MASS QUIZLET 2

An HIV positive patient presents with worsening dementia, fever, headache, and right hemiparesis. MRI of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. Which of the following is the treatment of choice?

A. Sulfadiazine and pyrimethamine

B. Trimethoprim-sulfamethoxazole

C. Radiation therapy

D. Ventricular shunt placement

(c) A. Toxoplasmosis is commonly noted in HIV positive patients and presents with multiple ring-enhancing lesions. Treatment of choice for possible toxoplasmosis is sulfadiazine and pyrimethamine.

(u) B. Trimethoprim-sulfamethoxazole is used for prophylaxis of toxoplasmosis, but not for treatment of acute infection.

(u) C. Radiation therapy is indicated in CNS lymphoma, which typically presents with a single lesion.

(u) D. Shunt placement is not indicated in patients with toxoplasmosis.

A 52 year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study?

A. Stool for occult blood

B. Stool cultures

C. Sigmoidoscopy

D. Abdominal CT scan

(c) A. FOBT Occult bleeding, as evidenced by the patient's history of black stools, is initially verified by a positive fecal occult blood test.

(u) B. Stool cultures are indicated in the evaluation of acute diarrhea and not for the evaluation of acute GI bleeding.

(u) C. Melena suggests a source of bleeding that is proximal to the ligament of Treitz, not a lower GI bleed.

Sigmoidoscopy is used to evaluate only lower GI bleeding sources.

(u) D. *Abdominal CT scan is indicated for evaluation of obscure bleeding in order to exclude a pancreatic or hepatic source of bleeding if endoscopy fails to identify the source.

Which of the following is a cause of prerenal azotemia?

A. Infection

B. Renal toxins

C. Poor renal perfusion

D. Urinary tract obstruction

(u) A. Infection is associated with interstitial nephritis, which is considered a cause of intrinsic renal azotemia.

(u) B. This is one of the causes of intrinsic renal azotemia.

(c) C. Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow

and glomerular ultrafiltration pressure are restored.

(u) D. Urinary tract obstruction is the cause of postrenal azotemia.

A 65 year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever, but has had photophobia and a stiff neck. Which of the following is the most likely diagnosis?

A. Transient ischemic attack

B. Bacterial meningitis

C. Migraine headache

D. Cryptococcosis

(u) A. Transient ischemic attacks present with focal neurological findings rather than headaches.

(a) B. Bacterial meningitis is typically acute in onset and causes fever, but immunocompromised patients may have a

slower onset and no fever.

(u) C. Migraines generally do not begin in this age group, and are not accompanied by nuchal rigidity.

(c) D.Cryptococcus is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients.

Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)?

A. Drooling

B. High fever

C. "Hot potato" voice

D. Barking cough

(u) A. Drooling and a "hot potato" voice are seen with epiglottitis, not viral croup.

(u) B. Fever is usually absent or low-grade in patients with viral croup.

(u) C. See A for explanation.

(c) D. Viral croup is characterized by a history of upper respiratory tract symptoms followed by onset of a barking

cough and stridor.

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30 minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment?

A. Chest x-ray

B. Sputum gram stain

C. Peak flow

D. Ventilation-perfusion scan

(u) A. A chest x-ray should be ordered in an asthmatic patient only if you are concerned about the presence of pneumonia or pneumothorax, neither of which is supported by the H&P findings noted above.

(u) B. A sputum gram stain is performed in patients who you suspect have an infectious process, such as pneumonia.

(c) C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

(u) D. A ventilation-perfusion scan (V/Q scan) is indicated in cases of suspected pulmonary embolism. The patient

above does not have any risk factors that would lead you to suspect such a diagnosis.

A 3 year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin A (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is

A. renal.

B. cardiac.

C. pulmonary.

D. hepatic.

(u) A. See B for explanation.

(c) B. cardiac The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery

aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain,

although a bacterial toxin with super antigen properties may be involved.

(u) C. See B for explanation.

(u) D. Children with Kawasaki syndrome may have associated hydrops of the gallbladder, but liver involvement is not

part of this disorder.

The DSM-IV classifies mental disorders by using five axes in completing the process. Axis III is used to identify which of the following?

A. Clinical disorders and other conditions that may be the focus of clinical attention

B. Any physical disorder or general medical condition that is present in addition to the mental disorder

C. The psychosocial and environmental problems that have had a significant contribution to the development or

exacerbation of the disorder

D. Personality disorders and/or mental retardation

(u) A. Axis I identifies clinical disorders and other conditions that may be the focus of clinical attention.

(c) B. Axis III identifies any physical disorder or general medical condition that is present in addition to the mental disorder.

(u) C. Axis IV identifies the psychosocial and environmental problems having a significant contribution to the disorder.

(u) D. Axis II identifies personality disorders and mental retardation.

A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals sinus tachycardia. Which of the following is the most likely diagnosis?

A. Atelectasis

B. Pneumothorax

C. Pulmonary embolism

D. Myocardial infarction

(u) A. Small atelectasis is commonly asymptomatic, while large atelectasis may produce signs of dyspnea and cough. Exam reveals absence of breath sounds in the area involved and dullness to percussion. A chest x-ray would reveal various findings dependent on the location of the atelectasis, but would not be normal.

(u) B. While a pneumothorax commonly presents with pleuritic chest pain and dyspnea, exam would reveal the presence of diminished breath sounds and hyperresonance on the involved side. A chest x-ray would reveal presence of a pleural line on the expiratory chest x-ray.

(c) C. This patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal.

(u) D. While a myocardial infarction usually presents with dyspnea, the chest pain is not usually pleuritic in nature. An EKG would commonly reveal ST segment changes which would be consistent with ischemia or infarct.

A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time?

A. Oral prednisone

B. Oral theophylline (Theo-Dur)

C. Salmeterol (Serevent) inhaler

D. Beclomethasone (Qvar)inhaler

(u) A. Oral corticosteroids, such as prednisone, are added to therapy in severe persistent asthma. While a course of oral corticosteroids may be needed for mild exacerbations of asthma, they are not added until inhaled corticosteroids have failed to control the symptoms.

(u) B. Due to its safety profile, oral theophylline is now considered a third or fourth line treatment option for asthma.

(u) C. Long acting inhaled beta2-agonists, such as salmeterol, are not added to the treatment regimen until the symptoms indicate a moderate persistent asthma. Long acting inhaled beta2-agonists should also not be used in place of inhaled steroids.

(c) D. This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control.

In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis?

A. Femur

B. Humerus

C. Vertebral spine

D. Tibia

(u) A. Long bones are most commonly affected with osteomyelitis in children.

(u) B. See A for explanation.

(c) C. The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection

(u) D. See A for explanation.

A 43 year-old asymptomatic diabetic female is found to have an elevated total calcium level of 12.4 mg/dL. Which of the following tests must be assessed in order to evaluate this laboratory abnormality?

A. Intact parathyroid hormone

B. Serum albumin

C. 24 hour urine calcium level

D. Complete blood count

(u) A. Intact parathyroid hormone levels are only obtained for patients with true hypercalcemia with an unknown etiology.

(c) B. serum albumin Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels.

(u) C. Demonstration of excessive calcium in the urine does not provide any additional information regarding the increased serum calcium.

(u) D. Complete blood count has no relationship to the serum calcium levels.

Which of the following conditions would cause a positive Kussmaul's sign on physical examination?

A. Left ventricular failure

B. Pulmonary edema

C. Coarctation of the aorta

D. Constrictive pericarditis

(u) A. Left ventricular failure results in the back-up of blood into the left atrium and then the pulmonary system so it would not be associated with Kussmaul's sign.

(u) B. Pulmonary edema primarily results in increased pulmonary pressures rather than having effects on the venous inflow into the heart.

(u) C. Coarctation of the aorta primarily affects outflow from the heart due to the stenosis resulting in delayed and decreased femoral pulses; it has no effect on causing Kussmaul's sign.

(c) D. Kussmaul's sign is an increase rather than the normal decrease in the CVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.

Treatment of Bell's palsy includes which of the following?

A. Acyclovir

B. Reassurance of the patient's recovery

C. Referral to a neurosurgeon

D. Electromyography

(u) A. See B for explanation.

(c) B. Bell's palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell's palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell's palsy.

(u) C. See B for explanation.

(u) D. See B for explanation.

During a baseball game, a 22 year-old college student is hit in the right eye by a baseball. He complains of blurry vision in that eye. On physical exam, the physician assistant notes proptosis of the right eye, and limitation of movement in all directions. On CT scan, which of the following is most likely to be seen?

