BASELINE PRE-TEST 2024 LATEST QUESTIONS WITH ACTUAL SOLUTIONS!!

A 65-year-old man is seen for loose stools 3 times per day for 1 week. Two weeks prior he began a 6-week course of ciprofloxacin for prostatitis. There is no blood in his stool. His past medical history is notable for atrial fibrillation, hypertension, and gout. He takes atenolol, warfarin, hydrochlorothiazide, and allopurinol. He smoked 2 packs per day for 30 years but quit 10 years ago. He no longer drinks, but he drank heavily until 10 years ago. He does not use drugs. He works as a plumber. His mother and father both died of heart attacks in their 80s. He has not noted any bruising, epistaxis, or bleeding gums. His temperature is 36.7, heart rate 89, blood pressure 115/84, respiratory rate 16, and oxygen saturation 98% on room air. He weighs 70kg. He is alert and oriented and in no acute distress. His physical examination is normal, and he has no ecchymoses. His WBC count is 7,800/microliter, hemoglobin 14.6 g/ - ANS 4. hold warfarin and recheck INR in 2-3 days A 22-year-old man presents for a pre-marital evaluation. He is asymptomatic and feels well. His past medical history is notable for sickle cell trait. He takes a multivitamin and has no allergies. He does not smoke, drink, or use drugs. He is a card dealer at a casino. His ROS and exam are negative. His fiancée is also asymptomatic and has been diagnosed with alpha-thalassemia trait based on hemoglobin electrophoresis. She is an immigrant from Kenya and works in public relations. What is the chance they will have a child with sickle cell disease? 1. 0% 2. 25% 3. 50% 4. 67% 5. 100% - ANS 1. 0% A 64-year-old African American man presents with fatigue. His thyroid-stimulating hormone level is normal, but he was found to have a normocytic anemia with a hemoglobin level of 9 g/dL. He has a reticulocyte count of 4%, and his ferritin level is normal. His lactate dehydrogenase level is modestly elevated, as is his indirect bilirubin level. Haptoglobin levels are low. His history is significant for mechanical mitral valve replacement in his 40s when he had severe mitral regurgitation due to endocarditis. A Coombs test is done and is negative. The hemoglobin electrophoresis is negative. A peripheral blood smear shows numerous irregularly shaped, jagged, asymmetric red blood cells. Which of the following is the most likely cause of this patient's anemia? 1. microangiopathic hemolytic anemia 2. immune hemolysis 3. thalassemia 4. sickle cell anemia 5. hereditary spherocytosis - ANS 1. microangiopathic hemolytic anemia A 61-year-old man with a history of hypertension complains of nocturia for the past several months. He also describes symptoms of urinary urgency, hesitancy, and dribbling during the same time period. He denies polyuria, polydipsia, and hematuria. He has no other complaints. DRE reveals a prostate of approximately 3 fingerbreadths wide. The prostate is soft, nontender, and there are no nodules. The rest of the physical examination is unremarkable. What is the next best step in the treatment of this patient? 1. order UA, urine culture, and PSA tests 2. order transurethral ultrasonography of the prostate 3. start alpha-1-receptor blockade 4. start 5-alpha-reductase inhibitor 5. expectant management with DRE and PSA annually - ANS 1. order UA, urine culture, and PSA tests A 32-year-old man complains of painful penile lesions. Physical examination reveals tender, soft, putty-like ulcers (see image). The patient also has a tender inguinal bubo. You suspect chancroid. Which of the following clinical characteristics or diagnostic tests for chancroid is 1. biopsy needed for a pathologic confirmation of the diagnosis 2. presents as tender lymphadenopathy and genital ulcers 3. Chlamydia trachomatis on lesion smear 4. diagnosis is clinical with no need for culture 5. Serologic testing for herpes simplex virus - ANS 2. presents as tender lymphadenopathy and genital ulcers A 21-year-old female presents with urinary retention, tender inguinal adenopathy, and lesions as shown. Which of the following is the most likely diagnosis? 1. herpes simplex virus primary infection 2. herpes simplex virus recurrent infection 3. Erosive lichen planus 4. recurrent treponema pallidum infection 5. primary treponema pallidum infection - ANS 1. herpes simplex virus primary infection A 35-year-old woman presents to your office with abnormal laboratory results. She admits to only mild fatigue and denies any nausea, vomiting, and diarrhea. There is no history of any abdominal pathology. On physical examination, her vital signs are stable and there is no abdominal or flank tenderness noted. Laboratory results show a sodium level of 140 mEq/L, a potassium level of 2.9 mEq/L, and a carbon dioxide level of 17 mEq/L. The serum creatinine level is 0.4 mEq/L and blood glucose is 68 mg/dL. The results are similar to blood work obtained 3 months ago. Urinalysis is positive for 2+ blood on urine dipstick. The microscopic examination shows 30-50 red blood cells/HPF. Urine pH is 6.0 on urine dip. Given the history and laboratory findings, which of the following would you expect to find? 1. calcium oxalate stones 2. magnesium ammonium phosphate stones 3. calcium phosphate stones 4. uric acid stones 5. cys - ANS 3. calcium phosphate stones A 65-year-old woman with a known history of diabetes for 15 years and hypertension for 9 years presents to you with a history of right flank pain and high-grade fever. She also notes hematuria, dysuria, rigors, sweating, and nausea for the past 5 days. She has no history of prior renal disease or other issues. On physical examination, her temperature is 103.6°F and blood pressure is 95/50 mm Hg. She appears flushed and has severe right costovertebral angle tenderness. No other abnormality is detected on physical examination. Laboratory investigations reveal hemoglobin of 12.4 g/dL and white blood cell (WBC) count of 24,000/mm3 Urea nitrogen = 19 mg/dL Creatinine = 1.3 mg/dL Sodium = 131 mEq/L Potassium = 3.0 mEq/L Urine analysis indicates: WBC = 135 cells/hpf Red blood cells, bacteria, and WBC casts = Numerous CT scan of her abdomen shows air in the left renal parenchyma. What is the most likely diagnosis? 1. t - ANS 3. emphysematous pyelonephritis A 25-year-old woman with no significant past medical history presents with a history of painless hematuria for the past week. The hematuria is not associated with any other urinary complaint like dysuria, urinary urgency, or frequency. She reports an upper respiratory tract infection that was treated with antibiotics 2-3 weeks ago. Her vitals are: blood pressure, 180/90 mm Hg; pulse, 89/min; and respiratory rate, 16/min. She is afebrile. Her extremities show no pitting edema and there are no changes on renal ultrasound. Her urinalysis shows: Specific gravity = 1.005 pH = 6 Blood = +1 Proteins = +1 Ketones, glucose = Nil Red blood cells = 10/hpf Epithelial cells = Nil Blood urea nitrogen = 70 mg/dL Creatinine = 2.6 mg/dL C3 and C4 levels = Low 24-hour urinary proteins = 1.4 g Kidney biopsy is also performed and light microscopy shows marked cellular proliferation and infiltration of neutrophils in the glomerular tu - ANS 5. no treatment needed A 45-year-old man witnessed an armed robbery of a convenience store 1 week prior to presenting to you for treatment. He complains of being constantly fearful, constantly watching for threats, and frequently feels as though he is watching the events of his life from the outside as a spectator. He often is unaware of where he is or how he got there. On further questioning, he also says that, even though his usual routine would normally include walking or driving by the store several times a day where the robbery occurred, he now avoids the street and takes large detours to avoid the area. He also refuses to enter convenience stores because the environment and certain objects commonly present in convenience stores like lottery tickets trigger extremely vivid and distressing memories. Which of the following is the most likely diagnosis for this patient? 