PANCE Practice Exam #2

You are treating a 20-year-old female with multiple aphthous ulcers. She complains of a moderate amount of pain. You decide to prescribe “magic mouthwash” for the patient to swish and spit. Which of the following combinations of medicines is appropriate?
A very commonly used combination of medicines to promote relief of discomfort and healing include liquid diphenhydramine, antacid, tetracycline, and 2% viscous xylocaine.

A 17-year-old male is brought to your Emergency Department by his girlfriend. She states that he has been behaving strangely for the last three days, with rapidly fluctuating moods ranging from euphoric to irritable and paranoid. The patient states that he is fine, just a little nervous about an upcoming test in school. His pulse is 126 beats per minute, BP 182/106, pupils are widely dilated, and he is diaphoretic. What is his most likely diagnosis?
A. Acute anxiety
B. Bipolar disorder
C. Cocaine intoxication
D. Heroin intoxication
he answer is C.
EXPLANATION: This patient’s presentation with tachycardia, hypertension, diaphoresis, and mydriasis along with the behavioral changes is consistent with cocaine intoxication

cause somnolence and pinpoint pupils
Heroin withdrawal

A 67-year-old man presents with pain and stiffness in his shoulders and hips lasting for several weeks with no history of trauma. He also has complaints of headache, throat pain, and jaw claudication. It is imperative to diagnose this patient promptly in order to prevent which of the following complications?
A. anemia
B. cerebral aneurysms
C. mononeuritis multiplex
D. ischemic optic neuropathy
E. respiratory tract complications
The answer is D.
EXPLANATION: The most urgent need for diagnosis of a patient with symptoms of polymyalgia rheumatica (PMR) and giant cell arteritis is to prevent blindness caused by ischemic optic neuropathy as a result of occlusive arteritis of the ophthalmic artery. Early diagnosis is imperative as the neurological damage to the optic nerve is not reversible. Most patients with this diagnosis will have a normochromic-normocytic anemia, but this does not create urgency in treatment. Cerebral aneurysms are not common findings with PMR; large vessels such as the subclavian and aorta may be involved in giant cell arthritis in 15% of patients. Mononeuritis multiplex commonly presents with painful paralysis of a shoulder, and respiratory tract complications are more nonclassic findings with the presentation of PMR.

During an ophthalmoscopic exam you notice deep retinal microvascular hemorrhages, and cotton wool spots. What is the most likely cause of her visual disorder?
The answer is D.
Diabetic retinopathy-EXPLANATION: The patient’s symptoms suggest a likelihood of diabetes. Retinal findings can include microaneurysms, deep hemorrhages, a flame-shaped hemorrhage, exudates, and cotton wool spots.

A newborn male is diagnosed with Christmas factor deficiency. What is the likelihood that he inherited this disorder from his father?
A. 0%
B. 25%
C. 50%
The answer is A.
EXPLANATION: All daughters of a hemophilic male are carriers of hemophilia, whereas all sons are normal. Hemophilia B (or Christmas factor deficiency) is one of only two sex-linked pattern-bleeding disorders, and as such the disease occurs almost exclusively in males. Sons of carriers have a 50% chance of being affected and daughters of carriers have a 50% chance of being carriers themselves.

A 2-month-old female presents for a well child check. The mother has no concerns and feels that the child is doing well. On exam, there is no evidence of cyanosis and the peripheral pulses are normal and equal. However, there is a fixed and widely split S2, a right ventricular heave, and a systolic ejection murmur present. The murmur is heard best at the left sternal border second intercostal space. What is the most common abnormality present on an ECG?
A. Atrioventricular heart block
B. Atrial fibrillation
C. Bifasicular block
D. Right axis deviation
The answer is D.
EXPLANATION: The most likely diagnosis is an atrial septal defect, which usually shows right axis deviation on ECG. The other ECG abnormalities listed do not commonly occur with an atrial septal defect.

A 28-year-old male smoker presents witha complaint of numbness and pain in his fingers. He notices thisafter being exposed to the cold. He states that his fingers appearpale or even blue at times. After warming, his fingers turn redbefore returning to their normal color. What should be includedin appropriate management of this condition?
A. Counsel the patient to stop smoking
B. Systemic glucocorticoids
C. Take aspirin prior to cold exposure
The answer is A.
EXPLANATION: This patient is experiencing Raynaud phenomenon. This is digitalischemia that can occur after exposure to cold or emotional stress. It is more common in smokers or patients whose occupation involvesusing vibratory tools. Management includes patient education toinclude cold avoidance behavior and wearing loose-fitting clothing.Cessation of smoking is imperative. Drug therapy is used in patientswith progressive and severe Raynaud’s.

A 45-year-old woman presents with weight gain, fatigue, dry skin, constipation, and oligomenorrhea. On physical exam, bradycardia and slow deep tendon reflexes are noted. Her free T4 is low and TSH is elevated. Which of the following medications may be responsible for her condition?
A. amiodarone
B. beta-blockers
C. levadopa
The answer is A.
EXPLANATION: Hypothyroidism is reported in up to 10% of patients taking amiodarone, an antiarrhythmic medication. With the high iodine content of the medication and the structural similarities to thyroxine, thyroid abnormalities occur. Common side effects of amiodarone include bradycardia and constipation, so laboratory evaluation for thyroid dysfunction must be used.

Common side effects of amiodarone
include bradycardia and constipation, so laboratory evaluation for thyroid dysfunction must be used.

A 3-week-old male infant is brought in by his mother due to his vomiting. The mother notes that a few days ago her son started vomiting after feeding, and it has become projectile in nature. The vomitus is non-bilious and contains no blood. The child seems hungry and nurses regularly, but the vomiting has become more frequent and is occurring with every feeding now. On physical examination, an oval mass is palpated in the right upper quadrant. Appropriate imaging is obtained and confirms the suspected diagnosis. What is the treatment of choice in this patient?
A. Acid supression
B. Dilatation of the lower esophageal sphincter
C. Diverting colostomy
D. Ladd procedure
E. Pyloromyotomy
The answer is E.
EXPLANATION: A pyloromyotomy involves an incision along the length of the pylorus, down to the mucosa, and is the treatment of choice in pyloric stenosis. Acid suppression is the treatment of choice in cases of peptic ulcer disease. Dilatation of the LES is performed in cases of achalasia of the esophagus. A diverting colostomy may be used in cases of Hirschsprung disease, after removal of the aganglionic section of colon. The Ladd procedure is used in surgical treatment of intestinal malrotation.

The rotator cuff is comprised of which four muscles?
Supraspinatus, infraspinatus, teres minor, subscapularis

The patient has a family history of thyroid cancer. You are concerned that the patient may have medullary thyroid cancer. Which of the following lab tests would you monitor in this patient after treatment?
serum calcitonin. Both calcitonin and CEA are secreted by medullary thyroid cancer cells, and are used both in diagnosis and monitoring of patients after treatment.

Alkaline phosphatase, is elevated in disorders of the
bone and biliary tract.

serum anti-thyroglobulin antibodies, are most commonly associated with
autoimmune disorders of the thyroid, such as Hashimoto’s thyroiditis.

Serum CA-125 has been used to investigate and follow patients with malignancies, such as?
ovarian cancer

A 76 year-old woman with steroid dependent chronic obstructive pulmonary disease is hospitalized with fever, chills, and a productive cough. The sputum gram stain shows many WBCs and small, pleomorphic gram-negative rods. Which of the following is the most likely causative agent?
A. Chlamydia pneumoniae
B. Haemophilus influenzae
C. Mycoplasma pneumoniae
The answer is B.
EXPLANATION: Haemophilus influenzae (B) is a gram-negative pleomorphic coccobacillus. Strep pneumonia (E) and Staph aureus (D) are gram positive organisms. Mycoplasma pneumonia (C) and Chlamydia pneumoniae (A) aren’t visible on gram stain.

An 8-month-old baby boy is brought in by his mother after noticing redness and swelling around his penis, which she retracted his foreskin to clean after a diaper change. She states the swelling has been increasing over the past 2 hours. His past medical history is unremarkable and he is uncircumcised. On physical examination you see the following:
Considering your suspected diagnosis, what would be the management of this patient?
A. Observation until the swelling decreases
B. Attempt manual reduction and get emergent urologic consultation
C. IV fluids and analgesics
D. Dorsal penile nerve block with lidocaine and epinephrine
he answer is B.
EXPLANATION: Paraphimosis occurs when a tight ring of foreskin is retracted proximal to the glans of the penis and becomes trapped in the retracted position. Impaired venous and lymphatic draining can cause swelling and is a true urologic emergency. Immediate attempt with manual reduction should be done and if unsuccessful an emergent surgical consult with urology is appropriate (B). If paraphimosis is not quickly reduced the arterial blood flow can become compromised leading to glans necrosis. Observation would increase the risk for necrosis (A). Manual reduction should be attempted immediately with or without a dorsal penile nerve block. If not reduced promptly then an emergent urologic surgical consult should be made. If a nerve block (D) is given it should be without epinephrine. IV fluids and analgesics (C) are used for sickle cell patients with priapism.

What age group is most at risk to develop osteoid osteoma?
A. Adolescents
B. Elderly
C. Middle-aged
The answer is A.
EXPLANATION: Osteoid osteoma is a benign bone forming tumor that usually develops during a patient’s second decade of life. This type of tumor is much more common in boys than girls and typically affects the lower extremities (femur and tibia primarily) and spine more than other areas of the body. Patients typically present with gradually progressive bone pain that is worse at night and does not correlate with activity level. The tumor produces high levels of prostaglandins, so symptoms usually improve in 20-25 minutes if the patient takes a medication like ibuprofen, ASA or other NSAIDS that are prostaglandin inhibitors. A lack of improvement in symptoms with these medications should lead health care providers to consider a different diagnosis. The pain of this condition may cause those afflicted in a leg to limp and have swelling, muscle atrophy or contractures and exquisite point tenderness. The condition usually resolves on its own over time, but symptomatic patients may require surgical resection or radioablation of the tumor.

A 29-year-old woman comes to the office because she “just keeps gaining weight and can’t stop.” Since she was last seen in the office at age 24, she has gained nearly 100#. Physical examination is remarkable for blood pressure of 140/92. She appears depressed. Her trunk and abdomen are heavy with normal-sized extremities. Her facial hair is dark and in a “male” distribution. Large dark violaceous striae are present on her abdomen and proximal extremities. Which of the following additional findings is most consistent with this presentation?
A. Buffalo hump
B. Doughy, thickened skin
C. Exophthalmos
The answer is A.
EXPLANATION: This woman appears to have Cushing Syndrome (hypercortisolism) which is characterized, in addition to the signs listed above, by plethoric facies, supraclavicular fatpads, and the so-called “buffalo hump.” Doughy, thickened skin (B) and thickened tongue (E) may be found in hypothyroidism, exophthalmos (C) in Graves disease, and lid lag (D) in hyperthyroidism from any cause.

A 30-year-old female presents to your office for a routine physical exam. She has not seen a health care provider in many years. Upon talking with the patient, you find out that she had been diagnosed with hypertension several years ago, but was unable to afford the antihypertensive medications that were prescribed to her. She has no complaints at this time. Upon exam of the head and neck, you note widened spaces between her lower incisor teeth and a large, fleshy nose. Her skin is oily and she demonstrates mild proximal muscle weakness. Her EKG reveals a left axis deviation and widened QRS. What is the most likely rationale for her clinical presentation?
A. Diabetes mellitus
B. Cushing’s syndrome
C. Hypothyroidism
D. Acromegaly
The answer is D.
The correct choice is D, acromegaly. Patients with acromegaly have an abundance of growth hormone secretion. This leads to excessive growth of many areas of the body including soft tissue. Patients with acromegaly also have an increased incidence of hypertension and left ventricular hypertrophy. None of the other choices will cause this patient’s constellation of symptoms. Patients with many endocrine disorders may develop weaknesses as seen in this patient, but the large nose and widely spaced teeth are characteristic of acromegaly.

A 41-year-old alcoholic male, who lives primarily on the streets, appears pale, cachectic, and mildly icteric. He is complaining of several weeks of increasing fatigue. Laboratory findings note an elevated MCV of 128. What other physical finding would most support the diagnosis for megaloblastic anemia?
A. Decreased vibration and position sense
B. Dementia
C. Difficulty with balance
D. Glossitis
E. Parethesias
The answer is D.
EXPLANATION: Features of folate deficiency are similar to vitamin B12 deficiency. However, there are none of the neurologic abnormalities associated with vitamin B12. Glossitis is the only non-neurologic finding in the PE that would support folate deficiency. Alcoholism and poor dietary intake also support the diagnosis of folate deficiency.

A 35-year-old male presents complaining of increasingly constant headaches, double vision centrally, and a progressive loss of peripheral vision for two weeks. He has no previous headache history and denies any other medical conditions. Physical examination reveals bitemporal hemianopsia without additional neurologic findings. What is the most likely diagnosis?
A. Acute ischemic stroke
B. Circle of Willis ruptured aneurysm
C. Migraine headache
D. Multiple sclerosis
E. Pituitary adenoma
The answer is E.
EXPLANATION: Pituitary adenomas, benign neoplasms associated with pituitary hormone secretory changes, may enlarge and become symptomatic. Symptoms are based upon the location and size of the tumor, and may include bitemporal hemianopsia, double vision, color desaturation, and visual acuity loss. Headaches may occur, due to associated pressure changes within the intrasellar space. Additional evaluation should include a T1-weighted MRI, screening laboratory tests, and a full ophthalmologic evaluation. These tests will also help evaluate for potential differential diagnoses, such as those listed. The patient’s history is not consistent with an acute ischemic stroke or migraine headache. Although an unruptured aneurysm may have very similar findings to a pituitary tumor, ruptured aneurysms present with acute headache, nausea, vomiting, and potential changes in consciousness. Multiple sclerosis (MS) should remain on the differential for this patient and will also be evaluated through MRI (although the current findings are more consistent with a pituitary adenoma), and additional neurologic findings would be likely with MS.

Which of the following pulmonary function test results demonstrates emphysema, a form of obstructive pulmonary dysfunction?
Total lung capacity represents the vital capacity, defined as the amount of gas exhaled after a maximal inhalation, plus the residual volume within the lung after maximum exhalation. With emphysema, the lung parenchymal damage and decreased elasticity results in all flow rates being reduced, including FEV1, FVC, and FEV1/FVC levels. Expiratory time is increased and gas trapping occurs, thus increasing the total lung capacity.

A soft tissue neck x-ray of a patient who complains of a progressively worsening sore throat reveals this lateral film (see image). Based on these findings, what is the initial treatment of choice for this patient?
pic-thumbprint sign
A. Endotracheal intubation
B. Intravenous steroids
C. Ribovirin injection
D. Incision and drainage
The answer is B.
EXPLANATION: This case of acute epiglottitis is treated with immediate intravenous steroids. Provided that the patient is able to maintain the airway and also keep oxygen saturation rates above 92%, the patient can improve with steroids and supportive care. Antiviral medications have little effect on the overall illness.

You decide to treat him with a proton pump inhibitor at this visit, and he achieves good symptomatic relief with this therapy. What length of therapy is appropriate in this patient?
If a patient achieves good symptomatic relief with a course of an empiric, once-daily proton pump inhibitor, therapy may be discontinued after eight to twelve weeks.

A 6-week-old male with sickle cell disease presents to the pediatric office for his well-child visit. When should this child begin taking daily prophylactic penicillin?
2months-Patients with sickle cell disease develop functional asplenia as early as 3 months of age and should begin treatment with prophylactic penicillin at 2 months of age to prevent infection by encapsulated organisms (i.e., pneumococcus).

Which of the following sets of disorders is commonly found in multiple endocrine neoplasia (MEN) 2A?
The three primary features of MEN type 2A include medullary thyroid carcinoma, parathyroid hyperplasia or adenoma, and pheochromocytoma.

pheochromocytoma, medullary thyroid carcinoma, and mucosal neuroma are disorders found in
MEN 2B

parathyroid adenoma, islet cell hyperplasia, and pituitary adenoma are found in
MEN I

Your patient is a 66-year-old female who has been dropping her coffee cup and concurrently slurring her speech. The episodes last for approximately 15 minutes. Her blood work, carotid dopplers, and MRI of the brain are normal and you suspect recurrent transient ischemic attacks (TIAs). Which of the following is NOT approved or recommended for the prevention of stroke in this patient?
A. aspirin
B. extended-release dipyridamole plus aspirin
C. clopidogrel
D. prasugrel
E. warfarin
The answer is E.
EXPLANATION: Aspirin, aspirin plus extended-release dipyridamole, and clopidogrel are all antiplatelet agents and approved for use to reduce recurrent TIAs and ischemic cerebrovascular accidents (CVAs). Prasugrel is not FDA-approved for this indication. Warfarin is an anticoagulant and has no role in prevention of either recurrent TIA or ischemic CVA.

Initial Treatment in TIA
Aspirin

A 73-year-old female with type 2 diabetes, hypertension, and hyperlipidemia presents to the emergency department complaining of left ear pain, and a yellowish-green, foul-smelling discharge that began about 3 weeks ago. On physical examination, the patient is afebrile and examination reveals a markedly edematous left ear canal draining purulent, green discharge. The tympanic membrane is unable to be visualized. Upon cranial nerve exam the patient has left-sided facial weakness. Which of the following diagnostic studies should be performed first in the initial evaluation of this patient?
A. CT scan of the head
B. Culture and sensitivity
C. Hemoglobin A1C
D. HSV-1 antibody testing
E. MRI of the brain
The answer is A.
EXPLANATION: The patient has malignant otitis externa that has most likely extended to osteomyelitis and impingement of the facial nerve. Emergent CT scan (A) is indicated over MRI (E) to assess the extent of disease and the presence of osteomyelitis. Malignant otitis externa is most commonly caused by pseudomonas and empirical antibiotic therapy can be initiated prior to culture and sensitivity (B). Assessment of the patient’s diabetes control (C) should occur, but isn’t the highest priority study to order first. HSV-1 antibody testing (D) is not indicated in this patient.

A 12-year-old female presents with linearlydistributed light brown papules on her arm. They are asymptomaticand have been present for several years. The mother states that theyappear to grow as the child grows. What treatment is necessary?
A. Cryotherapy
B. Laser ablation
C. No treatment is necessary
The answer is C.
EXPLANATION: This condition is consistent with a linear epidermal nevus. Theycan appear at any age, but are usually present at or shortly afterbirth. The pigmented papules are arranged linearly and can occuron any skin surface. They are not symptomatic and will grow withthe child. There is no treatment necessary.

A 24-year-old male has an eight-month history of loose thought associations, social withdrawal, auditory hallucinations, and deterioration in his personal appearance and hygiene. Upon examination, he is noted to have a flat affect, perceptual distortions, and behaves like he is detached from his own actions. If chosen for treatment, which of the following medications would require weekly white blood cell count monitoring for the first six months?
A. Clozapine (Clozaril)
B. Haloperidol (Haldol)
C. Olanzapine (Zyprexa)
D. Risperidone (Risperdal)
The answer is A.
EXPLANATION: Clozapine has a risk of agranulocytosis. While the risk is only 1%, weekly monitoring of the white blood cell count for the first six months, followed by monitoring of the white blood cell count every other week thereafter, is required. The other medications listed do not have the risk of agranulocytosis.

An 18-year-old female presents to your office with the complaint of palpitations for the last 2 months. The episodes are frequent and accompanied with lightheadedness and shortness of breath. The patient’s mother has taken her pulse when some of the episodes occur and states that the rate gets as high as 170 beats per minute. On exam, she is alert, awake, and oriented. Her resting pulse is 55 and her blood pressure is 122/65. Her lungs are clear throughout, and her cardiac exam revealed a regular rate and rhythm, without murmurs, rubs, or gallops. An ECG is obtained, as shown. Based on her history, physical exam, and ECG, what is the best pharmacologic treatment plan for this patient?
A. Flecanide
B. Hydrochlorothiazide
C. Lisinopril
D. Adenosine
The answer is A.
EXPLANATION: This patient is presenting with Wolff-Parkinson-White syndrome, as evidenced by the delta waves on the ECG. These conditions will generally occur in individuals at the onset of early adulthood. Management for this condition pharmacologically includes the use of class IC drugs, such as flecanide. Other choices include procainamide, sotalol, and amiodarone. Digoxin therapy may worsen and widen the QRS complex and place the patient into a ventricular tachycardia.

Which of the following would raise your suspicions the most and likely warrant consideration of testing for an inherited thrombophilia?
A. a deep femoral vein deep vein thrombosis (DVT) after a flight from Mumbai, India
B. an iliac vein DVT after a round trip bus trip to Atlantic City and playing slots all day
C. any DVT after a total knee replacement
D. an upper extremity DVT after tripping falling down a flight of stairs
The answer is D.
EXPLANATION: DVTs most commonly arise from the deep femoral veins and iliac arteries, most commonly in patients who smoke and take oral contraceptives, after immobilizing surgeries, and/or after immobilization due to long periods of time seated, including but not limited to airplane flights, bus rides, etc. Upper extremity DVTs are rare, even after trauma, and warrant a hypercoaguability work-up to rule out inherited disease.

Which of the following is the most common cause of hypoparathyroidism?
A. Familial hypoparathyroidism
B. Idiopathic hypoparathyroidism
C. Severe magnesium depletion
D. Surgical removal of the parathyroid
The answer is D.
Choice D, surgical removal of the parathyroid glands, is the correct answer. Surgery for head and neck cancer, thyroidectomy, and parathyroidectomy are the most common causes of hypoparathyroidism. Choices A, B, C, and E are all causes of hypoparathyroidism that occur more infrequently.

A 45-year-old woman with recent diagnosis of rheumatoid arthritis has begun treatment with celecoxib. She has been on this medication for 3 months and notes that her pain continues. Early signs of joint involvement are present in the patient’s hands. Which of the following medications is the most appropriate to add to her treatment?
A. aspirin
B. rituximab
C. etanercept
D. leflunomide
E. methotrexate
The answer is E.
EXPLANATION: The treatment of rheumatoid arthritis (RA) is aimed at reduction of pain, preservation of function, and prevention of deformity. Although non-steroidal anti-inflammatory drugs (NSAIDs) provide symptomatic relief, they do not alter progression or prevent erosion of the joint. Consequently, in addition to NSAID therapy, disease-modifying anti-rheumatological drugs (DMARDs) should also be initiated as soon as the diagnosis is confirmed. The most common initial DMARD used as treatment of choice in RA is methotrexate. Aspirin should not be added because of the increased risk of gastrointestinal side effects as well as having no effect on altering RA disease progression. Rituximab is a biological DMARD and is indicated to be added in patients with RA refractive to treatment with combination therapy of methotrexate and a tumor necrosis factor inhibitor (TNF). Etanercept is a TNF inhibitor. This class of medication is often added in patients with RA who are not responding to methotrexate therapy alone. Leflunomide is a pyrimidine synthesis inhibitor that is approved for the treatment of RA; however, it is contraindicated for use in premenopausal women secondary to its carcinogenic and teratogenic potential

A 38 year-old woman with severe-persistent asthma presents to the clinic complaining of nightly nighttime awakens and frequent use of her inhaled albuterol. Which of the following is an antibody that prevents IgE from binding to its receptor on mast cells and basophils and may be considered as a treatment for this patient?
A. adlimumab
B. daclizumab
C. etanercept
D. infliximab
E. omalizumab
The answer is E.
EXPLANATION: Omalizumab (E), is an antibody that prevents IgE from binding to its receptor on mast cells and is used in the treatment of allergic disease. Daclizumab (B) is anti-IL-2 antibody used to prevent acute rejection of organ transplants. Adlimumab (A), etanercept (C), and infliximab (D) bind TNF, thus inhibiting the action of TNF and are used in the treatment of disorders such as psoriasis and rheumatoid arthritis.

You are evaluating an 80-year-old female for the first time. She has a history of mild Alzheimer’s disease, for which she takes Aricept. She states that she feels fine but her daughter feels she is depressed and has been complaining of not feeling well. Her daughter admits that the patient has a history of primary hyperparathyroidism. What laboratory results would be most consistent with her diagnosis of hyperparathyroidism?
A. high serum calcium
B. low intact PTH
C. low cortisol
The answer is A.
EXPLANATION: The correct answer is (A). The hallmark of primary hyperparathyroidism is a high serum calcium and high intact PTH. A low intact PTH is consistent with hypoparathyroidism. The urine serum calcium is usually high in primary hyperparathyroidism. Cortisol is related to endocrine conditions affecting the adrenal cortex.

