ROSH PANCE Missed Questions

A patient presents with scrotal swelling suspicious for hydrocele. Which of the following is the most appropriate intervention at this time? AComplete metabolic panel and urinalysis BComputed tomography scan CSimple aspiration DSurgical consultation EUltrasonography

3- ultrasonography In any case of scrotal swelling, color Doppler ultrasonography is the first diagnostic test recommended.

Which of the following patients has a positive Mantoux test result? AA 32-year-old man who is immunocompetent with 15 mm induration BA 36-year-old woman with HIV and 6 mm of erythema but no induration CA 40-year-old healthy individual with 2 mm induration DA 42-year-old man who previously received bacillus Calmette-Guérin immunization against tuberculosis with 9 mm induration EA 51-year-old woman who uses intravenous drugs and has < 5 mm induration

A - A 32-year-old man who is immunocompetent with 15 mm induration Positive results vary, depending on the individual's risk factors for TB. Patients with ≥ 5 mm induration are considered positive if they have HIV, close contact with someone with active infection, previous chest X-ray findings suggestive of healed infection, or organ transplants and are on immunosuppressive agents. Patients with ≥ 10 mm induration are considered positive if they use intravenous drugs, have emigrated from endemic areas of the world, reside in long-term care facilities, or are under the age of 4 years. Induration ≥ 15 mm in otherwise healthy, immunocompetent adults is considered positive.

What is the most common cause of minor hemoptysis in the emergency department? AAcute bronchitis BBronchogenic carcinoma CPneumonia DPulmonary embolism ETuberculosis

A - Acute bronchitis Acute bronchitis is the most common cause of minor hemoptysis in the emergency department. Hemoptysis describes the presence of blood in sputum expectorated from the respiratory tract. Most episodes of hemoptysis are minor, with small amounts of blood. Life-threatening hemorrhage occurs in < 5% of patients with hemoptysis. Bronchitis results from inflammation in the bronchial tree and can lead to hemoptysis. Additionally, forceful coughing further irritates the inflamed mucos

A 74-year-old woman with a history of heart failure presents to the ED with shortness of breath. Her vital signs are a heart rate of 105 bpm, blood pressure of 180/90 mm Hg, and oxygen saturation of 87% on room air. Chest X-ray shows pulmonary edema. You are considering starting nitrates. Which of the following underlying conditions puts the patient at risk of developing nitrate-induced hypotension? AAortic stenosis BChronic obstructive pulmonary disease CMyocardial infarction involving the left ventricle DPulmonary edema EVolume overload

A - Aortic stenosis Nitrates are vasodilators, which decrease mean arterial pressure by reducing preload and afterload, and are first-line therapy for hypertensive acute heart failure. However, due to their vasodilatory effects, nitrates can precipitate or worsen hypotension and should not be used if hypotension is present. In addition, in preload-dependent states in which cardiac output depends on an adequate preload to the heart, administration of nitrates can result in critical hypotension. These preload-dependent states include aortic stenosis, volume depletion, right ventricular infarction, and hypertrophic obstructive cardiomyopathy.

Which of the following can cause reversible sensorineural hearing loss? AAspirin BCisplatin CErythromycin DGentamicin

A - Aspirin Aspirin - reversible. The rest cause permanent

A 35-year-old woman presents for palpitations for 2 months, sweating, tremors, and anxiety. She also reports 10 pounds of unintentional weight loss over the past 2 months and menstrual irregularities. She has a hx of celiac and takes no medications. no hx of anxiety, depression, chest pain, or SOB. Vitals: BP of 142/85, HR of 145 bpm, RR of 14, T of 99.0°F, and SpO2 of 99% on room air. Physical exam reveals a diffusely enlarged, nontender thyroid, exophthalmos, and warm, moist skin. Her labs are significant for a thyroid-stimulating hormone of 0.2 mU/L, T3 of 400 ng/dL, and a free T4 of 3.5 ng/dL. ECG shows an irregularly irregular rhythm, and chest radiographs reveal no abnormalities. What is the best next step in the management of this patient's condition? ABlock sympathetic hyperactivity BElectrical cardioversion CInhibit the release of stored thyroid hormone DInhibit thyroid hormone synthesis E RF ablation

A - Block sympathetic hyperactivity Management of this condition starts with blocking sympathetic hyperactivity to help control symptoms and heart rate. Propranolol, a beta-blocker, is the initial treatment of choice for patients with hyperthyroidism. Beta-blockers can help control symptoms of hyperthyroidism by blocking beta-adrenergic receptors in the heart and should be started in patients with hyperthyroidism as soon as possible unless they have a contraindication.

A 19-year-old man presents to the ED with facial and mouth pain after being assaulted with a club. On physical exam, you note significant swelling over the left inferior and lateral face and misalignment of the inferior premolars. Which of the following is the most likely location of this mandibular injury? ABody BCoronoid process CRamus DSymphysis

A - Body The body of the mandible is a frequent fracture site and is more likely to present with obvious signs of tooth misalignment during the physical exam, particularly involving the lower premolars or molars. Other common locations for mandibular fractures include the mandibular condyle and the angle of the mandible.

A 30-year-old woman with no prior medical history presents to the emergency department with abdominal pain, nausea, and vomiting for 2 days. Vital signs today include a HR of 111 bpm, BP of 126/70 mm Hg, RR of 20/min, oxygen saturation of 97% on room air, and T of 99.1°F. Physical examination reveals the patient to be actively vomiting with diffuse abdominal tenderness and upper abdominal distention. Laboratory findings include a white blood cell count of 10,000/μL, lipase of 250 U/L, aspartate aminotransferase of 35 U/L, alanine aminotransferase of 42 U/L, alkaline phosphatase of 85 U/L, and total bilirubin of 0.8 mg/dL. The patient's upright abdominal plain film is shown above. Which of the following is the most likely diagnosis? ACecal volvulus BGastric outlet obstruction CSigmoid volvulus DSmall bowel obstruction EToxic megacolon

A - Cecal volvulus

You diagnose a patient with myofascial pain syndrome. In an effort to decrease her overall pain levels, which of the following medications is most appropriate to prescribe? ACyclobenzaprine BHaloperidol COxycontin DPregabalin

A - Cyclobenzaprine Muscle relaxants, such as cyclobenzaprine, provide pain relief. NSAIDs, only when used in conjunction with other active treatment, are also beneficial for pain relief.

A 53yo M is brought into the ED, confused and disoriented. His partner reports he was feeling weak, nauseated and had multiple episodes of vom earlier. His partner also reports an inc in hiccuping, a metallic taste in his mouth, and general pruritus for several days. He states the pt avoid the doctor and has not been in several years. Vital signs include a BMI of 33.2, a BP 158/90, HR 98, RR 30, T of 99.6°F, and SpO2 of 94% PE reveals a regular rate and rhythm, rapid breathing, lungs CTAB, and a round, soft, and nontender abdomen w/0 masses. Dependent edema is noted in the lower extremities. Labs are notable for an elevated SCr level of 3.1 , an eGFRof 38, serum albumin of 3.6, and BGLof 290. A CBC is WNL, and UA is + for 3+ protein. What is the most likely underlying cause for his presenting symptoms? ADiabetes mellitus BNephrolithiasis CNephrotic syndrome DPolycystic kidney disease ERenal cell carcinoma

A - Diabetes mellitus The most common causes of chronic kidney disease are diabetes mellitus (type 2) and hypertension. In addition to being the leading cause of chronic kidney disease, diabetes is also the most common cause of end-stage kidney disease.Patients with kidney insufficiency leading to chronic kidney disease may be asymptomatic but will experience signs of uremia such as pruritus, nausea, vomiting, hiccups, and a metallic taste in the mouth with worsening disease. Uremic pericarditis, delirium, seizures, and coma are signs of more severe disease. Patients may also present with uremic frost, a manifestation of severe azotemia in which evaporating sweat leaves behind tiny yellow-white urea crystals on the skin, giving it a frosted appearance.

A 23-year-old man presents in status epilepticus by EMS. They have given multiple doses of benzodiazepines without response. Which of the following tests is most important at this time? AFingerstick glucose BLumbar puncture CNoncontrast head CT DSerum sodium level

A - Fingerstick glucose Because hypoglycemia can be rapidly identified, rapidly treated, and potentially fatal, fingerstick glucose should be part of the immediate workup of any patient who presents with altered mental status. Hypoglycemia is a common and easily treated cause of seizures that is frequently overlooked.

A 23-year-old man presents to your clinic for evaluation of fever, sore throat, headache, and a rash on his chest. He reports three new male sexual partners in the past 6 months. Physical exam reveals a temperature of 102°F, nontender cervical and axillary lymphadenopathy, pharyngeal edema without exudate, and a maculopapular rash on the chest and neck. Lab results show a white blood cell count of 3,200/µL and a lymphocyte count of 850/µL. Which of the following is the most likely diagnosis? A HIV B Mononucleosis C Pityriasis rosea D Syphilis E Systemic lupus erythematosus

A - HIV Acute HIV infection can present with a number of nonspecific symptoms that resemble other illnesses. Clinicians need a high degree of clinical suspicion to make the diagnosis. Patients may be reluctant to answer questions honestly about their sexual behavior or drug use or may not perceive their behavior as being high risk and thus omit important information during the history-taking. This can impede making a correct diagnosis. Patients presenting with fever, rash, pharyngitis, lymphadenopathy, and myalgias should have acute HIV infection included in the differential diagnosis.

