis? AImprovement on oral metronidazole BMultiple punctate hemorrhagic cervical lesions CPredominance of gram negative rods on gram stain DVaginal pH of 5.5

Predominance of gram negative rods on gram stain -----look at image ------------ bacterial vaginosis, an overgrowth of vaginal anaerobes. Women with bacterial vaginosis present with mild-to-moderate grey, homogenous dischargewithout pain or irritation of the vulva. A characteristic "fishy" amine odor is noted upon combination with potassium hydroxide. Under microscopy, vaginal secretions characteristically show "clue cells," squamous cells studded with bacteria.

A 56-year-old woman with a history of diabetes mellitus type 2 presents to your office with a complaint of bilateral foot pain. She describes the pain as a burning sensation that occurs with rest and improves with activity. Her most recent hemoglobin A1C was 11.3%. Which of the following is the most appropriate initial therapy? ALamotrigine BOxcarbazepine COxycodone DPregabalin

Pregabalin Peripheral neuropathy is a major cause of morbidity in patients with diabetes mellitus.

A 43-year old woman presents to the emergency department after being bitten on the lip by her dog. The laceration is approximately 4 cm long and 1.5 cm deep, extending vertically from the lower vermilion border to the inner oral mucosa. After thorough irrigation and debridement, which of the following is the best method for wound closure? ADelayed primary closure BPrimary closure with skin adhesive glue CPrimary closure with sutures DSecondary closure

Primary closure with sutures

A 40-year-old man with a history of pancreatic insufficiency and frequent pulmonary infections presents to his primary care office with a worsening productive cough and dyspnea. He is currently taking over-the-counter vitamin A, D, E, and K, prescription pancreatic enzyme replacements, and inhaled dornase alfa daily. He reports needing chest physical therapy and using bronchodilators daily. His baseline pulmonary function test shows a mixed obstructive and restrictive pattern. His vitals are heart rate 90 bpm, respiratory rate 22 breaths per minute, O2 saturation on room air at 94%, temperature 102°F, and blood pressure 130/84 mm Hg. His physical exam today is significant for persistent crackles to bilateral lower lungs. Which of the following pathogens is the most common cause of this patient's condition? 😨😨😨😨😨😨 AHaemophilus influenzae BMycoplasma pneumoniae CPseudomonas aeruginosa DStaphylococcus aureus EStreptococcus pneumoniae

Pseudomonas aeruginosa dx: cystic fibrosis, Autosomal recessive, CFTR gene History of multiple recurrent respiratory infections or failure to thrive Dx: newborn screen, elevated quantitative sweat chloride test Pseudomonas aeruginosa most common infecting bacteria in recurrent pulmonary infections Malabsorption (Vit ADEK), steatorrhea, pancreatic insufficiency Tx: airway clearance therapy, bronchodilators, DNase, pancreatic enzymes, empiric antibiotics (anti-pseudomonal), lung transplantation

A 32-year-old man with a benign medical history presents to the emergency department reporting swelling and pain in his right arm that came on gradually and worsened over the course of 2 days. He reports no injury to the arm, numbness, or weakness. He does note that the extremity feels "heavy." He is finding it difficult to work at his job as a landscaper. Vital signs are within normal limits. Physical exam reveals unilateral right upper extremity swelling without erythema or warmth. Pulses are easily palpable distally, and strength testing is equal bilaterally. Duplex ultrasound confirms the diagnosis. Which of the following would most likely be found in this patient's history? AFever BNeck pain COrthopnea DRecent strenuous upper extremity activity EUnintentional weight loss

Recent strenuous upper extremity activity involving arm movements that cause microtrauma to the subclavian vein. This typically occurs in young men in the dominant arm. dxVenous thrombosis What is the syndrome that describes effort-related primary upper extremity venous thrombosis? Answer: Paget-Schroetter syndrome Primary causes can be classified as idiopathic, secondary to costoclavicular junction abnormalities, or from effort-related thrombosis Secondary causes of upper extremity venous thrombosis include indwelling central venous catheters, malignancy, other hypercoagulable states, and miscellaneous causes, including surgery and immobility. Patients often present with pain and swelling. Other less common symptoms include numbness, heaviness, or paresthesias. Complications include pulmonary embolism and post-thrombotic syndrome ------------------------------------------------------------- vs Unintentional weight loss (E) is a sign of malignancy and should warrant a thorough evaluation, but this would be a less common cause of deep venous thrombosis in a young man without any significant medical history.

A 45-year-old woman presents with nonradicular, flexion-based lower back pain that began atraumatically 3 weeks ago. Her medical history is only significant for hypertension and nephrolithiasis. She reports no numbness, weakness, fever, and bowel or bladder changes and has no history of cancer. Physical exam is unremarkable. Which of the following is the best next step? AOrder a lumbar MRI with contrast BOrder a neurosurgical consultation for lumbar spine evaluation CRecommend bed rest for 5 days DRecommend continued activity within the limits of the pain

Recommend continued activity within the limits of the pain dx: acute low back pain w/out red flag symptom Lumbago Acute nonspecific low back pain Lack red flags Continue daily activities as tolerated Physical therapy, NSAIDs, muscle relaxants, opioids (only for refractory cases) Red flags that raise suspicion for a less benign process include night pain and weight loss (suspect neoplasm); fevers, chills, and sweats (spinal infection); acute bony tenderness (fracture); morning stiffness lasting > 30 minutes in young adults (seronegative spondyloarthropathy); and any neurologic deficit or bowel or bladder involvement (nerve root compression).

