Rosh Review

In which of the following clinical scenarios is an implantable cardioverter-defibrillator indicated for the prevention of ventricular dysrhythmias and sudden cardiac death? A A patient with a left ventricular ejection fraction < 35% and heart failure NYHA Functional Class II or III B A patient with a normal left ventricular ejection fraction and asymptomatic structural heart disease C A patient with sustained ventricular tachycardia in the setting of an acute myocardial infarction D A patient with sustained ventricular tachycardia in the setting of hyperkalemia

A A patient with a left ventricular ejection fraction < 35% and heart failure NYHA Functional Class II or III X B - obviously not. X C & D - hyperkalemia & acute ischemia are reversible causes, and correction of each cause is usually adequate to reduce the risk of sudden cardiac death.

A 2-week-old, ex-34-week male infant presents with fever and abdominal distension. The patient has decreased bowel sounds and bloody stool in his diaper. What test should be obtained to make the diagnosis? A Abdominal XR B CT of the abdomen and pelvis C MRI of the abdomen and pelvis D Urinalysis

A Abdominal XR Necrotizing Enterocolitis (NEC) - most children are premature, neonatal ICU, patients often discharged early if they are feeding & growing well but then present to the ED. Excessive feeding is a risk factor. Imaging with XR (shows intramural air, loss of symmetrical gas pattern, dilation of bowel loops).

The shoulder is most vulnerable to an anterior glenohumeral dislocation in which of the following positions? A Abduction and external rotation B Abduction and internal rotation C Adduction and external rotation D Adduction and internal rotation

A Abduction and external rotation A fall or tackle with the arm in this position can cause anterior shoulder dislocation. Posterior shoulder dislocations are less common & are associated with grand mal seizures or electric shock.

18F presents to the ED with dark-colored urine and malaise for the past three days. Her vital signs are BP 155/85 mm Hg, HR 80 bpm, RR 16/min, and T 36.7°C. On exam, you note 1+ pretibial edema. Urinalysis reveals proteinuria, hematuria, and RBC casts. Which of the following is the most likely diagnosis? A Acute glomerulonephritis B Acute tubular necrosis C Minimal change disease D Nephrotic syndrome

A Acute glomerulonephritis Acute GN: hematuria, proteinuria, & (especially) RBC casts are highly suggestive of the diagnosis. X B - Acute Tubular Necrosis: muddy brown casts. X C - Minimal Change Disease: in children, presents with proteinuria, edema, & HTN. X D - Nephrotic Syndrome: not associated with hematuria or RBC casts.

15M presents to the ED with lower back pain. He reports heavy lifting 3 weeks ago, with gradual onset of pain and no relief with symptomatic care. The pain is localized to the paraspinal muscles over his lumbar back. He reports normal urine output. Baseline labs are notable for a serum sodium of 140 mEq/L, potassium of 5.2 mEq/L, chloride of 110 mEq/L, bicarbonate of 25 mEq/L, BUN of 20 mg/dL, and creatinine of 2.3 mg/dL. A urinalysis shows hyaline casts, 5 WBCs/hpf, and 1+ protein. Which of the following is the most likely pathophysiology of his laboratory findings? A Acute interstitial nephritis B Acute tubular necrosis C Hypovolemia D Obstructive nephropathy

A Acute interstitial nephritis Acute Kidney Injury is shown by elevated Creatinine. Likely Acute Interstitial Nephritis (AIN) secondary to overuse of NSAIDs for back pain. UA may show WBCs, hyaline or granular casts, & proteinuria. X B - ATN - brown granular casts

70F with a long history of coronary artery disease is seen in cardiology clinic for routine follow up. She complains of continued angina despite medical therapy. She reports chest pain every time she walks to her mailbox. It does not occur at rest and is relieved by sublingual nitroglycerin. Her medications include carvedilol, amlodipine, daytime transdermal nitroglycerine, sublingual nitroglycerin, aspirin, and simvastatin. On PE her BP is 105/72, HR is 51 and RR 16. What is the next step in management? A Add ranolazine B Increase the dose of carvedilol C Increase the dose of simvastatin D Schedule 24 hour usage of transdermal nitroglycerin

A Add ranolazine Addition of Ranolazine should be considered in patients with chronic Stable Angina who remain symptomatic despite optimal doses of Beta Blockers, Ca Channel Blockers, & Nitrates. Ranolazine is a novel anti-anginal agent that causes selective inhibition of the late sodium channel - approved for treatment of chronic Stable Angina after failing standard medical therapy. Shown to be effective in reducing anginal symptoms & improving exercise capacity when added to conventional medical therapy.

A 65-year-old man presents to the ED for chest pain. You are concerned for acute coronary syndrome and want to administer aspirin, but the patient states that he develops angioedema to aspirin. Which of the following is the most appropriate next step in management? A Administer clopidogrel B Administer dipyridamole C Administer the lower dose, 81 mg of aspirin and observe closely for angioedema D Pretreat with corticosteroids and antihistamines and administer full-dose aspirin

A Administer clopidogrel Aspirin taken early in the course of MI has been shown to reduce mortaliy by 25%. Patients with Aspirin allergy are at risk for losing this benefit. The use of Clopidogrel was shown to be sufficient antiplatelet inhibitor when compared to Aspirin.

58F presents to your office with complaints of headache, a temperature of 101.1°F, anorexia, and morning stiffness in her hips and shoulders. She indicates that this morning her vision was blurry, whereas yesterday it was normal. Which of the following is the most appropriate next step in management? A Administration of 60 mg of prednisone and referral to ophthalmology B Administration of 800 mg of ibuprofen and referral to neurology C Administration of 800 mg of ibuprofen and referral to rheumatology D Supportive care only

A Administration of 60 mg of prednisone and referral to ophthalmology Giant Cell Arteritis should be suspected in middle-aged women presenting with HA, fever, signs of Polymyalgia Rheumatica, & vision changes. Treatment is prompt high-dose Prednisone with referral to ophthalmology.

A mother presents with her 3-year-old son concerned that he has been complaining that his "bottom is itchy." Diagnostic studies confirm a pinworm infection. What is the best treatment for his condition? A Albendazole B Nitazoxanide C Praziquantel D Triclabendazole

A Albendazole Enterobius vermicularis, or Pinworms, causes characteristic perianal pruritus. Treatment is a single dose of Albendazole or Pyrantel Pamoate my mouth, and a repeat dose in 2 weeks. Caregivers should be advised to prevent scratching an change sheets daily.

A 4-year-old girl presents to the emergency department with two days of nasal congestion. Tonight, she developed chest pain and difficulty breathing. She has increased work of breathing, tachypnea, scattered soft wheezes, and poor air movement at the bilateral lung bases. Which of the following is the most appropriate initial medication? A Albuterol B Magnesium sulfate C Prednisolone D Terbutaline

A Albuterol Child presentation is consistent with Asthma exacerbation. SABA (Albuterol) is 1st line treatment for wheezing & respiratory distress in children with asthma. In the ED, concurrent administration of nebulized Ipratropium is shown to decrease admission rate. Steroids (Dexamethasone, Methylprednisolone) should be given promptly, but their effect may not be noticeable for up to 4 hours.

A 27-year-old G1P0 woman at 12w gestation presents to the ED with a target-shaped erythematous rash after hiking through the woods in Wisconsin. What is the most appropriate therapy? A Amoxicillin 500 milligrams orally three times daily B Ceftriaxone 1 gram intravenously every 12 hours C Doxycycline 100 milligrams orally two times daily D Rifampin 600 milligrams orally once daily

A Amoxicillin 500 milligrams orally three times daily Erythema Migrans, hallmark of Lyme Disease. In pregnant women, treatment is Amoxicillin instead of Doxycycline.

Which of the following is an absolute contraindication to the measles, mumps and rubella vaccine? A Anaphylactic reaction to neomycin B Family history of seizure C History of autism D History of immune thrombocytopenia

A Anaphylactic reaction to neomycin MMR vaccine contains trace amounts of Neomycin, so patients with a history of anaphylaxis to Neomycin should NOT receive it. Other true contraindications include previous severe allergic reaction to any component of the vaccine, immunocompromise, pregnancy, hematologic or solid tumors, & HIV infection with immunosuppression.

A 31-year-old woman is diagnosed with her sixth spontaneous abortion. Which of the following is the most likely underlying diagnosis? A Antiphospholipid antibody syndrome B Hemophilia A CThrombotic thrombocytopenic purpura D Von Willebrand disease

A Antiphospholipid antibody syndrome Autoimmune disorder that is a well-recognized cause of acquired hypercoagulability. Should be suspected in patients with recurrent DVTs, recurrent spontaneous abortions, or recurrent CVAs, particularly in young people.

63M (right-handed) presents to ED 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. CT of the brain and CTA of his brain and neck were performed and by the time the scans were finished the patient had complete resolution of his symptoms. The CTA 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? A Aspirin B Clopidogrel C Dual antiplatelet therapy D Warfarin sodium

A Aspirin Transient Ischemic Attack: transient episode of neurologic dysfunction without acute infarction. In patients with a recent symptomatic Carotid stenosis of 70-99% who have at least 5 year life expectancy, a Carotid Endarterectomy (CEA) is recommended. For patients undergoing CEA, low-dose Aspirin should be started prior to procedure and continued for at least 3 months after CEA is done. X C - Dual antiplatelet therapy (Aspirin + Clopidogrel) is started prior to Carotid Artery Stenosis (CAS) which is done instead of CEA if the patient has radiation-induced stenosis, a Carotid lesion not accessible by surgery, or any disease that would increase risk of anesthesia or surgery.