A. Fracture of the medial orbital wall

B. Prolapse of orbital soft tissue

C. Hematoma of the orbit

D. Orbital emphysema

(u) A. Fracture of the medial orbital wall is associated with diplopia from medial rectus impingement, orbital emphysema and epistaxis.

(u) B. Prolapse of orbital soft tissue, including inferior rectus muscle, inferior oblique muscle, orbital fat, and connective tissue results in enophthalmos, ptosis, diplopia, anesthesia of the ipsilateral cheek and upper lip, and limitation of upward gaze and is seen with fractures of the orbital floor.

(c) C. Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma.

(u) D. Orbital emphysema is seen with fractures of the medial orbital wall or floor of the orbit into the maxillary and ethmoid sinuses respectively. It will not lead to proptosis.

In infants, the eyes should move in parallel without deviation by the age of

A. 2 weeks. B. 3 months. C. 6 months. D. 1 year.

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months.

(u) D. See C for explanation.

A 29 year-old male presents with complaint of substernal chest pain for 12 hours. The patient states that the pain radiates to his shoulders and is relieved with sitting forward. The patient admits to recent upper respiratory symptoms. On examination vital signs are BP 126/68, HR 86, RR 20, temp 100.3 degrees F. There is no JVD noted. Heart exam reveals regular rate and rhythm with no S3 or S4. There is a friction rub noted. Lungs are clear to auscultation. EKG shows diffuse ST segment elevation. What is the treatment of choice in this patient?

A. Pericardiocentesis

B. Nitroglycerin

C. Percutaneous coronary intervention

D. Indomethacin (Indocin)

(u) A. Pericardiocentesis is the treatment of choice in a patient with a pericardial effusion and cardiac tamponade, there is no evidence of either of these in this patient.

(u) B. Nitroglycerin is indicated in the treatment of chest pain related to angina.

(u) C. Percutaneous coronory intervention is the treatment of choice in a patient with an acute myocardial infarction.

(c) D. Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis.

As a general rule, sutures in the face should be removed in

A. 3 days. B. 5 days. C. 7 days. D. 10 days.

(u) A. See B for explanation.

(c) B. Sutures of the face should be removed in 5 days in order to allow for adequate healing and to limit the amount

of scarring.

(u) C. See B for explanation.

(u) D. See B for explanation.

When performing a rectal examination, prostatic massage is contraindicated in

A. acute bacterial prostatitis.

B. chronic bacterial prostatitis.

C. nonbacterial prostatitis.

D. prostatodynia.

(c) A. acute bacterial prostatitis Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.

(u) B. Prostate massage can be performed in the absence of fever. Expressed prostatic secretions are cultured to help identify the organism.

(u) C. Nonbacterial prostatitis is similar to chronic bacterial prostatitis, but no bacteria are cultured, and the cause may be unknown.

(u) D. Prostatodynia is a noninflammatory disorder involving voiding dysfunction and pelvic floor musculature dysfunction. There is no bacterial involvement.

A 19 year-old female presents with a sore throat for nearly two weeks. She complains of fatigue and a low-grade fever. On physical examination, there is cervical, axillary, and inguinal lymphadenopathy, and mild splenomegaly. On review of the blood smear, which of the following would be expected?

A. Atypical lymphocytes

B. Hypersegmented neutrophils

C. Hypochromic red blood cells

D. Schistocytes

(c) A. The hallmark of infectious mononucleosis is the presence of lymphocytosis with atypical large lymphocytes seen in the blood smear. These are larger than normal mature lymphocytes, stain more darkly, and frequently show vacuolated, foamy cytoplasm, and dark chromatin in the nucleus.

(u) B. Hypersegmented neutrophils are seen in vitamin B12 deficiency.

(u) C. Anemia, if seen in mononucleosis, is normocytic and normochromic.

(u) D. Schistocytes are noted in hemolytic anemias.

A 17 year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using "some drugs" but does not know what they were. On physical examination, temperature is 103 degrees F, BP 140/90, pulse 120, respirations 20. Remainder of the examination is unremarkable. Which of the following diagnostic studies will be of most help in managing this patient?

A. Drug screen

B. Urine dipstick

C. Complete blood count

D. Serum creatinine kinase

(a) A. Although a drug screen may identify specific drugs, the results will not alter the care of this patient.

(u) B. Urine dipstick is not sensitive for myoglobinuria.

(u) C. This patient is at risk for myoglobinuria, and a complete blood count will not alter the treatment.

(c) D. Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse.

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is

A. tuberculosis.

B. mycoplasma pneumonia.

C. pneumococcal pneumonia.

D. staphylococcal pneumonia.

(u) A. Most children with pulmonary tuberculosis are asymptomatic with few physical examination findings. The results of the diagnostic studies do not support tuberculosis as the most likely diagnosis.

(c) B. mycoplasma pneumonia. The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely.

(u) C. The clinical presentation of bacterial pneumonias in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis.

(u) D. See C for explanation.

Which of the following clinical manifestations is common in candidal vulvovaginitis?

A. Extreme vulvar irritation

B. Firm, painless ulcer

C. Tender lymphadenopathy

D. Purulent discharge

(c) A. Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous.

(u) B. A firm painless ulcer is seen in syphilis.

(u) C. Tender lymphadenopathy is associated with bacterial infections and is not a feature of candidal vulvovaginitis.

(u) D. Purulent discharge is noted in gonorrhea.

A 63 year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis?

A. Aortic dissection

B. Inferior wall myocardial infarction

C. Acute pericarditis

D. Pulmonary embolus

(u) A. A patient with aortic dissection will complain of tearing, ripping pain. EKG is often normal, but may reveal left ventricular strain pattern.

(c) B. Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment

29

elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction.

(u) C. Acute pericarditis presents with atypical chest pain and diffuse ST segment elevation.

(u) D. Pulmonary embolism often presents with either no EKG changes or sinus tachycardia. Classically described,

rarely seen findings include a large S wave in lead I, a Q wave with T wave inversion in lead III, ST segment depression in lead II, T wave inversion in leads V1-V4 and a transient right bundle branch block.

A 35 year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis?

A. Herpes Simplex Virus (HSV)

B. Molluscum Contagiosum Virus (MCV)

C. Human Papilloma Virus (HPV)

D. Syphilis

(c) A. The presentation seen on the Tzanck preparation is characteristic of HSV.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism?

A. Epstein-Barr virus

B. Group C Streptococcus

C. Coxsackievirus

D. Gonorrhea

(u) A. Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate.

(u) B. Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates

(c) C. Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx.

(u) D. Neisseria gonorrhea of the pharynx may be asymptomatic

A 12 month-old child with tetralogy of Fallot is most likely to have which of the following clinical features?

A. Chest pain

B. Cyanosis

C. Convulsions

D. Palpitations

(u) A. Chest pain is not a feature of tetralogy of Fallot.

(c) B. Cyanosis is very common in tetralogy of Fallot.

(u) C. Convulsions are occasionally seen as part of severe hypoxic spells in infancy rather than a feature of tetralogy

of Fallot.

(u) D. Palpitations are uncommon in tetralogy of Fallot.

Which of the following drugs is first-line therapy for schizophrenia?

A. Chlorpromazine (Thorazine)

B. Clozapine (Clozaril)

C. Haloperidol (Haldol)

D. Olanzapine (Zyprexa)

(u) A. The older, traditional antipsychotic agents, such as haloperidol and chlorpromazine have higher risk of side effects, including acute motor system side effects a long-term risk of tardive dyskinesias, and should not be considered as first-line drugs.

(u) B. Clozapine should not be considered a first-line therapy because of its hematopoietic and hepatic side effects.

(u) C. See A for explanation.

(c) D. Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychoticdrugs, such as olanzapine, risperidone, quetiapine, ziprasidone, and clozapine because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms.

A 25 year-old presents with pain in the proximal ulna after falling directly on the forearm. X-ray shows fracture of the

proximal 1/3rd of the ulna. There is an associated anterior radial head dislocation. What is the proper name for this condition?

A. Galeazzi fracture

B. Monteggia fracture

C. Colles' fracture

D. Smith fracture

(u)A. A Galeazzi fracture is a fracture along the length of the radius with injury to the distal radioulnar joint.

(c) B. A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head.

(u) C. A Colles' fracture is a fracture of the distal radius with dorsal displacement of the radial head.

(u) D. A Smith fracture is a fracture of the distal radius with ventral displacement of the radial head.

A 20 year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that extends into the scrotum. The patient denies any trauma. The most likely diagnosis is

A. an indirect inguinal hernia.

B. a direct inguinal hernia.

C. an obturator hernia.

D. a femoral hernia.

(c) A. An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum.

(u) B. A direct inguinal hernia is symmetrical, round and disappears easily with the patient lying down. It is the result of a weakness in the inguinal 3external ring. Hernial contents may radiate anteriorly rather than into the scrotum.

