2012

Question 1

72 y/o white male develops a rapidly growing epithelial tumor just in front of his right ear. Onset 6 woks ago. 1.5 cm in diameter w/ horny plug in the center. Diagnosis?

Answer 1

Keratocanthoma: benign growth. Treated by excisional biopsy which is also required to distinguish it from SCC. Very rarely turns malignant.

Question 2

8 yr old male brought to ED for acute asthma attack with onset 48 hrs earlier. Mom initiated emergency plan starting oral steroids and albuteril MDI. Child is alert with rr of 30, sating 94% on room air. Peak flow is 40% of predicted. What’s the next step?

Answer 2

Give IV mag sulfate

Question 3

56 y/o male with DM II has normal cardiac & renal function but failed to achieve adequate control of his DM with diet and multiple oral agents. His BMI is 30.1 & A1C is 9.1. Which medication is most likely to be beneficial in combo with insulin and diet therapy?

Answer 3

Metformin; it decreases cardiac risk, decreases weight gain & has a low risk of hypoglycemia

Question 4

78 y/o male in the hospital the day after a hip replacement has not voided in the past 12 hours. Cath is placed & 500mL is removed from his bladder. What is most likely to improve the success rate of a voiding trial?

Answer 4

Tamsulosin (flomax) at time of cath insertion. Alpha blockers have been shown to increase the success rate of voiding trials.

Question 5

Follow up visit for a 72 yr old CF with DM II. Daughter asks you to treat the lesion shown in figure 7, because it bothers the pt and itches, especially at night. Diagnosis?

Answer 5

Eczema claquele (zero tic eczema), common in elderly due to dry skin. Treat with wet compresses and antibiotics to remove crust and suppress infection followed by topical steroids and lubricant

Question 6

Which one is a proven strategy to reduce ACL tears in high school athletes?

Answer 6

Structured exercise stressing balance, strength, and proprioception.
Girls have a 10x greater risk than boys.

Question 7

22 yr old college student wants to discuss abdominal pain and constipation. She has had it for a few years, it is worse while at college. She has crampy pain & bloating relieved by deification. Her BM is firm, hard to pass and occur Q3 days. No vomiting, weight loss, blood in stools, or Melina. Regular menses, and no family history of GI or GU disease. On exam her abdomen is WNL. Treatment?

Answer 7

Therapeutic trial of luboprostone (amitiza) which is effective for constipation predominant IBS.

Question 8

Most likely diagnosis of condition in radiograph 4 is:

Answer 8

Dislocation of lunate.

Question 9

28 yr old male alcoholic presents with a 4 wk h/o fever, malaise, cough, sputum production, and weight loss. 12 hrs ago his cough increased and he noted frank blood in his sputum. Culture pending. CXR in figure 5. What test is needed prior to treatment?

Answer 9

Culture of sputum

Most likely a lung abscess from anearobes after aspiration. Should treat with clindamycin.

Question 10

58 y/o AAM presents to ED with a 6 hr h/o substernal pain. He has a h/o HTN. BP drops to 60 after getting nitroglycerin. EKG shown in figure 6. In addition to nitrate side effect, which of the following should be the first diagnosis considered?

Answer 10

RV MI.

This is usually an extension of an inferior MI. If hypotension develops with nitro immediately give 2L IVNS.

Question 11

70 yr old female with recurrent episodes of cough, voluminous sputum & dyspnea. No smoker, smoked a few as a teen. History not suggestive of pulmonary or liver disease. Exam is WNL except crackles at lung bases. CXR shows nonspecific markings at both bases. Most appropriate work up?

Answer 11

High resolution CT

Most likely bronchiectasis, high res CT is gold for diagnosing

Question 12

23 yr old female with recurrent epistaxis. Mother has hereditary hemorrhagic telangectasia. Contrast echo is needed to look for what likely associated condition?

Answer 12

Pulmonary AV malformation

Osler weber randu

Question 13

EKG in figure 2 shows?

There are no P waves

Answer 13

Atrial fib

Question 14

80 yr old male has a 4 he history of generalized abdominal pain, vomiting, and fever of 101. On exam you note generalized moderate abdominal tenderness, absent bowel sounds, and a normal rectal exam. Figure 1 shows abdominal film.
(Very little gas seen in colon)

Answer 14

Small bowel obstruction

Treat with IVF and surgical evaluation

Question 15

72 yr old male for follow up after his 3rd hospital stay for heart failure within the past 4 months. He is a widower who lives alone, and wants options for in-home nursing care. His sister and neighbor are with him. You have not seen this patient before. How should you interact with the 3 of them?