A 27-year-old man presents to the emergency department with a five-day complaint of substernal pleuritic chest pain, which worsens while lying supine. He is in no distress. A friction rub is noted over the precordium. The patient’s vital signs are as follows: temperature is 100.4°F, pulse rate is 94, respiratory rate is 20, and blood pressure is 136/84. An ECG reveals widespread diffuse ST elevations with PR interval depressions. He was recently treated for a viral respiratory infection. Which of the following is the most appropriate initial management for this patient?
A. Administer a broad spectrum antibiotic
B. Administer intravenous tissue plasminogen activator (T-PA)
C. Begin a nonsteroidal anti-inflammatory agent
The answer is C.
EXPLANATION: This patient’s diagnosis is acute inflammatory pericarditis. Viral infections are the most common cause of acute pericarditis, and males are the most commonly affected. A pericardial friction rub and EKG changes are characteristic of this diagnosis. Treatment is focused on the underlying inflammation, with NSAIDS being first-line and short course corticosteroids also being appropriate. Antibiotics are not indicated unless a bacterial etiology is confirmed or there are significant risk factors. Choices B, D, and E are not appropriate for this condition and could be harmful.

A 24-year-old male with thalassemia major who has received adequate transfusions, chelation therapy, and regular health checkups is in to establish care. He is 5’4″ with a BMI of 17. He eats a balanced healthy diet and gets regular exercise. You know that there are complications of this disease. What is the best next step for this patient?
A. Increase threshold for blood transfusions
B. Maintain sustained reduction of body iron
C. Obtain a Dexa scan for osteoporosis
The answer is B.
Maintaining sustained reductions in body iron has demonstrated increased overall survival rates through reductions in cardiac disease specifically due to siderosis. While these patients are at increased risk for osteoporosis and cardiac siderosis, the next best step in this patient is to maintain reduced iron levels. There is no place for increased blood transfusion or obtaining regular testosterone levels.

Which of the following joints has the lowest occurrence rate of osteoarthritis?
A. Elbows
B. Hands
C. Hips
he answer is A.
EXPLANATION: Because the elbow is not a weight bearing bone, the rate of osteoarthritis in the elbow is considerably less that what is found in locations like the hips, knees and spine. The hands have one of the highest rates of occurrence of osteoarthritis, likely due to their near constant use and propensity for minor (or major) injury. When elbow arthritis does develop it is often post-traumatic osteoarthritis related to a significant injury in the past that disrupted joint surface integrity or as a result of rheumatoid arthritis, a systemic illness. Osteoarthritis of the elbow will generally present with pain, stiffness, and decreased range of motion. Osteophytes that form on the medial elbow might be implicated should neurological symptoms develop that correlate with ulnar nerve distribution as this nerve does pass in close proximity to the elbow on the medial side.

A woman who is pregnant suffered a spontaneous abortion at 12 weeks gestation. She is now a G2P1Ab1 and is Rh negative. When should she receive her next Rhogam (Rho D immune globulin) shot?
A. Now
B. In one month
C. At conception of her next pregnancy
The answer is A.
EXPLANATION: Placental implantation occurred and separated with the spontaneous miscarriage. Therefore, there is a slight chance of isoimmunization, so Rhogam should be given now so that the mother does not develop antigens that can cross the placenta during the first half of the next pregnancy.

It is September and the radio is flooded with public service announcements recommending people get their flu shots early; flu is not yet endemic. Your patient, an 18 year old female, has come to see you in your family practice clinic with complaints of “flu-like” symptoms. She hoped the symptoms would resolve on their own, but it is now a week later and she is still experiencing them, and requests a rapid flu test. Which of the following is true regarding your patient and the rapid influenza tests?
A. It is best she waits at least a week before having you perform a rapid test, since a false negative may result if seen too soon from onset of symptoms.
B. You may warn your patient that given this time of year, the low prevalence in the community, and her delay in testing, the results are virtually useless and you would not recommend testing.
The answer is B.
EXPLANATION: The rapid tests vary in terms of sensitivity and specificity. Research indicates that sensitivities are approximately 50% to 70%, while specificities are approximately 90% to 95%. Specimens to be used with rapid tests generally should be collected as close as is possible to the start of symptoms and usually no more than four to five days later in adults. In very young children, influenza viruses can be shed for longer periods; therefore, in some instances, testing for a few days after this period may still be useful. Most importantly, the positive and negative predictive values vary considerably depending upon the prevalence of influenza in the community. False-positive (and true-negative) influenza test results are more likely to occur when disease prevalence is low, which is generally at the beginning and end of the influenza season, as is the case here. False-negative (and true-positive) influenza test results are more likely to occur when disease prevalence is high, which is typically at the height of the influenza season. When disease prevalence is relatively low, the positive predictive value (PPV) is low and false-positive test results are more likely. By contrast, when disease prevalence is low, the negative predictive value (NPV) is high, and negative results are more likely to be true.

A 25-year-old female presents with a complaint of dry, stinging hands for the past two months. She has never had any rashes or similar problems. She does not work. The patient stays home to care for her six-month-old baby. She has tried treating her hands with over-the-counter lotions, but reports that they sting upon application. What should appropriate management of this condition include?
A. triamcinolone 0.025% ointment bid, moisturize with petrolatum frequently, use gloves when hands in water B. withhold all treatments for one week and have patient undergo patch testing to determine allergen
C. punch biopsy at periphery of outbreak, and treat with ketoconazole cream for two weeks
The answer is A.
EXPLANATION: The patient is experiencing an irritant contact dermatitis, secondary to having her hands in water frequently and using diaper wipes, which can be very irritating due to the alcohol content. The appropriate treatment would consist of reducing the irritant (water and wipes) by using barrier protection (gloves). A mid-potency topical steroid, such as triamcinolone 0.025% ointment twice daily, until the irritation has improved is appropriate treatment. Petrolatum and petrolatum based emollients are best for frequent moisturization. The history given is classic for irritant dermatitis, and withholding treatment for one week along with patch testing is not necessary, unless the patient does not respond to conservative therapy. A biopsy is not indicated, as this is classic irritant dermatitis. Ketoconazole cream is an antifungal medications and bactroban is a topical antibiotic. This patient presentation is not typical for a fungal infection, and should not be treated with an antifungal unless a positive KOH or fungal culture has been done. The bactroban ointment can help prevent a secondary bacterial infection if fissures are present.

Upon funduscopic exam, you note marked hemorrhages in all quadrants and disc edema. The contralateral eye shows only mild hypertensive vascular changes. What is your diagnosis?
A. Macular degeneration
B. Retinal detachment
C. Central retinal artery occlusion
D. Cerebrovascular accident
E. Central retinal vein occlusion
The answer is E.
EXPLANATION: A central retinal vein occlusion is characterized by a “blood and thunder” fundus, with marked hemorrhages, tortuous vessels, and optic disc edema.

Which of the following medications is most likely to result in her blood pressure being elevated?
A. loratadine
B. simvastatin
C. pseudoephedrine
D. acetaminophen
E. lisinopril
The answer is C.
EXPLANATION: The correct answer is (B). Decongestants, such as pseudoephedrine, are known to increase blood pressure. Discontinuing pseudoephedrine and rechecking the blood pressure off of this medication may provide further information on the need for additional antihypertensive drug therapy. Loratadine, simvastatin, and acetaminophen are not known to cause secondary hypertension. Lisinopril is an ACE inhibitor used to treat blood pressure.

A 50-year-old male states that his eye is bothering him since yesterday. He complains of pain and redness. He states that he mowed his lawn yesterday and that it was windy outside. He attempted to irrigate the eye but still has significant irritation. He notes that it hurts to blink his eyes. What is the correct sequence of steps to treat this condition?
A. Anesthetic drops, irrigate the eye, and perform tonometry
B. Prescribe antibiotic cream and pain medication
C. Fluorescein stain, irrigate the eye, and prescribe antibiotic cream
D. Fluorescein stain and lid eversion
E. Anesthetic drops, fluorescein stain, and lid eversion
The answer is E.
EXPLANATION: The history suggests a retained foreign body to the upper eyelid. A fluorescein stain will reveal significant superficial vertical scratches on the cornea. An upper eyelid eversion must be done, to inspect for and remove the foreign body. If the practitioner is successful in removing the foreign body, relief of the irritation will be immediate.

A 40-year-old female presents to your office with symptoms of weight gain, hirsuitism, and easy bruising. Past medical and surgical history is noncontributory. She drinks one glass of wine on weekends and does not smoke cigarettes. She takes one multivitamin daily. Upon physical exam, you note facial fullness, central obesity, and thin skin. Which of the following is a valuable biochemical screening test for this patient that will aide in the diagnosis?
A. Dexamethasone suppression test
B. Radioactive iodine uptake
C. Glucose tolerance test
D. Cosyntropin stimulating test
The answer is A.
The correct choice is A, dexamethasone suppression test. This patient is presenting with classic signs and symptoms of Cushing’s syndrome. The dexamethasone suppression test is a simple test of the hypothalamic-pituitary-adrenal axis, and requires ingestion of oral dexamethasone at nighttime and a blood test in the morning hour, to measure the amount of plasma cortisol. Most patients with Cushing’s syndrome demonstrate a lack of normal axis suppression and present with a morning plasma cortisol level >5 mcg/dL. Choice B, radioactive iodine uptake, is used in patients with suspected thyroid disorders. Choice C, glucose tolerance test, is used in patients with suspected diabetes mellitus and in prenatal testing, to investigate gestational diabetes. Choice D, cosyntropin stimulating test, is used to investigate possible adrenal insufficiency. Choice E, plasma fractionated free metanephrines, is used in the diagnostic workup of pheochromocytoma.

A 62-year-old male presents with complaints of numbness in his hands and feet, with occasional foot drop, memory disturbance, fatigue, paleness, anorexia, nausea, and weight loss. He has a known history of diabetes and hypertension. Which of the following conditions is most likely responsible for these symptoms?
A. Autonomic neuropathy
B. Chronic renal failure
C. Diabetic polyneuropathy
D. Guillain Barre syndrome
E. Middle cerebral artery occlusion
The answer is B.
EXPLANATION: Chronic renal disease is associated with functional disturbances in all organ systems, including the central nervous system. Renal disease promotes CNS complications including neuropathies and neuromuscular irritability, along with systemic symptoms. The symptoms are typically progressive if the underlying renal disease is not addressed. Although other conditions promote similar neuropathies, such as diabetes, they are differentiated by the level of involvement, progression, and associated symptoms. With Guillain Barre, an acute polyradiculoneuropathy would be expected to progress, and have associated weakness. Cerebrovascular accidents are not typically accompanied by generalized systemic symptoms, and a middle cerebral artery occlusion would be expected to have contralateral hemiparesis and hemisensory deficit.

Two days following an uneventful 4-vessel CABG, a 57-year-old man develops a sudden onset of lightheadedness and palpitations. His vital signs are stable, and physical examination demonstrates no abnormalities. Given the results of his EKG, as shown (Figure 2)-a. flutter, which of the following is the most appropriate next step in management?
A. Direct-current cardioversion
B. Nitroglycerin patch
C. Digoxin 0.125 mg PO daily
D. Neurology consult
The answer is A.
EXPLANATION: Among the choices offered here, choice A is the most appropriate next step in management of a patient with new onset atrial flutter, as determined by EKG; it most effectively converts most patients to normal sinus rhythm. Choice B is inappropriate, as the patient is not demonstrating angina pectoris, and the EKG does not demonstrate evidence of ischemia or infarction. Choice C is inappropriate, as it is the least effective agent for slowing the ventricular response when compared to beta blockade or calcium channel blockers, all of which act by blocking the AV node (digixon may occasionally convert atrial flutter to atrial fibrillation). Choice D is inappropriate, as the patient’s symptoms of lightheadedness do not stem from neurologic changes. Choice E is inappropriate, as the patient’s symptoms do not stem from vertigo.

A 22-year-old man is brought to the emergency department by paramedics after having sustained a single stab wound along the left sternal border at the fourth intercostal space. Upon arrival to the emergency department, he was hypotensive and tachycardic. The neck veins were distended and heart sounds were muffled. Which of the following interventions is the most appropriate first-line management of this patient?
A. Left tube thoracostomy
B. Pericardiocentesis
C. Fluid resuscitation
The answer is B.
EXPLANATION: Cardiac tamponade is classically described by the triad of jugular venous distension (JVD), arterial hypotension, and muffled heart sounds. In the emergency department, suspicion of this clinically entity is usually confirmed by ultrasonography and is acutely treated by pericardiocentesis, which will be diagnostic, therapeutic, and buy time until a definitive procedure can be done. A left tube thoracostomy may be indicated in this patient but would not relieve symptoms. Fluid resuscitation though applied to all trauma patients would help stabilize the patient until more therapeutic interventions could be completed. Immediate intubation, even if indicated, would require a prophylactic tube thoracostomy to prevent the development of tension pneumothorax in the event of an unrecognized lung injury. Emergency thoracotomy will relieve the signs and symptoms associated with cardiac tamponade and allow for repair of any underlying cardiac injuries.

A 7-year-old is diagnosed with an acute case of hematogenous osteomyelitis accompanied with fever and leukocytosis. Based on your knowledge of the disease, which bone is most likely to present with the infection?
A. Feet
B. Hands
C. Long bones
The answer is C.
EXPLANATION: Fortunately, hematogenous osteomyelitis is not common in children, but when it does occur it primarily is found in the long bones. The femur, tibia and humerus are the most typical locations for osteomyelitis in children. The highly vascular metaphysis of long bones contribute to the potential for hematogenous spread of the implicated pathogen. Osteomyelitis can occur at any of the locations mentioned in the answer choices given, but at a significantly lower rate than in the long bones. The rate of occurrence at several selected locations is given below:
Feet – 9%
Femur 25%
Hands – 6%
Humerus – 13%
Pelvis – 8%
Radius/ulna – 6%
Tibia/fibula – 28%
Vertebrae – 2%

Which of the following is a tumor of bronchial origin that is known to grow rapidly and have diffuse metastases at the time of diagnosis?
Small cell lung cancer is a fast-growing, rapidly spreading form of lung cancer. Although the cells are small, they grow very quickly, metastasize to many parts of the body, and form large tumors. At the time of diagnosis, tumor spread is presumed. The growth and spread is considered much faster than that of non-small cell lung cancers. Staging is also different, utilizing a two-stage system based on the extent of spread.

A 58-year-old man is in the hospital postoperative day 3 after a laparoscopic right colon resection. Your morning labs reveal a serum potassium level of 2.9 mEq/L (normal 3.5-5.0 mEq/L) despite aggressive potassium replacement during the previous shift. At this time you should check which of the following laboratory values?
A. MagnesiumB. CalciumC. PhosphorousD. Sodium
The answer is A.
EXPLANATION: Hypokalemia is a common electrolyte disturbance in surgical patients. It can be caused by enhanced losses, hyperaldosteronism, inappropriate replacement, and intracellular shifts caused by alkalosis. Symptoms of hypokalemia may include constipation, neuromuscular weakness, diminished tendon reflexes, paralysis, and distinctive electrocardiographic changes. Concomitant deficiencies in magnesium can contribute significantly to the development of hypokalemia as well as hypocalcemia. In the surgical patient with persistent hypokalemia refractory to potassium administration, one should check magnesium levels and correct as appropriate.

Symptoms of hypokalemia may include :
constipation, neuromuscular weakness, diminished tendon reflexes, paralysis, and distinctive electrocardiographic changes

Mechanism of action of angiotensin-converting enzyme (ACE) inhibitors in controlling blood pressure and preventing or slowing kidney damage?
ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, thereby interrupting the renin-angiotensin-aldosterone system, which regulates blood pressure. The glomerular efferent arteriole dilates, given the decreased stimulus from angiotensin II to constrict. This lowers pressure in the glomerulus by lowering resistance to outflow. This effectively results in a decrease in GFR, resulting in increased serum creatinine and potassium levels. However, these changes are not necessarily indications to discontinue the ACE inhibitor. Usually, the creatinine increases 0.2 to 0.4 mg/dL and then levels out. Monitoring serum creatinine and potassium levels is indicated. If only mild increases occur and stabilize, or if there are no changes, the ACE inhibitor can, and should, be continued so that the patient derives the beneficial effect of the decline in pressure within the glomerulus, which will slow down the progression of CKD.

A 4 year old male presents with a fever for 5 days. His highest temperature was 39.4C. His mother brings him to the ED because she noticed this morning that his palms and soles were red. Now, there is blotchy erythema on the trunk with bulbar conjunctivitis and diffuse erythema on the tongue and prominent papillae. CBC shows leukocytosis. What is the appropriate management of this patient?
A. Hospitalization and IvIg
B. Hospitalization ad IV antibiotics
C. Outpatient antibiotics x 10 days
The answer is A.
EXPLANATION: This patient is exhibiting classic signs and symptoms of Kawasaki Disease. Complications of Kawasaki Disease include coronary artery aneurysms, myocarditis, myocardial ischemia or infarction, and stroke. Recommended treatment is hospitalization to monitor for complications and administration of IvIg with aspirin

What is the most appropriate management for the lesion shown, which is noticed on a 50-year-old female? Pic-melanoma
A. punch biopsyB. imiquimod cream 3x week C. excision with 1 cm margin D. cryotherapy
he answer is C.
EXPLANATION: The lesion is asymmetric with irregular margins. The optimal treatment of this lesion would be excision with 1 cm margins. A punch biopsy would only be performed if excision cannot be performed. Cryotherapy would destroy the lesion and prohibit a diagnosis and staging.

Assuming that a patient has maintained a normal baseline creatinine of 1.0 mg/dL with a normal glomerular filtration rate (GFR) of 100 mL/min, which of the following indicates a more significant change in the GFR?
A. increase in creatinine from 1.0 to 2.0 mg/dL
B. increase in creatinine from 2.0 to 4.0 mg/dL
C. increase in creatinine from 4.0 to 8.0 mg/dL
The answer is A.
EXPLANATION: GFR describes the amount of blood passing through the kidneys per minute. There is an inverse relationship between GFR and serum creatinine. In a patient with normal renal function, doubling of the serum creatinine represents a loss of approximately 50% of GFR. Using this information, the loss of GFR can be estimated from changes in the serum creatinine. For example, assume normal creatinine levels of 1.0 mg/dL and normal GFR of 100 mL/min. A doubling of the serum creatinine from 1.0 mg/dL to 2.0 mg/dL represents an approximate reduction in GFR from 100 mL/min to 50 mL/min (50% of GFR has been lost). Each additional doubling of the creatinine decreases the remaining GFR by approximately one half. When renal function is severely impaired, large increases in the creatinine (ie, from 8.0 to 16.0 mg/dL) represent only small decreases in GFR (from about 12 to 6 mL/min). This example emphasizes the importance of detecting increases in serum creatinine early. However, serum creatinine level does not become abnormal until ~25% of renal function is lost. Therefore, other methods of estimating GFR are more useful in detecting early decreases in GFR.

What is the appropriate first line treatment of lyme disease in a non-pregnant adult female with erythema migrans and no other symptoms of lyme disease and no known drug allergies?
In patients over the age of 9 exhibiting skin or joint manifestations of lyme disease, the first line treatment is Doxycycline 100 mg bid. Patients less than 9 or those who are allergic to Doxycycline should be treated with amoxicillin. Erythromycin is fourth line treatment for all age groups. Ceftriaxone is first line for patients with nervous system involvement.

A 46-year-old female complains of heartburn, steatorrhea, and a 20-lb weight loss. She was diagnosed with a solitary ulcer in the duodenal bulb, but it has been refractory to treatment. Imaging reveals the tumor but no hepatic metastasis. What is the recommended treatment in this patient to cure the disease?
A. Oral proton pump inhibitorsB. Resection of the entire duodenumC. Resection of the tumor
The answer is C.
EXPLANATION: The recommended treatment to cure localized disease in patients with Zollinger-Ellison syndrome is resection of the gastrinoma, before hepatic metastasis spread has occurred.

Which of the following supplements should the health care provider recommend that she take before conception and during early pregnancy for the prevention of neural tube defects in the fetus?
The answer is E.
EXPLANATION: Folic acid or folate (0.4 mg daily) has been shown to reduce the incidence of neural tube defects in offspring, especially when begun in the preconceptional period.

A patient presents to your office claiming that the FBI is trying to poison him. What would these types of beliefs be called?
A. somatic delusion
B. delusion of persecution
C. illusion
D. delusion of grandeur
E. hallucination
The answer is B.
EXPLANATION: Patients who have delusions of persecution often feel that people are taking pictures and tape recording them. Patients often believe that external agencies or relatives are attempting to harm them.

Your supervising physician asks you to advise him which finding is least likely to be suggestive of a thyroid malignancy in your 49-year-old female with a small palpable thyroid nodule. Which of the following choices would be least likely to suggest malignancy in this patient?
A. ultrasound showing lesion with microcalcifications
B. ultrasound showing a lesion of > 1 cm
C. hot nodule on 123I uptake scan
D. ultrasound showing a solid lesion
The answer is C.
EXPLANATION: The correct answer is (C). A hot nodule, which is a hyperfunctioning thyroid nodule, suggests a benign etiology. The other choices, including ultrasound findings of microcalcifications, solid lesions, and lesions > 1 cm, should increase your index of suspicion for possible malignancy. Cold nodules are nonfunctioning thyroid nodules, which should increase your suspicion, especially in combination with suspicious ultrasound and/or clinical examination findings.

Macrocytes are present on the peripheral smear and result from
failure of nuclear maturation commonly secondary to vitamin B12 or folate deficiency.

Which of the following is the primary function of pulmonary surfactant?
prevent the collapse of small lung alveoli–Because of their small size, many lung alveoli are prone to collapse. Pulmonary surfactant contains a high concentration of amphipathic phospholipid molecules, which lowers the surface tension of alveoli. According to the law of Laplace, a reduction of surface tension reduces the collapsing pressure on small alveoli and allows them to remain open. Pulmonary surfactant production does not typically begin until the 24th week of gestation; hence, an infant born before this time is at great risk for having collapsed alveoli.

A 28-year-old man has a positive HIV ELISA and Western Blot but has never had an opportunistic infection. Of the following laboratory parameters, which, if present, is consistent with a diagnosis of AIDS in this man?
The answer is A.
EXPLANATION: Persons with a CD4 count less than 200/mL or a CD4 percentage below 14% are now included in the Centers for Disease Control and Prevention category of “definitive AIDS diagnoses with laboratory evidence of HIV infection.” Persons with HIV-AIDS may have positive herpes titers or depressed platelet or white blood cell counts, but these are not diagnostic of AIDS in the absence of symptoms.

What is the most common cause of pneumothorax in a healthy patient?
Rupture of a bleb is thought to be more relevant to young, thin men, and also patients who have a family history of them, and smoking.

A 36-year-old male is brought to the emergency department in handcuffs, after he sustained a laceration to his left leg while trying to outrun the police. Apparently, he was driving a stolen car when he was pulled over for speeding. Upon talking with him, you learn that he has been in jail twice before for robbery. During the history and physical exam he appears callous and impulsive. What is the most appropriate classification for this personality disorder?
A. Antisocial
B. Avoidant
C. Narcissistic
D. Paranoid
The answer is A.
EXPLANATION: Antisocial personality disorder consists of clinical findings that include selfishness, callousness, promiscuousness, impulsive behavior, and an inability to learn from experience and legal problems. Avoidant personality disorder presents clinically as someone who fears rejection, overreacts failure, has poor social endeavors, and low self-esteem.

Disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention.
Narcissistic personality

Disorder would include defensiveness, being overly sensitive, secretive, suspicious, and hyper-alert, and having a limited emotional response.
Paranoid personality

Disorder would include being shy, introverted, withdrawn, and avoiding close relationships.
Schizoid personality disorder

A 30-year-old woman delivers a viable 7 pound 6 ounce female infant by normal spontaneous vaginal delivery. The infant was delivered and held below the introitus. The infant was dried, stimulated, and apgars were assigned. The cord was then clamped and the infant was placed on the maternal abdomen. Which of the following is a complication that can arise from this?
A. Hypovolemia
B. Hyperbilirubinemia
C. Hypoglycemia
The answer is B.
EXPLANATION: In a normal delivery, after the infant is delivered through the introitus it should not be held below it; excessive fluids can be passed to the infant, resulting in increased hematocrit and hemoglobin, which will hemolyze and cause hyperbilirubinemia.

A 70-year-old man, with a history of HTN and aortic valve replacement 3 months ago, presents with complaints of arthralgia, myalgia, anorexia, fatigue, and weight loss over the last month, with recent dyspnea on exertion and lower extremity edema. Vital signs are as follows: Temperature 38°C, BP 102/64, P 98, RR 20. On physical exam, a new high-pitched, blowing, decrescendo diastolic murmur is noted along the left lower sternal border. Two separate blood cultures are positive for S. aureus, and found to be methicillin-resistant. A transesophageal echocardiogram demonstrates a paravalvular abscess. Which of the following is the most appropriate therapy in the management of this patient?
A. IV vancomycin
B. IV vancomycin, IV gentamicin, and PO rifampin with surgical treatment
C. IV amphotericin plus flycytosine, and surgical treatment
The answer is B.
EXPLANATION: In patients with prosthetic valve infection with methicillin-resistant S. aureus, the treatment of choice is IV vancomycin for 6 to 8 weeks, plus IV or IM gentamicin for the initial 2 weeks secondary to nephrotoxicity, and PO rifampin for 6 to 8 weeks, with susceptibility to gentamicin determined before initiation of rifampin. Surgical therapy decreases mortality in patients with S. aureus endocarditis, from over 70% with medical therapy alone to 25%, and should be considered in patients with paravalvular abscesses and symptoms suggestive of moderate to severe refractory congestive heart failure. Therefore, choice B is the most appropriate next step in the management of this patient. Choice A does not offer sufficient coverage for methicillin-resistant S. aureus. Choice C is appropriate therapy for infective endocarditis when the causative organism is Candida. Outpatient antibiotic therapy is only appropriate in patients who are stable, without clinical or echocardiographic findings to suggest complications, and IV Ceftriaxone is not appropriate for the treatment of methicillin-resistant S. aureus prosthetic valve endocarditis. Choice E is appropriate therapy for pencillin-susceptible streptococci, such as S. bovis.