A previously healthy 20M presents to the ED 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. Labs 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? A Begin emergent plasma exchange B Hold treatment until labs for ADAMTS13 deficiency are completed C Prescribe cortisone cream and have the patient follow up with their primary care provider D Watchful waiting as the condition is self-limiting

A Begin emergent plasma exchange Thrombotic Thrombocytopenic Purpura (TTP) should immediately begin emergent plasma exchange, plus steroids and Rituximab. Platelet transfusion may also be needed in cases of severe thrombocytopenia. Condition is almost always fatal if not treated immediately. Classic TTP pentad of microangiopathic hemolytic anemia, thrombocytopenia, fever, acute renal failure, & severe neurologic findings. Acquired TTP is characterized by severe ADAMTS13 deficiency, but confirmation of the diagnosis should not delay treatment.

83M farmer presents to the ED with warmth, redness, and swelling in his left calf that has developed over the last 36 hours. Vital signs are BP of 130/95 mm Hg, HR of 75 bpm, RR of 15/min, T of 98.6°F, and BMI of 34 kg/m2. The patient has a history of atrial fibrillation and heart failure. Home medications include rivaroxaban, losartan, metoprolol, and furosemide for those conditions. On exam, his heart shows a regular rate and rhythm. There is edema and erythema in both legs, but the left one is noticeably warmer. You notice a 1-inch eschar just under the left knee that the patient attributes to bumping into some old machinery and make a note to order a tetanus shot. The CBC returns with a WBC of 11,500/μL (reference range 4,000-10,000/μL) with neutrophils predominant. What is the most likely causative organism of the suggested diagnosis? A Beta-hemolytic Streptococcus B Candida albicans C Methicillin-resistant Staphylococcus aureus D Pseudomonas aeruginosa E Streptococcus pneumoniae

A Beta-hemolytic Streptococcus Cellulitis - main causative organism is Beta-Hemolytic Strep, especially Strep pyogenes. Next most common cause is Staph aureus, including MRSA (but this is mostly only seen in patients with risk factors - recent hospitalization, treatment with antibiotics, HIV+, or on dialysis.)

20F presents with numbness in the left arm, left eye pain and blurry vision, and generalized weakness. She states she has had similar episodes in the past. PE reveals a visual acuity of 20/20 in the right eye and 20/100 in the left eye. She also has decreased sensation in the left arm. Which of the following lumbar puncture findings is most likely? A Cerebrospinal fluid pleocytosis and elevated IgG B Increased opening pressure C Positive India ink stain D Xanthochromia

A Cerebrospinal fluid pleocytosis and elevated IgG Multiple neurologic symptoms suggestive of Multiple Sclerosis. CSF analysis is abnormal in 90% of cases - pleocytosis and elevated Gamma Globulin (IgG). X B - inc. opening pressure in Idiopathic Intracranial HTN (Pseudotumor Cerebri). X C - positive India ink stain in Cryptococcal neoformans. X D - xanthochromia (yellowish) CSF seen in breakdown of hemoglobin in patients with Subarachnoid Hemorrhage.

21F with no prenatal care presents for lower abdominal pain and fever. She estimates she is approximately 7.5 months pregnant. She reports intermittent pain for 2 days and a gush of fluid shortly after the pain began. Her temp is 101.8F, PE is notable for purulent material in the vaginal vault. Which is the most likely diagnosis? A Chorioamnionitis B Endometritis C Pelvic inflammatory disease D Urinary tract infection

A Chorioamnionitis Chorioamnionitis (Intra-amniotic infection of chorion & amniotic layers). It is caused by an ascending infection of normal vaginal flora. Risk factors = PROM, preterm labor, multiple vaginal exams, and genital tract infections.

Which of the following is the most common cell type of ovarian cancer? A Epithelial B Germ C Granulosa D Stromal

A Epithelial 90% of Ovarian Cancers are of epithelial cell origin.

Which of the following drugs is most likely to be associated with the development of atrial tachydysrhythmias? A Ethanol B Gamma hydroxybutyrate (GHB) C Lorazepam D Phenobarbital

A Ethanol Ethanol use associated with development of atrial dysrhythmias, specifically Atrial Fibrillation. X B - GHB: bradycardia & hypotension X C, D - Lorazepam & Phenobarbital: not associated with dysrhythmias

36M presents to the ED after having a seizure. He has a folder full of medical records dating back 15 years. Several of the records are from other cities and states. It is now 11:00 pm on a Friday night. His primary care physician, neurologist, and psychiatrist are "out of town" and he believes that he needs to be admitted for the duration of the weekend. He has another episode of shaking in the ED and immediately following this he returns to his baseline. He is now awake and alert. You immediately draw a serum lactate and it is normal. Which of the following diagnoses should be strongly considered in this patient? A Factitious disorder B Functional neurological symptom disorder C Illness anxiety disorder D Somatic symptom disorder

A Factitious disorder Factitious Disorder Imposed on Self - individual feigns disease in an attempt to gain attention, sympathy, or reassurance. Often a longstanding history of medical shopping, frequent hospitalization, & extensive medical records. The normal serum lactate & lack of post-ictal state essentially rule out true seizure activity & support the fact that he is faking his seizure episodes. X B - Functional Neurologic Symptom Disorder is characterized by unexplained symptoms (blindness, paralysis, mutism) that is triggered by a psychological stressor. Medical workup will be normal.

A previously healthy 25-year-old woman presents to your office with complaints of nasal congestion, sneezing, and itchy eyes. These symptoms occur every spring. Which of the following is the most appropriate monotherapy? A Fluticasone nasal spray B Oral diphenhydramine C Oral montelukast D Phenylephrine nasal spray

A Fluticasone nasal spray Allergic Rhinitis first-line treatment is with glucocorticoid nasal sprays or 2nd generation antihistamines. X B - PO Diphenhydramine: 1st Gen Antihistamine, not first line therapy. X C - PO Montelukast: used in comorbid Asthma. X D - Phenylephrine nasal spray: nasal decongestants are not recommended due to Rhinitis Medicamentosa.

A 24-year-old athlete undergoes anterior cruciate ligament repair surgery. Two weeks later, he presents with excruciating pain distal to the knee. Fracture, soft tissue injury and intraarticular infection are ruled-out. Examination reveals a swollen, warm, red foot and ankle that is painfully sensitive to light touch. The other leg appears normal. The patient guards this area and active range-of-motion is restricted. Complete pinprick sensory testing is deferred as initial testing is too painful to continue. Vibration testing results in continued pain even after removal of the tuning fork. Which of the following medications will you most likely prescribe? A Gabapentin B Intranasal desmopressin C Intravenous immunoglobulin D Pyridostigmine

A Gabapentin Complex Regional Pain Syndrome is classically in post-surgical patients. Treat with steroid bursts, intranasal Calcitonin, NSAIDs, short-course opioids, Gabapentin, TCAs, or transdermal Clonidine or Lidocaine.

12M with history of eczema presents with a painful rash and general malaise. The rash has been worsening over the last week. Vital signs are HR of 98 bpm, RR of 18/min, SpO2 of 97% on room air, BP of 114/66 mm Hg, and a T of 100.9°F. PE reveals a rash that includes well-circumscribed erosions overlying skin that appears eczematous in the periorbital area, the bilateral antecubital fossa, and the bilateral popliteal fossa. There are several crops of vesicles in normal-appearing skin near the eczematous patches. Which of the following is the most likely pathogen? A Herpes simplex virus B Measles virus C Staphylococcus aureus D Streptococcus pyogenes E Trichophyton rubrum

A Herpes simplex virus Primary Eczema Herpeticum is a Herpes Simplex Virus infection in a patient with concurrent Atopic Dermatitis. The infection typically affects eczematous skin & then spreads to adjacent normal-appearing skin. Lesions initially appear as vesicles, then punched-out erosions. Can be painful, associated with fever, malaise, & irritability. Treat with oral antiviral therapy promptly to avoid hospitalization & complications. X B - Measles: rash is flat, red, blotchy and begins at the hairline spreading to neck & torso. X C - Staph aureus: when co-occurring with eczema, produces Impetigo with honey-colored crusting lesions. X D - Strep pyogenes: can cause Impetigo with associated itching, without pain or fever. X E - Trichophyton rubrum: causes Tinea infections.

43F with Type 2 DM presents for a routine visit. She brings home glucose logs that reveal elevated postprandial glucose levels and normal fasting glucose levels. Her current medications include metformin and once-daily long-acting insulin. Her Hgb A1C is 8.7%. The decision is made to add an additional three times daily therapy before meals for better glycemic control. Which of the following therapies is most appropriate? A Insulin aspart B Insulin detemir C Insulin glargine D Neutral protamine Hagedorn insulin E U-500 regular insulin

A Insulin aspart Insulin Aspart, Lispro, Glulisine have rapid onset of action and shorter duration, allowing for easier timing of meals & lower risk of hypoglycemia. Detemir, Glargine = long-acting NPH, Regular = intermediate-acting

A man presents to the emergency department with a blood pressure of 200/136 mm Hg and laboratory evidence of acute renal failure. Which of the following medications and initial blood pressure response rates are the most appropriate at this time? A Intravenous labetalol, to goal within 1 to 2 hours B Intravenous nicardipine, to goal within 6 to 12 hours C Oral clonidine, to a goal within 3 to 6 days D Oral magnesium sulfate, to a goal within 1 to 2 days

A Intravenous labetalol, to goal within 1 to 2 hours Hypertensive Emergency - severe HTN with evidence of end-organ damage. Treated with IV medications including Labetalol, Esmolol, Nicardipine, Hydralazine, Fenoldopam, Nitroglycerine, Nitroprusside, & Phentolamine. MAP should be reduced by 10-20% in the first hour, followed by a gradual reduction during the next 23 hours. X B - 6 to 12 hours is too long. X C & D - IV medications is needed, oral will not do.