Answer 15

Determine the reason each person is present today

Question 16

19 yr old sexually active female comes in for a routine checkup. She is healthy with no chronic conditions and dos not smoke. Which screen is supported by evidence?

Answer 16

Chlamydia infection

To reduce the risk of PID

Question 17

50 yr old presents for eval of dyspnea that tends to occur with exercise. She has a 40 pack year history of smoking and has exercise induced asthma. No other medical problems. Spirometry shows Normal expiration loop and flat inspiratory loop. Diagnosis?

Answer 17

Vocal cord dysfunction

Cords move Midline in inspire or expire causing an obstruction, often misdiagnosed as exercise induced asthma

Question 18

Which is true concerning hemoglobin A1C levels in DM?

Answer 18

Results can be misleading in pets wi sickle cell.

African Americans also have false high levels, the test is no good for pregnant people.

Question 19

65 yr old male in good health presents with a 2 day history of a sensation of pressure and hearing loss in her left ear. Exam unremarkable. Both tympanic membranes are normal. Audio gram shows a 30 decibel loss at 3 consecutive frequencies in left ear. Normal hearing on right. Tuning fork sounds lateralise to the right.

Answer 19

Treat with oral steroids

Pt most likely has sensorineural hearing loss.

Question 20

26 yr old male comes to ED with fever, and looks ill. Previously undocumented grade 3 murmur, TEE shows 1.5 cm vegetation on tricuspid. Most likely organism?

Answer 20

Staph aureus

Most likely an IV druggy

Question 21

Neurologically intact 77 yr old woman has low back pain after a fall 2 days ago. X-RAY spine shows compression fracture of L3 with 50% loss of vertebral height. Most appropriate treatment?

Answer 21

Calcitonin-salmon (miacalcin)

Question 22

What is the most common cause of death in AAM in the US?

Answer 22

Heart diseas

Question 23

45 yr old female has an all phosphor of twice normal level. She has pruritis. Everything else is WNL with no change 2 months later. Gamma-glutamyltranferase is elevated as is an anti-mitochondrial antibodies titer. Hepatic US is normal. Most likely diagnosis?

Answer 23

Primary biliary cirrhosis

Question 24

Previously healthy 27 yr old female complains of dysuria and urgency and frequency. She also has right flank pain, fever, chills, and nausea, and anorexia. Her temp is 101.2, pulse is 102, BP is 126/82. Supra public tenderness and right CVA tenderness. Pariah, hematuria, and leukocyte esterase positive UA. Leukocyte sis with a left shift. Treatment?

Answer 24

Outpatient ciprofloxican

Question 25

82 yr old female is hospitalized for pneumonia and sepsis. Advanced directive in place. If needed, who determines her decision making capacity?

Answer 25

Attending physician

Question 26

67 yr old female has anosmia. Only history is osteoporosis treated with fosamax. No sinus symptoms. Normal HEENT exam. What next?

Answer 26

MRI brain

Question 27

The AHA recommends BP goal of 130/80 or less in patients with

Answer 27

CKD

Question 28

78 yr old has chronic symptomatic orthostatic hypotension, likely related to diabetic autonomic dysfunction, which has failed to respond to usual treatment. She takes metformin, Lipitor, ASA, and lantus. What treatment would be most effective for her hypotension?

Answer 28

Midodrine

Question 29

34 yr old CF works as an engineer. She complains of fatigue, low energy, and depression. She has felt this way for most of her life. She denies any recent losses, is doing well at work, and recently got a promotion. She has no interests, no happy thoughts, low self esteem, no sleep problems, normal appetitie, no concentration problems. No SI, but doesn’t ca s if she dies. Medical eval is normal. Diagnosis?

Answer 29

Dysthymia disorder

Question 30

32 yr old G2P1 with long standing untreated HTN is at 8 woks EGA. BP is 156/114. Which med do you use?

Answer 30

Labetalol, trandate

Question 31

Which med is effective in treating borderline personality?

Answer 31

No currently available pharmacotherapy

Question 32

You are managing a pt who is critical,y ill and being placed on a vent. Management should include what, in order to prevent vent associated pneumonia?