A 32-year-old woman presents to the emergency department with dysuria, back pain, and fever for 2 days. She indicates she has had urinary tract infections in the past but never this severe. She reports no other significant medical history and does not take any medications. Vital signs show a BP of 132/80 mm Hg, HR of 114 bpm, RR of 16/min, and T of 102.2°F (39.0°C). Examination shows a moderately ill-appearing woman with bilateral costovertebral angle tenderness. What testing is required to make an appropriate diagnosis in this patient? AUrinalysis BUrinalysis and contrast-enhanced computed tomography of the abdomen and pelvis CUrinalysis and noncontrast-enhanced computed tomography of the abdomen and pelvis DUrinalysis and ultrasonography of the kidney parenchyma EUrinalysis and urine culture

A - Urinalysis This patient is presenting with signs and symptoms of acute pyelonephritis, a urinary tract infection of the kidney parenchyma and collecting system manifesting with the clinical syndrome of fever, chills, flank pain, and nausea or vomiting in conjunction with a urinalysis that is consistent with infection. Most patients with acute pyelonephritis do not need emergency imaging to secure the diagnosis of pyelonephritis.

A 12-year-old boy is brought to the clinic for progressively worsening blurry vision and generalized headaches that are worse in the morning. On further questioning, he is also revealed to have nausea, joint pain, itchy and peeling skin, dizziness, and irritability. Historically, he has been a healthy child, and his family follows an organic diet with additional supplements that include 2 tablespoons of cod liver oil and a multivitamin tablet a day. On exam, his weight dropped from the 50th percentile a year before to the 10th percentile currently. He has oily skin and hair and cracking at the corners of his mouth. Which of the following vitamins most likely caused his symptoms via chronic overdose? AVitamin A BVitamin C CVitamin D DVitamin E EVitamin K

A - Vitamin A Vitamin A toxicity can lead to increased intracranial pressure (associated with headaches, nausea, vomiting, dizziness, blurred vision), oily and peeling skin, cheilosis, alopecia, drowsiness, fatigue, decreased appetite, poor weight gain, joint pain, and liver damage (which leads to jaundice). Cod liver oil supplements contain high levels of vitamin A, which is a fat-soluble vitamin.

What drug can cause rhabdo? ADaptomycin BGentamicin CLevofloxacin DVancomycin

A - daptomycin Myopathy and rhabdomyolysis are known adverse effects of daptomycin, and therefore, creatine phosphokinase levels should be monitored weekly.

Which of the following statements is true regarding giant cell arteritis? AAortic involvement can lead to valvular disease and dissection BCorticosteroid therapy should be initiated only when biopsy confirms the disease CCTA is the preferred imaging modality DHistologic findings of inflammation are irreversible EIt is associated with sudden, painful binocular vision loss

A Aortic involvement can lead to valvular disease and dissection Temporal arteritis is a chronic segmental vasculitis of medium and large vessels. Aortic involvement can lead to valvular insufficiency, aortic arch syndrome, and dissection.

While performing a routine physical examination, a provider notices a distinct decrease in the strength of the patient's radial pulse during inspiration. Which of the following conditions does this patient likely have? AConstrictive pericarditis BDiabetes mellitus CSubclavian steal syndrome DTietze syndrome

A Constrictive pericarditis Pulsus paradoxus is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. When the drop is more than 10 mm Hg, it is referred to as pulsus paradoxus. Pulsus paradoxus is a sign that is indicative of several conditions, including cardiac tamponade, constrictive pericarditis, chronic sleep apnea, croup, and obstructive lung disease.

A 35-year-old man presents to the office with acute onset right flank pain radiating to the groin with intermittent nausea and vomiting. A urinalysis and computed tomography of the abdomen and pelvis without contrast were ordered. An urgent referral for outpatient urologist evaluation would be most appropriate for which of the following findings? AA 10.5 mm mid-ureteral stone BA 3 mm stone in the distal ureter CHydronephrosis with urinary tract infection DUreteral obstruction from a stone in a transplanted kidney

AA 10.5 mm mid-ureteral stone Stones that are > 8 mm in diameter, however, are unlikely to pass spontaneously and may require stent placement, percutaneous nephrostomy, extracorporeal shockwave lithotripsy, ureteroscopy, and nephrostolithotomy. Therefore, an urgent referral for outpatient urologist evaluation is recommended for a patient with a 10.5 mm mid-ureteral stone who is likely to need further management.

A 47-year-old man presents as a trauma activation after a head-on motor vehicle collision at 20 mph. He was a restrained driver and the airbags deployed. There were no drugs or alcohol involved. He is uncertain if he lost consciousness. EMS extricated him, put him in spinal immobilization, and splinted an obviously fractured femur. On the primary survey, his airway is protected, he is breathing easily, he is normotensive, and he has a Glasgow Coma Scale score of 15. Vital signs are within normal limits. The secondary survey is notable for a mildly tender right trapezius muscle and an ecchymotic and deformed left femur with normal distal neurovascular function. The presence of which historical or physical finding necessitates cervical spinal imaging per National Emergency X-Radiography Utilization Study criteria? ADistracting injury BMechanism of injury CParaspinal tenderness DPossible loss of consciousness

ADistracting injury NEXUS rules indicate that the patient can be clinically cleared of a cervical spinal injury. The presence of a single criterion necessitates imaging. A femur fracture is a distracting injury, thereby necessitating cervical imaging. CT imaging of the cervical spine is the initial test of choice to rule out a fracture in this situation.

A 30-year-old man presents to the emergency department after an abrupt onset of left flank pain that radiates to the left lower abdomen. The pain started last night and is intermittent and severe. The patient reports associated nausea, vomiting, chills, and hematuria. Vitals: HR of 115 bpm, BP of 160/110, RR 22, SpO2 98% , and T of 101.4°F. Physical examination reveals the patient to be writhing in pain with mild left-sided abdominal tenderness but no guarding or rebound tenderness. Urinalysis includes pyuria, large leukocyte esterase, bacteriuria, negative nitrites, and hematuria. The patient's creatinine is 0.8. CT of the abdomen and pelvis without contrast shows a 5 mm stone in the proximal left ureter with mild hydronephrosis. Which of the following is the strongest indication for urgent urologic intervention for this patient? AFever and chills BHematuria CHydronephrosis DStone position EStone size

AFever and chills The patient in the vignette has ureterolithiasis with systemic symptoms, such as fever and chills, and urinalysis findings concerning for urosepsis. Urosepsis (sepsis caused by infections of the urinary tract) due to a kidney stone is an indication for urgent urologic consultation. Outpatient urology referral is recommended for patients who have a stone > 10 mm in diameter or for patients who do not pass a stone after a 4-week trial of conservative management

A 65-year-old woman with a medical history of osteoporosis treated with alendronate presents to the clinic for assessment of her BP The patient was seen for her annual last month, and her BP was noted to be 140/88 . She has no prior history of hypertension, and her BP is 144/86 at her visit today. In addition, she has kept a log of home BP measurements for the past month, and her average BP reading is 140/89. Her other vital signs today include a heart rate of 85 bpm, respiratory rate of 20 per minute, oxygen saturation of 97% on room air, and temperature of 98.8°F. On physical examination, she has a regular rate and rhythm with lungs that are clear to auscultation, and she has no lower extremity edema. You decide to start her on a pharmacologic antihypertensive agent. Which of the following is the best choice for this patient? AAmlodipine BChlorthalidone CLisinopril DLosartan EMetoprolol

B - Chlorthalidone Chlorthalidone is the best initial antihypertensive pharmacologic agent for this patient because it is both a first-line antihypertensive and can help improve bone mineral density in patients with osteopenia or osteoporosis. Thiazide diuretics, such as chlorthalidone and hydrochlorothiazide, are thought to increase bone mineral density by increasing calcium reabsorption in the distal tubules of the kidneys.

A 33-year-old woman with a history of von Willebrand disease type 1 presents to the ED with prolonged epistaxis. Vital signs are within normal range, and nasal examination reveals oozing from the right naris despite applying pressure. Which of the following treatments is indicated for the management of her bleeding? ACryoprecipitate BDesmopressin CFactor VIII concentrate DFresh frozen plasma EIron infusion

B - Desmopressin A reduction in vWF activity will also be seen. In patients with mild mucosal bleeding, desmopressin is sufficient for treatment. Desmopressin acts by increasing circulating levels of factor VIII and vWF. It can be administered nasally or intravenously.

A patient presents with excessive urination and thirst. His vital signs include a blood pressure of 122/82 mm Hg, heart rate of 64 bpm, respiratory rate of 18/min, oxygen saturation of 99% on room air, and temperature of 98.3°F. His serum sodium level is 132 mEq/L, and urinalysis shows negative protein, negative glucose, and specific gravity of 1.001. Which of the following is the most appropriate next test to order for the evaluation of these symptoms? ACosyntropin stimulation test BDesmopressin stimulation test CDexamethasone suppression test DOctreotide suppression test EOral glucose tolerance test

B - Desmopressin stimulation test Once other causes, namely DM, are ruled out, a fluid deprivation test or desmopressin stimulation test is used to distinguish between the different types of arginine vasopressin disorder.