(u) C. Obturator hernia's are more commonly seen in elderly women and are rarely palpable in the groin.

(u) D. Femoral hernias are rare in males and do not typically reduce with lying down.

Which of the following oral hypoglycemic agents when used as monotherapy is most likely to cause hypoglycemia?

A. Glipizide (Glucotrol)

B. Metformin (Glucophage)

C. Pioglitazone (Actos)

D. Acarbose (Precose)

(c) A. Sulfonylureas increase insulin levels and predispose patients to hypoglycemia.

(u) B.

(u) C.

(u) D. Acarbose is an alpha glucosidase inhibitor that delays the absorption of carbohydrates in the diet. It does not cause hypoglycemia since it does not drive insulin into the cells.

A 23 year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis?

A. Hypertrophic cardiomyopathy

B. Aortic stenosis

C. Mitral regurgitation

D. Pulmonic stenosis

(c) A. Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining.

(u) B. Straining decreases the intensity of the murmur associated with aortic stenosis and squatting increases the intensity.

(u) C. Mitral regurgitation is characterized by a blowing systolic murmur that radiates to the axilla, it is not often associated with syncope.

(u) D. Pulmonic stenosis is a harsh systolic murmur with a widely split S2, and no change with maneuvers.

A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis?

A. Rheumatoid arthritis

B. Septic arthritis

C. Gouty arthritis

D. Osteoarthritis

(u) A. Rheumatoid arthritis usually involves more than one joint, primarily affecting metacarpophalangeal and wrist joints initially. Synovial fluid analysis would show moderate leukocytosis (< 50,000) with higher glucose levels.

(c) B. Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels.

(u) C. Although gout presents as monarticular process, it usually presents acutely without previous migratory arthralgias. Crystals are usually found in synovial analysis.

(u) D. Osteoarthritis effusions may be normal or show mild elevations of WBCs in the fluid analysis, but it is rarely monarticular.

When the diagnosis of gonococcal urethritis is confirmed, which of the following is the treatment of choice?

A. Ceftriaxone (Rocephin)

B. Amoxicillin (Amoxil)

C. Penicillin G benzathine (Bicillin LA)

D. Doxycycline (Vibramycin)

(c) A. Ceftriaxone is recommended therapy for gonococcal urethritis.

(u) B. Effective single-dose regimens for uncomplicated gonococcal urethritis include cefixime or one of the fluoroquinolones, but NOT amoxicillin due to penicillin-resistant strains of gonorrhea.

(u) C. Penicillin G benzathine is the treatment of choice for primary syphilis.

(u) D. Doxycycline is the treatment of choice for Chlamydia urethritis, not gonococcal urethritis.

Use of systemic corticosteroids can cause which of the following adverse effects in the eye?

A. Cortical blindness

B. Optic atrophy

C. Glaucoma

D. Papilledema

(u) A. Cortical blindness is a rare adverse effect when prescribing salicylates.

(u) B. Optic atrophy can occur as an adverse effect with lead compounds, amebicides, and MAO inhibitors.

(c) C. Glaucoma can be caused by the long-term use of steroids.

(u) D. Papilledema can be a side effect to many systemic medications.

A patient with which of the following is at highest risk for coronary artery disease?

A. Congenital heart disease

B. Polycystic ovary syndrome

C. Acute renal failure

D. Diabetes mellitus

(u) A. Congenital heart disease is not an established risk factor for coronary artery disease.

(u) B. While patients with polycystic ovary syndrome have hyperinsulimemia, they do not have the same poor

prognosis for coronary artery disease as patients with diabetes mellitus.

(u) C. Patients with acute renal failure are not at risk for coronary artery disease, although patients with diabetes and

chronic renal disease do have this risk.

(c) D. Patients with diabetes mellitus are in the same risk category for coronary artery disease as those patients with

established atherosclerotic disease.

Upon stroking of the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan. This is a positive

A. Kernig's sign.

B. Brudzinski's sign.

C. Babinski's sign.

D. Gower's sign.

(u) A. Kernig's sign is positive when pain is noted on straightening the knee after flexing both the hip and knee. (u) B. Brudzinski's sign occurs with neck flexion resulting in resultant flexion of the hips. It is a sign of meningeal

irritation.

(c) C. A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the

great toe dorsiflexes and the other toes fan in a positive test.

(u) D. A positive Gower's sign is noted in certain types of muscular dystrophy and is described as children rising to

stand by rolling over prone and pushing off the floor with arms while the legs remain extended.

Acute rebound hypertensive episodes have been reported to occur with the sudden withdrawal of

A. verapamil (Calan).

B. lisinopril (Prinivil).

C. clonidine (Catapres).

D. hydrochlorothiazide (HCTZ)

(u) A. Verapamil is a calcium channel blocker and there is no associated rebound hypertension after withdrawal. (u) B. Lisinopril is an ACE inhibitor, which is not associated with rebound hypertension.

(c) C. Clonidine (Catapres) is a central alpha agonist and abrupt withdrawal may produce a rebound hypertensive

crisis.

(u) D. Hydrochlorothiazide is a thiazide diuretic, which is not associated with rebound hypertension.

A 72 year-old female presents with vulvular pruritus for the last nine months, which has progressively worsened over the last two months. She states that she went through menopause at age 54 and has been on estrogen and progesterone therapy since that time. Physical examination reveals red lesions with white plaques on the vulva. What should the next course of management include?

A. Refer to a gynecologist for biopsy.

B. Refer to a dermatologist for antifungal therapy.

C. Treat with a topical steroid.

D. Treat with estrogen cream.

(c) A. Vulvular squamous cell hyperplasia causes thickening and hyperkeratosis of the vulva. The lesions are red and moist and cause intense pruritus over time the area becomes thickened and a white plaque may develop. Biopsy must be done to evaluate for intraepithelial neoplasm or invasive tumor.

(u) B. See A for explanation.

(u) C. See A for explanation.

(u) D. See A for explanation.

A 30 year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The most likely diagnosis is

A. placenta abruptio.

B. ectopic pregnancy.

C. pelvic inflammatory disease.

D. ruptured ovarian cyst.

(u) A. This is primarily a third trimester cause of vaginal bleeding.

(c) B. Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis.

(u) C. Pelvic inflammatory disease typically presents with fever, abdominal pain, purulent vaginal discharge, and

cervical motion tenderness.

(u) D. Acute pelvic pain may occur secondary to bleeding from the rupture of a hemorrhagic ovarian cyst, but no

adnexal mass would be palpable on pelvic examination.

A patient presents complaining of periumbilical pain. Which of the following anatomical sites is this finding associated with?

A. Bladder

B. Stomach

C. Pancreas

D. Small bowel

(u) A. Pain from the bladder, uterus, or colon causes hypogastric pain.

(u) B. Pain from the stomach, duodenum, or pancreas causes epigastric pain.

(u) C. See B for explanation.

(c) D. Pain from the small intestine, appendix, or proximal colon causes periumbilical pain.

A 38 year-old female with history of coarctation of the aorta repair at the age of two presents with fevers for four

39

weeks. The patient states that she has felt fatigued and achy during this time. Maximum temperature has been 102.1 degrees F. She denies cough, congestion, or other associated symptoms. Physical examination reveals a pale tired appearing female in no acute distress. Heart reveals a new grade III-IV/VI systolic ejection border at the apex, and a II/VI diastolic murmur at the right sternal border. What is the most likely diagnosis?

A. Acute myocardial infarction

B. Bacterial endocarditis

C. Acute pericarditis

D. Restrictive cardiomyopathy

(u) A. Acute MI presents with complaint of chest pain, SOB, not with fever and myalgias.

(c) B. Bacterial endocarditis presents as febrile illness lasting several days to weeks, commonly with nonspecific

symptoms, echocardiogram often reveals vegetations on affected valves.

(u) C. Pericarditis does not present with systolic or diastolic murmur or vegetation, more commonly pericardial friction

rub would be noted.

(u) D. Restrictive cardiomyopathy will show impaired diastolic filling on echocardiogram and is not associated with

fever.

A 45 year-old male presents with abdominal pain and one episode of mild hematemesis, which happened days ago. On physical examination, vital signs are stable and he is in no acute distress. Hemoglobin and hematocrit are unremarkable; endoscopy reveals non-bleeding small superficial ulceration of the duodenal bulb. Rapid urease test is positive. Which of the following is the most appropriate treatment at this time?

A. Schedule for a selective vagotomy and antrectomy

B. Start an antacid along with omeprazole (Prilosec)

C. Schedule elective ulcer excision and start sucralfate (Carafate)

D. Start omeprazole (Prilosec) and antibiotic therapy against H. pylori

(u) A. Medical therapy should be initiated prior to any consideration of surgery, which is rarely performed secondary to satisfactory ulcer healing with medical therapy.

