ROSH Medical Exam
A patient presents to the clinic complaining of a tearing pain with bowel movements and reports small
streaks of blood on the toilet paper. A physical examination of the patient's anus reveals a lesion most
likely in which of the following anatomic locations? ANS ANS post midline
A 32-year-old man is admitted to the intensive care unit with a high fever, severe headache, vomiting,
and rash for three days. Physical exam reveals a petechial rash involving the palms and soles that began
on his wrists and ankles. Labs reveal dehydration and acute renal failure. Which of the following
diagnostic tests would be most useful in securing a diagnosis? ANS ANS skin biopsy ANS RMSF
42-year-old woman presents to the emergency department after a suicide attempt. The patient was
depressed two days ago and took an entire bottle of acetaminophen. She initially felt slightly nauseous
and generally unwell but was otherwise asymptomatic. A family member convinced her to come to the
emergency department for further evaluation. Which of the following history or physical exam findings
is most consistent with toxic acetaminophen ingestion ANS ANS
33-year-old woman presents to the clinic for obstetric care. She reports a history of two consecutive,
painless second-trimester miscarriages. Her past medical history is remarkable for previous conization
for cervical intraepithelial neoplasia. She is currently twelve weeks pregnant. Which of the following is
the most appropriate next step in management in this patient? ANS ANS
32-year-old woman with history of migraine headaches presents for evaluation of increased frequency
of headaches. She takes abortive medication for migraines 2-4 times weekly and misses several days of
work a month. You decide to start topiramate daily for migraine prophylaxis. Of the following, which
one is the most common side effect of this medication? ANS ANS paresthesia
Topiramate is an anticonvulsant used for migraine prevention and treatment of epilepsy. Central
nervous system side effects are the most common and include paresthesias, nervousness, fatigue,
ataxia, drowsiness, lack of concentration, dizziness and confusion. Topiramate should be initiated at a
,low dose and gradually titrated to the recommended dose to reduce the risk of these side effects. Also,
topiramate should not be discontinued abruptly, but instead decreased gradually over weeks, as sudden
cessation may increase the risk for seizure.
In addition to anticonvulsants, antihypertensive agents and antidepressants are sometimes used for
migraine prophylaxis. Beta-blockers and tricyclic antidepressants are commonly used. Patients with a
history of bronchospastic disease should avoid nonselective beta-blockers, such as propranolol, due to
the possible side effect of bronchospasm (B). Tricyclic antidepressants antagonize muscarinic receptors
leading to dry mouth (A), constipation, urinary retention, and sometimes blurred vision. Topiramate is
used in the prevention of seizures (D) as well as migraines, and seizure is also a potential side effect of
abrupt discontinuation of topiramate
A 65-year-old man presents to his physician for a gradual decline in exertional fortitude and dyspnea on
exertion that has been getting worse over the past two months. Physical exam demonstrates a mid-
systolic murmur heard best at the second intercostal space near the right sternal border. The murmur
decreases with isometric handgrip and Valsalva maneuvers. What is the most likely diagnosis? ANS ANS
24-year-old woman presents with dysuria, urgency, and urinary frequency for the last three days. Today,
she developed nausea, flank pain, and a fever. What is the most likely diagnosis? ANS ANS
19-month-old boy is brought into the emergency department by his parents with concern for
intermittent cough and fever for the past 3 days. On exam, he has a mild inspiratory stridor and a
barking cough. Exam of the posterior oropharynx is unremarkable and his oxygen saturation is 98% on
room air. An anteroposterior soft tissue neck X-ray and chest X-ray are obtained. Which of the following
findings on imaging is most consistent with the diagnosis? ANS ANS
75-year-old man with a past medical history of lung cancer presents to the Emergency Department
complaining of three days of low back pain, bilateral lower extremity weakness, and urinary retention.