A 6-year-old girl with no significant medical history and normal speech development presents to the office with her parent for a follow-up evaluation. She was last seen in the office 3 weeks ago when she was diagnosed with bilateral acute otitis media, and amoxicillin was prescribed. She has since completed the 7-day course of antibiotics. Her fever and pain have resolved, but she appears to have difficulty hearing per her parents. Her vital signs are all within normal range. On the physical examination, the ears demonstrate a normal external auditory canal with a retracted tympanic membrane. There is amber-colored fluid behind both tympanic membranes with observable air-fluid levels. There is no erythema. The cone of light and bony landmarks are visible. Rinne testing demonstrates bone conduction greater than air conduction in both ears. Which of the following clinical interventions would be most appropriate at this time? APrescribe amoxicillin with clavulanic acid BRecommend a nasal decongestant CRecommend an antihistamine DRecommend watchful waiting ERefer to otolaryngology urgently

Recommend watchful waiting dxOtitis media with effusion refers to fluid within the middle ear without signs of infection Management • Spontaneous resolution Autoinsufflation • Myringotomy What tympanogram result would be observed in a patient with otitis media with effusion? Answer: Type B.

A 37-year-old woman at 23 weeks gestation presents to the ED with moderate vaginal bleeding. Ultrasound detects the conditions for abruptio placentae, and she is admitted to the intensive care unit. Continuous fetal heartbeat monitoring is reassuring. The patient is not in labor. Her blood is drawn for a complete blood count and type and cross-screen in the case of transfusion. At the start of the morning shift, the overnight nurse reports a recent increase in bleeding and blood oozing from around the intravenous catheter. Vitals are BP of 115/85 mm Hg, HR of 101 bpm, RR of 17/min, oxygen saturation of 98% on room air, and T of 98.6°F. A nonblanching rash has appeared on her eyelids. Transfusion of blood products is started. Which of the following laboratory findings is associated with the patient's condition? ADecreased fibrin degradation products BElevated platelet levels CElevated white blood cells DPositive direct Coombs test EReduced plasma fibrinogen

Reduced plasma fibrinogen dx:acute disseminated intravascular coagulation (DIC) # blood oozing from site of insertion and Ptt/Pt stuff unbalanced Management requires close attention to trends in coagulation studies, such as prothrombin time and activated partial prothrombin time, which will be prolonged in acute DIC, as well as a close eye on levels of fibrinogen, an acute-phase reactant to excess bleeding, which can quickly become depleted. Platelet levels and hemoglobin and hematocrit are also monitored to determine the need for transfusion. Direct treatment with clotting factors, such as recombinant factor VIIa, is considered high risk but sometimes necessary.

A 34-year-old man presents to his primary care provider with hearing loss and painless otorrhea. He has a past medical history of recurrent serous otitis media and seasonal allergies. He denies any allergies to medication. Otoscopic exam reveals an intact, pearly-gray tympanic membrane and a pale mass of granulation tissue near the pars flaccida. The tragus is nontender to palpation. Which of the following is the most appropriate next step in management? AOfloxacin otic drops BOral amoxicillin-clavulanate CReferral to audiologist DReferral to otolaryngologist

Referral to otolaryngologist dx: cholesteatoma should be referred to otolaryngologist for surgical evaluation. A cholesteatoma is a keratinized, desquamated collection of epithelial cells located in the middle ear. Cholesteatomas can erode into the ossicles, mastoid, or temporal bone. Painless otorrhea is the hallmark symptom. Some patients are completely asymptomatic. Conductive hearing loss may occur if erosion into the ossicles has occurred or if the tympanic membrane is perforated. Acquired Cholesteatoma Patient will have a history of chronic ear infections or tympanostomy tubes Painless otorrhea PE will show yellow or white mass behind the tympanic membrane Treatment is tympanomastoid surgery

A 10-year-old girl presents to the Emergency Department with weakness in her legs. It began yesterday and since has progressed up her legs. Reflexes are diminished in her bilateral lower extremities and are normal in her upper extremities. Sensation is intact throughout. She denies recent illness or sick contacts. Her family returned from a camping trip at a national park last week, but otherwise she has not traveled. During the camping trip, the child ate canned and boxed foods that the family had packed, as well as fish that the family caught and cooked. They also went hiking and swam in a freshwater stream. What intervention is most likely to improve the child's symptoms? ABotulism immune globulin BIntravenous Immunoglobulin CPyridostigmine DRemoval of a tick from the child

Removal of a tick from the child dx Tick paralysis Tick toxin → ↓ ACh release Symmetric ascending paralysis Remove tick→ self-resolving The child's ascending weakness and lower extremity hyporeflexia are concerning for Guillain-Barré syndrome or tick paralysis. --------------------------------------------------------------- vs botulism, which is characterized by descending weakness with early involvement of cranial nerves. Bulbar palsy and dysphagia are common early symptoms.

Which one of the following is the most common manifestation of abusive head trauma in infants? AEpidural hematoma BRetinal hemorrhage CSubarachnoid hemorrhage DSubdural hematoma

Retinal hemorrhage ------------------------------------------------------------- vs Epidural hematoma (A), subarachnoid hemorrhage (C), and subdural hematoma (D) all occur in abusive head trauma but less often than retinal hemorrhages do.