16M presents to the office with a complaint of ten headaches over the last 3 months. These headaches last 8-10 hours and are unilateral, pulsatile, worse with physical activity, and often accompanied by N/V. The headaches have caused him to miss school. Ibuprofen has given minimal relief. Which one of the following is the most likely diagnosis? A Cluster headache B Migraine headache C Rebound headache D Tension headache

B Migraine headache Migraines typically present in patients 10-30 years of age. Migraine without aura is a recurrent HA lasting 4-72 hours. Unilateral distribution, pulsatile quality, severe limitation of daily activities, & exacerbation with physical activity. PLUS one of the following: N/V, photosensitivity, & sensitivity to noise or smell.

22F presents to her gynecologist with multiple breast masses. She reports no nipple discharge or skin changes. On PE, two well-circumscribed 2 cm breast masses are palpated. US confirms two well-circumscribed, solid masses. A core-needle biopsy is ordered. Which of the following physical exam findings is consistent with a diagnosis of fibroadenoma? A Fluctuant and mobile B Nontender and mobile C Rubbery and fixed D Tender and fixed E Unilateral and fixed

B Nontender and mobile Fibroadenomas present as well-defined, rubbery, non-tender, and mobile masses on physical exam. X A - not fluctuant. X C - not fixed. X D - not tender or fixed. X E - may be unilateral or bilateral, but not fixed.

Analysis of a peripheral blood smear reveals a normocytic, normochromic anemia with blast cells and Auer rods. This is most consistent with what diagnosis? A Acute lymphoblastic leukemia B Acute myelogenous leukemia C Chronic lymphocytic leukemia D Chronic myelogenous leukemia

B Acute myelogenous leukemia Acute Myeloid Leukemia (AML) - most common acute leukemia in adults. Auer Rods are pathognomonic for AML - only found in myeloblasts.

35F with a history of suicidal ideations is brought to the ED approximately 10 hours after ingesting an unknown quantity of acetaminophen and ibuprofen. She is complaining of nausea and abdominal pain. Her BP is 150/80 mm Hg, HR is 90, RR is 18, and temp is 36.8C. PE reveals diffuse abdominal pain. What is the most appropriate next step in management? A Administer glutathione B Administer N-acetylcysteine C Arrange for hemodialysis D Determine acetaminophen level

B Administer N-acetylcysteine If a patient with Acetaminophen toxic ingestion arrives within the first 4 hours after ingestion, Acetaminophen & LFTs are obtained at 4 hours post-ingestion to determine if treatment is needed. If the patient arrives 8 hours post-ingestion or more, a loading dose of NAC is given immediately, and Acetaminophen levels and LFTs are drawn after.

45F presents with newly diagnosed DM Type 2. She has had her Hepatitis B vaccination, but wants to know if she needs any additional vaccinations. Which of the following is the most appropriate next step in her management? A Administer annual influenza vaccine only B Administer pneumococcus and annual influenza vaccine C The patient does not need any additional vaccines since she is up to date

B Administer pneumococcus and annual influenza vaccine DM requires annual Influenza, Pneumococcal, and Hepatitis B

54F 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 HTN and cerebrovascular accidents. She takes no medications and has no previous chronic diagnoses. Vital signs include BP 190/100 mm Hg, HR 82 beats per minute, temp 98.6°F, and RR 15 per minute. Her BMI is 22 kg/m². Her CMP and CBC are normal, as is her lipid panel and UA. ECG and CXR are normal. PE, including the fundoscopic exam, is WNL. Which of the following combination drug therapies would be the best choice for initial therapy for this patient? A Amlodipine plus diltiazem B Amlodipine plus lisinopril C Captopril plus losartan D Hydrochlorothiazide plus spironolactone E Spironolactone plus captopril

B Amlodipine plus lisinopril Severe HTN is classified as BP > 180 systolic &/or > 110 diastolic. It may be asymptomatic, or may be part of a Hypertensive Crisis where there is evidence of end-organ damage. She has no evidence of end-organ damage from her symptoms or diagnostic findings. Severe HTN can be treated in clinic even without a separate second reading. It should consist of a CCB (Amlodipine), ACE Inhibitor (Lisinopril), ARB, or Thiazide Diuretic. Combination therapy can be given if BP is 20 over goal systolic or 10 over goal diastolic. Combination therapy should involve meds from 2 different classes.

10M presents with lethargy and vomiting. His mother states he had 3 days of cough, rhinorrhea, sore throat, and fever, during which the nanny had been giving him an effervescent OTC medicine to help with his upset stomach. He seemed to be doing much better for a few days, until this morning when he became confused, agitated, and vomited. PE is remarkable for lethargy, mild icterus, and hepatomegaly. Labs show markedly elevated AST and ALT. Which medication is most likely responsible for the patient's presentation? A Acetaminophen B Aspirin C Guaifenesin D Ibuprofen

B Aspirin Reye Syndrome - Salicylate ingestion (Aspirin) during a viral illness (especially Chickenpox or Influenza) is associated with Reye Syndrome. Presents with AMS, cerebral edema, and hepatic dysfunction. Commonly in children.

45F with a history of hypothyroidism on levothyroxine presents to the clinic for routine monitoring of her TSH level. The patient reports she is feeling well and has been taking her levothyroxine as prescribed. Vital signs today include a HR of 105 bpm, BP of 135/84 mm Hg, RR of 20/minute, O2 sat of 98% on room air, and temp of 98.6°F. The patient's TSH level is 0.03 mU/L. Which complication is this patient most at risk for on her current dose of levothyroxine? A Acute kidney injury B Atrial fibrillation C Exophthalmos D Goiter E Hepatotoxicity

B Atrial fibrillation 2 of the main risks with over-replacement-caused Hyperthyroidism are Atrial Fibrillation & decreased bone mineral density (causing osteoporosis & increased risk of fractures).

42M with a history of HTN presents to the ED by ambulance after his wife called 911 out of concern for a possible overdose. The patient is confused and unable to answer questions upon arrival. His BP is 80/50 mm Hg, HR is 45 beats/minute, and RR is 12 breaths/minute. ECG findings include a prolonged PR interval. His glucose is 60 mg/dL. Which of the following is the most likely explanation? A Acetaminophen overdose B Beta-blocker overdose C Calcium-channel blocker overdose D Opioid overdose

B Beta-blocker overdose Beta Blocker Overdose - hypotension, bradycardia >>> hypoglycemia, hyperkalemia, arrhythmias, seizures. ECG can show prolonged PR or QRS intervals. Stabilize ABCs, then treat with boluses of isotonic IV fluids & Atropine. Severe poisoning needs IV Glucagon, high-dose Insulin + Glucose, calcium salts, & lipid emulsion therapy. Vasopressors (Epinephrine) can be used for hypotension. Single-dose Activated Charcoal is given for GI decontamination.

23M presents with leg pain for three months and requests hydromorphone for pain. The nurse approaches you because she believes the patient is "drug seeking" as he became extremely upset when she told him that he would have to wait for the doctor to evaluate him before pain medications could be given. Upon entering the room, the patient speaks pleasantly with you and compliments you on your kindness. He tells you that he only comes to this hospital because "it's the best in the world," and "none of the other doctors understand me." Upon informing the patient that you will not be prescribing hydromorphone, he becomes extremely upset and starts yelling. This patient is exhibiting traits that are consistent with which of the following personality disorders? A Antisocial B Borderline C Histrionic D Narcissistic

B Borderline In the ED, patients with Borderline PD will often "split" providers - they will act with affection & respect to some providers and act with anger & disregard to others. Substance abuse & drug seeking behavior are often seen with BPD.

A 16-month-old boy presents to the ED with a 12-hour history of severe, intermittent abdominal pain. Approximately every 20 minutes, the child draws his legs up to his chest and cries inconsolably. Between episodes, the child behaves normally. The child's vital signs are within normal limits. Physical exam is notable for a sausage-shaped mass on the right side of his abdomen. What is most common complication of the first-line treatment of his condition? A Bowel ischemia B Bowel perforation C Dumping syndrome D Nutrient malabsorption

B Bowel perforation Bowel Perforation is the most common complication of a pneumatic enema, the 1st-line treatment of Intussusception in stable children. US is the first-line diagnostic imaging tool, showing "target sign." Pneumatic/Air enema is the treatment of choice in stable patients. Surgery may be needed in unstable patients. X A - Bowel ischemia: can occur after surgery of the abdominal aorta. X C - Dumping Syndrome: common complication of gastric bypass surgery. X D - Nutrient malabsorption: can occur after surgical correction of Intussusception to remove ischemic bowel.

56M with a history of Type 2 DM has been taking metformin and sitagliptin for the past six months. Last week, the patient's hemoglobin A1C was 8.2%. The patient states that he has been compliant with his regimen. Which of the following agents would be most appropriate to add to this patient's regimen to achieve glycemic control? A Alogliptin B Canagliflozin C Exenatide D Insulin lispro

B Canagliflozin Metformin is a Biguanide and Sitagliptin is a DPP-4 Inhibitor. Canagliflozin is a SGLT2 Inhibitor that increases urinary excretion of glucose. Other suitable agents include Thiazolidinediones (Pioglitazone) or Long-acting basal Insulins (Detemir). X A - Alogliptin is another DPP-4 Inhibitor X C - Exenatide is a GLP-1 Agonist which has the same effect as DPP-4 Inhibitors (increasing Insulin secretion). X D - Insulin Lispro is a rapid-acting Insulin that is only appropriate for mealtime glycemic control, not long-acting control.