A 54-year-old man presents to the clinic 3 months after starting hydralazine for management of hypertension. The patient reports a low-grade fever, arthralgias, and a rash on sun-exposed areas. What adverse effect of hydralazine is this patient most likely experiencing? ADrug reaction with eosinophilia and systemic symptoms BDrug-induced lupus CDrug-induced vasculitis DToxic epidermal necrolysis

B - Drug-induced lupus Drug-induced lupus is seen in 10% of patients taking hydralazine and most often presents with fever, rash, myalgias, and arthralgias

A 45-year-old man with diabetes mellitus presents to your clinic for the first time. Which one of the following vaccines is recommended for him if he has not previously received it? AHepatitis A BHepatitis B CMeningococcal DRespiratory syncytial virus vaccine EVaricella-zoster

B - Hepatitis B According to current recommendations, the hepatitis B vaccine should be administered to all previously unvaccinated adults aged 19-59 with diabetes mellitus as soon as possible after the diagnosis of diabetes is made.

A 28-year-old woman presents to the emergency department for evaluation of acute dyspnea. She has no significant medical history. Vital signs include a blood pressure of 152/48 mm Hg, heart rate of 122 bpm, respiratory rate of 20 breaths/minute, and oxygen saturation of 97% on room air. Physical exam reveals tachycardia, warm extremities, wide pulse pressure, bounding pulses, a systolic flow murmur, exophthalmos, and a neck mass. Which of the following is the most likely diagnosis? AAortic Regurgitation BHigh-output heart failure CLow-output heart failure DMethamphetamine intoxication EPulmonary embolism

B - High-output heart failure This patient most likely has high-output heart failure secondary to thyrotoxicosis. High-output heart failure occurs when cardiac output is elevated in patients with reduced systemic vascular resistance. Examples include thyrotoxicosis, anemia, pregnancy, beriberi, and Paget disease. Patients with high-output heart failure usually have normal pump function, but it is not adequate to meet the high metabolic demands. In high-output heart failure, the heart rate is typically elevated, the pulse is usually bounding, and the pulse pressure is wide

A 74-year-old man presents to the ED with chest pain that radiates to his jaw and associated dyspnea. His medical history is significant for hypercholesterolemia, hypertension, and diabetes. He reports no nonmedical drug use. His vital signs are BP of 210/122 mm Hg, HR of 88 bpm, RR of 22/min, SpO2 of 95%, and T of 98.4°F. Physical exam reveals an anxious-appearing man but is otherwise normal. Chest X-ray reveals no abnormalities. His ECG is consistent with left ventricular hypertrophy. Which of the following is the most likely diagnosis? AAutonomic dysreflexia BHypertensive emergency CHypertensive urgency DPanic attack ESympathetic crisis

B - Hypertensive emergency A hypertensive emergency is a severe elevation in blood pressure with evidence of end-organ damage. This requires immediate lowering of blood pressure. There is no specific blood pressure at which hypertensive emergency occurs, but end-organ damage is less likely if the diastolic BP is < 130 mm Hg. The well-accepted criteria for hypertensive crises are systolic pressure ≥ 180 mm Hg or diastolic pressure ≥ 110 mm Hg. Symptoms of hypertensive emergency include chest pain, dyspnea, and neurologic deficits.

A 53-year-old man with a history of atrial fibrillation and hypertension presents with severe abdominal pain. He states the pain has been there for 3 days but got more severe today. Over the last 3 days, he has been unable to eat because the pain occurs after eating. Vital signs are T of 99.7°F, HR of 123 bpm, BP of 101/66 mm Hg, and RR of 24/min. Examination reveals an uncomfortable patient with diffuse mild abdominal tenderness to palpation without rebound or guarding. Stool guaiac is positive, and serum lactate is 4.8 mmol/L. Which of the following is most appropriate for further evaluation of the suspected condition? AObtain abdominal X-rays BObtain CT angiogram of the abdomen and pelvis CObtain CT scan of the abdomen and pelvis without IV contrast DObtain right upper quadrant abdominal ultrasound ESchedule for an esophagogastroduodenoscopy

B - Obtain CT angiogram of the abdomen and pelvis mesenteric ischemia, which is best diagnosed by CT angiogram he classic presentation of mesenteric ischemia is that of an older patient who presents with intermittent abdominal pain that is increased with eating. The pain is out of proportion to examination. An elevated lactate level is also highly suggestive of mesenteric ischemia and has a high sensitivity.

A 4-year-old boy presents with a laceration to his distal forearm. You consider using a topical tissue adhesive to close the wound. Which of the following is true of tissue adhesive use in lacerations? AIn wounds that require deep suture closure, the superficial layer should not be closed with skin adhesive BTissue adhesives have the equivalent strength of 5-0 nylon sutures CTissue adhesives should be avoided on areas of cosmetic importance DTissue adhesives should be used only for lacerations < 2 cm in length

B - Tissue adhesives have the equivalent strength of 5-0 nylon sutures

A 72-year-old woman is admitted to the intensive care unit for presumed sepsis. The patient requires the use of norepinephrine and vasopressin continuous infusions in order to maintain an adequate blood pressure. Which of the following adverse effects is most commonly associated with vasopressin? AHyperglycemia BHyponatremia CHypovolemia DTachycardia

B - hyponatremia Vasopressin is the exogenous form of antidiuretic hormone that acts as a vasoconstrictor in patients with vasodilatory shock. Vasopressin is most often used in hypotensive patients who fail to adequately respond to intravenous fluids and catecholamines (e.g., norepinephrine, dopamine, epinephrine). This increased water reabsorption causes a dilutional effect on sodium leading to hyponatremia. Other adverse effects of vasopressin therapy include renal hypoperfusion, dysrhythmias, and distal limb ischemia.

Which of the following patients with an asymptomatic abdominal aortic aneurysm should be offered an elective outpatient surgical repair? A22-year-old man with Ehlers-Danlos syndrome and aneurysm size of 3.5 cm B42-year-old man with hypertension, aneurysm size of 3.9 cm, and 0.9 cm aneurysm expansion in 6 months C52-year-old man with positive family history and aneurysm size of 4.5 cm D62-year-old man with tobacco use, aneurysm size 4.5 cm, and aneurysm growth of 0.2 cm in 2 years E72-year-old man with hyperlipidemia and aneurysm size 6.0 cm

B 42-year-old man with hypertension, aneurysm size of 3.9 cm, and 0.9 cm aneurysm expansion in 6 months Elective surgical correction of an asymptomatic AAA is offered to patients when AAA size is ≥ 5.5 cm in men or > 5.0 cm in women or when an AAA grows more than 0.5 cm over 6 months or > 1 cm per year. Therefore, the 42-year-old man with hypertension, aneurysm size of 3.9 cm, and 0.9 cm aneurysm expansion in 6 months should undergo elective repair.

A 35-year-old woman is being managed for multiple episodes of chest pain that have been awakening her from sleep on several early mornings for the past 2 months. An electrocardiogram after one episode showed ST elevation. Coronary angiography did not reveal any stenotic lesions. She has no cardiac risk factors and is otherwise healthy. Which of the following daily medications is most likely to provide relief from her condition? AAdenosine BAmlodipine CAspirin DPropranolol

B Amlodipine Amlodipine is the most appropriate selection to use as daily prophylaxis against the anginal pain caused by Prinzmetal (variant) angina.

An 85-year-old woman is experiencing exquisite pain distributed in a band-like fashion on her right ribcage. She describes the pain as a burning sensation. She recently completed a course of medication to treat a rash, but she does not remember the name of the rash or the medication. Which of the following would be most effective in treating this pain? ACapsaicin BGabapentin CHydrocortisone DOxycodone ERemdesivir

B Gabapentin treatments for moderate to severe postherpetic neuralgia include gabapentin and tricyclic antidepressants. Amitriptyline works by inhibiting reuptake of serotonin and norepinephrine by presynaptic neuronal membrane, which may increase synaptic concentration in the CNS. The exact mechanism of gabapentin in the treatment of postherpetic neuralgia is unknown.

Which of the following types of hemoglobin does hydroxyurea increase? AHemoglobin AA BHemoglobin F CHemoglobin H DHemoglobin SC EHemoglobin SS

B Hemoglobin F It works by increasing levels of fetal hemoglobin (HbF)

A 28-year-old woman with myasthenia gravis presents with progressive shortness of breath that started several hours ago. She takes pyridostigmine every 6 hours and has not missed any doses. Yesterday, she was prescribed an unknown antibiotic for sinusitis at an urgent care clinic. On exam, her vital signs are within normal limits, and she does not appear in respiratory distress. What is the best next step in the management of this patient's condition? ABegin intravenous immunoglobulin BMeasure negative inspiratory force CObtain a chest X-ray DStart corticosteroids

B Measure negative inspiratory force An objective measure of respiratory status (negative inspiratory force or forced vital capacity) should be trended to evaluate the need for mechanical ventilation.