A 50-year-old woman presents to the clinic with increasing shortness of breath and purulent sputum production for the past 7 days. She currently takes albuterol 90 mcg/inhalation every 6 hours and budesonide 360 mcg/inhalation every 12 hours for COPD and amlodipine 10 mg daily for hypertension. She smokes one pack of cigarettes per day. Her vital signs are within normal limits except for an oxygen saturation of 92% on room air. Physical exam reveals a woman with cachexia, erythematous nasal turbinates, and crackles on auscultation throughout her bilateral lung fields. Which of the following is a common precipitating factor for this patient's current diagnosis? AAllergen exposure BCalcium channel blocker therapy CExposure to hot climate DRhinovirus infection ESleep apnea

Rhinovirus infection The woman in the vignette is demonstrating signs and symptoms of an acute exacerbation of chronic obstructive pulmonary disease (COPD). Chronic Obstructive Pulmonary Disease (COPD) Main subtypes: chronic bronchitis, emphysema Hypoxemic patients should be given supplemental oxygen with SpO2 goal of 88-92% Management options include bronchodilators, anticholinergics, steroids, supplemental oxygen, noninvasive ventilation, smoking cessation, vaccinations, and antibiotics for severe disease, infection present, or those requiring ventilation

A 47-year-old man with a history of alcohol use disorder presents with severe abdominal pain, nausea, and vomiting for 1 day. Examination reveals marked epigastric tenderness to palpation. Labs show the following: Lipase: 4,300 U/L AST: 451 U/L ALT: 532 U/L Alkaline phosphatase: 313 U/L Total bilirubin: 5.3 mg/dL Which of the following is the best next step? ACT scan of the abdomen and pelvis BDischarge home if patient tolerates oral fluids CIntravenous antibiotics and admission DRight upper quadrant ultrasound

Right upper quadrant ultrasound dx: acute pancreatitis Acute Pancreatitis Sx: epigastric pain radiating to the back, worse when lying down and better when leaning forward, nausea, and vomiting PE: flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs: elevated lipase (best) and amylase Ranson criteria and APACHE II are used to predict the severity (Note: they are difficult to apply and have limitations) Glucose >200 AST >250 LDH >350 Age >55 y.o. WBC >16000 Caused by gallstones > alcohol, hypertriglyceridemia, drugs Treatment is IV fluids, analgesics Complications: necrotizing pancreatitis, pancreatic pseudocyst, pseudoaneurysm In general, a cutoff of twice the upper limit of normal is used to reduce the number of patients missed. An elevation in the patient's liver enzymes (AST and ALT), alkaline phosphatase, and bilirubin indicate a biliary etiology of pancreatitis. Confirmation should be obtained with an ultrasound of the right upper quadrant focused on the liver, gall bladder, and biliary tree. Determination of a biliary cause of pancreatitis is important because endoscopic retrograde cholangiopancreatography (ERCP) removal of gallstones has been shown to decrease mortality and morbidity, especially in patients with severe pancreatitis.

A 46-year-old obese man presents to the clinic complaining of recurrent heartburn. He reports compliance with optimal medical management and dietary modifications and has been unsuccessful at losing weight. Which of the following is a contraindication to surgical intervention and should be ruled out before proceeding? ABenign esophageal strictures BGastroparesis CHiatal hernia DScleroderma

Scleroderma due to the high incidence of postoperative dysphagia. One of the most serious complications of gastroesophageal reflux disease is Barrett esophagus, which manifests with alarm symptoms and undergoes malignant transformation into adenocarcinoma. dx: GERD

A 40-year-old man who plays weekend baseball as a pitcher presents to the office stating that for the last few months, his right shoulder feels like it is "going dead." He reports that the pain is progressively worsening, and now he is experiencing shoulder weakness with overhead activity. He also believes that he is throwing the baseball slower than previously. Which of the following is the most likely diagnosis? AAcromioclavicular joint injury BAdhesive capsulitis CGlenohumeral joint dislocation DRotator cuff tear

Rotator cuff tear supraspinatus (abduction), infraspinatus (external rotation), teres minor (external rotation), and subscapularis (internal rotation) muscles. It is often remembered by the mnemonic SITS. Patients are usually > 50 years of age and will often have significant pain with internal rotation and abduction above the head. Often, patients will complain of difficulty brushing their hair or have pain at night when rolling onto their shoulder. The condition can also occur in young patients, particularly baseball pitchers, who will often hear a "pop" caused by a tear in the rotator cuff. On exam, the drop arm test and empty can test are positive. weakness on exam and lack of full improvement after rehabilitative exercises and subacromial corticosteroid injection, you should suspect a tear rather than isolated impingement. Tears are diagnosed by MRI and often require surgical repair.

A patient is found to have the following basic metabolic panel results: sodium 143 mmol/L, potassium 3.6 mmol/L, chloride 107 mmol/L, bicarbonate 14 mmol/L, BUN 16 mg/dL, creatinine 1.2 mg/dL, and glucose 92 mg/dL. Which of the following is a possible cause of these laboratory results? AAddison disease BDiarrhea CRenal tubular acidosis DSalicylate toxicity

Salicylate toxicity This patient has a metabolic acidosis as defined by a decrease in serum bicarbonate concentration. The causes of metabolic acidosis can be divided into elevated anion gap and normal anion gap. The anion gap is calculated using the formula Na - (Cl + HCO3) and a normal anion gap is 10 +/- 2. In this example, the patient's anion gap is 22 (143 - (107 + 14)) and therefore considered elevated.