A 45-year-old male presents to your office complaining of severe unilateral eye pain with some photophobia for one day. He denies any history of trauma. On examination and with staining, you notice a dendritic lesion to the cornea, and an otherwise normal examination. Which of the following medications would be contraindicated in this patient?
A. atropine ophthalmic drops
B. azelastine ophthalmic drops
C. levofloxacin ophthalmic drops
D. prednisolone ophthalmic drops
The answer is D.
EXPLANATION: This patient has herpes simplex keratitis is an important cause of ocular morbidity. The ability of the virus to colonize the trigeminal ganglion leads to recurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency. The dendritic (branching) ulcer is the most characteristic manifestation. More extensive (“geographic”) ulcers also occur, particularly if topical corticosteroids have been used. Ophthalmic corticosteroids in cases of suspected herpes simplex keratitis are contraindicated.

You are reviewing laboratory results on a 60-year-old male from 2 days prior and note that the patient’s potassium was 5.6 mEq/L but otherwise his BMP is normal. You speak to the patient on the phone; he states he feels fine. Which of the following medications would most likely be responsible for the abnormal potassium?
A. clonidine
B. enalapril
C. hydralazine
he answer is B.
EXPLANATION: Hyperkalemia is a potential adverse reaction of ACE inhibitors such as enalapril. ACE inhibitors should be suspected as a cause of hyperkalemia and may require discontinuation.

A 29-year-old woman comes in for evaluation of “panic attacks.” She has no history of anxiety or depression. She says that during these episodes, which have been getting more frequent and more severe over the past month, she perspires heavily, feels highly anxious (“as though the end is coming”), and as if her heart is “going to jump out of my chest.” Recently she has also begun experiencing headaches during these attacks. Her best friend told her that her face gets really “blotchy” during the attacks and then “awfully red” afterwards. Her examination today is remarkable only for blood pressure of 160/100. What is the most sensitive test for diagnosing her condition?
A. plasma fractionated free metanephrines
B. serum chromogranin A
C. serum thyroid stimulating hormone
he answer is A.
EXPLANATION: The plasma fractionated free metanephrine test is the most sensitive test for a pheochromocytoma which this woman’s symptoms strongly suggest. Serum chromogranin A (B) is elevated in about 90% of patients and its level correlates with tumor size. Serum TSH (C) would not be appropriate since the symptoms are not as suggestive of hyperthyroidism as they are of pheochromocytoma. A positive plasma test should be followed by a urine fractionated metanephrine test and creatinine level (D). A urine toxicology screen (E) would be appropriate if cocaine use were suspected; however the symptoms more strongly suggest pheochromocytoma.

A 2-week-old male infant is being seen in the clinic for a profuse mucoid discharge from both eyes, with some associated tearing. On examination, you notice both eyes are hyperemic and the eyelids are red and swollen. Which of the following is the most likely cause of this patient’s ophthalmia neonatorum (conjunctivitis in the newborn)?
Chlamydial infections are the most common cause of conjunctivitis in newborns in developed countries. Other causes of ophthalmia neonatorum include reactions to silver nitrate prophylaxis, other bacterial infections such as gonococcal or staphylococcal, or viral organisms such as adenovirus or echovirus. Chlamydia trachomatis causes conjunctivitis and pneumonia in neonates. Treatment for chlamydial conjunctivitis should be with systemic erythromycin to treat the conjunctivitis and as prophylaxis against pneumonia.

A 59-year-old female with history of non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and chronic kidney disease (CKD) returns for follow-up of her labs. You note that she her GFR has decreased from 40 to 36 ml/min/1.73m2. What stage of chronic kidney disease is she currently?
A. 1
B. 2
C. 3
D. 4
E. 5
The answer is C.
EXPLANATION: There are five stages of CKD. Stage 3 Chronic kidney disease is referred to as a moderately decreased GRF between 30-59 ml/min/1.73m2. All other choices reflect different ranges of GRF above or below stage 3.

A 21-year-old female presents to clinic complaining of mild, low abdominal ache and intermittent dysuria. She denies N/V/D, and she is sexually active and uses condoms some of the time. Her LMP was 10 days ago, and she is a G0P0. Physical exam reveals a healthy female in no acute distress. Vitals are as follows: P 70, BP 120/80, T 99.9°F. Lungs are clear, CV RRR, abd soft non-tender, + BS. Pelvic exam reveals normal external genitalia, scant discharge, moderate cervical motion tenderness, and no adnexal masses. What is her most likely diagnosis?
A. Tubo-ovarian abscess
B. Gastroenteritis
C. Ectopic pregnancy
D. Cervicitis
E. Pelvic inflammatory disease
The answer is E.
EXPLANATION: Suspicion for PID should be very high in a young, healthy, and sexually active woman with cervical motion tenderness. She is not spotting and just menstruated, making ectopic pregnancy much less likely.

A sample of cervical mucus from a woman who desires pregnancy is dried on a slide and viewed under a microscope shows a fern-like pattern. This pattern indicates that the woman is most likely in which of the following states?
A. Menstruating
B. Ovulating
C. Pregnant
D. Postmenopausal
E. Post-ovulation
The answer is B.
EXPLANATION: Cervical mucus ferning is typical of ovulation or an anovulatory cycle where no progesterone has inhibited the ferning pattern.
During menstruation (A), any mucus would be obscured by blood. During pregnancy (C) and following ovulation (E), circulating progesterone causes the mucus to become thick and crumbly. The comparative lack of estrogen postmenopausally (D) also means that any cervical mucus will not fern.

A patient with severe hemophilia A is brought into the emergency department following an automobile accident. Concern is for hemorrhage. What is the best intervention to raise factor VIII levels to hemostatic levels?
A. Fresh frozen plasma
B. Cryoprecipitate
C. Recombinate
D. DDAVP (desmopressin)
E. EACA (aminocaproic acid)
The answer is E.
EXPLANATION: While fresh frozen plasma and cryoprecipitate have been used in the past for hemophilia A hemostatis, volumes may be too large or unable to reach levels to achieve hemostasis in severe hemophilic A patients. Recombinate is a commercial lyophilized factor VIII concentrate that can case factor VIII levels to reach hemostasis in smaller volumes, and do not have the disadvantages of plasma or cryopreciptate. DDAVP is not used in severe hemophilics. EACA is used to enhance hemostasis, but is not able to achieve initial hemostasis seen with recombinate therapy.

A 32 year-old obese woman presents to the clinic complaining of swelling, warmth, and redness of her left lower extremity. Doppler ultrasound confirms a deep venous thrombosis is the greater saphenous vein. Which of the following best describes the most likely pathophysiology underlying her thrombophilia?
A. Antithrombin deficiency
B. Increased plasma prothrombin
C. Protein C deficiency
D. Protein S deficiency
E. Resistance to activated protein C
Factor V Leiden is a common genetic mutation that results in resistance to activated protein C.
Increased plasma prothrombin concentration results from a prothrombin gene mutation (B), while deficiencies of antithrombin (A), protein C (C) and protein S (D) are rarer causes of prothrombotic states and are not directly associated with factor V Leiden mutation which is the most common cause of thrombophilia in this clinical scenario

A 30-year-old healthy female’s labs return showing an HDL of 28 mg/dl, LDL of 132 mg/dl, and total cholesterol of 185mg/dl. She is concerned due to a family history of coronary artery disease (CAD) on her father’s side in his 60s. She denies tobacco use. Her blood pressure is 108/50, P-64. She requests advice on what she can due to increase her HDL. What do you advise her?
A. atorvastatin
B. cholestyramine
C. ezetimibe
D. gemfibrozil
E. exercise
The answer is E.
EXPLANATION: The correct answer is (E). This patient is at very low risk of CAD based on the 10-year Framingham projections. Based on her < 1%, 10-year risk drug therapy is not indicated. Exercise has been shown to increase HDL. HDL is lower in patients who have a sedentary lifestyle or are obese. Her LDL may also be reduced with exercise, weight loss, and dietary modifications.

Which of the following is the appropriate treatment for acute Clostridium tetani infection?
tetanus immune globulin, tetanus toxoid, and flagyl—EXPLANATION: Clostridial tetani infection is a vaccine-preventable disease that results in approximately 50 cases/yr in the United States. Even with modern medical resources, one of four or one of five patients with generalized tetanus dies. Almost all cases occur in individuals who are not properly immunized. Sixty percent of cases occur in older adults for whom immunity has waned. Tetanus presents in different forms including generalized, localized, cephalad, and neonatal. Generalized is the most common and symptoms include mood changes, trismus, diaphoresis, dysphagia, and drooling. Later symptoms include painful flexion and adduction of the arms and pain with extension of the legs. Convulsions and spasms are possible, along with a variety of autonomic symptoms. Treatment includes airway protection, benzodiazepines for muscle spasm, tetanus immune globulin immediately, and three doses of tetanus toxoid given by the standard schedule. Metronidazole has been demonstrated to be the most effective antimicrobial. Labetalol may be used for catecholamine-induced hypertension but the patient must also be monitored for hypotension and bradycardia

A 50-year-old male presents to your office with symptoms of weight gain and easy bruising. He is currently being treated for hypertension. No surgical history is noted and family history is noncontributory. He does not drink alcohol. Upon questioning, he also notes some difficulty with climbing stairs. He has had to use the railing more often than in the past. A photo of the patient is shown below. Which of the following blood hormones hormone would most likely be found to be in excess?
A. Renin
B. Cortisol
C. Testosterone
D. Antidiuretic hormone
E. Thyroid stimulating
The answer is B.
The correct choice is B, Cortisol. The reader must first consider Cushing’s syndrome as the diagnosis for this patient. The clinical manifestations of Cushing’s syndrome are noted in this patient, and include easy bruising, proximal muscle weakness, pinkish-purple wide striae, weight gain, and central obesity. These findings are related to the excess Cortisol present in the plasma of these patients. In addition, hypertension is found in 75 to 85% of patients with Cushing’s syndrome. Choices A, rennin, and C, testosterone, are noted to be low or normal in patients with Cushing’s syndrome. Choice D, Antidiuretic hormone, is lacking in patients with diabetes insipidus. Choice E, thyroid stimulating hormone, is an anterior pituitary hormone that is essential in thyroid stimulation.

Which of the following medications is considered to be safest for treatment of hyperlipidemia in pregnancy?
Colesevelam (WelChol) is considered a Category B pregnancy risk. Both lovastatin and rosuvastatin (statins) are considered Pregnancy Category X and should be avoided in pregnancy. Ezetimibea and fenofibrate are both Pregnancy Category C.

Unicameral or simple bone cysts typically occur in what age group?
nicameral or simple bone cysts are fluid filled cysts with a fibrous lining that typically occur before the age of 20. Approximately 80% of these cysts occur in the proximal humerus or the proximal femur. The patients with this condition may present with pain, a limp, diminished use of a limb, or a pathologic fracture. Some unicameral bone cysts are found in asymptomatic patients incidentally on radiographs taken for another reason. Radiographic findings often include a lesion that involves the full diameter of the bone in the region of the metaphysis or metadiaphysis. Treatment is usually conservative since all such cysts will eventually resolve spontaneously with skeletal maturity. Symptomatic cysts are often aspirated and injected with methylprednisolone with some benefit. Activity level may need to be modified to decrease the chance of a pathologic fracture

Which of the following treatments will reduce hemolysis and increase hemoglobin levels for this patient?
A. Allogeneic stem cell transplant
B. Folic acid supplementation
C. Hydroxyurea
D. Prophylactic penicillinE. Pneumococcal vaccine
The answer is C.
EXPLANATION: Hydroxyurea directly reduces hemolysis and increases levels of fetal hemoglobin and reduces complications and transfusion frequency.
Sickle cell disease can be cured in 80% of individuals who receive a suitable transplant (A), but this procedure carries great risk and donors are difficult to identify.

A 42-year-old male presents with a history of low grade fever, cough, and myalgias for five days. He states that these symptoms began after a cave exploration trip along the Ohio River two weeks ago, and have since worsened. An x-ray reveals focal consolidation, and you suspect Histoplasmosis pneumonia. Which of the following is the first line treatment of choice?
A. Azithromycin
B. Doxycycline
C. Itraconazole
D. Terbinafine
The answer is C.
EXPLANATION: Histoplasmosis is caused by a dimorphic fungus, most commonly Histoplasma capsulatum (although other species exist). Within the United States, endemic areas include the Ohio and Mississippi river valleys. Additional areas of risk include other parts of North, South, and Central America, Africa, Mexico, and Central Asia. Large amounts of bird and bat droppings within specific soils promote the growth of the fungus, and exposure typically occurs during activities that disrupt the soil and aerosolize the spores. Depending upon the length and intensity of exposure, and the patient’s immune system and previous lung history, infections may range from asymptomatic to severe. Treatment is based upon the patient’s clinical picture, with mild to moderate disease being treated with oral antifungal agents.

An otherwise healthy 48-year-old male patient presents to your family practice clinic for a complete physical examination. He takes no medications. His vital signs, CBC, CMP, and TSH are normal. His fasting lipid panel reveals a total cholesterol of 280 mg/dL, LDL-C of 190 mg/dL. HDL-C of 38 mg/dL, and triglycerides of 151 mg/dL. What is your next step in his management?
A. Counsel him on target life style changes and recheck his lipid panel in three months and begin therapy if not to goal at that time.
B. Redraw his fasting lipid panel today, counsel him on target life style changes and begin therapy immediately if his follow up lipid panel is not to goal.
C. Counsel him on target life style changes, begin therapy with a statin at this time, and recheck his lipid panel in three months and adjust therapy.
The answer is C.
EXPLANATION: The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP-III) and subsequent revisions generally recommends that healthy male patients reach the following goals for cholesterol: low-density lipoprotein (LDL) of less than 100 mg/dL, high-density lipoprotein (HDL) of greater than 40 mg/dl in men and greater than 45 mg/dL in women, and triglycerides of less than 150 mg/dL. While counseling this patient on lifestyle changes is also important, it would be almost impossible for this patient to reduce his levels to goal without medication. A better strategy would be to combine lifestyle changes and initiate medication concurrently. Statins remain the first-line therapy for treatment of dyslipidemias.

The lower lid appears to be curled in toward the bulbar conjunctiva, with the eyelashes pointing inward. What is the name of this condition?
Aging causes a relaxation in the lower lid retractors, resulting in an entropion. This causes chronic irritation to the bulbar conjunctiva and corneal abrasions. Treatments include taping the lower lid to the cheek, botulinum toxin injection, or surgery.

A 64-year-old, nonsmoking male presents to the clinic with complaints of headache and dizziness. Initial labs reveal hemoglobin of 20.1 g/dl, hematocrit of 60%, and platelet count of 567,000.
Which of the following is the most likely diagnosis in this patient?
A. Acute myeloid leukemiaB. Chronic myeloid leukemiaC. Chronic obstructive pulmonary disease (COPD)
D. Multiple myeloma
E. Polycythemia vera
he answer is E.
EXPLANATION: Polycythemia vera often presents with complaints related to increased red blood cell mass, such as, headache, fatigue, and dizziness with elevated red blood cell mass with leukocytosis and/or thrombocytosis noted on CBC.
Chronic hypoxia from conditions such as COPD (C) can also cause elevated RBC mass, but is unlikely in this non-smoker. The patient lacks white blood cell abnormality symptoms (e.g., recurrent infections, elevated white count) making acute myeloid leukemia (A), chronic myeloid leukemia (B), or multiple myeloma (D) unlikely diagnoses.

An 8-year-old male presents to his primary care provider with the onset of a new rash, consisting of small, oval, discrete scaling plaques on his trunk, and a large red plaque with overlying thin, silvery scales in the gluteal cleft. Which of the following is a potentially important historical finding in this patient?
A. a recent history of group A strep infection
B. a family history of atopy
C. exposure to nickel in clothing
D. a personal history of allergies
The answer is A.
EXPLANATION: This is a classic guttate psoriasis. An acute strep infection is a known precipitating factor of guttate psoriasis. All patients need to be checked and treated for a strep infection. Atopy has no correlation with guttate psoriasis. It is not caused by contact with an allergen or irritant. It is also not caused by an allergic reaction.

A 70-year-old man with a history of hypertension, DM Type 2, and hyperlipidemia is seen for preoperative evaluation prior to left total knee replacement. On auscultation, a very soft high-frequency decrescendo early diastolic murmur is heard at the upper left sternal border. Utilizing isometric hand grip exercises, the murmur increases in intensity and can be heard radiating to the left sternal border and apex. Given the patient’s physical exam findings, which of the following is the most appropriate next step in the management of this patient?
A. Chest x-ray
B. Transesophageal echocardiogram
C. Holter monitor
D. Treadmill exercise stress test
E. Transthoracic echocardiogram
The answer is E.
EXPLANATION: Choice E, transthoracic echocardiogram, is a simple, sensitive and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in this patient. Choice A might be able to give evidence of cardiomegaly, but would not be sensitive enough to detect valvulopathy. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient who has no symptoms. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate for valvulopathy. In addition, a patient scheduled for left total knee replacement is unlikely to perform very well on a treadmill, thus the more appropriate test for preoperative evaluation, if necessary after transthoracic echocardiogram, would be a nuclear stress test.

A 22-year-old female presents to her obstetrical appointment at 39 weeks gestation. Her pregnancy to date has been uncomplicated. She is concerned that her infant may be larger than average, as her fundal height measures 41. On physical exam, her fetus is in a cephalic presentation, her cervix is soft and 1-cm dilated, and the fetus is at a -3 station. Her membranes are intact, she is not contracting, and her vitals are normal. She requests to be induced. For decreased risk of complication and optimal fetal outcome, when should she expect to be induced?
A. Now
B. At 40.5 weeks
C. 41.5 weeks
The answer is C.
EXPLANATION: In the absence of complication, the recommendation from ACOG is to wait for labor to occur. Large for gestational age is not an indication for induction in the absence of diabetes. Gestations greater than 42 weeks increase risk of fetal stillbirth.

A 24-year-old female presents with hyperpigmented macules on her cheeks, nose, and upper lip. They have been present for a couple of months. Her current medications include oral LoEstrin 24 Fe, cetirizine, and a multivitamin daily. What is the most likely diagnosis?
A. congenital nevus
B. melasma
C. post-inflammatory hyperpigmentation
D. café-au-lait macule
he answer is B.
EXPLANATION: The patient is experiencing melasma secondary to the use of oral contraceptives. This is a frequent cause of melasma. Melasma can also be precipitated by hormonal changes that occur during pregnancy. The condition will resolve upon discontinuation of the oral contraceptive. A congenital nevus is a nevus that presents within the first year of life. It is monitored in the same way as acquired nevi. They can be larger than acquired nevi, with only a slight increase in chance of malignant change over time. Post-inflammatory hyperpigmentation includes darker areas of pigmentation that can result after inflammation on the skin. Common causes include acne and atopic dermatitis. The hyperpigmentation will resolve over time. A Café-au-lait macule is a type of birthmark. It is usually light tan to light brown in appearance, and can vary greatly in size. They are usually benign, but can be associated with neurofibromatosis when more than six, with a diameter greater than 1.5 cm, are present.

A 2-year-old child presents to the pediatric office for a well child visit. The presence of which of the following risk factors places this child at high-risk for dental caries?
A. Child receives fluoride varnishes
B. Maternal smoking
C. Parents are of low socioeconomic status
The answer is C.
EXPLANATION: Factors that place children at high-risk for dental caries include the presence of white spots, cavities, or fillings on exam; mother/primary care giver having cavities; mother/primary caregiver being of low socioeconomic status (C); frequent between-meal sugar-containing snacks/beverages; or being put to bed with a bottle that contains sugary beverage. Fluoride (A) and fluoridated water (E) are protective. Maternal smoking (B) and single parenting (D) are not validated risk factors for dental caries.

A 32-year-old woman comes to your office for contraception. She has divorced her husband two weeks ago and is now dating several new boyfriends. She states she has started a new company just over a week ago and has sunk all of her money into it. Although she knows that businesses like hers have not done well lately, she is certain the market is about to shift in her favor. She states she must hurry and get back to work, that she hasn’t even had time to sleep for over a week. She speaks very rapidly and is pacing back and forth, seemingly unable to sit still. Conversation is difficult as she is easily distractible. She denies use of drugs or alcohol. She also denies any history of depression. What is her most likely diagnosis?
A. Bipolar disorder
B. Delusional disorder
C. Hypomanic episode
D. Manic episode
The answer is D.
EXPLANATION: The patient described is exhibiting behaviors consistent with a manic episode (D). Her symptoms have been present for over a week and are impairing her ability to function, so it is not hypomania (C). As she has no clear history of depression, it is likely that she will have a depressive episode in the future, which will allow for a diagnosis of bipolar disorder (A). She does exhibit grandiosity, but there are no clear delusions (B). Neurosis (E) is a more general term for cognitive distress including some form of anxiety.

How many types of primary osteoporosis are there?
Osteoporosis is a condition characterized by low bone mass, which increases the fragility of bones and leads to an increased risk of fracture. Osteoporosis is defined as being either primary or secondary and primary osteoporosis is further broken down into Type 1 and Type 2. Type 1 is related to decreased hormone levels – estrogen in women and testosterone in men, and is sometimes referred to as “postmenopausal osteoporosis.” It is six times more common in women and results in loss of trabecular bone. Type 1 primary osteoporosis often presents with vertebral compression fractures or fractures of the distal radius after a fall. Type 2 primary osteoporosis is sometimes referred to as “senile osteoporosis” and generally occurs in patients over 70 years of age. It is twice as common in women as men and occurs due to a diminished capacity to make new bone. The most common types of fractures found in this type of osteoarthritis are hip and pelvic fractures. Secondary osteoporosis occurs at a somewhat higher rate in men versus women and is caused by some other medical condition that produces bone loss. Common causes include long-term steroid use, various endocrine abnormalities, and neoplastic diseases such as multiple

Tumor necrosis factor (TNF) inhibitors are most often considered for use in patients with rheumatoid arthritis (RA) that does not respond to initial therapy. Which of the following screenings should occur before a patient is placed on this class of medication?
PPD Test—Patients being treated for rheumatoid arthritis with tumor necrosis factor (TNF) inhibitors are at increased risk for developing an opportunistic infection, such as tuberculosis (TB). It is recommended that screening for the presence of latent TB occur before TNF inhibitors are started. There is no specific indication to order a chest x-ray, allergy testing, liver function tests, or serum BUN and creatinine prior to initiation of TNF inhibitors.

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. Prior to examining him, you have reviewed his chart. Laboratory findings demonstrate troponins x 3, which are negative for myocardial ischemia. His EKG demonstrates diffuse ST segment elevations throughout. Which of the following physical exam findings would be most likely in this patient?
A. Roth spots
B. Splenic enlargement
C. Janeway lesions
D. Pericardial friction rub
The answer is D.
EXPLANATION: Choice D is the most likely finding, as this patient is exhibiting signs, symptoms, and EKG findings pathognomonic for acute pericarditis, which is likely infectious in the setting of a patient with HIV. A pericardial friction rub is heard best with the patient in a seated position, during expiration, and is frequently found in patients with pericarditis. Choice A B, C, and E are physical exam findings seen in acute bacterial endocarditis.

A 53-year-old man is taking a proton pump inhibitor for GERD symptoms, a beta blocker and a thiazide diuretic for hypertension, an SSRI for depression, and an over-the-counter NSAID as needed for aches and pains. He has developed gynecomastia and laboratory studies reveal an elevated prolactin level. If his hyperprolactinemai is due to one of his medications, which is the most likely cause?
A. the beta blocker
B. the NSAID
C. the proton pump inhibitor
D. the SSRI
The answer is D.
EXPLANATION: Many medications cause hyperprolactinemia, including SSRIs, tricyclic antidepressants, and antipsychotics. Hydralazine and methyldopa, but not beta blockers (A), may also raise prolactin levels; likewise opioids, but not NSAIDS (B). Cimetidine and ranitidine, but not proton pump inhibitors (C) are included among possible pharmaceutical causes. Thiazide diuretics (E) are not know to raise prolactin levels.