Which of the following is one of the most common causes of bacterial foodborne disease in the United States? AEnterotoxigenic Escherichia coli BSalmonella CShigella DVibrio cholerae

B Salmonella

A 21-year-old woman presents to the clinic with a rash that began 4 days ago while she was on vacation in Punta Cana. The rash is mildly pruritic and painful. Her BP is 114/78 mm Hg, HR is 64 bpm, RR is 18/min, SpO2 is 100% on room air, and T is 98.6°F. A rash is noted on sun-exposed areas, including the upper and lower extremities, chest, back, shoulders, and face. The rash is erythematous and edematous with small, scattered vesicles, and desquamation, mainly on the shoulders. She has not changed soaps, lotions, detergents, or cosmetics. She started taking a new daily medication for acne vulgaris just prior to her vacation. Which of the following is the most likely diagnosis? ABenzoyl peroxide-induced phototoxicity BDoxycycline-induced phototoxicity CErythromycin-induced phototoxicity DPhytophotodermatitis EStevens-Johnson syndrome

BDoxycycline-induced phototoxicity

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

BInfantile spasms signs and symptoms consistent with infantile spasms or West syndrome. Infantile spasms are defined by the triad of the following findings: clusters of myoclonic seizures on awakening, hypsarrhythmia pattern on electroencephalogram, and developmental delay. Signs and symptoms of infantile spasms usually begin at 4-8 months of age but are rare beyond 1 year of age

A 35-year-old woman is being evaluated at her annual wellness exam. She has no complaints and generally feels healthy. She has no past medical history and takes no medications. She walks 30 minutes five days per week with no dyspnea or discomfort. On physical exam her blood pressure is 118/68, pulse 64/min and respiration rate is 13/min. Her body mass index is 22. Cardiac auscultation reveals a 2/6 mid-systolic crescendo-decrescendo murmur heard best at the left lower sternal border without radiation. She has a normal S1 and S2 and normal cardiac impulse. Lungs are clear and peripheral pulses are normal. Electrocardiogram is normal. What is the next appropriate step in management? ACardiac magnetic resonance imaging BNo additional testing CTransesophageal echocardiography DTransthoracic echocardiography

BNo additional testing No additional testing is indicated in this patient. She most likely has a benign systolic ejection murmur. This is a common clinical situation and reassurance is appropriate.

A 12-year-old boy presented to your office 1 week ago for evaluation 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? AAntistreptolysin O titer BBlood cultures CC-reactive protein DComplete blood count EThroat culture

C - C-reactive protein Acute rheumatic fever (ARF) is an inflammatory, autoimmune response that develops after infection with group A Streptococcus (GAS). Measurement of C-reactive protein or erythrocyte sedimentation rate can be used to monitor the progression of the acute disease.

A healthy 6yo boy presents to the ED with bloody diarrhea. Started 1wk ago, watery stools (up to 10 per day) were noted. Mom states there is no recent travel, abx use, or sick contacts. Vitals are a HR 118 BPM oxygen SPo2 100%, and rectal temp of 100.94°F. PE reveals a mildly tender abdomen without localization, rebound, guarding, or peritoneal signs. You note grossly bloody stool on rectal exam. A brief discussion with his pediatrician confirms invasive bacterial diarrhea; a stool culture +Shigella. Which of the following is true regarding this condition? AAntibiotics should be avoided because this is a severe case and the patient is at highest risk of developing HUS BAntidiarrheal agents are indicated, given the frequency of loose stools CExtraintestinal manifestations such as hallucinations, confusion, and seizures may occur DOral rehydration should be avoided; IV fluids should be initiated

C - Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur Dysentery (diarrhea with significant blood, pus, and mucus) occurs in approximately 33% of patients. Some patients may also develop extraintestinal manifestations such as reactive arthritis, seizures, and hallucinations. The general management of diarrhea from a bacterial source is oral rehydration and avoidance of anti-diarrheal agents. Antibiotics should not be given to young, healthy individuals and should be reserved for immunocompromised, bacteremic, or hospitalized patients.

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

C - Exudate with positive cytology exudates herald the presence of some traumatic injury or inflammation. Exudate can be infectious in nature, as in viral, bacterial or fungal pericarditis, or even myocarditis and endocarditis. Exudates are also commonly associated with autoimmune rheumatic conditions, such as rheumatoid arthritis or systemic lupus erythematosus. Cancer, either primary or metastatic, can also produce a pericardial exudate

A 47-year-old woman presents to your office for follow-up on newly diagnosed hypothyroidism. You prescribed levothyroxine 6 weeks ago after her TSH was noted to be 12.8 µU/mL. She has been taking her medication as instructed, and her symptoms improved. Retesting of her TSH shows a level of 8.6 µU/mL. Which of the following is the best next step in management? AChange medication to a thyroid hormone preparation containing T3 BDecrease dose of levothyroxine and repeat TSH testing in 6 weeks CIncrease dose of levothyroxine and repeat TSH testing in 6 weeks DMaintain current dose of levothyroxine and repeat TSH testing in 6 weeks ETest for serum anti-thyroid peroxidase antibodies

C - Increase dose of levothyroxine and repeat TSH testing in 6 weeks It takes approximately 6 weeks to achieve a steady-state TSH concentration. Once thyroid hormone replacement is initiated, TSH should be rechecked in 6 weeks. An elevated TSH after 6 weeks indicates that there is not enough thyroid hormone because the lack of thyroid hormone stimulates the anterior pituitary to produce more TSH.

A 19-year-old woman presents with pain in her mouth. She underwent an extraction of an impacted molar 3 days before the onset of her pain. Her pain had been improving. However, it began worsening acutely today. Which of the following is the most appropriate treatment? ADilute hydrogen peroxide rinses BIncision and drainage CIodoform gauze packing moistened with oil of clove DRoot canal

C - Iodoform gauze packing moistened with oil of clove This patient likely has a dry socket, also known as acute alveolar osteitis. Treatment includes packing the open socket with iodoform gauze. The gauze is saturated with either a medicated dental paste or eugenol (oil of cloves). Patients will require analgesia and may benefit from a nerve block.

A 65-year-old man presents to his primary care clinic for a 3-mo f/u. He was diagnosed with stage 2 CKD 3 months ago. He reports no headache, fatigue, or any other symptoms. He has a medical hx of DM and HTN, takes metformin 1,000 mg twice daily, exenatide 10 mcg subcutaneously twice daily, and hydrochlorothiazide 25 mg daily. He reports no smoking, drinks two beers per week, no drugs. Vitals are normal, BMI of 38. Physical exam is unremarkable. His laboratory results reveal a glucose of 122 mg/dL, his urine is without any proteinuria or glucosuria, and his GFR today is 55 mL/min/1.73m2. Which of the following is a recommended dietary intake for patients with this new diagnosis? AIncrease dietary fat to > 60% of total energy intake BIncrease protein intake to > 2.5 g/kg/day CLimit K+ intake to keep within normal range DReduce phosphorus intake to 2 and 3 g/day ERestrict Na intake to between 2,500 and 5,000

C - Limit K+ intake to keep within normal range Patients with CKD are at increased risk of disorders of fluid and electrolyte balance, such as hyperkalemia. Potassium intake should be limited to keep it within a normal range with specific restriction requirements based on the individual. A low-salt diet (< 2 g/day) is also recommended.

A substrate is a medication that is metabolized by CYP450 isoenzymes in the gastrointestinal tract and liver. Substrates are subject to drug interactions with agents that inhibit or induce the enzyme. Substrate inhibition may result in drug toxicity while induction may result in lack of efficacy. Which of the following benzodiazepines is the best choice for use in the presence of liver failure or concomitant CYP450 interacting drugs? AChlordiazepoxide BDiazepam CLorazepam DMidazolam

C - Lorazepam

A 54-year-old man with a long-standing history of alcohol use disorder presents to the clinic for a regular follow-up. He was diagnosed with liver cirrhosis 2 years ago, and recent imaging studies show the presence of esophageal varices. He has no prior bleeding episodes. His vital signs are within reference range, and his physical examination reveals mild splenomegaly but no ascites or jaundice. What is the most appropriate medication to prescribe to prevent the primary occurrence of variceal hemorrhage in this patient? AFamotidine BMetoprolol CNadolol DOctreotide EPantoprazole

C - Nadolol Nonselective beta-blockers, such as nadolol, are used for the primary prophylaxis of variceal bleeding and have demonstrated a decrease in the risk of variceal bleeding. A long-acting preparation of propranolol or nadolol may be started. Metoprolol (B) is a selective beta-blocker. Selective beta-blockers primarily act on beta-1 adrenergic receptors and have little impact on portal pressure reduction.

A 14-year-old girl presents for evaluation. Three weeks ago, she collided with an opponent while playing soccer. She was assessed on the field and reported a headache and dizziness. She was instructed to sit out for the remainder of the game. She continues to have a headache, dizziness, and difficulty concentrating. Which of the following is the most likely diagnosis? AConcussion BMigraine without aura CPostconcussion syndrome DSecond impact syndrome ETension headache

C - Postconcussion syndrome Postconcussion syndrome is the sequelae of a mild traumatic brain injury or concussion that is defined by the continuation of symptoms of headache, dizziness, and cognitive impairment. While the specific timeline that separates a concussion from postconcussion syndrome is still not well established, symptoms that continue 7-10 days after the initial injury are considered to be caused by post-concussion syndrome.