Digital rectal exam demonstrates decreased rectal tone. What is the most likely diagnosis? ANS ANS
27-year-old tall, thin male presents to the emergency room with moderate right-sided chest pain and
dyspnea. He says it started quickly while he was watching television 30 minutes ago. He is tachypneic
and tachycardic, however his heart rate and blood pressure are stable at this point. Lung exam reveals
,decreased breath sounds at his right lung field. Which of the following other physical exam findings
would be expected in this patient? ANS ANS decr right sided tactile frem
45-year-old man with a history of obesity and diabetes mellitus presents to the emergency department
complaining of abdominal pain that radiates to his back, and nausea and vomiting. Physical examination
reveals tenderness in his epigastrium and yellow deposits are noted on the extensor surfaces of his
forearms. Which of the following will most likely be seen on his lipid panel? ANS ANS markedly elevated
TG
54-year-old woman presents with intermittent numbness and tingling in the first three digits of her right
hand for the last week. The symptoms are exacerbated by knitting or typing. Physical exam reveals
positive Phalen and Tinel signs. What is the most likely diagnosis? ANS ANS carpal tunnel
16-year-old female competitive runner complains of pain and tenderness over her shins when she runs.
On physical exam you notice point tenderness over her left tibia. X-rays are normal but MRI reveals a
hairline fracture in the tibia. She has suffered multiple stress fractures of this bone before. A prompt
workup should be initiated for which of the following disorders? ANS ANS hypopara
55-year-old man presents to his pulmonologist with progressive shortness of breath over the past year.
He was previously healthy and now can barely make it up the stairs in his home. A chest radiograph
shows enlargement of the pulmonary arteries with a normal sized cardiac shadow and normal-
appearing lung fields. An echocardiogram is performed showing a normal-shaped left ventricle and
thickened myocardium in the right ventricle. Which diagnosis is most likely in this patient? ANS ANS
pulm arterial HTN
42-year-old man presents via emergency medical services after an injury that occurred while he was
working. There was an explosion at the chemical plant where he was employed. An initial survey of the
patient shows deep-partial thickness burns of his neck and face along with burns of varying degrees on
his torso and hands. There is soot in his nose and mouth. Which of the following is the most appropriate
next step in managing this patient? ANS ANS prepare for emergent intubation
24-year-old previously healthy woman presents to the ED complaining that she cannot move her legs.
The symptoms occurred suddenly after she was told that her fiancé died in a motorcycle accident. She
denies any associated symptoms, including pain. The sensation and deep tendon reflexes in her lower
, extremities are normal. She has normal muscle tone. What is the most likely diagnosis? ANS ANS
conversion d/o
32-year-old man presents with severe bilateral eye pain that started in the late evening while watching
television. He works as a welder during the day. He has associated tearing, photophobia, and foreign
body sensation. He does not use contact lenses. Visual acuity in 20/40 OD and 20/40 OS. His eye
examination after fluorescein staining is seen above. What is the most likely diagnosis? ANS ANS UV
keratitis
72-year-old man presents with worsening low back pain for the past one month. The pain is worse with
extension of his back and after walking for several minutes. The pain is relieved with sitting. Physical
exam shows that extension of the spine produces pain radiating down his bilateral legs. Which of the
following is the most likely diagnosis? ANS ANS spinal stenosis
47-year-old man presents as a trauma activation after a head-on motor vehicle crash at 20 mph. He was
a restrained driver and the airbags did deploy. There were no drugs or alcohol involved. He is uncertain
if he lost consciousness. EMS extricated him, put him in spinal immobilization, and splinted an obviously
fractured femur. On primary survey, his airway is protected, he is breathing easily, and is normotensive.
Vital signs are within normal limits. Secondary survey is notable for a GCS score of 15, a mildly tender
right trapezius muscle, and an ecchymotic and deformed left femur with normal distal neurovascular
function. The presence of which historical or physical finding necessitates cervical spinal imaging? ANS
ANS mech of injury
5-year-old girl presents with a blistering rash surrounding her mouth and extending into her nares after
a recent head cold. A close examination of the area reveals multiple pus-filled blisters that erupt with
minimal pressure, and diffuse honey-colored crusting lesions. Which of the following tests would best
reveal the cause of this eruption and guide treatment? ANS ANS
Which of the following signs is a normal finding during early pregnancy? ANS ANS chadwick
21-year-old woman presents with pelvic pain that has been worsening over the last two days. She
reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin, copious
vaginal discharge, cervical motion tenderness, and a mass in the left adnexa. Pregnancy test is negative.
