AAFP

Question 1

Midshaft posteromedial tibial stress fx

- he can walk without pain, but NOT run without pain

Answer 1

Air stirrup leg brace

Question 2

Decreased sexual desire, spontaneous erections, reduced beard growth

Answer 2

test for total testosterone (late-onset male hypogonadism)

Question 3

Hypothyroid pt taking levo, TSH 0.2 (0.5-5.0). Next most appropriate step?

Answer 3

Decrease levo dosage

Question 4

Sharp, searing, severe heel pain. Worst after prolong sitting, in the morning getting out of bed. Gets better with walking, but worst at end of day. Works as floor nurse, on feet all day. PE: point tenderness on plantar surface of heel at medial calcaneal tuberosity. How to treat? Dx?

Answer 4

Over-the-counter heel inserts

Plantar fasciitis

Question 5

3yo infant, 3 day h/o fever and refusal to eat. Oral ulcers on buccal mucosa, soft palate, tongue, and lips. Cervical LAD. No rash. Tx? Dx?

Answer 5

Acyclovir suspension

HSV-1

Question 6

ABD sxs w/ vesicular rash

Answer 6

Celiac sprue

Question 7

Absolute contraindications for ECT?

Answer 7

None

Question 8

MC cause of refractory HTN?

Answer 8

Primary Hyperaldosteronism

measure plasma aldosterone/renin ratio
ratio >20 and aldosterone >15 ng/dL

Question 9

Sxs of CAP in child

Who are most susceptible

when is outpatient okay?

How to treat?

Answer 9

fever, cyanosis, any respiratory findings

<2 yo attending daycare

no signs of toxicity, hypoxemia, respiratory distress, or dehydration

Strep Pneumo MC –> high-dose amoxicillin

Question 10

When to introduce solid foods?

Answer 10

4-6 months

Extrusion reflex (pushing foreign material out of mouth with tongue)

Question 11

Soccer player, sudden cutting maneuver, right foot planted and ankle locked she felt her knee pop. She has moderate pain and swelling, loss knee hyperextension. Which test is abnormal?

Answer 11

Lachman test (most accurate 84%, vs. Anterior drawer test 62%)

Question 12

Pt w/ MGUS, when does it become Multiple Myeloma?

Answer 12

Evidence of end-organ damage

• Hypercalcemia
• Renal Failure
• Anemia
• Skeletal lesions

Question 13

60yo AAM w/h/o DM for 15yrs reports 1 week h/o left lower leg weakness, giving way of the knee, discomfort in anterior thigh. No trauma. Decreased pinprick and light touch, reduced motor strength on hip flexion and knee extension. MC dx?

Answer 13

Femoral neuropathy (a/w DM, but not directly caused by DM)

**Diabetic polyneuropathy characterized by symmetric and distal limb sensory and motor deficits.

**Meralgia paresthesia (no motor)

**Spinal stenosis pain but no neuro sx

**Iliofemoral atherosclerosis causes intermittent claudication but no motor weakness

Question 14

Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the:

Answer 14

Ovary

also reduce endometrial and colorectal

Question 15

Polymyalgia Rheumatica tx?

Answer 15

Dramatic response to corticosteroids

Question 16

Become apathetic, lost interest in job and hobbies, accused of making sexually harassing comments and inappropriate touching at work, no longer helps with household chores, difficulty expressing himself and his speech can lack meaning.

Answer 16

Frontotemporal dementia (Pick’s disease)

Question 17

88yo M hospitalized for 3 days, found cachetic and dehydrated at time of admission, started IVF and is now euvolemic, began nasogastric tube feeding and has now developed nausea, vomiting, hypotension, and delirium. What electrolyte abnormality?

Answer 17

Hypophosphatemia

Refeeding syndrome - fatal shifts in fluid and electrolytes that may occur in malnourished patients receiving artificial refeeding. Results from hormonal and metabolic changes and may cause serious clinical complications.

Question 18

Decrease risk of oral candidiasis for ICS in asthmatics?

Answer 18

Use valved holding chamber. Also rinsing the mouth after each administration.

Question 19

3-month h/o hoarseness

Answer 19

Laryngoscopy

Question 20

MC cause of right heart failure in adults?

Answer 20

Left heart failure

Also myocarditis, pulmonary stenosis, VSD

Question 21

Morphine identified in an employee taking a prescribed cough medicine containing codeine

Answer 21

Negative drug test

Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication.

Question 22

Morphine identified in an employee undergoing a prescribed methadone pain management program

Answer 22

Positive drug test

Morphine is not a metabolite of methadone

Question 23

Diazepam (Valium) identified in an employee taking oxazepam prescribed by a physician

Answer 23

Positive drug test for Valium

Oxazepam is a metabolite of diazepam but the reverse is not true

Question 24

Tetrahydrocannabinol identified in an employee taking prescribed tramadol (Ultram)

Answer 24

Positive drug test for THC

Tetrahydrocannabinol would not be found in the urine as a result of tramadol use

Question 25

18yo M w/ sore throat, LAD, fatigue. No airway compromise, heterophil antibody positive. Management includes?

Answer 25

Avoidance of contact sports Hydration, NSAIDs, throat sprays or lozenges NO: bed rest, steroids, antivirals

Question 26

65yo M w/h/o metastatic lung cancer hospitalized because of decreased appetite, lethargy, confusion. Serum calcium......................... 15.8 mg/dL (N 8.4–10.0) Serum phosphorus...................... 3.9 mg/dL (N 2.6–4.2) Serum creatinine. ...................... 1.1 mg/dL (N 0.7–1.3) Total serum protein..................... 5.0 g/dL (N 6.0–8.0) Albumin.............................. 3.1 g/dL (N 3.7–4.8) Most appropriate initial management?

Answer 26

Normal saline IV Initial management of hypercalcemia of malignancy includes fluid replacement w/ normal saline to correct volume depletion and enhance renal calcium excretion. Although IV Pamidronate has become the mainstay of treatment for hypercalcemia of malignancy, it is considered only after the hypercalcemic patient has been rendered euvolemic by saline repletion. The same is true for other calcium lowering agents.

Question 27

Why myomectomy over ribroid embolization?

Answer 27

Desire for future pregnancy Uterine fibroid embolization requires a shorter hospitalization and less time off work. General anethesia is not required, and a blood transfusion is unlikely to be needed. Uterine fibroids can recur or develop after either myomectomy or embolization

Question 28

Brown to black leopard spotting of colonic mucosa in 70yo AAM. Next step?

Answer 28

Review his medications Melanosis coli - benign condition resulting from abuse of anthraquinone laxatives such as cascara, senna, or aloe. The condition resolves with discontinuation of the medication.

Question 29

Valsalva maneuver will typically cause the intensity of a systolic murmur to increase in patients with what condition?

Answer 29

HOCM Valsalva decreases venous return to heart (decreases preload)

Question 30

12yo M w/ left hip pain. Overweight, afebrile, walks with a limp but no recall of injury.

Answer 30

Slipped Capital Femoral Epiphysis (SCFE)

Question 31

Associated w/ Percutaneous Endoscopic Gastrostomy (PEG) tubes

Answer 31

Increased use of restraints ADL drops so low, have to make a decision to insert PEG tubes. In general, they suck.

Question 32

58yo M w/ acute bronchitis. "cold goes into my chest and lingers for months." 30 smoking hx. PE: scattered rhonchi. CXR 4 months ago negative except hyperinflation and flattened diaphragm. Next diagnostic step?

Answer 32

Spirometry Distinguish between COPD and Asthma. COPD: pressure of outflow obstruction is not fully reversible, demonstrated by postbronchodilator spirometry showing FEV//FVC ratio of <70%

Question 33

50yo F w/ right eye pain. PE: no redness but reports pain w/ eye movement. Cause?

Answer 33

An orbital problem (inflamm, infxn, tumor invasion) Other sxs: diplopia, proptosis

Question 34

30 F asks for Colonoscopy, father was dx at age 58. No other FMHx.

Answer 34

High risk (one first-degree, at least two second-degree relatives) Start colonscopy at age 40 or 10 yrs before the earliest dx relative, Q5yrs.

Question 35

64yo AAM w/ persistnet pleuritic pain. Low-grade fever. Meds: simvastatin, lisinopril, baby ASA, spironolactone, furosemide, isosorbide mononitrate, hydralazine, carvedilol, nitroglycerin. CXR normal. Dx of pleurisy is made. Which med caused this?