A 36-year-old woman who works on a farm has a right eye mass that is seen in the image above. Which of the following is the most likely diagnosis? ACataract BPinguecula CPterygium DXanthelasma

C - Pterygium

Which of the following is necessary to confirm the diagnosis of scoliosis? AAdam's forward bend test BMagnetic resonance imaging CRadiography DScoliometer

C - Radiography A number of screening measures are used to determine the likelihood of scoliosis, but radiography is needed for the diagnosis of scoliosis as determined by the Cobb angle.

A 60-year-old man presents for follow-up after his recent annual examination 1 week ago. He is bedridden and unable to walk following a stroke several months ago. He also has type 1 diabetes mellitus and uses insulin. Vital signs today include a BP of 110/70 mm Hg, HR of 72 bpm, RR of 17/minute, and T of 37.0°C. Laboratory results reveal elevated serum low-density lipoprotein and triglycerides, low serum albumin, and high levels of protein on urinalysis. Nephrotic syndrome is suspected. Where would the clinician most likely detect edema on the physical exam? AHands BLower legs CSacrum DThighs EUpper arms

C - Sacrum Peripheral edema is generally seen in the lower extremities, as those areas are where excess interstitial water will collect in an ambulatory patient. In a nonambulatory patient, the fluid will collect around the sacrum. Because fluid is influenced by posture, weight loss or weight gain is another way to monitor edema or the efficacy of diuretic therapy in these patients.

A 23yo M presents to PCP for eval of possible depression. He feels sad and hopeless most days of the week for the past month. He has a lack of interest in activities that he used to enjoy. He also has had issues with constipation and feeling tired most of the day. He has lost 3 jobs in last 8 mos. He reports he feels his coworkers changed passwords and data so he could not be successful. Sometimes, he hears voices telling him his coworkers are out to get him. He has heard the voices for the past 6 months. PMH is unremarkable. He does not drink any alcohol or use any drugs. Vitals wnl On physical exam, he appears disheveled and avoids eye contact. His speech is disorganized and tangential, and his affect is flat. A UDS is negative. What is the most likely diagnosis? ABipolar I disorder BMDD with psychotic features CSchizoaffective disorder DSchizoid personality disorder ESubstance-induced psychosis

C - Schizoaffective disorder Schizoaffective disorder is a condition in which patients meet the criteria for a diagnosis of schizophrenia and also have a mood disorder, including mania, depression, and a mixed mood disorder. The psychotic symptoms cannot occur exclusively during the mood disorder and must be present for at least 2 weeks without the mood disorder.

A 68-year-old woman presents to the clinic for evaluation of fatigue, muscle weakness, and diffuse bone pain. She also reports experiencing frequent urination and kidney stones over the past few months. Vital signs include a blood pressure of 120/80 mm Hg, heart rate of 78 bpm, respiratory rate of 19/min, oxygen saturation of 98% on room air, and temperature of 98.9°F. Laboratory studies show a calcium level of 11.0 mg/dL and a parathyroid hormone level of 85 pg/mL. Which of the following findings would be most consistent with the suspected diagnosis? AChvostek sign BDecreased serum magnesium level CDecreased serum phosphate level DHyperreflexia EHypotension

CDecreased serum phosphate level Calcium and phosphate have an inverse relationship with one another. increase in PTH levels will promote the excretion of phosphate in the kidneys, causing serum levels of phosphate to decrease. Hyperparathyroidism is the most common cause of hypercalcemia and can be classified as primary, secondary, or tertiary.

A 46-year-old G2P2 woman presents to her gynecologist's office with a 6-month history of irregular, heavy menses. She states her cramps are no worse than usual, and she does not have dyspareunia or postcoital bleeding. Her vital signs include a BP of 124/75 mm Hg, HR of 78 bpm, RR of 16/min, SpO2 of 99%, T of 98.9°F, and BMI of 32 kg/m2. Physical examination reveals a normal-appearing cervix and a smooth, regularly shaped uterus that is nontender and not enlarged. Which of the following is the most likely diagnosis? AAdenomyosis BCervical polyps CEndometrial hyperplasia DEndometriosis EUterine leiomyoma

CEndometrial hyperplasia Ovulatory dysfunction and endometrial hyperplasia are the most common causes of abnormal uterine bleeding in patients who have obesity. Hyperplasia, or proliferation of the endometrium, is the result of unopposed estrogen over a period of time. Risk factors for hyperplasia include increasing age, obesity, diabetes, polycystic ovary syndrome, and certain genetic mutations.

A patient presents to the clinic with symptoms of shortness of breath and intermittent palpitations. She reports no new medications and has a medical history significant for hypothyroidism and generalized anxiety disorder, for which she takes levothyroxine and sertraline. Vital signs include HR 182 bpm, RR 18 breaths per minute, BP 133/87 mm Hg, T 98.8°F, and SpO2 99% on room air. Physical exam reveals a rapid pulse with otherwise unremarkable findings. Results from the patient's telemetry strip are shown above, and the first-line pharmaceutical treatment is administered. Which of the following side effects is most likely to occur? AAcute decompensated heart failure BAgranulocytosis CFacial flushing DPulmonary fibrosis ETissue necrosis

CFacial flushing The most common adverse effects of adenosine include facial flushing, transient or new cardiac dysrhythmia after conversion, seizure, and hyper- or hypotension. Older patients are at an increased risk for hemodynamic side effects, bradycardia, and atrioventricular block.

A 3-year-old boy is brought to the emergency department by his parent because of possible poisoning. He was found in the garage with furniture polish on his cheeks, mouth, and clothes. The parent saw him coughing but reports no choking or vomiting. On examination, the boy is active with normal vital signs. Which of the following is the best next step? AConsult pulmonology BGive activated charcoal CObtain chest X-ray DPerform gastric lavage

CObtain chest X-ray Aspiration is characterized by coughing, which usually is the first clinical finding. It is important to obtain a chest radiograph. It may initially be normal, but it can often show abnormalities within 6 hours of exposure in patients who have aspirated.

A 70-year-old woman presents to the ED after collapsing at home earlier that day. She stood up out of bed that morning, felt lightheaded, and collapsed onto the floor. Her spouse estimates she was unconscious for about 30 seconds. She has hypertension, for which she takes metoprolol succinate, and has not fainted before. Prior to the event, she did not experience nausea, diaphoresis, palpitations, chest discomfort, or shortness of breath. Her electrocardiogram is shown above. Which of the following options is the most likely diagnosis? AAortic stenosis BCardiac dysrhythmia COrthostatic hypotension DTransient ischemic attack EVasovagal syncope

COrthostatic hypotension Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg upon sitting or standing. The major causes of orthostatic hypotension are drug effects (antihypertensives, antidepressants), decreased intravascular volume, primary or secondary autonomic insufficiency, aging, and alcohol consumption. Syncope due to orthostatic hypotension frequently occurs due to a posture change from supine to erect.

A 45-year-old chemist presents to the emergency department after accidentally spilling elemental sodium on his left hand and forearm 30 minutes prior to arrival. What is the most appropriate next step? AApplication of topical calcium gluconate BCopious irrigation with water CCover the affected area with a wet dressing DCover the affected area with mineral oil EIntravenous fluid resuscitation

D - Cover the affected area with mineral oil The first step in managing elemental metal burns is to cover the affected area with mineral oil, sand, or foam from a Class D fire extinguisher. Chemicals that should not be immediately irrigated with water include dry lime, elemental metals (e.g., sodium, potassium, magnesium, and phosphorus), and phenols. Treatment for elemental metal burns involves removal of the substance and cover the affected area in mineral oil to prevent further exposure to air and moisture.

What is the most common cause of rectal bleeding in an adult? AAnal fissure BColon cancer CDiverticulitis DHemorrhoids EInflammatory bowel disease

D - Hemorrhoids

A 48-year-old woman presents with nausea and vomiting. She underwent an appendectomy 3 days ago and now reports she has not had a bowel movement since the surgery. She reports no fever or chills. On examination, her abdomen is distended and tympanic to percussion, with decreased bowel sounds. Her abdominal X-ray is shown above. Which electrolyte abnormality commonly causes the suspected diagnosis? AHyperkalemia BHypermagnesemia CHypernatremia DHypokalemia EHyponatremia

D - Hypokalemia Postoperative ileus is a common condition characterized by temporary impairment of bowel motility following surgical procedures, particularly abdominal surgeries. Hypokalemia is common in the postoperative period and may cause an ileus.

A 38-year-old man presents to the clinic for evaluation of gradually increasing shoe size, ring size, and protrusion of the lower jaw over the past few years. Vital signs include a BP of 140/90 mm Hg, HR of 85 bmp, RR of 18/min, and SpO2 of 99% on room air. On examination, you note an enlarged tongue, coarse facial features, and thickened skin. Based on the clinical presentation, which of the following laboratory tests should be ordered first to investigate the underlying cause of this patient's symptoms? AAdrenocorticotropic hormone BGrowth hormone CHemoglobin A1C DInsulin-like growth factor 1 EThyroid-stimulating hormone

D - Insulin-like growth factor 1 Acromegaly is a rare disease that occurs as a result of persistent hypersecretion of growth hormone (GH). An excess amount of GH causes hepatic secretion of insulin-like growth factor 1 (IGF-1). Testing of GH after administration of oral glucose should be done after elevated IGF-1 levels are determined. Pituitary MRI is the initial radiologic test ordered after elevated GH and IGF-1 levels are determined.