A pelvic ultrasound reveals a complex multiloculated left adnexal mass. Which of the following
A patient presents to the clinic complaining of a tearing pain with bowel movements and reports small
streaks of blood on the toilet paper. A physical examination of the patient's anus reveals a lesion most
likely in which of the following anatomic locations? ANS ANS post midline
A 32-year-old man is admitted to the intensive care unit with a high fever, severe headache, vomiting,
and rash for three days. Physical exam reveals a petechial rash involving the palms and soles that began
on his wrists and ankles. Labs reveal dehydration and acute renal failure. Which of the following
diagnostic tests would be most useful in securing a diagnosis? ANS ANS skin biopsy ANS RMSF
42-year-old woman presents to the emergency department after a suicide attempt. The patient was
depressed two days ago and took an entire bottle of acetaminophen. She initially felt slightly nauseous
and generally unwell but was otherwise asymptomatic. A family member convinced her to come to the
emergency department for further evaluation. Which of the following history or physical exam findings
is most consistent with toxic acetaminophen ingestion ANS ANS
33-year-old woman presents to the clinic for obstetric care. She reports a history of two consecutive,
painless second-trimester miscarriages. Her past medical history is remarkable for previous conization
for cervical intraepithelial neoplasia. She is currently twelve weeks pregnant. Which of the following is
the most appropriate next step in management in this patient? ANS ANS
32-year-old woman with history of migraine headaches presents for evaluation of increased frequency
of headaches. She takes abortive medication for migraines 2-4 times weekly and misses several days of
work a month. You decide to start topiramate daily for migraine prophylaxis. Of the following, which
one is the most common side effect of this medication? ANS ANS paresthesia
Topiramate is an anticonvulsant used for migraine prevention and treatment of epilepsy. Central
nervous system side effects are the most common and include paresthesias, nervousness, fatigue,
ataxia, drowsiness, lack of concentration, dizziness and confusion. Topiramate should be initiated at a
,low dose and gradually titrated to the recommended dose to reduce the risk of these side effects. Also,
topiramate should not be discontinued abruptly, but instead decreased gradually over weeks, as sudden
cessation may increase the risk for seizure.
In addition to anticonvulsants, antihypertensive agents and antidepressants are sometimes used for
migraine prophylaxis. Beta-blockers and tricyclic antidepressants are commonly used. Patients with a
history of bronchospastic disease should avoid nonselective beta-blockers, such as propranolol, due to
the possible side effect of bronchospasm (B). Tricyclic antidepressants antagonize muscarinic receptors
leading to dry mouth (A), constipation, urinary retention, and sometimes blurred vision. Topiramate is
used in the prevention of seizures (D) as well as migraines, and seizure is also a potential side effect of
abrupt discontinuation of topiramate
A 65-year-old man presents to his physician for a gradual decline in exertional fortitude and dyspnea on
exertion that has been getting worse over the past two months. Physical exam demonstrates a mid-
systolic murmur heard best at the second intercostal space near the right sternal border. The murmur
decreases with isometric handgrip and Valsalva maneuvers. What is the most likely diagnosis? ANS ANS
24-year-old woman presents with dysuria, urgency, and urinary frequency for the last three days. Today,
she developed nausea, flank pain, and a fever. What is the most likely diagnosis? ANS ANS
19-month-old boy is brought into the emergency department by his parents with concern for
intermittent cough and fever for the past 3 days. On exam, he has a mild inspiratory stridor and a
barking cough. Exam of the posterior oropharynx is unremarkable and his oxygen saturation is 98% on
room air. An anteroposterior soft tissue neck X-ray and chest X-ray are obtained. Which of the following
findings on imaging is most consistent with the diagnosis? ANS ANS
75-year-old man with a past medical history of lung cancer presents to the Emergency Department
complaining of three days of low back pain, bilateral lower extremity weakness, and urinary retention.