Answer 35

``` "SHIPP" Sulfonamides Hydralazine INH Procainamide Phenytoin ```

Question 36

30yo M presents to ED for racing heart, h/o WPW. Tx?

Answer 36

Procainamide Adenosine, digoxin, CCB act by blocking conduction through the AV node, which may increase the ventricular rate paradoxically, initiating V Fib. These drugs are contraindicated in WPW.

Question 37

Which drug are contraindicated in the second and third trimesters of pregnancy?

Answer 37

Doxycycline Risk of permanent discoloration of tooth enamel in the fetus.

Question 38

25yo adds 5 ounces of red wine a day, adding 100 calories to his diet. What effect will 3000 calories a month have on his body 10 yrs later?

Answer 38

No direct relation between daily calorie consumption and weight. His weight will increase slightly and then stabilize

Question 39

Just dx mild persistent asthma in 13 AAF. Initial medical management includes?

Answer 39

SABA (albuterol) PRN and ICS daily

Question 40

Pt w/ RA should be screen for TB before which med?

Answer 40

Infliximab, Adalimumab, Certolizumab, Golimumab TNF-alpha inhibitors a/w increased risk of infxn (TB and candidiasis).

Question 41

42yo M w/h/o IVDA, HCV antibody enzyme immunoassay and recombinant immunoblot assay are both reported as positive. The quantitative HCV RNA polymerase chain reaction test is negative. Tests are consistent with?

Answer 41

Past infxn w/ HCV that is now resolved HCV antibody enzyme immunoassay - positive: should be followed by confirmatory test such as recombinant immunoblot assay (negative indicates false-positive antibody test, positive must be followed by HCV RNA PCR used to measure the amount of virus int he blood to distinguish active from resolved HCV infxn) In this case, the results of the test indicate that the patient had a past infection with HCV that is now resolved.

Question 42

Nursing-home resident develops skin ulcer w/ MRSA before discharge. Infection control when she returns to nursing home?

Answer 42

Strict handwashing practices by all staff, visitors, and residents

Question 43

Metformin (Glucophage) should be stopped prior to which one of the following, and withheld until 48 hours after completion of the test?

Answer 43

CT Angiography Since reduction in renal function (pyelography or angiography) can cause lactic acidosis in pts taking Metformin, the drug should be d/c 48 hours before and restarted 48 hours after the procedure if renal function is normal.

Question 44

Recognition by the patient that the obsessions or compulsions are excessive or unreasonable

Answer 44

Obsessive-compulsive disorder

Question 45

82yo w/ fever, difficulty breathing, cough productive of purulent sputum. O2 sat 86%, CXR w/ new infiltrate, pt is hospitalized. Most appropriate IV abx?

Answer 45

Ceftazidime, Levofloxacin, Vancomycin Coverage for MRSA and Pseudomonas

Question 46

Safe anti-depressant/mood stabilizer during pregnancy?

Answer 46

Fluoxetine (Prozac) and most SSRI Paroxetine is an SSRI contraindicated during pregnancy. No Benzos (Xanax), Lithium, Bupropion.

Question 47

11mo M w/ several paroxysms of ABD pain in last 2 hours. Episodes last 1-2 minutes, infant screams, turns pale, and doubles up. PE: fullness in the RUQ. Dx?

Answer 47

Intussusception (classic presentation, under age 2 w/ paroxysms of colicky ABD pain, palpable mass) Malrotation presents within first 4 weeks of life and characterized by bilious vomiting.

Question 48

62yo M w/h/o prostate cancer, well-controlled HTN, and severe osteoporosis. Brachytherapy and androgen deprivation for his prostate cancer. Meds: Lisinopril, alendronate, calcium, vitamin D. Never smoked, exercises 5x/week. What to consider next to treat osteoporosis?

Answer 48

Teriparatide (recombinant PTH analog given subQ daily, increases osteoblastic activity) Indicated for severe osteoporosis, pts w/ multiple risk factors, or pts w/ failure of bisphosphonate therapy.

Question 49

20yo F presents w/ painful and frequent urination of gradual onset over past week. No h/o UTI. No a/ hematuria, flank pain, suprapubic pain, fever, pruritis, discharge. UA/UCx with pyuria but no growth. Abx for 2 days w/ no relief. What agent?

Answer 49

Chlamydia trachomatis Sexually transmitted urethritis caused by Chlam, GC, HSV. Tx includes tetracycline (doxy) and search for other STD.

Question 50

82yo M recent fall middle of night to bo to bathroom. H/o bilateral dense cataracts, increased stance width and walks carefully and cautiously with arms and legs abducted. "En bloc" turn. Most likely cuase of this patient's gait and balance disorder?

Answer 50

Visual impairment "Timed Up and Go" test is reliable diagnostic tool for gait and balance d/o. Time <10 seconds is considered normal. Time >14 seconds is a/w increased risk of falls Time >20 seconds suggest severe gait impairment Abducted arms and legs, careful walking on ice movements, wide-based stance, "en bloc" turns. Cerebellar degeneration have ataxic gait that is wide-based and staggering. Parkinson's disease patients have a typical gait that is short-stepped and shuffling, with hips knees spine flexed and may also exhibit festination and "en bloc" turns. Motor neuropathy causes a "steppage gait" resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping.

Question 51

17 yo F h/o anorexia, BMI 17.4, serum electrolyte and EKG are normal. Intervention?

Answer 51

Family-based treatment

Question 52

42yo M w/ well-controlled T2DM presents w/ influenza like sxs of sudden onset HA, fever, myalgia, sore throat, cough. CDC recommends intiating treatment in this situation:

Answer 52

on basis of clinical sxs alone.

Question 53

52yo M has had a chronic course of multiple vague and exaggerated symptoms for which no cause has been found despite extensive testing. Most effective management approach for this patient?

Answer 53

Schedule for regular appointments Q2-4 wks

Question 54

Who should be advised to take aspirin, 81mg daily, for the primary prevention of stroke?

Answer 54

- Men 45-79yo risks for MI outweighs risk of GI bleed - Women 55-79yo risks for Ischemic stroke outweighs risk of GI bleed - Not over 80yo - Against women <55yo, men <45yo

Question 55

12mo F w/ Hgb of 9.0 (10.5-13.5), started whole milk at 9mo, appears healthy and otherwise no FMHx, CBC reveals mild microcytic hypochromic anemia with RBC poikilocytosis, RDW elevated. Next Step?

Answer 55

Prescribe oral iron Iron def is most likely. Patient's response to trial of iron would be most helpful in establishing dx, additional tests might be necessary if there is no response.

Question 56

Because of safety concerns, what med should be used only as additive therapy and not as monotherapy for asthma patients?

Answer 56

LABA Because of risk of asthma exacerbation or asthma-related death.

Question 57

16yo M w/ FMHx of Crohn's disease presents w/ intermittent loose stools and has up to three bowel movements per day. No fever, pain, hematochezia, wt loss, or any extra-GI sxs. PE normal. Most appropriate preliminary testing?

Answer 57

CBC, CMP, ESR IBD diagnosed via hx, labs, endoscopy. Endoscopy reserved for more severe sxs or those prelim labs shows risks.

Question 58

3do F develops rash, no cmplx, good prenatal care. Not irritable or in distress, afebrile, feeding well. PE: maculopapular rash and pustules on face, trunk, proximal extremities. Palms and soles are spared. A stain of pustule shows eosinophils. Most likely dx?

Answer 58

Erythema toxicum neonatorum

Question 59

Staphylococcal pyoderma

Answer 59

Vesicular rash | Stain shows polymorphonuclear leukocytes and clusters of gram-positive bacteria.

Question 60

51yo F w/ hyperplastic polyp, no FMHx for colon cancer. Most appropriate follow-up colonoscopy schedule?

Answer 60

10 years Small (<10mm) hyperplastic polyps from rectum or sigmoid are not neoplastic. One or two small tubular adenomas: 5-10yrs Three of more tubular adenomas: 3yrs

Question 61

Tx for symptomatic MVP?

Answer 61

Beta-blockers (Propranolol) Lifestyle changes: reduction of caffeine and alcohol Orthostatic hypotension can be managed w/ volume expansion (increase salt intake)

Question 62

52yo M w/ stable CAD and controlled HTN asks prevention of altitude sickness. Pt has sulfa allergy. Most appropriate step?

Answer 62

Dexamethasone Acetazolamide is effective, but contraindicated in pts w/ sulfa allergy. If used, should be started one day before ascent and continued until pt acclimatizes at the highest point.

Question 63

Most commonly implicated in Interstitial nephritis?

Answer 63

Abx (penicillins, cephalosporins, sulfonamides) MC drug-related cause of acute interstitial nephritis. Corticosteroids may be useful for treating this condition.

Question 64

Effective at improving symptoms of varicose veins?

Answer 64

Horse chestnut seed extract

Question 65

Contraindications to breastfeeding

Answer 65

- HSV lesion on breasts - Maternal seropositive CMV ONLY of recent onset or mothers of low birthweight infants - Active maternal TB - Post radioactive isotopes, chemotherapies, recreational drugs, or certain prescription drugs

Question 66

MC cause of erythema multiforme

Answer 66

HSV

Question 67

25yo M presents w/ right index finger pain for past 4 days. Progressively worse, swollen and held in flexed position. Pain increases with passive extension, TTP from tip of finer into palm. Most appropriate management?

Answer 67

Surgical drainage and Abx (later stages: >48hrs) Abx and splinting (early onset: <48hrs) Pyogenic tenosynovitis **NEVER use steroids on infected joint

Question 68

81yo M T2DM w/ HgA1c 10.9%, already on maximum dosage of glipizide. Problems with renal insufficiency and moderate ischemic cardiomyopathy. Most appropriate change in regimen?

Answer 68

Start insulin. Metformin - contraindicated in renal insufficiency Sitagliptin - should not be added to a sulfonylurea, dosage has to be lowered in renal insuff, does not result in diabetic control when used alone Pioglitazone - can cause fluid retention and therefore would be a good choice for a patient with cardiomyopathy

Question 69

What seafood poisoning requires more than just supportive therapy?

Answer 69

Scombroid poisoning - improperly stored scrombroid fish such as tina. mackerel, wahoo, bonito (dark meat fish), but also some non-scombroid fish may cause poisoning. Poisoning is due to high levels of histamine and saurine resulting from bacterial catabolism of histidine.

Question 70

22yo F w/ dizziness after 2 weeks ago developed gastroenteritis that other family members also had. Since been lighheaded when standing, feels her heart race, and gets HAs or blurred vision if she does not sit or lie down. No passing out, has not been able to work due to sxs. PE: normal except heart rate, 72 when lying or sitting, 112 when standing. BP remains unchanged. Routine labs and EKG normal. Most likely cause of patient's condition?

Answer 70