A 44-year-old businessman is having worsening hearing loss in his right ear over several months. He says it sounds as though everyone is "mumbling." He also endorses feeling persistently off-balance. He denies tinnitus. Which of the following clinical interventions is most appropriate for this patient? AEducation on using the Epley maneuver BPrescribe acetazolamide and recommend a low sodium diet CPrescribe oral prednisone tapered over 10 days DSchedule an auditory canal MRI

Schedule an auditory canal MRI dx:Vestibular Schwannoma Formerly known as acoustic neuroma Patient presents with gradual hearing loss, tinnitus, balance disturbance Diagnosis is made by MRI with gadolinium Most commonly caused by CN VIII tumor Management includes observation, microsurgical excision, or stereotactic radiotherapy unilateral with a steady deterioration in speech discrimination. While sudden vertigo is unlikely, a persistent disequilibrium is common. Tinnitus occasionally occurs. A contrast-enhanced MRI of the auditory canal will allow for visualization of the lesion. The decision to pursue treatment must be based on the individual patient's tumor size, age, and overall health. Management options include microsurgical excision, stereotactic radiotherapy, or simply observation. Though most acoustic neuromas form unilaterally, which genetic condition should be suspected in patients with bilateral acoustic neuroma formation? Answer: Bilateral acoustic neuromas may occur in patients with neurofibromatosis 2. ------------------------------------------------------------- vs Education on using the Epley maneuver (A) is the appropriate intervention to manage benign paroxysmal positioning vertigo (BPPV). However, the classic presentation is BPPV is sudden onset vertigo, usually related to swift head movements. Unilateral hearing loss is not caused by BPPV. Prescribing acetazolamide and recommending a low sodium diet (B) is the correct treatment for hearing loss and vertigo caused by Ménière's Syndrome, which usually causes episodes of vertigo lasting from 20 minutes to several hours, as well as low-frequency hearing loss and roaring tinnitus. The duration of this patient's symptoms do not fit those of Ménière's Syndrome. Promptly prescribing an oral prednisone taper (C) would be necessary in managing any sudden sensory hearing loss to prevent patients from developing lasting deafness. This patient, however, had been having worsening hearing loss over several months, and corticosteroids appear to not be effective for sudden sensory hearing loss after 6 weeks of impairment has passed.

A 62-year-old man with a history of chronic obstructive pulmonary disease presents with cough, headache, dyspnea, and watery diarrhea that started 6 days ago. He was seen at a local urgent care 4 days ago and prescribed amoxicillin-clavulanate without improvement. He is ill-appearing with a fever of 38.7°C and inspiratory rales on auscultation. Which of the following results would be most consistent with his diagnosis? ARight upper lobe infiltrate with bulging fissure on chest X-ray BSerum potassium 6 mEq/L CSerum sodium 128 mEq/L DSputum gram stain with gram positive cocci in pairs

Serum sodium 128 mEq/L dx: legionella " Cough plus diahrea' Patient presents with fevers, malaise, myalgias, cough, and GI symptoms Labs will show leukocytosis, elevated liver transaminases, and hyponatremia CXR will show unilateral patchy alveolar lower lobe infiltrates Most commonly caused by gram-negative bacillus and is found in aquatic environments Treatment is azithromycin

Which of the following is correct about cardiac biomarkers during a myocardial infarction? ACreatine kinase serial testing is highly specific for cardiac tissue damage BMyocardial infarction can be ruled out with a single serum myoglobin CSerum troponin I rises faster than creatine kinase-MB during myocardial ischemia DTroponin I or T levels return to normal in 2-3 days

Serum troponin I rises faster than creatine kinase-MB during myocardial ischemia Cardiac Biomarkers Troponin Highest sensitivity and specificity Time detectable from onset: 3-12 hours Peak: 24-48 hours Return to baseline: 5-14 days CK-MB Time detectable from onset: 3-12 hours Peak: 24 hours Return to baseline: 48-72 hrs Useful for Dx of reinfarction Myoglobin First to appear, first to peak, first to decline Lacks specificity

A mother brings her 12-month-old daughter for routine vaccinations. She is up to date with her vaccinations. The girl has a history of a simple febrile seizure at 10 months of age and has a history of respiratory distress after eating eggs. She lives with her parents and her paternal grandmother who is currently undergoing chemotherapy for breast cancer. Because of anxiety of her daughter getting a fever and a febrile seizure, the patient's mother would like to spread out her vaccines. Today she would like her daughter to get the varicella vaccine. She would like to bring the patient back to the office in 2 weeks to get her measles-mumps-rubella (MMR) vaccine but you explain this is contraindicated. Why can the patient not get the MMR vaccine then? AHer risk of vaccine-induced seizure BShe has an anaphylactic egg allergy CShe is living with an immunosuppressed family member DShe must wait 4 weeks between live vaccines

She must wait at least 4 weeks between getting live vaccines if they are not initially given concurrently.