1. Post-traumatic stress disorder 2. Subsyndromal acute stress d - ANS 5. Acute stress disorder A 26-year-old woman presents complaining of auditory command hallucinations. She also describes episodes of depersonalization in which she feels as if she was observing herself from the outside, and other times when she feels the world around her is not real, as well as episodes of amnesia that cause her to forget what she has done for several hours at a time. Her final complaint involves visual disturbances resembling episodic blindness. However, vision tests and neurologic examinations are unremarkable. She is accompanied by her husband, who also says that she appears extremely angry and vengeful at times, but never remembers acting this way afterward. Which of the dissociative symptoms described is required to make the diagnosis of dissociative identity disorder? 1. amnesia and the presence of multiple personality states 2. depersonalization and amnesia 3. derealization and the auditory hallucinations 4. audi - ANS 1. amnesia and the presence of multiple personality states A 43-year-old man is brought to you by his wife because he has started drinking more than usual and spends money beyond his means. He presents with an irritable mood, talks loud and fast, and sees no reason to be in treatment. He claims that he is indispensable at his place of employment because nothing can go forward without him. He also describes himself as an important figure in his hometown who plays a major role in local politics as well as pulls the strings behind the scenes. He quickly changes topics and is barely able to follow the interview. A review of his medical records shows that he has had two major depressive episodes within the last 12 months. His wife adds that before the depressive episodes he was similarly "over the top" as he is at the time of the current interview. Each of these intermittent episodes lasted several weeks. A similar phase also occurred between the two depressive episodes. Which o - ANS 1. rapid cycling bipolar disorder I An HIV test run on a 32-year-old man who abuses heroin has returned a positive result. After 1 year of indecision and no follow-up, the patient decides he is ready to start antiretroviral treatment. Because of his long-standing and ongoing heroin use, he is at risk for drug use complications. Which of the following diagnoses related to his cardiovascular system should be particularly considered during this patient's baseline examination? 1. cardiomyopathy, peri/endocarditis, pulmonary hypertension, valvular insufficiency 2. cardiomyopathy, peri/endocarditis, tachycardia, hypertension, valvular insufficiency 3. cardiomyopathy, pericarditis, tachycardia, pulmonary hypertension, valvular insufficiency 4. peri/endocarditis, pulmonary hypertension, valvular insufficiency 5. cardiomyopathy, peri/endocarditis, pulmonary hypertension, valvular insufficiency, peripheral vascular disease - ANS 1. cardiomyopathy, peri/endocarditis, pulmonary hypertension, valvular insufficiency A 61-year-old woman has developed anxieties over the last year that meet the diagnostic criteria for generalized anxiety disorder. She works as a shop attendant in a grocery store and, in her personal life, has had an ongoing and severe conflict with her daughter. She experiences chronic lower back pain and has diabetes and high blood pressure. Which of the following factors may worsen the outcome of cognitive behavioral therapy in this patient? 1. Interpersonal conflict and poor physical health 2. Poor physical health 3. Interpersonal conflict 4. Female sex 5. Low socioeconomic status - ANS 1. Interpersonal conflict and poor physical health A 36-year-old man presents with a mild burn. His blood pressure is 150/90 mm Hg and his pulse is 90 bpm. He is highly agitated and unable to focus on the clinical interview at hand, but instead paces the room and frequently and randomly changes topics. He appears aggressive, and his behavior is increasingly erratic. Repeated and insistent questions reveal that he ingested cocaine about 45 minutes ago. Of the following, which medications are the best option for the management of this patient's cocaine intoxication? 1. none 2. benzodiazepines are required 3. benzodiazepines not required, but may be considered 4. topiramate, disulfiram, or modafinil 5. topiramate, disulfiram, or benzodiazepines - ANS 3. benzodiazepines not required, but may be considered A 55-year-old man with a history of chronic obstructive pulmonary disease (COPD) and hypertension, comes in with acute dyspnea, and has run out of his medications. He complains of palpitations for less than 24 hours. His vital signs are BP, 140/85; P, 105; RR, 20; T, 98.6 F; pulse oximetry is 92% on room air. His exam is remarkable for a rapid heart rate of uncertain rhythm, and his lung exam shows decreased air movement. His lab work includes a calcium 8.9 mg/dL; magnesium 2 mg/dL; potassium 3.8 meq/L (click here for reference lab values) ECG shows variable rate around 105; p waves of varying morphology; variable P-P, PR, and R-R intervals (see below ECG). What is the most appropriate treatment, given these ECG findings? 1. Magnesium IV 2. 100%FiO2 via non-rebreather mask 3. Diltiazem 4. Nebulized beta-agonists 5. Synchronized cardioversion - ANS 4. Nebulized beta-agonists A 75-year-old woman with a 20-year history of chronic obstructive pulmonary disease (COPD) and parathyroid disease complains that her heart is "beating funny." Which of the following is the most commonly seen dysrhythmia associated with COPD? 1. ventricular tachycardia 2. premature ventricular contractions 3. torsades des points 4. sinus bradycardia 5. atrial fibrillation - ANS 5. atrial fibrillation Community-acquired pneumonia (CAP) is usually defined as an infection of the lung peranchyma in a patient who was neither hospitalized nor a resident of a long-term care facility for two weeks prior to the onset of symptoms. Despite advances in diagnostic modalities, antibiotic therapies, and vaccines, it is estimated that four million cases of CAP occur annually in the US, resulting in 10 million physician visits and 1.0 million hospital admissions. Which of the following statements is true regarding the mortality rates/risks associated with CAP in immunocompetent adults? 1. The mortality rate for patients with CAP treated as outpatients ranges from 1-5%. 2. In patients requiring admission to an ICU, mortality rates exceed 30%. 3. Despite the introduction of new antibiotics, the mortality rate of patients hospitalized with CAP has increased over the last two decades. 4. Age over 65 is an independent risk for dying - ANS 5. all of the above Bacterial infection does not occur directly after aspiration unless the material is feculent or grossly contaminated. However, infiltrates eventually develop in 86-94% of patients after significant gastric aspiration. Bacterial isolates from aspiration pneumonia commonly recover many organisms. However, antibiotic therapy must be specifically expanded to include which classes of organisms? 1. Anaerobes and gram-negative enterics 2. Pneumococcus and P. aeruginosa 3. Staphylococcus and enterococcus 4. E. corrodens and P. multocida - ANS 1. Anaerobes and gram-negative enterics A critical patient was admitted two days ago for multiple trauma. He now has labored breathing and hypoxia on 60% O2. Chest x-ray shows bilateral alveolar infiltrates; a Swan-Ganz catheter shows a normal wedge pressure. If infection is ruled out, the most likely diagnosis is __. 1. ARDS (acute respiratory distress syndrome) 2. cardiogenic pulmonary edema 3. eosinophilic pneumonitis 4. multiple pulmonary emboli - ANS 1. ARDS (acute respiratory distress syndrome) A 28-year-old male presents with fever for 3 days, sore throat and trouble swallowing. His voice is muffled. He has trismus and foul smelling breath. Which of the following conditions would not give the above clinical picture? 