Postural orthostatic tachycardia syndrome (POTS) Rise in heart rate >30 beats/min or by heart rate >120 beats/min within 10 minutes of being in the upright position. Symptoms include position-dependent HA, ABD pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lit down quickly enough. Most prevalent in white females between 15-50yrs. Genetic predisposition, often incited after a prolong viral illness, and has a component of deconditioning. Tx: adequate fluid and salt intake, followed by regular aerobic exercise, beta-blockers

Question 71

Greatest risk factor for AAA

Answer 71

Smoking

Question 72

TSH 7.6 (0.4-5.1), free T4 within normal range

Answer 72

Subclinical hypothyroidism Elevated TSH and normal thyroid hormone in asymptomatic pt.

Question 73

Tinea infection in children that always require systemic antifungal therapy

Answer 73

Tinea capitis Need systemic therapy to penetrate the affected hair shafts. Tinea cruris and tinea pedis rarely require systemic therapy. Tinea corporis and tinea versicolor benefit from both oral and topical treatment, but localized infections only need topical.

Question 74

BNP 459, what can you assume?

Answer 74

Unsure diagnosis BNP lacks specificity necessary to function as absolute indicator of acute HF.

Question 75

Preop on 55yo F w/ T2DM, unable to climb stairs or do heavy work at home, otherwise denies chest pain and healthy. Appropriate study prior to surgery?

Answer 75

Dipyridamole-thallium scan (cardiac stress test) Preop eval: - perioperative CV risk of procedure - fxn status of pt - clinical factors that may increase risk (DM, stroke, renal insuff., h/o HF, angina, previous MI)

Question 76

62yo M taking omeprazole for over year for GERD. Asx, no problems w/ drug, ask about SE and benefits of continuing therapy. What do you tell him?

Answer 76

Decreased B12 absorption Increased likelihood of pneumonia Increased likelihood of C diff Decreased Ca2+ absorption (hip fx)

Question 77

48yo F AUB, periods last 3-5 days longer than usual, heavier, and some intermenstrual bleeding. PE: unremarkable, except parous cervix w/ dark blood at os and in vagina. No orthostatic hypotension, hgb 11.5, neg pregnancy test. Most important next step?

Answer 77

Endometrial Bx Pt >35yo w/ AUB must have endometrial bx to exclude hyperplasia or cancer. Next would be TSH.

Question 78

75yo AAM w/ no h/o cardiac presents w/ SOB and general weakness. sxs developed within 24hrs. PE: HR 160, rales to base of scapula bilat, moderate JVD, hepatojugular reflux. BP 90/55, becomes weak and diaphoretic when stand and complains of precordial pressure. EKG reveals atrial flutter w/ 2:1 block. Management?

Answer 78

Electrical cardioversion Hemodynamically unstable, otherwise digoxin or verapamil

Question 79

60yo M w/ HTN, 170/95, h/o lacunar stroke 10yrs ago. No other health problems, no smoke, no alcohol. ROS: minor residual weakness in his right upper extremity resulting from his remote stroke. Counsel him on lifestyle modifications, what is most appropriate treatment of HTN?

Answer 79

Thiazide diuretic and ACE inhibitor combo | CCB as well in JNC-8

Question 80

Activation of sympathetic branch will decrease what in CV system?

Answer 80

PR interval Increases HR, coronary flow rate, metabolic demand, contractility

Question 81

40yo F w/ chronic plaque psoriasis requests topical treatment. Most effective and fewest SE?

Answer 81

high-potency corticosteroids (fewer local reactions) & topical vitamin D

Question 82

43yo M w/ unipolar depression develops treatment resistance. Increases in SSRI and SNRI, currently taking citalopram 60mg daily. Most effective adjunctive therapy?

Answer 82

Lithium Bicarbonate or LOW dose T3

Question 83

4yo ABD pain and 3+ proteinuria. 3 days later pain resolves, repeat UA shows 2+ proteinuria w/ normal findings on micro, BMP also normal. Most appropriate next step?

Answer 83

Sopt first morning urine protein/creatinine ratio

Question 84

25yo M w/ 1 week of neck pain w/ radiation to left hand, intermittent numbness and tingling in left arm. Positive Spurling's. Cervical radiographs are negative. Most appropriate step?

Answer 84

NSAIDs for pain relief Pts w/ acute cervical radiculopathy and normal radiographs can be treated conservatively. Referral to a specialist should be reserved for pts who have persistent pain after 6-8 weeks of conservative management and for those with signs of instability.

Question 85

21yo AAF confused and delirious for 2 days. No PMHx, no meds. Recently returns from Southeast Asia. In ED, has several convulsions and rapidly comatose. 100.3F BP 80/50. No sxs meningeal irritation, normal CN. PE: mild, bilat, symm increase in DTR. Laboratory Findings Hemoglobin........................... 7.0 g/dL (N 12.0–16.0) Hematocrit............................ 20% (N 36–46) WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6500/mm3 (N 4300–10,800) Platelets. ............................. 450,000/mm3 (N 150,000–350,000) Serum bilirubin Total............................... 5.0 mg/dL (N 0.3–1.1) Direct.............................. 1.0 mg/dL (N 0.1–0.4) The urine is dark red and positive for hemoglobin. CT of the brain shows neither bleeding nor infarction. The most likely diagnosis is:

Answer 85

Malaria Clinical clues: - Travel hx - Prodrome of delirium or erratic behavior - Unarousable coma following convulsion - Fever - Lack of FND in presence of diffuse, symmetric encephalopathy - Normochromic, normocytic anemia Tx: IV quinidine gluconate

Question 86

Ask stroke pt to stick out tongue, pt unable to do this, but a few moments later he performs this movement spontaneously.

Answer 86

Apraxia transmission disturbance on the output side, which interferes with skilled movements.

Question 87

Agnosia

Answer 87

Inability to recognize previously familiar sensory input, and is a modality-bound deficit i.e., it results in a loss of ability to recognize objects.

Question 88

Aphasia

Answer 88

Language disorder, and expressive aphasia is a loss of the ability to express language

Question 89

Astereognosis

Answer 89

Ability to recognize objects by palpation in one hand bit not the other

Question 90

Should be avoided w/ pt w/ limited English proficiency

Answer 90

Using an educated adult family member Using a trained, qualified interpreter for pts w/ limited English proficiency leads to fewer hospitalizations, less reliance on testing, a higher likelihood of making the correct dx and providing appropriate treatment, and better patient understanding of conditions and therapies.

Question 91

Primigravida 38 weeks gestation is concerned that her fetus is getting too large and wants to know what interventions could prevent complications from a large baby. On exam, her uterine fundus measures 41cm from pubic symphysis. U/S is performed and fetal weight estimates 4000g (8lb 13oz). What do we do next?

Answer 91

Await spontaneous labor Induction of labor increases the cesarean rate C/S if fetal weight is >4500g in mother w/ DM, or >5000g in absence of DM (ACOG)

Question 92

65yo F morbidly obese presents w/ intertrigo in axilla. On exam, detect small, reddish-brown macules that are coalescing into larger patches w/ sharp borders. Most appropriate topical treatment?

Answer 92

Erythromycin Intertrigo is inflammation of skinfolds caused by skin-on-skin friction and is common on opposing cutaneous or mucocutaneous surfaces. Secondary cutaneous bacterial and fungal infections are common complications (Corynebacterium minutissimum).

Question 93

6yo M for the third time in 3 months w/ persistently painful hand condition. No improvement after amoxicillin, TMP-SMX. PE: retraction of proximal nail fold, absence of cuticle, and erythema and tenderness around nail fold area. Thumb and second and third fingers are affected both hands. First-line tx?

Answer 93

Topical corticosteroid cream Chronic paronychia. A/w chronic immersion in water, contact w/ soaps or detergents, use of certain systemic drugs (antiretrovirals, retinoids), and finger-sucking.

Question 94

90yo M w/ 5yr hx of progressive hearing loss. MC type of hearing loss at this age?

Answer 94

Presbycusis (sensorineural) - predominantly high frequencies

Question 95

44yo F suffers from OSA complains of swelling of her legs. BMI 44.1, RR 12, BP 120/78, O2 86% on RA. EKG and CXR normal. PFT shows restrictive pattern w/ no signs of abnormal diffusion. Elevated bicarb. What treatment reduces mortality rate?

Answer 95

CPAP or Bi-PAP This pt has obesity-hypoventilation syndrome (Pickwickian syndrome). Pts are: - obese - OSA - chronic daytime hypoxia and CO2 retention

Question 96

38yo daycare worker complains of cold that will not go away. Runny nose, malaise, 100F. After 2 weeks, coughing fits sometimes so severe she vomits. No immunizations since freshman year in college, does not smoke. PE: excessive lacrimation and conjuctival injection. Lungs are clear. Dx?

Answer 96

Pertussis - immunity from vaccination rarely lasts more than 12 years Prodrome phase that lasts 1-2 weeks similar to URI. It progresses to more severe cough after the second week. Cough is paroxysmal and may be severe enough to cause vomiting or fracture ribs. Patients are rarely febrile, but may have increased lacrimation and conjuctival injection.

Question 97

Thrombosed external hemorrhoid diagnosed within first 24hrs best treated by?

Answer 97

Thrombectomy under local anesthesia Because there is somatic innervation, the pain is intense, and increases with edema. Treatment involves excision of the acutely thrombosed tissue under local anesthesia, mild pain medication, and sitz baths. It is inappropriate to use procedures that would increase the pain, such as banding or cryotherapy. Total hemorrhoidectomy is inappropriate and unnecessary.

Question 98

Characteristic of patellofemoral pain syndrome in adolescent females?

Answer 98

Inadequate hip abductor strength Patellofemoral pain syndrome is a common overuse injury observed in adolescent girls. The condition is characterized anterior knee pain associated with activity. Pain is exacerbated by going up or down stairs or running hilly terrain. It is a/w inadequate hip abductor and core strength. Therefore, a prescription for a rehabilitation program is recommended. Surgical intervention is rarely required.

Question 99

Medication that increases insulin sensitivity

Answer 99

Pioglitazone

Question 100

Most effective for smokeless tobacco cessation?

Answer 100

Behavioral interventions Telephone counseling, dental examination, have been shown to be helpful for promoting smokeless tobacco cessation. Studies examining mint snuff tobacco substitute, buproprion, and nicotine replacement in patch or gum form did not show any significant benefit.

Question 101

81yo AAF complains of increasing fatigue over past several months. Skin and hair feels dry and often feels cold, intermittent swallowing difficulties. PMHx: CAD w/ metoprolol. HR 56, dry skin, brittle hair, slow relaxation phase of DTR. TSH 63.2 (0.5-5.0). Next step?

Answer 101

Start levothyroxine Autoimmune hypothyroidism is common in elderly women.

Question 102

What is associated with vacuum-assisted delivery?

Answer 102