(u) B. While proton pump inhibitors, such as omeprazole, have excellent results in healing duodenal ulcers, this regimen will not treat the H. pylori infection that is documented by the positive rapid urease test.

(u) C. While sucralfate can be utilized as a cytoprotectant agent in treatment of active ulcer disease or in maintenance of healed ulcers, surgery to remove the ulcer is not warranted as initial therapy.

(c) D. Treatment goals of H. pylori associated ulcers include eradicating the infection with appropriate antibiotics as well as use of a proton pump inhibitor, such as omeprazole, to promote ulcer healing.

A 60 year-old patient with COPD characteristic of emphysema presents with a cough and increased sputum production. The following information is noted: Temperature 100°F (37.8°C); Respiratory rate 20/min; Heart rate 88 beats/min; pH 7.44; PaO2 75 mmHg; PaCO2 40 mmHg; O2 saturation 92%. Physical examination is remarkable for increased AP diameter, diminished breath sounds without wheezes, rhonchi, or other signs of respiratory distress. Which of the following would be an appropriate treatment for this patient?

A. Broad-spectrum antibiotic

B. Admission to the hospital

C. Oxygen at 6 L/min by nasal cannula

D. Brief course of oral theophylline

(c) A. broad-spec abx Sputum production is extremely variable from patient to patient, but any increase in sputum with a history of COPD reported by a patient must be regarded as potentially infectious and treated promptly.

(u) B. Admission is only warranted if the patient's respiratory status requires ventilatory assistance. This patient's blood gases are unremarkable for a patient with COPD and the patient is not in respiratory distress.

(u) C. Oxygen therapy should only be used for severe hypoxemia and should only be given at a low concentration, such as 2 L/min. Higher dose oxygen may stop the hypoxemic ventilatory drive.

(u) D. Oral theophylline is considered a secondary bronchodilator. The use of a metered-dose inhaler would be a preferable first-line treatment if this method of treatment were chosen.

Which of the following conditions will not produce a transudative pleural effusion?

A. Kaposi's sarcoma

B. Pneumonia

C. Cirrhosis

D. Mesothelioma

(u) A. Kaposi's sarcoma, pneumonia, or mesothelioma will produce a transudative pleural effusion.

(u) B. See A for explanation.

(c) C. Transudative pleural effusions result from alteration in the formation of pleural fluid, the absorption of pleural

fluid, or both, by systemic factors. Local factors affecting pleural fluid absorption and/or formation produce

exudative pleural effusions.

(u) D. See A for explanation.

A 23 year-old female with history of palpitations presents for evaluation. She admits to acute onset of rapid heart beating lasting seconds to minutes with associated shortness of breath and chest pain. The patient states she can relieve her symptoms with valsalva. Which of the following is the most appropriate diagnostic study to establish a definitive diagnosis in this patient?

A. Cardiac catheterization

B. Cardiac MRI

C. Chest CT scan

D. Electrophysiology study

(u) A. Cardiac catheterization evaluates coronary arteries but has no role in the diagnosis of supraventricular tachycardia.

(u) B. Cardiac MRI cannot diagnose and define pathway of supraventricular tachycardia.

(u) C. Chest CT scan will not establish definitive diagnosis of supraventricular tachycardia.

(c) D. Electrophysiology study is useful in establishing the diagnosis and pathway of complex arrhythmias such as supraventricular tachycardia.

The finding of egophony is most consistent with

A. emphysema.

B. atelectasis.

C. pneumothorax.

D. lobar pneumonia.

(u) A. Emphysema presents with diminished or absent breath sounds and hyperresonance to percussion without egophony.

(u) B. Atelectasis most commonly has decreased breath sounds and dullness to percussion without egophony.

(u) C. Pneumothorax presents with absent breath sounds, tactile fremitus, and resonance to percussion without

egophony.

(c) D. Egophony occurs with consolidation caused by lobar pneumonia.

A patient presents with edema, which is most noticeable in the hands and face. Laboratory findings include proteinuria, hypoalbuminemia, and hyperlipidemia. The most likely diagnosis is

A. congestive heart failure.

B. end-stage liver disease.

C. nephrotic syndrome.

D. malnutrition.

(u) A. Dependent edema is the most typical finding with CHF. Laboratory findings do not generally include proteinuria or hypoalbuminemia.

(u) B. Symptoms of end-stage liver disease usually include increased abdominal girth indicating ascites. Hypoalbuminemia can occur as a result of malnutrition or concurrently with nephrotic syndrome.

(c) C. Proteinuria, hyperlipidemia, and hypoalbuminemia are consistent with nephrotic syndrome.

(u) D. Malnutrition is marked by physical wasting, not edema. Hypoalbuminemia may be seen, but hyperlipidemia is

not typical.

Which of the following can be used to treat chronic bacterial prostatitis?

A. Penicillin

B. Cephalexin (Keflex)

C. Nitrofurantoin (Macrobid)

D. Levofloxacin (Levaquin)

(u) A. See D for explanation.

(u) B. See D for explanation.

(u)\C. See D for explanation.

(c) D. Chronic bacterial prostatitis (Type II prostatitis) can be difficult to treat and requires the use of fluoroquinolones or trimethoprim-sulfamethoxazole, both of which penetrate the prostate.

A 25 year-old male with history of syncope presents for evaluation. The patient admits to intermittent episodes of rapid heart beating that resolve spontaneously. 12 Lead EKG shows delta waves and a short PR interval. Which of the following is the treatment of choice in this patient?

A. Radiofrequency catheter ablation

B. Verapamil (Calan)

C. Percutaneous coronary intervention

D. Digoxin (Lanoxin)

(c) A. Radiofrequency catheter ablation is the treatment of choice on patients with accessory pathways, such as Wolff-Parkinson-White Syndrome.

(h) B. Calcium channel blockers such as verapamil decrease refractoriness of the accessory pathway or increase that of the AV node leading to faster ventricular rates, therefore calcium channel blockers should be avoided in patients with WPW.

(u) C. Percutaneous coronary intervention is indicated in the treatment of coronary artery disease, not preexcitation syndromes.

(h) D. Digoxin decreases refractoriness of the accessory pathway and increases that of the AV node leading to faster ventricular rates. It should therefore be avoided in patients with WPW.

Gallstones usually result in biliary symptoms by causing inflammation or obstruction following migration into the common bile duct or

A. cystic duct.

B. pancreatic duct.

C. duodenal ampulla.

D. common hepatic duct.

(c) A. Obstruction of the cystic duct by gallstones causes the typical symptom of biliary colic. Once obstructed the gallbladder distends and becomes edematous and inflamed. Gallstones can also migrate into the common bile duct through the cystic duct leading to a condition known as choledocholithiasis.

(u) B. Obstruction of the pancreatic duct leads to development of acute pancreatitis.

(u) C. The duodenal ampulla is the area where the pancreatic duct and the common bile duct empty into the

duodenum. Gallstones do not cause obstruction at this distal site.

(u) D. The common hepatic duct from the liver joins the cystic duct from the gallbladder to form the common bile duct.

Stone migration occurs along the pathway of the cystic duct to the common bile duct, not along the common hepatic duct.

An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient?

A. Administer nebulized corticosteroids

B. Admit to the hospital

C. Oral antimicrobial therapy

D. Endotracheal intubation

(u) A. Inhaled corticosteroids are not utilized in the management of community-acquired pneumonia.

(c) B. Admit Community acquired pneumonia is the most deadly infectious disease in the U.S. Important risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, altered mental status, respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30.

(u) C. Due to the age of the patient, comorbid diseases, and current signs of respiratory distress, intravenous not oral antimicrobial therapy is indicated.

(u) D. Endotracheal intubation is indicated for respiratory failure unresponsive to conservative management.

An 80 year-old female presents with pain in her vertebral column. Radiography reveals compression fracture of T12 that is consistent with osteoporotic compression fracture. Which of the following treatment modalities has the potential to cause analgesia of the fracture site with its use?

A. Calcitonin (Miacalcin) nasal spray

B. Alendronate (Fosamax)

C. Raloxifene (Evista)

D. Combined estrogen and progesterone (Prempro) therapy

(c) A. Calcitonin has the ability to cause analgesia when used for acute compression fracture of the vertebral body. (u) B. Alendronate is effective in building new bone for a patient with osteoporosis but has no associated analgesic

effect.

(u) C. Raloxifene is a selective estrogen receptor modulator and has positive effects on bone density when used to

treat osteoporosis. Raloxifene, however, has no analgesic properties.