Answer 32

Elevation of head of bed

Question 33

24 yr old female with a 10 day h/o cough productive of green sputum. PMHx unremarkable, immunization s are UTD. Afebrile, pulse 89, respiration 24, oxygen sat 95 on room air. What is the best management for this condition?

Answer 33

Reassurance that symptoms will resolve on their own.

Bronchitis, 90% viral

Question 34

66 yr old CF presents for a routine physical. Problems include HTN, DM, HLD, and GERd - all controlled with Rx. Bone density is consistent with osteopenia. She takes calcium carbonate. What med will reduce her absorption of calcium carbonate?

Answer 34

Prilosec (omeprazole)

Question 35

50 yr old male presents with erythroderma and fever. He has not had a sore throat, rhinorrhea, cough, or urinary symptoms. His current meds are lisinopril, atenolol, and allopurinol. On exam he has a BP of 110/90, pulse of 90, and temp of 101.5. The skin is remarkable for marked erythema over 90% of his body with tenderness. His mental status is clear and his neck is supple, mildly tender adenopathy is noted in neck, axilla, and groin. No oral ulceration or ocular symptoms. WBC 150000 with 20% eosinophils. AST is 100, ALT is 110. Most likely diagnosis?

Answer 35

DRESS Syndrome (drug reaction with eosinophilia and systemic symptoms).
Treat with steroids. Common causes are carbamazepine, phenytoin, lamotrigine, phenobarbital, allopurinol (has highest mortality rate)

Question 36

84 yr old female presents for follow up of multiple chronic conditions. She is usually accompanied by her daughter who lives near by, but today her son & his wife who live out of town are with her. They are supportive but are insistent that the patient see a specialists for a problem that she has previously decided not to peruse further. The patient wants to avoid conflict, but doesn’t want to see a specialist. How do you deal with this?

Answer 36

Maintain neutrality & avoid triangulation

Question 37

38 yr old female has spontaneous ROM with thick mec just prior to delivery of a male infant at 40 wks gestation. Oropharyngeal suction is performed prior to delivery of the shoulders. Upon delivery the infant has spontaneous respirations, pulse of 120, cyanosis of the hands and feet, and good tone. What is the appropriate immediate management?

Answer 37

Expectant management

Only incubate and suction below the vocal cords if the infant is not vigorous or has signs of respiratory distress

Question 38

40 yr old male with DM has the following FLP:
Total cholesterol 204
Triglycerides 223
LDL 112
HDL 42
He is currently taking simvastatin 40 mg, what is the proper treatment now?

Answer 38

Switch to atorvastatin

It is better at lowering LDL

Question 39

12 yr old male presents with a 2 Day history of fever, myalgias, and rhinorrhea. He is otherwise healthy, you suspect influenza. What next?

Answer 39

Systemic treatment only.

Do not use antivirals in otherwise healthy people

Question 40

Patients with which of the following should be hospitalized and treated emergently?

• drug induced thrombocytopenia
• congenital thrombocytopenia
• gestational thrombocytopenia
• TTP
• thrombocytopenia associate with Lyme disdase

Answer 40

TTP

It has a 30% mortality rate. Treat with plasma exchange.

Question 41

An unconscious 22 yr old male is brought to the ED. His RR is 8, pulse is 60, and pupils are miotic. Most likely cause?

Answer 41

Narcotic overdose.

Treat with naloxone.

Question 42

39 yr old male with history of alcoholism presents with complaints of abdominal pain, vomiting, and nausea after a recent binge. He ha eaten little since the onset of symptoms 3 days ago. Labs suggest alcoholic ketoacidosis. Bicarbonate is 16. In addition to thiamine what else do you do?

Answer 42

Give NS and glucose.

Question 43

52 yr old female sees you for the first time to establish care for her stable COPD. Since losing her insurance 4 months ago she has been off of all of her meds except for a short acting bronchodilator. She quit smoking 2 yrs ago. She has a frequent chronic cough and dyspnea when climbing stairs. FEV1 is 55%. Oxygen saturation is 90 on room air. In addition to the SABD she is taking recommended maintenance would either be an inhailed long acting anticholinergic or

Answer 43

A long acting beta agonist

Question 44

62 yr old female presents because of painless rectal bleeding. Over the past several months she has occasionally noticed blood on the toiled tissue and in her stool. She also reports periodic anal itching and discharge with protrusion of rectal tissue during BM that resolves spontaneously. She had a normal colonoscopy at age 50. Abdominal exam is normal, DRE is not painful and no mass is palpated. However, her stool is positive for occult blood. Anoscopy demonstrates dilated purplish blue beings above the dentate line. What has the best evidence for reducing symptoms in this situation?