A 3-year-old boy is undergoing a diagnostic work-up for a hereditary cause of a moderate anemia. Lab studies reveal a microcytic anemia and an increased reticulocyte count. Labs also reveal hyperbilirubinemia and an increased mean corpuscular hemoglobin concentration. An osmotic fragility test is abnormal. Which of the following may be eventually considered as a treatment option for this disorder? AAllogeneic hematopoietic stem cell transplantation BAvoidance of oxidative drugs COral hydroxyurea DSplenectomy

Splenectomy dx:Hereditary Spherocytosis Patient presents with symptoms of anemia: fatigue or pallor Positive family history Labs will show microcytic or normocytic anemia and is the only disorder that will cause an increase in mean corpuscular hemoglobin concentration (MCHC) Peripheral smear will show spherocytes and Howell-Jolly body Most commonly caused by an autosomal dominant genetic disease Treatment includes daily folic acid Spherocytosis is the only disorder that will cause an increase in mean corpuscular hemoglobin concentration (MCHC). Coombs test indicating autoimmune hemolysis will be negative.

Which of the following statements is correct regarding the classification of heart failure? AStage A refers to patients with symptoms at rest BStage B refers to patients with valvular dysfunction who are symptomatic CStage C refers to patients with left ventricular dysfunction who are symptomatic with exertion DStage D refers to patients who are at risk of congestive heart failure but have no left ventricular dysfunction

Stage C refers to patients with left ventricular dysfunction who are symptomatic with exertion Heart Failure Staging and Classification American Heart Association/American College of Cardiology staging Stage A: high risk without symptoms or disease Stage B: structural disease without Sx Stage C: structural disease with Sx Stage D: refractory heart failure New York Heart Association classification I: asymptomatic II: Sx with ordinary activity III: asymptomatic only at rest IV: Sx at rest

A 31-year-old woman with diabetes mellitus type 2 presents with worsening left ear pain and fever for 1 week. Examination reveals an ill-appearing woman with a minimally swollen external auditory canal and swelling, warmth, and tenderness around the left ear. The patient was started on antibiotic drops for her ear 1 week ago, but her symptoms have worsened. What management is indicated? AContinue topical antibiotics BIncision and drainage CStart high-dose amoxicillin DStart intravenous ciprofloxacin and admit

Start intravenous ciprofloxacin and admit dx:necrotizing otitis externa and should be started on intravenous antibiotics that cover pseudomonal species and admitted for further evaluation. What cranial nerve is most commonly affected in necrotizing otitis externa? Answer: The facial nerve.(7thCN) Otitis Externa History of swimming or moisture exposure Malodorous discharge and pruritus PE will show pain with palpation of tragus or pinna Most commonly caused by Pseudomonas aeruginosa Treatment is topical antimicrobials with or without steroids Necrotizing otitis externa: a complication seen in those with diabetes or immunocompromise Management😩😩😩😩😩 • Ciprofloxacin monotherapy • Ciprofloxacin plus antipseudomonal beta-lactam for severe illness, immunocompromised state, or local ciprofloxacin resistance

A 30-year-old man with a medical history of asthma, for which he takes as-needed albuterol, and alcohol use disorder presents to the emergency department with bloody diarrhea for the past 2 weeks. The patient reports associated abdominal pain and nausea and states there is blood and mucus in his stools. He was traveling in Nicaragua 3 weeks ago. The patient initially presented to his primary care clinician a week ago, and he was treated with ciprofloxacin, but his symptoms did not improve. Vital signs include a HR of 112 bpm, BP of 125/85 mm Hg, RR of 20/min, oxygen saturation of 95% on room air, and T of 100.2°F. Physical examination reveals right upper quadrant tenderness. Laboratory studies are notable for a white blood cell count of 14,000 cells/µL, alkaline phosphatase of 500 IU/L, aspartate aminotransferase of 80 U/L, and alanine aminotransferase of 85 U/L. Which of the following is the recommended next step in management for the suspected condition? ABlood and stool culture BContinue with antibiotics for 10 days CGiardia stool antigen testing DStool microscopy for cysts or trophozoites EVisual inspection of the colon

Stool microscopy for cysts or trophozoites dx: Intestinal amebiasis is a condition caused by the protozoan Entamoeba histolytica.

Which of the following bacteria most commonly causes acute mastoiditis? AHaemophilus influenzae BPseudomonas aeruginosa CStaphylococcus aureus DStreptococcus pneumoniae

Streptococcus pneumoniae Mastoiditis Patient presents with fever, otalgia, pain, and erythema posterior to the ear PE will show forward displacement of the external ear Most commonly caused by a complication from preceding acute otitis media Treatment is admission and IV antibiotics vs What organism is associated with malignant otitis externa? Answer: Pseudomonas aeruginosa

ou are caring for a patient who is diagnosed with pancreatic adenocarcinoma. The oncologist makes a note of a positive Trousseau syndrome in the documentation. Which of the following is she referring to? ANontender palpable gallbladder BPalpable left supraclavicular lymph node CPopliteal pain with abrupt ankle dorsiflexion DTender migratory thrombophlebitis

Tender migratory thrombophlebitis Pancreatic Cancer Risk factors: history of smoking Sx: abdominal or epigastric pain, painless jaundice, weight loss, anorexia Labs: CA 19-9 serum marker useful in monitoring Dx: U/S, ERCP or MRCP, CT, endoscopic ultrasound Management:Resectable disease: Whipple procedure (pancreaticodudenectomy) + adjuvant chemoUnresectable disease: FOLFIRINOX or gemcitabine-based chemo Most common type is adenocarcinoma Poor prognosis ---------------------------------------------------------- palpable nontender gallbladder (Courvoisier sign) another sign of pancreatic cancer

Posterior short leg splint and non-weight-bearing status dx: Jones fractures refer to fractures of the proximal diaphysis of the fifth metatarsal near the intermetatarsal joint.