(u) D. Combined hormonal therapy may have positive effects on bone density but it has no analgesic properties.

A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment?

A. Decrease the oxygen flow rate.

B. Administer oral corticosteroids.

C. Intubate the patient.

D. Administer salmeterol (Serevent)

(h) A. Decreasing the oxygen flow rate would be harmful as it would decrease the amount of oxygen delivered to the patient.

(u) B. Administration of steroids is an important treatment modality but this patient is in respiratory failure and needs more immediate therapy.

(c) C. This person has increasing respiratory failure as indicated by the raising PaCO2 levels. Intubation is required at this time.

(h) D. Long-acting beta agonist therapy such as salmeterol is not utilized for rescue therapy.

To further assess ascites in a patient, the physician assistant instructs the patient to turn onto one side while performing percussion. Which of the following is the reason for this maneuver?

A. Testing for shifting of dullness on percussion

B. Shifting of internal organs making percussion easier

C. Trying to elicit any pain while moving

D. Trying to produce a caput medusa

(c) A. In ascites, dullness shifts to the more dependent side as the fluid relocates into dependent space, while tympany shifts to the top as the gas-filled organs float to the top of the ascitic fluid.

(u) B. See A for explanation.

(u) C. Pain with movement is associated with peritonitis and not ascites.

(u) D. Caput medusa is the dilation of the superficial abdominal veins due to increased intraabdominal fluid

accumulation. It is visible with the patient standing and does not need a special maneuver for identification.

A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected?

A. T6 B. T8 C. T10 D. T12

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. The dermatome T10 is at the level of the umbilicus. (u) D. See C for explanation.

A 25 year-old female graduate student presents to the student health center for the eighth time in three weeks to be sure she does not have meningitis. She read that there was a student on campus who had meningitis last month, and now she has headaches and is requesting to be tested to make sure she does not have meningitis. She has been evaluated at each visit, and physical examination has been completely normal each time. Which of the following is the most likely diagnosis?

A. Conversion disorder

B. Hypochondriasis

C. Malingering

D. Somatization disorder

(u) A. Conversion disorder is characterized by onset of symptoms or deficits mimicking neurologic or medical illness, but the etiology is psychological.

(c) B. Hypochondriasis is the chronic preoccupation with the idea of having a serious disease, which is usually not amenable to reassurance

(u) C. Malingering is the intentional production or feigning of physical or psychological signs and symptoms for some gain.

(u) D. Somatization disorder is characterized by complaints of pain, often related to gastrointestinal and sexual dysfunction, and pseudoneurological symptoms.

A 29 year-old patient with idiopathic thrombocytopenia purpura (ITP) is treated with prednisone therapy. Despite therapy, platelet counts remain consistently below 20,000/microliter over the course of 6 weeks. Which of the following is the most appropriate intervention for this patient?

A. Aspirin

B. Intravenous immunoglobulin

C. Danazol (Danocrine)

D. Splenectomy

(h) A. Aspirin inhibits platelet function and could lead to significant bleeding and death of this patient.

(u) B. Intravenous immunoglobulin can be utilized for short-term treatment, but the platelet count is likely to return tobaseline within a month.

(u) C. Danazol is typically reserved for ITP that fails to respond to splenectomy.

(c) D. Persistently low platelet counts (< 20,000) require effective long-term treatment, and splenectomy is the treatment of choice.

Which of the following clinical findings would be seen in a patient with food poisoning caused by Staphylococcus aureus?

A. Ingestion of mayonnaise-based salads 48 hours earlier B. Bloody diarrhea with mucus for one week

C. Abdominal cramps and vomiting for 48 hours

D. High fever for 1 week

(u) A. A preformed toxin causes staphylococcal food poisoning; it has a short incubation period of 1-8 hours.

(u) B. Because Staphylococcus aureus does not invade the mucus, blood and mucus are not seen with this

noninflammatory cause of food poisoning.

(c) C. Abdominal cramps, nausea, vomiting, and watery diarrhea typically last 1-2 days with staphylococcal food poisoning.

(u) D. Staphylococcal food poisoning may be associated with low-grade fever or subnormal temperature.

Which of the following diagnostic tests should be ordered initially to evaluate for suspected deep venous thrombosis of the leg?

A. Venogram

B. Arteriogram

C. Duplex ultrasound

D. Impedance plethysmography

(u) A. Venogram has been replaced by noninvasive tests due to discomfort, cost, technical difficulties, and complications, such as phlebitis.

(h) B. Thrombophlebitis is a venous problem, not an arterial one. Any unnecessary invasive procedure is potentially harmful.

(c) C. Ultrasound is the technique of choice to detect deep venous thrombosis in the leg.

(a) D. Impedance plethysmography is equivalent to ultrasound in detecting thrombi of the femoral and popliteal veins,but it may miss early, nonocclusive thrombi.

A 26 year-old man is stung by a bee, and shortly thereafter, a wheal develops at the site of the sting. He soon feels flushed and develops hives, rhinorrhea, and tightness in the chest. He is seen in the urgent care center. Immediate therapy should be to

A. transfer him to a local hospital emergency department. B. apply a cold compress to site of the sting.

C. administer subcutaneous epinephrine.

D. administer oral albuterol.

(u) A. Systemic (anaphylactic) reactions can rapidly become life-threatening. Delay in treatment may cause death.

(u) B. This is only supportive local therapy and does not address the need to treat the systemic reaction present.

(c) C. Epinephrine hydrochloride 1:1000, 0.2 to 0.5 mL subcutaneously is indicated for the initial treatment of this

systemic reaction. Additional injections may be given every 20 to 30 minutes if needed.

(u) D. Albuterol is indicated in the presence of bronchospasm (suggested by the presence of chest tightness), but would be delivered by an aerosol, not an oral, route.

An 18 year-old sexually active female was seen in the student health clinic 1 week ago for a sore throat. A streptococcal antigen test was positive, and she was given a prescription for oral penicillin. After 3 days, she stopped her medication because she felt better. She now presents with a severe sore throat. On physical examination, she has a temperature of 102.6° F (39.2° C), marked pharyngeal erythema, medial deviation of the soft palate on the left, tender left anterior cervical adenopathy, and a "hot potato" voice. The rest of her history and physical examination are unremarkable. Which of the following is the most likely diagnosis?

A. Recurrent streptococcal pharyngitis

B. Infectious mononucleosis

C. Gonococcal pharyngitis

D. Peritonsillar abscess

(u) A. This presentation suggests a complication of an incompletely treated streptococcal pharyngitis rather than recurrent disease.

(u) B. Infectious mononucleosis may present with severe sore throat, fever, and cervical adenopathy in this age group, but would not cause deviation of the soft palate or the muffled voice.

(u) C. Gonococcal pharyngitis usually follows a more indolent course than this patient's presentation.

(c) D. The soft palate deviation and a muffled voice are classic signs of peritonsillar abscess.

A 36 year-old patient with cardiomyopathy secondary to viral myocarditis develops fatigue, increasing dyspnea, and lower extremity edema over the past 3 days. He denies fever. A chest x-ray shows no significant increase in heart size, but reveals prominence of the superior pulmonary vessels. Based on these clinical findings, which of the following is the most likely diagnosis?

A. Heart failure

B. Subacute bacterial endocarditis

C. Pulmonary embolus

D. Pneumonia

(c) A. Given the presence of cardiomyopathy, the patient's heart has decreased functional reserve. The symptoms and chest x-ray findings are typical of congestive heart failure.

(u) B. Endocarditis occurs as a result of infection that primarily occurs in the blood stream. Endocarditis would present with signs of infection or seeding rather than signs of heart failure.

(u) C. Pulmonary embolus usually presents with an acute onset of chest pain, severe dyspnea, and anxiety.

(u) D. Pneumonia is less likely since there is no fever and edema is not usually associated with pneumonia.

Which of the following is first-line treatment for symptomatic bradyarrhythmias due to sick sinus syndrome (SSS)?

A. Permanent pacemaker

B. Radiofrequency ablation

C. Antiarrhythmics

D. Anticoagulation therapy

(c) A. Permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in sick sinus syndrome.

(u) B. Radiofrequency ablation is used for the treatment of accessory pathways in the heart.

(u) C. See A for explanation.

(u) D. See A for explanation.

What type of chest pain is most commonly associated with a dissecting aortic aneurysm?

A. Squeezing

B. Dull, aching

C. Ripping, tearing

D. Burning

(u) A. Squeezing pain is more characteristic of angina or esophageal pain.

(u) B. Dull, aching pain is more characteristic of chest wall pain, possibly angina, or anxiety.

(c) C. A dissecting aortic aneurysm often presents with a very severe ripping, tearing-like pain.