Answer 44

Fiber supplementation. She has grade 2 internal hemorrhoids.

Question 45

70 y/o female presents with recurrent episodes of cough, voluminous sputum production, and dyspnea. History does not suggest a cause for liver or pulm dz. PE is WNL, except for crackles at both lung bases. CXR shows nonspecific markings at both bases. What is the most appropriate next step?

Answer 45

High resolution CT, which is good standard for diagnosing bronchiectasis

Question 46

A previously healthy 24 y/o female presents with a 10 day history of facial pain and fever. She has TTP over her maxillary sinus on the left. Treatment?

Answer 46

Oral antibiotics for any sinus complaints lasting 10 days or longer

Question 47

50 y/o female with 3wks of rash that is pruritic with flat topped violaceous papules 3-4mm in size. Located primarily on volatile wrists, forearms, lower legs, and dorsa of feet. When it first appeared she went to the ED & was treated for possible scabies, but has not had improvement with treatment. Which treatment is indicated now?

Answer 47

Clobetasol (cormex, temovate) 0.05% ointment for classic lichen planus

Question 48

Which one of the following children should be referred immediately for eval of speech delay?

Answer 48

3 yr old who has a vocab of 50 words

Question 49

35 yr old female immigrated from a rural village in Southeast Asia. She has had a low grade fever and nonproductive cough for 1 wk. she has crackles, but no signs of effusion on CXR. However there are several 1-2mm oval infiltrates on CXR. Cause?

Answer 49

Ascaris lumbricoides

Question 50

1st time mom calls for advice on nipple pain during breast feeding. She is 6 days postpartum. Which would be most effective?

Answer 50

Education on positioning

Question 51

Previously healthy 29 yr old pediatric nurse has a 3 day history of malaise, arthralgias, and nonpruritic rash. Rash is faint, macula papule, irregular, reticulate exam them covering thighs and inner upper arms. Summetric synnovitis is present on several distal and proximal interphalangeal joints & metacarpals. Small effusions, erythema and tenderness in left wrist and right elbow. Cause?

Answer 51

Parvovirus B19 (5ths dz, erythema infectiosum)

Question 52

In counseling a 35 yr old female about smoking cessation, you find that her biggest concern is weight gain. Which of the following is strongly associated w/ weight gain?

Answer 52

Varencicline (chantix)

Question 53

You diagnose polymialgia rheumatica in a 72 yr old fe,ale. This is a new diagnosis for her & she has not had any treatment yet. Best initial treatment?

Answer 53

Prednisone 15mg daily with a slow taper

Question 54

Otherwise healthy 53 yr old male presents with acute SOA and pleuritic chest pain. O2 sats 85% on room air. Hemodynamically stable. Had an appy 2 wks ago with a complicated abscess post-op requiring a wk long hospital stay. Initial test?

Answer 54

CT angiography of chest to rule to PE

Question 55

52 yr old male presents with major depressive disorder. He reports a decreased libido and is concerned about the impact of meds on his sex life. Which med is least likely to cause sexual dysfunction?

Answer 55

Bupropion (Wellbutrin)

Question 56

44 yr old female has recently lost her best friend to ovarian cancer. She has no family history of cancer, but requests screening for ovarian cancer. Her PE & pelvic exam are WNL. According to guidelines, which would be best for this patient?

Answer 56

No screening

Question 57

A pregnant 22 yr old G2P1 develops an acute DVT in her left leg during the 3rd trimester. She had a csection for her 1st delivery & wants to breast feed. Treatment?

Answer 57

Low molecular weight heparin

Question 58

40yr old male presents with a new rash. On exam you note multiple erythematous to yellow dome shaped papules on the extensor surfaces of his extremities, buttocks, and hands. They are tender & pruritic. Biopsy reveals foamy macrophages and dermal lipids. This rash is associated with?

Answer 58

Hypertriglyceridemia

Question 59

For most patients, which one of the following is the most effective treatment for anemia of chronic disease?

Answer 59

Optimal management of underlying disease