1. Epiglottitis 2. Ludwig`s angina 3. Parotitis 4. Peritonsillar abscess 5. Retropharyngeal abscess - ANS 3. Parotitis In ARDS (acute respiratory distress syndrome), the permeability of the pulmonary microvascular membrane increases, allowing colloid to leak out. The gradient of colloid oncotic pressure across the membrane is lost. In this situation, is the formation of pulmonary edema fluid more or less sensitive to changes in left ventricular filling pressure than in cardiogenic pulmonary edema? 1. more 2. less 3. no significant difference - ANS 1. more In the early morning hours, a man presents to the urgent care clinic with severe dyspnea, tachypnea, cyanosis, and tachycardia. On examination, he has right-sided rales, rhonchi, and wheezes, and is coughing up copious frothy blood-tinged sputum. He states that last night, "he had two beers and passed out." Clinical exam suggests normal left ventricular function. You should suspect __. 1. aspiration pneumonitis 2. varicella pneumonia 3. Goodpasture`s syndrome 4. Staphylococcal pneumonia 5. Septic pulmonary emboli 6. congestive heart failure - ANS 1. aspiration pneumonitis An elderly patient with a history of "lung trouble" is wheeled into an examination room. He claims to be short of breath in the triage area, despite 4 nebulizer treatments at home. His respiratory rate is rapid (> 36 breaths/minute). On listening to the chest you hear little air movement. His pulse oximetry is reading 50%. Appropriate management of this patient's condition would include which of the following? 1. endotracheal intubation with the ventilator set on a rate of 8-10 2. endotracheal intubation with the ventilator set on a rate of 20-24 3. withhold sedatives or neuromuscular blocking agents after intubation, due to risk of central nervous system depression 4. draw an arterial blood gas STAT and await the results to determine the need for endotracheal intubation 5. avoid supplemental oxygen, which would suppress his hypoxic drive - ANS 1. endotracheal intubation with the ventilator set on a rate of 8-10 A 28-year-old male presents with fever for 3 days, sore throat and trouble swallowing. His voice is muffled. He has trismus and foul smelling breath. He becomes more dyspneic and develops stridor. From the list below, choose the best option for managing this patient's airway. 1. BiPAP 2. Blind insertion airway device (BIAD), such as the Combitube 3. Blind Nasotracheal intubation 4. Cricothyrotomy 5. Fiber optic guided endotracheal intubation - ANS 5. Fiber optic guided endotracheal intubation A patient with chronic obstructive pulmonary disease primarily due to chronic obstructive bronchitis would be likely to show which of the following? 1. thin body habitus with weight loss 2. pursed lip breathing 3. accessory muscle use 4. cyanosis 5. hyperinflation and an increased anteroposterior diameter - ANS 4. cyanosis A 42-year-old patient presents with dyspnea, fever, chills, and right-sided pleuritic chest pain. Auscultation of the right lung field reveals diminished breath sounds and dullness to percussion. Spontaneous splinting of the painful right side is noted. Chest x-ray shows fluid in the pleural space, with an air-fluid level. A decubitus film does not layer out. The best diagnosis is __. 1. empyema 2. pleural effusion 3. pneumonia 4. lung abscess - ANS 1. empyema A 74-year-old man with history of hypertension, asthma, and prostate cancer presents with fever for 4 days and back pain. He is a heavy alcohol drinker. He denies cough, shortness of breath, or chest pain. Vitals on examination are heart rate 101 beats/minute, blood pressure 148/96 mm Hg, temperature 38.4°C, and respiratory rate 20 breaths/minute. He has a soft systolic murmur predominantly in the aortic area and scattered rhonchi in both lungs. Hemoglobin level is 10.9 g/dL, white blood cell (WBC) count is 14,200/mm3 (neutrophils 94.1%), blood urea nitrogen level is 30 mg/dL, and creatinine level is 1.6 mg/dL. Urinalysis shows 7-10 WBCs per high-power field. Chest X-ray reveals an infiltrate consistent with right lower lobe pneumonia. You start the patient on intravenous antibiotics. On the second day of admission, the patient becomes confused and develops nuchal rigidity. Lumbar puncture reveals cloudy spinal fl - ANS 1. pneumococcal pneumonia, endocarditis, and meningitis A 25-year old male lawyer from New York presents with a sudden onset of cough, fever, and chills 4 hours earlier. The patient denies any nausea or vomiting. He lives with his wife and is a nonsmoker. He is otherwise healthy and has not recently been in contact with any hospital or health care facility. On physical examination, he has a temperature of 38.3°C, pulse of 110 beats/minute, blood pressure of 130/90 mm Hg, and respiratory rate of 20 breaths/minute. There are crackles heard on the base of the left lung. The patient is awake and alert and has no meningeal signs. A chest X-ray confirms the presence of a left lobar pneumonia. A complete blood count shows 10,900/mm3 with a predominance of neutrophils. Blood urea nitrogen level is 12 mg/dL. Which of the following oral antibiotics is appropriate for the treatment of this patient? 1. doxycycline 2. cefoxitin 3. trimethoprim/sulfamethoxazole 4. dicloxacillin - ANS 1. doxycycline A 43-year-old man from Massachusetts with a history of type 1 diabetes mellitus well controlled on insulin presents to you with a rash (see figure). He does not recall any tick bites, but he does like to be outdoors. He is afebrile and does not have any other symptoms or findings on physical examination. What is the most appropriate next step for the management of this patient's condition? 1. cefuroxime for 14 days 2. doxycycline for 7 days 3. amoxicillin for 7 days 4. enzyme-linked immunosorbent assay and confirmatory Western blot 5. Frequency of diagnosis is increasing rapidly; however, Rocky Mountain Spotted Fever (RMSF) is more common. - ANS 1. cefuroxime for 14 days A 29-year-old female presents with a complaint of fever and a sore throat for one week, accompanied by increasing dysphagia. On examination, the patient appears ill with shaking chills. Her vitals are: T 40.1 C, P 128, BP 100/65, RR 26 and unlabored. Her tonsils are enlarged, erythematous and covered with a white exudate. Palpation of the neck shows L>R tender, enlarged nodes over the sternocleidomastoid muscle and a generalized, poorly defined swelling of the neck. There is no trismus or parotid tenderness, and the patient's voice sounds normal. What needs to be the primary concern in this patient? 1. The patient is at risk for Lemierre's syndrome 2. The patient might develop endocarditis 3. The patient might develop a rash if put on penicillin containing antibiotics 4. The patient might not be able to conceive in the future 5. The patient's partner should be questioned about symptoms - ANS 1. The patient is at risk for Lemierre's syndrome A 43-year old speaker at a conference is brought in for sudden onset of severe vertigo with nausea, vomiting, and diaphoresis. He also complains of a unilateral hearing loss and a roaring tinnitus on that side. What statement is true about his most likely diagnosis? 