(u) D. Burning pain is more characteristic of esophageal reflux, esophagitis, or tracheobronchitis.

Which of the following views on plain films is preferred to identify spondylolysis?

A. Anterior B. Posterior C. Oblique D. Lateral

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. The defect in the pars articularis (usually bilateral) is best visualized on the oblique projections on plain films. (u) D. See C for explanation.

A 15 year-old softball player presents after jamming the distal tip of her finger into severe flexion. She is unable to extend the distal phalanx and she has pain on palpation of the distal interphalangeal joint. X-ray of the hand fails to reveal any associated avulsion fracture. Which of the following is the treatment of choice?

A. Open reduction and internal fixation

B. Continuous extension of the DIP with splinting

C. Continuous flexion of the PIP with splinting

D. Application of short arm cast

(u) A. See B for explanation.

(c) B. The treatment of choice for a tear in the extensor tendon of the finger is continuous extension of the DIP via

splinting for 6 to 8 weeks.

(u) C. See B for explanation.

(u) D. Short arm casting is indicated in wrist and metacarpal injuries but not in DIP extensor injuries.

A 57 year-old male was working on his farm, when some manure was slung hitting his left eye. He presents several days after with a red, tearing, painful eye. Fluorescein stain reveals uptake over the cornea looking like a shallow crater. Which of the following interventions would be harmful?

A. Ophthalmic antibiotics

B. Pressure patch

C. Examination for visual acuity

D. Copious irrigation

(u) A. Ophthalmic antibiotics and copious irrigation are indicated when treating a patient with a suspected corneal ulcer due to an infectious cause.

(c) B. Patching of the eye after abrasion associated with organic material contamination is contraindicated due to increased risk of fungal infection.

(u) C. Examination for assessment of visual acuity should be performed.

(u) D. See A for explanation.

A 75 year-old female falls on her outstretched arm. She sustains a humeral mid-shaft fracture. Nerve impingement occurs due to the fracture. What is the most likely physical examination abnormality that will be encountered?

A. Inability to extend the wrist against resistance

B. Numbness over the deltoid muscle in the shoulder

C. Winging of the scapula

D. Weakness of the rotator cuff

(c) A. The radial nerve is most likely entrapped by this fracture. Radial nerve damage will cause an inability to extend the wrist against resistance.

(u) B. Axillary nerve injury results in numbness over the deltoid muscle; this nerve is more commonly injured in proximal humeral fractures and anterior shoulder dislocations.

(u) C. Injury to the long thoracic nerve causes winging of the scapula due to its innervation of the serratus anterior muscle.

(u) D. Injury to the subscapular nerve results in weakness and pain of the infraspinatus muscle; this injury is commonly seen in volleyball players from repetitive stress.

A 16 year-old male involved in a fight sustained a laceration to his right upper eyelid. He is unable to open his eye, and a possible laceration of the globe is suspected. Which of the following is the next step?

A. Use a slit lamp to determine the extent of the injury.

B. Use fluorescein strips to determine the extent of injury.

C. Apply a metal eye shield and refer to an ophthalmologist.

D. Apply antibiotic ointment to the lid and recheck in 24 hours.

(h) A. See C for explanation.

(h) B. See C for explanation.

(c) C. Protect the eye from any pressure with a rigid metal eye shield and refer for immediate ophthalmologic

consultation. Avoid unnecessary actions that would delay treatment or cause further injury.

(h) D. See C for explanation.

A 72 year-old patient with a history of hypertension and atrial fibrillation presents with episodes of weakness, numbness, and paresthesias in the right arm. At the same time, she notes speech difficulty and loss of vision in her left eye. These symptoms come on abruptly and clear within minutes. Physical examination is normal except for the previously known arrhythmia. Which of the following is the most likely diagnosis?

A. Focal seizure

B. Migraine headache

C. Hypoglycemic episodes

D. Transient ischemic attack

(u) A. Focal seizures usually cause abnormal motor movement rather than weakness or loss of feeling.

(u) B. Patients with migraines commonly have a history of episodes since adolescence.

(u) C. Hypoglycemic episodes do not present with focal neurological findings.

(c) D. This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.

Which of the following physical examination findings would be consistent with a pleural effusion?

A. Hyperresonance to percussion

B. Increased tactile fremitus

C. Unilateral lag on chest expansion

D. Egophony

(u) A. Hyperresonance to percussion would be suggestive of emphysema or pneumothorax.

(u) B. Increased tactile fremitus would be consistent with a consolidation.

(c) C. A lag on chest expansion may be seen in the presence of a pleural effusion.

(u) D. The presence of egophony would be consistent with a consolidation.

A 26 year-old female arrives in the emergency department with friends who say she was standing in front of her church, dressed in a white bathrobe, claiming to be the Virgin Mary and handing out $100 bills to all passers-by. Her friends noted that she had been depressed lately, but now seems completely euphoric. She had a similar episode two years ago. Which of the following is the most appropriate treatment?

A. Inpatient olanzapine (Zyprexa) therapy

B. Inpatient electroconvulsive therapy

C. Outpatient paroxetine (Paxil) therapy

D. Outpatient psychotherapy

(c) A. Treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants.

(u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

A 19 year-old patient was involved in a motor vehicle crash and brought to the emergency department fully immobilized. The patient sustained multiple blunt injuries to the chest and abdomen. During the trauma assessment, there was no blood at the urethral meatus and a Foley catheter was placed. The urine was positive for blood on the dipstick. Which of the following is the most appropriate diagnostic test?

A. Retrograde urethrography

B. CT scan of abdomen and pelvis

C. Serum haptoglobin

D. Urine myoglobin

(u) A. A retrograde urethrogram should be performed when blood is found at the external urinary meatus prior to insertion of a catheter.

(c) B. CT scan of the abdomen and pelvis is indicated in blunt trauma including those resulting in hematuria or when renal injury is suspected.

(u) C. A decreased serum haptoglobin is seen in hemolysis and does not provide information on renal status.

(u) D. A positive test for blood in the absence of red blood cells on urine examination suggests myoglobinuria, and

should be confirmed by electrophoresis.

A 52 year-old male with history of hypertension and hyperlipidemia presents with an acute myocardial infarction. Urgent cardiac catheterization is performed and shows a 90% occlusion of the left anterior descending artery. The other arteries have minimal disease. Ejection fraction is 45%. Which of the following is the treatment of choice in this patient?

A. Coronary artery bypass grafting (CABG)

B. Streptokinase

C. Percutaneous coronary intervention (PCI)

D. Warfarin (Coumadin)*

(u) A. Percutaneous coronary intervention is a better, less invasive alternative to CABG for single vessel coronary artery disease.

(h) B. Streptokinase is not commonly used for treatment of acute myocardial infarction because it is ineffective at opening the occluded artery and reducing mortality. Streptokinase would be harmful because it would increase the risk of bleeding.

(c) C. Immediate coronary angiography and primary percutaneous coronary intervention (PCI) have been shown to be superior to thrombolysis.

(u) D. Warfarin is used to prevent thrombosis and not for acute treatment.

An 18 year-old male presents with pain in his wrist after he fell off of a moving motor cycle. Physical examination reveals tenderness in the anatomic snuffbox. No fracture is noted on plain radiography of the wrist. Which of the following is the recommended treatment for this patient?

A. Ace wrap of the wrist

B. Closed reduction of the fracture site

C. Thumb spica cast application

D. Open reduction of the fracture site

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. Even with normal initial radiographs, patients with a consistent history and tenderness in the anatomical

snuffbox are treated as a stable fracture with immobilization in a thumb spica cast. Casting is recommended for all presumed nondisplaced scaphoid fractures.

(u) D. See C for explanation.

Early clues to impending delirium tremens include

A. agitation and decreased cognition.

B. visual hallucinations and diaphoresis.

C. autonomic hyperactivity and dehydration.

D. mental confusion and sensory hyperacuity.

(c) A. Anxiety, decreased cognition, tremulousness, increasing irritability, and hyperactivity are common early clues to impending delirium tremens.

(u) B. Mental confusion, tremor, sensory hyperacuity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances, seizures, and cardiovascular abnormalities are common signs and/or symptoms of full-blown delirium tremens.

(u) C. See B for explanation. (u) D. See B for explanation.

A 36 year-old woman admits that her husband has abused her for over ten years. You should inform the woman that she is at most risk for injury or death

A. just before a holiday.

B. just after leaving an abusive spouse.

C. when an abusive spouse arrives home after work.

D. when an abusive spouse has been drinking heavily.

(u) A. See B for explanation.

(c) B. Women are more likely to be assaulted or murdered when attempting to report the abuse or leave the abusive

relationship; up to 75% of domestic assaults occur after separation.