A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 1. His echocardiogram demonstrates normal LV systolic function and normal valvular function. He states that his symptoms began 3 days ago, and had gotten worse in the last 2 hours. What would be the most appropriate next step in management?
A. Morphine, oxygen, nitroglycerin sublingually, aspirin 81 mg PO X 4
B. Reassurance and anxiolytics
C. Diltiazem 20 mg bolus IVP over 2 minutes, then diltiazem 10 mg/h IV infusion
D. Aspirin 81 mg two tablets PO
E. Dopamine 5 mcg/kg/min
he answer is C.
EXPLANATION: Choice C is correct; as the patient is demonstrating atrial fibrillation with RVR, the appropriate therapy now that acute myocardial infarction has been ruled out, and as the patient is beyond the therapeutic window for immediate direct current electrocardioversion, is heart rate control. Choice A is inappropriate, as this is standard therapy for acute MI. Choice B can be used in patients suffering palpitations associated with panic attacks. Choice D is insufficient anticoagulation therapy. Choice E is inappropriate as the patient is not in need of pressor support.

A 22-year-old African American male presents to the emergency department with complaints of syncope, which occurred during intense physical exertion. He did not have symptoms prior to exercise, but states that he started having chest pain and shortness of breath right before the syncopal episode. Upon physical examination, he is afebrile, his pulse rate is 93, his respiratory rate is 16, and his blood pressure is 142/100. His lungs are clear, and a cardiovascular examination reveals a bisferiens carotid pulse and a loud S4. The electrocardiogram shows a normal sinus rhythm with ventricular hypertrophy, and q-waves in the septal leads. Which of the following tests is most useful to render an accurate diagnosis?
A. Echocardiography
B. Holter monitor
C. Exercise treadmill
The answer is A.
EXPLANATION: This patient presents with a history that is consistent with restrictive cardiomyopathy. While this is not a common diagnosis, it usually presents in younger males who experience symptoms while exerting themselves. Echocardiography is the best assessment test to determine wall motion and thickness of the myocardium. It can also assess any valvular disorders or areas of decreased wall motion abnormalities.

A patient exhibits air hunger and labored, deep respirations due to increased stimulation of the respiratory center in the brain. Which of the following is the most likely cause?
A. Congestive heart failure
B. Metabolic acidosis
C. Obstructive sleep apnea
D. Respiratory acidosis
The answer is B.
EXPLANATION: Kussmaul’s respiration is a form of respiratory compensation, and is most commonly associated with metabolic acidosis. During early acidosis, breathing may be rapid, but when advanced the breaths become deep, slow and labored with an urge to breathe described as “air hunger.” The other etiologies suggest other causes of breathing variation, such as tachypnea, apnea, and Cheyne-Stokes respiration.

Your patient is an eight-year-old boy who presents with a long history of aggression to people and animals, destruction of property, deceitfulness, and serious violation of the rules. He most likely can be diagnosed with:
A. Asperger’s syndrome
B. Attention deficit/hyperactivity disorder
C. Conduct disorder
D. Oppositional defiant disorder
The answer is C.
EXPLANATION: Conduct disorder (C) is defined as a persistent pattern of defiance, aggression towards people, animals, and/or property, and violation of the rights of others. Asperger’s (A) is on the autism spectrum, ADHD (B) involves lack of ability to focus, ODD (D) generally does not involve aggression and is not as long-standing, and mental retardation (E) involves decreased intellectual ability. Symptoms of conduct disorder may often overlap with ADHD as well as with bipolar disorder, but in conduct disorder the defiant attitude is constant and aggression is more prominent.

A 56-year-old male patient is diagnosed with prostatitis. Which of the following is the least appropriate antibiotic to prescribe in the family practice setting?
A. ceftriaxone
B. doxycycline
C. levofloxacin
D. trimethoprim-sulfamethoxazole (TMP-SMX)
E. All are appropriate antibiotics for this patient in this setting.
The answer is A.
EXPLANATION: The response to antibiotics in acute bacterial prostatis is usually prompt, perhaps because drugs penetrate readily into the acutely inflamed prostate Antibiotic selection should be guided by results of urine cultures and susceptibility results. Appropriate empiric antibiotics include a fluroquinolone (i.e.levofloxacin 500 mg once daily) or TMP/SMX (one double-strength tablet every 12 hours). Patients who are too ill for oral therapy or are septic on presentation should be hospitalized for initial parenteral treatment (intravenous quinolones with or without an aminoglycoside). Ceftriaxone would not be recommended as first-line.

A 56-year-old chronic alcoholic presents with signs of anemia. Laboratories reveal a moderate anemia with a hematocrit of 30% (45 to 62%) and a dimorphic population of red cells, one normal and one hypochromic. The MCV (mean corpuscular volume) is normal, the serum iron level is elevated, and the transferrin saturation is high. The diagnosis was made using which diagnostic study?
A. 24-hour urine for porphyrin
B. Bone marrow biopsy
C. Echocardiogram
D. Ferritin level
E. Liver biopsy
The answer is B.
EXPLANATION: Diagnosis of sideroblastic anemia is made by examination of the bone marrow, using Prussian blue staining and noting the presence of ringed sideroblasts, which are cells with iron deposits encircling the red cell nucleus. None of the other studies are useful in making this diagnosis.

inhibit the transpeptidation reaction leading to cell wall destruction
Beta lactam abx- ex- pcn

While seeing a 12-week-old baby girl for her well-child checkup, it is noticed that she has tearing from her left eye. There is a small reddened area that is swollen and she cries when it is touched. The swollen area is just below the medial inferior eyelid. There is also constant tearing from this same eye. Her mother says it just started about 2 days ago and is getting worse. What is the most likely cause of this problem?
A. blepharitis
B. conjunctivitis
C. dacryocystitis
he answer is C.
EXPLANATION: Dacryocystitis, whether acute or chronic, is usually secondary to bacterial infections. It presents as an acutely inflamed swelling and tender area over the lacrimal sac just medial and inferior to the inner canthus of the eye. Because the lacrimal sac is inflamed and blocked there is tearing and usually purulent discharge from the eye. There may also be an orbital cellulitis. Treatment consists of oral and topical antibiotics and warm compresses, and surgical drainage may also be indicated. After the acute episode and for chronic cases, surgical correction of the nasolacrimal obstruction is required. Anterior uveitis typically presents with pain, photophobia, blurred vision, and injection without exudates. Blepharitis is an inflammation of the lid margin that presents with crusty debris along the lashes. Unless there is a concomitant conjunctival infection, there is typically no injection noted.

A patient presents with clinical features of thrombotic thrombocytopenic purpura. They also have an associated diarrhea positive hemolytic uremic syndrome. Which is the best treatment option for this patient?
A. Aspirin and dipyridamole
B. Glucocorticoids
C. Plasma exchange
D. Splenectomy and prostacyclin
E. Supportive therapy and dialysis
The answer is E.
EXPLANATION: This patient has a diarrhea-associated hemolytic uremic syndrome with clinical features of TTP. D+HUS is associated with infectious etiologies, usually through food borne illnesses. Treatment consists of supportive therapy, treating the underlying infection, and dialysis if renal function warrants. All other therapies listed are used in the treatment of TTP or diarrhea negative HUS.

A 24-year-old woman comes to your office complaining of anxiety. The patient had witnessed a traumatic event 3 days earlier that made her feel fearful. She has not been able to tell her family about this experience. She now feels like she is numb and in a dazed, dreamlike state with poor concentration, and difficulty sleeping. She experienced a flashback of the event yesterday. What is the most likely diagnosis?
A. post-traumatic stress disorder
B. dissociative fugue
C. psychosis
D. acute stress disorder
The answer is D.
EXPLANATION: Acute stress disorder is characterized by experiencing or witnessing a traumatic event where the person felt threatened by death or injury or the people they witnessed. The person feels fearful and helpless. Symptoms usually occur within a month of the event, last 2 days, and resolve in a month. The person feels numb, has lack of awareness of surroundings, and sees everything in a dreamlike state. Sometimes they develop amnesia. Flashbacks or recurrent images can occur with acute stress disorder. Difficulty sleeping, poor concentration, anhedonia, irritability, and despair are associated with this disorder. If not treated at the early stages, the patient is at risk of developing PTSD.

A 37-year-old female presents to the office complaining of increasing heavy vaginal bleeding with her menses. CBC reveals an iron deficient anemia. Her pelvic exam is notable for a moderately enlarged uterus. A transvaginal ultrasound reveals a 3-cm leiomyoma and a 15-cm leiomyoma. The patient wishes to preserve her fertility. Appropriate management would include which of the following?
A. Expectant management aimed at pain reduction
B. Bilateral uterine artery embolization
C. Reduction of blood loss with combined oral contraceptives
D. Immediate hysterectomy
E. Gonadotropin-releasing hormone analog followed by myomectomy
The answer is E.
EXPLANATION: GRH causes a reversible hypogonadism, which reduces tumor size, makes surgical intervention safer, and reduces bleeding. The patient wishes to preserve her fertility, making embolization and hysterectomy non-viable options. COC do not significantly reduce bleeding, and do not regress the tumor for optimal surgical removal.

An Rh-negative, 5-year-old male child presents with acute onset of petechiae and purpura after an acute viral illness. In addition, he has episodes of epistaxis. Which of the following is a treatment option if his platelet count falls below 20,000/mm3, but he is not actively bleeding?
A. platelet transfusions
B. IV anti-D (WinRho SD) 50-70 mg/kg/dose
C. prednisone 2.4 mg/kg/24 hours x 2 weeks
D. splenectomy
The answer is C.
EXPLANATION: In patients with idiopathic thrombocytopenic purpura, treatment options should be initiated when platelet counts fall below 20,000, regardless of whether there is active bleeding or not. Without active bleeding the treatment options include prednisone 2-4 mg/kg/24 hours for 2 weeks; IV immunoglobulin 1 g/kg/24 hours for 1 to 2 days, or IV anti-D 50-75 μg/kg/dose for Rh-positive patients. Splenectomy is indicated for life-threatening bleeding. There is currently no indication for platelet transfusion and none of the above treatments are considered optimal, because in the majority of children, it will resolve on its own within 6 months.

You suspect that a 5-year-old patient has allergic conjunctivitis. Which of the following symptoms or signs would best support this diagnosis?
A. Itching
B. Fever
C. Preauricular adenopathy
The answer is A.
EXPLANATION: Allergic conjunctivitis is characterized by itching, tearing, redness, and chemosis, with itching being uncommon in other common forms of conjunctivitis (A). Fever (B) and sore throat (E) are more likely to occur in viral or bacterial conjunctivitis. Preauricular adneopathy (C) typically occurs in viral or chlamydial conjunctivitis.

A patient presents with a several year history of developing coarse facial features, prognathism, widely spaced teeth, and sleep apnea. Upon exam, you also note oily skin and high blood pressure. What is the most likely cause of this patient’s symptoms?
A. Pituitary adenoma
B. Pheochromocytoma
C. GHRH secreting hypothalamic tumor
The answer is A.
The correct choice is A, pituitary adenoma. The patient is presenting with classic signs and symptoms of acromegaly. This disorder is caused most commonly by a growth hormone secreting pituitary adenoma. On rare occasions, it has been caused by choice C, a GHRH secreting hypothalamic tumor. Choice B, pheochromocytoma, is a tumor of the adrenal glands that causes high blood pressure, but does not cause the classic body features of acromegaly. Choice D, adrenal carcinoma, and choice E, ectopic ACTH secretion, may cause Cushing’s syndrome, but not acromegaly.

A 65-year-old man presents to the clinic complaining of fatigue, weakness, paresthesias, and an unsteady gait. Physical exam reveals decreased vibratory sensation and lack of proprioceptive feedback, noted on Romberg testing. CBC reveals hemoglobin of 10.7 g/dl, hematocrit of 32.1% and MCV 117.6 fL. Which of the following is the most appropriate treatment?
A. Erythropoietin
B. Ferrous sulfate
C. Folic acid
D. Metformin
E. Vitamin B12
he answer is E.
EXPLANATION: The patient most likely has vitamin B12 deficiency, as evidenced by the macrocytic anemia and neurological signs and symptoms. The patient should be treated with vitamin B12.
Anemia secondary to chronic kidney disease (A) typically presents as a normocytic, normochromic anemia. Iron deficiency anemia (B) presents as a microcytic, hypochromic anemia. Folate deficiency (C) typically presents as a macrocytic anemia, but without the classic neurological symptoms consistent with vitamin B12 deficiency.

A patient describes a desire for close relationships and to be more successful at work. However, she views herself as being undesirable and inferior. Because of these feelings she avoids social activities and extra occupational projects out of fear of criticism, rejection, and embarrassment. Which diagnosis would best fit this description?
A. avoidant personality disorderB. borderline personality disorderC. histrionic personality disorde
The answer is A.
EXPLANATION: An individual with avoidant personality disorder differs from schizoid in that they desire interaction and closeness but are unable to overcome their deep seated self-beliefs and fears. They tend to be less impulsive and more stable than borderline personality disorder patients and have less of a need to be the center of attention than those with histrionic personality disorders.

Koplik spots are a differentiating diagnostic feature of which of the following viral exanthems?
A. rubellaB. measlesC. varicella
The answer is B.
EXPLANATION: Koplik’s spots, white lesions on the buccal mucosa, are characteristic of measles. The rash in measles usually presents as a red-brown rash starting with the head and moving caudally. It follows a 3- to 4-day prodrome consisting of fever, nasal drainage, conjunctivitis, and cough. Varicella may also present with mucosal lesions but they are vesicular on an erythematous base. Parvovirus, rubella, and Kawasaki disease generally do not have mucosal involvement.

white lesions on the buccal mucosa
Koplik spots seen in measles

A 35-year-old female presents to discuss non-permanent methods of birth control. She is a G3P2, PMH negative. She is a smoker. Which method of contraception would have the lowest risk profile for her?
A. Combination low dose pill daily
B. Injectable progestin monthly
C. Transdermal combination patch
D. Levonorgestrel intrauterine device
E. Copper intrauterine device
The answer is E.
EXPLANATION: A women who is over 35 and smokes is at high risk for cardiovascular complications. All choices except the copper IUD contain hormones, which may increase the risk of complications. The copper IUD is long term but non-permanent.

presents as a red-brown rash starting with the head and moving caudally. It follows a 3- to 4-day prodrome consisting of fever, nasal drainage, conjunctivitis, and cough.
measles

A father brings his son to the family practice clinic for a concern for coarctation of the aorta. The father was recently diagnosed with this disease, and he is concerned that his 5-year-old son may have it as well. What is the cardinal physical finding in coarctation of the aorta?
A. Decreased or absent femoral pulses
B. Systolic machinery-type murmur
C. Holosystolic murmur at the lower left sternal border
The answer is A.
EXPLANATION: Decreased or absent femoral pulses is the correct answer.

A systolic machinery-type murmur is classic for
Patent ductus arteriosus.

A holosystolic murmur at the lower left sternal border is most commonly seen with a
ventricular septal defect.

A thrill in the carotid arteries is associated w/
aortic stenosis

Which of the following is the most common congenital heart malformation?
Ventricular septal defect, a hole between the two ventricles, can be cyanotic or acyanotic based on the size of the defect, and accounts for 30% of cases of congenital heart disease.

consisting of a ventricular septal defect, overriding aorta, pulmonic/subpulmonic stenosis, and right ventricular hypertrophy, accounts for 10% of congential heart disease.
Tetralogy of Fallot

An embryonic malformation resulting in the aorta arising from the right ventricle and the pulmonary artery arising from the left ventricle.
Transposition of great vessels

A 16-year-old girl is brought to the emergency department by ambulance after reportedly ingesting “a bottle of aspirin.” Vital signs are temperature 37.8°C oral; pulse 94/min; respirations 30/min; blood pressure 100/68 mm Hg. What would you expect the blood gases to show that would confirm she had swallowed the aspirin?
A. anion gap metabolic acidosis with respiratory acidosis
B. nonanion gap metabolic acidosis with respiratory alkalosis
C. anion gap metabolic acidosis with respiratory alkalosis
The answer is C.
EXPLANATION: An acute salicylate overdose (greater than 150 mg/kg) will produce symptoms of salicylate intoxication. Chronic salicylate intoxication occurs with ingestion of greater than 100 mg/kg/day for at least 2 days. Salicylates affect most organ systems, leading to various metabolic abnormalities. Because salicylates are a gastric irritant, symptoms of vomiting and diarrhea occur soon after the overdose, which may contribute to the development of dehydration. Salicylates stimulate the respiratory center leading to hyperventilation and hyperpnea resulting in respiratory alkalosis and compensatory alkaluria. A characteristic feature of salicylate intoxication is the coexistence of a respiratory alkalosis with a widened anion gap metabolic acidosis.

A 14-year-old boy presents to the emergency department with acute scrotal pain and vomiting for the past 2 hours. His left testicle is in extreme pain and he states the pain started while playing basketball in gym class. On physical examination you find that the affected testicle is swollen, high-riding, tender and has an abnormal transverse lie. After confirming your diagnosis with a doppler ultrasound, what would be the management of this patient?
A. Local anesthesia and observation
B. Surgical exploration and orchidopexy
C. IV antibiotics
The answer is B.
EXPLANATION: Testicular torsion is most common between ages 12-18 with the classic presentation of abrupt and severe onset of pain with nausea/vomiting, swollen, tender, high-riding testis, and abnormal transverse lie. It is confirmed by Doppler ultrasound and emergent surgical exploration is indicated with an excellent rate of testicular salvage if symptoms are present <6 hours (B). Manual detorsion (E) and anesthesia can be given but definitive therapy is emergent bilateral orchidopexy. Oral or IV antibiotics (C) can be given to treat epididymitis pending cultures. Scrotal support, limitation of activity, and oral analgesics (D) are used in non-emergent torsion of the testicular appendage, which is confirmed on ultrasound. Local anesthesia and observation is not adequate treatment when time is critical to save the vascular supply to the testicle, this would risk necrosis (A)

A 32-year-old man who is HIV positive has a seizure. On presentation to the emergency department (ED) he is confused and unsure of what happened. His partner reports that he had been complaining of headache in the days preceding the event. CT scanning of the head demonstrates five peripheral contrast-enhancing lesions. What is the most likely diagnosis?
A. AIDS dementia complex
B. central nervous system lymphoma
C. cryptococcal meningitis
D. progressive multifocal leukoencephalopathy
E. toxoplasmosis
The answer is E.
EXPLANATION: The most common space-occupying CNS lesion in patients with HIV is toxoplasmosis. This condition may present with headache, focal neurologic deficits, seizures, and/or mental status changes. The typical appearance on brain imaging is that of multiple contrast-enhancing lesions in the periphery, particularly the basal ganglia. CNS lymphoma is more typically a single lesion. AIDS dementia complex presents a diagnosis of exclusion, without a characteristic appearance on imaging. The diagnosis of cryptococcal meningitis is made by examination of the spinal fluid, while PML imaging shows nonenhancing white matter lesions without mass effect.

The most common space-occupying CNS lesion in patients with HIV is
toxoplasmosis

A 54-year-old man presents to the emergency department with crampy abdominal pain, nausea, and vomiting. The patient has not passed gas or had a bowel movement for at least 10 hours. On examination, the abdomen is distended and there are high-pitched bowel sounds with rushes. A plain radiograph of the abdomen reveals cecal distension to 12 cm. What is the most appropriate definitive management for this patient?
A. Intravenous fluids
B. Nasogastric suction
C. Observation
D. Surgical exploration
The answer is D.
EXPLANATION: Massive distention of the cecum, as detected on plain radiograph, is typically seen in “closed loop” obstructions where the ileocecal valve is competent. When distention approaches 12 cm, there is an increased risk of perforation and/or gangrene. Expedient surgical intervention is indicated. Although observation with intravenous fluids and nasogastric decompression are important adjuncts to management, surgical exploration is the only way to rapidly address this emergent situation.

A 78-year-old Caucasian female has a 3-year history of stiffness and achiness of bilateral shoulders and hips. She has been tested for rheumatoid arthritis in the past and has been found negative. Multiple radiographs of her hips and shoulders are unremarkable. She admits that she was placed on prednisone for an allergic reaction and noted a temporary resolution of her symptoms. For the past two weeks she complains of increasing symptoms now involving her neck and pain in her jaw with chewing. Today she noticed that her scalp is sore when she brushed her hair on the right side. What test is the gold standard for diagnosis of this patient’s current symptoms?
A. ESR 60 mm/h
B. temporal artery biopsy
C. Elevated CRP
The answer is B.
EXPLANATION: The correct answer is (B). This patient has long standing symptoms of polymyalgia rheumatica (PMR) with current symptoms suggestive of giant cell (temporal) arteritis. Temporal artery biopsy is considered the gold standard for diagnosis of giant cell (temporal) arteritis. Patients with temporal arteritis may have an elevated erythrocyte sedimentation rate (ESR) or CRP, but this is not required for diagnosis. A color ultrasound of the temporal artery will sometimes show edema or stenosis of the affected artery but is not very sensitive for giant cell arteritis. MRA is used for diagnosis of larger arteries with vasculitis and not routinely used in the diagnosis of temporal arteritis.

Release of which of the following substances is triggered by pituitary growth hormone and promotes growth of other tissues in the body?
A. C-pepide
B. IL-I
C. IGF-I
The answer is C.
The correct choice is C, IGF-I or insulin like growth factor I. This growth factor leads to increased DNA, RNA, and protein synthesis, which leads to overgrowth of bone, soft tissue, and cartilage. Choice A, c-peptide, is a part of the prohormone of insulin. Choice B, IL-I or interleukin I, is an important cytokine that promotes cell activation. Choice D, thyroxine, potentiates the actions of growth hormone on tissues.

A 33-year-old G1P0 presents for evaluation of her inability to conceive a pregnancy for six months. She menstruates monthly. Her past medical history is significant for PID x 2, for which she was hospitalized for IV antibiotics. Her Chlamydia, GC, and pap smear are normal. When should a more comprehensive evaluation for her infertility begin?
A. Now
B. 6 months
C. 12 months
The answer is A.
EXPLANATION: A comprehensive work up should begin now, due to her advancing age and history of significant PID, which may require surgical treatment.

A patient with no history of treatment for primary syphilis presents with symptoms and signs consistent with secondary syphilis. The most common sign of secondary syphilis is
A. generalized lymphadenopathy
B. aseptic meningitis
C. alopecia
D. generalized maculopapular rash
The answer is D.
EXPLANATION: Secondary syphilis generally manifests itself a month or two after appearance of the primary chancre. Patients will complain of headache, fever, sore throat, and malaise and will exhibit generalized lymphadenopathy along with a maculopapular rash that begins at the sides of the trunk and later spreads over the rest of the body. The skin lesions may coalesce in warm moist areas, such as the perineum, and form large, flat-topped, pale papules termed condyloma lata. Skin and mucosal lesions are the most common signs of secondary syphilis. Aseptic meningitis and alopecia may also occur in secondary syphilis. Formation of granulomatous nodules (gummas) is not a feature of secondary disease, but rather is the hallmark of tertiary syphilis.

A 29-year-old man who is HIV positive has developed dark purple papular nonblanching lesions between the toes of his right foot. He has no other symptoms. Careful examination shows that this is the only area of involvement. His CD4 count is 150 cells/mL. Of the following, what is the most appropriate treatment?
A. alpha interferon
B. chemotherapy with daunorubicin, bleomycin, and vinblastine
C. intralesional vinblastine
he answer is C.
EXPLANATION: Kaposi sarcoma that is in a limited area of the skin may be treated with intralesional vinblastine or by simply observing it over time. Liposomal doxorubicin and alpha interferon are used for extensive or aggressive skin disease, while combination chemotherapy is used for visceral disease.

A 70-year-old male is being followed for his chronic lymphocytic leukemia. On prior examination, he was staged at Binet Stage A, with three cervical lymph nodes and one right axillary lymph node palpated. Six months later he is seen for follow-up, where he now has five palpable cervical lymph nodes and two left and one right axillary node. His lymphocyte count has risen from 12,500 to 18,300. What is the best therapy at this time?
A. Alemtuzumab
B. Chlorambucil
C. Continue monitoring
The answer is C.
EXPLANATION: This patient continues to remain in Binet Stage A, and therefore would not benefit from beginning any additional therapy. Monitoring should be continued. If they would develop 3/5 lymphoid regions of involvement (cervical, axillary, ileofemoral, splenomegaly, or hepatomegaly) or doubling of the lymphocyte count in less than six months, then adding additional therapy would be indicated. Fludarabine is first-line therapy for progressing CLL. Chlorambucil is the main alkylating agent used in CLL. Alemtuzumab is a monoclonal antibody specific for human CD52, found on most lymphocytes and useful in CLL treatment. Etoposide is used in patients who failed alkylator-based chemotherapy.

A two-year-old male presents with a noduleon the side of his index finger. His mother states that he has hadthis nodule on one prior occurrence during infancy, and it resolved onits own. What is the most likely diagnosis?
A. Digital fibroma
B. Juvenile xanthogranuloma
C. Molluscum contagiosum
D. Verruca vulgaris
The answer is A.
EXPLANATION: This child has a recurrent digital fibroma. It is a smooth, firm,pink nodule that occurs on the fingers and toes up through earlychildhood. Surgical excision is recommended so that the functionof the digit is not impaired.