A patient is diagnosed with ventilator-associated pneumonia in the medical intensive care unit and the decision is made to initiate broad-spectrum antibiotics with antipseudomonal coverage. Which of the following is Pseudomonas aeruginosa susceptible to? A Cefazolin B Cefepime C Cefpodoxime D Ceftriaxone

B Cefepime Pseudomonas is susceptible to 4th Generation Cephalosporins - Cefepime, Cefquinome.

30F is pregnant with her third child. Her medical history is significant for cocaine abuse. She delivered her first and second low-birth-weight children preterm. Both of these children have congenital abnormalities. Which of the following diseases is this third fetus most at risk of developing? A Cerebellar ataxia B Cerebral palsy C Charcot-Marie-Tooth disease D Cystic fibrosis

B Cerebral palsy CP is caused by a non-progressive CNS insult that occurs during fetal or infant development. Risk factors = low birth weight, sibling history of congenital malformation, maternal mental retardation, substance abuse (especially cocaine), and birth injury.

You are caring for a patient with rheumatoid arthritis. A rheumatologist refills this patient's medications, but does not order the proper laboratory testing used to monitor for adverse side effects. You decide to begin such monitoring. Which of the following is most commonly serially monitored in patients on disease-modifying antirheumatic drugs (DMARDs)? A Chest radiograph B Complete blood count C Rheumatoid factor D Thyroid function test

B Complete blood count Rheumatoid Arthritis can be treated with DMARDs that can have significant side effects. One of the most common DMARD adverse effect is bone marrow suppression, especially with Sulfasalazine, Methotrexate, Gold preparations, Leflunomide, Cyclosporine, & Azathioprine. Monitor bone marrow health with serial CBCs.

62M with a history of DM type 2 and HLD presents to his family medicine clinic to discuss his most recent blood work. His vital signs are HR of 80 bpm, RR of 18/min, T of 98.6°F, and BP of 130/84 mm Hg. His cholesterol is well controlled on atorvastatin. His total cholesterol is 180 mg/dL, HDL is 60 mg/dL, and LDL is 70 mg/dL. However, he has suboptimal control of his sugars while on metformin, with an A1C at 8.9%. Based on his most recent labs, his primary care clinician discussed adding pioglitazone to his regimen. Which of the following black box warnings should this patient be educated about? A Bladder cancer B Congestive heart failure C Hepatic injury D Hypoglycemia E Lactic acidosis

B Congestive heart failure Thiazolidinediones such as Pioglitazone increase Insulin sensitivity by increasing Glucose utilization in peripheral adipose & muscle tissue. Side effects include edema, weight gain, fluid retention. Possible increase in bladder cancer, specifically with Pioglitazone. Single black box warning for Pioglitazone is CHF. In general, Thiazolidinediones should not be used in patients with HF, history of fractures, active liver disease, bladder cancer, T1DM, pregnancy, or macular edema.

Which of the following conditions is associated with a pericardial knock on auscultation? A Acute pericarditis B Constrictive pericarditis C Pericardial tamponade D Restrictive cardiomyopathy

B Constrictive pericarditis Constrictive Pericarditis - caused by inflammatory & reparative process from a pericardial injury, leading to a fibrous thickening of the pericardium. Clinical presentation mimics heart failure & restrictive cardiomyopathy. PE shows Kussmaul's Sign, Pulsus Paradoxus, & Pericardial Knock. X A - Acute Pericarditis - friction rub. X C - Pericardial Tamponade - distant or soft heart sounds. X D - Restrictive CM - S3, often S4.

34F presents with concerns about contraception. She is in a monogamous relationship & wishes to maintain long-term fertility. She has regular menstrual cycles that are typically 28 days and consist of light bleeding for 4-5 days. She experienced menarche at 11 y.o. Medical history significant for essential HTN and hypothyroidism, currently taking lisinopril & levothyroxine. Vitals are BP 145/96 mmHg, HR 88 bpm, SpO2 98% on room air, and T 98.4F. PE shows no abnormalities. She is concerned about taking a prescription that may cause weight gain or nausea. Which of the following is the most appropriate contraceptive method for this patient? A Combined estrogen-progestin oral contraceptives B Copper-containing intrauterine device C Estrogen-progestin vaginal ring D Implantable etonogestrel E Transdermal contraceptive patch

B Copper-containing intrauterine device Copper IUD has a 10-year lifespan, is highly effective, and has minor side effects that does not include weight gain. It is easily reversible, and non-hormonal. An IUD is a good choice for patients with a history of VTE, migraine with aura, or uncontrolled HTN (which this patient has!). X A - OCP is contraindicated in patients with increased risk of CV sequelae, including uncontrolled DM or HTN or smokers. X C - contains estrogen and has similar side effect and risk profile as OCP. X D - can cause weight gain or irregular vaginal bleeding. X E - contains estrogen.

Which of the following is commonly the first reported symptom of aortic stenosis? A Chest pain B Dyspnea C Syncope D Vomiting

B Dyspnea Aortic Stenosis - dyspnea is often the first symptom to appear, followed by chest pain & then syncope (triad!!). Narrow pulse pressure may be present.

Which of the following findings is most suggestive of Pneumocystis jirovecii pneumonia in a patient with suspected HIV infection and shortness of breath? A Bradycardia despite relative volume depletion B Elevated serum lactate dehydrogenase C Hyponatremia D Unilateral lobar consolidation on chest radiograph

B Elevated serum lactate dehydrogenase PJP - insidious nonproductive cough, dyspnea, unexplained fever > 2 weeks, chest pain, & fatigue. The greater the elevation of LDH, the worse the prognosis.

5M with hemophilia A presents to the ED via ambulance after sustaining a head injury. Per the patient's parents, the child was climbing a tree earlier in the day when he fell from a height of approximately 4 feet and hit his head on the sidewalk. The parents report he initially only had mild pain on the side of his head. Approximately 45 minutes ago, he started to report a headache and began vomiting. He became somnolent shortly after. His blood pressure is 128/86 mm Hg, heart rate is 80 bpm, respiratory rate is 36/min, and oxygen saturation is 96%. He is afebrile. On exam, the patient is sleepy but arousable to painful stimuli. His right pupil is noted to be 9 mm and unreactive to light. What is the most likely diagnosis? A Concussion B Epidural hematoma C Intraparenchymal hemorrhage D Subarachnoid hemorrhage E Subdural hematoma

B Epidural hematoma Epidural Hematoma is most commonly due to head trauma, & concurrent skull fracture is often observed. Middle Meningeal Artery is most commonly torn. Often in young adults, especially children with bleeding disorders. Brief episode of LOC, followed by a lucid interval. HA, somnolence, confusion, N/V, & seizures can develop as the hematoma expands leading to increased intracranial pressure. Anisocoria & altered level of consciousness may be seen. CT shows a lenticular collection of blood that does not cross suture lines. LP is contraindicated due to risk of herniation. Craniotomy & hematoma evacuation is the mainstay of treatment.

A 27-year-old woman presents to your office with complaints of depression and thoughts of suicide. She is interested in starting both counseling and medication to address her symptoms. Which of the following is the safest medication to consider prescribing? A Amitriptyline B Fluoxetine C Nortriptyline D Venlafaxine

B Fluoxetine SSRIs (Fluoxetine) are safer in the case of overdose than other agents. X D - Venlafaxine: SNRI that is dangerous in overdose and should be avoided in patients deemed high risk for suicide.

50F presents to the clinic with 2 weeks of right lateral hip pain. The patient reports no trauma, clear mechanism of injury, or associated back pain. Vital signs today include a HR of 82 bpm, BP of 130/84 mm Hg, RR of 20 breaths per minute, O2 sat of 99% on room air, and temp of 98.6°F. PE reveals right lateral hip tenderness with the maximal tenderness at the posterosuperior aspect of the bony prominence near the lateral proximal thigh. The patient has full active and passive range of motion of the right hip. Which of the following is the most likely diagnosis? A Adductor muscle strain B Greater trochanteric pain syndrome C Hip osteoarthritis D Iliotibial band syndrome E Lumbar radiculopathy

B Greater trochanteric pain syndrome Common cause of lateral hip pain, more often in women than men. Clinical diagnosis and usually self-limited in 1-2 years. Goal of treatment is pain management with heating pad, activity modification, non-Opioid analgesics (Acetaminophen, NSAID), & PT. Steroid injections may help as well.

A 5-month-old girl presents to the ED with her parents who are concerned about brief episodes of "whole body muscle contraction." On PE, the child has poor head control and absent palmar grasp. Her electroencephalogram shows hypsarrhythmia. Which of the following is the most likely diagnosis? A Cerebral palsy B Infantile spasms C Kernicterus D Tay-Sachs disease

B Infantile spasms Infantile Spasms or "West Syndrome" defined by a triad: (1) clusters of myoclonic seizures on awakening, (2) hypsarrhythmia pattern on EEG, and (3) developmental delay. LP should be considered to rule out Meningitis or Encephalitis.

Which of the following tuberculosis medications is commonly associated with a lupus-like syndrome? A Ethambutol B Isoniazid C Levofloxacin D Rifampin

B Isoniazid Isoniazid is associated with the development of Lupus-Like Syndrome. Drug-induced Lupus is like SLE but self-resolving. Presents with arthralgias, rash, serositis, and myalgias. Other meds that cause it include: Hydralazine, Procainamide, Methyldopa, Chlorpromazine, Quinidine, Minocycline, & Phenytoin. Cessation of the offending med often resolves it.