Increased incidence of shoulder dystocia Also higher rates of neonatal cephalhematoma and retinal hemorrhage compared to forceps delivery.

Question 103

21yo F presents w/ acute pelvic pain of several days. Exam reveals right-sided tenderness and a general fullness in that area. In addition to labs, what image study?

Answer 103

Transvaginal U/S The best initial imaging study for acute pelvic pain in women is transvaginal U/S. Provides the greatest level of detail regarding the uterus and adnexae, superior to transcutaneous U/S.

Question 104

27yo F presents to ED w/ bloody diarrhea and ABD cramping. Ate a rare hamburger few days ago. Stool specimen positive for E. coli O:157. What next?

Answer 104

Monitor her renal function. Her family members are at risk since 20% of cases result from secondary spread. Biggest concern: HUS.

Question 105

Recommended for Adolescent population by USPSTF

Answer 105

Chlamydia screening in sexually active, nonpregnant females <25yo.

Question 106

75yo M presents w/ loss of interest in usual activities. Increasingly withdrawn since wife passed away 8 months ago. Lost 18lbs. No alcohol. BP 105/70. Labs all normal. Pt admits he would be fine if he got some sleep. MMSE normal. Most appropriate medication?

Answer 106

Mirtazapine Trazodone may be useful for insomnia, but is not recommended as primary antidepressant bc it causes orthostatic hypotension. Buproprion would aggravate pt's insomnia. TCA may be effective but are no longer first-line bc SE.

Question 107

55yo F h/o HTN, HLP, OA of knees develops acute gout and has hyperuricemia. Discontinue what med?

Answer 107

HCTZ HyperGLUC - glucose - lactic acid - uric acid - calcium

Question 108

Pt w/ CKD presents w/ chronic normocytic anemia w/ hgb 7.8. Best outcome is predicted if raise hgb to?

Answer 108

10-12

Question 109

25yo F presents to ED w/ respiratory distress. Complains of SOB, wheezing, coughing, choking sensation w/o obvious precipitant. On ICS for 2 months w/o any improvement of sx. Albuterol does not consistently relieve sx. Spirometry shows normal FEV1, FVC, FEV1/FVC ratio, and a flattened inspiratory loop. Most likely diagnosis?

Answer 109

Vocal cord dysfunction Idiopathic d/o commonly seen in patients in their twenties and thirties which vocal cords partially collapse or close on inspiration. It mimics asthma. Sx include episodic tightness of the throat, a choking sensation, SOB, coughing. PE will show inspiration worse than expiration. Sensation of throat tightening or choking also helps to differentiate it from asthma. PFT are normal, except flattening of the inspiratory loop, which is diagnostic of EXTRA THORACIC AIRWAY COMPRESSION. Fiberoptic laryngoscopy shows paradoxical inspiratory and/or expiratory partial closure of the vocal cords. Vocal cord dysfunction is treated with speech therapy, breathing techniques, reassurance, and breathing a helium-oxygen mixture (heliox).

Question 110

In pt w/ suddent onset dyspnea, what makes a pulmonary embolus more likely?

Answer 110

Chest Pain (pleuritic chest pain)

Question 111

2yo stumbles but his mother keeps him from falling by pulling on his right hand. An hour later, the child refuses to use his right arm and cries when his mother tries to move it. Most likely dx?

Answer 111

Subluxation of the radial head "Nursemaid's elbow" MC in <5yo, when child's hand is suddenly jerked up, forcing the elbow into extension and causing the radial head to slip out from the annular ligament.

Question 112

3wo presents w/ fever and increasing fussiness. 102.5F, HR 200, not breastfeeding, fewer wet diapers, no nasal congestion or cough, no sick contacts. Full sepsis workout and admitted. What IV abx for empiric coverage?

Answer 112

Ampicillin and Cefotaxime any child <29days w/ fever should undergo complete sepsis workup. MC are GBS and E coli.

Question 113

8yo M comes to ED w/ acute asthma attack since 48hrs. Mother initiated asthma action plan, started oral prednisolone by meter-dose inhaler w/ spacer Q 3-4hrs. Pt is alert, RR30, O2sat 94% on RA, wheezing. Peak flow is 40% of predicted value. Next step?

Answer 113

Administer IV magnesium sulfate Repeated doses of a SABA and correction of hypoxia are the main tx in ED. Nebulizer tx is no better than meter-dose inhaler w/ spacer. In children already receiving standard treatment w/ albutero; and corticosteroids the addition of IV Magnesium Sulfate has been shown to improve lung function and reduce the need for hospitalization.

Question 114

73yo F w/ long hx of RA has normocytic normochromic anemia. Hgb 9.8 (12.0-16.0) w/ decreased serum iron, decreased TIBC, and increased ferritin. Most appropriate treatment?

Answer 114

Treatment of the RA

Question 115

What would suggest that the sudden and unexpected death of a healthy infant resulted from Deliberate Suffocation rather than sudden infant death syndrome?

Answer 115

SIDS MC during first 6mo, and may present w/ clenched fists, serosanguineous blood-tinged mucoid discharge, lividity and mottling in dependent areas. Suffocation: - Age >6mo - Previous similar sibling deaths - Simultaneous twin deaths - Pulmonary hemorrhage

Question 116

50yo F passed 6 calcium oxalate stones over 4 yrs. Most appropriate advice?

Answer 116

Take potassium citrate w/ meals Low sodium, restricted-protein diet w/ increased fluid intake reduces stone formation. Potassium citrate increases urinary pH and urinary citrate.

Question 117

22yo F presents w/ right lower leg pain. Pain when pressing her shin. Been training for a marathon over 4 months and has increased running frequency and distance. Runs almost everyday and averages 40miles per week. No pain at rest, pain intensifies w/ weight bearing and ambulation. TTP over anterior aspect of mid-tibia. Trace edema localized to the area of tenderness. What image study?

Answer 117

Plain radiographs Stress fracture - plain films should be initial imaging bc high availability and low cost.

Question 118

23yo M ED w/ slurred speech, confusion, ataxia. Works as mechanic, known to consume alcohol heavily in past, appears intoxicated, but no odor. BMP shows CO2 10 (20-30), blood alcohol level is <10 (0.01%), UA shows calcium oxalate crystals, RBC count of 10-20/hpf. Woods lamp examination shows fluorescence. Arterial pH 7.25. Most appropriate at this point?

Answer 118

Tx: Fomepizole (Antizol) Ethylene glycol poisoning should be suspected in patients w/ metabolic acidosis of unknown cause and subsequent renal failure. Should be suspected in pt who seems intoxicated but has no odor, anion gap metabolic acidosis, hypocalcemia, urinary crystals, and nontoxic blood alcohol levels. Ethylene glycol is found in products such as engine coolant, de-icing solution, and carpet and fabric cleaners. Ingestion of 100mL of ethylene glycol by an adult can result in toxicity.

Question 119

67yo M w/ HTN and CKD presents w/ recent onset excessive thirst, frequent urination, and blurred vision. BG 270, hgb A1c 8.5%, BUN 32, creatinine 2.3, GFR 28mL/min. Which med?

Answer 119

Glipizide Metformin be AVOIDED in pts w/ creatinine >1.5 for men or >1.4 for women. Glyburide has an active metabolite that is eliminated renally. This can accumulate in pts w/ CKD and cause hypoglycemia.

Question 120

60yo M has a DRUG-ELUTING STENT placed in his right coronary artery. He will require treatment to prevent stent thrombosis, and once his treatment period is completed he will be placed on aspirin, 75-165mg/day indefinitely. What is the preferred initial regimen for preventing stent thrombosis?

Answer 120

Aspirin (162-325mg/day) and Clopidogrel, both for 12 months Bare metal stent - combined therapy for 1 month Sirolimus-eluting stent - 3 months Other drug-eluting stent - 6 months

Question 121

57yo M executive sees you because of "shaky hands." Tremor noticeable when holding something or writing, and is more prominent in his hand vs. his shoulder. Better after a beer or two. Gait normal, no resting tremor. Hx of intolerance to beta-blockers. What meds is best choice?

Answer 121

Primidone for essential tremor

Question 122

60yo F w/ 1yr hx of urinary incontinence. Suddenly feel the need to urinate and can barely make it to the bathroom. Meds: HCTZ. PE: vaginal mucosa is pale and somewhat dry. minimal prolapse of vagina l and urtheral areas. Most appropriate next step?

Answer 122

Oral anticholinergic for urge incontinence

Question 123

42yo F w/ BG 110, Lipids and BP normal, BMI 30.5. No sxs of DM. hgb A1c 6.3%. Most appropriate at this time?

Answer 123

Lifestyle modifications. ADA recommends testing to detect T2DM in asx pts w/ BMI >25 and one or more risk factors. RF include: physical inactivity, HTN, HDL <35, TG >250, h/o cardiovascular disease, hgb A1c >5.7%, h/o gestational DM or delivery of infant weighing >4kg (>9lbs), h/o PCOS. DM dx: - BG >126 on two separate occasions - random BG >200 BG 100-125, glucose of 140-199 2hrs after 75g glucose load, or hgb A1c 5.7%-6.9% signifies impaired glucose tolerance. Pts meeting these criteria have significantly higher risk of progression to DM and should be counseled about lifestyle modifications such as weight loss and exercise.

Question 124

Consistent w/ spinal stenosis but not with a herniated vertebral disk?

Answer 124

Pain relieved by sitting Causes of low back pain include vertebral disk herniation and spinal stenosis. Numbness and muscle weakness is present in both. Pain from spinal stenosis is relieved by sitting and aggravated by standing, whereas the opposite is true for pain from herniated disk.

Question 125

56yo M w/ T2DM has normal cardiac and renal fxn but has fail to control DM w/ diet and oral agents. BMI 30.1, hgb A1c 9.1. What drug is most likely to be beneficial in combination with insulin and diet therapy?

Answer 125

Metformin Reduce cardiovascular risk, decrease risk of weight gain, unlike some oral agents it does not significantly increase the risk of hypoglycemia.

Question 126

2wo breastfeeding w/ occasional formula supp. Recommendation for vitamin D intake?

Answer 126

Vitamin D 400IU daily Should be started within 2 months of birth

Question 127

60yo M recovering from non-Q-wave MI, 40 pack yr hx, currently smoking pack a day, FMHx of CAD. Cards lab showed no indication for coronary artery procedures. BMI 27.5, BP 130/70. FBG 85, total chol 195, LDL 95. Least likely to improve this pt's cardiovascular outcome?

Answer 127

Weight reduction is least helpful Dietary management may be appropriate, but weight reduction would do little. Beta-blockers, statins, antiplatelet, smoking cessation will all help.

Question 128

78yo M after hip-replacement surgery, has not voided in 12 hrs, urethral catheter placed and 500mL removed. Most likely to improve success rate of voiding trial?

Answer 128

Tamsulosin (Flomax) 0.4mg daily at the time of catheter insertion Urinary retention is a common problem in hospitalized pts, especially following certain types of surgeries. Starting an alpha-blocker at the time of insertion of the urethral catheter has been shown to increase the success of a voiding trial. Voiding trial success rates have not been shown to be improved by leaving the catheter in for 2 weeks, immediate removal of the catheter, using a specialized catheter, or antibiotic prophylaxis.