The patient's foot X-ray is shown above. Which of the following is the recommended initial management of this patient's presentation?

A 4-year-old girl presents to your office with a fever for the last 7 days. Her mother reports that her temperature was as high as 104.4°F and decreases with ibuprofen but does not resolve. She reports that her daughter has been irritable and, even when her fever goes down, still acts uncomfortable. She complained of abdominal pain and had several episodes of vomiting but no diarrhea. On physical examination, her temperature is 103.0°F, pulse 118, respiratory rate 26 breaths per minute, and blood pressure 110/80. She has bilateral injected conjunctiva but no discharge is noted. Her lips are red and cracked and her posterior pharynx is erythematous, as well. Her tongue is dark red and has enlarged fungiform papillae. She has anterior and posterior cervical lymphadenopathy, with a right anterior node measuring 18 mm. Her fingers and hands are swollen and she pulls away and cries when you try to move her wrist and says "ouch." Regarding the patient's suspected condition, which of the following is true? ACoronary artery aneurysms typically present within 10 days BHigh-dose aspirin should be initiated and continued in this patient for 6 weeks duration CLive vaccines should be delayed for 3 mo

The risk for developing coronary artery aneurysms is greatest for children under 1 year of age dx: Kawasaki disease Kawasaki Disease Children < 5 years old History of high fever × 5 days Conjunctivitis, rash, adenopathy, strawberry tongue, hand or foot edema, fever #1 cause of pediatric acquired heart disease, risk for coronary artery aneurysm CRASH and burn: conjunctivitis, rash, adenopathy, strawberry tongue, hand or foot edema, uncontrolled high fever Tx: IVIG + aspirin

A 10-year-old boy presents with otalgia and hearing loss in the right ear for the past two days. Physical exam reveals a swollen and partially occluded right ear canal with otorrhea. The tympanic membrane appears normal. He has pain with movement of the tragus. Palpation of the surrounding structures and mastoid area is unremarkable. Which of the following is the best initial treatment? AOral antibiotic BTopical antibiotic CTopical antiseptic DTopical glucocorticoid

Topical antibiotic dx: Acute otitis externa History of swimming or moisture exposure Malodorous discharge and pruritus PE will show pain with palpation of tragus or pinna Most commonly caused by Pseudomonas aeruginosa Treatment is topical antimicrobials with or without steroids Necrotizing otitis externa: a complication seen in those with diabetes or immunocompromise

A 55-year-old woman complains of itchy patches on her wrists for the past week. She denies new exposures, medication changes, or other areas of involvement. Physical exam reveals purple, polygonal, papular lesions on the volar aspect of the wrists. Close inspection reveals tiny, white lines on the surface of the lesions. What is the best initial treatment for this skin disorder? AOral acitretin BOral diphenhydramine CTopical fluocinonide DTopical tacrolimus

Topical fluocinonide dx: lichen planus associated with Hep C Patient presents with pruritic skin discolorations on ankles or wrists PE will show pruritic, purple, polygonal papules (four Ps) and fine, white lines (Wickham striae) Treatment is corticosteroids

A 55-year-old man presents to the coronary care unit with persistent ventricular tachycardia after undergoing an ablation for atrial fibrillation. The patient has been receiving infusions of amiodarone and lidocaine. The cardiology team decides to initiate procainamide 100 mg intravenously every five minutes up to 1 gram. Which of the following adverse effects is most important to consider when administering procainamide? AAcute kidney injury BNeutropenia CRespiratory depression DTorsades de pointes

Torsades de pointes Procainamide is a class Ia cardiac antidysrhythmic agent that primarily blocks sodium channels but also slows potassium efflux resulting in prolonged duration of the action potential, which in turn may increase the QTc interval leading to torsades de pointes.

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

Total parenteral nutrition is an alternative to chronic low dose steroids The drug choice will be dependent on the disease site. Patients with mild-to-moderate Crohn's disease will manifest varying degrees of symptoms but will be able to tolerate oral nutrition without dehydration, significant (>10 percent) weight loss, abdominal tenderness, mass, obstruction, or toxicity. Many treatment options exist for these patients, including 5-ASA drugs, corticosteroids, antibiotics, probiotics, antidiarrheal medications and dietary changes. Patients who have failed treatment for mild-to-moderate disease or who manifest severe abdominal pain, significant weight loss, fever, nausea and vomiting, or fever are considered to have moderate-to-severe Crohn's disease. These patients often require hospitalization for intravenous glucocorticoids and often require treatment with biologic agents to obtain remission. Fulminant Crohn's disease is marked by such symptoms as high fevers, persistent vomiting, signs of abscess formation, peritoneal signs, intestinal obstruction, or patients whose symptoms persist despite glucocorticoid therapy or despite therapy with a biologic agent. Some of these patients will require surgical management. Many of these patients will require chronic, low-dose steroid therapy. ----------------------------------------------------------------- vs Total parenteral nutrition is not recommended in those with short bowel syndrome (D) is incorrect. Short bowel syndrome is the result of the removal of large portions of the small intestine. Patients with Crohn's disease are prone to abscess formation or stricture formation and at times surgical resection of the affected intestinal portion is necessary. When large portions of the small intestine are removed, malabsorption is common. This malabsorption can lead to life threatening nutritional deficiencies. In such cases, total parenteral nutrition may be life-saving. Patients tolerate enteral feedings well after total parenteral nutrition is discontinued (A) is false. On the contrary, many patients relapse once total parenteral nutrition is stopped. For this reason, total parenteral nutrition is occasionally administered long-term in refractory Crohn's disease