A 4 year-old male presents to the emergency department with vomiting, severe abdominal pain, and diarrhea that occurred 2 hours after “getting candy from Grandma’s purse”. Which of the following medications did the child most likely ingest?
A. Cisplatin
B. Erythropoietin
C. Ferrous sulfate
D. Lisinopril
E. Vincristine
The answer is C.
EXPLANATION: Stage 1 of iron toxicity secondary to ferrous sulfate ingestion (C) is characterized by acute GI irritation; this is followed by a latent phase (Stage 2) that can then progress to systemic iron toxicity (Stage 3), that can progress to hepatic failure (Stage 4) or delayed sequelae (Stage 5). Cisplatin (A), erythropoietin (B), and vincristine (E) are parenterally administered and unlikely to be present in a patient’s purse. Lisinopril (D) toxicity consists of cardiovascular symptomatology (e.g., hypotension and tachycardia).

A 55-year-old woman with a history of mitral stenosis, secondary to rheumatic heart disease, presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that recently she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. Which of the following tachyarrhythmias is she most likely to demonstrate on EKG?
A. Ventricular tachycardia
B. Atrial flutter
C. Ventricular fibrillation
The answer is B.
EXPLANATION: Choice B is correct. As patients with mitral stenosis age, and their mitral stenosis progresses to moderate or moderately severe mitral stenosis (most commonly after their fourth decade), the incidence of atrial arrhythmias—including premature atrial contractions, paroxysmal tachycardia, atrial flutter, and atrial fibrillation—increases. Choices A, C, D, and E are less likely, given that they are ventricular arrhythmias.

A 28-year-old female presents with a gradual progression of fatigue and pallor over the last few months. Initial CBC results show a hemoglobin of 10.4 mg/dL, hematocrit of 32%, an MCV of 112 fL, and a reticulocyte count of 0.1%.
Which of the following is the most likely pathophysiologic mechanism responsible for her anemia?
A. Acute blood loss
B. Defective bone marrow/stem cell function
C. Defective DNA production D. Defective hemoglobin production
E. Increased destruction of red blood cells
The answer is C.
EXPLANATION: The patient most likely has an underlying vitamin B12 or folate deficiency resulting in macrocytosis (MCV of 112 fL).
Defective DNA production (C) results in failure of RBC maturation and macrocytosis (elevated MCV). Acute blood loss (A) would present more acutely and with normal hemoglobin, hematocrit, and MCV until hemodilution occurs and lowers the hemoglobin concentration and hematocrit. Defective bone marrow/stem cell function (B) tends to produce normocytic red blood cells. Microcytic, hypochromic anemia results from defective hemoglobin production (D). Hemolysis (E) is less likely than vitamin B12 and folate deficiency, but can be confirmed or ruled out through the assessment of the reticulocyte count (increased reticulocyte will increase the MCV and be inconsistent with a nutritional deficiency) and further hematologic labs as necessary.

A 58-year-old female patient has a history of cirrhosis. She undergoes a diagnostic endoscopy, which shows large varices. Which of the following medications is the most appropriate to reduce the risk of a first variceal hemorrhage?
A. Beta blocker
B. ACE inhibitor
C. Calcium channel blocker
D. Angiotensin receptor blocker
E. Alpha blocker
The answer is A.
EXPLANATION: The correct answer is a beta blocker. This is the recommended medication to reduce the risk of first variceal hemorrhage in patients with large or small varices, who either have variceal red wale marks or advanced cirrhosis.

Which of the following medications, used for the treatment of Tourette syndrome, has been associated with long-term extrapyramidal side effects?
A. Clonazepam
B. Clonidine
C. Haloperidal
D. Metoclopramide
E. Risperidone
The answer is C.
EXPLANATION: Haldol, a typical antipsychotic agent, has been shown to be effective for symptomatic treatment of patients with Tourette syndrome. Haldol blocks dopaminergic action and decreases psychomotor agitation. It is linked to a high frequency of extrapyramidal side effects, likely due to this action. It also has sedative properties within the limbic system. Other medications, such as atypical psychotics, benzodiazepines, alpha-2 agonists, and dopamine-blockers have been used for Tourette management. Each medication should be monitored for effectiveness and side effects, as other medications can cause extrapyramidal side effects, such as metoclopramide.

A 23 year-old male with cystic fibrosis inquires about the availability of treatments that can help improve his lung function. Which of the following treatments is most effective at reversing the pulmonary effects of cystic fibrosis?
A. Albuterol
B. Azithromycin
C. Inhaled hypertonic saline
D. Inhaled levofloxacin
E. Ivacaftor
The answer is E.
EXPLANATION: Ivacaftor (E) is the only treatment that restores function of the CFTR protein in cystic fibrosis patients with a G551D mutation thereby reversing the effects of the disease, approximately 5% of all cystic fibrosis patients have the G551D mutation. Albuterol (A) and hypertonic saline (C) are indicated to improve lung function and mucous clearance. Azithromycin (B) and inhaled levofloxacin (D) are used to treat chronic infection/colonization with pseudomonous.

A 42-year-old healthy male presents to the emergency department with the complaint of a progressively worsening sore throat, and difficulty swallowing over the past 48 hours. He also complains of a subjective fever, but denies any headaches, nausea, or vomiting. On exam, the patient is afebrile and in mild distress, with a presentation of leaning forward on the exam table. His TM examination is normal, there is no rhinorrhea, and the oropharynx is patent without signs of stridor. His lungs are clear, and he has a regular rhythm on cardiac exam. What diagnostic test is indicated for a definitive diagnosis?
A. Chest x-ray
B. Complete blood count (CBC)
C. Nasal bacterial culture
D. Soft tissue neck x-ray
E. CT scan of the neck
The answer is D.
EXPLANATION: This patient has a presentation that is consistent with acute epiglottitis. While ensuring that the airway is patent and the patient can maintain the airway, the first step in determining the diagnosis is a soft tissue neck x-ray, to determine inflammation to the epiglottis. While rare, epiglottitis can be from a bacterial infection, and can be quite serious and sometimes fatal.

A 4-month-old male presents for a well child check. He is healthy and the mother feels that the child is eating and growing well. On examination, there is no evidence of cyanosis. The peripheral pulses are normal and equal. There is a medium-pitched harsh pansystolic murmur that is heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split. What is the most likely finding on ECG?
A. Left ventricular hypertrophy
B. Normal ECG
C. Right axis deviation
D. Supraventricular tachycardia
E. Sick sinus syndrome
The answer is B.
EXPLANATION: In this scenario the patient most likely has a small left-to-right shunt of a ventricular septal defect, given the clinical exam findings. The ECG is most frequently normal in a patient with a small ventricular septal defect. If the patient had a large left-to-right shunt left ventricular hypertrophy would be a possibility. The other choices are not commonly seen on ECG when a ventricular septal defect is present.

harsh pansystolic murmur that is heard best at the left sternal border at the fourth intercostal space. There is no heave or thrill present. The murmur radiates over the entire precordium and the S2 is physiologically split.
ventricular septal defect

A 58-year-old female two days status-post coronary artery bypass graft (CABG) surgery is being treated with heparin to prevent thrombosis. Her routine CBC reveals a hemoglobin of 11.2 mg/dL, hematocrit of 35%, WBC count of 5.6, and platelet count of 22,000. In addition to discontinuing heparin, which of the following is the most appropriate intervention?
A. Administer prednisone
B. Administer warfarin
C. Bone marrow aspirate
D. CT of the abdomen
E. Observation
The answer is B.
EXPLANATION: The patient most likely has developed heparin-induced thrombocytopenia (HIT), which is associated with qualitative platelet function changes that result in increased risk of thrombosis. She should begin warfarin (B) and be evaluated for thrombosis (e.g., lower extremity Dopplers).
Prednisone (A) is not indicated for the treatment of HIT, and a bone marrow aspirate (C) would not aid in establishing the diagnosis. CT of the abdomen (D) would be indicated if she had symptoms consistent with thrombosis in that region, and observation (E) fails to address her increased thrombotic risk.

A 50-year-old woman with a history of hypertension complains of chest tightness and dyspnea while walking up one flight of stairs. She recently experienced an episode of near-syncope while walking her dog. She denies a history of rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border radiating to the carotids bilaterally. Troponin levels are negative at 0, 3, and 6 hours. Her EKG demonstrates evidence of left ventricular hypertrophy. A transthoracic echocardiogram reveals significant aortic stenosis secondary to congenital bicuspid aortic valve, left ventricular hypertrophy, and normal left ventricular systolic function. Which of the following is the most appropriate next step in management?
A. Cardiac catheterization followed by aortic valve replacement
B. Monitoring via repeat transthoracic echocardiogram in 6 months
C. Monitoring via transesophageal echocardiogram in 6 months
The answer is A.
EXPLANATION: In symptomatic patients demonstrating significant aortic stenosis, aortic valve replacement after cardiac catheterization, to evaluate for coronary artery disease and possible concomitant coronary artery bypass surgery with aortic valve replacement, is indicated. As the patient is demonstrating the classic symptoms of severe aortic stenosis, choice A is the most appropriate next step in management. Choices B and C are thus inappropriate, as the patient is already symptomatic. If the patient were not symptomatic, choice B would be a viable choice compared to choice C, because it is less invasive than transesophageal echocardiogram. Choice D would be inappropriate, as strenuous physical activity should be avoided in patients with severe aortic stenosis. Choice E is appropriate therapy for patients at risk for ventricular tachycardia/fibrillation.

A 42-year-old woman with a history of migraine cephalgia and Raynaud’s phenomenon comes to the emergency department with complaints of severe chest discomfort that occurs at rest every morning (at approximately 10 AM). An EKG performed during an episode of chest discomfort demonstrates transient ST segment elevation, which is relieved with sublingual nitroglycerin. There is no troponin elevation. Cardiac catheterization is performed, and reveals coronary artery spasm, which corresponds with ST segment elevation, and no significant coronary artery stenosis. Which of the following choices is the most likely diagnosis?
A. Pericarditis
B. Acute myocardial infarction
C. Costochondritis
D. Prinzmetal angina
The answer is D.
EXPLANATION: Prinzmetal angina, or variant angina pectoris, is defined as coronary artery spasm associated with ST-segment elevation, and usually occurs at rest and at the same time of the day. Patients with a history of migraine cephalgia and Raynaud’s phenomenon demonstrate Prinzmetal angina more frequently than the rest of the patient population. This can occur in patients with normal coronary arteries and with coronary artery stenosis. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves with sitting up, as well as a pericardial friction rub. Choice B, acute myocardial infarction, would present with troponin elevation, and is unlikely in the setting of a patient with normal coronary arteries on cardiac catheterization. Choices C and E would not be relieved with sublingual nitroglycerin or demonstrate transient ST-segment

A 24-year-old man presenting to the clinic 1 week ago was diagnosed with depression and subsequently prescribed 10 mg/day of fluoxetine. He unexpectedly shows up today and states that he is not experiencing any improvement since starting the medication. What is the best treatment option at this time?
A. double the dose of fluoxetine to 20 mg/day
B. maintain the current dose of fluoxetine and comfort the patient that the medication may still take at least 1 to 2 more weeks to work
C. discontinue the fluoxetine and start sertraline
The answer is B.
EXPLANATION: Alleviation of symptoms associated with depression is typically slow in onset following initiation with SSRIs. Fluoxetine, for instance, can take anywhere between 2 to 6 weeks to achieve substantial benefit when used for depression. After just 1 week of therapy, there is little justification to increase the current dose or switch to another SSRI such as sertraline. Switching the patient to a TCA such as amitriptyline at this point would further delay symptom relief, as TCAs can take several weeks to produce improvement. Compared to SSRIs, TCAs are also more likely to create unwanted side effects such as weight gain, orthostatic hypotension, and constipation. Combining an SSRI with a monoamine oxidase inhibitor (MAOI) such as phenelzine can cause serotonin syndrome that can be lethal. In order to avoid interaction between SSRIs and MAOIs, it is recommended that at least 4 to 5 weeks pass after discontinuing one and starting the other.

A 50-year-old woman with a history of hypertension complains of chest tightness and dyspnea while walking up one flight of stairs. She recently experienced an episode of near-syncope while walking her dog. She denies a history of rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border, radiating to the carotids bilaterally. Troponin levels are negative at 0, 3, and 6 hours. Her EKG demonstrates evidence of left ventricular hypertrophy. Given the patient’s physical exam findings and recent symptoms, which of the following is the most appropriate next diagnostic study?
A. Chest X-ray
B. Transesophageal echocardiogram
C. Holter monitor
D. Treadmill exercise stress test
E. Transthoracic echocardiogram
The answer is E.
EXPLANATION: Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in a patient in this age group, who is likely demonstrating severe aortic stenosis secondary to a congenital bicuspid valve. Patients with a congenital bicuspid aortic valve typically develop symptoms once the valve leaflets have become calcified and thickened, secondary to the undue stress over many years on a structurally abnormal aortic valve. Choice A might be able to give evidence of cardiomegaly or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy, if present. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient, who has no symptoms of palpitations. Choice D, although a useful diagnostic tool for the evaluation of exercise tolerance and in patients complaining of chest pain, does not allow direct visualization of the heart valves to evaluate the degree of aortic stenosis; as the patient is likely demonstrating severe aortic stenosis, cardiac catheterization to evaluate for coronary artery disease prior to surgery will need to be performed.

A mother presents with her 6-year-old childwho has a rash on his arm. The rash which is a discrete, red or flesh-colored, flat-topped, thickened area that is linear in nature with papules with scale has remained unchanged despite the use of topical steroids for one month. The lesion is asymptomatic.What is the most likely diagnosis?
A. Atopic dermatitis
B. Lichen striatus
C. Morphea
The answer is B.
EXPLANATION: Lichen striatus is a benign rash consisting of linearly configured,shiny, and flat lesions that occur on any skin surface. This rashoccurs suddenly and resolves on its own in several weeks. The etiologyis unknown.

A 30-year-old male presents to your office complaining of sinus and facial pain, congestion, and purulent nasal discharge for one month. He has been treated with two courses of different antibiotics by another provider, and does not feel any improvement in his symptoms. What diagnostic test is indicated?
A. Plain sinus radiographs
B. MRI
C. Aspiration and culture of maxillary sinuses
D. CT scan
E. Ultrasound of sinuses
The answer is D.
EXPLANATION: A CT scan is the current preferred method for sinus imaging of chronic sinusitis. CT imaging has better visualization of mucosal thickening air-fluid levels and bone structures. Plain radiographs and CT scans are of limited use in acute sinusitis, because viral pathogens that cause sinus abnormalities are indistinguishable from bacterial causes.

A 34-year-old diabetic female complains of amenorrhea for the past 2 months. Last week she tested positive for strep pharyngitis and is currently being treated. She admits that she has not been using birth control. Her urine HCG is positive. Her current medications are listed in the choices below. Which of the following medications should you discontinue?
A. amoxicillin
B. lisinopril
C. acetaminophen
D. humalog insulin
E. methyldopa
The answer is B.
EXPLANATION: The correct answer is (B). Lisinopril, an ACE inhibitor, is contraindicated in pregnancy due to known problems with fetal toxicity and should be stopped as soon as possible once pregnancy is confirmed. If a patient is planning on becoming pregnant the ACE inhibitor should also be discontinued. ARBs should also be avoided. Choices (A), (C), and (D), and (E) can be used safely in pregnancy and are considered category B. Methyldopa is preferred in the treatment of hypertension in pregnancy and its safety is supported by evidence.

A 43-year-old male presents to the Emergency Department complaining of right eye pain after treating his yard with fertilizer and lime. He attempted to flush his eye at home without relief of pain. Which of the following is the most appropriate initial step in managing this patient’s symptoms?
A. Double evert his eyelids to look for remaining foreign bodies
B. Fluorescein stain his eye
C. Instill proparacaine 0.5% ophthalmic solution
D. Irrigate his eye until the pH is between 6.8 and 7.4
E. Refer to ophthalomogist
The answer is C.
EXPLANATION: The patient requires all of the above steps and should be given pain relief (C) prior to thoroughly flushing the eye (D), removing foreign bodies (A), assessing for corneal injuries (B), and referring to ophthalmology (E).

Which of the following is the third component of the atopic triad, besides allergic rhinitis and asthma?
Atopic dermatits, or eczema, is the third chronic finding, along with asthma and allergic rhinitis, in patients who are atopic. Urticaria are common in acute and chronic allergies.

A 51-year-old female undergoing chemotherapy for stage IIC breast cancer presents to her primary care provider with a complaint of fatigue, becoming tired very easily, and an inability to perform any of her normal daily activities. What is the most common reversible cause of chemotherapeutic -related fatigue?
A. anemia
B. anxiety
C. chronic pain
The answer is A.
EXPLANATION: Fatigue is one of the most common symptoms in cancer patients, experienced by 70% to 100% of those receiving cancer treatment. It is most commonly related to the chemotherapeutic agent itself and will resolve when treatment is completed. In the interim, anemia is the most common cause and this can be treated with hematopoietic growth factors, erythropoietin (epoetin alfa and epoetin beta), granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF).

A 23-year-old female presents with a history of rigid thought patterns and a need for control. She sees herself as a perfectionist. She discloses that she feels a need to check the locks on her doors at home once every 30 minutes. She is consumed with these thoughts about locking the doors. What is the most likely classification for her personality disorder?
A. Histrionic
B. Narcissistic
C. Obsessive-compulsive
D. Paranoid
The answer is C.
EXPLANATION: Clinical findings of obsessive-compulsive disorder include being a perfectionist, egocentric, and indecisive, with rigid thought patterns and need for control. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Narcissistic personality disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention. Clinical findings of someone who has paranoid personality disorder would include defensiveness, being overly sensitive, secretive, suspicious, hyper-alert, and with a limited emotional response. Schizotypal clinical findings include being superstitious, socially isolated, and suspicious, and having limited personality ability, odd speech, and eccentric behaviors.

A 78-year-old male presents to the office due to increasing exertional dyspnea and cough for the past week. Physical exam reveals an S3 gallop, mild JVD, and 2+ pitting edema of the bilateral lower extremities. The patient has had mild congestive heart failure in the past. A chest x-ray reveals prominent pulmonary vasculature without any additional complications. The patient’s current medications are aspirin and simvastatin daily. He has no drug allergies. Which of the following is the most appropriate initial management for this patient?
A. Angiotensin II receptor blocker
B. β blocker
C. Calcium channel blocker
D. Nitrate
E. Thiazide diuretic plus ACE inhibitor
The answer is E.
EXPLANATION: ACE inhibitors are recommended, as first line treatment for symptomatic congestive heart failure, based upon clinical trials, reveal an approximately 20% reduction in CHF mortality in symptomatic heart failure patients. Diuretics provide CHF symptom improvement and promote water and sodium excretion to decrease intravascular volume. blockers and Angiotensin II receptor blockers are also beneficial for CHF patients. Nitrates are usually reserved for acute or decompensating patients. Calcium channel blockers may accelerate CHF progression and should be used with caution.

On physical exam, a drop in systolic blood pressure of 20 mm Hg is noted upon inspiration. What is this physical exam finding known as?
A. Pulsus parvus
B. Pulsus alternans
C. Bisferiens pulses
D. Pulsus bigeminus
E. Pulsus paradoxus
The answer is E.
EXPLANATION: Pulsus paradoxus is defined as a decrease in systolic arterial pressure of greater than 10 mmHg. It is an accentuation of the normal decrease in systolic arterial pressure of less then 10mm Hg that normally accompanies inspiration. It is frequently noted in patients with pericardial tamponade.

a small weak pulse.
Pulsus parvus

is noted in patients who despite a regular rhythm, demonstrate a regular alteration of the pressure pulse amplitude. This is frequently found in patients with severe left ventricular systolic dysfunction.
Pulsus alternans

a pulse with two systolic peaks, commonly seen in patients with aortic regurgitation or hypertrophic cardiomyopathy.
bisferiens pulse

What absolute tissue pressure generally is used as a guideline for diagnosing compartment syndrome?
A. 10 mm Hg
B. 20 mm Hg
C. 30 mm Hg
D. 40 mm Hg
The answer is C.
EXPLANATION: Many trauma surgery services use an absolute tissue pressure of approximately 30 mm Hg as the threshold for diagnosing compartment syndrome. Based on the entire clinical picture, patients with numbers in that range or higher will likely require surgical decompression with a fasciotomy, while lower numbers will probably be managed with a more conservative approach.

A 2-year-old baby girl is brought to the ED with a history of abdominal pain and diarrhea. Mother states that the child was playing normally and then “doubled over” with what appears to be abdominal pain. The abdomen appears slightly distended and is tender to palpation. While in the ED the child has a bloody, diarrheal bowel movement. Which of the following is the most likely diagnosis?
A. pyloric stenosis
B. mesenteric ischemia
C. Crohn disease
D. intussusception
E. Hirschsprung disease
The answer is D.
EXPLANATION: Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. The patient develops paroxysms of pain followed by bloody bowel movements. Pyloric stenosis typically presents prior to the age of 6 months with vomiting but not with diarrhea. Hirschsprung disease results from an absence of ganglion cells in the colon and typically presents early in life with failure to pass meconium, followed by vomiting and abdominal distension. The typical age of onset is later in adolescence in Crohn disease and in the elderly in mesenteric ischemia.

An 18-year-old female comes to the emergency room stating she was raped just a few hours ago. She is not otherwise harmed, but does admit to a history of physical abuse between the ages of six and eight at the hands of a family member. Given this history, you know she is at higher than average risk for post-traumatic stress syndrome. You care for her immediate medical needs and are ready to release her. In counseling her on next steps, which of the following is most critical in order to improve her prognosis?
A. Begin therapy as soon as possible
B. Begin treatment with a serotonin uptake inhibitor
C. Begin treatment with a beta blocker to reduce symptom
The answer is A.
EXPLANATION: Therapy to aid in working through the traumatic experience (A), instituted as soon as possible after the event, has proven to be the most helpful way to avert or minimize post-traumatic stress disorder. This patient does not currently have any symptoms of PTSD, so pharmacologic treatment is not indicated. In a patient who is diagnosed with PTSD, SSRIs (B) may be helpful in reducing panic and improving sleep, beta-blockers (C) may reduce symptoms of anxiety, and prazosin (D) may help with sleep. Legal procedures (E) may help a patient in dealing with the event, but there are no data supporting this as a therapeutic intervention.

A 24-year-old man with a recent history of a viral illness comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient’s temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates no acute process. Which of the following is the most appropriate treatment for this patient?
A. Morphine
B. Enoxaparin
C. Nitroglycerin
D. Penicillin V
E. Indomethacin
The answer is E.
EXPLANATION: Choice E, indomethacin 25-75 mg QID, and bed rest would be the most appropriate treatment in a patient with acute viral pericarditis, as a nonsteroidal anti-inflammatory agent will ameliorate the inflammatory process. Choices A and C are appropriate in a patient suspected of acute coronary syndrome. Choice B, enoxaparin, is contraindicated in patients with pericarditis, as anticoagulants could lead to worsening of pericardial effusion and cardiac tamponade, especially if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively.

Which of the following is a potential complication of acute pyelonephritis?
A. perinephric abscess
B. renal vein thrombosis
C. allergic interstitial nephritis
The answer is A.
EXPLANATION: Because pyelonephritis is an infectious disease, the most likely complication is a perinephric abscess, which occurs as the result of inadequate therapy. Since it is not vascular in origin, renal vein thrombosis would not occur. Allergic interstitial nephritis is caused by an antigen-antibody reaction, which does not occur with acute pyelonephritis. Struvite stones are due to chronic infection with urease-producing organisms, such as Proteus and Pseudomonas, not to an acute infection. Hepatic failure can be a complication of acute renal failure, but not acute pyelonephritis.

A 37-year-old female, who is two weeks post caesarean section, develops acute dyspnea and chest pain. A chest CT reveals a left segmental perfusion defect. Which of the following is the next step in the management of this patient?
A. Aspirin
B. Embolectomy
C. Heparin
The answer is C.
EXPLANATION: Heparin is indicated as initial therapy for acute pulmonary thromboembolism, followed by oral anticoagulation with warfarin. Heparin promotes the effect of antithrombin, which inhibits factors Xa, IXa, Xia, and XIIa, and has been shown to decrease mortality and recurrent pulmonary embolism. Streptokinase, a thrombolytic agent, is recommended for hemodynamically unstable patients being treated with heparin, but with continued risk of death. Embolectomy, although associated with increased mortality, is another alternative for these patients. Pulmonary angiography, the gold standard for pulmonary embolus diagnosis, is being replaced with helical contrasted CT, due to angiography’s invasiveness, time involvement, and cost. Aspirin, an antithrombotic agent, inhibits platelet aggregation and is effective for preventing platelet thrombosis. It also has a role in thrombosis prevention. However, anticoagulation with heparin remains the mainstay of therapy for pulmonary embolus.