Question 129

Unconscious 22yo M in ED, RR 8/min, HR 60, pupils are miotic. Most likely dx?

Answer 129

Narcotics overdose Most important PE is the size of the pupils. Tolerance rarely reduces the miotic effects of narcotic medications. A patient who is comatose, with decreased breathing, a slow pulse, and small pupils should be strongly suspected of having overdosed on a narcotic. Naloxone should be administered to reverse these effects. The response to treatment with naloxone is irregular. Cerebral infarction in the pontine angle, organophosphate poisoning, phenothiazine overdose, and treatment for glaucoma can also cause constricted pupils, but these associations are seen much less frequently than narcotics overdose.

Question 130

Most likely finding in giardiasis?

Answer 130

Foul-smelling stool/flatus

Question 131

12yo M bitten by stray cat 24hrs ago. Painful and bled, parents rinsed and covered w/ bandage. Received tetanus last year. Afebrile, stable vitals, site is warm and TTP w/ surrounding erythema apprx 3cm. Most likely infectious agent?

Answer 131

Pasteurella multocida Pasteurella species are isolated from up to 50% of dog bite wounds and up to 75% of cat bite wounds, and the hand is considered a high-risk area for infection (SOR A). Although much more rare, Capnocytophaga canimorsus, a fastidious gram-negative rod, can cause bacteremia and fatal sepsis after animal bites, especially in asplenic patients or those with underlying hepatic disease. Anaerobes isolated from dog and cat bite wounds include Bacteroides, Fusobacterium, Porphyromonas, Prevotella, Propionibacterium and Peptostreptococcus. In addition to animal oral flora, human skin flora are also important pathogens, but are less commonly isolated. These can include streptococci and staphylococci, including methicillin-resistant Staphylococcus aureus (MRSA). Coverage for MRSA may be especially important if the patient has risk factors for colonization with community-acquired MRSA. Pets can also become colonized with MRSA and transmit it via bites and scratches. Cat bites that become infected with Pasteurella multocida can be complicated by cellulitis, which may form around the wound within 24 hours and is often accompanied by redness, tenderness, and warmth. The use of prophylactic antibiotics is associated with a statistically significant reduction in the rate of infection in hand bites (SOR A). If infection develops and is left untreated, the most common complications are tenosynovitis and abscess formation; however, local complications can include septic arthritis and osteomyelitis. Fever, regional adenopathy, and lymphangitis are also seen.

Question 132

3yo toilet-trained F presents w/ red rash on perineum for 5 days. Pruritic and spreading. Treated w/ nystatin w/ no improvement. PE: homogeneous beefy red rash surrounding vulva and anus. Most likely etiology?

Answer 132

Group A Streptococcus pyogenes Similar to GAS strep throat, and often coexist.

Question 133

35yo M w/ vague chest pain while sitting at his desk. Right-sided, sharp and brief pain. No hemoptysis and the pain does not seem pleuritic. PE, EKG, O2 sat are unremarkable. CXR shows 10% right pneumothorax.

Answer 133

Obtain repeat CXR in 24-48hrs.

Question 134

Provides best evidence for a given therapeutic intervention?

Answer 134

Systemic review of randomized, controlled trials.

Question 135

46yo F complains of 3 month hx of hoarseness and nocturnal wheezing, repeatedly clears her throat and feels like something stuck in her throat. Most likely related to?

Answer 135

GERD Acid laryngitis is a group of respiratory symptoms related to GERD. Sxs of hoarseness (especially in the morning), a repeated need to clear the throat, and noturnal or early morning wheezing may occur singly or in varying combinations, and are believed to be caused by gastric contents irritating the larynx and hypopharynx.

Question 136

Healthcare worker repeated developed rash on hands after using latex gloves. Rash is papular and pruritic, w/ vesicles. Latex allergy is confirmed by skin patch testing. What foods is most likely to provoke an allergic response in this patient?

Answer 136

Avocados Latex allergy management includes preventing exposure and treating reactions. Pts w/ latex allergy can reduce their risk of exposure by avoiding direct contact w/ common latex products. Additionally, they should be aware of foods w/ cross-reactive proteins. Foods that have the highest association w/ latex allergy includes avocados, bananas, chestnuts, and kiwi.

Question 137

High-dose methadone use is associated w. which cardiac arrhythmia?

Answer 137

Torsades de pointes related to QT prolongation and torsades de pointes.

Question 138

17yo F at 20wks presents w/ 2day h/o painful vesicular lesions on her labia. First time, last sexual contact 10 days ago, low grade fever, malaise, HA, mild and diffuse ABD pain. Few firm, tender inguinal nodes. What test most sensitive for confirming dx?

Answer 138

DNA PCR testing is 95% sensitive as long as an ulcer is present, w/ 90% specificity. Cx virus from infected lesion. Tzank prep and Pap smear can detect cellular changes, but both have low sensitivity.

Question 139

Dermatitis and folliculitis a/w swimming pools and hot tubs are often caused by?

Answer 139

Pseudomonas

Question 140

40yo F presents w/ fatigue, weight gain (10lbs in several months). PE unremarkable. Labs: TSH 0.03 (0.4-4.0) and free T4 1.0 (1.5-5.5). Dx?

Answer 140

Pituitary failure (secondary hypothyroidism)

Question 141

45yo M presents w/ A fib, ventricular rate of 70-75 beats/min. Otherwise healthy, lab workup and EKG normal. Most appropriate management?

Answer 141

Aspirin 325 mg daily A fib MC arrhythmia, and its prevalence increases w/ age. Major risk w/ a fib is stroke, and patient's risk can be determined by the CHA2D2 VASc score

Question 142

77yo M end-stage colon cancer. Taking opioids at higher doses to control symtoms of pain and dyspnea. What SE does not diminish over time?

Answer 142

Constipation This effect should be anticipated and recommendations for prevention and treatment should be discussed when initiating opioids.

Question 143

Best initial therapy for RA?

Answer 143

Disease-modifying drugs (Methotrexate)

Question 144

Most appropriate treatment for uncomplicated acute bronchitis?

Answer 144

Supportive care only Respiratory viruses most common cause of acute bronchitis.

Question 145

25yo F w/ asthma uses albuterol only before running, now wakes up SOB four times per month. Went to ED for increased dyspnea during peak ragweed season and remained overnight until symptoms improved. Best treatment option now?

Answer 145

Inhaled Fluticasone daily

Question 146

40yo M w/ HIV infxn and PCP. ABG shows increased A-a gradient and pO2 60. CDC normal but CD4 150. In addition to TMP-SMX, what med should also be prescribed?

Answer 146

Corticosteroids Any patient whose initial pO2 on RA <70mmHg.

Question 147

75yo F just had hip surgery to correct fx femoral neck. 2yr h/o DM treated w/ pioglitazone, metformin. PE: mildly overweight and bandage on her left hip. CBC and BMP normal except glucose of 200. hgb A1c 6.8%. Best management of her DM at this time?

Answer 147

Continue her usual medications Current evidence indicates that traditional sliding-scale insulin as the only means of controlling glucose in hospitalized pts is inadequate. For pts in ICU, using an insulin drip to maintain tight glucose control decreases the risk of sepsis but has no mortality benefit. Metformin should be stopped if the serum creatinine level is >1.5 mg/dL in men or >1.4 mg/dL in women, or if an imaging procedure requiring contrast is needed. If adequate control has been demonstrated and no contraindications are noted, the patient's usual medication regimen should be continued.

Question 148

28yo M complains of right wrist pain since falling 2 weeks ago. TTP in anatomic snuffbox. XR reveals nondisplaced fx of distal one-third of the carpal navicular bone (scaphoid). Most appropriate management?

Answer 148

Thumb spica cast

Question 149

88yo F nursing home resident w/ multiple comorbidities and advanced Alzheimer's disease. Never completed advance directives and no longer has ability to make decisions. Family inquires about hospice services for this patient.

Answer 149

Decision to enter hospice care is reversible Patients may elect to return to Medicare Part A. Individuals who reside in nursing homes and assisted-living facilities are elligible for the Medicare hospice benefit. Patients with end-stage Alzheimer's disease are eligible for Medicare hospice benefit if they meet criteria for hospice. If the patient lacks decision-making capacity, a family member or guardian may elect the Medicare hospice benefit for the patient. The patient must be certified by the hospice medical director and primary physician TO HAVE A LIFE EXPECTANCY OF LESS THAN 6 MONTHS to qualify for hospice services. This requirement is the same whether or not the patient resides in a nursing home.

Question 150

28yo M w/ recent onset intermittent urethral discharge accompanied by dysuria. Heterosexual, no prior h/o STI, acquired new sexual partner a month ago. No regional LAD or ulcers, gentle milking of the urethra produces no discharge. Eval of first-void urine specimen reveals 15 WBCs/hpf. You treat him with oral azithromycin 1g, ceftriaxone 125mg intramuscularly. Tests for gonorrhea, chlamydia, syphilis, HIV, Hep B are negative. He returns 2 months later w/ persistent urethral discharge. No relationships w/ different sexual partner, is confident that his current partner has only had sexual contact w/ him. Repeat tests and again treat w/ oral azithromycin. According to CDC testing and tx guidelines, what drug should be added to this treatment?

Answer 150

Metronidazole (Flagyl) Initial workup for urethritis in men includes GC/Chlam testing of penile discharge or urine, UA w/ microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and Hep B testing. Empiric treatment for men w/ purulent urethral discharge or a positive urine test (positive leukocyte esterase or >10 WBCs/hpf in the first-void urine sediment) includes: - azithromycin, 1g PO daily, -OR- doxycycline, 100mg PO BID for 7 days, PLUS - cetriazone 125mg IM -OR- cefixime400mg PO single dose If patient presents w/ same complaint within 3 months, does not have new sexual partner, the tests should be repeated, and consideration should be given to obtain Cx for myocplasma or Ureaplasma and Tichomonas from urethral/urine. Treatement includes: - azithromycin 500mg PO daily, -OR- doxycycline 100mg PO BID for 7 days PLUS - metronidazole 2g PO single dose

Question 151

When are two doses of varicella vaccine recommended?

Answer 151

All children with normal immune status Unless they are immunocompromised, in which case they should not be immunized against varicella, or with other live-virus vaccines