Which one of the following is true concerning the use of hemoglobin A1C levels to diagnose diabetes mellitus? AA level > 5.0% is diagnostic of diabetes mellitus BAll adults should have an HbA1C checked every 3 years according to USPSTF guidelines CIncreases in measured HbA1C may occur in the setting of erythropoietin treatment DResults can be misleading in patients with sickle cell disease EThe test is useful to diagnose diabetes during pregnancy

D - Results can be misleading in patients with sickle cell disease Sickle cell disease and other hemoglobinopathies cause hemolysis, which causes HbA1C measurements to be falsely low. Conditions that decrease mean erythrocyte age, such as recent transfusions or increased erythropoiesis secondary to hemolysis, blood loss, or anemia, will have falsely decreased levels of HbA1C. Conditions that have an increasing mean erythrocyte age, such as asplenia, tend to increase HbA1C levels.

Which nerve root is affected in a patient with loss of the ankle jerk reflex? AC5 BL4 CL5 DS1

D - S1 S1 is responsible for ankle jerk reflex (Achilles reflex)

A 59-year-old man with a history of HTN, HLD, and chronic low back pain presents for evaluation of sudden-onset abdominal pain that radiates to his right shoulder. His current medication regimen includes enalapril, propranolol, aspirin, ibuprofen, and atorvastatin. He describes intense, diffuse abdominal pain that began 2 hours ago and has since decreased in severity. Vitals: HR 133 bpm, RR 20/min, BP 102/82 mm Hg, T 95.7°F, and SpO2 95%. PE reveals an ill-appearing man w a weak radial pulse and cool extremities. Abdo palpation demonstrates marked abdominal rigidity and right lower quadrant tenderness. Cardiac biomarkers are WNL, and initial ECG normal. Which of the following is the best next step in intervention following initial stabilization? ABarium swallow study BMaintenance intravenous fluids and bowel rest CNasogastric tube placement and serial abdominal exams DSurgical consultation EUpper endoscopy

D - Surgical consultation Free perforation may occur when a lesion ulcerates through the gastrointestinal wall. Any patient with a suspected perforated ulcer should be stabilized urgently with supportive care, including a nothing by mouth diet, fluid resuscitation, and a proton pump inhibitor and antibiotics given intravenously. Continued abdominal contamination and hemorrhage from a perforated peptic ulcer necessitates immediate surgical consultation

A 17-year-old boy presents to the emergency department after being tackled while playing football. He is unable to bear weight on his left ankle. On physical exam, he is tender to palpation over the anterior tibiofibular ligament. Dorsiflexing while externally rotating the ankle reproduces his pain. Plain radiographs reveals a diastasis between the distal tibia and fibula, but no fractures. Which of the following is the most likely diagnosis? AAchilles tendon sprain BAnterior talofibular ligament sprain CLateral collateral ligament sprain DSyndesmotic ankle sprain

D - Syndesmotic ankle sprain This boy most likely has a syndesmotic ankle sprain, or high ankle sprain. A syndesmotic sprain involves a ligamentous injury to one or more of the distal tibiofibular syndesmosis. The ankle joint is made up of the tibia, fibula, and the talus. Ankle radiographs may demonstrate diastasis between the tibia and fibula depending upon the severity of the sprain.

Which of the following is the best management of corneal abrasions once the diagnosis is made? ADaily topical corticosteroids BOral antibiotics and an eye patch CTopical anesthetic eye drops DTopical antibiotics and pain controls EUrgent ophthalmology consultation

D - Topical antibiotics and pain controls The best management for corneal abrasions is topical antibiotics and pain control. Topical antibiotics, such as erythromycin ointment or trimethoprim-polymyxin B drops, help prevent secondary bacterial infection, particularly in individuals with a high risk, such as contact lens wearers (who require antipseudomonal coverage like fluoroquinolones). Pain control can be achieved with oral NSAIDs or topical cycloplegics, and patients should be counseled to avoid rubbing their eyes and to return for worsening symptoms. Small, uncomplicated abrasions typically heal within 24-48 hours without sequelae.

A 52-year-old woman presents to her primary care provider's office with a pruritic rash on her chest. She has a past medical history of morbid obesity, type 2 diabetes mellitus, and hypertension. On exam, there is a sharply demarcated area of erythema underneath both breasts. Direct microscopy of skin scrapings reveals oval budding yeast and pseudohyphae. Which of the following is the most appropriate management? AOral fluconazole BOral prednisone COral terbinafine DTopical econazole ETopical mupirocin

D - Topical econazole Topical antifungal medication is effective and well tolerated in most patients with mild to moderate infections. Oral agents may be required when topical therapy has failed or if there are multiple intertriginous areas involved.

A 68-year-old man presents to the emergency department with reports of fatigue and confusion. His vital signs are within normal limits except for a pulse of 38 beats per minute and a blood pressure of 90/50 mm Hg. The patient has no preexisting illness, takes no medications, and has had no surgeries. Laboratory values, including troponins, are within normal limits. An ECG was performed and is shown above. Administration of intravenous atropine and dopamine does not improve symptoms or vital signs. Which of the following is the best next step? A Administer intravenous dobutamine B Administer intravenous lidocaine C Administer oral levothyroxine D Perform transcutaneous pacing E Refer to surgery for pacemaker implantation

D - perform transcutaneous pacing When atropine is not effective, dopamine may be infused at a rate of 5-20 mcg/kg/minute. If the patient does not respond favorably to atropine or dopamine and remains symptomatic and unstable, transcutaneous pacing should be performed until the cause of the bradycardia can be determined. If the definitive cause of the bradycardia is irreversible, such as sinoatrial node dysfunction unrelated to medication, then the definitive treatment is an implantable pacemaker.

At what diameter is referral for elective surgical repair of an abdominal aortic aneurysm generally recommended in asymptomatic patients? A≥ 2.5 cm B≥ 4.0 cm C≥ 5.0 cm D≥ 5.5 cm E≥ 6.0 cm

D - ≥5.5cm Patients with an aneurysm greater than or equal to 5.5 cm in diameter or an aneurysm that expands more than 0.5 cm in six months should be referred for immediate surgical repair by either open repair or endovascular repair.

A 10-year-old boy presents to the emergency department with left ear pain and fever. The ear pain has been present for 4 days, and the fevers started 2 days prior to presentation. He has been unable to sleep on his left side due to the pain. His vital signs show a temperature of 39.2°C, heart rate of 100 bpm, blood pressure of 95/70 mm Hg, respiratory rate of 16/min, and oxygen saturation of 99%. On examination, his left ear appears displaced, and there is postauricular erythema and tenderness. The external canal is erythematous, and there is fluid behind the left tympanic membrane. Which of the following is the best next step? ABegin otic drops BInitiate oral antibiotic therapy CObtain an ultrasound of the neck vasculature DPerform CT scan of the temporal bones

D Perform CT scan of the temporal bones CT scan of the temporal bones is an appropriate diagnostic test in cases of acute mastoiditis in order to delineate bony involvement. Acute mastoiditis is defined as inflammation of the mastoid air cells. Antibiotic therapy will typically halt the progression and reverse the inflammation. However, the infection can spread to the periosteum or the bone, leading to acute mastoiditis with periosteitis, subperiosteal abscess, or osteitis

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

D Removal of a tick from the child The child's ascending weakness and lower extremity hyporeflexia are concerning for Guillain-Barré syndrome or tick paralysis. Botulism is descending weakness.

A 45-year-old man presents to your office with questions about prostate cancer screening. He does not have a family history of prostate cancer and wants to know at what age he should begin screening. Which of the following is the most appropriate next step in management, according to the USPSTF? ABegin screening at age 50 BOrder serum prostate-specific antigen now, then begin screening at age 50 CPerform an initial digital rectal exam now, then begin screening at age 50 DScreening is not recommended ESerum prostate-specific antigen and digital rectal exam now

D Screening is not recommended The USPSTF guidelines for prostate cancer screening focus on an individualized approach, especially regarding the use of prostate-specific antigen (PSA) testing. For patients aged 55-69 years, the decision to undergo PSA screening should be based on a discussion of potential benefits and harms with a health care clinician, considering the patient's values and preferences.

A 17-year-old girl presents with dysuria and vaginal itching. A speculum exam reveals the findings seen above. Which of the following statements is correct regarding this diagnosis? AA fishy odor is present when vaginal discharge is mixed with potassium hydroxide BMetronidazole is the recommended treatment CMultiple petechiae are often seen on the vaginal wall DThe pH of the discharge is < 4.5 EVaginal discharge is often foul smelling

D The pH of the discharge is < 4.5 Candidal vaginitis is characterized by a thick, curdy-white (cottage cheese-like) discharge. Patients typically report vaginal itching, dysuria, and dyspareunia. The pH of the discharge is < 4.5, whereas the pH of the other causes of vaginitis is > 4.5.