A 41-year-old male presents due to concerns regarding headaches. He states that for the past month and a half he has had daily headaches, described as aching, which he notes are worse first thing in the morning and do not seem to change with activity or position. He has noted that when he drives, his left hand seems weaker on the steering wheel, and he drops things more often. He denies any other neurologic symptoms or recent illnesses. A physical exam reveals weakness of the left hand, forearm, and upper arm, with mildly decreased reflexes. There are no other significant findings. Which of the following is the most likely diagnosis?
A. Amyotrophic lateral sclerosis
B. Intracerebral neoplasm
C. Lyme encephalitis
D. Simple partial seizure
The answer is B.
EXPLANATION: Headaches and neurological changes may be seen with many conditions. However, intracerebral neoplasms are often associated with persistent headaches and described as worse in the morning, and may involve neurologic disturbances of many forms, based on the location of the lesion. Coordination deficits, sensory deficits, ataxia, and limb involvement are often seen with brainstem lesions. Amyotrophic lateral sclerosis, a progressive, degenerative nerve disorder with associated weakness, may have similar symptoms, but is not classically associated with headaches. With Lyme encephalitis, signs and symptoms such as fever, vomiting, meningeal signs, and photophobia would be expected. Simple partial seizures are not associated with headaches, although focal neurologic findings are possible. Transient ischemic attacks may have associated headache and neurologic symptoms, but should have improving symptoms and resolution within 24 hours, and are not likely to recur consistently.

Which of the following is the most common cause of short stature worldwide?
A. Acromegaly
B. Malnutrition
C. Prader-Willi syndrome
The answer is B.
The correct choice is B, malnutrition. When not associated with chronic diseases, this is the most common cause of short stature worldwide. Children with malnutrition commonly present with failure of weight gain before growth rate decreases. A dietary history is key to the diagnosis, as well as a history of any parasites in the local area. Choice A, acromegaly, is a disorder of growth hormone excess. Choice C, Prader-Willi syndrome, choice D, congenital growth hormone deficiency, and choice E, IGF-I receptor deficiency, have been found to cause short stature, but are not seen as commonly as malnutrition.

Which of the following types of renal calculi is associated with an infectious cause?
A. struvite
B. uric acid
C. calcium oxalate
The answer is A.
EXPLANATION: Struvite stones form when urea-splitting organisms, such as Proteus, Klebsiella, Pseudomonas, and Staphylococcus, are present in the urinary tract. Ammonia is formed when urease breaks down urea. This results in an alkaline urine, which decreases the solubility of struvite, favoring the production of stones. Calcium stones result from hyperabsorption of calcium in the intestine, impaired renal tubular reabsorption of calcium, primary hyperparathyroidism, intestinal hyperabsorption of oxalate, and hypocitraturia. Uric acid stones are due to hyperuricosuria or a urinary pH <5.5, which causes uric acid to dissociate. They are also the only radiolucent calculi. Cystinuria, an inborn error of metabolism, results in cystine stones.

Your patient is a 42-year-old male who comes to you because, after a recent move to the country, he finds he has an excessive fear of snakes leading to extreme anxiety. He realizes that this fear has been present since childhood, but was not much of a problem before. What is your diagnosis?
A. Conversion disorder
B. Factitious disorder
C. Generalized anxiety disorder
D. Social phobia
E. Specific phobia
The answer is E.
EXPLANATION: Specific phobia (E) is the fear of a very specific object or situation that the individual knows to be excessive. Social phobia (D) involves performance, while generalized anxiety (C) involves anxiety without a known stimulus. Conversion disorder (A) and factitious disorder (B) are both somatoform disorders, involving somatic symptoms with a psychogenic cause.

In taking the family history of your 25-year-old male patient, you discover that he has numerous relatives with breast and ovarian cancers. In the past, his mother received genetic counseling and testing for the BRCA1 and BRCA2 gene mutations and was found to be positive for a mutant allele. What is his risk for developing this genetic cancer?
A. His chance is 0%, because this is not transmitted to men.
B. 25%
C. 50%
D. 75%
E. 100%
The answer is C.
EXPLANATION: BRCA1 and BRCA2 gene mutations are expressed in the cells of breast and other tissue, where they help repair damaged DNA, or destroy cells if DNA cannot be repaired. If the BRCA1 or BRCA2 itself is damaged, damaged DNA is not repaired properly and this increases risks for certain cancers. These genes are inherited in an autosomal dominant manner so if his mother is positive (and his father is not), his risk is 50%, and he is also at increased risk for not only breast cancer, but also prostate, pancreatic, and other cancers.

These lesions are visible on a 14-year-old female’s forehead. What medication is this disorder best treated with?
pic-open and closed comedones
A. topical retinoids
B. topical erythromycin
C. topical Benzoyl peroxide and erythromycin
D. oral Doxycycline 100 mg bid
The answer is A.
EXPLANATION: The lesions are comedones (open and closed). Optimal treatment should be with topical retinoids such as tretinoin and adapalene, as these are comedolytic. Topical erythromycin is indicated in inflammatory acne, not comedonal acne as pictured. Benzoyl peroxide only has mild comedolytic activity and erythromycin has none. This combination medication would be more appropriate for inflammatory acne. Doxycycline has no comedolytic activity.

opening snap, loud S1, and a very soft diastolic rumbling murmur is auscultated. When the patient is placed in the left lateral decubitus position, the murmur is accentuated, and heard best at the apex. With inspiration, the murmur does not increase in amplitude. Which of the following is the most likely finding on echocardiogram?
mitral stenosis, is the most likely finding in a patient with a history of rheumatic fever presenting with a possible opening snap, loud S1, and a very soft diastolic rumbling murmur which is heard best at the cardiac apex and accentuated by placing the patient in the left lateral decubitus position.

A systolic murmur, which increases with inspiration and is heard best at the left lower sternal border.
tricuspid regurgitation,

presents with a diastolic murmur, and with inspiration, the murmur increases. It is also heard best at the left lower sternal border.
Tricuspid stenosis

if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow.
atrial septal defect

A diastolic murmur, decrescendo murmur heard best at the left sternal border.
Aortic regurgitation/insufficiency

Which of the following is the most likely pathogen responsible for bronchiectasis?
A. Corynebacterium diphtheriae
B. Streptococcus pneumoniae
C. parainfluenza virus
The answer is B.
EXPLANATION: Bronchiectasis has numerous etiologies. Most commonly, cultures reveal normal oral flora from the lower respiratory tract: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa. Parainfluenza viruses typically are responsible for croup. Corynebacterium diphtheriae is the causative organism for diphtheria. Rhinovirus is the most common pathogen isolated with acute viral rhinitis or the common cold

most common pathogen isolated with acute viral rhinitis or the common cold.
Rhinovirus

A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked swelling is noted externally to the left eye. There was no loss of consciousness. Upon physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this information, what is the most likely diagnosis?
A. Zygomatic arch fractureB. Orbital blowout fractureC. Le Fort I fracture
The answer is B.
EXPLANATION: Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve. A

describes a transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum.
Le Fort I fracture

describes a pyramidal through the central maxilla and hard palate. Movement of the hard palate and nose occurs, but not the eyes.
Le Fort II fracture

describes a craniofacial disjunction, wherein the entire face is separated from the skull due to fractures of the frontozygomatic suture line, across the orbit and through the base of the nose, and ethmoids. The entire face shifts, with the globes held in place only by the optic nerve.
Le Fort III fracture

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency department complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted, with over 200 mL of pericardial fluid described. Which of the following would be this patient’s most likely electrocardiographic finding (Figure 7)?
A. Torsades de pointes
B. U waves
C. Electrical alternans with sinus tachycardia
D. Peaked T waves
E. Convex elevation of the J point
The answer is C.
EXPLANATION: Choice C, electrical alternans with sinus tachycardia, a beat-to-beat alteration in one or more components of the ECG signal, is considered a specific sign of pericardial effusion, often with cardiac tamponade, as it represents the periodic swinging motion of the heart in the effusion at a frequency that is ½ the heart rate. Choice A, torsades de pointes, is a type of ventricular tachycardia frequently seen, and is associated with electrolyte disturbances or the use of certain types of antiarrhythmic drugs. Choice B, U waves, are associated with hypokalemia. Choice D is frequently noted with severe hyperkalemia. Choice E, convex elevation of the J point, is seen in patients suffering from hypothermia.

A 34-year-old female with a definitive diagnosis of multiple sclerosis presents with an acute symptomatic exacerbation for two days, causing difficulty ambulating and markedly painful paresthesias, which is affecting her ability to sleep. She is currently on Interferon-β-1A, although she admits to missing some recent doses. Which of the following medications is most appropriate for treating her acute exacerbation?
A. Glatiramer acetate
B. Interferon-β-1B
C. Mitoxantrone
D. Natalizumab
E. Prednisone
The answer is E.
EXPLANATION: Multiple sclerosis (MS) therapy is often discussed by the goal of the treatment. Medications, such as the glucocorticoids, are utilized for acute exacerbations or initial episodes of MS, to decrease exacerbation severity. Additionally, they are used for associated conditions, such as optic neuritis. Steroids have not been shown to decrease MS progression or impact the relapse rate.
Other medications have shown to be beneficial regarding altering disease progression and/or the relapse rate. These medications include Interferon-β agents, glatiramer acetate, and Natalizumab. Mitoxantrone, an antineoplastic agent, is also indicated as an MS disease-altering agent, but due to a high risk of cardiotoxicity with prolonged use, it is a second-line agent

Your patient is a 26-year-old male in whom you’ve diagnosed major depression. You wish to start him on pharmacologic therapy, but he expresses significant concern regarding sexual side effects. Which of the following depression medications is an option that will reduce the risk of sexual dysfunction?
A. Bupropion
B. Citalopram
C. Fluoxetine
D. Paroxetine
E. Venlafaxine
The answer is A.
EXPLANATION: The correct answer is bupropion (A). All the SSRIs, including citalopram (B), fluoxetine (C), and paroxetine (D), as well as venlafaxine (E), which is a combination serotonin and norepinephrine reuptake inhibitor (SNRI), have high rates of sexual side effects for men and women. Bupropion is a norepinephrine and dopamine reuptake inhibitor and can be helpful in averting or reducing both sexual side effects and weight gain. It is also indicated for smoking cessation.

A 2-year-old child presents to the emergency department via ambulance due to a seizure lasting approximately 2 minutes with jerking and somnolence. En route in the ambulance her vital signs are: temperature 39°C rectal; pulse 120/min; respirations 32/min; blood pressure 110/64 mm Hg. Upon further questioning, her mother claimed she had a runny nose yesterday. On physical examination, she is sleepy but arousable with negative Kernig and Brudzinski signs. Which of the following seizures is the MOST likely diagnosis?
A. absence seizure
B. complex partial seizure
C. febrile seizure
D. simple partial seizure
The answer is C.
EXPLANATION: A febrile seizure is a brief (less than 15 minutes), generalized, symmetric, tonic-clonic seizure associated with a febrile illness (temperature greater than 38.8°C) without any central nervous system infection or neurologic cause. An absence (petit mal) seizure is a brief (2 to 25 seconds) loss of consciousness that can occur multiple times per day. There is no loss of tone, and frequently the only observable behaviors are staring or minor movements such as lip smacking and semipurposeful movements of the hands. There is no postictal period. Complex partial seizures (psychomotor) have varied symptoms including alterations in consciousness, unresponsiveness, and repetitive complex motor activities that are purposeless. Often, at the beginning of the attack, there is a psychoillusory phenomenon such as hallucinations, visual distortions, visceral sensations, or feelings of intense emotions. Simple partial seizures include focal motor, adversive, and somatosensory seizures. Manifestations of these seizures are varied including hallucinatory, psychoillusory, or complex emotional phenomena. Children will interact normally with their environment, with the exception of those limitations imposed by the seizure. Following the seizure (minutes to hours), there may be transient paralysis of the affected body part.

A 47-year-old female patient is diagnosed with a duodenal ulcer. She was determined to have H. pylori infection. Which of the following antibiotics is indicated for the eradication of H. pylori in the treatment of peptic ulcer disease?
A. Metronidazole
B. Cephalexin
C. Trimethoprim-sulfamethoxazole
D. Gentamycin
The answer is A.
EXPLANATION: Of the antibiotics listed, metronidazole is the only one that has the indication in the treatment of H. pylori induced peptic ulcers.

A 6-year-old male presents with multiple lesions on his shins. The lesions are annular dermal plaques with a central depression. There are no epidermal changes. He states the lesions are asymptomatic. The child has no other medical problems and is a normal active child. What is the most likely diagnosis?
A. necrobiosis lipoidica
B. tinea corporis
C. granuloma annulare
D. atopic dermatitis
The answer is C.
EXPLANATION: This is the classic distribution of granuloma annulare. These lesions commonly occur over bony surfaces and are thought to be secondary to minor trauma (such as playing soccer, normal play activities, or insect bites). The lesions will spontaneously resolve and no treatment is indicated. The distribution in this patient is similar to that of classic necrobiosis lipoidica; however, the dermal changes are classic for granuloma annulare. Necrobiosis lipoidica starts as brown-red plaques that evolve to become waxy appearing. They are commonly misdiagnosed as tinea corporis; however, there are no epidermal changes such as scaling. The lesions are completely dermal. Atopic dermatitis in a 6-year-old child is most commonly distributed on the flexural surfaces and consists of red scaling plaques that are pruritic.

An 8-year-old girl is rushed to the emergency department by her parents because she has become delirious. The child was diagnosed with influenza three days prior. Her parents say that she had begun vomiting yesterday, almost nonstop, and has not been able to hold down fluids. They also note that she has been breathing rapidly. Your exam reveals a tachypneic, disoriented female with hyperreflexia, a positive babinski reflex, and liver enlargement. CSF analysis reveals a normal protein and cell count. What is the most likely diagnosis?
A. Bacterial meningitis
B. Guillain Barre syndrome
C. Measles encephalitis
D. Reye’s syndrome
E. Viral meningitis
The answer is D.
EXPLANATION: Although rare, Reye’s syndrome is associated with viral infections, salicylate use during illness, and metabolic disorders. Illness is associated with liver fat deposition and degeneration, intractable vomiting, and mental status changes, which may progress to seizures, delirium, and coma. Cerebral edema contributes to these changes and other neurologic findings. Meningeal signs are more consistent with meningitis. Measles encephalitis typically presents days to weeks after the pathognomic measles exanthem and clinical findings. Guillain Barre has been associated with influenza infection, and signs and symptoms would include evolving weakness with ascending paralysis and extremity dysesthesias.

A 14-year-old boy presents to the emergency department with acute scrotal pain and vomiting for the past 2 hours. His left testicle is in extreme pain and he states the pain started while playing basketball in gym class. On physical exam of the affected testicle, which of the following findings would suggest testicular torsion?
A. Transillumination
B. Positive Prehn’s sign
C. Positive cremasteric reflex
D. Abnormal transverse lie
The answer is D.
EXPLANATION: Testicular torsion is most common between ages 12-18 with the classic presentation of abrupt and severe onset of pain with nausea/vomiting. The testicle on physical examination is painful, swollen, high-riding, tender, and has an abnormal transverse lie (D).

Transillumination (A) is when light is placed behind the scrotum and fluid is illuminated in cases of ?
hydroceles

is pain relief with elevating the scrotum and is positive in cases of epididymitis.
Prehn’s sign

A normal finding that causes elevation of the testis on the ipsilateral side when the inner aspect of the inner thigh is stroked.
The cremasteric reflex

A mass of enlarged veins or “bag of worms,” is a finding associated with?
Varicocele.

A 29-year-old woman comes in for evaluation of an increased vaginal discharge for the past week. She describes it as “sort of whitish gray with a disgusting odor.” She has no other symptoms. She has had no new sexual partners, has taken no antibiotics, and has not used any new hygiene products. Examination reveals no vulvar erythema. She does have an adherent whitish discharge in the vaginal vault, but no vaginal erythema. Whiff test of the secretions is positive. Microscopic examination of saline and potassium hydroxide preparations is most likely to reveal which of the following?
A. Clue cells
B. Increased polymorphonucleocytes
C. Motile flagellates
D. Small, rounded parabasal epithelial cells
The answer is A.
EXPLANATION: Examination of vaginal secretions in a woman with bacterial vaginosis demonstrates the presence of clue cells, which are epithelial cells that appear granulated due to G vaginalis cells adhering to them.

Motile flagellates
vaginal trichomoniasis

Spores and filaments (E) (pseudohyphae)
Candidias

Your patient is a 14-year-old female, 5’4″ weighing 80 pounds. Her menstrual cycle started at age 10 but stopped one year ago when she became concerned about her weight and began focusing on diet and exercise. Her mother brings her to the emergency room, stating she will only eat salads and runs 2 hours daily. What is the first consideration in the management of this patient?
A. Behavioral modification
B. Family therapy
C. Individual psychotherapy
D. Nutritional restoration
The answer is D.
EXPLANATION: Nutritional deficiencies (D) such as dehydration and electrolyte imbalances must be urgently corrected. After metabolic imbalances have been addressed, a comprehensive, inter-disciplinary approach is optimal, with the primary goal of weight restoration. Behavioral, family, and individual therapies (A, B, and C) should all be a part of the longer-term management plan, and pharmacological therapy (E) may also be helpful.

Which of the following medications, used for the treatment of Tourette syndrome, has been associated with long-term extrapyramidal side effects?
A. Clonazepam
B. Clonidine
C. Haloperidal
D. Metoclopramide
E. Risperidone
Haldol, a typical antipsychotic agent, has been shown to be effective for symptomatic treatment of patients with Tourette syndrome. Haldol blocks dopaminergic action and decreases psychomotor agitation. It is linked to a high frequency of extrapyramidal side effects, likely due to this action. It also has sedative properties within the limbic system. Other medications, such as atypical psychotics, benzodiazepines, alpha-2 agonists, and dopamine-blockers have been used for Tourette management. Each medication should be monitored for effectiveness and side effects, as other medications can cause extrapyramidal side effects, such as metoclopramide.

A 39-year-old male patient presents with low back pain with radiation to the right leg. On examination you place the right hip in a flexed position, and as you palpate between the iscial tuberosity and the greater tronchanter of the femur the patient complains of radiation of pain down his right leg. Based on this history and exam, which nerve was affected by this part of the examination maneuver?
A. Femoral
B. Peroneal
C. Saphenous
D. Sciatic
The answer is D.
EXPLANATION: The sciatic nerve does lie midway between the ischial tuberosity and greater trochanter and it can be palpated when the patient is in a hip flexed position. The gluteus maximus obscures the nerve from being effectively palpated when the leg is in an extended position. Tenderness of the sciatic nerve can be caused by a lumbar disk herniation, direct trauma, or spasm of the nearby pyriformis muscle. The femoral nerve is a deep structure that lies lateral to the femoral artery and is not considered to be palpable. The femoral nerve is responsible for the L1-3 dermatomes and for supplying motor function to the iliopsoas muscle. The peroneal nerve originates from the sciatic nerve and splits into the superficial and deep peroneal nerves, which are responsible for much of the sensory and motor nerve function in the lower leg. The saphenous nerve originates from the femoral nerve in the femoral triangle and runs down the medial aspect of the leg. The sural nerve has medial and lateral components that are found in the lower leg. The medial cutaneous sural nerve arises from the tibial nerve just below the knee and eventually connects with peroneal nerve to form the sural nerve. On the lateral side of the lower leg, the sural nerve arises from the common peroneal nerve just above the knee and eventual connects with the previously discussed medial branch to form the sural nerve.

A 22-year-old woman with a history of scoliosis presents to the office with complaints of retrosternal chest discomfort, occurring frequently at rest and lasting for several hours at a time. She is currently experiencing this chest discomfort during the office visit, but has never experienced this while working out three days per week. On physical exam, a mid-systolic click is noted. With standing, the click moves closer to S1. An EKG demonstrates normal sinus rhythm at 76 bpm, with no acute ST or T wave changes. A transthoracic echocardiogram reveals mild prolapse of the posterior leaflet of the mitral valve. Which of the following would be the most appropriate next step in the management of this patient?
A. Reassurance and monitoring with periodic transthoracic echocardiogram B. Cardiac catheterization
C. Infectious endocarditis prophylaxis
The answer is A.
EXPLANATION: Choice A, reassurance and monitoring with periodic transthoracic echocardiogram, is the most appropriate choice given the patient’s findings on echocardiogram. Most patients with mitral valve prolapse are asymptomatic, and do not demonstrate significant progression of their valvulopathy over their lifetime. Periodic transthoracic echocardiogram allows a noninvasive, highly sensitive method of monitoring. Choice B, cardiac catheterization, is useful for evaluation of coronary artery anatomy and for evaluation of valvulopathy; however, it is invasive, and usually reserved for investigation of serious valvular dysfunction, and/or following a stress test suggestive of myocardial ischemia. The chest pain experienced by patients with mitral valve prolapse is varied in presentation, and in this setting, with a young patient with no cardiac risk factors, unlikely to be secondary to coronary artery disease. According to the American Heart Association’s most recent guidelines, patients with mitral valve prolapse alone do not require infectious endocarditis prophylaxis, so choice C is inappropriate. Choice D, mitral valve replacement, is only indicated with severe mitral valve prolapse, resulting in severe mitral regurgitation. Choice E, transesophageal echocardiogram, while an excellent diagnostic tool for the evaluation of mitral valve disease, would be more invasive than monitoring via transthoracic echocardiogram, and thus would not be an appropriate choice in this patient with only mild mitral valve prolapse

You are a physician assistant working in family practice. A 54-year-old male with a history of hypertension comes to your office complaining of fatigue. Which of the following medications is the most likely cause of the complaint and the EKG findings below?
pic-sinus bradycardia
A. hydralazine
B. losartan
C. metoprolol
D. captopril
E. terazosin
The answer is C.
EXPLANATION: The correct answer is (C). This patient has a sinus bradycardia with a heat rate of about 38 bpm. Metoprolol is a beta blocker known to cause bradycardia. ARBs (such as losartan) and ACE inhibitors (such as captopril) are unlikely to cause bradycardia. Hydralazine an alpha blocker that may cause symptomatic hypotension, but it is unlikely to cause bradycardia. Hydralazine, a direct vasodilator, is more likely to cause tachycardia. Terazosin does not have an effect on rate.

consolidation in the left lower lobe. What do you expect to hear when you percuss this patient’s left lower thorax?
Consolidation leads to dullness (A) to percussion

Sound noted with organ percussion
Flat sound

Sounds are noted in pneumothorax
hyperresonant

normal lung parenchyma results in what sound?
resonance

percussion of the gastric air bubble leads what sound?
tympanic

A 45-year-old patient came in to see his health care provider today, to discuss the results of his last annual assessment. He was told that he had developed type 2 diabetes mellitus. One of the recommendations from the physician assistant included a visit to an ophthalmologist. The physician assistant was concerned after seeing new capillaries, macular edema, and fibrous tissue within the retina during his funduscopic exam. What type of ocular complication does this patient most likely have at this time?
A. Background retinopathy
B. Closed angle glaucoma
C. Macular degeneration
D. Diabetic cataracts
E. Proliferative retinopathy
The answer is E.
The correct choice is E, proliferative retinopathy. The distinguishing factor in the patient’s presentation, which signals this disorder, is the development of newly formed vessels. Proliferative retinopathy is the leading cause of blindness in the United States. Up to 20% of patients with type 2 diabetes have retinopathy at the time of diagnosis. Choice A, background retinopathy, or simple retinopathy includes retinal microaneurysms, hemorrhages, exudates, and edema, without new vessel formation. Choice B, closed angle glaucoma, is relatively uncommon in patients with diabetes, except after cataract extraction. Choice C, macular degeneration, is not associated with diabetes mellitus specifically. Choice D, diabetic cataracts, tends to occur in patients with diabetes earlier than the general population, and may correlate with the severity of the disease.

The eggs of this parasite are detected by microscopic examination of clear adhesive tape that has been pressed to the child’s anus in the morning, prior to bathing. What parasite is most likely to be identified by this test method?
A. Ancylostoma duodenale (hookworm)
B. Ascaris lumbricoides (ascaris)
C. enterobiasis (pinworm)
The answer is C.
EXPLANATION: Enterobiasis or pinworms is a worldwide infection that affects people of all ages and socioeconomic levels. It especially affects children. The classic manifestation of this problem is nocturnal anal pruritis and sleeplessness. The sleeplessness may be secondary to the migration of female worms to the perianal area to lay eggs, during which the tape may pick up the larvae. Transmission of the worms occurs when children ingest the eggs that are present on their hands (from scratching), in the bedclothes, or in house dust. After hatching in the stomach, the larvae migrate to the cecum where they mature into adults. The treatment of choice for pinworms is pyrantel pamoate or mebendazole. Albendazole may also be used. For eradication of this parasite, often the entire family must be treated at once. Ascaris is a helminthiasis infection that is ingested and excreted in the stool. Diagnosis is made by stool examination for the characteristic eggs. Hookworms are found in warm, damp soil and penetrate the skin. From there the infection can spread to the lungs where they ascend into the trachea to be swallowed and live in the intestine. Diagnosis is made by stool examination for the eggs. Whipworm is ingested from the soil and lives in the intestine; detection is also made by egg in the feces.