(u) C. See B for explanation.

(u) D. See B for explanation.

A patient presents with an acutely painful and cold left leg. Distal pulses are absent. Leg is cyanotic. There are no signs of gangrene or other open lesions. Symptoms occurred one hour ago. Which of the following treatments is most appropriate?

A. Vena cava filter

B. Embolectomy

C. Amputation

D. Aspirin

(u) A. Vena cava filters are used in the management of venous thromboembolic disease when anticoagulation cannot be done.

(c) B. Embolectomy within 4 to 6 hours is the treatment of choice.

(h) C. Amputation is done only when no viable tissue is present. Cutting off a viable limb is never a good idea.

(u) D. Aspirin is used in the prevention and treatment of coronary disease and has no role in the treatment of

peripheral arterial embolism.

A 53 year-old male is seen in the emergency department following a motor vehicle collision in which his knee impacted against the dashboard. The patient has a posterior knee dislocation that is promptly reduced in the emergency department. The patient currently has a palpable pulse in the dorsalis pedis and posterior tibial areas. Which of the following studies is mandatory?

A. Anterior plain film of knee

B. Sunrise view of the knee

C. Measurement of compartment pressures

D. Angiography

(u) A. See D for explanation.

(u) B. See D for explanation.

(u) C. Compartment pressures are performed in cases of suspected compartment syndrome, not to determine the

patency of the popliteal artery.

(c) D. The popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and

should be evaluated with an arteriogram despite the presence of pedal pulses.

A 70 year-old presents with headache and neck stiffness. On physical exam, the patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL, and glucose 35 mg/dL. Which of the following is the most appropriate treatment?

A. Acyclovir (Zovirax)

B. Fluconazole (Diflucan)

C. Ampicillin and ceftriaxone (Rocephin)

D. Penicillin and chloramphenicol (Chloromycetin)

(u) A. Acyclovir is used to treat meningitis secondary to herpes. Viral meningitis presents with increase number of lymphocytes and elevated glucose in the CSF .

(u) B. Fluconazole is used to treat fungal meningitis. Fungal meningitis, typically noted in immunocompromised hosts, presents with increase number of lymphocytes in the CSF.

(c) C. Ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes , which is common in the elderly. Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia

(u) D. Penicillin and chloramphenicol is used to treat bacterial meningitis, secondary to Neisseria meningitidis. Bacterial meningitis due to N

A 74 year-old female is being treated for mild hypertension. She is found at home with right hemiparesis and brought to the emergency department. Her daughter states that the patient fell in her kitchen 2 days ago, but had no complaints at that time. She did state that her mother sounded a little confused this morning. The patient's left pupil is dilated. Which of the following diagnostic studies should be ordered first?

A. MRI of the brain

B. CT scan of the brain

C. Skull x-ray

D. Lumbar puncture

(u) A. See B for explanation.

(c) B. This patient presents with a history of minor trauma and progressive neurological abnormalities consistent with subdural hematoma. Diagnosis would be confirmed by CT scan, which is less expensive and more sensitive for blood than an MRI.

(u) C. Skull x-rays would not be helpful because they evaluate bony, not soft tissue, injury.

(h) D. A lumbar puncture is contraindicated because of the potential for brain herniation.

Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes?

A. Cerebrovascular disease

B. Encephalitis

C. Tumor

D. Idiopathic epilepsy

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or

alcohol withdrawal.

(u) D. See C for explanation.

A 32 year-old presents with a 3-day history of diarrhea. The patient denies blood, mucus, or night awakening with diarrhea. He recently returned from a business trip to Canada. On physical examination, the patient is afebrile and vital signs reveal BP 115/80, pulse is 76, and respirations are 14. The abdominal examination reveals hyperactive bowel sounds, but is otherwise unremarkable. Which of the following is the most appropriate initial intervention?

A. Stool for culture, ova, and parasites

B. Proctosigmoidoscopy

C. Metronidazole (Flagyl)

D. Supportive treatment

(u) A. Stool culture and examination for ova and parasites are indicated when the diarrhea has persisted longer than 3 weeks or is associated with abdominal pain, fever, and/or bloody stools.

(u) B. Proctosigmoidoscopy is indicated when inflammatory bowel disease is suspected on the basis of fever, bloody diarrhea, or abdominal pain.

(u) C. Metronidazole is indicated with a confirmed diagnosis of Giardia lamblia or amebic disease.

(c) D. Symptomatic treatment, including dietary management and over-the-counter antidiarrheals, is indicated for afebrile patients with watery diarrhea of less than 5 days duration.

A 62 year-old male presents with complaints of vague epigastric abdominal pain associated with jaundice and generalized pruritus. Physical examination reveals jaundice and a palpable non-tender gallbladder, but is otherwise unremarkable. Which of the following is the most likely diagnosis?

A. Viral hepatitis

B. Pancreatic cancer

C. Acute cholecystitis

D. Gilbert's syndrome

(u) A. While viral hepatitis may cause jaundice, the liver is enlarged and tender.

(c) B. Pancreatic cancer is suggested by the vague epigastric pain with the jaundice resulting from biliary obstruction due to cancer involving the pancreatic head. The presence of a palpable non-tender gallbladder (Courvoisier's sign) also indicates obstruction due to the cancer.

(u) C. While acute cholecystitis may present with jaundice and an enlarged gallbladder, the pain is classically colicky and located in the right upper quadrant. On physical examination with deep inspiration and palpation of the right subcostal area increased pain and respiratory arrest (Murphy's sign) is usually seen.

(u) D. Gilbert's syndrome is the most common of the hereditary hyperbilirubinemias. It is most often diagnosed near puberty or adult life based on results of a comprehensive metabolic panel.

A 65 year-old male presents with back pain two days after he was shoveling snow. The patient complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected?

A. L3-L4 B. L4-L5 C. L5-S1 D. S1-S2

(u) A. See C for explanation.

(u) B. See C for explanation.

(c) C. The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 discaffects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus

muscles.

(u) D. See C for explanation.

A 22 year-old female presents to the emergency department with rapid heart rate. She appears quite thin and dehydrated. She denies that she is thin, stating "I am so fat that I can hardly stand myself! That is why I exercise every day." She runs twelve to fifteen miles a day, and on weekends also bicycles forty to fifty miles. Her LMP was six months ago. On exam, she is 5' 6" tall and weighs 98 pounds. Temp 98 degrees F, pulse 100, respirations 18, BP 98/60. EKG shows sinus tachycardia. Laboratory findings include Na 138 mEq/L, K 2.8 mEq/L, Cl 91 mEq/L, BUN 35 mg/dL, Creatinine 1.1 mg/dL. Which of the following is the next most appropriate treatment?

A. Propylthiouracil (PTU) and individual psychotherapy

B. Hormone replacement and cognitive therapy

C. Weight restoration and family therapy

D. IV hydration and antidepressant therapy

(u) A. Propylthiouracil is used to treat hyperthyroidism, not anorexia nervosa.

(u) B. Hormone replacement is not indicated for the amenorrhea of anorexia nervosa, but nutritional support may help.

(c) C. Weight restoration and family therapy Anorexia nervosa requires a comprehensive, multidisciplinary approach to treatment that integrates medical management, individual psychotherapy, and family therapy. Currently, the best results have been shown with weight restoration accompanied by family therapy for patients with adolescent-onset anorexia nervosa and individual therapy for patients with onset after 18 years of age. Inpatient treatment is often required.

(u) D. Antidepressant therapy may be useful in bulimia nervosa.

Which of the following is the most common cause for acute myocardial infarction?

A. Occlusion caused by coronary microemboli

B. Thrombus development at a site of vascular injury

C. Congenital abnormalities

D. Severe coronary artery spasm

(u) A. Coronary microemboli occlusion is a rare cause of acute myocardial infarction.

(c) B. Acute myocardial infarction occurs when a coronary artery thrombus develops rapidly at a site of vascular injury. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis, so that a mural thrombus forms at the site of rupture and leads to coronary artery occlusion.

(u) C. Congenital abnormalities are rare causes of acute MI.

(u) D. Severe coronary artery spasm is more likely to result in Prinzmetal's angina rather than true infarction.

Which of the following rotator cuff tendons is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament?

A. Supraspinatus

B. Infraspinatus

C. Teres minor

D. Subscapularis

(c) A. A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is most commonly seen with the supraspinatus tendon, the long head of the biceps tendon and/or the subacromial bursa.

(u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

A 13 year-old boy with leukemia presents with epistaxis for 2 hours. The bleeding site appears to be from Kiesselbach's area. The most appropriate intervention is

A. electrocautery of the bleeding site.

B. silver nitrate application.

C. posterior nasal packing.

D. intranasal petrolatum gauze.

(u) A. Cautery is not used because the edges of the cauterized area may begin to bleed.