A 45-year-old woman presents to the clinic reporting painful blisters on her trunk, arms, and face and in her mouth that developed over the past 2 weeks. Her medical history is positive for gastroesophageal reflux disease, treated with pantoprazole 40 mg daily for the past 6 months. She reports no prior surgeries, drug or environmental allergies, or prodromal symptoms. Vital signs are a blood pressure of 120/80 mm Hg, heart rate of 80 beats/minute, respirations of 16/minute, and temperature of 98.8°F. Physical exam reveals shallow ulcerations of the soft palate and buccal mucosa and erythematous bullae on the trunk, arms, and face. No bullae are present on the palms or soles. New bullae form when lateral pressure is applied to intact skin near existing bullae. What is the most likely diagnosis? ABullous pemphigoid BErythema multiforme CPemphigus foliaceus DPemphigus vulgaris EStevens-Johnson syndrome

DPemphigus vulgaris Pemphigus vulgaris is an uncommon, autoimmune, bullous skin disorder caused by autoantibodies directed against desmogleins in the epidermis. Most commonly, patients are affected between the ages of 40 and 60 years old. Bullous pemphigoid (A) is more common in individuals aged 60 years and older and is also a bullous autoimmune disease. However, bullous pemphigoid is intensely pruritic, and bullae are tense

Which of the following groups of patients should be screened for hepatitis C? AChildren starting daycare BCollege students living in a dorm CNursing home residents DPeople aged 18 to 79 years EPeople with a history of hepatitis A

DPeople aged 18 to 79 years

A 19-year-old college student presents dead-on-arrival to the ED. An autopsy reveals significant calcification of the aortic valve cusps. Upon review of his medical history, you would most likely find documentation of a murmur heard in which of the following locations? AApex BLeft, fourth intercostal space CRight, fourth intercostal space DRight, second intercostal space

DRight, second intercostal space

A 57-year-old woman is brought by ambulance to the emergency room. Three hours ago she began having a headache with nausea and noticed a loss of sensation on most of the right side of her body. A non-contrast computed tomography scan of her head shows a 2 cm area of enhancement in the brain parenchyma. Which of the following is the most likely location of the patient's lesion? ACerebellum BFrontal lobe CTemporal lobe DThalamus

DThalamus A thalamic hemorrhage classically presents with contralateral hemisensory loss.

A patient was treated for an upper respiratory tract infection 2 weeks ago. She now presents with one day of 7/10 facial pain with bending forward, as well as difficulty blowing her runny nose. Examination reveals frontal bone tenderness to percussion and nasal erythema and drainage. Her temperature is 100°F. Which of the following is the most appropriate management option for this patient? Antihistamines Computed tomography of the frontal sinuses Decongestants Otolaryngological referral

Decongestants Treatment begins with analgesics, decongestants and saline nasal irrigation. If the presenting temperature is greater than 101°F, or symptoms are severe or worsening or last longer than 7 days, begin antibiotic treatment with amoxicillin-clavulanate.

A 7-day-old infant presents for eye discharge. He was born at home with the aid of a midwife. His vital signs include a blood pressure of 76/40 mm Hg, heart rate of 190 bpm, respiratory rate of 45/min, oxygen saturation of 97% on room air, and temperature of 36.7°C (98.1°F). On exam, the infant has copious mucopurulent discharge from both eyes, swollen eyelids, and chemosis. Which of the following is the most appropriate treatment? AIntramuscular ceftriaxoneYour Answer BOphthalmic ciprofloxacin COphthalmic erythromycin DOral azithromycin EOral erythromycin

E - Oral erythromycin Oral erythromycin is the treatment of choice for neonatal chlamydial conjunctivitis.

28-year-old woman presents to your office for evaluation of mood swings. She tells you that she constantly fights with her partner and gets angry easily. She often uses cocaine and binge eats when under stress. Last month, she held a knife to her wrist during an argument with her partner but did not follow through with the suicide attempt. Which of the following is the most appropriate next step in management? AAdmit to an inpatient psychiatric unit BBegin a mood stabilizer CBegin course of amitriptyline DBegin course of lorazepam EBegin dialectical behavioral therapy

E - Begin dialectical behavioral therapy First-line treatment for patients with BPD is psychotherapy. Dialectical behavioral therapy is preferred and most effective. It includes skills training, mindful practice, and offers monitoring for and intervention in cases of BPD crises.

A 1-week-old boy is brought to the ED for evaluation of seizures. At home, his parent noticed jittery bilateral leg movements that cannot be stopped when the legs are held. The neonate was born at full term to a 25-year-old G2P2 mother with limited prenatal care. There were no complications at delivery. In the ED, vital signs are within normal limits, with an unremarkable neurologic examination. The infant appears to have abnormal facial features consisting of a small mouth, cleft palate, low-set ears, and a widened distance between the inner canthi with short palpebral fissures. Which of the following abnormal laboratory findings is most consistent with the diagnosis? AAnemia BHigh TSH CHyperglycemia DHyperkalemia EHypocalcemia

E - Hypocalcemia The infant has abnormal facial features and presents with seizures, which is suspicious for DiGeorge syndrome. Patients typically present in the first week after birth with signs of hypocalcemia such as tetany or seizures secondary to hypoplastic or absent parathyroid glands.

Which of the following is a common cause of hypomagnesemia? Antacid use Hypoparathyroidism Hypothyroidism Lithium therapy Malnutrition

E - Malnutrition Chronic malnourishment, such as that seen in chronic alcohol use, children with severely restricted diets, or older patients, is a common cause of hypomagnesemia. Other risk factors are eating disorders and cancer. In addition to poor nutrition, hypomagnesemia can be seen in patients on diuretic agents and a number of other medications (e.g., aminoglycosides and proton pump inhibitors). Patients commonly have concurrent hypokalemia, and presenting symptoms and signs are likely due to both of these abnormalities.

A 19-year-old woman presents to the emergency department with pelvic pain that has been worsening over the last 4 days. She reports associated nausea and several episodes of emesis today. Vital signs include a blood pressure of 113/68 mm Hg, heart rate of 112 bpm, and oral temperature of 38.4°C (101.1°F). Pelvic examination reveals purulent vaginal discharge, cervical motion tenderness, and fullness in the left adnexa on palpation. Urine pregnancy test is negative. Which of the following would be the most appropriate next step in management? AAdminister intramuscular ceftriaxone BBegin oral metronidazole and azithromycin CEmergent gynecology consult DObtain a complete blood count and urinalysis EOrder a pelvic ultrasound

E - Order a pelvic ultrasound This patient has symptoms consistent with a tubo-ovarian abscess (TOA), and a pelvic ultrasound is the radiographic modality of choice to evaluate adnexal mass or fullness.

A 4-year-old boy presents to urgent care with a new onset of a rash and toxic appearance. His caregiver says he became fussy and started refusing food about a week ago. Fever and malaise have persisted, despite use of liquid acetaminophen, and the rash appeared on his chest 3 days ago. Vitals are BP of 90/60 mm Hg, HR of 125 bpm, RR of 20 bpm, T of 102.1°F, and oxygen saturation of 97%. On exam, you identify a diffuse, maculopapular blanching rash on the chest, antecubital fossa, and anterior forearms with some desquamation at the fingertips. Sclera are clear, pharynx is slightly erythematous, tongue is somewhat swollen and red with pronounced papillae, and cervical lymph nodes are undetectable. What is the most likely diagnosis? AHand, foot, and mouth disease BKawasaki disease CRocky Mountain spotted fever DRoseola infantum EScarlet fever

E - Scarlet fever The diffuse red rash, or scarlatina, is often described as a sandpaper rash for its maculopapular nature. It begins on the chest and spreads to the extremities, with desquamation of the hands and feet. The papules can become petechial and converge in lines known as Pastia lines. A red, bumpy tongue, often called strawberry tongue, is a well known manifestation, along with circumoral pallor. Anterior cervical lymphadenopathy with tenderness is often present. Four of these five symptoms are required for diagnosis of kawasaki: bilateral conjunctivitis; erythema of lips, tongue, and oral mucosa; skin abnormalities of the hands and feet; polymorphous rash; and cervical lymphadenopathy. This patient does not have conjunctivitis or cervical lymphadenopathy. An elevated C-reactive protein level and erythrocyte sedimentation rate will reflect systemic inflammation.

A 55-year-old woman presents with fever, malaise, and a facial rash. She has a history of diabetes mellitus, for which she takes metformin. Vital signs include a temperature of 102.1°F, heart rate of 115 bpm, respiratory rate of 16/min, oxygen saturation of 97%, and blood pressure of 110/68 mm Hg. On physical examination there is a 5 cm by 6 cm area of deep erythema with induration and sharply demarcated borders involving the right cheek area. Which of the following pathogens is most frequently implicated in this patient's diagnosis? AClostridium perfringens BHaemophilus influenzae CStaphylococcus epidermidis DStaphylococcus saprophyticus EStreptococcus pyogenes

E - Streptococcus pyogenes Streptococcus pyogenes is the predominant pathogen in erysipelas. It is a group A beta-hemolytic streptococci that is also known to cause streptococcal pharyngitis, scarlet fever, and rheumatic fever. Effective antibiotic choices include penicillins, cephalosporins, and macrolides.