Digital rectal exam demonstrates decreased rectal tone. What is the most likely diagnosis? ANS ANS
27-year-old tall, thin male presents to the emergency room with moderate right-sided chest pain and
dyspnea. He says it started quickly while he was watching television 30 minutes ago. He is tachypneic
and tachycardic, however his heart rate and blood pressure are stable at this point. Lung exam reveals
,decreased breath sounds at his right lung field. Which of the following other physical exam findings
would be expected in this patient? ANS ANS decr right sided tactile frem
45-year-old man with a history of obesity and diabetes mellitus presents to the emergency department
complaining of abdominal pain that radiates to his back, and nausea and vomiting. Physical examination
reveals tenderness in his epigastrium and yellow deposits are noted on the extensor surfaces of his
forearms. Which of the following will most likely be seen on his lipid panel? ANS ANS markedly elevated
TG
54-year-old woman presents with intermittent numbness and tingling in the first three digits of her right
hand for the last week. The symptoms are exacerbated by knitting or typing. Physical exam reveals
positive Phalen and Tinel signs. What is the most likely diagnosis? ANS ANS carpal tunnel
16-year-old female competitive runner complains of pain and tenderness over her shins when she runs.
On physical exam you notice point tenderness over her left tibia. X-rays are normal but MRI reveals a
hairline fracture in the tibia. She has suffered multiple stress fractures of this bone before. A prompt
workup should be initiated for which of the following disorders? ANS ANS hypopara
55-year-old man presents to his pulmonologist with progressive shortness of breath over the past year.
He was previously healthy and now can barely make it up the stairs in his home. A chest radiograph
shows enlargement of the pulmonary arteries with a normal sized cardiac shadow and normal-
appearing lung fields. An echocardiogram is performed showing a normal-shaped left ventricle and
thickened myocardium in the right ventricle. Which diagnosis is most likely in this patient? ANS ANS
pulm arterial HTN
42-year-old man presents via emergency medical services after an injury that occurred while he was
working. There was an explosion at the chemical plant where he was employed. An initial survey of the
patient shows deep-partial thickness burns of his neck and face along with burns of varying degrees on
his torso and hands. There is soot in his nose and mouth. Which of the following is the most appropriate
next step in managing this patient? ANS ANS prepare for emergent intubation
24-year-old previously healthy woman presents to the ED complaining that she cannot move her legs.
The symptoms occurred suddenly after she was told that her fiancé died in a motorcycle accident. She
denies any associated symptoms, including pain. The sensation and deep tendon reflexes in her lower
, extremities are normal. She has normal muscle tone. What is the most likely diagnosis? ANS ANS
conversion d/o
32-year-old man presents with severe bilateral eye pain that started in the late evening while watching
television. He works as a welder during the day. He has associated tearing, photophobia, and foreign
body sensation. He does not use contact lenses. Visual acuity in 20/40 OD and 20/40 OS. His eye
examination after fluorescein staining is seen above. What is the most likely diagnosis? ANS ANS UV
keratitis
72-year-old man presents with worsening low back pain for the past one month. The pain is worse with
extension of his back and after walking for several minutes. The pain is relieved with sitting. Physical
exam shows that extension of the spine produces pain radiating down his bilateral legs. Which of the
following is the most likely diagnosis? ANS ANS spinal stenosis
47-year-old man presents as a trauma activation after a head-on motor vehicle crash at 20 mph. He was
a restrained driver and the airbags did deploy. There were no drugs or alcohol involved. He is uncertain
if he lost consciousness. EMS extricated him, put him in spinal immobilization, and splinted an obviously
fractured femur. On primary survey, his airway is protected, he is breathing easily, and is normotensive.
Vital signs are within normal limits. Secondary survey is notable for a GCS score of 15, a mildly tender
right trapezius muscle, and an ecchymotic and deformed left femur with normal distal neurovascular
function. The presence of which historical or physical finding necessitates cervical spinal imaging? ANS
ANS mech of injury
5-year-old girl presents with a blistering rash surrounding her mouth and extending into her nares after
a recent head cold. A close examination of the area reveals multiple pus-filled blisters that erupt with
minimal pressure, and diffuse honey-colored crusting lesions. Which of the following tests would best
reveal the cause of this eruption and guide treatment? ANS ANS
Which of the following signs is a normal finding during early pregnancy? ANS ANS chadwick
21-year-old woman presents with pelvic pain that has been worsening over the last two days. She
reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin, copious
vaginal discharge, cervical motion tenderness, and a mass in the left adnexa. Pregnancy test is negative.
A pelvic ultrasound reveals a complex multiloculated left adnexal mass. Which of the following