1. This disease rarely becomes bilateral 2. Attacks last an average of 24-48 hours 3. The disease is thought to be caused by problems with regulating endolymph volume 4. Deafness resolves between attacks 5. Attacks typically occur once or twice a year and are precipitated by stress. - ANS 3. The disease is thought to be caused by problems with regulating endolymph volume A 60 year-old female comes to your office complaining of double vision but only when looking to her left. This started 10 days prior after a brief right, retro-orbital headache. The headache has since resolved. She has a history of type 2 diabetes. She has no history of any injury. Her pupillary examination is normal. A CT of the brain is normal. The patient looking to her left. Which of this patient's cranial nerves is malfunctioning: 1. right CN III 2. left CN VI 3. left CN III 4. right CN VI - ANS 1. right CN III A 76-year-old female patient who looks well (see image #1) complains of a one-day, low-grade fever and cough. Her grandchildren are coming to visit, so she would like to take some antibiotics to get rid of her cold faster. She asks for liquid antibiotics because lately, she has also experienced increasing dysphagia and odynophagia. Images # 2 and #3 show her pharynx. Her lungs are clear. How would you manage this case? 1. Perform needle aspiration, start on antibiotics 2. Consult otolaryngology for incision and drainage in the operating room. 3. Admit to internal medicine for IV antibiotics 4. Order CT-Scan 5. Question about immunization status and exposure to farm animals - ANS 4. Order CT-Scan A 28-year-old male complains of fever, a sore throat, dysphagia, odynophagia, and neck pain. On examination, the patient's voice is noted to be muffled and the posterior aspect of the oropharynx appears to be swollen. There is no trismus or noticeable external swelling. Which of the following is an acceptable action for managing this patient? 1. Keep patient in upright/leaning forward position 2. Gently palpate the bulge to assess readiness for incision and drainage 3. Gently rock trachea side to side to assess presence or absence of tracheal "rock sign" 4. Perform a needle aspiration of the bulge, start IV antibiotics, admit 5. Immobilize neck to prevent extension of infection and atraumatic atlantoaxial separation - ANS 3. Gently rock trachea side to side to assess presence or absence of tracheal "rock sign" A 34-year-old male presented to you with eye pain, redness, and discharge (see below). He has a history of glaucoma and has had a trabeculectomy. His visual acuity is markedly decreased. Purulent discharge is seen streaming from the bleb. Intraocular pressure is 4 mmHg. The physical finding seen here is called: 1. positive ring sign 2. positive Seidel test 3. hypopyon 4. hutchinson`s sign - ANS 2. positive Seidel test A 54 year-old male complains of right eye swelling and itching. Two days prior, a bug flew into his eye while he was riding his motorcycle. The patient is LEAST LIKELY to benefit from which of the following medications? 1. naphthazoline/antazoline 2. emedastine 3. artificial tears 4. erythromycin - ANS 4. erythromycin An 86-year-old male, who wears hearing aids and recently returned from living in the Pacific for a year, complains of a painful, itchy left ear since he landed in the USA four days ago. He is afebrile and states that he has no other illnesses. On exam, his left tympanic membrane and external ear canal are noted to be erythematous and edematous and there is a mildly odorous, seropurulent secretion. The tympanic membrane itself is mobile. Which organism(s) is (are) the most common cause for this presentation? 1. H. influenzae 2. Fungi 3. Mixed aerobic and anaerobic bacteria 4. Staphylococcal species 5. P. aeruginosa - ANS 5. P. aeruginosa On average, visual acuity should be checked in patients with a visual complaint before any medications are instilled into the eye. in which clinical situation is it more important to treat the condition before obtaining a visual acuity? 1. caustic eye exposure 2. foreign body sensation 3. open globe 4. diplopia - ANS 1. caustic eye exposure A 64-year-old female presents with shortness of breath, orthopnea, and fatigue. She has hypertension, coronary artery disease, and uncontrolled diabetes. On exam her blood pressure is 180/90 mmHg. Her respirations are 26 breaths/min. She is afebrile. She has a systolic murmur with an S3. She has bibasilar crackles and bilateral lower extremity edema. Her EKG shows evidence of left ventricular hypertrophy, Q waves, and non-specific T wave changes. Her chest x-ray reveals vascular engorgement and an enlarged heart. Her echo reveals an ejection fraction of 25% with some mitral regurgitation. Which of the following is the most likely cause of her cardiomyopathy? 1. hypertension 2. valvular disease 3. ischemic heart disease 4. toxins 5. infection - ANS 3. ischemic heart disease A 62-year-old male with a history of systolic heart failure and hypertension presents with a new history of left-sided chest pressure on exertion that resolves with rest. The heart failure is treated with furosemide and an angiotensin-converting enzyme inhibitor. An electrocardiogram is obtained: His vital signs are notable for elevated blood pressure. Physical exam is unremarkable. Which test is indicated next to evaluate his chest pain? 1. coronary angiography 2. stress testing with nuclear perfusion imaging 3. stress echocardiography 4. cardiac magnetic resonance imaging 5. computed tomography angiography - ANS 1. coronary angiography A 66-year-old African American woman has heart failure that remains symptomatic despite therapy with angiotensin-converting enzyme inhibitor, diuretics, and beta-blocker. Her last echocardiogram showed an ejection fraction of 25%. She continues to be dyspneic and fatigued from light activity around the house. What therapy has been shown to have a specific benefit in African Americans when added to standard therapy? 1. clonidine 2. nesiritide infusion 3. dobutamine infusion 4. coenzyme Q-10 5. hydralazine and isosorbide dinitrate - ANS 5. hydralazine and isosorbide dinitrate A 42-year-old male presents to the emergency department with a painful red area over his left forearm for 1 day. His medical history is notable for hypertension controlled by hydrochlorothiazide. He has a 40 pack-year smoking history and drinks 3 beers daily. On examination he has an erythematous, hot, swollen area on the flexor surface of his forearm with a palpable, painful cord. You also notice several black ulcers on his fingers and toes. Complete blood count, complete metabolic panel, antinuclear antibody, C3, rheumatoid factor, anti-Scl-70, anti-centromere antibody, and anti-phospholipid antibodies are all normal. Transthoracic echocardiogram is normal. What is the most important part of his management? 1. bilirubin 2. warfarin 3. corticosteroids 4. smoking cessation 5. alcohol cessation - ANS 4. smoking cessation A 62-year-old female presents with complaint of left foot pain and swelling (see image below). The circumference of her left calf measured 10 cm below tibial tuberosity is 4 cm larger that the diameter of her right calf. There is no swelling of her left thigh. This problem has started almost a week ago without any preceding trauma. She has recently traveled to Florida and returned 2 weeks ago. She has spent almost 8 hours in her car. She is otherwise healthy. Her only medications are fish oil supplement and hydrochlorothiazide for hypertension. The Wells criteria for deep vein thrombosis would most support which of the following tests? 1. Doppler compression ultrasound 2. magnetic resonance imaging 3. CT venography 4. contrast venography 5. D-dimer - ANS 1. Doppler compression ultrasound A 71-year-old African American male presents for an annual physical examination. He has a repeated blood pressure of 150/80 mm Hg, and you diagnose him with essential hypertension. He feels somewhat depressed and is taking citalopram 10 mg daily. He has been also complaining of nocturia and dribbling of several months' duration. He has no other complaints. He never smoked and drinks occasionally. He denies drug use. His family history includes prostate cancer in his father at age 55. He has been diagnosed with dyslipidemia in the past and is taking simvastatin 40 mg daily. He exercises regularly in the gym. His routine chemistries and complete blood count are normal; however, his lipid panel shows total cholesterol of 225 mg/dL, low-density lipoprotein cholesterol of 180 mg/dL, high-density lipoprotein cholesterol of 35 mg/dL, and triglycerides of 260 mg/dL. Which antihypertensive agent would be most appropriate? 