A 24-year-old woman presents to the office reporting progressive fatigue for the past several months. She is otherwise healthy and not on any medications. Her menstrual cycles are regular, lasting between 3 and 5 days, and she uses about five or six regular tampons per day. Her temperature is 98.6°F, blood pressure is 112/75 mm Hg, heart rate is 85 bpm, oxygen saturation is 98% on room air, and respiratory rate is 22/min. A physical exam is unremarkable. Her CBC reveals a hemoglobin of 10.2 g/dL and a mean corpuscular volume of 72 fL. The patient is prescribed daily oral ferrous sulfate and returns for a follow-up in 6 weeks. A repeat CBC is unchanged. Which of the following is the most likely diagnosis? AAplastic anemia BHereditary spherocytosis CIron deficiency anemia DSideroblastic anemia EThalassemia

E - Thalassemia The most common type of thalassemia is thalassemia minor, with the beta form being more common than the alpha form. Patients with this condition will typically have a hypochromic (due to low mean corpuscular hemoglobin) and microcytic (low mean corpuscular volume) anemia on a CBC. Additionally, there may be an elevated reticulocyte count and a normal to elevated RBC count due to more small and pale RBCs being produced. The mild forms of thalassemia are commonly mistaken for iron deficiency anemia. Iron deficiency anemia can be ruled out with an unsuccessful trial of iron therapy, as in this patient, or with further iron studies, which will be unremarkable or reveal an elevated transferrin saturation or ferritin.

A 34-year-old health care worker presents to the urgent care clinic with concerns about worsening nosebleeds. She has a history of untreated hepatitis C, uncontrolled hyperlipidemia, and migraine headaches that she manages with meditation. She has experienced numerous episodes of epistaxis over the last few months, and her gums bleed while brushing her teeth. She reports no significant pain. Vital signs today are a BP of 111/81 mm Hg, HR of 89 bpm, RR of 15/minute, and T of 98.5°F. Her liver and spleen are not palpable. Preliminary blood work reveals a platelet count of 21,000/µL. Which of the following findings is likely to be seen on physical exam? ADelayed procedural bleeding BHemarthrosis CLarge soft tissue hematoma DPale palpebral conjunctivae EWet purpura

E - Wet purpura Wet purpura is consistent with thrombocytopenia. Wet purpura refers to purpura that occurs on a mucosal surface. Patients will commonly refer to these as blood blisters. Wet purpura is a sign of more serious bleeding, as platelet counts are typically low in order for wet purpura to occur.

A 72-year-old man presents to the clinic with new, generalized itching for the past week. It is waking him up at night, and he is having difficulty sleeping. He reports a history of diabetes mellitus and hypertension for which he takes metformin and lisinopril. He was recently diagnosed with Hodgkin lymphoma. He was a welder prior to retirement and reports he has some arthritis in both hands which is managed with massage. An image is shown above. What is the most likely diagnosis? AContact dermatitis BDermatitis herpetiformis CDyshidrotic eczema DNummular eczema EScabies

E - scabies Symptoms are widespread itching that patients often describe as the "worst itching of my life." Common sites of infestation include the axillae, finger webs, wrists, elbows, girdle area, and feet. Men will often present with papular lesions of the penis. The diagnostic finding is a thin, serpiginous burrow with a black speck at the end where the mite resides.

A lifelong strict adherence to which of the following diets is recommended to properly treat an individual with phenylketonuria? AHigh in beans, low in vegetables BHigh in dairy, low in fruits CHigh in meats, low in beans DHigh in starches, low in fruits EHigh in vegetables, low in meats

E High in vegetables, low in meats low-phenylalanine diet This diet requires a decrease or elimination of beef, pork, chicken, nuts, beans, and dairy products; a limited intake of potatoes, starches, pasta, and bread; and a liberal intake of fruits and vegetables. Nutritional supplements are also required.

A 56-year-old man presents to the emergency department with mouth pain and difficulty swallowing, worsening over the past day. He reports that he does not have a primary care physician and has not seen a dentist in more than 12 years. He has smoked one pack of cigarettes per day for the past 35 years. BP 152/95, HR 122 bpm, temp is 101.2°F, SpO2 95%, and RR is 26/min. PE: he is drooling and has unintelligible speech 2/2 trismus. The submandibular area of the neck is swollen, tender, and indurated but without palpable LAD. Visualization of the oropharynx is attempted, which reveals a tender and elevated floor of the mouth. No tonsillar enlargement or asymmetry, no uvular deviation, no posterior pharynx enlargement. Based on the suspected diagnosis, what is the most likely source for the patient's infection? AEpiglottis BMastoid air cells CMaxillary sinus DParotid gland E Roots of Teeth

E Roots of Teeth Ludwig angina is an otolaryngologic emergency involving an aggressive polymicrobial deep neck cellulitis in the submandibular space. The infection begins in the floor of the mouth, most commonly from an odontogenic source (such as roots of the teeth).

A 60-year-old man who has an 18 pack-year smoking history presents to his pulmonologist for an evaluation of his COPD. He quit smoking 5 years ago and underwent a colonoscopy 8 years ago, which was unremarkable. He received the 20-valent pneumococcal conjugate vaccine 4 years ago and his influenza vaccine this year. Which of the following should be offered to this patient? AA second dose of the pneumococcal vaccine BAnnual screening for lung cancer with low-dose CT scan CRepeat colonoscopy DTuberculin skin testing EZoster vaccine

E Zoster vaccine A double dose of the zoster vaccine is recommended for adults aged ≥ 50 years, regardless of whether they report a previous episode of herpes zoster. A person who reports a negative history of varicella can still receive the zoster vaccine.

A 50-year-old man with fair skin presents to the clinic with a bump on his face that he first noticed about a year ago. It has been slowly growing during this time, but due to his work as a fisherman, he has not had time off to have it evaluated. On physical exam, you note a small, flesh-colored, hyperkeratotic papule with central ulceration that bleeds easily on palpation. What is the most likely diagnosis? AActinic keratosis BBasal cell carcinoma CMalignant melanoma DSebaceous hyperplasia ESquamous cell carcinoma

E- Squamous cell carcinoma Squamous cell carcinoma often presents as erythematous or flesh-colored papules or nodules with hyperkeratosis and central erosions or ulcerations. Any tenderness, bleeding, or palpable underlying substance increases the suspicion of squamous cell carcinoma, making it the most likely diagnosis for this patient

A 6-month-old girl is brought to the clinic for routine health supervision visit. She interacts well with her parents. She can babble and roll over. She has also started eating solid food. The family is going on a vacation to Philippines for 2 weeks. The parents express concern that there is currently a measles outbreak in Manila. Which of the following is the best statement regarding measles transmission? AAttack rate of measles in a susceptible individual exposed to measles is 50 percent BContagiousness is estimated to be from 3 days before the appearance of rash to 3 days afterward CInfectious respiratory secretions can remain airborne for up to 3 hours DMeasles is not transmitted in public spaces ETransmission occurs via person-to-person contact as well as airborne spread

E- Transmission occurs via person-to-person contact as well as airborne spread

A 67-year-old woman presents with shortness of breath and a cough for 3 days. In the ED, her vital signs are a BP of 120/76 mm Hg, HR of 108 bpm, RR of 20/min, SpO2 of 97% on room air, and T of 101.2°F (38.4°C). A chest X-ray shows a left lower lobe consolidation. Which aspect of the medical history would support a diagnosis of Staphylococcus aureus as the most likely cause of her pneumonia? AAlcohol consumption BGastrointestinal symptoms CHistory of COPD DRecent sulfonamide therapy ERecent viral symptoms

ERecent viral symptoms A recent history of fever, chills, rhinorrhea, and myalgias (viral symptoms) raises suspicion for a recent influenza infection. Staphylococcus aureus is a common pathogen causing pneumonia in those currently or recently infected with influenza virus.

A 4-week-old infant is brought to the office for a well-child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure. Which of the following would be the most appropriate next step? AAttempt closed reduction in the office BOrder a plain radiograph of the pelvis CReassure that the problem resolves spontaneously in 90% of cases and follow up in 2 weeks DRecommend triple diapering and follow up in 2 weeks ERefer for orthopedic consultation

ERefer for orthopedic consultation if there is any question of a hip problem on examination by 2-4 weeks of age, dependent on the clinician, the recommendation is to refer to a specialist for further testing and treatment. Immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. This patient should be referred for orthopedic consultation.

A 27-year-old woman presents to the clinic reporting urinary urgency, frequency, and dysuria for the past 2 days. She has associated symptoms of nausea and chills. She states she has never experienced anything like this before. She notes vaginal intercourse with her monogamous partner earlier this week. She reports no history of sexually transmitted infections and no significant medical or surgical history. She takes a multivitamin daily but reports no prescription medication. Vital signs include HR of 112 bpm, BP of 120/80 mm Hg, RR of 16/min, oxygen saturation of 98% on room air, and T of 100.6°F. Physical examination is positive for costovertebral angle tenderness. Beta HCG is negative. A diagnosis of pyelonephritis is made. Which of the following findings will best differentiate simple cystitis and pyelonephritis? ABacteriuria BLeukocytosis CMicroscopic hematuria DPyuria EWhite blood cell casts

EWhite blood cell casts To differentiate pyelonephritis from acute cystitis, white blood cell casts may be seen in urinalysis. These white cell casts indicate a kidney origin for the pyuria.