Which of the following is associated with pernicious anemia? A Homocysteine levels are decreased B Methylmalonic acid is increased C Normocytic erythrocytes D Vitamin B12 elevation

B Methylmalonic acid is increased Pernicious Anemia (Vitamin B12 Deficiency) = elevated MMA & Homocysteine. Folate Deficiency Anemia = elevated Homocysteine, normal MMA.

47M presents to the ED with active tonic-clonic seizure activity. Initial vital signs include T 97.5°F, BP 125/80 mm Hg, HR 110 bpm. IV access is established and the administration of anticonvulsant therapy is initiated. The seizure activity ceases. Repeat vital signs include T 98°F, BP 80/40 mm Hg, HR 45 bpm, RR 12 brpm. Which of the following anticonvulsant agents was most likely administered and is responsible for these physiologic changes? A Carbamazepine B Phenytoin C Topiramate D Valproic acid

B Phenytoin Phenytoin can cause cardiovascular collapse when infused rapidly, due to diluent of propylene glycol (a myocardial depressant). Serum levels should be closely monitored during infusion at a max rate of 50 mg/min. Fosphenytoin has advantages over Phenytoin, including IM administration, aqueous solubility, & tissue hyporeacticity.

A 19-year-old woman presents to the ED with pain and dyschromatopsia in her right eye. She also describes varying degrees of intermittent paresthesias over the previous month and occasional transient gait disturbance. An MRI shows white matter pathology. Which of the following lumbar puncture findings is associated with her condition? A IgM and IgG antibodies to Borrelia burgdorferi B Pleocytosis and oligoclonal bands of immunoglobulin G C Positive VDRL test D Xanthochromia

B Pleocytosis and oligoclonal bands of immunoglobulin G Multiple Sclerosis characteristic CSF finding

34F presents with elbow pain and diminished arm movement following a fall on her outstretched hand. Initial history and physical exam are notable for pain, swelling, and tenderness over the lateral elbow, and inability to fully extend the elbow. Which of the following is indicative of a radial head fracture? A Displacement of the radiocapitellar line B Posterior fat pad sign C Pronator sign D Wrist drop

B Posterior fat pad sign Radial head fractures following FOOSH present with localized swelling, tenderness, & decreased motion of elbow. XR shows elevation of the anterior or posterior fat pads (or both), creating the "Sail Sign." Treat with sling & outpatient ortho follow-up.

A 13-month-old boy is brought by his anxious parents to the clinic because of a rash. For the previous three days, he has been having high-grade fever that is lysed by ibuprofen. Then today, he became afebrile, and the mother noted the appearance of a rash on the neck and trunk. On physical examination, his temperature is 37.3°C, heart rate is 104 beats per minute, respiratory rate is 25 cycles per minute. His skin examination reveals blanching maculopapular rash on the neck and trunk that has spread to the face and extremities. Which of the following is the most likely diagnosis? A Measles B Roseola C Rubella D Scarlet fever

B Roseola Roseola - peak prevalence between 7-13 months. Classic presentation begins with a high fever that lasts 3-4 days, often accompanied by irritability. As the fever abates, a blanching macular or maculopapular rash develops first on neck/trunk then spreading to face & extremities. Rash lasts 1-2 days and is usually non-pruritic. X A - Measles: prodrome of cough, coryza, & Koplik spots. Rash begins on face & spreads down the body. X C - Rubella: simultaneous low-grade fever & rash that begins on face & spreads down the body. X D - Scarlet Fever: diffuse, erythematous, & sandpaper-like rash that occurs with or after pharyngitis.

A breastfeeding 28F presents for evaluation of a painful right breast "lump" 3 weeks after delivery of a healthy newborn. Exam reveals localized erythematous edema of the right breast, a 7/10 painfully palpable discrete induration, and thick yellow nipple discharge. The nipple and areola are not excoriated. The left breast is unremarkable. You refer the patient for a drainage procedure. In the meantime, which of the following is the most appropriate initial plan? A Continue breastfeeding with the left breast only, antibiotics are not recommended B Start antibiotics and continue breastfeeding with either breast C Start antibiotics and stop breastfeeding D Stop breastfeeding, antibiotics are not recommended

B Start antibiotics and continue breastfeeding with either breast Breastfeeding-associated lactation mastitis leading to a breast abscess - recommended treatment plant involves drainage & antibiotics (Dicloxacillin, Cephalexin, or Clindamycin). Even with significant infection, continue breastfeeding with either breast unless the drainage procedure incision interferes with infant latch-on.

45M presents from home with a complaint of abdominal pain. A review of his previous visits shows two prior evaluations for similar abdominal pain during which he revealed that he had swallowed writing utensils. Endoscopic removal of the writing utensils was required in both cases. An X-ray today confirms the presence of a pen in the esophagus. What is his most likely diagnosis? A Borderline personality disorder B Drug-seeking behavior C Factitious disorder D Malingering

C Factitious disorder Factitious Disorder Imposed on Self - patients feign illness to obtain attention, sympathy, or play sick role. Patients will intentionally fake physical findings and may self-harm.

28M presents with scrotal swelling and pain. Exam reveals a left, nontender, swollen spermatic cord that feels like a "bag of worms." The swelling reduces when the patient moves to a supine position. There are no skin lesions, hernia or testicular abnormalities. In addition to scrotal US, you may consider ordering further imaging with attention to which of the following organs? A Ascending colon B Descending colon C Kidney D Urinary bladder

C Kidney Primary Varicocele is usually idiopathic, Secondary Varicocele can occur due to abdominal mass compression of the renal veins or superior mesenteric artery compression of the left renal vein. Varicoceles are not life threatening but may decrease testicular artery flow & infertility. Should be evaluated further with US & possible abdominal imaging.

45M with a history of alcohol use disorder presents with numbness and weakness of the left hand. He states he slept on a bench last night and awoke this morning with the symptoms. Physical examination reveals decreased sensation over the first, second, and third digits and a wrist drop is present. What management is indicated? A CT of the cervical spine B MRI of the brain C Noncontrast CT scan of the head D Wrist splint and follow up with neurology

D Wrist splint and follow up with neurology Radial Nerve Palsy or "Saturday Night" Palsy.

A 34-year old resident physician from Iowa presents for a health examination prior to hospital employment. His examination is unremarkable, but a chest radiograph shows bilateral lung fields with BB-sized calcifications and hilar adenopathy. A PPD skin test is negative. The findings in this patient are most likely a result of which of the following? A Coccidioidomycosis B Cryptococcosis C Histoplasmosis D Tuberculosis

C Histoplasmosis Most people with normal immunity who develop Histoplasmosis are asymptomatic. CXR finding is a solitary pulmonary calcification. Cavitation is rare, but hilar & mediastinal adenopathy is seen often. Highly prevalent in Midwestern US, especially with exposure to bird or bat droppings. Culture is gold standard for diagnosis, but fungal staining is faster. Amphotericin B is the agent of choice for treatment. X A - Coccidioidomycosis: seen usually in the southwestern US. X B - Cryptococcosis: may present with fever, malaise, cough, pleuritic pain, & hemoptysis. X D - Tuberculosis: positive PPD unless severely immunocompromised.

48F presents with nausea and vomiting. She underwent an appendectomy 3 days ago. A contrast-enhanced CT of the abdomen and pelvis reveals an ileus. What electrolyte abnormality commonly causes an ileus? A Hyperkalemia B Hypernatremia C Hypokalemia D Hyponatremia

C Hypokalemia Post-operative Ileus appears to be associated with inhibitory neural reflexes, inflammation, & neuro-humoral peptides. Hypokalemia is common in the post-op period and may cause Ileus because it changes gut motility.

27F with no reported medical history presents to the ED after falling onto her left shoulder while playing soccer. Vitals today are WNL. PE reveals a regular tenderness, edema, and bruising at the mid-aspect of her left clavicle. Her sensation is intact in her bilateral extremities, and her radial pulse is noted to be decreased on the left side. XR shows a displaced fracture of the left clavicle. Which is the next best step in management? A Admission for ORIF B Compartment pressure measurement C CT angiogram of the left upper extremity D Discharge home with arm sling and orthopedic follow-up E Venous US of the left upper extremity

C CT angiogram of the left upper extremity Clavicle fracture + decreased radial pulse is concerning for associated vascular injury. The next step is to confirm by CTA. Thoracic Outlet Syndrome is due to compression of neurovascular structures as they pass through the thoracic outlet between the clavicle and the first rib. Vascular TOS requires vascular surgery consultation and often surgical management. Neurovascular compromise needs to be addressed first, before management of the fracture itself.

A 23-year-old man presents with swelling and pain of his elbow. On examination, he has swelling over the olecranon. He has full range of motion at the joint. Vital signs are normal. What management is indicated? A Arthrocentesis B Aspiration C Compression dressing and nonsteroidal anti-inflammatory drugs D Incision and drainage

C Compression dressing and nonsteroidal anti-inflammatory drugs Olecranon Bursitis - manage with a compression dressing, ice, and NSAIDs. Olecranon bursa may become inflamed due to repetitive minor trauma. Patients present with pain, swelling, & tenderness over the olecranon.

41F presents to ED with 8-hour history of left-sided epigastric pain that radiates to her back. She vomited four times overnight after going out to eat. The patient's vitals are remarkable for HR 112 bpm, T 99.4F, RR 20/min. Urine is negative for pregnancy but positive for glucose. She has epigastric tenderness but not rigidity and cannot lie down due to pain. You order a 2 L bolus of saline with an opioid for pain. Labs show serum glucose 280 mg/dL, amylase 240 U/L, lipase 311 U/L, liver enzymes WNL. Bedside US of gallbladder is negative for cholelithiasis. Patient is admitted to the surgery floor, and pain has improved significantly after 2 days. Additional blood work shows a triglyceride level of 1090 mg/dL. What key management should be discussed with her besides diabetes medication and dietary changes? A Elective cholecystectomy B Extended-release niacin therapy C Long-term fenofibrate D Long-term rosuvastatin E Trial of disulfiram

C Long-term fenofibrate Acute Pancreatitis presentation due to Hypertriglyceridemia. Treat with aggressive fluid resuscitation, pain relief with IV opioid, and NPO status until stabilization. Main etiologies include gallstones, chronic alcohol use, and hypertriglyceridemia. Fibrates such as Fenofibrate (preferred over Gemfibrozil) are the most effective agents for hypertriglyceridemia.