1 - ANS 5. terazosin During a review for cardiovascular risk factors in a 47-year-old male who presents for epistaxis, you find out that he has a 3-month history of substernal discomfort that appears during moderate exercise and disappears after some rest. The episodes are usually accompanied by some dyspnea and dizziness. He recently used his friend's nitroglycerin pill and noticed that this resolves his pain quicker than rest alone. You diagnose him with: 1. stable angina 2. unstable angina 3. Prinzmetal's angina 4. anxiety 5. congestive heart failure - ANS 1. stable angina The 2010 American Heart Association algorithm for treating tachyarrhythmias has been simplified to include fewer recommended drugs. The treatment of tachyarrhythmias is still somewhat complex with the same drug being beneficial for one type of tachyarrhythmias but detrimental for another. Which statement is FALSE with regards to the drugs in the tachycardia algorithm? 1. Adenosine should not be given to a patient with atrial fibrillation who is known to have a pre-excitation syndrome (i.e., WPW). 2. The major side effect of Amiodarone is hypotension and bradycardia, which can be prevented by slowing down the infusion. 3. Diltiazem is considered harmful when given to a patient with atrial fibrillation or atrial flutter due to a pre-excitation syndrome (i.e., WPW). 4. Beta-blockers are contraindicated in patients with second- or third- degree heart block and in patients with atrial fibrillation or atrial flutter due - ANS 5. Magnesium has been shown to increase the rate of atrial fibrillation with a rapid ventricular response and is contraindicated in this rhythm. A 67-year-old man presents complaining of several months of exertional dyspnea and wheezing that worsened after a large Thanksgiving meal. He is a former pack-a-day smoker. He has hyperlipidemia for which he takes simvastatin. The patient denies chest pain or edema. On physical exam, the physician detects wheezes. He orders laboratory tests and a chest x-ray, which is shown: What finding on this x-ray is suggestive of heart failure? 1. alveolar edema 2. Kerley B lines 3. cardiomegaly 4. interstitial edema 5. pleural effusion - ANS 3. cardiomegaly A 67-year-old woman has had New York Heart Association class III heart failure due to chronic systolic congestive heart failure. She takes furosemide, metolazone, bisoprolol, and ramipril in recommended doses, but she is frustrated with her current limitations and lack of symptomatic improvement. She presents with an exacerbation of congestive heart failure, and the cardiologist on call asks whether she has any evidence of cardiac dyssynchrony that may suggest the need for biventricular pacing. What is currently the most accepted measure of cardiac dyssynchrony? 1. paradoxical septal wall motion 2. QRS duration longer than 0.12 seconds 3. pulse pressure 4. ventricular filling time 5. elevated brain natriuretic peptide level - ANS 2. QRS duration longer than 0.12 seconds A 66-year-old woman presents with a 6-week history of exertional dyspnea and ankle edema. She has no smoking history. The patient's symptoms started after a trip to Asia, and she wonders if she picked up an infection while traveling. Her chest x-ray is normal, and she has no rales on exam. An echocardiogram shows a moderately dilated right ventricle and moderate elevation in pulmonary artery pressure. What test should her physician consider next? 1. myocardial biopsy 2. thyroid stimulating hormone levels 3. high-resolution chest CT 4. stress echocardiogram 5. stress myocardial perfusion imaging - ANS 3. high-resolution chest CT A 45-year-old male presents with a tender, palpable vein on the medial aspect of his left thigh. It is overlaid by erythematous skin and associated with some edema as well (see below). He reports that this has developed over the last 2 days. He has a history of hypertension and is taking lisinopril and hydrochlorothiazide. He also takes fish oil and multivitamin supplements. He smokes ½ PPD and does not drink. He never had any episodes of thrombophlebitis before and he does not have a family history of "blood clots." Doppler ultrasound of lower extremities does not reveal any deep vein involvement, and only shows an isolated thrombus in a tributary of the great saphenous vein. How would you treat this patient? 1. nonsteroidal anti-inflammatory drugs 2. corticosteroids 3. enoxaparin or fondaparinux 4. unfractionated heparin 5. warfarin - ANS 1. nonsteroidal anti-inflammatory drugs A 70-year-old female nonsmoker with a history of hypertension presents with new complaints of chronic shortness of breath at night and with exertion. She has no chest pain. She has lower extremity edema. She also has a history of a remote heart attack. On physical exam her blood pressure is 140/82 mmHg, and her pulse is 74. Respirations are 18 breaths/minute. She is afebrile. She has an S3 and a faint systolic murmur. Her lungs have mild bibasilar crackles. She has a nontender abdomen. She has pitting edema to her lower extremities. She has normal cardiac enzymes. Her thyroid stimulating hormone level, complete blood count, and chem 7 are normal. She has a mildly elevated BNP. Her EKG shows Q waves in inferior leads. Her chest x-ray shows cardiomegaly and mild venous congestion. Her echo shows a dilated cardiomyopathy with an ejection fraction of 35%. She takes aspirin and a beta-blocker. What is the next best treatm - ANS 5. angiotensin-converting enzyme inhibitors A 60-year-old man presents to the hospital with chest pain, dyspnea and diaphoresis. His blood pressure is 85/55 mm Hg, his pulse is 110, and he is tachypneic and anxious appearing. On chest auscultation he has a weak apical pulse. His skin is notable for pallor. He has jugular venous distension. His x-ray is shown below: What is the in-hospital mortality of patients presenting in this manner? 1. 5% 2. 10% 3. 25% 4. 50% 5. 35% - ANS 4. 50% A 45-year-old male presents to your clinic with worsening right calf and foot pain. His vital signs include HR 70, BP 130/80 mm Hg, RR 18, and temperature 97.6 F. Cardiovascular exam is normal. Pulses of the right foot are difficult to palpate, but Doppler probe is able to pick up audible arterial flow in both the dorsalis pedis and posterior tibialis arteries. His toes appear dusky (see figure). There is partial loss of sensation over the foot and lower calf, which feel cool to touch. There also are hair loss and atrophic skin on the same area. The patient is able to extend and flex his foot and his toes on both sides. His medications include lisinopril, aspirin, and metformin. How would you classify his arterial occlusion? 1. viable 2. marginally threatened 3. immediately threatened 4. irreversible 5. nonviable - ANS 2. marginally threatened A 76-year-old man with a reduced left ventricular ejection fraction of 35% presents with a complaint of episodes of palpitations that are accompanied by dyspnea. The episodes happen several times a day and spontaneously terminate. His current medications include lisinopril, carvedilol, furosemide, aspirin, and atorvastatin. Initially, he has a regular pulse of 90 and a blood pressure of 110/78 mm Hg. His electrolytes and renal function are normal, as is his thyroid-stimulating hormone. While being observed, he became dyspneic and lightheaded with the rhythm shown: After several minutes, the patient reverted to a sinus rhythm and his symptoms abated. Which antiarrhythmic drug could be considered in this patient to maintain a normal rhythm? 