(u) B. Silver nitrate is not used in children because it increases the risk for nasal septal perforation.

(u) C. Posterior nasal packing is indicated for posterior bleeds in the inferior meatus.

(c) D. Petrolatum gauze will provide pressure to the bleeding point while the cause of bleeding is corrected.

Which of the following is the most common cause of arterial embolization?

A. Rheumatic heart disease

B. Myxoma

C. Atrial fibrillation

D. Venous thrombosis

(u) A. Rheumatic heart disease is a rare cause of embolization

(u) B. Myxoma is a rare cause of embolization.

(c) C. Atrial fibrillation is present in 60-70% of patients with arterial emboli and is associated with left atrial appendage thrombus.

(u) D. Venous thrombosis may be a cause of embolization paradoxically, but is uncommon.

A 25 year-old man presents with odynophagia and dysphagia. On endoscopic examination, small, white, patches with surrounding erythema are noted. Silver stain is positive for hyphae. The best treatment option for this patient is

A. acyclovir (Zovirax).

B. omeprazole (Prilosec).

C. fluconazole (Diflucan).

D. penicillin G.

(u) A. Acyclovir is an antiviral used in the treatment of herpes esophagitis.

(u) B. Omeprazole is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease with

esophageal ulceration and peptic ulcer disease and is not indicated in the treatment of infectious esophagitis.

(c) C. The patient has Candida esophagitis and the treatment of choice is fluconazole.

(u) D. Penicillin G is an antibiotic and is not effective against fungal infections.

The most common arrhythmia encountered in patients with mitral stenosis is

A. atrial flutter.

B. atrial fibrillation.

C. paroxysmal atrial tachycardia.

D. atrio-ventricular dissociation.

(u) A. See B for explanation.

(c) B. Mitral stenosis leads to enlargement of the left atrium, which is the major predisposing risk factor for the

development of atrial fibrillation.

(u) C. See B for explanation.

(u) D. See B for explanation.

A mother brings her teenage daughter to the emergency department. The teenager is anxious, tremulous, and in a dysphoric mood. She reports recent nightmares and insatiable hunger. Which of the following diagnostic tests would likely yield the most important information?

A. Serum TSH

B. Urine drug screen

C. Minnesota Multiphasic Personality Inventory (MMPI) D. Electroencephalogram (EEG)

(u) A. While hyperthyroidism can cause tremor and sometimes hunger, it is not associated with a dysphoric mood. It also generally occurs in early adulthood.

(c) B. A drug screen would be helpful for many drugs of abuse that might cause these symptoms, but may not be definitive for amphetamines.

(u) C. The MMPI is an objective personality assessment instrument. There is no indication for its use here.

(u) D. While an EEG might be useful later (assuming the drug screen was negative), there is no history to indicate

use of this test early on.

A 75 year-old woman presents to the office with complaint of vision loss. Examination reveals a palpable cord in the temporal region. Which of the following is the most helpful initial test to order on this patient?

A. Carotid ultrasound

B. Chest x-ray

C. Complete blood count

D. Erythrocyte sedimentation rate

(u) A. See D for explanation.

(u) B. See D for explanation.

(u) C. See D for explanation.

(c) D. The patient is suspected of having temporal arteritis. This disease is most commonly noted in patients over age 50 and should be suspected in patients with sudden vision loss and a palpable cord in the temporal region. Erythrocyte sedimentation rate is almost always increased in this disease.

A 53 year-old male with history of hypertension presents complaining of recent 4/10 left-sided chest pain with exertion that is relieved with rest. He states the pain usually lasts approximately 4 minutes and is relieved with rest. Heart examination reveals regular rate and rhythm with no S3, S4, or murmur. Lungs are clear to auscultation bilaterally. Electrocardiogram reveals no acute changes. Which of the following is the most appropriate initial step in the evaluation of this patient?

A. Cardiac catheterization

B. CT Angiogram of the chest

C. Echocardiogram

D. Nuclear stress test

(u) A. This patient has signs and symptoms consistent with stable angina. Noninvasive diagnostic testing is preferred in this patient.

(u) B. CT angiogram may be useful for the evaluation of chest pain, however its role in routine practice has not been established.

(u) C. This patient has signs and symptoms of stable angina. There are no signs of valvular heart disease on examination. While an echocardiogram may be performed at some point, it is not the best initial diagnostic step to determine the etiology of the patient's angina.

(c) D. Nuclear stress testing is the most appropriate initial diagnostic study in the evaluation of a patient with signs and symptoms consistent with stable angina.

A 33 year-old male presents to your office with a complaint of right knee injury associated with pain and swelling. He states he was running after his loose dog and suddenly stopped, hyperextended his knee, heard a pop and noticed immediate swelling. On physical examination, the Lachman test and anterior drawer test demonstrates joint laxity. Which of the following ligaments is most likely injured?

A. Medial collateral

B. Lateral collateral

C. Posterior cruciate

D. Anterior cruciate

(u) A. Medial collateral ligament injuries often occur with rotational injuries or direct impact to the lateral knee. Tenderness medially with laxity with valgus (medial) stress is noted.

(u) B. Lateral collateral ligament injury causes pain mostly on the lateral aspect of the knee and patients can experience knee buckling with normal gait. Tenderness laterally with laxity with varus (lateral) stress is noted.

(u) C. Posterior cruciate ligament injuries occur with an outside directed force, often a posterior directed force such as a knee striking a dashboard. The patients often do not hear a pop. A posterior drawer test or posterior sag test can be useful in the diagnosis.

(c) D. Anterior cruciate ligament injuries occur with sudden deceleration injuries. Patients often hear a pop and the diagnosis is aided by assessing the anterior drawer test and Lachman test. The immediate swelling as well as laxity with anterior drawer test and Lachman test should raise suspicion of anterior cruciate ligamental injury.

A 22 year-old woman comes to the office because her urine is cola-colored and she has not urinated since yesterday morning. Her past medical history is significant for pharyngitis two weeks ago. Her mother and grandmother have type 2 diabetes. Her blood pressure is 146/92mmHG. On physical examination, she has edema of her face and hands. Which of the following is the most likely diagnosis?

A. Glomerulonephritis

B. Acute tubular necrosis

C. Nephrolithiasis

D. Diabetic nephropathy

(c) A. Glomerulonephritis presents with hematuria, cola-colored urine, oliguria, and edema of the face and eyes in the morning. Urinalysis reveals red blood cells, mild proteinuria and red blood cell casts. Glomerulonephritis can occur 1-3 weeks after a strep infection.

(u) B. Acute tubular necrosis is caused by acute kidney injury, such as a nephrotoxin, and is associated with uremic symptoms which include nausea, vomiting, malaise, and altered mental status. Granular casts are nonspecific and may be seen in acute tubular necrosis.

(u) C. Nephrolithiasis usually presents as a sudden onset of colicky flank pain with associated nausea and vomiting. Urinalysis often reveals gross or microscopic hematuria.

(u) D. Diabetic nephropathy is the most common cause of end stage renal disease in the United States. Urine examination reveals albuminuria.

A 15 year-old girl is hit in the right eye by a golf ball. There is swelling and ecchymosis of the orbit. She complains of double vision. The right eye does not move with downward gaze or right lateral gaze. Which of the following diagnostic tests will provide the most accurate information regarding this injury?

A. Facial x-ray

B. Schiotz tonometry

C. Fluorescein angiography

D. Slit lamp biomicroscopy

(c) A. X-ray films may show a blow-out fracture of the orbital floor. Such fractures may lead to oculomotor nerve entrapment or may lead to swelling that impinges on the nerve, causing decreased eye movements.

(u) B. Schiotz tonometry is used to evaluate intraocular pressures; elevated pressure indicates glaucoma.

(u) C. Fluorescein angiography is used to evaluate retinopathies.

(u) D. Slit lamp biomicroscopy is used to evaluate lid contour, lesions, lashes, conjunctiva, sclera, cornea, anterior chamber, and lens.

A 68 year-old male with a history of atrial fibrillation treated with warfarin (Coumadin) presents to the emergency department after vomiting large amounts of bright red blood. INR is 3. Which of the following is most appropriate to rapidly lower the patient's INR?

A. Discontinue warfarin

B. Administer fresh frozen plasma

C. Administer protamine sulfate

D. Administer heparin sulphate

(u) A. This will not immediately reverse the effects of warfarin.

(c) B. Fresh frozen plasma is the most rapid way to lower the patient's INR.

(u) C. Protamine sulfate is used to neutralize heparin sulphate not warfarin.

(h) D. Heparin administration would increase the bleeding and be harmful.