Question 152

What is the FDA black box warning on all TZDs like pioglitazone?

Answer 152

Heart Failure Also contraindicated in T1DM, hepatic disease, and premenopausal anovulatory women.

Question 153

5mo F 1 day h/o axillary temp 100.6F and mild irritability. PE: running nose, moderately distorted immobile red right eardrum. No hx of illness or otitis in past. Most appropriate management?

Answer 153

Amoxicillin 80-90mg/kg/day BID for 10 days AAFP and AAP advocate 10-day course of amoxicillin for children under 2 yrs if dx is uncertain.

Question 154

G1P1 3wks postpartum complains of bilateral nipple pain w/ breastfeeding. Soreness in the beginning, current pain began 3 days ago, worsening and inhibiting feeding, and present between feeds. PE: erythema and cracking of the areola. Most likely cause?

Answer 154

Candida infection Bilateral nipple pain with and between feedings after initial soreness has resolved is usually due to Candida. Pain from engorgement typically resolves after feeding. Mastitis is usually unilateral and is associated with systemic symptoms and wedge-shaped erythema of the breast tissue. Improper latch-on is painful only during feedings. Eczema isolated to the nipple, while reasonable part of the differential, would be much more unusual.

Question 155

8yo M presents cervical lymphadenitis. Kitten at home, concerned about cat-scratch disease. Abx against bartonella henselae?

Answer 155

Azithromycin Shown to reduce duration of LAD in cat-scratch disease. Other abx that have been used include: rifampin, ciprofloxacin, TMP-SMX, gentamicin.

Question 156

USPSTF recommendation on fluoride supplementation.

Answer 156

Children over the age of 6mo receive oral fluoride supp if primary drinking water source is deficient.

Question 157

Enlarged tongue (Macroglossia) a/w?

Answer 157

Amyloidosis May be part of a syndrome found in developmental conditions such as Down syndrome, or may be caused by a tumor (hemangioma or lymphangioma), metabolic disease such as primary amyloidosis, or endocrine distrubance such as acromegaly or cretinism. A "bald" tongue may be associated with xerostomia, pernicious anemia, iron deficiency anemia, pellagra, or syphilis.

Question 158

3yo M occasional spells of turning blue in the middle of crying. PE unremarkable, Labs normal (including hgb).

Answer 158

Reassure parents that this is a benign condition and will resolve as the child gets older. Between 6mo and 6yo. Check for iron def anemia w/ hgb.

Question 159

36yo M complains of clear rhinorrhea, nasal congestion, and watery itchy eyes for several months. H/o dust mite allergies. Most likely provide relief of symptoms?

Answer 159

Intranasal corticosteroids Pt has classic sxs of allergic rhinitis. Intranasal corticosteroids are considered mainstay of treatment for mild to moderate cases.

Question 160

57yo F serum calcium level of 11.1 mg/dL (8.9-10.5), remainder unremarkable, including BUN and creatinine. Otherwise healthy. F/u labs show calcium unchanged, normal vitamin D, and elevated PTH. Cause?

Answer 160

Primary hyperparathyroidism

Question 161

53yo F presents to ED following fall. Ankle fx and BP 160/100. Tells ED she is not aware of any previous medical problems. PE unremarkable. Confirmed the BP is new problem. What next?

Answer 161

Perform no further evaluation of HTN, but ask pt to f/u within one month

Question 162

23mo child is brought to your office w/ 2 day hx of fever 102F, cough, wheezing, mildly labored breathing. No prior episodes, no improvement w/ aerosolized bronchodilator. What is indicated next?

Answer 162

Supportive care only Typical findings of bronchiolitis, caused by RSV. Bronchodilator treatment may be tried once and discontinued if there is no improvement. Treatment usually consists of supportive care only, including oxygen and IVF if indicated.

Question 163

Contraindication for use of levonorgestrel (Mirena)?

Answer 163

Current PID Contraindications include uterine anomalies, postpartum endometritis, untreated cervicitis, and current PID.

Question 164

Best management of localized, well-differentiated prostate cancer in men older than 65?

Answer 164

Watchful waiting For men older than 65 yrs w/ small-volume, low-grade disease and a 10- to 15- year life expectancy, the risk of complications from treatment outweighs any decreased risk of dying from prostate cancer.

Question 165

67yo M w/ severe periumbilical pain, vomiting, and diarrhea, began suddenly several hours ago. Temp and BP normal, RR 28/min. ABD slightly distended, soft, and diffusely tender, bowel sounds normal. Clear lungs, rapid and irregularly irregular heartbeat, and pale left forearm and hand with no palpable left brachial pulse. Right arm and lower ext normal. Blood in both stool and urine. Hgb 16.4 (13.0-18.0) and WBC 25,300 (4300-10,800). Diagnostic imaging procedure?

Answer 165

Celiac and mesenteric arteriography The sudden onset of severe abdominal pain, vomiting, and diarrhea in a patient with a cardiac source of emboli and evidence of a separate embolic event makes superior mesenteric artery embolization likely. In this case, evidence of a brachial artery embolus and a cardiac rhythm indicating atrial fibrillation suggest the diagnosis. Some patients may have a surprisingly normal abdominal examination in spite of severe pain. Microscopic hematuria and blood in the stool may both occur with embolization, and severe leukocytosis is present in more than two-thirds of patients with this problem.

Question 166

Threshold for prophylactic platelet transfusion in most patients?

Answer 166

10,000 Platelet transfusion decreases the risk of spontaneous bleeding in such patients. A count below 50,000 is an indication for platelet transfusion in pts undergoing an invasive procedure.

Question 167

Best medication to prevent hip fracture?

Answer 167

Alendronate Only zoledronic acid, risedronate, and alendronate have been confirmed in sufficiently powered studies to prevent hip fracture, and these are the anti-osteoporosis drugs of choice.

Question 168

The sensitivity of a test is defined as?

Answer 168

Percentage of patients

Question 169

28yo F w/ irregular menses. No period for 6 months. Concerned about weight gain, worsening acne, dark hair on upper lip, chin, and periareolar region. Also intrested in becoming pregnant. Started exercise, helped lose weight, but continues to have amenorrhea. Negative beta-hCG, mild elevation in testosterone, and glucose intolerance. Medication to induce ovulation?

Answer 169

Metformin First-line agents for ovulation induction and treatment of infertility in patients w/ PCOS include Metformin and Clomiphene, alone or in combination, as well as rosiglitazone. OCP - menstrual irregularities Spironolactone - hirsutism

Question 170

Shown to be effective adjunctive tx for venous ulcers to compression therapy?

Answer 170

Pentoxifylline

Question 171

75yo M suffer anteroseptal MI, four hrs later BP 65/40, PCWP is 8 mmHg. Best therapy in this instance?

Answer 171

Infusion of normal saline PCWP of 8 mmHg suggests hypovolemia. Normal saline should be given, and 5% dextrose is not a reliable volume expander.

Question 172

72yo M w/ COPD presents w/ acute exacerbation marked by increased sputum production and SOB. O2 sat 88% on RA, diffuse inspiratory and expiratory wheezes bilaterally. Addition to O2 and bronchodilators, what else most appropriate?

Answer 172

Systemic corticosteroids and Abx Acute exacerbations of COPD are very common, with most caused by superimposed infections. Supplemental oxygen, antibiotics, and bronchodilators are used for management. Systemic corticosteroids, either oral or parenteral, have been shown to significantly reduce treatment failures and improve lung function and dyspnea over the first 72 hours, although there is an increased risk of adverse drug reactions.

Question 173

You are writing a prescription for amoxicillin for a 6-year-old female with acute otitis media. Her mother has had an anaphylactic reaction to penicillin in the past and is concerned that she may have passed this trait down to her daughter. You reassure her that this is not usually the case but warn her about potential signs of an allergic reaction. Which one of the following is the most concerning early symptom of a dangerous drug reaction? A) Tachycardia and elevated blood pressure B) Small, bright, erythematous macules diffusely over the trunk C) Pruritus around the mouth and on the palms of the hands and soles of the feet D) Eczematous patches in the antecubital and popliteal fossae E) Diarrhea with blood on the tissue paper

Answer 173

C) Pruritus around the mouth and on the palms of the hands and soles of the feet Allergic reactions to medications have four primary mechanisms, referred to as Gell and Coombs classifications. The most frequent forms are type I reactions, which are immediate and mediated through IgE, and type IV reactions, which are delayed and mediated through T-cell hypersensitization. Severe type I reactions are often referred to as anaphylaxis and are the most likely to be life threatening with very little warning. Recognition of the early signs of anaphylaxis is the first step in preventing such catastrophes. Anaphylactic reactions result from a massive release of histamine and start with pruritus around the mouth, on the scalp, and on the palms and soles; flushing of the face and neck, with rhinitis and conjunctivitis; angioedema of the oral mucosa, especially of the pharynx and larynx; severe urticaria; dyspnea and bronchospasm (especially in known asthmatics); and hypotension. A delay in lifesaving therapy during this phase will result in full shock, hypotension, and death. Type IV reactions usually result in benign, diffuse erythematous macules on the trunk and proximal extremities, often referred to as a drug rash. These reactions infrequently become more severe and rarely are life threatening. In severe cases the lesions become painful and palpable, and may involve blistering, mucositis, and ecchymosis.

Question 174

Single-dose prophylaxis against Lyme disease after Ixodes scapularis tick bite?

Answer 174

Doxycycline In controlled studies, it has been shown that a single 200-mg dose of doxycycline given within 72 hours after an Ixodes scapularis tick bite can prevent the development of Lyme disease.

Question 175

63yo M presents w/ daughter, wife recently passed. Well controlled T2DM, otherwise healthy. When should he receive pneumococcal vaccine?

Answer 175

Now and repeat dose once at age 68 Immunization before the age of 65 is recommended for certain subgroups of adults, including institutionalized individuals over the age of 50; those with chronic cardiac or pulmonary disease, diabetes mellitus, anatomic asplenia, chronic liver disease, or kidney failure; and health-care workers. It is recommended that those receiving the vaccine before the age of 65 receive an additional dose at age 65 or 5 years after the first dose, whichever is later.

Question 176