The treatment of choice for pinworms
pyrantel pamoate or mebendazole. Albendazole may also be used. For eradication of this parasite, often the entire family must be treated at once.

A 55-year-old woman with a history of mitral stenosis (secondary to rheumatic heart disease) presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that recently she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. On EKG, she demonstrates atrial flutter with 2:1 AV block. Which of the following medications is contraindicated in treatment of her atrial flutter?
A. Diltiazem
B. Carvedilol
C. Lopressor
D. Lisinopril
E. Quinidine
The answer is E.
EXPLANATION: In patients with atrial flutter, choices A, B, and C would help to achieve better heart rate control. Choice D, lisinopril, would not be contraindicated, but would not assist with heart rate control. Choice E, quinidine, is contraindicated as the atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur.

A 67 year-old with chronic kidney disease presents to the clinic with a hemoglobin of 8.6 mg/dl and hematocrit of 24%. Which of the following agents, if administered, can further increase this patient’s risk of thrombotic vascular events?
A. Cyanocobalamin
B. Erythropoietin
C. Ferrous sulfate
D. Folic acid
The answer is B.
EXPLANATION: Erythropoietin (B) increases red blood cell mass and toxicity may lead to increased blood viscosity and potential thrombotic events.
Cyanocobalamin (A), ferrous sulfate (C), folic acid (D), and niacin (E) don’t increase thrombotic risk.

A patient who is suspected of having pneumonia produces a sputum sample that grows gram-positive diplococci in chains (see image). What is the best choice of antibiotics for this type of patient?
A. Penicillins
B. Cephalosporins
C. Fluroquinolones
D. Aminoglycosides
E. Macrolides
The answer is A.
EXPLANATION: This patient is having an infection that is consistent with the bacterium Streptococcus pneumoniae. The best and most appropriate treatment for this pathogen is penicillins.

A 37-year-old woman under your care is diagnosed with bipolar I disorder. As part of her drug regimen, you prescribe lithium carbonate as long-term maintenance therapy. Which of the following would be most appropriate to perform or order prior to the initiation of lithium carbonate?
A. electrocardiogram
B. fasting plasma glucose
C. liver function tests
D. serum creatinine
E. urine culture
The answer is D.
EXPLANATION: Patients on chronic lithium carbonate therapy have an approximate 10% to 20% risk of developing renal problems such as glomerulosclerosis, tubular atrophy, or interstitial nephritis. Each of these conditions can lead to filtration problems and a subsequent rise in serum creatinine. Hence, it is advised to obtain a baseline serum creatinine prior to administering lithium carbonate to follow any changes that may occur in renal function during therapy. It is also advised that lithium carbonate be avoided in patients with pre-existing renal disease.

Which of the following drugs is contraindicated for the physician assistant because of its potential for hepatotoxicity in the setting of HIV prophylaxis?
Nevirapine should be avoided for HIV prophylaxis as reports have linked it to hepatotoxicity in the prophylactic setting.

This HIV med may cause rash and fever
Abacavir

This HIV med causes kidney stones
indinavir

This HIV med causes rash and peripheral neuropathy
lamivudine

This HIV med causes anemia, neutropenia, nausea, malaise, headache, insomnia, and myopathy.
zidovudine

A 28-year-old female presents with a gradual progression of fatigue and pallor over the last few months. Initial CBC results show a hemoglobin of 10.4 mg/dL, hematocrit of 32%, an MCV of 112 fL, and a reticulocyte count of 0.1%.
Which of the following is the most likely pathophysiologic mechanism responsible for her anemia?
A. Chronic blood loss
B. Defective bone marrow/stem cell function
C. Defective DNA production
D. Defective hemoglobin production
E. Increased destruction of red blood cells
The answer is E.
EXPLANATION: The time course of the patient’s presentation is consistent with multiple episodes of acute hemolysis.
Defects in bone marrow (B) or red blood cell precursors (C and D) are refuted by the elevated reticulocyte count. Chronic blood loss (A) would have a more insidious, gradual onset and likely result in a decreased MCV.

Which of the following organisms causes dysentery and has a cystic form that contaminates the water supply through poor handling of human sewage and can be spread through anal intercourse in homosexual men?
A. Vibrio cholera
B. Entamoeba histolytica
C. hookworm
D. salmonella
E. giardia
The answer is B.
EXPLANATION: Entamoeba histolytica has two stages in its life cycle. In the active stage in the human intestine, it causes symptoms of dysentery, abdominal pain, stool mucus, and tenesmus. In the dormant stage, the cystic form is excreted in the stool and in developing nations frequently contaminates the supply of drinking water. When the amoeba is in the dormant stage, the cystic form can be excreted in the stool and, in the case of food handlers with poor personal hygiene, be transmitted to others. In addition, because of the cystic stage, individuals engaging in anal intercourse can transmit the infection unknowingly. Diagnosis is made by microscopic evaluation of a stool wet prep and confirmed by serology. Treatment includes agents such as metronidazole or tinidazole. (

A 76-year-old man, is brought to the emergency department by his niece after she found him wandering around his yard in the cold wearing only a tee shirt and jeans. When she set up his pill container about 36 hours earlier, he seemed his usual self but, in retrospect, possibly a little more confused than usual. The niece says that he has “high blood,” treated with a “white fluid pill,” “sugar diabetes,” treated with an oral medication, and early “old timer’s” dementia treated with “a memory pill.” Vital signs include an oral temperature of 100.8F, pulse 100 beats per minute, respirations 24 and somewhat shallow, and blood pressure of 88/52. Initial examination reveals a slightly dehydrated, stuporous man appearing older than his stated age, who smells strongly of urine. He has no lateralizing signs. What is the most likely cause of the mental status changes?
A. hyperglycemic hyperosmolar state
B. lactic acidosis
C. stroke
D. urinary tract infection
E. worsening dementia
The answer is A.
EXPLANATION: The combination of confusion and dehydration in a patient with diabetes type 2 who is taking a diuretic strongly suggest hyperosmolar state. Patients with lactic acidosis (B) have marked hyperventilation and, usually, signs and symptoms of a serious illness. The lack of lateralizing signs makes a stroke (C) less likely. Urinary tract infection (D) could certainly cause confusion and incontinence in an elderly man and should be investigated. Alzheimer dementia (E) progresses slowly; sudden decompensation is usually due to delirium.

A 49-year-old female with a known history of hypertension presents to the emergency department with a generalized headache that is throbbing. She states she had run out of her normal blood pressure medication about a week ago and since then she has noticed that her headache came about and has been getting worse. She denies any nausea, vomiting, visual changes, chest pain, or other symptoms. On exam the patient has a BP 227/120, P 78, R 18. Her HEENT exam is essentially normal, lungs are clear to auscultation, and heart is a regular rhythm without murmur or gallop. Given this clinical situation, which medication would be the most appropriate to address the patients condition?
A. IV nitroprusside
B. Oral furosemide
C. Spironolactone
D. IV labetalol
E. Oral hydralazine
The answer is D.
EXPLANATION: This patient’s clinical situation is one of a hypertensive emergency. In this situation the goal is to bring down the systolic pressure to prevent end organ damage. Given the possible choices, the best choice would be intravenous labetalol (D) due to its effective quick onset, and its ability to be tolerated with most patients. While oral furosemide (B) and hydralazine (E) can both be effective in managing hypertension, the IV dosing of labetalol would be the better choice. Nitroprusside (A) is no longer a treatment option. Spironolactone (C) would not have strong enough effects to appropriately lower the blood pressure in an efficient manner.

A 23 year-old woman presents to the clinic complaining of abrupt onset of severe pallor, fatigue and dyspnea on exertion. Initial CBC reveals a hemoglobin of 9.6 mg/dL and an MCV of 87 fL. Which of the following best describes the cause of the abnormality pictured in the the patient’s peripheral smear? (note photo taken from figure 29-13 in Harrison’s)- schitzocytes
A. Absent or non-functioning spleen
B. Failure of nuclear maturation
C. Intravascular hemolysis
D. Lead intoxication
E. Presence of uremia
The answer is C.
EXPLANATION: Schizocytes are present on the peripheral smear and result from intravascular hemolysis.

A patient presents with hyperleukocytosis (WBC 100,000). The bone marrow is consistent with T-cell ALL. The uric acid is less than 7.0 mg/dl. Prior to starting chemotherapy, what is the best therapy to initiate on this patient?
A. Allopurinol and IV fluids
B. Aluminum hydroxide and calcium carbonate
C. Glucocorticoids and vincristine
The answer is A.
EXPLANATION: Hyperuricemia is often a finding in patients with hyperleukocytosis. The optimal treatment is to start IV fluids, due to numbers of circulating white cells and allopurinol, to treat hyperuricemia. The use of aluminum hydroxide is appropriate if they have hyperphosphatemia, and calcium carbonate if they have a low serum calcium concentration. Glucocorticoids and vincristine are used with hyperleukocytosis of >400,000. Leukapheresis and cranial irradiation are used for patients with extreme leukocytosis of >400,000. Sevelamer is used to treat hyperphosphatemia, and mercaptopurine is a byproduct produced during production of leukemic cells.

You are evaluating a 69-year-old female who complains of an intermittent sensation of hot flashes, flushing of her face/chest, and pruritus after starting a new medication for her cholesterol. Which of the following medications is the most likely cause of her symptoms?
A. niacin
B. lovastatin
C. gemfibrozil
D. ezetimibe
The answer is A.
EXPLANATION: The correct answer is (A). Niacin has a characteristic side effect of hot flashes, flushing, and pruritus. These symptoms can be reduced by addition of ASA or a nonsteroidal anti-inflammatory drug (NSAID) if there are no contraindications. The other choices are unlikely to cause this combination of symptoms.

During a hospitalization for pneumonia, troponin levels are drawn on a 62-year old-man with a history of hypertension, hyperlipidemia, and chronic tobacco use, and found to be elevated above the 99th percentile of normal. If acute myocardial infarction is ruled out, which of the following disease entities could also cause troponin elevation?
A. Mitral regurgitation
B. Gout
C. Parkinson’s disease
D. Sepsis
The answer is D.
EXPLANATION: Choice D, sepsis, is one of a long list of disease entities that can cause troponin elevation, including arrhythmias (both tachycardic and bradycardic), aortic valve disease, hypertrophic cardiomyopathy, invasive cardiac surgeries and procedures, severe pulmonary hypertension, pulmonary embolism, myocardial infiltrative diseases (such as amyloidosis, sarcoidosis, scleroderma, and hemochromatosis), acute respiratory failure, burns, pericarditis, endocarditis, myocarditis, and even occasionally due to extreme athletic activities such as marathon running. Not included on this long list, however, are choices A, B, C, and

Which of the following etiologies is the most common cause of nontraumatic subarachnoid hemorrhage (SAH)?
A. Cerebral aneurysm
B. Poorly controlled hypertension
C. Anticoagulant use
The answer is A.
EXPLANATION: Congenital cerebral aneurysms or Berry aneurysms account for 75% to 80% of nontraumatic subarachnoid hemorrhages (SAHs). Poorly controlled hypertension and anticoagulant use are more commonly associated with intracerebral hemorrhages (ICH). AVMs can cause either SAH or ICH.

A 36 year-old woman with no significant past medical history presents with gradual onset of dyspnea and fatigue leading to an episode of “fainting” this morning. Physical exam reveals increased jugular venous pressure, weak carotid pulses, clear lungs, and a loud S2. What is the most likely diagnosis?
A. Aortic stenosis
B. Cardiac tamponade
C. Mitral Regurgitation
D. Pulmonary fibrosis
E. Pulmonary hypertension
The answer is E.
EXPLANATION: The patients symptoms are due to decreased cardiac output resulting from decreased preload associated with pulmonary hypertension (E). Aortic stenosis (A) presents more commonly in geriatric patients who present with a murmur. Cardiac tamponade (B) can decrease cardiac output, but would lead to decreased heart sounds. Mitral regurgitation (C) would cause pulmonary edema and rales in conjunction with increased jugular venous pressure. Pulmonary fibrosis (E) is unlikely in this patient with normal lung sounds.

A 75-year-old man with type 2 diabetes presents to the emergency department with a 2-day history of confusion and lethargy. On physical exam, notable dehydration, tachycardia, and confused mental state is noted. Serum sodium, potassium, magnesium, and chloride levels are normal. The arterial blood gases are normal and serum ketones are negative. The abnormal laboratory findings are as follows:
glucose- 700 (nl 74-106) osm-380 (nl 275-296)
Given this information, what is the most likely diagnosis?
A. diabetic ketoacidosisB. hyperglycemic hyperosmolar stateC. hypoglycemiaD. dehydration
The answer is B.
EXPLANATION: A hyperglycemic hyperosmolar state is characterized by dehydration, significant hyperglycemia, and an elevated serum osmolality with an insignificant or negative ketosis. Because of the lack of ketosis, the patient may present with a gradual onset of symptoms, and it can go unnoticed until the dehydration becomes more severe than in ketoacidosis.

A 35-year-old woman comes to see you with symptoms of anxiety, sweating, and tremors. She has no history of diabetes, liver or kidney failure, hormone deficiencies, or past surgeries. She states that she is not currently prescribed any medications and does not drink alcohol. She is concerned that she will not be able to continue to care for her husband, who has a long history of diabetes mellitus. She is asking you to give her some medication to stop her symptoms.
Initial lab results are as follows:
Plasma glucose = 54 mg/dL (70-110 mg/dL)
TSH = 2.0 mIU/L (0.34-4.25 uIU/mL)
Insulin = 35 uU/mL (2.0-20 uU/mL)
C-peptide= 0.4 ng/mL (0.5-2.0 ng/mL)
Her symptoms are relieved with the drinking of orange juice. What is the most likely cause of her hypoglycemia?
A. Alimentary hypoglycemia
B. Factitious hypoglycemia
C. Beta cell insulinoma
D. Congenital hyperinsulinism
The answer is B.
The correct choice is B, factitious hypoglycemia. This occurs when patients accidentally or on purpose self-administer insulin or an insulin secretagogue. This occurs most commonly among health care personnel, patients with diabetes or family members of those with diabetes, and people with a history of other factitious diseases. It can also happen secondary to a pharmacy error. Patients with this disorder will have increased measured insulin without the physiologic corresponding increase in C-peptide. Choice A, alimentary hypoglycemia, is a cause of hypoglycemia in patients with a history of gastrectomy. Choice C, beta cell insulinoma would present with elevated levels of both insulin and C-peptide. Choice D, congenital hyperinsulinism would have presented itself earlier than in a patient who is 35 years old. Choice E, reactive hypoglycemia, occurs after eating a meal and must be documented in this fashion.

perform or order prior to the initiation of lithium carbonate
Serum Creatinine

what is the recommended screening protocol for this patient according to the American Diabetes Association (ADA)?
screen everyone older than 45 years of age every three years. In addition, the ADA recommends screening for younger people if they are overweight and have at least one additional risk factor, such as positive family history, hypertension, and/or vascular disease. The other choices are not recommended by the ADA for screening the general population for diabetes mellitus.

A 33-year-old IV drug user presents to the emergency department with chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. Two separate blood cultures are positive for S.aureus. Which of the following physical exam findings would confirm a clinical diagnosis of infective endocarditis, according to the Duke criteria?
A. Increase in valvular regurgitation
B. Irregularly irregularly pulse
C. Osler’s nodes
D. Buccal hemmorhages
The answer is C.
EXPLANATION: Choice C, Osler’s nodes, confirms the clinical diagnosis of infective endocarditis, as it is a minor criteria. The Duke criteria for the clinical diagnosis of infective endocarditis requires the documentation of two major criteria, or one major criteria and three minor criteria, or five minor criteria. The patient demonstrates the presence of one major criteria (two separate blood cultures with typical microorganisms for infective endocarditis) and two minor criteria (fever greater than 38.0°C and predisposing condition of IV drug use). Only a new valvular regurgitation, not an increase or change in preexisting murmur, is considered sufficient to qualify as a major criteria, so choice A is incorrect. An irregularly irregular pulse, choice B, is commonly seen in patients with atrial fibrillation, not with infective endocarditis. Choice D, conjunctival hemorrhages, not buccal hemorrhages, are one of the minor criteria. Choice E, Koplik spots, are buccal lesions seen in patients infected with measles, whereas the presence of Roth’s spots does fulfill one of the minor criteria.

She is currently 16 weeks gestation by ultrasound. Her pregnancy has had no complications to date. She is a non-smoker and takes her prenatal vitamin. What routine obstetric lab should be offered at this visit?
AFP testing is only available between 15 and 20 weeks gestation. HIV is done on initial visit and amniocentesis is offered for risk factors, advanced age, or abnormal AFP. 3D ultrasound is not routine standard of care, and diabetic screening is done between 24 and 32 weeks gestation.

A 64-year-old man has been experiencing signs and symptoms compatible with diverticular disease for the past 3 weeks. He now presents to the emergency department malnourished with severe left-sided lower abdominal pain. After appropriate workup and hydration, he is taken to the operating room where a perforated sigmoid colon is discovered with gross contamination. What is the most appropriate surgical intervention at this time?
A. Left colectomy with primary anastomosis
B. Hartmann procedure
C. Proctocolectomy
The answer is B.
EXPLANATION: This vignette is consistent with an emergent resection in an unprepared patient. The most appropriate therapy for an acute perforation is a Hartmann procedure, which includes resection of the affected portion of the bowel, a temporary diverting colostomy, and oversewing of the distal rectal stump; the second stage of the procedure will involve taking down the colostomy with anastomosis to the rectal stump. A colectomy with a primary anastomosis should not be done when the bowel is unprepared due to the significant risk of infection and leakage of the bowel at the site of the anastomosis. Abdominoperineal resection is used in the treatment of malignant disease of the lower rectum. In this procedure, a permanent colostomy is created and the entire rectum, anal canal, and anus are removed. In the management of benign disease of the lower rectum, a proctocolectomy is appropriate to preserve anal function.

A 28-year-old male presents with hypotension, marked tachypnea, and severe dyspnea following a fistfight. A physical exam reveals ecchymoses over the lateral left rib cage, hyperresonance on the left, and tracheal shift to the right. Which of the following is the most appropriate next step for management of this patient?
A. Anesthesia consultation
B. Chest CT scan
C. Chest x-ray
D. Needle thoracostomy to the second intercostal space, midclavicular line
The answer is D.
The diagnosis for this patient is a traumatic tension pneumothorax, a true medical emergency. Diagnosis can be made based on physical exam findings. Although definitive treatment with a properly placed tube thoracostomy is preferred, choice E has the position incorrect. Needle decompression in the second intercostal space, midclavicular line is the correct choice, with this remaining in place until a chest tube is properly in place.

Which of the following examinations is a major component of routine monitoring of chronic, open angle glaucoma?
A. Pupillary response
B. Corneal reflex testing
C. Visual field testing
he answer is C.
EXPLANATION: Tonometry, gonioscopy, monitoring of the disc-to-cup ratio, and visual field examination are the routine exams done when monitoring primary open angle glaucoma.

A 60-year-old female presents for a routine physical exam. She has not seen a health care provider in over 30 years. She has no significant past medical history and is taking no medications. Her surgical history includes only carpal tunnel repair five years ago. Upon review of symptoms, she notes feeling somewhat tired. She attributes that to old age. Vital signs include BP 110/55, pulse 55 bpm, and respirations 16 per minute. Upon exam you note an enlarged, firm thyroid, thickening of her skin, and puffy facial features and pallor. A portion of blood tests that you ordered is shown below:
Serum TSH = 4.4 uIU/mL
Hemoglobin = 10.0 g/dL
Hematocrit = 30%
MCV = 101
Fasting plasma glucose = 105 mg/dL
BUN = 10 mg/dL
Creatinie = 0.6 ng/mL
Which of the following is the most appropriate intervention?
A. Lithium carbonate 300 mg PO twice daily
B. Resection of the anterior pituitary
C. Levothyroxin 50 to 100 ug PO daily
The answer is C.
The correct choice is C, levothyroxin 50 to 100 ug PO daily. This patient has classic signs and symptoms of hypothyroidism and required thyroid hormone supplementation. The most common form of hypothyroidism is primary hypothyroidism (e.g. Hashimoto’s thyroiditis), and the most common thyroid hormone supplementation is levothyroxine. Choice A, lithium carbonate 300 mg PO twice daily, is a medication used in patients with psychiatric disorders and is known to cause hypothyroidism. Choice B, resection of the anterior pituitary, is not indicated without evidence of a tumor or other pituitary pathology. Secondary hypothyroidism related to the anterior pituitary is quite rare. Choice D, ferrous sulfate 325 mg PO three times daily, is a common treatment protocol for patients with iron deficiency anemia. This patient’s MCV is elevated, indicating large red blood cells, as seen in disorders such as vitamin B12 deficiency or folic acid deficiency. Patients with iron deficiency anemia present with microcytic hypochromic anemia. Choice E, radioactive iodine protocol, is a treatment used in patients with hyperthyroidism.

An elective induction is considered safe when the Bishops score is greater than what number?
A. 6
B. 7
C. 8
D. 9
The answer is C.
EXPLANATION: A Bishop score greater than 9 is considered a positive predictor for safe delivery in a term pregnancy.

Chronic NSAID use is a known cause of peptic ulcer disease. Which of the following NSAIDs is the least likely to lead to ulcer formation?
A. Aspirin
B. Ibuprofen
C. Naproxen
D. Celecoxib
The answer is D.
EXPLANATION: Celecoxib is the only selective NSAID listed in the choices. Coxibs preferentially inhibit COX-2, the principle enzyme involved at sites of inflammation, while sparing COX-1. COX-1 is involved in mucosal cytoprotection in the stomach and duodenum. All the other choices listed are nonselective NSAIDs, and inhibit both COX-1 and COX-2 enzymes.

A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following should be ordered to confirm the suspected diagnosis?
A. Arterial blood gas
B. Inspiratory and forced expiratory chest x-rays
C. PA and lateral chest x-ray
The answer is B.
EXPLANATION: The patient most likely has aspirated a foreign body. This is best evaluated through the demonstration of inspiratory localized hyperinflation and expiratory mediastinal shift (B) on chest x-ray. ABG (A) results will vary depending on the severity of airway obstruction. PA and lateral chest x-rays (C) are typically normal. PEFR (D) and Spirometry (E) are not typically able to accurately assess this localized airway obstruction.

Which of the following diseases is associated with the development of nasal polyps?
Nasal polyps are most commonly idiopathic although they may develop secondary to allergic rhinitis (B), or cystic fibrosis. Chronic sinusitis (C) may result from obstruction of the sinus drainage secondary to a polyp. Amyloidosis (A) and Wegener’s granulomatosis (E) lead to the development of lesions with histology and appearance different than a benign nasal polyp.

A 48-year-old African American male presents with dyspnea, 2-pillow orthopnea, and swelling to his lower legs that has developed over the last month. He also complains of fatigue and decreased exercise tolerance, stating that he has trouble climbing one flight of steps. On physical examination, his blood pressure is 178/98, pulse rate is 102, and respiratory rate is 20. There is 5 cm JVD, crackles at the bilateral lung fields, and tachycardia and an S3 is heard on cardiac auscultation. There is 2+ pitting edema to the lower extremities. His electrocardiogram reveals a sinus tachycardia at a rate of 105 and left ventricular hypertrophy. The chest x-ray reveals cardiomegaly with increased interstitial markings in all lung fields. There is a small right pleural effusion that blunts the costophrenic angle. What is the initial medication of choice for treatment of this patient’s edema?
A. Hydrochlorothiazide
B. Diltiazem
C. Amiodarone
D. Terazosin
The answer is A.
EXPLANATION: Thiazide diuretics are indicated for the initial treatment of fluid overload related to dilated cardiomyopathy. Calcium channel blockers are to be avoided, as they can worsen heart failure. Amiodarone is utilized for arrhythmic events and not purely for heart failure.

A 63-year-old female presents with deep bone pain in both legs. Laboratory evaluation reveals Bence-Jones proteinuria and a monoclonal spike on serum electrophoresis. Which of the following vaccines should this patient receive as part of her management?
A. Diphtheria
B. Human Papilloma Virus (HPV)
C. Pertussis
D. Pneumococcal
The answer is D.
EXPLANATION: Patients with multiple myeloma are at risk from infections, especially from encapsulated organisms such as Haemophilus influenzae and pneumococcus.
Pneumococcal vaccines should be administered, but the patient response is decreased based on their current immunodeficiency. DTaP (A and C), HPV (B), and varicella (E) vaccines are appropriate for this patient based on general immunization guidelines for adults, but not of increased necessity based on her diagnosis.

he best initial diagnostic study for a suspected perforated peptic ulcer is which of the following?
A. abdominal ultrasound
B. upper GI barium swallow
C. esophagogastroduodenoscopy (EGD)
D. upright/decubitus abdominal plain film
The answer is D.
EXPLANATION: The presence of free intraperitoneal air on an upright or decubitus film in the majority of patients with peptic ulcer perforation. This finding along with a classic history of sudden onset of severe abdominal pain and a rigid, quiet abdomen should establish the diagnosis in most cases without the need for further studies. Barium studies are contraindicated in patients with a possible perforation.