What is the most common cause of an intracranial neoplasm? A Astrocytoma B Meningioma C Metastases D Pituitary adenoma

C Metastases

A patient with a history of diabetes mellitus, hypertension, coronary artery disease and hypothyroidism is being discharged after a cardiac catheterization with placement of a drug eluting stent. Which of the following medications must be temporarily held post catheterization? A Clopidogrel B Levothyroxine C Metformin D Ramipril

C Metformin Metformin must be withheld for 48 hours after the administration of a contrast agent. IV contrast media while receiving Metformin can cause Lactic Acidosis. If renal function is normal at 48 hours, the Metformin can be restarted.

A 77-year-old woman presents with dizziness and being light headed. She denies any new medications or other recent changes. Vitals are temperature 98.0°F, blood pressure 93/56 mm Hg, and pulse 72 bpm. Physical exam is unremarkable. Her medications include metoprolol 50 mg daily, atorvastatin 10 mg daily, vitamin D 1,000 IU daily, and acetaminophen 500 mg as needed. Which of the following is the most likely cause of her dizziness? A Acetaminophen use B Atorvastatin use C Metoprolol use D Vitamin D supplementation

C Metoprolol use Beta Blocker toxicity: dizziness (especially in the elderly), orthostatic hypotension.

18M agricultural laborer presents with an intensely sore throat and fever. He reports he has never been sick before. The patient's vaccination history is not available. Vitals are BP of 110/65 mm Hg, HR of 70 bpm, RR of 12 bpm, T of 100.8°F, and BMI of 20 kg/m2. The submandibular area shows significant edema, and laryngoscopic exam reveals a dull-colored, leathery plaque adhering to the right tonsil, which bleeds upon scraping. What is one of the potential complications of this patient's disease? A Esophagitis B Hemolytic uremic syndrome C Myocarditis D Reactive arthritis E Splenic rupture

C Myocarditis Diphtheria has been fairly well eliminated in the US due to Tdap vaccination. Patient with unknown vaccination history + presentation suspicious for Diphtheria (pseudomembrane oral lesions that bleed when scraped, sore throat, barking cough, hoarse, cervical LNs, submandibular swelling). Major complications include Myocarditis, Nephritis, Polyneuropathy, and Thrombocytopenia. Treat with Penicillin or Erythromycin, and treat toxin separately with neutralizing antitoxin. Notify the CDC

A patient presents with complaints of edema, malaise and sudsy urine. A microscopic urinalysis shows oval fat bodies and a Maltese cross pattern under polarized light. These findings are most consistent with which of the following diagnoses? A Glomerular nephritis B Nephritic syndrome C Nephrotic syndrome D Polycystic kidney disease

C Nephrotic syndrome Sudsy/foamy urine indicates high level of proteinuria. Oval fat bodies, Maltese cross pattern both point to Nephrotic Syndrome. Lipiduria is highly sensitive for Nephrotic Syndrome. X A - GN: UA shows hematuria rather than lipiduria. X B - Nephritic Syndrome: hematuria, proteinuria, HTN, & mild uremia but no lipiduria. X D - PCKD: UA shows proteinuria, hematuria, pyuria, & bacteriuria.

27M otherwise healthy presents with facial pain and low grade fever. For the last two days, he has felt congested and noticed green drainage from his nose. Which of the following is the most appropriate management? A Antihistamines B CT scan of the sinuses C Nonsteroidal anti-inflammatory drugs D Systemic antibiotics

C Nonsteroidal anti-inflammatory drugs Acute Sinusitis is inflammation of the nasal cavity & paranasal sinuses lasting < 4 weeks. MCC is viral infection. Only consider a bacterial cause if the symptoms last more than 7-10 days. Treatment with symptomatic control with NSAIDs (Ibuprofen) for pain relief.

3M is brought to the ED by his father because of possible poisoning. He was found in the garage with furniture polish on his cheeks, mouth, and clothes. The father saw him coughing but denies choking or vomiting. On exam, the boy is active with normal vital signs. Which of the following is the next best step? A Consult pulmonology B Give activated charcoal C Obtain chest X-ray D Perform gastric lavage

C Obtain chest X-ray Hydrocarbon toxicity can be caused by furniture polish. CXR is important because it may initially be normal, but often shows abnormalities within 6 hours of exposure. Can progress rapidly to ARDS and respiratory failure.

23M with a history of ulcerative colitis presents with abdominal pain and vomiting. On exam, he is febrile with a HR of 125 beats per minutes and BP of 92/63 mm Hg. He has diffuse abdominal tenderness and distention. Which of the following imaging studies is most appropriate to diagnose toxic megacolon? A Colonoscopy B Computed tomography C Plain radiography D Ultrasound

C Plain radiography Evidence of Toxic Megacolon on plain radiographys = colonic dilation 6+ cm. X A - Colonoscopy risky due to risk of perforation. X B - CT may help with management, identifying etiology or complications, but is not first line diagnostic study. X D - US may be used as well, but not the study of choice for diagnosis.

Which of the following clinical findings differentiates rheumatoid arthritis from osteoarthritis? A Involvement of the proximal interphalangeal joints B Polyarticular involvement C Presence of constitutional symptoms D Symmetric joint involvement

C Presence of constitutional symptoms OA & RA share many features, but constitutional symptoms are only seen in RA. Fever, weakness, & musculoskeletal pain lasting for weeks to months.

29F has a 10-year history of migraine headaches. She had been using ergotamine to abort her headaches, but is now having one or two headaches per week that are interfering with work. Which of the following is the most appropriate preventive therapy? A Ketorolac B Promethazine C Propranolol D Sumatriptan

C Propranolol Prophylaxis for migraine headaches: Beta Blocker (Propranolol), Antiepileptics (Topiramate, Valproic Acid), Calcium Channel Blockers (Verapamil), & TCAs (Amitriptyline) and recently approved Botulinum Toxin A injections. X A - Ketorolac is an NSAID, not used for prevention. X B - Promethazine is an antiemetic if a patient has N/V with migraines, but is not preventive. X D - Sumatriptan is an abortive when given subcutaneously, but is not preventive.

45M presents with left leg pain. He describes a sudden onset pain in his calf area while playing basketball with his son. On exam, you squeeze his right calf and elicit plantar flexion of the right foot. When you do the same with his left calf there is no plantar flexion of his left foot. You administer ibuprofen and place the left leg in a posterior splint. Which of the following is the most appropriate next step in management? A Obtain X-rays of the ankle and foot B Prescribe physical therapy C Refer to orthopedic surgery D Screen for autoimmune diseases

C Refer to orthopedic surgery Positive Thompson Test to diagnose Achilles Tendon Rupture. Early operative repair is associated with lower risk of re-rupture & possibly improved functional outcomes BUT also has a higher rate of complications. Decision depends on various factors and should be made by consult with orthopedic surgeon. X A - XR of ankle/foot are not routinely indicated for Achilles tendon rupture.

You suspect an unresponsive patient actually has psychogenic coma. You decide to proceed with caloric testing. After instilling cold fluid into the left ear, what do you expect to see on eye movements if the patient has intact brainstem function? A Downward fast-beating nystagmus B Leftward fast-beating nystagmus C Rightward fast-beating nystagmus D Lack of nystagmus

C Rightward fast-beating nystagmus With intact brainstem function, caloric testing elicits nystagmus with both a fast and slow component. Elicited movements depend on the temperature of the water. Cold water in an ear = fast-beating nystagmus moves to the opposite ear. Warm water in ear = fast-beating nystagmus moves to the same ear. When patients are truly comatose, they no longer have nystagmus response to caloric stimulation.

A 53-year-old man presents to the family health clinic with concerns about a rash on his face. He was recently on a boating trip, but 2 weeks later, the painful "sunburn" on his face has not gone away. Vital signs are a BP of 126/80 mm Hg, HR of 75 bpm, RR of 16/min, T of 98.4°F, and BMI of 32 kg/m2. You observe erythema in a symmetric malar distribution and fine telangiectasias around his nose. No pustules are evident. After visiting briefly about his alcohol and tobacco use, which he has been trying to limit, which of the following is the most appropriate next step in management of his rash? A Antinuclear antibody testing B Emollient C Sunscreen and reduce sun exposure D Topical corticosteroids E Topical retinoids

C Sunscreen and reduce sun exposure History of Rosacea that can cause an outbreak in response to triggers such as sun exposure, spicy food, alcohol, wind, & temperature extremes. Encourage patients to avoid triggers, use sunscreen, & avoid sun exposure. Topical medications such as Oxymetazolin, Brimonidine, Metronidazole, Ivermectin, & Azelaic Acid can also be prescribed.

37M presents to the ED after he crashed his dirt bike going over a jump. You note a 5 cm wound to his right leg with a significant amount of dirt and debris. He does not think he has had a tetanus vaccine in the past as his mother is against vaccines. Which of the following is the most appropriate management? A Tetanus immunoglobulin B Tetanus immunoglobulin and metronidazole C Tetanus immunoglobulin and tetanus vaccine D Tetanus vaccine

C Tetanus immunoglobulin and tetanus vaccine Patient has never been immunized before = requires the Tetanus vaccine. Patient has never been immunized before AND has a dirty, high-risk wound = requires Tetanus Immune Globulin as well.