50yo M w/ solitary 5mm pulmonary nodule on CXR. OA only medical problem. Quit smoking 10 yrs ago. Most appropriate f/u for pulmonary nodule?

Answer 176

Chest CT Pulmonary nodules are common and can either benign or malignant. American College of Chest Physicians (ACCP), Eval of pulmonary nodules based on size and risk factors. Lesions >8mm in diameter w/ ground-glass appearance, an irregular border, and a doubling time of 1 month to 1 year suggest malignancy, but smaller lesions should also be evaluated, especially w/h/o smoking. CT is the modality of choice to reevaluate pulmonary nodules seen on CXR.

Question 177

Early palliative care in pts w/ terminal illness, which includes symptom management, psychosocial support, and assistance w/ decision making, has been shown to improve what?

Answer 177

Decrease depressive symptoms It has been shown that palliative care offered early in the course of a terminal disease has many benefits. Palliative care leads to improvement in a patient’s quality of life and mood, and patients who receive palliative care often have fewer symptoms of depression than those who do not receive palliative care. In addition, palliative care reduces aggressive end-of-life care and thus reduces health care costs. Palliative care does not reduce the need for hospice, but in fact enables patients to enter hospice care earlier and perhaps for longer. Palliative care has been shown to extend survival times in terminal patients (SOR B).

Question 178

An example of secondary prevention

Answer 178

Blood pressure screening at a local church Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex). Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (e.g., routine Papanicolaou tests; screening for hypertension, diabetes, or hyperlipidemia). Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications (e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post–myocardial infarction prophylaxis with β-blockers and aspirin).

Question 179

4mo M in respiratory distress. PE: grade 4/6 pansystolic murmur, best heard at lower left sternal border. He is acyanotic. CXR shows an enlarged heart and increased pulmonary vascular markings, an EKG shows combined ventricular hypertrophy. Most likely dx?

Answer 179

VSD VSD causes overload of both ventricles, since the blood is shunted left to right. The murmur is harsh and holosystolic, generally heard best at the lower left sternal border. As the volume of the shunting increases, cardiac enlargement and increased pulmonary vascular markings can be seen on a chest radiograph.

Question 180

55yo M presents for f/u on hypercholesterolemia and HTN. Good health, does not smoke, drinks alcohol frequently. Meds: multivitamin daily, aspirin 81mg daily, lisinopril 10mg daily, lovastatin 20mg daily. VS wnl, BMI 33.4. Today ALT level is 55 (10-45) and AST 44 (10-37). Rest of LFT normal. Cause?

Answer 180

Metabolic syndrome (NAFLD) MC cause of abnormal liver tests in developed world. Increases w/ age, BMI, and triglyceride concentration. Also a/w DM, HTN, insulin resistance. There is a significant overlap between metabolic syndrome and diabetes mellitus, and NAFLD is regarded as the liver manifestation of insulin resistance. Statin therapy is considered safe in such individuals and can improve liver enzyme levels and reduce cardiovascular morbidity in patients with mild to moderately abnormal liver tests that are potentially attributable to NAFLD.

Question 181

67yo F admitted w/ severe CAP. Urine should be tested for which antigens?

Answer 181

Legionella In patients with severe pneumonia, the urine should be tested for antigens to Legionella and pneumococcus. Two blood cultures should also be drawn, but these are positive in only 10%–20% of all patients with community-acquired pneumonia.

Question 182

22yo M presents w/ 2-hr h/o painful right scrotal mass. PE raises concerns that pt may have testicular torsion. Image study of choice?

Answer 182

Color duplex Doppler U/S Doppler ultrasonography is essential because it will show increased flow in orchitis, normal or increased flow in carcinoma, and decreased blood flow in testicular torsion.

Question 183

22yo M w/ acute low back pain w/o paresthesias or other neurologic signs. No LE weakness. Treatment shown to be of most benefit?

Answer 183

Resumption of physical activity as tolerated For patients who have acute back pain w/o sciatic involvement, a return to normal activities as tolerated has been shown to be more beneficial than either bed rest or basic exercise program. Bed rest for more than 2 or 4 days in pts w/ acute low back pain is ineffective and may be harmful. Pts should be instructed to remain active. Injections should be considered only if conservative therapy fails.

Question 184

68yo F post elective surgery, POD-3 suddenly develops hypoxia, fever, tachycardia, hypotension. Start high rate IVF and empiric abx. 2hrs into tx, BP remains at 80 mmHg systolic w/ sluggish urine output. What hormones should be assessed?

Answer 184

Cortisol Pts suffering from critical illness w/ exaggerated inflammatory response often have relative cortisol deficiency. This can cause hypotension refractory to IVF resuscitation, and evidence is mounting that survival is increased if these pts are treated w/ IV corticosteroids during acute management. Cortisol levels can be assessed w/ single serum reading, or by the change in cortisol level after stimulation w/ cosyntropin.

Question 185

In order to be eligible for Medicare hospice benefits, a pt must be entitled to Medicare Part A and?

Answer 185

Have a life expectancy of 6 months or less In order to be eligible for this benefit, patients must be entitled to Medicare Part A and be certified by both the personal physician and the hospice medical director as having a life expectancy of 6 months or less.

Question 186

7yo F w/ exercised-induced asthma, but also has had exacerbations unrelated to exercise. Premedicated w/ albuterol w/ spacer 5days/wk. Also needed albuterol to tx sxs once or twice per wk and had one exacerbation requiring medical treatment in the past year. No night sxs. Albuterol PRN is only med. After reinforcing asthma education, which one of the following would be most appropriate?

Answer 186

No change in medication regimen "Rules of Two" - Children under age of 12 Not well controlled if they have had sxs or used a beta agonist for symptom relief more than twice per wk, had two or more nocturnal awakenings, or had two or more exacerbations requiring systemic corticosteroids in past year. For >12yo, must have more than two nocturnal awakenings per month to classify as not well controlled.

Question 187

A young F at labor develops frank eclampsia. What is best choice of anticonvulsant?

Answer 187

Magnesium sulfate Intravenous magnesium sulfate reduces the risk of subsequent seizures in women with eclampsia compared with placebo, and with fewer adverse effects for the mother and baby compared with phenytoin or diazepam. The newer oral agents have no role in this emergency.

Question 188

What symptoms are associated with a history of sexual abuse in females?

Answer 188

Lifelong functional GI disorders A comprehensive, systematic literature review found an association of sexual abuse with a lifelong history of functional gastrointestinal disorders, irrespective of the age of the victim at the time of abuse.

Question 189

82yo M suffers from chronic back pain. On warfarin for chronic Afib, tamsulosin for BPH, and famotidine for GERD. What analgesic med will have least potential SES?

Answer 189

Lidoderm patch Topical lidocaine produces very low serum levels of active drug, resulting in very few adverse effects.

Question 190

At 18mo visit, what is most specific sign of Autism?

Answer 190

Delayed attainment of social skill milestones Delayed attainment of social skill milestones is the earliest and most specific sign of autism. Delayed or odd use of language is a common, but less specific early sign.

Question 191

55yo M presents w/ 2yr h/o persistent, worsening neck stiffness. Over past month, stiffness a/w left thumb tingling. Most appropriate study to eval pt's complaints?

Answer 191

Cervical spine series

Question 192

LMWH and warfarin started on pt w/ PE. When can LMWH be stopped?

Answer 192

After 5 days, if the INR has been >2.0 for 24 hrs

Question 193

70yo M avid runner curious as why his exercise performance is decreasing. Why?

Answer 193

Decrease in Cardiac Output Cardiovascular changes associated with aging include decreased cardiac output, maximum heart rate, and stroke volume, as well as increased systolic and diastolic blood pressure. Respiratory changes include an increase in residual lung volume and a decrease in vital capacity. Other changes include decreases in nerve conduction, proprioception and balance, maximum O2 uptake, bone mass, muscle strength, and flexibility. Most of these changes, however, can be reduced in degree by a regular aerobic and resistance training program.

Question 194

24yo M presents w/ sore throat for 2 days. Mild congestion, dry cough, 99.0F, pharynz is red w/o exudates, no anterior cervical nodes. TM normal, chest clear. Most appropriate tx?

Answer 194

Analgesics and supportive care only Centor Criteria: - tonsillar exudates - tender anterior cervical LAD - absence of cough - history of fever 3-4 (+) has 40-60% ppv 3-4 (-) has 80% npv Patients with four positive criteria should be treated with antibiotics, those with three positive criteria should be tested and treated if positive, and those with 0–1 positive criteria should be treated with analgesics and supportive care only. This patient has only one of the Centor criteria, and should therefore not be tested or treated with antibiotics.

Question 195

8yo M w/ recurrent HAs. At least twice a wk, often require miss school. Sometimes nauseated and being in dark helps. Mother has h/o migraines as a child. Child's only other medical issue is constipation. Head CT negative. Best for preventing episodes?

Answer 195

Propranolol This patient most likely is suffering from recurrent migraine headaches; at the described frequency and intensity, he meets the criteria for prophylactic medication. Ibuprofen or acetaminophen could still be used as rescue medications, but a daily agent is indicated and propranolol is the best choice for this patient (SOR B). Sumatriptan is not approved for children under the age of 12 years. Carbamazepine has significant side effects and requires monitoring. Amitriptyline is a commonly used agent, but it could worsen his constipation.

Question 196

12yo F develops fever, knee pain w/ swelling, diffuse ABD pain, palpable purpuric rash. CBC and platelet normal. Complications?

Answer 196

Kidneys (HSP) This patient has Henoch-Schönlein purpura. This condition is associated with a palpable purpuric rash, without thrombocytopenia. Other diagnostic criteria include bowel angina (diffuse abdominal pain or bowel ischemia), age ≤20, renal involvement, and a biopsy showing predominant immunoglobulin A deposition. The long-term prognosis depends on the severity of renal involvement. Almost all children with Henoch-Schönlein purpura have a spontaneous resolution, but 5% may develop end-stage renal disease. Therefore, patients with renal involvement require careful monitoring (SOR A).