1. sotalol 2. procainamide 3. amiodarone 4. propafenone 5. flecainide - ANS 3. amiodarone A 68-year-old woman with a history of type 2 diabetes mellitus and diabetic retinopathy presents for a routine follow-up after missing several appointments in the past. She complains of a number of hypoglycemic episodes in the last few months and requests you to cut down her current regimen of insulin. Her previous blood sugar readings have been in the normal range even with decreased doses of insulin. She also complains of easy fatigability, shortness of breath with mild exertion, and moderate weight loss in the last 6 months. Physical examination reveals a pale and weak-looking woman, with BP of 155/70 mm Hg, pulse of 84/min, RR of 18/min, and pedal edema of 2+. A basic metabolic panel is notable for creatinine of 7.0 mg/dL and blood urea nitrogen (BUN) of 115 mg/dL. Which of the following is the most appropriate next step in management? 1. decrease the dose of insulin and follow-up in 4 months 2. start dialys - ANS 2. start dialysis An 80-year-old man with type 2 diabetes has recurrent episodes of symptomatic hypoglycemia while on glipizide and pioglitazone. These medications are stopped, but he continues to complain of episodes of lightheadedness, confusion, and sweating in the morning that resolve with eating. He is brought in by his granddaughter, who has type 1 diabetes and is very worried about him. He is admitted for a 72 hour fast and his labs are shown below: Normal Range 5-25 2-26.8 0.8-3.1 31-187 Time (hr) Glucose Insulin uIU/ml Pro-insulin pM/L C-peptideng/ml Sulfonylurea screen IGF ng/ml 0 112 4 119 9 108 Negative 116 What is the next step in his management? 1. abdominal CT with thin cuts through the pancreas to look for an islet-cell tumor 2. corticotropin stimulation test 3. social services consult for nursing home placement as he has continued to take his oral medications 4. adult protective services refe - ANS 1. abdominal CT with thin cuts through the pancreas to look for an islet-cell tumor A 35-year-old man presents with agitation and tremor. He has no past medical history and takes no medications. He smokes ½ pack per day and drinks alcohol socially, but does not use drugs. He works as a baker. His review of systems is positive for diarrhea, heat intolerance, and decreased libido. His exam shows a temperature of 37.9, heart rate 110, blood pressure 110/75, RR 14, and O2 saturation 99% on room air. His HEENT exam results are normal. His thyroid is pronounced, without tenderness or discrete nodules. His heart is rapid but regular without murmurs. His lungs are clear, and his abdomen is benign. He has a fine intention tremor. His labs show a TSH of <0.01 microU/mL (normal: 0.5-5 μU/mL) and a free T4 of 30 ng/dL (normal: 0.9-2.3 ng/dL). What is the next step in workup? 1. radioactive iodine uptake and scan 2. comprehensive urine drug screen 3. thyroid peroxidase antibodies 4. thyroid-stimulating hormone - ANS 1. radioactive iodine uptake and scan A 30-year-old man requests a prescription and social services. He states that he has recently lost his job and hasn't taken his insulin for the last 2 days. On inquiry, he denies any history of nausea, vomiting, abdominal pain, or any other physical symptoms. An on-duty resident checks his stat blood sugar level and orders a urine specimen for ketones. Meanwhile, the man starts to vomit, and his blood sugar levels are now very high (890 mg/dL). Other labs are: HCO3 = 8 mEq/L K = 3.4 mEq/L Anion gap = 34 mmol/L Which of the following options should be started as an initial treatment? 1. glucagon by IV drip 2. intravenous fluids and insulin 3. IV bicarbonate until blood levels become normal 4. use of IV fluids only up to 50 mL/hour to avoid volume overload 5. supplemental phosphorous in the form of potassium phosphate - ANS 2. intravenous fluids and insulin A 35-year-old man presents with fatigue and lethargy for the last 6 months. He has no medical history. He takes a multivitamin but no other medications. He smokes 1 pack of cigarettes per week and drinks 1 glass of wine per night. He does not use drugs. He is the manager at a Banana Republic clothing store. His review of symptoms is a notable 15-pound weight loss over the past six months. His temperature is 37.4, heart rate 95, blood pressure 110/65, respiratory rate 14, and saturation 99% on room air. His HEENT, neck, heart, lung, abdomen, and neurologic exam results are normal. Skin is notable for a tanned appearance. His labs show a normal CBC, sodium 130, potassium 5.1, chloride 110, bicarbonate 25, BUN 13, creatinine 0.8, and glucose 90. His baseline cortisol is 3 mcg/dL (low). Thirty and 60 minutes after the injection of 250 mcg of corticotrophin (ACTH), his cortisol level is 4 mcg/dL. What is the most likely d - ANS 1. Addison's disease A 72-year-old female established herself with you as her primary care physician. She is a known diabetic whose condition is managed by diet, lifestyle modification, and metformin 500 mg BID. She has a glucometer at home and occasionally measures fasting and postprandial glucose. She reports the fasting values to be between 90 and 110 mg/dL and postprandial values as high as 190 mg/dL. She does not recall ever having a measurement of hemoglobin A1C performed. You perform a point of care measurement that yields the value of 7.2%. Your patient asks you how this number can be translated into glucose level. You answer that it corresponds to a mean glucose level in the last 3 months of: 1. 110 mg/dL 2. 130 mg/dL 3. 160 mg/dL 4. 180 mg/dL 5. 210 mg/dL - ANS 3. 160 mg/dL A 45-year-old truck driver presents complaining of worsening rectal pain. The vital signs are normal. External examination of the anal area is as seen below: The best first step in treating this patient's thrombosed hemorrhoid is which of the following: 1. high fiber diet with stool softeners 2. avoidance of prolonged sitting 3. daily Sitz bath 4. surgical incision and drainage 5. prescription steroid creams - ANS 4. surgical incision and drainage A 74-year-old woman presents with a recent 15-pound weight loss. She has a decreased appetite, constipation, and crampy abdominal pain. She has a history of a cholecystectomy and appendectomy. She has uncontrolled diabetes and hypertension. On physical exam her pulse is 96. Her blood pressure is 140/80. She has a temperature of 98°Fahrenheit. She appears cachexic. Her lungs are clear and cardiac exam reveals a regular rate and rhythm with a systolic murmur. Her abdominal exam is significant for pain with light palpation and hypoactive bowel sounds. She seems quite distended. Her rectal exam is guaic positive. Her CBC, AST/ALT, and electrolytes are normal. On x-ray, her large bowel is distended. What is the most likely cause of her obstruction? 1. carcinoma 2. diverticulitis 3. volvulus 4. adhesions 5. hernia - ANS 1. carcinoma A 51-year-old man presents with falls, confusion, and increased lethargy and somnolence over the last day. His past medical history is notable for migraines and cirrhosis due to alcohol abuse. He has no allergies and takes furosemide 40mg daily, propanolol 100mg BID, and ibuprofen as needed. He does not smoke or use drugs. He quit drinking 6 months ago but he used to drink a 12 pack of light beer per night. He works as a house painter. His family history is unremarkable. His last bowel movement was this morning and it was brown. His review of symptoms is otherwise negative. His temperature is 37.7° Celsius, heart rate 101, blood pressure 96/64, respiratory rate 16, and oxygen saturation 98% on room air. He is lethargic but in no respiratory distress. He has mild scleral icterus but normal fundi. His neck is supple. His heart is rapid but regular with a III/VI systolic ejection murmur at the RUSB. His lungs are clear - ANS 3. one liter normal saline bolus and 40 mEQ of potassium chloride A 25-year-old male comes in with a year of recurrent bouts of abdominal pain and diarrhea that is usually blood streaked. He was diagnosed with ulcerative colitis based on endoscopic biopsies. He has been having up to 4 bowel movements a day throughout the day and night. He has a loss of appetite. His temperature is 99°Fahrenheit. His blood pressure is 110/60. His pulse is 80. His abdomen is mildly tender to palpation with normal bowel sounds. His rectal is guaic positive. His WBC is 5000/µL. Hgb 12.5 g/dL. His chem 7 and liver tests are normal. What is the first line treatment for his symptoms after adequate hydration and diagnostic testing? 