A 6-year-old girl presents with a limp. The parents noted that the girl was having difficulty walking for the past two days. They deny trauma or fever but did note a cold one week prior. On physical exam, the girl appears well and is afebrile, with the left hip held flexed and abducted. Laboratory tests reveal normal erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and WBC. Ultrasound shows the presence of joint effusion of the left hip. Which of the following is the most likely diagnosis? AMyositis BSeptic arthritis CStress fracture DTransient synovitis

Transient Synovitis Patient will be a child 3-10 years old History of URI within 1-2 weeks Unilateral hip pain Normal or mildly elevated inflammatory markers Treatment is supportive with NSAIDs

Which of the following is most characteristic of a patient with idiopathic intracranial hypertension? AAbnormal CSF chemistry analysis BOpening pressure of 15 cm H2O on lumbar puncture CTransient visual loss DUnilateral papilledema

Transient visual loss Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Risk factors: female sex, obesity, meds (tetracycline, OCPs, vitamin A, steroids) Sx: diffuse headache and visual blurring, peripheral vision loss PE: bilateral papilledema, CN VI palsy Elevated opening pressure on LP Treatment is acetazolamide, serial LPs, weight loss It is most commonly seen in young, obese women of childbearing age. Additional risk factors include the use of oral contraceptives, anabolic steroids, tetracyclines, and vitamin A. Headache is the predominant presenting symptom. The headache is usually generalized and made worse by maneuvers that impair cerebral venous return (e.g. Valsalva and bending forward). Visual complaints occur commonly and patients may have transient visual disturbances several times a day. ------------------------------------------------------------------ vs The opening pressure on lumbar puncture is elevated due to the intracranial hypertension. An opening pressure of 20 cm of H2O would be considered the upper limits of normal. In patients who are obese, a pressure >25 cm H2O is considered abnormal and in non-obese patients, a pressure of >20 cm H2O. Therefore a pressure of 15 cm H2O (B) would be considered normal

An otherwise healthy 42-year-old woman presents with three days of dysuria, urinary frequency, and urinary urgency. Her urine dipstick reveals moderate nitrites, leukocyte esterase and blood. On physical exam she has no costovertebral angle tenderness. She denies nausea, vomiting, fevers, and chills. Which of the following is the most appropriate next step? ACheck urine culture to determine antibiotic choice and treat with phenazopyridine now BRefer the patient to the emergency room for pyelonephritis CTreat with five days of 100 mg nitrofurantoin twice daily and check culture and sensitivity DTreat with seven days of 875 mg amoxicillin twice daily and check culture and sensitivity ETreat with ten days of amoxicillin-clavulanate and check culture and sensitivity

Treat with five days of 100 mg nitrofurantoin twice daily and check culture and sensitivity dx:uncomplicated cystitis characterized by the absence of fever, flank pain, or other suspicion of pyelonephritis

You discover a blowing, holosystolic murmur in a newborn boy, heard loudest at the left sternal border. A pediatric cardiologist diagnoses Ebstein's anomaly. In addition to a malformed right atrium and ventricle, which of the following abnormalities would you most expect to see on this patient's echocardiogram? ALeft ventricular hypertrophy BOverriding aorta CTricuspid insufficiency DTricuspid stenosis

Tricuspid insufficiency Causes: tricuspid ring stretching > pulmonary HTN, endocarditis, rheumatic heart disease Pansystolic murmur at left (or right) sternal border JVP: giant C-V wave Atrial fibrillation What is the classic physical sign associated with tricuspid regurgitation? Answer: A large, bounding v wave is seen during jugular vein inspection. Also, a pulsatile liver may be palpable. manifests as a blowing, pansystolic murmur. It is commonly associated with a thrill. It is most intense in the left, fourth intercostal space, however, it can radiate to the apex, making it difficult to differentiate from a mitral regurgitation murmur.

A 22-year-old woman presents with pelvic pain that has been worsening over the last three days and vaginal discharge for the last week. She has associated nausea and chills. Physical exam reveals cervical motion tenderness and a mass in the right adnexa. Pregnancy test is negative. A pelvic ultrasound reveals a complex multiloculated right adnexal mass. Which of the following is the most likely diagnosis? AAcute appendicitis BOvarian torsion CPolycystic ovarian syndrome DTubo-ovarian abscess

Tubo-ovarian abscess often follows pelvic inflammatory disease (PID) and infection with sexually transmitted infections, particularly N. gonorrhoeae and C. trachomatis. Most commonly caused by a complication of pelvic inflammatory disease Sx: lower abdominal pain, fever, vaginal discharge PE: unilateral adnexal tenderness Dx: pelvic ultrasound Tx: intravenous antibiotics, surgical drainage, or both pelvic ultrasound is the radiographic imaging study of choice and can show a complex multiloculated fluid collection or mass. A CT scan may be preferred in some patients to rule out other causes of an acute abdomen. Treatment plans include gynecologic consultation, hospital admission, and intravenous antibiotics. Large abscesses may require drainage. Ruptured abscesses are a life-threatening emergency and require surgery.