Question 197

Beers Criteria, what NSAID should be avoided in geriatric pts?

Answer 197

Indomethacin The Beers criteria, a list of drugs that should generally be avoided by older patients, was developed by expert consensus, and was last updated in 2002. Indomethacin is on the list due to its propensity to produce more central nervous system adverse effects than other NSAIDs.

Question 198

Medication for T2DM produce significant weight loss?

Answer 198

Exenatide Metformin and incretin mimetics help obese pts lose significant amount of weight.

Question 199

7yo F resists going to school. Complains not feeling well every morning, when forcibly taken to school begs to return home, once home playful and normal. Also resists usual swimming lessons. Frequent nightmares where one of her parents dies. Dx?

Answer 199

Separation anxiety disorder

Question 200

23yo F presents 6 days after giving birth to first child, pregnancy complicated by preeclampsia. Reports brief crying spells, irritability, poor sleep, and nervousness. Even littlest thing can set her off. H/o major depression 2 yrs ago resolved w/ psychotherapy and SSRI tx. Greatest risk factor for postpartum depression?

Answer 200

Previous h/o depression

Question 201

40yo M recently dx w/ IBS after extensive testing by GI. Predominant sxs are diarrhea and pain. Found to be helpful in controlled trials?

Answer 201

Peppermint oil

Question 202

32yo F 6 wk h/o increasing HA, which she now describes as severe. BMI 32.4, otherwise PE unremarkable. Neuro exam normal. CT of head normal, LP w/ elevated pressure. Management should be directed toward preventing which one of the following?

Answer 202

Visual loss (Pseudotumor cerebri)

Question 203

USPSTF recommendations regarding general screening for COPD?

Answer 203

No routine screening for COPD w/ spirometry USPSTF recommends against screening adults for COPD. Spirometry is indicated for pts who have symptoms suggestive of COPD, but not for healthy adults.

Question 204

27yo F presents w/ 2 wks general pruritus. Lap chole 3 wks earlier. Intermittent RUQ pain since surgery, taking acetaminophen w/ hydrocodone for pain relief. Scleral icterus on examination. Dx?

Answer 204

Retained common duct stone Post-cholecystectomy pain a/w jaundice, pruritus is classic for retained common duct stone. Hydrocodone toxicity can cause pruritus, but not pain or jaundice

Question 205

In the elderly, highest risk of heat wave-related death?

Answer 205

Homebound Factors a/w higher risk of heat-related death include being confined to bed, not leaving home daily, and being unable to care for oneself. Living alone during a heat wave is a/w increased risk of death, but this increase is not statistically significant. Among medical conditions, the highest risk is a/w pre-existing psychiatric illness, followed by CVD, use of psychotropic meds, and pulm dz.

Question 206

NIH criterion for gastric bypass surgery?

Answer 206

BMI >40 BMI 35-40 w/ comorbidities Refractory to other methods Eval from multidisciplinary team

Question 207

66yo M w/ HTN become difficult to manage after several years. BUN 40 (5-25) and serum creatinine 2.1 (0.6-1.5).

Answer 207

Duplex Doppler U/S Preferred initial test for renovascular HTN in pts w/ impaired renal fxn.

Question 208

24yo primigravida has n/v a/w pregnancy. ACOG recommendation for first-line?

Answer 208

Doxylamine (unisom) and vitamin B6

Question 209

45yo WM develops disabling tremulousness, loss of voice, and marked sense of forceful and rapid heartbeat whenever he must speak to large groups. Med that will enable him to give presentations?

Answer 209

Propranolol

Question 210

2yo WM, mother concerned bc not yet walking. PE unremarkable. Speech and other development normal for age. Most appropriate test?

Answer 210

Serum creatinine kinase level (Duchenne muscular dystrophy - most common neuromuscular d/o of childhood) Hypothyroidism and PKU could also present as delayed walking. However, these dz cause significant mental retardation and would be a/w global development delay. Furthermore, these d/o are dx in neonatal period by routine screening. D/o of amino acid metabolism present in the newborn period w/ FOT, poor feeding, and lethargy.

Question 211

80yo F started on Warfarin for Afib. According to American College of Chest Physicians guidelines, initial dose in this pt should NOT exceed?

Answer 211

5mg In elderly, or in pts who have conditions such as HF, liver dz, or h/o recent surgery.

Question 212

32yo WF exp increasing hair growth on chin/chest, acne, irregular menstrual periods for over year. No meds. Most appropriate next step?

Answer 212

Lab testing (not metformin or pelvic U/S) Elevated early morning total testosterone is most often associated with polycystic ovary syndrome, but other causes of hyperandrogenism and other endocrinopathies should be eliminated. These studies should include pregnancy testing if the patient has amenorrhea, as well as a serum prolactin level to exclude hyperprolactinemia. DHEA-S and early morning 17-hydroxyprogesterone can detect adrenal hyperandrogenism and congenital adrenal hyperplasia. Assessment for Cushing syndrome, thyroid disease, or acromegaly is appropriate if associated signs or symptoms are present. Pelvic ultrasonography can be performed to evaluate for ovarian neoplasm or polycystic ovaries, although PCOS is a clinical diagnosis and ultrasonography has a low sensitivity.

Question 213

Proven strategy to reduce ACL tears in high-school athletes?

Answer 213

Structured exercises stressing balance, muscle strength, and proprioception

Question 214

56yo WM w/ lower leg claudication occurs when he walks approx one block, relieved by rest. H/o DM, HLP, hgb A1c 5.9%, LDL 95. Stopped smoking 1yr ago. PE normal except barely palpable dorsalis pedis and posterior tibial pulses. ABI of 0.7 w/ decreased flow. Most appropriate tx?

Answer 214

Cilostazol (pletal) Symptomatic arterial vascular disease. Already initiated two important changes: smoking cessation and walking program. Cilostazol has been shown to help with intermittent claudication, but additional antiplatelet agents are not likely to improve his symptoms. Fish oil and warfarin have not been found to be helpful in the management of this condition.

Question 215

2yo M suggested ingestion of diltiazem 90 minutes ago. Child not in distress. Advise her to do what?

Answer 215

Transport child to hospital for admission to PICU for observation. Substantial toxicity can occur w/ one or two tablets, and all children suspected of ingesting a CCB should be admitted to PICU for monitoring and management.

Question 216

55yo WM w/ weakness and HA. Describes annoying pruritus that occurs frequently after hot shower. PE: enlarged spleen. Hgb 21, hct 63%. What will confirm dx?

Answer 216

Low serum erythropoietin level Polycythemia vera. Pruritus after hot shower (aquagenic pruritus) and the presence of splenomegaly helps to clinically distinguish polycythemia vera from other causes of erythrocytosis. Specific criteria for dx of polycythemia vera include an elevated red cell mass, normal PaO2 (>92%), presence of splenomegaly. In addition, patients usually exhibit thrombocytosis (platelet count >400,000/mm3 ), leukocytosis (WBC>12,000/mm3 ), a low serum erythropoietin level, and an elevated leukocyte alkaline phosphatase score. High carboxyhemoglobin levels are associated with secondary polycythemia.

Question 217

73yo M ICU after emergent appendectomy. He appears confused, speech rambling and incoherent, disoriented to person, place, and time. His wife says he was sleepy but otherwise acting normal 2 hrs ago. On exam has normal vitals and no fever. PE and labs normal. Most likely cause?

Answer 217

Delirium

Question 218

75yo M develops C. diff and tx w/ 10 days metronidazole (flagyl) 500mg orally TID. Diarrhea recurs 10 days after he completes course of tx. Most appropriate next step?

Answer 218

Repeat course of metronidazole Clostridium difficile infection is more common with aging and can be treated with either metronidazole or vancomycin daily. For mild recurrent disease, repeating the course of the original agent is appropriate (SOR B). Multiple recurrences or severe disease warrants the use of both agents. The effectiveness of probiotics such as Lactobacillus remains uncertain. Intravenous vancomycin has not been effective. Antiperistaltic drugs should be avoided.

Question 219

39yo M w/h/o alcoholism presents w/ complaints of ABD pain, vomiting, and nausea following recent binge. Eaten little since onset of sxs 3 days ago. Lab suggest alcoholic ketoacidosis. Serum bicarb 16.3 (22.0-26.0) In addition to thiamine, what other treatment should be provided?

Answer 219

Normal saline and glucose Alcoholic ketoacidosis generally occurs in a patient who has been drinking heavily without eating. Blood glucose levels are usually low or normal, and volume depletion associated with nausea, vomiting, and abdominal pain is the norm. Patients typically have high osmolal and anion gaps. Treatment of alcoholic ketoacidosis includes vigorous volume repletion with normal saline, along with administration of thiamine and glucose. Only in the rare presence of marked acidemia (pH <7.10) is the administration of bicarbonate thought to be necessary.

Question 220

59yo M w/ known cirrhosis begin to show lower ABD distention. U/S confirms ascites. Initial tx of choice?

Answer 220

Spironolactone (aldactone) In patients with grade 2 ascites (visible clinically by abdominal distention, not just with ultrasonography), the initial treatment of choice is diuretics along with salt restriction. Aldosterone antagonists such as spironolactone are more effective than loop diuretics such as furosemide (SOR A).

Question 221

American soldier return from Middle East develops papule on forearm starts to ulcerate and form shallow annular lesion w/ raised margins. No signs of healing after 3 months. No systemic symptoms. Most likely dx?

Answer 221

Leishmaniasis The indolent course of the sore described favors the dx of cutaneous leishmaniasis.

Question 222

Mantoux Tuberculin skin test that should be read as NEGATIVE for latent TB infxn

Answer 222

9mm induration on a hospital-based nurse who had a test with 2mm induration 1 year ago. There are three different cutoffs by CDC (based on level of risk and consideration of immunocompetence): Highest risk - immunocompromised, HIV, transplant, household contacts of TB pt = 5mm Medium risk - increase exposure or risk, children, nursing home employee, correctional facilities, homeless shelters, recent immigrant, IVDA, hospital workers, those w/ chronic dz = 10mm **CAVEAT** Repeated testing - healthcare workers, 10mm within 2yrs considered positive --> thus nurse w/ 9mm that was tested last year would be negative Low risk - 15mm