Your patient comes to the office for a follow up of her atrial fibrillation and hypertension. She has noted that she have been more tired than usual. Laboratory findings include a thyroid-stimulating hormone (TSH) < 0.05 mU/L. What medication is the most likely cause of her laboratory findings? A. cardizem B. amiodarone C. warfarin
The answer is B.
EXPLANATION: The correct answer is (B). Amiodarone is an antiarrhythmic medication containing iodine that is commonly used in treatment of atrial fibrillation. The use of amiodarone can cause thyrotoxicosis by several mechanisms and may also cause hypothyroidism. In this case the patients suppressed TSH would suggest the presence of amiodarone induced thyrotoxicosis. A high T3 and FT4 would support your diagnosis. All the other choices used in the treatment of atrial fibrillation would not cause thyroid dysfunction.

A 53-year-old woman presents to clinic complaining of amenorrhea, irritability, and hot flashes for 6 months. She would like to try hormone replacement therapy. You are counseling her about possible risks versus benefits. Which of the following is a benefit of combined estrogen progestin therapy?
A. A decreased risk of breast cancer
B. A decreased risk of myocardial infarction
C. A decreased risk of stroke
D. A decrease in somatic symptoms
The answer is D.
EXPLANATION: The WHI study showed increase chance of cardiovascular risks and breast cancer, and showed no improvement in prevention of cognitive decline.

A 32 year-old male presents to the emergency department in Acute Renal Insufficiency (AKI). Which of the following conditions would be most likely observed in intrinsic AKI?
A. Septic shock
B. Congestive heart failure
C. Benign prostatic hypertrophy
D. NSAID overdose
E. Chronic liver failure
The answer is A.
EXPLANATION: The most common causes of intrinsic AKI are sepsis, ischemia, and nephrotoxins, both endogenous and exogenous.

Which type of acute kidney injury can be caused from hypovolemia, decreased cardiac output, decreased circulation of blood volume (CHF, liver failure), and impaired renal autoregulation (NSAIDs, ACE-I/ARB, cyclosporine)?
Prerenal

Which type of AKI causes include bladder outlet obstruction including bladder stones and BPH.
Postrenal

A 42-year-old male with a past medical history of renal failure and diabetes type II presents with facial swelling and pain. He states that it has been getting worse since it started five days ago. He also states that the side of his cheek became acutely swollen and painful five days ago when he was eating. His physical exam reveals a markedly swollen left submandibular space, with a firm and tender 1.5 cm nodule, palpable near the mandible, on the left side. When pressed, pus is seen coming out of the submandibular salivary duct. What is the most likely diagnosis?
A. Sialolithiasis
B. Parotitis
C. Ludwig’s angina
D. Sialadenitis
The answer is D.
EXPLANATION: The history and physical exam is consistent with suppurative sialadenitis. The preceding episode of pain and swelling while eating indicates that the patient may have a salivary duct stone, which predisposed the patient to the salivary gland infection.

A bilateral submandibular and sublingual abcess, most often caused by infected mandibular molars.
Ludwig’s angina

is seen in mumps, a bilateral inflammation of the parotid glands caused by paramixovirus.
Parotitis

salivary duct stones without infection, are unilateral, and can affect the sublingual, submandibular, and parotid glands.
Sialolithiasis

A 24-year-old G1P1 presents to the office complaining of a red, tender area of her right breast. She is four weeks postpartum and is nursing her infant with good success. She complains of no other symptoms. On physical exam, her vitals are normal. Lungs CTA, CV RRR, left breast is normal, right breast has a 3-cm area that is warm with erythema, and no mass or area of fluctuance is noted. She has a MRSA mastitis. How did she most likely contract the infection?
A. Community acquired
B. Hospital acquired
C. From her infant
The answer is C.
EXPLANATION: Infants usually contract MRSA due to poor hand washing technique from the hospital staff, but it is then spread to the mother via the infant.

A 23 year-old woman seeks guidance on foods, medications, and supplements that can help increase the amount of iron supplement. Which of the following is the best advice to provide this patient?
A. Co-administer with a calcium supplement
B. Co-administer with proton pump inhibitors
C. Co-administer with vitamin C
The answer is C.
EXPLANATION: An acidic achieved through presence of additional acids (C) (e.g., ascorbic acid) increases absorption of iron.Food (E), other heavy metals (A), and basic stomach environments (B, D) negatively affect the absorption of iron.

A 58-year-old female presents to the outpatient clinic complaining of 1 week of rhinorrhea, nonproductive cough, and hoarseness. On physical exam she is noted to have erythematous nasal mucosa and decreased phonation without significant nasal discharge, sinus tenderness, pharyngeal erythema, or lymphadenopathy. Which of the following is the most likely causative organism for this patient’s condition?
A. Clostridium diphtheriae
B. Group A streptococcus
C. Moraxella catarrhalis
D. Mycobacterium tuberculosis
E. Rhinovirus
The answer is E.
EXPLANATION: The presence of acute hoarseness associated with an upper respiratory infection is consistent with laryngitis, which may be caused by all of the organisms above (A-E), but most likely has a viral (E) etiology.

A 78-year-old woman with chronic, open-angle glaucoma (COAG) presents to the outpatient clinic complaining of fatigue, and near syncope. She just began eye drops for her glaucoma 3 days ago. Which of the following ophthalmic drop medications is likely causing her side effects?
A. Bimatoprost
B. Brimonidine
C. Brinzolamide
D. Dipivefrin
E. Timolol
The answer is E.
EXPLANATION: Open angle glaucoma is typically treated first-line with beta adrenergic blocking agents (E) or prostaglandin analogs (A). A common side effect of beta adrenergic agents is their systemic absorption and subsequent beta blockade sides effects (i.e. decreased pulse, blood pressure) leading to symptoms such as fatigue, pre-syncope, or syncope. Treatments (B), (C), and (D) are not typically first-line agents and lack the beta blockade side effects this patient is experiencing

A 38-year-old male complains of increasing fatigue, weakness, weight loss, and intermittent nausea, vomiting, and diarrhea over the past few months. He has noted some agitation at times. When this first started he thought that this was related to a virus but the GI symptoms have reoccurred on multiple occasions. Labs show a complete blood count (CBC) within the normal reference range. He is noted to have hyponatremia. On examination you note the multiple areas of hyperpigmentation as seen below. His blood pressure in the office is 100/50, P = 66, T = 97.1°F. What test would you order to confirm your suspected diagnosis? pic- hyperpigmented hands
A. dexamethasone suppression test
B. vasopressin challenge test
C. radioactive iodine uptake scanD. cosyntropin stimulation test
E. follicular stimulation test
The answer is D.
EXPLANATION: The correct answer is (D). The patient’s symptoms and examination findings are consistent with a diagnosis of Addison’s disease, which is most likely due to an autoimmune process that destroys the adrenal glands resulting in a chronic adrenal insufficiency. The cosyntropin (ACTH) stimulation test should reveal a low am cortisol level and an elevated ACTH level if he has Addison’s disease. The dexamethasone suppression test, choice (A), is a laboratory test for Cushing’s syndrome. The vasopressin challenge test, choice (B), is a laboratory test for diagnosis of diabetes insipidus. A radioactive iodine uptake scan, choice (C), is used in the diagnosis of thyroid disease (hyperthyroidism and thyroid nodules). A follicular stimulation test, choice (E), is a factitious test.

A 24-year-old female presents with low self-esteem and lack of confidence. While obtaining the history, you learn that she has a long history of recurrent maladaptive behavior. She has a tendency to blame others and has almost no introspective ability. She also has significant difficulties with interpersonal relationships. What is the most likely diagnosis?
A. Delusional disorder
B. Dysthymia
C. Personality disorder
D. Schizoaffective disorder
E. Schizophrenic disorder
The answer is C.
EXPLANATION: This patient is exhibiting all of the features of a personality disorder.

characterized by symptoms of persistent, non-bizarre delusions that include minimal impairment of daily functioning.
Delusional disorder

characterized by a chronic depressive disturbance that is present for at least two years and includes symptoms of sadness, loss of interest, and withdrawal from activities.
Dysthymia

characterized by affective symptoms that develop alongside psychotic manifestations.
Schizoaffective disorder

characterized by a severe disruption of thinking, mood, and overall behavior, as well as the inability to properly filter stimuli.
Schizophrenic disorder

A patient presents to the clinic with a family member. Upon obtaining history from the patient, he responds with excessive details of his symptoms and the reason for his visit. He is unable to answer a question directly without signification elaboration. What problem does this patient have?
A. circumstantiality
B. derailment
C. incoherence
The answer is A.
EXPLANATION: Circumstantiality is seen in someone who eventually gets to the point after a delay in the thought process.

a disturbance in thought causing the person to start a train of thought, but never getting to the point.
Tangentiality

when a patient skips to another subject. This mainly occurs if a topic is brought up that the patient does not wish to discuss.
Derailment

Which of the following is the first sign of puberty in a normal male?
The first sign of pubertal development in boys is the enlargement of testicular size and occurs at the mean age of 11.6 years. Genital stages accelerate before pubic hair development, which occurs, on average, at 13.4 years of age. The deepening of the voice and the development of chest and axillary hair usually occurs in midpuberty or 2 years after the growth of pubic hair.

A 23-year-old female has been seen in your Emergency Department after being beaten by her husband. As you counsel her before she leaves, which of the following will you recommend?
A. Avoiding the behavior that brought on the attack
B. Couples counselling
C. Leaving the relationship
D. Prosecuting her husband
E. Referral to a local women’s shelter
The answer is E.
EXPLANATION: The appropriate course of action when working with a person who has suffered intimate partner violence is to validate his or her experience, document clearly and non-judgmentally, and assess immediate safety. Referrals to appropriate resources (E) should be made, but decisions regarding the relationship (B, C) and any legal action (D) should be left to the patient rather than continuing a pattern of controlling behavior. Suggesting she avoid behaviors that provoke her attacker (A) puts the blame on the victim.

Which of the following is indicated to confirm the diagnosis of celiac sprue in a patient with positive serologic testing?
A. stool for fecal fat
B. barium enema
C. intestinal biopsy
The answer is C.
EXPLANATION: Intestinal biopsy is the most specific test in establishing the diagnosis of celiac sprue in a patient who has a positive test for IgA endomysial antibody. Classic symptoms of malabsorption are more common in infants but less common in adults. Stool for fecal fat would be a nonspecific finding. Antimitochondrial antibodies are seen in patients with primary biliary cirrhosis.

What is the chief complaint associated with bladder cancer?
The most common complaint of bladder cancer is painless hematuria, which occurs in 85% to 90% of patients. Additional symptoms of bladder irritability, and urinary frequency, urgency, and dysuria are the second most common presentation and are usually associated with invasive bladder cancer.

A 70-year-old man, with a history of HTN and aortic valve replacement 3 months ago, presents with complaints of arthralgia, myalgia, anorexia, fatigue, and weight loss over the last month, with recent dyspnea on exertion and lower extremity edema. Vital signs are as follows: Temperature 38°C, BP 102/64, P 98, RR 20. On physical exam, a new high-pitched, blowing, decrescendo diastolic murmur is noted along the left lower sternal border. Two separate blood cultures are positive for S. aureus. Which of the following is the most appropriate next diagnostic study?
A. EKG
B. CXR
C. TTE
D. ESR
E. TEE
The answer is E.
EXPLANATION: Choice E, TEE or transesophageal echocardiogram, would be most useful in establishing a diagnosis of infective endocarditis, as a positive echocardiogram demonstrating presence of a vegetation would satisfy one of the Duke criteria’s major criteria, as well as determine the extent of the prosthetic valvular dysfunction, if present. TEE is more sensitive than TTE, transthoracic echocardiogram, for detecting vegetations, so choice C is incorrect. Choices A and B, EKG and CXR, should be performed as part of this patient’s evaluation, but would be less useful than TEE in establishing a diagnosis of infective endocarditis. Choice D, erythrocyte sedimentation rates, are frequently elevated in patients with endocarditis, but are not specific to the diagnosis of endocarditis.

A 16-year-old male high school wrestler presents to your family practice clinic with a fluctuant 3 cm by 3 cm abscess to his back superior and lateral to his scapula. Which of the following is the most appropriate treatment?
A. amoxicillin-clavulanate orally for 10 days
B. cephalexin orally for 10 days
C. trimethoprim sulfamethoxazole orally for 10 days
D. vancomycin intravenously for 10 days
E. incision and drainage is likely to resolve the abscess without the need for medications
The answer is E.
EXPLANATION: The causative agent of this abscess is most likely caused by community-acquired methicillin-resistant S aureus (caMRSA). Infectious Diseases Society of America (IDSA) guidelines issued in January of 2011 generally recommend incision and drainage alone for fluctuant abscesses in an otherwise immunocompetent patient.

Which of the following symptoms is most frequently reported in patients that have peptic ulcer disease?
Dyspepsia (epigastric pain) is the hallmark of peptic ulcer disease and is present in 80 to 90% of patients. The abdominal pain is typically described as dull, gnawing, aching or “hunger like,” but isn’t typically described as sharp. Relief of pain with food is reported in about 50% of patients. Furthermoe, 66% of patients with duodenal ulcers and 33% of patients with gastric ulcers report nocturnal pain that awakens them at night. Significant vomiting is not typical of uncomplicated peptic ulcer disease, and is more suggestive of gastric outlet obstruction or gastric malignancy.

A 33-year-old woman presents with an itchy vaginal discharge for the past 2 days. She has been healthy other than a recent sinus infection for which she took a 10-day course of amoxicillin. Her husband is her only sexual partner and he has no symptoms. On examination, the vulva is noted to be slightly erythematous and swollen with some evidence of excoriation. Discharge is white and clumpy. Provided the most likely diagnosis is confirmed on microscopy, first-line therapy is
A. metronidazole 500 mg i po bid for 1 week
B. metronidazole 500 mg 4 tablets po at HS x 1 night
C. fluconazole 150 mg i po x 1 day
The answer is C.
EXPLANATION: The clinical presentation is consistent with vulvovaginal candidiasis. The recent oral antibiotic use increased her risk for developing the infection. The white clumpy discharge and relatively benign bimanual examination support the diagnosis, which is confirmed by 10% potassium hydroxide wet mount of the secretions. Treatment for an uncomplicated case may include topical or oral antifungals. Oral fluconazole in the one dose regimen is effective, convenient, and likely to increase compliance. The metronidazole regimens are appropriate for bacterial vaginosis and trichomoniasis, respectively. Rocephin is an option for gonococcal infection and would likely worsen the candidiasis.

A 25-year-old female presents for an ultrasound after having a positive home pregnancy test. She has an unremarkable past medical history and physical exam. She states she has been feeling fine without any abdominal discomfort or vaginal bleeding noted. On ultrasound you determine she is 10 weeks pregnant. You note a noncomplex unilateral mass on her left ovary measuring 2 cm in diameter. Which treatment option would be best for your suspected diagnosis?
A. Salpingo-oophorectomy
B. Termination of pregnancy
C. Surgical exploration
D. Biopsy of the mass
E. Observation
The answer is E.
EXPLANATION: As many as 1-4% of pregnant woman are diagnosed with an adnexal mass and the majority are functional cysts that spontaneously resolve by week 16 of gestation. More than 90% of unilateral, noncomplex masses less than 5 cm in diameter noted in the first trimester are functional and resolve spontaneously. Surgery would be considered for three main reasons: rupture, torsion, and malignancy. In this case, malignancy and torsion are not suspected on appearance of ultrasound and an unremarkable physical exam, not indicating a need for biopsy (D). The size is under 5 cm without an increased risk of rupture. If the mass is present after 14 weeks gestation, is complex, growing in size, or becomes symptomatic, then surgical exploration (C) and pathologic identification are warranted. Termination of pregnancy (B) and salpingo-oophorectomy (A) would be indicated in cases of rupture or miscarriage.

A 45-year-old presents with a markedly tender nodule protruding from the edge of his upper eyelid. He states that this has been present for 12 hours. No discharge is seen. He denies visual problems. What is the most likely diagnosis?
A. Blepharitis
B. Chalazion
C. Dacryocyctitis
D. Hordeolum
E. Conjunctivitis
The answer is D.
EXPLANATION: A hordeolum (sty) is caused by an acute infection of the Zeis or Moll’s glands of the eyelid. Symptoms include pain and tenderness. An “internal hordeolum” points to the inner conjunctiva of the lid and an “external hordeolum” points to the skin surface of the eyelid.

During the first year of life, what would be the expected average growth for an infant who weighs 8 lb at birth?
A. 7 lb at 2 weeks, 14 lb at 6 months, 21 lb at 12 months
B. 7 lb at 2 weeks, 21 lb at 4 months, 28 lb at 12 months
C. 8 lb at 2 weeks, 16 lb at 4 months, 24 lb at 12 months
The answer is C.
EXPLANATION: During the first year of life, the average, expected increase in weight of a full-term infant is to regain the birth weight by 2 weeks of age, double the birth weight by 4 months of age, and triple the birth weight by 1 year of age.

22-year-old sexually active woman presents for her annual gynecologic evaluation. She reports one partner for the past 6 months and takes oral contraceptive pills as directed. Her periods have been regular. Her examination is unremarkable and her Pap smear returns with atypical squamous cells of undetermined significance and positive for human papillomavirus-16. The next most appropriate step for this patient is to
A. proceed with colposcopy
B. repeat Pap smear in 12 months
C. repeat Pap smear in 24 months
The answer is A.
EXPLANATION: Human papillomavirus subtypes 6, 11, 16, and 18 increase risk for the development of cervical cancer. In a young woman over 21 years old with atypical squamous cells of undetermined significance and positive HPV 16 subtype, the next step in evaluation is the colposcopic evaluation. Alternatively, she could be followed with Pap smears at 6 and 12 months. The LEEP procedure is indicated for those with recurrent histologic finding of cervical intraepithelial neoplasm grade 2 or 3

An adult with a high risk for bacterial endocarditis is scheduled for a dental extraction. The patient has a history of penicillin allergy. Which of the following is an appropriate oral prophylactic drug to give this patient?
A. amoxicillin
B. vancomycin
C. clindamycin
The answer is C.
EXPLANATION: The American Heart Association recommends that patients who are at moderate to high risk for bacterial endocarditis receive antibiotic prophylaxis prior to undergoing oral/dental, respiratory tract, or esophageal procedures. Amoxicillin 2.0 g orally 1 hour before the procedure is the standard regimen. Patients who have a history of amoxicillin/penicillin allergy may be given clindamycin, cephalexin, azithromycin, or clarithromycin. For adults, clindamycin is given at a dose of 600 mg po 1 hour before the procedure.

A 3-day-old infant has bilateral copious, yellow-green eye discharge and conjunctival inflammation. A Gram stain of this discharge reveals gram-negative intracellular diplococci. Which of the following antibiotics is the drug of choice for this infection?
A. ceftriaxone
B. cephalexin
C. erythromycin
D. gentamicin
The answer is A.
EXPLANATION: Gonococcal ophthalmia neonatorum presents as a unilateral or bilateral serosanguineous discharge and then within 24 hours the discharge becomes mucopurulent, followed by conjunctival injection and edema of the eyelids. The usual incubation period for Neiserria gonorrhea is 2 to 5 days; however, the infection may be present at birth or delayed greater than 5 days if there has been instillation of silver nitrate prophylaxis. A presumptive diagnosis is made by the demonstration of gram-negative intracellular diplococci on Gram stain. Definitive diagnosis is made by culture. Following a positive Gram stain and pending culture results, treatment should be promptly initiated with ceftriaxone (50 mg/kg/24 hours IV or IM for one dose not to exceed 125 mg), a third-generation cephalosporin with good coverage for gram-negative bacteria. An alternate drug is cefotaxime (100 mg/kg/24 hours IV or IM every 12 hours for 7 days or 100 mg/kg as a single dose), which is also a third-generation cephalosporin. Although erythromycin drops (0.5%) are used prophylactically for N gonorrhea, this is not an effective treatment. Gentamicin would be used for Pseudomonas, and Chlamydia is treated with erythromycin. Cephalexin as a first-generation cephalosporin does not have coverage for gram-negative bacteria.

An 87-year old female with a history of osteoporosis fell off of her porch steps. Without any other information and considering the diagnosis of osteoporosis, which two areas are most likely fractured?
he most affected areas from osteoporosis are the spine and hip (B) with the pelvis and wrist also being affected. Osteoporosis increases propensity of fractures from demineralization. Usually the patient is asymptomatic until the fracture occurs. The femoral neck is a common location for hip fractures of this nature. The hand, foot and knee, including the distal femur and proximal tibia, are not as frequently fractured resulting from osteoporosis in comparison with the hip and spine (A, C, D, and E). Osteoporosis increases propensity of fractures from demineralization.

Use of which of the following medications can result in hearing loss?
A. Cefalexin
B. Erythomycin
C. Gentamycin
The answer is C.
EXPLANATION: Gentamycin is an aminoglycoside, and can cause ototoxicity. Peak and trough levels must be drawn to determine the lowest effective dose. The remaining medications do not interfere with vestibular function.

A new patient is seen in your internal medicine office today. She is coming in to request the removal of several skin tags. She is a 55-year-old woman with a history of untreated acromegaly. A health maintenance plan is set up with the patient, and includes a colonoscopy. This patient is at increased risk for which of the following findings on colonoscopy?
A. Anal fissures
B. Ulcerative colitis
C. Colon polyps
D. Pseudomembranous colitis
The answer is C.
The correct choice is C, colon polyps. Approximately 30% of patients with acromegaly have been found to have colon polyps. These patients also have an increased risk of colon cancer. Patients with acromegaly have not been found to be at increased risk for the other response choices listed here.

A 68-year-old male presents to the clinic stating that his wife has noticed a resting tremor in his right hand, and that his gait is more shuffling over the past six months. Which of these findings on physical exam is most likely for the suspected diagnosis?
A. Aphasia
B. Atonia
C. Chorea
D. Hyperreflexia
E. Masked facies
The answer is E.
EXPLANATION: This patient exhibits classic findings of Parkinson’s disease. Parkinson’s is a nervous system disorder due to decreased dopamine, resulting from a degeneration of the dopaminergic nigrostriatal system. Symptoms may include a combination of tremor, rigidity, bradykinesia, progressive postural instability, slowing of automatic movements, gait changes, decreased facial expression, speech changes, and cognition deficits. Muscle strength and reflexes are typically preserved. Chorea, an irregular, rapid, and involuntary movement, is typically seen with Huntington’s and a variety of other disorders. Parkinson’s must be differentiated from other nervous system disorders.

A 37-year-old woman who takes no medication and is otherwise healthy has developed a spontaneous “bloody discharge” from her left breast. Examination reveals no tenderness, masses, dimpling, or asymmetry. Gentle pressure at the margin of the areola reveals single duct involvement. This most likely represents which of the following?
A. Fibroadenoma
B. Fibrocystic changes
C. Intraductal papilloma
The answer is C.
EXPLANATION: A unilateral serous or serosanguinous nipple discharge from a single duct is more likely a benign intraductal papilloma
A less-likely intraductal malignancy (D), however, is possible and must be ruled out. Fibroadenomas (A) and fibrocystic changes (B) are not usually associated with nipple discharge. A pituitary adenoma (E) is usually associated with galactorrhea, rather than a bloody discharge, from multiple ducts in both breasts.

A 54-year-old male patient presents to your office complaining of pain to the left eye with nausea, vomiting, and a headache after being brushed in the eye with his grandchild’s stuffed animal. On examination the conjunctiva is not injected, and the cornea has a steamy appearance. You cannot visualize the retina. The pupil is fixed and 4 mm. When you stain the eye you are unable to see any lesions or scratches. You suspect:
A. acute bacterial conjunctivitis
B. acute narrow angle glaucoma
C. allergic conjunctivitis
D. herpes simplex ophthalmicus
E. traumatic iritis
The answer is B.
EXPLANATION: Patients with acute glaucoma usually seek treatment immediately because of extreme pain and blurred vision, though there are subacute cases. The blurred vision is associated with halos around lights. Nausea and abdominal pain may occur. The eye is red, the cornea steamy, and the pupil moderately dilated and nonreactive to light. Intraocular pressure is usually over 50 mm Hg, producing a hard eye on palpation.

Which of the following examinations is a major component of routine monitoring of chronic, open angle glaucoma? A Pupillary response B Corneal reflex testing C Visual field testing D Accommodation E Visual acuity Visual Field Testing Tonometry, gonioscopy, monitoring of …

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%] 2. Client admitted 2 days ago with congestive …

This is the answer side of the first card in this set. Make sure you select “definition” in the “start with” box. Otherwise you will just see the answers first, which isn’t super productive. (I had to do this because …

congenital heart defects Patent ductus arteriosus, Atrial septal defect, Ventricular septal defect, Tetralogy of fallot, Coarctation of Aorta Coarctation of Aorta narrowing of the descending portion of the aorta, resulting in a limited flow of blood to the lower part …

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