A 3-week-old infant presents with projectile vomiting. Mom reports he has vomited after each feed for the last 24 hours. What electrolyte abnormality do you expect to see? A Hyperchloremic, hyperkalemic, metabolic alkalosis B Hyperchloremic, hypokalemic, metabolic alkalosis C Hypochloremic, hyperkalemic, metabolic alkalosis D Hypochloremic, hypokalemic, metabolic alkalosis

D Hypochloremic, hypokalemic, metabolic alkalosis Hypertrophic Pyloric Stenosis is one of the MCC of intestinal obstruction in infants. Emesis is non-bilious and after vigorous feeding. Continuous vomiting causes loss of both H+ & Cl- ions in the gastric juices. Renal compensation occurs, retaining H+ ions in exchange for K+ ions. Causes Hypochloremic, Hypokalemic, Metabolic Alkalosis.

23M presents with testicular pain for 3 hours. He denies any trauma. The pain is constant, sharp, and severe and is accompanied by nausea and vomiting. His vital signs are normal, except for a HR of 110 beats/min. On exam, there is no swelling, but the left testicle is extremely tender to palpation. The cremasteric reflex is absent. What management is indicated? A Ceftriaxone 250 mg IM x 1 and doxycycline 100 mg PO BID x 10 days B CT scan of the abdomen and pelvis without contrast C Immediate scrotal ultrasound followed by urology consultation D Immediate urology consultation followed by scrotal ultrasound

D Immediate urology consultation followed by scrotal ultrasound Testicular Torsion is a true urologic emergency. Urologic consultation must be immediately obtained as the only definitive way to diagnose & treat torsion is through exploration & detorsion in the OR. Manual detorsion can be attempted in the ED if there is a delay in the consult.

27F presents in the fall for her first prenatal visit. Her last menstrual period started 8 weeks ago. The patient reports she is in a monogamous relationship with one male partner. She has a family history of DM but has never been diagnosed with diabetes herself. Her BMI is 21 kg/m2. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, O2 saturation of 98% on room air, and T of 98.6°F. PE findings include a soft and nontender abdomen, no blood in vaginal vault, and a closed cervical os. Transvaginal US shows an intrauterine fetal pole with a fetal heart rate. Which of the following is indicated at this prenatal visit? A 24-hour urine collection for protein B Fasting blood glucose level C Group B Streptococcus screening D Inactivated influenza vaccine E Nucleic acid amplification testing for COVID-19

D Inactivated influenza vaccine CDC recommends that ALL pregnant patients receive an inactivated Influenza vaccine regardless of trimester. X A - urine dipstick is done at initial prenatal visit to screen for proteinuria. X B - she has normal BMI and does not need to be screened. X C - occurs at 35-37w X E - not recommended unless recently exposed or symptomatic.

52F 4 days post-MI presents with a new murmur. On exam, the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspneic at rest and has rales throughout all her lung fields. BP is 108/68 mmHg, HR 70 bpm. Which would be the definitive clinical intervention? A Coronary artery bypass surgery (CABG) B Immediate fluid bolus C Intra-aortic balloon counterpulsation D Mitral valve replacement

D Mitral valve replacement This patient is suffering from mitral valve regurgitation caused by papillary muscle rupture (which can be caused by acute MI). Mitral valve replacement is the definitive intervention to correct mitral regurgitation caused by papillary muscle rupture.

A patient presents with wheezing and dyspnea. His medical history is significant for asthma, seasonal allergies and rotator cuff repair. You notice that he has aspirin and nonsteroidal anti-inflammatories listed under allergies. If this patient's medical history also included "Samter's triad", which of the following would you expect to find during physical examination? A Blood clot B Hypertension C Jaundice D Nasal polyps

D Nasal polyps Samter's Triad: Asthma + Aspirin or NSAID sensitivity + Nasal Polyps

A 36-month-old boy is being evaluated at your office. Parents are concerned because he is short and has evidence of developmental delay with hypotonia. He was born at term with a birth weight of 3250 grams. He has a history of poor suck that required physical therapy. Recent fluorescence in situ hybridization was positive for a deletion on chromosome 15. This patient is at a higher risk of suffering from which of the following conditions? A Alzheimer disease B Congenital heart disease C Hypocalcemic seizures D Obesity

D Obesity Prader-Willi Syndrome is the most common syndromic form of obesity. Absence of expression of paternally-active genes on long arm of chromosome 15. Screening indications include hypotonia with poor suck, global developmental delay. Neonatal hypotonia is the hallmark feature. Learning difficulties, food-seeking behaviors, increased pain tolerance, decreased ability to vomit, obesity + complications of obesity, hypogonadism, osteoporosis, behavioral issues.

5F is rushed to the ED because of possible ingestion. She was unattended for a few minutes and later found playing with her grandmother's bag. The grandmother's bag contains OTC medications and herbal products. The girl complained to her grandmother that her ears were buzzing. Upon arrival at the ED, the girl had one episode of vomiting. Her examination was normal except for diaphoretic skin. Which of the following is the medication that most likely caused her symptoms? A Acetaminophen B Chlorpheniramine C Ibuprofen D Oil of wintergreen

D Oil of wintergreen Salicylism/Salicylate Toxicity (Oil of Wintergreen contains 5g of Salicylate in 1 tsp). Early signs = N/V, diaphoresis, tinnitus. Moderate toxicity = tachypnea, tachycardia, altered mental status. Severe toxicity = hyperthermia, coma, seizures. Initial treatment soon after ingestion involves GI decontamination with activated charcoal. Aggressive volume resuscitation & prompt Sodium Bicarbonate therapy, even before obtaining serum Salicylate levels. X A - Acetaminophen toxicity: nonspecific, N/V, asymptomatic, etc. X B - Chlorpheniramine (Antihistamine) toxicity: sedation, mild lethargy, flushed dry skin, hyperthermia, mydriasis, agitation, tremor. X C - Ibuprofen toxicity: well-tolerated, even in overdose. Large ingestions cause altered mental status & metabolic acidosis.

45M presents complaining of a "racing heart", palpitations, increased sweating, and headaches for the past three months. He denies any new life stressors and history of anxiety or panic attacks. He is not currently on any medications. The patient reports his father experienced similar symptoms when he was around the same age and was ultimately diagnosed with a tumor on his adrenal gland. Patient's BP in the office is 164/98 mm Hg and his HR is 88 beats per minute with a regular rhythm. PE reveals a diaphoretic, well developed man without focal neurological deficits. TSH and T3/T4 levels were all reported WNL. Which of the following diagnostic tests would be the most appropriate next step for this patient? A 24-hour urine fractionated metanephrines and catecholamines B CT scan C Genetic testing D Plasma fractionated metanephrines

D Plasma fractionated metanephrines Initial biochemical test performed on a patient considered high-risk for Pheochromocytoma. X A - 24-hour urine fractionated metanephrines & catecholamines is the initial biochemical test in patients considered low-risk for Pheochromocytoma. X B - should be done, but NOT the initial test. X C - indicated in this patient who has a positive family history, but NOT the initial test.

A 16-year-old boy is in clinic for a routine health check. He is doing well in school and has plans to join the military when he reaches 18 years of age. He practices and plays basketball about 60 minutes per day. He denies smoking and drug use. Physical examination is normal. At this visit, you recommend meningococcal vaccine booster. Which of the following is the best statement regarding meningococcal infection? A Chemoprophylaxis can be administered two weeks after exposure to the index case B Droplet precaution is not necessary for patients infected with meningococcal meningitis C Nasopharyngeal cultures are needed in determining the need for chemoprophylaxis D Prophylaxis is indicated in close contacts of patients with meningococcal infection

D Prophylaxis is indicated in close contacts of patients with meningococcal infection Antimicrobial chemoprophylaxis after identifying an index case, use of droplet precautions, vaccination prior to exposure, & avoidance of risk factors. Prophylaxis should be given to close contacts as soon as possible after the exposure.

Which of the following is a contraindication to the use of metformin in patients with type 2 diabetes mellitus? A Age greater than 70 years B Insulin use C Irritable bowel syndrome D Renal insufficiency

D Renal insufficiency Metformin (Biguanide) reduces hepatic glucose & improves glucose utilization peripherally. Contraindicated in patients with elevated serum Creatinine, GFR < 30. Other contraindications include CHF, radiographic contrast studies, acidosis, and patients with serious illness.

A 56-year-old man with a 10-year history of alcohol use disorder presents to the emergency room with nausea and dull, epigastric pain that radiates to the back for the past 2 hours. Which of the following lab values is associated with a poor prognosis for the suspected diagnosis? A Aspartate aminotransferase 200 units/L B Glucose 172 mg/dL C Serum lactate dehydrogenase 300 units/L D White blood cell count 18,000

D White blood cell count 18,000 Acute Pancreatitis Ranson's Criteria at admission: age > 55 y.o., WBCs > 16k, Glucose > 200, LDH > 350, AST > 250 At 48 hours: Hct decrease by > 10%, BUN increase by > 5, Calcium < 8, PaO2 < 60, base deficit > 4, fluid sequestration > 6 L.