1. 5-ASA 2. surgery 3. oral steroids 4. IV steroids 5. IV cyclosporine - ANS 1. 5-ASA A 20-year-old college student presents with 2 days of persistent abdominal pain. She rates the pain as severe and associated with nausea. She denies having any symptoms prior to 2 days ago, including pain. She denies alcohol in the last couple days. Her family medical history is unremarkable for gallstones or pancreatic disease. She visits with her primary care doctor yearly for an annual check up including blood work. You notice on examination that she has bruising across her chest wall and a small laceration. She has pain in the midepigastric region without guarding. There is no flank eccyhmosis. You suspect at this point she has pancreatitis. Based on her history and physical exam, what is the most likely possible cause of her pancreatitis? 1. The patient is a college student and has been drinking more than she admits to 2. gallstone pancreatitis 3. familial hypertriglyceridemia 4. drug-induced pancreatitis - ANS 5. posttraumatic pancreatitis from a recent car accident Which of the following is the most commonly used score to aid in the diagnosis of appendicitis? 1. Alvarado 2. Fermi 3. Lept 4. Bos 5. Hapt - ANS 1. Alvarado A 25-year-old man presents with severe intermittent substernal chest pain. It was sudden in onset and occurred while the patient was lying in bed. He describes months of discomfort with eating and drinking and feels that standing up helps food to pass to his stomach. Physical examination reveals a moderately distressed thin white male, with no abnormal findings. 12-lead ECG is normal. What is the most likely diagnosis? 1. Achalasia 2. Boerhaave`s syndrome 3. Duodenal ulcer 4. Gastric ulcer 5. Gastroesophageal reflux disease (GERD) - ANS 1. Achalasia A 21 year-old college student presents with a one day history of nausea, vomiting and fatigue. She has noted that her eyes have seemed yellow and that her urine is very dark. She has no history of liver disease or jaundice and she recalls no ill contacts. She is not currently sexually active and has never received a blood transfusion. Her history is significant for a spring break trip to Mexico five weeks prior. She was not ill during the trip. On examination, she has mild jaundice and there is a finger breadth of hepatomegaly. Her bilirubin is 4.2 mg/dl and her transaminases are all elevated. Her renal function is normal. Which of the following is the most likely vaccine-preventable traveler's infection causing her current illness? 1. Hepatitis B 2. Hepatitis A 3. Hepatitis C 4. Rotavirus 5. Norwalk virus - ANS 2. Hepatitis A A patient with acute abdominal pain is noted to alternately curl up in a fetal position and to writhe and move about restlessly. This suggests a __ source of pain. 1. somatic, with peritonitis 2. visceral, with peritonitis 3. visceral, without peritonitis 4. somatic, without peritonitis - ANS 3. visceral, without peritonitis An 85-year- old male has been hospitalized for 4 weeks. He was initially diagnosed with a myocardial infarction. Cardiac catheterization showed a left main lesion and the patient was subsequently taken for coronary artery bypass. Post operatively he developed fevers and was treated with Keflex for a presumed central catheter infection. Two weeks later he is now off antibiotics. On exam, his vitals are stable and he has not had a fever. His sternal wound is clean. He has no central venous lines and his foley catheter has been out for a week. Laboratory tests reveal a persistent leukocytosis with a wbc count of 12000, 13500, and 16000 respectively over the past 3 days. Blood cultures are negative. Urinalysis shows no protein, red blood cells or white blood cells. Which of the following would be an appropriate next step for the work up of the persistent leukocytosis? 1. Repeat blood cultures again 2. Repeat UA and - ANS 4. Check the stool for C. difficile toxin his patient has a long history of lesions on the face and back. They occasionally drain pus. Which of the following is the most likely diagnosis? 1. rosacea 2. acne vulgaris 3. steroid-induced acne 4. lupus erythematosus 5. furunculosis - ANS 2. acne vulgaris This patient acutely developed a painful vesicular eruption on one side of the face. Which of the following is the most likely diagnosis? 1. allergic contact dermatitis 2. herpes zoster 3. impetigo 4. scabies 5. varicella (chicken pox) - ANS 2. herpes zoster A 25-year-old fisherman with unknown past medical history is complaining of edema, erythema and pain in his right lower extremity that he first noticed this morning. Since then, he has watched the erythema spread higher on his ankle and then to his leg. On exam, he is febrile, appears ill and has erythema and edema to mid shin. The foot is violaceous on the medial aspect. No wound is found, but there are two large bullae that obscure the foot skin. Although the foot and ankle are tense, he does have ROM in the toes and ankle. What should you do to definitively diagnose this man? 1. The presence of bullae and a violaceous area allow for definitive diagnosis, no further workup needed. 2. Insert a needle into the dermis 1 cm from the advancing edge of cellulitis; if no pus is obtained, inject 1 ml bacteriostatic (not bacteriocidal) saline and reaspirate. 3. Do a punch biopsy of the skin. 4. Obtain a surgical consult - ANS 4. Obtain a surgical consult for a fascial biopsy. A symmetrical pattern of hypopigmentation has been developing over the past several months. Which of the following is the most likely diagnosis? 1. post inflammatory hypopigmentation. 2. pityriasis alba 3. tinea versicolor 4. vitiligo 5. leprosy - ANS 4. vitiligo A patient comes to your office with this eruption that has been present for 10 years, but recently has become much thicker and more extensive. He has recently noted "swollen glands" in his neck. Which of the following is the most likely diagnosis? 1. psoriasis 2. fungal (dermatophyte) infection 3. discoid lupus erythematosus 4. lichen planus 5. mycosis fungoides (cutaneous T-cell lymphoma) - ANS 5. mycosis fungoides (cutaneous T-cell lymphoma) A 49-year-old female in generally poor health presents with a 2-year history of numbness and tingling in both of her hands. She rarely visits the doctor but comes in today mainly because it is difficult for her to grasp a pen or pencil to write. She has no neck pain but states that her symptoms wake her at night. In her review of systems, she notes that her vision is worsening and that she urinates frequently. She also notes that she has smoked about 1 pack per day for 20 years. Her medical history is significant for hypercholesterolemia, for which she takes no medications, as well as untreated hypertension. She also has been diagnosed with mild asthma for which she was prescribed an albuterol inhaler. On physical examination, she is obese and appears older than stated age. Her exam is also remarkable for decreased sensation to both pinprick and light touch in the median nerve distribution of both hands. Which of t - ANS 1. diabetes mellitus A 19-year-old college student presents with a history of twisting her left ankle during soccer practice. She is unable to bear weight because of the pain, which is partially relieved with elevation, ice, and ibuprofen. On exam there is significant edema and tenderness of the left ankle. There is localized tenderness over the posteromedial aspect of the talus and increasing pain with passive plantar flexion. An x-ray is obtained and is shown below: What is the best management for this injury? 