A 32-year-old G1P1 woman presents to your clinic to discuss family planning. She would like to start trying to conceive but is worried because her 2-year-old daughter was born with a neural tube defect despite taking 0.4 mg of folic acid per day before the pregnancy and through the first trimester. She wants to know what she can do to minimize the risk of the next baby having this complication. Which of the following is the most appropriate recommendation for the patient to begin taking today? A0.4 mg of folic acid once per day B1 mg folic acid once per day C4 mg folic acid once per day D4 multivitamins containing 1 mg folic acid per day

Women with a previous pregnancy affected by a neural tube defect or with an affected parent should take 4 mg of folic acid (B9) once per day beginning at least one month prior to conception, through the first trimester, and decreasing to 0.4 mg per day after the first trimester. Prepregnancy Folic Acid B vitamin 400-800 mcg daily at least 1 month prior to conception If prior history of child with neural tube defect, take 4,000 mcg (10× more) Fortified foods

A 25-year-old woman presents to the office with reports of right eye redness, which began yesterday upon waking up from sleep. She noted mild discomfort and a significant amount of yellow drainage coming from the eye throughout the day but no changes to her vision. Her medical history is pertinent for myopia corrected with contact lenses. She takes no medications. Her vital signs are within normal range. Uncorrected visual acuity testing is OD 20/50, OS 20/50, and OU 20/40. On physical examination, the right conjunctiva is diffusely injected with the limbus spared. The left conjunctiva is noninjected. Mucopurulent drainage is noted at the right medial canthus. Fluorescein staining demonstrates no abnormalities. What complication is this patient most at risk for if her condition goes untreated? AEndophthalmitis BEpiscleritis CKeratitis DPreseptal cellulitis EUveitis

pseudomonas Keratitis dx: Conjunctivitis commonly presents as unilateral eye redness. bacterial keratitis, an infection of the cornea for which contact lens use is the greatest risk factor. Patients with bacterial keratitis may present with eye redness with circumcorneal injection, photophobia, vision changes, and foreign body sensation. A hypopyon may be present. Treatment • Antipseudomonal agents (gatifloxacin, ciprofloxacin) • Gentamicin, tobramycin Which pathogen is commonly associated with hyperacute conjunctivitis? Answer: Neisseria gonorrhoeae.

Which of the following conditions should prompt administration of the meningococcal vaccine prior to the standard 11 years of age? ACystic fibrosis BDiabetes mellitus CHypoplastic left heart DSickle cell anemia

sickle cell anemia who no longer have a functional spleen should receive the meningococcal vaccine. At what ages should a child with sickle cell anemia get additional pneumococcal vaccines with the 23-valent pneumococcal vaccine? Answer: At 2 and 5 years of age. ============================================== Cystic fibrosis (A), diabetes mellitus (B), and hypoplastic left heart (C) are not indications for early meningococcal vaccination, but early 23-valent pneumococcal vaccines are indicated in these patients. Complement deficiency is an indication for vaccination against meningococcus with similar guidelines as asplenic patients. Other indications to get an early meningococcal vaccine include HIV infection and travel to hyperendemic or epidemic locations, such as in the African meningitis belt or the Hajj pilgrimage

What level does the spinal cord terminate in adults?

the spinal cord (conus medullaris) terminates at the lower level of the L1 spinal nerve or the body of L2. ---------In infants, the cord terminates at L3 (B and C). Therefore, in infants, a spinal needle should be placed in the L4-L5 (D)or L5-S1 interspace.-------------- Lumbar Puncture Absolute contraindication: infection near LP site Adult needle placement: L3-L4 Infant needle placement: L4-L5 ​Opening pressure measurement accurate only in recumbent patients Xanthochromia (yellow): SAH, hyperbilirubinemia ↑ WBC = bacterial or fungal infection, leukemia, vasculitis ↑ PMN: bacterial infection ↑ RBC = SAH, traumatic tap ↓ glucose: bacterial or TB meningitis or CNS tumors ↑ protein: bacterial or TB meningitis, SAH, traumatic tap, MS, Guillain-Barré

1) A 26-year-old man presents to an express care center with concerns for hoarseness. He states that has been experiencing clear rhinorrhea, a mildly sore throat, and a slight cough for the last few days. He became more concerned this morning when he lost his voice. Which of the following is the most likely etiology for the diagnosis? AGroup A streptococcus BLaryngopharyngeal reflux CStreptococcus pneumoniae DViral syndrome 2) A 52-year-old man presents with one month of a hoarse voice. He denies vocal trauma, recent upper respiratory infection, allergies, cough, rhinorrhea, malaise or fever. His past medical history includes tobacco abuse, hypertension, hyperthyroidism and osteoarthritis. Which of the following is the most appropriate management decision at this time? AHome air humidification BLaryngoscopy CSpeech-language therapy referral DTympanometry

viral etiology is the most common cause of acute laryngitis 2) Laryngoscopy - look at image- Laryngitis Viral > bacterial Hoarseness Humidified air, hydration, and vocal rest Hoarseness is described as a coarse, scratchy sound with phonation. What are some causes of chronic laryngitis? Answer: Laryngopharyngeal reflux, allergies, smoking, chronic vocal abuse and inhaled corticosteroids. --------------------------------------------------------------- Group A streptococcus (A) typically causes more throat pain than that associated with laryngitis, as well as fever and lymphadenopathy. Laryngopharyngeal reflux (B) is a cause of acute laryngitis; however, that would not be associated with upper respiratory infection symptoms. Streptococcus pneumoniae (C) has been implicated in acute laryngitis; however, this is less common than viral etiologies.