8M presents to the ED via EMS after having a seizure. His parents are both at the bedside and report that the patient has had diarrhea with dark red mucus for 2 days. The diarrhea started watery and then progressed to dark red with mucus, and it also hurts when he has bowel movements. His vital signs are a HR of 90 bpm, RR of 19/min, O2 sat on room air of 99%, BP of 98/60 mm Hg, and T of 102.8°F. On PE, the patient has diffuse abdominal tenderness without guarding or rebound. Which of the following is the most common cause of this patient's suspected diagnosis? A Intussusception B Rotavirus C Salmonella D Shigella sonnei E Vibrio cholerae

D Shigella sonnei Shigella diagnosis by stool culture. Presents with high fever, abdominal cramps, bloody mucoid diarrhea. Can cause complications including seizure, bacteremia/sepsis, Reactive Arthritis, & HUS. X B - Rotavirus: watery diarrhea, abdominal pain, N/V (rare in Shigella), low-grade fever (he has high-grade). X C - Salmonella: undercooked poultry; abdominal pain, bloody mucoid diarrhea, gradual presentation of symptoms. X E - Vibrio cholerae: undercooked seafood; explosive rice-water diarrhea, abdominal pain, vomiting (rare in Shigella) & fever is rare.

Which of the following conditions should prompt administration of the meningococcal vaccine prior to the standard 11 years of age? A Cystic fibrosis B Diabetes mellitus C Hypoplastic left heart D Sickle cell anemia

D Sickle cell anemia Sickle Cell Anemia patients who no longer have a functional spleen should receive the Meningococcal vaccine. Autosplenectomy greatly increases the risk of serious infection from encapsulated organism, such as N. meningitides, Strep pneumoniae, & H. influenzae.

What finding is commonly seen with primary adrenal insufficiency but not secondary adrenal insufficiency? A Fever B Hypoglycemia C Hyponatremia D Skin hyperpigmentation

D Skin hyperpigmentation Hypothalamus secretes CRH, which activates the Anterior Pituitary to release ACTH, which then stimulates the Adrenal Cortex to produce & release Cortisol. Primary Adrenal Insufficiency causes decreased Cortisol release from adrenal cortex, but the HPA axis is intact. Therefore, decreased Cortisol release causes increased ACTH levels, causing melanocyte stimulation and hyperpigmentation.

27F presents to your office with complaints of pain and discomfort. She tells you that she has seen numerous doctors and none of them have been able to help her. Her symptoms today include nausea, irregular menses, weakness in her legs, headache, dysuria, dyspareunia, and back pain. She would like you to do a CT scan to determine the cause of her complaints. Which of the following is the most likely diagnosis? A Factitious disorder B Functional neurological symptom disorder C Malingering D Somatic symptom disorder

D Somatic symptom disorder Somatic Symptom Disorder - physical complaints from various organ systems. Excessive thoughts, feelings, & behaviors devoted to the symptoms. Symptoms may change over time. Patients may demand diagnostic testing. No evidence of deception. X A - Factitious Disorder: purposefully feigning illnesses, exaggerate symptoms, or mimic illness in order to be in the sick role and use deception to attain this goal. X B - Functional Neurologic Symptom Disorder: formerly known as Conversion Disorder; voluntary alterations in motor or sensory function without evidence of deceptive behavior. Symptoms not consistent with known medical or neurologic conditions.

45F presents, complaining of one day of vision loss in her left eye associated with a left retro-orbital headache. She denies trauma or preceding illness. On exam, her vital signs are T 36.8°C, BP 112/80 mm Hg, HR 74 bpm. Visual acuity is 20/20 in the right eye, 20/400 in the left eye, and 20/40 using both eyes. She has a left-sided afferent pupillary defect. Visual field testing reveals left-sided central vision loss. Which of the following is most accurate regarding her condition? A Strict blood glucose control reduces the likelihood for future recurrences B The diagnosis is confirmed by measurement of an intraocular pressure > 20 C The diagnosis is made by magnetic resonance venography D The syndrome is associated with multiple sclerosis E Therapy should be aimed at removing the acute obstruction of the ophthalmic artery

D The syndrome is associated with multiple sclerosis Optic Neuritis - acute monocular loss of vision with afferent pupillary defect that is always present.

65M presents to the ED due to new-onset seizures. He reports he has been feeling unwell over the past few weeks with symptoms including fever, headache, and weakness. His daughter is with him and reports that he has seemed "out of it" and "easily confused" over the past few months. Medical history is notable for HIV with a last CD4 count of 45 cells/mcL. His medications include dolutegravir, emtricitabine, and tenofovir disoproxil fumarate. He reports he does not always take his HIV medications because it is hard to remember three different pills. Vital signs include a BP of 112/72 mm Hg, HR of 105 bpm, RR of 18/min, and T of 102.5°F PE reveals left-sided global decreased motor strength and a slight resting tremor. Advanced imaging of the brain shows multiple ring-shaped contrast-enhancing cerebral lesions that involve the right basal ganglia. Which of the following pathogens is most likely responsible? A Cryptococcus neoformans B Herpes simplex virus C Rhabdoviridae D Toxoplasma gondii E Treponema pallidum

D Toxoplasma gondii Toxoplasmosis is the most common CNS space-occupying lesion in HIV patients, usually presenting as Toxoplasmosis Encephalitis in patients with CD4 < 50. CT shows multiple ring-shaped enhancing lesions in brain, usually involving the basal ganglia. Immunocompromised patients require treatment with Pyrimethamine + Sulfadiazine + Folinic Acid, then chemoprophylaxis to prevent reactivation of infection. X A - Cryptococcus neoformans: causes Fungal Meningitis. MRI shows lesions in brain parenchyma.

Which of the following statements is true regarding febrile seizures? A Administering acetaminophen and ibuprofen during a febrile illness has been shown to decrease the likelihood of seizure recurrence B Children who have had a simple febrile seizure have triple the rate of epilepsy as those who have not had a simple febrile seizure C Older children with a febrile seizure are more likely to have a recurrence than younger children with a febrile seizure D Treatment with long-term anticonvulsants does not lower the long-term risk of developing epilepsy

D Treatment with long-term anticonvulsants does not lower the long-term risk of developing epilepsy Children with simple febrile seizure have 1-2% rate of Epilepsy when compared to the general population's rate of < 1%. Treatment with long-term anticonvulsants does not affect this long-term risk of developing Epilepsy and is rarely warranted. X C - The younger the age of onset of a febrile seizure, the greater likelihood of recurrence.

A 23-year-old G1P0 woman presents to the ED with vaginal bleeding. She is 8w 2 days pregnant according to an outpatient US she had last week showing an intrauterine pregnancy with a detectable fetal HR. She describes the bleeding as lighter than a normal period and reports she is not passing any clots or tissue. Vital signs include a HR of 80 bpm, BP of 120/80 mm Hg, RR of 20/min, O2 sat of 98% on room air, and T of 98.6°F. PE includes a closed cervical os with a small amount of blood in the vaginal vault. Labs include a Hgb of 13 g/dL, Beta-hCG of 100,000 mIU/mL, and a blood type of A positive. TVUS in the ED shows an intrauterine pregnancy with a detectable fetal HR and appropriate interval growth since the last ultrasound. Which of the following is the most appropriate next step in management? A Administer progesterone B Administer Rho(D) immunoglobulin C Hospitalize for observation and bedrest D Perform serial beta-human chorionic gonadotropin measurements E Provide reassurance and outpatient follow up with ultrasound

E Provide reassurance and outpatient follow up with ultrasound Threatened Abortion is defined by vaginal bleeding with a closed cervix without passage of any products of conception before 20w gestation. Management is expectant with reassurance & repeat outpatient US to monitor for viability. There is no proven benefit of hospitalization & observation/bedrest plus it increases risk of a DVT/PE.

22F presents due to genital lesions for the past 2 days. She states the lesions are painful and tender. She reports no history of similar problems and no abdominal pain or changes in her menstrual cycle. She has a history of gonorrhea 2 years ago but, otherwise, has no significant medical history. She reports intercourse with multiple men and uses OCP for birth control. Her only medication is her oral birth control pill. Her vitals include a BP of 120/76 mm Hg, HR of 78 bpm, RR of 13/min, T of 99.9°F, and SpO2 of 100% on room air. During the genital exam, you note inguinal lymphadenopathy and multiple groups of small umbilicated vesicles with underlying erythema and ulcerations. What is the most sensitive diagnostic test for the most likely diagnosis? A Direct fluorescent antibody B Serologic testing C Tzanck smear D Viral culture E Viral polymerase chain reaction assay

E Viral polymerase chain reaction assay HSV is a common cause of genital herpes. Typical herpetic lesions appear as groups of small vesicles in the genital area with underlying erythema & central areas of depression (umbilication). Ulcerations & erosions often seen, and inguinal LNs are common. Confirm HSV with viral PCR assay (more sensitive than viral culture in patients with HSV).

32M with a history of von Willebrand disease presents to the ED after an altercation during a family reunion. He was punched in the right eye and is now experiencing reduced vision with eye pain and nausea. His BP is 130/84 mm Hg, and his remaining vital signs are WNL. Visual acuity testing demonstrates OS 20/15 with OD only able to discern light. Red light reflex is absent in the right eye, and blood is noted in the anterior chamber. There is no apparent foreign body with no abnormal fluorescein uptake. Extraocular eye movements are unrestricted, and there is no palpable crepitus or bony step-offs. Which of the following would be a potential complication of the patient's suspected diagnosis? A Endophthalmitis B No associated complications C Orbital cellulitis D Retinitis pigmentosa E Vision loss

E Vision loss Hyphema is an ophthalmologic emergency, usually from trauma to eye or head. May present as eye pain, vision loss, photophobia, N/V. Prompt ophthalmology consult, eye shield, & bed rest with head of bed elevated to 30 degrees. Antiemetics & analgesia to make patient comfortable. Avoid NSAIDs. Complications include permanent vision loss, straining of cornea, & orbital compartment syndrome.