1. Air-Stirrup Ankle Brace (Aircast) 2. internal fixation 3. cast immobilization for 6 weeks 4. taping 5. commercial walking boot or brace - ANS 3. cast immobilization for 6 weeks A 58-year-old man presents to you with an altered mental status and fever. He is undergoing chemotherapy for Hodgkin lymphoma. His family reports that he has been more confused over the past few days, appears unsteady, and is "not quite himself." When he developed a fever, the family brought him to the hospital. His vital signs are: BP, 96/80 mm Hg; HR, 101 beats/minute; RR, 20 breaths/minute; T, 100.6°F. He is awake but confused, oriented to person only, and is uncooperative. His left lower extremity is weaker than his right. CT of the head was ordered, and a lumbar puncture was performed. The cerebrospinal fluid Gram stain was negative, but pleocytosis was noted. Which of the following antibiotics should be started? 1. vancomycin 2. amphotericin B 3. ceftriaxone 4. ampicillin with gentamicin 5. cefotaxime and vancomycin - ANS 4. ampicillin with gentamicin A 28-year-old patient complains of an injury associated with a snapping sensation over the posterolateral ankle several weeks ago. He was diagnosed with an ankle sprain, but complains of persistent pain and swelling over the lateral retromalleolar area that is worsened when he plays racquetball. Examination shows an inability to evert the foot against resistance. What is the most likely diagnosis? 1. Calcaneal fracture 2. Lateral malleolar fracture 3. Talar dome fracture 4. Peroneal tendon dislocation 5. Posterior talofibular ligament rupture - ANS 4. Peroneal tendon dislocation An 18-year-old woman presents with hematuria and bloody diarrhea with abdominal colic about 2-3 weeks after an upper respiratory infection. On examination, you note the presence of a palpable, petechial rash and edema of the feet and ankles as pictured (see image). Of the following, which is the most appropriate presumptive diagnosis of Henoch-Schönlein purpura (HSP)? 1. Vasculitis is unusual in children and young adults. 2. HSP never spontaneously resolves. 3. The patient may have serious GI complications that respond to high-dose steroids. 4. The patient may have palpable purpura that favors the trunk and flexor surfaces of the extremities. 5. HSP is often complicated by myocarditis and fulminant congestive heart failure. - ANS 3. The patient may have serious GI complications that respond to high-dose steroids. A 47-year-old man presents to you with fever and cough. He is undergoing chemotherapy for non-Hodgkin lymphoma. His symptoms started 2-3 days prior to his presentation, and he reports that the cough is becoming worse and more productive of phlegm. His daughter had been sick with a sinus infection. His vital signs are: blood pressure, 110/80 mm Hg; heart rate, 116 beats/minute; respiratory rate, 22 breaths/minute; temperature, 101.6°F. He is in mild distress and his chest examination revealed fine crackles in the right lung field. Complete blood count revealed neutropenia. Blood cultures were drawn and sputum was sent for Gram stain and culture. A chest x-ray was obtained, and it did not reveal any infiltrates. What is the most appropriate next diagnostic test? 1. lumbar puncture 2. computed tomography (CT) of the sinuses 3. repeat the chest x-ray in 24 hours 4. computed tomography (CT) scan of the chest 5. nasal sw - ANS 4. computed tomography (CT) scan of the chest A 46-year-old man taking no previous medication is started on hydrochlorothiazide 25 mg for essential hypertension. Several days later he returns with a rash (see image). He complains of malaise, myalgia, and joint discomfort. This presentation is most consistent with which of the following? 1. Henoch-Schönlein purpura 2. Takayasu arteritis 3. hypersensitivity vasculitis 4. Churg-Strauss syndrome 5. microscopic polyangiitis - ANS 3. hypersensitivity vasculitis A 53-year-old woman was diagnosed with fibromyalgia a decade ago. She has been unable to work because of her widespread and chronic pain. The patient complains of chronic insomnia. She is afraid to do much because she feels that it will lead to an exacerbation of her pain. Her prior physician treated her with long-acting oxycodone, as well as short-acting oxycodone for breakthrough pain. The patient has recently relocated, and her new physicians endeavors to wean her off opioids and to employ non-pharmacologic therapies to improve her functioning. What type of psychotherapy has the most evidence of efficacy in fibromyalgia patients? 1. psychodynamic psychotherapy 2. cognitive behavioral therapy 3. humanistic-existential psychotherapy 4. transpersonal psychotherapy 5. psychoanalytical therapy - ANS 2. cognitive behavioral therapy A 34-year-old man presents complaining of 12 hours of intense pain in his left elbow (see below). He is a construction worker and recently sustained a laceration/abrasion in his right forearm for which he did not seek medical treatment. He states that he feels the pain is rapidly increasing in his elbow. On examination, he has a decreased range of motion in his right elbow due to pain in the posterior elbow area. He has a large, boggy mass on the posterior elbow that is warm and erythematous. Which is the following is the next best step in the management of this patient's condition? 1. aspiration of the bursa with Gram stain and culture 2. cold compresses applied to the elbow every 2 hours for the next 24 hours 3. corticosteroid injection into the large boggy mass 4. magnetic resonance imaging of the elbow joint 5. aspiration of the bursa with discharge to home and follow-up the next day - ANS 1. aspiration of the bursa with Gram stain and culture An 18-year-old African American woman has developed a malar rash, photophobia, proteinuria, and polyarticular arthritis. Her antinuclear antibody test is positive, as is her antibody to Sm nuclear antigen (anti-Sm) antibody test. She has not been on any medications and has no chronic illnesses. Her physician asks about any antecedent viral illness, and she does give a history of viral illness several months earlier. What virus has been associated with development of systemic lupus erythematosus? 1. Epstein-Barr virus 2. parvovirus B-19 3. adenovirus 4. human herpes virus 5. varicella - ANS 1. Epstein-Barr virus A 27-year-old male with a history of seizures presents after a typical seizure. His mental status has returned to normal. His physician prescribed phenytoin a year ago. Which of the following is the most likely reason for this seizure? 1. Head trauma 2. Lowered seizure threshold due to changes in sleep 3. Medication noncompliance 4. New medication interaction with anticonvulsant 5. Fever due to infectious process - ANS 3. Medication noncompliance A 24-year-old female complains of multiple fluctuating focal neurological findings over a period of 6 weeks. Her examination reveals decreased sensation of both lower legs up to the knees. Her MRI is seen here. What is the most likely diagnosis? 1. multiple sclerosis 2. Wernicke`s encephalopathy 3. hysteria 4. cryptococcal meningitis 5. cerebral toxoplasmosis - ANS 1. multiple sclerosis A 59-year-old woman presents with a 2-hour episode of left arm weakness and a 10-minute episode of "a shade falling" over her right eye. Her past medical history is notable for diabetes and pseudogout. She takes glipizide, metformin, and aspirin 325mg daily. She does not smoke, drink, or use drugs. Her review of systems is negative. Her temperature is 37.1, heart rate is 77, blood pressure 114/76, respiratory rate 14, and oxygen saturation 98% on room air. Her fundoscopic examination shows cutoff arteries in the right eye. There is a right carotid bruit. Her exam is otherwise normal. Her LDL is 88. EKG is normal sinus rhythm. She asks if she should be taking something stronger than aspirin. Which of the following would decrease her risk of stroke? 1. Change aspirin to warfarin 2. Increase aspirin dose to 1000mg daily 3. Change aspirin to clopidogrel 4. Change aspirin to dipyridamole 5. Add clopidogrel to aspi - ANS 3. Change aspirin to clopidogrel A 76 year